NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Serrice A '■'■ DICTIONARY OF practical Sttrncrg: COMPREHENDING ALL THE MOST INTERESTING IMPROVEMENTS, FROM THE EARLIEST TIMES DOWN TO THE PRESENT PERIOD; AN ACCOUNT OF THE INSTRUMENTS, REMEDIES, AND APPLICATIONS EMPLOYED IN SURGERY; THE ETYMOLOGY AND SIGNIFICATION OF THE PRINCIPAL TERMS ; Numerous References to Ancient and Modern Works, forming ioeeuier a " Catalogue Raisonn6t" of Surgical' Literature : WITH A VARIETY OF ORIGINAL FACTS AND OBSERVATIONS*. BY SAMUEL COOPED * FORMERLY SURGEON TO THE FORCES) MEMBER OF THE ROYAL COLLEGE OF ^UuEOSS OP THE MEDICAL AND CH1RURGICAL SOCIETY OF LOUDON ; AND OF THE MEDICAL SOCIETY OF MARSEILLE* WITH .NOTES AND AN APPENDIX, BY WILLIAM ANDERSON, U*' THE COLLEGE OF SURGEONS OF EDINBURGH ) PROFESSOR OF ANATOMY AMJ rHYSIOLOGY TO THE VERMONT ACADEMY OF MEDICINE J AND LECTURER ON SURGICAL ANATOMT IN NEW-YORK. IN TWO volume! . I§ L *? kL^X/a^ vol. i. VvW Zk'r, 1 KOil TUE FOURTH LONDON EDITION NEW-YORK : 1'UhLI-lTEU BY COLLINS & IlANNAY, -au PEARL-STREET. J. k J. Harper, Printers 1823. wo C UleJ ✓• 1 ) £1^ Southern District, of ISevv-York, ss. BE IT REMEMBERED, That on the second day of December, in the forty-seventu year of the Independence of the United Slates of America, Collins &. Hanhay, of the said District, have deposited in this office the title of a book, the right whereof they claim as proprietors, in the words following, to wit: " A Dictionary of Practical Surgery : comprehending all the most Interesting Improve- "ments, from the earliest times down to the present period ; an Account of the lrtstru- " ments, Remedies, and Applications employed in Surgery ; the Etymology and Signi- " fication of the Principal Terms, and Numerous References to Ancient and Modern " Works, forming together a " Catalogue Raisonnee" cf Surgical Literature; with a "Variety of Original Facts and Observations, by Samuel Cooper, formerly Surgeon to "the Forces ; Member of the Royal College of Surgeons ; of the Medical and Chirur- " gical Society of London ; and of the Medical Society of Marseilles. With Notes and "an Appendix, by William Anderson, of the College of Surgeons of Edinburgh; " Professor of Anatomy and Physiology to the Vermont Academy of Medicine; "and Lecturer on Surgieal Anatomy'in New-York." In conformity to the Act of the Congress of the United States, entitled " An Act for the encouragement of Learning, by securing the copies of Maps, Charts, and Books, to the authors and proprietors of such copies, during the times therein mentioned." And also to an Act, entitled " An Act supplementary to an Act, entitled An Act for the en- couragement of Learning, by securing the copies of Maps, Charts, and Books, to the authors and proprietors of such copies during the times therein mentioned, and extending the benefits thereof to the arts of designing, engraving, and etching historical and other prints." JAMES DILL, Clerk of tjie Southern District of New- Yorh. D". JOHN MILLER ADVERTISEMENT OP THE AMERICAN EDITOR. THE high celebrity which this Dictionary has already attained renders encomium unnecessary on the present occasion. As an apology, however, for reprinting the fourth edition in this country, it may be urged, that seven years have nearly elapsed from the last publication of this work in America, the second edition being then issued under the auspices of the late Professor Dorsey of Philadel- phia. Since that time much has been don,e, both in Great Britain and on the continent of Europe, to add to the stock of surgical knowledge; all which JVIr. Cooper has carefully recorded ; posting to the present period the improvements that have been made in this department of Science. In this labour his wonted candour is eminently conspicuous, and not to the exclusion of those other quali- ties which have been ranked among the excellencies of his former writings. It may nevertheless be asked, Why the necessity of an Ap- pendix ? In answering this, the Editor will not plead a custom in the country; but allege, that upon a close perusal of this edition, he has discovered, with surprise, an entire omissipn of some brilliant surgical achievements, that have their origin on this side the Atlantic. These having been long ago before the public, he is unable to explain why their record has escaped the author's eye. The expediency of their having a place in a book of this nature, he offers, therefore, as one excuse for the appearance of the Appendix. Another motive not less specious, is founded upon the propriety of giving information of some new surgical operations that have been performed in this country with success, but which have occur- red so recently, that any notices respecting them could not have reached our author in time to have had them inserted. And lastly, as there have been lately presented to the public some new ideas relating to the anatomical structure of the parts within the pelvis, which are supposed will influence the method of operating in lithotomy ; the Editor ventures to place them in an appendix, by way of making more known what he considers of the highest importance in (his department of operative surgery. To further these designs, he has taken occasion to extend the ar- ticle Anastomosis—That he might exhibit what he believes to he the only instance on record, wherein opportunity was afforded, of exa- mining into the circulation by anastomosis on the side of the neck and face, after the carotid artery had been tied in the human sub- ject. Aneurism—This has been also ei.lnrged to detail th< l- 'J. by Professor Mott on the arteria innominata in 181 C, perl r the purpose of interrupting the blood in its course to an aueui i of the subclavian artery. Under this head also the Editor has pro- posed a manner of operating for securing the common and internal iliacs, which is easy of accomplishment, and does not endanger the peritoneum, nor give so great opportunity for hernial protrusions as the methods which have been heretofore practised. Aorta—Under this head the Editor has in view to submit a me- thod of securing the aorta by ligature, without wounding the perito- neum, and with the least disturbance of that membrane. Hydrophobia—This article has been extended to give place to a paper, read Oct. 1821, by Dr. Michael Marochetli, to the Medico- Physical Society of Moscow, "■ Upon the hydrophobic virus, and the means of discovering its presence, and destroying its activity on an infected subject." Although we have not yet had an opportunity in this country to test the doctrine, we give it a place on account of the respectable source whence the information has emanated. Lithotomy—What is found in the Appendix relating to this sub- ject is intended to fix the surgeon's attention to the line for the in- cision through the prostate and neck of the bladder, in this operation. Ostko-Sarcoma—Under this head is detailed three cases of ope- ration upon the lower jaw by Professor Mott, of this city, for the removal of this disease. In two of these nearly one half of the bone was successfully taken away. In the third case, the bone was taken from the socket on the one side, and cut through just before the masseter muscle on the other; and although the patient sur- vived but until the evening of the fourth day, yet the circumstances were found to be such upon dissection, which forbid accounting for his death from the operation. These cases evince the high surgical talent of the operator. They must remain on record, aud become lasting memorials to the honour of merican surgery. In addition to these, several other articles have been enlarged upon in the Appendix. 38 Becknian-Street, ) New York, 1822. ( PREFACE TO THE FOURTH LONDON EDITION. The flattering reception with which this work has been honoured ; its extensive circulation, noi Oiily in this country, but abroad, and in the colonies ; the influence, which it may therefore be presumed to have over, the judgment and practice of some thousands of surgeons in different parts of the world ; and the quantity of good, or harm, which it may thus be the means of doing to society ; are reflections, which wYiuld not suffer its author to hesitate a moment about conscientiously doipg every thing in his power for its completion and improvement. And, were not writers frequently the worst judges of their own productions, his ambi- tion would lead him to hope, that he has not laboured in vain, and that at all events, if he has not been able to make the book in every respect complete and satisfactory, he has succeeded in bringing together a mass of valuable information, constituting a nearer approach to a full and cor- rect history of the Theory and Practice of Surgery, than any other pre- vious undertaking. Throughout the bonk, he has avoided a blind de- ference to great names, knowing that experience is the only infallible authority, and, upon every proposal, whether made in ancient or mo dern times, he has delivered his own sentiments with the same freedom and impartiality, which he would always court for opinions professed by himself. One thing is certain ; viz. that, as he is unconscious of per- sonal dislike to any man in the profession, if he occasionally differs from his brethren wrongly, he may be accused of ignorance, or want of judg- ment, but never of envy, or private animosity. His steady wish has been to offer an exposition of surgery, where right and wrong doctrines, and good and bad methods, are so contrasted, that the impression in fa- vour of what seems best for the relief of the patient, and the credit of the surgeon, may be rendered as plain and striking as possible. And, upon all controverted and doubtful points, he has uniformly endeavoured to let cases and facts weigh more, than any speculative considerations. To numerous friends and correspondents, who did the author the honour to notify to him various suggestions for the improvement of the work, he returns his grateful ackowledgments ; and, wherever it has been possible for him to avail himself of these welcome intimations, the opportunity has not been neglected, and the credit of them given to the gentlemen from whom they, were derived. Some of the following cases, proposals, and references, have been in- advertently omitted ; but others unavoidably, in consequence of the ar- ticles, to which they relate, having been printed at too early a period for the necessary insertions to be made in them. Amputation—Case of Amputation at the Hip-Joint, for the Removal of' an Osteosarcomatous Tumour, by R. Carmichael. Vid. Trans, of the Fel- hirs, 6Vc. of the Kins's and Queen's College of Physicians. Ireland, Vol. 3, Hvo. Dublin, 1820. The patient, a girl nineteen years of age. The operation was followed by her death on the fifth day. Aneurism—R. Carmichael, Observations on Varix and Venous Inflam- mation, with Instructions for operating with safety to the Femoral Vein in Poplitatal Aneurism. ' See Trans, of the Fellfzvs, <$-c. of the King's and Queen's College of Physicians, Ireland, Vol. 2, p. 357, &c. " The only part of the thigh, from Poupart's ligament to the tendon of the triceps, in which the femoral vein is not completely covered by the artery, lies within the space which extends from Poupart's ligament to where the artery meets the sartorius muscle. At the part of this space, most dis- tinct from Poupart's ligament, the vein begins to disclose itself at the pubal side of the artery, from beneath which it emerges more and more as it ascends." Mr. Carurichael's plan is to introduce the needle on the pubal side of the artery, where the vein presents itself to view, and can be most easily avoided. Anus, Abscesses of—T. Ribes, Recherches sur la Situation de VOri- fice Interne de la Fistula de VAnus, et sur les parties dans Vepaisseur des- quelles ces ulceres ont leur siege. See The Quarterly Journal of Foreign Medicine and Surgery, JVo. 8, Oct. 1820. In fistula in ano, the internal orifice, when there is one, is stated to be always within five or six lines above the point, at which the lining of the gut, and the skin conjoin, and generally capable of being seen, when the patient gently strains. This is an important observation, if correct. The advice of M. Ribes never to cut a fistula, unless the inner orifice can be found, is quite repugnant to the doctrines of Mr. Pott, with whom the author of this Dictionary is still disposed to concur. Anus, Artificial—Cured by Mr. G. F. Collier, on the Taliacotian principles. See Med. and Phjsical Journ. for June, 1820. In this case, the feces used to escape chiefly when the patient was costive. Bronchocele—The Memoirs of Dr. Coindet on iodine, should have been mentioned in the references. The earliest of these interesting pa- pers was read to the Helvetian Physical Society, July 25, 182*0. Burs*: Mucosa—Some interesting pathological and practical remarks on inflammation of bursa? mucosae are contained in Brodie's Obs. on Dis- tases of the Joints, p. 305, 4rc 8z>o. Lond. 1818. Granulations—Sir Everard Home in Philosophical Trans, for 1819. The discovery, here alluded to, is briefly noticed in the account of the properties and uses of pus, in the article Suppuration;. Fractures—A new method of treating old fractures, which have lost all tendency to unite, was successfully tried by the late Mr. Henry Cline and has been recently practised by Sir Astley Cooper. It consists in cutting down to the ends of the fracture, scraping them well with a scal- pel, and then rubbing them with a piece of caustic potassa, so as to destroy the parts of the bone indisposed to union, and at the same time excite such changes in the adjacent portions of bone, as will lead to an attempt at reparation, the formation of callus, and a reunion of the living bone after the detachment of the dead fragments. A few weeks a»o the author of this work was present at an operation of this kind done by his friend Mr. Earle ; but as the case is now under treatment and this gentleman will probably soon favour the public with the particulars himself, it is judged unnecessary to offer here any premature observa tions on the merits of the practice, of which no just estimate can vet be formed, on account of the very small numbers of trials hitherto made of it. Like other methods, however, it appear? not alwavs to have «ur - eeded ; but, whether it will do so more frequently, than the plans, lot which it is substituted, and with less suffering than the seton produces, lime and experience must determine. Lithotomy through the Rectum—It appears from a recent state- ment, that altogether 15 patients have been operated upon in this way, and that only one case terminated fatally, ten being completely cured, and four quite well, with the exception of trivial urinary fistulas. See Journ. Complem. du Diet, des Sciences Med. T. 10, p. 180, 8vo. Paris, 1821. Venereal Disease—Recent investigations into this difficult subject tend to confirm an observation, made by Fallopius, Palmarius, and other writers of former times, that when mercury is not administered, the bones are seldom affected with nodes, or caries. However, it is not to be suppossed, that the non-mercurial treatment is never followed by swellings of the bone, or periosteum. In Mr. Abernethy's Works, Vol. I. or in Vol. II. of this Dictionary, a case is recorded, where a young medical student, in consequence of the infection of a scratch on his finger with the matter of a bubo, had a variety of secondary symptoms, and among them, a thickening of the periosteum on the forehead, and a true corona veneris. The case was treated from the beginning to the end without mercury, and every symptom disappeared. Mr. Abernethy, according to the doctrines formerly in vogue, supposed that the disease could not be syphilis, because the recovery was effected without the reputed specific; but as this criterion is now proved to be erroneous, the above case would be set down as venereal by the generality of mo- dern surgeons. A day or two ago, Mr. M'Gregor, seiior surgeon to the Lock Hospital, mentioned to the author two decided examples of nodes in patients, who had never used any mercury from the commencement of their cases ; but who were obliged to have recourse to this medicine for the cure of these and other secondary complaints. In Mr. Aberne- thy's case, it has been stated, that the corona veneris, as well as the other symptoms, yielded without mercury. Mr. M'Gregor inclines to the opinion, that syphilis is capable of a spontaneous cure only where the constitution is good ; yet, as the army reports include some thou- sands of cases, taken promiscuously and cured without the specific, there is some difficulty in explaining the invincible resistance of a few cases to the non-mercurial practice by any supposition of badness of constitution, in the general sense of the expression ; and it must be pre- sumed, that, where many thousands of individuals are treated promis- cuously without mercury, and ultimately recover, their constitutions could not all have been healthy. Mr. M'Gregor, however, may be correct, inasmuch as some uncommon peculiarity of constitution may sometimes present itself, in which the use of mercury is absolutely ne- cessary for the removal of syphilitic complaints. As far as the experi- ence of the author of this work goes, the frequency of nodes and caries has been considerably lessened since moderate courses of mercury have been substituted for violent salivations; an opinion, in which he is happy to find himself joined by his friend, Mr. M'Gregor. South Crescent, Bedford-Square-, P»r. 11, 1821. DICTIONARY OF PRACTICAL SURGERY. Tide mark (*)'will signify, that the Word which it precedes is further spoken of in the Appendix. ABD ABAPTISTON, or Abaptista (from a, priv. and Cimtfo, immergo, to sink under.) Galen, Fabricius ab Aquapendente, and especially Scultetus, in his Armamenta- rium Chirurgicum, so denominate the crown of the trepan, because this part of the in- strument formerly had a conical shape, which kept it from penetrating the cranium too rapidly, so as to plunge the teeth in the dura mater and brain. It would be quite su- perfluous here to inquire, whether there was any ground for this apprehension in the ruder periods of the surgical art, when the skilful management of the trepan might not be so well understood as at the present day. While it is admitted by modern surgeons, that mischief may be done by letting the saw penetrate too deeply, they do not find it necessary or adviseable, to obviate the pos- sibility of such an accident, by using a co- nical trepan, with which it would be diffi- cult to make any perforation at all; but guard against the danger by observing par- ticular rules and cautions laid down in ano- ther part of this book. (See Trephine.) It is remarked by Mr. S. Sharpe, that the great labour of working so slowly and diffi- cultly (with a conical saw) is not only very inconvenient to an operator, but by no means serviceable to the operation; for, notwithstanding the saw be cylindrical, and works without any other impediment than what lies before the teeth, yet, even with this advantage, the operation goes on so gradually, that, in all his experience, he never found the least danger of suddenly passing through to the brain, when care was taken not to lean too hard on the instru- ment at the period of the bone being almost sawn through. (Operations of Surgery,p. 161, Ed. 3 ; also I'Encyclopedic Mithodique, Partie Chir. art. Abaptiston.) •ABDOMEN. The belly. The term is said to be derived from the Latin verb abdo, to hide, because many of the chief viscera of the body are here concealed. When a surgeon speaks of the cavity of the abdomen, he confines his meaning to the space, which is included within the bag of the peritoneum. Hence, neither the Vol. I 2 ABD kidneys, nor the pelvic viscera, are, strictly speaking, parts of the abdomen. Anatomists have distinguished this large cavity into different regions, the terms allot- ted to which are so very frequent in the lan- guage of surgical books, that some account of them in this Dictionary seems indispen- sable. The middle of the upper part of the ab- domen, from the ensiform cartilage as low down as a line drawn directly across the greatest convexity of the cartilages of the ribs, is called the epigastric region. The spaces at the sides of the epigastric region are termed, the right and left hypo- chondria, or hypochondriac regions. The umbilical region extends from the navel upwards to the line, forming the lower boundary of the epigastric region, and downwards to a line drawn across from one anterior superior spinous process of the ilium to the other. The middle space, below the last line, down the os pubis, is named the hypogas- tric region. The parts of the abdomen, situated on the outside of the umbilical region to the right and left, or externally with respect to two perpendicular lines drawn from the greatest convexities of the cartilages of the seventh true ribs, are named the ilia, or flanks. On each side of the hypogastric re- gion is situated the inguinal region, or groin. The whole of the back part of the abdomen has only one technical appellation, viz. the lumbar region, or loins. The abdomen is apart of the body claim- ing the particular attention of every practi- cal surgeon ; for, it is the frequent situation of several of the most important surgical diseases. It is also very much exposed to wounds, and various operations on different. parts of it are often indispensable. One of the most common afflictions, to which man- kind are subject, is that in which some of the bowels protrude, pushing out before them a portion of the peritoneum. This disease is called hernia, and ought to be well understood by every practitioner, who, however, can never acquire the necessary 10 ABD0ME> knowledge, without being perfectly and mi- nutely acquainted with the anatomy of the abdomen. In dropsical cases, it is frequently proper to tap the abdomen, and this opera- tiou, named paracentesis, simple as it may seem, requires more consideration, and at- tention to anatomy, than surgeons often bestow on the subject. The abdomen is also exceedingly liable to be wounded. See Hernia, Paiacentesis, and Wounds. Abdomen, abscesses of the. These may take place either within the cavity of the belly, or at some point of its circumference, and may be either of an acute, or chronic nature. Women are generally considered more liable, than men, to abscesses in and about the abdomen : the abscesses named lumbar being elsewhere treated of, are here excluded from consideration. Collections of purulent matter, resembling turbid whey, and containing whitish or yellowish flakes, are not unfrequcntly formed in the cavity of the peritoneum, as one of the effects of in flanimation accompanying puerperal fever. —(Stoll, Hat. Med. 4. p. 103 ; Lassus, Pa- thologic, Chir. T. 1, p. 137, JVouvelle Edit. tiro. Paris, 1809.) In lying-in women, abscesses frequently form between the abdominal muscles and (lie peritoneum, especially just above the groin. They are cases, which have been very correctly described by Conradi. Be- fore the integuments project, the diagnosis is often attended with difficulty, and some- times an obscurity prevails several weeks ; for, the patients seem as if affected with slight colic pains, which yield to common treatment, particularly external applica- tions, but soon return. Thus, unless the vicinity of Poupart's ligament be carefully examined, in which situation some very painful point, or a hardness, or elevation can be detected; the abscess may remain concealed until a large prominence, or the extension of the matter down the thigh, lameness, Sic. make the nature of the case completely manifest. As the peritoneum, adjoining the abscess, is always thickened by the preceding inflammation, Conradi assures us, that there is no danger of the col- lection of matter bursting inwards. Some abscesses indeed have been so enormous, that the matter actually pushed the viscera out of their places, yet all this happened without being followed by any inward bursting of the disease. The whole danger depends upon the duration of the complaint, and the extent to which the matter spreads. \ timely detection of the nature of the case, the use of emollient applications, and the making of an early opening, generally brings the disease to a speedy and favourable ter- mination.—(See Arnemami's Magazin far die Wundarzneiunssenschaft, 1 B.p. 175.8vo. Gail. 1797.) Chronic tumours of the mesentery, which, in scrophulous children, sometimes slowly terminate in suppuration, and the diseases of the ovary, and other abdominal viscera, bringing on the formation of matter, are often the cause of purulent extravasation, §reat emaciation, hectic *ymptoms, and eath. However, sometimes salutary ad- hesions are produced between the viscera, by which means an outlet is obtained for the matter through the bladder, anus, or vagina. Thus (says Lassus) in the case of a woman who had had for a long while pains in the right lumbar region, which were supposed to proceed from suppuration of the kidney, because pus was voided with the urine, the right kidney was found after death in the natural state ; but an ab«cess existed in the right ovary, that was adherent to the bladder into which the pus had passed through an ulcerated communication. In another patient, who had voided pus by the anus, the right kidney was suppurated, and adhered to the colon, with which it com- municated by a preternatural aperture. A woman had for many years a hard consider- able tumour in the abdomen : at length the pain, which she suffered from the disease, became intolerable ; and just at the mo- ment when her death was apprehended, an immense quantity of pus was suddenly dis- charged from the vagina. The pain abated; the swelling of the belly subsided ; merely the remains of the objuration were now perceptible ; and the woman's health be- came perfectly re-established. (Lassus, Pa- thologie, Chir. T. 1, p. 138.) The abscesses, which sometimes form be- tween the peritoneum and abdominal mus- cles, or between the layers of these muscles, or under the integuments of the abdomen, are attended with considerable variety, ac- cording as they happen to be chronic, or acute ; circumscribed, or diffused ; small, or extensive. Those of the acute or phleg- monous kind sometimes follow stabs and contusions, and are particularly noticed in the article Wounds. These are cases, which demand especial care, because, if notcheck- ed and kept within certain limits, they may prove fatal, many examples of which are upon record. (See Commerc. Literar. Noric. 1741, P 100; Eller, Medic, and Chir. An- merkungen, P. 108, fc.) As for chronic ex- ternal abscesses of the abdomen, they should be opened early, and treated on the principles explained in the article Lumbar Abscess. For further information, respecting ab- scesses of the parietes of the abdomen, the reader may consult Commerc. Literar. JVoric 1736, hebd. 37; C.Bell, System of Dissections, Tab. 1. Bourienne, in Joum it ™-e"^' I' Ah P' M> Collomf>- Med. Chir. Werke, Obs. 28; J. H. Furstenau, Diss. Abscessuum musculorum abdominis, LrC"J? tnfta1uc exempla, Rintel, 1742 Hoftmann,deFeerc Tertiana, Obs. 7. vid. Op. t J 0Heu*™a™, Vermuchle Bemer- SnfJ' £ *£ T> iH Medkal 'ommunica. swn ,J;c- Riverus, Obs. Communicat. Obs 2 J; Kinship in Memoirs of the Medical So- cietyoj[London, 2. Ab. 52; Wrede, Collec- tanea Chir. T.1. Hard indigestible substances, after be mg swallowed, are not luifrrqunntly dis- ABDOMEN. charged from abscesses formed in some of the abdominal regions. (See De La Grange, in Museum der Heilkunde, 4. B. P. 154 : a fishbone, which had been swallowed, found in the abscess; Petit, Trait, des Mai. Chir. T. 2,p. 226: awl, without a handle, extracted from an abscess of the abdomen ; and many other analogous cases) Encysted tumours sometimes form be- tween the peritoneum and abdominal mus- cles, and attain an immense size, before they burst; a remarkable specimen of w hich is detailed by Gooch. (Chirurgical Works, Vol. 2. p. 144. $■<:. 8vo. Lond. 1792.) In this case, the spontaneous opening of the navel was enlarged with caustic, and the cyst ex- tracted ; but, before a cure could be effected, it became necessary to make a depending opening, and introduce a seton. Swellings of this nature, however, are only noticed here, on account of their resemblance to circumscribed chronic abscesses of the pa- rietes of the abdomen. Abdomen, Pulsations in the. From the article Aneurism, the reader will understand, that, though it be the common nature of this disease to be attended with throbbing, it is not every pulsating tumour, which is an aneurism. The cases, usually called abdo- minal or epigastric pulsations, often furnish a proof of the correctness of the preceding remark. The authors, who have treated of the latter affection with the greatest dis- crimination, are Dr. Albers, of Bremen, and Mr. Allan Burns, of Glasgow. Some of the pulsatrons here referred to are a conse- quence of organic disease, capable of de- monstration on dissection; while the rest are not attended with any such appearance, and have therefore been regarded as ner- vous. The pulsation is not always produced by the impulse communicated to some solid tumour, or substance between the hand and the artery, but is sometimes certainly dependent on a nervous affection of the vessel itself. (On Diseases of the Heart, p. 263.) Hippocrates, in his book " De Morbis Popularibus," makes mention of three pa- tients, affected with extraordinary pulsations in the abdomen. As one of these cases originated from obstructed menses, it was probably not the result of any organic dis- ease. (Hippocraiis Opera Omnia, ex edit. Feesii. Francof. 1621. lib. 5. sect. 7. p. 1144.) In order to remove a difficulty, which may be. at first experienced in believing how nri artery, not affected with aneurismal enlargement, can communicate to the parts which lie over it such movements as are frequently remarked in cases of abdominal pulsations, a fact pointed out by Mr. Hun- ter, should be remembered : in speaking of the actual dilatation of an artery, he says, that when the vessel is " covered by the in- teguments, the .apparent effect is much greater than itrSaTteis in the artery itself; ibr, in laying such an artery bare, the nearer we come to it, the less visible is its ;>ul>.itinii; and when laid bare, its motion i- Ii.irdlv to hr either felt or seen." (Trta- ■ v t1, Hhnd. Vc p. 175.4ln. Lond. 1794.1 And this observation will apply to all tu- mours and indurations situated over a large artery. In the epigastric region of a certain patient, Taberranus felt not only a pulsa- tion, but a tumour as large as the fist, with all the other usual symptoms of an aneu- rism. On opening the body after death, he was therefore surprised to find, instead of this disease, a considerable scirrhous tumour in the middle of the mesentery, so closely connected to the large vessels, as to com- press the aorta, by the pulsations of which it had been lifted up. (Obs. Anal. ed. 2. No. 9.) Dr. Albers quotes an extraordinary case from Tulpius : the patient, a laborious man, but subject to bilious attacks, was sometimes affected with violent throbbings of the spleen. These pulsations were not only very pain- ful, but could be heard at a distance, and their number distinctly counted, when the hand was applied to the part. What seems almost incredible, it is alleged, that Tulpius could hear them at the distance of thirty feet! Their violence increased, or dimi- nished, according as the patient was more or less bilious, and sometimes they entirely ceased, when his health improved ; but al- ways recurred, as soon as the chylopoietic organs got out of order again. After the pa- tient's death, permission could not be ob- tained to open the body. (Tulpii Obser- vations Medicce. Amst. 1652. lib. 2. cap. 28.) The case of a female, recorded by Pech- lin, is then adduced, which consisted of a complication of symptoms, amongst which the only one, claiming attention here, was an annoying throbbing in the abdomen. The pulsation, which was quite evident, Was felt by Pechlin when he placed his hand upon the linea alba, and corresponded to the pulse at the wrist. The patient fancied, that a monster was in her abdomen ; but Pechlin comforted her with the assurance, that the throbbing was only the motion of the large artery, rendered perceptible by her extreme emaciation. She lived three years with this disease, suffering at times severely from convulsions, of which she at last died. Pechlin was informed, that before her death; her body was shortened two feet, the ribs being bent down to the ossa pubis, and the whole vertebral column curved forwards. (Pechlini Observationum Physico-Mcdicarum, libri Ires. Hamburgi, 1691, lib. 2, Obs. 6.) According to Bonetus, pulsations in the left hypochondrium are not unfrequent, and it was his belief that they were produ- ced by the cceliac artery. He cites several cases of this disorder from other writers, the tenor of which is to prove, that the cceliac'ar- tery and mesenteric vessels must have been affected, as they were found after death di- lated and filled with black blood. (Sepul- chretum Anatomicum, lib. 1. sect. 9. Obs. 9, 26, 27, 30, 38, 42, 44, 45, and 46.) The conjecture of Bonetus and others, how- ever, respecting the frequency of abdomi- nal pulsations from dilatation of the cceliac and mesenteric arteries, by no means coin- cides with the results of modern observa- \BDOME> lion?. Mr. Wilson, whose dissections have been very numerous, says, that he has met with only one instance of true aneurism, affecting any of the branches of the aorta, which are distributed to the abdominal viscera. This casS was an aneurism ef the left branch of the hepatic artery. (Lectures on the Blood, and on the Anatomy, Physiology, and Surgical Pathology of the Vascular Sys- tem, fyc. p. 379. 8vo. Lond 1819.) Bontius was present at the opening of an inhabitant of Batavia, who had been afflicted three years with a disease, the exact nature of which could never be made out during life. When the hand was applied above, or below the navel, a pulsation was felt like that of the heart, or an artery, and as forcible as the motion of a child in the womb. It was synchronous to the pulsation of the heart and arteries. Hence, Bontius concluded, that the case was owing to some affection of the heart. The vena cava, instead of con- taining blood, was filled with a medullary substance, which, pressing against the aorta, is supposed to have excited the extraordi- nary pulsations in that vessel. The heart was unusually dilated, and flabby. The two ventricles were very large, and filled with dark-coloured blood. The liver was of nearly twice the natural siz<;, its substance being of a light colour. The gall-bladder resembled that of a bullock, and was filled with viscid bile nearly as thick as an extract. (Jacobi Bonlii de Medicina Indorum, libri 4. Lugd. 1718. Obs. 8. p. 101.) __ Lewenhoek met with an instance of a similar pulsation, which he imputed to ir- regular action of the diaphragm, the pulse at the wrist not being affected. The disor- der lasted three days, during which the func- tions of the alimentary canal were so much interrupted, that the patient was expected to die. (Philosophical Trans, from 1719 to 1733, abr. by J. Fames, fyc. Lond. 1734. vol. 7. p. 683.) Ballonius recites the case of a man, affect- ed with a quartan fever, gout, and other complaints, who had so violent a pulsation in the left hypocliondrium, that it was sup- posed to originate from an aneurism. The patient died suddenly (as Ballonius imagin- ed) of a rupture of one of the vessels of the spleen. (Ballonii Epidemicorum el Ephtme- ridum, libri 2. Venctiis, 1734. Consiliorum Med. Lib. 1. p. 379.) Dr. Albers has also described the particu- lars of a man's case, recorded by Burg- graf, and entitled " Diuturna, magna, et valde molesta pulsatio in epigastric" (Vid. Acta JYalur. Cur. Norimb. 1740, Vol. 6, Obs. 131.) Burggraf gives his reasons for believing, that, in this instance, the pulsa- tion arose neither from the aorta nor from the cceliac artery ; and suspects that it was caused by a dilatation of that considerable branch of the inferior mesenteric artery, which inosculates with the branch of the superior mesenteric. This idea, however, which was merely surmise, could not be correct, as the patient was cured by taking in the form of pills, even' morning and even- ing , halt a dram of a mass composed of ?qual parts of Gum Ammoniac, taur. Minor, and Venice soap. Then follows an example taken also from Burggraf. (Anserlesene Med. Falle and Gu- tachten, Frankf. Am. M. 1784, S. 300.) A young man, after experiencing some com- plaints of the stomach, began to feel pain and tenderness about the scrobiculus cordis. At length a pulsation was detected just be- low the ensitorni cartilage. It was not very considerable when the stomach was empty, but always incivax.'d after a meal. In the course of the disease, the patient had various ,4) symptoms of dyspepsia, and became so cos- tive, that he had a motion only once in three or four days. Various opinions were given by the physicians concerning the nature of the disease, about which, however, Burggraf finally leaves the reader in the dark. Dr. Albers details the particulars of ano- ther case from the work last quoted, (p. 310.) The patient, a young woman, three and twenty years of age, whose menses had been obstructed five months, became affect- ed with violent throbbings in the epigastric region, which were synchronous to the pul- sations of the heart, and so forcible, that they seemed as if they proceeded from a displacement of the latter organ into the up- per part of the abdomen. Dr. Massuet of Amsterdam considered the affection alto- gether as an effect of obstructed menstrua- tion and hysterics, and of course, prescribed medicines calculated to re-establish that evacuation. Some physicians of Leipsic,J however, who were probably quite mistaken,.* looked upon the case as an aneurism either of the arteria gastrica, or gartro-epiploica, * and ordered repeated venesection, aperi- ents, and a bandage. In the valuable essay of Albertinus, on diseases of the heart, as a cause of difficult respiration, there is a passage where he is speaking of the diagnosis of enlargement* of the heart, aneurism of the curvature of the aortae, he, which Dr. Albers cites, as deserving attention in the present subject. " Verumtamen extra pectus ubi deficiente solido arcu costarum, tantum difficultatis in hac indagine non ostenditur, me satis scio plunes mdicavisse ex eo, quod vasis diame- trum non auctum perceperim validas, assi-j duasque arteriaj ccpliaca, vcl aorta; in abX domine pulsationes fuisse sine dilatatione, 1 nee judicium meum eventus fefellit " (Lt Bonomensi Scienliarvm el Artium Instiffl>, atque Academia Comment. Bononice 1748 T. 1. p. 3S7.) ' ' " An example follows from the writings of he celebrated Stork. After death, the svmn torn, were found to have .rllff KnV X ease of the pancreas, which weighed thu4 teen pounds, and containedfc farce cSt* fi led with lamellated blood, , (jSSLmV dicu,, Vindob. 1760, p. 245 )# ( The subsequent case, sonJeWhat analo- gous to the former, isfrom a different author A man agedJo, complained of ^n^< the left side"ofrtne abdomen, midway be yveen the mfebilicu* and crista of the ilium ABDOMEN. 13 ft Emaciation, weakness, distress of counte- nance, anorexia, constipation succeeded. At length, a large pulsating tumour was dis- covered in the epigastric region. The case was now pronounced aneurism of the abdo- minal aorta. There was no nausea, nor vomiting, except that some days before death, a quantity of fetid, blackish fluid was twice or thrice voided. No fever. The swelling caused a sense of constriction ra therthan pain, and the throbbings became more perceptible. The pulse was feeble, but slow and regular. After de;th,thc stomach was found adhering to the liver, pancreas, and abdomen ; and a cancerous tumour occu- pying its internal surface from the duodenum to the insertion of the oesophagus, the coats of the stomach being an inch thick. The surface of the pancreas was also diseased, and the pylorus, situated in the midst of the cancerous mass, was contracted by the thickening of the parietes of the stomach, and obstructed by numerous fungi. The liver was large, but apparently sound ; the spleen small. The aorta, the cceliac trunk, and its branches were quite natural. (See Journ. de Med. per Leroux, Oct. 1815, and Medico-Chir. Journ. Vol. I. p. 289.) Morgagni describes the case of a woman, 44 years of age, who, after a suppression of the menses for some months, was attacked with palpitations in the epigastrium. Mor- gagni, on applying his hand to the part, felt a large hard body moving forcibly. At first, it was regarded as an aneurism in the ab- domen ; but, as there were.no similar throb- bings in the chest, and there was nothing extraordinary in the pulse at the wrists, Morgagni concluded, that the movements in question could not depend upon the heart. Neither did he take the disease for an aneu- rism, because the throbbings did not cor- respond to the pulse. As for the large in- durated mass, it appeared to him more easy to say what it was not, than what it was: it could not be merely a globus hystericus, which never beats like an aneurism. Mor- gagni considered the case as an hysterical spasmodic complaint, ordered the patient to be bled, and the following day the pulsa- tions ceased. (Morgagni, de Sedibus et Cau- sMorborum, T.2, Epist. 39, 18.) Aaskow relates a case, in which, after the subsidence of a hard painful swelling un- der the upper false ribs of the right side, a peculiar throbbing movement presented it- self in the same part. The phenomenon was imputed to the diaphragm : " et in loco dolentesingularis motus palpitationis instar, evidenter enim compiciebatur,quasi muscu- lusdiapbragmatisse constringendopartes vi- cinas coniprimeret et extrorsiim protrude- rct.'' (Acta Soeietatis Medicte JJavniensis. Havnie,YiTl, Vol. 1, p. 208, $-5.) V Senac has spoken of these avSominal pulsations, as sometimes occurring in hypo- chondriacal and chlorotic patientf? and as they frequently subside, witfBfitl earing any vestige behind, he set* them dowir\hs ner- vous affections. (Tlfkitiits Mai. du Gaur.) Df; Haen had undjw'His care/i hypochon- ¥ driacal patient, affected with pulsations in the abdomen; which, with other complaints, were dispelled by means of brisk opening medicines. (Heilung's Methode Uberseizt von Plattner, Leipz. 1782. 2. B. S. 29.) Thilenius observed a flatulence of the stomach, which he represents as having been epidemic, and attended, in some pa- tients, with pulsations at the scrobiculus cordis. (Med. Chir. Bemerk. Franhf. 1789. S. 211,-217.) My friend, »1r. Hodgson, also, in speak- ing of pulsations in the epigastrium, which are not the consequence of organic disease, and occur in irritable hypochondriac sub- jects, states his opinion, that, in some in- stances such pulsations were a consequence of distention of the stomach with air, which was thrown against the abdominal muscles by the pulsation of the great bloodvessels; and in these cases, the throbbing was di- minished by the eructations. (Onthe Dis- eases of Arteries and Veins, p. 96.) These abdominal pulsations are also de- scribed by Zuliani, as a symptom of hypo- chondriasis and hysteria (De Apoplexia, Lijs. 1790 p.79.) They also happen in cer- tain febrile diseases. (Versuchttberden Pem- phygus und das Blasi nfieber von C. G. C. Bra- une, Leips.'1795, S. 24 ; and Dr. R. Jackson on the Fevers of Jamaica, 8ro. Lond. 1791.) In a dissertation on cramp in the stomach, Hau remarks. " Quin immo, ubi diutius vexavit gastrodynia, continuos aegrotans persentit spasmos, ut et haud raro pulsatio- nem quandam plane singularem. in cardia et ventriculo, pulsui autem cordis minime syn- chrone." (Diss, de Gastrodynia, Upsal. 1797.) In the same essay is also given an account of a man, who had violent palpi- tations in the epigastric region, apparently first excited by the larva of the musca pen- dula, many of which were vomited up. Pinel is another writer who describes these abdominal pulsations, as an occasional symptom ef hypochondriasis. " Palpita- tions du ca>ur et quelquefois une sorte de pulsation irreguliere, dans quelque partie de l'abdomen." (Nosographie Philosophique. T. 2, p. 25, Paris, an. 6.) Dr. Albers details some cases which fell under his own notice. A young woman, whose menses were upon her, and who had been for some days constipated, was seized with frequent fainting fits and febrile symp- toms, occasionally voiding from the bowels a quantity of dark matter, each evacuation of which was followed by a swoon. One morning at five o'clock Dr. Albers was sent for, as it was feared the patient was about to die. She was extremely exhausted, and the fainting fits followed each other, with hardly any intervals. She could just say, "I feel a throbbing in the belly;" and, when Dr. Albers applied his hand to the pr.rt, Hft felt a violent pulsation, extending from the ensiform cartilage down to about \ the bifurcation of the aorta. The action of the heart was weaker than natural; the pulse at the wrist very small, but not quicker than it had been on the precedijtg'day, and ABDOMEN was not synchronous to the throbbing in the abdomen. Dr. Albers confesses, that at first he took the case for an aneurism. Dr. M'iyerhoff was of the same opinion. Ano- ther physician, however, Dr. Weinholt, en- tertained doubts of the complaint being aneurismal, saying, that he recollected having read some similar cases in Morgagni. These gentlemen decided to persevere in the employment of opening medicines and clysters, combining opium with the former. Under this plan, the pulsations in the abdo- men and tightness of the chest diminished in a few days. The stools were at lirst of the colour of chocolate, but afterwards re- sumed ther natural appearance. The throb- bings, in a. weakened form, however, were perceptible for six weeks longer. The pa- tient at length got quite well, and was re- maining so four years afterwards. A man, about 40, severely afflicted with hypochondriasis, threat oppression of the chest, corstipation, and tension of the abdo- men, tendency to fainting, &u:., complained to Dr. Albers, that he felt as if his heart had fallen down into his belly, where he was annoyed with an incessant throbbing. In- deed when Dr. Albers examined the abdo- minal parietes, he could feel a very strong pulsation, and, what is curious, could trace it not only along the track of the aorta, but in the course of the left iliac artery. The pulse at the wrist, which was small,frequent, and hard, did not correspond with the ab- dominal pulsations. For several days, the evacuations from the bowels had been as black as pitch. After the employment of gentle purgatives, all the complaints quickly abated, though the throbbings were feebly perceptible for nine months afterwards. The next case,-which Dr. Albers met with, is very interesting. A robust sailor, whose bowels were so constipated, that hardly the strongest purgative could affect them, was seized with constant pain in the left hypo- chondrium. With this complaint were soon joined great pain in the back, and a sensation as if something alive moved about in the belly from one side to the other, and thence extended up to the neck, followed by the vomiting of a greenish matter. At the same time, he felt in the left side a pulsation, which he took for that of the heart, and which continued the whole of his illness. The pulse at the wrist was natural, and synchronous with that in the abdomen. In the beginning of the disorder, the patient was obliged to sit with his body very much inclined forward, as no other posture could be endured For the first week opening medicines afforded so much relief, that he was sometimes quite free from pain for six or eight hours. After a time, a round swel- ling formed in the left hypochondria^ end reached to the navel, and attainedmitb in- credible quickness the size of a ehildji head. Indeed, it could now be traced beyond the umbilicus to the right side. The motions were quite of a dark colour, or else red blood and a ' puriform matter was dis- charged^ Sometimes the blood voided wt^ t % of a bright red colour, sometimes it was dark, coagulated, and mixed with bile, the patient was at length worn out with febrile symptoms, and died. On opening the body, Dr. Albers found a swelling in the middl* of the mesentery, the texture of which can- not be easily described, and the circumfer- ence of which was 16 French inches. The stomach was filled with coagulated blood? The spleen, pancreas, and liver were sound; but the gall-bladder was of prodigious size, and contained a very thick viscid bile. The arteria cceliaca, arteria coronaria ventriculi, and the arteria mesenterica, were preter- naturally dilated, and full of dark coloured blood. He speaks of them, however, only as being in an enlarged, not an aneurismal state. Dr. Albers thinks it highly probable that it was one of these vessels, by which the pulsations had been occasioned. Dr. Albers has also seen these abdominal pulsations in a paralytic female; and in 8 lunatic, who was afterwards seized with apoplexy. He likewise met with a married woman, the mother of several children, in whom these throbbings took place invari- ably at the commencement of pregnancy, and were a surer sign of this state than other usual effects, as stoppage of the menses, &c. After the third month, however, they used to cease altogether. Many valuable practical observations on cases attended with hemorrhages from the intestinal canal, my limits here oblige me te pass over. According to Dr. Albers, he- morrhoidal patients, especially when put to inconvenience by compression of the tu- mours, often complain of throbbings about the spleen, which are plain even to the hand. The same gentleman says, that be has often remarked these pulsations in hypo- chondriacal and hysterical patients, who were put to much distress by the occur- rence, as they supposed their hearts were out of their right places. (J. F. Albers, flier PuUalionen im Unterleibe, 8vo. Bremen, 1803.) The differences pointed out by this able physician, between these pulsations and those of internal aneurism, will be presei noticed. Dr. Parry makes a few interesting . marks on such abdominal pulsations as ex cite apprehensions of aneurism. In any persons not very fat and lying upon their backs, he says, the pulse of the aorta can "rS t* u'1,' 'i stronS Pressure be made a little to the left of the median line, about half way between the navel and sorobiculus cordis In certain instances, the pulsation is painfully felt by the patient himself. In many casesipf this kind, particularly in ner- vous individuals, the sense of pulsation^ f th V 1 "*£}.?* nret""atural action ■ }uG^- rW^le> in other e^mples, k is the e&rt of the pressure of some hard substance tfpon thj descending norta, deter mining a disprop»ionate quantity of blood to the_head, « antfglvingto the hand placed on tfe abdomen, and sometimes even to 4 ABSCESS. 15 the eye, the appearance of a beating so near the surface, as to lead inexperienced observers to conclude, that the aorta is mor- bidly dilated." According to Dr. Parry, the most common causes are collections of foeces in the colon, requiring repeated and active purgatives, which must bring away almost incredible discharges of sterco- raceous matter before the aortal pulsation subsides. (See Parry's Elements of Patho- logy, fyc. and the Medico-Chir. Journ. and Review, Vol. 1, p. 157) Another cause of a temporary appearance of pulsation or movement in the abdomen, not mentioned by any of the preceding authors, is the power which some persons have of putting portions of the recti mus- cles separately into strong convulsive ac- tion. I have seen a large abscess of the loins, attended with distinct and forcible pulsations, corresponding to those of the aorta. According to Mr. Allan Burns, a beating is generally felt about the pit of the stomach, in the advanced stage of chronic inflamma- tion of the heart: in this case, when the pericardium is closely adherent to the latter organ, it is corrugated at every contraction of the ventricles, and the diaphragm and liver are elevated. The ventricle, how- ever, having completely emptied itself, is again distended, and, in proportion to the degree of dilatation,the liver and diaphragm descend, whereby an impulse is communi- cated in the epigastric region. (On Diseases of the Heart, p. 263.) This valuable writer cites the remark of Morgagni, (Epist. 17, art. 23,) that sometimes in dilatation of the heart, this organ descends so far as to push the diaphragm into the hypochondrium, and pulsate in that situation, so that the dis- ease is mistaken for an aneurism of the cceliac artery. In Mr. Burns's work, a me- morable case of this description is related. An erroneous judgment is the more likely to be formed in such examples, because the pulsations of the heart and tumour are not exactly simultaneous ; for, it is not the heart which is felt directly beating, but the liver, which, by the action of the heart, is thrown forwards. Hence, the palpable in- terval between the stroke of the heart, and the movement of the liver. Preternatural pulsation about the epigas- trium is also stated by Mr. A. Burns, to be sometimes occasioned by encysted tu- mours, attached either to the lower surface of the diaphragm, or formed between the layers of the pericardium towards the dia- phragm, as happened in an instance re- corded by Lancisi. Another cause specified by Mr. A. Burns, is enlargement of the vena cava, or of the right auricle of the heart. Senac describes a case, in which^tiie vena cava was as large as the arm, andithere had been a vio- lent pulsation in the epigastrium. The next cause, enumerated by the same gentleman, is increased solidity of the lungs, more especially of their lower acute mar- gins, where tney overlap the pericardium. In this case, the pulsation is about the scro- biculus cordis. Mr. A. Burns likewise comprises several other causes of epigastric or abdominal pul- sations, already illustrated in the foregoing part of this article, indurations of the pan- creas, scirrhus of the pylorus, tumours in the mesentery, or any solid increase of sub- stance about the abdominal aorta, or its principal branches; and, lastly, it is called a peculiar affection of the vascular system itself. The following observations, on the cri- teria between various abdominal pulsations and those of aneurism, appear interesting. According to Dr. Albers, an internal aneurism originates gradually, and the pul- sations increase in strength by degrees. Other abdominal pulsations, on the con- trary, begin suddenly, and are more violent in the beginning, abating after they have lasted some time. In an aneurism, the pulsation is syn- chronous with the stroke of the artery at the wrist; but this is not regularly the case with other pulsations. Should the patient be affected with me- lancholia, hypochondriasis, hysteria, or other nervous complaints, void blood from the stomach, or a black matter from the bowels; should there be any hardness or swelling of any of the abdominal viscera discoverable by the touch, the probability is, that the pulsations are not owing to an in- ternal aneurism. With the exception of cases, in which these pulsations are owing to mechanical impediments to the circulation, Dr. Albers believes, that they are mostly a symptom of some nervous affection. He also thinks that the surprise, excitedbythese throbbings, arises only from their strength and situa- tion, other analogous, strong pulsations, as for instance, those of the heart, or of the caro- tids, being common enough in hypochon- driacal and hysterical persons. The same gentleman also adverts to the increased action, which, in inflammation and fevers, is often more conspicuous in some parts of the sanguiferous system, than in others. (uber Pulsationem im Unterleibe, p. 63, &c. Bremen, 8vo. 1803.) Much important addi- tional information on this subject may be found in Observations on some of the most frequent and important Diseases of the Heart; on Aneurism of the Thoracic Aorta; on Pre- ternatural Pulsation in the Epigastric Re- gion, &.c. By Allan Burns, p. 262., fyc. 8vo. Edinb. 1809. ABSCESS. This term signifies a tu- mour containing pus, or a collection of purulent matter. Authors differ about the original derivation of the word. The most common opinion is, that it comes from the Latin absedo, to depart, because parts, which were before contiguous, become separated, or depart from each other. Abscesses are divided into two princi- pal kinds, viz. acute and chronic. For every thing, relative to the former, see Suppura- tion ; and, for information concerning tht J«i ACT latter, refer to Lumbar Abscess, bee also Abdomen, Antrum, Anus Abscesses of, Bubo, Empyema, Hypopium, Mammary Abscess, Whitlow, 4-c. ACETIC ACID, Vinegar. Distilled Vi- negar. Acetum. Vinegar is an article ol very considerable use in surgery. Mixed with farinaceous substances, it is frequently applied to sprained joints, and, in conjunc- tion with alcohol and water, it makes an eligible lotion for many cas^s, in which it is desirable to keep up an evaporation from the surface of the inflamed parts. Vinegar was once considered as useful in quicken- ing the exfoliation of dead bone, which effect was ascribed to its property of dis- solving phosphate of lime. Its application to this purpose, however, seems hardly admissible, for reasons, which will be well understood, from a perusal of what is said on the subject of Necrosis. The excellent effects of vinegar, when immediately ap- plied to burns and scalds, were taken par- ticular notice of by Mr. Cleghorn, a brewer in Edinburgh, whose sentiments were deemed, by Mr. Hunter, worthy of publica- tion. (See Med. Facts and Observations, Vol. II. and the Art. Burns.) In chronic inflammations of the eyes, and eyelids, and in certain instances, in which the eyes arc weak and watery, vine- gar is sometimes recommended as an use- ful ingredient in the collyrium. After ge- neral and topical bleeding, it is said to be an efficacious remedy even in cases of acute ophthalnay. Whenever vinegar is applied to the eye, it is in a diluted state, as may be seen in another part of this work. (See Collyrium Acidi Acelici.) In the form of a collyrium, it is alleged to be the best lotion for clearing the eye of any small particles of lime which happen to have fallen into, and become adherent to it, on the inside of the eyelids. (See A. T. Thomson's Depensatory, p. 8. Ed. 2.) Very strong vinegar may be obtained by freezing and separating the water, which is mixed with the acid. When concen- trated, either in this manner, or by distil- lation, it is said to be an excellent styptic for stopping violent hemorrhage from the nose. With this view, it may be used either as an injection or a lotion, in which lint is to be dipped, and introduced up the nostril. Vinegar in all its forms is sometimes em- ployed for obviating the smell of sick rooms. The strongest acetic acid which can be made, is found also to be one of the most certain and convenient applications for the destruction of warts, and corns, care being taken not to injure with it the sur- rounding skin. ACHILLES, Tendon of. See Tendons. ACIDS. See Acetic Acid ; Muriatic Acid; and Nitrous and Nilric Acids. ACTUAL CAUTFJtY. A heated iron, formerly much used in surgery for the ex- tirpation and cure of diseases. The instru- ment was made in various shapes, adapted to different cases, and it was often applied through a canula, in order that no injury JEGY ir.i'ht be done to the surrounding pailf- Actual cauteries were so called in OPP0"; tion to other applications, which, U">ueo they were not really hot, produced the same effect as fire, and consequently were named virtual or potential cauteries. 1 he actual cautery is still in use upon the conti- nent ; and by foreign surgeons, we are not .infrequently criticised for our general aver- sion to what they distinguish by the ap- pellation of an heroic remedy. F°uteau> Percy, Dupuytren,Larrey, Roux, and Mau- noir, are all advocates for the practice ; and the latter gentleman, when he was lately in England, took the opportunity of reminding British surgeons of their error, in totally abandoning, as they now do, the employment of heated irons in the busi- ness of their profession. (See his Observa- tions on the Use of the Actual Cautery, Med. Chir. Trans. Vol. IX. p. 364, fyc.) "ACUPUNCTURE (from acus, a needle, and pungo, to prick.) The operation of making small punctures in certain parts of the body with a needle, for the purpose of relieving diseases, as is practised in Siam, Japan, and other oriental countries, for the cure of headachs, lethargies, con- vulsions, colics, &.c. (See Phil. Trans. No. 148; and Willi. Ten. Rhyne, de Arthritide, Mantissa Schematica,fyc. 8v». Lond. 1683.) The practice of acupuncture is not followed in England. In a modern French work, it has been highly commended; but, the author sets such a rash example, and is so wild in his expectations of what may be done by the thrust of a needle, that the tenor of his observations will not meet with many approvers. For instance, in one case, he ventured to pierce the epigastric region so deeply, that the coats of the stomach were supposed to have been perforated: this was done for the cure of an obstinate cough, and is alleged to have effected a cure ! But if this be not enough to excite wonder, I am sure the author's suggestion to run a long needle into the right ventricle of the heart, in cases of asphyxia, must create that sensa- tion. (See Berlioz, Mem. sur les Maladies Chroniques, et sur VAcupuncture, p. 305- 309, 8vo. Paris, 1816.) ADHESIVE INFLAMMATION. That kind of inflammation, which makes parts of the body adhere, or grow together. It is the process, by which recent incised wounds are often united, without any sup- puration, and it is frequently synonymous with union by the first intention. (See Union by the First Intention.) JEGYLOPS (from «|, a goat, and «4, an eye.) A disease so named from the sup- position that goats were very subject to it The term means a sore just under the inner angle of the eye. The best modern surgeons seem to con- sider the aegylops, only as a stage of the fistula lachrymalis. Mr. Pott remarks when the skin covering the lachrymal sac' has been for some time inflamed, or sub- ject to frequently returning inflammation* it most commonly happens, that the punc' ALVINE CONCRETIONS 17 ta lachrymalia are affected by it, and the fluid, not having an opportunity of passing off by them, distends the inflamed skin, so that, at last, it becomes sloughy, and bursts externally. This is the state of the dis- ease, which is called perfect aigylops, or cegylops. (Pott on Fistula Lachrymalis.) ^Egylops was a very common term with the old surgical writers, who certainly did not suspect, that obstruction in the lachry- mal parts of the eye, is so frequently the cause of the sore, as it really is. The skin over the lachrymal sac must undoubtedly be, like that in every other situation, sub- ject to inflammation and abscesses ; but, Ave do not find, that sores unconnected with disease of the lachrymal sac, are here so frequent, as to merit a distinct appellation. AERUGO (Subacetas Cupri.) Prepared verdigris is occasionally employed by sur- geons as an escharotic. Mixed with an equal quantity of powdered lyttae, it is sometimes used as an application for de- stroying warts and other excrescences. At present, the old practice of attempting to destroy the surface of chancres with it, with the view of hindering the absorption of the venereal pofson, and rendering the exhibition of mercury needless, appears to be exploded. AGARIC. A species of fungus growing on the oak, and formerly much celebrated for its efficacy in stopping bleeding. (See HemorrliageA) ALBUGO (from albus, white.) A white opacity of the cornea, not of a superfi- cial kind, but affecting the very substance of this membrane. The disease is similar to the leucoma, with which it will be con- sidered. (See Leitcoma.) ALPHONSIN is the name of an instru- ment for extracting balls. It is so called from the name of its inventor Alphonso Ferrier, a Neapolitian physician. It consists of three branches, which separate from each other by their elasticity, but are capable of being closed by means of a tube in which they are included. ALUM. (An Arabic word.) Alum, either in its simple state, or deprived of its water of crystallization, by being burnt, has long been used in surgery. The ingenious author of the Pharmacopoeia Chirurgica remarks, that except for external use, as a dry pow- der, the virtues of alum are not improved by exposure to fire. Ten grains of alum, made into a bolus with conserve of roses, are given thrice a day at Guy's Hospital, in such cases, as demand powerful tonic, or astringent remedies. In a relaxed state of the urinary passages, or want of power of the sphincter vesica?, small doses of alum have been found of service. Alum is em- ployed as an ingredient in several astringent lotions, gargles, injections, and collyria. It is also recommended by Dr. Perceval as a remedy for counteracting the poison of lead. Burnt alum is a mild caustic, and is a principal ingredient in most styptic powders. ALVINE CONCRETIONS. Compre- Yni. 1 3 hending under this head both gall-stones and intestinal concretions, an interesting subject presents itself, certain parts of which have been chiefly elucidated in modem times,as will be hereafter explained : where the concretions voided are very numerous, they are generally gall-stones. Thus Dr. Coe relates an instance in which seventy were discharged in one day. In the same short time Petermann knew of seventy-two berngvoided from one individual; Birch,one hundred ; Barbette, Sloane, and Vogel, two hundred; and Russell, four hundred. A patient, under the care of Van Swieten, had voided two hundred, and was still con- tinuing to expel others. Riverius speaks of another patient, who had voided calculi from the bowels for several years whenever he went to stool. (Observ. Commun.) Fer- nelius likewise adverts to cases, in which the concretions evacuated were innumer- able. (Pathol, lib. 6. cap. 9.) But if we take a view of alvine concretions generally, and include all their different kinds, we sha^l find that they are of various sizes. Most of them are not larger than a pea or nut; but others are as large as an orange, and weigh four pounds. (See Monro's Morbid Anal, of the Human Gullet, fyc. and Medico-Chir. Journ. vol. 4. p. 188.) Mor- gagni saw one, which equalled in size a moderate finger, and Gooch, Guettard, Heu- ermann, Mareschal, Mem. de I'Acad. Royale de Chir. t. 3. p. 55.) and others have seen concretions of this nature, which were too voluminous to pass out of the rectum with- out surgical aid. In certain examples, re- corded by Heuermann and Mareschal, the passage of the concretion outward lacerated the sphincter ani. Horstius speaks of one concretion, which was as large as an apple. (Epist. 1.2. sect. 2. Opp. 2. p. 237.) and Mar- cellus Donatus, Schwind, (Schmucker's Verm. Sehriflen, 2. b. p. 129.) Hooke, Ve- nette, and Hecquet, give the particulars of other examples, in which the concretion> discharged were as large as a hen's egg. Mr. Charles White extracted two from the rectum which were nearly as big as the first; (Cases in Surgery, p. 18.) and in a boy, who had died in an emaciated state, after continued pain in the abdomen, attended with frequent attacks of ileus, Mr. Hey found in the transverse arch of the colon so large a concretion, that it could not pass any further along the bowel, and appeared to have been the sole cause of the boys death. (Practical Observations in Surgery, p. 509, ed. 2.) An analogous case is also re- ported by White (p. 28.) It is stated, in the Mem. de I'Acad. de Chir. that Duhamel saw a concretion that had been discharged, which was two inches and a half in length, one inch and a half in diameter, three inches and a half in circumference, and the weight of which was three drams and a half. But, judging by their weight, how much larger those must have been, which were seen by Scroekius and Lettaom, and weighed ten drams; that reported by Dolceus, which weighed two ounces; that recorded by- 191 alum: CONCRETION.- Orteschi, which, besides weighing two oun- ces, two drams and a half, is said to have been eight inches in circumference, ami to have been taken out by force; that re- corded by Sthaarschmidt," which weighed four ounces , and lastly the specimen cited byPlouquet, (Literatura Med. Dig. vol. 1. p. 171.) the weight of which is alleged to have been half a pound. (Samml. Mid. Wahrnthm, 9. b. p. 231.) It is observed by Rubini, that although examples of alvine concretions being discharged by vomiting are not so frequent as the foregoing cases ; yet they are tolerably numerous. Many of them have been collected by Schenck ; and others are recorded by Breyn (Phil. Trans. No. 479 ;) by Orteschi in his Journal; by Moreali (DelV Uscila di una Pietra, per la Via del Esophago. Modena, 1781 ;) by Bor- sieri; and by a long list of other writers, whose names and publications are specified by Plouquet. (Lit Med. Dig. art. Calculus, Vomitus, &,-c.) With this class of substances, says Rubini, may also be arranged those concretions which are found upon dissec- tion, either in the intestines or stomach, whence, probably, in time they might have been expelled. Facts of this description are recorded by Portal, Vic.q d'Azyr, Jacqui- nelle, Chandron,&c. The cases recited by White and Hey, in which the colon was completely obstructed, I have already men- tioned ; and to these may be added the in- stance quoted by Rubini, in which Professor Meckel found the jejunum entirely blocked up by a similar substance. (See Pensieri sulla varia origine e natura de corpi calcolosi, che vengono lalvolta espulsi dal lubo gastrico, Memoria,p. 5 and 6. Alo. Verona, 1808. Rubini observes, that, with respect to the origin of alvine concretions, whether dis- charged from the alimentary canal upwards or downwards, some of them appear to be formed in that canal itself, while others pass into it from other situations; and they all admit of being distinguished according to the place of their origin and formation into three kinds; 1. hepatic, or biliary: 2. gas- tric, or intestinal: and 3. (what this author terms) mixed or hepaiico-gastric. Hepatic alvine concretions, as the name implies, are derived from some point of the hepatic system ; the gastric, or intestinal, are formed within the alimentary canal; and the mixed commence in the hepatic organs, but after- wards get into the bowels, where they ac- quire an increased size. On the subject of hepatic concretions, or biliary calculi, or gall-stones (as they are usually named,) there is no point of this system in which they do not occasionally form. Riedlin found them in the surface of the liver. Sorbait met with a biliary cal- culus, as large as a goose's egg, adhering to i\° peritoneal covering of the liver ; and a ■i.-;i3f case is recorded by Benivenio. Tal- Poraoie, Saurau, and Heberden have "i c~lc.ili within the substance of the ; while Biasius, Fallopius, Columbus, Ei'.ysch, Henricus ab Heers, and Morgagni, record examples in which the concretions were in the parenchyma of that organ. Plater, Reverhorst, Glisson, Morgagni, and Wallhcr have seen them in the biliary ducts, as probably were those which Columbus and Camenicus say they found in the vena porta?. Walther and Dietrick found calculi in the ductus hepaticus ; Ruysch and Soem- mering in the ductus cysticus ; and Dietrick, Galeazzi, and Richter in the ductus chole- docus. Greisel, Benivenio, Eller, Morgagni, Dargeat, and DHervillay have seen calcuH included in morbid cysts, attached either to the liver or the gall-bladder. The place, however, where calculi are found in the greatest number, and with most frequency, is the cavity of the gall bladder itself. Here thev are sometimes single, their size varying up to that magnitude which completely fills that cavity, as Save, (Journ. de Savans, Sipt. 1697.) Halle, "and Isenilamm have no- ticed; while sometimes their number amounts to a hundred, or even a thousand, of different sizes. Rubini possesses a gall- bladder which contains above a hundred small calculi; and formerly I had a similar number, which I found in the body of a fe- male. Van Svvielen met with a hundred; Haller, a hundred and forty ; Stieber, two hundred ; F. Plater, three hundred ; Wal- ther, five hundred; Mentzki, seven hun- dred ; Baillie, a thousand : Hunter, eleven hundred; Pare, sixteen hundred; Stork, two thousand ; and Meckel, several thou- sands. (Handb. der Pathol. Anat. b. 2. p. 460.) All hepatic concretions, however, are not calculated to pass from the place of their origin into the intestines, but only such as are situated in the ductus hepaticus, or its main branches, in the gall-bladder, the ductus cysticus, or the ductus choledocus. When their size is not disproportionate to the diameter of the ducts, they pass with facility; but when their dimensions are larger than those ducts can naturally admit, the latter become stretched and dilated, whence arise the sharp pains and colic which attend the disorder, analogous to the sufferings produced by the descent of large calculi from the kidneys to the bladder. The reality of these dilatations of the he- patic ducts is proved by dissection. Heister found the orifice of the ductus choledocus, which is usually very small, so much enlar- ged that it could receive a finger; and Vicq d Azyr saw this duct enlarged through its la-SociMRoyale de Medecine, an. 1779, p. fS'l 5 Tl'l" dissecting a body, found the ductus choledocus so dilated that it re- sembled a kind 0f bag, in which severa cal- cul..were included. Mr.Thomas has likewise seen two cases in which the point of the forefinger read! y passed from the duode- num into the gall-bladder. (See Med Chi Trans. Vol.6. p.m.) Morgagifsaw £ duct in one instance large enough to hold I lar instances trom Bezold, Trew, Vernov 3 and others. We may conceive how dSP . ted this tube must have been in a case re- ' ALVINE CONCRETIONS. IS corded by Richter, Where, though it was not completely obstructed, a calculus weighing three ounces and a half was lodged within it. (Rubini, op. cit. p. 7—10.) With regard to those concretions which are distinguished by the epithet gastric or in- testinal, some are formed in the cavity of the stomach ; the rest in one or other of the intestines. They remain for a greater or lesser period in the place of their forma- tion, according as they happen to be lighter or heavier, smoother or rougher, more or less adherent, or as local or general circum- stances are more or less favourable to their retention or expulsion. Sometimes they continue undischarged until they have at- tained a very considerable size. In parti- cular instances, instead of remaining con- stantly in one place, they successively pass through the whole iength of the intestinal tube, lodging at different points for a greater or lesser time. In the works of Haller and Conradi may be seen representations of,the points of the intestinal canal where these concretions have been found. The alvine concretion, of which Mareschal has given an account, was some years in traversing all the convolutions of the bowels. These gastric or alvine concretions, which are very common in animals, are less frequent in the human subject, as the observations of Fourcroy and Vauquelin prove ; which are inserted in their valuable essay on this subject in the Annates du Museum Nationale ttnistoire Natvrelle de Paris. In the horse they are sometimes of an enormous size, as we may learn from an instance on record, in which the concretion weighed thirteen pounds. (Voigt, Magazin fur das Neueste der Naturkunde, 3 B.p. 578.) As for the third species, which Rubini names mixed or hepatico-gastric, they have their beginning in the hepatic organs, and augment in the intestinal tube. Here, if the extraneous body be detained, and the con- tents of the bowels have a disposition to become thickened and condensed round it as a nucleus, it may be rendered larger by additional strata of matter, and would increase sinejlnt-, if a stop were not put to the augmentation by the narrowness of the canal, or an effort made for the expulsion of the concretion. Morgagni cites two instan- ces of this sort of concretion : one from Gemma, the other from Bezold ; and he gives his opinion, that another alvine cal- culus spoken of by Vater must have been of the same nature. Dr. Coe describes another interesting specimen; and others are referred to by Vandermonde, Moreali, Portal, &c. Perhaps, says Rubini, the in- stances of this kind would have been more numerous if all the concretions discharged from the bowels had been noted with greater attention, and the hepatios-gastric substan- ces not confounded with the hepatic. The lodgment of these concretions in the intes- tinal canal is of uncertain duration, and de- pends upon a variety of circumstances. Vandermonde gives the history of a calcu- li*, which, as far as could be judged of by the pain in the right hypochondrium, and the change of symptoms, must have passed into the duodenum in the month of Janua- ry, and then continued in the bowels until August, when it was discharged from the rectum. The crystallized appearance of alvine concretions is generally so conspicuous that it has not escaped the attention of several of the old writers, as we may convince our- selves of by referring to the works of Corn. Gemma, Greisel, Baglivi, Scultetus, &.c. It was noticed by Haller in his Elementa Phy- siologic, vol. 6, and by Morgagni in his Epist. 37, de Sedibus et Causis, &c. If, says Rubini, these crystallizations are not always plainly visible, distinct, and regular, this de- pends either upon their imperfection; the heterogeneous nature of the accumulated matter; or particular unfavourable circum- stances, which equally affect the process of crystallization out of the body. Now, as all crystallizations depend upon the^ fluids, in which they form, and from which they receive their crystallizing ele- ments, it must be evident that, inasmuch as the fluids of the hepatic organs differ in their constituent principles from the fluids contained in the intestinal canal, the con- cretions produced in the first system must differ from those which originate in the se- cond ; whilst the hepatico-gastric calculi will combine the nature and properties of both together. The fluid from which hepatic concretions are formed is unquestionably the bile, either some or all its ingredients entering into their composition. Indeed, previously to the new chymical doctrines, hepatic calculi were generally considered as being simply condensed indurated bile. From investigations made in more mo- dern times, however, when the art of ana- lysis has attained a precision of which the old chymistry was not susceptible, it ap- pears, that, although human biliary calculi yield the same products as the bile, there is contained in them more or less of a pecu- liar substance, which was named by the celebrated Fourcroy, adipocire. (Mem. de I'Acad. des Sciences, 1789. p. 323.) The presence of this substance in the concre- tion is of such importance, that, when it is abundant and in large proportion, the calculus is regular, and the crystallization well finished ; and when it is in small quantity, the crystallization is confused and disordered, the calculus only exhibiting an irregular misshapen concretion, more like a clot than true crystals. The kind of adipocire, which constitutes the base of all human biliary calculi, has some re- semblance to spermaceti. Both Fourcroy and Dr. Bostock, who analyzed it, found it composed entirely of carbon, hydrogen, and oxygen. It melts, but requires a heat superior to that of boiling water: in fu- sion it has a smell like wax ; and on cool- ing, forms a substance which breaks into crystalline laminae. It is not soluble in alcohol in the fold -, but when the alcohol 20 ALVINE CONCRETIONS i» boiled on it, it is di.-.-olvcd in a propor- tion, according to Fourcroy, of one part in nineteen ; according to Dr. Bostock, one in thirty. (Nicholson's Journ. Svo. vol. 4. p. 137.) The solution when it cools, de- posits light brilliant scales. It is soluble in ether in the cold, and more abundantly if the ether be heated. Oil of turpentine dissolves in general biliary calculi; and, according to Green, it dissolves those which consist almost entirely of this pecu- liar matter; yet Dr. Bostock has remarked, that oil of turpentine acts on it with diffi- culty, and even when digested with it at a boiling heat, dissolves it only in a small de- gree. Pure soda, and potassa dissolve it completely, and reduce it to a saponaceous state. Ammonia, as Dr. Bostock has re- marked, exerts little action on it, except when boiling. Nitric acid dissolves it, and, recording to Fourcroy, converts it into a species of liquid similar to the oil of cam- phor. This, as Dr. Bostock has remarked, becomes concrete, but w ithout any crystal- line structure, and is more soluble in ether i.nd the alkalis, than the original matter. " This substance (Fourcroy has observ- ed,) is contained in greater or less quan- tity, in nearly all the human biliary calculi, more or less intermixed with other matter, but still so far predominant as to form their basis. Hence, they partake of its proper- ties ; are fusible, inflammable, and more or less soluble, in the agents which dissolve it." (See Murray's Syst. of Chymistry, vol. 4, p. 594, Ed. 2.) Fourcroy, on exposing the above peculiar substance to the action of oxygenated muriatic acid, saw it whiten- ed, and afterwards resume its former silvery hue. However, Rubini repeated this experiment, and found that the white- ness, which was contracted, remained per- manent. While the hepatic system contains a fluid which is always nearly of the same quality, viz. the bile, the alimentary canal, as Rubini observes, contains a hundred different fluids, and is continually occupied by substances, of various natures, kinds, and properties, consisting of food, drink, and several secretions. All the principles, which are to serve for the formation and renewal of the different species of living solids, and of the many kinds of fluids, at first remain more or less time in the ali- mentary canal, and there undergo pecu- liar changes. All the principles, which, under different circumstances, may con- tribute to the production of morbid con- cretions, either in the gall-bladder, the urinary bladder, the kidneys, or in any other part of the body, where they ever occur, pass at first into the intestinal canal, where they continue for some time. Such a multiplicity of principles, disposed to crystallize, and be converted into calculi, would very often, almost daily, produce these concretions in the bowels, were there not many circumstances, which coun- teract this tendency, as, for instance, exer- cise, the incessant motion of the matter itself along the intestinal tube, the vai ely of these elements, whereby their reqms.te tendency to unite is disturbed and\X\* decomposing and recon.posmg '"fl"enc« of the gastric secretions, whereby paits arc uVted,gdisposed of dissolved, and analo- gous matter kept divided, Uo. But, when- ever these circumstances are not actively- operating, as may be the case in a noose, or fold of the bowels, or in some preterna- tural cyst belonging to them ; whenever the intestinal fluids undergo such an alteration, that the. production of these concretions cannot be prevented; or, lastly, whenever some favourable circumstance, such as au extraneous nucleus, forms a centre of re- union for particular elements; then the saline matter, which is most disposed to crystallize, and the earthy and mucilagi- nous substances, fcc. are attracted toge- ther, and produce more or less perfect crys- tallizations. A chymical analysis of some intestinal calculi, first made by Konig, and afterwards by Slare, (Philosophical Transactions) proves that when they are exposed to a strong heat in distillation, they yield water, ammonia, and a lixivious salt, a caput mortuum remaining behind. Cadet, in analyzing a similar concretion, found, in addition to the above products, phosphorus. The muriate of ammonia was afterwards discovered ; and Gioberti, Four- croy, and Vauquelin, in their histories of the intestinal concretions, met with in ani- mals, describe them as composed of the acidulous phosphate of lime, phosphate of magnesia, and of the ammoniacal-magne- sian phosphate. Some specimens, contained in the Edin- burgh museum, were very carefully exam- ined by Dr. T. Thomson : they at first swam in water, but afterwards sunk ; the specific gravity varying from 1-376 to 1-540. Cold water, acquired from them a brownish tinge, and took up albumen, which separated in white flakes by boiling. There was also a peculiar brown substance, at first dissolving in water, but rendered nearly insoluble by slow evaporation; soluble in alcohol; and most nearly resembling vegetable extract. The specimens likewise contained muriate of soda, crystallizing on spontaeous evapo- ration of the water: phosphate of lime, pre- cipitated by ammonia; sulphate of soda in minute proportion ; and, perhaps, sulphate of lime. Alcohol dissolved the peculiar brown matter and some of the salts; caus- tic potash, the albumen, brown matter, and perhaps some of the salts ; and muriatic acid a proportion of phosphate of lime. Af- ter all, there remained a peculiar substance, having the colour and texture of the calcu- lus ; ,n very short threads, light, resembling cork, or rather agaric ; tasteless, insolublf in water, alcohol ether, potash-ley, and muriatic acid ; being blackened, and partly reduced to charcoal by sulphuric acid slowly dissolving by heat, without effer' vescence, in nitric acid ; and leavinz on evaporation a whithh residue, of &.,"' taste, and imperfect lv -oluble in water ALUM lUflUtfcTiONs. iii burning with a bright flame; but differing from all other animal and vegetable sub- stances hitherto examined, and distinguish- able from wood, by its insolubility in pot- ash-ley. The calculi consisted of alternate layers, or intimate mixtures of this sub- stance and phosphate of lime, to which the albumen and brown matter served as a ce- ment, the other substances being in small proportions. Phosphate of lime, mixed with a brown animal matter, formed the external crust of some of the specimens. On the surface of a few were noticed crys- tals of phosphate of ammonia and magne- sia. The presence of neither potash, am- monia, carbonate of lime, uric acid, nor urea, could be detected. Varieties have also been found by Dr. Henry and Mr. Brande, which were exclu- sively composed of magnesia, of which the patients had been in the habit of taking vast quantities. (See Thomson's Obs. in Mon- ro's morbid Anatomy of the human Gullet, fyc. p. 36, or in Medico-Chir. Journ. vol. 4,p. 188, 189.) From some recent observations made by Dr. Wollaston, it appears probable, that the above fibrous light thready substance is deri- ved from oats, which are so commonly taken as food in Scotland. " If the oat-seed be divested of its husk, minute needles or beards, forming a small brush, are seen planted at one of its ends. Dr. YVollaston, on examining these nee- dles, and comparing them with similar ones detached from the calculi, and forming the velvet substance in question, satisfied him- self beyond all doubt of their perfect iden- tity." (Marcet on calculous Disorders, p. 130, 8vo. London, 1817.) As for the mixed, or hepatico-gastric cal- culi, they have for their nucleus a biliary concretion, round which other substances contained in the bowels adhere : hence, it is evident, that as they are formed at two distinct periods, in two different situations, and among various fluids, two distinct com- positions must be the result. Although, says Rubini, there has hitherto been no scienti- fic analysis of this species of calculus, ex- cepting the very imperfect one by Moreali, reason shows clearly enough that, if two separate analyses were made, one of the nucleus, the other of the surrounding mat- ter, there would be obtained from the nuc- leus the same elements, as those of an hepa- tic calculus, and from the rest those of an intestinal concretion. (See Pensieri sulla Varia Origine, fyc. de' Corpi calcolosi che vengono espulsi dal lubo gastrico, p. 15—17.) As the same author remarks, the forego- ing principles will enable us to determine with greater precision, than formerly, the characters, which appertain to the several classes of calculi, liable to be voided from the intestinal canal; characters, by meatis of which there can be no difficulty in de- ciding, from the appearance of one of these concretions, the place of its origin, and its peculiar nature. The hepatic calculus, be- ing composed of bile, and also of adipocire, its characters will be such as indicate the predominance of an uniform, oleaginous, and (what Rubini terms) a well animalized principle. The gastric, or intestinal calcu- lus, arising from the union of various salts, earths, and other principles, which happen to be in the alimentary canal, will have very different characters, generally indi- cating its earthy, saline composition. Last- ly ; the hepatico-gastric calculus will pre- sent an union of the different characters; viz. in the centre, the characters of the he- patic calculus; more externally, those of the gastric. The criteria for distinguishing the seve- ral kinds of calculi from each other, may be divided into two classes ; those which may be termed external, being derived from accidental circumstances attending the foreign body; and others, which "may be called internal, being deduced from the inherent characters, belonging to the com- position and nature of these concretions. The first of these external criteria, is the age of the patient. C. Stephanus, Hoff- mann, Durande, and Morgagni all agree, that biliary calculi seldom oocur, except in subjects of advanced age, and never in youth. And Haller writes, " Juniores et pueros, quantum 7iovi, numquam adfligit morbus." Morgagni states, that he has met with sixty-one old persons who had alvine concretions, but only eight young persons, not one of whom was a child, the youngest being twelve years of age, and the eldest twenty-nine. To these I may add the in- stance, reported by Saye, in which a stone as large as a hen's egg, was found in the gall-bladder of a young female aged only twelve. (See Journ. des Savans, Sept. 1697.) The cause of this difference is attempted tu be explained by Morgagni ; but probably a more rational explanation than that sug- gested by him, will be found in the analy- sis of the bile of old and young subjects, as made by Fourcroy and other modern chy- mists. From these and other observations, collected by Rubini, it is rational to con- clude, that when an aplvine concretion is dis-« charged from a young subject the chances are that it is not a biliary one ; though, if the patient be of advanced age, it is not to be inferred, that the foreign substance expelled must certainly be hepatic, because gastric or intestinal concretions are common to individuals of every age. (Rubini, op. cit. p. 18.) Indeed, with the latter kind of cal- culi, men of advanced age and women are said to be most frequently afflicted; chil- dren and young persons rarely suffering, unless the formation of such bodies has been produced by the presence of fruit-stones, or other indigestible substances which serve as nuclei. (See Richerana's Nosographie Chir. T. 3. p. 433, Ed. 4.) These concre- tions have likewise been noticed in patients, who have been confined by disease a long while in a recumbent posture. With respect to another criterion, dedu- ced from the patient being also afflicted with urinary calculi, there cannot be a doubt ot ALVINE CONCRETIONS. Us invalidity, though proposed by so great a man as Morgagni. The concurrence of the two disorders in the same individual, when it happens, is purely accidental. Suffice it to add, that Haller, in his pathological works, expressly mentions the rarity of uri- nary calculi at Gottingen, where cases of gall-stones are extremely frequent. A third criterion is drawn from the symp- toms which precede, or accompany the expulsion of the calculus. Sense of heavi- ness, irritation, and pain in the region of tbe liver, pain about the ensiform cartilage and navel, bilious vomiting, jaundice, and either looseness of the bowels or constipa- tion, are the symptoms, which (especially when they frequently occur) indicate the bepatic origin of the calculus, and proceed from its passing through the narrow ducts of the liver or gall-bladder towards the in- testines. The most careful observations have proved, however, that these symp- toms are only to be depended upon when taken collectively, and that no single one gives any certain information. Also, if their presence be sufficient to prove the hepatic origin of the calculus, their absence can by no means be regarded as a proof of the concretion being of the intestinal kind. (Rubini, p. 19.) Fourth criterion. A calculus voided may be set down as undoubtedly hepatic, if ac- companied by others, which are unequivo- cally of this nature. In a case recorded by Brunner, and in another by Vater, the ab- sence of certain symptoms in the first, and the magnitude of the calculus in the second, created doubts whether the concretions were not more likely to be of the intesti- nal kind, than of the hepatic. At length, the bodies having been opened, the pre- sence of other similar calculi in the gall- bladders afforded an adequate criterion. Morgagni lays down a fifth criterion, de- duced from the number of the calculi void- ed ; which,if very numerous, are to be con- sidered as biliary. Rubini points out, how- ever, the fallacy of this test; both hepatic and gastric concretiojis being sometimes single, sometimes in various numbers, even up to a thousand; and he refers to a case where a very large number of concretions of the gastric description were voided, as reported by Konig. The test, here suggest- ed, however, may be considered as gene- rally valid; for, the number of intestinal concretions is rarely more than two, though sometimes very considerable. (T. Thomson. See Med. Chir. Journ. Vol. 4, p. 189.) I shall now follow Rubini, and notice those characters of alvine concretions, which he calls internal, and are deduced from their quality and composition, begin- ning with the criterion furnished by the size of the extraneous substance voided. As the biliary ducts are narrow, it is obvious that, if the calculus be above a certain size, it cannot have passed through those narrow tubes, and consequently must be either of the gastric description, or mixed, having quitted the hepatic system when it was small, and afterwards increased within the alimentary canal. Unquestionably, as Ru- bini admits, this criterion has considerable weight, especially when the discharge of the calculus has not been preceded by pain, or other symptoms indicating such violent dis- tension, as the above ducts, must hava suf- fered from the passage of the foreign body. These may certainly be dilated in a remark- able degree; but, it can never happen without pain, irritation, and a serious train of sympathetic effects. The ca-e in which tbe dilatation takes place slowly and insen- sibly, if not hypothetical, is uncommon. This criterion is adopted by Moreau in the Mem. de. I'Acad. de Chirurgie; and Bonte has availed himself of it in Vandermonde'g Journal, for determining, that a calculus, of which he has published an account, was first formed in the hepatic organs, and then attained a larger size in the intestinal canal. As Rubini remarks, however, it is plain, that this criterion will only apply to large, and not to diminutive concretions. A second criterion is the colour of the calculus; a test admitted by Moreau ; who asserts, that biliary calculi are yellow, or green, and intestinal ones grayish brown, or black. But, says Rubini, one need only look at various specimens of alvine concre- tions, and read the statements of authors, who have.seen a great many of them, par- ticularly Morgagni and Soemmering, to comprehend, that any criterion, deduced from their colour, is most fallacious, every species of them presenting great variety in this particular. And, it is to be remem- bered, that the bile and the intestinal fluids, whence these concretions are formed, differ in colour in different individuals, according to a variety of circumstances, in health and disease. The smaller intestinal concretions, examined by Dr. T. Thomson, destitute of coating, resembled bad yellow ochre; the larger were encrusted with an earthy mat- ter, of a coffee colour, and purple, or sometimes white. (See Monro on the Hu- man Gullet, fa. and Med. Chir. Journ. Vol IV. p. 188.) Third criterion. The presence or ab- sence of a nucleus will enable one to judge, whether a calculus be gastric, or he- patic. A biliary concretion has no nucleus, properly so called; that is to say, it has no foreign body in its centre. When a .m"^.™6-^^"> made of «»ch a calcu- lus, one either finds a cavity in its middle surbstncen°thing',by^h!ch Ms £* ** resto? ifaC„an,be ^ sJing™hed from the narV of' h^ nucleils different from the other rcton°sfJ^em^in,?.re.t;0"',be aPP"ent there, nevertheless invariably bile On The trary, every gastric Ln£tio?h£ £"• andV^" ex1trT°US nolens, as Fourcroy ™i? \Uulin have «*Plained in their el say upon the intestinal calculi met wl£? animals. Ruysch in the Phil. Trans I? an account of 80me alvine co^Zl ALVINE CONCRETIONS, OS which were formed round grains of seed. Birch records an example of a crystallized calculus, formed round a leaden bullet. Haller met with a calculus, in the centre of which was an iron nail. Concretions, form- ed upon fruit-stones, are recorded by Clarke, White, and Hey, and also in the Edinb. Med. Essays. Instances, in which the nucleus was a small portion of bone, are related in the latter work, and also by Hooke, and Coe. Homberg and others de- scribe alvine concretions, formed round in- durated excrementitious matter ; and many similar cases are specified by Vallisnieri, Vanswieten, and others. In the hepatico- gastric calculus, the biliary concretion serves as a nucleus for the gastric. Accord- ing to Dr. T. Thomson, the nucleus is commonly a cherry-stone, a small piece of bone, or a biliary calculus. (See Med. Chir. Journ. Vol. IV. p. 188.) A fourth criterion is deduced from a cer- tain unctuosity, which belongs to biliary calculi, but not to those of the gastric class. This character is more palpable, when the calculus has been recently voided, or when it is handled with warm fingers. The unc- tuosity is still more evident, when the con- cretion is cut, or sawn, as then the knife, saw, or fingers, become smeared with sapo- naceous particles* which adhere to them. In order to denote an hepatic calculus, however, the unctuosity must pervade its whole substance, and not merely appear to- wards its outside ; for, a gastric, earthy, sa- line concretion may by accident become coated, as it passes through the bowels, with a stratum of bile, or saponaceous matter. When the unctuesity is deficient externally, or in the outer laminae of a calculus, but is found in its interior, when cut, it is a clear indication of the hepatico-gastric formation of the concretion. Fifth criterion. The specific gravity of a calculus, the property which it has of floating or sinking in water, has been long considered as a test of its species. The he- patic calculus is generally specifically light- er than water, as most oily substances are ; on the contrary, gastric calculi are specifi- cally heavier than water, like all earthy sa- line matter, and of coarse sink in that fluid. This criterion was often employed by Re- verhorsl, Fernelius, and others, for distin- guishing various concretions. But, it is by no means regular, as many biliary calculi swim only a little while, and then sink. The specific gravity of that analyzed by Dr. Ure of Glasgow, was 10135. (See Med. Chir. Jour. Vol. IV. p. 179.) Rubini observes, this test will not answer for hepatico-gas- tric calculi, which are subject to great anomalies. (Pensieri, fyc. p. 22.) Never- theless, the most correct modern examina- tions prove, that gastric concretions have a specific gravity, varying from 1-376 to 1-540, (Dr. T. Thomson in Monro's Morb. Anal, &,-c.) and, consequently, their general character is to be heavier than biliary calculi. A sixth criterion is that proposed by Vicq d'Azyr, in the Me"m. de I'Acad. Royale de Med. and deduced from the figure Of the crystallization. According to this writer, intestinal concretions crystallize in concen- tric laminae, shaped like a cock's comb, while the crystallizations of biliary calculi are radiated and needle-shaped. Although this criterion is ingeniously founded upon the known laws, by which every crystal- lized substance assumes a peculiar and de- terminate shape, yet it may be generally ob- served, with respect to the mark of distinc- tion here proposed, that the concretions, of which we are now speaking, are usually too compound, and too much disturbed in their crystallization, to exhibit a regularity, for which simplicity and quietude are indis- pensable. Hence, many of these concre- tions do not present the slightest vestige of crystallization, while others scarcely show a trace of it, in the midst of a large missha- pen mass. With respect to the special shape assigned by Vicq d'Azyr, to the two classes of alvine concretions, it maybe ob- served, that his specimens were taken from animals, and that consequently, the infer- ences made from them are not applicable to substances of an analogous nature, dischar- ged from the human body ; because, as the bile varies in different animals, so must the formative principles of the calculous crys- tallizations. It is further remarked by Ru- bini, that the substance termed adipocire, which is the basis of biliary concretions, was not found by Poulletier'in hepatic cal- culi taken from horned cattle. A seventh criterion is founded upon the inflammability of an alvine calculus. A bi- liary concretion being commonly made up altogether of unctuous matter, liquefies when subjected to heat, smokes, emits a flame, and burns. When this experiment is made in close vessels, the products are hydrogen, carbonic acid gas, oil, and ammonia ; some carbon and earth remaining behind. An intestinal concretion, on the other hand, decrepitates, or turns black, but does not burn. The eighth criterion depends upon the solubility of calculi in an oily menstruum. Haller dissolved biliary calculi in oil of tur- pentine ; Dietrick found them soluble in oil of sweet almonds; and Gren in oils in ge- neral. But, intestinal calculi are not so readily dissolved by any of these menstrua. The ninth criterion is founded upon the solubility of the calculus in alcohol. In bi- liary calculi, this solubility is not always the same. Having already spoken upon this point, however, it is unnecessary to dwell upon it; and I sh ill merely add, that while hepatic concretions are always more or less dissolved by alcohol, those of the gastric kind resi.-t this menstruum. Though the above criteria are interesting, as tending to establish distinctions betwixt the different species of alvine concretions, it merits attention, that not one of them, taken separately, is at all certain and pa- thognomonic. It may happen, says Rubi- ni, that some peculiarity in the biliary se- cretion, and an irregularity in (he crystalli- 24 ALVINE CONCRETIONS. zafion and accumulation of the matter, may cause salts and earths to predominate in he- patic concretions, in which circumstance, their usual oily quality will be defective. On the other hand, in the formation of an intestinal concretion, oily adipose matter may accidentally adhere to it, so as to dis- guise its wonted character. If uniformity of characters and physical properties depend upon uniformity of elementary constituent principles, it can hardly happen even in the natural healthy state of the secretions, be- cause age, sex, and other particular circum- stances of the individual, will always make a difference in the proportions of those principles. How then can identity of results be expected in a diseased state of the pro- cess of secretion ?— Such reflections may explain, how Morgagni, among others, met with many biliary calculi, which were not inflammable ; with others, which did not give a yellow tinge to water; and with some which floated, or sunk in water, ac- cording as they had been recently, or long discharged; while Gren found some 01 these calculi insoluble in alcohol, fcc. (Ru- bini, p. 24, 25.) Moreali put a piece of the outer part of an alvine1 concretion into nitrous acid, when a considerable effervescence took place, and the substance afterwards completely dissolved. Now, as this calculus had a nucleus, it must have been of the hepatico- gastric kind, and the experiment was there- fore made only with the intestinal part of it. Should the experiment be often repeated with the same result, says Rubini, it would furnish another criterion for distinguishing the two species of calculi; those being in- intestinal, which effervesce, and others be- ing hepatic, which do not effervesce, but yield globules of wax-like oily mafter. (p. 28.) >■> For additional chymical observations on biliary and other alvine concretions, the reader is particularly referred to Rubini's interesting memoir, Vicq d'Azyr's essay iu the Hist, de la Societe Royale de Mede- cine, an. 1779; the writings of Fourcroy and Vauquelin ; Thomson's account of tho* subject in Monro's Morbid Anatomy of the Human Gullet. k.c; Marcet on calculous Disorders; and some interesting experi- ments by Dr. Ure, related in a paper by Mr. Kennedy, in Medico-Chir. Jour. Vol. 4. p. 177, fee. With respect to the treatment of cases of biliary calculi, the subject not being gene- rally one, for which any surgical proceed- ing is adviseable, I may be very brief. The medicine, which is alleged by Durande, a physician at Dijon, to be the best solvent for them, consists of three parts of sulphu- ric ether, and two parts of oil of turpen- tine. It is to be given in the dose of 3ij every morning; purgatives being previous- ly exhibited for a few days. The efficacy of this medicine is also corroborated by Soemmering and Richter. To these state- ments, however, some doubts must be at- tached, because what symptoms and cir- cumstances will ever unequivocally prove, that there were biliary calculi in the bow- els ; and that they have been dissolved by this medicine? And how can the product of such solution be got at and examined? But, admitting the authenticity of the cases, doubts must exist of the solvent action of of the remedy, since at a temperature, be- low that of the human body, the ether se- parates from the turpentine and is volatili- zed. (See Diet, des Sciences Med. T. 3, p. 464 465.) A calculus in the gall-bladder, or one of the biliary ducts, sometimes produces so much irritation, that inflammation and sup- puration take place, and if the abscess point outwardly, the stone may escape external- ly, and a termination be put to the patient's sufferings. Heberden records a case of this description ; and another is given by Mr. Blagden. (See Med. Trans, of the College of Physicians, Vol. 5. and Thomas in Med. Chir. Trans. Vol. 6. p. 106. And for other instances, the following works referred to by Plouquet: Acrel. Diss de Cholelithis, Upsal, 1788. p. 204; Act. Natur. Cur. Vol. 6. Obs. 69; Bartholinus, Act. Hafn. 4, Obs. 46; Block, Med. Bemerk, p. 27 ; Gooch's Works, Vol. 2, 157—161; Johnston in Phil. Trans. Vol. 60, p. 2, 548; Petit, Mem. de I'Acad. de Chir. I, p. 182—185; Sandiforl, Tab. Anat Fasc. 3; Schlichting in Bald. N. Magaz. 9 6. p. 210 ; Vogler in Museum der Heilknnde, 4 b. p. 91; Haller, Collect. Diss. Pruct. 3, No. 107.) The eminent J. L Petit, as is well known, suggested. the bold practice of making, under certain circumstances, an incision into the gall-bladder, in-order to extract biliary calculi. This proceeding is liable to serious objections, arising not only from the usual difficulty of knowing positively that there is a calculus in the gall-bladder, but also from the difficulty of ascertaining that this viscus is adherent to the. peri- toneum, without which state of things, the operation would cause" an extravasation of bile, enteritis, and death. Petit himself, indeed, mentions three cases, in which distention of the gall-bladder was mis- taken for an abscess, and punctured... In two of these examples, the consequences were fataL there having been no adhesioR between ;that organ and the peritoneum to prevent the bile from getting amongst the bowels; the other patient was saved by this fortunate circumstance. (See Traite des Mai. Chir. T. 1, 262, £c.) How^ ever, if a case were to present itself iu which an abscess had formed, and brokenj leaving an aperture in which the calculul f,?«'fi^epla»ly fe.U'tlu' surSeon would.be justified in attempting to make a sufficient opening for its extraction. The symptoms, induced by the lodgment of large concretions in the bowels, a?e 0f . formidable description : severe pains in the stomach and bowels, diarrhoea, Violent vo- mitings of blood and mucus, adisch"™, thin fetid matter from the rectum, a fiftl rulty of voiding the excrement. an afflicting V.\iAUROSIS. -'6 tenesmus, extreme emaciation, and debi- lity. That the foregoing account is not at all exaggerated, may be seen by a perusal of the cases, and remarks published by Mr. C. White of Manchester, and Mr. Hey of Leeds. In cases, like that reported by Mr. Hey, {Pract. Obs. P. 509. Ed. 2.) where the colon was entirely obstructed, surgeons have been advised to cut into that bowel, and extract the foreign body. Let the inexpe- rienced admirer of curious feats with the scalpel, however, pause a little, before he ventures to make up his mind upon this matter; and, at all events, let him know that some serious mistakes have nearly been made " upon the very bold operation of cutting out these concretions, when lodged in the colon, proposed by Dr. Mon- ro senior, (See Monro's Morbid Anatomy of the Human Gullet, fyc. P. 63.) we think it our duty to state, that the diagnosis is so difficult, that, in one case, where the ope- . ration was strongly advised, it turned out, upon dissection, that the disease was a scirrhous pylorus." (See Edinb. Med. and iurg. Journ. No. 33. P. 112.) Sometimes patients ultimately get well by voiding the concretions either by vo- miting or stool. Mr. Charles White gives us an account of some such instances ; in one fourteen concretions on plum-stones were discharged from the anus ; in another twenty-one similar bodies were ejected from the stomach. When such concretions are not particu- larly large and indurated, they sometimes admit of expulsion by doses of castor oil, oleaginous clysters, fcc. But, in other instances, their extraction must be attempt- ed, if their situation in the rectum will permit. It may be done with a pair of lithotomy forceps, or with the sort of scoop used for takiug fragments -of stone out of the bladder. In this manner Mr. C. White succeeded in removing two alvine concre- tions from the rectum, nearly as big as his fist. When the sphincter ani will not allow the concretion to be taken out, the muscle should be divided at its posterior angle. According to Richerand, such a division does not permanently weaken its fibres in a perceptible degree, and its paralysis never originates from this cause. (Nosogr. Chir. T. 3, p. 434. Edit. 4.) Mareschal, after a proper dilatation with a scalpel, extracted from the rectum an alvine 'concretion, which weighed two ounces and a half, and was of an ovoid form, its greatest diameter being two inches eight lines, and its smaller one inch seven lines. (See M4m. de V Acad, de Chir.) A. Petermann, Scrutinium Icteri ex calcu- lis vesicula Fellis, occasione casus cujusdam singularis. Lips. 1696. Alb. Haller, De Calculis Ftlleis frequenlioribus Observa- tions, 4to. Gott. 1749. T. Coe, A Treatise on Biliary Concretions, Svo. Lond. 1757. Imbert, De Variis Cafrulorvin Bilinrum Spe- Vor.. J i debus, tyc. 4to. Monsp. i'toS. he l',-ic>, Diss, de Calculo Biliario, et sectione fellew. vesicula, 4to. Traj. ad Rlicn. 1759. Wal ther de Concrementis Terrestribus in variis partibus corporis humani reperiis. Fol. Aerol. 1775 : the most valuable work on the subject at this period. Hochstetter, De Cho- lehthis Humanis, 4to. Tub. 1763. Vicq d: Azyr, Hist, de la Sociilt Royale de Med. 1799. An exceeding valuable production, particularly as far as regards the kinds of crystallization observable in hepatic and in- testinal calculi. Durande, Memoire. sur les pitrres biliares, et sur I'efficacitd du melange d'ilher vitriolique et dAesprit de tiribinthine dans les colique hApatique produites par ces concretions, dans vol. 1 des Mem. de I'Acad. de Dijon, Svo. p. 199. an. 1783. S. T. Soem- mering, De Concrementis biliariis Corporis humani, 8vo. Traj. ad Rhen. 1795. B. Brunie, Essai sur les Calculs biliaires, 4to. Paris, 1803. Fourcroy, Mem. de I'Acad. des Sciences, 1789. and Syst. des Connoissances Chim. T. 10, p. 53—60. Dr. Bostock, in Ni- cholson's Journal, Vol. 4, p. 137. Marcet's Chymical History and Medical Treatment of Calculous Disorders, Svo. Lond. 1817. J. F. Meckel, Handbuch der Pathol. Anat. B. 2, p. 455, $-e. Leipz. 1818. P. Rubini, Pensieri sulla varia Origine e Natura de Corpi calco- losi che vengono talvolla espulsi dal Tubo Gastrico Memoria, 4to. Verona, 1808. James Kennedy, An Account of a Morbid Concretion discharged from the Rectum of the Human Female, and in its Chymical Characters closely rtsembling Ambergris; with Historical Remarks: see Medico Chir. Journal, Vol. 4. p. 177, fyc. 1817. This paper contains a good deal of useful matter, deserving the notice of every body wishing to investigate the history and nature of alvine concretions. Monro's Morbid Anatomy of the Human Gullet, Stomach, and Intestines, Svo. Edinb. 1811. The account of alvine concre- tions in this work is one of the best and most comprehensive. Diet, des Sciences Med. art. Bezoard, et Calculs Biliaires. N"othing of much consequence in either of these articles. Moscovius, Diss, de Calculorum Animalium eorumque in primis biliosorum origine et na- tura. Berol. 1812. Cases in Surgery, by C. White, 8vo. Lond. 1770, p. 17. Philos. Trans, abridged, Vol. 5, p. 256, et seq. Edinb. Med. Essays and Obs. vol. l,p.30I. Ibid. vol. 5, p. 431. Essays Phys. and Lite- rary, vol. 2, p. 345. Leigh's Natural History of Lancashire, plate 1, fig. 4. W. Hey's Practical Obs. in Surgery, p. 607, ed. 2. Richerand, Nosographie Chirurgieale, t. 3, p. 433. ed. 4. Thomas, in Med. Chir. Trans- actions, vol. 6, p. 98. *AMAUROSIS (from ct[x*upw, to obscure.) Gulta screna. Suffusio nigra. Fr. L'Amau- rose; Germ. Schwarzer Staar. According to Beer, the term amaurosis properly means that diminution or total loss of sight, which immediately depends upon a morbid state of the retina and optic nerve, whether this morbid state exist as the only defect, or be complicated with other mischief; whether it be a primary affection, or a secondary AMAlROal.- >nc, induced by previous disease of other parts of the eye. From this definition, which comprehends every form of amaurosis, it is evident that this affection does not uniformly take place as a single independent disorder; but not unfrequjiitly presents itself as a sympto- matic effect of some other disease of the eye ; a fact exemplified in cases of hydroph- llalmia,cirsophtlialmia, glaucoma, Sic. And as Mr Wardrop observes, amaurosis, in its usual acceptation, signifies a symptom of disease, as well as a distinct affection. (Es- says on the Morbid Anatomy of the Human Eye, vol. 2. p. 165. 8vo. Lond. 1818.) With respect to the mere name of the kind of disease, which is here implied by amau- rosis, its correctness will remain the same, whether the iris be moveable or immove- able ; whether the pupil be preternaturally enlarged or contracted ; and whether it be perfectly clear and transparent, or more or less turbid ; for the name only refers to the morbid state of the retina and optic nerve, and not to the condition of the sight in general. When the long-established name of amaurosis is received with this precise meaning, there will not be the slightest danger of confounding this disease with other affections of the eye. However, when it is wished to make out the very different forms and kinds of amaurosis, the foregoing appearances of the iris and pupil are considerations of great importance. (See Beer's Lehre von den Augenkrankheiten, b. 2. p. 420, 4-c. Wien. 1817.) Amaurosis does not constantly attack both eyes at the same time. Frequently one is attacked some time after the other; and it is not unusual even for one eye to remain *ound during life, while the other is com- pletely blind. This depends in part upon the disposition to the disease in one eye being quite local, and in part upon the causes giving rise to the complaint extend- ing their operation only to the eye affect- ed. Where, also, the origin of amaurosis seems to depend altogether upon constitu- tional causes, as in gouty and syphilitic patients, he, one eye is not unfrequently attacked much sooner than the other; though, in these examples, it is more rare to find the eye, which does not suffer at first, continue perfectly unaffected. (Beer, b. 2. p. 422.) As a general observation, Mr. Wardrop thinks it may be remarked, that, when only one eye becomes at first amau- rotic, from a sympathetic affection, there is little danger of the other eye becoming blind; but. that when amaurosis is pro- duced by any organic change in one eye, the other is in danger of becoming sympa- thetically affected. (Essays un the Morbid Anatomy of the Human Eye, vol. 2. p. 190.) Amaurosis does not completely hinder vi- sion, a diminished power of seeing often remaining during life. Hence the division of cases into perfect and imperfect, which latter, however, sometimes attain a degree in which the patient is only ju-t able to distinguish light, the direction ui its r»ys» and its degree. Imperfect amaurosis, besides being charac- terized by a considerable weakness of sight, approaching to real blindness (Amblyopia Amaurotica,) is mostly complicated with a greater or lesser number of other morbid appearances, which merit serious attention. Among the most important of these symptomatic appearances of imperfect amaurosis, is a defective interrupted vision (visits inlerruptus.) For instance, when the patient is reading, single syllables, words, or lines, cannot be seen, unless the eye be first directed to them by a movement of the whole head, and greater or lesser portions of other objects are, in the same manner, undistinguishable. Sometimes amaurotic patients can see only the upper or lower, or the left or the right half of objects. (Vi- susdimidiatus; Amaurosis dimidiata;'Hani- opia; Hemiopsia.) Sometimes, when the patient shuts one eye, he can only distinguish the halves of objects ; but, if he open both eyes, he sees every thing iu its natural form. In this case, according to Scbmucker, one eye is sound, and only some fibres of the nerve of sight are injured in the other. (Vermischle Chir. Schrift. b. 2. p. 12.) There are likewise some not very un- common cases of imperfect amaurosis, in which the patient cannot see an object, un- less it be held in a particular direction before the eye; but when the eye or head is moved in the least, he loses all view of the thing, and cannot easily get sight of it again. (Beer, Lehre von den Au- genkrankheiten, b. 2. p. 424.) On this part of the subject, it is remarked by Richter, that patients who may be said to be entire- ly blind, sometimes have a small part of the retina which is still susceptible of the impression of light, and is usually situated towards one side of the eye. This obliquity of sight was long ago pointed out by the late Mr. William Hey of Leeds, as common in the present disease. (See Med. Observa- tions and Inquiries, vol. 5.) Richter men- tions, that, in one man, who was in other respects entirely bereft of vision, this sen- sible point of the retina was situated ob- liquely over the nose, and so small, that it was always a considerable time before its ..tuation could be discovered. He adds, mat * was so sensible, as not only to dis- dfoSnt*? Y1' Jnt even the sP're of » it h?L P. /^'mg to this author, the first an?6 °Vhe e?e ,hat seftms ^ be KUto serene m°u "^""'j ^^ ln *• K Snts I; uHenC\ the generality of ESauroais rn f™ & beSinning imperfect diately before then? (Xf °h *? imme' darzn" b. :,. "Kap% ^to^W. *? t*/ Obs.andlnq.vol.5) ° H*y m Mcd W8nl-°f U,e m°st c°mmon symptoms of. beginning amaurosis is an annXJLT • the patient's fancy, as if gnat/or „ie '" flying about before his eves ,"•** w;Te AMAUROSIS. carum, Myodesopsia.) Sometimes transpa- rent, dark-streaked, circular, or serpentine diminutive bodies appear as if flying in greater or lesser numbers before the eyes, often suddenly ascending, and as quickly falling down again, and chiefly annoying the patient and confusing his sight when he looks at strongly illuminated or white ob- jects. The substances thus appearing to fly about before the patient's eyes are term- ed by Writers Scotomata, Muscat volilantes, .Vouches volantes. (Beer, Lehre, fyc. B.2.p. 424.) The term scotoma, however, is not always received exactly in the foregoing sense; for, Richter says, sometimes the malady seems to be confined to a single little spot in the eye, in which case, the patient is conscious of having before the retina an immoveable black speck. It is to this particular instance that some patho- logists apply the term scotoma. These scotomata gradually increase, be- eome less and less transparent, and atlength, are so connected together, that they form a kind of network, or gauze, by which all objects are more or less obscured. This is another symptom of amaurosis, technically called visus reticulalus. The network com- monly has the peculiarity of being black in very light situations, or when white sub- stances are before the eye ; while, in dark places, it is quite shining, and, as it were, of a bluish white hue. like silver, though some- times of a red-yellow, golden colour. A not uncommon symptom of imperfect amaurosis is the patient's seeing every ob- ject indistinctly in a rainbow-like, some- times tremulous, and generally very daz- zling light; while, in the dark especially, blue or yellow flashes, or fiery balls seem suddenly to pass before his eyes when the eyelids are shut, and excite considerable alarm. (Visus Ivxidus; Marmoryge Hippo- cralis; Photopsia.) In imperfect amaurosis, the sensibility of the retina may be so augmented, that tbe patient shuns all very light places, particu- larly those in which the light is strongly reflected into the eye, and, in order yet to discern in some measure large objects, he feels himself obliged always to seek shady, darkish situations, or to screen his eyes, out of doors, with a green shade, or green glasses. This state is termed by Beer, Lichtscheue. (Photophobia.) Under these circumstances, it sometimes happens, that the patient for a very short time, for exam- ple a few moments, or (what is very un- common) for a more considerable period, is able of himself to discern the smallest objects in a very weak light more plainly and accurately than the best eye can hard- ly do in a good light. Yet, excepting at such period, the patient with the above de- gree of light is not capable of seeing even larger objects. This infirmity of sight re- ceives the name of oxyopia. Sometimes, in the early stage of amauro- sis, all objects seem covered with a dense mist; while, in other instances, this mist 'ir«t pre«entar instances, the bit i 5 POMes.es a power of motion, activ tv Pso th»f "°Ving With "Common activity, so that, in a very moderate light, it will contract in an unusual degree and nearly close the pupil. (Anfanf,™' ?< Wundarzn. B. 3. p. 424, Edit. 1796 f Two or threo remarkpbb- in<=tanr*s of tno AMAURoala active state of the ins, iu cases of amauro- sis, were some years ago shown to me by Mr. Albert, then staff surgeon of the York Hospital, Chelsea, and I have seen some other similar cases in St. Bartholomew's Hospital. Most of the patients in question had not the least power of distinguishing the difference between total darkness and the vivid light of the sun, or a candle placed just before their eyes. Janin and Richter have likewise seen the pupil capa- ble of motion in this disease, and Schmucker has twice seen the same fact. In some anomalous cases, when the strength of the light is suddenly increased, the pupil expands with more or less ce- lerity. I have already adverted to the occasional moveableness of the iris, notwithstanding the insensible state of the retina. Let me next take notice of a case which sometimes presents itself, and is quite the reverse of this last. The nerves of the iris may be paralytic, while those of sight continue un- impaired. Schmucker tells us, he was ac- quainted with a woman, whose pupil was uncommonly distended, and totally inca- pable of motion. Her sight was very weak, and spectacles were of no use to her. She could scarcely discern any thing by day, or in a strong light; but she could see rather better at night and in dark places. This infirmity of sight depended upon the dilated paralytic state of the pupil, by which too many rays of light were admitted into the eye; and the reason why the patient could see better at night was, because the pupil, in its natural state, always becomes widened and dilated in a dark situation. (See Vermischte Chirurgische Schriften, Von J.L. Schmucker, Band 2, p. 13, 14.) Frequently, in amaurosis, when the sight of only one eye is lost, and the other re- tains its full power of vision, not the slight- est defect can be discovered, as long as the patient keeps both eyes open; but the in- stant the sound eye is completely covered, the iris becomes perfectly motionless, its pupillary margin assumes an angular shape, and the pupil expands, being sometimes evidently drawn towards the edge of the cornea. (Beer, Lehre von den Augenkrank. B. 2. p. 438.) Besides the above appearances of the pupil and iris, amaurosis is attended with other characteristic phenomena, which oc- cur, under certain circumstances, in the form, texture, and state of other parts of the eye, and adjoining organs. Thus, the pa- tient often complains of a peculiar trouble- some dryness of the eye, or of a sensation as if the eyeball were about to be pressed out of its socket; and, indeed, says Beer, diK- may sometimes hear a grating noise, and "distinguish a fluctuation in the orbit behind the eye-ball, when this organ is pressed upon by the finger, or moved in various directions, though neither its cir- cumference be enlarged, nor any tendency to exophthalmia be really present. Nor is it very uncommon to find the affected eye preternaturaliy hard, soli, or even quite flaccid; but it is less common to find the dimensions of the globe of the eye increas- ed, or the organ affected with atrophy. (Beer, Vol. cit. p. 438.) The principal subjective morbid effects, which appertain to amaurosis, have been already described in speaking of the several defects of vision, which accompany an amaurotic weakness of sight. Besides these, however, there are other subjective symp- toms, which merit attention. For instance, the patient feels in the eye and surrounding parts an irksome sensation, without any actual pain, and complains of a remarkable sense of fulness, or weight in the organ. Amaurotic patients are also frequently attacked with sudden violent giddiness, which usually ends in a considerable dimi- nution of the eyesight, and sometimes in severe general headach. Occasionally they fancy that small atoms of dust are lodged under the eyelids, and are fearful of mov- ing either these parts or the eye. It is also well known, that many persons become amaurotic, while labouring under severe hemicrania, which either extend from or to the diseased eye ; while, on other occa- sions, the most violent pains are confined particularly to the region of the eyebrow, and have the appearance of being strictly periodical. In certain other cases, the pain is wandering, and shoots in every direc- tion about the eyebrow. These painful feelings often precede the amaurotic blind- ness a considerable time, and often first take place when one or both eyes are al- ready blind; but the pains and loss of sight are not unfrequently produced toge- ther. Lastly, some patients are met with, in whom the worst pains only last until the amaurosis is perfectly formed, when they gradually and permanently cease. In all these painful cases of amaurosis, the pain and the blindness chiefly depend upon the same cause, and one is seldom the occasion of the other. Sometimes amau- rotic patients experience such violent pain, that they lose their senses, and grow deli- rious; but in these cases, if we can credit the assertion of Beer, important morbid changes in the bones of the skull, or the brain itself, are invariably noticed after death. (See Lehre von den Augenkr. B. 2, p. 439.) In some amaurotic patients, le- thargic symptoms may be remarked: in others restlessness ; and, more rarely, delirium in all its degrees, either as a tran- sient or permanent affection. Paralytic appearances may precede amaurosis, either in the vicinity of the eye, or in the muscles of the face, or in a distant situation, as the extremities. Some- times they accompany the disease, and sometimes closely follow the amaurotic amblyopia; such a case of amaurosis being not unfrequently the forerunner of a fatal attack of apoplexy. In the same way convulsive symptoms may be conjoined with amaurosis, and when they first eccur in the complete stage :n AMAUROSIS of the latter disease. Beer pronounces them a very unfavourable omen for the patient's life. But, according to the same experienced oculist, when in a case of perfect amauro- sis, several of the other external senses are affected; and lastly, when the internal senses begin to suffer, when, for instance, the hearing, and then the smell, and taste are lost, and afterwards the memory and other intellectual powers fail, the patient's speedy dissolution may be expected. (See Lehre, von den Augenkrankh. B. 2, p. 441, Wien. 1817.) As Professor Beer correctly observes, age cannot be considered a predisposing cause of amaurosis, as it is of a cataract; for there are many more blind persons who have been deprived of their sight by amau- rosis in their best days, than of old persons thus attacked. Amaurosis spares no age, not even the new-born infant. Neither does sex nor race appear to have any influence over the origin of the complaint; but it would seem that dark eyes, especially those which are called black, are more disposed to amaurotic blindness than such as are light coloured. According to Beer's experience, for every gray or blue eye affected with amaurosis, there are five and twenty or thirty brown or black ones, thus diseased. In the pecu- liar constitution of the eye, then, as well as in a sangunieous and choleric tempera- ment, there exists a tendency to the dis- order. More frequently than cataract, amaurosis is found to be a true hereditary disease. This is so much the case, that most of the members of a family, for more than one generation, may lose their sight from amau- rosis at a certain period of life. Beer says, that he is acquainted with more than one family in which this has happened; and, what merits attention, the women of one of these families, down to the third genera- tion, became completely and permanently blind from amaurosis on the cessation of the menses, while all the others, who had had children, were unaffected. But the males of this unfortunate family, who, as well as the females, have very dark brown eyes, all seem to be weak-sighted, though none of them are yet blind. (Lehre von den Augenkrankheiten, b. 2. p. 443.) In women, especially those with black eyes, the time when the menses stop is a dangerous period for the commencement of amaurosis, particularly that form of it which Beer chooses to denominate gouty. According to the same writer, patients, whose piles used to bleed periodically for a long time, but are now suddenly stopped, and whose eyes are dark, are often attacked with amaurosis. One of the less common causes of amau- rosis is an idiosyncrasy iu relation to this or that sort of nutriment or medicine, or this or that particular state of the body. Here is IX) be reckoned the amaurotic weakness of -i^lit. of the perfert amaurosis, which comes on at the very commencement Ol pregnancy, and subsides after delivery, but always attended with dyspepsia and insu- perable vomiting. This species of amau- rosis, however, should be carefully distin- guished from that which sometimes first originates in the final months of pregnancy, and chiefly from strong and long-continued determination of blood to the head and eves, particularly when the bowels are at the same time loaded, and the patient con- stipated. This latter case u sually continues till after delivery; or, if the labour be tedious, difficult, and attended with consi- derable efforts, the blindness may first attain its complete form at the time of delivery, and not afterwards subside. Beer saw a young Jewess, who at the very beginning of her first three pregnan- cies, which followed each other very quickly, regularly used to lose her sight, becoming completely amaurotic between the third and fourth months ; and, on the two first occasions, she continued blind till after delivery; but, in the third instance, • the power of vision never returned at all. Beer twice had under his care another wo-„ man, who was attacked with amaurosis* ^ whenever she drank chocolate; but, upon . leaving off that drink, she never afterwards had any complaint in her eyes. If we are to believe Professor Beer, the abuse of bitter substances, as of chicory in coffee, bitter malt liquors, and bitter medi-. cines, especially quasia, is unquestionably? a predisposing cause of amaurosis. -< The abuse of narcotic poisonous sub-' stances may induce amaurosis; immode-1 rate doses of opium, hyoscyamus, belladon- na, &.c. Lead will do the same thing. Beer mentions a case in which the only assignable cause was the exhibition of pills, containing the extractum cynoglossi. One not unfrequent and very important,. cause of amaurosis is hysteria and hypo** chondriasis, with which must be included infarction generally, and induration of one or more of the abdominal viscera, especi- ally the liver. (Beer, Lehre, A-c. B. 2. p. 444-46.). According to Richter, the remote causes1 of gutta serena may be properly divided into three'principal classes, the differences of which indicate three general methods of treatment. It is alleged, that the first class of causes seem to depend upon an extraordinary plethora and turgidity of the blood-vessels of the brain, or of those of the optic nerves and retinae, upon which last parts a degree; of pressure is thereby supposed to be occa-' sioned. A considerable plethora, espe- cially when the patient heats himself, or lets his head hang down, will frequently excite* i the appearance of black specks before the, - eyes, and sometimes complete blindness, A P'ethoric per3on (says Richter,) who - held his breath, and looked at a white walin was conscious of discerning a kind of n7^ work, which alternately appeared and dis appeared with the diastole and synolo of AMAUROSIS. W lue arteries. Tins phenomenon, it is con- jectured, originated from the plethoric state of the vessels of the retina. Boer- haave mentions a man, who always lost his sight on getting tipsy, and regained it on becoming sober. Richter thinks it likely, that it is in this manner that the disease is produced, by the suppression of some habitual discharge of blood, by not being bled according to cus- tom, by the stoppage of the menses, and by the cessation of hemorrhage from piles; circumstances, which, if We can give cre- dit to all the accounts of Richter, Scarpa, Schmucker, and other experienced writers on the subject, frequently give rise to gutta serena. In the same manner, the com- plaint may be brought on by great bodily exertions, which must determine a more rapid current of blood to the head. Rich- ter informs us of a man who became blind all on a sudden, while carrying a heavy burden up stairs. He tells us of another man, who laboured excessively hard for three days in succession, exerting his strength very much, and who became blind at the end of the third day. Pregnant wo- men, in like manner, are sometimes bereft of their sight during the time of labour. Schmucker has recorded a remarkable in- stance of this in a strong young woman, thirty years old, and of a full habit. When- ever she was pregnant, she was troubled with violent sickness till the time of deli- very, so that nothing would stop in her stomach. She was bled three or four times without effect. Towards the ninth month her sight grew weak, and for eight or ten days before parturition she was quite blind. The pupil of the eye was greatly enlarged, but retained its shining black appearance. She recovered her sight im- mediately after delivery, and did not suffer any particular complaints. Schmucker assures us, that he has been three times a witness of this extraordinary circumstance. {Vermischte Chir. Schriften, Band 2, p. 6,, edit. 1786.1 Richter speaks of a person who lost his sight during a violent fit of vomiting. Schmucker acquaints us, that it is not uncommon for soldiers, who are performing forced marches in hot weather, to become blind all on a sudden. All great exertions of strength, when the body is plethoric, or heated, or bent forwards with the head in a low posture, are usually attended with some danger of bringing on amaurosis. The blindness which follows external in- juries of the head, is' ranked by Richter among the preceding class of cases. A man who received a smart box on the ear, says this author, lost his sight on the spot. Richter conceives it probable, that a con- cussion of the head may sometimes produce an atony of the blood-vessels, giving rise to (heir dilatation, and consequent pressure on the adjacent nerves: perhaps, it is more likely, that the blow itself actually ruptures them, and produces an effusion of blood. Richter suspects that the gutta serena, Vol. !- 5 which originates during a violent ophthal- my, or during a severe inflammatory fever, may be of the same nature. He thinks it probable, that persons, who become blind while exposing themselves to the burning sun, with their heads uncovered, have their sight impaired in a similar way. Beer also coincides with Schmucker, Richter, and others, in regarding as a fre- quent cause of amaurosis, repeated and long continued determinations of blood to the head and eyes, produced by various circumstances,—viz. by pregnancy ; a te- dious and difficult labour; lifting and carry- ing heavy burdens, especially with the arms raised up ; all kinds of work in which the eyesight and intellectual faculties are intensely exerted, with the head bent for- wards, and the abdomen compressed, as is the case with shoemakers, tailors, &.c.; every sudden stoppage of natural or preter- natural long established discharges of blood, as that of the menses, lochia, or hemorrhoids; the omission of an habitual venesection at some particular season of the year; severe and obstinate vomiting; forced marches in hot dry weather; scro- fulous and other swellings of considerable size in the neck, pressing upon the jugular veins, and obstructing the return of blood from the head ; the use of a pediluvium, or warm bath, the water of which is of high temperature ; hard drinking ; violent gusts of passion ; frequent and obstinate consti- pation ; and hard straining at stool. These causes are more likely to occasion amau- rosis, in proportion as the individual i- young and plethoric. (Beer Lehre von den Augenkr. B. 2. p. 446.) The second class of causes are supposed to operate, by weakening eifter the whole body, or the eye aloae,v*nd they indicate the general or topical use of tftnic remedies. In the first case, the gutta serena appears as a symptom of considerable universal de- , bility of the whole system ; in the second case, the disease Is altogether local. Every great general weakness of body, let it pro- ceed from any cause whatsoever, may be followed by a loss of sight. The gutta sere- na, if we can give credit to the statement of Richter, has sometimes been the conse- quence of a tedious diarrhoea, a violent cholera morbus, profuse hemorrhage, and immoderate salivations. He informs us of a dropsical woman, who became blind on the water being let out of her abdomen. According to the same author, no general weakening causes operate upon the eyes, and occasion total blindness so powerfully and often, as premature and excessive in- dulgence in venereal pleasures. The causes are various which operate locally in weakening the eyes. Nothing has a greater tendency to debilitate these organs than keeping them fixed veiy atten- tively, for a long while, upon minute ob- jects. But, however long and assiduously objects are viewed, if they are diversified, the eye suffers much less than when they 34 UiALKOsI:- arc all of the ~>.iuc kind. A iivquent change in the objects which we look at has a material effect iu strengthening and re- freshing the eve. The sight is particularly injured by looking at objects with only one eye at a time, as is done with telescopes and magnifying glasses ; for when one eye remains shut the pupil of that which is open always becomes dilated beyond its natural diameter, and lets an extraordinary quantity of light into the organ. The eye is generally very much hurt, by being em- ployed in the close inspection of brilliant, light-coloured, shining objects. They are greatly mistaken, says Richter, who think that they save their eyes when they illumi- nate the object which they wish to see, in the evening, with more lights, or with a lamp that intercepts and collects all the rays of light, and reflects them upon the body which is to be looked at. Richter makes mention of a man, who, in the mid- dle of winter, went a journey on horseback, through a snowy country, while the sun was shining quite bright, and who was at- tacked with amaurosis. He speaks of another person, who lost his sight, in con- sequence of the chamber in which he lay being suddenly illuminated by a vivid flash of lightning. A man was one night seized with blindness, while he had his eyes fixed on the moon in a fit of contemplation. Richter also expresses his belief, that a con-' cussion of the head, from external violence, may sometimes operate directly on the nerves, to as to weaken and render them completely paralytic. Professor Beer corroborates the fore- going statement; for, he says, among the most.frequeft causes is to be -considered every abuse of the eyesight, especially in dark-eyed person*! as a long and close in- spection of one object, particularly with a microscope, when the thing examined is very brilliant, or reflects back much light into the eye. Hence, the view of jewels at night, and long journeys through snowy countries, &c. are conducive to the disease. In this respect, every kind of employment which strains the eyes much, and requires a strong reflected light, must be considered injurious. Thus reverberating lamps, like Argand's ; a white wall opposite the win- dows, and illuminated with the sun's rays, and looking a long while at the moon, or more especially the sun, with the unassist- ed eye, are circumstances likely to bring on the disease. That a flash of lightning, especially when it suddenly wakes a person in the Bight-lime out of a sound sleep, may produce an amaurotic amblyopia in an irri- table eye, or even. perfect blindness, is a well-known fact; and, it is on tbe same principle, that going suddenly out of a dark bed-room immediately after waking in the morning into an apartment that commands an open extensive prospect, must be hurtful to an irritable eye, though the bad effects may only be very slow. Here is also to be included every kind of over irritation of the eye by light, as happens to typhoid pa- tients, when they lie with then- eyes.open all the day in a large sunny chamber.* \ cry often the cause of amaurosis consists iu local or constitutional debility, proceed- ing from impairment of the nerves in gene- ral, or of the nerves of the head, especially those of the forehead and eyebrow; either from a concussion of the spinal marrow, falls from a considerable height with the weight of the whole body upon the heels; concussions of the eye-ball, sometimes caused by violent artificially excited sneez- ing, but more generally by contusions of the eye with blunt weapons, kc. If we are to believe Beer, and other foreign prac- titioners, considerable direct weakness may arise from cholera, long-continued ^diar- rhoea, salivation, and the incessant spitting of tobacco-smokers ; bleedings; injudicious tapping of the abdomen ; excessive indul- gence in venery, and the misemployment of issues. A general debility, which has the worst effect on the eyes, may also arise from long trouble ; tedious vexation, and worldly cares, especially when the diet is poor and bad ; also from a deficiency of proper food; long watching; violent and sudden fright ; imprudently washing the eyes with very cold water, especially when they are already weakish and irritable; and keeping them long in a dark place, particularly when they are also exerted a good deal in some particular kinds of la- bour, a case which Beer says is very fre- quent in Vienna. The amaurosis, follow- ing typhus, without any unusual irritation of the eye by light. Beer also refers to genera] debility. (Lehre von den Augenkr. B. 2. p. 449.) The third class of causes consists of irri- tations, which in some inexplicable way affect the optic nerves, and render them insensible of the impression of the light. Most of these irritations are asserted to lie in the abdominal viscera, whence they sympathetically operate upon the eyes. The observations of Richter, Scarpa, and Schmucker, all tend to confirm, that amau- rosis more frequently arises from irritation in the gastric organs than any other cause whatever. It may often be ascertained, that patients with amaurosis have suffered much trouble, and long grief, or been agi- tated with repeated vexations, anger, and other passions, which are supposed to have a great effect in disordering the bilious se- cretion, and the digestive functions in gene- ral Richter tells us of a man, who.lost bis sight a few hours.after being in a violent passion, and recovered it again the pfai day, upon taking "an emetic, by whicfTT considerable quantity of bile was evacuated. A woman is also cited, who became blind whenever she was troubled with what are* termed acidities in the stomach, (Sep An-* fangs, der Wundarzn. B. 3, Kap. 14.) ttow- ever, according to Beer, the imperfect amaurosis seldom depends upon disorder of the gastric organs, excepting the case from worms: (Lthre von den Augenkr. B 2 v 456.) a very important difference of om- AMAUROSIS. nion from that entertained by Schmucker, Richter, and Scnrpa. The continental surgeons are excessively comprehensive in their ideas of the causes of gutta serena, and, with many truths, they blend an evident quantity of unestablished conjectures, and palpable absurdities. I believe, it will generally be found, that, when surgical writers assign a multitude of causes for any disease, they deal very much in mere supposition. It would be idle cre- dulity, indeed, to put faith in the assertions concerning amaurosis being occasioned by the bad treatment of particular fevers, sup- pressed diarrhoeas, the repulsion of eruptive complaints, &ic. There is no reason why a person should not become blind about the time when another disorder gives way; but we ought to have some other ground for the doctrines, to which allusion is made, before we can presume to offer them as entitled to confidence. These observa- tions apply to some of the causes of amau- rosis enumerated by Beer, of whose senti- ments I mean presently to give a full ac- count. Worms in the alimentary canal are al- leged to be sometimes tbe cause of amau- rosis ; and, since a disordered state of the gastric organs is universally acknow'edged to be frequently concerned in the produc- tion of blindness, we can have no difficulty in conceiving that worms may likewise have the same effect. Besides gastric irri- tations, there are some others which class as causes of this disease. A violent fright, which is considered as being a frequent remote cause of gutta serena, is supposed by Richter to operate chiefly by irritating the nerves. The blindness sometimes proceeds from a mechanical kind of irritation. A man re- ceived in his right orbit a small shot, which pierced the upper eyelid, and lodged at the upper part of the socket, between the eyelid and eyeball, so that it could be felt externally. Richter adds, that this patient shortly afterwards became blind in the left eye ; but recovered his sight in it again upon the excision of the shot (Anfangsgr. der Wundarzn. Band 3, p. 439.) Sometimes, says this experienced sur- geon, the irritation, exciting amaurosis, seems to have its seat in the mucuous mem- brane of the nose and frontal sinuses. We have already adverted to the unusually dry stale of the nostril, that has been suspected of being occasionally conducive to this spe- cies of blindness. According to Beer,' several constitutional disorders, but more especially gout, are fre- quently concerned in the production of amaurosis. Respecting the causes of amaurosis, the following remarks by Beer claim attention. Variou-* swellings in the orbit, as, for in- stance, encysted tumours, tophi, hydatids iu the sheath of the optic nerve, may, and must gradually produce complete amau- rosis by their pressure upon the optic nerves and retinft These rasec ^VG ntiinlly characterized by a protrusion of the eye from its socket. (See Exophthalmia.) In the same manner, different morbid changes in the brain itself, and in tbe bones of the cranium in particular, may be the direct cause of amaurosis: for example, hydrocephalus internus, caries, and exos- toses at the basis of the skull. Just as amaurosis is frequently a pure symptomatic effect of various disordered states of the constitution, so may different morbid changes, occasioned in the eye by those states of the health, become the proxi- mate cause of amaurosis, as hydrophthalmia, cirsophthalmia, dissolution of the vitreous humour, glaucoma, &cc. From a contagious atmosphere, which is generally injurious to the eyes, an amau- rotic blindness may originate, though but very rarely, and, as it would seem, only through the powerful influence of such state of the air over the whole sanguiferous and nervous system. Debilitated, nervous, weak-sighted persons, by remaining long in the atmosphere of a privy (Chornel, M4m. de Paris, 1711, Obs. Anat. 5. and Ramazzvni, De Morbis Artificum, c. 13.) that of a deep cellar, or exposed to coal-smoke, may be suddenly attacked with amaurosis; and Beer assures us, that his experience con- firms the truth of these reports. (Lehre, fyc. 6. 2. p. 452.) A sympathetic affection of the nerves of the eye, with a carious grinder in the upper jaw-bone, is one of the most uncommon causes of amaurotic blind- ness. A case, not yet duly considered, and very like the amblyopia senilis, consists of an in- cessantly diminishing secretion of the pig- mentum nigrum upon (he tunica Ruyschi- ana, choroidea, and uvea, which secretion indeed, in some individuals, earlier and more considerably; in others, later and in a slighter degree, recedes with other secre- tions of a different nature. In consumptive persons, this change happens in a remark- able degree, so that the patients are gradu- ally quite bereft of vision. (See Beer's Lehre von den Augenkr. B. 2. p. 451, fyc.) For a variety of additional facts and obser- vations respecting the causes of amaurosis, I would advise the reader to consult War- drop's Essays on the Morbid Anatomy of the Human Eye, vol. 2. chap. 45; a work re- plete with valuable information. It is remarked by professor Beer, that amaurosis, when completely formed, has hitherto been but rarely cured. This (says he) may depend, in the first place, upon our far too imperfect knowledge of the nerves, and of their genuine and compli- cated disorders. Secondly, it may equally depend upon the present very defective etiology of amaurosis. Thirdly, the fre- quent incurability of amaurosis also very materially proceeds from the causes of the disease being, in most instances, nol only obscured, but exceedingly complicated; and even when, detected, many of them will not. admit of removal, because they have 'heir foundation either in th«» constitution 36 i/the eye, long r\isting defects of physical *od moral education, protracted bad habits o f youth, or the unmanageable behaviour of the patient. Fourthly, we must take into the account the unconscientious indolence of the practitioner, who so often positively declines rendering the patientany assistance at all; or, if for the sake of lucre he at- tempt any thing, it is only an empirical mode of treatment, by which means every chance of benefit is annihilated, while an active and intelligent surgeon might per- haps preserve vision, and bring it to perfec- tion again. When there is a probability of relieving amaurosis, the cure is mostly tedious, and beset with many difficulties, though the blindness has originated and formed sud- denly, the utmost attention, and the great- est practical skill, being requisite on the part of the surgeon. Hence, as Beer observes, even in favourable cases, cither the patient himself, the surgeon, or both of them, lose all inclination to persevere in the treatment, and the unfortunate victim is either left to bis fate, or consigned to impudent, merce- nary quacks. In amaurosis, the difficulty of cure is na- turally in proportion to the variety and num- ber of causes of the complaint; and the more readily the surgeon makes himself acquainted w ith them, and the more certain- ly he obviates them, the more surely and quickly does the cure follow. It may be considered as generally true, that every amaurotic weakness of sight, and every completely formed amaurosis, are at- tended with the greatest probability of cure, where they began suddenly, and were quickly developed ; for experience proves, that, in these cases; the whole of the causes of the disease are much more frequently and earlier comprehended than when the complaint has been several years in forming. —(Beer, Lehre von den Augenkr. b. 2.p. 454 —56.) This observation perfectly coincides With the account given by Schmucker, who says, that many of these suddenly formed cases have fallen under his notice, and been more easy of cure, than when the disorder had come on in a more gradual way. (See Vermischte Chir. Sehriften, b. 2.) A case may happen, nay, it happens not unfrequently, says professor Beer, (which, considering the imperfect etiology of amau- rosis, cannot be wondered at,) that the sur- geon, after the most careful investigation, can absolutely detect no particular cause of the existing amaurotic blindness, in which event, the prognosis must in every respect be very uncertain and unfavourable, since only empirical treatment can be tried, which rarely answers; and, even when a cure in this manner does follow, it is frequently quite accidental. As will be seen in the account of each particular species of amaurosis, tbe affected eye is sometimes so conditioned, that the complete incurability, sooner or later, may be prognosticated with entire certainty, and AMAUROSIS. this even tliougha degree of vision may now ^TherTare amaurotic patients in whom every treatment does harm, the disease ma- khi^uninterrupted advances to perpetual b Sdncss This observation especially «. fers to local remedies, of the danger of which, under certain circumstances, the pa- tient should be carefully warned In general, the more complete the amau- rosis is, and the longer the patient ha. been deprived not only of vision, but of all sen- sibility to light, the less hope is there of sight being ever re-established. When one eye has been completely bereft of sight by amaurosis, and the surgeon can find out little or no cause for the infirmity, there is strong reason for apprehending that the other eye will sooner or later become blind. This is a fact amply proved by ex- perience, and the exceptions are very rare. According to Beer, the idea entertained by some writers is not built upon experi- ence, that amaurotic patients, in whom the iris is still moveable, and the pupil not very much dilated, are more easily and frequent- ly cured than others in whom the iris i? perfectly motionless, and the pupil exceed- ingly dilated. For sometimes, during the treatment, or even spontaneously, the iris, after being quite immoveable, recovers its power of motion, yet the patient may not, at the same time, regain the slightest degree of vision; and on the other hand, many cases of perfect amaurosis are cured, with- out the iris recovering any of its mobility, and the pupil remains dilated during the remainder of the patient's life. (Lehre von den Augenkr. b. 2. p. 458.) Richter also thinks, that the moveable or immoveable state of the pupil can neither be consi- dered as a favourable nor unfavourable cir- cumstance. Sometimes, says he, an amau- rosis may be cured, which is attended' with a pupil extraordinarily dilated, and entirely motionless; and sometimes the disorder proves incurable, notwithstanding the pupil be of its proper-size, and capable of motion. There are likewise examples, in which the pupil recovers its moveableness, in the course of the treatment, although nothing will succeed in restoring the eyesight. (An- fangsgr. der Wundarzn. b. 3. p. 424. 8te. Golt. 1795.) In some very rare instances, says Beer, amaurotic blindness has been cu^ed by some apparently accidental, or indeed morbid effect, without any assistance from art; by hemorrhage from the nose, an intermittent fever, a blow on the head, k.c. The same experienced writer operated successfully ^•hf/r °f aPatientwith cataracts, foj w.S^a been previously depressed too far aga.nst the retina, so that th^ ure gave rise to amaurosis, which, after conti- nuing eight years, was suddenly removed by thepatier, 's accidentally falling o™obed and pitching upon the top of his headlff' (Lehre von den Augenkr. b. 2. p. 458% head7U The following observations, made bv „,„. r fesrorBeer, respecting the rrognoshf^ AMAUROSIS. 37 not fail to prove interesting. There is a species of amaurosis, which gradually dimi- nishes of itself; for instance, that which arises from hard drinking, or the effect of narcotic poisons, belladonna, opium, hyos- cyamus,&c. Sometimes imperfect amaurosis goes away, without any assistance from art, in consequence of tbe accession of some other disease, as an eruption, a discharge of matter from the ear, bleeding from piles, the menses, &c. Also, in most cases, when the surgeon is so fortunate as to cure amaurosis, either by scientific or empirical methods, there still continues, for life, a considerable degree of amblyopia, more especially if the amaurosis has been complete. Sometimes, by successful treatment, vi- sion is in a great measure, or even entirely, restored in one eye ; yet the other remains completely blind; or one eye sees again much sooner than its fellow, although they were both affected together with an equal degree of blindness. It often happens that, though a material degree of vision returns in the course of the treatment, the faculty is restricted to a cir- tumscribed point of the retina, so that the patient is enabled to see objects plainly only when they are held in a particular di- rection before him ; while, in-other direc- tions, they are either quite invisible, or very indistinct. (Beer, Lehre von den Aug- enkr. b. 2. p. 459,60.) Professor Scarpa, of Pavia, has given an excellent account of the prognosis in cases of amaurosis. Some of his doctrines, how- ever, founded on the humoral pathology, are hypothetical, and therefore purposely omitted in the following account. It also deserves notice, that the case supposed to originate from injury of the supraorbitary nerve, is not always incurable. Scarpa only knows of one such cure, viz. the ex- ample recorded by Valsalva. (Dissert. 2.§ 11.) But additional instances are reported by Hey (Med. Obs. and Inq. vol. 5.) by Larrey (M4m. de. Chir. Militaire, t. 4. p. 181.), and Dr. Hennen (Principles of Mili- tary Surgery, p. 346. ed. 2.) According to Mr. Wardrop, it is only when this nerve is wounded, or injured, and not divided, that amaurosis takes place; for the blindness may sometimes be cured by making a com- plete division of the trunk nearest its origin. (Essays on the Morbid Anatomy of the Hu- man Eye, vol. 2. p. 180.) Amaurosis is divided by Scarpa into the perfect, or imperfect; inveterate, or recent ; and continued, or periodical. The perfect, inveterate amaurosis, attended with organic injury of the substance, con- stituting the immediate organ of sight, says Scarpa, is a disease absolutely incurable. The imperfect, recent amaurosis, particularly that which is periodical, is commonly cura- ble ; for it is mostly sympathetic with the •t'lte of the stomach and prim?' vise, or dependent on causes which, though they affect the immediate organ of sight, are ca- pable of being dispersed, without leaving any vestige of impaired organization in the optic nerve or retina. When amaurosis has prevailed several years, in persons of advanced age, whose eyesight has been weak from their youth ; when it has come on slowly, at first with a morbid irritability of the retina, and then with a gradual diminution of sense in this part, till total blindness was the con- sequence ; when the pupil is motionless, not circular, and not much dilated ; when it is widened in such a degree, that the iris seems as if It were wanting, and the margin ot this opening is irregular and jagged; and, when the bottom of the eye, independently of any opacity of the crystalline lens, pre- sents an unusual paleness, like that of horn, sometimes partaking of green, and reflected from the thickened retina, the disease may be generally set down as incurable. Kieser *joins Scarpa in representing this alteration as an unfavourable omen, adding, that it only takes place in examples of long stand- ing, and, that when it is considerable, the disease is incurable Langenbeck differs, however, from both these authors, and par- ticularly from Kieser, assuring us, not only that he has often seen this discolouration of the bottom of the eye in the early stage of amaurosis, but seen patients in this state soon cured. The cases which he has pub- lished, in proof of this statement, I have read with care, and find them completely satisfactory. Langenbeck agrees with other writers in imputing the appearance to a morbid change of the retina, and the treat- ment which he prescribes consists in the in- ternal exhibition of the oxymuriate of mer- cury in small doses, and friction with mer- curial ointment on the eyebrow and temple. (See Langenbeck's Neue Bibl.ftirde Chirur- gie, 1 b. p. 64—69, $-c. Gottingen, 1815.) Cases, says Scarpa, maybe deemed irre- mediable, which are attended with pain all over the bead, and a continual sensation of tightness in the eyeball; which are prece- ded by a violent, protracted excitement of the nervous system, and then by general debility, and languor of the constitution, as after masturbation, premature venery, and hard drinking. There is no remedy for cases connected with epileptic fits, or fre- quent spasmodic hemicrania; nor for such as are the consequence of violent, long- continued, internal ophthalmia. Cases are incurable, also, when produced by violent concussions of the head, direct blows on the globe of the eye, or a violent contusion, or other injury of the supraorbitary nerve, and this, whether the disease take place im- mediately after the blow, or some weeks subsequently to the healing of the wound of the eyebrow. Amaurosis is also incu- rable, when occasioned by foreign bodies in the eyeball, lues venera, or exostoses about the orbit. Lastly, amaurosis is abso- lutely irremediable, when conjoined with a AMAUROSIS. maaiiest change in the figure and dimen- sions of the eyeball. On the contrary, all cases of imperfect, recent amaurosis, whether the blindness be total or partial, are mostly curable, when not produced by causes, capable of contu- sing or destroying the organic structure of the optic nerve, and retina. This is especial- ly true when the retina is in some degree sensible to the impression of light. Recent, sudden cases, in which the pupil is not ex- eessively dilated, and its circle remains regular, while the bottom of the eye is ff a deep black colour; cases, unaccom- panied with any acute, continual pain in the head and eyebrow, or any sense of con- striction in the globe of the eye itself; cases, which originate from violent anger, deep sor- row, fright, excessive fulness of the stomach, a foul state of this viscus, general pletho- ra, or the same partial affection of the bead, suppression of the menses, habitual bleedings from the nose, piles, &ic. great loss of blood, nervous debility, not too invete- rate, and in young subjects, are all, gene- rally speaking, curable. Amaurosis is also, for the most part, remediable, when produ- ced by convulsions, or the efforts of diffi- cult parturition; when it arises during the course, or towards the termination of acute, or intermittent fevers; and when it is peri- odical, coming on at intervals, such as every day, every three days, every month, &.c. (Scarpa, < Osservazioni suite Malattie degli Occhi. cap. 20. Venez. 1802.) In general, when the treatment proves successful, the return of the power of vi- sion is accompanied with a regression of the same characteristic effects, which were disclosed in the gradual advance of the dis- order, viz. appearances as if there were be- fore the eyes flashes of light, a cobweb, network, mist, or flaky substances. (Beer, Lehre. von dm Augenkr. b. 2. p. 460. Wien. 1817.) Upon the commencement of the cure, there is also a return of the obliquity of sight; one of the most constant symptoms of imperfect amaurosis. This is a circum- stance, which Mr. Hey took particular no- tice of in some cases, which fell under his observation many years ago: he says, that it was most remarkable in those persons who had totally lost the sight in either eye ; for, in them, the most oblique rays of light seemed to make the first perceptible im- pression upon the retina; and, in propor- tion as that nervous coat regained its sensi- bility, the sight became more direct and natural. (See Med. Obs. and Inq. vol. 5.) TF.rATMEST OF AMAUROSIS, OH GUTTA SERENA. these objects, must be clear enough ro« tbe preceding observations, pert'C"1^ those concerning the etiology of the eta ease ; and hence it is not surprising that, amaurosis should so frequently resist every, endeavour to cure it. The plan of treatment is to be regulated, first by the number and kinds of circum-1 stances, which determine the form of the1 disorder ; secondly, by its presence, degree,' nnd duration. When only the chief causes i can be ascertained, a scientific mode oft treatment may always be instituted; though I here it is very necessary to pay the utrao* t attention to those morbid effects in the con., slitution, and in the eye in particular,, which appear to have no connexion with the causes of amaurosis, and merely exist as ' accidental cotemporary defects. ' If no particular circumstances can be ' assigned as the cause of amaurosis, the ' surgeon has no alternative but the adoption ' of some empirical method of treatment; i but, exclaims professor Beer, wo to the i patient whose surgeon, under these circum- i stances, draws from a heap of what are | considered remedies for amaurosis, as from a lottery, the first as the best! In order to avoid this erroneous method; ' at all events, to do no harm, if no good be practicable, and not perhaps to render a ' half-blind person completely blind, instead ' of improving, or at least preserving, what- { ever remnant of vision there may be ; the i surgeon should act with great caution, and i constantly bear in his mind, first, the con- i stitution, sex, and age of the patientjrie- | condly, his ordinary employments, and , general mode of living ; and, thirdly, the principal morbid appearances under which the amaurosis originated and was deve- ' loped. (Beer, Lehre von den Augenkr.fi>. 2. p. 462.) But, what will be of the greatest assistance, is a correct acquaintance with ' the remedies for amaurosis in general, and ' the circumstances under which the use of i this or that particular means is likely to be« i useful or detrimental. I know of no writer who has been so minute on this part of the subject as professor Beer, whose sentiments (be it also remarked) are here in many re- spects different from those of Richter and Scarpa; for, like the surgeons of this me- ' tropoliB, he rarely employs the emetic plan ' of treatment, which, according to-his prin- ' whJSJL* "♦I* °"y ^effectual,^bathurtful, ' dtrZ 7he b'indness is attended with > eves^'Sr of b,0<>« to the head and . or wK ; &' T accel"ated circulation, i dTatheS VertonHin by) * ^t ' employments emi • °nS' resPecting the , for the ".^5 emet,cs>. end other n?eans Where amaurosis is to be fundamentally cured, not upon empirical, but scientific . principles, all the causes of the disorder lunity. (See OnttaS at afuture oppor- must be ascertained, and, if possible re- time, I shall PnH».. -f.™1a') Jn t,le mean moved, as in the treatment ©f every other complaint. How often, however, it is im- ">ssible to arromnlish the on^ or other of t-e,IsWe7dTavrrTo)offe'ra iiccount of the nnntV.- a Sen« AMAUROSIS. 39 the second of these valuable writers, and already detailed in the foregoing pages ; for I need not repeat that, whenever the method of cure can be directed against the causes of the disease, it is the most proper and scientific. The present article will, then, close with a description of the four forms into which Professor Beer divides amaurosis, and a history of their varieties, symptoms, and treatment, according to the doctrines and experience of this eminent oculist. In that species of amaurosis, which arises from the first class of causes specified by Richter, namely, from those which seem to induce the disease, by means of a preterna- tural fulness and dilatation of the blood- vessels of the brain, or eye, the indication is evidently to lessen the quantity of blood, and diminish the determination of it to the head. For this purpose, tbe patient may be bled in the arm, temporal artery, or foot. This evacuation is to be repeated as often as seems necessary; and it will be better to begin with taking away from twelve to sixteen ounces. We are also advised by Schmucker to apply ten or twelve leeches to the neck and temples. The efficacy of bleeding, in the cure of particular cases of gutta serena, is strikingly exemplified by numerous well authenti- cated observations. Richter informs us of a woman, who, on leaving off having chil- dren, lost her sight-, but recovered it again by being only once bled in the foot. A spontaneous hemorrhage from the nose also cured a young woman, who had been blind for several weeks. (Anfangsgr. der Wundarzn. b. 3. p. 442.) General bleeding sometimes proves inef- fectual, unless assisted by topical. Leeches may be applied to the temples, or cupping glasses to the back part of the neck. When the disorder is connected with chlorosis, or the cessation of bleeding from piles, leeches may be put on the perineum, the inside of th«4high, or the sacrum. Local bleeding, however, seldom avails, except the whole mass of blood has been previously dimi- nished by the prudent employment of tbe lancet. Besides bleeding, the surgeon may advantageously have recourse to other means at the same time; as, for instance, emollient clysters, purgatives, blisters, bathiug the feet in warm water, &c. In some cases all the foregoing means fail in producing the desired benefit, even when they have been followed up, as far as the state of the pulse and strength of the constitution will allow. Here the continu- ance of the disease may depend, either upon the stoppnge of some wonted evacu- ation of blood, or else upon some other cause of the first class. In the first of these cases (says Richter,) experience proves, that the disease will sometimes not give way before the accustomed discharge is re- established, on which the malady depends, notwithstanding evacuants may be em- ployed in any way. whatsoever. A woman, '* lio (as this author acquaints us) had lost her sight, in consequence of a sudden sup- pression of the menses, did not recover it again till three months after the return of the menstrual discharge, notwithstanding every sort of evacuation was tried. He also tells us of another woman, who had been blind half a year, and did not men- struate, and to whose external parts of ge- neration leeches were several times applied. As often as the leeches were put on (says Richter,) the menses in part recommenced; and, as long as they made their appearance, which was seldom above two hours, the woman always enjoyed a degree of vi- sion. (Anfangsgr. der Wundarzn. b. 3. p. 443.) For the amaurosis, arising from suppres- sion of the menses, Scarpa recommends leeches to the labia pudendi, bathing the feet in warm water, and afterwards exhi- biting an emetic, and the resolvent pills, of which I shall presently speak. If these means fail in establishing the menstrual discharge, he says, great confidence may be placed in a stream of electricity, con- ducted from the loins across the pelvis, in every direction, and thence repeatedly to the thighs and feet. He enjoins us not to despair at want of success at first, as the plan frequently succeeds, after a trial of several w'eeks. For the amaurosis, proceeding from the stoppage of an habitual copious bleeding from piles, Scarpa recommends the appli- cation of leeches and fomentations to the hemorrhoidal veins, then giving the patient an emetic, and afterwards the opening pills hereafter described. (Saggio di Osserva- zioni e d'esperienze suite principal! molattie degli occhi, cap. 19.) When the disease does not originate from the stoppage of any natural or habi- tual discharge of blood, and does not yield to the evacuating plan, Richter thinks, that the surgeon is justified in concluding, that the preternaturally dilated vessels have not regained their proper tone and diameter, and that he ought to employ topical corro- borant remedies, particularly cold water. In this kind of case, Richter is an advocate for washing and bathing the whole head with cold water, especially the part about the eyes: a method, be says, which may often be practised after evacuations, with singular and remarkable efficacy. When the return of sight cannot be brought about in this manner, Richter ad- vises us to try such means, as seem calcula- ted to stimulate the nerves, and remove the torpid affection of the optic nerves in particu- lar. Of these last remedies, says he, emetics are the principal and most effectual. Soldiers, who lose their sight in performing forced marches, in hot weather, very commonly have it re-established again, by being im- mediately bled, and taking an emetic the next day. (See Schmucker's Chir. Wahrneh- mungen 1. Thtil.) We come now to the consideration of that species of the gutta serena, which is re- garded ns-the effect of some unuatural fcri- du. AMAUROSIS. tatiou. Here, according to the precepts delivered by Richter, we should endeavour to discover what the particular irritation is, and then endeavour to effect its removal. When it cannot be exactly detected, we are recommended generally to em- ploy such remedies, as will lessen the sensibility of the nerves, and render them less apt to be affected by any kind of irri- tation. Sometimes the irritation is both discover- able and removeable, and still the effect, that is to say, the blindness, continues. In this circumstance, Richter thinks, that the surgeon should endeavour to obviate the impression, which the irritation has left up- on the nerves, by the use of anodynes; or else, try to remove the torpor of the nerves by stimulants. But, according to Schmucker, Richter, and Scarpa, the curable imperfect amauro- sis commonly depends on some disease, or irritation, existing in the gastric system, oc- casionally complicated with general ner- vous debility, in which the eyes participate. Hence, in the majority of cases, we are as- sured, that the chief indications are, to free the alimentary canal from all irritating mat- ter, improve the state of the chylopoietic viscera, and invigorate the nervous system in general, aud the nerves of the eye in par- ticular. For an adult, dissolve three grains of an- timonium tartarizatum in four ounces of water, and give a spoonful of this solution, every half hour, until nausea and copious vomiting are produced. The next day some opening powders are to be exhibited, consisting of an ounce of the supertartrate of potash, and one grain of antimonium tar- tarizatum, divided into six equal parts. The patient must take one of these in the morn- ing, another four hours afterwards, and a third in the evening, for eight or ten days in succession. They will create a little nausea, a few more evacuations from the bowels than usual, and, perhaps, in the course of a few days, vomiting. If the pa- tient, during their use, should make vain efforts to vomit, complain of bitterness in his mouth,loss of appetite,and no renovation of sight, the emetic, as at first directed, is to be prescribed again. This is to be repeated a third and fourth time, should the morbid state of the gastric system, the bitter taste in the mouth, the tension of the hypochondria, the acid eructations, and the inclination to vomit, make it necessary. The first emetic often produces only an evacuation of an aqueous fluid, blended with a little mucus; but, if it be repeated, a few days after the resolvent powders have been administered, it then occasions a discharge of a considera- ble quantity of a yellow, greenish matter, to the infinite relief of the stomach, head, and eyes. The stomach having been thus emptied, Schmucker^-or Richter's resolvent pills are to be ordered. These are comnosed as follows : R Gum. Sagapeu. Galbar Sagapeu. J in. >' Venet. ) Sap. Venet. Rhei optim. 3'ss _ Tart. Emet. gr. xvi. Sue. liquerit 3j «ant PllulaB Sran' (lu,n- Three of these pills to be taken every morning and evening for a month, or six weeks. R Gum. Ammoniac. Ass. foetid. Sap. Venet. > an. ^ij Rad. Valer. s. p. Summit. Arnicae. Tart. Emet. gr. xviij. fiant pilulae gran, quinque. Six to be taken thrice a day for several weeks. The pills are here directed, to be made larger, than Schmucker and Richter order, so that the number in one dose may be di- minished; for, to prescribe 15 pills, three times a day, might seem absurd to the ge- nerality of patients in this country. When the above plan has rectified the state of the stomach, and partly effected the restoration of sight, such remedies must be employed, as strengthen the digestive organs, and excite the vigour of the ner- vous system in general, and of the rTerves of the eye in particular. A powder is to be prescribed, composed of an ounce of bark, and half an ounce of valerian, divided into six equal parts, one of which is to be taken in tbe morning, and another in the evening, in any convenient vehicle, for, at least, five or six weeks. During this time, the pa- tient's nourishment must consist of tender succulent meat, and wholesome broths, with a moderate quantity of wine, and pro- per exercise in a salubrious air. For exci- ting the action of the nerves of the eye, the vapour of liquor ammonia;, properly direct- ed against the eye, is of the greatest ser- vice. This remedy is applied by holding a small vessel, containing it, sufficiently near the eye to make this organ feel a smarting, occasioned by the very penetrating vapours, with which it is enveloped, and which cause a copious secretion of tears, and a redness, in less than half an hour after the beginning^ of the application. It is now proper to'^ stop, and repeat the application three^er' four hours afterwards. The plan must jfe thus followed up till the incomplete amiu- rosis is quite cured. The ammoniacal va- pours should be used as soon as the stomach has been freed from all irritating matter, and they should not be discontinued, till long after the eye has been cured. • 7^eLoperatlon of thesfe vapours may be aided by other external stimulants, applied to such other parts of the body as have a greatdealff sympathy with the eyes. Of MrnZ arrbJ,sters »the nape of the neck; friction on he eyebrow with the anodyne, liquor; the irritation of the nerves of the nostrils by sternutative powders, lji e «,.„.' composed of two grain* of turbith nlinerair nnd a scruple of powdered betonyTaves- AJSIAfcROSlS-. 41 and, lastly, a stream of electricity. For some additional observations on the effect of electricity in cases of amaurosis, see Gutta Serena. Bark, which is efficacious in intermittent fevers, and other periodical diseases, far from curing the periodical amaurosis, seems to exasperate it, rendering its return more frequent, and of longer duration. On the other hand, this disease is most commonly cured, in a very short time, by exhibiting first emetics, then opening pills containing antimonium tartarizatum, and gummy sapo- naceous substances, aud lastly, corrobo- rants, and even bark, which was before use- less and hurtful. Such is the statement of Professor Scarpa, which agrees with the sentiments already cited from Richter, respecting the effect of bark in periodical amaurosis. As if, how- ever, practitioners were doomed always to differ, and learners to bepuzzled, Beer tells us, that he has seen only two cases of peri- odical intermittent amaurosis, both of which were soon perfectly cured by large doses of bark. Other periodical amaurotic affec- tions be has seen, however, attendant on intermittent fever, but they spontaneously subsided with the febrile paroxysms, with- out any particular treatment being applied to the eyes. Sometimes, when the parox- ysms recurred frequently, a considerable weakness of sight remained after them; but, this always went off of itself, except in a single instance, in which the functions of the eyes were perfectly re-established by the exhibition of arniea, joined with bitters. (See Beer's Lehre von der Augenkr. B. 2, p. 585.) In the two cases, which were unaccom- panied with fever, the vitreous humour had the appearance of being turbid during the attacks, but regained its natural clearness on each return of vision, the loss of which used to be complete. Here we see ano- ther instance, in which a cloudiness behind the pupil in amaurosis did not impede the cure, and went away in the most ready manner. Possibly, the opacity, which iu speaking of the prognosis, I said that Lan- genbeck had not found to prevent the cure of certain cases, might also have had its seat in the vitreous humour, and not de- pended upon disease of the retina. Scarpa finds, that the above plan of curing the recent imperfect amaurosis succeeds iu the majority of cases, where the disease is only sympathetic, or dependent en the mor- bid state of the gastric system. But, there are cases, iu the/ormation of which many other causes operate, besides the most fre- quent one already, stated. These demand the employment of particular curative means, in addition to those which have been already described. Such is, for example, the imperfect amaurosis,, which occurs sud- denly, in consequence of the body being excessively heated, or exposure to the sun, or violent anger, in plethoric subjects. This case requires, in particular, general and to- ■>ical evacuation^ ofolaod- and the appH- '■Vor. I 6 cation of cold washes to tbe eyes aud whole head. An emetic should next be given, and afterwards a purge of potassae tartras, or small repeated doses of antimonium tartari- zatum. Schmucker relates, that by means of bleeding and an emetic, he has often re- stored the eyesight of soldiers, who had lost it in making forced marches, with very heavy burdens. Iu amaurosis, suddenly occasioned by violent anger, an emetic is the more strongly indicated after bleeding, as the blindness, thus arising, is always at- tended with a bitter taste in the mouth, ten- sion of the hypochondria, and continual nausea. Richter gives an account of a clergyman, who became completely blind, after being in a furious passion, and whose eyesight was restored the very next day, by means of an emetic, which was given with a view of relieving some obvious marks of bilious disorder in the stomach. Scarpa's treatment of the imperfect amaurosis brought on by fevers, deep sor- row, great loss of blood, intense study, and forced exertions of the eyes on very minute or brilliant objects, consists also in remov- ing all irritation from the stomach, and af- terwards strengthening the nervous system in general, and the nerves of the eye in particular. In the case originating from fevers, the emetic and opening pills are to be given ; then bark, steel medicines, and bitters; while the vapours of the liquor am- monia? are applied to the eye itself. When the disorder has been brought on by grief, or fright, the stomach and intes- tines are to be emptied by means of anti- monium tartarizatum, and the opening pills; and the cure is to be completed by giving bark and valerian; applying the vapour of liquor ammonia to the eyes ; ordering nou- rishing/easily digestible food; diverting the patient's mind, and fixing it on agreeable objects, and recommending moderate exer- cise. The amaurosis from fright is said to require a longer perseverance in such treat- ment, than the case from sorrow. (Scarpa's Osservas. Cap. 19.) The third species of gutta serena, or that which arises from debilitating causes, is of two kinds; in one, the disease is the conse- quence of a general weakness of the body; in the other, it is the effect of debility, which is confined to the eye itself, and does not exteud to the whole constitution. According to Scarpa, the incomplete amaurosis from general nervous debility, copious hemorrhage, convulsions ab inani- iione, and long continued intense study, especially by candlelight, is less a ease of real amaurosis, than a weakness of sight from a fatigued state of the nerves, espe- cially of those constituting the immediate or- gan of sight. When this complaint is recent in a young subject, it may be cured, or di- minished by emptying the alimentary canal with small repeated doses of rhubarb, and then giving tonic cordial remedies. At the same time, the patient must abstain from every thing that has a tendency to weaken the nervous system, and, consequently, the- 42- UIAUROSIs eyesight. Aticr emptying the stomach and bowels, it is proper to prescribe the de- coction of bark with valerian, or the infu- sion of quassia with the addition of a few drops of sulphuric ether to each dose, with nourishing, easily digestible food. The aromatic spirituous vapours (mentioned in the article Ophiholmy) may then be topi- tally applied ; or if these prove ineffectual, the vapour of liquor ammoniac. The pa- tient must take exercise on foot, horseback, or in a carriage, in a wholesome, dry air, in warm weather, and avail himself of sea- bathing. He must avoid all thoughts of care, and refrain from fixing his eyes on minute shining objects. In proportion as the energy of the nervous system returns, and the constitution is strengthened, the sight is restored. In order to preserve and improve this useful sense, the patient must adopt, above all things, every measure cal- culated to maintain the tone of the stomach, and moderate the impression of light on the retina. This object can easily be fulfilled by always wearing flat green glasses before the eyes, in a vivid light. (Saggio di Osser- vaz. Cap. 19.) When the weakness is confined to the eye only, Richter thinks the topical em- ployment of corroborant applications alone necessary. Bathing the eye with cold wa- ter, says he, is one of the most powerful means of strengthening the eye. The pa- tient should dip in cold water a compress, doubled into eight folds, and sufficiently large to cover the whole face and forehead, and this he should keep applied, as long as it continues cold. Or, else, he should fre- quently apply cold water to bis eyes and face with his hand, on a piece of rag. The eye may also be strengthened by re- peatedly applying blisters of a semi-lunar shape above the eyebrows, just long enough to excite redness. Richter likewise speaks favourably of rubbing the upper eyelid, several times a day, with a mixture of the tinctura lyttae and spiritus serpilli, great care being taken, that none of the application come into contact with the eye itself. Spi- rituous and aromatic remedies in general, are also proper. (Anfangsgr der Wundarz B. 3, p. 452.) When no probable cause whatsoever can be assigned for the disease, the surgeon is justified in employing such remedies, as have been proved by experience to be sometimes capable of relieving the affection, although upon what principle is utterly unknown. The chief means of this kind are emetics given in small doses, so as to excite nausea' and occasionally in larger ones, in order to produce vomiting; Schmucker's pills, the composition of which has been already de- scribed, sometimes assisted with the exhibi- tion of arnica and valerian; preparations of mercury either alone, or in conjunction with sarsaparilla, cicuta, or sulphur auratum antimonii; valerian in powder, either alone or joined with decoction of bark, containing either subcarbonate of ammonia, or sul- phuric ether; Pulsatilla, in the form of an extract or au infu^on ; tbe exiractum iiyos. cyami albi, with or without antimonial wine, and various other medicines and ap- plications, which will be considered under the head Gutta Serena. To this article, I would refer the reader, before he makes up his mind about any empirical method of treatment, because he will there find many cautions and instructions given by Beer re- specting the remedies for amaurosis in gene- ral. To bis remarks, I have also annexed such others on the same topic, as appeared to me interesting. In the following view of amaurosis, chiefly taken from the valuable writings of Prof. Beer, the reader will find a more complete history of the different forms of the disease, and their varieties, than has previously been drawn up in our language. The only points, on which Beer perhaps ventures too far, are those relating to the etiology of the several cases; a subject, in which he dis- plays the usual credulity of the continental surgeons. With his observations, I have taken the liberty to blend a few additional remarks, not caring about the length of the article, where the matter seemed new and interesting. 1. OF THE DIFFERENT FORMS OF AMAUROSIS IN GENERAL. Beer reckons four species of amaurosis. The first is a genuine uncomplicated amaurosis, the characteristic symptom of which consists peculiarly and entirely in an impairment or loss of vision, without any morbid change in the organic matter of the eye. Secondly; there is an amaurosis, which, besides being attended with a diminutio%or total loss of vision, is also accompanied with appearances of disease in the organic matter of the eye. Thirdly ; there is another amaurosis, in which, together with the above principal symptom, viz. weakness, or loss of sight, there are also morbid phenomena exhibited in the form of the eye in general, or its particular textures, and especially in, the action of the irritable parts. Lastly ; Beer says, he can often point out • an amaurosis, in which all the characteri*-* tic symptoms of the three preceding cases are more or less combined. (See Lehre von den Augenkr. B. 2, p. 478.) Professor Beer's First Species of Amaurosis. The genuine uncomplicated amaurosis, consisting of a mere diajbution or loss of sight, without the appearance of an* other defect, is one of the most uncommon forms rating Dt' notron,y because singly ope- £*S SSi"*£W' Jut*«w> tUycan n?rvL ^ dlfeCt,y UP°n the V'C In the true uncomplicated amanrnsfoJ merely the vital qualities of the oSc^SW and retma are affected, and after StMH AMAUROSIS 43 thing preternatural can be traced in those parts, either within or on the outside of the eyeball. It is in short, the case, in which the functions of the retina have become im- perfect, or destroyed, the eye appearing in other respects sound. According to Beer, this simple unmixed form of amaurosis is subdivisible into that amaurotic weakness of sight, or blindness, which depends upon the vitality, or rather sensibility of the optic nerve and retina be- ing too highly raised, and into another case, the proximate cause of which is peculiarly and entirely referable to depression of such vitality or sensibility. The first example is much less common than the second. The general symptoms of the simple un- complicated species of amaurosis, putting out of consideration the morbid increase, or diminution of the sensibility of the optic nerve, are thus described by Professor Beer. In the first place, all morbid appearances are absent, which might be produced in the amaurotic eye by any one preternatural change in the texture, form, or state of that organ. Hence we are obliged to trust al- most exclusively to the patient's assertion, that his sight is bad, or quite gone; and not ■infrequently, it is necessary, especially in judicial cases, to employ political artifices, in order to determine whether such asser- tion be true, particularly when the patient affirms that the blindness is restricted to one eye. Secondly; when tbe amaurosis is indeed nearly,or quite formed in oneeye, a slight degree of strabismus is at most per- ceptible, arising from the circumstance of the patient's not fixing the eye affected up- on any object. This degree of strabismus is noticed by Ackermann and Fischer, as the surest sign of amaurosis. (See Klinische Annalen von Jena \st. p. 144.) And it is par- ticularly pointed out by Richter, as an in- variable attendant upon amaurosis. The patient, says he, not only does not turn ei- ther eye towards any object, in such a man- ner, that the object looked at is in the axis of vision; but, he does not turn both his eyes towards the same thing. This was re- garded by Richter, as the only symptom, which we can trust, where implicit confi- dence should not be put in the mere assu- rance of the patient, that he cannot see, while all the coats and humours of the eyes present their natural appearance. (See An- fangsgr. der Wundarzn. B. 3. Kap. 14.) Pro- vided this observation be correct, it must be highly interesting to the military surgeon, amaurosis being a common affliction of sol- diers, many of whom, however, endeavour to avoid service by pretending to labour under a disqualification, which they well know does not necessarily produce any very considerable alteration in the natural appearance of the part affected. Thirdly ; while the disorder is only iu the stage of amblyopia, the patient always complains of continually multiplying muscae volitantes, or of the visus reticulatus, or nebulosus. Fourthly; luminous forms appear before the eyes: especially in the dark, even when the patient is entirely blind. Fifthly; the decrease of vision goes on to complete blindness, without any material interrup- tion, or retrogression. Sixthly; when only one eye is quite blind, and the eyesight on the other side is perfectly undisturbed, there is one infallible symptom of this amaurosis, namely, if the sound eye be very carefully covered, the pupil of the blind one immediately expands, and the iris becomes quite motionless, notwithstanding the diseased eye be exposed to the strongest light possible. However, this criterion is mostly wanting, because the amaurosis, which is attended with no appearance of defect, except loss of vision, is seldom confined to one eye, but usually affects both. (See Lehre von den Augenkr. B. 2. p. 481—82. I. Of the genuine uncomplicated Amaurosis; dependent upon what Beer terms preterna- turally high Vitality, or rather, as we. should say, a Morbid Increase of Sensibility of the Optic Nerve. This form ef amaurosis is described by Beer as having two stages: in the first, the patient never becomes blind; the eyesight being lost at the end of the second stage. This species of amaurosis always forms with great quickness, so that the limits between the two stages are frequently very indis- tinct. The first stage commences with a pecu- liar sensation of fulness in the eye-ball, conjoined with continually increasing, vio- lent, and annoying luminous appearances, and a remarkable weakness of sight. These symptoms are soon followed by a stupify- ing constantly increasing headach, during which the power of vision manifestly dimi- nishes, without the slightest defect being perceptible either in the eye itself, or its surrounding parts. The patient, however, is always marked by an athletic constitu- tion, or at all events, by such symptoms of general and local plethora, and of a phlo- gistic diathesis, as cannot be mistaken. Upon the advance of the disorder into its second stage, the headach becomes irregu- lar, being less violent at some periods than others; the patient feels as if there were before his eyes, a thick net, or gauze, which, in a bright light, appears quite black, but in the shade, fiery and shining. This net or gauze, when there is any temporary de- termination of blood to the head and eyes, as in straining at stool, is immediately rendered considerably more dense ; and when such determination of blood is often repeated, or long maintained, the density at length remains much greater than before, and con- sequently, the patient suddenly grows more blind, and is very quickly quite bereft of vision. This complete loss of sight, in the second stage, if efficient assistance be not given, is ultimately produced by the progress of the disease, even without any accidental determination of blood, though never quite suddenly. At last all power of discerning the light is abolished, under in- •14 AMAlTROSfS cessant slupifying beadachs, which are sometimes weaker, sometimes stronger, and are attended with a sensation, as if the dimensions of the eye were increased, and indeed, it really feels harder, than in the healthy state. All those circumstances, which produce a long and repeated determination of blood to the head and eyes, must be considered as the principal causes of this kind of amau- rosis. Beer especially adverts to the habit of sleeping at night with the head low, in individuals who retire early to rest, and with their arms extended above their head. Here also the observations are nearly all applicable, which have been already deli- vered respecting the effects of immoderate- ly exerting the eyesight and intellects, and concerning the too great irritation of the eye by the light in typhoid fevers. Nor, in the etiology of this species of amaurosis, should what has been stated about idiosyn- crasies be forgotten. (Lehre von den Au- genkr. p. 483—85.) While the first stage has not yet termina- ted, and consequently while the power of vision is not obliterated, if the patient can and will put himself without delay into the requisite condition for the cure, a favourable prognosis may invariably be given. But the prognosis is much less promising, when the second stage has already begun, or is threatening to begin, and consequently when the power of seeing is either com- pletely or nearly destroyed, notwithstand- ing the blindness may not be of more than two days' standing ; particularly, if the pa- tient cannot immediately have the best as- sistance. However, some slight hope of a re-establishment of sight may always be entertained, even though the amaurosis be complete, if it be not of long standing. But when the disorderhasexistedseveral months, it is hardly ever practicable to do more than restore a very partial degree of vision. When, in typhus fever, this amaurosis has been brought on altogether by the immode- rate irritation of the light, Beer has con- stantly found the case quite irremediable, the general debility, which often lasts so long after typhus, having no slight share in the prevention of a cure. The prognosis is most favourable, when the amaurosis de- pends upon some idiosyncrasy which is known, and can be at once removed ; and very discouraging is the prospect of relief when many different causes are concerned in the production of the complaint: while that true sympathetic amaurosis, which arises not merely from over exertion of the eye, but also from great and immoderate mental application, is very serious, both with respect to the fate of the eye itself and the life of the patient, amaurosis, under these circumstances, being not unfrequent- ly the forerunner of impairment of the in- tellects, or absolute mania. (Beer, vol cit p. 486.) * ' A.s in this species of amaurosis, a deter- mination of blood to the head and eyes is BeveT altogether abepnt, ajid has generally had a great share in the first production o| the complaint, it must be self-evident, that during the whole course of the disease, every thing should be rigorously avoided which can tend to bring on such determi- nation of blood, or disturbance of the cir- culation ; and, when these states already exiM, no pains must be spared to lessen and remove them. Hence, when general plethora prevails, venesection, especially in the foot, is the earliest indication ; and, if this be not effectual, and the local plethora in the head and eyes still continues, topical bleeding with leeches, fee. must be practis- ed. But, if no signs of universal plethora exist, and there be merely a determination of blood to the head and eyes, local bleed- ing will be sufficient. At the same timp, bathing the feet in lukewarm water, con- taining salt, or mustard, or applying sinap- isms of mustard to the calves, and using gentle opening clysters, aperient medicines, cooling drinks, and a strict vegetable diet, will very much contribute to lessen the determination of blood, and any existing impetuosity of the circulation. These an- tiphlogistic curative means must be aided by keeping the eyes in a natural, yet com. plete state of rest, and in particular by keeping the whole body quiet in the re- cumbent posture, with the irritation of what would otherwise be only an ordinary degree of light, constantly diminished. Nay, in typhoid patients, attacked with this form of amaurosis, the interception of the light by blinds and eyescreens, or a light fine linen bandage, will be of itself effectual to arrest the disorder at once, and prevent blindness, unless the first stage be already too far advanced. When the most carefnl adoption of the foregoing means is only followed by an imperfect and slow return of vision, the treatment is to be aided by cold bathing of the eye, in practising which care must be taken not to let the patient's head lean forwards. According to Beer, the sympathetic amaurosis, unaccompanied by any appearance of organic disease, and brought on by immoderate exertion of the brain, always demands, in its first stage, not only local, but general antiphlogistic treatment, even though no particular pletho- ra may be present. When the surgeon meets with this spe- eies of amaurosis in the second stage, local fluid stimulants, and tonic remedies, mint hrst be gradually employed. These are to be applied, partly by rubbing them upon the eyebrow, and partly in the fonn'of the vapour of ether directed immediately against tbe eye. An attempt must also be made to re- s ore the sensibility of the optic nerve, by ^hfac,ents>and> if these be unavailing by lels a^fanS aS °C^iion a shock of the ves- hat ltfZTV■ WJhe"' however, it is clear that iniments and vapours of ether are quite ineffectual, these local measSes mS be combined with suitable general meanl a light nutritious diet; an alio™,, if wine and ho-. i • i • .°wance of w.me an.u r'eftr; daily exercise in th» »»« air, part nearly in sunsbinv me*dow? P^ AMAUROSIS. 4b the patient be rather fatigued ; the slow as- cent of hilly places ; the exercise of pump- ing or sawing wood in winter; bathing in mineral steel waters, fac and the empirical use of antiparalytic and tonic remedies, among which latter, steel medicines are to be employed with the greatest circum- spection. (Beer, Lehre von den Augenkr. b. 2. p. 487—88.) 2. Of the genuine uncomplicated amau- rosis, which arises from (what Beer denomi- nates) preternatural depression of the vitality (sensibility) of the optic nerve. According to Beer, this amaurosis differs from the preceding, by its formation being scarcely ever quick, but usually very slow, and its not exhibiting any traces of those two very different stages, which are pecu- liar to the other case. It also invariably commences with tbe visus reticulatus, or nebulosus, without any alternation with a blinding glare of light; and the eyesight is sometimes considerably better, and some- times weaker, which always depends upon the accidental operation of internal or ex- ternal circumstances. Thus, it may be no- ticed, that, in these cases, immediately after a good repast, the enjoyment of excellent wine and liquor, after unexpected great joy, after the spirits have been raised by the pleasures of a convivial party, or direct- ly after a violent fit of anger, the sight un- dergoes great amendment. On the other hand, sudden fright, great anxiety, profound grief, loss of sleep, long fasting, fee. con- stantly produce an immediate aggravation of the blindness; and the difference be- tween these effects is, that the melioration of the eyesight never continues long, while the diminution of it not only remains, but gets worse and worse. It is not at all un- common for this species of amaurosis, to make its appearance as a nightblindness, because common artificial light is much too feeble to make due impression upon the di- minished sensibility of the optic nerve; and consequently these patients always show a partiality to a very strong light. To such weaksighted individuals, the flame of a candle, or the moon, appears as if cover- ed by a dense vail, with an expanded halo round it of various colours. There is no complaint made of pain in the head or eyes ; and no sensation of fulness or weight is experienced in the eyeball; much less are there any empirical symptoms of the disease in the structure and form of the eye, or in the action of its irritable textures ; but the amaurosis, especially when it has been long complete, is usually conjoined with a debi- litated habit. Every thing, says professor Beer, which tends to produce considerable constitu- tional weakness, either locally in the eyes, or both locally and constitutionally, must at least be regarded as a more or less obvi- ous cause of this amaurosis ; that is to say, when the case is a mere impairment or loss tit" «=i£ht without other morbid nppearnncps -. for, as we shall presently find, there are several kinds of amaurosis, which, though they depend upon direct local debility, or local and general debility together, do not by any means arise in the form of simple diminution or loss of sight, free from every appearance of complication and disease in the eye : here belong especially shocks af- fecting the optic nerve, the brain, or the whole nervous system, produced rather by moral than physical causes; for a simple physical shock of the nerves, especially when it falls directly upon the eye, com- monly produces at once a considerable di- minution of cohesion in the nervous texture, as is more or less evinced by the appear- ances of the eye in general, and by the action of its irritable parts in particular. Secondly must be reckoned every very con- siderable and long-continued loss of blood or other nutritious fluid. Thirdly, a long residence in a dark place, and the entire nonemployment of the eye. Fourthly, the debility of age, and dulness of the whole nervous system, particularly when the pa- tient's eyesight has been abused in his youth by immoderate exertion, and the eyes are of a dark colour. Fifthly, the present form of amaurosis sometimes comes on as an im- mediate consequence of typhus, especially when the fever has been attended with severe diarrhoea, and nasal hemorrhage, not of a critical, but of a mere symptomatic kind, hardly admitting of suppression; but, iu the latter case, the amaurotic blindness is rarely complete. Beer questions whether, in typhoid patients, the absorption of the fat in the orbit, and the extraordinary re- traction of the globe of the eye into that cavity, may not have a share in producing this amaurotic weakness of sight. (Lehre von den Augenkr. b. 2. p. 491,92.) With respect to the prognosis, this species of uncomplicated amaurosis, unattended with any defect in the structure of the eye, is generally much seldomer curable than the former, because the cause of the disorder usually consists of an assemblage of many concealed and difficultly discoverable cir- cumstances, and because it is rarely possi- ble to put the patient under all the condi- tions, which are essential to the cure, even when the causes of the disease are under- stood ; as for instance, when the disease has arisen from extreme indigence, or do- mestic trouble. Even when a cure is ef- fected, it is with the greatest difficulty, and not till after a considerable time. Hence, though circumstances may have a favoura- ble appearance, no promise should be made, and when the amaurosis is already com- plete and of long standing, great patience must be enjoined during the treatment. In very poor persons, and in hospitals, says Beer, this species of amaurosis may always be regarded as incurable, because, in such examples, the operation of the medi- cines indicated can never be properly se- conded by diet, nutritious food, mental en- couragement, and reqnisite exerrWe in art open pure air. 46 VAIAIROSIS At the commencement of the disorder, the depressed vitality (or rather sensibility) of the optic nerve should be raised, if pos- sible, by the gradual use of stimulating liniments, and the vapour of ether. The rest of the treatment, recommended by Beer, resembles that of the second stage of amaurosis from morbid sensibility of the optic nerve. His plan is also to try the use of weak remedies first, and then gradually those which have the most powerful opera- tion. (Beer, vol. cit. p. 493, 94.) Beer's Second Species of Amaurosis ; Cat-eye Amaurosis. This species of the disorder, of which Beer has yet met with but one form, rarely increases to complete blindness ; it occurs chiefly in very old persons, and it is perhaps this affection to which some oculists have given the unmeaning name of amblyopia senilis. Sometimes, however, this kina of amaurosis takes place in young persons and children; and one circumstance, that de- mands particular notice, in its nosology, is, that it always takes place either in thin dwindled, old, gray-headed subjects, nearly in the state of marasmus senilis, in whom consequently the exchange of organic matter is carried on but tardily, or else in young subjects, who are unhealthy, and dis- posed to consumption, hectical adults, ema- ciated children, and as a consequence, of severe injuries of the eye. While this amaurosis is not perfectly formed, the iris retains its mobility, and the pupil is neither pret the eye.) Hippocrates means by this word, in his Aph. 31. Sect. 3. the dimness of sight, to which old people are subject. Modern writers generally understand by amblyopia, incomplete amaurosis, or the weakness of sight attending certain stages and forms of this disorder. (See L'Encyclo- pedie Methodique; Partie Chirurgicale ; Art. Amblyopic) AMMONLE MUR1AS, AMMONIA, MU- RIATA, or Sal Ammoniac. Its chief use in surgery is as an external discutient applica- tion. (See Lotio Amman. Muriatx, cum Acelo.) Mr. Justamoud recommends the following application to milk-abscesses : r*; Ammonia? Muriatae ^j. Spiiitus Roris marini Jbj \li--«:e. Linen rags are to be wet with the AMPITATIU.V remedy, and kept continually applied to the part affected. There can be little doubt of the utility of this lotion in dispersing the induration- left after mammary abscesses ; b .t, while these cases are accompanied with much pain, tension, and inflammation, emollient fo- mentations and poultices are to be prefer- red. * AMPUTATION, (from amputalio.) This term signifies the operation of cutting off a limb, or other part of the body, as the breast, penis, &c. Such an operation frequently becomes in- dispensably proper, on the principle of sa- crificing a branch, as it were, for tbe sake of taking the only rational chance of suving the trunk itself. Indeed, the suggestion of this measure, in cases of mortification, where there is no chance of the parts re- covering, may be said to be derived from nature herself, w ho by a process, to w hich I shall advert in speaking of mortification, detaches the dead from the living parts; this separation is followed by cicatrization, and the patient recovers. The necessity for amputation has always existed, and ever will continue, as long as the destructive effects of injuries and dis- eases of the iimbs cannot be obviated in any other manner, As Graefe observes, there was once a period, (I should say, about forty years ago) when the operation was more frequently practised, than at present, and this fact is to be imputed less to the caprice of surgeons, than to the imperfec- tion of the means which used to be em- ployed for the relief of local diseases. For then aneurisms of the limbs, and some other cases, at present treated with success, were always deemed incurable without amputation. Boucher, Gervaise, Faure,and Bilguer inveighed against the frequent per- formance of amputation on the field of bat- tle ; yet their arguments must prove of lit- tle value, unless a path were at the same time traced, which would conduct us to the method of remedying the circumstances which form the necessity for the operation. When this condition is fulfilled, and more effectual modes of treatment are devised, as for instance, with respect to tbe gunshot wounds, specified by Bilguer, then the necessity for amputation in such cases would cease of itself. (Normen for die Ablusung grosserer Gliedmassen, p. 13, 4to. Berlin 1812.) As the author of another valuable mo- dern work has said, it is an excellent obser- vation, founded on the purest humanitv, and justified by the soundest professional principles, that to save one limb is infinitely more honourable to the surgeon, than to have performed numerous amputations, however successful; but it is a remark, notwithstand- ing its quaintness, fully as true, that it is much better for a man to " live with three limbs, than to die with four." (Henuen on Military Surgery, p. 251, Ed. 2.) To this saying should be added the reflec- tion, that some unfortunate beings, influ- enced by a relish for life, have been known to submit to the loss of all their legs and arms and yet recover. In the H6tel des I ivalides at Paris, mutilated objects are in recollection, who had lost their thighs ai.d arms, so that, unless assisted, they could not stir, and it was necessary to feed and wait upon them, like new-born infants, (Maraud Opusc. de Chir, p. 183, and Gratft Op. cit. p. 23.) The amputation of the large limbs wti anciently practised under many disadvan- tages. The best way of making the inci- sions was unknown; the ignorance of the old surgeons of the right method of stopping hemorrhage was the death of a large pro- portion of the patients, who had courage to submit to the operation ; the mode of heal- ing the wound by the first intention was not understood, or not duly appreciated; aud the instruments were as awkward and clum- sy, as the dressings were irritating and im- proper. Modern practitioners have materially simplified all the chief operations in surge- ry ; an object, which has been accomplish- ed not merely by letting anatomical science be the main guide of their proceedings; not simply by devising more judicious, and lea painful methods; not only by diminishing the number, and improving the construc- tion of instruments; but also in a very es- sential degree by abandoning the use of > multitude of external applications, most of which were useless or hurtful. The Greek, Roman, and Arabian practi- tioners amputated limbs with feelings of alarm, and, in general, with the most me- lancholy results; while modern surgeon! proceed to the operation completely fear- less, well knowing that it mostly proves successful: hence, as Graefe justly remarks, nothing can be more evident, than that the patient's safety must depend very much upon the kind of practice. (SeeJVormw fur die Abltisung grdsserer Gliedmassen t 1.) By practice, is here implied the mm in which the operation is performed, uie way in which the wound is dressed, and the w hole of the after-treatment. But, much improved as amputation has been, it cannot be dissembled, that it isas operation at once terrible to bear, dreadful to behold, and sometimes severe and fatal in the conseqences which it itself produces, while the patient, if saved, is left forever afterwards n a crippled mutilated state Hence, it is the surgeon's duty never to have recourse to so serious a proceeding, without a perfect and well-grounded con viction of its necessity. Amputation should be generally regarded as the last expedient to which a surgeon ought to resort; anei pedient justifiable, as a late writer says, only when the pait is either already gan- grenous, or the seat of so much injury, or d»ease, that the attempt to preserve it anj onger, would expose the patient's life « Med^Tp.t^' (Dict' ** M°» Mthough, says a dislingui,hed mo^ OlPUTATIOiY. 60 surgeon, this amounts lo a confession, that the cure of some local disorders is not with- in the limits of our art, yet, on the other hand, it furnishes a proof, that surgery may be the means of saving life under circum- stances, which, without its assistance, would infallibly have a fatal termination. The operation is adopted as the safest mea- sure ; the cause is removed for the preven- tion of consequences. (Graefe.Op.cit.p. 14.) Nothing can be more absurd, or more misapplied, than the censures sometimes passed upon amputation, because the body is mutilated by it, &.c. Although, as a mo- dern writer remarks, the objection proves the limitation of human knowledge and ability, it must be very unfair on this ac- count to throw blame on surgery, or the practitioner who thus saves the patient's life. For, without dwelling upon the fact, that a humane surgeon would never ampu- tate through a mere love of operating, and without urgent cause, one may simply ask, are all diseases in their nature curable ? Does not (he surgeon cure such as are cura- ble, without mutilation ? And are not cases, which were in the beginning remediable, often first brought to the surgeon, when from neglect they have become totally in- curable ? Is it not his duty then to employ the only means left for saving the patient ? And is not the preservation of a long and healthy life a compensation for the sacri- fice ? Would it not be just as reasonable to blame an architect, wrhen the irresistible force of lightning or a bomb destroys his building ? Indeed, is it not rather a greater honour to surgery, that, even when death has already taken possession,asit were, of apart, and is threatening inevitable destruction to the whole, a means is yet furnished, not only for saving the patient's life, but for bringing him into a state, in which he may recover his former good health ? (Brunnin- ghausen, Erfahrungen und Bemerkungeripber Die Amputation, p.11,12mo. Bamberg, 1818.) Though amputation is in every respect much better, than in former times, and its right performance is by no means difficult; I would not wish to be thought to say, that it is always or even usually done secundum artem, because long opportunities of obser- vation have convinced me of the contrary; and the reason of the knife being yet so badly handled in this part of surgery, may generally be imputed to carelessness, slo- venly habits, or, what is as bad, a want of ordinary dexterity. There are several egregious faults in the method of amputa- ting, which even many hospital surgeons in this metropolis are guilty of; but these we shall find, when we criticise them, are, for the most part, easily avoidable, without any particular share of skill being required. A greater difficulty is to ascertain with pre- cision the cases, which demand the opera- lion ; those in which it may be dispensed with; and the exact periods at which it should be practised. These are considera- tions requiring profound attention, and the brightest talei>r> The most exncrt opera- tor. T ' Q tor (as Mr. O'Halloran observes) may not always be the best surgeon. To do justice to the sick and ourselves, we must, in many cases, rather avoid than perform capital operations; and with respect to amputa- tion, if we consider the many cases, in which it has been unnecessarily undertaken, or done at unseasonable periods, it may be suspected, that this operation, upon the whole, may have done more mischief than good. At all events, it is not enough for a surgeon to know how to operate ; he must also know when to do it. (See O'Halloran on Gangrene and Sphacelus ; preface.) For such reasons, I shall first take a view of the circumstances, under which, the best surgeons deem amputation necessary: though it may be proper to observe, that, in each of the articles, relative to the par- ticular diseases and injuries, which ever call for the operation, additional information will be offered. 1. Compound fractures. In a compound fracture, the necessity for amputation is not altogether proportioned to the seriousness of the accident, but also frequently depends in part upon other cir- cumstances. For example, in the field and on board of a crowded ship, it is not con- stantly in the surgeon's power to pay such attention as the cases demand, nor to pro- cure for the patient the proper degree of rest and good accommodation. In the field, there is often a necessity for transporting the wounded from one place to another. Under these circumstances, it is proper to have immediate recourse to amputation, in numerous cases of bad compound fractures, some of which, perhaps, might not abso- lutely demand the operation, were the pa- tients so situated, as to be capable of recei- ving all the advantages of the best and most scientific treatment in a well-ventilated quiet house, or hospital, furnished with every desirable convenience. At the same time, daily experience proves, that there are many other cases, in which it would be improper to have recourse to the knife, even under the most unfavourable circumstances of the above description. So, when a compound fracture occurs, in which the soft parts have not been considerably injured; in which the bones have been broken in such a direction that they can be easily set and kept in their proper position, or in which there is only one bone broken, amputation would be unnecessary and cruel, But, when the soft parts have been more extensively hurt, and the bones have been so badly broken, that perfect quietude and incessant care are required to afford any chance of recovery, it is a good general rule to amputate whenever these advan- tages cannot be obtained. The bad air in crowded hospitals and Iarge'cities, a circumstance so detrimental to wounds in general, is another consideration which may seriously lessen the chances of saving a badly broken limb, and should bo remembered in weighing the reasons for and against ampliation. •ft \MPb'TAilo\ On this part of tl e subject, I find the sentiments of Graefe interesting: besides an absolute, says he, there is a relative, necessity for amputation: it is'the most mournful, and proceeds altogether from un- favourable external circumstnnces, though, alas! in many cases nearly unavoidable, when life is to be preserved. In war, every bloody action furnishes proof of what has been stated. The number of the wounded is immense ; the number of surgeons for the duty too limited. The supplies most needed are at a distance. In these emer- gencies, though the military surgeon may from routine and genius be able to suggest the quickest method of obtaining what is wanted, know how to avail himself of every advantage, which circumstances per- mit, and to contrive tolerable substitutes for such things as are deficient, yet, this will not always do. Were we (says Graefe) here to complain of the Prussian government not providing din assistance for the defend- ers of our native soil, to many the remon- strance would only appear reasonable. Yet, they who manage the medical affairs of the Prussian army may not constantly have it in their power to avert the inconve- nience. The general cannot foretel the number and nature of the wounds, which may happen, so as to enable tbe medical department to take with them exactly the apparatus required, without encumbering the army w ith a redundance of useless arti- cles. The enemy, perhaps, captures the me- dical stores ; or the rapid movements of particular corps cut us off from the princi- pal depots. Detachments often skirmish at remote points. The hospitals may lie seve- ral miles in the rear of the line ; and, for want of means, the transport of the imper- fectly dressed wounded may continue night and day. Hardly are the sufferers brought into the nearest hospital, in the most pitiful state from pain, anxiety, and cold, when an order is given to break up, and they must be conveyed still further towards their grave ; and a thousand other circumstances, as Graefe observes, which deprive the wounded of the requisite attendance, and essential number of surgeons, together with the most necessary stores, make it desirable to simplify every wound as much as possi- ble ; which, indeed, is the only means of shunning the reproach, that while we are endeavouring to save one man's limb, we let another die. Who doubts, says Graefe, that a soldier with a gunshot wound, complicated with a smashed state of the bones, may sometimes be saved, without loss of his limb, by em- ploying all the means, which the resources of Mirgery offer ? But these very resources are often wanting in a campaign ; and the business of dressing the patient would oc- cupy the surgeon several hours daily, du- ring which his useful assistance could not be extended to other sufferers, Notwith- standing the utmost care, tbe removal of patients from one place to another frequent- ly makes their wounds extremely danger- ous, or fatal; and we now lose many a man, who, had he undergone amputation, would have been able to bear the journey. (See Normen far die Abltisung grosserer Glh edmassen, p. 15, 16.) From what I have seen of the ill effects of moving patients with bad compound fractures of the lower extremity, produced bv «unshot Violence, I am convinced, that, asa^general rule, it is better to perform ana- putation ; but, if this be not done, and an attempt is to be made to save the member, it will be more humane, when the army is retreating, and the enemy are not savages, to leave such wounded behind, than sub- ject them to all the fatal mischief of hastily and roughly transporting them in such a condition. It gives me particular pleasure to find the preceding sentiment confirmed by Dr. Hennen, whose knowledge and ex- perience in military surgery entitle all his opinions to the greatest attention : in noti- cing what ought to be done with the wounded, when the army is compelled to retreat, he says, " it then becomes the duty of a certain proportion of the hospital staff to devote themselvesfor their wounded,and become prisoners of war along with them; and it may be an encouragement to the in- experienced, while it is grateful to me, to observe, that I have never witnessed, nor traced, on inquiry, an act of unnecessary severity practised either by the French or English armies on their wounded prison" ers." Compound fractures of the thigh, produ- ced by gunshot violence, too often have an unfavourable termination, especially when the accident has been caused by grape shot, or even a musket-ball, fired from a mode* rate distance,and the patient is moved from one place to another after the receipt of the injury. In the military hospital at Ouden- bosch, in the spring of 1814, I had charge of about eight bad compound fractures of the thigh, of which cases only one escaped a fatal termination. This was an instance, in which the femur was broken a little way above the knee. Another patient was ex- tricated by amputation from the perils, im- mediately arising from the splintered dis- placed state of the bone, tbe serious injury of the muscles, and enormous abscesses, but was unfortunately lost by secondary he- morrhage. All these patients had not merely been struck by grape-shot, or else by balls fired from a short distance, but they had been moved from Bergen-op- Zoom into my hospital, five or six days. after the receipt of the injury, the very worst period possible, on account of the inflammation being then most violent. From the ill success of these cases, many a surgeon, who saw them, might be inclined to think, that immediate amputation ought generally to be performed for all compound fractures of the thigh, as soon after the- re- ceipt of the injury as possible. And such is my own sentiment, whenever the acci- dent has been earned in the violent man* AMPUTATION. »>7 uev above specified, or whenever the pa- tient must be moved any distance in a wa- gon after the occurrence of the injury. It may be right to state, however, that I have known more than one compound fracture of the thigh cured, where the accident had not been occasioned by gunshot violence, and I have been informed of one or two successful cases, where the bone was bro- ken by a pistol-ball. However, these may only have been lucky escapes, deviations from what is common, and not entitled to any stress with the view of affecting the general excellent rule of amputating, where the thigh-bone is broken by gunshot vio- lence. As Mr. Guthrie bas accurately observed, one circumstance, which increases the dan- ger of fractures of the femur, from gunshot violence, is, that the bone is very often broken obliquely, the fracture extend- ing far above and below the point immedi- ately struck by the ball. (On Gunshot Wounds, p. 189, 190.) This disposition of the thigh-bone to be splintered for several inches when hit by a ball, and the increased danger, arising from the occurrence, are also very particularly commented upon by the experienced Schmucker, who was sur- geon-general to the Prussian armies in the campaigns of Frederick the Great. (See his Vermisehte Chirurgische Schriften, B. 1. p. 39. 8t>o. Berlin, 1785.) In several of the cases which were under the care of Dr. Cole and myself in Holland, the bone was split longitudinally, to the exteut of seven or eight inches. According to Schmucker, all fractures of the middle or upper part of the femur, are attended with great danger. " But (says he) if the fracture be situated at the lowest part of tbe bone, the risk is considerably less, the muscles here not being so power- ful ; in such a case, therefore, amputation should not be performed, before every other means has been fairly tried ; and very fre- quently I have treated fractures of this kind with success, though the limb some- times continued stiff. But (says Schmuck- er) if the bone be completely fractured or splintered by a ball at its middle, or above that point, I never wait for the bad symp- toms to commence, but amputate ere they originate, and, when the operation has been done early enough, most of my pa- tients have been saved. However, when some days had transpired, and inflammation swelling, and fever had come on, I must candidly confess, that the issue was not always fortunate. Yet the operation should not, on this account, be dispensed with; for, if only a few can thus be saved out of ma- ny, some benefit is obtained, as, without this step, such few would also perish." (Vermisehte Chir. Schriften, B. 1. p. 42.) What I saw of compound fractures of the thigh, after the assault on Bergen-op-Zoom, we may remark, coincides with the results of Schmucker's ample experience; for the only two patients who got over the bad symptom* proceeding rlirectly from the fracture, were one whose remarwas bro- ken near the knee ; and another, whose limb I took off, on account of a fracture of the middle of the bone, accompanied with abscesses of surprising extent. The latter was a case, however, in which the limb ought to have been removed earlier. The following remarks by Mr. Guthrie, I consi- der judicious and correct. " The danger and difficulty of cure, at- tendant on fractures of the femar from gunshot wounds, depend much on the part of the bone injured ; and. in the conside- ration of these circumstances, it will be useful to divide it into five parts. Of these, the head and neck included iu tbe capsular ligament, may be considered the first; the body of the bone, which may be divided into three parts, and the spongy portion of the lower end of the bone exterior to the capsular ligament, forming the fifth part. Of these, the fractures of the first kind are, I believe, always ultimately fatal, although life may be prolonged for some time. The upper third of the body of the bone, if bad- ly fractured, generally causes death at the end of six or eight weeks of acute suffering. I have seen few escape, and then not with a useful limb, that had been badly fractured in the middle part. Fractures of the lower or fifth division, are in the next degree dan- gerous, as they generally affect the joint; and the least dangerous are fractures of the lower third of the body of the bone. Of these even I do not mean to conceal, that when there is much shattered bone, the danger is great, so that a fractured thigh by gunshot, even without particular injury of the soft parts, is one of the most dangerous kinds of wounds that can occur." (See Guthrie on Gunshot Wounds, p. 190.) In compound fractures, as Mr. Pott has correctly pointed out, there are three points of time when amputation may be proper. The first of these is immediately, or as soon as possible after the receipt of the injury. The second is, when the bones continue for a great length of time without any disposi- tion to unite, and the discharge from the wound has been so long, and is so large,that the patient's strength fails, and general symptoms foreboding dissolution come on. The third is, when a mortification has taken such complete possession of the soft parts of the inferior portion of the limb, quite down to the bone, that upon the separation of such parts,, the bone or bones shall be left bare in the interspace. The first and second of these are matters of very serious consideration. The third hardly requires any. When a compound fracture is caused by the passage of a very heavy body over a limb; such, for instance, as the broad wheel of a wagon or loaded cart, or by the fall of a very ponderous body on it, or by a can- non shot, or by any other means so violent as to break the bones into many fragments, and so to tear, bruise, and wound the soft Starts, that there shall be good reason to ear, that there will not be vessels sufficien' VMPUTATION. to carry en the circulation with the parts below the fracture, it becomes, as Mr. Pott observes, a matter of the most serious con- sideration, whether an attempt to save such a limb will not occasion loss of life. This consideration must be before any degree of inflammation has seized the part, and there- fore must be immediately after the acci- dent. When inflammation, tension, and a disposition to gangrene in the limb have arisen, the period is highly disadvantageous for operating, and the patient's chances of being saved by amputation, under these cir- cumstances, are much smaller than before the changes here spoken of had taken place. At the same time, there are certain exam- ples of mortification from external causes, where, as far as one can judge from the re- sults of later experience than that of Mr. Pott, the surgeon should not defer amputa- tion, even though the disorder be yet in a spreading state, attended with considerable swelling and tension reaching far up the limb. This is a subject, however, which will require more explanation hereafter. (See what is presently said on Mortification.) Nor are the cases, to which reference is made, meant to affect the general truth of the observation, delivered by the most ex- perienced surgeons of every age, that when a limb is extensively swelled and inflamed, with a part of it either in a state of spread- ing mortification, orready to become gangre- nous, the period is so uufavourable for am- putation, that very few patients, so circum- stanced, ever recover after the operation. Nor is it meant to be insinuated, that in the very cases which form exceptions to the general rule of not amputating before the tendency to gangrene has ceased, the pa- tient might not have had an infinitely better chance of his life, had the operation been done immediately after the first receipt of the injury, before any disposition to gan- grene had bad time to be produced. The necessity of immediate or very early decision, in this case, makes this a very delicate part of practice; for, however pressing tbe case may seem to the surgeon, it will not, in general, appear in the same light to the patient, to the relations, or to bystanders. They will be inclined to re- gard the proposition as arising from igno- rance, or an inclination to save trouble, or a desire to operate ; and it will often re- quire more firmness on the part of the prac- titioner, and more resignation and confi- dence on the part of the patient, than is ge- nerally met with, to submit to such a severe operation, in such a seeming hurry, and upon so little apparent deliberation; and yet it often happens, that the suffering this point of time to pass, decides the patient's fate. This necessity of early decision arises from the quick tendency to mortification, which ensues in the injured limb, and too often ends in the patient's death. That this is no exaggeration, says Pott, melancholy and frequent experience evinces, even in those whose constitutions, previous to the accident, were in good order, but: rowtf more in those, who have been heatedly violent exercise or labour, or liquor, or who have lead very debauched and intemperate lives, or who have habits naturally inflam- mable and irritable. This is often the case when the fracture happens to the middle part of the bones, but is much more likely to happen when any of the large joints are concerned. In many of these cases, a de- termination for or against amputation, is re- ally a determination for or against the pa- tient's existence. That it would have been impossible to have saved some limbs, which have been cut off, no man will pretend to say; but this does not render the practice injudi- cious. Do not the majority of those who get into the above hazardous condition, and on whom amputation is not performed, perish in consequence of their wounds? Have not many lives been preserved by amputation, which, from the same circum- stances, would otherwise most probably have been lost ? Pressing and urgent as the state of a compound fracture may be, at this first point of time, still it will be a matter of choice, whether the limb shall be removed or not; but, at the second period, the ope- ration must be submitted to, or the patient must die. The most unpromising appearances at first, do not necessarily, or constantly end unfortunately. Sometimes, after the most threatening first symptoms, after considera- ble length of time, great discharges ot matter, and large exfoliations of bone, suc- cess shall ultimately be obtained, and the patient shall recover his health and the use of his limb. But sometimes, after the most judicious treatment through every stage of the dis- ease ; after the united efforts of physic and surgery, the sore, instead ofi granulating kindly, and contracting daily to a smaller size, shall remain as large as at first, with* tawny, spongy surface, discharging a large quantity of thin sanies, instead of a small one of good matter; the fractured ends of the bones, instead of tending to exfoliate, or to unite, will remain as perfectly loose and disunited as at first, while the patient shall lose his sleep, his appetite, and bis strength; a hectic fever, with a quick, small, hard pulse, profuse sweats, and col- liquative purging, contributing at the same time to bring him to the brink of the grave, notwithstanding every kind of assistance: in tnese circumstances, if amputation be not performed Mr. Pott asks, what else can res- tI P^'?ntfroin destruction ? whirl? } d and last Per»od is a matter Too oftr6^"0.1 r„equire much considerate on?he£? the '.nflammation consequent? aJda„nJUryl.mstead °f producing absce* mLSioTiT' tends to Serene, J so ranid Tf'^ Pr°5ress of which is often so rapid, as to destroy the patient in a verf tn J™* °-f ^e, constitutingnat v3 sort of c**e in whlch amp,,tn,f0n «h0S AMPUTATION. G9 .have been immediately performed. But sometimes even this dreadful malady is, by the help of art, put a stop to, but not until it has totally destroyed all the surrounding muscles, tendons, and membranes quite down to the bone, which, upon the separa- tion of the mortified parts, is left quite bare, and all circulation between the parts above and those below, is by this totally cut off. In this instance, whether the surgeon saw through the bare bone, or leave the separa- tion to be effected by nature, the patient must lose his limb. (See Pott's Remarks on the Necessity, <£»c of Amputation in certain Cases, fyc. Chir. Works,rol.3.) For the consideration of a variety of complicated cases, which affect the ques- tion of amputation in compound fractures, I must refer to the article Gunshot Wounds. 2. Extensive contused and lacerated wounds. These form the second class of general cases requiring amputation. Wounds with- out fracture are not often so bad as to re- quire this operation. When a limb, how- ever, is extensively contused and lacerated, and its principal blood-vessels are injured, so that there is no hope of a continuance of the circulation, the immediate removal of the member should be recommended, whether the bones be injured or not. Also, since no effort on the part of the surgeon can preserve a limb so injured, and such wounds are more likely to mortify than any others, the sooner the operation is under- taken the better. In these cases, as in those of compound fractures, though amputation may not al- ways be necessary at first, it may become so afterwards. The foregoing observations, relative to the second period of compound fractures, are equally applicable to badly lacerated vvouuds, unattended with injury of the bones* Sometimes a rapid mortifi- cation comes on ; or a profuse suppuration, which the system can no longer endure. (Encyclopidie Methodique ; Partie Chir.t. 1. p. 80.) 3. Cases in which part of a limb has been carried away by a cannon ball. When part of a limb has been torn off by a cannon ball, or any other cause, capable of producing a "Similar effect, the formation of a good and serviceable stump, the great- er facility of healing the clean, regular wound of amputation, and the benefit of a far more expeditious as well as of a sound- er cure, are the principal reasons which here make the operation adviseable. This was an instance, in which some for- mer surgeons disputed the necessity of am- putation. They urged as a reason for their opinion, that the limb being already re- moved, it is better to endeavour to cure the wound as speedily as possible, than in- crease the patient's sufferings and danger, by making him submit to amputation. It must be remembered, however, that the bones are generally shattered, and reduced into numerous fragments; the muscle^ and ten* dons are unequally divided, and their ends torn and contused. Now, none of the old surgeons questioned tbe absolute necessity of extracting the splinters of bone, and cut- ting away the irregular extremities of the tendons and muscles, which operations would require a longer time than amputa- tion itself. Besides, we should recollect, that, by making the incision above the in- jured part, so as to be enabled to cover the bone with flesh and integuments, perfectly free from injury, the extent of the wound is so diminished, that the healing can be ac- complished in one third of the time which would otherwise be requisite, and a much firmer cicatrix is also obtained. Such re- flections must convince us, that amputation here holds forth very great advantages. It cannot increase the patient's danger, and, as for the momentary augmentation of pain, which he suffers, he is amply compensated by all the benefits resulting from the opera- tion. See Gunshot Wounds. 4. Mortification. Mortification is another cause, which, when advanced to a certain degree, renders amputation indispensably proper. We have noticed, that bad compound fractures, and wounds, often terminate in the death of the injured limb. Such surgeons as have been determined, at all events, to oppose the per- formance of amputation, have pretended, that the operation is here totally useless. They assert, that when the mortification is only in a slight degree, it may be cured, and that when it has spread to a considera- ble extent, the patient will perish, whether amputation be performed or not. But this way of viewing things is so contrary to facts, and the experience of every impartial practitioner, that I shall make no attempt to refute the assertion. While it is allowed that it would be very bad practice, to ampu- tate on every slight appearance of gangrene, it is equally a fact, that when the disorder affects the substance of a member, the opera- tion is generally the safest and most advan- tageous measure. Nay, there are, as we shall presently see, certain forms of mortifica- tion, in which the early performance of amputation is the only chance of saving the patient. Practitioners have entertained very op- posite opinions, concerning the period when one should operate in cases of mortification. Some pretend, that whenever the disorder presents itself, and especially when it is the effect of external violence, we should am- putate immediately the mortification has decidedly begun to form, and while the mischief is in a spreading state. Others believe, that the operation should never be undertaken, before the progress of the dis- order has stopped, ev«»i not till the dead parts have begun to separate from the living ones. The advocates for the speedy perform- ance of amputation declare, that the further progress of the mortification may be stop- TJJ AMPLIATION ped, and the liic of tbe patient preserved, by cutting above the parts affected. How- ever, according to the reports of the greater number of eminent surgical writers, this practice is highly dangerous, and undeserv- ing of confidence. Whatever pains may be taken in the operation, only to divide sound parts, there is no certainty of suc- ceeding iu this object, and the most skilful practitioner may be deceived. The skin may appear to be perfectly sound and free from inflammation, while the muscles w Inch it covers, and the parts immediately sur- rounding tbe bone, may actually be in a gangrenous state. But even when the soft parts are found free from apparent dis- temper, on making the incision, still, if the operator should not have waited till the mortification has ceased to spread, the stump will almost always be attacked by gangrene. Surgeons, who have had op- portunities of frequently seeing wounds which have a tendency to mortify, enter- tain the latter opinion. Such was the sen- timent of Pott, who says, that he has often seen the experiment made, of amputating a limb in which gangrene had begun to show itself, but never saw it succeed, and it inva- riably hastened the patient's death. The operation may be postponed, how,- ever, too long. Mr. S. Sharp, in particular, recommended too much delay, advising the operation never to be done till the natural separation of the mortified parts had consi- derably advanced. Mr. Sharp was a sur- geon of immense experience ; and bis au- thority carries with it the greatest weight. But perhaps he was too zealous in his oppo sition to a practice, the peril of which he had so often beheld. When the mortifica- tion has ceased spreading, there is no occasion for further delay. We now ob- tain, just as certainly, all the benefits of the operation, and get rid of a mass of putridity, the exhalations from whieh poison the at- mosphere which the patient breathes, and are highly detrimental to his health. Nay, according to the reports of writers, patients in these circumstances may actually fall victims to the absorption of the putrid mat- ter which is suffered to remain too long. However, this danger would not be so con- siderable as that which would arise from too precipitate an operation ; and it is bet- ter to defer amputation a little more than is absolutely requisite, than run any risk of doing tbe operation before it is certain that the parts have lost their tendency to gangrene. In the article Mortification, we have no- ticed particular cases of gangrene, where, according to the experience of M. Larrey, the surgeon is not to wait for the line of separation being formed, but have recourse to tbe immediate performance of amputa- tion. The experience of Mr. Lawrence tends also to confirm the propriety of such practice. (See Medico-Chir. Trans, vol. 6, p. l&6,^c.) In an example, where a large part of the nrm was deeply affected with gangrene from external violence, and the disorder was yet making rapid progress, I once r* commended the performance ot amputt. tion at the shoulder joint. On the whole, this instance was favourable to the practice; for, though the patient died at the end of a fortnight, probably he would not have lived twenty-four hours, had the operation not been done ; nor was the stump attacked with mortification, a circumstance worthy of attention, because it is a danger pan} culariy insisted upon by the opponents of amputation, under the preceding circum- stances ; and, had it not been for a large abscess, which formed in the back, as was supposed, from a violent blow received in the fall, which produced the original injury, there were well-grounded hopes of reco- very. The patient, here spoken of, was attended by Dr Blicke. There is likewise a species of gangrew, which is pointed out by Mr. Guthrie, as re- quiring early amputation. " A soldier (sayi he) shall receive a flesh-wound from a musket ball in the middle of tbe thigh, which passed through the limb apparently, on a superficial inspection, without injuring the main artery ; or it shall pass close be- hind the femur, where the artery turns to the back part of the bone; or it may gi through the middle of the bone, from be- hind forwards, between the condyles of the femur into the knee joint; and the patient shall walk to the surgeon with little asaut- ance, be superficially dressed, and, in man; cases, considered slightly wounded; J4, the femoral artery, and vein of the whob of these cases, and, indeed, in many other!, shall be wounded, or cut across, and tbe local inflammation be so slight as to obtain little attention. On the third, or fourth day, the patient shows his toes discoloured, and complains of pain and coldness in the limb below the wound, the constitution be- gins to sympathize with the iajury, and the surgeon probably thinks the case extraoi* nary. Perhaps, he suspects the real state of thf injury; but is surprised that a wound of the femoral, or popliteal artery, with * little attendant injury, could cause mortifi- cation, Sic. He is anxious to do somethiMU but, mortification, or at least gangreaoHjht ving commenced, be must, accordingTF general rule, await the formation of theliu of separation. The temperature of the leg, a little above the gangrene, is good, pee haps higher than natural ; he hopes it wtl not extend farther, and it probably does re- main stationary for a little time. At last, ,nmPartSt.0rifinany affected, the toes, be- ^f/pha.Cue,a,ted> and g»»grene quieklj 2K?\!,ptte Leg as f" *» the wounded vZ'S? Wb'ch time tbe P^ent dies." disaster , ifUrp0fe of Preventing such • vSn Ja'v. KerC *5? arte^' or aW»< commends tbCen ivided> Mr. Guthrie n> AMPUTATION. 51 redness ot the part, has passed higher np, than the ankle. (See Guthrie on Gunshot Wounds, p. 60, 61. 6. White-swellings. Scrofulous joints, with diseased bones, and distempered ligaments, and cartilages, is another case, in which amputation may become absolutely necessary. As Mr.£ott remarks, there is one circumstance attend- ing this complaint, often rendering it parti culariy unpleasant, which is, that the sub- jects are most frequently young children, so as to be incapable of determining for themselves, which inflicts a very distress- ing task on their nearest relations. All the efforts of physic and surgery often prove absolutely ineffectual, not only to cure, but even to retard the disease in question. Notwithstanding many cases admit of cure, there are numerous others which do not so. The disease often begins in the very inmost recesses of the cellular texture of the heads of the bones, forming the large articula- tions, such as the hip, knee, ankle, and elbow; the bones become diseased in a manner, which we shall explain in the article (Joirds,) sometimes with great pain and symptomatic fever; sometimes with very little of either, at least in the begin- ning. The cartilages covering the ends of these bones, and designed for the mobility of tbe joints, are totally destroyed ; the epiphyses in young subjects are either par- tially or totally separated from the said bones; the ligaments of tbe joints are so thickened, and spoiled by the distemper, as to lose all natural appearance, and become quite unfit for all the purposes for which they were intended: the parts appointed for the secretion of the synovia, become dis- tempered in like manner; all these toge- ther furnish a large quantity of stinking sanious matter, which is discharged either through artificial openings made for the purpose, or through small ulcerated ones. These openings commonly lead to bones which are diseased through their whole tex- ture. When the disease has got into this jtate, the constant pain, irritation, and dis- charge, bring on hectic symptoms of the nost destructive kind, such as total loss of ippetite, rest, and strength, profuse night iweats, and as profuse purgings, which foil ill the efforts of medicine, and bring the latient to the brink of destruction. It is an incontestable truth, that, unless imputation be performed, a patient thus [ituated must perish ; and it is equally true, hat numbers, in the same circumstances, 'iy submitting to the operation, have reco- ^red vigorous health. (See Pott on Am- 'utation. • It is a fact, highly important to be known, *5at, in these cases, amputation is attended Vith more success when performed late iau when undertaken at an early period efore the disease has made great advances. his is particularly fortunate, as it affords 'me for giving a fair trial to such remedies H are best calculated to check the progress of the disorder, and obviate all necessity for the operation. (Encyclopedic Millvod- ique, Tom. 1, p. 88.) See Joints—White- swelling. 6. Exostoses. Here it will be sufficient merely to men- tion, that this disease may render amputa- tion necessary, when the tumour becomes hurtful to the health, or insupportable, on account of its weight, or other circum- stances, and cannot be removed by any of the plans specified in the article Exostoses. 7'. Necrosis. Another distemper, sometimes producing a necessity for amputation, is necrosis, or the death of the whole, or of a very consi- derable part of the bones of the extremities, accompanied with such extensive absdessesj such disease of the soft parts, such dis^ . order of the constitution, and prostration of strength, that every hope of a cure being effected by a natural process must be re- nounced. By necrosis-, is here meant, not merely some disease, which destroys theS surface of a bone, but one which extends its depredations to the whole of the internal substance, and that from end to end. Por- tions of the bones die from a variety of causes, such as struma, lues venerea', deep- seated abscesses, pressure, he.; and bones in this state, when properly treated, often exfoliate, and cast off their dead parts. But, when the whole substance of a bone becomes diseased, from end to end, fre- quently no means will avail. In the words of Mr. Pott, the use of the scalper, the ras- patory, and the rugine, for the removal of the diseased surface of bones; of the tre- phine, for perforating into the internal texture of the diseased bone, and of exfoli- ating applications, (if there be any such which merit the name,) will prove in many instances unavailing, and, unless the whole bone be removed by amputation, the patient will die. Mr. Pott's refutation of Bilguer, who asserts that amputation is not requisite in these instances; is a masterly and most convincing production ; but I would not ex- actly do as the former of these writers has done, and positively affirm, that every ex- tensive necrosis, affecting a bone, nearly its whole length, must inevitably require amputation. The power of nature in re- storing the bones is sometimes wonderful, as will be hereafter explained. (See JVe- crosis.) The very late period, at which an exten- sive necrosis may follow the injury of a bone, and make amputation necessary, is sometimes almost incredible. Schmucker details the case of a captain, who received a musket-ball through the left arm, four or five inches above the elbow. The bone was violently struck, but not broken ; se- veral exfoliations followed, and, after more than a year's treatment, the patient appear- ed perfectly cured. For nine years this officer remained well; but, at the end of? this time, being on a journey, he was a*> ja \MP11ATI0N. tacked wiiii pain aud inflammation in the wounded part, and febrile symptoms. He hastened to Berlin, and put himself under the care of Theden and Schmucker, who found an abscess in the situation of tbe for- mer wound, and, as an opening had been already made, the bone could be felt strip- ped of its periosteum. At length, a piece of bone exfoliated, and became loose, precise- ly under the brachial artery, which inter- fered with its removal. Notwithstanding the discharge, the elbow-joint continued swelled, and there were red points observ- able, not only above that joint, but also over the heads of the ulna and radius, indi- cating disease of those bones. Amputation was therefore performed by Theden, and the patient got quite well. On examining the os bracbii, a splinter was found three inches in length, and one in breadth, its edges being thin and sharp, while its centre was more than three lines thick. The bone, every where about the place, where it had been struck by the ball, seemed to consist of callus, without any medullary cavity, and the whole of it down to the elbow had no periosteum. The cartilage appeared also disposed to separate, and the periosteum was detached from the radius and ulna, which were likewise affected with necrosis. (See Schmucker's Vermisehte Chir. Schriften. B.l.p. 23. Ed.2.) 8. Cancerous and other inveterate diseases, such as fungus fuematodes. Cancerous, inveterate diseases, and ma- lignant incurable ulcers on the limbs, some- times render amputation a matter of neces- sity. In treating of cancer, we shall re- mark that little or no confidence can be placed either in internal or any kind of to- pical remedies, and that there is nothing, except the total separation of the part af- fected, upon which any rational hopes of cure can be built. Cancer is not frequently seen on tbe extremities. Every man of expe- rience, however, must occasionally have seen, in this situation, if not actually can- cer, diseases quite as intractable, and which cannot be cured, except by removing the affected part. This may often be accom- plished, without cutting off the whole limb. But, when the disease has spread beyond certain bounds, amputation, above tbe part affected, is the only thing to which re- course can be had with any hope of success. Sometimes when the operation has been delayed too long, even amputation itself will not effect a cure. In a few cases of fungus haematodes, the operation has suc- ceeded, however, when the disease had re- appeared after a cure had been seemingly achieved by the excision of the diseased parts. Yet, from what 1 have seen of fun- gus hasuiatodei}, I should much doubt, whether the benefit obtained by amputation would be lasting, as when this disease shows itself only externally, internal organs are mostly at the same time similarly affected. (See Fungus Hcematodes.) Besides cancerous, there are other ulcers, which may rentier ampuiut ion indispeniable. Thus when an extensive ulcer, of any sort whatsoever, is evidently impairing the health ; when, instead of yielding to reme- dies, it becomes larger and more inveterate; when, iu short, it puts life in imminent dan- ger; amputation should be advised. 9. Various tumours. Thatthere are numerous swellings, which destroy the texture of the limbs, renderio; them useless; causing dreadful suffering and bringing the patients into the mostde. bilitated state, no man of observation can fail to have seen. When such tumours can neither be dispersed, nor cut out with safe- ty, amputation of the limb is the only re. source. Mr. Pott has particularly described a n> mour affecting the leg, for which the ope- ration is sometimes requisite. It has iti seat in the middle of the calf of the leg,«r rather more towards its upper part, under the gastrocnemius and soleus muscles. I( begins by a small, hard, deep-seated swelling, sometimes very painful, sometimes but little so, and only hindering the patient's exer- cises. It does not alter the natural colour of the skin, at least until it has attained a considerable size. It enlarges gradually, does not soften as it enlarges, but continues through the greatest part of it incompres- sibly hard, and, when it is got to a large size, it seems to contain a fluid, which may be felt towards the bottom, or resting, as it were, on the back part of the bones. If an opening be made for the discharge of this fluid, it must be made very deep, ana through a strangely distempered mass. This fluid is generally small in quantity, and consisti of a sanies mixed with grumous blood: the discharge of it produces very little diminu- tion of the tumour, and very high symptom: of irritation and inflammation'come on,ssi advancing with great rapidity, and M* exquisite pain, very soon destroy the pa- tient, either by the fever, which is high, and unremitting, or by a mortification of th> whole leg. If amputation has not ben performed, and the patient dies, after the tumour has been freely opened, the morti- fied and putrid state of the parts, prevents all satisfactory examination ; but, if the limb was removed, without any previous opera- tion, (and which Mr. Pott, in his experi- ence, found to be the only way of preser- ving the patient's life) the posterior tibia! artery will be found to be enlarged, dis- tempered, and burst; the muscles of the calf to have been converted into a strangely morbid mass; and the posterior part ot both the tibia and fibula more or less cari- ous. (Pott on Amputation.) It seems only necessary to subdue at**- ther species of tumour to illustrate the » cessity of amputation. The following c*» is related by Mr. Abernethy. A woman n?a"iai?,,i!tediin^ St Bartho»omew,s B> pital with a hard tumour in the ham. » »• breadth. She had also a tumour in fit* A.MPLTATluA .uf the thigh, a utile above the patella, of lesser size and hardness. The tumour in the ham, by its pressure on the nerves and vessels, had greatly benumbed the sensibi- lity, and obstructed the circulation of the leg, so that the limb was very cedematous. As it appeared impossible to remove this tu- mour, and its origin and connexions were unknown, amputation was performed. On examining the amputated limb, the tumour in the ham could only be divided with a saw. Several slices were taken out of it by this means, and appeared to consist of a coagulable and vascular substance, in the interstices of which, a great deal of bony matter was deposited. The remainder of the tumour was macerated and dried, and it appeared to be formed of an irregular and compact deposition of the earth of bone. The tumour on the front of I he thigh was of the same nature as that of the ham, but contained so little lime, that it could be cut with a knife. The thigh bone was not at all diseased, which is mentioned, because when bony matter is deposited in a limb, it generally arises from the disease of a bone. (Surgical Observations, 1804.) Before the late facts and improvements, relative to the treatment of aneurisms, these cases, on the extremities, were gene- rally set down as requiring amputation. Even Mr. Pott, and J. L. Petit, wrote in re- commendation of such practice, and their observations on this subject are among the few parts of their writings, which the en- largement of surgical knowledge, since their time, has rendered objectionable. The surgeon to whom the honour of first cor- recting this erroneous doctrine belongs, is A. N. Guenault, who opposed the advice delivered on this subject by Petit. (Haller, Disp. Chir. vol. 5. p. 155.) I shall conclude these remarks on the ca- ses requiring amputation, with advising sur- geons never to undertake this serious opera- tion, without consulting the opinions of other professional men, whenever their ad- vice can be obtained. Tie best operators are often deficient in that invaluable kind Jof judgment, by which the cases, absolutely demanding amputation, are discriminated from others, in which the operation may be wisely postponed, and a chance taken of preserving the limb. j Historical Remarks on Amputation. J The history of amputation evinces, that the steps of surgery to perfection are slow, and that they even sometimes deviate from the straight path, though upon ail essential Joints no retrogradation has overtaken place. Here nature has acted as the guide, and the burgeon's chief merit has consisted in obey- ing the hints which she herself has thrown Out. As already mentioned, the following latural occurrence, no doubt, was one of 'he circumstances, which first led to the >old practice of amputation; in conse- quence of disease, and grievous local inju- les, whole limbs were sometimes seized vith mortification. In the majority of ca- ses, this was attended with sj much consti- tutional disturbance, that the patients died ; but, in other less numerous instances, the mortification was confined to the part; sup- puration was established between the dead and living parts ; the whole of the morti- fied limb fell off; the suppurating surfaces healed up ; and thus, by the powers of na- ture, the patients were restored to health. Here was clearly proved the possibility of recovery, notwithstanding the loss of a limb. The surgeon, as Brunninghausen re- marks, viewed with surprise this course of nature, and hardly ventured to promote it by the feeble means formerly employed, which, however, were not really needed. But, as the mortified parts, previously to their detachment, caused great annoyance by their fetor, a surgical attempt was at length made to get rid of them ; in doing which, the knife was always kept from touching the living flesh, on account of a well-grounded fear of bleeding, for the suppression of which no effectual methods were known. Such was the practice that prevailed from Hippocrates down to Celsus. (Erfahr., ^c. aber die Amp. p. 14.) " Partes autem corporis,"quae infra terminos denigra- tionis fuerint, ubi jam prorsus emortuse fuerint et dolorem non senserint, ad articu- los auferendae ea cautioneut ne vulnus inft- ratur," fyc. (De Articulis, sect. 6.) Here we find, that the earliest mode of amputa- tion was that done at the joints. A. C. Celsus, who lived in the reign of Tiberius, and whose book, de Re Medica, should be i«ead by every surgeon, has left us a short description of the mode of am- putating the gangrenous limbs. (Lib. 7. c. 33.) It has been often remarked, that Cel- sus has left no instructions for securing the divided blood-vessels ; but it has not been commonly noticed, that, in his chapter on wounds, he directs us to stop hemorrhage by taking hold of the vessels, then tying them in two places, and dividing the in- termediate portion. If this measure can- not be adopted, he advises the use of a cauterizing iron. Several hints are to be met with in the writings of Celsus, from which it may be inferred, that the ligature of bleeding vessels was sometimes practi- sed at the early age in which he lived; and this supposition is strengthened, by a frag- ment of Archigenes, preserved by Coc- chius, on the subject of amputation, where he speaks of tying, or sewing, the blood- vessels. We are not, however, in posses- sion of all the writings of medical authors, prior to the time of Galen, and must there* fore remain iu doubt upon this point. (Recs's Cyclopaedia, Art. Amputation.) This anouymous writer argues, therefore, with some appearance of reason, that If amputation often proved fatal in the days. of Celsus." sajpe in ipso opere," as the ex- pression is, it was owiug to the want of some efficacious method of compressing the blood-vessels, during the operation it- self ; for, whether the use of the ligature' were known to the ancients or not. no :i AMPUTATION doubt exists about their ignorance of the tourniquet. But, admitting that the ancients were not altogether uninformed of tbe plan of tying arteries, it cannot be credited, that they adopted the practice to any extent; for, if they had they would not have con- tinued so partial to the cautery, boiling oils, and a farrago of astringent applica- tions. They would also never nave had re- course to the barbarous method of cutting the flesh with a red-hot knife, with the view of stopping the hemorrhage by con- verting the whole surface of the stump into an eschar. Painful iu its execution, and horrid in its consequence, as this burning operation was, it seldom proved a lasting antidote to the bleeding, which generally came on in a fatal manner, as soon as the sloughs were loose. On this part of the subject, my own ideas fully agree with those of a distinguished foreign surgeon, who says, that although the document left us may prove that the ligature was known to the ancients, and employed in cases of aneurisms and wounded,blood-vessels, nay, that the arteries were secured with a needle and ligature ; yet the practice could not have been extended to the operation of am- putation, since with the custom of making the incisions in the dead parts, the method scarcely admitted of being put in execution. (Brtlnninghausen, Erfahr. uber die, Amput. p. 29.) Ambrose Pare, therefore, seems to me to deserve as much praise for the intro- duction of the ligature into common use, as if no allusion to this method whatsoever had existed in the writings of Celsus and other ancients. The different parts of the operation, me- riting particular attention, are, the choice of the part of the limb where the incisions are to begin ; the measures for guarding against bleeding during the operation ; the division of the integuments, muscles, and bones, which is to be accomplished in such a manner, that the whole surface of the stump will afterwards be covered with skin; tying the arteries, which should be done without including the nerves, or any other adjacent part; placing the integuments in a proper position after the operation ; and, finally, the subsequent treatment of the wound. At the period of making the incision, the ancients contented themselves with having the skin forcibly drawn upward by an assist- ant ; they next divided, with one sweep of the knife, the integuments and flesh down to the bone, and, afterwards, sawed the bone on a level with the soft parts, which were drawn upward. Celsus considered it better to let the incision encroach upon the living flesh, than leave any of the diseased parts behind. " El polius ex sana parte atiquid e.rcidatur, quam e.r agra relinqua- lur." (De Medicina, Lib. 7. c. 33.) It appears, however, that his views ex- tended further than those of most of his contemporaries, and even his followers, al- mo«t ilnwn to modern time*. After cutting the muscles down to the bone, bosays,that the flesh should be reflected, and detached an- dernealh with a scalpel, m order to denudta portion of the bone, whtchisthen to be taw, as near as possible to the healthy flesh, winch remains adherent. He states that, when this plan is pursued, the skin around tki wound will be so loose, that it can almost bt made to cover the extremity of the hont. It is to be lamented, that this advice, inculca- ted by Celsus, should not have been cam* prehended, or that it should have been so neglected, as to stand in need, as it were, of a new discoverer, and that a suggestion of such importance should have remained so long useless. But, the factjs, hemorrhage formerly rendered amputation so dangerott, that the ancient surgeons could not derail much attention to any thing else in tbe operation, and practitioners amputated to seldom, that we read in Albucasis, that he positively refused to cut off a person's'hand, lest a fatal hemorrhage should ensue, and the patient did it himself and recovered. Over that part of the stump, which the small quantity of preserved skin would not co- ver, Celsus recommended compresses, and a sponge dipped in vinegar to be laid. (Dc Re Medica, Lib. 7. e. 33.) Archigenes, who was born at Apamk/fa Syria, was the disciple of Agathinus/id physician to Philip, king of that coaMfy. He repaired to Rome, where he practised physic and surgery, in the reign of the em- peror Trajan, about 108 years after the birth of Christ. (Portal, Hist, de VAnatomit ef de la Chirurgie, Vol. I, p. 61.) In the his- tory of amputation, the name of Archi- genes is conspicuous, not only because he is supposed to have been acquainted with the use of the needle and ligature for the stoppage of bleeding, but because bis de- scription of the operation is in some it- spects more minute than that of Celsas. For the hinderance of loss of blood ii tbe operation, says Sprengel, (Geschicktt dtr Chir. B. 1, p. 404, Halle, 1805,) he finU all tied up the vessels, and often the whole limb over which he also sprinkled.cold wait The integuments were then drawn upwaiUs from the wound, and confined there with a band ; and after the limb was off, he ew- terized the stump, and applied folded com- presses. The band was now loosened, and a mixture of leeks and salt laid on the stump, to which were also applied oil and cerate. (Nicet. Coll. Chir. p. 155.) Such was likewise the practice of Heliodoras, who thus early made objections to thephn of cutting off a limb by a single stroke, a proposal that was renewed in far later dayi the same author has also spoken of ana* tatmg at the joints; a method, of which he disapproves. (Meet. Coll. Chir. p. 186.) However Galen entertained a favourable opinion of it, on account of its safety*^ expcd.t.on rComm. 4, in lib.dTXf r!,J ^alen-s precepts concerninr aB» tat.on are, upon the whole, very SKE given by Hippocrates; for he &reZ oS dead part* to be cut. and the fi'^T,2 ump to-b» AMPUTATION. '>o Cauterized. (De Arte Cvrativa ad Glouco- nem, lib. 2.) By all the old writers, ampu- tation was entirely restricted to cases of mortification ; further they were afraid to go ; and this precept, and all the other doctrines of Galen, may be said to have been the guide of the whole surgical profession for full fourteen centuries. The timid Arabians were not partial to amputation, and even in cases of mortifi- cation, generally preferred a farrago of use- less applications, like Armenian bole, &c. Paulus JEgineta, like Galen, deviated from Celsus's good rule of making the incisions in the healthy parts, and only approved of making the requisite division near them. (Lib. 4, c. 19, p. 140.) Avicenna, however, repeated the directions left by the Greek Writers, (Can. lib. 4. Fen. 3,tr. 1, p. 454.) and Abu'l Kasem proposed doing the ope- ration with a red-hot knife. (Chirurg. lib. 1. Sect. 52, p. 99.) In the middle ages, little was done for the improvement of am- putation. In the 14th century, gunpowder was invented, and soon applied to the pur- poses of war, so that an abundance of cases must have presented themselves, in which the wise maxim of not deferring amputa- tion, until mortification had come on, but of preventing the mischief by the opera- tion, ought to have struck an intelligent surgeon. One might also expect that prac- titioners would now have been led to make the incisions in the sound flesh. Unfortu- nately, the invention of gunpowder, and its immediate consequences in surgery, hap- pened at a period when practitioners were ill qualified to profit by the new lessons of experience set before them. The writings of their predecessors furnished them with no directions how they ought to act, and they were themselves too much confound- ed at the sight of the mischief, for which they were consulted, to be able to form any correct opinion about causes and effects. Their first idea was, that the ter- rible symptoms proceeded from the parts being actually burned, and they afterwards inclined to the belief, that gun-shot wounds were poisoned. Hence, the most absurd modes of treatment were instituted, and as Brunningbausen expresses himself, human nature groaned under a new evil, for which there were for some time no true plans of relief. (Erfahr. ty*. fiber die Amp. c. 19.) This deplorable state was the natural result of the depression of science in general, and of the healing art in particular, in the days to which I now refer. In these mid- dle ages, as they are called, the population of all Europe was plunged in the deepest ignorance ; and whatever little knowledge remained, either of the arts, or languages, was monopolized by the priesthood, the physicians of those times, who, instead of studying the volume of nature, wasted most of their time in discussing the doc- trines of Galen. Surgery itself sunk to the lowest ebb, as may be well conceived from the decrees issued at Rheims, by pope Boni- face the eighth, forbidding any of the clergy to do any thing themselves, which drew blood, and, of course, all the opera- tive part of surgery, that which required most skill and science, was transferred to a set of illiterate, low-bred mechanics, far inferior to the worst country-farriers of modern times. Yet, the clergy, who were here scrupulously averse to soiling their own hands with blood, or hurting their own tender feelings by viewing the agony of their fellow-creatures submitted to opera- tions, had no hesitation in taking the chief emoluments and honours of the profession, or in turning over these poor sufferers to men more qualified to torture and murder, than give relief; and what nearly staggers all credulity, the same professors of Chris- tianity, who shuddered to spill a drop of blood themselves, on a proper occasion, as Haller observes, eagerly had a hand, and acted an important part in every sanguina- ry war, where it was possible for them to interfere. In these dismal days for surgery, the advice delivered by Celsus was renew- ed by Theodoricus, who used to administer opium and hemlock previously to the ope- ration, for the purpose of rendering the patient less sensible of pain, and afterwards vinegar and fennel were given, with the view of dispersing the intoxicating effects of the preceding medicines. (Chirurg. lib. 3, c. 10.) The renowned Guido di Cauliaco was the inventor of the plan of taking off limbs, without any bloodshed. It is better, says he, for the limb to drop off, than be cut off, as in the latter circumstance, the conduct of the surgeon is viewed with spite, be- cause it is supposed, that the part might have been saved. Guido's practice con- sisted in covering the whole membrane with pitch-plaster, and applying round one of the joints so tight a band, that the parts below the constriction ultimately dropped off. (Chirurg. tr. 6, Doctr. 1. Cap. 8.) As Sprengel next observes, the method of am- putating, suggested by Celsus, was again revived by Gersdorf, who after the opera- tion, not only drew down over the stump the skin which had been retracted, but applied a hog's or bullock's bladder over the stump, so as to render all burning and stitching of the parts needless. (Feldbuch der Wundarzn. fol. 63.) Bartholomew Maggi also endeavoured to preserve a con- siderable flap of integuments for covering the stump. (De Vulner. bombard, etsclope. 4to. Bonon. 1552; see Sprengel's Geschichte der Chirurgie, p. 404, 406, 8vo. Halle, 1805.) At length, in the 15th century, the revi- val of learning occurred first in Italy. Men now began to think for themselves again, and physicians turned from compi- lations and scholastic nonsense, to the con- sideration of nature. Anatomy was culti- vated with great ardour, and made brilliant progress under the eminent characters of the time : De la Torre, Berengarius Carpi, Vesalius, Fallopius, Eustachius, and others, who were also for the most part very dis- AMPUTATION tinguishedMirgcons. "Jn lialiaScknliarum malrr. medici se nunquam chirurgia abdica- runt. Seeiilo 15 el 16, professores medici academiat Bononiensis, Palavincr, it aliarum in Italia illustrium scholarum et mann cura- rerun!, tt consilio, et inter istos riros summi chirurgi etstiterunt." (Haller, Bibl. Chir. p. I. p. 161.) Practitioners now ventured to amputate limbs in the sound part for other incurable diseases, besides mortification ; but, the art of stopping hemorrhage after the operation continued imperfect. Though the method of applying the ligature in ca- ses of wounded arteries and aneurisms was understood, yet^ from some unaccountable causes, the practice was never thought of in amputations. Even Fallopius knew of no other means for stopping the bleeding, but the cautery. (De Turn, pro-tern. p. 665.) On the whole, the stoppage of bleeding was not attended with a degree of success proportionate to the advances of the healing art in general. Straps, bands, and compresses were indeed put round the member; but, as the circulation of the blood was not yet correctly known, they were not applied in the proper places; boing arranged either close to the wound, or several of them put at random round the limb. Tbe effects of such immoderate- ly tight, long-continued constriction, could be nothing less than gangrene, and hence, tbe actual cautery was still chiefly employ- ed. The other means for suppressing he- morrhage scarcely merit the name. Ter- rified at the insecurity and ill consequences of such expedients, .1. de Vigo, (Practicain Chirurgia Copiosa, 491, Romm, 1514,) and Fabricius ab Aquapendente, (Op. Chir. Venet. 1619,) disapproved of amputating in the sound flesh, and returned to the princi- ple, inculcated by the ancients, of making the incision in the mortified parts. Others endeavoured to lessen the peril of the bleeding by the rapidity with which the limb was removed, and the instantaneous application of the cautery. For this pur- pose, L. Botalli invented a sort of guillo- tine, by means of which a member was severed from the body in an instant, (De Curandis vulnenbus sclopetorum, Lugd. 1560;) while others laid a sharp axe upon the limb, and effected the dismemberment by the blow of a wooden mallet. An ex- ample of this barbarous practice is record- ed by Fabricius Hildanus, called by his countrymen the patriarch and ornament of the German surgery. In consequence of this fear of bleeding, before he knew of the use of the ligature, he was himself ac- customed to amputate with a red-hot knife, the representation of which is given in his work. (De Gangrana et Sphacelo, Op.) Hildanus became a better surgeon, how- ever, as he grew older, and, in the end, partly contributed to the improvement of amputation, inasmuch as he made the incisions completely in the sound parts, and adopted the method of tyin? the arte- ries, as then recently proposed by Pare, but unfnrfunaMv. in weak r>er«on °r sut«* bandage, to he' AMPUTATION. 17. limb, or, else, what 19 better, to let an as- sistant gripe the limb firm with both hands, and press with his fingers over the course of the bleeding vessel, so as to stop the hemorrhage; then, with a square-edged needle, about four inches long, and a thread, four times doubled, the surgeon must se- cure the artery in the following manner. Thrust the armed needle into the outside of the flesh, half a finger's breadth from the vessel which bleeds, and bring it out at the same distance from the bleeding orifice; then surround the vessel with the ligature, pass it back again to within one finger's breadth of the place, where it first entered, and tie a fast knot upon a folded slip of linen rag, to prevent its hurting the flesh. By this means, says Pare, the orifice of the artery will be agglutinated to the adjoining flesh so firmly, as not to yield one drop of blood: but, if the hemorrhage were not considerable, he contented himself with the application of astringent powders, &c. " Thus did this famous surgeon endea- vour, by his single example and precepts, to exclude the barbarous use of hot irons in amputation. He says, he knew not of any such practice among the old surgeons ; ex- cept that Galen recommended us to tie bleeding vessels, towards their origin, in accidental wounds: and he thought proper to do the same in cases of amputation. But, in an apology, at the end of his book, Pare has quoted, in his own defence, a dozen authors, who employed or recom- mended the ligature before him; and he might have cited many more. " From the statement we have here given, it may be seen how far the best wri- ters of almost every country have erred in ascribing the original invention of tying ar- teries to Ambrose Pare. Great merit, in- deed, was due to him, for the part he took in extending, and even reviving this incom- parable practice : nay, if is not certain, whether any one before him had ever applied the needle and ligature in similar cases, i. e. after amputation; but how very wide of the truth Mr. John Bell's recent account of this matter is, will appear to every person, who will inquire into the facts themselves ; for not only were ligatures and needles in use among the ancients, but likewise the tenu- culum, or hook to fay hold of the bleeding vessels when they had buried themselves in the muscles. We refer our inquisitive readers to Avicenna, iEtius Albucacis, Brunus, The-e odoric, Guido di Cauliaco, John de Vigo, L., Bertapaelia, Tagaultius, Petrus Argillata, Andreas a Cruce, &.c. &o. where they will find enough to satisfy them on this head." [Rees's Cyclopedia, art. Amputation.) I shall not here expatiate upon the ill- treatment, which Pare, experienced from the base and ignorant (lourmelin ; nor upon the slowness and reluctance, with which the Sgenerality of surgeons renounced the cautery or the ligature. These circumstances may be conceived from what has been already stated. Suffice to add, upon the authority of Dio- nis, that, almost 100 years after Pare, a but- ton of vitriol was ordinarily employed in the^ Hdtel Dieu at Paris for the stoppage of hemorrhage in amputation. And Dionis was the first Frenchman, who openly taught and recommended Pare's method. This however happened towards the close of the 17th century, while Pare lived to- wards the end of the 16th. (Dionis Cours d'Opkrat. Paris 1707.) As Pare, like the rest of the old sur- geons, used to cut directly down to the bone, many of the stumps, which he made, must have been badly covered with flesh, apd ill-fitted for bearing pressure. But, all that I have read on the subject of amputa- tion impresses me with a strong conviction, that, in former times, the projection of the end of the bone, the sugar-loaf form of the stump, the frequent exfoliations, and the dif- ficulty in healing the part, and keeping it healed, were as much owing to the mischief done with the cautery, the rude way of dressing the stump, and ignorance of the right method of promoting union by the first intention, as to the mode of operating, or any other circumstance. By many surgeons, however, the tying of arteries continued to be deemed too trouble- some, and hence, they persisted in the barba- rous use of the actual cautery : of this num- ber were Pigrai, (Epitome des Prtceples de Med. et de Chir. 8vo. Rouen, 1642.) F. Plaz- zoni, (De Vuln. Sclopet. 4to. Venet. 1618,) and P. M. Rossi, (Consult, et Observ. Svo. Francof. 1616.) Nay, so difficult was it to eradicate the blind attachment to the an- cients, that theodorus Baronius, a profes- sor at Cremona, publicly declared in 1609, that he would rather err with Galen, than follow the advice of any other person; and Van Hoorne seems even to have coun- tenanced the detestable machine of Botalli. (M/«g0T6^V», p. 75.) What, asks Brttnninghausen, was the rea- son why the ligature of the arteries, which is now regarded by the surgeons of all civi- lized nations, as the best, easiest, and safest method of stopping hemorrhage after am- putation, should so long have remained una- dopted ? Besides the prejudice for the opi- nions of the ancients, already mentioned, another cause was undoubtedly the imper- fect knowledge of the circulation of the blood, a correct description of which was first delivered by the immortal Harvey early in the 17tn century. (Excercitatio Anat. de Mortu Cordis et Sanguinis in Ani- malibus. Francof. 1628.) For some time, this grand discovery met with violent op- position ; but, after it had been acknow- ledged as an eternal truth, a happy applica- tion of it was made to surgery by a French surgeon, named Morell, who at the siege of Besancon in 1674, invented the field-tour- niquet, by means of which more certain pressure was made on the trunk of the ar- tery. By this simple invention, founded however on a kno-v ge of the circulation, the surgeon rnuld at option let the blood of 78 AMPUTATION. the stump spirt out, or stop its jet entirely ; and now, both during and after the opera- tion, he was first enabled to command the hemorrhage, and coolly and judicious- ly employ whatever measures were indi- cated ; for the most powerful bandages and pressure, previously in use, either stopped the circulation in the whole limb, or could not be made to have the right effect with sufficient quickness. (Brtinninghausen Er- fahr. fyc. aber die Amp p. 36.) Morell's tourniquet, however, was very imperfect, and it was not till the year 1718, that J. L. Petit, whose name shines so brightly in the history of surgery, invented the kind of tourniquet now employed. Richard Wiseman, who is justly con- sidered as the father of good English surge- ry, saw the necessity of making the incision in the sound parts, because gangrene does not always spread evenly, but frequently extends much higher up one side of the limb, than the other. He deemed the ac- tual cautery objectionable, as the sloughs were so long in being thrown off. He ap- plied a ligature round the limb, two inches above the limits of the mortification, and drawing up the muscles, made the incision with a large curved knife, w ith the back of which he scraped off the periosteum. The bag, or sort of retractor, employed by Fa- bricius Hildanus, Wiseman thought unne- cessary, as the muscles spontaneously drew themselves up as soon as divided. He tied the blood-vessels after the manner of Par6, and deprecated all burning of the stump. After the operation, he drew the flaps over the bone, and either fastened them in this position with stiches, or a tight bandage, though he generally preferred the former, as the surest means of keeping the end of the bone from protruding. Across the stump, he laid a pledget of wax-cerate, aud over this a thick layer of Armenian bole and other styptics, and the whole was covered with a bullock's bladder, and a roller applied spirally from the upper part of the remaining portion of the limb, down to the extremity of the stump. On the third day, the dressings were taken off, and a digestive ointment applied. (Chirurg. Treatises, vol. 2, p. 220, 800. Lond 1690.) From this time, amputation may be considered as being an infinitely safer pro- ceeding, than what it used to be ; for, as we have explained, the ligature of the arte- * ries was now practised and commended in Germany by F. Hildanus, in England by Wiseman, and in France by Dionis. Much however remained to be done. The wound was large, and suppurated long and pro- fusely ; the healing was slow ; the ends of the bones perished, and projecting far be- yond the soft parts, retarded the cure so long, that the patient was not unfrequently worn out. Hence the best surgeons began seriously to consider what further could be done, with the view of lessening the ex- posed =nrface of the wound, and making a better covering of flesh for the ends of the According to Sprengel, most of the old surgeons preserved a flap of flesh, and he is therefore by no means disposed to regard our countryman Lowdham, as the inventor of this method, though it is acknowledged, that tbe latter surgeon's practice was novel, inasmuch as the flap was formed by making an oblique incision through tbe integuments from below upwards. (See James Yonjtt't Currus Triumphalis e Terebintho, 8vo. Lond. 1679, and Sprengel's Gesckichte der Chvur- gie, B. I. p. 408.) Here, if Sprengel means, that many of the old surgeons endeavoured to preserve a partial covering of flesh for the bone, there can be no doubt of his cor- rectness, because we find, that they drew back the flesh before they divided it, and Celsus and some others even did more, for, after cutting down to the bone, they detached the flesh further from it upwards, previous- ly to taking the saw; but, on the contrary, if Sprengel wish us to believe, that there were practitioners, who previously to Lowdham, in the operation of amputation, formed what in England is usually under- stood by a flap, that is, a portion of flesh, generally of a semilunar shape, and saved particularly from one side of the member for covering the bone, I cannot see any reason for coinciding with Sprengel's obser- vation. Upon the merit of Lowdham's sug- gestions, and the practice and principles inculcated by J. Yonge, some reflections lately sent me by Mr. Carwardine, I insert with great pleasure, as perhaps he is right in thinking, that the last edition of this work did not do justice to the memory of the lat- ter writer. " At the time Yonge wrote (1679) ays Mr. Carwardine, it was supposed impossi- ble to heal a stump before the bone had ei- foliated, and therefore, no surgeon would venture upon an attempt at uniting the sur- face by the first intention. Now this union by the first intention, was the chief object of ' y°.nSe in proposing the flap operation, and it is to him, and not to Mr. Alanson, who wrote precisely 100 years after him, that we must attribute the honour of this improvement. It is related in a letter ad- dressed to his friend Thomas Hobs, chirar- geon in London, dated Plymouth, August 3, 1678, and published 1679, at the end of his Currus Triumphalis e Terebintho. It begins thus :— " Sir, I find by yours that you are sur- prised with the intimation I gave you, of a way of amputating large members, so as to ,'re to fure them per symphysin in thru weeks; and without fouling o/scaling the evinr'» I " 3 Parad°* Which I Will nOff firsttak™ y°,U l° ^e a truth> after I have thTre is a not,ce.of what you affirm, that found n <,,herwi«, but that wh.Tf. 2 AMPUTATION. 7tr tumated, and the caries come off there- by. " Yonge then acknowledges, that it was from an ingenious brother, Mr. C. Lowd- ham of Exeter, that he had the first hint thereof. He then describes the opera- tion—the laying down the flap over the face of the stump, and sewing it by four or five stitches, &c. After this Yonge proceeds with a methodical enumeration of the ad- vantages of this mode of operating over all others then in use, viz. that it is more speedy—the cure not occupying o fourth of the usual time—no suppuration—no ex- foliation—less danger of hemorrhage—not liable to break open again from slight inju- ry—and lastly, much better adapted to the pressure from an artificial leg, &.c. " The foregoing abstract will show, (says Mr. Carwardine,) how far Mr. O'Halloran's method, presently to be described, in which he dresses the flap and the stump as distinct surfaces, can be regarded as a revival of Lowdham's operation, or whether it has been superseded or improved upon by the mechanical ingenuity of tbe Dutch and French surgeons. The apparatus of M. de la Faye and Verduin appear to have been merely clumsy and unscientific contrivances for the suppression of hemorrhage. Garen- geot's operation bad also for its object to supersede the use of the ligature, which, however, after twelve years practice, he was obliged to give up, and tie the vessel before he laid down the flap: (the particu- lars of all these methods the reader will presently meet with.) Opinions therefore founded upon the practice of these gentle- men, I conceive cannot fairly be admitted as evidence against the flap operation of Lowdham, which nevertheless appears sinking in the estimation of the best mo- dern surgeons : perhaps no material advan- tage is gained by it over tbe common mode of operating in the lower extremities, as now practised ; but, even here, cases may occur where we are glad to resort to it. A few yearn since, I attended a patient, in consul- tation with a friend at Dunmow, in Essex, where we thought it necessary to remove a man's leg for a caries of the tibia. An ul- ceration in front extended so high, that no integument could be saved ; and the limb would have been removed above the knee, if I had not suggested the propriety of mak- ing a flap from the calf of the leg. The tibia was obliged to be sawn as high as possible, but the flap was left sufficiently* long to cover the surface, and that most im- portant object, tbe bend of the knee, was preserved to bear the pressure of a wooden leg. In the removal of the arm at the shoulder joint, doubtless tbe advantages of making a flap from the deltoid, &c. are suf- ficiently established; but, in the mode of dressing, I presume, that no English surgeou will admit, that the practice of M. Larrey (perhaps the most eminent surgeon that has been formed by the wars of Bonaparte, and whose practice will be hereafter noticed,) ran supersede (he method of Yonge for Lowdham,) who wrote 140 years before him ! Larrey introduces charpie beneath the flap to prevent union by the first inten- tion ! Lowdham's object is simply to lay tbe flap over tbe wound to prevent exfoli- ation, and to heal the surface ' per symphi- sin' in three weeks." To the correctness of these sentiments of Mr. Carwardine, I be- lieve, that every impartial surgeon will bear witness; and it merely remains for me to thank him for his obliging communication, and say, that I have recently looked over the copy of the Currus Triumphalis e Te- rebintho, preserved in the valuable library of the Medical and Chirurgical Society, and find, that what he has stated is fully confirmed by the contents of that an- cient work. At the same time, I retain the belief, that the example set by Mr. Alanson, with respect to the proper me- thod of dressing stumps, aud obtaining a speedy union of the wound, is entitled to the praise of posterity, because his advice was so well enforced that it soon produced a revolution in practice; while the cor- rect suggestions of Lowdham and Yonge, like the hint in Celsus, of the double in- cision, had sunk into oblivion, or were only known to a few admirers of surgical anti- quities. As Sprengel remarks, Purmann, Dionis, (Cours d'Oper. de Chir. p. 611.) De la Vau- guyon, (Traite1 Compl. des Oper. de Chir. p. 531,) and most other surgeons of the seven- teenth century, continued the method of first drawing up the integuments, and then applying a band round the member. Dio- nis also took particular pains to recommend the ligature of the vessels, and expresses a strong aversion to the actual cautery. Neither did he approve of amputation at the knee joint, because he thought that the patella, which must be left behind, would impede the healing of the stump, and he was apprehensive of the articular surface of the femur becoming diseased. De la Vauguyon relied upon the styptic properties of vitriol, and he praised drawing back the muscles by means of the kind of bag in- vented by Fabricius Hildanus. Taking off the limbs at the joints was first commended again in modern times by J. Munnicks, who was more partial to styp- tics, than the ligature ; and for dressing the wound employed compresses and sticking plaster. (Chirurgia, p. 101.) Marquest de la Mothe adopted the plan of operating recommended by Dionis; he was also one of the first who made common use of the tourniquet in amputations, after- wards drawing out the vessels with the forceps and tying them. (Traite" Compl. de Chir. Vol.3, p. 171.) Lowdham's original suggestion of amputating with a flap has been briefly noticed. About eighteen years after Yonge's publication, Peter Verduin, an eminent surgeon at Amsterdam, sub-; mitted to the judgment of the profession a new kind of flap amputation, which he had put in practice. (See Dis. Epistolica dc Nova Artimm. deeurtandorvm ratione, Sm AMPLIATION Amst. 1696.) The following are the chief particulars of Verduin's flap operation. Two compresses were applied, one under the ham, and the other on the course of the large vessels. The thigh was wrapped in a fine linen cloth, which was sustained by some turns of a roller. This apparatus was covered with a piece of leather, six inches broad, furnished with three straps with buckles, to secure it round the part. The tourniquet was placed in the usual manner. The part, above the place in- tended to be amputated, was surrounded with a leather strap. Tbe point of a crook- ed knife, which was made to pass as near to the back part of the bones as possible, was thrust in on one side of the leg, and made to come out on the other. The knife was then carried down nearly to the tendo achillis, and thus it separated almost the whole calf of the leg. The flap being formed, the operation was finished in the ordinary manner. The wound was then washed with a wet sponge, in order to clear it from the fragments of sawn bone. The leather strap, which served to secure the flesh, was next loosened, and the flap laid over the stump. The wound was dressed with lycoperdon, lint, and tow, over which was put a bladder, sustained by strips of sticking-plaster. Upon this bladder was placed an instrument, called a retinaculum, consisting of a compress, and a concave plate, which were made to press upon the stump, by means of two straps, that crossed each other, and were attached to the broad leather strap surrounding the thigh. In 1702, Sabonrin, an able surgeon at Geneva, gave an account of Verduin's prac- tice to the Royal Academy of Sciences, which, however, declined to pronounce any judgment about it, without further ex- perience. Though this method of amputation was objected to by Konerding, in'a tract pub- lished at Amsterdam in 1705, it was after- terwards highly extolled by P. Massuet, on account of the quickness with which the stump healed, the safety with which the flap served for the stoppage of the hemor- rhage, and the avoidance of exfoliation by the non-exposure of the bone. He also dwelt upon the excellency of the stump for the application of an artificial foot. (De VAmputation a lambeau, Svo. Paris, 1756.) Heister disapproved of the flap amputation, because it appeared to him, that the irrita- tion of the flesh by the projecting bones was apt to cause pain and inflammation : he operated himself after the manner of Dionis, and was strongly in favour of the use of ligatures. Some excellent precepts were delivered by J. L. Petit concerning amputation. He improved the tourniquet; and, instead of the large crooked amputating knife, for- merly employed, fii=t brought into use the straight more moderate-sized knives with sharp backs, now seen in the hands of the best surgeons, because much better calcu- lated than crooked knives for dividing the flesh by a sawing movement, which is ihe. only right and surgical way of attempting to cut any part of the human body. He proved that making the division in the mortified parts was frequently followed by hemorrhage ; and for the suppression of bleeding he thought it the best principle promote the formation of a coagulum, (M6m. de I'Acad. des Sciences, an. 1732, p. 285. See Hemorrhage.) For compressing the vessels, he employed an instrument, which covered the stump, like Verduin's retinaculum, and made pressure by means of a screw. His only objection to Ver- duin's method was, that the extension of gangrene up the limb frequently hindered the formation of so large a flap. He laid down the valuable general maxim of al- ways removing as much bone, and as little flesh, as possible ; for which purpose, he invented what is termed the double incision, or dividing the business of cutting through the soft parts into two stages. About an inch higher than the place where he meant .to saw through the bones, he first made the circular cut through the integuments down to the muscles ; the skin was then pulled up so as to leave the flesh uncovered to the ex- tent of an inch, and the muscles were now divided at the highest point of their expo- sure. Lastly, the flesh was held out of the; way with a retractor, and the bone was sawn through high enough up to allow of its extremity being well covered with flesh and integuments. The greatest defect m the doctrines of Petit, relative to amputa- tion, was the confidence he put in pressure, instead of the ligature. (Traite" des Malad. Chir. vol. 3, p. 126.) The first performance of amputation at the shoulder-joint, by Le Dran, and the improvements and alterations of that operation suggested by Garengeof, De la Faye, Desault, kc. I shall notice in a future section. In chronological order, the next event claiming notice, in the history of amputa- tion, was the promulgation of an opinion by T. R. Gagnier, that Verduin's flap-ampu- tation might be traced back to times of great antiquity, the method described by Celsus being very similar. (Haller, Diss. Chir. vol. 5, p. 161.) On this point, with reference to Lowdham, the true inventor of the flap-operation, I have already deli- vered my own sentiments. The flap-amputation of the leg, after Ver- duin's manner, was tried by De la Faye, who found that the pressure of the flap was not enough to check bleeding from all the vessels, as it only operated on the anterior tibial artery, and, by pressing the flesh more fhi^,ams- ,the e,,d of "the bones, he thought the risk of mortification would be occasioned. madeerdo^and Sabouri"> as we have seea^ «ons £fl?nC "T Two French sur- CR2!: »nd Vermale, afterward^ uiougnt, that it would be better to save aX flap from each side of the limb. Th«vTver** also advocates for tying the VP.«X I? bringing the two flaps into contact s " AMPUTATION. Si procure their speedy union, and prevent exfoliations aud profuse suppuration. However, there is some difference in their methods of forming the flaps. Ravaton, who submitted his plan to the French Aca- demy in 1739, made three deep incisions down to the bone; first, a circular one, with a crooked knife, within four fingcr- breadlhs of the bone intended to be sawn ; and then with a somewhat larger knife ; the two others perpendicularly to the first, one at the forepart, and the other at the back of the limb; and, taking care not to touch the principal vessels, he detached the two flaps from the bone. Vermale formed the separate flaps by two incisions. After applying the tourni- Siet, he surrounded the part with two red reads, at the distance of) four finger- breadths from each other; one at the place where the bone was to be sawn ; the other at the place where the incision of the flaps was to terminate. He afterwards thrust a long bistoury down to the bone, at the forepart of the limb ; turned it round the circumference, so that it might come out at the opposite part; then directing the edge of the knife along the bone, he cut down to the inferior thread, where he sepa- rated the first flap, which, as the author says, was of a round or conical figure at its extremity. The second flap was made in a similar way on the interior side of the member. (Traite" des Playes d'Armes d feu, par Ravaton, Svo. Paris, 1750; De la Faye, in Mem. de V Acad, de Chir. T. 5, ed. \2mo. Vermale, Obs. de Chir. 8vo. Manheim 1767.) In presence of M. Quesnay, Garengeot performed the flap amputation according to the method of Verduin and Sabourin. We know, that they made no ligature on the vessels, and that their intention was, that the flap, when applied to the stump, and sustained by a particular apparatus, should reunite, and stop all bleeding. Garengeot's patient died on the third day after the operation ; and hemorrhage was allowed to have had a considerable share in producing death. The multiplicity of machines described by Verduin, La Faye, &c. had no other end, but that of keeping the flap near the orifices of the vessels, so as to compress and close them. Garengeot reflected that, to obtain a just degree of this compression was very difficult, as the most considerable vessels were situated between the two bones, and, in general, when cut, withdrew themselves. Hence, be determined in fu- ture to employ ligatures. With these views, twelve years after the foregoing case, Garengeot performed a flap amputation of the arm, preserving two flaps, according to the method communi- cated to the Academy by Ravaton. The brachial artery was tied, and the patient got well, without any exfoliations. Garengeot made a third trial of this ope- ration on a soldier dangerously wounded Vol.. 11 in the right foot by the bursting of a bomb, which fractured the interior part of the two bones of the leg, and several of the foot: the patient got well in twenty-seven day.>. In this operation, one single flap was made. Garengeot was fearful, however, that the quick union might create some dif- ficulty of withdrawing the ligatures, and he therefore took a means of hindering adhe- sion where they were situated ; but, of this objectionable plan, I shall not speak. He rightly preferred dressing and bandaging the stump to the use of the compressing machines invented by Verduin and La Faye; and his choice of a straight knife, instead of a crooked one, was equally judi- cious. The preceding case dictated a truth, which will last as long as surgery itself,— viz. that it is advantageous to apply the li- gatures in such manner as to embrace no more than the vessel, so that they may fall off the sooner, and the parts more quickly unite. (M. de Garengeot, in Me" moires de I'Acad. de Chirurgie, Tom. 5, in \2mo.) At one time, a frequent objection, urged against (he foregoing methods, was, that, when the fresh-cut flap was immediately laid over the stump, inflammation and ab- scesses were apt to ensue. Hence, in 1765, Sylvester O'Halloran, a surgeon at Lime- rick^was led to make the experiment of deferring laying down the flap till the end of the first eight, or twelve days after the operation, when it was conjectured that the risk of inflammation and abscesses might be abated. The tenor of Mr. O'Halloran s book is apparently corroborated by the facts brought forward. Here we see one of the grand points, insisted upon by our wor- thy countryman James Yonge, viz. the chance of an immediate union of the wound from laying down the flap without delay, suddenly given up, and because the uound could not always be healed without suppuration, it was determined that it never should do so. However, it is consolatory to find, that O'HaHoran's suggestion only now exists in the history, and not in this practice of surgery. Alexander Monro, se- nior, was a great opposer of certain me- thods, which originated among the French surgeons, and, in particular, he disapproved of tbe tourniquet : he secured the vessels with needles and ligatures ; and was the inventor of a bandage, which has been ex- tensively approved of under the name of Monro's roller. (Medical Essays of Edinb. Vol. 4, p. 2r>7.) Bromfield, like Le Dran, restricted am- putation to a few cases ; and he did nov acknowledge its necessity, as a matter of course, in every case of gangrene, much less in every instance of white-swelling, or caries. From a passage, which I have cited from Dr. Rees's Cyclopaedia, it would seem that the tenaculum was known to the ancients ; yet, according to geueral opi- nion, (and I cannot affirm that it is incorrect from any, pasv.'gc in my recollection.) AMPLIATIO-N Bromfield is allowed to be the first snrgeon who employed this very useful instrument. (Chir. Cases and Obs. Vol. 1, p. 41, Svo. Lond. 1773.) About the year 1742, the removal of thighs without bloodshed, was a subject a good deal broached. A single case, record- ed by Schaarschmid, where a mortified thigh separated without hemorrhage, was the foundation of the scheme. The arteries were completely blocked up, and tbe parts insensible. (Haller, Dis. Chir. Vol.5, p. 155.) A similar occurrence was related by Acrel (Chir. httndels.p. 557;) and Lalouette professed himself a believer in the security from hemorrhage, on account of the vessels being filled with coagula, and approved therefore of letting dead parts be removed, or rather fall off, without bloodshed. (Hal- ler, Diss. Chir. Vol. 5, p. 273.) Bagieu, an experienced French military surgeon, in cases where the projecting bone of the stump was affected with necrosis, ventured to amputate a second time, and urged a variety of arguments in defence of the practice. (Mem. de I'Acad. de Chir. T. 2, p. 274.) He coincided with Le Dran and Bromfield, however, about tbe pro- priety of restricting amputation to few cases, and has related numerous examples of limbs being saved, which, according to the doctrines then in vogue, ought to have been cutoff. (Deux Leltres d'un Chir. de VArmie, \2mo. Paris, 1750.) M. Louis, a French surgeon of extraordi- nary talents, introduced the plan of dividing the loose muscles first, and lastly those which are closely connected with the bone. This eminent man took notice, that the muscles of the thigh became retracted in an unequal degree, after being divided. Those which are superficial, and extend along the limb, more or less obliquely, without being attached to the bone, were drawn up with greater force, and in a greater degree, than others, which are deeply situated, in some measure, parallel to the axis of the femur, and fixed to this bone throughout their whole length. The retraction begins the very instant when the muscles are cut, and is not completed till a short time has elaps- ed. Hence, the effect should be promoted, and be as perfect as possible, before the bone is sawn. In the amputation of the thigh, M. Louis was always desirous of letting the muscles contract as far as they could, and, for this reason, he was rather averse to using the tourniquet, as the circu- lar pressure of this instrument rather coun- teracted what he wished to take place, and hence he at one time preferred letting an assistant make pressure on the artery, though he subsequently expressed his ap- probation of the tourniquet proposed by M. Pipelet for compressing the femoral ar- tery. (Mim. de V Acad, de Chir. Vol.4,p. 60, 4to.) Actuated by such principles, M. Louis practiced p kind of double incision different from thatof Cueselden and Petit, and diftr. ent also from Alanson's method, wb.ch. I shall hereafter notice. By the first stroke, he cut, at the same time, both the intega, ments and the loose superficial muscles; bv tbe second, he divided those muscltt, which are deep, and closely adherent to the femur. On the first, deep, circular cat being completed, M. Louis used to remove a band, which was placed round the Hob, above the track of the knife. This, was ta- ken off, in order to allow the divided mus- cles to become retracted without any im- pediment. He next cut the deep adhetaat muscles, on a level with the surface* •( those loose ones, which had been divided in the first incision, and which had now at- tained their utmost state of retraction. In this way, he could evidently saw the bone very high up, and tbe painful dissection of the skin from the muscles was avoided. M. Louis was conscious, that there was more necessity for saving muscle than skin; and he knew, that, when an incision is made at once down to the bone, the retrac- tion of the divided muscles always left the edge of the skin projecting a considerable way beyond them. Hence he deemed the plan of first saving a portion of skin, bv dissecting it from the muscles, and turning it up, quite unnecessary. As the bone should always be sawn rather higher than the division of the soft parts, Louis, like J. L. Petit, and most other judicious surgeoni, highly approved of the employment of i retractor. He was likewise the author of some valuable instructions for preventing the protrusion of the bone after the opera- tion. (See Mim. de VAcad.de Chir. 7". 2, p. 268—410, fyc. 4/o.) The impartial reader, who takes the trouble to read the remark' on amputation, published by this greatest of all the French surgeons of the last cen- tury, with the exception perhaps of J.L Petit, and Desault, will at once be impress- ed with the force and perspicuity of bh matter, and with the evident proprietyflfl good deal of the practice inculcated. .** In England, Cheselden, and not J. L.Pe- tit, is regarded as the surgeon who revuwd Celsus's method, in proposing to divide tbe soft parts by a double incision; that is,by cutting the skin and cellular substance first, and then, by dividing the muscles, dowaH the bone, on a level with the edge of ti skin, so that the bone might be sawn higbei up, and its end be more completely covered with skin. Whether Cheselden had the priority in this improvement, I cannot p* sutne to say ; but, he gave an account oft ni Gataker's translation of Le Dran's 1 "ie.?n the, operations, as early as 1 IW Was„lonS P»or to the appearance felden Pf°Sumous writings ; and Mr. O aDuren.f"rtf-r mGn«<>™, that, during StlhrdoubieSoT ^ -^ In order to hinder the stUBm fn«m < AMPUTATION 33 which sometimes happened notwithstand- ing every improvement hitherto mentioned, a circular bandage was employed, which acted by supporting the skin and muscles, and preventing their retraction. This bandage, when properly applied, from the upper part of the limb downward, fulfilled, in a certain measure, the end proposed, though many stumps yet turned out very badly. Mr. Sharp was induced therefore to revive the very ancient plan of bringing the edges of the skin together with sutures; but, the pain and other inconveniences of this method were such, that it was never extensively adopted ; and Mr. Sharp him- self ultimately abandoned it. The cross bandage, however, which he used to put over the end of the stump, remains in fa- shion even at the present day. (Treatise on the Oper. p. 216; Critical Inquiry, p. 268.) It is to be regretted, that an excel- lent modern surgeon, the late Mr. Hey, should have commended so much as he has done the use of sutures, in bringing toge- ther the edges of the wound after amputa- tion. (Practical Observations in Surgery, p. 534. Edit. 2.) In opposition to Louis, the inefficiency of his method for hindering the protrusion of the bone was asserted by Valentin, who thought the object might be better attained by dividing the parts while they were in a state of tension ; for which purpose, he re- commended changing the posture of the limb, according to the parts which he was about to cut. (Richerches Critiques sur la Chirurgie moderne, 8ro. Amst. 1772.) Va- lentin's proposal seems never to have made much impression on the profession ; whe- ther on account of its inconvenience, or inefficacy, I know not: certain it is, many cases present themselves, in which the pos- ture of a limb absolutely could not be changed during the operation, owing to the nature of the disease, or could not be alter- ed without extreme agony to the patient. At this period arose the celebrated con- troversy about the propriety of amputation in general. As Sprengel remarks, several French surgeons now began to be con- vinced, with Le Dran and Bagieu, that the operation was undertaken on too light grounds, and, in particular, that bad com- plicated fractures might be healed very well without amputation. Such was the doctrine of Boucher (Mem. de I'Acad. de Chir. T 2, p. 301,) Gervaise (Anfangsgr. der Wundarzn. 8vo. Strasb. 1755,) and Faure (Mtm. qui ont concourupour le prix de I'Ac. de Chir. Vol. 1, p 100.) The latter especially urged the prudence of delay, in gun-shot wounds, and comminuted injuries of the bones. But, (lie writer, who at this time made most noise in the world, by his general condemnation of amputation, was Bilguer, {Diss, de Membrorum Amputatione, Sro. ^ Hal. 1761,) whose sentiments have received so complete a refutation from his own contemporaries, Pott, (Chir. Works, Vol. 2,) Morand, (Opuse. de Chir. T. 1, p. -**2 N and de La Martin "ere (Mrm. de VAmd de Chir. Vol. 4, p. I,) and also from later writers, to whom reference will be made in speaking of Gun-shot Wounds. Even Bil- guer himself was compelled to admit the necessity of amputation in cases of gan- grene. (Anweis fur die Feldwundurzte, S. 170.) Bilguer's colleague, the celebrated Schmucker, inclined to the same doctrines, and has detailed several cases, where limbs were not only shattered, but actually car- ried away by balls, yet where a cure fol- lowed without amputation. One of his maxims was, that it was better for the member to be taken off by gun-shot, than by the surgeon's knife, as the ball operated on a healthy subject, the knife on a person debilitated by an hospital. (Chir. Wahrn. Th. 2. S. 493 ) In a later valuable essay on this subject, he restricts amputation to shattered limbs, affected with gangrene. His mode of operating was that of M. Louis. He sanctioned joint-operations at the hip and shoulder; but condemned those of the knee and elbow, as never answering. (Verm. Schrift. Th. 1. S. 3.) Soon after the middle of the last century, the practice of amputating at the joints be- gan to excite increased attention; but, as this is a topic, to which I must presently return, it is unnecessary now to dwell upon it. The writings of Puthod, Wohler, Bras- dor, Barbct, Sabatier, Park, Moreau, and Vennandois, in relation to this subject de- serve particular notice. I now come to Mr. Alanson, whose name cuts as great a figure in the history of am- putation, as that of any surgeon yet men- tioned. His chief objects were to hinder a protrusion of the bone, and promote union by the first intention. He rejected the band, which used formerly to be put round the limb for the guidance of the knife, as altogether useless, and an impediment to the quick performance or the circular inci- sion through the skin. When the tourni- quet had been appFied, an assistant grasped the integuments with both hands, and drew them and the muscles firmly upwards. The operator then fixed his eye upon the proper part, where he was to begin the incision, which was made with considerable facility and despatch, the knife passing with greater quickness in consequence of the tense state of the integuments. After the incision through the integu- ments, the assistant still continued a steady support of the parts, while Mr. Alanson se- parated the 'cellular and ligamentous at- tachments with the point of his knife, till as much skin had been drawn up as would, with the united assistance of the particular division of the muscles hereafter recom- mended, fully cover the whole surface oi the wound. Then, instead of applying the knife close to the edge of the integuments, und dividing the muscles in a circular per- pendicular manner down to the bone, Mr Alanson proceeded as follows-, when opera- ting upon the thigh, and standing on the out- side of the limb, he annlied the edr/e of hi- AMPLIATION knife, under the edge ol the supported inte- guments, upon the inner margin of the vastus internus muscle, and cut obliquely through rhat and the adjacent muscles, upwards as to the limb, and down to the bone, so as to lay it bare, about three or four finger- breadths higher than is usually done, by the common perpendicular circular incision. He now drew the knife towards himself, then keeping its point upon the bone, and tbe edge iu the same oblique line already pointed out for the former incision, he divi- ded the rest of the muscles in that direction all round the limb; the point of the knife being in contact with, and revolving round the bone through the whole of the division. According to Mr Alanson, the speedy execution of the above directed incision, will be much expedited, by one assistant continuing a firm and steady elevation of tbe parts, and another attending to preserve the skin from being wounded, as the knife goes through the muscles, at the under part of the limb. Mr. Alanson censures the old method of depriving tbe bone of its perios- teum to a considerable extent, above and below the part, where he saw was to pass, not only as creating unnecessary delay, but since the periosteum serves to support the vessels in their passage to the bone, as apt to produce exfoliations, above the part where the bone is to be divided with the saw. Instead of this practice, he advises first the application of the retractor, as ad- vised by Gooch and Bromfield; and then denuding the bone at tbe part, where the aw is to pass, whereby the bone may be kiu n off higher than is usually practised ; a material object in preventing a projection of the bone, and forming a small circatrix. If the flesh of a stump, formed in the thigh, agreeably to the foregoing plan, be gently brought forward after the operation, and the surface of the wound be then viewed, it may be said to resemble in some degree, a conical cavity, the apex of which is the extremity of the bone ; and the parts thus divided, are obviously the best calcula- ted to prevent a sugar-loaf stump. The part where the bone is to be laid bare, whether two, three, or four finger- breadths higher than the edge of the retract- ed integuments; or, in other words, the quantity of muscular substance to be taken out, in making the double incision, must be regulated by considering tiic length of the limb, and the quantity of skin that has been previously saved by dividing the mem- branous attachments. The quantity of skin saved, and muscular s;ibsfance taken out, must be in such exact proportion to each other, that the whole surface of the wound Mill afterwards be easily covered, and the limb not more shortened, than is necessary to obtain this end. After the removal of the limb, Mr. Alan- son drew each bleeding artery gently out with the tenaculum, and tied it as nakedly as possible, with a common slender ligature. When the large vessels had been tied, the tourniquet was immediatelv slackened, and the wound well cleaned, in order to detec* any vessel, that might otherwise have re- Lined concealed with its orifice blocked iTpw.lh coagulated blood ; and before the wound was dressed, its whole surface was examined with the greatest accuracy, by which means Mr. Alanson frequently obser- ved a pulsation, where no hemorrhage previously appeared, and turned out a small clot of blood from within the orifice of a considerable artery. He urges bestowing particular attention in making every vessel secure which is likely to bleed on the at- tack of the symptomatic fever ; for besides the fatigue and pain, to which such an ac- cident immediately exposes the patient, it seriously interrupts the desired union of the wound." He used always to clean the whole surface of the wound well with a sponge and warm water, as he thought, that the lodgment of any coagulated blood would be a considerable obstruction to a quick union of the parts. The skin and muscles were now gently brought forwards ; a flannel roller was pal round the body, and carried two or three times rather tightly round the upper part of the thigh, as at this point, it was intended to form what Mr. Alanson called a sufficient basis, which materially added to the support of the skin and musles. The roller was then carried down in a circular direction to the extremity of the stump, not so tight u to press rudely or forcibly, but so as to give an easy support to the parts. The skin and muscles were now placed over the bone, in such a direction, that the wound appeared only as a line across tbe face of tbe stump, with the angles at each side, from which points, the ligatures were left out, as their vicinity to either angl' might direct. The skin was easily secured in this posture by long slips of linen, or lint of the breadth of about two fingers, spread with cerate, or any cooling ointment, li the skin did not easily meet, strips of stick- ing plaster were preferred. These were applied from below upwards, across tbe face of the stump, and over them a sof tow-pledget and compress of linen; the whole being retained with the many4«W bandage, and two tails placed perpendh* larly, in order to retain the dressings ijm the face of tbe stump. * • Mr. Alanson censured the plan of raiswf the end of the stump far from the surface of the bed with pillows, as the post# muscles were retracted by it; and he«J» sidered it best to raise the stump abootl* a bands breadth from the surface of the H i>y which means the muscles were putin«« easy relaxed position. The raany-UiW bandage Mr Alanson found much W# fv ns«l ""r than the woo,len caP> f*r** Ls anrl fPrmevrtim« to support tlied**- eems well ,ob*erves> tha* thouSh ,hi nose if n tCa,CU,ated toa»swer thatpoM Sr.ii^.je?."" with. ParticularS lackvE the skin .9 liable to be. drawn back*7 from the face of the stumn • n wound be dre«ed. withJn?hrTy,™1 3dH 1 AMPUTATION. 86 the stump to remove the cap. (See Alanson's Practical Obs. on Amputation, Svo. Lond. 1779.) The chief peculiarity of Alanson's me- thod of operating, namely, the mode in which he recommends theoblique division of the muscles to be performed, did not, however, meet with universal approbation, and his extensive dissection of the skin from the muscles was complained of as exces- sively painful. The formation of a conical wound, by following Alanson's directions, was regarded by several as impracticable. (See Marten's Paradoxieen, B. 1. S. 88; Loeffier, Beytrage 1. No. 7; Wardenburgh, Briefe Eints Arztes 2. B p. 20; Richter, Anfangsgr. vol. 7 ; Graefe, Normen, fyc. p. 8; Hey. Pract. Obs.) In my opinion, there can be no doubt of the truth of some of the criticisms made by these, and some other writers, on the impossibility of making a wound, with a regular conical cavity, by observing the directions given by Alanson ; for, if the knife be carried round the member with its edge turned obliquely upwards towards the bone, it will pass spirally, and, of course, the end of the incision will be considerably higher, than tbe beginning. But, although Alanson pro- bably never did himself exactly what he has stated, 1 am sure, that his proposition of making an oblique division of the mus- cles all round the member, has been the source of great improvement in amputations in general, and is what is usually aimed at by all the best modern surgeons. It is true, they do not actually perform the oblique incision all round the limb, by one stroke, or revolution of the knife round the bone, as Alanson says that he did ; but, they ac- complish their purpose by repeated, distinct, aud suitable applications of the edge of the instrument, turned obliquely upwards towards the bone, or bones. Among others, Mynors found fault with some of Alanson's instructions, and thought every desideratum might be more certainly attained by saving skin enough, and then cutting through the muscles. The first incision, however, he directs obliquely up- wards through the iuteguments, while they were drawn up by an assistant, and he then cut down to the bone. (Pract. Thoughts on Amputation, 8vo. Birmingh. 1783.) Spren- gel considers Mynors's plan mereley as a revival of Celsus's method, as it had in view only the preservation of skin, and not the formation of a fleshy cushion. (Gcs- chichte der Chir. B. I. p. 426.) Kirkland endeavoured to improve My- nors's plan, by cutting off a piece of skin at each angle of the stump, so as to keep the integuments from being thrown into folds ; and, in opposition to Pott, he de- fended the sentiments of Bilguer concerning the successful management of desperate cases, without amputation (On the present State of Surgery, p. 273, and Thoughts on Amputation, 8vo. Lond. 1780.) B. Bell used to operate very much in the ^nmc way as Mynors: and, when it seemed advantageous to make a flap, he did not disapprove of the plans suggested by Rava- ton, Verduin, and Alanson. (Syst. of Sur- gery) An interesting paper on amputation was some years ago published by Loder; its chief purport was to defend Alanson's me- thod, with some slight modifications. (Chir. und Medic. Beobacht. B. l.'p. 20. 8vo. 1794.) However, the alterations suggested by Lo- der, do not seem to Graefe at all adequate to the removal of the difficulties, with which the mode of cutting the flesh exactly after Alanson's directions is complicated. (Nor- men far die Abl. grosserer Gliedmassen, p. 8, 4/o. Berlin 1812.) The removal of limbs without bloodshed, proposed by Guido di Cauliaco in the 14th century, has met with modern defenders in J. Wrabetz and W. G. Plouquet. J. Wra- betz, with a ligature which was daily made tighter, took off an arm above the elbow. In the fissure, he sprinkled a styptic powder. On the fourth day, the flesh was severed down to the bone, which was sawn through. (Geschichte eines ohne Messer abgesetzten Oberarms. 8vo. Freyb. 1782.) Plouquet thought the plan suited to emaciated timid subjects ; but not well adapted to the leg, or forearm. (Von der unblutigen Abnehmung der Glieder,8vo. Tub. 1786.) Some other modes of doing flap amputa- tions, and in particular, the suggestions and improvements, made by Hey, Chopart, Dupuytren, Larrey, and other modern practitioners, will be noticed in the descrip- tion of the amputation of particular mem- bers. In the mean time, I shall conclude this section with mentioning the laudable attempts madeat different periods, to render the patient less sensible of the agony pro- duced by the removal of a limb. Theodori- cus, as we have said, administered for this purpose opium and hemlock, and though he was imitated by many of the ancient surgeons, few moderns have deemed the practice worthy of being continued. Guido made the experiment of benumbing the parts with a tight ligature ; but a machine, devised a few years ago in England, ex- pressly for the object of stupifying the nerves of a limb previously to amputation, is perhaps not undeserving of further consi- deration. (See ./. Moore's Method of pre- venting, or diminishing Pain in several Operations of Surgery, 8vo. Lond. 1784.) The great reason of the latter plan being given up, is, that some patients have made more complaint of the sufferings occasioned by the process of dulling the sensibility of the nerves, than of the agony of amputation itself, without any such expedient. Yet, daily experience proves, that the pressure caused on the sciatic nerve by sitting with the pelvis in a certain position, will com- pletely benumb the foot and leg, and this with such an absence of pain, that the per- son so affected is actually unaware of his foot being asleep, as it is termed, until he tries to walk. On the little g-od done by warming and oiling i- <• rutting instrument5, St AMPUTATION a. method recently much commended, (Faust und Hunold aber die Aim uidung des Oehls und der Warme, p. 3-23, Leipzig, 1806,) I am sure it is unnecessary for me to com- ment. AMPUTATION OF Till THIGH. The thigh ought always to be amputated as low as the disease will allow, so that as little of the limb may be cut off as possible, the pain may not be greater than necessary, and the surface of the wound have less ex- tent than would otherwise happen. (Saba- tier, Med. Ob. p. 350. /. 3. Ed. 2.) The pa- tient is to be placed on a firm table, with his back properly supported by pillows, and assistants, who are also to hold his hands, and keep him from moving too much du- ring the operation. The ankle of the sound limb is to be fastened, by means of a strong band, or garter, to the nearest leg of the table. Here, however, through an imprudent solicitude to obtain the above advantages, let not the surgeon ever be unmindful of the great axiom in surgical operations, that all the diseased parts should be removed ; but, let him be assured of the truth of what Graefe inculcates, that it is more pardona- ble to cut away too much, than too little. (Normenfttr die Ablosung grosserer Gliedm. p. 60.) At the same time I do not agree with some modern writers, who deem it necessary to amputate beyond the limits of every abscess and sinus, which may extend very far above a diseased joint, or com- pound fracture. Many of these suppura- tions arc only like ordinary abscesses, and finally get well, after the main disease or injury is removed, as I have often seen. Were it an invariable rule to cut off a limb, above every collection of matter, some- times five, or six inches more of the thigh would be sacrificed, than circumstances ab- solutely demanded, and the greater danger of a high, thau a low operation, would be encountered. However, in all cases, v here the bone is suspected to be unsound, or the muscles arc effected with the morbid chan- ges, peculiar to fungus haematodes, or other incurable diseases, the operation should be practised sufficiently high to take away all the distempered parts. In secondary am- putations, where there has been much sup- puration in the limb, and a sinus runs up, Mr. Guthrie says, that if tbe sinus extend only a short way betw een the muscles, the membrane lining it may be dissected out ; but, if the matter has lain upon the bone, this will have become diseased, and ampu- tation should be done high enough to re- move the affected part of it. (On Gunshot Wounds, p. 87.) Many writers disapprove of amputating too close to the knee (Graefe, Op. cit. p. 60;) and Langenbeck urges one objection to il, not specified by any other author, viz. that, if the operation be done lower down than two hand-breadths above the '■<-n*i: the femo-al arterv shrink into the aponeurotic sheath, which it here receives from the vastus internus and triceps, and cannot be drawn out with the forceps so ™o be separately tied, without first slit tine up that sheath. Hence, he recom- mends cutting through tbe muscles at the distance above the knee already mentioned. (Bibl fnr die Chir. B.\,p. 571, 12mo. Gott. 1806.) But when I come to look at the breadth of two adult hands, and see how much of the limb would be sacrificed, at all events, only to save a little trouble, I cannot bring my mind to concur with Lan- genbeck, the remedy being worse than the evil alleged. The next thing is the application of the tourniquet. (See Tourniquet.) The pad should be placed exactly over the femoral artery, in as high a situation as can be con- veniently done. When the thigh is to be amputated high up, it is better to let an as- sistant compress the femoral artery in the groin, with any commodious instrument, furnished with a round blunt end, calcula- ted for making direct pressure on the ves- sel without injuring the integuments.— Some authors indeed give a general pre- ference to this method, whether the thigh be amputated high up, or low down, eicept where skilful assistants are not at hand, (Parouse, Opuscules de Chir. p. 188. Bran- ninghausen, Erfahr. tiber die Amp. p. 273. Langenbeck, Bibl. Chir. p. 564.) Were the patient, however, in a debilitated state, and unable to bear loss of blood, as there might, in this way, be some considerable bleeding, by reason of the anastomoses with the branches of the internal iliac artery, I should feel disposed to employ the tourni- quet whenever circumstances would admit of its application. In amputations of the thigh, the great objection to the use of this instrument, is, that it impedes the free and immediate retraction of the loose muscles after they have been cut, the consequence of which is, that the surgeon cannot divide so high, as he otherwise could do, those deeper muscles which are more fixed and attached to the bone. Yet, in order to have the bone well covered with flesh, and no danger of a sugar-loaf stump, the latter ob- ject is one of infinite importance. Perhaps the best general rule is, to abandon the ap- plication of the tourniquet in amputations, done as high as the middle of the thigh, except where the patient is remarkably' weak, so that he cannot bear the smallest oss of blood, and there is no steady intel- ligent assistant at hand, to whom the com- pression of the artery in the groin can be prudently confided. When, however, the operation is to be done much higher up, of whnfil !ne .en!P»°yment of a tourniquet is wholly inadmissible remov^S"/^ fight °r ,eft thiSh is t0 be toTam?o„t,,8i,C,ISt0.,naryfor th« °P«*ator great advantae ^T''5 ri&ht "*>. The great advantage of this situation seems to be, that the surgeon's left hand can £ th£ more conveniently, and quicklv h^nSr"- m»o n,e. than if he were ahvav? t0 ^T AMPUTATiOJS. &7 on the same side, as the limb he is about to amputate. This seems to be the only assignable reason for th.s habit: for, when the left thigh is to be amputated, it is cer- tainly some inconvenience to have the right limb, between the operator, and the one that is to be removed. But this is found less inconvenient, than not having the left hand next tbe wound. Mr. Guthrie, in speaking of amputations on the two lower thirds of the thigh, ob- serves, that " in these cases the tourniquet should be used ;" but in operations high up the thigh, he joins all other surgeons in re- commending the inguinal artery to be com- pressed against the os pubis. (On Gunshot Wounds, p. 202.) The utility of slackening the tourniquet completely, however, as soon as the principal vessels are secured, a piece of advice delivered by this excellent surgeon, I presume, cannot be right on the ground, which be specifies, viz. the impe- diment made by the strap of the instrument to the retraction of the muscles, and the consequent difficulty in high operations of sawing the bone, because in common prac- tice, the bone is always sawn before any of the vessels are secured; and loosening the tourniquet entirely, while any arterial branches still require the ligature, must ge- nerally be objectionable, if loss of blood be a disadvantage. In flap-amputations, high up the limb, indeed, where the arte- ries are sometimes tied, before the division of the bone, the employment of a tourni- quet at all is quite out of the question. We know that it was an opinion of the late Mr. J. Bell, that the flow of blood through a large artery could not be com- pletely stopped by pressure ; and Mr. Hey of Leeds adopted a similar notion, in con- sequence of seeing a case, in which the ap- plication of two tourniquets to the thigh did not restrain the hemorrhage from a fungus hamiatodes of the limb. He says; the pressure of the tourniquet does not completely obstruct the passage of blood in the arteries ; it only diminishes so much of the force of the current, as to enable the vessels, in a sound state, to exert their natural contractile power so effectually as to prevent hemorrhage. (See Hey's Pract. Ob.p. 257. 258, Ed. 2.) Of the inaccuracy of this doctrine, no man can doubt, who pees the femoral artery with its open mouth on the face of a slump not bleeding, while the tourniquet is tight, or skilful pressure is kept up, but throwing out its blood to a great distance, the instant the pressure is discontinued. Nor, I apprehend, can any surgeon, who has amputated at the shoul- der, and seen how completely pressure commands the flow of blood through the open-mouthed axillary artery, join in the sentiment of John Bell and Hey upon this particular point. Here 1 can speak with confidence, because I have myself amputa- ted at the shoulder, and assisted at this operation several times, and found the statements of the preceding writers per- fectly and clearly contradicted. Were any further testimony required, I might cite that of Dr. Hennen, who mentions, among other facts, that in a shoulder joint case operated upon by Mr. Dease, the amount of blood, lost from the principal artery, was no more than the quantity contained between the point of pressure, and the point of incision through the vessels. (Principles of Military Surgery, p. 257, Ed. 2.) The same fact presented itself in the example, where I recently assisted Dr. Blicke, in private practice. How then are we to explain the occa- sional continuance of bleeding, notwith- standing the pressure of one, or even two tourniquets ? Without doubt, "by the fact, that the pads of these instruments, when not duly arranged, do more harm than good, by raising the band off the vessel, and, perhaps also in Mr. Hey's example, by the additional consideration, that tumours of the fungus haematodes kind, include a large quantity of blood, and will bleed pro- fusely, and for a considerable time after the main supply of blood to them is cut off. The same thing happens in the dis- ease, called aneurism by anastamosis, as I have had several opportunities of witness- ing, but in no instance more strikingly, than in one, where, some time after Mr. Hodgson had tied the radial and ulnar ar- teries, Mr. Lawrence divided every part of tbe finger, excepting the tendons and bone, and yet a considerable bleeding went on from the further side of the wound. (See Jlfed. Chir. Trans, vol. 9, p. 216.) The application of the tourniquet is gene- rally left too much to assistants; but, as far as my judgment extends, no operator is justified in commencing bis incisions, before he has examined and fully satisfied him- self, that the instrument is correctly appli- ed. Mr. Guthrie candidly tells us, that he once lost an officer, in consequence of he- morrhage during the operation, although the tourniquet was in the charge of a sur- geon of ability ; and the advice with which he follows this statement, is worth recol- lecting : " In a case of this kind, where it (the tourniquet) is found of little benefit, the surgeon should not continue twisting and turning it, whilst his patient is bleeding, but quit it altogether, and compress the artery against the pubis." This maxim, I think, cannot be too highly commended. The shape and size of the pad of the tourniquet are deemed by surgeons matters of importance. At St. Bartholomew's, the pads employed are very firm, being compo- sed of wood, or cork covered with leather, and rather thicker than the thumb, the up- per surface being flat, and the lower, which is put against the thigh, being convex. They are about an inch and a half in length. Such pads answer extremely well, as I can affirm from the observation of some hun- dreds of amputations in that hospital. A common fault formerly was the employ- ment of pads which were too large, and soft, and not judiciously shaned. As Mr, bS AMPUTATIO> C. Hutchinson remarks, the principal ob- jection to a large pad is, that the band of the tourniquet is so much raised by it, that a considerable space is left on each side of it, where no compression is made on the limb, however closely the instrument may be screwed, and thus there will be a risk of hemorrhage from such vessels as happen to be in these situations. The same gentle- man uses a pad, which is not thicker than a finger, and places it obliquely over the artery, so as to preclude the possibility of displacement. (Pract Obs. in Surgery, p. 21-23.) Mr. Guthrie says, " the pad should be firm and rather narrow, and carefully held directly over the artery, while the ends of the bandage, in which it is con- tained, are pinned on the thigh. The strap of the tourniquet is then to be put round the limb, the instrument itself being direct- ly over the pad, with the screw entirely free. The strap is then to be drawn tight, and buckled on the outside, so as to pre- vent its slipping, and not interfere with the screw, which is to be turned until the pres- sure is sufficiently strong to stop the circu- lation. If the screw require to be turned, for more than half its number of turns to effect this, the strap is not sufficiently tight, or the pad has not been well applied ; and they must be replaced." (On Gunshot Wounds, p. 204.) In two amputations at St. Bartholomew's Hospital, I saw the tourniquet break after the soft parts bad been divided, and, as in one of these cases a good deal of blood was lost, because another tourniquet happened not to be in the room, and pressure on the ar- tery in the groin was not immediately adopt- ed, 1 coincide with such writers, as recom- mend the rule of always having two tourni- quets ready. Graefe even goes so far as to ad- vise putting both of them round the limb before the operation commences. (Nor- men fur die Ablosung grosserer Gliedmassen, p. 48;) but, the frequency of a tourniquet breaking is not so great, I believe, as to de- mand such precaution, and the plan would be very objectionable in thigh amputations, where it is a material advantage to have plenty of room between the place of tbe incision and the band which goes round the limb. An assistant, firmly grasping the thigh with both hands, is to draw upward the skin and muscles, while the surgeon, beginning with that part of the edge of the knife, which is towards the handle, makes a cir- cular incision, as quickly as possible through the integuments down to the fascia, or, as Mr. Guthrie and Dr. Hennen recom- mend, even complelely through it. Accord- ing to Mr. Guthrie, the b"t takes care, after making the cutaneous inr;s;0n, to have the integuments, and sibJaSr AMPUTATION'. 8y flesh very firmly drawn up before commen- cing the oblique division of the muscles. This retraction he also strongly advises to be done uniformly and smoothly all round the member, lest, in dividing the muscles, any irregular projection of the skin interfere with the requisite movements of the knife. (Normenfur die Alb. grosserer Gliedmassen. p. 103.) However, Langenbeck, another of the most skilful operators on the conti- nent, prefers detaching the integuments from the fascia for about two finger-breadths. (Bibl. fur die Chir. 6.1. p. 567.) as is perhaps the most common practice in the London hospitals. Brilnninghausen thinks skin a better and more durable covering for the end of the bone, than muscular fibres, which after a time dwindle away, and hence he computes the quantity of integuments which ought to be saved, by the measure of the circumference ajid diameter of the member. Thus, when the limb is nine in- ches in its circumference, the diameter is about three : therefore, one inch and a half of skin on each side is to be saved. (Er- fahr. fyc. Uber die Amp. p. 75.) But this author cuts the muscles perpendicularly, so that he is obliged to separate much more skin from the flesh than is necessary, when the incision through the muscles is carried obliquely upward. Mr. Hay's method of calculation, which I shall presently notice, appears more adapted to ordinary practice; and he says, " the division of the posterior muscles may be begun at half an inch, and that of the anterior, at three quarters, above the place where the integuments were di- vided." (Pract. Obs. in Surgery, p. 528, Ed. 2.) With a view of preventing the ne- cessity of dissecting the skin from the fascia, Mr. Guthrie, as already noticed, commends the plan of cutting through the fascia, to- gether with the integuments by the first stroke of the knife, and retracting these parts at the same time, instead of detaching them from each other. If this method be found perfectly efficient, and it be not ob- jectionable, as exposing the muscles to be cut unnecessarily. I think the reason spe- cified against it by Langenbeck, and ex- plained in a preceding page, not weighty enough to form a just ground for rejecting a practice, which conies with the alleged advantage of superseding the necessity for all painful dissection of the skin from the muscles. However, in secondary amputa- tions of the thigh, if the integuments be unsound, and will not retract, Mr. Guthrie approves of their being dissected back to an equal distance all round. (On Gunshot Wounds, p. 205—208.) Dr. Hennen, by giving an oblique direction to all the inci- sions through the muscles, obviates the necessity for much dissection of the integ- uments, and, he says, that, in a small limb, he has repeatedly performed the operation with one sweep of the knife, cutting ob- liquely inwards and upwards at once to the bone. (Principles of Military Surgery, p 265, Ed. 2.) This author, like Mr. Guthrie, also recommends carrying the knife through Vox. I. 12 the fascia in the first circular incision ; and so does Mr. C. Hutchinson, who makes no mention of dissecting back the skin, but simply states, that the " integuments and fascia being divided by a circular incision, aud retracted upwards, as high as is judged necessary, the superficial muscles should next be divided, &c." (Pract. Obs. in Sur- gery, p. 23, 8vo. Lona. 1816.) We are therefore to conclude, that he joins Graefe and others in thinking the separation of the skin from the fascia unnecessary. My own observations in practice, lead me to believe. that the dissection of the integuments from the subjacent parts used formerly to be carried to an extent beyond all moderation and necessity, and that as it is a most pain- ful proceeding, and hurtful by forming a large loose pouch for the lodgment of mat- ter, it ought to be abandoned by every sur- geon, who follows the method of sawing the bone considerably higher, than the first cut through the superficial muscles. I am not, however, prepared to assert, that no dissection at all is generally requisite, but am rather disposed to believe the moderate adoption of it, as recommended by Mr. Hey, the most prudent. This gentleman, like Desault, (CEuvres Chir. T. 21, p. 545.) is an advocate for amputating with a triple incision, and for preserving such a quantity of muscular flesh and integuments, as are proportionate to the diameter of the limb. By a triple incision, he means first an in- cision through the integuments alone ; se- condly, an incision through all the muscles, made somewhat higher, than that through the integuments ; and thirdly, another in- cision through that part of the muscular flesh, which adheres to the bone, made round that point of the bone, where the saw is to be applied. The proper distance of these incisions from each other, he says, must be determined by tbe thickness of the limb, upon which the operation is to be performed ; making allowance for the re- traction of the integuments, and of those muscles which are not adherent to the bone. Supposing the circumference of the limb to be twelve inches, where the bone is to be divided, the diameter is about four in- ches, and, if no retraction of the integu- ments were to take place a sufficient co- vering of the stump would be afforded by making the first incision at the distance of two inches from the place where the bone is to be sawn, that is, at the distance of the semidiameter of the limb on each side. But, as the integuments, when in a sound state, always recede after they are divided, it is useful to make some allowance for this recession ; and to make the first incision, in this case at least two inches and a half, or three inches, below the place where the bone is to be sawn. As the posterior mus- cles of the thigh retract a great deal in the process of healing, Mr. Hey advises their division to be begun half an inch above the place where the integuments were cut, and the anterior muscles three quarters of an inch. The integuments, says he, will au AMPUTATION retract a little both above and below the place, where they were divided ; but, the distance from that place must be computed from the mark left upon the surface of the muscles in dividing the integuments. Thus, in fact, in a common thigh amputation, Mr. Hey deemed it necessary to detach the skin from the muscles merely to the extent of half an inch at the back part of tbe limb, and of three quarters in front: a very different practice from the old custom of making quite a bag of integuments, and turning them back, like the upper piece of a glove is turned down, or rather as the sleeves of a coat are turned up. In common amputations of the thigh, Roux strongly disapproves of separating the skin far from the muscles, as a circum- stance highly unfavourable to the healing of the wound by adhesion ; he divides only a few of the cellular bonds between the integuments and fascia ; and occasion- ally he bas imitated M. Louis in Gutting through the skin, and superficial muscles together. (Mem. sur la Reunion de laplaie apres V Amputation, fyc.p. 9.) I believe the generality of the best mo- dern operators are now convinced of the impropriety of dividing the muscles ex- actly in the manner directed by Mr. Alan- son, viz. by letting the knife revolve unin- terruptedly all round the bone with its edge turned obliquely upwards, towards the point where it is intended to apply the saw. It is a topic, indeed, to which I have already called the reader's attention in the foregoing columns. Langenbeck says, that he is perfectly convinced of the impossibi- lity of forming a conical wound with one stroke of a large amputating knife, and joins Mr. Hey in approving of the triple incision. (Bibl. fur die Chir. b l,p. 564.) The objections first urged by Wardenburgh against Alanson's method, are mathemati- cally correct, inasmuch as the course of the edge of the knife, in this gentleman's method, must be spiral, and the end of tbe incision be considerably higher, than the beginning of it. Such must be the result of performing the division of the muscles all round the limb by one continued stroke of the knife, with its edge directed ob- liquely, upwards; for the idea of making the knife revolve in this manner, while its point is confined to an imaginary, regular, determinate circle on the bone, I believe is now abandoned, as not really practicable. Yet, with the exception of Desault, who confined himself to the triple incision, conducted on the principles of M. Louis, (QHuvres Chir. T. 2, p. 647,) few experien- ced surgeons refuse to acknowledge, that, in this operation, immense advantage does proceed from the oblique division of the muscles, the honour of bringing which me- thod into practice, Mr. Alanson still un- questionably merits, however he may have erred in recommending the conical wound to be made with one sweep of the knife Nor are there many living surgeons, who entertain a doubt of the excellence of the principle, inculcated by M. Loins, respeef. ing the utility of dividing the loose super. ficial muscles first, and then such as are deeper and adherent to the bone. In fact, a combination of this last method, with the oblique division of the muscles, not exactly by one. but several strokes of the knife, constitutes the mode of amputating at pre- sent most extensively adopted, and some- times termed, as already mentioned, anno- tation by a triple incision. Thus, after the skin is cut, and as much of it retracted and saved as is deemed necessary, the operator next cuts through the loose muscles of the thigh, at the edge of the retracted skin, first those on the forepart of the limb, and then sucb as are situated behind. For this pur- pose, he makes two, or more sweeps of the knife as may be found necessary, carefully directing them obliquely upwards toward the point, where he means to saw the bone. The oblique division of the muscles does not merely enable the operator to saw the bone higher up than he could otherwise do, and leaves at the same time more muscle covering its extremity, but it is a preserva- tion of sound undetached integuments, which assuredly form the most efficient and durable covering for the stump. I say this, without precisely coinciding with Brunninghausen, who trusting entirely to skin for covering his stumps, makes an ei- tensive detachment of it from the muscles, and then cuts straight down to the bone. The loose muscles, actually cut through, now retract considerably, leaving those which are deeper and attached to the bone, in a condition to be cut higher up, than could have been previously done. Lastly, these are also to be divided by the edge of the knife directed obliquely upwards to- ward the place, where the saw is to be ap- plied. Some operators do more than this, for after cutting down to the bone, they follow the plan of Celsus, and detach the flesh from its whole circumference upwards with a scalpel, to the extent of about ano- ther inch, in order to be enabled to saw the bone still higher up. " Inter sanam ri- tialamque partem incidenda scalpello, can usque ad os, reducenda ab eo sana can, tl circa os subsecanda est, ut ea quoque partt aliquid ossis nudetur." This method, I think, deserves commendation, because it may have considerable effect in hindering a protrusion of the bone, if it does not, in conjunction with the foregoing method of operating, and judicious dressings, ren- der this disagreeable event quite impossible. As long as I live, however, I shall never Lrlg6. a*P?°.r so,dier, whose thigh had been amputated m Bergen-op-Zoom, and who was bought about ten days after the ope- bo eh nt° the military bosPital atOuden- un on nrnder my care- N°t the slightest Place BKny Part ?f the wou"d had taken fascia'on SSCS •hJBd 2>rmed ""der * lasua on every side of the stuDH). the loose skin was literally a large D""Jf' % uent matter; the muscles were ^jRo a.mostnothing,and1heirremaT„^eTrai«, AMPUTATION. 91 and shrinking still further away from the With respect to Desault's method of am- extremity of the bone, which protruded at putating the thigh by a circular incision, least three inches beyond the soft parts, already mentioned, he considered turning This unfortunate man had been attacked the knife obliquely upwards quite unneces- with chronic tetanus soon after the opera- sary : his plan was to cut through the mus- tion, and, probably, it was to the distur- cles, layer after layer with the precaution bance of the stump by the effects of thai of retracting the first stratum before he di- disease, and to the strong and continual vided the second : the latter was then cut tendency of the muscles to retract them- through on a level with the flesh that had selves, induced by this state of the system, been previously divided and retracted; and the deplorable state of the stump was to so on down to the bone. This, says he, 1V1 be attributed. He lingered nearly a fort- the right way of forming a true hollow cone, night in the hospital before he died, pre- of which the integuments, which were viously to which event large abscesses, drawn up before the muscles were cut, form communicating with the hollow of the the base, from which are gradually continu- stump, surrounded the greater part of the ed the various layers of muscles, and fhe pelvis. As I had every reason to believe highest point of which is the bone itself. that the operation had been skilfully done, Desault owns, that this method is somewhat perhaps when I say that the above mode of tedious and painful: but, in his opinion, amputating will make a protrusion of the these disadvantages are more than counter- bone impossible, it is not exactly correct, balanced by the benefits procured for the as the occurrence may sometimes originate patient. ((Em-res Chir. de Desault par Bi from causes, which are quite independent of chat, T. 2. p. 547.) the particular way, in which the operation Having cut all the muscular fibres on has been executed. every'side, down to the bone, a piece of The practice of detaching the bone from linen, somewhat broader than the diameter the circumjacent flesh to the extent of of the wound, should be torn at one end, about an inch, after the other principal in- along its middle part, to the extent of cisions are completed, as advised by Celsus about eight or ten inches. This is called a and Louis, 1 have sometimes seen done at retractor, and is applied by placing tbe ex- St. Bartholomew's Hospital, and have prac- posed part of the bone in the slit, and tised myself on other occasions, with the drawing the ends of the linen upward on decided advantage of letting the bone be each side of the stump. In this manner, sawn higher up, than could otherwise have the retractor will obviously keep every part been effected. Mr. Guthrie, after the inci- of the surface of the wound out of the sious are carried down to the bone, even way of the saw. Graefe thinks, that, in recommends dissecting back the muscles amputations of parts, where there is only from it "for the space of two, or three in- one bone, the unslit portion of the linen ches, as the size of the limb, or other cir- should always be applied over the anterior cumstunces may require ;" but, I should be muscles, as these ought constantly to be reluctant myself to imitate the practice to most evenly kept back, so that no projec- this extent, though inclined to think most tion of them may interfere with the action favourably of it within more moderate of the saw. (Normeii fur die Ablosung limits. If we reckon that three inches of grosserer Gliedm.p. 105.) This is a prefe- the member lie between the first circular rence, however, which may not be of great cut in the skin and the place, where the importance, though I confess, that there knife arrives at the bone, and then take appears some reason in what Graefe has away two or three inches more of the fe- stated. That meritorious surgeon, J. L. mur, it is clear that, in many examples, we Petit, whose name I always mention with should be getting very high up the limb, pleasure, strongly commends the use of and, if a detachment of the muscles from the retractor, tbe ends of which he drew the bone to the extent of two or three in- over the anterior muscles : he says, that he ches were thus made, it would at all events has employed this simple and natural be of no service, unless the bone would means, but, that it did not suit the taste of admit of being sawn at this great distance every body, especially of those who con- from the termination of the oblique divi- sider all the merit of an operation to consist sion of the muscles. However, if this in the quickness of its performance, or who were truly practicable (a point, which I think it satisfactory reasoning to say, this is leave for others to discuss) it would certain- not their way. (Traite des Mai. "chir. T. ly be consonant to the excellent general 3, p. 152.) I have seen the saw do so much maxim, laid down by J. L. Petit, that in mischief, in consequence of the operator amputation as much of the bone, and as neglecting to use the retractor, that my con- little of the flesh, should be taken away as science obliges me to censure such sur- possible. (See Traite des Mai Chir. T 3. geons as neglect to defend the soft parts by p. 15t>.) When this final detachment of this simple contrivance. There are some the deep muscles from the bone is adopted, who have rejected the use of the retractor, particular care, as Roux observes, should because they have seen it get under the be taken always to divide the thick aponeu- teeth of the saw, and obstruct the r.ction of ro.si<, connecting the triceps to the linea the instrument; but, this very circumstance aspera. (Mem. sur la reunion de la Plaie adduced against the retractor, is, when con- nprts I'Amputnlion. p. 10.) «idered. the stroD?e?t one that could possi ;x- ASXPOTAIltiS- hly be brought forward in its favour, as the surface of the wound itself, and particularly the edges of the skin, would, in all proba- bility, suffer the same fate as the linen, by getting under the teeth of the saw, if no re- tractor were employed, in attempting to saw the bone high up, as closely as possible to the soft parts. I think no one can urge any, but the most frivolous objections to ing of blood, to hit with the saw the pre, cise line at which the remains of the pen- osteum terminate; and, in confirmation of the safety of Petifs practice, Mr. Guthrie's experience may be adduced, who says "I have often sawn through the bone, without previously touching the periosteum, and the stumps have been as soon healed, and with as little inconvenience, as any others." the use of the retractor; and 1 "know, that (On Gun-shot Wounds p. 88.) A very mo- many who have been with myself eye-wit- dern author, impressed, like many others, nesses of the mischief frequently done by the saw in amputations, are deeply impress- ed with an aversion to the neglect of this bandage. I have often seen the soft parts skilfully divided, and I have, in these some instances, seen the operators, directly after- wards, lose all the praise, which every one was ready to bestow, by their actually saw- ing through one half of the ends of the muscles together with the bone. Men who have had fortitude not to utter a sigh, nor to let a groan be heard, in the previous suf- ferings, have now had their involuntary cries extorted from them by unnecessary, unjustifiable torture. But, besides defend- ing the surface of the stump from the teeth of the saw, the retractor will undoubtedly enable the operator to saw the bone higher up, than he could otherwise do. Another proceeding, which seems fit for reprobation, and which, indeed, Mr Alan- son very properly condemned, is the prac- tice of scraping up the periosteum with the knife, as far as the muscles will allow. Nothing seems more probable, than that this may be the cause of the exfoliations which occasionally happen after amputa- tions. At all events, it is a superfluous, use- less measure, as a sharp saw, such as ought to be employed, will never be impeded by so slender a membrane as the periosteum. All that the operator ought to do, is to take care to cut completely down to the bone, all round its circumference. Thus a circu- lar division of the periosteum will be made, and upon this precise situation the saw should be placed. This is the method which was approved of by J. L. Petit. (Traite" des Mai. Chir. T. 3, p. 159.) It is what I have always done and recommended; yet, it must be confessed, that differences of opinion prevail about the necessity, and modes of dividing the periosteum. Graefe, in common with several others, entertains considerable apprehension of the effects of the periosteum being torn and lacerated by the saw, exfoliations of the bone and ab- scesses up to the joint being possible con- sequences of the rude separation and in- flammation of this membrane. Hence, he is an advocate for making a circular cut through at the place where the saw is to be applied, and then scraping away all below this point in the direction downwards. (Normen fur die Abl. grosserer Gliedm. p. 265, and 105.) Perhaps, no very great ob- jection may lie against this mode, which is not uncommonly followed, though I have some doubts of its real utility, a it scarcely *eciD9 practicable, in the midst of the ooz- with the fear of tearing the periosteum with the saw, differs from them in thinking it best to scrape the periosteum upwards, by which means, he says, that at least half an inch of this membrane, and a proportionate quantity of muscular fibres, may be pre- served for covering the end of the bone, inasmuch as the muscular fibres, adherent to the periosteum, will remain connected with it; an advantage, which this author deems very important while the edges of the bone are sharp. In amputation below the knee, he considers the method highly useful, as the sharp edge of the tibia may be not merely covered with skin, but pe- riosteum, and the cellular membrane con- nected with it. Since his adoption of this practice, he assures us, that he has not for a very long time seen any exfoliation of the tibia, and never any protrusion of the bone of a stump. (Brunninghausen Erfahr, fyc. uber die Amp p. 65. 66. 8»o. Bomft. 1818. Such are the sentiments of a gentle- man who has published a valuable tract on amputation, as well as some other works of deserved reputation. His opinion is un- questionably the reverse of what is mostly prevalent in England ; and I think his prac- tice liable to the objection, that the disad- vantages of scraping the bone at all, and denuding it, may exceed the benefit sup- posed to proceed from afterwards bringing down the detached membrane over its sharp margin, even admitting this to be al- ways practicable. But, in no part of the oporation of ampu- tation do operators in general display more awkwardness, than in sawing the bone, though, if we except directing the saw against the flesh, the faults are here less pernicious in their consequences than the errors already noticed. At the time of sawing the bone, much depends upon the assistant who holds the limb. If he elevate the lower portion of the thigh bone too much, the saw becomes so pinched that il cannot work. On the other hand, if be Rllovv the weight of the leg to operate too much, the thigh bone breaks before it is nearly sawn through, and its extremity " splintered It is one of the most common remarks of such persons, as are in the habit of frequently seeing amputations, that the part ot these operations, which a piaia carpenter would do well, foils the skill of • °2T ,SUI-geon, and few operators acquit themselves well in the management of thisZZr,^ fthem -be?in «« aetioi ot this instrument, by moving it jn - AirUi. ».on contrary to the inclination of jfs lee* AMPUTATION. S3 Many, seemingly through confusion, endea- vour to shorten this part of the operation, by making short, very rapid, and most con- vulsive strokes, with the saw. Almost all operators fall into the error of bearing too heavily on the instrument. That operator will saw best, who makes the first stroke of the saw, by applying its heel to the bone, and drawing the instrument across the part, towards himself.soas tomakeaslightgroove in the bone, which serves very materially to steady the future operations of the in- strument ; and who makes long, regular sweeps with the saw, rather slowly than quickly, rather lightly than heavily. But, there is often a fault in the construction of the saw itself, which impedes its action, quite independently of any fault on the part of the surgeon. I allude to not having the edge of the instrument a little broader, than its blade. When the saw is well made, the teeth always make plenty of space for the movement of the rest of the instru- ment. The instrument, as Mr. Guthrie recommends, should cut with both edges, backwards and forwards, which expedites the operation, and (what is of more conse- quence) helps to prevent splintering when the bone is nearly divided, because the division can be finished by the backward motions, which are the most gentle. (On Gunshot Wounds, p. 89.) Graefe commends the plan of oiling the saw, for the purpose of facilitating its action ; (Normenfur die Abl. grosserer Glied- massen, p. 65.) and though the method is innocent enough, the best "operators in this metropolis do not consider it sufficiently important for adoption. If the bone should happen to break before the sawing is finished, the sharp pointed, projecting spiculae, thus occasioned, must be removed by means of a strong, cutting sort of forceps, termed 6one nippers. The perpendicular division of the bone leaves a sharp edge at the extremity of its circum- ference : it is not the common practice to take any measures for the removal of such sharpness; yet, Graefe recommends filing it away, (Op. cit. p. 66,) and Mr. C. Hutch- inson makes it an invariable rule, whether there be any occasion to use the bone nip- pers or not, " to take off the asperities, and scrape, or endeavour somewhat to round, the sharp cut edge of the bone, with a strong blunt scalpel, in orderto prevent the soft parts from being injured when brought over the end of the bone in forming the stump." (Pract. Obs. in Surgery, p. 24.) Though I have not followed this' practice, or rather the part of it, which relates to cutting off the edge of the bone, nor seen it adopted in London in amputation of the thigh, I know of no objection to it, unless it be on the score of its inutility, and the delay, which it occasions. All projecting points of bone, it is the ordinary custom to remove. After the removal of the limb, the femo- ral artery is to be immediately taken hold of with a pair of forceps, and tied with a firm round small ligature, the best being that kind which is recommended and used by my friend Mr. Lawrence, (See Ligature) care being taken to leave the accompanying branches of the anterior crural nerve out of the noose. None of the surrounding flesh ought to be tied, though the ligature should undoubtedly be placed round the ar- tery, just where this vessel emerges from its lateral connexions. Mr. Hey has been accus- tomed to tie the femoral artery twice, lea- ving a small space between the ligatures, and this method has been constantly used in the Leeds Infirmary. Some reasons against this plan will be found in the article (Hemorrhage.) The other arteries are usually taken up with a tenaculum. After tying as many vessels as require it, one half of each ligature is to be cut off, near the knot on the surface of the stump. One portion is quite sufficient for withdrawing the ligature when this becomes loose, and the other being only an extraneous body, and productive of irritation and suppuration, should never be allowed to remain. My friend, Dr. Hennen, in his excellent publication, ascribes the improvement of removing one half of the ligature, to Mr. James Veitch, a naval surgeon, who, in April, 1S06, published some valuable pre- cepts relative to the mode of tying the ar- teries in amputation (See Edinb. Med. and Surgical Journal, Vol.2, p. 176.) But highly as I approve of the tenor of the anonymous paper here referred to, it is impossible for mc ♦o suppose Mr. Veitch could be the first, who suggested such improvement. When I went as an apprentice to St. Bartholomew's hospital, in 1797, no surgeon of that hospi- tal ever followed any other mode, and the practice was then so far from being new- there, that gentlemen, who were at the hos- pital seven years before myself, saw one half of each ligature regularly cut off the first time they went into the operating thea- tre of that munificent institution The use of very broad ligatures, and the inclusion of a considerable quantity of flesh in the noose together with the vessel, were also practices quite exploded at St. Bartholo- mew's at the very beginning of my appren- ticeship. Mr. Veitch, however, seems to merit the honour of having been perhaps the first to set the example of lying every vessel, the femoral, as well as the smaller arteries, with a single silk thread, taking care to in- clude, as far as possible, nothing but the ar- tery ; and when this had been done, he took oft' one half of each ligature, as near as pos- sible to the knot,'' so that the foreign mat- ter introduced was a mere trifle, compared with what I had been accustomed to see." (Edinb. Med. and Surg. Journ. Vol. 2 p. 178.) The use of a single silk thread was then the part of these improvements, probably originating with Mr. Veitch, though the principles which led to this innovation, were unquestionably first established by Dr. Jones. Mr. Alanson directs the ends of the liga- tures to he left hanging out at the two e*- W AMPUTATION. tremities of the Wound, according as their nearness may point out as best. But when a ligature is situated in the centre of the wound, it is best to bring it out between the strips of adhesive plaster, at the nearest part of the surface ; otherwise its running across one half the wound to get at either angle, would create a great deal of unne- cessary irritation and suppuration. The advantages of this method of placing the ends of the ligatures were well explained by Mr. Veitch, but, his practice, like the innovation of cutting off the half of each ligature, as been common iu the London hospitals, and at St. Bartholomew's in par- ticular, many years earlier, I presume, than the case referred to by this gentleman, since it has been familiarly adopted in those insti- tutions ever since 1797, as I can testify from my own personal observation. These re- marks are offered, without the slightest intention of detracting from the merits of the above-mentioned paper, which is re- plete with valuable advice; nor am I influ- enced by any design of throwing honour on the memory or character of any other individual at the expense of Mr. Veitch, being at this time unacquainted with the exact periods, when either this improve- ment, or that of removing the half of each ligature commenced. M. Roux is one of the few remaining modern surgeons, who declare their preference to the method of bringing out all the ligatures at the lower angle of the wound, the benefit of having them brought out thus down, so as to keep up a drain for any pus that may form, being in his opinion greater, than that of arranging them at the points of the wound nearest to them. Mem. sur la Reunion de la Plaie apre's I'Amp. p. 12.) As Dr. Hennen observes, the reducing the immoderate size of ligatures; the separa- ting the threads of which they were com- posed, and placing them at convenient points along the face of the stump, or wound; and the actual removal of one half of each ligature, were amendments very slowly made ; but, (says he,) " an improve- ment, which appears to me of great conse- quence, was the last of introduction, and is now the slowest of adoption, although the artery once secured, and the value of adhe- sion duly acknowledged, it is the most obvious of all. I allude to the plan of removing the ends of the ligature altogether, and thus leaving to an extensive wound the greatest possible chance of immediate union." The first printed mention of this practice, as far as Dr. Hennen's investiga- tions have discovered, was in a letter writ- ten by Mr. Haire, dated Southminster, Es sex, Nov. 1786 " The ligatures," says this gentleman, " sometimes became trouble- some and retarded the cure. An intimate friend of mine, a surgeon of great abilities, proposed to cut the ends of them off close to the knot, and thus leave them to them- selves. By following this plan, we have seen stumps healed in the course of ten days. The slwrt Ugatx>re thvs left in, commonly made its way out by a small opening in a short fame, without any trouble or the patient bay sensible of pain." (See Lond. Med. Jowt. Vol. 7.) Certainly, considering the thick. ness of the ligatures in use at the above p». riod, this testimony of the success of the method, as Dr Hennen remarks, is very satisfactory. (Principles of Military Surgeif, p. 181, Ed. 2.) In a letter received byi» from Mr. Dunn, surgeon at Scarborough, and dated June 3, 1819, he tells me,'«jjfy predecessor Mr. J. Wilson, the late partner of Mr. Travis, amputated a limb in 1792,«r 93, and cut off the ligatures close to the arteries, and no trouble ensued. He did this from the recommendation of Dr. Balcombe, of York, who had seen the method practised on the continent." In September, lt>!3, Dr. Hennen, who was serving with the army in Spain, began the adoption of the plan, which, he expected, would not only prove useful in promoting immediate union, but in obviating any accidental violence to the ligatures, and the wrong interference of the younger dressers in trying to pull them away. Between September and January, thirty-four cases were treated in this way, without any inconvenience following, or the small particles of silk left behind giving rise to any apparent irritation. Dr. Hennen also presented to Sir J. M'Grigor, some of the small circles of silk, a part of which had come away with the dressings, while others had floated out on opening the little pustules, which formed over the face of the stump at the points, where the arte- ries bad been tied. Some few of the liga- tures never made their appearance, and the patients complained of no uneasiness what ever. Convinced of the utility of the me- thod Dr. Hennen, afterwards published an account of it. (See Lond. Med. Repotittrj, Vol. 3.p. 177 and Vol 5.p.221.) Thisge* tleman subsequently found that Dr. Mil- well of Dumfries had adopted the plan as far back as 1798 ; and Dr. Ferguson, who was at Stockholm during the peace of Amiens, saw it also then followed by so»e of the surgeons of that city, without anj ill effects. (Hennen's Military Surgery, p 175,-178, Ed. 2.) In July, 1814, Mr. Law- rence communicated to the Medical and Chirurgical Society of London, some case! and observations highly in favour of the practice; and the particularity, which he lays much stress upon, is using for the purpose minute firm ligatures composed of what a cal ed dentist's silk. (See Med. Chir. Trm Vol. 6^p. 156.) And, in a paper of later date he says, his further experience had «°til ♦ ud the usefu,ness of the method, ,„7 ath,s P,an> by diminishing irritation and inflammation, and simplifying tbe pro- the ™ d/very materially promt* n*encemof^°f the Patient' and the c0^ diced ill P„e surSeon> whi>e it has not pre- effect in ?P,,setlue"««, or any unpleasrf his own ^ ^ Which h*ve come under ms own observation." According to Mr Lawrence, the small knots of sTL11mi separate early, and come ^^J^gS- AMPUTATION. 95 charge; that where the integuments have united by the first intention, the ligatures often come out rather later, with very tri- fling suppuration, and that, m some instan- ces, they remain quietly in the part. (Obs. eit. Vol 8, p. 490.) After the battle of Waterloo, it was tried in many cases both by Mr. Collier, and my- self, though our ligatures were certainly not so minute and eligible as those employed by my friend Mr. Lawrence. As I joined the army in the field after nine days, and was therefore obliged to leave my patients at Brussels to the care of others, I lost the opportunity of witnessing the effects of this method. But, from Mr. Collier, I after- wards learned, that the new plan and the common oue appeared in his judgment lo answer about equally well; which report, considering that we did not use the smallest ligatures, must be regarded as favourable. When the plan is tried, single strong threads and silks, or rather the kind of ligature, which will be described in another place, (See Ligature,) should be employed; for, otherwise the knots would be large, and likely to create suppuration and future trouble. The practice has likewise been tried by M. Delpech at Montpelier ; but, it is not explained, whether he used single threads, or silks, or whether any inconve- niences resulted from the method (See Relation d'un Voyage fait a Londres en 1814, ou Parallele de la Chirurgie Angloise avec fa Chirurgie Francoise by P. J. Roux, 8vo. 1816.) Yet candour requires me to state, that the method is not universally adopted, and that one well informed writer, as I shall hereafter notice, (See Hemorrhage,) has recited a case and some experiments, which are unfavourable to the practice. (Cross, in Lond. Med. Repository, Vol. 7,p. 355.) Mr. Guthrie has also in two or three instances seen some ill looking abscesses arise from the presence of the bits of liga- ture, though he approves of the plan where the wound will not unite by the first inten- tion, which, however, can rarely be known beforehand. (On Gun-shot Wounds, p. 941.) My friend, Mr. Downing, deputy inspec- tor of military hospitals, formerly saw this practice tried; but he informs me, it did not answer, as repeated suppurations and discharges of bits of ligatures followed from time to time, after the patients conceived themselves cured. But, probably, the large thick ligatures in common use some years ago, were here employed, and if this were the case, the experiments cannot be com- pared to that made with a minute ligature of dentist's silk. Sometimes, the sawn surface of the bone itself bleeds rather profusely. When this happens, it is an excellent plan, which I have often seen my late master, Mr. Rams- den, and others, adopt with the greatest suecess, to hold a compress of lint over the end of the bone, during the time requisite for securing the rest of the vessels. At the end of this- period, the compress may gene- rally be taken away, the bleeding from the bone having entirely ceased. As Monro remarks, the surgeon ought not to content himself with tying only such vessels, as he observes throwing out blood, while the pa- tient is faint with pain : he should endea- vour to rouse him from that faintish state by a cordial ; and then wiping off the coagu- lated blood with a sponge, wet in warm water, he should examine narrowly all the surface of the stump; for, otherwise, he may expect to be obliged by a fresh hemor- rhage to undo all the dressings. (On Am- putation of the Larger Extremities, p. 475, Monro's Works.) When there is merely an oozing from small vessels, Bromfield's advice to loosen the tourniquet completely, is highly proper, as this measure, and washing the stump with a little cold water, will put an entire stop to such bleeding, without any occasion for more ligatures. A good deal of blood is sometimes lost from the mouths of the larger veins, and where they bleed much in debilitated subjects, I think Dr. Hennen is right in recommending them to be tied. (On Military Surgery,p 264.) There is no necessity for doing so, however, in ordinary cases ; nor should I be disposed to imitate Mr. Hey, who, in consequence of having seen a few instances of bleeding from the femoral vein, generally enclosed that vessel in the ligature along with the artery. (Prac- tical Obs. in Surgery, p. 530. Ed. 2.) This method, however, was sanctioned by De- sault, who says, that if the vein be left open, and the bandage at the upper part of the limb be too tight, the flood regurgitates downwards, and hemorrhage takes place, as this surgeon assures us, he has often seen. When the vein and artery lie close together, as often happens, one branch of the forceps is to be introduced into the artery, and the other into the vein, which being done, the two vessels are to be drawn out together, and included in one ligature, but, if they are not so near together, they must be tied separately (CEuvres Chir. de Desault par Bichat, T. 2, p. 550. Svo. Paris, 1801.) At St. Bartholomew's, it is not the usual practice to tie the femoral vein, though it has been occasionally done ; and, except in particular cases, I consider the custom wrong, because a ligature on a large vein sometimes excites a dangerous and fatal inflammation within the vessel, while the intervention of the vein between the one side of the circle of the ligature and the artery, must rather tend to hinder the thread from operating in the most desirable manner upon the latter vessel. The wound is now to be evenly closed with strips of sticking plaster, so that the edges of the cut skin may form only a straight line across the face of the stump. This was the mode commended by Alan- son, and is what is preferred by the gene- rality of the best surgeons in this country. It is also advised by Graefe. (Normenf&r die Abl. grdsserer Gliedm. p. 106. Guthrie on Gunshot Wounds, p. 208.) Over these s» AMPUTATION- plasters, and the ends of the ligatures, it is best to place some pieces of lint, spread with the unguentum spermatis ceti, in or- der to keep such lint from sticking, which becomes an exceedingly troublesome cir- cumstance, when the dressings are to be removed. I am decidedly averse to the general plan of loading the stump with a large mass of plasters, pledgets, compresses, flannels, &.c.; and I see no reason, why the strips of adhesive plaster, and a pledget of simple ointment, should not suffice, when supported by two cross bandages, and a common linen roller, applied spirally round the limb, from above downward. Tbe first turn of the roller, indeed, should be fixed round tbe pelvis, while the lower circles secure the cross bandages, often called the Malta-cross, over the end of the stump. It is also an excellent method to leave some little interspaces between the plasters, and in summer to keep the linen bandages constantly wet with cold water. In this way any discharge will readily escape, and the pans, being kept cool, will be less dis- posed to hemorrhage and inflammation. I am completely of opinion with Mr. Alanson, that the elastic woollen cap, com- monly placed over all the bandages and dressings, if not put on with a great deal of care, has a tendency to push the skin back- ward from the extremities of the stump, and as it must also heat the part, its employ- ment ought apparently to be discontinued. If possible, the dressings should never be removed before the fourth day, not reckon- ing the one on which the amputation is performed. Monro set down the fifth, sixth, or seventh day, as generally soon enough for this purpose. He allows, how- ever, that, if the smell of the wound should become offensive, the outer dressings may be removed sooner. Even when the dress- ings are to be taken away, it will frequent- ly be found useful not to remove one strip of plaster; but the stump must be made clean, and any discharge washed away. These and other valuable precepts, derived from the eminent Dr. A. Monro senior, are worthy their great source, and the correct- ness of them promises to be acknowledged for ever. The manner of renewing the dressings of stumps, is indeed a very important business, which should never be intrusted to mere novices; for in taking off the straps of sticking plaster, if great care be not taken, the slight and newly formed adhesions may be torn asunder. Thus, as Mr. A. C. Hut- chinson has remarked, if the strap be pulled off by holding one end of it at nearly a right angle with tbe adhering part, the flap will be raised up with it, and thus a separa- tion of the newly united parts will be pro- duced. " My plan (says he) is to reflect the raised end of the strap close down upon the adhering part, and to bring it gently forward with one hand, while the removing part of the strap is followed by two fingers of the other placed upon tbe skin, &c.; and when one end is detached from its ad- benon, as far as the line ot incision on uje E o. the stump, in like manner the other end is brought down and wholly removed. (Pract. Obs. p. 46.) In order to facilitate the removal of the plasters, and save the patient a great deal of pain, 1 have always followed the plan of letting warmish water drop over them from a sponge for a few minutes previously to the attempt to remove them. In the early part of the treatment, it is also a valuable rule never to have every strap of plaster off at once, so as to leave the flesh quite unsup- ported. Some skill and care are also inva- riably necessary, in order to avoid pulling away the ligatures at the same time with the other dressings. At the end of five or six days, the snr- geon may begin to try, in a very gentle manner, whether any of the ligatures are loose ; observing rather to twist, than sud- denly pull them directly outward. How- ever, he should not use the smallest force, nor persist if the trial create pain. One would hardly try, whether the ligature on the main artery were loose, before the eighth or ninth day. If minute ligatures made of dentists silk be employed, and both their ends cut off close to the knot, of course, this delicate business of trying to get rid of the irritation of those foreign bo- dies is entirely superseded. Though, in the above account, I have di- rected the edges of the wound, after the amputation of the thigh, to be brought to- gether in such a way, that the wound shall appear as a line across the face of the stump, yet there are instances in which the bone seems most easily and conveniently covered, by making the line of the wound in a perpendicular direction. Mr. B. Bell, indeed, generally approwl of it, as affording a ready outlet for matter; it is likewise directed by Mr. C. Bell, (Op, Surgery, Vol. 1;) by Koux (M6m. swr It Reunion immediate de la Plaie apres I'Amf. p. 11;) and by Dr. Hennen (On Jfiiilarj Surgery, p. 165. Ed. 2.) On the other hand, Mr. C. Hutchinson objects to it, because it seems to him, that when a stump, thus put up, is laid on a pil- low, the pressure tends to separate and open the lower part of the wound. (Prod. Obs. on Surgery, p. 37.) It is curious to remark, however, 4W the thing which leads this gentleman to dis- approve of the plan, is one which would be urged in its favour by Roux, and so* other surgeons, who actually take the pre- caution of never closing the lower angle of the wound, in order that whatever dis- charge occurs may find a ready outlet (Mem. ctt.p. 14J Mr. Alanson objected to this method, » ^ening that the cicatrix afterw ards becate hnnti ,mmediately over the end of the to m.SLe Pressure of which was very like*) St Tarfv/?6 part ulcerate- However^ bt. Bartholomew's Hospital, a this* was andethT Hg° amfP^ate>uta- tion dans la conlinuile des membrts et plus parliculi^rement encore de I'amputation circu- laire." (P. 128. Paraltile de la Chirurgie Anglaise avec la Chirurgie Francaise, 8vo. Paris, 1815.) M. Roux, however, has cu- riously omitted to explain in his book, what arc the advantages of not bringing the edges of the wound together, and why he calls prejudice the partiality to a method, the superior efficacy of which is continuallv de- monstrated in every hospital of London. He does not indeed presume to condemn the practice altogether; on the contrary, be allows it to be proper in certain cases; yet he contends that it ought to be confined within particular limits. (P. 130. See, also, Mem. et Obs. sur la Reunion immidiate de la Plaie apris I'Amputaiion, tyc. 8vo. Paris, 1814.) In this tract, which is well drawn up, Roux proves most convincingly the benefits of union by tbe first intention, after ampu- tation of the thigh by the circular incision ; but, strangely enough, his prejudices hinder him from advising the practice to be ex- tended to other amputations. He does not positively condemn it in the arm, though he thinks the method less necessary, be- cause amputation there is less dangerous than in the thigh, fee. (P. 45.) To such futile reasoning is this author reduced by the unsoundness of his doctrine. He also deems the attempt at union by the first in- tention counterindicated, where limbs are amputated for injuries, which violently con- tuse and crush the parts (P. 48,) and where the limb is much wasted. (P. 50.) In the latter condition, however, he thinks De- sault's flap amputation may be done, and an effort made to heal the wound by adhe- sion. In one case, be did this with success. (P. 61.) Richerand informs us, that Dubois at Paris follows the plan with a success equal to that of the London surgeons. For some years past, he has himself also constantly endeavoured to accomplish union by the first intention, after all the amputations which he has had occasion to practise, and he succeeds at least in three out of four. " The method is preferable (says he) to the old one, in whatever point of view it is considered. This union is more expedi- tious, a few days being sufficient for its completion. A woman, whose thigh I took off in 1810, was very well in a week, &c. Besides the advantage of a quick cure, and such quickness is especially of great im- portance, where the patient has been much reduced, so that he would hardly be able to bear a long suppuration, union by the first intention has the recommendation of sa- ving the patient from a great deal of pain, the flap of integuments, with which the bleeding surface of the stump is covered, being much less irritating to the flesh, than the softest charpie would be, &c. Three years have elapsed since the publication of the third edition of this book. During this interval, I have performed more than a hundred and fifty amputations, and the uti- lity of immediate union has been more and more proved to me." (Nosographie Chir- urg. p 475, 477. Edit. 4.) But, notwithstanding these and other en- comiums on the practice, Richerand, like other French surgeons-, is not an advocate for it in certain cases, as, for instance, limbs shattered by gunshot wounds, or af- fected with hospital gangrene. Here, he maintains, that it hardly ever succeeds. (P. 478.> But. (hoii«h it be true that ampn- AMPUTATION. tations after gunshot-wounds do not gene- rally heal so well, as many other cases, it cannot be denied that they do sometimes unite more or less by the first intention, and why should not the chance be taken ? It is productive of no danger ; there is no- thing better to be tried ; and, if it fail, what is the barm ? Why, the wound will then heal by suppuration, and the granulating process, just as soon, as if the hollow of the stump had been filled with charpie, or left open; it will in fact heal in a way, which is less advantageous, than union by the first intention, but which is the best which can now happen. From what has been said, it appears, that the practice of healing the wound by the first intention after amputation is less gene- ral in France, than it is in England ; a cir- cumstance which may perhaps be explained by the fact of its being much newer to the French than to us. Every improvement must encounter for a time the opposition of prejudice ; but, one so important as that which we are considering, must at length prevail, and meet with universal adoption. Our extraordinary partiality to union by the first intention arises from a conviction of its superior efficacy, and is a decisive proof of the goodness of English surgery in respect to wounds. The observations of Roux and Richerand tend to prove, that Ihey are not altogether unaware of its ad- vantages, and they therefore recommend it for certain cases ; but, their backwardness to extend it to all amputations, without ex- ception, is little in favour of the parallel, which they are so fond of advancing be- tween French and English surgery. However, that stumps may fall into a state, in which the pressure of all plasters and bandages whatever should be most carefully avoided, and emollient poultices used, is a truth of which every surgeon of experience must be fully convinced. This happens whenever the parts are affected with considerable tension, inflammation, and swelling, or painful acute abscesses. There is also no utility in keeping the edges of the wound very closely compressed to- gether, when all chance of adhesion is past, and the parts must heal by the granulating process. My friend, Mr. Guthrie, after am- putations, performed from necessity in parts not in a healthy state, as in most secondary amputations after compound fractures of the thigh, does not insist upon the edges of the wound being brought into close contact by sticking plaster, compress, and bandage. In these cases, he also recommends the bone to be sawn an inch shorter than usual, or than would be necessary under other eircumstances, in order to prevent its pro- trusion, and the ligatures to be cut off close to the knots, so as to lessen irritation. The integuments and muscles are to be brought forward, and retained so by a moderately tight roller, but not laid down against the bone. Some fine lint, smeared with cerate or oil, is to be put between the edges of the wound ; and a piece of linen and a Malta-cross over it, supported by a tew light turns of the roller. «• In some cases (says Mr. Guthrie,) I have put one, and even two straps of plaster over the stump to keep the edges approximated, without being m con- tact ; and, where the parts are but little diseased, this may be attempted ; but, if the stump becomes uneasy, they should be cut, and a poultice applied. When only a part of the stump has appeared to slough, I have found the spiritus camphorae alone, or di- luted with a watery solution of opium, ap- plied with the lint, very useful." (On Gun- shot Wounds, p. 104.) The reasons, which induced Mr. Guthrie to incline to the plan of not bringing tog*. ther the edges of the wound, in cases of this description, must be learned by reference to his own valuable work. His cases and arguments are entitled to serious conside- ration ; and though they, as well as the ob- servations of Roux, (M4m. sur la Reunion immediate de la Plaie apres I'Amputaiion, 8vo. Paris, 1814,) leave me unconvinced of the usefulness of not bringing the edges of the wound together, immediately after the amputation of bad compound fractures, there are some of his observations respect- ing the injurious effects of too much pres- sure in certain conditions of the stump, per- fectly agreeing with my own sentiments. At present, I have never seen any case of amputation, in which I should not have thought the surgeon wrong, had he not brought the sides of the wound together directly after the operation, so as to afford the chance of union by the first intention. HEMORRHAGE AFTER AMPUTATION. Bleeding, after the operation, is of two kinds, in regard to the time, when it occurs. The first takes place within twenty-four hours after the operation. Hence, an as- sistant should always be left with the pa- tient, with directions carefully and repeat- edly to look at the stump, and if any bleed- ing should arise, to apply the tourniqnety until further aid be obtained. In case no assistance can be spared for this purpose, as must frequently happen in country prac- tice, the tourniquet should always be left slackly round the limb, and the nurse, or patient, himself, directed to turn the screw of the instrument, in order to tighten it in case of need. A slack tourniquet left round the limb, after amputation, cannot do harm, and its not having been ready in this way, has cost many patients their lives, as I have known instances of. This kind of hemorrhage has often ben known to arise from the pressure of a tight bandage round the stump. As Monro oh- when"ii.E? C'rCUlar ,Urns of •*• banda* n thp f8* ' mUSt St°P the return ol *** aVreateUrtar"e-°"S Vei"S' andthus bY maki"? ferte * whEK8tan0e t0 the b,ood in tbe8r- io i theZ , ana.9tomos« with them, occa- aS« « St|"JCl,ngJ,?wer of the hear« ** KlTtherh te\and ferCe n,ore Wood into ineir other branches ; but, thesr- i,«:„. nit m the amputation, will pour ouUhi? W^J and so hemorrhage is bWt on^gj AMPUTATION. °9 much pressure round the stump is highly de- serving of reprobation; and whenever there is an universal oozing of blood, I wrould re- commend the operator to be sure, that the circulation in tbe superficial veins is not im- peded by the tightness of any bandage or tourniquet. If the bleeding should not be from an artery of consequence, the application of linen, dipped in the cold water, will some- times check it, and the disagreeable neces- sity for removing the dressings and open- ing the wound, may thus be avoided. But, it often happens, that the wound must be opened, and the bleeding vessel tied. This is a very painful proceeding to the patient, and when the dressings have been applied some hours, so that the stump has had time to inflame, nothing can exceed the suffering to which the patient is now subjected. Here we see the prudence of being particularly careful at first to tie every suspicious vessel. The second sort of hemorrhage, after amputation, arises from ulceration of the large arteries, and may occur a month after the operation, when the ligatures are all away, and the patient seems nearly well. Two such cases are related by Mr. Brom- field (Vol. I. p. 307.) This kind of bleed- ing is less common than formerly, now the plan of covering the stump with sound skin is adopted. When the bleeding vessel is large, there is no chance of putting the pa- tient out of danger, except by cutting down to the vessel, and tying it. The trunk of the vessel, however, may sometimes be more conveniently tied, than the bleeding branch itself. Mr. Hey makes mention of a particular port of hemorrhage, after the operation : " I have seen (says he,) a few instances of the integuments becoming so contracted after the operation, as to compress the veins just above the extremity of the stump, and bring on after some hours a copious hemor- rhage. When it has appeared clear to me, that the hemorrhage was venous, I have made a division of the integuments, on one side of the thigh, sufficient to remove the stricture, and this method has immediately suppressed the hemorrhage." (P. 530. Edit. 2.) I have never yet met with a case, in which a hemorrhage was unequivocally produced by a contraction of the integu- ments. Dr. Hennen says, that be has seen only one example, and it was successfully treated by loosening the bandage, and moistening the dressings with cold water. (On Military Surgery, p. 264. Ed. 2.) Doubts may therefore be entertained, whe- ther the cause was the pressure of the in- teguments, or of the roller, on the veins. In Mr. Guthrie's truly practical work, there are some excellent remarks on the he- morrhages, which, in the irritable and sloughing state of a stump, frequently take place from the small branches, or from the main trunks of the arteries, in consequence nt ulceration It is ('says he) not always easy to discover the bleeding vessel, or when discovered, to secure it on the face of the stump ; for, as the ulcerative process has not ceased, and the end of the artery, which is to be secured, is not sound, no healthy action takes place. The ligature very soon cuts its way through, or is thrown off, and the hemorrhage returns ; or, some other branch is opened, and another ligature is required, which is equally uncertain ; and under this succession of ligatures and he- morrhages, the patient dies. Here, cutting down to the principal artery, in preference to another amputation, has often succeed- ed ; but, under certain circumstances, it fails, and amputation becomes ultimately necessary. At the same time, it is allowed, that this operation may also fail. On the whole, Mr .Guthrie professes himself to bean advocate in most cases for tying the artery in the first instance; and if this proceeding should not answer, he would then amputate. However, the practice of taking up the artery in these cases, he thinks, should not be adopted indiscriminately, the doctrines of aneurism not being here applicable, be- cause there is a wounded vessel, with an external opening. " In the thigh, the ope- ration is less certain, than in the arm, and especially, if it is not the main artery that bleeds; for, the branch, from which the he- morrhage proceeds may come from the profunda, and tying the artery in the groin on such opinion would be doing a serious operation, and one, which probably would not succeed; for, the anastomosing bran- ches would restore the circulation in the stump in a short time, and again establish the bleeding. If it is the femoial artery that bleeds, and the ligature is applied high, it is very liable to a return of hemorrhage. To obviate these difficulties, the part, from which the bleeding comes should be well studied, and the shortest distance from the stump carefully noted, at which compres- sion on the artery commands the bleeding ; and, at this spot, the ligature should be ap- plied, provided it is not within the sphere of the inflammation of the stump." (On Gun- shot Wounds,p. 105-106.) Thus far the advice seems to me correct and valuable; but, where the hemorrhage could bo restrained by taking up the artery in the groin, though not lower down, I doubt the propriety of preferring amputation to this other far less severe operation, admitting that the effici- ency of a ligature above the profunda, has been proved in the manner judiciously re- commended by Mr. Guthrie, viz. by means of pressure. The following is the council offered by Mr. Hey in a case of this nature. " When we are under the necessity of amputating a limb, that has suffered great contusion, though the operation is perform- ed upon a part apparently sound, the wound sometimes becomes sloughy and ill condi- tioned. No good granulations arise to cover the extremities of the arteries ; but tbe liga- tures cut through these vessels, or becoming loose. eea°e to make a sufficient pressure 100 AMPUTATION upon them, and heuce repeated hemorrha- ges ensue. This is a dangerous state for a patient; for, if the vessels are taken up afresh with the needle, the hemorrhage will now and then return in the course of two, or three days. In such eases, the applica- tion of dry sponge, cut transversely, as di- rected by Mr. White (Cases in Surgery,) has been found singularly useful, and has saved the life of the patient. But, a constant pressure must be kept upon tbe pieces of sponge, by the fingers of a succession of assistants, till granulations begin to arise upon the stump, and the prospect of future hemorrhage disappear* Tbis method is of the greatest importance after amputation on the thigh, or leg, where the great vessels are deeply seated. In the aim, above the el- bow, where the vessels are more superfi- cial, the great artery may betaken up, with a portion of muscular flesh, above the sur- face of the stump, by making first an inci- sion through the integuments. My col- league. Mr. Logan, has done this twice within the last year, with complete success, when repeated ligatures, applied in the usual way, had failed. " In the morbid sloughy state of the stump, abovementioned,the application of lint, soaked in a liquid, composed of equal quantities of lemon-juice and rectified spi- rit of wine, has been found very advanta- geous, and has caused it to put on soon a healthy aspect." (P. 536, 537, edit. 2.) ON PROTRUSION OF THE BONE. It is clearly proved by the observations of M. Louis, that this disagreeable conse- quence may be generally prevented by ta- king care to divide the loose muscles first, and (after their complete retraction, which will be favoured by no band, nor tourniquet being applied round thelimb,)by observing to divide with a bistoury the muscles which are adherent to the bone ; for instance, the crural muscle, and the point of adhesion of the vasti and triceps at the posterior spine of the femur. By this method, the bone may be very easily sawn three finger- breadths higher than it can be, if no atten- tion be paid to beginning with the division of the loose muscles, and conclndipg with that of such as are more attached to the bone. The protrusion of the bones will never take place, so long as they are immediately encompassed with the fleshy substance of the muscles : this proposition is incontesta- ble. The state of the skin, whether longer or shorter, conduces nothing to this protru- sion ; nor will the inconvenience be pre- vented by drawing the skin upward, and preserving as much of it as possible. (See Mim.surla Saillie del'Os apr3, Paris 1806. A description of Desault's, or rather Ver- male's mode of operating, being given in the 4lh Ed. of the First Lines of the Prac- tice of Surgery, Vol. 2,1 need not here re- peat it, nor say, by how many respectable names tbe practice is sanctioned. Of late. the operation has been done by my friend Mr. Vincent in St. Bartholomew's Hospital, who showed me a few weeks ago a capital stump, which he had made in this manner, and which had healed with great expedi- tion. By Mr. Guthrie, the flap-operation is con- sidered pieferable to the circular incision at the upper part of the thigh, " as it per- mits the head of the bone to be removed, if found necessary, allows it to be examined and cut shorter with greater ease, and makes a much better covering afterwards." (On Gunshot Wounds, p. 200 ) In military surgery, flap-amputation of the thigh is often advantageous, because all the flesh on one side of the limb is fre- quently torn away, or left in so terribly a mangled state, as to be unfit for making a covering for the end of the bone. Here a flap, sufficient to cover the whole face of the stump, should be saved from the sound flesh on the other side of the limb. When the surgeon chooses the flap-amputation, not from necessity, as under these last circum- stances, and the flesh is sound all round the member, the best way is to save a flap on each side of the limb, by making two semi- circular cuts, the convexities of which ex- tend in a parallel manner forwards, and the terminations of which meet at the upper and lower surfaces of the limb. The skin is not to be at all dissected from the mus- cles, which are to be obliquely divided as high as the base of the flap on each side. However, though this is the best plan, par- ticular cases may require a flap to be made from the anterior, or even the posterior side of the thigh. The latter method should never be followed, but from necessity 102 AMPLIATION (See Hey's Pract. Obs. in Surgery, p. 631, Ed. 2.) According to Mr. Guthrie, the difference between the flap-operation, at the upper part of the thigh, and that at the hip, con- sists in its being done lower down, and in the flaps being saved more immediately from the external and internal sides of the thigh, the inner flap being the largest, in order to prevent the inconvenience, which might arise from the external one being tightly stretched over the end of the bone. For the same reason, Mr. Guthrie also recom- mends the bone U, be sawn off close to tbe lesser trochanter, even when the nature of the injury would allow of its being left an inch longer. (On Gunshot Wounds, p. 200.) Flap-amputation of the thigh, after the manner of Vermale, is now preferred to the common mode by Klein, one of the best operating surgeons in Germany. Of seven cases, in which he adopted this method, the greater number were healed in ten days, and the rest in three weeks; and this suc- cess determined him in future always to practise it. After this mode, he finds there is no danger of the muscles retracting them- selves, and leaving the end of the bone pro- truding, even though the patient be trans- ported from one place to another. With respect to the occasional difficulty of taking up the obliquely cut vessels, Klein admits this objection, but thinks that it equally ap- plies to Alanson's method. He lays great stress on the utility of giving due support to the flaps with compresses and a roller. (See Practische Ansichten der bedeulendsten chirurgischen Operationen, p. 35—38, 4/o. Stuttgart, 1816.) In one instance, where a ball had broken the upper third of the femur, and mortifica- tion had spread so far towards the great trochanter and buttock, that it was impos- sible to operate, except by the flap-opera- tion, or by taking the head of the bone out of the joint, Klein made a broad flap six Inches long at the inner and upper part of the thigh, and then he cut the soft parts straight across just below the great trochan- ter, so as to make this wound meet tbe ter- mination of the incision,by which the inner flap was formed. This patient got perfect- ly well in three weeks; (Op. cit. p. 39.) and so did another very similar case opera- ted upon by the same gentleman, (p. 43. Where the bleeding is considerable, the femoral artery and profunda should be tied previously to sawing the bone ; but, if th© vessels are well commanded by the pressure, the sawing ought to be first com- pleted. AMPUTATION BELOW THE KNEE. In treating of amputation of the thigh, I have remarked, that as much of the limb as possible should be preserved. The longer it is after the operation, the stronger and more useful will it be found. But when tbe leg is to be amputated, authors have set it down, as almost an in vnriable rule, that the operation is to be performed a little way be- low the knee, even though the disease, fo, which the limb is removed, may be situated in the foot, or ankle, and would allow the operation to be done much further down, The common practice is to make the inci- sion through the integuments, just low enough to enable the operator to saw the bones, about four inches below the lowest part of the patella. This degree of lownes? is usually deemed necessary, in order am to deprive the stump of that power of me- tion, which arises from the flexor tendon of the leg continuing undivided. It is ad- leged also, as a reason for this mode of pro- ceeding, that it is quite sufficient lo preserve a few inches of the leg, in order to afford the body a proper surface of support, in walking with a wooden leg, whereat if i i larger portion were saved, the superflmm- ' part would be a great inconvenienceiothia walking, and sitting down, without being of the smallest utility, in any respect what- ever. However, as I shall presently no- tice, experience proves, that, where accord- ing to these maxims, an injury, or disease would dictate the performance of amputa- tion above the knee, the practice of ampt- tating below this joint, but much higher; than is generally sanctioned, may be tok lowed with advantage. The tourniquet should be applied to tbe femoral artery, about two-thirds of the way down the thigh, just before the vessel per- forates the tendon of the triceps muscle. This place is much more convenient thin the ham, where it is very difficult to com- press the vessel against the bone. The pa- tient is to be placed upon a firm table, uh the amputation of the thigh, and the leg be* ing properly held by one assistant, while the integuments are drawn upward by another, the surgeon, with one quick stroke of tba knife, is to make a circular incision through the integuments all round the limb. Some recommend the operator to stand on the in- side of the leg, in order that he may be able to saw both bones at once. No reflections could ever make me perceive, that anyceal advantage ought strictly to be imputed* this plan. Many suppose this methoeVtW minishes the chance of the fibula being sP'"'tered, this bone being completely di- vided rather sooner than the tibia. Bat splintering the bones generally arises from the assistant depressing the limb too much, »L- **not suPP°rling it enough. If the assistant were to be guilty of this misman- 3?^?i?'♦£ wouid °e difficult to explai, Z& ?fe^lb,c\shou,d not be sp.intei*ii- of ft hU6 fibula' when a "rtain thickness time i, ? lawn thro»gh. At the same Son nrJ*"*[ be, ad™tted, that if tbe sur- Hmb Pthf".standi"g on the inside of tbe rfusinJ^ " "° °bJecti<>n to it at the time venience ?n havfn J ♦W? ls ?reat C0D* the wound Mis th5 left, hand next * H-,e,Kave seen many hos^f^t AMPUTATION. 103 in amputating the right leg, cut the soft parts, while they stood on the outside of the limb, and having done this part of the operation, they proceeded to the other side of the memberforthe purpose of applyingthe saw. I have only to repeat, that, I do not think any particular reason exists against sawing the two bones together, yet, in such manner, as to let the fibula be divided en- tirely through first; and, the advantage of fixing this bone against the tibia by the pres- sure of the hands of the assistants, while the surgeon is sawing it, is another circumstance, which influences a great many writers to commend the latter plan. Graefe, who, as already mentioned, prefers the true flap- operation, does not think it adviseable for the surgeon to stand on the inside of the limb in his method of operating, because when the knife is introduced through the muscles of the calf, its point would be apt to go between the two bones. (Normen fur die Abl. grdsse- rer Gliedm. p. 130.) The following are the precepts, given by him respecting the saw- ing of the bones. They should, he says, be divided as high as possible ; and, during this part of the operation, the fibula is to be firmly pressed by the assistant against the tibia, above and below the wound, so as not to be shaken too much in consequence of the weak- nessof its upperarticularconnexion. Graefe then directs the surgeon, as he stands on the outside of the limb, to apply the saw, as high as possible, close to tbe periosteum, with the handle downwards, and to saw both the bones together, until a groove deep enough for the guidance of the saw is made in each of them. The foot is now to be turned very much inwards, and the fibula com- pletely divided, the handle of the saw being depressed as far as practicable. The foot is then to be inclined outwards, and the tibia cut through, the saw, with its handle ele- vated, being placed in the furrow already prepared for it. By beginning with making a groove in both bones, we are sure, says Graefe, of sawing them through exactly at the same height The plan of beginning the division of the bones with the handle of the saw depressed, however, must certainly be inconvenient. A circular cut having been made through the integuments, about two inches below the place where it is intended to saw the bones, the next object is to preserve skin enough to • over the front of the tibia, and the part of the stump, corresponding to the situation of the tibialis anticus, extensor longus pollicis pedis, and other muscles, between the tibia and fibula, and those covering the latter bone. Throughout this extent, there are no bulky muscles which can be made very ser- viceable in covering the end of the stump, and consequently the operator must take care to preserve sufficient skin in this situa- tion, by dissecting it from the parts beneath, and turning it up. On the back part of the leg, on the con- trary, the skin should never be uselessly de- tached to a great extent from the large gas- trocnemius mu-.cle, which, with thesoleus, will here form a sufficient mass for covering the stump. However, the experience which I had in the army, taught me the truth of a remark made by Graefe, that, in forming the posterior flap of muscle, it is a matter of the highest importance to let the integu- ments be somewhat longer than it; for, otherwise, when it is turned forward, as it must be for the purpose of covering the ends of the bones, its front edge will be left uncovered by integuments, which being the outermost describe a greater circumference than the deeper muscular flap. (Normen fur die Abl. grdsserer Gliedm. p. 131.) I was fully convinced of the truth of this ob- servation, by two amputations which were done by myself, one in the neighbourhood of Antwerp, in 1814, and the other at Brus- sels, the day after the battle of Waterloo. Yet Graefe, who performs the flap-amputa- tion, strictly so called, (that is to say, the operation in which a flap of skin, corres- ponding in shape to the flap of muscle, is preserved) does not himself detach the skin from the muscles of the calf at all, but, at the time of making the incision in that situ- ation, directs one assistant to pullupthe in- teguments, while another bends the foot as much as possible, which manoeuvres have the effect of letting the muscles be cut ra- ther shorter than the skin. Unfortunately, however, in many cases, the very nature of the disease, or injury, for which the opera- tion is performed, would not admit of these proceedings. Nor in a very muscular limb, would they be likely to suffice, as Graefe himself confesses, since, in such cases, he recommends the use of a knife bent late- rally, for the purpose of excavating, as it were, as the incision is made, the thick muscular flap. (Op. cit. p. 134.) In the common method, with the circular incision, I am disposed to think it best, therefore, to let a small quantity of skin be detached and saved at the back part of the leg, so that there may be a certainty of having enough to cover well the extremity of the divided muscles of the calf. As soon as the skin has been separated in front, and on the outside of the leg, the surgeon is to de- tach the skin from the calf for about an inch, and having reflected or drawn this preserved portion out of the way, he is to place the edge of the knife close to the edge of the retracted or reflected skin at the back of the limb, and cut obliquely upwards through the muscles of the calf, from the inner edge of the tibia quite across the fibula, supposing the operator to be on the outside of the right leg, and that it is this member, which is undergoing removal. In performing this last incision, as M. Louis well observes, it is essential to incline the edge of the knife obliquely upwards. In this manner the skin will be longer than the muscles, and the cure will be considerably accelerated. (Mem. de I'Acad. de Chirur slits to receive the two bones, care being taken to let the unslit part be applied to the muscles of the calf, as particularly advised by Graefe. (Op. cit. p. 136.) In the leg, there are only three principal arteries, requiring ligatures, viz. the ante- rior and posterior tibial, and tbe peroneal or fibular arteries. In addition to these, however, there are sometimes large mus- cular branches, which require to be taken up. The anterior tibial artery will be found in front of the interosseous membrane, and between the extremities of the bones ; the fibular artery behind tbe fibula ; and the posterior tibial, situated more inwardly than the last among the first of the soleus, near the tibia. (C. Bell, Oper. Surgery, vol. \.p. 385.) When the soft parts have been cut in the preceding way, the bones sawn, and the ar- teries tied, the wound is to be closed by bringing the flap of skin over the front and external part of the stump, so as to meet the flap composed of the gastrocnemius, soleus, and integuments on the opposite side. This should be done without letting any tight strap of plaster press the skin against the sharp edge of the tibia, a serious and hurtful practice, which has often occa- sioned ulceration and sloughing of the in- teguments, and protrusion and necrosis of the bone. It is this danger which leads Mr. Guthrie to prefer closing the wound vertically, or nearly so, and applying the adhesive straps from side to side. (On Gunshot Wounds, p. 221.) I think, how- ever, the above mode of operating almost necessarily requires the wound to be closed, so as to form a line, extending in a direc- tion from the tibia to the fibula. But, where a great deal of skin is saved all round the limb, and the muscles of the calf are not chiefly calculated upon for covering the bones, the perpendicular line of the wound will answer verv w'.ll. Many surgeons, however, operate differ- entlv They first make the circular incision through the skin, two inches below where they mean to saw the bones. They n.lt detach the skin from the muscles and bonei equally all round the limb to the extent of about a couple of inches. The integuments are. then turned up, and a division of fit muscles made all round down to the bones, on a level with a line where the detach- ment of the skin has terminated. The parts between the bones are afterwards cut through, &.c. The hemorrhage havingbeen stopped, the integuments are drawn down over the stump. Here, I think, the wound might be closed so as to let the cicatrix be perpendicular; yet Richerand recommendi it to be united from before backward, be- cause (says he) the greatest diameter of the stump is from without irtward. (JVotocto- phie Chirurg. t. 4 p. 485—486. edit. 4.) In the army, the practice has sometimes been adopted of sawing off the sharp up- per ridge of the tibia; but I can offer no exact judgment on the merits of the inno- vation, which is making only slow progress. It has been done a few times at St. Bartho- lomew's, and I should have no objection to giving it a fair trial, especially as it has the sanction of Mr. Guthrie, who says, that,in thin persons, where the spine of tin tibia is very sharp, this part should be removed with the saw. (p. 222.) Occasionally, surgeons have also remo- ved the small remnant of the fibula, and such was sometimes the practice of Larrey, when he amputated nearer the knee thai common. (Mem. de Chir. Mil. T. 3. i 389.) Whether the above plan of amputating the leg so high up, when the foot or ankle is the part diseased or injured, be on the whole most advantageous, I cannot presume to determine. There are certainly many clever men who condemn the practice, and though we see it pursued by the best sur- geons in this metropolis, we may safely assert, that the matter requires further considera- tion. If it were a decided point, that the common custom of bending the knee.ftf the sake of bearing the weight of the body on its anterior part, were the only one na- missible, after amputation of the leg, there could be no doubt of the propriety of per- forming the operation a little way below the knee, in preference to any other sin* tion. But, since there have been numerous instances of persons walking very securely with machines, which allow them to make use of the knee, and are more pleasfng to the eye, on account of their perfect resem- blance to a natural limb; and since aho, the operation at the lower part of the leg * more easy of performance, and safer, tb« vnen done high up; some very eminent surgeons have thought that it ought alwayi TJll iT near the aMk,e> when possible, instead of near the knee. Mr. White of Manchester, in a nanefl ted 1769 (Med. Obs. and Inq. '„„? \ PS us, that he took the hint < o amp^te $ AMPUTATION. iOu nbove the ankle, from seeinga case, in which this had been done by a simple incision, with such success, that the patient could walkextremely well, though with a machine that was very badly constructed. After this, Mr. While began to operate above the ankle with the double incision : and he in- vented a machine much better calculated for the patient to walk upon. In 1773, Mr. Bromfield published his Chirurgical Cases and Observations, wherein he mentions his having begun about the year 1740 to amputate above the ankle, in a case of gangrene of this part of the leg. The patient walked so well, with the aid of a very simple machine, both along a level surface, and in going up and down stair?, that it was difficult to perceive he had lost his foot. Mr. Bromfield was persuaded, however, to give up this practice, until he learned that, in 1754, a Mr. Wright had thrice amputated in this way with success, when he again had recourse to it, without the least unpleasant consequences. (See Chir. Cases and Obs. vol. l.p. 189, fa.) The advantage of amputating a little be- low the knee is, that pressure in walking with a wooden leg is entirely confined to the front of the limb, and the cicatrix itself ;s not subjected to irritation. ^ After ampu- tating at the ankle, the pressure in walking operates directly on the cicatrix; but if the mechanical contrivances for walking are now brought to such perfection, that this pressure does no harm, the operation, per- haps, ought not to be entirely abandoned. According to Sabatier, however, the plan has been extensively tried in France, and not found to answer, the stump being inca- pable of bearing pressure, and not continu- ing healed. (Medicine Operaloire, T. 3. p. 377. edit. 2.) Baron Larrey also speaks of it as an objectionable operation, not merely because some patients, as for instance, sol- diers, have not the means of providing themselves with artificial legs, of the above description, but because it is almost always followed by bad symptoms, owing to the small quantity of cellular substance and flesh, and the thickness of the bone at this part of the leg, whereby cicatrization is impeded. A nervous irritation is more apt to be produced by this, than the common mode of operating, and the suppuration, which is always sanious, takes place with difficulty. "I have (says Larrey,) seen many amputations done at this part, but nearly all the patients died of nervous fe- ver, or tetanus." (Mim. de Chir. Mil. t. 3. p. 394.) In the foregoing columns, I have given some account of the flap-amputation of the leg, as done by Lowdham, Verduin, Garen- geot, Vermale, and others, and, in particu- lar, the practice of O'Halloran has been touched upon, whose chief peculiarity, viz. that of not laying down the flap until ten or twelve days had elapsed, was unques- tionably his greatest error, though the idea may have been admired and followed by a few speculators in modem times. (St o V.n. f 14 Paroisse, Opusc.de Chir. p. 196, ^-c. Paris, 1806.) This last author, who is a general approver of flap-amputations, leaves the stump unclosed for some days after the re- moval of the limb ; but what surprises me is, to hear, that, in one of the finest hospi- tals in this metropolis, three or four trials have been made, in the course of the last year, of a modification of this absurd prac- tice, after amputation by the circular inci- sion. Instead of bringing the sides of the wound together, the stumps were only par- tially closed, and kept for a day or two co- vered with wet linen. The last patient whom I heard of as having been treated in this manner, died a few days after the ope- ration ; and it gives me pleasure^to hear, that all further intention of subjecting more patients to the experiment, in the hospital alluded to, is given up. In flap-amputations below the knee, Alanson and Lucas conjectured, that the cure might be rendered more safe, easy, and expeditious, by applying the flap, with the view of uniting it by the first intention. The following case explains Mr. Alan- son's flap-operation. The disease was in the left leg, the patient, therefore, lay on his right side, upon a table of convenient height, so as to turn the part to be first cut fully into view. The intended line where the knife was to pass in forming the flap. had been previously marked out with ink. A longitudinal incision was made with a common scalpel, about the middle of the side of the leg ; first on the outside, then on the inside, and across the tendo Achillis : hence, the intended flap was formed, first by incisions through the skin and adi- pose membrane, and then completed by pushing a catling through the muscular parts in the upper incised point, and af er- wards carrying it out below, in the direc- tion of the line already mentioned. The flap was thick, containing the whole sub- stance of the tendo Achillis. The usual double incision was made ; the retractor applied to defend the soft parts; and the bone divided, as high as possible with the saw. The flap was placed in contact with the naked stump, and retained there, at first, by three superficial stitches, between which adhesive plasters were used. Notwithstand- standing the patient caught an infectious fever a few days afterwards, the stump healed in three weeks, except half an inch at the inner angle, where the principal vent had been. In another week, the wound was reduced to a spongy substance, about the size of a split-pea. This, being touch- ed with caustic, healed in a few days. The man was soon able to use an artificial leg, with which he walked remarkably weii. He went several voyages to sea, and did his business with great activity. He bore the pressure of the machine to- tally upon the end of the stump, and wn- not troubled with the least excoriation or soreness. In the next instance, in which Mr Alatj IO0 AMPLIATION son operated, be ioriued the flap by push- ing a double-edged knife through the leg, and passing it downwards and then out- wards, in a line, first marked out for the direction of the knife. In this way, the flap was more quickly made. (Alanson on Amputation.) The leg should be completely extended during the operation ; and kept in that pos- ture till the wound is perfectly healed. We shall next notice Mr. Hey's method. This gentleman is satisfied, that very near the ankle is not the most proper place for this kind of amputation. Some cases occurring, in which, from a scrophulous habit, the wound at the stump would not heal completely, nor remain healed, Mr. Hey determined to try whether amputation, in a more muscular part, would not secure a complete healing, and give the patient an opportunity of resting his knee on the common wooden leg, or using a socket, as he might find most convenient. Mr. Hey now prefers this method, and has reduced it to certain measures. It had been customary, at the Leeds Infirmary, to make the length of the flap equal to one-third of the circumference of the leg. This was determined by the eye of the operator, who usually pushed the catling through the leg, near the posterior part of the fibula. Mr. Hey, finding the flap'was not always of the proper breadth, began to determine this by measure, and now operates as follows: to ascertain the place where the bones are to be sawn, to- gether with the length and breadth of the flap, he draws upon the limb five lines, three circular, and two longitudinal ones. He first measures the length of the leg from the highest part of the tibia fo the middle of the inferior protuberance of the fibula. At the mid-point, between the knee and ankle, he makes the first or highest circular mark upon the leg. Here the bones are to be sawn. Here Mr. Hey also measures the circumference of the leg, and thence deter- mines the length and breadth of the flap, each of which is to be equal to one-third of the circumference. In measuring the circumference of the limb, Mr. Hey em- ploys a piece of marked tape, or riband, and places one end of it on the front edge of the tibia. Supposing the circumference to be twelve inches, he makes a dot in the circular mark on each side of the leg, four inches from the anterior edge of the tibia. These dots must, of course, be four inches apart behind. From each of these dots, Mr. Hey draws a straight line downwards, four inches in length, and parallel to the front edge of the tibia. These lines show the direction which the catling is to take in making the flap. At the termination of these lines, Mr. Hey makes a second mark round the limb, to show the place where the flap is to end. Lastly, a third circular mark is to be made, an inch below the upper one, first made for the purpose of directing the circular cut through the integu- Tent«. in front of the limb. The calling for making the flap, should be longer than those commonly employed in amputations. Mr Hey uses one which is seven inches long in the blade, and blunt at the back, to avoid making any longitudinal wound of the arteries, which i^ very difficult to close with a ligature ; and, for the same reason, he pushes the catling through the leg a little below the place where such muscles are to be divided, as are not included in the flap. The limb being nearly horizontal, and the fibula upward, he pushes the cat- ling through the leg, where the dot was made, and carries it downward along the longitudinal mark, till it approaches the lowest circular mark, a little below which the instrument is brought out. The flap being held back, Mr. Hey divides the in- teguments on the front of the limb along the course of the second circular mark. The muscles not included in the flap, are then divided a little below the place where the bones are to be sawn. No great quan- tity of these muscles can be saved, nor is it necessary, as the flap contains a sufficient portion of the gastrocnemius and soleus mus- cles, to make a cushion for the ends of the bones. After sawing the bones, Mr. Hey advises a little of the end of the tendon of the gastrocnemius to be cut off, as it is apt to project beyond the skin, when the flap is put down ; and he recommends the large crural nerve, when found on the inner sur- face of the flap, to be dissected out, lest it should suffer compression. As strips of adhesive plaster cause great pressure on the end of the stump, Mr. Hey prefers using sutures for keeping the flap applied; small strips of court-plaster being put between the ligatures. The sutures may be cut out on the eighth or ninth day, and the flap supported by plasters. Mr. C. Bell describes another sort of flap-amputation. The operation is not to be done so low, as there will not be asof- ficiency of muscle to cover the end of tbe bones. An oblique cut is to be made, with the large amputating knife, upward, through the skin of the back part of the leg. The assistant is to draw up the skin, and the knife is to be again applied to the upper margin of the wound, and carried obliquely upward till it reaches the bones. The knife. without being withdrawn, is next to he car- ried, in a circular direction, over tbetibh and fascia, covering the tibialis antiens, until it meets the angle of the first incision on the outside of the limb, Thesur^eonh then to pierce tbe interosseous membrane, kc. The sawing being completed, and the arteries secured, the flap is to be laid down- and the integuments of the two sides «f the wound will be found to meet. (0p» tire Surgery, vol. 1.) Langenbeck disap- proves of the plan of pushing the knife through the calf of the lig, as practiced by Alanson, Hey, Graefe, Sic. because an inei- &'!Cn V'*&?n may ru" the I,oint * I l?onnl -e tW° bo'"rS' a"d in *»•» way* ' w oirnd is never made evenly. His maDBii "f forming the flap i- very s&|" ?,, V- f AMPUTATION. 107 Bell's, except that he makes first three cuts in the integuments, two longitudinal and one transverse, by which the shape of the flap of skin is determined. (Bibl. fur dei Chir. B.l.p. 571.) The regular flap-amputation of the leg, I mean that operation in which the circular incision is abandoned, and a semi-circular flap both of skin and muscle preserved, is often considered more painful than the common method, because it cannot be done with equal celerity. Yet when we come to see what respectable names are recorded in its favour, how soon the stump generally heals, how well the ends of the bones are covered, and how all dissection of the integuments from the fascia is avoid- ed in this mode of operating, at least as far as the flap extends, the method must be allowed to possess weighty recommenda- tions. Indeed in its present improved state, and with the peculiar fitness of such a stump for adhesion, this operation, I think, is again rather rising in the estimation of the pro- fession. In 1816, Klein had performed flap- amputation of the leg, about twenty times. If the flap should happen to be made too large, he particularly dwells on the propriety of removing part of it at once ; and, when it is too short, he enjoins carrying the inci- sion a little further upwards without delay. He confesses that the plau is attended with some little trouble in securing the interos- seous arteries, which are apt to retract considerably, but, such has been the success of his practice, that out of twenty cases, seventeen got well, and most of them very soon, without the least exfoliation ; and the other three died of typhus. (Praetische Ansichten der bedeutendsten Chir. Op. Ires. Heft. p. 47.) In the same work, this ex- perienced surgeon, convinced how much more quickly and certainly the wound heals after amputations with two flaps, than those with one, has suggested a plan of amputa- ting below the knee, so as to form two ■r lateral flaps. I regret that my limits prevent me from entering into a description of it. I have already specified the principal . reasons, which nave established the com- mon custom of amputating the leg, about four inches below the patella, and, if the disease or injury will not admit of the operation being done thus low, of removing , the limb above the knee joint. In the Egyptian campaign, however, Baron Larrey .performed two amputations very near the ,knee joint, almost on a level with the head of the fibula, which he judged proper to extirpate. The successful result of these operations dispelled the fear, which this experienced surgeon previously entertained lbout amputating in the thick part of the lpper head of the tibia; for, no caries of his spongy portion of the bone, no bad jffects on the knee-joint, and no anchylosis )f the stump ensued ; and, with the difl'er- snce of a few days, the wound healed as eadily, as that made i:i the common place •f election, viz. three or four finger breadths 'elow the tuberosity of the ia. >'iuce the above-mentioned campaign, Larrey has adopted this practice in many cases, where it was impossible to have operated at the usual place, and he assures us, the success fully equalled what attends operations done at the ordinary distance from the knee. In 1806, another French military surgeon, who had tried this method himself, published a dissertation, in which he commended opera- ting, where circumstances required it, much higher than the point allowed by generally received rules. Larrey differs, however, from Garrigues, in forbidding amputation higher than the level of the tuberosity of the tibia, the thick portion of which may be sawn, but not above the insertion of the tendon of the patella. A transverse line, drawn from this point, usually passes below the articulation of the fibula, and over the lower portion of the uppermost part of the condyles of the tibia: but as the relative positions of the heads of the two bones to each other differ somewhat in different individuals, Larrey makes the tu- berosity of the tibia the point, above which the bone should never be sawn. By cutting higher, the ligament of the patella is sepa- rated from its insertion : the bursa mucosa. situated underneath it, is wounded; and the ligaments at the sides of the joint are injured; whence arise retraction of the patella, effusion of the synovia, and such disease of the knee-joint, as may ren- der another amputation indispensable. By making the division on a level with the tuberosity of the tibia, the attachment of the ligament of the patella is preserved, as well as that of the flexor tendons of the leg, which-are requisite for tbe motion of the stump. The bursa mucosa is left untouched j and the head of the bone is sawn low enough to avoid creating a risk of caries. But, says Larrey, if this mode of amputa- ting below the knee be compared with am- putation of the thigh, as recommended by authors for the cases in which the new method is proposed, the advantages of the latter are considerable. In the first place, life is less endangered, because a smaller portion of the body is removed. The ope- ration is as easy in one situation as the other. The stumps heal with equal facility. Larrey has never seen the spongy part of the tibia become carious, nor perceptibly exfoliate. When the remaining portion of the fibula is very short, as usually happens, it ought to be taken away, as it is an useless body, inconvenient for the employment of a wooden leg. Larrey directs as much skin as possible to be preserved, and making a perpendicular incision through that part of it, which covers the tibia, in order to hinder the bone from making its way through it by ulceration. With a stump, thus formed, comprising the knee and one or two finger breadths of the leg, the patient has a firm point of sup- port, on which he can securely walk with- out a stick. The stump admits also of an artificial leg of the'natural shape being worn,. the knee boms; always bent, provided tho it's, AMPUTATION length of the stump do not exceed the dia- meter of the calf of the artificial limb. 'Mcm.de Chir. militaire, T. 3. p. 386—394.) From a passage, quoted from Mr. Bromfield, (Chir. Obs.Sf Cases, vol. l.p. 185.) by Mr. (iuthrie, it would seem, that the first of these gentlemen advised amputating as near to the knee as conld be done without risk of cutting the ligament of the patella, so that the stump might not extend beyond the wooden leg. On the whole, Mr. Guth- rie's own observations are very favourable to this practice ; but he candidly acknow- ledges his belief, that " it would not succeed when indiscriminately done in the hospitals t»f large cities," though it may frequently !>e practised in the army with advantage, provided the surgeon saw through the tibia below its tuberosity. (On Gunshot Wounds, p. 223, and 227.) Upon looking over the details of the cases recorded by Larrey in confirmation of the above statement, I was :-truck with one important fact, which does not justify a part of his commendations; \iz. moat of the stumps were above four months in healing; and that which healed most quickly was not well before the sixty- eighth day. (6'te Mem. de Chir. Mil. T. 3. p. 57, 397, 398, fa.) Hence, unless it be supposed, that the wounds produced by amputation below the knee in the ordinary manner, are generally thus long in healing, as treated by the French surgeons, the infer- ence is rather unfavourable to the method so highly commended by Larrey, though I am far from wishing to assert that, even if the stumps cannot usually be healed in less time, more than a full compensation for this disadvantage is not obtained by some of the benefits above enumerated. However, in order to be able to pronounce any posi- tive judgment on the merits of this mode of operating, it would be requisite not only to see two or three successful cases just after their cure, but to examine the state of a tolerable number of stumps, sometime after they had been subjected lo the pressure of an artificial leg. AMPUTATION OF THE ARM. The structure of the arm is very analo- gous to that of the thigh : like the latter it contains only one bone, round which the muscles are arranged. The interior mus- cles are attached to the os brachii, while the more superficial ones extend along the limb, without being at all adherent. The first consist of the brachial is interims, and the two short heads of the triceps : the se- rond, of the biceps, and long head of the'tri- ceps. Hence, amputation is here to be done in the same way as in the thigh, un- less when we are necessitated to amputate very high up, above the insertion of the deltoid muscle. In tbe arm, says Graefe, the incisions through the muscles should even be made more obliquely upwards than in the thigh, where the muscles are more bulky, by which means two inches of mus. cle may be saved, besides the retracted in- teguments ; an abundance for covering the Mump, were the arm full ten inches in cir- eumferencc. (Normen fur die Abl. grow rer, Gliedm. p. 109.) The patient being properly seated, the arm is to be raised from the side, and, if the disease will allow it, into a horizontal posi- tion As I have seen some inconvenience- produced by the patient's fainting in the midst of the operation, I join Graefe and some other practitioners in thinking that the patient, if circumstances will allow, should be placed upon a table in the recumbent position. (Normen fur die Ablosimg gr*. serer Gliedm. p. 108.) The surgeon is to stand on the outside of the limb, apply the tourniquet as high as possible, and to haw the skin and muscles which he is about to di- vide, made tense by the hands of an assis- tant. The soft parts are next to be divided, as much of this limb being pre served as pos sible. The retractor to be applied, the bone sawn with the usual precautions, and the bleeding stopped in the ordinary way, cart being taken to leave the radial nerve out of the ligature, which is put round the brachial artery. The wound is then to be closed so as to form a transverse line, the dressings are to be applied, and the patient put to bed, with the wound a little elevated from tbe surface of the bedding. In taking off the arm, I entirely coincide with Mr. Guthrie, with regard to the useless- ness of dissecting back the integuments, their effectual retraction by an assistant, after their complete division, being quite enough ; (On Gunshot Wounds, p. 854.) but, as I have in variably imitated Graefe and others, in making the incisions through (he muscles with the edge of the knife turned very obliquely upwards, it has not appeared to me necessary, after cutting down to (he bone in this manner, to clear away the mus- cles from it to the extent of an inch an ahalf, or two inches higher. Instead also of attempt- ing to perform the circular oblique incision through the muscles with one stroke of the knife, the objections to which have been noticed in the description of amputation cl the thigh, I have made it a rale to divid- the loose biceps muscle, as soon as the in- teguments had been cut and retracted, ind of letting it fully recede, before the division of the rest of the soft parts was begun. If the disease should require the arm t" be taken off at its upper part, there would be no room for the application of the tour niquet. Here, instead of putting a com press in the axilla, and having it held firm!;- upon the artery by a by-stander, as advise bySabatier,it is more eligible to make pres- sure on the artery as it passes over the h> nb, of which method I shall speak in treat i"p' of amputation at the shoulder-joi* V> ith a straight bistoury, the surgeon isnn« to make a transverse incision down to uV hone, a little above the lower extremity« the deltoid muscle. Two other longiu* SrlnCrS£nS made a,°»gthe front and bit* ecige ot this muscle, now form a flan wlB must be detached,'and reflated l3 the rest of the soft'parts of V^b ^? AMPUTATION. 109 be divided by a circular cut, made on a level with the base of the flap, and the operation finished like a common anputation. (Saba- lier, Midecine Operatolre, t. 3, p. 375, fa. ed. 2.) As a matter of choice, and not at all of necessity, the arm may be amputated with two flaps ; one anterior; the other posterior. The first should be formed of the skin and biceps, and be three or four inches in length ; the other is to be of the same size, and composed of the triceps and integu- ments. The muscular flesh, close to the bone, is now to be divided all round, and the saw used. Klein of late has preferred this to the common method, having adopted it in nine cases. So well is the end of the bone al- ways covered, that a protrusion of it is im- possible. (Practische Ansichten der Chirur- gischen Operationen. p. 44.) When the arm is injured very high up, Baron Larrey differs from Sabatier, and pre- fers amputation at the shoulder joint to pre- serving a short stump, containing the upper end of the humerus; for, says he, if this bone eannot be divided at least on a level with the tendinous insertion of the deltoid, the stump is retracted towards the arm-pit by the pectoralis major and latissimus dorsi; the ligatures on the vessels irritate the bra- chial plexus of nerves ; great pain, and ner- vous twitchings, often ending in tetanus, are produced ; the stump continues swelled; and, in the end, the humerus is fixed by anchylosis to the shoulder, so that this por- tion of the arm remains altogether useless, and renders the patient liable to accidents. -' 1 have seen (says Larrey) many officers and soldiers, who, on these accounts, were sorry that they had not undergone amputa- tion at the shoulder." (Mem de Chir. Mil. T. 3. p. 53, 400.) Mr. Guthrie also states, that when amp - tation by the circular incision is attempted at the insertion of the pectoralis major, the bone will generally protrude after a few dressings. However, he entirely dissents from Larrey, respecting the necessity of ta- king off the limb at the shoulder, and pre- fers doing it from half an inch to an inch and a half below the tuberosities of the hu- merus, as the state of the injury may re- quire. Two incisions are to commence, one or two finger-breadths below the acromion ; and the inner one is to be extended directly across the under side of the limb, till it meets the lower point of the outer wound. Thus the under part of the arm is cut by a circular incision ; the upper in the same manner as it sometimes is in removing the limb at the shoulder joint. Without detach- ing the skin from the muscles, these are cut through ; the soft parts are held out of the way of the saw ; the bone is sawn ; the ves- sels secured; and the flaps brought together, -o as to form a line from the acromion downwards. (Gunshot Wounds, p. 337, fa.) I am decidedly of opinion, that in the de- scription of cases referred to, either this me- "thod. or Sabatier's operation, should be preferred to the removal of the whole limb at the shoulder joint. AMPUTATION OF THE FOREARM. The wisest maxim, with respect to the place for making the incision, is to cut off as little of the limb as possible. This fact is perfectly established, though it is true that Larrey, in consequence of his mode of dress- ing the stump, has not experienced success in his amputations done in the tendinous part of the forearm. The forearm is to be held by two assistants, one of whom is to take hold of the elbow, the other of the wrist. The tourni- quet is to be applied to the lower part of the arm, and the assistant holding the elbow, should draw up the integuments, so as to make them tense. The circular incision is then to be made down to the fascia; from this as much skin is to be detached, reflected and saved, as is necessary for covering the ends of the bones, and the muscles are to be cutonalevel with the reflected skin, the knife being at the same time directed obliquely upward. As many of the muscles are deep- ly situated between the two bones of the forearm, too much attention cannot be paid to dividing all of them, with a double- edged knife introduced between the radius and ulna. The soft parts are to be protected from the saw by a linen retractor. It is generally recommended to saw the two bones to- gether, for which purpose the forearm should be placed in the utmost state of pro- nation. In any other position, the ulna is situated almost directly under the radius. The ulnar, radial, and two interosseous ar- teries, are those, which usually require a ligature. Graefe removes the forearm by making a flap from the flesh in front of the limb, and then extending the wound quite round the member. (Normen far die Ablosung grdss- erer Gliedm. p. 138, fa. 4to. Berlin, 1812.) Mr. Guthrie makes two flaps, one in front, the other on the back of the forearm ; but, above the middle of this part of the limb, he prefers the circular incision. (On Gunshot Wounds, p. 373—374.) Dr. Hennen also expresses his approbation of amputating the forearm, so as to make two semilunar flaps : (Principles of Military Surgery, p. 265, edit. 2 ;) which is the method recommended and practised by Klein. (Practische Ansichten be- deutendslen operationem Heft, p. 45.) these flap-operations of the forearm are rather proceedings of choice, than of necessity; for, I have seen this part of the limb removed in numberless instances by the circular inci- sion, and can hardly remember a case, in which the stump turned out badly. In ma- king the inner flap, the radial and ulnar ar- teries must obviously be in danger of being wounded higher up, than the point where they are quite cut through, as Mr. Guthrie candidly acknowledges; an accident which I think might give rise to a great deal of trouble. With respect to Larrey's preference to amputating in the fleshy part of the fore- llu AMPUTATIO.V arm, though tlie case would admit of the operation being done much lower, I need only say, he would find no reason for this choice, were he to practise union by the first intention, at every opportunity, as is the lustom iu England. The hand may be amputated at the joint of the wrist, whenever the disease does not extend too high, and a flap can be made of the integuments of the back of the hand. Richerand. thinks such an operation some- times preferable to amputation above the joint. (Nosogr. Chirurg. T. 4, p. 506, edit. 4.) AMPUTATIOW AT THE HIP-JOINT The very idea of this formidable opera- tion, for a long while, checked the hand even of the most ready advocate for the use of the amputating knife, and every mind shuddered at so extensive a mutila- tion. Still, it could not be denied that the chance of saving life occasionally depended upon a submission to the greatest temporary suffering, and that without the most cruel of sacrifices, the preservation of the patient was totally impossible. Dreadful as the amputation at the hip appeared, both in respect to the magnitude of the part of the body to be removed, and the extent of the wound caused by such removal, the despe- rate nature of somejcases at length begun to incline surgeons to view more dispas- sionately a scheme, at which the mind at first must naturally have revolted. Morand is the earliest practitioner, who made this severe operation the subject of considera- ble attention, (Opuscules de Chir. T. 1. p. 176, Svo. 1768,) and in the year 1739, two essays on the same topic were communica- ted to the Royal Academy of Surgery at Paris, by two of his pupils, Volner and Pe- thod. In 1743, Ravaton wished to have performed amputation at the hip-joint in a case of gunshot fracture of the trochanter major, and neck of the thigh bone, but was prevented by the opposition of other sur- geons. (Chir. d'Arm. p. 323, fyc.) In 1748, the propriety of attempting the opera- tion was urged by l'Alouette. (Disp. Chir. Halleri, t. 5, p. 265.) At length, the Royal Academy of Surgery at Paris thought the subjecthighly deserving of further investi- gation, as it appeared to several of its mem- bers, that there were circumstances under which its performance might be adviseable. Iu the year 1756, they therefore proposed the following question, as the grand prize subject; In the case, in which amputation of the hip-joint should appear to be the only resource for saving the patient's life, lo deter- mine ichelher this operation ought to be practised, and what would be the best way of performing it ? No satisfactory memoirs having been presented, the same subject was proposed in 1759. The approbation of the Academy was now conferred on a paper written by Barbet, in which tbe propriety of amputating at the hip-joint was defended, and some of the cases demanding tine opera- tion specified. If, for instance, a cannon lall.or anv otherviol^ntlvcont'^insicausp. had carried off or crushed the thigh, hi „, to leave only a few parts to be cut to make the separation complete, he thought a sln. geon ought not to hesitate about doing it, The same author conceived that a sphace- lus, extending to the circumference of the joint, and destroying the greatest part of the surrounding flesh, might also render tbe operation equally necessary and easy. (See Salatier, Med Opiraloire, t.3, p. 271,$*.) Cases were also adduced, where the sur- geon completed the separation of the dml parts with a knife. However, this cannot be considered as amputation at the hip-joint. Dividing a few dead fibres was a thing of no importance, in regard to the liklihooil of its creating any bad symptoms. The proceed- ing, in fact, seems to me to have no analog-, at all to the bloody operation of taking thi> thigh bone out of the socket. It is quite a different thing, when the operator'has to cut through parts, which bleed profusely, and are endued with life and sensibility. In addition to the memoir by Barbef, thirty-three other essays were offered to the academy, the majority of which were filled with arguments in favour of the operation; and, besides these productions, two other memoirs were published at Paris, one by Goursand in 1758, explaining a new method of operating, and another by Moublet, (Set; Journ. de Medic, an. 1759.) in which, says Professor Thomson, the operation is very ably considered in all its different relations. (Obs. made in the Mil. Hospitals in Belgium, p. 260, 63.) Some of the first modern surgeons con- demn the proceeding. The following are Mr. Pott's sentiments : " M. Bilguer, and M. Tissot, are the only people whom I have met with, or heard of, in the profession, who speak of an amputation in the joint of the hip, as an adviseable thing, or as being preferable to the same operation in the,' thigh." After a quotation or two, he con- tinues ; "that amputation in the joint of the hip is not an impracticable operation (al- though it be a dreadful one) I very well know. I cannot say, that I have ever done it, but I have seen it done, and am now very sure I shall never do it, unless it be on a dead body. The parallel, which is drawn between this operation and that in the shoulder will not hold. In the latter it some- times happens, that the caries is confined to the head of the os humeri, and that the scapula is perfectly sound and unaffected. Jn the case of a carious hip-joint, this never is the fact; the acetabulum ischii, and parts about, are always, more or less, in the same stale, or at least in a distempered one, and so indeed most frequentlyare the parts with- (Luu Pe[VlSC Lc- (Pott °" imputation.) CaJhseri has difficulty in supposing any cir- f eSi' m W-h.ith the amputation could Chi « Ti^k*en,ritu h°Pe* of success. (Syst. nicLit a fu-48' Tom- 2- edil- 1800.) And Richerand thinks, that, unless the linib be nearly separated by the disease, „Occident, a prulent nurgcon ,ho«M declino rankTn' amputation. hi the attempt. (Nosogr. Chir. Tom. 4. p. 519. edit. 4.) As Professor Thomson has justly ob- served, it is a remarkable fact in the history of surgery, that an operation, which had been invented in Fiance, and concerning which so much had been written in that country, should have been first actually put in practice in England. " I have been in- formed, (says he) that the operation was performed in London by the late Mr. H. Thomson. Surgeon to the London Hospi- tal, and imagine that it must have been bis operation, to which Mr. Pott alludes." (Obs. made in the Mil. Hospitals in Belgium, p. 264J At all events, whether this was the identical case which Mr. Pott saw, or not, the example referred to by this distin- guished surgeon is the earliest instance of the operation being actually performed. It was even repeated in this country before it was ever practised on the continent, as far as can be made out from the records of the profession ; for, it was performed by Mr.Kerr,of Northampton,on agirl, between eleven and twelve years of age, in a case of diseased hip; a case, in which 1 am now completely satisfied that it ought never to be attempted, for the reason laid down by Mr Pott. In fact, Mr.Kerr, after removing the limb, found the acetabulum, and all the adjacent parts of the ossa innominata, cari- ous. But, the experiment was here rendered still more hopeless, by the patient being consumptive. Yet with all these disadvan- tages, the girl lived till the eighteenth day from the operation, and, after death, her lungs were found to be a complete mass of disease, one of them being totally reduced to matter. (See Duncan's Med. Commen- taries, vol. 6, p. 337, 8i!o. Lond. 1779.) M. Larrey performed this operation twice in Egypt; and once, while be was a surgeon to the French army on the Rhine. He was encouraged to make these attempts to save his patients by the consideration, that he had already preserved some lives by ampu- tating either both thighs, both legs, or both arms, or removing the humerus at the shoul- der joint. Larrey has also the true merit of having first done the operation in the only description of cases, in which perhaps it ought everto be performed; viz. gunshotinjuriesof bead, neck, and upper part of the femur, with, or without injury of the femoral ar- tery, or where the limb had been carried away by a shell, or cannon-ball, too high up to admit of amputation in the ordinary man- ner. However, he also regards as fit occa- sionsforamputationatthe hip-joint, circum- stances in which, from gunshot violence, the limb is seized, or threatened with gan- grene, nearly up to the hip. (Mim. de Chir. Mil. t. 2. p. 18o.) Severe as the operation is, Larrey con- tends, that it i.- anactof humanity, if it ever is the means of saving'lives, wliich are in danger, and, he argues, that it is justifiable Iiy the old maxim of Hippocrates, "Ad ex- irenins morbus extrema remedia." To the i-liicf" objections, which have been made to it, he replies, 1st, That the wound is more alarming than dangerous. The Cesarean operation, (says he) has been successfully performed on the living female, and is still recommended by many practitioners. L'Au- monier, principal surgeon of the Rouen Hospital, has successfully removed a scir- rhous ovary of considerable size. Examples are recorded of the arm and scapula being torn away, and the patients soon recovering. Besides, the surgeon has it in his power to lessen the wound, produced by the opera- tion. 2dly. The dangers of hemorrhage may be obviated by the assistants tempor- arily placing their fingers on the mouths of the cut vessels, until ligatures can be ap- plied. In confirmation of his sentiments, con- cerning the propriety of the operation, Lar- rey adverts to a fact reported by Morand, where a soldier had both his legs amputated very high up, and also both his arms so near the shoulders, that he could hold nothing in his armpits. Yet, mutilated as he was, he enjoyed good health. (Opusculesde Chir. p. 183.) And Larrey, in his own work, has recorded several instances, in which the whole of a limb was removed, or more than the halves of both the upper or lower ex- tremities of the same subject, without any fatal constitutional disturbance. (Mim. de Chir. Mil. t. 2. p. 182-184.) One of his pa- tients above alluded to, survived the opera- tion a week, at the end of which he was car- ried off by the plague ; and the others died, after being conveyed, in a very uneasy manner, during the precipitate march of the army. (See Relation de VExpedition de VAnnie d'Orient en Egypt, fa. p. 319, 8ro. Pan's, 1803.) At the battle of Wagram, Lar- rey operated at the hip-joint on two sol- diers of the imperial guard, under very unfavourable circumstances; and the events were fatal in a few hours. (Mim. de Chir. Mil. T. 3, p. 349.) Larrey used to operate as follows: he be- gan with making an incision in the track of the inguinal artery in the bend of the groin, and, after carefully excluding the nerve, which is more externally situated, he tied this vessel, with the aid of a semi- circular curved needle, as closely as possi- ble to Poupart's ligament, in order that the ligature, which was placed above the origin of the circumflex arteries and the profunda, might obviate all inconvenience from the bleeding, which might otherwise happen from their numerous branches. This being done, a straight knife was perpendicularly plunged between the tendons of the mus- cles attached to the trochanter minor and the base of the neck of tbe femur, so as to bring out its point at the back part of the limb, or in a diametrically opposite situation to its first entrance ; and now by directing the knife obliquely inwards and downwards, a flap, which was not to be too large, was made of the soft parts at the inner and up- per portion of the limb. This flap was now- drawn towards the scrotum by an assistant. and the articulation was brought into view 11. A.MI'l TAliO\. The obturator artery, and some branches of the pudental, wounded by making the flap, were immediately tied. The thigh was now put into the state of abduction ; the inner part of the orbicular ligament, made tense by this position, was divided, and the joint opened. The ligarneutuin teres was then to be cut, and the bone dislocated. The knife was next to be brought to the outside of the great trochanter, and an external flap formed of the soft parts, calculated to meet that which had been made at the in- side of the limb. In proceeding through the operation, Larrey secured, as soon as they were divided, the obturator arteries, and se- veral branches of the pudendal, gluteal, and ischiatic arteries. The two flaps were brought together, and kept in this position, with strips of adhesive plaster, and a wool- len spica bandage. (See Mini, de Chir. Mil. t. 2. p. 186, 188.) In the Russian Campaign, Larrey had two more opportunities of amputating at the hip- joint. In the first instance, he operated upon a Russian at Witepsk, whose thigh bone was broken to pieces up to the trochanter, and the soft parts of two-thirds of the thick- ness of the limb destroyed. This man went on as favourably as possible until the 25th day from the operation, the parts being healed except at two points, where the liga- tures had been brought out ; but, unfortu- nately a scarcity of provisions now occur- red from some neglect, or another ; and the patient on the 29th or 30th day, fell a vic- tim. The second operation was done on a French dragoon after the battle of Mozaisk, who was afterwards seen perfectly cured by the surgeon major, at Orcha, who received him there, and made a report of the fact to Larrey by letter. (See Mim. de Chir. Mil. T. 4,p. 26-50-51,8do. Paris, 1817.) In 1812, M Baffos, surgeon to the Hopital des Enfans Malades at Paris, amputated at the hip nearly in the manner of Larrey, ex- cept that he only compressed the artery in the groin, and did not begin with tying it, a method to which Larrey himself now gives the preference. (See Mim. de Chir. Mil. T. 4. p. 434.) The patient was a child, seven years old, and the case a dis- eased hip. The patient got well of the wound ; but died of a scrofula, three months afterwards. The cotyloid cavity was found full of fungous flesh, and the os innomina- tum carious. As the latter state always exists in the diseased hip-joint, the whole of the disease does not admit of removal by rimputation, and consequently the attempt ought ncvertobemade. (See Joints,Diseases of.) The plan of operating, adopted by Baffos, is considered, I believe, by all surgeons of the present day, better than that formerly advised by Larrey, inasmuch as the objec- tionable and unnecessary preliminary mea- 'iire of taking up the artery in the groin, instead of simply compressing it against the os pubis, was rejected. Cutting down to the artery as a precaution against hemor- vhntre. i> doing a double operation, and put- tine the patient to needless suffering: u wa- the earliest method, having been proposed by Volther and Puthod. Who was the first it has been publicly recommended by Mr Abernethy, in his anatomical lectures for the last thirty years : it is twenty-three years since I began to attend his courses. and, in the exhibition of this operation, by the circular incision upon the dead subject, compression of the artery in the groin was then advised, and, as I have stated, not for the first time. Larrey's practice also of running a long narrow knife through the limb, in order to form the inner flap, i< highly objectionable, as the parts can never be divided in this vague manner without considerable irregularity. 1 am glad to find Mr. Guthrie has entered his protest against it, and recommended making the incisions for both flaps from without inwards; (On Gunshot Wounds, p. 178.) an improvment, which would have been right in advising for other flap-amputations. When serving with the army in Holland in 1814, I assisted Dr. Cole in the performance of this operation. The plan adopted by him, is the same as has been taught by Mr. Aber- nethy, in his lectures for the last thirty years, The flow of blood through the fermoral ar- tery was stopped by compressing the vessrl in the groin with tbe handle of a key rovercJ with lint. The thigh was then amputated as high as possible, close below the trochanters, The fermoral artery was immediately se- cured, and afterwards every other vessel re- quiring ligature. An incision was now made directly on the acetabulum, and the head of the bone removed with the utmost facility and expedition. The patient lost even less blood, than in an ordinary amputation, awl the wound admitted of being brought to- gether with adhesive plaster in the best man nerpossible, so as to represent a transverc line. I am sorry to add, that the patient lived only till the following day. In one dreadful case of fracture of the upper partof the femur by a grape shot, when the open- tion had been delayed too long, the whole limb being inundated with matter, andhV upper end of the lower portion of the bone projecting through the flesh backward, I ventured to perform the same operation at Oudenbosch in Holland, a few days after the assault on Bergen-op-Zoon ; and, here happened, what must often occur; instantly after the devision of the soft parts, the bone being broken to pieces, the limb came off, leaving thehead of the bone, the trochanters. and a small piece below them projecting Had not the man appeared in a very bad way by the time the vessels had been se cured, I should now have removed the bead ;nht„ bone [ b,«t the shock of the ope«fe tion was such, that be survived it but afcP TlTl^ ° rgh Scarce,3r ar,y hl0(>d was lot. 1 he mode of operating, by the circular I* •">?n is preferred bv Graefe. «.C „" "J? ingly apj)ear.s to consider it as ;, new mc AMPUTATION. 113 tliod. ^\omw.u fur die Abl. grosserer Gliedm p. 118.) It has also been proposed by Mr. Veitch, with the modification of leaving an inch or two of the bone projecting, which is done, without giving any additional pain, by dissecting off the soft partsbelow the first in- cisions down to the bone. This projecting piece is intenc-d to serve as a lever, with which the head of the bone is to be got out of the acetabulum. (Edinb. Med and Surg. Journ. vol.3, p. Y2'>) Ingenious as this sug- gestion may be, I do not regard it as an im- portant practical improvement; 1st, because in almostallcases, where the operation is ne- cessary, the bone is so fractured, that its divi- sion is already made by the injury : 2dly, because the scheme is unnecessary ; for in Dr. Cole's case, where I assisted, the head of the femur was removed from the aceta- bulum with the utmost facility, by merely making an incision over that cavity, cutting the ligaments, and availing ourselves of the small piece of bone accidentally projecting. In fact, in all gunshot injuries, requiring this operation, excepting a few instances of spreading gangrene from wounds, the bone is usually broken too high for Mr. Veitch's method to be practicable. With the same view of facilitating the exit of the head of (he bone from the acetabulum, Graefe (p. 123.) recommends dividing the transverse ligament completingthe brim of the anterior and inferior side of the socket. From my having once seen one of the first anatomists in London, with a powerful young assistant, and tbe whole length of the unbroken femur tor a lever, baffled for nearly half an hour before he could dislocate the head of the bone, I supposed Graefe's maxim worth re- collecting. I am acquainted with only three cases, in which amputation at the hip-joint proved successful. The first operation was that done by Mr. Brownrigg, surgeon to the forces, on the 12th of December, 1812. The upper part of the thigh bone had been bro- ken by a gunshot, near Merida, in Spain, the 29th of December, 1811. The man was some time ago living at Spalding, in Lin- colnshire, in perfect health. The second successful operation was that performed by Larrey, at Witepsk. The third was done by Mr. Guthrie, in the Netherlands, on a French prisoner of war, who completely recovered. On the other hand, the examples which have failed are numerous, though under- taken by surgeons of reputation and ability. Mr. Guthrie, Dr. Emery, Mr. Brownrigg, Larrey, Mr. Brodie, Drs. Blick and Cole, and ina-iy other military practitioners, have had opportunities of amputating at the hip without success. No one can expect, however, this opera- lion not to fail in a large proportion of the cases, in which it is attempted : this must always happen, let it be done in the most skilful manner possible. Yet, as there are unquestionably some descriptions of injury, where life must inevitably be lost, if this proceeding be rejected ; <-, 114 AMPUTANWX 52 Gebietc der /'lactisclieii Med. ^c.) Paroisse Opusc. de Chir. p. 208 ;) Graefe (Normen, 4to. Berlin, 1812.) The sentiments of these three surgeons, however, are not founded upon any cases of their own, in which the operation was performed ; yet as being men of considerable experience and talents, their sanction may be proper, as a counterbalance to the opinions of some other men of eminence, who, without any personal experience of their own, have con- demned the proceeding, as unfit to be at- tempted. AMPUTATION AT THE SHOULDER JOINT. H. F. Le Dran performed the first ope- ration of this kind, of which the particulars are recorded. It was in a case of caries and exostosis, reaching from the middle to the neck of the humerus. Le Dran began with rendering himself master of the bleed- ing ; for which purpose, he introduced a straight needle, and a strong ligature under the.artery. This was passed from the front to the back part of the arm, as closely to the axilla and bone as possible. The liga- ture, then including the vessels, the flesh surrounding them, and the skin covering them, was tightened over a compress. Le Dran, with a straight narrow knife, then made a transverse incision through the skin and deltoid muscle down to the joint, and through the ligament surrounding the head of the humerus. An assistant now raised the arm, and dislocated the head of the bone from the cavity of the scapula. This allowed the knife to be passed with ease between the bone and the flesh. Le Dran then carried the knife downward, keeping its edge always somewhat inclined towards the bone. In this manner, he gradually cut through all the parts, as far as a little below the ligature. As there was a large flap, Le Dran made a second ligature with a curved needle, which ligature included a great deal of flesh, the redundant portion of which was cut off together with the first ligature, which had become useless. The cure was completed in about ten weeks. (Obs. de Chir. T. I, p. 315, Paris 1731 ; and Traite de Oper. p. 365.) Le Dran (the son) who published this memorable case, does not state, that the operation was a new one, and it appears, from the Recher.ckes Criti- trues sur I'origine, fa. de la Chirurgie en France, and from La Faye's notes on Dio- uis, that it had been previously practised by Morand, the father. Garengeot thought that the ligature might be applied by means of a curved needle, with sharp edges, and, in order to lessen the wound, he directs the incision to begin two or three finger-breadths below the acromion, across the deltoid muscle, so as to form one flap, then a lower one was made in the axilla; and after the second ligature had been applied, the two flaps were brought into contact. (Traite des Oper. de Chir. t. 3. p. o30. M*m. de Acad. de Chir. T. 2, p. 261.1 La Fave extended the improvement* further After placing the patient in n chair, and bringing the arm into a horizontal po- sition, he made, with a common bistoury, a transverse incision into the deltoid mus- cle, down to the bone, four finder-breadths below tbe acromion. Two other incisions, one in front, the other behind, descended perpendicularly to this first, and made a large flap of the figure of a trapezium, which was detached and turned up towards the top of the shoulder. The two heads of the biceps, the tendons of the upra-spi- natus, infra-spinatus, teres minor and sub- scapularis, and the capsular ligament, were next divided. Now, when the assistant, who held the lower part of the limb, made the bone describe the motion of a lever upward, the head of the bone was easily dislocated. La Faye next carried his inci- sion downward, along the inner part of the arm, until he was able to feel the vessels, which he tied as near the axilla as possible. The separation of the limb was then completed a finger's breadth below the ligature. The flap was then brought down over the glenoid cavity, and the wound was dressed. (See Nouvelle Methode pour fair I'Operation de I'Ampulnlion dans I'arti- culation du Bras avec I'Omoplate, par M. La Faye, iu Mim. de I'Acad. de t'hirurgit, Tom. 5, p. 195, Edit, in \2mo.) With res- pect to La Faye, it is curious to remark i coincidence between him and Larrey: the latter, though generally averse to attempt to unite stumps by the first intention, is an advocate for this practice after hip-joint amputations ; so La Faye, who was fearful of laying down the flap, after amputation of the leg, had no such apprehension at the shoulder. La Faye's method is yet regarded as one o! the most approved, where the state of tbe soft parts will admit of it. But, it is ab- surd to think of applying any one plan to all the various states, in which the injured or diseased limb may present itself. It is advised by Larrey himself, when a wound extends through the upper part of the arm, breaking the bone, and injuring the soft parts. Here, says he, it would be impossible to form an anterior and a pos- terior flap, for the soft parts in these situa- tions have been destroyed. On the contra- ry, when the deltoid is shot away, La Faye's plan is inadmissible. (Mem. de Chir. MS T 2. p. 167) The advantages of La Faye's plan are obvious. As only one ligature was applied, the patient was saved a great deal of pais the flap connected with the acromion WK capable of covering the whole surface of the wound, and was more easily applied and kept on tbe s-turap, than the lowermost oi the two flaps uhich Garengeot recom- mftw" ' and th*; discharge found a ready outlet downwu,-.!s. s»^Iri' S' Sharp r«-'«o«imended the folk*-, ngplan. .«T,ie patient's am, beineh«tf membrana adipoM.. from the upper part r' AMPUTATION. 115 the shoulder across the pectoral muscle, down lo the arm-pit, then turning the knife with its edge upwards, divide that muscle and part of the deltoid, all which may be done without danger of wounding the great vessels, which will become exposed by Hies, openings. If they be not, cut still more of the deltoiii muscle, and carry the arm backward. Then with a strong liga- ture, havi.ig tied the artery and vein, pur- sue the circular incision through the joint, and carefully divide the vessels at a con- siderable distance below the ligature ; the other small vessels arc to be stopped, as in other cases. "In doing this operation, regard should be had to the saving as much skin as pos- sible, and to the situation of the processus acromion, which, projecting considerably beyond the joint, an unwary operator would be apt to cut upon." (Operations of Sur- K*ry.) Bromfield used to have pressure made on the artery above the clavicle. His inci- sion began on the inside of the arm, by the edge of the deltoid muscle, as high up as where the pectoralis goes over the axilla, to its insertion into the humerus. Cutting through the integuments and muscles, he continuedhis incision obliquely downwards, and outwards, as far as a little below the termination of the deltoid muscle. Then carrying on the incision transversely for a small space in a semicircular direction, the wound was next extended to the external part of the arm, as high up as the fold of the integuments in the axilla. The flap, thus shaped, when raised from the hume- rus, was intended to fill up the axilla, after the removal of the limb. Bromfield's next incision began at the acromion, and, being carried through the skin and deltoid down to the bone, terminated in the semicircular incision above described, and it was so guided, that it left the outer portion of the divided flap larger than the inner one. Bromfield then passed his knife under the lower edge of the internal half-flap, and dissected it up as high as possible. The tendon of the pectoral muscle was thus exposed, under which he now passed his left forefinger, which served as a conductor to a probe-pointed curved bistoury. With this, he now divided the attachment of that muscle to the humerus. If the vessels were not now sufficiently brought into view, he cut through the outer head of the biceps, and tied them (artery and vein) each with two strong ligatures about half an inch apart. The vessels were then cut through in the interspace, and the nerve was divi- ded much higher than the artery. The external flap was now raised sufficiently to expose the joint; and the muscles and capsular ligament having been cut through in the superior and lateral pnrls, the hu- merus slipped out of the glenoid cavity, im- mediately the ami was carried a little backward. Lastly, he ligatures and ves- sels being held out of the way, the soft part« toward* the axilla were divided iu a semicircular direction. (Chir. Obs. and Cases, vol. 1. p. 249—252. 8t'o. London, 1773.) The unnecessary tediousness, and, I may add, severity of Bromfield's method, have long withdrawn from it the approba- tion uf modem operators. The division of the flap into two portions ; its extraordinary length ; and the painful dissection practi- sed to get at the artery; were serious faults in the operation. In 1774, Alanson amputated at the shoulder-joint, as follows: the subclavian artery was compressed by the fingers of an assistant. An incision was made about a hand's breadth below the acromion, and carried through the integuments all round the limb. The deltoid and posterior mus- cles were then obliquely divided up to the capsular ligament. The tendon of the bi- ceps, and the capsular ligament upon the anterior and posterior part of the joint, were now cut through. One of the circum- flex arteries, which bleed a good deal, was next tied The great pectoral muscle, the rest of the capsule, and all the other parts, except the vessels and nerves, were then divided, but previously to cutting the ves- sels, a temporary ligature was put round them. Thus the separation of the limb was completed. The mouths of the vessels were drawn out, and tied, and the tempora- ry ligature taken away. Lastly, the sides of the wound were brought together, so as to make a transverse line. Graefe, seem- ing not to recollect that amputation by the circular incision directed obliquely upwards, bad been practised by Alanson, mentions it as a new proposition. In one case, after operating in this manner, his patient was quite well in three weeks; and, with the particular sort of knife which he uses, and which is broadest towards its point, he pre- tends to be able to make the oblique inci- sion through the muscles all round the limb with one sweep. Of course, he is very careful to make pressure on the artery, both with Mohrenheim's compressor applied un- der the clavicle, and the fingers of an assis- tant above it. (See Normen fur die Abl. grosserer Gliedm.p. 110,$»c.) In proof of the possibility of making the oblique incision quite evenly with one stroke of his particu- lar knife, he injected a female subject, did the operation, and caused the stump to be drawn from nature. (See Plate 2, of his Work.) In 1760, P. II. Dahl published at Gottin- gen a Latin dissertation on amputation at the shoulder. In this tract a tourniquet was proposed, the pad of which was calcu- lated to press upon the subclavian artery under the clavicle, and enabled the opera- tor to dispense with tying the vessels in the first instance. Camper had observed, thai if the scapula were pushed backward, and tbe axillary artery pressed with the linger between the clavicle, coracoid process, and great pectoral muscle, the pulse at the wrist might be instantly stopped. Dahl's tourniquet wi.s obviously con- structed, in eonseouenee of what Camper 116 A.MPITATKLV had ob>er\eu. it i> made of a curved, elas- tic plate of steel, fo the shortest end of w'nrh a pad is attached, capable of project- ing further by means of a screw. The in- strument embraces the shoulder from be- hind forward, while the pad presses on the hollowunder the clavicle,between the mar- gins of the deltoid and pectoral muscles. The long extremity of tbe steel plate, which descends behind the shoulder, Is fixed to the body by a sort of belt. The pad is depress- ed, until the pulsation of the axillary arte- ry is stopped. Further experiments have proved, how- ever, that this tourniquet may be dispensed with, and the flow of blood in the axillary commanded, by properly compressing this vessel with a pad, or even the fingers alone, as some operators prefer, at the place where it emerges from between the scaleni muscles, above the middle part of the clavicle. Thus ihe artery is pressed between the pad or lingers and the first rib, across which it runs. In some plans of operation, hereafter to be described, all compression of the artery, either above or below the clavicle, is dis- pensed with. Some practitioners, forgetful of the hori- zontal posture iu which the patient is usu- ally placed attrr the operation, have feared that, in La Faye's method, the lower flap may sometimes confine the discharge. In order to avoid this inconvenience, Desault recommended the formation of two flaps, one of which was anterior, the other pos- terior. The axillary artery was compress- ed from above the clavicle, ;.t its coming out from between the scaleni muscles, while the integuments and flesh of the up- per and internal part of the arm were pushed away from the humerus. A knife was plunged between these and the other soft parts behind, to make the anterior flap. Tbe arm being inclined backward and out- ward, the humeral artery was tied, the ar- ticulation opened, and the head of the bone dislocated. The knife was then carried downward and backward, so as to form the posterior flap ; the incisions meeting in the axilla. (See Sabatier's Medicine Ope- raloire, t. 3. p. 393—399. edit. 2.) Larrey, who has had frequent opportuni- ties of amputating at the shoulder-joint, has aimed at the same object which Desault did, but, in his earlier operations, he was in the habit of beginning with the formation of tbe external, or posterior flap, for the fol- lowing reason : by proceeding in this way, the surgeon can tie the humeral artery more safely, because the ligature is applied after the operation is entirely finished, and con- sequently at a time when there is nothing to be attended to but the hemorrhage. Thus, the patient being placed on a stool, and well supported, the arm is to be raised fi-oni the side, and the axillary artery com- pressed from above the clavicle. The in- teguments and other soft parts of the upper and outer parts of tbe arm are then to be pushed away from the humerus, and the ■external flu;' formed. It is now very e.isy to cut the tendons ot the infra-spiuatus, ;ni,| teres minor, and open the outside of the joint The limb is to be carried inward, and luxated backward. The tendons of the supra-spinatus and biceps are to be divided, and as soon as the head of the bone is out of the glenoid cavity, the knife is to be carried along the internal part of the head and neck of the humerus, with its edge close to the bone. An internal flap, equal to the external one, is to be formed, con- sisting of a portion of the deltoid, great pectoral, biceps,andcoraco-brachialis, mus- cles, and including the brachial vessels ami nerves. The artery is to be taken hold of with a pair of forceps, and tied. Any other vessels, which require a ligature, arc- also now to be secured. Larrey puts some charpie betwixt the flaps, and brings them towards each other by the usual means. (See Mem. de Chir. Militaire, t. 2. p. 170.) Of this method of putting charpie to pre- vent union by the first intention, I enter- tain the most unfavourable opinion. When Larrey published his campaign in Egypt, he had operated in this way on nine- teen patients, thirteen of whom recovered. But, at a subsequent period, he and his col- leagues had amputated at the shoulder, in the above manner, in upwards of a hun- dred cases, more than ninety of which recovered. (Mim. de Chir. Mil. t. 4. />. 432. Svo. Paris, 1817.) In his later operations, he has adopted the innovation of first making a longitudi- nal incision from the acromion to about an inch below the neck of the humerus, down to the bone, so as to divide the fleshy part of the deltoid into two even parts. This cut, he says, facilitates and renders more exact the rest of the operation. From this wound, the incisions for the flaps are con- tinued. Having made the foregoing inci- sion, " I direct an assistant to draw up the skin of the arm towards the shoulder, and I form the anterior and posteriorflaps bytwo oblique strokes of the knife made from with- in outwards and downwards, so as to cut through the tendons of the pectoralis major and latissimu - dorsi. There is no risk of injuring the axillary vessels, as they are out of the reach of the point of the knife. The cellular connexions of these two flaps are to be divided, and the flaps themselves raised by an assistant, who, at the same time, is to compress the two divided cir- cumflex arteries. The whole joint'is now- exposed. By a third sweep of the knife, carried circularly over the head of the humerus, the capsule and tendons runnin* n£ar ^e articulation are cut; and the head a l°ne bein8 Alined a little out- wards, the knife is to be carried along its posterior part, in order to finish the section mVnt • te"chnous a°d ligamentous attach- LmMu!«,nh-hard,rP;cUoa- The assistant now nbPx f fh'* f°™«nsers over the brachial arterv' Z PurPos* of compressing the artery and commanding the current of blood through it. Lastly, the ed/eo the knife is turned backward-, an(?X whole AMPUTATION. 117 lasciculus of axillary vessels are cut throagh, on a level with the lower angles of the two flaps; and in front of the assist- ant's fingers. The patient does not lose a drop of blood ; and ere the compression is remitted, the extremity of the axillary ar- tery is readily seen, taken up with a pair of forceps, and tied. The circumflex arteries are next secured, which completes the ope- ration." (M-m. de Chir. Mil. t. 4. p. 428. Paris, 1817.) In addition to these impor- tant deviations from his earlier method, he now brings the flaps together with two or three straps of adhesive plaster, and inter- poses no charpie. (P. 429.) It should be observed, also, that he lays no stress on first making the outer flap; though, from the description, it does not exactly appear which flap he now begins with. He has changed, likewise, on another point of im- portance ; viz. instead of preferring La Faye's plan, in certain examples already specified, he affirms, that the above descri- bed way of operating is applicable to almost every case met with in military practice. First, because all gunshot wounds, generally, which mutilate the arm, so as to create the necessity for the operation, part- ly or entirely destroy the centre of the deltoid, while there is always enough flesh left at the sides for making the two Haps. Secondly, because, in the very rare instan- ces, where the lateral parts of the shoulder are destroyed, and the middle untouched, no advantage would be gained by operating in La Faye's manner, as Larrey conceives that the detached flap would slough or be- come, as he terms it, disorganized. Here Larrey now prefers dividing the middle piece of flesh, and giving the flaps the same shape as if they were uninjured. He even asserts, that the operation, done without any Haps at all, answers better, than any method, in which the surgeon preserves flaps not naturally intended for the part. Thus, when all the flesh of the shoulder has been shot away, he has seen surgeons cover the glenoid cavity with a flap, saved from the soft parts of the axilla ; but such flupsinvariably sloughed, hemorrhages ensu- ed, and the patients died. (P. 430, 431.) Some of these latter observations are, clearly enough, the result of great par- tiality to a particular method of operating; because who can doubt, when the lateral parts of the shoulder are injured, as they frequently are (and not very rarely, as Larrey asserts,) by the passage of a musket- ball through the shoulder, from before backwards, that the right method is that of f.a Faye ; or the same operation, with the slight difference of making the flap of a '.-einicircnlar shape ? It was for cases of this 'description that Mr. Collier and I operated after La Faye's plan, with perfect success, after the battle of Waterloo; and a poor fellow of the rifle brigade, who was brought \n too late for operation, and died of slough- ing,had hisshoulderjinjuredin thesameway, 'the middle of the deltoid being untouched, [and shot-h< some change in the mode of accomplishing the latter object might be rendered necessary by elevuting tbe limb durinsr the operation itself. Mr. lib AMPUTVITOfS Guthrie commences the first incision imme- diately below the acromion, and with a gentle curve, extends it downwards and in- wards, through the integuments only, a lit- tle below the anterior fold of the armpit. The second incision outwards is made after the same manner, but is carried rather fur- ther down, so as to expose the long head of the triceps at the under edge of the deltoid. The third incision, commencing at the same spot as the first, but following the margin of the retracted skin, divides the deltoid on that side down to the bone, and exposes the insertion of the pectoralis major, which must be cut through. This flap is now to be raised, so as to expose tbe head of the bone. The fourth incision outwards divides the deltoid muscle down to the bone, when the posterior flap is to be well turned back, so as to bring into view the teres minor and infra-spinatus passing from the scapula to the great tuberosity of the humerus. The outer and inner flap being now raised, the head of the bone may be rolled a little out- wards, the teres minor and infra-spinatus cut, and an opening made into the joint. The capsular ligament, supra-spinatus, and long head of the biceps are then divided. The inner side of the capsule Is now cut through, together with the subscapularis muscle, as it approaches its insertion, into the lesser tuberosity of the humerus. The long head of the triceps is next divided, and, lastly, with one sweep of the knife, the rest of the soft parts are cut, together with the axillary artery, veins, and nerve. (On Gun- shot Wounds.p 274-276.) The doubtful part of this method seems to be, that of cutting the circumflex arteries twice, which, when they bleed much, ought to be secured with- out any delay, more especially in seconda- ry operations, where every drop of blood is of consequence. The principle laid down by Desault, that in operative surgery in ge- neral, all important vessels should be tied, if possible, ere other things are done, is one of the most valuable maxims which can be in- culcated. On this point I should more strongly differ from Larrey. who, in bis la- test method, takes no measures in the first stage of the operation for commanding the flow of blood, as the assistant merely presses the axillary artery between bis fin- gers just before it is divided. Some of the modern French surgeons were earlier, than Larrey, in dispensing with the \4.) 1 «■• '•\'hcn *J?e scapula is shattered, ofeo** ~ -tmI [rSe«KraSn'Cnt3-shonld ,,e taken aw*- - • "«, it the acromion be broken and * '" :vm„Rnt of i, pointed „„,, °g*j£ # AMPUTATION. 119 sharp rough portion should be sawn off, as was practised long ago by M. Faure. (See Mim. de I'Acad. de Chir. t. 6. p. 114.) In one rase, indeed, Larrey found it necessary to take away more than two-thirds of the scapula, and the humeral end of the clavicle. (Mim. de Chir. Mil. t. 4. p. 432.) Sawing off, part of the acromion, and coracoid pro- cess, as a general rule, seems to me quite unnecessary (See. Fr.tzcr on the Shoulder- joint Operation. Svo Lond. 1813,) and im- proper, not only as producing delay, but by wounding other parts which should not be at all disturbed. (See Guthrie on Gunshot Wounds, p. 285, 286, &.c.) The practce of scraping away the cartilage of the glenoid cavity, except when it is diseased, is not of greater value. Amputation at the shoulder has been partly superscdedby a preferable operation, even in cases in which it would formerly have been deemed quite indispensable, such as considerable gunshot fractures of thehead of the humerus; a caries of the substance of this part, &c. Boucher in 1753, proved, that considerable wounds, extending into the shoulder-joint, might be successfully treated, by extracting the fragments and splinters of bone. (Mim. de I'Arad de Chir. t. 2, p. 287 et 461.) Instances are also re- corded, in which when the head and neck of the humerus in children hid been totally disunited from the body of that bone, a cure was accomplished by making such in- cisions as allowed the portions of bone, now become extraneous bodies, to be ta- ken away. The earliest case of this kind on record is that in which M. Thomas, a surgeon at Pezenas in Languedoc, removed the separated head of the humerus in 1740, which, in a child four years of age, present- ed itself loose in an incision, which had been previously made fir the extraction of some sequestra. The particulars may be read in Guthrie's valuable work. (On Gunshot Wounds, p 215, fyc.) Mr. White, of Manchester, proceeded further, for he made a deep incision at the upper part of the arm, dislocated the head of the humerus, which he knew was carious, and, pushing it through the wound, took it off with a saw. He began an incision at the orifice of a si- nus situated just below the processus acro- mion, and extended the wound down to the middle of the humerus by which all the subjacent bone was brought into view. He then took hold of the patient's elbow, and easily forcing the upper head of the hume- rus out of its socket, he brought it so en- tirely out of the wound, that he readily grasped it in his left han.l, and held it there till he had sawn it off with a common am- putation saw, having first applied a paste- board card betwixt the bone* and the skin. The patient did not lose more than two ounces of blood, only a small artery, which partly surrounded the joint, being wounded, which was easily secured. In about five or six weeks, the part from which the bone had been taken, had acqui- red a considerable degree of firmness, and the boy was able to lilt a pretty heavy- weight. At the end of two months, a large piece of the whole substance of the hume- rus was ready to separate from the sound bone, and with a pair of forceps it was ea- sily removed. After this exfoliation the wound healed very fast; and, iu four months after the operation, the boy was discharged perfectly cured. On comparing this arm with the other, it was not quite an inch shorter ; the boy had the perfect use of it, and could not only elevate his arm to any height, but perform the rotary motion as well as ever. The figure of the arm wis not at all altered. Mr. White did not make use of any splints, machine, or bandage, during the cure, in order to confine the limb strictly in one certain situation, nor was the pa- tient's arm ever dressed in bed, but while he was sitting in a chair, and as soon as he could bear it standing up. To this method, Mr. White attributed the preservation of the motion of the joint. " As this is the first operation of the kind that has been performed, or at least made public, (says Mr. White) I thought the rela- tion of it might possibly conduce to the im- provement of the art. That ingenious sur- geon, Mr. Gooch, has indeed related three instances of the heads of bones being sawn off in compound luxations. In one of these cases, the lower heads of the tibia and fibula were sawn off, in another, that of the radius; and, in the third, that of the second None of the thumb ; but these were in manyrespects different from the present case. I believe it will seldom happen, that this operation will not be greatly preferable to amputa- tion of the arm of the scapula, as this last is generally performed for a caries of the upper head of the os humeri, and as the preservation of a limb is always of the ut- most consequence, and what every surgeon of the least humanity would at all times wish for, but particularly where, as in this case, the whole limb, and its actions, are preserved entire, the cure no ways protract- ed, and the danger of the operation most undoubtedly less. For though amputation is often indispensably necessary, and fre- quently attended with little danger or incon- venience when only part of a limb is remo- ved, yet when the whole is lost, the danger is greatly increased, and the loss irrepara- ble." Mr. White concludes, with suggesting an analogous operation for removing the head of the femur, in lieu of amputation at the hip. Something of this kind is indeed reported to have been actuallv done on a girl with success. (See Joannis Mulder Oratio de Mtrilis P. Campcri, fa. p. 81. Cases in Surgery, by C. White, p. 57. or Phil. Trans Vol.59 for'1769.) Here, however, the acetabulum and ossa innominata being always, or generally, more diseased than the head of the femur, neither of these operations, I think, ought to be at- tempted. Long after the publication of White's case, viz. in 1767, an example, in which Vigaroux adopted the same practice, in 1788, was communicated to the profW 120 AMPITAIIO.V sion : the result, however, was unfortunate, the patient, a lad seventeen year* of age, having died soon after the experiment. (See GAurris de Chir. Prat.par I. M. I. Vigaroux (fits.) Montp. 1812.) Bent, of Newcastle, has inserted a similar rase to Mr. White's in the 64th vol. of the Philosophical Transactions. White made only one incision, from the vicinity of the acromion down to the middle of the arm. Bent, not being able to get at the head of the bone through the wound which he had made, from the clavicle to 'he attachment of the pectoral muscle, detached a portion of the deltoid, where it is connected with the cla- vicle, and another part, where it is adherent to the humerus. A third successful case is also reported in the 69th vol. of the same work, p. 6. Afterwards, Bromfield published some directions for the guidance of the sur- geon in the execution of such operations. (Chir. Obs. and Cases.) Sabatier has proposed making two cuts at the upper part of the arm, which meet below like the lettPr V, ex- tirpating the flap, dividing the inner head of the biceps, and capsular ligament ; disloca- ling the bead of the bone, and sawing it off. (Mi'.derinc Opcratoire,t. 3.) I think the eases recorded by White and Bent are truly important, inasmuch as they appear to have been the earliest models of a practice, which may sometimes supersede all occasion for one of the most formidable and mutilating operations of surgery. To military and naval surgeons, these cases cannot fail to be highly interesting, as they must have frequent opportunities of availing themselves of the instruction which they af- ford. Larrey, who was surgeon general tothe French army in Egypt, employed the prac- tice, with the greatest success, in case, of gunshot wounds. He thereby saved limbs, which, according to ordinary precepts and opinions, would have been ajust grouudfor amputating at the shoulder ; and, when it is considered, not only that a most dangerous operation is avoided, but that an upper ex- tremity is saved, for which no substitute can be applied, we must allow that the plan, first suggested and practised by Mr. White, cannot be too highly appreciated. When the arm was fractured near its upper extre- niit)- by a musket-ball, most surgeons for- merly deemed it necessary to amputate the limb. Here, says Larrey, it would be use- less to dilate the entrance and exit of the ball, because a sufficient opening could not be prudently made in this way for the ex- traction of the head of the bone. Vet this body is nowan extraneous substance, having lost its connexion with the body of the hu- merus, and its presence exciting irritation and inflammation of the joint, abscesses, ne- crosis, ice. Here Larrey seems to imply, that the detached h^ad of the bone cannot unite again ; an assertion which, I have no doubt, is quite incorrect, as I have attended several cases in which the humerus was broken very, high up, yet united without difficuby. 'j ne bad symptoms, which he so '■mphatir-ally attribute's to the detachment of the head from the body of the bone, arc in realitv the effect- of the gunshot violence itself." If, therefore, the head of the bone were merely broken off, and it and the neighbouring part of the bone not splintered, noAhe flesh not more extensively injured than would arise from the passage of amns- ket-ball, and the joint itself not involved,! should question the propriety of having re- course, at once, either to the extraction of the bead of the bone, or amputation at the shoulder. When the bone is shattered, the ease is often very different, and Larrey'; practice is then commendable. In confirma- tion of these sentiments, I may mention Mr. Guthrie's opinion, who, in reference tothe extraction of the head of the bone, says, he does not consider a perfect fracture of the humerus, an inch below its head (although there be evident separation,) as demanding even this operation, as he has known such cases do well, when treated as other com- pound fractures, except that the motion of the joint was nearly lost. (On Gh/«/io/ Wounds, p. 329.) However, it is fair to men- tion, that Mr. Guthrie inclines to amputation at the shoulder when the body of the bonp is splintered, or has long fissures in it, in which sentiment he is probably right, Tbe other operation seems principally calcula- ted for cases, in which the dama^T is re- stricted to the head and uppermost portion of the bone. According to Mr. Guthrie, when the ball passes out with little injury to the bone, and the openings already made are not suffi- cient to admit of a moderate examination with the point of the finger, the wound should be enlarged. However, othersmigbt argue, that such dilatation should be made only when the bone is felt to be seriously broken, and the fragments will probably re- quire immediate removal. But whatevei course be adopted, the most rigorous anti- phlogistic treatment will be proper; and, if abscesses form, dependingopeningssbould be made for the discharge. " Larrey says, " I have had the good for- tune, on ten different occasions, to super- sede the necessity for amputation at the shoulder, by the complete and immediate extraction of the head of the humerus orils splinters, without delay. I perform the ope- ration in the following maimer: I make an incision in the centre'of the deltoid muscle, and parallel tt»-its fibres, carrying tbe incisioi a* low down as possible. I get the edgesof the wound drawn asunder, in order to lay bare tbe articulation, of which the capsule Is generally opened by the first incision,and by means of a probe-pointed bistoury, 1 de- tach with the greatest ease from their inser- tions the tendons of the supra and infra spinati, of the teres minor, of the subscaj* wis and of the long head of the biceps; men l uoengage the head of the humerus, and remove it through the wound in wed* oid by means of my fingers, or of an eleW Zi r, -7-§ ,he "'•'"■'•■'■'•"upto the shoulder, of a,H„l! '" ? Pu°pe.r posiliou witlx the aid of asbng and a bendase. Such i> the ope- AMPUTATION 121 ration, which I performed on ten patients, in extirpating the head of the humerus; one of these died of the hospital fever, two of tbe scuivy, at Alexandria, and the fourth, after he was cured, died of the plague on our return to Syria. The rest returned to France in good health. Insomethearmbe- came anchylosed to the shoulder, and in others, an artificialjo'mt,allowingof motion, was formed.'' (See Mem. de Chir. Militaire, 1.2. p. 176.) Another successful case, of the same kind, has been more recently pub- lished by Mr. Morel. (See Medico-Chirurg. Trans, vol. 7. p. 161.) Mr. Guthrie thinks it not sufficient to make a simple incision through the deltoid mus- cle into the capsular ligament, and take away the fragments of bone, but urges the removal at the same time of a considerable part of the capsular ligament, lest disease still go on in the joint. Also, as it is im- possible to know, beforehand, in what state the hone may be below the fracture (that is, with respect to fissures running more or less down it,) he advises the incision, designed for the extraction of the splintered head of the bone, to be made in a situation where, if amputation at the joint be found indis- pensable, it will be of advantage. Mr. Guthrie likewise describes the manner of turning out the head of the bone in these cases, and sawing it off; the necessity of which, however, I do not clearly compre- hend, unless the taking away of any sharp spicula of the upper end of the body of the bone be implied, which may be right. (On Gunshot Wounds, p. 333—335.) My ideas, however, chiefly extend to the removal of loose fragments, and splinters, and, with re- spect to sawing off the head of the bone, this is a proceeding, I suppose, necessarily limited to the kind of case reported by Mr. White. IMPUTATION OK THE HEADS OF BONES. In a letter, dated 1782, and addressed to Mr. Pott, Mr. Park, surgeon of the Liver- pool Hospital, made the proposal of totally extirpating many diseased joints, by which the limbs might be preserved, with such a share of motion as to be of considerable use. Mr. Park's scheme, in short, was to re- move entirely the extremities of all the bones, which from the diseased joint, with the whole, or as much as possible, of the capsular ligament; and to obtain a cure by means of callus, or by uniting the femur to the tibia, when the operation was done on the knee ; and the humerus to the radius Hiid ulna, when it was done on the elbow ; so as to have no moveable articulation in those situations. To determine whether the popliteal ves- sels could be avoided, without much diffi- culty, in the excision of the knee, Mr. Park made an experiment on the dead subject. An incision was made, beginning about two inches above the upper end of the patella, aud Vor. f 16 extending about as far below its lower part. Another one was made across this at right angles, immediately above the patella down to the bone, and nearly half round the limb, the leg being in an extended state. The lower angles formed by these incisions were raised, so as to lay bare the capsular ligament ; the patella was then taken out; the upper angles were raised, so as fairly to denude the head of the femur, and to allow a small catling to be passed across the pos- terior flat part of the bone, immediately above the condyles, care neing taken to keep one of the flat sides of the point of the in- strument rvU- close to the bone all the way. The calling being withdrawn, an elastic spatula was introduced in its place, to guard the soft parts, while the femur was sawn. The head of the bone thus separated, was carefully dissected out; the head of the tibia was then with ease turned out, and sawn off, and as much as possible of the capsular ligament dissected away, leaving only the posterior part covering the vessels, which, on examination, had been in very little danger of being wounded. The next attempt was on the elbow ; -a simple longitudinal incision was made from about two inches above, to the same dis- tance below, the point of the olecranon. The integuments having been raised, an at- tempt was made to divide the lateral liga- ments, and dislocate the joint; but this be- ing found difficult, the olecranon was sawn off, after which the joint could be easily dis- located, without any transverse incision, the lower extremity of the os humeri sawn off, and afterwards the heads of the radius and ulna. This appeared an easy work ; but Mr. Park conceives the case will be difficult in a diseased state of the parts, and that a crucial incision would be requisite, as well as dividing the humerusabove the con- dyles, in the way done with respect to the thigh bone. Mr. Park first operated, July 2,1781, on a strong, robust sailor, aged33, who had a dis- eased knee, of ten years standing. The man's sufferings were daily increasing, and bis health declining. Mr. Park, in the opera- tion, wished to avoid making the transverse incision, thinking that after removing the patella, he could effect his object by the longitudinal one ; but it was found that the difference between a healthy and diseased state of parts, deceived him in this expecta- tion. Hence the idea was relinquished, and the transverse incision made. The opera- tion was finished exactly as the one on the dead subject related above. The quantity of bone removed was very little more than two inches of the femur, and rather more than one inch of the tibia. The only artery divided was one on the front of the knee, and it ceased lo bleed before the operation was concluded, but the ends of the bones bled very freely. In order to keep the re- dundant integuments from falling inwards, and the edges of the wounds in tolerable contact, a few sutures were used. The 122 AMPUTATION. dressings were light and superficial, and the limb was put in a tin case, sufficiently long or hand, as, in- TH'.* i:-i?e,y Was in the habit of ^nS- -3 evlr haSR ,Ul-SU,rge°n' La"genbeck, hUJ awavth8 d?^»ed«'eady mode of tak'uw bone* frnTitAle fir,Ser'witu ^ metacarpal rer wiffS. V m*Z"T> °r ,he ring fin- ger, with its metacarpal bone. from th6e „. 4 AMPUTATION. 125 liculation of the latter with the os magnum and os cuneiforme. In order to find out these articulations, he draws a line from tbe upper head of the metacarpal bone of the thumb straight across to the metacarpal bone of the finger to be extirpated, and, at thi~ place, he begins his first incision, which runs towards each side of the fin- ger, like an inverted V. The bone is then separated all round from the soft parts, and dislocated from the carpus, when nothing remains to be done but to cut the parts to- wards the palm, where the wound is also made to resemble an inverted V, but does not extend any farther than is necessary to complete the separation. (See Langen- beek's Bibl B. \,p. 575. and Plate 3, F. 1.) This is unquestionably a simple and excel- lent method of operating, which Langen- beck also recommends as the best way of removing such bones of the metatarsus, as are not situated at the sides of the foot; care being taken to save a flap from the sole. It is often difficult, however, to know with certainty, whether the disease is confined lo the metacarpal, or metatarsal bones; and, if it be not, and the. carpus, or tarsus be af- fected, the operation will not answer, and amputation be indispensable. This happened in one of Langenbcck's cases, in which he had removed one of the metacar- pal bones. Modern surgeons never amputate the : whole of the foot, or hand, when there is a reasonable chance of preserving any use- i ful portion of it though the rest may be most severely shattered. Thus, where a soldier had been struck bv a grape shot : which shattered the metacarpal hones of , the little and ring fingers, grazed the middle • finger, and tore up the integuments on the palm and back of the hand, Mr. Guthrie succeeded in saving the two fingers and ; thumb, although, in the removal of the ; other parts, no regular flaps could be made £fnr covering the wound. (On Gunshot ■: Wounds, p. 382.) In winter campaigns, ^the toes, and more or less of the foot, are often attacked with mortification from cold. In this circumstance, when the disorder does not extend beyond the middle of the foot, or the toes, it is only necessary to cut .away the gangrenous part. On the first en- trance of the French army into Holland Rafter the revolution, Paroisse met with ma- ,ny of these cases, in which it was neces- sary merely to take away the metatarsal bones, or sometimes those of the tarsus. All the patients, operated upon in this manner Tor the effects of cold, were cured ; walk- ing afterwards with more or less difficulty, according as the portion of the foot taken »way had been greater or smaller. (Opus- cules de Chir. p. 218.) " M.Boux,in his late publication, finds fault with our ignorance of Chopart's method of •emoving a part of the foot. He says, " I im certain, the principal surgeons in Eng- and, have never practised, and are even otally unacquainted with the amputation ■>f the foot at the junction of the two halves of the tarsus, or Chopart's opera- tion.*' (Voyage fait a Londres en 1814, on Parallele de la Chirurgie Angloise avec la Chirurgie Francoue, p. 338 ) As it is an operation of considerable merit, I think it will be useful to introduce a description of it in the present work. It is performed in the nearly parallel articulations of the os calcis with the os cuboides, and of the as- tragalus with the os naviculare. Thus the heel is preserved, on which the patient can afterwards walk. The performance of it is simple. The tourniquet having been ap- plied, the surgeon is to make a transverse incision through the skin, which covers the instep, two inches from the ankle joint. He is to divide the skin, and the extensor tendons, and muscles in that situation, so as to expose the convexity of the tarsus. He is next to make on each side a small longitudinal incision, which is to begin be- low and a little in front of the malleolus, and is to end at one of the extremities of the first incision. After having formed in this way a flap of integuments, he is to let. it be drawn upward by the assistant who holds the leg. There is no occasion to dis- sect and reflect the flap; for the cellular substance connecting the skin with the subjacent aponeurosis is so loose, that it can easily be drawn up above the place, where the joint of the calcaneum with the cuboides, and of that between the astraga- lus and scaphoides ought to be opened, The surgeon will penetrate the last the most easily, particularly by taking for his guidance, the eminence, which indicates the attachment of the tibialis anticus muscle to the inside of the os naviculare. The joint of the os cuboides and os calcis lies pretty nearly in the same transverse line, but lather obliquely forward. The ligaments having been cut, the foot falls back. The bistoury is then to be put down, and the straight knife used, with which a flap of the soft parts is to be formed under the tarsus and matatarsus, long enough to admit of being applied to the naked bones so as en- tirely to cover them. It is to be maintained in this position with three or four strips of adhesive plaster, which are to extend from the heel, over the flap, to the inferior and anterior part of the leg. Chopart used to tie every artery as soon as it was divided. On the instep, the continua- tion of the anterior tibial artery will require a ligature ; and, in the sole, the internal and external plantar arteries, in the thickness of the flap of soft parts, must generally be taken up. One half of each ligature is to be cut away, and the other one is to be left hanging out between tbe plasters, at the nearest and most convenient point. Walther and Graefe have given some very precise directions for the performance of this operation. A rut is first made, be- ginning half an inch below the outer ankle, and extending forwards along the side of the foot two inches. Another similar incision is then made from one inch below the inner ankle. The foot is now to be bent up- wards, and tbe two first cuts united by a transverse incision, two finger-breadths from the front of the tibia. A flap is then dissected up, as far back as the commence- ment of the lateral incisions, or a line cor- responding to the articulation of the astraga- lus with the os naviculare, and of the os calcis with the os cuboides. An assistant now checks the bleeding by applying the points of his fingers on the mouths of such vessels as bleed profusely, and holds up the flap. The extremity of the foot is now to be firmly inclined downwards, so as to stretch the ligaments connecting the tarsal bones together. The ligaments between the astragalus and os navicnlare are to be first cut, when the foot may be twisted somewhat outwards, and the ligaments be- tween the os calcis and os cuboides divided. The division is lastly completed by cutting AMPUTATIO Nouvelle Mithode pourfaire loperation 1. Novveite jwci«»»^ r»- .j —■ - /■-■ •"■<"< de VAmputation ^ns VArUeulaUon duBr* avec t'Omoplntc, par M. De la Faye. P. H Dahl Dis. de Humeri Amputatwne ex Ariin- to Golt 1760. Hisloire de I'Amputation, siiivant la Methode de Verduin et Sabourk, avec la Description d'un nouvel instrument p,,ur cette Opiralion, par M. De la %t P. II. F. Verduin, Dis. Episiolaris dt JVom Arluum decurtandorum Ration e,\2mo..hnl 1696. Miyens de rewire plus simple et pi* s.lrc VAmputation '• Lambeau, par M. dt Ga- rengeot. Observation sur la Resection de I'Ot, aprls I'Amputaiion de la Cuisse,parM. Vty- ret. Mimoire sur la Saillie de rOsapr» I'Amputaiion des Membres ; oh I'on examm les causes de eel inconvinient, les moyttuil) remidier, et ceux de la prercnir, par M Louis. Second Mimoire sur I'Amputation des Grandes Extrimitis, par M. Louis. Tit through the soft parts regularly from above foregoing Essays are in Mim. de I'Acad. it downwards, with the precaution of direct- Chirurgie, Tom. 5, Edit. 12mo. R. de Vtf. ing the amputating knife so as to leave a flap composed of part of tbe sole of the foot. (See Abhandl. aus dem Gebiete der Pract. Med. fa.Landshut, 1810, B. \,p. 152, fy Graefe Normen fur die Abl. grosserer Gliedm. p. 142.) Sometimes, in consequence of the soft parts of the instep being all gangrenous or otherwise destroyed, it is necessary to make the flap entirely from the sole of the foot, as Klein was obliged to do in one of his cases. (Practische Ansichten bedeutendsten Chir. Operationen. H. l.p.28.) Indeed, Riche- rand thinks this mode generally advanta- feous, as the line of the cicatrix is not pla- ed at the lower end of the stump, where it would be most exposed to injury. (Nosogr. Chir. T. 2,p. 502, fa. Ed. 4.) Langenbeck and Klein also condemn the painful and un- necessary measure of dissecting up a flap from the instep, as advised by Walther and Graefe. Chopart himself, as we have seen, merely drew back the integuments of the instep, without making any detachment of them from the subjacent parts. When the ends of the flexor tendons of the toes pro- ject too much from the inner surface of the lower flap, they are to be cut shorter, as Klein particularly directs; and 1 consider his advice not to use sutures for keeping the flap applied, but merely strips of sticking plaster, perfectly judicious. (Op.cit. p. 33-34.) The following sources of instruction, on the subject of amputation, are particularly entitled to notice: Celsus de Re Medicd. Ouvres de Pari, livre 12, chap. 30, 33. James Yonge, Currus Triumphalis i Tere- bintho, Svo. Lond. 1679. R. Wiseman, Chir. Treatises, 4to. Lond. 1692. Sharp's Opera- tions of Surgery, chap. 37, and Critical In- quiry into the present State of Surgery, chap. 8. Ravaton's Traite des Plaies d'Armes a Feu, Paris, 1768. Berlrandi, Traili des Opirations de Chirurgie, chap. 23. Le Dran's Obs. de Chir Paris, 1731, and his Traili des Opirations de Chirurgie, Paris, 1742, and the English Translation with the additions of Cheselden, by Galaker, Ijmd. 1749. Hcister's Instit. Chirurg. Pars 2. Sect. male, Obs. et Rimarques de Chirurgit pro- lique ; Manheim, 1767. Essai sur les Ampu- tations dans les Articles, par M. Rrasihr, i» T. J5, Mem. de I'Acad. de Chir. J. U. fii/pw de Membrorum Amputatione rarissimt adm- nislranda aut quasi abroganda, 4lo. Halt Magd. 1761. White's Cases in Surgaj, 1770. Bromfield's Chirurgical Observation and Cases, Vol. 1. chap. 2. Svo. 1778. 0' Halloran's complete Treatise on Gangrttt, fa., with a new method of Amputation,9n. Dub.l 765. Alanson's Prac.Obs. onArnvutitm Ed. 2.1782. J. L. Petit, Traili des Malita Chir. T. 3, Paris, 1774, or the later El. 1790. R. Mynor's Practical Th ought i m Amputation, Birmingh. 1783. T. Kirkimi, Thoughts on Amputation, fa. Sro. Ud 1780. Loder, Comment, de Nova Alansoni, Amputationis Methodo, Progr. 1. 7, In. 1784, or Chir. Med. Beobachlungen, to, Weimar, 1794. J. F. Tschepius, Cam it Amputatione Femoris non Cruenta, Holt, 1742. (Haller Disp. Chir. 5,239.) Mum na, Neue Med. Chir. Beobacht. Berlin, 1796; P. F. Walther, Abhandl. aus dem GebidUP Prakt Medicin, besonders der Chirurgie nd Augenheilkunde, B. 1, Landshut, 1810; Kern, Ueber die Handlungsweise bey «Vr Absetaung der Glieder. Wien, 1814; 6 Kloss, De Amputatione Humeri ex Arliah, 4/o. Frantof 1811 ; W. W. Fraser,anEm on the Shoulder-joint Operation, 8vo. Lott. 1813. H. Robbi, De Via ac Ratione,?* ohm membrorum Amputatio institutatst,®- Lips. 1815. J. p. R0UX) Memoire el 0bt.it la Riunion Immediate de la Plait epm VAmputation, Svo. Paris, 1814 J- c House, Amputationis Ossium pr&cipua qvt- dum momenta. Lips. 1801. J. F. D.Ere*, Practical Observations on Cataract andekmi t-upil and on the Amputation of the At* * the Shoulder, fyc. Svo. Lond. 1815. H. I vrunmnghausen, Erfahrungen und Ba» kungen uber die AmputaHen, Svo. Bo* '»is. Langenbeck, Bibl. fur die Chmtpi Vn»£ b^fa 8»o. (Jolt. 1816. P-& vrZeHTm™' °- "'' qUa in PartibusMtttto rnZTi^.^:U\amPllt^ne rulneratis J» 18°3. Graefe, > tanda sunt. 4to. Lvd ANASTOMOSIS. 127 men fur die Ablosung grosserer Gliedm. 4to. 1813. K7etn, Practische Ansichten bedeu- dtndslen Chir. Op. II. l,4to. Stuttg. 1816. A. C. Hutchinson, some Practical Observations in Surgery, Svo. Lond. 1816. And further Obs. on the proper Period for amputating in Gunshot IVunds, fa. Svo. Lond. 1819. Dr. Hennen, Principles of Military Surgery, 2d Ed. Svo. Lond. 1820; a work replete with valuable practical information. Potl's Re- marks on Amputation. Sabatier's Midccine Opiratoire, Tom. 3, Ed. 2. Hey's Practical Observations in Surgery, Edit. 2. Remar- ques et Observations sur VAmputation des Membres, in Oeuvres Chir. de Besault par Bichat, T. 2. Encyclopidie Mithodique Par- tie Chirurgicale, Tom. 1. art. Amputation. P. J. Roux, De la risection, ou du relranche- ment de Portions d'Os malades, soit dans les articulations, soit hors des Articulations, 4to. Paris, 1812. Rees's Cyclopaedia, art. Ampu- tation. Vermisehte Chirurgische Schriften, ion J. L. Schmucker, Band 1. J. Bell's Principles of Surgery. Cases of the Excision of carious Joints, by Park and Moreau, pub- lished by Dr. Jeffray. Operative Surgery by C. Bell, Vol. 1. Richters Anfangsgrunde der Wundarzneykunst, Band. 7. Riche- rand's Nosographie Chirurgicale, Tom. 4, Edit. 4. B. Bell's Surgery, Vol. 5. Mimoire sur I'Amputaiion des Membres, in Pelletan's Clinique Chirurgicale, Tom.3. Gooch'sChi- frurgical Works,variouspartsof lhe3 Volumes. .Larrey's Relation Chirurgicale de VArmit d'Orient en Egyple el Sytie, and Mem. de Chirurgie Militaire : books which should be in the library of every surgeon. Guthrie on ; Gunshot Wounds, Svo. Lond. 1815 ; a publi- cation which cannot be too attentively studied by every surgeon who wishes to know when as well as how to amputateincasesefgunshot inju- ry. Callisen's Systema Chirurgice Hoditrna, Pars Posterior, Edit. 1800. Roux, Parallele de la Chirurgie Angloise avec la Chirurgie Francoise, p. 336, fy-c. Paris, 1815. Law- rence on a New Method of Tying Arteries, fa., Medico-Chir. Trans. Vol.6, p. 156, <^-c. Report of Obs. made in the Military Hospitals of Belgium, by Professor Thomson, 1817. Diclionnaire des Sciences Medicates, art. Am- nutation. AMYLUM. Starch. Powdered starch is ' sometimes used as an external application to erysipelas; but, chiefly, in clysters, when ithe neck of the bladder is affected with tspasra. The following is the formula used at St. Bartholomew's Hospital, fi Mucila- »inis Amyli, Aquae distillatae: sing. ?ij Tinct. Opii guttas qu.idraginta: Misce. ;; » ANASTOMOSIS, (from *vr their running and opening into each )ther, by which the continuance of a free circulation of the blood is greatly ensured, md the danger of mortification lessened. The immense importance of this part of our tructure, in all cases in which the main irtery, or veins of a limb are obliterated, is particularly conspicuous in the disease call- ed aneurism. (See Aneurism.) Nay, such has been the providence of nature in this respect, that, even where the thoracic aorta has been completely ob- structed, the channels for the conveyance of the blood to the lower extremities have yet been found adequate to that purpose. This was proved in an example where the obstruction had been gradually produced by disease, and the anastomosing vessels of course had had time for enlargement; for, this is a very different case, from that in which a ligature is suddenly applied to the aorta; though, as far as can be deduced from the particulars of some experiments made on dogs by Mr. A. Cooper, and of one operation in which this gentleman tied the human abdominal aorta, (Surgical Es- says, Pari 1, p. 101,) blood will still pass to tbe lower extremities in sufficient quantity for their nutrition. At least, this inference is safely deducible from the very memora- ble operation to which I have referred, sub- ject to one important condition, viz. that there be no additional cause of impediment to the passage of blood, to the lower ex- tremities, besides the ligature above the bi- furcation of the aorta. When Mr. A. Coop- er tied the human aorta in the abdomen, the experiment was made as the only possible means of hindering a man from bleeding to death, who had a large aneurism of the ex- ternal iliac artery actually beginning to bleed, and extending too high to admit of any thing else being done. Now, although the unfortunate patient was not saved, and it must be acknowledged that the chances of any other result were very small, the case furnished the important proof, that, if the abdominal aorta be suddenly and com- pletely obstructed, the blood may yet pass in adequate quantity to the lower extremi- ties, provided there exist no other cause of impediment to the passage of the blood into those members; for, on the side, occu- pied by the aneurism, the circulation in the limb was stopped, while, in the opposite limb, the circulation and natural warmth were preserved. To this subject, I shall hereafter return. (See Aorta.) The changes which take place in the ar- terial system of the limb, when the main artery is rendered impervious by the ap- plication of a ligature, are well described by Mr. Hodgson: " The blood, meeting with an obstacle to its progress through the accustomed channel, is thrown in greater quantity, and with greater force, into those branches, which arise above the seat of the obstruction. The ramifications of these branches, iu consequence of the unu- sual influx of blood, undergo a remarkable dilatation ; the more minute vessels also, by which they anastomose with corresponding ramifications, arising from branches given off below the obstruction, are from the same cause sufficiently enlarged to allow a free passage of the blood into the inferior trunks of the limb. At first, the circulation 128 ANCHYLOSIS. is in this manner carried on through a con- geries of minute anastomosing arteries : in a short time, a few of these channels be- co"- 3 more enlarged than the rest: as these i. .ease in size, the smaller vessels gradu- ally collapse, and ultimately a few large communications constitute permanent chan- nels through which the blood is transmitted to the parts, that it is destined to supply. This is one mode by which a collateral cir- culation is established. " But, in some situations, more direct and ostensible inosculations are provided ; so that when one channel is obstructed the blood passes at once through the other in a sufficient stream for the nourishment of the part, which it is destined to supply. Under these circumstances, no dilatation of the collateral branches is necessary: the cir- culation in such instances, may be said to be constantly carried on through inoscula- ting trunks. These great communications principally exist in the extremities of the body, where the dilating impulse, which the blood receives from the heart, is of course diminished. Thus, the radial artery inosculates freely with the ulnar; the ante- rior with the posterior tibial; and the in- ternal carotid with the vertebral arteries. Two modes therefore exist, by which arte- ries communicate with each other—the anastomoses of minute ramifications, and the direct inosculations of trunks." (See Hodgson on the Diseases of Arteries and Veins, p. 234.) Refer also to Inosculation. The best general account of the inoscula- tions, in relation to aneurism, is contained in Scarpa's Treatise on Aneurism; more especially, the Italian edition, which is em- bellished with beautiful engravings. AJVCHYLOPS,(from *>x'»ne*r> and WO the eye.) Same as ^Egylops. ANCHYLOSIS, (from ayxuxo?, crooked.) This denotes an intimate union of two bones, which were naturally connected by a moveable kind of joint. All joints origi- nally designed for motion, may become anchylosed, that is, the heads of the bones, forming them, may become so consolidated together, that no degree of motion what- ever can take place. Bernard Conner (De stupendo ossium coalilu) describes an in- stance of a general anchylosis of all the bones of the human body. A still more curious fact is mentioned in the Hist, of the Acad, of Sciences, 1716, of a child 23 months old, affected with an universal anchylosis. In the advanced periods of life, anchylosis more readily occurs, than in the earlier parts of it. The author of the article An- chylosis in the Encyclopedic Mithodique, mentions his having preserved a specimen, in which the femur is so anchylosed with the tibia and patella, that both the compact and spongy substances of these bones ap- pear to be common to them all, without the least perceptible line of separation between them. In old subjects, the same kind of union is commonly observable between the vertebrae, and between these and the heads ol the rib«. The greater, or lesser degree of immobi. lity has caused anchylosis to be distin- guished into the true and false. In the truf auchvlosis, the bones have grown together so completely, that not the smallest degree of motion can take place, and the caseii positively incurable. The position, in which the joint has become tbusinalterably fixed, makes a material difference in the incon- venience resulting from the occurrence Tbe false anchylosis is that, in which the bones have not completely grown together, so that their motion is only diminished, not destroyed. Tbe true anchylosis is some- times termed complete\; the false, iiicwn- plete. In young subjects in particular, anchylo- sis is seldom an original affection, hut ge- nerally the consequence of some other disease. It very often occurs after frac- tures, in the vicinity of joints ; after sprain- and dislocations attended with a great deal of contusion; and after white swelling? and abscesses in joints. Aneurisms, and swellings and abscesses on the outside of a joint, may also induce anchylosis. In short, every thing which keeps a joint long mo- tionless may give rise to the affection, which is generally the more complete the longer such causes have operated. When a bone is fractured near a joint, the limb is kept motionless by the appara- tus, during the whole time requisite lor uniting the bones. The subsequent inflam- mation also extends to the articulation^ attacks the ligaments and surrounding part' Sometimes, these only become more thick ened and rigid : on other occasions, the in- flammation produces a mutual adhesion of the articular surfaces. Hence fractures so situated, are more serious, than when tbe; occur at the middle part of a bone. Though common fractures leave, after their cure, a certain degree of stiffness in the adjaceat joints, this is different from true anchylosis; it merely arises from the inactivity, ii which the muscles and articular surfaces have been kept for a time, and may gene- rally be cured by gradually exercising, and increasing the motion of the limb. The position of an anchylosed limb ii» thing of great importance. When abscev ses form near the joints of the fingers, and the tendons mortify, the fingers should h bent, that they may anchylose in that posi- tion, which renders the hand much man useful, than if the lingers were permanent!) extended. On the contrary, when there u danger of anchylosis, the knee ahoalJ always be kept as straight as possible. * same plan is to be pursued, when the heal of the thigh bone is dislocated in cos* quence of a diseased hip. When the elb* cannot be prevented from becoming anchy- losed, the joint should always be keptbn* No attempt should ever be made to ANEURISM. 131 tended with particular circumstances, mark- ing its difference from another form of dilatation, which, as I shall explain, per- haps ought not to be set down as aneuris- mal,) the swelling is commonly named a true, or genuine aneurism. In such cases, the artery is either enlarged at only a small part of its track, and the tumour has a de- terminate border, or the vessel is dilated for a considerable length, in which circum- stance the.swelling is oblong, and loses it- self so gradually in the surrounding parts, that its margin cannot be exactly ascer- tained. The first case, which is the most common, is termed the circumscribed true aneurism; the last, the diffused true aneu- rism ; a case, however, which would be looked upon by Scarpa only as a specimen of dilatation, different in several particulars from aneurism, as will be hereafter noticed. When blood escapes from a wound, or rup- ture, of an artery, into the adjoining cellular substance, the swelling is denominated the spurious, or false aneurism. In this in- stance, the blood either collects in one mass, distends the cellular substance, and condenses it into a cyst, so as to form a dis- tinctly circumscribed tumour; or it is inject- ed into all the cavities of the surrounding cellular substance, and extends along the course of the great vessels, from one end of the limb to the other, thus producing an ir- regular, oblong swelling. The first case is named the circumscribed false aneurism ; the second, the diffused false aneurism. (Rich- ter's Anfangsgr. B. 1.) These appellations are in my opinion pre- ferable to the term cylindrical, applied by Sauvages to true aneurisms, or sacciform, proposed by Morgagni for false aneurisms. (Advers. Anat. 2, Aortie Animadv. 38, et Epist. Anat. 17, No. 27.) Because, as we shall see in the course of this article, though true aneurisms (including dilatations of all the arterial coats of every kind,) do mostly affect the whole circumference of the ves- sel, and must therefore partake of a cylin- drical shape, there are exceptions, in which a distinct circumscribed sac, composed of all the coats of the vessel, projects from one side of an artery, the diameter of which may not be at all increased. Here the dis- ease might rather be named sacciform, the very appellation suggested by Morgagni for false aneurisms, in which the disease gene- rally originates in this shape, from whatever particular side of the vessel the inner coats have given way. We see also that the sub- ject actually demands more numerous dis- tinctions, since aneurisms undergo iu their progress various changes, which sometimes make an immense, and even a very sudden difference in their shape, cases which were at first circumscribed, afterwards becoming diffused. The symptoms of the circumscribed true aneurism take place as follows: The first thing the patient perceives is an extraordi- nary throbbing in some particular situation, and, on paying a little more attention, he discovers there a small pulsating tumour, which entirely disappears when compressed, but returns again as soon as the pressure is removed. It is commonly unattended with pain, or change in the colour of the skin. When once the tumour has originated, it continually grows larger, and, at length, at- tains a very considerable size. In propor- tion as it becomes larger, its pulsations become weaker, and, indeed, they are almost quite lost, when the disease has ac- quired much magnitude. The diminution of the pulsation has been ascribed to the coats of the artery losing their dilatable and elastic quality, in proportion as they arc distended and indurated, and, consequently, the aneurismal sac being no longer capable of an alternate diastole and systole from the action of the heart. The fact is also im- puted to the lamellated coagulated blood, deposited on the inner surface of the sac, particularly in large aneurisms, in which some of the blood is always interrupted in its motion. Immediately, such coagulated blood lodges in the sac, pressure can only produce a partial disappearance of the swell- ing. This deposition of lamellated coagu- lum in the aneurismal sac is a circumstance of considerable importance ; for, it has been well explained by Mr. Hodgson, that it is the mode by which the spontaneous cure of tbe disease is in most instances effected. " One of the circumstances, which, in the most early stage, generally attend the for- mation of aneurism (says this author,) is the establishment of that process, which is the basis of its future cure. The blood, which enters the sac soon after its formation, gene- rally leaves upon its internal surface a stra- tum of coagulum, and successive depositions of the fibrous part of the blood gradually diminish the cavity of the tumour. At length the sac becomes entirely filled with this substance, and the deposition of it generally continues in the artery, which supplies the disease, forming a firm plug of coagulum, which extends on both sides of the sac to the next important ramifications that are given off from the artery. The circulation through the vessel is thus prevented, the blood is conveyed by collateral channels, and another process is instituted, whereby the bulk of the tumour is removed, &c." (On the Diseases of Arteries, fyc. p. 114.) Whether there is any truth in Kreysig's con- jecture, that some of the lymph may exude from the inside of the sac itself, I cannot pretend to say. He owns, however, that the inner concentric layers presenting the appearance of being deposited last, is a cir- cumstance rather against his surmise,though he adverts to some other circumstances which incline him to look upon the opinion as possibly correct. (German Transl. of Mr. Hodgson's Work, p. 124.) In a preceding paragraph, I have spoken of the diastole and systole of the aneuris- mal sac; for, it is the general belief.that the pulsation of the tumour is produced by the jet of blood into it at each stroke of the heart. This opinion, however, is dis- puted by an eminent writer, who asks, Is it 132 ANEURISM true, that the pulsation of aneurisms pro- ceeds from the entrance of a more consi- derable stream of blood into the sac, and the distention of the swelling thereby pro- duced? In aneurisms, which have only a narrow communication with the arterial tube, or which are filled with laminated coagula, the idea, says he, is quite inad- missible: the aneurism is rather shaken, as it were, like other different swellings in the vicinity of an artery, by tbe stroke of the heart occasioning a stretching of the whole arterial system, and at the same time com- municating an impulse to the column of blood. (Kreysig, Germ. Tr. of Mr. Hodg- son's Work, p. 143.) Here, however, I am by no means disposed to coincide with this distinguished physician, whose sentiments appear to me to be refuted by the fact, that, whenever any change happens, calculated lo lessen or entirely stop tbe influx of blood into tbe sac, the pulsation either diminishes, or ceases in proportion. Thus, when Krey- sig adverted to the pulsation of aneurisms, in which much coagulated blood was depo- sited, he might at the same time have men- tioned the effect, which such deposition has in weakening the pulsation, the layers of coagulated blood within the tumour being in the natural mode of cure, as Mr. Hodgson has correctly explained, " the means by which the force of the circulation is re- moved from the sac, and the fatal termina- tion of the disease by rupture is prevented." (On Diseases of Art. and Veins, p. 126.; In proportion as the aneurismal sac grows larger, the communication of blood into the artery beyond the tumour is lessened. Hence, in this state, the pulse, below the swelling, becomes weak and small, and the limb frequently cold, and cedematous. On dissection, the lower continuation of the artery is found preternaturally small and contracted. The pressure of the tumour on the adjacent parts may also produce a va- riety of symptoms, ulceration, caries, &.c. Sometimes (says Richter,) an accidental contusion, or concussion, may detach a piece of coagulum from the inner surface of the cyst, and the circulation through the sac be obstructed by it: nay, he asserts, that the coagulum may possibly be impelled quite into the artery below, so as to induce important changes. Tbe danger of an aneu- rism arrives when it is on the point of bursting, by which occurrence the patient usually bleeds to death, and this sometimes in a few seconds. The fatal event may ge- nerally be foreseen, as the part about to give way becomes particularly tense, ele- vated, thin, soft, and of a dark purple co- lour. (Richter's Anfangsgr. Band. I.) A large axillary aneurism, which burst in St. Bartholomew's Hospital some years ago, did not burst by ulceration, but, by the de- tachment of a small slough from a conical, discoloured part of the'tumour; and soon after this case fell under my observation, I had an opportunity of seeing the process, by which an inguinal aneurism burst: at a certain point, the turn our became more coni- cal, thin, and inflamed, and here a slough, about an inch in width, was formed. On the dead part becoming loose, a profuse bleeding began, which was stopped for a short time by pressure, but soon returned with increasing violence, and put an end to the. patient's misery. We are then to con- elude, that external aneurisms do not burst by ulceration, but by the formation and de- tachment of a slough. I believe this is a fact, which was first particularly pointed out in the early editions of my work, and it gives me pleasure to find, that it is a state- ment which entirely coincides with that subsequently made by several writers of eminence, especially Mr. A.Burns (OnDis- eases of the Heart, p. 225,) and Boyer (Traiti des Maladies Chirurgicales, T.2,p. 98.) As far as my information extends, Mr. A, Burns first explained the very different mode of rupture which happens in internal aneu- risms ; these, he observed, generally burst by actual laceration, and not by sphacelation of the cyst. (On Diseases of the Heart, p. 225.) But a still more particular account of the process, by which external and internal aneurisms burst, is delivered by Mr. Hodg- son. When the sac points externally, (saya this gentleman,) it rarely or never bursts by laceration, but the extreme distention causes the integuments and investing parts to slough, and upon the separation of tbe eschar, the blood issues from the tumour. A similar process takes place, when the dis- ease extends into a cavity, which is lined by a mucous membrane, as the oesophagus,in- testines, bladder, &c. In such cases, the cavity of the aneurism is generally exposed by the separation, of a slough, which has formed upon its most distended part, and not by laceration. But, when the sac pro-jests into a cavity lined by a serous membrane, as the pleura, the peritoneum, the pericar- dium, &.c. sloughing of these membranes does not take pface, but, the parietes of the tumour having become extremely thin in consequence of distention, at length bunt by a crack, or fissure, through which the blood is discharged. (On the Diseases of Arteries, fa. p. 85.) When the aneurism is of considerable size, the collateral arteries, which origitala above the swelling, are manifestly enlarged. Boyer informs us, that, in dissecting tbe lower extremity of a patient, on whom De- sault had operated eight months previously for a popliteal aneurism, he found in the substance of the great sciatic nerve an ar- tery, whose diameter was equal to that of the radial at the wrist. This vessel had its origin from the ischiatic artery, and de- scended to the back part of the knee, where it anastomosed with the upper articular arteries. Boyer had also noticed in the Sa/"ie s,ubJ*"ct before the operation, that one of the branches of the upper internal articu- lar artery was so much enlarged, that * pulsation could be plainly felt on the in- ternal condyle of the thigh-bone. (Op. A p- «■*•) It is such enlargement of the roll* teral arteries above the disease, which ««• ANEURISM. 133 arcs to the limb below the tumour an ade- quate supply of blood when the obstruction lo its passage through the diseased artery becomes considerable, or when this vessel has been rendered totallv impervious by a surgical operation performed for the cure of ihe complaint. In the advanced stage of an aneurism, Ihe skin is found extremely thin, and con- founded, as it Here, with the aneurismal sac. The cavities of the cellular substance near the disease are either filled with serum or totally obliterated by adhesion. The adjacent muscle.-, whether they lie over the aneurism, or to one side of it, are stretched, displaced, dwindled, and sometimes con- founded with other parts. It is the same with the large nervous cords situated at the circumference of the tumour: they are push- ed out of their natural situation, diminished in size, sometimes adherent to the outside of the sac, and so changed as scarcely to ad- mit of being known again. Lastly, the car- tilages and the bones themselves are not exempt from the mischief which the aneu- rismal swelling produces in all the surround- ing parts: they are gradually destroyed, and, at length, not the least trace of their substance remains, just in the same way as the bones of the cranium are destroyed by fungous tumours of the dura mater. (See Dura Mater.) Even the cartilages of the larynx, and rings of tbe trachea, are some- times destroyed; this tube is pierced, and the blood escapes into it, or the aneurism bursts into the oesophagus. (Boyer, Traili des Maladies Chirurgicales, T. 2, /. 99.) As I shall hereafter explain, however, the pres- sure of an aneurismal tumour more quickly produces an absorption of bone, than of cartilage. While an aneurism is small and recent, it does not generally cause much pain, nor seriously impede the functions of the limb. But, when it has increased, several compli- cations are produced. Thus, the dragging of the saphenal nerve, by femoral aneurisms, frequently occasions acute pain in the course of this nerve as far as the great toe. The distention of the sciatic nerve by the popli- teal aneurism, sometimes brings on intolera- ble pain, which extends to all the parts to which this nerve is distributed, and which can hardly ever be appeased by the topical 'use of opiate applications. The compres- sion of the veins and lymphatics gives rise to oedema, numbness, and coldness of the limb. And, finally, the long-continued pres- 'sure of the aneurism on the neighbouring bones causes their destruction. (Boyer, p. 105, T. 2.) v » • P i in cases of true aneurism, the coats of the artery are not always iu the same state, the •kind of changes observed depending upon the progress of the tumour. In the early stage of the disease, either the whole cy- linder of the vessel, or only a part of its circumference, is dilated ; but, this period s generally of short duration, especially in irteries of middling size, because their mid- He coat is capable of les.-, resistance, than that of the larger arleries, like the aorta, where this coat is yellowish, firm, and very elastic. As Breschet remarks, this difference of resistance in the middle coat of the aorta, and the branches given off from it, accounts for the rarity of true aneurisms either in the small arteries, or those of middling size, and their greater frequency in the principal trunk of tbe arterial system. At length, in consequence of the increa- sing distention, some of the coats of the ar- tery, possessing the least elasticity, give way, and these are found to be the internal and middle coats, while the external onestill makes resistance, and continues to be more and more dilated by the lateral impulse of the blood. The second stage of true aneurism, is that which is mostly met with, that, in which the tumour increases more rapidly, and there- fore begins to excite greater attention. The disease, when it has attained this form, is in point of fact no longer a true aneurism ; but a case which Monro distinguished by the name of the consecutive, or external mixed false aneurism. In this stage, the pa- tient's life is endangered, and death often brought on by the rupture of tbe tumour. Examinations of the dead subject, under these circumstances, have frequently led to mistaken notions, and, doubtless, if various swellings of this kind had not been found in different degrees, or stages, in the same in- dividual, one might be disposed to join Scarpa in the belief, that no aneurism con- sists of dilatation of all the arterial coats. (Breschet, Fr. Transl. of Mr. Hodgson's work, p. 128, 129.) The false aneurism is always attended with at least a rupture, or giving way of the inner coat of the vessel, and usually with a breach in both this and the muscular coat, the outer elastic tunic forming the pouch in which the blood collects. But, after the swelling has attained a certain size, this coat also bursts, and then the blood either be- comes diffused, or a large circumscribed space is formed for it by the condensation of the surrounding cellular membrane. False aneurisms, when produced by a wound, or puncture, are of course from the first at- tended with a division of all the coats of the vessel. This form of the disease is ofteu seen at the bend of the arm, where the ar- tery is exposed to injury in venesection. (See Hemorrhage.) In this circumstance, as soon as the puncture is made, the blood gushes out with unusual force, and in a bright scarlet,irregular,interrupted current; flowing out, however, in an even, and less rapid stream, when pressure is applied high- er up, than the wound. These last are the most decisive marks of the artery bein<^ opened ; for blood may issue from a vein with great rapidity, and in a broken current, when the vessel is turgid, and situated im- mediately over the artery, which imparts its motion to it. The surgeon endeavours precipitately to stop the hemorrhage by pressure, and in general a diffused false aneurism is the result. The external wound 551 AMPUTATION. in the skin is closed, so that the blood can- not escape ; but, this does not hinder it/rom passing into the cellular substance. The swelling, thus produced, is uneven, often knotty, and extends upward and downward along the track of the vessel. The skin is also usually of a dark purple colour. Its size increases, as loiu as the internal he- morrhage continues, and, if this should pro- ceed beyond certain bounds, mortification of the limb ensues. Such is the diffused false aneurism from a wound. The circumscribed false aneurism, from a wound, or puncture, arises in the followiug manner. When proper pressure has been made in the first instance, so as to suppress the hemorrhage ; but, the bandage has af- terwards been removed too soon, or before the artery has healed, the blood passes through the unclosed wound, or that which it has burst open again, into the cellular substance. As this has now become ag- glutinated by the preceding pressure, the blood cannot diffuse itself into its cells, and, consequently, a mass of it collects in the' vi- cinity of the aperture of the artery, and distends the cellular substance into the form of a sac Sometimes, though not often, this circumscribed false aneurism, originates immediately after the opening is made in the artery. This chiefly happens when the aperture in the vessel is exceedingly small, and, consequently, when the hemorrhage takes place so slowly, that the blood, which is first diffused, coagulates, and prevents the entrance of that which follows into the ca- vities of the cellular substance, and of course, its diffusion. False aneurisms, pro- ceeding from the rupture of the inner coats of an artery, are always at first circum- scribed by the resistance of the outer tunic. The circumscribed false aneurism consists of a sac, composed of the external coat of the artery, or, in case this has given way, it is composed of an artificial pouch, formed among whatever parts happen to be in the vicinity of the burst artery. This cavity is filled with blood, and situated close to the artery, with which it has a communication. Hence, in false aneurisms, a throbbing is al- ways perceptible, and is more manifest, the smaller such tumours are. The larger the sac becomes, the less elastic it is, and the greater is the quantity of laminated coagula in it; so that in very large aneurisms of this kind, the pulsation is sometimes wholly lost. J The tumour is at first small, and on com- pression entirely disappears ; but, returns as soon as this is removed. It also dimi- nishes, when the artery above it is com- pressed, but, resumes its wonted magnitude, immediately such pressure is discontinued. When there is coagulated blood in tbe sac, pressure is no longer capable of producing a total disappearance of the tumour, which is now hard. The swelling is not painful, and the integuments are not changed in co- lour. It continually increases in size, and, at length, attains a prodigious magnitude. The following are generally enumerated, as the discriminating differences between circumscribed true and false aneurism: the true aneurism readily yields to pressure, and as readily recurs on its removal; the false one yields very gradually, and return in the same way ; and, as it contains hum. nated coagula, it cannot be reduced htft same degree by compression, as an aneurism formed by a dilatation of the arterial coats, where such strata of coagulated blood are usually absent. Frequently, a hissing sound is audible, when the blood gushes into the sac. The pulsation of the false aneurism i< always more feeble, and, as the tumour en- larges, is sooner lost, than that of tbe tree one, which throbs after it has acquired a con- siderable volume. (See Richter'sAnfaum B.l.) FORMATION OF ANEURISMS. If the doctrines of Scarpa, published in 1804, had proved correct, tbe grand distinc- tion of aneurism into/rue and/akeniustban been rejected, as erroneous: "for,"say! he " after a very considerable numberof in- vestigations, instituted on thebodiesof those who have died of internal, or externni aneu- risms, I have ascertained, in the most certain and unequivocal manner, that there isonly one kind, or form of this disease ; viz.tnal caused by a solution of continuity, or rup- ture of the proper coats of the artery,ai effusion of blood into the surroundinfeet hilar substance : which solution of continc- ity is occasioned sdmetimes by a wound,! steatomatous, earthy degeneration, a cor roding ulcer, or a rupture of the proper coats of the artery, I mean the internal anil muscular, without the concurrence of a preternatural dilatation of these coats being essential to the formation of this disease; and, therefore, that every aneurism, wbe ther it be internal, or external, circom- scribed, or diffused, is always formed by effu- sion." (Treatise on Aneurism; Traml-ty Wishart, Pref.) According to Scarpa, it is an error to suppose, that the aneurism at the curvatore, or iu the trunk of the aorta, produced byi violent and sudden exertion of the whole body, or of the heart in particular, and pit- ceded by a congenital relaxation of a cer- tain portion of this artery, or a moiW weakness of its coats, ought always to b« considered, as a tumour formed by the dis- tention, or dilatation of the proper coats ot the artery itself, that is, of its internal anil fibrous coats. Scarpa considers it quite de- monstrable, that such aneurisms are pro- duced by a corrosion and rupture of lb* tunics, and, consequently, by the effusionof arterial blood under the cellular sheath,« other membrane, covering the vessel. ■ ever there be a certain degree of precede ,i! j-1'0"' U is not essential to constitaK the disease : for it is not a constant occr rence, most aneurisms are unprecededbf* Un-" 5°S.en?tases'inwhichananeo* is preceded and accompanied with a celt* degree of dilatation of the who|e dia«e* ANEURISM. 135 of the curvature of the aorta, there is an evident difference between an artery simply enlarged in diameter, and the pouch, which forms an aneurismal sac. Careful dissections, says Scarpa, will prove, that the aorta contributes nothing to the formation of the aneurismal sac and that this is merely the cellular membrane, which, in the sound state, covered the artery, or that soft cellular sheath, which the artery received in common with the neighbouring Starts. This is raised by the blood into the onnof a tumour,and is covered, in common with the artery, by a smooth membrane. This eminent professor does not deny, that, from congenital relaxation, the proper coats of the aorta may occasionally yield and become disposed to rupture ; but, he will not admit, that dilatation of this artery precedes and accompanies all its aneurisms, or that its proper coats ever yield so much to distention, as to form the aneurismal sac. The root of an aneurism of the aorta never includes the whole circumference of the artery; but the aneurismal sac arises from one side in the form of an appendix, or tuberosity. On the contrary, the dilatation of the artery always extends lo its whole circumference, and, therefore, differs essentially from aneurism. Thus, he u/ges, that there is a remarkable difference between a dilated and an aneu- rismatic artery, although these tioo affections are sometimes found combined together, es- pecially at the origin of the aorta. If we also consider that the dilatation of an artery may exist, without any organic affection, the blood being always in the cavity of the vessel : that in an artery so affected, there is never collected any grumous blood, or polypous layers; that the dilatation never forms a tumour of considerable bulk ; and, that while the continuity of the propercoats remains uninterrupted, the circulation of the blood is not at all, or not so sensibly 'changed, we shall be obliged to allow, that 'aneurism differs essentially from one kind of dilatation of an artery. Some additional remarks on this topic, more recentl/published by Scarpa, will be presently considered. By dissections of arteries, both in the sound and morbid state, Scarpa endeavours to demonstrate what share the proper and constituent coats of the artery have in the formation of the aneurismal sac, and what belongs to the cellular covering, and other adventitious membranes surrounding the artery. The covering of an artery is merely an adventitious sheath, which the vessel re- ceives in common with the parts in the vi- cinity of which it runs. On cutting an ar- tery across in its natural situation, the seg- ment of the cut vessel retires and conceals itself in this sheath. This cellular covering is most evident round the curvature and trunk of the aorta, the carotid, mesenteric, and renal arteries ; it is less dense round the trunks of the bra- chial, femoral, and popliteal arteries. The pleura lies over the cellular sheath of the arch of the aorta, and over that of the thoracic aorta; while that of the abdominal aorta is covered by the peritoneum. Both these smooth membranes adhere to, aud surround, two-thirds of the circumference of the vessel. The great arteries of the extremities are not covered, in addition to the cellular substance, by any smooth membrane of this sort, but by a cellular sheath, which is demonstrably distinct from the adipose membrane, and serves to inclose the vessels, and connect them with the contiguous parts. When air, or any other fluid, is injected by a small hole made artificially, between the cellular covering, and the subjacent muscular coat of the artery, the injected matter elevates into a tumour the cellular membrane, which closely embraces the ar- tery, without properly destroying its cells, which it distends in a remarkable manner. When melted wax is injected, and pushed with much force, the cellular sheath of the artery is not only raised over the vessel, like a tumour, but, the internal cells of that covering are also lacerated, and, on exami- ning afterwards the capsule of the artificial tumour, it appears as if it were formed of several layers, rough and irregular inter- nally, smooth and polished externally. The same thing happens when any injection is pushed with such force into an artery, as to rupture the internal and muscular coats at some point of their circumference. Ni- cholls performed this experiment several times before the Royal Society. (Philos. Trans, an. 1728.) As soon as the internal coat is ruptured, the muscular one also gives way ; but, the external cellular sheath, being of an interlaced texture, and the thin laminae, of which it is composed, being not simply applied to one another, but, reci- procally intermixed, is capable of support- ing great distention, by yielding gradually to the impulse of the blood, without being torn, or ruptured. Scarpa is farther of opinion, that the same phenomena may be observed, when the internal coat of the aorta becomes so diseased, as to be ruptured by the repeated jets of blood from the heart. In this cir- cumstance, the blood, impelled by the heart, begins immediately to ooze through the connexions of the fibres of the muscular coat, and gradually to be effused into the interstices of the celluar covering, forming, for a certain extent, a kind of ecchymosis, or extravasation of blood, slightly elevated upon the artery. Afterwards, the points of contact, between the edges of the fibres of the muscular coat, being insensibly sepa- rated, the arterial blood, penetrating be- tween them, fills and elevates, in a remark- able manner, the cellular covering of the artery, and raises it after the manner of an incipient tumour. Thus, the fibres and lay- ers of the muscular coat being wasted or lacerated, or simply separated from each other, the arterial blood is carried with great force, and in greater quantity than before, into the cellular sheath of thearterv, 136 Ol'.t KISM. which it forces more outwards ; and, finally, the divisions between the interstices of the cellular coat, being ruptured, it is converted into a sac, which is filled with polypous con- cretions, and fluid blood, and at last forms, strictly speaking, the aneurismal sac. The internal texture, although apparently com- posed of membranes placed one over the other, is, in fact, very different from that of the proper coats of the artery, notwith- standing the injured vessel and aneurismal sac are both covered externally, insthe tho- rax andabdomen, with a smooth membrane. Scarpa has examined a considerable number of aneurisms, of the arch, and of the thoracic, and abdominal trunk, of the aorta, without finding a single one, in which tne rupture of the proper coats of the artery wis not evident, and in which, consequent- ly, the sac was produced by a substance completely different from the internal and muscular coats. The aneurismal sac never comprehends the whole circumference of the vessel. At the place where the tumour joins the side of the tube, the aneurismal sac presents a kind of constriction, beyond which it becomes more or less expanded. This would never happen, or rather the contrary circumstance would occur, if the sac were formed by an equable distention of the tube and proper coats of the affected artery, in incipient aneurisms at least, the greatest size of the tumour would then be in the artery itself, or root of the swelling, while its fundus would be the least. But, whether aneurisms be re- cent and small, or of long standing and large, the passage from the artery is always narrow, and the fundus of the swelling greater in pro- portion to its distance from the vessel. The sac is always covered by the same soft dilatable cellular substance, which united the artery in a sound state to the circumja- cent parts. Such cellular substance, in aneurisms of the thoracic aorta, is covered by the pleura, and, in those of the abdomi- nal aorta, by the peritoneum, which mem- branes include the sac and ruptured artery, presenting outwardly a continued smooth surface, just as if the artery itself were dila- ted. But, if the aorta be opened lengthwise on tbe side opposite the constriction, or neck of the tumour, the place of the ulcera- tion, or rupture, of the proper coats of the artery, immediately appears within the vessel on the side opposite to that of the incision. The edge of the fissure, which has taken place, is sometimes fringed, often callous, and hard, and through it it was, that the blood formed itself a passage into the cellular sheath, which is converted into the ane^: cidentally furrows, or fissures exist on the in- side of the morbid dilatation, tbe fibrins may be deposited in these rough plaeevhlt only in tbem. These fissures and iaeqsjl' ties of the internal surface of the morbid^ dilated artery, he regards strictly as ao O0I beginnings of another disease of the Veen*, quite different from dilatation, that is, d aneurism subsequent to dilatation. SeeJaV moria sulla Legatura delle principaHAtt** degli Arti, con una Appendice all' Oper*** Aneurismafol.Pavia, 1817, or the Trent** Aneurism, transl. by Wishart, Ed. *, f- 119, Edinb. 1819. •*>' In this manner, no doubt, Scarpa 9**" account for the presence of lamellated* gula in the case reported by Mr. A. Bora*. (On Diseases of the Heart, p. 306,) (been* the latter gentleman himself; for reasons* ready detailed in the foregoing pages, & not regard the expansion of all tbecoat^ ine artery, as corresponding to tbe morbid dilatation implied by Scarpa. Thus 9aaf lurther agrees with other modern writer*,■ admitting the possibility of SSi£K»* mmg ingrafted, as it were. in^eofihej« ANEURISM. Hi .nnatural dilatations, more than one exam- ple of which combination were indeed reci- ted in his first work. In that treatise, be has asserted, that what he calls morbid dilatation, always extends to the whole circumference of the vessel. But, this point seems from Ihe appendix to be renounced, as he now observes, "Where the morbid dilatation is partial, or on one side of the artery, like a thimble, (for, very frequently, even in the arch of the aorta, this partial dilatation does not exceed the size of half a bean,) the entrance for tbe blood into this capsule is as large as the bottom of tbe sac." (Transl. by Wishart, p. 120, Ed. 2.) According to Scarpa, where the morbid dilatation occu- pies the whole circumference of the arterial tube, the tumour always retains a cylindrical or oval form ; and, if situated in such man- ner, that it can be compressed, it yields very readily to pressure, and almost disappears; and, after death, is found much smaller, than during life. On the contrary, aneurism, whether preceded by dilatation, or not. con- stantly originate* from one side of the rup- tured artery. The entrance for the blood is small, compared with the size of the fundus of the sac ; the tumour assumes an irregular shape ; yields with difficulty to pressure; re- tains nearly the same size in the dead, that it had in the living body ; and, its sac, in- stead of becoming thinner as tbe swelling enlarges, like the coats of an artery do, when they are simply affected with dilata- tion, attains greater thickness, the larger tbe aneurism grows. These essential differences, between the two diseases, are illustrated by an interesting case, met with by Professor Vacca, where a patient died with an aneurism of one subclavian artery, and a simple morbid dilatation of the whole circumference of the other. (See Sprengel, Storia delle Operas, di Chir. Trad. Ital. Parte 2, p. 294.) When these two different affections are si- tuated in the thorax, or abdomen, it is im- possible to discriminate them from each other before death. The symptoms, occa- sioned by the pressure of the tumour on the viscera, must be nearly the same, whether caused by a morbid dilatation, or an aneu- rism. The means for retarding their fatal termination is also the same in both forms of tbe disease. With regard to the possibility of cure, however, Scarpa says, that there is great difference; for, when the case is an in- ternal aneurism, there may be some slight hope of a radical cure by the efforts of na- ture and art, which hope can never be enter- tained in a case of morbid dilatation; a fact, which is accounted for by no laminated coa- gula being deposited in the latter disease. (On Aneurism, transl. by Wishart, p. 124, Ed. 2.) A great deal of the latter statement coincides with tbe observations of Mr. Hodgson, who particularly notices, that be has never met with lamellated coagula in such sacs, as consist either in a general, or partial dilatation of the coats of tbe vessel. (On diseases of Arteries, fa. p. 82.) Whether this ever takes place in such cases may still be a question, because if Professor Naigele has given a correct description of the aneu- rism of the abdominal aorta, already men- tioned, which aneurism was of large size, and consisted of a dilatation of all the coats of the vessel, there was in this rare example a large quantity of these layers of coagulated blood. Yet, whether the professor actually means the fibrine, arranged in laminae, or only common coagulated blood, which, as every one knows, may be found either in the cysts of dilated, or of ruptured arteries, may admit of doubt. The statement, there- fore, made by Hodgson and Scarpa, may not be contrary to what was really seen by Na?- gele aud Ackermann. The following case, however, observed by Laennec, and quoted by a modern writer, must (if correctly re- ported,) afford not only an unequivocal spe- cimen of aneurism by dilatation of all the coats of the aona, but, of laminated coagu- la within its cavity. " Iu homine enim, qui repente sub atrocissimis pectoris doloi ibus corruit, praster aortum adscendentem in aneurysma ita expansam, ut neonati infantis caput aequaret, cystidem aneurismalicam im- mediate supra arteriae ccsliacae ortam magni- tudine nucis juglandis invenit, quae luculen- fer ostendit sinum communicantem cum arteries cylindre per foramen magnitudine amygdalae, diametro totius arteria? illo loco non mutato. Saccus hie cultro anatomico accurate ac subtiliter subjectus, eamdem structuram,easdemostendit membranas, qui- bus gaudebat arteria, e cujus latere excreve- rat; caeterum massis grumosis, sive fibrosis erat impletus. Inde igitur patet, hoc aneu- rysma sacciforme et laterali et partiali qui- dem tunicarum aorta? dilatatione ortum es- se." (J. H. G. Ehrhardt, De Aneurysmate, Aorta;, p. 13, 4to. Lips. 1820.) From what has been stated, it appears then, that there is only one principal point of dif- ference between Scarpa and other writers, and this resolves itself into the question, whether a dilatation of an artery, arising at one particular side of the vessel, and lined by its internal coat, ought not to be regard- ed as an aneurism, because its communica- tion with the tube of the artery is more ca- pacious, than what exists in other aneurisms, where the inner coat has given way, and because it rarely (perhaps never) contains laminated coagula, unless fissures should bap- pen to exist at some points of the inner ar- terial tunic thus expanded. The greater number of aneurisms increase gradually, and sooner or later incline to the side, on which tbe least resistance is experi- enced. De Haen mentions an aneurism of the aorta, which first made its appearance between tbe second and third ribs of the left side, and, whieh instead of growing larger, as is usual, subsided, and could neither be seen, nor felt, for more than a month before the patient's decease, although, on opening the body, a tumour of the arch of the aorta was found, three times as large as the first. De Haen imputes the sudden disappearance of the swelling to its weight, the yielding of the parts with which it was connected, and to U2 \NEURISM. its gravitating into the chest, when the pa- tient lay on his right side ; for, the difficulty of breathing, and other complaints, produ- ced by the pressure on the lungs, underwent a material increase, as soon as the tumour ceased to protrude. The pulsations which accompany true aneurisms, continue to be strong, until the in- ner coats of the vessel give way, or the lay- ers of coagulated blood, lodged in the sac, are numerous. Hence, when soft swellings, situated near any large arteries, lose their pulsatory motion, their course, precise situ- ation, and other circumstances, ought to be most carefully investigated, before any deci- sion i« made about the mode of treatment. In St. Bartholomews hospital, 1 saw a man, about three years ago, who had a large swelling of great solidity, occupying the ham, and apparently extending a good way forwards round the condyles of the fe- mur. Its hardness, shape, large size, and en- tire freedom from pulsation, not only then, but at an earlier period, as far as could be collected from the patient's own account, led to the belief, that the case was probably a tumour complicated with exostosis of the femur, and as this opinion seemed to be confirmed by no fluid escaping from a puncture made with a lancet, amputation was performed. To our surprise, however, dissection proved, that the disease was a large diffused popliteal aneurism, in which the spontaneous cure by an obliteration of the sac with coagula was taking place. (See Med. Chir. Trans. Vol. 8, p. 497.) In many instances, the most fatal acci- dents have happened, in consequence of incisions having been made in aneurisms, which were mistaken for abscesses, because there was no pulsation. Vesalius was con- sulted about a tumour of the back, which he pronounced to be an aneurism. Soon afterwards, an imprudent practitioner made an opening in the swelling, and the patient bled to death in a very short time. Ruysch relates, that a friend of his, having opened a tumour near the heel, which was not supposed to be an aneurism, the greatest difficulty was experienced in suppressing the hemorrhage. De Haen speaks of a patient, who died in consequence of an opening, which was made in a similar swelling at the knee, although Boerhaave had given his ad- vice against the performance of such an operation. Palfin, Schlitting, Warner, and others, have recorded mistakes of the same kind. (Sabatier, Tom. 3. p. 167.) Riche- rand informs us, that Ferrand, head surgeon of the H6tel-Dieu, mistook an axillary aneurism for an abscess, plunged his bistou- ry into the swelling, and killed the patient. " J'ai efe timoin d'erreurs semblables, com- mises par les praticiens non mains fameux ; et si des aniurismes externes on passe a ceux des arteres placies a I'iniirieur, les erreurs ne sont ni moins ordinaires ni de moindre conse- quence. (Nosogr. Chir. T. 4, p. 75, Ed. 2.) Notwithstanding a pulsation » 144 a:\eurism. 100, Ed. 2.) and others, that cartilage is less rapidly destroyed by the pressure of an aneurism than bone. This fact is strikingly illustrated in a case of aneurism of the tho- racic aorta, recorded in another modern publication: the bodies of the vertebras from the fourth down to the ninth were carious; the four lowermost particularly so ; yet, the intervertebral cartilages were not material- ly affected, (F. L. Kreysig, Die Krankheiten des Herzcns, B. 3, p. 176, 8vo. Berlin. 1817.) A case is related by Pelletan, which is highly interesting, not only as exemplifying the degree, in which internal aneurisms may injure the vertebrae; but also as showing the occasional possibility of such diseases being mistaken for rheumatism, or a lumbar ab- scess, with or without caries of the spine. After various complaints, like those of rheumatism, an oval tumour, imperfectly circumscribed, presented itself in the right iliac region, in the track of the psoas mus- cle. It was attended with a distinct fluctu- ation, and might easily have been mistaken for a collection of matter. But, on attentive examination, pulsations were felt, which, as they increased from day to day, left no further doubt concerning the nature of the swelling. On opening the body after death, an aneu- rismal tumour of prodigious size was dis- covered. It filled the cavity of the abdomen, from the lumbar and iliac regions of the right side, to the lumbar region of the left side, and it extended from the trunk of the cceliac artery down to the bifurcation of the aorta. The trunk of the aorta divided the tumour into two pouches, of which the right was far the largest, occupying the iliac and lumbar regions. The swelling enve- loped the right kidney, and was externally covered by the peritoneum, which mem- brane was pushed to some distance from the bowels. The quantity of blood, which the aneurism contained, was about five pints; three of which were >\\ its right ca- vity, and two in its left. This fluid was nearly all in a coagulated state, the coagula being arranged in concentric layers, as is usual in such cases. The centre of the dis- ease presented an oval opening, about three inches long, and one broad, formed in the posterior part of the aorta, between the coeliac and superior mesenteric arteries. Opposite to this aperture, the bodies of the two last dorsal, and of tbe two first lumbar vertebrae, were destroyed; an ordinary effect of aneurism on such bones as happen to be near them, but which effect Pelletan had never previously seen take place in so considerable a degree. In fact, in this case, while the patient was alive, the lowermost dorsal vertebrae had actually caused a de- formed appearance externally, from the effect of the pressure of the tumour on that part of the spine. This was the largest aneu- rism Pelletan ever saw; and he ascribes the man's death to nearly the whole mass of the blood being in the aneurismal sac, as most of the vessels, and the heart itself, were quite empty. (Clinique Chir. T. I, f, 97, 100.) CAUSES OF ANEURISM. Aneurisms often seem to originate spon- taneously, it being in many instance* ex. ceedingly difficult to assign any cause for the commencement of the disease. Among the circumstances, which predispose to aneurisms, however, the large size of the vessels may undoubtedly be reckoned Those trunks, which are near the heart, are said to have much thinner parietes, in re- lation to the magnitude of the column of blood, with which they are filled, than the arteries of smaller diameter; and since the lateral pressure of this fluid against the sides of the arteries is in a ratio to the magnitude of these vessels, it follows, that aneurisms must be much more frequent in the trunks near the heart, than in such as are remote from the source of the circulation. (Riche- rand, Nosogr. Chir. T. 4, p. 72. Edit. 2.) The whole arterial system is liable to aneu- risms ; but, says Pelletan, experience proves that the internal arteries are much more frequently affected, than those which are external. (Clinique Chirurgicale, Tom.]. p. 54.) The curvatures of the arteries are another predisposing cause of the disease, and, ac- cording to Richerand, such cause has mani- fest effect in determining the formation of the great sinus of the aorta, the dilatation, which exists between the cross and the origin of this large artery, and is the more considerable, the older the person is: Mon- ro even thought, that one half of old per- sons have an aneurism at the beginning of the aorta. • And with respect to aneurisms in general, which are preceded by calca- reous depositions, thickening, and disease of the coats of the vessel, they are most fre- quently met with in persons of advanced age. Aneurisms from wounds are of come often seen in individuals of every age. b old people, the coats of the arteries W subject to a disease, which renders them in- capable of making due resistance to thela- teral impulse of the blood. The disease, here alluded to, is what is described in a foregoing part of this article, one common effect of which is the deposition of calcare- ous matter between the inner and muscular coats of the arteries. " People in the earlf part of life, says Mr. Wilson, are not very subject to these calcareous depositions; bat, I have occasionally met with them in the arteries of very young people. I have K* a well-marked deposition of the phosphiH of lime in the arteries of a child under tare* years of age." He adds, that few persons, above the age of sixty, are free from ibe* ossifications. (See Lectures on the Blo*\ and on the Anatomy, Pathology, fa. of * Vascular System, p. 375, Lond*18l9.) a nough spontaneous aneurisms are at* aST. in o|d Persons, the disease h* absolutely confined to them ; for I ase** Mr. Docker at Canterbury in an operation A.NElklsM. l4* /orthecure ol a popliteal aneurism in a posti- lion, whose age must have been under thirty; and Mr. Wilson says, that he has met with several-instances of the disease in the aorta and other vessels, where the patients were not more than forty years of age. (Op. cil. p. 376.) Richerand affirms, that, out of twelve popliteal aneurisms, which he has seen in hospital, or private practice,ten were caused by a violent extension of the leg. This statement, he says, will derive confirmation from the following experiment. Place the knee of a dead subject on the edge of a firm table, and press on the heel, so as forcibly to extend the leg far enough to make ihe ligaments of the ham snap. Now dissect the parts, cut out the artery, and examine its parietes in a good light, when the lacerations of the middle coat will be observable, and rendered manifest by the circumstance of those places appearing semitransparent, where the fibres are sepa- rated, the parietes at such points merely consisting of the internal and external tuuics. (Nosograph'c Cu'.r. x'om. 4, p. 73, 14, Edit. 2.) But, the insufficiency of this explanation is clear enough from the fact, that such violence, as is requisite to b.-eak the ligameuts of the knee, cannot be ima- ginedto happen in the accidents which or- dinarily bring on aneurism in the ham. The implicit belief also which Richerand , seems to place in the idea, that the lacera- tion of the middle coat of an artery will , bring on an aneurism, while the inner coat | is perfect, will appear* to be unfounded, , when it is remembered, that Hunter, Home, : and Scarpa, even dissected off the external ;and middle coats of arteries, without being jable in this manner to cause an aneurism. Nay, where the experiment has been made (pf applying a tight ligature to an artery, and immediately removing it again in order to determine whether the division of both the inner coats of the vessel would terminate m an obliteration of the tube of tbe vessel, too aneurism has been the consequence. Pelletan accounts for the frequency of "popliteal aneurisms somewhat differently *trom Richerand : speaking of the two prin- eipal motions of tbe knee, viz. extension Kind flexion,he remarks, that the first of these as so limited, that it is actually an incipient lexion, necessarily produced by the curva- ture backward both of the condyles of the H'emur, and those of the tibia. This curva- ture, which would seem to protect the po- pliteal artery against any dangerous elon- gation, that might otherwise be caused by a forcible extension of the joint, becomes Kibe very source of such an elongation in persons, who are accustomed to keep their *unbs bent, or who, from this state, proceed ■rastily and violently to extend the leg he arterial tubes are really shortened, when tie limbs are iu the state of flexion, and •'•igthened, when the extension of the .lerubers renders it necessary. Hence, says pelletan, it is manifest, that an habitual Hortciied slate of these vessels, and their v"'- I * ]y sudden elongation, must be attended with hazard of rupturing their parietes. (Clinique Chirurgicale, Tom. l.p. 112.) . The opinion of Pelletan, however, is quite untenable ; because Mr. Hodgson has several times repeated the experiment mentioned by Richerand, and found, as this gentleman did, that the coats of the artery were never lacerated, unless the degree of violence had been such as to rupture the ligaments of the knee. (On Diseases of Av leries, fa. p. 64.) Aneurisms are exceedingly common is the aorta, and they are particularly often met with in the popliteal artery. The ves- sels, which are next to these the most usual- ly affected, are the crural, common carotid^ subclavian, and brachial arteries. The tem- poral and occipital arteries, and those of the leg, foot, forearm, and hand, are far less frequently the situations of.the present dis- ease. But, although it is true, that the larger arteries are the most subject to the ordinary species of aneurisms, the smaller arteries seem to be more immediately con- cerned in the formation of one peculiar aneurismal disease, now well known by the name of the aneurism by anastomosis, of which I shall hereafter speak. According to surgical writers, the causes of aneurisms operate either by weakening the arterial parietes, or by increasing tbe la- teral impulse of the blood against the side.* of these vessels. It is said to be in both these ways, that the disease is occasioned by violent contusions of the arteries, the abuse of spirituous drinks, frequent mer- curial courses, fits of anger, rough exercise, exertions in lifting heavy burdens, kc. In certain persons, aneurisms appear to depend upon a particular organic disposition. Of this description was the subject, whose ar- teries, on examination after death, were found by LancM affected with several aneurisms of various sizes. I have known a person have an aneurism of one axillary artery, which disease got spontaneously well, but, was soon afterwards followed by a similar swelling of the opposite axillary ar- tery, which last affliction proved fatal. I have seen another instance, in which an aneurism of the popliteal artery was ac- companied with one of the femoral in the other limb. Boyer mentions a patient, who died of a femoral aneurism in la Charite, at Paris, and who had also another aneurism of the popliteal artery, equal in size to a walnut. (Boyer's Traiti des Mala- dies Chirurgicales, fyc.p. 102. T. 2.) The most remarkable case, however, proving the ex- istence of a disposition to aneurisms in the whole arterial system, is mentioned by Pelle- tan. "J'ai pourtant vu plusieurs fois ces nombreux aneurismes occupant indistincte- ment les grosses ou les petites arteres, mais surtout celles des capacites : j'en ai compti soixante-trou sur un seul houime, depuis le volume d'une areline jusqu'a celui de la moitti d'un auf de poule." (Clinique Chi- rurgicale, Tom. 2. p. 1.) 14«j ANEURISM Aneurisms, and those diseases of the coats of arteries, which precede the formation of aneurism, are much less frequently met with in women than men. (Lassus Patho- logic, Chir. T.l.p. 348.) A few years be- fore John Hunter died, Mr. Wilson heard him remark, that he had only met with one woman affected with true aneurism. (Ana- tomy, Pathology, fa. of the Vascular System, p. 376.) Mr. Hodgson drew up the follow- ing table, exhibiting the comparative fre- quency of aneurisms in the two sexes in different cases of this disease, and also in the different arteries of the body, as deduced from examples, either seen by himself du- ring the lives of the patients, or soon after their death. H o 70 £L a 21 16 8 7 2 2 6 6 12 12 16 14 63 56 Of tbe ascending aorta, the arteria innominata, and arch of the aorta - - Descending aorta - - - Carotid artery - - - - Subclavian and axillary - Inguinal artery - - - - Femoral and popliteal - This table does not include aneurisms ari- sing from wounded arteries, nor aneurisms from anastomosis. (See Hodgson's Treatise on the Diseases of Arteries and Veins, p. 87.) It was observed by Morgagni, and it has been noticed in this country, that popliteal aneurisms occur with particular frequency in postilions and coachmen, whose employ- ments oblige them to sit a good deal with their knees bent. In France, the men who clean out the dissecting rooms, aud procure dead bodies for anatomists, are said al- most all of them to die of aneurismal dis- eases. Richerand remarks, that he never knew any of these persons, who were not addicted to drinking, and he comments on the debility, which their intemperance and disgusting business together must tend to produce. (Nosogr. Chir. T. 4. p. 74, Edit. 2.) Aneurisms are supposed by Roux to be much more frequent in England than France ; a circumstance, which, before he proves it to be a fact, he vaguely refers to the mode of life, and kind of labour, to which a large part of the population of Eng- land are subjected. Indeed, he connects this surmise with a reason for the very cul- tivated state of this part of knowledge in England, thinks, that we have been placed in favourable circumstances for perfecting the treatment of aneurisms, and acknow ledges, that we have contributed more than his countrymen, both in the last and present century, to the improvement of this branch of Surgery. (Roux Parallele de la Chirur- gie Angloise avec la Chirurgie Francoise, fa. p. 249.) But, ere M. Roux ventured into such conjectures, he ought at least to have specified what particular ocenpations and kind of labour are known by Englishmen themselves to be frequently conducive to aneurism, for, with the exception of pos. tilions and coachmen, of whom there are also abundance in France, I am not aware that any determinate class of persons are found in this country to be affected with particular frequency. In some instances, aneurisms of the axil. lary artery appear to have arisen from vio- lent extension of the limb. (See the cases re- corded by Pelletan in Clinique Chirurgictkl Tom. 2. p. 49, and 83.) In other examples, related by the same interesting practical writer, aneurisms arose from reiterated con- tusions and rough pressure on parts. (Op cit. p. 10, P. 14.) The extremity of a fractured bone mar injure an artery, and give rise to an aneurism, instances of which are recorded by Pelletan, (Op. cit. Tom. 1, p. 178,) and Duvernej (Traili des Mat. des os, T. 1.) In Pelletan'! case, the disease followed a fracture of the lower third of the leg. An aneurism of the anterior tibial artery, from such a cause, is also described by Mr. C. White. (Casein Surgery, p. 141.) The following case of an aneurism of the humeral artery, after amputation, is record- ed by Warner: C. D. was afflicted with a enries of the joint of the elbow, which was attended w ilh such circumstances, as ren- dered the amputation of the limb'necessary The operation was performed at a proper distance above the diseased part, and the vessels were taken up with needles and liga- tures. In a few days the humeral artery became so dilated above the ligature upon it as to endanger its bursting. Hence it was judged necessary to perform the operation for the aneurism, which was done, and the vessel secured by ligature, above the upper estrt- mity of its distended coats. Every thing now went on, for some time, exceedinjrj) well, when suddenly the artery again dila- ted, and was in danger of bursting above the second ligature. These circumstancesmade it necessary to repeat the operation for tbe aneurism. From this time, every thingwent on successfully, till the stump \vn30ntbe point of being healed ; when, quite unci- pectedly, the artery appeared a third fuse diseased in the same manner as it had been previously, for which reason, a third opera- tion for aneurism was determined on, and performed. The last operation was near the axilla,and was not followed by any relapse. Could the several aneurisms of the ha meral artery, (says Mr. Warner) beattribu ted to the sudden check alone, which the blood met with from tbe extremity of the vessel being secured by ligature ; or is Uo*' more reasonable to suppose, that the con* of the artery, nearly as high up as the a* were originally diseased and weaken* i be latter, in the opinion of this ju*BJa» writer, seems the most probable way » accounting for the successive returns of* disease of the vessel: since it is found ft* A.NEUWSM. m; experience, that such accidents have been very rarely known to occur after amputa- tions, either of the arm, or thigh, where nearly the same resistance must be made to the circulation in every subject of an equal age and vigour, who has undergone such operation. If it should be supposed, that the several dilatations of the coats of the vessel, con- tinues Mr. Warner, arose merely from the check in the circulation, it will not be easy to account foi- the final success of this ope- ration ; and, especially when we reflect, that the force of the blood is increased in proportion to its nearness to the heart. (See Casts in Surgery, p. 139, 140, Edit. 4.) Ruysch has related an observation some- what similar. (Obs. Anat. Chir. T. 1 p. 4.) Aneurisms sometimes follow the injury, which a large artery suffers in gunshot wounds. The passage of a bullet through the thigh, in one example, gave rise to a femoral aneurism. (See the Parisian Chirur- gical Journal, vol. 2. p. 109.) The same cause produced an aneurism high up the thigh of a soldier, who was under the care of my friend Mr. Collier at Brussels, after the battle of Waterloo. PROGNOSIS. In cases of aneurism, the prognosis varies according to a variety of important circum- stances. The disease may generally be consi- dered as exceedingly dangerous; for, if left to itself, it almost always terminates in rup- ture, and the patient dies of hemorrhage. There are on record some examples, howe- ver, in which a spontaneous cure took place, and aneurismal swellings have been known to lose their pulsation, become hard, smaller, and gradually reduced to an indolent tuber- cle, which has entirely disappeared. After death, the artery, hi such instances, has been found obliterated, and converted into a liga- mentous cord, without any vestige of the aneurism being left. Aneurisms are also sometimes attacked with mortification ; the sac and adjacent parts slough away; the artery is closed with coagulum ; and thus a cure is effected. Lastly, tumours, having all the character of aneurisms, have been known to disappear under the employmentof such pressure, as was certainly too feeble to in- tercept entirely the course of the blood. Such examples of success, however,are not common, and whenever they happen, it is because the entrance of blood into the sac is prevented by that already contained in it having coagulated, and because the artery above the swelling becomes filled with coa- gulum. They must, infact^have been cured on the veiy same principle, which renders the surgical operation successful. Nothing is subject to more variety, than the duration of an aneurism previously to its rupture, tbe tumour bursting sooner or later, according as the patient happens to lead a life of labour, or ease, of intempe- rance, or moderation. Even the bursting of an internal aneurism may not immediately kill the patient, as the following uncommon mitance proves;, a stonecutter died in the hospital Saint Loois with an enormous aneu- rism, situated on the left side of the lumbar vertebrae. Thejoody was opened by Riche- rand, who found, that the external tumour consisted of blood, which had been effused into a cyst, that was formed in the midst of the cellular substance of the loini. This fluid had passed into the situation specified, by making its way through the muscles. The tract, through which it came, led into another aneurismal sac, contained in the abdomen, and situated behind the perito- neum, on the left side of the lumbar verte- brae. In endeavouring to discover, whence the extravasated blood proceeded, Riche- rand found, that the abdominal aorta was entire, though in contact with the swelling. The original affection consisted of an aneu- rismal dilatation of the inferior portion of the thoracic aorta, which had burst at the point, where it lies betwixt the crura of the dia- phragm. The blood had probably escaped very slowly, and it had accumulated in the cellular substance, which surrounds the kidney, so thatthree cysts had burst succes- sively, before the patient died. (Nosogr. Chir. T. 4. p. 82. Edit. 2.) Every aneurism so situated that it cannot be compressed, nor tied above the swelling, is for the most part absolutely incurable. But, it should be recollected, that sometimes the size of the swelling appenrs to leave no room for the application of a ligature above it, while things are in reality otherwise, in consequence of the communication between the sac andtheartery,bearing no proportion to the magnitude of the tumour itself. At the present day, also, enlightened by anato- mical knowledge, and encouraged by suc- cessful experience, surgeons boldly follow the largest arteries, even within the bounda- ries of the chest and abdomen, as we shall presently relate, and numerous facts have now proved, that few external aneurisms are beyond the reach of modern surgery. It being certain, that aneurisms cannot com- monly be cured, except by an obliteration of the affected artery, it follows, that the circulation must be carried on by the supe- rior and inferior collateral branches, or else the limb will mortify. Experience proves, that the impediment to the passage of the blood, through the diseased artery, obliges this fluid to pass through the collateral branches, which gradually acquire an in- crease of size. It is therefore a common notion, that it must be in favour of the suc- cess of the operation, if the disease be of a certain standing ; and in direct opposition to the sentiments of Kirkland, Boyer even asserts, that the most successful operations have been those performed on persons, who have had the disease a long while. (Traili des Maladies Chirurg. T. 2. p. 116.) There is this objection to delay, however, that the tumour becomes so large, and the effects of its pressure so extensive and in- jurious, that, after the artery is tied, great inflammation, suppuration, and sloughing, often attack the swelling itself, and the pa- tient falls a victim to.what wrould not have 1't ANEURISM fiecnrred, bait tbe operation been done ooner. The large size of an aneurism, as Mr. Hodg- son has rightly observed, is a circumstance, which materially prevents the establish- ment of a collateral circulation. When the tumour has acquired an immense bulk, it has probably destroyed the parts, in which some of the principal anastomosing bran- ches are situated ; or by its pressure it may prevent their dilatation. (See Hodgson on the Diseases of Arteries and Veins, p. 259.) The practice of permitting an aneurism to increase, that the collateral branches may become enlarged, (says this gentleman) is not onlvunnecessary but injurious, inasmuch as thatthe increase of the tumour must be attended with a destruction of the surround- ing parts, which will render the cure of the disease more tedious and uncertain. (P. 266.) The most successful operations, which I have seen, wTere performed before the aneu- rismal swellings were very large. However, notwithstanding the great disadvantages of letting the swelling become bulky before the operation, the fact appears scarcely yet to have made due impression, and surgeons are yet blinded with the plausible scheme of giving time for the collateral vessels to en- large : at least, I infer, that things are so, from having lately seen a patient, who had been advised to let the operation be post- poned on such a ground, though the swell- ing in the ham was already as large as an rgg-' The surgeon should not be afraid of ope- rating, although appearances of gangrene may have taken place on the tumour ; for, as Mr, Hodgson remarks, should it burst afterwards, it is probable, that both extremi- ties of the artery in the sac will be closed with coagulum. (Hodgson, p. 805.) Mr. A. Cooper tied the external iliac artery in two cases of Inguinal aneurism, when gan- grene existed, and though the tumours burst, no hemorrhage ensued. The coagulum was discharged ; the sac granulated ; and the sores gradually healed. (Medico Chir. Trans, Vol. 4. p. 431.) J he effects of the pressure of aneurisms Upon the bones, are justly regarded as an unpleasant complication, when they take place in an extensive degree, and, according to writers, they may sometimes induce a necessity for amputation. (Boyer, Traite des Mai. Chir. t. 2. p. 117.) However, I have never seen a case of this description ; and Mr. Hodgson, as we have already ex- plained, informs us, thatthe affection of the bones is hardly ever attended with exfolia- tions, or the formation of pus, so that if the aneurism can be cured, the bones will re- cover their healthy state, without undergo- ing those process which take place in the cure of caries, or necrosis. (On Dis- eases of Arteries and V ins, p. 80.) At the same time, there can be no doubt, that where the tumour has been allowed to at- tain a large size, before an attempt is made >*v rure ie, and where, from this cause, •>«{!» th* r*fM»bbourinir «oft parts nnd the bone have suffered considerably, the com- pletion of a cure, that is to say, the full re. storation of the use of the limb, must be far more distant than in other cases, where the cure is attempted in an earlier stage. Here, then, we see another reason against the pernicious doctrine of waiting for the en- largement of the anastomosing vessels, in addition to that which has been urged in tba previous column. The age, constitution, and state of the patient's health are also to be considered in the prognosis; for they undoubtedly make a great difference in the chance of success after the operation. The operation, however, should not be rejected on account of the age of the pa- tient, if the circumstances of the case in other respects appear to demand it; for it has often succeeded at very advanced periods of life. " I have seen several aneu- risms cured by the modern operation, in pa- tients above sixty years of age." (Hodgson, p. 304.) A fact to which my own opportu- nities of observation enable me also to bear witness. When an aneurism exists in the course of the aorta, the violent action of the heart, excited by an operation in the extremities, may cause it to burst, and prove instantane- ously fatal. Two cases have recently oc- curred in this metropolis, in which the pa- tients died from such a cause during opera- tions for popliteal aneurisms. (See Hodgson on Diseases of Arteries, p. 306. London Med. Review, vol. 2. p. 240. and Burns on Distant of the Heart, p. 226.) Were the coexistencs of the internal aneurism known, the opera- tion for the other tumour would be improper, and the surgeon should limit the treatmentto palliative means. Experience confirms, however, that the circumstance of there being two aneurisnu in the limbs should not (prevent the opera- tion, which is to be practised at separate periods. Facts in support of this statement are quoted by Mr. Hodgson. (P. 310.) OP THE SPONTANEOUS CURE, AND GEIERll IRFATMENT Or ANEURISMS. The obliteration of the sac, in eona** quence of a deposition of lamellated coagn- lum in its cavity, as Mr. Hodgson has well described, is the mode by which the sponta- neous cure of aneurism is in most instances effected. The blood soon deposits npon the inner surface of the sac a stratum of coagulum ; and successive depositions of tba fibrous part of the blood by degrees lessen the cavity of the tumour. At length, the sac becomes entirely filled with this sob- stance, and the deposition of it generally. continues in the artery on both sides of tbs sac as far as the giving off of the next fa* branches. The circulation through the «s- set is thus prevented ; the blood is convey- ed by collateral channels ; and another ore- ♦C.?rL '"sti,uted> whereby the bulk of * ZTr L re.mo7d- (*W*on on the V* msn of Artmes, fa. p. utf Such HesOl" ANEURISM. 149 •le increase of the coagulated blood in the sac is indicated by the tumour becoming more solid, and its pulsation weak, or cea- sing altogether. Another mode in which the disease is spontaneously cured, happens as follows: an aneurism is sometimes deeply attacked with inflammation aid gangrene ; a dense, compact, bloody coagulum is formed with- in the vessel, shutting up its canal, and com- pletely interrupting the course of the blood into the sac. Hence the sphacelation which follows, and the bursting of the integuments and aneurismal sac, are never accompanied by a fatal hemorrhage ; and the patient is cured of the gangrene and aneurism, if he has strength sufficient to bear the derange- ment of the health necessarily attendant on so considerable an attack of inflammation and gangrene. When a patient dies of hemorrhage, after the mortification of an aneurism, it is be- cause only a portion of the integuments and sac has slouched, without the root of the aneurism, and especially the arterial trunk, being similarly affected. For cases illustrative of this statement, refer to Hodg- son on Diseases of Arteries, p. 103, fa. A third way, in which an aneurism may be spontaneously cured, is by the tumour compressing the artery above, so as to pro- duce adhesion of its sides, and obliteration of its cavity. This mode of cure must be un- common : it has been adverted to by Sir E. Home, Scarpa, Dr. John Thomson, and others ; but some facts, tending to prove it, have been collected by Mr. Hodgson, and are published in his useful work. (See p. 107, fa.) e " The surgical treatmentof aneurism (says this gentleman,) consists in the obliteration of the cavity of the artery communicating with the sac, so that the ingress of the blood into the latter is either entirely prevented, or the stream which passes through it is supplied only by anastomosing branches, and consequently the force of the circula- tion is so much diminished, that the in- crease of the tumour is prevented, and the deposition of coagulum is promoted. By the absorption of its contents, and the gra- dual contraction of the sac, the cure is ulti- mately accomplished. The blood is con- veyed to the parts, which it is destined to supply, by collateral vessels, some of which being gradually enlarged, constitute perma- nent channels for the circulation. The ob- literation of the artery is effected by the ex- citement of such a degree of inflammation in its coats, as shall produce adhesion of its side. These objects have been at- tempted by the compression or the liga- ture of the artery. The latter method con- stitutes the operation for aneurism." (P 166.) v ' According to Scarpa, a complete cure of an aneurism cannot be effected, in whatever part of the body the tumour is situated, unless the artery, from which the aneurism isderived, be, by nature or art, obliterated and concerted into a perfectly sqjid, ligamentous substance, for a certain extent above and below the place of the ulceration, laceration, or wound. When aneurisms are cured by compression, the cure is never accomplished, as some have supposed, by the pressure strengthen- ing the dilated proper coats of the artery, and restoring, especially to the muscular coat, the power of propelling the blood along the tube of the artery, as it did pre- viously to its supposed dilatation. M. Petit, and Foubert, thought, that the natural cu- rative process sometimes consisted in a species of clot, which closed the laceration, ulceration, or wound of the artery, and re- sisted the impulse of the blood, so as still to preserve the continuity of the coats of the artery, and the pervious state of the vessel. Haller imbibed a similar sentiment, from experiments made on frogs. If the foregoing statement of Scarpa, re- specting the obliteration, of the tube of the adjacent portion of the artery, when an aneurism is cured, had been delivered merely as what is the most common course of things, it would not have been incorrect; but when he denies the possibility of the calibre of the vessel being ever preserved, whether the disease be cured by art or na- ture, he is exceeding the bounds of accu- racy. Notwithstanding aneurisms cannot in ge- neral be cured, as Scarpa has explained, unless the artery be rendered impervious for some extent above and below the tu- mour, I believe we must make an exception to this observation with respect to the few aneurisms of the aorta (especially those of its arch,) which, according to the records of surgery, have been diminished and cured by Valsalva's treatment. In such examples, we are not to suppose that the aorta be- comes obliterated at its very beginning; but that the diminution of the quantity of circulating blood, the reduced impetus of this fluid, the lessened distention of the aneu- rismal sac, the general weakness induced in the constitution, and the increased acti- vity of the lymphatic system, all necessary effects of Valsalva's method, have com- bined to bring about a partial subsidence of the tumour. " It is a common opinion (says Mr. Hodg- son,) that the radical cure of an aneurism cannot take place, without the obliteration of the artery, from which the disease origi- nates. It is probably owing to this idea, that aneurisms of the aorta have generally been considered as incurable diseases, and consequently that so little attention has been given to their treatment." (P. 118.) The facts, however, which this gentleman lias related, satisfactorily prove, 1st. That a deposition of coagulum may take place in an aneurismal sac, to such an extent as en- tirely to preclude the communication be- tween its cavity and that of the artery from which it originates. Secondly, that a sac, thus filled with coagulum, cannot prove fa- tal by rupture ; and thirdly, that the gradual absorption of its contents, and the conse- quent contraction of the sac. may proceed l*u A.MaftlSM. lo such an extent as to effect t7 bend of the arm, found the brachial artery obliterated, and converted into a solid cy- linder, for three inches below the place of the ligature, and as far as the division into the radial and ulnar arteries ; but the recur- rent radial and ulnar branches had become so much enlarged, that, taken together, they exceeded the size of the brachial artery, above the situation of the ligature. In the dead body it is found, that an anatomical injection will pass more freely from one ex- tremity to the other of an aneurismatic, than of a sound limb, and this even when no vessels are visibly enlarged. Although it be self-evident, that the circulation through the collateral vessels ought to be much more easy and quick the lower down the ligature is applied to the principal trunk; yet expe- rience shows, that this difference is not to be estimated very high ; for in cases of pop- liteal aneurism, caiteris paribus, the success is the same, whether the femoral artery be tied very low down, or very high up in the thigh. (Scarpa.) This facility Of the passage of the blood through the lateral vessels, is not the same in subjects of all ages ; and, in the same subject, it is not the same in the inferior, as In the superior extremity. An age under forty-five, and the operation being done on the arm, which is nearer the sourer ->f the circulation, than the lower extremity, In- creases the chance of success. However, notwithstanding these are the opinions of Scarpa, and as general ones may not be in- correct, surgeons in England now operate for aneurisms of the lower extremity, and on patients much older than forty-five, with i degree of confidence, which nothing but great success could inspire. According to Scarpa, the circumstances diiefly preventive of success, especially in he popliteal and femoral aneurisms, are the ollowing: rigidity, atony, or disorganiza- ion of the principal anastomoses, between he superior and inferior arteries of the am and leg ; sometimes depending on an dvanced age, or on it, together with the trge size of the aneurism, which, by long mtinuedpressure, has caused a great change i the neighbouring parts ; or sometimes on eatomatous, ulcerated, earthy, cartilagi- ous disorganization of the proper coats of "le artery, not confined to the seat of the ipture, but extending a great way above id below the aneurism, and also to the •incipal popliteal recurrent arteries, tibial 'teries, and, occasionally, to portions of e whole track of the superficial femoral tery. Sometimes the pressure of large leurisms renders the thigh bone carious. such circumstances, the ligature is apt to » I in closing the trunk of the artery ; and, »'it should succeed, the state of theanasto- ' J'ing vessels will not admit of a sufficient antity of blood being conveyed into the iter part of the limb: Hence, when the tient is much advanced in life, languid, d sickly; when the internal coat of the : ery is rigid, and incapable of being united a ligature ; when the aneurism is of Ions V'oi. I A~ e standing, and considerable size, with caries of the os femoris, or tibia; when the leg is weak and cold, much swelled, heavy, and cedematous ; Scarpa considers the operation contra^indicated. I must, however, declare in this place, that I have seen very large aneurisms, as well as aneurisms in persons of advanced age, cured by the Hunterian plan, in St. Bartholomew's Hospital; and, with respect to the affection of the bones, though it may be an unfavourable circum- stance, its consequences are not so serious as those of ordinary caries, as I have al- ready explained. It appears, then, that the obliteration of the artery, for a certain extent above and below the place of rupture, forms the primary indication in the radical cure of aneurism, whether compression or the liga- ture be employed ; all other means are only auxiliary. Internal remedies may be useful, inasmuch as they tend to moderate the de- termination of the blood towards the place, where the artery has been tied orcompressed. In the articles Hemorrhage, and Ligature, I have related in detail the effects of the li- gature upon a tied artery, and particularly the various processes which arise from its application, and terminate in the permanent obliteration of the vessel. In the same pla- ces, 1 have explained what are the best li- gatures for use, as well as the safest manner of using them. Confining myself in the se- quel of this article, to what expressly relates to aneurism, 1 shall here merely annex the following general directions, as stated by Mr. Hodgson. First, The cord should be thin and round, such a ligature being most likely to effect a clean division of thej internal and middle coats of the vessel, and not liable to occa- sion extensive ulceration or sloughing. Secondly, The ligature should be tight, in order to ensure the complete division of the internal and middle coats, and to pre- vent its detachment, it being almost impos- sible, even with the thinnest ligature, entire- ly to cut through a healthy artery. Thirdly, the vessel should be detached from its connexions only to such an extent as is necessary for the passage of the liga- ture underneath it. Fourthly, The immediate adhesion of the wound should be promoted by all such means as are known to promote that pro- cess in general. (On the Diseases of Arteries, p. 225, 226.) In the course of his experiments upon brutes, to ascertain the operation of the li- gature, Dr. Jones arrived at a fact, which offered the probability of leading to an im- provement in the operation for aneurism. (Treatise on Hemorrhage, chap. 3.) $, When a small firm ligature is applied to an artery, it causes a division of the internal and mid- dle coats ; and if it be afterwards removed, an effusion of lymph takes place between the cut surfaces into the cavity of the ves- sel. If several divisions of the internal and middle coats be thus affected in the viciuity of each other, the effusion of lymph was 1»4 ANF.L'RISM. found by Dr. Jones to be sufficiently cxten ~ive to obliterate the cavity of the vessel. In the year 1Sih"». Mr. C. Hutchinson tied the brachial arteries of two dogs, and re- moved the ligatures immediately after their application : in both instances, as he assures us, the complete obliteration of the canal of the artery was the consequence of the operation. (5ee his Practical Observations in Surgery, p. 103.) If immediately after the operation for aneurism, the ligature could be removed, and yet the vessel be- come obliterated, it would be highly advan- tageous, as there would then be left in the wound no extraneous substance to prevent its union, or promote secondary hemor- rhage by extending the sloughing, or ulcer- ative process too far. It is to be regretted, that success has not attended the repetition of the experiment by others. Mr. Hodgson tried it, but the artery did not become im- pervious. (See Experiments, A. fy B. p. 228, 229, of this gentleman's work.) Mr. Dalrymple, of Norwich, made the experi- ment not less than seven times on the horse, and three times on sheep, and failed in every instance in obtaining the same result as Dr. Jones. Not only was no coagulum formed,but,even where the animal had been suffered toliveuntilthe thirteenth, fifteenth, and eighteenth days after the ope- ration, the canal of the artery was notfound obliterated. In every instance, indeed, ifj calibre was contracted ; but it was still ca- pable of transmitting a lessened column of blood. (Travers, in Med. Chir. Trans. Vol. 4, p. 442.) Thus, it appears, that an effu- sion of lymph is an invariable consequence of the operation, and as Mr. Travers has ob- served,the want of union is therefore owing to the opposite sides of the vessel not being retained in a state of contact, so as to al- low of their adhesion. The presence of the ligature, in the common mode of its ap- plication, effects this object; and for the success of Dr. Jones's experiment, it ap- peared only necessary, that the .opposite sides of the wounded vessel should be re- tained in contact, until their adhesion was sufficiently [accomplished to resist the pas- sage of the blood through the tube. This object might probably be effected by com- pression ; but, the inconveniences attend- ing such a degree of pressure, as would re- tain the opposite sides of an artery in contact at the bottom of a recent wound, are too great to permit its employment. It occur- red to Mr. Travers, that if a ligature were applied to an artery, and suffered to remain only a few hours, the adhesion of the wounded surfaces would be sufficiently ac- complished to ensure the obliteration of the canal; and by the removal of the ligature at this period, the inconveniences attending its stay would be obviated. The danger produced by the residence of a ligature up- on an artery, arises from the irritation, which, as a foreign body, it produces in its coats. Ulceration has never been observed to commence in less than twenty-four hours after the application of a ligature ; whilst it is an ascertained fact, that lymph is iu a If. vourable state for organization in less tbaa six hours, in a wound the sides of which are preserved in contact. (Jones, chap. 4, tip. 1.) If it be sufficient, therefore, to ensure their adhesion, that the wounded coats of an artery be kept in contact by a ligature only three or four hours, ulceration and sloughing may in a great degree, be obviated by pronioting the immediate adhesion of the wound. Justified by this reasoning,Mr, Travers performed several experiments, by which he ascertained, that if a ligature were kept six, two, or even one hour upon the carotid artery of a horse, and then re- moved, the adhesion was sufficiently ad- vanced to effect the permanent obliteration of tbe canal. It appeared probable, that the same result would be obtained upon the healthy artery of a human subject. (See Travers's Obs. in Med. Chir. Trans. Vol. i and Hodgson's Treatise on the Distasti of Arteries and Veins, p. 228, et. seq.) Mr. A. Cooper appears to have performed one operation for a popliteal aneurism, with a view of ascertaining the efficacy of sucha method on the human subject. He com- pletely stopped the flow of blood for thirty- two hours, and then removed the ligature; but the pulsations of the tumour commen- ced again. He next applied the ligaturefor ty hours longer, at the end of which time, no pulsation recurred on the ligature being taken away. On the twelfth day, however, a considerable bleeding took place, tad it was necessary to take up the vessel anew. Mr. A. C. Hutchinson has tried tliis me- thod, as modified by Mr. Travers, in an ope- ration, which he performed for a popliteal aneurism in a sailor, in Nov. 1813. A dou- ble ligature was passed under thefeasertl ■ artery. The ligatures were tied with loop). or slip-knots, about a quarter of an inch of the vessel being left undivided between then , All that now remained of the pulsation is , the tumour, was a slight undulatory motile. Nearly six hours having elapsed from Ik application of the ligatures, the wound** carefully opened, and the ligatures untied and removed, without the slightest dbtar- bance of the vessel. In less than half • minute afterwards, the artery became (In- tended with blood, and the pulsations ii the tumour were as strong as they had been before the operation. Mr. Hutchinsonfhe« applied two fresh ligatures; hemorrbj|»«r i terwards came on ; amputation was per- formed, and the patient died. (Set Ft* heal Observations in Surgery, p. 102, *>•) Now, as Mr. Hutchinson chose to afjfj other ligatures, on finding that thepukn*" returned, the above ease only prove*,** the artery is not obliterated in about * hours, and we are left in the dark resp»* ing the grand question, namely, whether* vessel would have become obliterated If the effusion of coagulating lymph and* [ adhesivefinflammation, notwithstandint;* „ return of circulation through it A" f<>FtlB liemorrhage which occurred,! thinkitBi* have been expected, considering the*- \ ANEURISM. Wr sure of the arterial tube. But, says be,«" sometimes happens, at least in man, * ANEUA1SM 157 ilie pressure made by the circular ligature produces the ulcerative process more quickly in the artery, than the adhesive inflamma- tion. In fact, the circular ligature ulcerates the artery in general about the third day after the operation ; and the adhesive in- flammation does not always complete its course in this period of time. During this delay of the adhesive inflammation, the ul- cerative process, occasioned by the pressure of the ligature, attacks more quickly even than surgeons generally suppose, the exter- nal cellular sheath of the artery, and pene- trates into the cavity of the yet pervious vessel—and this of course with increased quickness, when the inner coats of the ar- tery are already divided by the ligature. The .dangers of non-adhesion and too rapid ulceration of the artery, Scarpa thinks are placed at the greatest distance by pre- serving undivided all the three coats of the vessel under the pressure of the ligature ; and hence, his partiality to larger ligatures, iluin are now used by the best surgeons in England, and to tbe interposition of a cy- linder of linen between the knot atad the vessel, as recommended by Pare, Heister, and Platner. If, however, he has bad rea- son to suspect, that a simple circular liga- ture has frequently failed in England, be- cause other innovations have been occa- sionally substituted for it, and because we slwuld not have nought for a better, if we had already had the best, how much more vul- nerable u his own practice on a similar principle ; since, generally speaking, it has not retained half so many approvers as they who still express their preference to other methods, and more especially to the use of a single ligature, uncomplicated with other extraneous substances. Is it proba- ble, he asks, that the single circular ligature, which was formerly used with doubtful success by the greatest surgeons, should now have become, as is pretended, the most certain means of preventing secondary hemorrhage ? " It is now wished (says he) to ascribe the failures of Mr. Hunter, and of many other operators, not to the circular ligature, but to the improper treat- ment of the wound in general, and in par- ticular to the introduction into it of lint, and, more especially, to the irritation occa- sioned by the ligature of reserve." On the contrary, it is argued by Scarpa, that, though Mr. Hunter, after his first trials, sim- plified the local treatment, though all skil- ful surgeons merely covered the wound with a pledget of soft ointment, and most of them omitted the reserve-ligature, yet, not- withstanding these reforms, secondary he- morrhage after the use of a simple circular ligature was not rendered less frequent. (On Aneurism, p. -23, ed. 2.) With respect to the latter general assertion, its incorrect- ness may be learned by reference to the de- tails of \lr. Hunter's own operations, and by going into the principal hospitals of this metropolis, where the use of a simple circu- lar ligature for the cure of aneurisms very rarely fails, as far as secondary hemorrhage is. concerned. Why then did the operation more frequently fail here in former times ? The answer is plain : the kind of ligature now employed in England, cannot be com- paredto what was used in Mr. Hunter's time, or even to what was here in fashion five and twenty years ago. And, besides the uni- versal rejection of ligatures of reserve, prac- titioners now have a more thorough com- prehension of what ought to be avoided in the operation, have a just fear of separating and (listurbing the artery too much, know how to appreciate the advantage of closing the wound, and attach due importance to the choice of smaller or more eligible liga- tures. (See Hemorrhage and Ligature.) When, therefore, Scarpa supposes, that in England the practice with the circular liga- ture in the treatment of aneurism, is mate- rially the same now, as heretofore, and that secondary hemorrhage is as frequent, he has not availed himself of all the information on this subject, which he might have ac- quired from Mr. Wishart, the able transla- tor of his writings on aneurism, or from an attentive perusal of Mr. Hodgson's valua- ble treatise. In an equality of circumstances, condu- cive to the success of the Hunterian opera- tion, Scarpa thinks, that the fact is not proved, as it is presumed to be, that the rup- ture of the internal and middle coats of the artery does excite the adhesive inflamma- tion and union of the artery more effec- tually, than is done by the simple compres- sion and close contact of its two opposite internal parietes in a sound and uninjured state. This remark is partly true, and partly incorrect, atthosame lime that it involves a question, which must be deferred till we come to the article Hemorrhage. The truth in the observation is, that an artery may generally be rendered impervious with to- lerable certainty, by compressing its op- posite parietes steadily and firmly together for a certain time, without dividing its inner coats : the inaccuracy of it depends upon the fact, that, surgeons have no instrument, nor contrivance (not excepting even the ligature of four or six threads, with the in- terposition of the cylinder of linen spread with ointment,) which can retain the op- posed undivided surfaces of the inner coats of the vessel closely together in the man- ner commended by Scarpa, and for the due time, without the objection of denuding more of the artery, than need be done in the application of a small ligature, or with- out the serious inconvenience, and risk, ne- cessarily attending the introduction of a larger quantity of extraneous matter into the wound, than is desirable, with the view of averting all chance of the ulceration of the artery reaching beyond prudent limits. And, when metallic instruments are used for the same purpose, objections not less real are incurred, as will be hereafter more particularly explained. Scarpa considers his mode of ligature ought to be preferred, as combining the tri- ple advantage of preserving entire all the lift ANEURISM three coats of the artery ; of exciting quick- ly, and in a proper degree, the adhesive in- flammation in them ; and of retarding, as much as possible, the ulcerative process of the arterial tube. Partly impressed, however, with the truth of the tenets laid down by Or. Jones (See Hemorrhage,) Scarpa enjoins attention to the following rules. I. Not to insulate and detach the artery any further, View is necessa- ry for allowing a ligature to be passed around it. 2. Not to let the cylinder of linen exceed a line in length, or a little more above and below the breadth of the tape, which is about a line for the large arteries of the ex- tremities. 3. That the ligature be not too tight. 4. And that it be never applied immedi- atclybelow the originofa large lateral branch. (See Scarpa on Aneurism, p. 44, Ed. 2.) Some further consideration of Scarpa's mode of applying the ligature will be intro- duced in the article Hemorrhage ; and I now proceed to notice his sentiments concerning the advantage which may be derived from removing the ligature iu cases of aneurism, as soon as the tube of the vessel has been obliterated by the adhesive inflammation. Now, from the facts recorded by Scarpa, it is inferred, that, with the kind of ligature and the cylinder of linen used in his prac- tice, the closure of the artery by the adhe- sive inflammation and the two internal co- agula is sufficiently far advanced on the third, or fourth day after the operation, to resist the impulse of the blood ; and hence (says he) there is no rational motive for waiting beyond this time for the spontaneous sepa- ration of the ligature, or for allowing it, by its further presence, to ulcerate, and even open the artery at the principal point of ad- hesion. He then comments on the advan- tages to the wound, derived from the remo- val of all extraneous matter from it on the third, or fourth day. With respect to the general period of such removal, however, he makes one exception, viz. the case of great and evident debility from sickly con- stitution, or very advanced age, as it is ob- served, that, in such patients, the reunion of a simple wound is frequently protracted to tbe sixth day. In cases of this descrip- tion, Scarpa recommends delaying the re- moval of the ligature to the completion of the fifth or sixth day, but under the ex- press condition, that the ligature has been applied with the interposition of a cylinder of linen ; as it is proved, that a common cir- cular ligature causes ulceration of the artery before the third day, and it is not till the sixth day that the external coat of the ves sel begins to ulcerate, when the other mo- dification of the ligature is adopted, (p. 50.) Scarpa supports the preceding advice by four cases, in which his kind of ligature was applied, and withdrawn at the end of the third, or fourth day, and the arterial tube obliterated. However, I do not think, that in England, these cases, when minutely and attentively considered, will be regarded as inducements to persevere in the use of temporary ligature- In every instance. the wound is described as suppurating, and sometimes plentifully. In one, the foot mortified, and amputation became neces«». ry. In another, the very day after the dis- turbance of removing the ligature, tba thigh was attacked with erysipelas, and, on the eiirbth day, the wound is represented as he'msfoul, and the erysipelas not yet cured. Independently of the uncertainty of the period, when the arterial tube is closed by the adhesive inflammation in various p». tients, it appears to me, thatthe disturbance of the vessel and wound, by the steps ne- cessary for the loosening and removal of the ligature, will ever form an insuperable ob- jection to the practice. Scarpa appears to have some apprehension of this kind him- self; for he remarks, " In the act of remo- ving the ligature, there can be no doubt it is of great consequence, that the artery be not rudely handled, or stretched. And, indeed, if, on untying the running knot, the subjacent knot could be with the samefaci lity untied, we could not wish for a better mode of performing this part of the opera- tion. But, the knot, although a simple one, is not so readily untied, as the running knot, on account of the moisture, with which the threads forming the ligature are soaked, or because the ligature has been previously waxed." (P. 64, Ed. 2.) In fact, his ap- prehensions then lead him to suggest tba scheme of placing, previously to makingfha knot, a thread longitudinally, on each side of the cylinder, and at the time of removing the ligature, the threads are to be drawn in opposite directions, in order to undo the knot, without displacing, or stretching tbe artery. Thus, instead of one small ligature, which is all that an English surgeon leaves in the wound, Scarpa recommends his liga- ture of four, or six threads, a roll of linen, and two other threads; a quantity of extra- neous substances, which cannot fail to be a source of irritation and serious mischief. I shall therefore take leave of the proposal of removing the ligature on the third, or fourth day, or any other particular day, with ei- pressing my belief, that, if there were only the followingjobjection to the plan, it would neverbe adopted in this country; namely,the advocates for this practice are necessarily obliged to renounce the infinite advantage of bringing the edges of the wound together directly after the operation. Had the sug- gestion of Dr. Jones proved invariably correct, and the ligature admitted of being withdrawn immediately after the inner coati of the vessel had been divided by it, the case would have been very different, as there would then have been no foreign body at all left in the wound ; the parts might have been immediately brought together with the greatest chance of union by the first inten- tion, and no subsequent disturbance either of the artery, or of the wound, would have been incurred. Tbe next practice, whieh I shall notice, u that of applying two ligatures to the artery, and cutting it through in the interspace. This suggestion maybe said to be as ancient U ANEURISM. t»9 ihe time of Celsus, who has advised this me- thod to be followed in the treatment of a wounded artery -. "Qua (arteria) sanguinem fundunt apprehendenda, circaque id quod ic- tum est duobus locis deligandte interciden- daque sunt, ut inse ipsecoeant, et nihilhorni- nus ora reclusa habeant." (De Medicina, Lib. 5, c. 26, § 21.) The fact is curious, though I mention it without the least inten- tion of detracting from tbe great merits of se- veral modern surgeons, that the Greeks were acquainted with the practice, lately recom- mended, of tying and dividing the trunk of Ihe artery high above the tumour, as will appear from the following extract: (AZlii. 4. Serm. Tetr. 4. cap. 10.) At veroquod incubili cavilate fit aneurisma, hoc modo per chirur- giam aggredimur.- primum arteria superne ab ala ad cubitum per intertiam brachii parte simplicem sectionem, tribus, aut qualuor digi- tis infra alam, per longitudinem faeimus, ubi maxime at tactum arteria octurrit.- atque ea paulalim denudala, deinceps incumbentia torpuscula sensim excoriamus at separamus, et ipsam arteriam cetco uncino attraclam duobus fili vinculis probe adstringimus, me- diamque inter duo i>tnc<...V dissecamus ; et sec- tionem polline Ihuris explemus, at linamentis inditis congruas dehgationes adhibemus. Afterwards we are directed to open the aneurismal tumour ut ihe bend of the elbow, and when the blood has been evacuated, to lie tbe artery twice, and divide it again. If the ancients bad only omitted the latter part of their operation, they would abso- lutely have left nothing to be discovered by the moderns. This method of applying two ligatures to the artery, aud dividing the vessel between them, wus revived in France about half a century ago by Tenon, who, as well as some later surgeons, was totally unacquainted with its antiquity. (See Pelletan's Clinique Chirurgicale, T. l.p. 192.) Atone time, it had also modern advocates in Mr.Abernethy and Professor Maunoir, of Geneva, each of whom supposed tbe plan an invention of his own. (See Surgical and Physiol. Essays, Part 3,8vo. Lond. 1797, and MimoiresPhy- siologiqucs tl Pratiques sur I'Aneurisme fa. 8io. Geneve, 1802.) When an artery is laid bare, and detached from its natural connexions, and the middle of such detached portion tied with a single ligature, as was Mr. Hunter's practice, Mr. Abernethy conceived, that the vessel, so cir- cumstanced, would necessarily inflame, and be very likely to ulcerate. The occurrence of bleeding from this cause at first led to a practice, which this gentleman justly cen- sures, viz. applying a second ligature above the first, and leaving it loose, but ready to be tightened, in case of hemorrhage. As the second ligature, however, must keep a cer- tain portion of the artery separated from the surrounding parts, and must, as an extraneous substance, irritate the inflamed vessel, it must make its ulceration still more apt to follow. The great object, therefore, which Mr. Abernethy insisted upon, was that of applying the ligature close lo that part of the artery, which lies among its natural con- nexions ; a just principle, tbe truth and uti- lity of which still remain incontrovertible, though there may be a better way of accom- plishing what Mr. Abernethy intended, than the measures which this gentleman was led to recommend. The peculiarity in Mr. Abernetby's first operation consisted in applying two ligatures round the artery, close lo where it was sur- rounded with its natural connexions. For this purpose, be passed two common sized ligatures beneath the femoral vessels, and having shifted one upwards, the other down- waids, as far as these vessels were detached) he tied both the ligatures firmly. The evert of this case was successful. An uneasy sensation of tightness, however, extending from the wound down to the knee, and continuing for many days after the ope- ration, made Mr. Abernethy determine, in any luture case, to divide the artery between tbe two ligatures, so as to leave it quite lax. Mr. Abernethy next relates a case of pop- liteal aneurism, for which Sir Charles Blicke operated, and divided the artery between the ligatures. The man did not experience the above kind of uneasiness; and no he- morrhage ensued when the ligatures came away, although there was reason to think, that the whole arterial system bad a tenden- cy to aneurism, as there was also another tumour of this kind iu the opposite thigh. The reasoning, which induced this gentle- man to revive this ancient practice, was ingenious; for, when the artery was tied with two ligatures, and divided, in the fore- going manner, it was argued, that it would be quite lax, possess its natural attachments, and be as nearly as possible in tbe same cir- cumstances as a tied artery upon tbe face of a stump. Strictly speaking, however, as Mr. Hodgson first pointed out, an artery tied in two places, and divided in the inter- space, cannot be regarded as placed exactly N in the same condition, as an artery tied in amputation. In the latter case, the retraction of the vessel corresponds with that of the surrounding parts, which are divided at the same instant, end therefore its relative con- nexions stand as before the operation. But, in the operation for aneurism, the retraction of the artery takes place, without being at- tended with a corresponding retraction of its connexions. How far the retraction of the artery is beneficial, or injurious, is by no means evident; and the advantages arising from it may in most situations be obtained, without dividing the vessel, by placing the limb in a bent position. One important ob- ject, however, is gained by the division of the artery; namely, ihat it is generally in that case tied closeto its connexions; and it is very evident how liable the application of the ligature in the middle of a denuded ex- tent of the vessel must be to produce ulcera- tion or sloughing of its coats. The'same object, however, will be gained by tying t|ie undi- vided artery close to its connexions at the end nearest to (he heart; and the existence of a single ligature at the bottom of the wound will be less liable lo give rise to sup- puration and the formation of stiiusc. than KM ANEURISM the employment of two. When an artery is div'nlei*, the portions situated beyond the ligatures must slough, and prove an addition- al cause of suppuration in the wound. Ex- perience has amply proved the safety of employing a single ligature, and it is at pre- sent used by many of the most experienced operators In this country. (See Hodgson's Treatise on the Diseases of Arttries, fa. p. 221, fa.) According to Scarpa, numerous examples of the failure of the plan of applying two ligatures, and cutting through the artery in the interspace, are already generally known to the profession, and there are many ex- pert and ingenious surgeons, who do not dissemble the disadvantage and uncertainty of this practice. He speaks of one failure, which occurred to Mr. Abernethy himself. But, I entertain doubts how far any infer- ence against the method can be drawn from Monteggia's instance, in which a ligature of reserve had been used. Nor can I un- derstand, how a circumstance, which Scar- pa strongly insists upon, can be well found- ed, I mean, the danger of the ligature be- ing forced off the mouth of the artery bv the impulse of the blood. Any risk of this kind cannot exist if the ligature be duly ap- plied, as Dr. Jones hasjpartiaularly explained; and, at all events, how can it be greater here, than after amputation, where it is not usually made a subject of complaint ? In- deed, the several examples of secondary hemorrhage, after this method, quoted by Scarpa from the practice of Monteggia, Morigi, and Assalini, may be more ration- ally imputed either to reserve ligatures hav- ing been also used, or the common fear in Italy of applying the ligatures tightly ; in which event, one can readily suppose, that the ligature might really slip, or by remaining a long time on the vessel might give rise to dangerous ulceration. Thus, Morigi speaks of one case, in which the bleeding occurred on the nineteenth day. (Scarpa on Aneurism, p. 14, Ed. 2.) On the wbole, I am disposed to believe, that when this method has been executed precisely ac- cording to Mr. Abernethy's directions, it has not often failed ; and I am acquainted with only one case in London, in which it was followed by secondary hemorrhage. How- ever,inthe year 1807, Mr. Norman, of Bath, tied the femoral artery with two ligatures, and divided the vessel between them ; the upper ligature came away on the sixteenth day after the operation ; the lower one on the fifteenth ; and the following day a pro- fuse hemorrhage came on, the patient losing a pound of blood. Pressure with a com- press and wet bandage was continued for some time, and the wound healed. (See Med. Chir. Trans. Vol 10, p. 123.) This is the only case of secondary hemorrhage, which he has met with after operating for aneurisms. Scarpa very properly urges, that the ap- plication of two ligatures, and dividing the artery in the interspace, can never be an eligible mode, where the smallness of the space, the depth of the artery, and the im- portance of the surrounding parts, do not permit the vessel to be separated .and insn- lated to such an extent, as is renuired for dividing it, with a probability of the divi- sion of it being sufficiently distant from the two ligatures. Such, for example, are the eases of ligature of the carotid in the vicinitv of the stern.im ; of the iliac, above Poupart's ligament; of the internal iliac, a little below its origin from the common iliac; of the axillary artery between the point of the coracoid process and the acromial portion of the clavicle: or of the subclavian in its passage between the sca- leni muscles. Scarpa then comments oi the difficulty and even impossibility of hi- king up the end of the truncated artery again in many situations, were hemorrhage to ensue; and he joins Mr. Hodgson in thinking the advantages of the method, even where it is practicable, by no means demonstrated. Nay, he goes further; for he agrees with Heister, Callisen, and Rich- ter in setting it down as worse than useless, on account of the portion of the artery between the ligatures being converted intij a dead and putrid substance, which rest'up- on the bottom of the wound, from which it aannot be removed, until the two ligatures are separated. Here, deeply impressed with the truth of principles, which perhaps he has rather lost sight of in speaking of hit own particular method, he comments on the little probability of the wound uniting, underthe disadvantage of twoligatureslian»- ing out of it, and of sloughs at its bottom. He argues correctly, that the laying hare, and insulating a large portion of artery, would often beobjectiorlable on the ground, that it could not be done, without the sur- geon being obliged to apply the principal ligature too near the origin of a large late- ral branch ; as, for example, would be the case in a case of inguinal aneurism, situa- ted an inch and a quarter below the origin of the profunda. Thus, a coagulum could not be formed, and the artery would be in danger of not being closed. On the con- trary, by employing only a single ligature at an inch and a quarter below the origin of the profunda, the operation would be equally simple and successful. (Scarpa^ Aneurism, p. 19—21, Ed. 2.) ~J The frequent occurrence of accidents•>' terthe introduction of Mr. Hunter's opera- tion, however, might have been ascribed to more probable causes, than the condi- tion of an undivided artery, upon which the ligature was applied. The employment of numerous ligatures gradually tightened, or the introduction of extraneous bodies into the wound, were alone sufficient to pro-.. duce ulceration of the artery: and suesH practices were adopted in most of taltv, cases, in which secondary hemorrhage toeriv place. ° „ After the reasons, which have been urged against the plan of tying the artery with two ligatures, and dividing it in the interspace.it may appear superfluous to notice a modifi- cation of thi.v practice, inten(|P,i .,,. a g^gp ANEURISM. 1*1 nty against the slipping of the ligature. But, as the proposal has had the approba- tion of some men of eminence, and I heard of an instance in which it was practised not long'ago, the subject may still be worthy of notice. Mr. A. Cooper has published a case of popliteal aneurism, in which the femoral artery had been tied with two ligatures, as firmly as could be done without risk of cutting it through. " But (says this gentle- man) as I was proceeding to dress the wound, 1 saw a stream of blood issuing from the artery, and when the blood was sponged away, one of the ligatures was found detached from the vessel. Soon after the other was also forced off, and thus the divided femoral artery was left without a lig- ature, and unless immediate assistance had been afforded him, the patient must have perished under hemorrhage." The same kind of accident has occurred in Mr. Cline's practice. These events naturally induced Mr. A. Cooper to reflect on the means, which were to be employed to obviate them, and the first which suggested itself was to include a larger portion of the artery between the two ligatures. But this plan was given up when it was recollected, that many branches of arteries must be divided, and that it was a mode of security which could only apply to particular cases of aneurism, since in some situations of that disease, there is scarcely any length of vessel be- tween the tumour and principal anastomo- sing branch of the artery. Mr. A. Cooper thinks, that a plan of greater security, and more general appli- cation, consists in conveying the ligatures, by means of two blunt needles, under the artery, an inch asunder, and close to the coats of the vessel, excluding the vein and nerve, but passing the threads through the cellular membrane surrounding the artery. When these are tied, and the artery is divi- ded between them, the ligatures will be prevented from slipping from the artery by the cellular membrane through which they are passed. Mr. \. Codper next relates a case of aneurism after bleeding, which he cured by this way of operating. " But although this plan, as to the event, answered my expectations, yet a different mode of securing the ligature, suggested to me by my young friend Mr. H. Cline, struck me so forcibly for its simplicity and secu- rity, that I felt immediately disposed to adopt it. Mr. A. Cooper put the new plan fo the test of experiment in operating for a popli- teal aneurism on Henry Figg, aged 29. i" An incision being made on the middle of the inner part of the thigh, and the femoral artery exposed, the artery was separated from the vein and nerve, and all the sur- rounding parts, to the extent of an inch, an eye-probe, armed with a double ligature having a curved needle at each end, was conveyed under the artery, and the probe cutaway. The ligature nearest the groin was first tied ; the other was separated an inch from the first and also tied. Then the needles were passed through the coats of the artery, close to the ligatures between them, and the ends of each thread were again tied over the knots, made in fasten- ing the first circular application of the lig- atures. Thus, a barrier was formed, be- yond which the ligature could not pass." The event of this operation was successful. (Med. and Phys. Journ. Vol. 8.) Upon the foregoing proposal a few ob- servations are necessary; and these I shall offer with due deference to the emi- nent surgeon, whose fame alone has attach- ed undue importance to the innovation. It appears to have been mentioned by Dionis, and to have been noticed by some subsequent writers. In the 13th chapter, on hemorrhage, in Richter's Anfangsgrunde der Wundarzneykunst, we read the following passage* " The artery, when drawn out, is to be twice surrounded with the common liga- ture. This is to be tied in a knot, and when the artery is large, one end of the ligature is to be passed, by means of a needle, through the vessel before the knot, then both ends are to be tied together, and left hanging out of the wound, as in the or- dinary way." Ed. 3.1799. What power can possibly force the liga- ture, when tied with due tightness, off the extremity of the vessel ? No action of the heart, or artery itself, no turgid state of this vessel, could do so. If a piece of string were tied round any tube for the purpose of preventing a fluid from escaping from its mouth, provided the string were applied with due tightness, and the knot in such a manner as not to yield, no fluid could pos- sibly escape, however great the propelling power might be, provided the string and structure of the tube did not break. And, if a ligature were applied so slackly as to slip, who can doubt, that hemorrhage would still follow, even though the ligature were carried through the end of the vessel, and tied in the foregoing way? Where ligatures have slipped off, very soon after being applied, I conclude* that the arteries either could not have been tied with sufficient tightness, perhaps through an unfounded fear of the ligature cutting its way completely through all the coats of an artery, or else that the knot, or noose became slack, from causes, which will be understood by considering, what is said'on this matter in the article Hemorrhage. The inner coats of the artery, we know, from the experiments of Dr. Jones, ought to be cut through when the artery is pro- perly tied, because the circumstance is always useful in promoting the effusion of lymph, within the vessel, and the pro- cess of obliteration by the adhesive inflam- mation . The preceding method is so contrary to the grand principle of always avoiding the detachment of the artery from its surround- ing connexions, and is so inconsistent with VNELRl^M- the wise maxim of doing the operation with as little disturbance of the vessel as possi- ble, that it is not surprising that it should have met with only a small number of fol- lowers. In fact, it is not only liable to every objection which can be urged against the double ligature and division of the artery, as formely proposed by Celsus, and a few of tbe moderns, but, on account of its greater tediousness, more extensive se- paration and destruction of the vessel, and other reasons, is still less worthy of imita- tion. With respect to ligatures of reserve, the interposition of agaric, cork, and other hard substances between the knot and the artery, these contrivances are now so fully reject- ed by all good surgeons, for reasons which will be quite intelligible, after the perusal of another part of this work, (See Hemorrhage,) that I shall not at present detain the reader with animadversions on their danger. As for several kinds of metallic compressors, intended to be applied to the exposed ar- tery, for the purpose of rendering it im- pervious, they are inventions which have been made and extolled by some surgeons of high repute, whose names would give importance even to a less meritorious pro- position. Dubois conceived, that hemorrhage might sometimes proceed from the circumstance of a ligature making its way too fast through the artery. He thought, also, that the sud- den stoppage of the current of blood by a tight ligature might bring on gangrene of the limb, particularly, where the aneurism was not of long standing, so that the colla- teral branches had not had time to enlarge. Dubois, therefore, proposed a method of gradually stopping the flow of blood through the artery ; and, by this ingenious imitation of the process of nature, to promote the gradual dilatation of the collateral arteries, and obviate all risk of gangrene in the lower part of the limb. This gentleman put his plan in execution, and two instances of suc- cess are recorded. The cases were popli- teal aneurisms. A ligature was passed under the artery in the manner of Hunter; its two ends were then put through an in- strument, called a serre-nceud, with which the compression was gradually increased. It is stated, that, in one of these cases, the plan made the artery inflame and become impervious, in the course of the first night, so that on the following day the throbbing of the tumour had ceased. (Richerand, Nosogr. Chir. T. 4, p. 109, Edit. 4.) Here, however, it is to be suspected, that the pressure of the apparatus was greater, than was calculated ; and that the stoppage of the pulsation was more owing either to this cause, or to the coagulation of the blood, in the sac and adjoining portion of the artery, than to the process of obliteration, which could hardly have been so rapidly accom- plished. Assalini's compressor is on instrument, calculated, as its inventor "states, to produce an obliteration of tbe trunks of arteries. without dividing, or injuring their coats, fl is nothing more, than a small pair of silver forceps, the blades of which are broad tai flat at their extremities, between which 4a artery is compressed. A spring, composed of a piece of elastic steel, is attached to Wi inside of one of the handles, and by press- ing against the opposite handle, retains the flat ends of the blades in contact1 This spring is intended to be very weak in its operation ; but, by means of a screw, which passes through the handles, the pressure ad« mits of being regulated and increased at the option of the surgeon. A representation of Assalini's compressor may be seen in his Manuale di Chirurgia, parte Prima, p. 113. In the same book, or, in my friend Mr. Hodgson's valuable Trea- tise on the Diseases of Arteries and Veins, which every practical surgeon ought to possess, a case may be perused, in which this instrument was successfully^employed by Professor Monteggia, and withdrawn en- tirely, as early as sixty hours after its appli- cation. This last distinguished surgeon also used the compressor in an example, in which the femoral artery was wounded, and bled in an alarming degree. After forty hours, the pressure was lessened, and, in four hours more, as not a drop of blood is- sued from the vessel, and there seemed to be no good in leaving an extraneous body in the wound any longer, the instrument was taken out altogether. (See AsiaM't Manuale di Chirurgta, p. 110.) When Assalini was in England,heat quainted Mr. Hodgson, that, in two cases of popliteal aneurism, in which he had himself employed this means of obliterating the fe- moral artery, the instrument was removed at the expiration of twenty-four hours; no pulsation returned in the tumours; and the patients were speedily cured. With respect to the particular merit of this invention, it certainly possesses tbe recommendationTof ingenuity; but,it ope- rates much in the snme manner, as several other mechanical contrivances, the sent- nceud of Desault, the presse-artire of Des- champs, that of Mr. Crampton, (See -tferf- Chir Trans. Vol. 7.) the pincers of Baron Percy, &.c. If there be a real advantage in the division of the internal coats of aB artery by the ligatnre, as the experiments of Jones seem to prove, and as many of At bestsurgeons in this country inculcate, (8e« Hemorrhage and Ligature,) then the eoa- pressor cannot bean eligible means of obli- terating an artery. It maybe said,how- ever, that experience has proved its effica- cy ; but, let it be recollected, that almost every method of operating for aneurisms has sometimes answered. Further eif* rience is requisite to determine, whether Assalini's compressor would succeed « often as, or more frequently than, tbe »• entific application of the right kind of lip tures (See Ligature) which may pe*af* seem slower in their effect, only been* they are not in general removed as early« Assalini's instrument. In fact, the c*f*T' ANEURISM. IM wrents of Mr. Travers have now proved, currence happened from the division of thr that the ligature is the quickest in its ope- inner coats of the artery, though Mr. War- ration. (See Med. Chir. Trans. Vol. 6, p. ner himself suspected, with more probabi- g^3 i,c \ lity, that it proceeded from a diseased state In 1816, some ingenious observations of the vessel. Besides, this event, be it were published by Mr. Crampton, on the produced in whatever manner it may, is so effects of the ligature and of compression rare, that I only know of three examples of in obliterating arteries. The purport of it on record, and have never known it occur his remarks is to prove, like the later obser- during the last 23 years, that I have been in vations of Scarpa ; 1st, That the oblitera- the constant habit of seeing numerous ope- tionof an artery can very certainly be effect- rations performed. In Mr. Warner's time, ed, independently of the rupture, or such large ligatures were also in use, that it division of any of its coats; 2dly, That appears to me, they were more likely merely this operation of the ligature, so far from to press the sides of the artery together, being essential to the process, not unfre- like Mr.Cramplon'sprewe-ar'er-e, than effect quently defeats it. (See Med. Chir. Trans, a complete division of the inner coats of Vol. 7, p. 344,345.) the vessel, as is accomplished by the small With respect to the first of these asser- ligatures in modern use. lions, I presume that all practical surgeons Those metallic instruments, intended have known and admitted it, especially, if to be applied directly to an exposed artery. the words very certainly he left out. Every for the purpose of obliterating it by corn- system of surgery, for half a century past, pression, are liable, as Scarpa remarks, to has recorded the occasional cureofaneu- all the inconveniences, which are insepara- rism by different modes of compression, by ble from the presence of hard bodies, intro- wbich the adhesive inflammation is excited duced, and kept for several days in the bot- in the artery, or the coagulation of the torn of a wound ; especially when this i< blood in the aneurismal sac brought about, recent, in which case, they cannot be rc- As, however, the most experienced sur- tained in a proper direction without diffi- geons have found the method less certain culty, or exactly at such a depth, as will than the use of the ligature, it is not re- not be attended with hurtful pressure upon presented by any modern writers, as deser- the wound itself, and important parts in its ving equal confidence ; though there are vicinity. And, with regard to the forceps circumstances, in which simple pressure of Assalini, Monteggia has observed, " if may be sometimes tried, with a hope of the obliteration of the artery is retarded, the doing away all occasion for an operation, forceps equally divides the artery by causing The cases, however, in which compression the death of the included portion. I also saw, is applied directly to the artery itself by in one case, the extremity of the instrument means of ligatures, with the intervention of resting at the boltomfof the wound on the subja- other substances, as advised by Scarpa, &tc. cent femoral vein, rupture its anterior half or by various contrivances, like those of also, although we were sure il had not been the serre-ncflud, the presse-artere, and Assa- included by it." (Institue. di Chir. Ed. 2, T. Uni's forceps, all require the exposure of 2.) And although Cumano, in a case of the artery; and if commendable, therefore, popliteal aneurism, obtained on the fourth cannot be so on the principle of saving the day, the closure of the femoral artery, by patient the pain ofan operation, but because means of Assalini's forceps, he does not they are more effectual than the employ- conceal that the cure of the wound was ment of the ligature. This last point re- rather difficult; and in comparing the liga- mains to be proved- From the compare- ture with the forceps, he adds his belief, tively small number of instances, in which that if an equal result is derived from both, the preceding modes of compression have the preference will be given to the ligature, been practised, I could quote several exam- unless the other instrument be brought to pies of failure, were it necessary. such perfection that the inconveniences will With regard to Mr. Crampton's second be removed, from which he found ic not ex- assertion, that the division of the inner empt, though the operation succeeded. coats of the vessel, so far from being essen- (Annali di Med. del Dottore Omodei, Settem- tial to the process of obliteration, not un- tVe 1807. p. 309, and Scarpa on Aneurism, frequently defeats it, I think the last part of p. 45, Ed. 2.) Some experiments were a the observation is altogether unproved. We few years ago instituted by Mr. Travers, in must admit, that the division of the inner order to determine the merit of Assalini's coats is not essential, because arteries some- forceps, compared with the ligature: and times become obliterated under a variety of his conclusion from the facts elucidated in circumstances, in which such division is not the investigation is, that the ligature is a made; but still, the great question remains, more powerful means for affecting the obli- whether it renders the processmore certain, teration of the tube ofan artery. (See Mr. Crampton founds his conclusion, that it Med. Chir. Trans. Vol. 6, p. 643, fa.) not unfrequently prevents tbe obliteration, My friend, Mr. Lawrence, a few years and gives rise to secondary hemorrhage, ago, extended to operations for aneurism upon a few very uncommon cases,in which the method of tying the artery with a very aneurismal swellings have taken place small firm silk ligature, the whole of which above the ligature. (See Warner's Case, p. is immediately afterwards cut off, with the 123 of this Dictionary.) Here Mr. Cramp- exception of the noose and knot, and an ton presumes, without proof, that the oc- endeavour then made to heal the. wound itVi aNEUUKW. by the first intention. In a case of popli- teal aneurism, Mr. Carwardine,late of Tbax- ted, tied the femoral artery in this manner, and the wound united entirely by the first intention, not a particle of pus having been formed at any time ; and the part continued perfectly sound at the distance of some months from the operation. On the 29th of March, 1817, 1 saw Mr. Lawrence try tbe practice in a similar case : with the ex- ception of the integuments, the wound uni- ted by adhesion. However it continued to discbarge a small quantity of matter till the end of May, when the ligature came away, and it healed firmly. In an aneurism of the humeral artery, Mr. R. Watson, of Stour- port, Worcestershire, tied that vessel and cut off the ends of the ligature, as proposed by Mr. Lawrence. The operation was done on the 2d of March, and the wound was quite healed by the 10th of April. On the 3d of May, a small tubercle which had been felt under the skin, in the centre of the ci- catrix, appeared above the skin, and proved to be the knot of the ligature. There was no inflammation or discharge; but, the ring of the ligature was firmly impacted in the centre of the cicatrix. In about a week from this time, the whole of it was expelled. In another case, where Mr. Hodgson tied the ulnar artery, and cut off the ends of the small ligature, the skin healed over the ves- sel, but a firm almost cartilaginous knot gra- dually formed, from the centre of which the bit of ligature was extracted five or six months afterwards by a small puncture. For additional observations on this part of the subject, See Med. Chir. Trans. Vol. 8, p. 490, fa. Mr. Carwardine's case is a strong one in favour of this method : but, I am not aware, that sufficiently numerous trials of it have been made to enable one to form a correct estimate of its merits. With the exception of the example communicated by Mr. Car- wardine to Mr. Lawrence, I apprehend, that, on the whole, the cures on record can- not be said to have been completed sooner, than generally occurs in other instances, in which one end of the small circular ligature is left for the removal of the noose. Thus, in two cases, where the practice was tried by Mr. Norman, of Bath, the results were by no means encouraging. Jn one of these in- stances, a part of the wound appeared to have united by the first intention, but matter afterwards formed, and it was a considerable time before the ulcer healed. The ligature was never seen to come away ; but from the circumstance of the suppuration, Mr. Norman apprehends, that it must have been voided. In a second example, the attempt to procure a permanent adhesion of the parts over the ligature did not succeed; a long and troublesome suppuration ensued, and the wound was not healed till tbe latter end of April, though the operation was done on the 7thof March, (Norman, in Med. Chir. Trans. Vol. 10, p. ,120—121.) As catgut, however, was employed for the »ligatures in these two operations, I do not know, that it is fair to consider the method exactly as that recommended by my friend mc. Uk rence, who particularly directs very saanO) ligatures of dentist's silk to be used. But, besides the diflerent material employed, wi are left uninformed of the thickness of th« catgut; and, in this respect also there would probably be no greater similarity between the ligatures of these gentlemen, than there is in regard to the substanees, of which such ligatures were made. In favour of catgut, as a ligature, when the ends of it are to be cut off, a case-published by Mr. A Cooper deserves particular notice. The wound was found completely united ontha fourth day after the operation, notwith- standing the patient was eighty years of age The catgut, previously to its application, was softened in warm water. The recovery was complete; a fact, strongly proving the propriety of not rejecting an operation on account of age, if no other objections ei- ist. (See Surgical Essays, pari 1, p. 126.) Alluding, however, to silk ligatures, if we take into the account the little ulcerations, suppurations, and hard knots, which oc- curred even after their use in this manner, I fear, that, though these complaints might be attended with no severe inconvenience, they will deter many surgeons from adopt- ing the innovation ; unless it can be proved that these inconveniences, slight as they were, were counterbalanced by the quicker healing of the incision, or some other de- cided benefit. As a mode, attended with the least possible risk of being followed by secondary hemorrhage, however, I consi- der it inferior to no practice, which has yet been suggested ; nor do I know of any se- rious objections to it in any point of view, provided exactly such ligatures are used as Mr. Lawrence recommends. In cases of aneurism, a single small liga- ture, composed of dentist's silk, inkle, or twine, is now usually preferred by the ma- jority of the best surgeons in England; but, as the right qualities of ligatnree aw elsewhere considered, (See Hemorrhagemi Ligature) I need not here dwell upoi the subject. It is not meant to assert, that the use of a single ligature is never followed by secondary hemorrhage ; for this would be untrue. The accident I believe will some- times happen after this, or any other mode, under certain circumstances, and in unfa- vourable subjects. A fact of this kind we find recorded, which happened in the practice of a truly eminent and experienced surgeon ; (See A. Burns on Diseases of'#« Heart, p. 230;) but, from the inquiries, which I have made, it appears to me proved, that, emleris paribus, a single small ligausni, applied with as little disturbance and detach- ment of the artery as possible, will be more rarely followed by secondary hemorrkajjer abscesses, sinuses, he. than any ottat* known method. Thus, in the several cases, reported by Mr. Norman, the singleligatore was never followed by any of those incon- veniences, whicb, be justly thinks, will be rarer after this practice, than any other, it the artery be not removed from *' situation, or more detached, it,*- th» Ii* AM'.lTilSM. lure separates it." (See Med. Chir. Trans. lot. 10,;/. 123.) b Before entering into the consideration of particular aneurisms, I wish to mention a few other circumstances, worthy the atten- tion of every practical surgeon. The first is the partial entrance of blood into the aneurismal sac, after the artery has been tied at some distance from the tumour. This fact was first particularly pointed out, and its reasons explained by Sir E. Home, who published three examples of its occurrence. (See Tran. of a Soc. for the improvemeid of Med. and Chir. Knowledge, vol. 1, p. 173, fy vol. 2, p. 239.) But, the circumstance had never, I believe, been considered with due attention, until Mr. Hodgson made it one of the subjects of his reflections in his valuable treatise. " When an artery is tied close to an aneu- rismal sac, the ingress of blood into the lat- ter is in most instances prevented; the coagulum, which it contains, is absorbed, and the membranes of which the sac is composed, gradually contract, until its ca- vity is permanently obliterated. But, when the artery is tied at a distance from the dis- ease, the ingress of blood into the latter is not altogether prevented ; for, the anasto- mosing branches, which open intb the trunk, below the seat of the ligature, convey a stream, which passes through the aneurism. The impulse of this current, however, is so trifling, that the enlargement of the sac not only ceases, but the deposition of coagulum in it increases, in consequence of the lan- guid state of the circulation. The coagu- lum accumulates, until the cavity, of the sac, and the mouth of the artery leading in- to it, are obliterated," kc. (See Hodgson on the Diseases of Arteries, p. 266.) This fact, which is of great importance, both in a practical and pathological point of view, is proved, (says this gentleman,) 1st, by the occasional recurrence of pulsation in the tumour after the operation ; 2dly, by cases in which the cavity of the sac has been exposed, and hemorrhage has been the consequence ; and 3dly, by dissection, in which it has been found, that the cavity of the aneurism, as well as that of the ar- tery, from which it originated, was pervious, from the part which was obliterated by the direct^operation of the ligature. For a detail of the facts relative to this interesting point, the reader is referred to Mr. Hodgson's valuable publication (P 267, et. seq.) v ' Some very uncommon instances are re- corded, in which the return or continuance ot pulsation in the tumour is said to have prevented the cure ; the aneurismal sac ha- ving begun to enlarge again. The two rases of this kind, however, which hap- pened in the practice of Pott and Guerin (,lr.au-<>f a Sof for the Imp. of Med. 1 T K,TvV°oL l,P' m>* Journ. di la Soc. de Santf, No. 3, p. 197.) cannot be well de- pended upon.asit may be doubted, whether the artery had really been tied. Some bet- ter established facts, relating to this part of 165 the subject, have been very igcently pub lished. One is a case by Dr." Monteath, jun. of Glasgow, which is very remarkable ; as the disease, viz. a popliteal aneurism, re- curred nine months after the femoral artery had been unequivocally tied in the upper third of the thigh. On the 27th of Febru- ary, 1819, this gentleman performed the operation, using a single ligature, the pulsa- tion of the tumour in the ham instantly ceased ; and the wound healed by the first intention, except where the ligature was situated, which came away on the thirtieth day. By thistime,thetumourwasdiminished to|one half of its original size, and, in two months more, only a hard knot was percept tible, in which no pulsation whatever could be felt. After the considerable lapse of time, above specified, the patient informed Dr. Monteath, that the tumour had reap- peared, being rather larger than a plum. The pulsation in it was distinct, though not so strong as an ordinary aneurism. As the size of the swelling, and strength of the pulsation, increased gradually, a compress and bandage were applied, without confine- ment ; but, as this treatment was ineffectual, the patient was afterwards kept in bed, bled, and put on a spare diet. A thick compress was placed over the tumour, and, the limb was firmly bandaged from the toes to the groin. A trial of this plan for three days not having produced any benefit, a tight tourniquet was applied over the tu- mour ; butthe pain was such in half an hour, that the instrument was taken off, from which moment no pulsation was felt. Next day the tumour not only did not throb, but had a firm feel ; and, the bandage being continued, the cure was gradually comple- ted. Had the disease not yielded to these means, Dr. Monteath meant to have tied the inguinal, or external iliac artery, with he view of cutting off the supply of blood to the sac,through the anastomosingbranch- 510— oPa on ^"e"™»» by Wishart, p. k ^J6 !:Txfernal iliac artery was taken up by Mr. Norman, of Bath, for the cure of an mguinal aneurism, and when the collateral cii-culation was fully established a few days alter the operation, the tumour was again supplied with blood in sufficient quantity to produce a distinct pulsation ; « a fact, (says Mr. Norman) of practical importance as it shows, that though the ligature on the Imc artery stops the direct influx of blood nto the tumour, and is the means, by which he disease is cured, yet that there ex- sts a necessity for employing strict rest, the antiphlogistic regimen, and in some cases, the abstraction of blood, to assist na- ture in her operation of obliterating the aneurism." And, in another instance, after the same gentleman bad tied the femoral artery for the cure of popliteal aneurism, the tumour, afterwards recurred in such a whffinS^"1"011 d°ubt was ^tertained hi itulJ dlSCaSe ^UJd have bee« cured by «he ligature, on the femoral arterv, had ;66 ANEURISM not continued and rather powerful pres- sure been adopted (Med. Chir. Tran. Vol. 10,p.99, 118, fyc.) M. Roux, in a late work, has offered some criticisms on the English method of operating for aneurisms. It would hardly be fair play to endeavour to offer a serious refutation of them, because when he wrote, it was his misfortune not to he duly informed of all the facts and experiments recorded in the inestimable treatise on hemorrhage byjhe late Dr. Jones. " Still less confi- dent, than we are (says Roux,) in the treat- ment by compression, and in the use of to- pical remedies for the cure of external aneurisms, the English surgeons have im- mediate recourse to the operation with the ligature. Hunter's method is that which they universally practise. They will not even allow, that there are any cases, in which the operation by opening the sac should be preferred, he. And it is singu- lar, the very same motive, which would incline us in some cases of aneurisms, pro- perly so called, to adopt the operation of opening the sac, is alleged by the English surgeons as a circumstance in favour of the Hunterian method. Let us suppose an aneu- rism so formed, that near the centre of the tumour, or rather near the opening, by which the artery communicates with the swelling, are situated the orifices of the col- laterial arteries, which would be useful for the re-establishment of the circulation. Here, it is clear, that in practising the operation by the Hunterian method, that is to say, in tying tbe artery above the tumour, the last ramifications are not indeed sacrificed; but the orifices and first branches of these col- laterial arteries. Let there be, for example, at the upper part of the femoral artery an aneurism, which, though formed originally below the origin of the profunda, now ex- tends above it. Here it is manifest that, in tying the femoral artery above the swelling, we should lose the important resource of the profunda for re-establishing the circulation in the lower part of the limb. The desire and hope of saving the profunda would, in such a case, make us adopt the operation of opening the sac, in preference to the Hun- terian method; and Scarpahimself,so great an advocate for this last mode, Scarpa, who seems only to fhave composed his work to cry up this method, makes an exception of the case, which I have just been supposing. The English surgeons, on the contrary, would urge the following objection to the operation by opening the sac in this, and other analogous examples. They contend, that the Jigatnres would be applied too near to the origin of the collateral arteries, which are to receive the blood after the operation. They are prepossessed with the idea, that, when an arterial trunk is tied at a given point, the too great proximity of the principal collateral arteries disposes to subsequent hemorrhage ; kc." (p. 256,257.) a circumstance, which M. Roux, seems to doubt. Now, before attemptins to reply to these observations, we ought to know what eiaw distance Roux means, when he speaks of thelprofunda, or a large collateral artery, originating near the opening by which the aneurism communicates with the main u- tery. Here he is not at all precise ; and were he to tie the femoral artery immedi*. tely below the point, where the profundi arises, he would expose his patient to great danger of bleeding. I say this, well aware of the case which he has adduced to prow the contrary. In the example brought for- ward, he applied several ligatures: (p. 260.) some of which were the ligatures datitntt, or loose ligatures left ready to be tightened in case of need. These were of course higher up, than the ligature, which wn tightened. It is therefore impossible, that this last could have been close to the origin of the profunda. There must have beta room left for the application of tbe ligatum d'attente ; and be it also recollected, that the French still persist in the use of huge flat cords, and not small firm round ligature*, which are now found to be most advan- tageous. (See Hemorrhage.) In this part of the dictionary, we shall find, that tbe nearness of a collateral vessel impedes the formation of the internal coagulum, which has a material share in the process by whieh the artery is closed. With respect to the circumstance of hemor- rhage being raorelikely to follow, when the ligature is placed close below, than at some distance from a great collateral artery,there cannot be a doubt of the fact. Boux,wbea in London, saw an occurrence of this kind himself, and has published it in his book, ft was a case, in which Mr. A. Coopertiedthe external iliac artery ; but the patient died of hemorrhage a fortnight afterwards, aid on opening the body, it was ascertained! that the obturator artery, which usually ari- ses either from the trunk of the internal iliac, or from the epigastric, proceeded from the external iliac, and arose immediately above the point, to which the ligature wfc applied. (See ParalUle de la Chir. M- gloise avec la Chir. Francoise, fa. fl. 27B, 279.) From a preparation, spoken of by Mr. Travers, and some experiments made by the same gentleman, it would appear, thatthe presence of a collateral branch hinders tbe formation of the internal coagulum, and will pot always prevent the closure of the vessel by the adhesive inflammation, la the preparation referred to, a ligature tffc applied to the external iliac, betweea tk epigastric and circumflex iliac arteries, " and having been in contact with the former at the angle which it makes at * origin from the iliac, ulceration had take* place, and the bleeding had proved fatal I here was no coagulum formed in tat ^ trunk, though the operation had been per- formed several days, the circulation throat* the epigastric having continued. But * lymph-plug at the seat of the ligature o* * iliac artery was complete." Med Chir. Tr** ANEtfRISM, 167 V*L 6, p. 656.) Indeed, it must be allow- ed, with this gentleman, thatthe fluidity of the blood does not prevent the adhesive pro- cess, a fact, which, he observes, is also proved in tbe indirect obstruction of a ves- sel, by means of a temporary ligature or compressor. When, therefore, the vicinity of a Lrge branch to the ligature is spoken of as a circumstance conducive to seconda- ry hemorrhage, I mean, that it is so inasmuch as the internal coagulum is regarded as use- ful in promoting the closure of the vessel, and its formation is prevented. Brasdor first, and afterwards the celebra- ted Desault conceived, that, when an aneu- rism was so situated, that a ligature could not be applied to the artery leading to the swelling, a cure might possibly arise from tying tbe vessel, on that side of the tumour, which was most remote from the heart. Desault conjectured, that by this means, the circulation through the sac would be stopped, the blood in it would coagulate, that the circulation would go on by the collateral arteries, and that the tumour would be finally absorbed. These specu- lations, however, were not found to answer in practice. Deschamps tied the femoral ortery below an inguinal aneurism ; but the progress of the disease, instead of being checked, seemed to be accelerated by this novel experiment. The operator was obli- ged, as a last resource, to open the tumour, and try to take up the vessel. In this at- tempt, the patient lost a large quantity of blood, and died eight hours afterwards. (See OSuvres Chir. de Desault par Bichat, Tom. 2,p. 563, and RecueilPiriodique dela Societe de Midecine de Paris, Tom.b. JVo.J17.) The operation of tying the artery below the tumour was some time ago repeated by Mr. A. Cooper, not for an aneurism of the femoral artery in the groin, but for an aneu- rism of the external iliac, where tying the artery above the swelling was impractica- ble. The femoral artery was therefore tied immediately below Poupart's ligament, be- tween the origins of the epigastric and the profunda. The pulsations of the tumour continued ; but, the progress of tbe disease was checked. After a time, indeed, the swellingdecreased, and this in so considera- ble a manner, that hopes began to be enter- tained, that perhaps the external iliac artery might soon admit of being tied above the disease. The ligatures came away without any ufavourable occurrence, and when the wound was healed, the patient was sent into the country for the benefit of the change of air. The tumour, however, gave way, an extravasation of blood took place in the abdomen and cellular membrane of the pel- vis, and the patient died. Mr. A. Cooper hud no opportunity of seeing the case, and the body could not be opened, so that fur- ther particulars were not obtained. The memorable instance, in which this gentleman tied the aorta, in a case of ingui- nal aneurism, extending very high up, and already burst, I shall notice under the head Aorta. I shall finish these general observations on the treatment of eiternal aneurisms, or such as admit more particularly of surgical treatment, with observing, that, in England, surgeons now lose few patients either from gangrene of the limb or secondary hemor- rhage ; and this notwithstanding they may sometimes prefer applying a ligature above the profunda to cutting open the aneurismal tumour. I firmly believe, that such match- less success is to be totally ascribed to the perfections in their mode of operating; the choice of a proper kind fof ligature ; the right plan of applying it; the rejection of the employment of several ligatures at a time; and the great care which istaken to pro- mote the healing of the wound, as quickly as possible ; the avoidance of ail unneces- sary and hurtful extraneous substances in the wound ; and above all, the relinquish- ment of the formidable proceeding of cut- ting open the tumour. In the consideration of particular aneu- risms, I shall begin with those which may be cured by a surgical operation; and, here we shall be fully satisfied, that, " I'art de guirir ne triomphe jamais plus heureuse- ment que; lorsqu'il peut employer la midecine efficace, e'est a dire, les moyens chirurgicaux ouoperatoires." (Clinique Chirurgicale, Tom. 1, p. 110.) OF THE POPLITEAL ANEURISM, AND OPERATION FOR ITS CURE. Notwithstanding the solitary example in which M. A. Severinus, early in the 17th century, tied the ^femoral artery near Pou- part's ligament in a case of aneurism, (De Efficac. Med. Lib. 1, p. 2. e. 51,) the prac- tice of tying arteries, wounded either by accident or in the performance of surgical operations, and even the plan of tying the humeral artery for the cure of the aneu- rism at the bend of the arm, were known long before the operation for the relief of the popliteal aneurism was attempted. The considerable size of the femoral artery ; its deep situation, the urgent symptoms of the disease, and ignorance of the resources of nature for transmitting blood into the limb, after the ligature of the vessel, are the cir- cumstances, which appear to have deterred former surgeons from this operation. Valsalva treated popliteal aneurisms on the debilitating method, and published one or two equivocal proofs of its success. In Pelletan's first memoir on aneurism, and in the third vol. of Sabatier's Medecine Ope- ratoire, as I shall hereafter notice again, are two cases of axillary aneurisms, which were cured by Valsalva's treatment. But, encouraging as such examples may be, ex- perience is not yet sufficiently favourable to this practice to allow it to bear a compa- rison, in point of efficacy, with the surgical operation, or to justify the general rejec- tion of this last more certain means of cure. As Pelletan admits, Valsalva's treatment is extremely severe; the event of it doubtful; i#S ANF.LTUSM and should the plan fail, the patient might not be left in a condition to bear an opera- tion, for the success of which it seems ne- cessary, that a certain strength of vascular action should exist, in order that the blood may be freely transmitted through such ar- terial branches, as are to supply the places of the main trunk, after this last has been tied. The time, therefore, has not yet arrived, when surgical operations for the relief of aneurisms should be relinquished. (Pelle- tan, Clinique Chirurgicale, T. 1. p. 114.) The cure of popliteal aneurisms by means of compression is occasionally ef- fected ; but, it happens too seldom to claim a great deal of confidence, or to lessen in any material degree the utility and import- ance of operative surgery in this part of practice. Pelletan records the cure of one popliteal aneurism by compression and ab- solute repose, during eleven months (T- 1. p. 115,) Boyer relates two instances^Trails des Mai. Chir. p. 204, T. 2,) one is mention- ed by Richerand (Diet, des Sciences Med. T. 2, p. 96;) the practice of Dubois is said to have furnished several examples of the same success (Vfil. cit. p. 97 ;) and a case, in which Dupuytren effected a cure by com- pressing the femoral artery by means ofan instrument applied just above the place where the vessel perforates the tendon of the triceps muscle, is detailed by Breschet. (Fr. Transl. of Mr. Hodgson's work, T. l,n. 249, fa.) The circumstances, under which the em- ployment of compression affords the best chance of success, have been already men- tioned, as well as the prudence of assisting this plan with perfect quietude, venesec- tion, spare diet, ar J cold astringent applica- tions, especially ice, which was first re- commended by Donald Monro, and has subsequently been most highly praised by Guerin. Aneurisms in general, and, among them, the popliteal case, are all attended with some little chance of a spontaneous cure ; yet this desirable event is' too uncommon tobea judicious reason for postponing the opera- tion, especially, as it is the usual course of the disease to continue to increase 7 while m the early stage the cure may be more speedily accomplished. In fact, the expe- rience of modern operators leaves no room for apprehending, that the anastomoses will not suffice for the due nourishment of the leg and consequently proves, that waiting be- yond a certain time for the enlargement of the collateral vessels to take place is alto- gether an unnecessary and disadvantageous method. Popliteal aneurisms, as well as other external tumours of the same nature, stand the best chance of a spontaneous cure, when any cause induces a general, violent, and deep inflammation all over the swelling; for, then the communication be- tween the sac and artery is likely to become closed with coagulating lymph, and the pul- sation of the tamour to be suddenly and permanently stopped. If in this state, the disease sloughs, and the patient s ccn^dtu tion holds out, the coagulated blood in the sac and the sloughs, are" gradually de- tached, leaving a deep ulcer, which aft mately heals. An example, in which a pop. liteal aneurism was cured by such a process, is related in the Trans, of a Society fir th Improvement of Med. and'fihirurgieal Knot. ledge, Vol. 2, p. 268. In former times, when all hopes of curia; a popliteal aneurism by Valsalva's method, by compression, or a natural process, were at an end, amputation of the limb was consi- dered as the sole and necessary means of saving the patient's life. But, about fifty years ago, the confidence of surgeons hi the sufficiency of the anastomosing renab or the continuance of the circulation bwtj to increase, and, in opposition to the tench of J. L. Petit, and Pott, experience soon proved, that, in general, not only might the patient's life be saved, but his limb also, and this, without any operation, that could be compared with amputation, in regard to severity. On looking back to the history of amputation, we shall find, that A.N. Guenault was one of the earliest writers, who disapproved of amputation, asnottro- ly indispensable for the cure of popliteal aneurism. It is alleged, that Teislere, Molinelli, Guattani, Mazotti, and some other celebra- ted Italian surgeons, were the first, who ventured to tie the popliteal artery for the Cure of aneurism. The path, as Pelletan remarks, had been pointed out to them by Winslow and Haller, whose valuable des- criptions and plates of the arterial anasto- moses about the knee joint, showed by what means the lower part of the limb would be nourished, after a ligature had been planed on the principal arterial trunk. For almost thirty years, however, the practice of tying the popliteal artery was confined to the Italian surgeons. Pelletan believes, that he was the first, who attempted such an operation at Paris nearly thirty years a»i (alluding to about the year 1780, the <* nique Chirurgicale being dated 1810.) However, this operation of opening 41 tumour and tying the popliteal artery itself, was a severe and often a fatal proceeding, and does not admit of being compared with the Hunterian operation, in point either 0! simplicity, safety, or success, as I shall ei- plain, after the detail of a few particulars relating to the popliteal aneurism. On whatever side of the artery the tu- mour is produced, it can be plainly felt in the hollow between the hamstrings, and ht general its nature is as easily ascertained by the pulsation in every part of the tumour. Though the disease may not occur in the popliteal artery so often as in the aorta itself, it certainly is seen more frequently in the former vessel, than any other branch, which the aorta sends off. As Sir E. Home he* observed, this circumstance has never been satisfactorily explained ; and, what is rather ^rl»US'ln many recent instances of th* disease, the patients have been coachn*" AN-EKRIS-y f«iy uiu poauiiions. Morgagni found aneurisms «f the aorta most frequent in guides, post- boys, and other persons, who sit almost continually on horseback ; a fact, which he imputes to the concussion and agitation to which such persons are exposed. Some al- lusion to this subject has already been made in the foregoing pages. Whether an expla- nation of the frequency of popliteul aneu- risms can be correctly referred to the ob- struction, which the circulation iu the artery must experience, when the knee is iu a ^tate of flexion, may be questioned, though it is on a similar principle, that the great frequency of aneurisms of the curvature of the aorta is attempted to be solved. (Home in Trans, of a Society for the Improvement *f Med. and Chir. Knowledge, Vol. 1, fa, ind Monro in Ed. Med. Essays, Vol. 5.) Were this the only, or even the principal cause, surely one could have reason to ex- pect aneurisms to be at least as frequent in rhe axilla, and at tbe bend of the elbow, as in the ham. The popliteal aneurism was generally suppoied to arise from a weakness in the coats of the artery, independently of disease. If '.his were true, we might reasonably con- clude, that, except at the dilated part, the vessel would be sound. Then the old prac- tice of opening the sac, tying the artery above and below it, and leaving the bag to suppurate and heal up, would naturally present itself. Mr. Hunter, finding, that the arterial coats were altered in the struc- ture higher up, than the tumour, and that the artery, immediately above the sac, sel- dom united when tied ; but, that, when the ligature came away, the bleeding destroyed the patient ; concluded, that some disease affected the coats of the vessel, before the actual occurrence of the aneurism. Dissa- tisfied with Haller's experiments on frogs, showing that weakness alone could give rise to aneurism, he tried what would hap- pen in a quadruped, whose vessels were very similar in structure to the human. Having denuded above an inch of the caro- tid artery of a dog, and removed its external coat, he dissected oft' the other coats, layer after layer, till what retnaicad was so thin, that the blood could be seen through it. In about three weeks, the dog was killed, when the wound was found closed over the artery, which was neither increased nor diminished in size. It being conjectured, that the prevention of aneurism, perhaps, arose from the parts be- ing immediately laid down onthe weakened portion of the artery, Sir E. Home strippod off the outer layers of the femoral artery of a dog, placed lint over the exposed part of the vessel to keep it from uniting to the -ides of the wound, and, in six weeks, killed the animal, and injected the artery, which wum neither enlarged, nor diminished, its coats having regained their natural-thick- ness and appearance. These experiments strengthened Mr. Hun- ter's belief, that aneurismal arteries are dis- ced ; that the morbid afrri tion frcnuentiv Vnr.l .-..->' extends a good way from the sac along the vessels; and thatthe cause of failure in the old operation, arose from tying a diseased artery, which was incapable of uniting, before the ligature sepirated. These reflections led him to propose taking up the artery in the anterior part of the thigh, at some distance from the diseased portion, so as to diminish the risk of hemorrhage, and be enabled to get at the vessel again, in case it should bleed. The stream of blood into the sac being stopped, he concluded, tbat the sac and its contents would be absorbed, and the tumour gradually disappear, so as to render any opening of it unnecessary. The first operation of this kind, ever done, was performed on a coachman, by Mr. Hunter, in St. George's Hospital. De- cember, 1785. An incision was made eu the anterior and inner part of the thigh, rather below its middle, which wound was continued obliquely across the inner edge of the sartorine muscle, and made large, in order to facilitate doing whatever might be necessary. The fascia, covering the artery, was then laid bare, for about three inches, after which the vessel itself could be felt. A cut, about an inch long, was then made through the fascia, along the side of the ar- tery and the fuscia dissected off. Thus tbe vessel was exposed. Having disengaged it from its connexions with the knife and a thin spatula, Mr. Hunter put a double liga- ture under it, by means of an eye-probe The doubled ligature was then cut, so a.- to make two separate ones. The artery was now tied with both these ligatures, but, .?• slightly as only lo compress the sides together. Two additional ligatures were similarly ap- plied a little lower, with a view of compress sing some length of artery, so as to make- amends for the want of tightness, as it was wished to avoid great pressure on any one part of the vessel. The ligatures were left hang- ing out of the wound, which was closed with sticking plaster. On the second day, the aneurism had lost one third of its size3 and, on the fourth, the wound was every where healed, except where the ligatures were situated. On the ninth, there was it considerable discharge of blood from the apertures of the ligatures, but it ceased on applying a tourniquet, and did not recur. On the fifteenth day, after the operation some of the ligatures came away, followeai by a small quantity of matter, and about the latter end of January J 786, the man went out of the hospital, the tumour having be- come still less. In the course of the spring. abscesses in the vicinity of the cicatrix fol- lowed, and some pieces of ligature weir occasionally discharged. In the beginning of July, a piece of lipture, about one inch long, came away, after which the swelling went off entirely, and ihe man left the hos- pital again on the 8th, perfectly well, there being no appearance of swelling in the ham. This subject died of a fever in March, 1787, and, on dissection, the femoral arter\ was found impervious from the giving off i>!' «4v\ arteria profunda down to ihe place 17U vM'l K1S.M uf the ligature, and ttu unification had ta- ken place for an inch and a half along the course of this part of the vessel. Below this portion, the vessel was pervious, till just before it came to the aneurismal sac, where it was again closed. What remained of the sac was somewhat larger than a hen's egg, and it had no remains of the lower opening into the popliteal artery. The rest of the particulars of this dissection are very inte- resting. (See Trans, of a Society for the Im- erovement of M>J. and Chir. Knowledge, Vol. 1, p. 153.) This celebrated case completely establ ished the important fact, that simply taking off the force of the circulation is sufficient to cure an aneurism, as the tumour is after- wards diminished and removed by the ac- tion of the absorbent vessels. In order to confirm the same fact, Sir E. Home related a case of femoral aneurism, which got well without an operation, but, on a similar principle, to what occurs, when the artery is tied. A trial of pressure had been made without avail. The tumour became very large, and such inflammation took place in the sac and integuments, that mortification was impending : no pulsation ( ould now be felt in the tumour, or the ar- tery above it. The correct inference of Sir E. Home was, that a coagulum, which we know always occurs in an artery previously to mortification,seemingly to prevent bleed- ing, had formed in this instance, and in con- junction with the effusion of coagulable lymph about the root of the aneurism, had kept the blood from entering the sac. Mr. Hunter's second operation was on a trooper. Instead of using several ligatures, which were found hurtful, he tied the artery and vein with a single strong one ; but, un- luckily, the experiment was made of dress- ing the wound from the bottom, instead of attempting to unite it at once: and the event was, that the man died of hemorrhage. After this case, Mr. Hunter's practice was to tie the artery alone with one strong liga- ture, and unite the wound as speedily as possible. Having recorded Mr. Hunter's cases, which first established the present method of operating for the cure of popliteal aneu- risms, I shall not repeat the strong reasons which exist against the employment of re- serve-ligatures, metallic compressors ; two ligatures, with the division of the ves- sel between them ; the interposition of pieces of linen, wood, cork, agaric, he. be- tween the knot and the vessel; for the use of large ligatures; and other contrivances, the merits, or rather demerits, of which have been already fully considered in the prece- ding section. My next duty is to explain the method of performing the Hunterian operation, as brought to its modern state of improvement, and adapted to the wise prin- ciples, which first emanated from the valua- ble experiments and investigations of Dr. Jones. (See Hemorrhage.) Iu the arrangement of the assistants, one '•f theai MiouM be. ?o placed, that if re- quired, iu consequence ot any accident wound of that vessel in the operation, be can compress the femoral artery as it passe* over the briin of the pelvis ; but, as Scarpa justly observes, no pressure of this kind is "to be made, unless the accident referred to should happen, because the pulsations of the artery, inasmuch as they indicate the track of the vessel, must tend materially to facili- tate the operation. The surgeon, says Scar- pa, is to explore with his forefinger the course of the artery from the crural arch downwards, and when he comes to \ht place, where tbe vibration of this vessel be- gins to be less distinctly felt, this point is U he fixed upon for the lower end of the ex- ternal incision. This angle of the wound wjll fall nearly on the inner edge of the sartorius, just where this muscle crosses ilir track of the femoral artery, and at the very apex of the triangle formed by the conver- gence of the triceps and vastus internus. A little more than three inches above the place here fixed upon, the surgeon is to be- gin with a convex-edged bistoury, tbe in- cision through the integuments and cellular substance, and carry the wound down the thigh, in a slightly oblique line, from with- out inwards, so as to make it follow the course of the artery, as far as the apei of the above-mentioned triangular space, or the point where the vessel passes under the inner edge of the sartorius muscle. In order to make this first external incision with correctness, I consider it a good rule always to take particular notice of the line dei cribed by the sartorius on the thigh, the in- ner margin of which muscle at the place where it meets Ihe artery, as we have seta, forms at once the lower boundary of the in- cision, and an important guide to the vessel itself. By observing the track of the sarto- rius attentively, we shall likewise avoid all chance of making the wound too low down. so as to have this muscle intervening be- tween the incision and the artery ; a greater source of embarrassment in the operatioa, and of troublesome consequences after- wards than, perhaps, any other error; for. when this has happened,- and the surgeon has not room enough afforded by the higher part of the wound to get at the artery above the sartorius, he is compelled to dis sect and raise up this muscle from Us natu ral connexions, ere he can plainly discoier the vessel. This inconvenience made a deep impression on me in the first ease where I tied the femoral artery, for the in tervention of the sartorius in a stout soldier upon whom the operation was done, threw me into the dilemma of either dissecting ai the outer edge of this muscle and drawin. it inwards, or of enlarging the wound ip wards. The latter proceeding was that to which I gave the preference, because i1 seemed to me an excellent maxim in thu operation, to avoid making ai.v further* tacliment of parts from their natural efl» J'exions, than is absolutely necessary,a**1 knew, that when the wound was extend* a little higher up, the arte, v >. n„|c| ,,rr*r ANEL'WSM. 171 -eh more superficially, quite unconcealed by any muscle, whatever. Strongly, there- fore, as my principles have led me to con- demn Scarpa's modification of the ligature, his use of from four to six threads, and his interposition of a roll of linen between the knot and the vessel, I feel pleasure in ex- pressing my conviction of one excellence in his mode of operating; an improvement. which is now obtaining, if it ha3 not already obtained, the universal approbation of the Mirgioal profession. This amendment con- sists iu making the incision in the upper third of the thigh, or a little higher, than ' lie place, where Mr. Hunter used to make the wound. Scarpa's reason for this prac- tice is to avoid the necessity of removing ihe sartorius muscle too much from its position, or of turning it back, to bring the artery into view, so as to be tied. I have seen ihe bcst operators, even professors of anatomy, embarrassed, by having the sartorius muscle immediately in their way after the first incision, and as the vessel is more superficial a little higher up, the place h further from tbe diseased part of the Rr- tery, and there is no hazard of the anasto- moses failing to keep up the circulation ; 'this part of Scarpa's practice is highly de- serving of imitation. " The part of the limb (observes Mr. Hodgson,) in which the femoral artery can be tied with the greatest facility, is between four and five inches below Poupart's liga- ment. The profunda generally arises from tbe femoral artery an inch and a half, or an inch and three quarters, below Poupart's ligament; it very rarely arises so low as two inches. If, therefore, the ligature be applied to the femoral artery at the distance of four or five inches below Poupart's li- gament, the surgeon will not be embarras- sed by meeting with the profunda during the operation, and the chance of causing secondary hemorrhage, by tying the artery close to the origin of this vessel, will be ob- viated." (On the Discasts of Arteries, fa. J..434.) 'Ihe trouble, arising from cutting too low down, so as to have the sartorius interve- ning between the outer wound and the ar- tery, maybe more accurately estimated, when it is known that Desault, for the re- nioval of this inconvenience considered it right actually to make a-complete trans. verse division of that muscle, a thing, which, it is said, may be done, without any ill consequences. (Boyer's Traite dis Mai. Chir. T. 2, p. Uo.) I shall not presume, how- r\rr. to second this last piece of advice, because, though it may have been done by Desault, it appears to me, that the artery- can always be taken up very well, without the proceeding here recommended. A lew years ago, Mr. C. Hutchinson pub- lished a tract, in which he advocated the practice of making the incision at (lie outer edge of the sartorius, and'then raising that inmcle, and drawing it inwards, in order to in rive at the artery. This advice proceed- ed from the apprehension, that the plan of taking up the femoral artery at the inner edge of the sartorius was attended with risk of injuring tbe saphena vein, and large lymphatics. (Letter on the Operation for popliteal Aneurism, 1811.) The same method is commended by Boyer, and Roux, (Nov- reaux Element de MAd. Operatoire, T. 1. /'. 729) when the operation is done low down iu the thigh. But, as operating in this situa- tion is liable to the several objections of approaching too near the disease, of aiming at taking up the artery where it lies more deeply, than it does higher up, and, of every inconvenience which may arise from the interposition, dissection, and reflection of the satorius muscle, the method must be rejected, unless it can be proved, that se many disadvantages are fully counterbalan- ced by other considerations. If the plan which I shall presently recommend be adopted, there will never be the slightest risk of wounding the saphena vein ; and, therefore, I do not consider it adviseable or necessary, for the avoidance of this acci- dent, to make the wound precisely upon the sartorius, as my intelligent friend Mr. Hodg- son suggests ; a method, attended with thr inconvenience of having the fibres of that muscle between the external wound, and the arterj'. and perhaps inconsistent with the excellent directionswhich he afterwards delivers, concerning the right mode of per- forming the external incision, when he say.«. with Scarpa, that this cut should be "con- tinued down to the fibres, which form the in- ner margin of the sartorius." (On Diseases of Arteries, fa. p. 436.) Now, if the point where this margin first lies over the artery, be the proper place for the lower termination of the external inci- sion, we shall clearly be deviating from the precise course of the vessel by letting the higher portion of the wound be over the fibres of that muscle. And, when it is fur- flier reflected, that the serious evils of wounding the trunks of the lymphatics in this operation are not demonstrated in mo- dern practice, while the saphena vein may always be avoided with certainty and faci- lity, I cannot admit, that there is any solid reason for letting the situation and direction of the external wound be determined by- such apprehensions. At all events, for th« motivesabove explained,it should be a fixed maxim in this operation never to extend the wound lower than the point, where the in- ner margin of the sartorius crosses tin. ar- tery ; and then all detachment and displace- ment of this muscle will be unnecessary; and every embarrassment, which might proceed from its interposition between the outer wound and the artery, will be com- pletely avoided. The skin and cellular substance are to bo divided, in the situation, and to the extent above specified down to the femoral fascia, under which the artery lies, and may be felt beating. The next object, therefore, is to divide the fascia, which is here much thinner than at the outer side of the limb, and may be cut rrifh naother »froke of the hisfoiiry ; 172 AN^MUSA*- • r(wVifH is safer with tne view of abstain- ing from all cbance of wounding the artery) a slight cut may first be made in the fascia, the division of which may then be made to the requisite extent by introducing under it a grooved director, on which the further incision may be made with perfect security. The fascia is to be divided in the direction *t the external wound ; but, to what extent is a point on which surgical writers differ, and. indeed, they must here differ, as long as" they are not unanimous about tbe method of appyling the ligature round the artery; because, if it be intended to use a broad li- gature, with a cylindrical piece of linen i-itcrpr;~d brf,-^en it and the artery, or es- w'cinliv ii it je designed to apply two liga- tures and divide t'ic vessel in the interspace, more of the artery must be exposed, and of course more of the fascia must be cut. than when it is simply meant to surround the vessel with a single small ligature. Such ope- rators also as have contracted the pernicious habit of insulating the artery all round sufficiently far to let them thrust their finger under it, will likewise require an extensive opening in tbe fascia. Such detachment of the vessel for an inch or more, for the pur- pose of placing the finger under it, is a measure which deserves to be condemned in the strongest terms, as it is the very thing, which produces some risk of inju- ring the saphena vein, and has a tendency '9 bring on secondary hemorrhage, inas- much as it occasions unnecessary handling, "tretchin?, and disturbance of the artery and surrounding parts, and an inevitable divi- -ion of the vessels, by which the arterial <-.oats are supplied with blood. According to Mr. Hodgson, the extent of 'h* eut in tbe fapcia should be about an inch ; for he wisely avoids all unnecessary -: p.ration of the artery from its surround- 'm.,' parts. On tbe contrary, Scarpa, who insulates and raises the vessel, previously to ryingit, insists upon the prudence of cut- ting the fascia, the v. hole length of the ex- ternal wound ; for, says he, if this practice i>e neglected, it most frequently happens, that, in the succeeding inflammatory stage, ihe bottom of the wound swells and be- comes very tense, and the matter, which i= farmed under the fascia, not finding a ready exit, occasions abscesses which seriously re- tard the cure. But, Scarpa, instead of plan- ning a method of relieving the consequen- ces, might have employed himself more to thepurpose in considering how they were t» be prevented, and why in his method >'hey most frequently happen. Now, without laying any stress upon two waxed ligatures, each composed of six threads, with no additional extraneous substance, viz. a roll of linen in the noose, we should '•: more surprised to hear, that the wound after his method did not become affected with swelling, tension, and suppuration, than that these were the usual effects. After describing th« division of the fascia, he ob- serve.' : " With the point ef the forefinger of th' ■'•f' >■" id. n'r'ini; ifivching fh.r fewirril artery, thr sui-■ *u will stf*,*tf 'd _tr*m tit cellular substance, which hrs it laterally ni posteriorly to the contiguous muscles; and making the point of thesam * finger passgraA,. ally under and behind the femoral artery (m. posingthesurgeonhasnotenormomlylargtfa. gers) he will raise it alone from the bottom of the wound, or (when itcannot be ayoided)alo»'g with the femoral vein. If it is along uilk the femoral rein, the surgeon, holding the tir- tery and vein thus raised, and almost out #/ the wound, will cautiously separate the t«r from the artery with a bistoury, orspatulay'tr simply with his fingers, fa." (See Smtft1 on Aneurism, p. 280, Ed. 2.) When we combine the irritation and rain- chief of all this work with the ill effects of filling the bottom of the wound with soft lint, I would ask. what more certain plan rould Scarpa, or any other person, have suggested for bringing on the unplea- sant state of the wound, which lie de- scribes as most frequently taking placer 1 shall suppose the fascia has now been divided, under which the surgeon distinctly feels the pulsations of the femoral artery, which is still invested by the cellularsbcatb. The femoral vein lies directly under this vessel, while the branches of the anterior crural nerve, separated from it by dtsrte cellular substance, are more externally, yet somewhat more deeply situated. The next object, therefore, is to pass a single ligature round the artery, without including, or, in any manner meddling with tbe subjacent femoral vein, or, detaching and disturbing the artery. For this purpose, the best di- rection is that given by my friend, Mr Lawrence: "after dissecting down to tbe artery, a slight scratch or incision may hr made through the sheath, close to the side of the vessel. Then, with a narrow anen- rism needle, nearly pointed at the end, tad made as thin at its edge as it can be withoot cutting, a single silk ligature is to be con- veyed round it, the point of the needle being kept in contact with the artery. S needle of this form makes its way easily through the cellular substance, and the ves- sel is detached only in the track of the in- strument." (See Med. Chir. Trans. Vol. i.) Of the kind of ligature to be employed I need only say here, that it should be atin- gle one, composed of firm materials, in or- der to avoid the necessity for increasing ju diameter more than would be desirable.tof reasons elsewhere considered. (See He- morrhage and Ligature.) The ligature ha- ving been put under the artery, one end of it i9 to be drawn completely through *• track made for it by the needle, which'* strument is then to be taken nwav, leaving the ligature under the vessel. Tlie ligature! is now to be tied in a steady firm manner, but without any immoderate force, which can never be necessary even for the dirisiw of the inner coats of the vessel. In this part of the operation, a few practitioaea* give tha preference to what is termed the surgeon's kvot, and cannend this ptu °f fartemng the lh*um-, flp[an. which n*- ONEIRISM. 173 aists ni putting the end of the cord twice through the noose, before the constriction is made. The only good of the surgeon's knot is, that it does i.-t so readily slip and loosen as a common one ; but ccnrpa thinks a simple knot best, as it does not, like the other, prevent the surgeon from calculating Ihe force, with which the artery is constrict- ed. (On Aneurism, p. 281, Ed. 2.) And, besides this reason agaiusi the surgeon's knot, another objection to it is the irregularity, with which a ligature in this form will lie round the vessel. A simple noose should therefore be first made and tightened, and then a second one, so as to firm a common knot; and, now, as a mutter of precaution against the possibility of the ligature slip- ping and becoming loose, the surgeon, if he pleases, can tie the knot once again. One end of the ligature is next to be cut off near the knot; and the sides oi the wound are to be brought together with strips of adhe- sive plaster, the irritation of sutures being carefully avoided. The remaining end of the ligature should always be brought out at the nearest point of the external wound to the knot on the artery. The effects, which in general immediately follow tbe operation, are a total cessation of the pulsation of the aneurismal tumour, a manifest sinking and flaccidity of the s» ell- ing; a diminution of pain in the seat of tbe disease ; and a strong vibration of the arti- cular arteries round the knee. As Mr. Hodgson has remarked, the unusual influx of blood into tbe minute ramifications, when a main artery is suddenly rendered impervious, is generally attended with a re- markable increase in the temperature of the limb. After tying the femoral artery for the cure of popliteal aneurism, the same phenomenon occurs, at least after a short time, during which the temperature of the leg and foot frequently continues lower, than that of the sound limb. But, in a few hours, it generally rises, and is some- times several degrees higher, than that of the opposite member. This state lasts se- veral days, at the end of which time, the heat of the limb, which has been operated upon, will be found to be about the same ns ehat of other parts of the body. (Hodgson on Diseases of Arteries, fa. p. 256.) It is only while the limb is colder titan natural, that it ought ever to be fomented or cover- ed with flannel. In particular examples, there is no increase of temperature in the limb at any period nfter the operation; a fact, which Mr. Hodgson refers to the pro- bability of a collateral circulation having already been established, in consequence of the obstruction to the passage of the blood through the main artery by the accu- mulation of the coagulum in the aneurismal sac. Of course, unless a collateral circula- tion be established, the operation cannot succeed, as the lunb will mortify: it be- hoves us, therefore, to be nware ol the cir- cumstances, which may prevent the due transmission of the blood to the inferior part of the limb. These are ably explain- er ed and commented upon in Mr. Hodgson's work ; 1st, An eiteusive transverse wound, by which the principal anastomosing branches are divided. 2dly, Tight banda- ges and pressure, operating so as to ob- struct the same vessels. 3dly, The im- mense bulk of the tumour, and the pres- sure upon the principal collateral arteries. 4thly, Calculous depositions in thf; coats of the arteries of the limb. 5thly, Advanced age. 6thly, A languid state of the circula- tion ; a fact, indicating the urongness of venesection ; as a general practice after the operation,though it may yet be right to adopt this treatment, where the pulsations return in the tumour with unusual strength, and appear to stop the diminution of the swell- ing, as already mentioned. 7thly, The ab- straction of heat from the limb by cold evaporating lotions; a plan, which can only be right, when there is a great increase of heat in the limb, a tendency to inflam- mation, or a return of strong pulsations in the tumour. When the operation is done, according to the principles laid down in this article, the patient is not too old, nor enfeebled, and the after-treatment is properly conduct- ed, mortification may now be said to be a rare event. 1 have seen but one example of gangrene, and in that, only one toe, and a portion of the skin of the instep, sloughed in a very debilitated subject. This partial gangrene of the foot has been particularly noticed by Deschamps and Scarpa, the latter of whom regards it as an unusual thing, on- ly likely to happen in old, weak, or unheal- thy subjects; and "at any rate, (says he,) if this should happen in any of these ener- vated individuals, the patients may console themselves for the loss of one, or two of their toes, with the cure of a popliteal aneu- rism, and the avoidance of a painful and dangerous incision iu the ham, and of the tedious suppuration, which would have fol- lowed it." V\ hen the operation succeeds, a conside- rable portion of the artery above the aneu- rismal tumour is rendered impervious, the vessel indeed being sometimes converted into a solid cord from the origin of the profunda to that of the tibial arteries. (.'/. Cooper, Med. ( hir. Trans. Vol. 2, p. £54.) In general, however, the obliteration of the artery is less extensive ; a fact particularly noticed in one of Mr. Hunters cases, (Trans. of a Soc. for the Improvement of Med. and Chir. Knowledge, Vol \,p. 153,) and vainly urged by Deschamps, os a proof of the in- sufficiency of the new method. (See Ob- servations et Reflexions sur la Ligature des principalis Arleres blessis et panic nil r^mevi surl'.tiievrhme de I'ArUrc /'v/AHtr, p. 7^ J'rris, 1797.) It appears from t!i observa- tions of Mr. Hodgson, that the artery gene- rally becomes impervious, for the space of three, or four fingers' breadth, at the place where tin ligature is applied; below which part its tube is unclosed, and continues so for some distance, when the obliteration again ronamenre*, and descends along a •* I I 1*1 ANEl-'RISM- t onsiderable extent of the popliteal artery to the origin of the inferior articular, or tibial arteries. Thus, says this author, an insulated portion of the femoral artery pre- serves its cavity, from each of which con- siderable anastomosing branches arise : the upper branches convey blood into the ves- sel, and the lower transmit it into anasto- mosing chh.inels, that originate below the knee. (On Diseases of Arteries, fa. p. 278.) Now, as Mr. Hodgson is unacquainted with any case, except that recorded by Mr. A. Cooper, where after the modern operation, the artery was obliterated from tbe seat of disease in the bam to the part, at which the ligature was applied, be thinks it probable, that, in most instance, a double collateral circulation exists in the limb, after this me- thod of cure. In consequence of tbe motion of the blood being more or less impeded in the aneurismal sac by the application of the li- gature to the femoral artery, the aneurismal cavity soon becomes i op-nletely filled with coagula, which even block up the adjoining portion of the arterial t be. ihe coagula- ted b'o';l iu the sac is afterwards absorbed ; and a gradual diminution, and final disap- pearance of the aneurism in the ham ensue ; with the exception of a slight induration, which sometimes remains, composed of a remnant of the sac itself, or of the fibrous part of the blood. This slight hardness, which occurs in the bottom of the cavity of the ham, occasion- no inconvenience, and does not hinder tbe patient from performing the motions of the knee and leg w ith quick- ness and safety. (Scarpa,p. 257, Ed. 2.) When the advantages of the foregoing method of operating are contrasted with the dangers and severity of the practice of lay- ing open the aneurismal tumour, and ap plying ligatures round the diseased part of ihe vessel, it is surprising to find any living surgeons still expressing a preference to the latter mode of treatment under any circum- stances whatsoever. Yet, Boyer, Roux, and a few of the modern French surgeons are in this way of thinking, which reminds me of their slowness to adopt, at every op- portunity, union by Xhf first intention, one of the greatest and most decided advances to perfection ever made in the practice of surgery-. The severity and difficulties of the old method of operating, in cases of popli- teal aneurism, are most faithfully depicted by Scarpa. In the ham, says he, the artery lies very deep. The space is limited and narrow, within which it can be brought into view aud tied, without risk of tying along with it, or of destroying, some of the prin- cipal anastomoses formed by the articular arteries of the knee. On account of the depth of the artery, it is difficult to pass any instrument round it, without including other parts, and it is no less difficult to draw the ligature on the vessel with a proper degree of tightness. Scarpa then comments on the disadvantages of tying the lacerated, diseased part of the vessel, which is some- times so high up, that, in order to apply the ligature above it, it is necessary to en through the long head of the triceps 8m] make a passage through into the thigh. Or, the diseased, or lacerated part of the artery is situated so low down in the calf of the leg, that it is impossible to avoid including either in the incision, or the ligature, the lower anastomosing articular arteries, on the preservation of which the circulation and life of the subjacent part of the limb in a great measure depend. We must add to all this the violence, which must lie done to the great sciatic nerve, which an assi? tant must bold drawn to one side of the wound nearly the whole time of the opera tion. The proceeding is also liable toother great difficulties, as may be seen from ■ case reported by Masotti, (Dis.sulMeam. ma, p. 53,) where the popliteal arlerv wi- so firmh united, and, as it were, confused with the vein, tu nerve, the tendons*/the neighbouring muscles, and the periosteutr that the cavity of the ham presented the appearance of an intricate mass ot part., not easily separable from one another Lastly, the operation leaves a large deep wound, laying open the whole cavity of the ham, and followed by copioas suppu- ration, sinuses, and necrosis of the headso! the femur and tibia. If the patient he no: hurried into his grave by these affections, and even if the parts in the ham heal, tbe patient is almost always left with aa incurable contraction of the knee, and per- petual lameness. Thus,_Masotti (Op.nf.i. 17,) relates one case, where the subsequent effects were such as to destroy the soft parts in the cavity of the ham, in such > degree, as not to leave any vestige ofarlery, vein, or sciatic nerve, and the patient re- mained all tbe rest of his life with a paralytic leg, and ulcers and fistula; all round the knee. (Scarpa on Aneurism, p. 251-258, Ed. 2.) I shall now advert to a few facts in the history of surgery, which eventually led tn the bold and successful operations, adopted in modern times, for the cure of aneurisms of the femoral and popliteal arteries. Tbe earliest case, of which the particulars are recorded, amounting to a satisfactoryantM that the lower extremity might batdssf supplied with blood, notwithstanding tba femoral artery had been tied high up i« d* thigh, is the example, related by M. A. Se verinus, of a false aneurism of the tlii?» abouteight fingers' breadth below the grew. caused by a musket-ball wound. In tbfa in- stance, Severinus tied the femoral artery above and below the aperture in it, a"*" not only was the patient's life saved,bat the use of the limb also preserved. (Cat" rurgia Efficacis, P 2. Enarratoria.)> * next authentic case of the ligataiW ** femoral artery, is ti at reported bySaviar*. where M. Bottentuit, in 1688, tiedtlfr* tery on account of a false aneurism, there- suit of a sword wound at the inner and af per part of the thigh. The surgeons, called into consultation, were immediately et* vinced. that the only thing to be done ** v.NElKISM 175 lo take up the temoral artery; but, they were fearful, lest the patient should perish of bleeding, ere the opening in the vessel rould be found, and, in case the artery were secured, they apprehended the ob- struction of the circulation would be fol- lowed by mortification of the limb. The patient was therefore first prepared for his fate bv the administration of the sacrament. A band was then applied round the upper part of the limb, and tightened by means of a stick, with which it was twisted, a piece of pasteboard being put under the knot, in order to render the constriction less painful. The tumour was then opened, the clotted blood extracted, and the opening in the ar- tery detected by slackening the tourniquet. A curved needle, armed with a double liga- ture, was then introduced under the femoral artery, and one of the cords was tied above, and tie other below, the wound in the ves- sel. Then follows a curious passage, show- ing the operator's judgment at that time, respecting the impropriety of interposing any cylinder of linen between the knot of the ligature and the artery, as some of the old surgeons at that time used to do, as well as a few of the moderns. " On ue mit point de petites compresses sur le corps de I'artere au dessus du nceud, comme font quelques uns, parceque Von jugea qu'il etoit d'une grande consequence, de Her tres-etroite- ment une artere si considerable, ce que Von n'autoit pas He surdefaire en interposant la petite compresse,fa." For greater security, assistants, who relieved each other in turn, kept up constant pressure on the tied part of the vessel for twenty-four hours In six weeks, the patient recovered, and afterwards enjoyed such good health, that he went through several campaigns. (Saviard, Nou- rcau ricueil d'Observations Chir. Obs. 63, 12mo. Paris, 1702.; Now, with respect to these two cases, it merits attention, that, though Heister, Mor- gagni, and others, endeavoured to explain the success, by supposing, that each of the jtatients iu question must have had two fe- moral arteries, both Severinus, and Saviard, were wise enough to avoid making any such erroneous inference themselves. At a later period, Guattani laid bare the femoral artery, as it passed underPoupart's ligament, compressed it against the ramus of the pubes, by means of graduated compresses, retained with a firm roller, and thus ob- tained the speedy obliteration of the vessel, and cured the aneurism, which had been first injudiciously opened. (De Exlernis Anevrysmatibus, Hist. 15,4fo Roma-. 1772.) In the same book is given the case of an inguinal aneurism, which when it had con- tinued three months, and become equal in Aize to a large fist, was attacked with gan- jime, whereby the aneurismal sac was quickly destroyed, and the femoral artery was obliterated for a considerable extent from the crural arch downwards. Tbe 'loughs were thrown off, however, and the ulcer hod in a great measure healed, when liiei p»tifn» fell a victi-n to debiliiv. (ffi*r 17.) Here it is to be remarked, that, during the five weeks this man lived after the ob- literation of* the femoral artery, above the origin of the profunda, not only the circu- lation and life of the whole limb were pre- served, but the auxiliary arteries, coming from within the pelvis, proved capable of limiting the progress of the mortification of the parts round the aneurism, and of commencing the healing process, in a man- ner, which raised great hopes of a cure. A similar fact is also recorded by Dr. Clarke. (Duncan's Med. Comment. Vol. 3.) These, and other cases, which might be quoted, furnished ample proof of the effi- ciency of the anastomosing vessels in the support of the limb, though the femoral ar- tery had been tied, or obliterated in a very high situation. Besides these facts, surgeons derived every encouragement to attempt the cure of popliteal aneurism, by the ligature of the artery above the tumour, from the elucidations given by Winslow and Haller concerning the numberless inosculations, which exist between the upper and lower articular arteries. Haller even drew the conclusion, that, if the course of the blood were intercepted in the popliteal artery, between the origins of the two orders, of articular branches, such anastomoses would suffice for carrying on the circula- tion in the leg. And at length, Heister. weighing the anatomical observations of Winslow and Haller, and the facts record- ed by Severinus and Saviard, first propo- sed applying to popliteal aneurisms, an operation, which, with the exception of those two cases, had until that time been restricted chiefly to aneurisms of the bra- chial artery. (Dis. de genuum Struelura eorumquemorbis. Disp. Chir. Halleri, T.4.) It was in Italy that the earliest opera- tions were undertaken for the cure of popli- teal aneurisms, by Guattani or rather by a German surgeon, named Keysler, as would appear from a letter writen by Testa, to Co- tunni. (See Pellelan's Cliniqui Chir. T. 1.) The success, obtained by those surgeons, soon emboldened others to imitate them, and by degrees the practice of tying the femoral artery became common both in cases of aneurism and wounds ; and from the observations of Heister, (Haller Disp. Chir. T. 5.) Acrell, (Murray de Aneurysm. Femoris,) Leslie, (Edinb. Med. Comment- Hamilton, (B. Bell's Surgery, V. 1,) Burs'- chall, (Med. Obs. and Inq. Vol. 3.) Leber. (Dehaen, Ratio Medendi, T. 7.) and Jussy, (Ancien. Journ.de Med. T. 42.) it was prov- ed beyond the shadow of a doubt, that the circulation might coninue in the limb, after the obliteration of the femoral arterv, whether such obliteration were effected bv direct pressure, or the ligature. The exact period when the first operation of laying open the tumour and tying thr popliteal artery, was performed in England is not, as far as I know, particularlv speci- ned. However, judging from the obs^rva Hftn-s ->=-de on ti-its pracfire i„ u, writin-n. a\ku;i>\i of Pott, (R .marks on Palsy, fa. Svo. Lond. 1779,) of Wilmer (Cases and Remarks in Surgery, 8vo. Lond. 1779,) of Kiiklaud (ThouglUs on Amputation. Sio. Lond. 1780,) and of others, it is clear, that this method of treatment hod been often done in this country earlier than the dates of those works, and as wouil appear with little, or no success. The earliest attempt of tins kind in France was made by t.opart in 1781, (Roux. Noureaux Elemans de Med. Operatoire, T. 1, p. 556,) about five and twenty years after tbe examples set by Guattani in Italy ; but Chopai t iail«:il in his •endeavours to "repress the bleeding i."i>m the cipossd cavity of the tumour, and was therefore obliged to amputate the limb. Subsequently to Ibis attempt, the operation was undertaken by Fell, ian in two instan- ces, the terminations of which were sac cessful: consequently, this surgeo-. maybe regarded as entitled to the houonr of hav- ing proved to his countrymen the possibi- lity of curing the popliteal aneurism by laying open the tumour, and securing the artery in the ham. The severity and frequent ill success of (his method of operating I have already noticed, nor shall I repeat tbe objections to it With respect to the Hunterian prac- tice, the great peculiarities of which were tying the artery at some distance above the disease, and not opening the swelling at all, Richerand seems offended, that Hunter's name should be affixed to an ope- ration, which he conceives was in reality the invention of Guillemeau. Here we observe, iEtius again puts in a prior claim, and with much more effect, because the method, of which he speaks, truly resem- bled Mr. Hunter's, inasmuch as the vessel is directed to be tied at some distance above the swelling, while Guillemeau only tied the artery close above the disease, and opened the swelling, a serious deviation from the Hunterian practice. Guillemeau, a contemporary, and disciple of Ambrose Fare, having to treat an aneu- rism, at the bend of the arm, the conse- quence of bleeding, exposed the artery above the tumour, tied this vessel, then opened the sac, took out the coagulated blood, and dressed the wound, which healed by suppuration. After more than a century, Anel, on being consulted about a similar case, tied the artery above the s .selling, which was left to itself. The pulsations ceased, the. tumour became smaller, and hard, and after some months, no traces of the disease were perceptible. In 1785, Desault operated in the same manner for a popliteal aneurism : the swell- ing diminished by one half, and the throb- bings ceased : on the 20th day, it burst, coa- gulated blood and pus were discharged in large quantities, and the wound, after con- tinuing a long time fistulous, at length heal- ed. Towards the end of the same year, says liicheraud, Hunter applied the ligature -oinew hat differently ; instead of placing :- close to tbe swellin.' or directly ub,ve it, he put it on the inferior part of the feuiurai artery. (See Nosogr. Chir. T. 4,j». U8,g<> edit. 2.) Unquestionably, A. el did, in one solitary instance, tie the hu -. ;il artt ry i..: mediately i-.bow in aneurism a ;he bend ot the arm and effected a cure <-. itbout opening th* swelling. (Smiedela ■ •uvclle Methoie de guerir les fistules luc!>. >fmales, p £»1, Turin, 1714;) but he did not think of air plying the plan to the femoral artery, or draw the attention of the French surgnoas sufficiently to tbe matter, to make the l«t. ter imitate his operation ; on the contiary, th' inetliod fell hit" oblivion, und was ne' ver repeated. With regard to Desaull's operation, said to have been iune in au earlier part of 1785, than Mr. Hunter's first op ration, it is only necessary to say, that Desault tiej the popliteal artery itself,while jthc grand object i< Mr. Hunter's method "was to take np Ihe femoral artery, at a dis- tance from tbe disease, and that it is tbii last mode alone, which has gained such approbation, and been attended with unpa- ralleled success. The French surgeons have not practised th,-; Hunterian operation with the same de- gree of success, with which it is now per- formed iu England, and, consequently,they very commonly pursue the old method of opening the sac, &c. Even professor Boyer avers his relinquishment of what be eills Anel's pl„n. (Traite des Mai. Chit T. 2. p. 148.) But, we shall not be surpri- sed at their ill success, when we hear that they neglect the right principles, on which ligatures ought to he applied to arteries, a.- explained by Dr. Jones in his work on he- morrhage. Even Baron Dupuytren ad- heres to the use of ligatures of reserre; and Boyer applies four loose ligatures round the artery, besides two tight ones; and con- sequently a large portion of the vessel lies separated from its natural connexion!, and irritated by these extraneous substances Hunter's first operation nearly failed ah* on account of so many ligatures, none of which were tightened so as to cut through the inner coats of the artery, and thus pro- mote its closure.. (See Hemorrhage.) I" reference to the operation for popliteal aneurism, Rosenmuller's Chir. Anat. PI*'" deserve to be consulted, Part 3, Tab. 8&9 Scarpa's matchless engravings, and Haller Icoues, should likewise be examined. A.KKURISSIS OF THE LEG, FOOT, FOKEAn* AKD HIND. Doubts were not long ago entertained respecting the possibility of curing *• aneurism at the upper part of the calf*1 the leg by tying the femoral artery in ** middle of the thigh. (Inslituto Hal- * Scienze ed Arti. Vol. 1, Parle 2, p• 2b"6-' The author, here referred to, was led »r this uncertainty to have recourse in <* instance to the. severe method of lay'0! open the tumour, in order to get at the rev sel lower down. On ti,i= ',*n Aneurism, p. 83; 4to. 1S07.) Mr. Tomlinson, of the same towu, ** also an early performer of the operation' hr appfied ■ rdy one fisatare. and. of couf« ANEURis.'u, le-it the artery undivided : the event was attended with perfect success. The following is Mr. A. Cooper's mode of operating, as described by Mr. Hodgson. A semilunar incision is made " through the integuments, in the direction of the fibres of the aponeurosis of the external oblique muscle. One extremity of this incision will be situated near the,4pine of the ilium ; the other will terminate a little above the inner margin of the abdominal ring. The aponeurosis of the external oblique muscle will be exposed, and is to be divided throughout the extent and in the direction of the external wound. The flap, which is thus formed, being raised, tbe spermatic cord will be seen passing under the margin of the internal oblique, and transverse mus- cles. The opening in the fascia, which lines the transverse muscle, through which the spermatic cord passes, is situated in the midspace between the anterior superior supine of the ilium, and the symphysis pubis. The epigastric artery runs precisely along the inner margin of this opening, beneath which the external iliac artery is situated. If the finger, therefore, be passed under the spermatic cord, through this opening in the fascia, it will come into immediate contact with the artery, which lies on the outside of the external iliac vein. The artery and vein are connected together by a dense cellular membrane, which must be separated to enable the operator to pass a ligature, by means of an aneurism needle, round the former." (On Diseases of Arteries, p. 421— 422.) The foregoing incision, the convexity of xvhich is turned outward, and downward, extends from within and a little labove the anterior superior spinous process of the ilium to above and a little within the middle part of Poupart's ligament. Mr. Norman, of Bath, who has tried both modes of operating, found that proposed by Mr. A. Cooper, a more easy way of finding the external iliac artery, than the longitu- dinal incision practised by Mr. Abernethy. " The objection, (says Mr, Norman,) to Mr. Cooper's mode of operating in cases, where the tumour extends high up, is by no means well founded ; for the lower part of the bag, of the peritoneum, lying on the edge of Poupart's ligament, must in every rase be exposed and detached, in order to get at the artery, which lies behind the posterior part of that membrane, and this is most easily effected by an incision in the direction of Poupart's ligament; whilst two- thirds of the. longitudinal incision are made on a part of the peritoneum, which lines the abdominal muscles, and the lower portion only of the incision, reaches that part of the membrane, which is to be separated. The consequences of this are, that the perito- neum is in much greater danger of being wounded, and that the probability of a hernia forming after the cure, is much in- creased by the extensive division of the oblique muscles." (See Med. Chir. Tran. rrtl.W,ji. 101) As far as I :»m able to judge, these remarks arc well founded, and they coincide with some observation*, which were made some years ago by Roux, who, while he inclined to Mr. Abernethy's method, saw the disadvantage of letting the direction of the wound in this instance correspond to the course of the artery. Hence, after many trials on the dead sub- ject, he laid down the rule, that the begin- ning of the wound should never be further, than half an inch from, and a very little hfgher, than the anterior superior spine of" the ilium, and that it should be carried very obliquely downwards, to the middle of Poupart's ligament. (See Nouveaux Elc- mens de Med. Op. T. 1, p. 147. fa.) _ • In a case, operated upon by Mr. Kirby, a hernia followed, in the situation where the abdominal muscles had been divided. (See Cases icitk Observations, p. 109, 8i*o. Lond. 1819.) Dr. Post in one case found the perite- neum so thickened and diseased, that he could not raise it from (he subjacent parts.. and he was obliged to make an opening in it. The protruding viscera were then pushed back, and, with a needle, a ligature was in- troduced under the artery, the peritoneum being also included in the ligature. Not- withstanding the disadvantageous method of operating, and the return of pulsation in the swelling, the patient had so far recover- ed in three months, as to have regained the use of the limb. (See American Med. and Phil. Reg. vol. 4, p. 443.) In one remarkable case, Mr. Newbiggbi. by tying 'the external iliac artery, curest both an ingninal an popliteal aneurism te- gether. (See Edin. Med. fy Surg. Journal, for Jan. 1816, p. 71, fa.) The many operations, which have now been done on the external iliac artery, have impressed me with a conviction, that in subjects under a certain age, there is no reason to fear, that the anastomoses will not generally suffice for the supply of the lower extremity. Out of twenty-five cases, I only know of three, in which the limb was at- tacked with gangrene. These three were patients of Mr. A. Cooper, Bouchet, of Lyons, and Mr. Collier. The proportion is not so much as one in eight. The three* instances of gangrene were not all in the circumstances, which permitted the event lo be imputed to' the anastomoses not having had sufficicnttime to enlarge, though perhaps Mr. Collier's case was such. On the other hand, we are lo notice, that Dr. Cole's patient was operated upon a few days after the wound, and yet the limb was duly supplied with blood, and did not be- come gangrenous. Jt appears therefore to me, that the occasional occurrence of gan- grene cannot be admitted as a just reason for delay, until the collateral vessels have had time to enlarge. I believe, that in all aneurismal diseases, early operating is the best, and most judicious practice. This was one principal cause, as Kirkland ob- serves, which occasioned the bad sneces.-t of thr-Hrl surgTin* in the trea'we*nf oTpw»- 18© A.NEl ft ISM. - liteal aneurisan1-, nod he i^re-tnld many years ago, that operations for the cure of aneurisms would answer better, if not de- ferred so long as formerly, (jm-c Thoughts on Amputation, fa. 8ro. Lond. 17S0.) I join Kirkland in this sentiment, not without recollecting, that all aneurisms are attended with a chance of getting spontaneously well in the course of time. 1 saw the in- guinal aneurism which did so, uuder Mr. Albert, iu the York hospital; but as this also is a rare incident, I do not believe, that it ought to influence us against haying speedy recourse to an operation. Besides, the cure by inflammation and sloughing, appears to me to be attended in reality with more peril, than a well-executed operation, and consequently, has less recommenda- tions, than many may imagine. Had not Mr. Albert's patient been a very strong man, he would certainly have fallen a vic- tim to the extensive disease, which the bursting and sloughing of the tumour created. Thus, Delaporte's patient died of the mass of disease, which the tumour itself made ; for it had been suffered to attain too large a size, so that when it inflamed, the effects were fatal. (See Richerand, Nosog. Chir. T.4,p. 113, edit. 4.) I believe Dr. Wilmot's observation is perfectly correct, that, if a comparison were made between tbe operation of tying the external iliac artery and that of tying the artery in the thigh, we should find the re- coveries after the first more frequent, in proportion to the number of times it has been done, than after common operations lower down. (See Dublin Hospital Rep. fa. vol. 2, p. 214.) I subjoin a list of some of the successful r xamples of this operation. Mr. Abernethy, two cases, (Surgical Works, vol. If) Freer and Tomlinson, 2, (Freer on Aneurism, 1807.) Mr. A. Cooper, 4, (Hodgson on Dis- eases of Arteries, p. 417.) Goodlad, 1, (Edin. Med. &Sur. Journ. vol. 8.p. 32.) Mr. Brodie, 1, (Hodgson, op. cit. p. 419.) Lawrence, 1, (Med. Chir. Trans.vol.6.p.205.) J. S. Soden, 1, (Same work, vol. 7. p. 536.) G. Norman, 1, (Same work, vol. 10. p. 95, fa.) Bouchet, 1, i Roux Med. Opiratoire, T. 1. p. 744.) J. S. Dorsey, (Elements of Surgery, vol. 2, p. 180, Philadelphia, 1S13.) Mouland, 1, (Bulletins de la Faculti de Midecine de Paris, T. 5. p. 535.) Dupuytren, 1. (French Transl. of Mr. Hodgson's Work, T. 2. p. 125.) Dr. Cole, 1, (Rapport des Travaux de la Societi d'Emulation de la fille de Cambrai, 1817, or Lond. Med. Repository.) Dr. Wilmot. 1, (Dublin Hospital Reports, vol. 2. p. 208, fa.) Kirby, 1, (Cases with Ob- servations, fa. 8vo. Lond. 1819,) Dr. Post, 1, (American Med. ^ Philos. Register, vol. 4.) Newbiggin, (Edin. Med. i,- Surg. Journ. January, 1816) Some particulars of the case of ruptured inguinal aneurism, in which Mr. A. Cooper tied the aorta, will be hereafter noticed. (See Aorta.) Rosenmuller's Chir. Anat. Plates, in illus- tration efth" operation •jftvln^ the external iliac artery, nieiii notice, (rscrpurf3,fa*. 2, 7, and 1».) CASES OF C.LVTJEKl. ANEURISM CURED lv TT1NO THE INTERNAL ILIAC ARTIRy. The glutajal artery is large ; from its situa- tion, liable to wounds; from its size, sub- ject to aneurism. Dr. Jeffrey, of Glasgow, was consulted inia case, where the gluueal artery had been wounded. He urged tbe propriety of tying the vessel where it had been injured. This sensible advice wan at first rejected, and when the friends at latt consented, the operation was too late, as while preparation was making for it, the tumour burst, and the patient expired in i few moments. Theden also mentions an instanee, in which the glutteal artery was wounded In the dilatation of a gunshot wound, and the patient lost his life. (See Scarpaon Aneu- rism, p. 407, Ed. 2.) Mr. John Bell, however, tied the glutaeal artery in a case where it was wounded, and the patient was saved. Mr. Stevens, surgeon in Santa Cruz, the gentleman who has proved the practicable- ness of putting a ligature round the inter- nal iliac artery, informs us, that " one of the first surgeons in London had a patient with glutaeal aneurism. The tumour was large ; allowed to burst ; and the person bled to death. " I sincerely trust, says he, that the fol- lowing case may be the means of preventui; such an occurrence in future. " Maila, a negro-woman, from the Bam- bara country in Africa, went imported «- a slave into the West Indies in the year 1790. She was purchased for the estate Enfield Green ; now the property of the heirs of P. Ferrall, Esq. I saw her first iu the beginning of December, 1812. She had a tumour on the left hip, over the scia- tic notch. It was nearly as large as achflo*' head, and pulsating very strongly. She could assign no cause for the disease. It had commenced about nine months before, with slight pain in the part; and had gradual- ly increased to its present size. She was now much reduced, in great misery, ape ready to submit to any operation." (?f Medico-Chir. Trans. Vol. 5. p. 425.) After a few more particulars, Mr. Stevem notices, that he had tied the internal iliar on the dead body, and that he believed i might be done with safety on the living- The following is some account of this operation, as practised upon the above ne- gro-woman. " On the 27th December, 1812, (saja Mr. Stevens,) I tied the artery in the pre- sence of Dr. Lang, Dr. Van Brackle, »Vh Nelthropp, and Mr. Ford, tbe manager of the estate. " An incision, about five inches in length. was made on the left side, in the lower and lateral part of the abdomen, parallel *& the epigastric arterv. and nearlv half »» ANEURISM. is I ineh on the outer side of it. The skin, the superficial fascia, and the three thin abdo- minal muscles, were successively divided ; the peritoneum was separated from its loose connexion with the iliacus internus and psoas magnus ; it was then turned almost directly inwards, in a direction, from the anterior superior spinous process of the ilium, to the division of the common iliac artery. In the cavity, which I had now made, I felt for the internal iliac,insinuated tbe point of my fore-finger behind it, and then pressed the artery betwixt my finger and thumb. Dv. Lang now felt the aneu- rism behind ; the pulsation had entirely ceased, and the tumour was disappearing. I examined the vessel in the pelvis; it was healthy and free from its neighbouring con- nexions. I then passed a ligature behind the artery, and tied it about half an inch from its origin. The tumour disappeared almost immediately after the operation, and the wound healed kindly. About the end of the third week the ligature came away, and in six weeks the woman was perfectly well." , This is the first, example, in which the internal iliac has been tied. The operation was not attended with much difficulty, nor pain, and not an ounce of blood was lost. Mr. Stevens had no difficulty in avoiding the ureter, which, when the peritoneum was turned inwards, followed it. Had it remained over the artery, Mr. Stevens says, that he could easily have turned it aside with his finger. (See a particular history of this case in.M.dico-Chirurg. Trans. Vol. 5, p. 422, he.) A second instance, in which the internal iliac artery was tied, was some time ago communicated to the public. The opera- tion was performed by Mr. Atkinson, of York, on account of a glutaeal aneurism. The following are a few of the parti- culars, as related by this gentleman: Thomas Cost, aged 29, presented himself at the York County Hospital, April 29th, 1817. He was a tall, strong, active bargeman, not corpulent, but very muscular. He was en- during great pain from a large renitent, pul- sating tumour, situated under the gluta;us of the right sida ; an obvious aneurism. It had existed about nine months, and was the consequence of a blow from a stone. In a consultation with Dr. Lanson and Dr. Wake, the necessity of the operation was de- termined upon, and it was performed onthe 12th of May, withoutany material difficulty, or interruption, except such as was the con- sequence of the division of, and bleeding from, the small muscular arteries. Havinggot command of the internal iliac artery within the pelvis, (which, says Mr. Atkinson, re- quired the complete length of the fingers to accomplish,) it was tied. Sufficient proof of its beins; the identical artery was re- peatedly obtained, by the pressure upon it stopping the pulsation, and causin.- a subsi- dence of tbe tumour. Dr. Wake, Mr. Ward and all the pupils, were quite assured of the circumstance. The artery being then tied the pulsation of the swelling entirely ceased. Some delay in placing the ligature arose from the needle not being sufficiently pliable; but, for future operations of this kind, Mr. Atkinson very properly recommends the ligature to be put round the artery by means ofan instrument, resembling a catheter, the wire of which has a little ring at its extre- mity, and can be pushed out some way be- yond the end of the tube. The patient went on tolerably well for some time after the operation ; the pulse never exceeded 130, and after a time sunk to 85 or 90. He became exhausted, how- ever, partly by the discharge, and partly by hemorrhage, and died on the 31st of May, about nineteen days after the opera- tion. Iu the dissection, the cavity, ou the external part of the peritoneum, in the situation of the incision, was completely filled with coagulated blood. " The ligature, on moving a part of this (blood) with a sponge, readily followed it, and, without doubt, had been disengaged for some days." The internal iliac, which appeared to have been tied, had separated about an inch and a half from the bifurcation with the external iliac. By " separated" I conclude Mr. Atkinson means that the upper part of the internal iliac was separated from the con- tinuation of the same vessel. (See Medical and Phys. Jour. vol. 38,p. 267, fa.) Although this gentleman has not given a very clear account of some part of the dissection, and he has also omitted to describe the place of his external incision, or the exact parts, which he divided in the operation, yet, I think that all the circumstances of the case taken together, leave not the smallest doubt, of the internal iliac artery having been ac- tually lied. The complete stoppage of the pulsation, as soon as the ligature was ap- plied, and the testimony of several respecta- ble practitioners, who were present, seem, indeed, to remove all ambiguity. The pro- fession, I think, are- much indebted to Mr. Atkinson for this important communication; which was in some measure, required, in order to confirm Mr. Stevens's similar case, as, it is well known, that some distinguished anatomists and surgeons in this metropolis have expressed very strong doubts of the practicable nature of the operation. In a modern publication are given a few particulars of a case, which was supposed to be an aneurism of the gluteal artery, and cured by means of pressure, a light vegeta- ble diet, gentle laxatives, and digitalis. (See Trans, of the Fellows, fa. of the King's and Queen's College of Physicians in Ireland, vol. 1, p. 41, 8i'o. Dub. 1817.) From the very imperfect account here given of the tumour, it is impossible to form any conclusion, re- specting its nature. Sandifort has recorded an instance of an aneurism of the internal iliac artery itself. (See Tabula; Anatomicte, fa. Pracedit Obs. de Aneurysmal Arteria. Iliaca: internee, rariore ischiadis Ntrvosne causa, fol. Lw«r, p. 215.) " In these cases (says Mr. Hodgson) the only unusual circumstances, which was observed during the life of the patients, was the deficiency of the pulse at the wrist. The limbs were well nourished, although a considerable extent of the main artery (the subclavian) was obliterated, even before it had given off any branches." (P. 47) This vessel w.is tied by a Mr. Hall in Cheshire, when it had been grounded with a scythe, and its ends exposed ; the arm was preserved, though it remained somewhat weakened, which might be owing to the division of some large nerve. (See J. Bell, on Wounds, p. 60, edit. 3, and Scaipa, p. 372.) Mr. White, of Manchester, relates another instance of this vessel being tied, in the case of a wound ; but, mortification of the limb"and death followed. Three of the nerves were found included iu the liga- ture. (London Med. Journ. V. 4.) In cases of wounds of the axillary, or any other large arteries of the extremities, the surgeon, before proceeding to apply a ligature, should first ascertain the precise place of the wound in the artery ; and, for this pur- pose, it may sometimes be proper, in cer- tain wounds of the shoulder, to make an incision in the axilla so as expose the inju- red part of the vessel ; or, if circumstances do not forbid it, the external wound may be dilated, until the exact part where the arte- ry has been wounded is discovered. In proof of the propriety of acting in this manner, and applying a ligature above and below the wound in the vessel, Scar- pa quotes a case, in which such pract ce was successful on a patient under M. Maunoi., of Geneva : t,ie artery had been injured with a sabre near the head of the humerus : but, after the wounded part of the vessel had been traced, and secured in the way above suggested, the patient a boy fourteen years of a<;e, was saved from the dangers of hemorrhage and recovered the use of his arm, as fast as tHis was possi- ble, with trfe loss of the first phalanges of the three last fingers from {.-angrene. (See Scarpa on Aneurism, p. 412, Ed. 2, and Journ. de Med. T. 40, Mars 1811.) There are two modes of operating for axillary aneiivi'ms; one by cutting below the clavicle, in order to take up the axillary artery itself; tbe ether, by making the wound above the bo»e, for the purpose « securing the subclavian artery at the point where it emerges from behind the auterior scalenus muscle. The. first of these methods has been at- tempted by Desault, Pelletan, Mr. Ketite, Mr. Chamberlaine, &-c It was in a caseof wound of the axillary artery, that Desault operated. An incision, six inches long, wai made below the external third of the clavi- cle ; two thoracic arteries cut were imme- diately tied ; the two lower thirds of the great pectoral muscle were next divided with a bistoury guided on a director: a large quantity of coagulated blood was now discharged ; and the artery was directly (j. ken hold of, and tied, together with the brachial plexus of the nerves. The arm mortified, and the patient died. This can, we must agree with Scarpa, was not a fair trial of the operation, inasmuch as Ihe in- clusion of the plexus of nerves in the li^n- ture was an improper measure, and must have promoted the occurrence of sphacelus. It seems also probable from the account, that the vein was likewise tied; another serious and objectionable proceeding. Be- sides, it is worthy of notice that the case was a wound of the axillary artery, attend- ed with a copious effusion of blood in the cellular membrane. In all examples of rhii kind, gangrene is more readily induced, than when the case is a i.ere circumscribed aneurismal tumour. (See QZuvrtt Chir.di Desault par Bichal, Tome 2, p 553.) As for Pelletan's example, it hardly deserve! ret-i tal, because the operation in fact was not achieved. His colleagues objected to di- viding the pectoral muscle; a random thrust was made with a needle and liga- ture ; but, the artery was not included, and the experiment was not repeated. (See Clinique Chirurgicale, Tom. 2, Obs. 7, p.49) In a case of axillary aneurism, which had actually burst, and the hemorrhage from which could only be stopped by pressing the artery against tbe first rib, Mr. Keate, the surgeon-general, practised the follovvinj operation, which was attended with com- pletely successful consequences. This Rea- tleman determined on taking up tbe artery above the dise;;ed and ruptured part,jn ''' passage over the first ri! Accordingly, he mad.' an incision obliqurly downw;irds,Ji- vided the fibres of the pectoral muscle, ihatt were in h;s way, and, when he came to the artery, passed a curved, blunt-pointed, sil- ver needle, armed double, as he conceived under the artery, and tied two of the er.d* After a careful examination, finding that the artery pulsated below the ligature, ht de- termined on passing another ligature bighsi up, and nearer to the clavicle : he, die**" fore, passed the needle more deeply,'° ,5 evidently to include the artery. In a f** days the swelling of the arm began to sub- side, the wound suppurated, and the h> tures came away with the dressings. The arm afterwards recovered its feeling, »" II.c patient regained, in a preat mease* VNXURIS.U 183 ihe entire motion of i ;.e> shoulder, &,c. (See Med. Review and Magazine for 1801.) Mr. Keate's operation is objectionable, inasmuch as it was a dive made with a needle, and attended with great danger of wounding and tying parts which should be left undisturbed. Mr. R. Chamberlaine, of Kingston, Ja- maica, took up the axillary artery below the clavicle, in a patient, who had an aneu- rism in the left axilla, occasioned by a wound with a cutlasa on the fifth of October, 1814. On the 10th of January, the tumour had considerably increased, and was less compressible than it had been when first seen by Mr. Chamberlaine. The operation was done on the 17th of January, 1815 : " a transverse incision, of three inches in length, was made through the skin and pla- tysma myoides, along and upon the lower edge of the clavicle, three fingers' breadth from the sternal end of that bone, and ter- minating about an inch from tbe acromion scapulae. This incision divided a small ar- tery, which was immediately secured. A second incision, of three inches in length, was also made obliquely through the inte- guments over the deltoid and pectoral mus- cles, meeting the first nearly in the centre. The cellular membrane and fat, lying be- tween them at the upper part, were now removed. The next step consisted in de- taching the clavicular portion of the pecto- ralis major, and taking away the fat and cellular membrane lying over the subcla- Tian vessels. The artery was now brought into view, and its pulsations made it clearly distinguishable from the contiguous parts." After several ineffectual efforts, Mr. Cham- berlaine succeeded in conveying a ligature under it, by means of an eye-probe, curved for the purpose, and the point of which was brought up with the aid of a pair of forceps. On the 22d of February, the wound was completely healed ; the aneurismal tumour reduced to the size of a turkey's egg, and very solid ; the arm smaller than its fellow, but its muscular power improving. (See Medico-Chv. Trans. Vol. 6,p. 128, fa.) Mr. Chamberlaine expresses his conviction, thatthe operation would have been much facilitated, had he been furnished with the instruments described in Mr. Ramsden's work for passing the ligature under the artery. The subclavian artery might be got at below the clavicle, as follows : the surgeon is to make an incision, through the integu- ments, about an inch from the sternal end of this bone. The cut is to run in the di- rection towards the acromion, deviating a little downward from a line parallel to that of the clavicle. This wound will bring into view some fibres of the great pectoral mus- cle originating from the last-mentioned bone. These are next to be divided. Some cellular substance will be found under- neath, which is to be carefully raised with a pair of dissecting forceps, and cut. The operator will thus arrive at the great sub- rfavian vein, and cephalic vein uniting with ^ or. f. •" it. Under the subclavian vein, and a iittl? further backward, more under the clavicle, the subclavian artery may be felt and tied. (See C. Bell's Operative Surgery, Vol. 2. p. 370.) On the whole, however, I think, Mr. Hodgson's directions for the performance of this operation, are the. best which have been given. A semilunar incision through the integuments, which is to have its con- vexity downwards, and to begin about an inch from the sternal end of the clavicle, being continued towards tbe acromion for the extent of three or four inches, so as to end near the anterior margin of the deltoid muscle, without reaching into the space be- tween the deltoid and pectoral muscle, in order to avoid wounding the cephalic vein. This incision will expose the fibres of the pectoral muscle, which are now to be di- vided in the direction and extent of the ex- ternal wound. The flap is then to be rai- sed, by dividing the loose cellular mem- brane, which connects the pectoral mus- cle to the parts underneath it. Tbe pecto- ralis minor will now be seen crossing the. inferior part of the wound; and by intro- ducing his finger between the upper edge of this muscle and the clavicle, the surgeon may feel the pulsations of the axillary arte- ry. Here one of the cervical nerves lies above, but in contact with the artery ; the other nerves are behind it. In the dead subject, the axillary vein is situated below it; but, in the living, the vein is distended,- and conceals the artery. The cellular membrane, connecting these parts, is to be- separated by careful dissection, or by lace- rating it with a blunt instrument. A liga- ture having been drawn under the artery with an aneurism-needle, the ends of the cord are to be raised, and a finger passed. down, so as to compress the part surround- ed by the ligature. If the arteiy be inclu- ded, the pulsation in the aneurism will im- mediately cease. This precaution is highly necessary, lest one of the cervical nerve* should be tied, instead of the artery. (See Hodgson on Diseases of Arteries, fa. p. 362.) When an aneurism extends a certain way inwards, or towards the trachea, the opera- tion below the clavicle becomes impracti- cable, and it is now requisite to make the incision above that bone, and take up the subclavian artery at the point, where it comes out from between the scaleni mus- cles, and lies on the flat surface of the first rib. In the dead subject, without any tumour under the clavicle, this operation is easy enough ;" but in a living patient, the diffi- > culty is much increased, by a large axillary aneurism, for then the clavicle becomes so much elevated, and the. artery lies so deeplv below it, that the vessel can hardly have "a ligature carried under it, without a particu- lar needle for the purpose. This was the ca?^ in an attempt which I once saw made to tie the artery, and in which one of the cer- vical nerves, affected by the pulsation of the artery, was mistaken for it, and tied, so 18G ANEURISM- that the aneurism .s.rou atterw ards burst, and a fatal hemorrhage arose. Hence, the ad- vice given by my friend Mr. Hodgson always to operate in this case while the tu- mour is small, cannot be too well remem- bered. The chief difficulty in the operation is that of passing the ligature under the ar- tery ; but, it may be done with the aid of an ingenious needle, which Mr. Ramsden has described, and which is exactly similar in principle to Desault's aiguille c\ rcssort. In order to avoid the inconveniences of the needles ordinarily used for conveying ligatures under deep arteries, Desault (says Bichat) invented " une aiguille a ressort." composed of a silver tube, or sheath, which was strait at one end, and bent at the other in a semicircular form. This sheath enclo- sed an elastic wire, the projecting extremi- ty of which was accurately fitted to the end of the sheath, and perforated with a t.ans- verse eye. The instrument was passed un- der tbe artery, and, as soon as it had reach- ed the other side of the vessel, the sheath was kept fixed, while an assistant pushed the elastic wire, which,rising from the bot- tom of the wound, presented the aperture or eye to the surgeon, who now passed the ligature through this opening. The wire was next drawn back into its .sheath again, aud tbe whole instrument brought from be- neath the artery, by which means the liga- ture was conveyed under the vessel. (See CEuvres Chir.de Desault, par Bichat, Tom. 2, p. 560.) The invention of this needle makes a ma- terial diminution in the difficulty of taking up the subclavian artery from above the clavicle; nor can it be wondered, that, without such an instrument, the operation should have baffled even so skilful a surgeon as Mr. A. Cooper. (See Lond. Med. Re- view. Vol. 2, p. 200.) The following example is the first, in which the attempt to tie the subclavian ar- tery by cutting above the clavicle, was ever accomplished. John Townly, a tailor, aged thirty-two, addicted to excessive intoxication, of an un- healthy and peculiarly anxious counte- nance, was admitted into St. Bartholomew's Hospital on Tuesday the 2d of November, 1809, on account of an aneurism in the light axilla. The prominent part of the tu- mour in the axilla was about half as big as a large orange, and there was also much en- largement and distention underneath the pectoral muscle, so that the elbow could not be brought near the side of the body. " The temperature of both arms," says Mr. Ramsden, " was alike, and the pulse in the radial artery of each of them was cor- respondent. After the patient had been put to bed, some blood taken from the left arm, and his bowels emptied, his pulse, which, on his admission, had been at 130, became less frequent; his countenance ap- peared more tranquil; and he experienced some remission of the distressing sensations in the affected arm; this relief, however, was of short duration; (he'weisht and in- cumbrance of his arm soon became more and more oppressive, and, in resistance to every medical assistance, his nights were again passed without sleep, and his counte- nance reassumed the anxiety which had characterized it when he first presented himself for advice." On the sixth day after his admission, it was agreed, in consultation, that as the tu- mour (although increasing) did not appear immediately to endanger the life of the pa- tient, from any probability of its bursting suddenly, it would be adviseable yet to post- pone the operation,for the purposed allow- ing the greatest possible time for the anas- tomosing vessels to become enlarged; and, in the meanwhile, that the case should be most vigilantly watched. "* About this period of the case, the pulsa- tion of the radial artery of the affected arm gradually became more obscure, and soon after cither ceased, or was lost in the oede- ma of tbe forearm and hand. On the evening of the twelfth day, a dark spot appeared on the centre of the tumour. surrounded by imflammation, which threa- tened a more extensive destruction of the skin. A father postponement of the ope- ration being deemed inadmissible, Mr. Ramsden performed it the next day in the following manner: " A transverse incision was made through the skin and platysma myoides atdtg, and upon the upper edge of the clavicle, about two inches and a half in length, beginning it nearest to the shoulder, and terminating its inner extremity at about half an inch within the outward edge of the stemo- cleido-mastoideus muscle. This incision divided a small superficial artery, which was directly secured. The skin, above the clavicle, being then pinched up, between my own thumb and finger, and those of an assistant, I divided it, from within, outwards and upwards, in the line of the outward edge of the sterno-cleido-mastoideui mns- cle, to the extent of two inches. " My object, in pinching up the skin for tbe second incision, was to expose at once the superficial veins, and by dissecting them carefully from the cellular membrane, to place them out of my way, without wounding them. This provision provedte be useful, for it rer.dered the flow of blood during the operation very trifling, compa- ratively with what might otherwise have been expected ; and thereby, enabled me with the greatest facility to bring into vie* those parts, which were tov direct me to the artery. " My aasistant having now lowered the shoulder, for the purpose of placing tr> first incision above the clavicle, (whicl 1 had designedly made along and upon nV.t bone) 1 continued the dissection with my scalpel, until I bad distinctly brought into sight the edge of the anterior scalenus mus- cle, immediately below the angle, which is lormed by the traversing belly of the omo- hyoideus.andthe edge of thesterno-cleid"- rnastoideus and bavin? placed my finr ANEURISM. uu the artery, at the point where it presents itself between the scaleni, I found no diffi- culty in tracing it without touching any of the nerves to the lower edge of the upper rib, at which part, I detached it with my finger nail for the purpose of applying the ligature. " Here, however, arose an embarrassment, which (although I was not unprepared for it) greatly exceeded my expectation. I had learned from repeatedly performing this operation, many years since, on the dead subject, that to pass the ligature under the subclavian artery, with the needle com- monly uaed in aneurisms, would be imprac- ticable ; 1 had, therefore, provided myself with instruments of various forms and cur- vatures to meet the difficulty, each of which most readily conveyed the ligature underneath the artery; but, would serve me no farther; for, being made of solid materials, and fixed into handles, they would not allow of their points being brought up again at the very short curva- ture, which the narrowness of the space, between the rib and the clavicle, afforded, and which, in this particular case, was ren- dered of unusual depth, by the previous elevation of the shoulder by the tumour. " After trying various means to overcome this difficulty, a probe of ductile metal was at length handed me, which I passed under the artery, and bringing up its point with a pair of small forceps, 1 succeeded in passing on the ligature, and then tied the subclavian artery at the part, where I had previously de- tached it for that purpose. The drawing ofthe knot was unattended with pain, the wound was closed by the dry suture, and the pa- tient was then returned to his bed." (See Practical Observations on the Sclerocele, fa. to which are added four cases of operations for Aneurisms, p. 276, fa.) It only seems necessary for me to add, that immediately, the artery was tied, the pulsation of the swelling ceased ; that the arm of the same side continued to be freely supplied with blood, and was even rather warmer than the opposite arm ; that the operation, which was severe from the length of time it took up, was after a time followed by considerable indisposition; that the patient died about five days after its performance ; that, after the artery had been tied, the oedema of the arm, and the aneurismal tumour partly subsided; and, that on examination after death, nothing, but the vessel, was found included in the ligature. In this publication are descriptions of instruments, which will be of great service to any future performer of this operation. The chief one is a needle, resembling that, which was invented and used by Desault, and of which 1 have already endeavoured to give an idea By means of this instrument, I conceive, that the main difficulty of the operation will not in future be experienced. Had Mr. Ramsden had its assistance, his patient would have been detained a very little time in tbe operating theatre, and the event of the case might have been com- pletely successful. Having witnessed all the circumstances of the case, the infer- ence, that I drew from them was, that, ii the operation could have been done in a moderate time, which now seems practi- cable with the aid of the aiguille a ressort, the case in all probability would have end- ed well. The preceding case is particu- larly memorable, as being the first instance, in which the subclavian artery was scienti- fically tied, without any random thrust of a needle, and without the inclusion of any part besides the artery in the ligature. It furnished encouragement to repeat the ex- periment, held out the hope, that axillary aneurisms might be cured as well as inguinal ones; and confirmed the competency of the anastomosing arteries to nourish the whole upper extremity, when the subcla- vian is tied where it emerges from behind the anterior scalenus muscle. In the year 1811 the subclavian artery was tied in the London Hospital, in a case of axillary aneurism, by Sir W. Blizard, who found no difficulty in getting the liga- ture under the artery, with a common aneu- rism needle. A single ligature was applied. At first, hopes of recovery were eutertained; but the patient, who was old and debilitated, afterwards sunk, and died on the fourth day. (See Hodgson's Treatise, p. 375.) In the year 1815, Mr. Thomas Blizard tied the subclavian artery, in the same hos- pital. The case was an aneurism in the left axilla, and, like all the other examples of this kind upon record, was attended with great pain in the tumour and limb. There was no pulse in the left radial artery, though there was scarcely any difference in the temperature of both arms. " An incision, about three inches in length, was made through the integuments at the root of the neck, on the acromial side, and parallel with the external jugular vein. The pla- tysma myodes being divided, the cellular membrane was separated with the finger, until the pulsation of the subclavian artery was felt where the vessel passes over the first rib. The finger being pressed upon this part of the artery, the cellular sheath investing it was carefully opened with the point of a knife. A ligature was then con- veyed underneath the artery, by a common aneurism-needle with the greatest facility." As soon as the ligature was tied, the pulsa- tion in the tumour ceased. On the second day after the operation, the left arm began to have more feeling, and was as warm as the right. However, difficulty of breathing, twitchings, delirium, he. afterwards ensued, and the patient died on the evening of the eighth day, previously to which event the ring and middle fingers turned black. On opening the body, the pericardium exhibi- ted the effects of a high degree of inflam- mation, and the heart was covered with flakes of lymph, its posterior surface being of a deep red colour. The inner membrane of the ascending aorta was of a bright scar- let hue, was much diseased and studded 188 AMiLlUSM. with white patches. A rciHtish appearance was also noticed in the lining of the right carotid, left subclavian, and even the abdo- minal aorta. The boundaries of the aneu- rismal tumour were in astate of sphacelation. These are all the circumstances which I wish here to notice ; but more particulars may be perused in Mr. Hodgson's work, p. 602. It is remarkable, that in the cases opera- ted upon in the London Hospital, there was no difficulty experienced in passing the liga- ture under the artery with a common aneu- rism-needle, a circumstance which must have depended upon the space between the clavicle and the first rib having been less deep in these instances than tbe two which fell under my own observation, or in others which occurred in the practice of Dr. Colles and Mr. A. Cooper. (See Lond. Med. Re- iieu,vol. 2. p. 200, and Edinb. Med. and Surg. Journ. January, 1815.) In Dr. Colles's first case, the artery was lied before it reached the scaleni muscles, as the tumour, which was in the right subcla- vian artery, extended from the sternal ori- gin of the .-terno-mastoid muscle along the clavicle, a little beyond the arch of that bone, and rose nearly two inches above it, in a conical form, the apex of the cone be- ing situated at the outer edge of the forego- Snic muscle. After a tedious dissection, it was found, that only a quarter ofan inch of the artery wvs sound, and on this portion the ligature was placed. Great difficulty was encountered in passing it round the ar- tery, and the pleura was supposed to have been slightly wounded. Before tightening the ligature, the breathing became labo- rious, and the patient complained of oppres- sion about the heart. These symptoms, in- deed, were so violent, that it was judged prudent not immediately to tighten the li- gature. On the fourth day, however, the artery was constricted, when the pulse at the wrist ceased, the patient not seeming to suffer much from what had been done. The patient then went on pretty well till the ninth day, when he was seized with a sense of strangling, and pain about his heart, and becoming delirious, died in nine hours after the beginning of this attack. Ou dissection, the aorta was found diseased, and the dis- ease extending into the subclavian arteiy. In another instance, Dr. Colles tied this vessel at tbe point, where it emerges from between the scaleni muscles, without any particular difficulty. The operation, how- ever, w as soon followed by a train of severe symptoms, delirium, and mortification, and the patient died on the fifth day. (See Edinb. Med. and Surg. Journ. January, IS 15.; The first case, in which complete success attended the operation of tying the subcla- vian artery, where it first comes from be- hind tbe anterior scalenus muscle, was that under the care of Dr. Post, of New-York. The patient wasa gentleman, with an aneu- rism in tbe left axilla. Dr. Post performed the uperaflon on tbeSthof September, 1817, in the following manner. u An incision, commencing at the outer edge of the ten- don of the mastoid muscle, was carried through the integuments about three inches in length, in a direction deviating a little from a parallel line with the clavicle. This divided the external jugular vein, the bleed- ing of which required a ligature for its sup. pression ; and, in proceeding with the ope- ration, three or four arterial branches were cut, which it was also necessary to secure. The subclavian artery was then sought for immediately external to the scaleni muscles, and was easily laid bare. Passing over the artery at this place, in contact with it, were three considerable branches of nerves, run- ning downwards towards the chest, from tbe plexus above. These were separated, and a ligature passed under the artery, with great facility, by the instrument well adapt- ed to this purpose, invented by Drs. Parish, Hartshorne, and Hewson, of Philadelphia. On tying tbe ligature, all pulsation ceased in the limb." In the afternoon, the tempe- rature of the limb was observed to be rather higher, than that of the other arm. On the 17th of September, the aneurismal tumour burst, and about three ounces of dark coa- gulated blood were discharged. On the 26th the ligature came away from the sub- clavian artery. Oct. 11, the wound was entirely healed, and on the 16th of the same month, the patient required no further at- tendance, his only complaints being now a little occasional pain in the fingers, and a superficial sinus at the part where the tu- mour burst. (See Medico-Chir. Trans.vol.9. p. 185, fa.) The instructions, delivered by Mr. Hodg- son, for the performance of this operation, are the best with which 1 am acquainted. When the subclavian artery (says this gen- tleman) has emerged from behind the ante- rior scalenus muscle, it passes obliquely- over the flat surface of the first rib, with which it is in immediate contact. The cer- vical nerves are situated above, and a little behind the artery: the subclavian vein passes before it, and underneath the clavi- cle. If the finger be passed down the acro- mial margin of the anterior scalenus muscle, the artery will be found in the angle, form- ed by the origin of that muscle from tbe first rib. The shoulder being drawn down as much as possible, tbe skin is to be divi- ded, immediately above the clavicle, from the external margin of the clavicular por- tion of the mastoid muscle, to the margin of the clavicular insertion of the trapezius. No advantage whatever is gained by cutting the clavicular attachment of the steruo- cleido-mastoideus. The exposed fibres of the platysma myodes are now to be care- fully divided, without wounding the exter- nal jugular vein, which lies immediately under them, near the middle of the incision, and should be detached, and drawn towards the shoulder with a blunt hook. The cellu- lar membrane, in tbe middle of the incision, is then to be cut, or separated with the fin- ger, until the surgeon arrive* at the ar.ro' ANEURISM- USt niial edge of the anterior scalenus. He passes his finger down the margin of this muscle, until he reaches the part where it arises from the first rib, and in the angle, formed by the origin of the muscle from the rib, he will feel the artery. The liga- ture is now to be conveyed under the ves- sel, with an aneurism-needle, or that re- commended by Desault. ( Hodgson on the Diseases of Arteries, fa. p. 376, fa.) Breschet thinks, that the safest and easi- est method is that adopted by Dupuytren, as follows : an incision, three or four inches long, is to be made at the lower and outer part of the neck, and extended to the cla- -vicle. This first incision, situated behind the external edge of the sterno-mastoid muscle, should go through the skin, the cel- lular membrane, and platysma myoides. Some venous branches, running into the jugulars, will then be met with, which should be surrounded by a double ligature, and divided in the interspace. A director is then to be introduced under the omohyoi- deus muscle, in order to facilitate its divi- sion, and the surgeon will at length reach the external edge of the anterior scalenus. A curved probe-pointed bistoury is then to be gradually and cautiously passed behind that muscle, with the flat surface of the blade against it, and deeply enough to di- vide the external third, or half of the fibres of the same muscle, or even all of them, if requisite. The insulated artery will then be felt at the bottom of the wound, situated in the area of a triangle, the upper side of which is formed by the brachial plexus, the lower by the subclavian vein, and the in- ner by the scalenus. A ligature is then con- veyed under the artery by means of the needle invented by Deschamps. (See French Transl. of Mr. Hodgson's work, T. 2, p. 126.) Whether cutting the anterior scalenus and omohyoideus will facilitate the operation is questionable; but the assertion, that these measures increase its safety, is what I cannot understand. With respect to the mode of tying the subclavian artery on the tracheal side of the scalenus, we have seen that it was perform- ed by Dr. Colles, and the event of the case was fatal. Descriptions of the operation may be found in Mr. Hodgson's work, p. 382. When I consider the manner in which the subclavian artery, before it passes be- hind the anterior scalenus, is surrounded by parts of great importance, I can scarcely bring my mind to think, that the measures, requisite for taking up the vessel in this si- tuation, will ever leave the patient much chance, of recovery. " Between the aorta and scaleni muscles (says Mr. A. Burns) the subclavian arteries are connected with several important vessels and nerves. They are in the vicinity of the nervus vagus, of the recurrent laryngeal nerve, of the sym- pathetic nerve, of the phrenic nerve, and the subclavian vein ; and, on the left side, (he subclavian artery is intimately connect- i-d with the termination of the thoracic »«''ict. The e parts are all grouped together iu a very narrow space?, and the perplexity of their dissection is further increased by the interlacement of the different nerves with one another. The natural connex- ions of these parts are best shown by mere- ly raising the sternal extremity of the sterno-mastoid muscle. If this be done, the nervus vagus will be brought into view, lying on the forepart of the subclavian ar- tery, almost directly behind the sternal end of the clavicle ; and exactly opposite to thrj nervus vagus, but behind the artery, the lower cervical ganglion of the sympathetic nerve will be brought into view. The re- current nerve, on the right side, hooks round the subclavian artery, and, in its course towards the larynx, ascends along the tracheal side of the sympathetic nerve. On the left side, it twines round the arch of the aorta, and, in mounting upward, is in- terposed between the subclavian artery and oesophagus. The subclavian vein lies an- terior to the artery, and, in [the col- lapsed state, sinks nearer to the thorax;" but, when distended in the living body, it overlaps the artery. The thoracic duct en- ters the subclavian vein, about the eighth of an inch nearer to the acromion than the point, where the internal jugular vein emp- ties itself into the subclavian vein. The termination of the thoracic duct is situated between tbe sternal and clavicular portions of the sterno-mastoid muscle. (A. Burns, on the Surgical Anatomy of the Head and Neck, p. 28.) It has been proposed to tie the arteria in- nominata in cases of aneurism of the subcla- vian artery. From a variety of facts, spe- cified by a late interesting writer, it seems probable, that the brain and arm would re- ceive an adequate supply of blood, although the arteria innominata were obliterated. On the whole, however, I fully coincide with Mr. Hodgson in condemning the pro- posal. The chief objections to it arise from the difficulty of the operation in the livin«- subject; from the inflammation likely fobs thereby excited among the important neigh- bouring parts; from tbe dan«er of hemor- rhage, iu consequence of the adhesion of the vessel being likely to be broken by the force of the circulation; and, lastly, from the equal practicableness of tying the subcla- vian artery, in most cases, on the tracheal side of the scalenus. (See Hodgson on Dis- eases of Arteries, p. 384.) A case, in which an axillary aneurism, unattended with pulsation, was punctured, and the child bled to death, is noticed in a modern periodical work. (See Med. Chir. Journ. vol. 4. p. 78) For anatomical views of the parts con- cerned in the operation of taking up the subclavian artery, consult Rosenmuller's Chir. Anat. Plates, Part 2, Tab. 8 and 9.) Some Valuable anatomical remarks, in relation to the operation, are given by Mr. A. Burns. (Surgical Anatomy of the w»<' and Neck. p. 2S. ^i-O 1W ANEURISM CAROTID A5ECRJSU5. There is no part of the body where the diagnosis of aneurisms is more liable to mis- fake, than in the neck. Here the disease is particularly apt to be confounded with tumours of another nature. We have al- ready cited, in this article, examples in which aneurisms of the arch of the aorta so resembled those of the carotid, as to have deceived the surgeon who was consulted. The swelling of the lymphatic glands, or of the cellular substance which surrounds the carotid artery ; the. enlargement of the thyroid gland; and especially abscesses, may resemble an aneurism by the pulsa- tions, communicated to them by the neigh- bouring artery On the other hand, aneu- risms of long standing, which no longer throb, and the integuments over which are changed in colour, and likely to burst, may the more easily be mistaken by an inatten- tive practitioner for chronic abscesses, as the neck is remarkably often the seat of such diseases. (Boyer, Traite1 des Maladies Chirurgicales, t. 2, f. 185.) Scarpa mentions one unfortunate patient, who was killed by a knife being plunged in a carotid aneurism, on the supposition that the case was an abscess. I need scarcely observe, that by opening a carotid aneurism, a surgeon would ex- pose himself to the disgrace and mortifica- tion of seeing the patient die under his bands, as happened in tbe example cited by Harderus. (Apiar. Observationum, Obs. 86.) The possibility of tying the carotid artery, in cases of wounds and aneurisms, with- out any injurious effect on the functions of the brain, is now completely proved. Petit mentions, that the aJvocate Viellard, had an aneurism at the bifurcation of the right carotid, for the cure of which he was order- ed a very spare diet, and directed to avoid all violent exercise. Three months after this prescription, the tumour had evidently diminished ; and, at last, it was converted into asmall, hard, oblong knot, without any pulsation. The patient having died of apo- plexy, seven years afterwards, the right ca- rotid was found closed up and obliterated, from its bifurcation, as low down as the right subclavian artery. (Acad, des Sciences de Paris, an. 1765.) Haller dissected a wo- man whose left carotid was impervious. Opuscula Pathol. Obs. 19, Tab. 1.) An ex- ample of the total closure of both carotids, in consequence of ossification, is stated by Koberwein to be recorded by Jadelot. (German Transl. of Mr. Hodgson's work, p. 293.; Hebenstreit, vol. 4, p. 266. ed. 3. of his Translation of B. Bell's Surgery, men- tions a case, in which the carotid artery was wounded, in the extirpation of a scirrhous tumour. The hemorrhage would have been fatal, had not the surgeon immedi- ately tied the trunk of tbe vessel. The pa- tient lived many years afterwardV. This is probably the earliest authentic instance, in which a ligature was applied to the carotid nr'e'-v Mr. /Wrrr-*'-y'; cafe is perhaps the second ; and that in which Mr. Fleui- ing, a naval surgeon, tied the common caro- tid in a sailor, who attempted suicide, and who wassaved by the operation, is still later, not having occurred till the year 1803. (See Med. Chir. Journ. vol. 3. p. 2.) Dr. Baillie knew an instance, in which on* carotid was eutirely obstructed, and tLr diameter of the other considerably lessened, without any apparent ill effects on the brain! (See Trans, of a Society for the Impmt. ment of Med. and Chir. Knowledge, vof.l.p. 121.) Mr. A. Cooper has also recorded an example, in which tbe left carotid wus ob- structed by the pressure of an aneurism of the aorta ; and yet, during life, no paralyaii, nor impairment of the intellects had occur red. (See Med. Chir. Trans.vol. l.p.223.) A similar case is related by Pelletan. (C/iroW Chir. t. l.p.68.) Mr. Abernethy was under the necessity of tying the trunk of the carotid, in the cue of a large lacerated wound of the neck, in which accident the internal carotid and tbe chief branches of the external carotid were wounded. Tbe patient at first went on wall-, but, in the ni^ht, he became delirious and convulsed, and died about thirty hours after the ligature was applied. This case fell under my own notice, and the inference which 1 drew was, that the man died mora from the great quantity of blood which ha lost, and the severe -mischief done to tbe parts in the neck, than from any effect of the ligature of the artery on the brain. In another instance, in which the common carotid was tied, on account of a wound of the external carotid, by a musket-ball, complicated with fracture of the condyle and coracoid process of the lower jaw, every thing went on favourably until the seventh day after the operation. Neither the intellectual faculties, nor the functions of the organs of sense, had been at all dis- turbed. But, at that period, stupor,conn- sion of ideas, restlessness, a small unsteady pulse, discoloration of the face, and loss of strength came on, followed in the eveningby a violent paroxysm of fever. On the eighth day, three copious hemorrhages took place from the whole surface of the wound, and, on the ninth, the man died. In this case, however, the affection of the brain, and tbe other unfavourable symptoms, would be ascribed by nobody to the effects of the liga- ture on the carotid, but every one would see the cause in the severe and extensi" local mischief, produced partly by the musket-ball, and partly by the mode in which the operation was perfonned,the sur- geon having extended his incisions from the parotid gland to within an inch of the clavicle ! (See Journ. Giniral de Mtd-f/t par Sedillot.) That the carotid may be tied without in- juring 'the functions of the brain, and lW aneurisms of this artery admit of beat? cured by the operation, is not fully prov^ The following is the second instance, ^ which I hsve been pre«ent at the operatioi A.\t,oUlaAi JII) •f tying the carotid trunk on account of a wound. A soldier of the 44th regiment was wound- ed in the neck, with a pike, at the battle of Waterloo, and was brought to Brussels. After he had been some little time in the hospital, the bleeding, which had stopped, recurred with great violence, both from the mouth and the external wound itself; and it was therefore judged necessary to tie the common carotid, which was done by my friend Mr. Collier. The operation was per- formed by making an incision along the inner edge of the sterno-cleido-mastoidsus, raising this muscle from the sheath including the artery, &c. and holding aside the jugu- lar and lower thyroid veins, which swelled up every instant to a very large size, so as to overlap the artery. This vessel being dis- engaged from the nerve, was then tied. Though the operation was done by candle- light, it was skilfully performed, and re- flects great credit on Mr. Collier. A detail of the case may be found in a modern work. (Med. Chir Trans, vol. 7. p. 107.) Another example, in which the carotid artery was tied, and the patient saved, in a case where it was wounded with a penknife, has been recently published by Dr. John Brown, surgeon to the county of Meath In- firmary. (See Dublin Hospital Reports, ool. l.p. 301, fa.) In this instance, the internal jugular vein " did not appear, nor was it a source of the slightest inconvenience during the operation." (P. 305.) A case, very analogous to the foregoing, is recorded by Mr. Hodgson, and the event equally suc- cessful. "The jugular vein afforded no trouble in the operation : it was not even seen." A gradual improvement of the pow- er of deglutition marked the gradual subsi- dence of tbe tumour, which pressed against the pharynx- Nor was any change percei- ved in the state of the patient's mind after this operation, who remained as she had been previously, melancholy and dejected. (P. 332.) Acrel mentions an example, in which the i arotid artery was wounded by a gunshot, and the hemorrhage permanently stopped by'compression. A similar cise is related by Van Home, in his annotations to the work of Botallus. (De Vvln. Sclopetis.) Baron Larrey has likewise related a case, in which the carotid was wo ::ided by a mus- ket-ball, and life saved by Ihe instant appli- cation of pressure. (Mem. de Chir. Mil. t l.p. 309.) However, considering the size of the vessel, and its unfavourable situation for being effectually and steadily compress- ed, some doubts may be entertained, whether the vessel wounded might not ra- ther have been one of its branches. On Friday, November 1, 1806, Mr. A Cooper operated on Mary Edwprds, aged forty-four, who had an aneurism ->i the right carotid artery. At tbi- time, the tumoar reached from the vicinity of the chin to beyond the an^le of the jaw, and down- ward to within two inches and a half from ihf clavicle. The swelling bau a strong pulsatory mo- tion. The woman also complained of a particular tenderness of the scalp, on the same side of the head, and of such a throb- bing in the brain, as prevented her from sleeping. An incision, two inches long, was made at the inner edge of the sterno-cleido-mas- toideus muscle, from the lower part of the tumour to the clavicle. This wound expo- sed the omo-hyoideus and sterno-hyoideus muscles, which being drawn aside toward* the trachea, the jugular vein presented it- self to view. The motion of this vein produced the only difficulty in the opera- tion, as, under the different states of breath- ing, the vessel sometimes became tense and distended under the knife, and then suddenly collapsed. Mr. A. Cooper introduced hi-- finger into the wound to keep the vein out of the way of the knife, and, having exposed the carotid artery by another cut, he passed two ligatures under this vessel by means of a curved aneurism-needle. Care was taken to exclude the recurrent nerve on the one hand, and the par vagum on the other. The ligatures were then tied about half an inch asunder ; but the intervening portion of the artery was left undivided. Tbe pulsation of the swelling ceased im- mediately the vessel was tied, and, on the day after the operation, the throbbing in the brain had subsided, while no diminution of nervous energy in any part of the body could be observed. The patient was occasionally afflicted with bad fits of coughing, but upon the whole, went on at first pretty well. On the eighth day, however, a paralysis of the left leg and arm was noticed, attended with a great deal of constitutional irritation. November 8th, the patient could move her arm rather bet- ter ; but became unable to swallow solids. Nov. 12th, the palsy of her arm had now almost disappeared. The ligatures came away. November 14th, she was in every respect better ; she swallowed with less dif- ficulty ; and the tumour was smaller, and quite free from pain. On the 17th, she be- came very ;ll ;the tumour increased in size, and was sore when pressed. Tbe wound was as large as immediately after the opera- tion, and discharged a sauious serum. Great difficulty of swallowing, and a most distress- ing cou^h, were also experienced. The pulse was nmet>-six, and the lef' arm again very weak. O- the 21st, the patient died, the difficulty of swallowing having pre- viously become (-till greater, attended with a fui cher increase of the tumour, tie skin over which had acquired a brownish red colour. On openirg the swelling after death, the ancurisinal sac was found inflamed, and the clot ot blood in it was suirouoded with a. considerable quantity of pus. The inflam- mation extended on the outside of the sac, along the par vagum, nearly to the basis of the skull. The glottis was almost closed, and the lining of the trachea was inflamed and rovered with coagulating lymph. The vNt.LrUSAi'- pharynx was so compressed by the tumour, which bad been suddenly enlarged by the inflammation, that a bougie, of the size of a goose-quill, could hardly be introduced into the cesophagus. Mr. Cooper concludes with expressing his opinion, that these causes of failure may, in future, be avoided f>y operating before ihe tumour is of such size ns to make pressure on important parts ; or, if the swelling should be large, by opening it, and letting out its contents, as soon as inflam- ynation comes on. (See Med. Chir. Trans. vol. 1.) Mr. Cline operated for a carotid aneurism, December 16, 1808, in St. Thomas's Hospi- lal. The tumour was very large, and bad increased with great rapidity. The pressure of the swelling was such, as to interrupt both respiration and deglutition, and to put the larynx out of its natural position. The patient had besides a frequent and trouble- some cough. The pain was confined to the tumour and same side of the face. These symptoms seemed relieved during the first twelve hours after the operation. They then became worse, particularly the cough and difficulty of breathing, and a violent irritative fever took place. The man died on the 19th of the same month. (See Lon- don Med. Review, No. 3.) In the month of June, 1808, Mr. Astley Cooper operated, in Guy'6 Hospital, on a man, aged 50, who had a carotid aneurism attended with pain on one side of the head, throbbing in the brain, hoarseness, cough, slight difficulty of breathing, nausea, giddi- ness, he. The patient got quite well, and resumed his occupation as a porter. There was afterwards no perceptible pulsation in the facial and temporal arteries of the aneurismal side of the face. On the opposite side, the temporal artery became unusually large. The tumour was at last quite absorbed, though a pulsation existed in it till the beginning of September. The man's intellects remained perfect; bis nervous system was unaffected ; and the severe pain, which, before the operation, used to affect the aneurismal side of the head, never returned. The swelling, at the time of tbe opera- tion, was about as large as a pullet's egg, and situated on the left side about the acute angle, made by the bifurcation of the com- mon carotid, just under the angleof the jaw. Mr. A. Cooper began the incision oppo- site the middle of the thyroid cartilage, at the base of the tumour, and extended the wound to within an inch of the clavicle, on the inner side of the sterno-cleido-mas- foideus muscle. On raising the margin of i his muscle, the omo-hyoideus could be distinctly seen crossing the sbeath of the vessels, and the nervus descendens noni was also brought into view. The sterno- rleido-mastoideus was now separated from the omo-hyoideus, when tbe jugular vein was seen. This vessel became so distended at every expiration as to cover the artery. When the vein was drawn to one side, the par vagum was manifest, lying between that vessel and the carotid artery, but a litllato the outer side of the artery. The nerve was easily avoided. A double ligature was then conveyed un- der the artery with a blunt iron probe. The lower ligature was immediately tied, and the upper one was also drawn tight, as soon as about an inch of the artery had been se- parated from the surrounding parts above the first ligature, so as to allow the spcood to be tied at this height. A needle and thread were passed through the vessel be- low one ligature, and above the other. The artery was then divided. la t little more than nine weeks, the wound was quite healed, and tbe patient entirely recovered. (See Med. Chir. Tram. Vol. ].) Another successful instance, in which the carotid was tied for the cure of an aneurism, is related in a work, to which 1 alwayi have the greatest pleasure in referring. (See Hodgson's Treatise on the Diseases of Arteries, p. 329.) Mr. Travers, surgeon to St. Thoma-'i Hospital tied the carotid artery in a woman who had an aneurism by anastomosis in the left orbit. The disease had pushed the eye out of its socket. Two small ligatures were applied, which came away on the twenty- first and twenty-second day. No hemor- rhage, nor impairment of the functions of the brain took place, and the disease in the orbit was effectually cured. (See Med. Chit. Trans. Vol. 2.) Another highly interesting example, in which an aneurism by anastomosis in the orbit was effectually cured by tying the carotid artery, is recorded by Mr. Dalrym- pie, surgeon at Norwich. This gentleman performed the operation on the 12th of November, 1812. The patient was a ftnale, aged 44. The protrusion of the eye was relieved in proportion as the swelling, di- minished. The violent headachs also sub- sided ; but the eyesight was irrecoverably lost. (See Med. Chir. Trans. Vol 6. p. 111.) An interesting case, in which my fritld Mr. Vincent tied the carotid trunk for an aneurism, is published in the 10th vol. of the latter work. (P. 212, he.) In this eiara- pie, the internal jugular vein did not ap- pear to be at all in the way during the ope- ration ; some of the fibres of the omo-hyoi- deus, however, could not be conveniently drawn aside, and were therefore divided. A single ligature was applied; the pul* tion in the tumour did not entirely cease,** first, when the artery was tied, but it did* two days afterwards; and the swelling was rapidly diminishing. The ligature cane away about three weeks after the operation, and there was every hope of a cure; bat between the fourth and fifth week, a consi- derable swelling occurred between l** wound and the jaw, impeding degtatiuoj but not the breathing. This state was Mr lowed by febrile symptoms^ increased «el. Vo, I. Mr. A. Burns cou->iueiea aueur-ism of the thoracic aorta more frequent, perhaps, than that of any other vessel in the body. " I have had (says he) an opportunity of ex- amining fourteen, who had died of this dis- ease, but have not seen more than three in- stances of external aneurism." (On Disease? of the Heart, fa. p. 21o.) These proportions, however, would not at all correspond to common observation, external aneurisms taken collectively, be- ing supposed to be about as numerous, as those of the aorta alone, a calculation long ago made by Dr. A. Monro, primus. It was the opinion of Dr. W. Hunter, that. the aneurismal sac was composed of the dilated coats of the artery, which parts na- ture thickened and studded with ossifica- tions, after the origin of the disease, for the purpose of resisting its increase. Mr. Hodgson also in his iate excellent publica- tion, declares his decided belief, and adduces facts to prove, that many aneurisms of the aorta are formed by dilatation. Scarpa ar- gues, however, that the generality of aneu- risms of the aorta-are the consequence of a rupture of the proper coats of this large vessel ; and that the cellular sheath of the artery is what becomes distended into the thickened and ossified aneurismal sac. Dr.W. Hunter considered the ossifications of the sac as consequences of the disease ; but Haller looked upon such scales of bone: in the aorta as the very cause of the affec- tion, by rendering the artery inelastic and incapable of yielding to each pulsation of the heart. It is unquestionably true, that aneurisms of tbe aorta are most common in persons who are advanced in life, and, it is equally well known, that the aorta of every oM subject, whether affected with aneurism, or not, is almost al ways marked in some plac e or another, with ossifications, or, rather, with calcareous concretions. Such productions appear to occasion a decay, or absorption of the muscular and inner coats of the vessel, so that at length the force of the blood makes the artery give way, and this fluid, collecting on the outside of the laceration, or rupture, gradually distends the external sheath of the artery into the aneurismal sac, which itself becomes at last of consi- derable thickness, and studded with ossified specks. " If any person, who is not prejudiced iif favour of the common doctrine, with regard to the nature and proximate cause of this disease, (says Scarpa) will examine, not hastily and superficially, but, with care and by dissection, the intimate structure and texture of the aneurism of the aorta, un- folding withparticular attention the proper and common coats of this artery, and, in succession, those which constitute the aneu- rismal sac, in order to ascertain distinctly the textureand limitsof both, he will clearly see, thatthe aorta,properly speaking,contributes nothing to the formation of the aneurismal sac, and, that, consequently, the sac is mere ly ihe cellular membrar?^ whiri^ in *'t. »i V.M-ll'Kl&M. iound state, covered the artery, or that soft cellular sheath, which the artery received in common with the neighbouring part? ibis cellular substance, being raised and compressed by the blood, effused from the corroded or lacerated artery, assumes the form of acircumscribed tumour, covered ex- ternally, in common with the artery, by a smooth membrane, such as the pleura in the thorax, and the peritoneum in the abdo- men." Scarpa then comments upon the differen- ces of mere dilatation of an artery from aneurism, a subject which has been already fully considered in the foregoing pages. (Scarpa on the Anatomy, Pathology, and Sur- gical Treatment of Aneurism, Transl. by Wishart. p. 55, 66.) As I have already explained in the fore- going pages, the sentiments of this eminent anatomist are not adopted by the generality of surgeons ; or rather his doctrine is not carried by others to the extent which he has insisted upon, and it would be useless repeti- tion to bring before the reader again the facts, which prove that his statements are liable to many exceptions. A case, how- ever, recited by Rou\, which I have met with since the foregoing pages were printed, merits notice ; it was an instance, in which a popliteal aneurism, unattended with pul- sation,had been mistaken for an abscess, and punctured, whereby the patient lost his life. On dissecting the limb, Roux says, " the three coats of tbe artery participated in the dilatation, and the case was one of the clearest specimens, which I have ever seen of a true aneurism." (Nouveaux Element deMcd. Opiratoire, T. 4,517.) All arguments, brought against the pos- sibility of a dilatation of the inner coat, and founded on the inelastic structure of that membrane, must likewise be completely re- futed by another fact, demonstrated by morbid preparations, collected by Dubois and Dupuytren where the inner coat of the aorta is alone dilated, protruding through the outer tunics, in the form of a distinct swelling, somewhat like a hernia. (Roux Op. cit. p. 49.) In whatever manner aneurisms of tbe aorta are formed, there are no diseases, which are more justly dreaded, or which more completely fill the surgeon, as well as Hie patient, with despair. No affliction, in- deed, can be more truly deplorable ; for, the sufferings, which are occasioned, hardly ever admit even of palliation, and the in- stances of recovery are so very few, that no consolatory expectation can be indulged of avoiding the fatal end, to which the -isease naturally brings the miserable suf- - rer. The existence of aneurisms of the aorta " scarcely ever known with certainty, be- '"re they have advanced so far as to be at- >ided with an external pulsation, and a tumour, that admits of being felt, or even w v;'i. In very thin subjects, the throbbing ot the abdominal aorta is sometimes unu- sually plain through the integuments and viscera, and this has occasionally given rise to tbe suspicion of nn aneurism', a circaan- stance, which deserves to be remembered by everysurgeon, desirous of not pronoun- cing a wrong opinion. The preteraitaN pulsations, however, which are liable to be mistaken for those of aortic aneurisms, art of various kinds, and form a subject, to which tbe attention of Dr. Albers. of Bre men, the late Mr. A. Burns, and others, Im been very usefully directed. (See Abdo- men.) While thoracic aneurisms of the aorta ore accompanied with no degree of external swelling, the symptoms are all equivocal and might dejaend on a disease of tic heart, angina pectoris, phthisis pulmonale, he. Violent and irregular throbbings fre- quently occur between the fourth and fifth true ribs of the left side : the same irregu- larity of the pulse prevails as often proceed* from organic affections of the heart; the respiration is exceedingly obstructed; the voice altered; and, in a more advanced period of the malady, the patient is at times almost suffocated. The pressure of the In- ternal swelling on the trachea, bronchia, and lungs, is sufficient to account for this difficulty of breathing. In many instances. the irritation and compression, produced by the tumour, occasion an absorption of the greater part of the lungs, and abscesses and tubercles throughout the portion which re mains. Even the function of deglutition suffers interruption in consequence of the pressure made on the oesophagus, whkh may even be in a state of ulceration. Thus, in an example recently published, we read that " the cavity of the windpipe was oat ly obliterated from the pressure of tba aneurism ; and the extremities of four af its cartilages lay in the oesophagus, bjffiag entered that canal, through an ulcer in in coats." (Trans, of a Society forth* Imprvp- ment of Med. and Chir. Knowledge, V. I p.'83.) After what has been stated, it cannot« surprising, that, ere the disease manifesto itself externally, affections of the lungs,« strictures of the oesophagus, should often be suspected. (Hodgson, p. 91.) An aneurism of the arteria innominate, not discovered till after the patient bid died of suffocation, gave rise to greatdii- culty of drawing air into the chest, withe* any other symptom calculated to Ihn* light on the nature of the disease. flj aneurismal swelling was situated behiadw first bone of the sternum, and pressed up* the trachea. The front of this tab* ■» pushed in by the tumour, so as to presents convex prominence on the inner surface. which,_ however, diminished its area ia » very slight degree. Mr. Lawrence add** this fact to prove, that spasm of the aircefc may be tbe cause of great distress in break- ing. " The termination of this case (as* he) is the more remarkable, inasmuch as» another patient, an aneurism rising oa*« the arch of the aorta, and pressing on "V eorresponding part of tbe trachea. ™ "'' ANECTvi.-M 19,'. produce ulceration of the internal mem- brane, under which there was a slight ap- jmarance of coagulated blood, caused no affection of the breath at all. The person died of a different complaint, and the discovery of tbe aneurismal tumour, which was very small, and filled with firm la- minated coagula, was quite accidental." (Med. Chir. Trans. Vol. 6. p. 227.) Thus, we find, in thoracic aneurisms, at least, previously to their attainment of a certain sine, that no regularity prevails even with regard to difficulty of breathing, the symptom, which a priori one might suppose would invariably be present. I have mentioned, that the symptoms of thoracic aneurisms, previously to the for- mation of any outward swelling, often re- semble those of phthisis, and the latter is -ometimes actually supposed to be tbe dis- ease under which the patient is labouring. But, there is one distinction between the cases, which is pointed out by Mr. Hodg- son, and may be of use, in combination with other circumstances, in facilitating, the diagnosis : " in phthisis, the expectora- tion is either puriform, or thick, andclotted; but, in aneurisms, which are not accom- panied with disease in the lungs, as far as I have observed, it always consists of a thin -frothy mucus." (On Diseases of Arteries, fa. p. 93.) According to Kreysig's experience, the cough comes on at irregular periods, is vio- lent, and attended with great efforts, the expectorated matter being forced up by the vehemence. He agrees with Mr. Hodg- son, respecting the general quality of what is expectorated, where thoracic aneurisms nre not complicated with diseased lungs; but, he says, that the matter coughed up, also, frequently consists of masses of lymph, blended with brick-red particles of blood, which masses, when thrown into water, seem as if they were composed of a ball of stringy substances. (German .Transl. of the latter work, p. 137.) From a review of many cases of aortic aneurisms, Mr. A. Burns was inclined to think, that when the ascending aorta is aneurismal, the breathing is more affected, than when the arch of the vessel is enlar- ged, but, that in the latter case, the impedi- ment to deglutition is greatest. (On Diseases of the Heart, fa. p. 244.) The way, in which aneurisms of the tho- racic aorta prove fatal, is subject to consi- derable variety. TliC3e swellings do not ah ways destroy the patient by hemorrhage: in numerous instaueea, the magnitude of slhe disease so impedes respiration, that death seems induced by suffocation, and not a drop of blood is found internally ef- used. Frequently, (to use the description if Mr. John Bell) before tbe awful and fatal lemorrhage has had time to occur, the pa-. ient perishes of sufferings too great for lature to bear. The aneurismal tumour so ills the chest, so oppresses the lungs, com- presses the trachea, and curbs the course of the drtrendinj blood, that the sv«teni,wiih a poor circulation of ill-oxydated blood, i.* quite exhausted. And, thus, though the patient is saved from the most terrible sceuo of all, he suffers great miseries; he experi- ences in his chest severe pains, which he compares with the stabbing of knives; terrible palpitations; an awful sense of sinking within him ; a sound within his breast, as if of the rushing of waters ; a continual sense of his condition; sudden startings during the night; fearful dreams and dangers of suffocation, until with sleep- less nights, miserable thoughts by day, and the gradual decline of an ill-supported sys- tem, he grows weak, dropsical, and expires. (See Anatomy of the Human Body, by John Bell, Vol. 2, Edit. 3, p. 234,235.) Mr. A.Burns saw two examples, in which the patient3 died i;:-i~ntaneously, though their aneurismal tumours were very small,~ and had not bur^t. Both these patients were in tbe early stage of pregnancy. (On Diseases of the Heart, p. 236.) The situations, in which aneurisms of the curvature of the aorta burst, are different in different cases. Sometimes the swelling bursts into the cavity of the chest, or that of the pericardium, and the patient drops suddenly down. When the coats of the aorta give way within the pericardium, where tbey only receive a slight external membranous covering, this is apt to be also ruptured at the same time, so as to bring on copious effusion of blood, which oppresses the action of the heart, and produces imme- diate death. In other examples, the blood is effused into the trachea, or bronchia, and the patient, after violent cougbings and ejections of blood from tbe mouth, expires. Sometimes, after the tumour has become closely adherent to the lungs, it bursts into the aircells, through which the blood is widely diffused. An example of this termi- nation of the disease was observed by Laennec; who also saw another case, in which, if the patient had lived a little long- er, tho same occurrence in all probability would have happened. Ehrhardt says, that he is not aware that this mode of rupture has been noticed by other writers. (De Aneurysmate Aortee, p. 21,4lo. Lips. 1820.) In certain cases, the swelling beats its way through the ribs, destroys the verte- bra*, and injures the spinal marrow, so that the patient suffers a species of death, somewhat less violent and sudr den. But, although aneurisms in the chest do sometimes present at the back, a circumstance, that depends on the particular situation of the disease, (See Pelletan's Clinique Chirurgicale, Tom. 1, Obs. 7, p. 84.) they more commonly rise to- wards the upper part of the breast, where atJu-obbing tumour occurs, which has caused an absorption of the opposing parts of the ribs, and sternum : and sometimes dislocated the clavicles. Corvisart saw an instance, in which an aneurism of the aorta * had dislocated the sternal extremity of the " clavicle ; and Duverney makes mention of a case, in which, besides the displacement 1V6 ANEb'Rl-M and injury oi the clavicle, the sternum and scapula were partially destroyed. Guatta- ni speaks of an example, in which the cla- vicle was bent by alarge aneurism, of which a portion, as large as a pigeon's egg, pro- jected above the bone. (Lauth, p. 168.) And Morgagni has described a case, where the upper bone of the sternum, the sternal ends of the clavicles, and the adjoining ribs, were destroyed by the pressure of a large aneurism of the front of the curvature of the aorta, and the disease presented itself externally somewhat in the form of a bile. (Epist. 26, art. 9.) The swelling now pulsates in an alarming way. The blood is only retained by a thin covering of livid skin, which is becoming thinner and thinner. At length, a point of the tumour puts on a more conical, thin, and inflamed appearance than the rest; a slough is formed, and, on this becoming loose, the patient is sometimes instanta- neously carried off by a sudden gush of blood. An extraordinary ease of aneurism of the aorta is related by Dr. C. W. Wells. The disease, being unattended with any ex- ternal swelling, it seems, was not compre- hended during the patient's lifetime. The following is an abstract of the symp- toms, aud particulars of the case. Mr. A. B. a gentleman, thirty-five years of age, and temperate in his habits, became affected in 1789 with symptoms, which were thought to denote the approach of pulmonary con- sumption. These, however, after some time, entirely disappeared. In 1798, he was attacked with a slight hemiplegia, from which he also recovered, with tbe excep- tion of an inconsiderable sense of coldness iu the foot, which had been paralytic. In March, 1804, he complained of being fre- quently troubled with a noise in his ears, flatulence in his bowels, and pains in his Lands and feet, sometimes attended with slight swellings in the same parts. From , ..forwards imparted it to others. Thus, a. Morgagni was passing through Bologna, in 1728, Stancazi, a phy- sician of that place, is said to have informed him of Valsalva's practice. (See on this subject, Kreysig, Uber die Hcrzkrankheilen, B. 2, p. 728.) After taking away a good deal of blood by venesection, Valsalva used next to di- minish the quantity of food gradually, till the patient at length was allowed only half a pint of soup in the morning, and a quarter of a pint iu the evening, and a very small quantity of water, medicated with mucilage of quinces, or with the lapis of osteocolla. When the patient had been so reduced as to be incapable of getting out of his bed, Valsalva used to give him more nourish- ment till this extreme debility was removed. Valsalva was sure, that some aneurisms, thus treated, had got well, because every symptom disappeared, and his conviction was verified by an opportunity which he had of dissecting the body of a person that had been cured of this disease, and after- wards died of another affection ; for the artery, which had been dilated, was found rontracted, and in some degree callous. Morgagni relates, that this method of treating aneurisms, is somewhat like the plan, which Bernard Gengha tried with success, as well as Lancisi, and he refers us to the 24th chapter of the 2d vol. of the Anatomy of the one, and to lib. 2. cap. 4, of the Treatise on the Heart and Aneurisms, of the other. But, Sabatier tells us, that, in consequence of this instruction, he ex- amined both these works, without finding any thing on the subject. However this may be, we are informed by the latter, that he has seen the good effects of the practice in an officer, who had an alarming aneurism in front of the humeral extremity of the clavicle, in consequence of a sword wound in the axilla. The patient, after having been bled several times, was confined to his bed, and kept to an extremely low diet. Tie ivas allowed, as drink, only a very acid land of lemonade. He took pills contain- ing alum, and the swelling was covered with a bag full of tan mill dn-t, which was every now and fie'i '.ell v.*»t with port wine. -By a perseverance in this treatment, the swelling was reduced to a smallish hard tubercle, having no pulsation, and a per- fect cure ensued. (See Sabatier Medtcmt Opiratoire, Tom. 3, p. 170—172.) A French surgeon named Guerin, has written in favour of the efficacy of applying ice water, or pounded ice, to aneurismal swellings; apian, which he represonti,as being often of itself sufficient to effect a cure. This topical employment of cold ap- plications may be rationally and convenient- ly adopted in conjunction with, Valsalva < practice. The most interesting and convincing facts, in proof of the efficacy of this mode m treatment, were published a few years ago by Pelletan. Indeed, upon the whole, 1 have no hesitation in saying, that I never read any modern collection of surgical cases, which have appeared to me more valuable, than those which compose the Clinique Chirurgicale of this experienced writer. The following extract from a well- written critique on this work will serve to convey to the reader some idea of the im- portant information contained in the me- moir on internal aneurisms. " The intent in the treatment is to reduce the patient gradually to as extreme a degree of weak- ness, as is possible, without immediately endangering life. It is done by absolute rest, a rigorous diet, and bleeding; to these means, M. Pelletan adds the external ap- plication of ice, or cold and astringent washes, he. He has here detailed many cases from his own practice, of partial, or complete success, which cannot be too ge- nerally known, as they may be the means of creating in some, and of confirming in others, a good opinion of the only method of treatment, which has been found at all efficacious in a dreadful, and not unfrequent, organic disease. " Of the cases here recorded, some ap- pear to have been cured ; in others, the treatment had marked good effects. In extreme cases, at best, it afforded but par* tial and temporary relief. We can notic* but a few of these cases, which are, in every respect, highly interesting. In one, a robust man, an aneurism at the root of the aorta, with a pulsating tumour of the size of aa egg, projecting between the ribs, (the edges of which were already partly absorbed) was reduced, so as to recede within the ribs in the course of eight days. At the end of this time, the patient refused to anb- mit any longer. The tumour did not appear again for nearly a year, although here- turned to very drunken and irregular habits He died in about two years and a half, with the tumour again appearing, and much increased in volume. The aneurismal sac communicated with the aorta, by a smooth and round opening, opposite to one of the sigmoid valves. Theoican be no doubt of the efficacy of the treatment in this case; ji.1-1 !:\-hieh,y probable, that his health and his hfe might have been long preserved. "Ut for his own indi«eretion. In a ct"-. 4XEU1USM. 19? somewhat similar, but not so far advanced, the patient appears to have been cured. There was a swelling on the right side of the breast, about six inches in circumference, with a very strong beating. Tbe pulsation was accompanied with a pain, which stretched towards the scapula and the occi- put. It was evident, that the disease was an aneurism of the great arch of the aorta. The patient was a crier, of a strong frame, who was accustomed to drink freely. In tbe four first days, he was bled eight times, drawing three basins, " palettes," in the morning, and two in the evening. On the fifth, the pains and the beating were much lessened, but tbe pulse was still full. He was again bled once The pulse was in a favourable state, as to strength, till the seventh day, when it again rose, and the man was twice bled. During this time, the man was kept to a most rigorous diet. A cold poultice of linseed and vinegar was placed on the tu- mour, and renewed when it became warm. At the end of eight days, the good effects of this plan were very evident ; the pain and ihe pulsation were gone. The patient, (hough weak, was in health and tranquil. He was now allowed more food by degrees. At the end of four weeks from the com- mencement of the treatment, he left the H6tel Dieu well. He afterwards led a sober life, and became fatter, without any vestige of disease, except a slight and deep pulsa- tion at the part, in which the aorta may always be felt beating in its natural state. He died two or three years after, of another complaint. His death was not known, and the body,was not examined. (See London Med. Review, Vol. 5, v. 123.) Pelletan also curea by similar treatment a. large axillary aneurism, which was deemed beyond the reach of operative surgery. On the thirteenth day, the patient was reduced to a degree of weakness, which alarmed many ofthe observers. From that time, all pulsation in the tumour ceased. The con- tents were gradually absorbed ; and the pa- tient returned to his former laborious life with his arm as strong as ever. The pulse at the wrist was lost in consequence of the obliteration of the axillary artery, and the limb only receiving blood through the branches of the subclavian artery. " II y a beaucoup d'exemples, d'aneurismes gueris spontanement et sans le secoursde I'art; (says Pelletan) mais on ne peut leur comparer le cos que nous venons de dicrire; Velat ex- treme de la maladie, V energie desmoyens em- ployes, et Veffet immediat et successif qui en c*t resulte, prouvent asses que le nieces a He dti. tout cntier a Vart." (Clinique ChirurM<. by caustic, I should think by no means ad- viseable. '• this aneurism, as Mr. John Bell ob- serves, is a mere congeries of active ves- sels, which will not be cured by opening it; all attempts to obliterate the disease with caustics, after a simple incision, have proved unsuccessful, nor does the interceptioo of particular vessels, which lead to it, aitct the tumour; the whole group of vessels must be extirpated. In varicose veins, or in a neurisms of individual arteries, or in extra- vasations of blood, such as that produced under the scalp from blows upon the tern. poral artery, or in those aneurisms, pro- duced in school-boys by pulling the hair, and, also, iu those bloody effusions from blows on the head, which have a distinct pulsation, the process of cutting up the varix, aneurism, or extravasation*- ena- bles yon to obliterate the vessel and perform an easy cure. But, in this enlargement of innumerable small vessels, in this aneurism by anastomosis, the rule is, not to cut into, but to cut it out.' These purple and ill- looking tumours, because they are large, beating, painful, covered with scabs, and bleeding, like a cancer in the last stage of ulceration, have been but too often pro- nounced cancers! incurable bleeding can- cers ! and the remarks, which I have made, while they tend, in some measure, to ex- plain the nature and consequences of the disease, will remind you of various unhappy cases, where either partial incisions only had been practised, or the patient left en- tirely to his fate. (Principles of Surgery, Vol. 1.) The following case, recorded by Mr Wardrop, affords a valuable illustration of the nature and structure of one form of this disease. A child was born with a very large subcutaneous na?vus on the back part of the neck. It was of the form and size of half an ordinary orange. The tumour had been daily increasing, and, when Mr, Wardrop saw it, ten days after birth, tbe skin had given way, and a profuse hemor- rhage had taken place. The swelling was very soft and compressible : squeezed in the hand, it yielded like a sponge, and was re- ducible to one third of i*« original size. On removing the pressure, however, the tu- mour rapidly filled again, and the skin re- sumed its purple colour. '; Conceiving tbn immediate extirpation of the tumonr th( only chance of saving the infant, (says Mr Wartfrop,) I removed it as expeditiously as possible, and made the incision of the inte- guments, beyond the boundary of the tu- mour; aware of the danger of hemorrhage where such tumours are cut into. So pro- fuse, however, was the bleeding, that, though the whole mass was easily removed by a.few incisions, tbe child expired. " The tumour having been injected, by throwing coloured size into a few of the larger vessels, its intimate structure coulal be accurately examined. Several of the vessels, which, from the thinness of their coar=, appeared to be vt-irr*, were of a lar?e ANEURISM. 2uj size, and there was one sufficiently big to admit a full-sized bougie." This vessel was fully as large as the carotid artery of an infant. The boundaries of the tumour ap- peared distinct, some healthy cellular mem- brane surrounding it, which was traversed by the blood vessels. On tracing these ves- sels lo the diseased mass, they penetrated into a spongy structure, composed of numerous celle and canals, of a variety of forms and sizes, all of which were filled with the in- jection, and communicated directly with the ramifications of the vessels. These cells and canals had a smooth and polished surface, and, in some parts, resembled very much tbe cavities of the heart, fibres crossing them in various directions, like the colum- nar tendineai. The opening in the skin, through which the blood had escaped du- ring life, communicated directly with one of the large cells, into which the largest ves- sel also passed. (Wardrop in Med Chir. Trans. Vol.9, p. 203.) In the section on carotid aneurisms, I have mentioned the cases, in which Mr. Travers and Mr. Dalrymple cured aneurisms by anastomosis in the orbit, by tying the common carotid artery. These facts prove, that aneurism by anastomosis, like many other diseases, sometimes admits of being cured, on the principle of cutting off, or lessening the supply of blood to the part affected. However, surgeons must not be too confi- dent of being always'ableto cure the disease, by tying the main artery, from which the swejlingreceives its supply of blood ; and the great cause of failure is the impossibility of preventing in tome situations the transmis- sion of a considerable quantity of blood into the tumour, through the anastomosing vessels. In fact, every vessel, artery, and vein, around the disease, seems to be en- larged and turgid ; and the inosculations are so infinite, that no point of the circumfe- rence of the swelling can be imagined, which is free from them. Ltieune Duinand was bom with two small red marks on the anti- helix of the right ear. Until the age of twelve years, the chief inconveniences were a sensation of itching about the part, occa- sional bleeding from it, and the greater size of this, than of the other ear. The disease now extended itself over the whole antihe- lix, and to the helix and concha; and the upper part of the car became twice as lar ;e as natural. Slight alternate dilatations and contractions begun to be perceptible in the tumour, which was of a violent colour, and covered by very thin skin. Soon after- wards, any accidental motion of the patient's hat, was sufficient to excite copious hemor- rhages, which were difficult to suppress, and at the same time, that they produced great weakness, caused a temporary diminution of the tumour und its pulsations. At length, the disease began to raise up the scalp for the distance of an inch around the meatus auditorius, and the hemorrhages lo be more irequcntand alarming. Pressure was next applied to the temporal, auricular and oc- cipital arteries; but, as the patient could not endure it, the two first of these vessels were tied, the only benefit from which was a slight diminution in the pulsation andTiulk of the swelling. This treatment did not prevent the return of hemorrhage, and, therefore, forty-three days after the first operation, a ligature was applied to the oc- cipital artery, which proceeding was equally ineffectual. As the disease continued to make progress, the patient entered the Ho- tel-Dieu, where, on the 8th of April, 1818, Dupuytren tried What effect tying the trunk of the carotid artery would produce on the swelling. As soon as the ligature was ap- plied, the throbbings ceased, and the tumour underwent a quick and considerable dimi- nution. On the 17th day, slight expansions and contractions of the diseased part of the ear were again perceptible, though the swell- ing had diminished one third. An attempt was now made to compress the tumour by- covering it with plaster of Paris : a plan which was somewhat painful, though it less- ened the size of the disease. After being sixty-three days in the hospital, the patient was discharged, at which period,the tumour was diminished one third ; the throbbings had returned; but, no unpleasant noises continued to affect the ear. (See Breschet's Tr. of Mr. Hodgson's Work, T. 2, p. 296.) An infant, six weeks old, was brought to Mr. Wardrop, on account of an aneurism by anastomosis, (a subcutaneous najvus) ot a very unusual size, situated on the left cheek. The base of the tumour extended from the temple to beyond the angle of the jaw, completely enveloping the cartilage of the ear. At its upper part, there was an ulcer, about three inches in diameter, pre- senting a sloughingappearance. The tumour was soft and doughy ; its size could be much diminished by pressure ; there was a throb- bing in it; and a strong pulsation in tbe ad- jacent vessels. The disease was daily in- creasing, and several profuse hemorrhages had taken place from the ulcerated part. Mr. Wardrop, knowing from the case, to which I have already adverted, the danger of attempting to extirpate so large a tumour of this nature, was led to tiy what benefit might be obtained by tying the carotid ar- tery. A few hours after this operation, the tumour became soft and pliable, its purple colour disappeared, and the tortuous veins collapsed. On the second day, the skin had re- sumed its natural pale colour, and the ulcera- tion continued to e\!'\id. On the third, the tumour still diminished. On the fourth, the swelling had considerably increased again ; the integuments covering it had become livid ; and the veins turgid. The inoscula- ting branches of the temporal and occipital arteries had become greatly enlarged. A small quantity of blood had oozed from the ulcer. After remaining without much altera- tion, the tumour on the seventh day had again evidently diminished. On the ninth the ulceration was extending itself slowly, and the tumour was lessened fully one half On the twelfth the child's health was mate 206 ANEURISM. rially improving. The auricular portion of the swelling had now so much diminished, that the cartilage of the ear had fallen into its natural situation. After a poultice had been applied for two days, the central por- tion of the swelling, which appeared like a mass of hardened blood, was softened, and Mi. Wardrop removed considerable por- tions of it. On the thirteenth, the vhild be- came very ill, and died the following day, exhausted by the irritation of an ulcer, which had involved the whole surface of an enormous tumour. Mr. Wardrop thinks the advantages likely to occur from the plan of lying the main arteries, supplying tumours of this nature with blood, are the diminution of the size of the disease; the less- ening of the danger of hemorrhage, if theul- cerative process has commenced ; and, the rendering it practicable to remove the swelling with the knife, though the opera- tion may previously have been dangerous, or impracticable. (See Med. Chir. Trans. Vol. 9. p. 206-214, fa.) Instead of en- deavouring to promote ulceration in any of these cases, my own sentiments would in- cline me to leave the business of removing the diseased mass quietly to the absorbents, or, at most, I would only assist them with pressure, or by covering the tumour with plaster of Paris. The next case of aneurism by anastomo- sis, which I shall briefly notice, was one which was under the care of my friend Mr. Lawrence, and situated on the right finger of the right hand, in a young Woman about twenty years of age. The disease was at- tended with painful sensations extending to various parts of the limb and the breast, and the arm was disqualified for any kind of ex- ertion. In January 1815, Mr.Hodgson had ta- ken up the radialand ulnar arteries, and the eonseqences of theoperation were an entire cessation of beating, collapse of the swell- ing, and relief from pain ; but, these symp- toms all recurred in a few days. Finding compression unavailing, and the sufferings of the patient increasing, Mr. Lawrence proposed amputation of the .finger at the metacarpal joint: but, as this suggestion was not approved of, he recommended the patient to try the effects of a division of all ihe soft parts, by a circular incision close to the palm, so as to cut off the supply of blood. This operation Mr. Lawrrence per- formed in the presence of Mr. George Young and myself, in as complete a man- ner as can possibly be conceived. All the ^oft parts, excepting the flexor tendons, with their theca and the extensor-tendon, were divided. The digital artery, which bad pulsated so evidently in the palm of the hand, was fully equal in size to the ra- dial, or ulnar of an adult, and was the prin- cipal nutrient vessel of the disease. After tying this and the opposite one, we were surprised at finding so strong a jet of ar- terial blood from the other orifices of these two vessels, as to render ligatures necessary. I can here only add, that the whole finger beyond the cut wHled very consider- v)' the incision healed slowly ; the swelling subsided, but did not entirely disappear; the integuments recovered their natural co- lour; the pulsation and pain were re- moved ; and tbe patient so far recovered the use of her arm, that she could work at her needle for an hour together, and ime tbe arm for most purposes. (See Wardrop's Obs. on one species of Nttvus in Mid. Ckir Trans. Vol. 9, p 216.) For infm mation on aneurism, consult G Arnaud on Aneurisms, 8vo. S. C. Liuwr Dt Ossescentia Arttriwum Senili,4to. Mm'. burgi, 1817. A. F. Walther, Programme it Anturysmate, Argent, 1738. (Haller Ditp Chir. 5, 189.) A. de Haller, De Aortic Vt- ntcquc Cava gravioribus quibusdam Morbii Observation**, 4to. Gott. 1749. F. Thierry, Qureslio, fa. An tutior faciliorque vulgari detur Aneurysmatis Chirurgiea curalio? (Haller, Disp. Chir. 5, 211.) H. Peliat dt Aneurysmale, -Monsp. 174Q. Lauth Scnpio rum Lntinorum de Aneurysmatibut Collutio, 4lo. Argent, 1785, which work contains.it- man's Diss.de Aneurysmate, 1773, GuaLtam. de Externis Ane.urismatibut, 4to. Home. 1772; Lancisi'de Aneurysmatibut, Argent. 1785 ; Matanide Aneurysmaticis Precurdio- rum Morbis Anhnadcersiones.\78b; Verbrug- ge. Disstrtatio Anatomieo Chirursica dt Aneury.imufc, 1773; Weltinns dt Aneurys- mate ! < co Pectoris Externo Hemiplegia Sobole, Basil, 1750; Murray, Observalionti in Aneurysmata Femoris, 1781; True, Aneurysmatis Spurii post Fence Baiiliee Sectionem Orti, Historia ct Curatio. Set also an account of Mr. Hunter's Meihoi o) performing the Operation for the cure of lh> Popliteal Aneurism, by Sir E. Home, in Trans, of a Society for the Improvement •/ Med. and Chir. Knowledge, V. 1, p. 138, and V. 2, p. 285. Subalier's Midecine Oven- toire, T. 3, V. 2. The several volumes of the Medico-Chirurgical Transactions. Cases m Surgery, by J. Warner, p. 141, fa. Edit. 4. J. B Her aud, Dt Aneurysmatibus Externit Monsp. 1775. J.F.L. Deschamps, 0bs.tt Reflexions sur la Ligature des principle* Arteres blesses, et particulie'rement sur /' Am- ritme de I'Arterepoplitee, Svo, Parit, 1797 Richerand's Nosographie Chirurgicale, f. 4- Ed. 4. Pelletan"* Clinique Chirurgiult, 7 1, et 2. A. Bums'* Surgical Anatomy of tkt Head and Neck. 8vo. Edinb 181\, and Ob- servations on the Diseases of the Heart, if* Svo. Edinb. 1809. Ramsden'* Practical Ob- servations vn the Scleroc-lt, with four cam of operations for aneurism, Svo. £*nflM8IL CEucrts Chirurgicales de Desault par Bithtl, T. 2, p. 553. S. C. Lucre qucedam Obseru- tiones Anatomica. circa Nervos Arlerilt adev.nli.s ft comitantes, 4to. Francof. 1810. Wells in Transactions of a Society for Utt Improvement of Med. and Chir Knowledge, V. 3, j,. 81—85, fa. (i. ,p. Schtid, Obi. Med. Chir. de Aneurysmate, 8vo. Hardertiti, 1792. Corvisnrt, Essaisur les MaladiuttJ* Lesions Organiques du Cwuret des Grot Vis- seaux. Edit. 2, or Transl. by C. II Hebb, 8r« Lond 1813. C. Bell's Operative Surgery, V I- r.d. 2. John Relfr Principle'of Snrzrni. ANE a NT V. l.-Richttr's Anfangsgr. der \1 undarznti/■ kunst, B. 1. Abernethy s Surgical Works, V.\. Monro's Observ. in the VImb. Med- Essays. Various productions in the Med. Observ. and Inquiries. The article Aneurism in Rees's Cyclopaedia. J. P. Maunoir. Mi- moires Physiologiques et Pratiques sur VAneu- risme et la ligature, 8vo. Gtneve. 1802. Freer's Observations on Aneurism, 4to. Lond. 1807; and a Treatise on the Anatomy, Patho- logy, and Surgical Treatment of Aneurism by A."Scarpa, translated by J. H. Wishart, 1808. The original Italian was published 1804 • Ant. Scarpa, Mrmoria sulla Ligatura delle PrincipaliArfrrie delle Arti, con una Appen- dice all' Opera sull' Aneurisma. fol. Pavia, 1817. This tract, and a great deal of valua- ble additional matter, are contained in the 2d Edition of Scarpa's Work on Aneurism by Mr. Wishart, Svo. Edinb. 1819. Callisen's Systema Chirurgix Hodierna, Part 2, p. 645, fa. Edit. 1798. Bayer's Traili des Maladies Chir. T. 2, p. 84. fa. A. C Hutch- ison, Letter on Popliteal Aneurism. 8ro Lond. 1811. Hodgson on the Diseases of Arteries and Veins, London, 1815, a work of ihe greatest accuracy and merit. Transl. into German by Dr. Koberwein, with additions by this gentleman, and Dr. Kreysig. Svo. Han- nor. 1817; and also Transl. into French, with valuable annotations by Breschet, 2 Tomes, 8vo. Paris, 1819. Roux, Nouveaux Element de Medecine Optratoire; T. 1 Also Roux, Voyage fait a Londres en 1814, ou Parallele de la Chirurgie Anglaise avec la Chirurgie Francaise, p. 248, fa. Paris, 1815. D. Fried. Lud. Kreysig, Die Krankheiten des Herzens. 4 Bdnde, Svo. Berlin, 1814—17. C. D Knhln, De Aneurysmate Exlerno, 4to.Jencr:, 1816. A.J. Risetlhueber, Mem. sur la Ligature'et VApplatissement de I'Artire, dans V Operation de I'Aneurisme Poplite, 8vo. A. V. Berling- hieri Memoria sopra I'Allacciatura dell' Arte- rie, Svo. Pisa, 1819. Lassus Pathologic Chir. T. \,p. 347, fa. Leveilli Nouvelle Doctrine Chirurgicale, T. 4, p. 213, fa. T. F. Baltz, De Ophthalmia Catarrhali Bellica, fa.; Prcemittituf F. C. Neegele Epistola, qua His- foria et Descriptio Aneurysmatis, quod in Aorta abdominali observavit,4to. Heidelberg, 1816. J. Cole, Expose du Traitement d'un ■ hieurisme inguinale par la Ligature de I'Ar- fere Iliaque Exteme, Svo. Cambrai, 1817; and London Medical Repository for May, 1820. Hennen's Military Surgery, p. 183- 185,393,4-c. Ed. 2, Edinb. 1820. J.Kirby, Ca- fes, fa. 8vo. Lond. 1819. C Fred. Hubner de Aneurysmatibus; Gott. 1807. Manuale di Chirurgia del Cav. Assalini; Milano, 1812. The author's main object is to recommend his compressor. (A. F Grafe, Angiektasie, ein Benlrag zur ralionellen Cur und Erkenntniss der Gefass-ausdehnungen. This appears to me to be a valuable work, on account of the great many facts and interesting cases. lo which it refers. I can here only mention a few things, which are noticed in it Walt- her found five small calculi in the veins of the bladder. Stenzal met w ith a fatty tu- mour, as large as a hen's egg, in the curva- ture of the aorta, and several smaller swcll- "ics of (he same kind in ih<> *£, a burning coal.) See Carbuncle. ANTIMONIAL POWDER; pclvis a.\- timonialis. In all cases, where it is desira- ble to promote the secretions in general, and those ©f the kidneys, skin, and alimen- tary canal, in particular, it is proper to have recourse to antimonial medicines. In in- flammation of the brain and its membranes, and, in every instance, in which there exist? an inflammation of a viscus of high import- ance in the system, antimony should be ex- hibited, and, in general, the antimonial powder is as eligible a prescription as any. For an adult, from two to five grains may be ordered,?and the dose, if requisite, may be repeated, three or four times a day. In or- der to increase its action on the bowels, it is frequently conjoined with calomel in the form of pills. ANTIMONIUM MURIATUM. This has often been named, butter of antimony, and is employed in surgery as a caustic. ANTIMONIU M TARTARIZATUM, (Emetic Tartar.) This medicine is well known as the most common emetic. For this purpose, it may be given in either or' the following ways, as the indications of the case may demand. ft. Antimonii Tart. gr-ij. Aq. distil. |iv. Misce et cola. Dosis ^Tij. pro emetico,; vel ~ss quadrante quoque horae, donee superveuerit vomitus. If tar- tarised antimony be exhibited merely to ex- cite a diaphorcesis, ,half an ounce, or one table spoonful, of the above mixture is to be given once every six hours. WTRUM. Diseases of. This cavity i«i A.MKLA1 liable to a viintiy 01 diseases, Sometimes us membranous lining inflames, and se- nates an extraordinary quantity of mucus, or pus; at other times, in consequence of inflammation, or other causes, it is the seat of various excrescences, polypi, and fungi. Even the bony parietes of the antrum are occasoinally affected with exostosis, or ca- ries. Sometimes it contains extraneous bodies ; and, it is even asserted, that insects may be generated there, and cause, for ma- ny years, very alllitting pains. COLLECTIONS OF MUCUS AND PUS. Inflammation of the membranous lining of the antrum sometimes produces an ex- traordinary secretion of mucus within that cavity, and the collected fluid being con- fined, the bony parietes of the cavity be- come expanded in a surprising degree. This disease, says Boyer, is sometimes ascribed lo a blow on the cheek, to caries of the teeth, or the projection of one of their fangs into the antrum. But, in general, the case takes place unpreceded by any of these causes, and without there being the least ground for suspecting what has given rise to the disorder. It is remarked, however, that collections of mucus within the antrum are most frequent in young subjects: of three patients, seen by Boyer, tbe eldest was not more than twenty. (Traite des Mai. Chir. T 6, p. 139) Whether the obliteration of the duct leading to the nose be a cause or only an effect of the disease, is, as Mr. Hun- ter observes, not easily determined ; but, from some of tbe symptoms there is great reason to suppose it an attendant. " If it be a cause, we may suppose, that the natu- ral mucus of these cavities, accumulating, irritates, and produces inflammation for its own exit; in the same manner, as an ob- struction to the passage of the tears through the ductus ad nasum produces an abscess of the lachrymal sac." (See Hunter's Natural Hist, of the Teeth, p. 174, Ed. 3.) The most interesting example of the effects of the lodgment of mucus in the antrum is that recorded by Dubois : a boy, between seven and eight years of age, was observed to have at tbe base of the ascending process of the upper jaw bone, on the left side, a small, very hard tumour: of the size of a nut. As it gave no pain, and did not appear to in- crease, his parents did not give themselves any concern about it. When he was about sixteen, however, the swelling began to in- crease, and to be somewhat painful. Be- fore he was eighteen, its augmentation was so considerable, that' the floor of the orbit was raised up by it: the eye thrust up- wards : tbe palpebral very much closed ; the arch of the palate pushed down in the form of a tumour; and the nostril almost effaced. Below the orbit, the cheek made a considerable prominence ; while the nose was thrown towards the opposite side otibe fare, and tbe skn at the upper part of the 'umon;-. below the lower eyelid, v. - of a •I'irnle i°d col-vir. and U;r- •»' •einr •■> Vr.-.' The upper lip was drawn upwards, .nidbe- hind it, all the gums on the left side were observed to project much further, tlian those on the opposite side of the face, and at this point alone the thinness of the bony parietes of the antrum was perceptible. The patient spoke, and breathed with great difficulty ; he slept uneasily, and his masti- cation was painful. The case was at first supposed by Dubois, Sabatier. Pelletan and Boyer, to be a fungus of the antrum, and an operation was considered adviseable. In proceeding to this measure, the first thins;, which attracted the notice of Dubois, wan a sort of fluctuation in the situation of the gum, behind the upper lip ; a circumstance which led him to give up the idea of the case being a fungus, though he expected that, on making an opening merely a small quantity of ichorous matter would escape, affording no kind of information. In thii place, however, he determined to make an incision, along the alveolary process, where- by a large quantity of a glutinous substance, like lymph, or what is found in cases of lu- nula, was discharged. A prope was now in- troduced, with which Dubois could feel a cavity equal in extent to the forepart of the tumour, and in moving the instrument about, with the view of learning, whether any fungus was present, it struck against a hard substance, which felt like one of tbi* incisor teeth, near the opening that had been made. Five days after this first opera- tion, Dubois extracted two incisors and one grinder, and then removed the corres- ponding part of the alveolary process. As the hemorrhage was profuse, the wound was now filled with dressinp, which in two days came away, and enabled Dubois to see with facility all the interior of the cavity. At its upper part, he perceived a white speck, which he supposed was pus, but on touching it with a probe, it turned out to be a tooth, which was then extracted, in doing which some force was requisite. The rest of the treatment merely consisted in injecting lotion* into the cavity, and applying common dressings. In about six weeks, all the hollow disap- peared ; but the swelling of the cheek,and palate, and the displacement of the nose, still continued. In the course of another year and a half, however, every vestige «A deformity was entirely removed. (Dubois, Bulletin de la Facultede Med. No. 8.) With respect to the treatment of collec- tions of mucus in the antrum, by means of injections, thrown into that cavity through the natural opening in it, while the head h inclined to the opposite side, for the pur- pose of facilitating the escape of the collect- ed fluid, as proposed by Jourdain in 1765 (Mem. de I' Acad, de Chir. T. 4, p. 357.) Deschamps and Boyer are of opinion, that the method is objectionable, not only be- cause it is difficult to find the aperture, which, ere the disease forms an outward swelling. i„ probably obliterated, tut ah" because the thickness of the lmie.Hs colled '.■d would make itimpo^-il..!.; for < b-mi ?^» ANTKwU. 209 t« wash it out witn injections. Hence, Boyer approves of the practice of opening the tumour in an eligible place, and to an extent sufficient for the discharge of the mucus. (Deschamps, Traite des Maladies des Fosses Nazales, et de leurs Sinus, p. 231, 8ro. Par. 1804 ; Boyer Traite des Mai. Chir. T. 6, p. 145, Svo. Paris, 1818.) Indeed, that Jourdain's proposal was attended with too much difficulty for common practice, was the sentence long at;o pronounced upon it by a committee of the Royal Aca- demy of Surgeons in France, nominated for the express purpose of inquiring into the merits of the,suggestion. The method of making an opening into the antrum, will be considered in the sequel of tbis article. As a general rule, I may here remark, that except where there is a tumour, or fungus to be extirpated, or a foreign body to be extracted from the antrum, it is quite unne- cessary to remove any part of the alveo- lary process, or cut away any of the bony parietes of the antrum, the drawing of one of the teeth situated below this cavity, and making a perforation in this situation, beiug the only kind of opening required. This aperture may be preserved as long as neces- sary by the introduction of a piece of elas- tic gum catheter, which is to be fastened to the adjacent teeth, and through which the secretion in tbe antrum may escape, or lo- tions be injected. (See Deschamps Traili des Mai. des Fosses Nazales, fa. p. 234.) However, as Hunter remarks, if the fore- part of the bone has been destroyed, even though the case be merely a collection of mucus, or pus. an opening may be made on the inside of the lip; but, on account of the difficulty of maintaining such an aper- ture, he still inclines to the practice of drawing one of the teeth. (Natural Hist. of the Teeth, p. 176, ed. 3.) Of all the above cases, abscesses are by far the most common. Violent blows on the cheek, inflammatory affections of the adjacent parts, and especially, of the pitui- tary membrane lining the nostrils, exposure to cold and damp, and, above all things, bad teeth, may bring on inflammation and sup- uration within the hollow of the upper jaw one. The first symptom is a sensation of pain, at first imagined to be a toothach, particularly if there should be a carious tooth at this part of the jaw. Such pain, however, extends more into the nose, than that usually does, which arises from a de- cayed tooth: it also affects, more or less, the eye, the orbit, and the situation of the frontal sinuses (See Hunter on the Teeth, p. 175, ed. 3.) But, even these symptoms are insufficient to characterize the disease, the nature of which is not unequivocally evinced, till a much later period. The com plaint is, in general, of much longer dura- tion, than one entirely dependent on a ca- ries of a tooth, and its violence increases more and more, until, at last, a hard tumour is perceptible below tbe cheek bone. By degrees tbe swelling extends over the whole ■ heek: but it afterwards ri-cs to a point. Vor. I and forms a vrry Litctiuiscribed hardness, which may be felt above the back grinders. This symptom is accompanied with redness, and sometimes with inflammation and sup- puration of the external parts. It is not uncommon, also, for the outward abscess lo communicate with that within the an- trum. The circumscribed elevation of the tu- mour, however, does not occur jn all cases, There are instances in which the matter makes its way towards the palate, causing the bones of this part to swell, and, at length, rendering them carious, unless timely assistance be given. There are other cases, in which the matter escapes between the fangs and sockets of the teeth. Lastly, there are certain examples, in which the matter formed in the antrum, makes its exit at the nostril of the same side, when the pa- tient is lying with his head on the opposite one, in a low position. If this mode of evacuation should be frequently repeated, it prevents the tumour, both from pointing externally, and bursting, as it would do if the purulent matter could find no other vent. But this evacuation of pus from the nostril is not very common ; for, according to Mr. Hunter, the opening between the autrum and cavity of the nose, is generally stopped up. This celebrated anatomist even seems inclined to think, as I have al- ready observed, that the disease may some- times be occasioned by the impervious state of this opening, in consequence of which obstruction, the natural mucus of the an- trum may collect there in such quantity, as to irritate and inflame the membrane, with which it is iu contact, just like as an obstruc- tion in the ductus nasalis hinders the passage of the tears into the nose, and causes an ab- scess in the lachrymal sac. This is a point, how-ever, on which even Mr. Hunter would not venture to speak w ith certainty; for it is by no means impossible that the imper- vious state of the opening is rather an ef- fect than tbe cause of the disease, since in- flammation in the antrum is often manifestly produced by causes of a different kind, and since the opening in question is not invaria- bly closed. Abscesses in the antrum require a free exit for their contents, and, if the surgeon neglects to procure such opening, the bones become more and more distended and push- ed out, and, finally, carious. When this happens, the pus makes its appearance, either towards the orbit, the alveoli, the palate, or, as is mostly the case, towards the cheek. The matter having thus made a way for its escape, the disease now be- comes fistulous. In all cases, whether the pus be simply confined in the antrum, or whether the case be conjoined with a carious affection of the bones, the principal indication is to dis- charge the matter. The ancients seem to have known very little about the treatment of diseases of the antrum. Drake, an English anatomist, is reputed to be the first proposer of a plan OiilUM. for curing abbesses of this cat iiy. (Anthro- pologia Nova. London, 1727.) Meibomius, however, a long while before him, had pro- posed, with the same intention, the extrac- tion of one or more of the teeth, in order that tbe matter might find an opening for its escape, through the sockets. This plan may be employed with success. The pus frequently has a tendency to make its way outward toward* the teeth ; it often affects their fangs; and, after their extraction, the whole of the abscess is seen to escape through the sockets. But this very simple plan will not suffice for all cases, as there are numerous instances, in which there is no communication between the alveoli and the antrum. Drake, and, perhaps, before him, Cow- per, took notice of the insufficiency of Me- ibomius's method, and, hence, they propo- sed makinga perforation through the socket into the antrum with an awl, for the purpose of letting out the matter, and injecting into the cavity such fluids as were judged proper. The extraction of one or more teeth, and the perforation of the alveoli, being essential steps in treating diseases of the antrum, we must consider what tooth ought to be taken out in preference to others. A caries, or even a mere continual ach- ing, of any particular tooth, in general ought to decide the choice. But, if all the teeth should be sound, which is not often the case, writers direct us to tap each of them gently, and to extract tbe one which gives most pain on this being done. When no information can be thus obtained, other < ircumstanees ought to guide us. All the grinding teeth, except the first, correspond with the antrum. They even -ometimes extend into this cavity, and the '; ngs are only covered with the pituitary j.iembrane. The bony lamella, which se- parates the antrum from the alveoli, is very thin, towards the back part of the upper jaw. Hence, when the choice is in our power, it is best to extract the third or fourth grinder, as, in this situation, the alveoli can be more easily perforated. Though, in general, the first grinder and ca- nine tooth do not communicate with the antrum, their fangs approach the side of it, and from their socket an opening may rea- dily be extended into that cavity. When one or more teeth are carious, they should be removed, because they are both useless and hurtful. The matter frequently makes its escape, as soon as a tooth is ex- tracted, in consequence of the fang ha- ving extended into the antrum, or rather in consequence of its bringing away with it a piece of the thin partition between it and the sinus. Perhaps a discharge may follow from the partition itself being carious. If the opening, thus produced, be sufficiently large to allow tbe matter to escape, the ope- ration is already completed. But, as it can easily be enlarged, it ought always to be .<-o when there is the least suspicion of its Kin. too small. However, when no pus1 makes its appearance, after h tooth is ex- tracted, the antrum must i>e opened by ai. troducing a pointed instrument in the di- rection of the alveoli. Some use a small trocar, or awl; others a gimblet for this purpose. The patient should sit on the ground, in a strong light, resting his head on the sur- geon's knee, who is to sit behind him. Im- mediately the instrument has reached the cavity, it is to be withdrawn. Its entrance into the antrum is easily known by the ces- sation of resistance. After the matter Li discharged, surgeons advise the opening to be closed with a wooden stopper, in order to prevent the entrance of eitraneous sub- stances. The stopper is to be taken out, several times a day, to allow the pus to escape. This plan soon disposes the parts affected to discontinue the suppuration, and resume their natural state. Sometimes, however, the pus continues to be discharged, for a long time after the operation, without any change occurring, in regard to its quality or quantity. In such instances, the cure may often be accelerated by employing injec- tions of brandy and water, lime-water, or a solution of the sulphate of zinc. Some surgeons prefer a silver cannula, or a piece of elastic gum catheter, instead of the stopper, as it can always be left per- vious except at meals. The examples re- corded, in which the extraction of a tootb, and the perforation of the bottom of the antrum, have been the means of curing ab- scesses in that cavity, are very numerous. (See Farmer's Select Cases, No. 9; Gooctis Cases, p. 63, new edition ; Palfyn Anatomie, fa.) If no opening were made in the antrum, the matter would make its way, sometimes towards the front of this cavity, which is very thin ; sometimes towards the mouth; and fistulous openings, and caries would in- evitably follow. When the bones are diseased, tbe abore plan will not accomplish a cure, until the affected pieces of bone exfoliate. A probe will generally enable us to detect any ca- ries in the antrum. The fetid smell, and ichorous appearance of the discharge, also leave little doubt that the bones are dis- eased ; and, in proportion as the bones free themselves of any dead portions, the dis- charge has less smell, and its consistence be- comes thicker. When there are loose pieces of dead bone, or other foreign bodies, to be extract- ed, it is requisite to make a larger opening in the antrum, than can be obtained at its lower part. Instances also occur, wherf patients have lost all the grinding teeth, and the sockets are quite obliterated, so that a perforation from below cannot be effected- Some practitioners object lo sacrificing a sound tooth. In these circumstances,itbai been advised to make a perforation in tbe antrum, above the alveolary processes Lamoner first proposed this method. H "insists in making a transverse incision,be- low the malar process, and above the roo! ANTRUM 211 01 the third grinder. Thus the gum and pe- riosteum are divided, and the bone exposed. A perforating instrument is to be conveyed into the middle of this incision, and the opening in the antrum made as large as re- quisite. (See Mem. de I'Acad. de Chir. T. 4, p. 351, and Gooch's Obs. append, p. 138.) There are some extensive exfoliations of the antrum, where it is absolutely neces- rary to expose a great part of the surface of the bone, and to cut away the dead pieces which are wedged, as it were, in the living ones. A small trephine may sometimes be advantageously applied to the malar pro- cess of the superior maxillary bone. Surgeons formerly treated carious affec- tions of the antrum in the most absurd and unscientific way, introducingsetons through its cavity, and even having recourse to the actual cautery. The moderns, however, are not much inclined to adopt this sort of practice. It is now known, that the detach- ment of a dead portion of bone, in other terms, the process of exfoliation, is nearly, if not entirely, the work of nature, in which the surgeon can at most act only a very inferior part. Indeed, he should limit his interference to preventing the lodgment of matter, maintainingstrict cleanliness, and removing the dead pieces of bone, as soon as they become loose. But, it is to be un- derstood, that there are occasional exam- ples, in which the dead portions of bone are so tedious of separation, and so wedged in the substance of the surrounding living hone, that an attempt may properly be made to cut them away. TUMOURS OF THE ANTRUM. Ruysch, Bordenave, Desault, Abernethy, Weinhold, and others, have recorded cases of polypous, fungous, and cancerous dis- eases of the antrum, and examples of this cavity being affected with exostosis. The indolence of any ordinary fleshy tumour in the antrum, while in an incipient state, certainly tends to conceal its existence; but such a disease rarely occurs without being accompanied with some affection of the neighbouring parts; and hence, its presence may generally be ascertained before it has attained such a size as to have altered in a serious degree the natural shape of the an- trum. This information may be acquired, by examining whether any of the teeth have become loose, or have spontaneously fallen out ; whether the alveolary processes are -•onnd, and whether there are any fungous excrescences making their appearance at the sockets, whether there is any habitual bleeding from one side of the nose ; any sarcomatous tumour at the side of the nostril, or towards the great angle of the eye. When the swelling, however, has at- tained a certain size, the bony parietes of the antrum always protrude, unless the body of the tumour should be situated in the nostril, and only its root in the antrum. This case, however, is very uncommon. As soon as a tumour is certainly known 'n exist in the antrum, the front part of thi* cavity should be opened, without waiting till the disease makes further progress. In a few instances, indeed, we may avail our- selves of the opening, which is sometimes found in the alveolary process, and enlarge it sufficiently to allow the tumour to be ex- tirpated. If the front of the antrum were freely opened, it would in general be better to cut away the disease in its interior. A swelling of the parietes of the antrum, in consequence of an abscess, or a sarco- matous tumour in its cavity, may lead us to suppose the case an enlargement of the bones, or an exostosis. The symptoms of the two first affections have been already detailed. One *ign of an exostosis, besides the absence of the symptoms characterizing an abscess or a sarcoma, is the thickened parietes of the antrum forming a solid re- sistance ; whereas, in cases of mere expan- sion, the dimensions of the surface of the bone being increased, while its substance is rendered proportionally thinner, the resist- ance is not so considerable- When such an exostosis depends upon a particular constitutional cause, and espe- cially upon one of a venereal nature, it must be attacked by remedies suited to this affection. But when the disease resists in- ternal remedies, and its magnitude is likely to produce an aggravation of the case, a portion of the bone may be removed with a trephine, or a cutting instrument. Such operations, however, require a great deal of delicacy and prudence. Mr. B. Bell, vol. 4, describes a kind of exostosis of the upper jaw, very different from what I have mentioned, since instead of its being distinguishable from other dis- eases of the antrum by the greater firmness of the tumour, the substance of the bone gradually acquires such suppleness and elasticity, that it yields to the pressure of the fingers, and immediately resumes its former plumpness when the pressure is dis- continued. If the bone be cut, it is found to be as soft as cartilage, and, in an ad- vanced stage of the disease, its consistence is almost gelatinous. The swelling increases gradually, and extends equally over the whole cheek, without becoming prominent at any particular point, or only so in the latter periods of the malady, when the soft parts inflame, and become affected. The complaint is described as totally incurable. Cutting and trephining the tumour, as re- commended in other cases of exostosis,only aggravate the patient's unhappy condition. Mr. Abernethy has related an account of a very singular disease of the antrum. The patient, who was thirty-four years of age, when the account was written, perceived. when about ten years old, a small tumour on bis left cheek, which gradually attained the size of a walnut, and then remained for some time stationary. About a year after- wards, the tumour having again enlarged, a caustic was applied to the integuments, so as to expose the bone. The actual cautery was next applied, and an opening thus made into the antrum. After the exfoliation, the ANTRIM- antrum became filled with a fungus, which rose out upon the cheek, and could not be restrained by any applications. Part of the fungus aMo made its way into the mouth, through the socket of (he second tricuspid tooth, the other teeth remaining natural. The disease continued in this state nine years, occasionally bleeding in'an alarming way. When the patient was in his twentieth year, the whole fungus sloughed away du- ring a fever, and never returned. After this, the sides of the aperture in the bone began to grow outwards, forming an exostosis, which rapidly attained to a great magni- tude. A small exostosis took place in the mouth, but became no larger than a horse- bean. Tbe exostosis of the maxillary bone was of an irregular figure, and projected from the whole circumference of tbe aperture a great way directly forward. Mr. Abernethy compared its appearance, when he was writing, with that of a large teacup fasten- ed upon tbe face, the bottom of which may be supposed to communicate with the an- trum. The diameter of the cup, formed by the circular edge of the bone, was three inches and a half; the depth two inches and seven-eighths. The general height of the sides of the exostosis, from the basis of the face, was two inches ; its walls \vere not thick, and terminated in a thin circular edge. The integuments, as they approached this edge became thinner, and they extend- ed over the edge into the cavity. The ex ostosis now reached to the nose in front, and to the masseter muscle behind ; above it included the very ridge ;of the orbit, and below it grew from the edge of the alveo- lary process. A line that would have se- parated the diseased from the sound bone would have included the orbit and nose, and indeed one half of the face. Mr. Abernethy saw no means of affording the man relief. (Trans, of a Society for the Im- provement of Med. and Chirurgical Know- ledge, vol.2.) See also a case related by Harrison. (New Lond. Med. Journ. vol. I. p.l.) In a case of fungus, which had distended the antrum, hindered the tears from passing down into the nose, raised the lower part of the orbit, caused a protrusion of the eye, made two of the grinding teeth fall out, and occasioned a carious opening in the front of the antrum, through which opening a piece of the fungus projected, Desault ope- rated as follows : the cheek was first de- tached from the os maxillare, by dividing the internal membrane of the mouth, at the place where it is reflected over this bone. Thus the outer surface of the bone was denuded of all the soft parts. A sharp per- forating instrument was applied to the mid- dle of this surface, and an opening made more forward than the one already existing. The plate of bone, situated between the two apertures, was removed with a little falciform knife, which, being directed from behind forward, made the division without difficulty. The opening thus obtained being insufficient,. Desault endeavoured to enlarge it below, by sacrificing the alveolary pm. cess. This he endeavoured to accomplish with the same instrument, but finding the resistance too great, he had recourse to a gouge and mallet. A considerable piece of the alveolary arch was thus detached, with- out any previous extraction of the corres- ponding teeth, three of which were removed by the same stroke. In this manner an opening was procured in the external and inferior part of the antrum, large enough to admit a walnut. Through this aperture a considerable part of the tumour was cut away with a knife, curved sideways, and fixed in its handle. A most profuse hemor- rhage took place ; bul, Desault, unalarroed, held a compress in the antrum, for a short time ; this being removed, the actual cau- tery was applied repeatedly to the rest of the fungus. The cavity was dressed with lint, dipped iu powdered colophony. On the eighteenth day, the swelling was evidently diminished, the eye less |pro- minent, and the epiphora less visible. But, at this period, a portion of fungus made its appearance again. This was almost entirely destroyed by applying the actual cautery twice. It appeared again, however, on the twenty-fifth day, and re- quired a third and last recourse to the cau- tery. From this time, the progress of the cure went on rapidly. Instead of fungous exerescenccs, healthy granulations were now formed in the bottom of the sinus. The parietes of the antrum, gradually ap- proaching each other, the large opening made in the operation was obliterated, and reduced to a small aperture, hardly large enough to admit a probe. Even this little opening was closed in the fourth month, it which time no vestiges of the disease re- mained, except the loss of teeth, and a very obvious depression just where they were situated. In all fungous diseases of the antrum, making a free exposure of them is an essen- tial part of the treatment ; if you neglect this melhod, how can you inform yourself of the size, form, and extent of the tumour? How could you remove the whole of the fungus, through a small opening, which would only allow you to see a very little portion of the excrescence ? How could you be certain that the disease were extir- pated to its very root ? Even when the antrum is freely opened, this circumstance can only be learnt with difficulty; and how could it be ascertained, whenonly apoint of the cavity is opened ? A portion, left be- hind, very soon gives origin to a fresh fnn- gus, the progress of which is more rapid, and the character more fatal, in consequence of being irritated by the surgical measures adopted. (CEuvres Chirurgicales de Desault, pur Bichat, t. 2.) See also other cases, re- corded by Canolles, (Ricueil Piriodiqut dt la Soc. de M6d. t. 2. No. 9.) Eichorn, (Ditt. de Poly pis tn Antro Highmori, Goett. 1814.) Sandifort, (Muteum Anat. vol. 2. Tab. 30-) Leveille,) R/cueil de (a Sor. fa f l.jf.24.4 ANTRUM Weinbold, (Von den Krankheiten der Ge- sichttknochen, p. 27. 4fo. Halle. 1818.) I imagine, that English surgeons, unaccus- tomed to use the actual cautery, will pe- ruse with a degree of aversion this means, so commonly employed in France by De- sault, and other celebrated surgeons Nor can I expect, that they will altogether ap- prove the use of the mallet and gouge, for making a free opening into the antrum. Perhaps, it might be better to trephine this cavity with a small instrument for the pur- pose, and then cut the fungus awuy. After removing as much of it as possible in this manner, some instrumeut of suitable pe might be used to scrape the part, where the tumour has its root. However, if there be any case in which potent and violent measures, l:ke those of Desault, are allow- able, it is the one of which we have just been treating. Inveterate diseases demand powerful means, and tampering with them is generally more hurtful than useful. There is an interesting case of a fungus in the maxillary sinus, related in the first volume of the Parisian Chirurgical Journal. It was at last cured by opening the antrum, apply'ugthe cautery, and tying the portion of the tumour which had made its way into the nose. In the second volume of the same work, is an excellent case, exhibiting the dreadful ravages which the disease may produce when left to itself. INSECTS 15 THE ANTRUM. It is said, that insects in this cavity may sometimes make an opening into it neces- sary. This ease, however, must be exceed- ingly rare ; and even what we find in authors (Pallas de" insectis viventibus intra rivenlia) appears so little authentic, that I should hardly have mentioned the circum- stance, if there were not, in a modern work, (Med. Comm. vol. 1.) a fact, which appears entitled to attention. Mr. iieysham, a me- dical practitioner at Carlisle, relates, that a strong woman, aged sixty, in the habit of taking a great deal of snuff, was subject, for several years, to acute pains in the an- trum, extending over one side of the head. These pains never entirely ceased, but were more severe in winter than'summer, and were always subject to frequent periodical exacerbations. The patient had taken se- veral anodyne medicines, and others, with- out benefit, and had twice undergone a course of mercury, by which her com- plaints had been increased. All her teeth on the affected side had been drawn. At length, it was determined to open the an- trum with a large trocar, though there were no symptoms of an abscess, nor of any other disease in this cavity. For four days, no benefit resulted from this opera- tion. During this space, bark injections, and the elixir of aloes, were introduced into the sinus. On the fifth duy, a dead in- sect was extracted, by means of a pair of forceps, from the mouth of the cavity. It va« more than an inch lone-, and thicker than a common quill. The patient now ex- perienced relief for several hours : but the pains afterwards recurred with as much se- verity as before ; oil was next injected into the antrum, and two other insects, similar to the former, were extracted. No others appeared, and the wound closed. The pains were not completely removed, but they were considerably diminished for se- veral months, at the end of which time they became worse than ever, particularly affectine the situation of the frontal sinus. Bordenave has published, in the twelfth and thirteenth volumes of the Mem. de I'Acad. de Chir edit. 12mo. two excellent papers on the diseases of the antrum In the thirteenth volume, he relates the histo- ry of a case, in which several small whitish worms, together with a piece of fetid fungus, were discharged from the antrum, after an opening had been made on account of an abscess of this cavity, attended with caries. (I' 381.) But, in this instance, the worms had probably been generated after the open- ing had been made in the cavity; for when they made their appearance, the opening had existed nine months. Deschamps refere to another case, in which M- Fortassin, his colleague at La Charite, found in the an- trum of a soldier, whom he was dissecting, a worm of the ascaris lumbricus kind, which was four inches in length. (Traiti des Mai. des Fosses Nazales, fa. p. 307.) Such an example is also recorded in one of the vo- lumes of the Journ. de Med. Were a case of this description to present itself in a liv- ing subject, it would be adviseable to in- ject oil into the cavity of the antrum, and then endeavour to wash out the extraneous substances by throwing into the sinus warm water by means of a syringe. See Precis d'Observations sur les Maladies du Sinus Max- illaire,par M. Bordenave, in Mem. de I'Acad. Royale de Chirurgie, t. 12. edit, in 12mo. Also Suite d'Observations on the same Sub- ject, by M. Bordenave, t. 13, of the said Work. L. H. Runge, De Morbis Pracipuis Sinuum Ossis Front is et Maxilla. Suptrioris, fa. Rintelii, 1750. Haller. Disp. Chir. 1. 205. LAEncyclopidie Mithodique, Partie Chirurgicale, art. Anire Maxillaire. Jour- dain, in Mim de I'Acad. de Chir. t. 4. p. 3"»7 ; also his Traite des Depits dans le Sinus Maxillaire, fa. 12mo. Paris, 17(50; his Traiti des Mai de la Bouche, t. 2 ; and Journ. de Mid. t. 21. p. 57, et I. 27. p. 52 —157. This author, who, in 1765, suggested to the Royal Academy of Surgery the method of injecting fluid into the antrum, through the natural opening, is said to have heen anti- cipated in the practice by Allouel, who first thought of the plan in 1737, and tried it with success in 1739; See Boyer, Trade des Mai. Chir. t. 6. p. 14°. Rimarques el Observa- tions sur les Maladies du Sinus Maxillaire, in CEuvres Chirurgicales de Desault par iichal, t. 2. p. 156. Desault'* Parisian Chirurgical Journal, vol. 1. and 2. Medical Communi- cations, vol. 1. Trans, of a Society for the Improvement of Med. and Chir. Knowledge, Vol. 2. Natural History of the Humin- 214 \NLC- Human Teeth, by John Hunter, p. 174. 175. edit. 3. Gooch's Chirurgical Works, vol 2. p. 61. and vol. 3. p. 161. edit. 1792. Calli- sen's Systema Chirurgite Hodierrue, t. 1. p. 31r>, Src. Dubois, in Bulletin de la Faculli de Medecine, N. 8. J. L. Deschamps- Traiti des Maladies des Fosses Nazales, et de leur Sinus, Svo. Paris, 1804 P. V. Lemicker, De Stnu Maxillari, ejusdem Morbis,fa Wur- ceb. I8l'9. C. A. Weinhold, Idcen fiber die abnormal Metnmorphosen der Highmorshohle, Leipz. 1810. C. A. Weinhold, Von den Krankheiten der Gesichlsknochen und Hirer Schlcimhaate, der Ansroltung eines grossen Polypen in der linken Oberkieferhohle, dem Verbuten der Einsinkens der Gichtischenund Venerischen Nase, und der Einselsung Ktinst- HcherChoanen,4io. Halle, 1818. ANUS. The lower termination of the great intestine, named the rectum, is so called, and its office' is to form an outlet for the feces The anus is furnished with muscles, which are peculiar to it, viz. the sphincter, which keeps it habitually closed, and the levatores ani, which serve to draw it up into its natural situation, after the expulsion of the fecis. It is also surrounded, as well as the whole of the neighbouring intestine, with muscular fibres, and a very loose sort of cellular substance. It is subject to vari- ous diseases, in which the aid of urgery is requisite: of these we shall next treat. IMPERFORATE ANUS. This complaint is sometimes met with, though not very often. As it is of the ut- most consequence that this and other mal- formations should not remain long un- known, one of the earliest duties of an accoucheur, after delivery, should be an examination of all the natural outlets of new-born infants. Such an inspection sometimes evinces, that the place in which the extremity of the rectum, or the anus, ought to be, is entirely, or partly, shut up by a membrane, or fleshy adhesion. In other instances, no vestige of the intestine can be found, as the skin re- tains its natural colour over tbe whole spdee between the parts of generation and the os coccygis, without being more eleva- ted in one place than another. In these cases, the intestine sometimes terminates in one or two culs de sac, about an inch up- ward from the ordinary situation of the anus. (See Baillie's Series of Engravings, Fasc. 4. Tab. 5.) Sometimes it does not descend lower than the upper part of the sacrum; sometimes it opens into the bladder, or vagi- na. Dr. Palmer dissected a case, where the colon, after reaching the vicinity of the left kidney, begun, as it descended, to form a sigmoid flexure; but, previously to its ar- rival at the concavity of the left ilium, made a sudden turn to the right; and crossing the psoas muscle, reached the projection of the sacrum, where it terminated, without tit all entering the pelvis With this malfor- mation wa« combined an imperforate mea- tus urinarius, and some considerable devia tions of the genital organs from their natural structure. (See Medico-Chir. Journ. vol. 1. p. 180. 8t>o. Lond. 1816.) Sometimes the colon terminates in a sar, and the rectum is entirely deficient. (See Beauregard, in Journ. de Med. t. 66.) ln. stances are also upon record, where the rec- tum opened into the urethra. (Brest. Samml. 1718, p. 702 ; Hist. d'l'Acad. Royale des Sci- ences. 1752; p 113; Hochstelter, in .Mel Wochenblatt, 1780, No. 18—1783,No. 19. Krelshmar, in Horn's Archiv. 1 B. p. 350.) When a surgeon is consulted, he mu*' not lose much time in deliberation; for, if a speedy opening be not made for the feces, the infant will certainly very soon perish, wilh symptoms similar to those of a strangulated hernia. After ascertaining the complaint, which is an easy matter, he should endeavour to learn, whether the anus is merely shut by a membrane, or fleshy ad- hesion, or whether the anus is altogether wanting, in consequence of the lower por- tion of the cavity of the gut being oblitera- ted, or the rectum not extending sufficiently far down. When a membrane, or production of the skin closes the opening of the rectum, the part producing the obstruction is somewhat different in colour from the neighbouring integuments. It is usually of a purple or livid hue, in consequence of the accumula- tion of the meconium on its inner surface. The meconium, propelled downward by the viscera above, forms a small roundish prominence, which yields like dough to the pressure of the fingers ; but immediately projects again when the pressure is remo- ved. When a fleshy adhesion closes thr intestine, the circumstance is obvious to the eye, if the part protrude, which is gene- rally the case. The finger feels greater hardness and resistance than when there is a mere membrane, and the livid colour of the meconium cannot be seen through the obstructing substance. These last signs alone are enough to con- vince The surgeon of the necessity of the operation ; but they do not clearly show, whether the intestine descends as far as it ought, in order to form a proper kind of anus. Complete information on this point, can only be acquired after the membrane or adhesion has been divided; or else after the child's death, when the operation ba< proved ineffectual. Though there be no mark to denote where the anus ought to be situated, and no degree of prominence. yielding, like soft dough, to the pressure of of the fingers, and rising again when such pressure is removed; yet it may happen, especially on our being consulted immedi- ately after the child is born, that, notwith- standing the absence of such symptoms, de- noting the presence of the meconium, a"d the natural extent of the intestine, as far as where the anus ought to be, the gut may exist, and have a cavity, as far as the mem- brane, or adhesion, closing it. When the anu«« is simolv rnvered with ANLS 21m skin, and its place pointed out by a promi- nence, arising from the contents of the rec- tum, w« have only to make an opening with a knife, sufficient to lei out the meco- nium. fLevret recommends making a cir- cular incision in the membrane; but a transverse cut is sufficient. A small tent of lint is afterwards to be introduced, in order to keep the opening from closing. If the anus should only be partly closed by a mem- brane, the opening may be dilated with a tent; but, if the aperture should be very small, it is preferable to use the bistoury for its enlargement. When no external appearance denotes where the situation of the anus ought to be, the case is much more serious and embar- rassing ; and this, whether the intestine is stopped up by a fleshy adhesion, or the co- alescence of its sides, or whether a part of the gut is wanting. However, it is the surgeon's duty to do every thing in his power to afford relief. For this purpose an incision, an inch long, is to be made in the situation where the anus ought to be, and the wound is to be carried more and more deeply in the natural direc- tion of the rectum. The cuts are not to be made directly upwards, nor in the axis of the pelvis, for the vagina, or bladder, might thus be wounded. On the contrary, the operator should cut backward, along the concavity of the os coccygis, where there is no danger of wounding any part of im- portance. In all cases of this kind, the sur- geon's finger is the best director. The ope- rator, guided by the index finger of his left hand, introduced within the os coccygis, is to dissect in the direction above recom- mended, until he reaches the feces, or has cut as far as he can reach with his finger, If he should fail in finding the meconium, as death must unavoidably follow, one more attempt ought to be made, by intro- ducing, upon tbe finger, a long trocar, in such a direction as seems best calculated for finding the rectum. By the prudent adoption of such proceed- ings, many infants have been preserved, which would otherwise have been devoted to certain death. Hildanus, La Motte, Roonhuyeen, and several others, have suc- cessfully adopted the above practice. Mr. B. Bell informs us, that he saw two of these cases, in which the intestine was very dis- tant from the integuments, and in which he was so successful as to form an anus, which fulfilled its office tolerably well for several years ; but he found it exceeding difficult to keep the. passage sufficiently large and pervious. As soon as he removed the dos- sils of lint, and other kinds of tents, used for maintaining the necessary dilatation, such a degree of contraction speedily fol- lowed, that the evacuation of the intestinal mutter bceuuie very difficult, for a long while aftcrw ards. He employed, at differ- ent tinie-, tents made of sponge, gentian root, and other substances, which swell on being moistened. But there always pro- duced so m-ich pain and irritation', that it was impossible to persevere in their use, After remarking such inconveniences, he condemns the use of tents.\ He is of opi- nion, that whoever makes * trial of them upon parts, as sensible as the rectum, will soon find, that the advice to use them fa wrong. Tents, made of very soft lint, dipped in oil, or rolls of bougie plaster, cause less irri- tation than those composed of any other materials. Though keeping the opening dilated may seem simple and easy, to such men as have had no opportunities of seeing cases of this descrip ion, it is far otherwise in practice. Mr. B. Bell assures us, that he never met with any disease which gave him so much trouble and embarrassment as he experien- ced in the two cases of this sort, which oc- curred in his practice. Although in both instances he at first made the openings suf- ficiently large, it was only by very assidu- ous attention, for eight or ten months, that the necessity for another operation, and even repeated operations, was prevented. When only tbe skin has been divided, the rest of the treatment is doubtless more sim- ple ; for, then, nothing more is requisite than keeping a piece of lint, for a few days, in the opening made with the knife. But, when the extremity of the rectum is at a certain distance, though we may generally hope to effect a cure, after having succeeded in giving vent to the intestinal matter; yet the treatment, after the operation, will al- ways demand, for a long while, a great deal of attention and care on the part of the sur- geon. The difficulty of success may be considered as, in some measure, proportion- ed to the depth of the necessary incision. In a case, like that recorded by Dr. Pal- mer, to which I have above adverted,the inutility of any attempt to discharge the feces by an operation, in the usual site of the anus, must be sufficiently obvious. (Medico-Chir Journ. Vol. I. p. 181.) Sometimes, while the anus appears per- vious and well-formed, infants suffer the same symptoms, as if there were no anus at all. The reason of this depends upon the intestine being occasionally closed by a membranous partition, situated more or less upward, above the aperture of the anus. (Courtiat, Nouvelles Obs. sur les Os. p. 147,) and sometimes the symptoms are owing to the termination of the gut in a cul-de-sac. 1 his erroneous formation may always be suspected, when an infant, whose anus is externally open, does not void any excre- ment, for two or three days after its birth, and, especially, when urgent symptoms arise, such as swelling of the belly, vomit- ing, he. We are now to endeavour to as- certain, whether the rectum is impervious above the anus, by altempting to inject clysters, or to introduce a probe. If the gut be shut up, there is nothing to be doae, but having recourse to the method descri- bed above, and forming a communication by means of a bistoury guided on the finger, or else with a pharyugotomu?. Iftheob ANL'S. Ftacle should only I'.ou.Mst oi a transverse membrane, the operation will be easy, and its success almost certain. But, if there should be a strangulation, or obstruction of the intestine, t*;e case is infinitely more se- rious. However, as the operation is the only resource for saving the child's life, we ought not to hesitate about performing it. When the anus is imperforate, the intes- tine sometimes opens into the vagina, or bladder. (Dumas in Recueil Periodique de la Soc. de Med. T. 3, N. 13. L'EreilU Rap- port des Travaux de la Soc. Philom. Vol 1, p. 145. Murray Diss. Arresis ani vesicalis. lips. 1794. Act. Nat. Cur. Vol. 8, Obs. 24, Vol. 9, Obs. 11, Roestel in Mursinna's Journ. far die Chir. 1, B.p. 517. 06*. Med. Decad. 2, No. 2.) The first of these cases is the least dangerous of all the malformations of this sort. The intestine may also open and terminate at two places, at the same time, viz. at the usual place, so as to form a pro- per anus, more or less perfect; and also in the vagina. If these two openings should be ample enough, for the easy evacuation of the ex- crement, nothing can be done at so tender an age; for, though voiding the feces through the vagina, is a most unpleasant inconvenience, yet, there is no effectual means of closing the opening of the intes- tine in this situation, nor could one be de- vised, which would not seriously incom- mode the infant. But, when the two openings are exceed- ingly small, and the alvine evacuations can- not readily pass out, even with the aid of clysters, the opening of the anus ought to be dilated by cannulas of different sizes. If fhis method should not avail, the knife must be'employed, and the wound dressed, as already explained. Forthe most part, the intestine has only one opening in the vagina. In this circumstance, as in the instance in which the feces have no vent at all. we must make an incision in that place, which the anus ought to occupy. The natural course of the feces being open- ed by this operation, which in such a case is not at all perilous, much less excrement xvill pass out of the vagina, and, of course, the infirmity will be diminished. By the introduction of a tube into the new anus, the communication between tbe rectum and vagina, might possibly be obliterated, and a perfect cure accomplished. The opening between the intestine and vagina, may, also, be too small for the easy evacuation of the feces, and even expose the infant to the same sort of dangerous symptoms, as it would be subject to, if the rectum had po- sitively no opening at all. In male infants, tbe rectum sometimes opens into tbe bladder, and, in this circum- Htance, there is generally no anus. the rase is easily known by the meconium be- ing blended with the urine, which acquires a thick greenish appearance, and is voided almost continually, though in small quanti- ties. Only the most fluid part of the meco- nium i • thus discharged. The tbirker part not getting from ihe rectum into the blad- der, nor from the bladder into the urethra greatly distends the intestines and bladder! and produces the same symptoms as take place in case: of total iinperforation Hence without tht speedy interference of art to form an anus, capable of giving vent to th^ feces, with which the urinary orguuscannot remain obstructed, the infant will inevitably die. This case must, therefore, be treated like the foregoing examples. Though we can hardly hope to prevent altogether the inconveniences, resulting from the rectum opening into the bladder, since even anew passage will not completely hinder the fecen from following the other course; yet we shall thus afford the child a very tood chance of preservation, and the only one which its situation will allow In cases, in which we cannot procure an outlet for the feces, by any of the methods pointed out above, it has been proposed by M. Littre, to make an opening above one of the groins, find out a portion of intestine, open it, fix it in this situation with a few stitches, and thus form an artificial anus. M. Sabatier was only acquainted with one case, in which this proceeding had been ac- tually done, viz. the example where M. Duret, a French naval surgeon operated. This gentleman cut into the abdomen at the lowerparlof the left iliac region, and having opened the sigmoid flexure of the colon, he fixed it near the wound. The child was saved by tbe formation ofan artificial anus; but at the age of twenty-five months, it continued to be troubled with a sort of pro- lapsus of the lining of the bowel. (See ft- cueil Periodique de la Soc. de Med. T. 4, JVe 19, fy Sabatier, Med. Operaloire, T. 3, v 336, Edit. 2.) Callisen conceives, that the descending colon may be most conveniently got at by- making an incision in the left lumbar re- gion, along the edge of the quadratus lum- borum muscle, and he prefers this mode of operating, to that of making the incision above the groin. (Syst. Chir. Hodierrut, T. 2, p. 688, 689.) Its advantages, however, are not obvious, and certainly it is on some accounts objectionable. (See Midetint Operatoire par Sabatier, Tom. 3, p. 330. Also Remarques sur Differens Vices de ion- formation, que les Enfans apportent en nau- sant, par M. Petit, in Mem. de I'Acad Royale de Chirurgie, Tom. 2, p. 236, Edit.in 12mo. H. A. Wrisberg, de pratlematuxaVx d raro inteslini Recti cum vesica urinaria coa- litu, et inde penoente ani defectu, 4lo. GUI 1779. Ford, in Med. Fads and Obs. Vol 1, No. 10, Chamitrlaine in Memoirs of the Med Soc. of Lond. Vol.5, No. 23. Uuht- rand'sNosograp/ue Chirurgicale, Tom.3, f •37, fa. Edit. 5. Callisen's Systema Ckie rurgUz Hodiernce, T. 2, p. 686, 'Edit. 1800; «S?E5 OF THE ANUS.--FISTULA IS A«0- ie custom of giving the appellation oi a to every collection of natter form^ ANL'S. r.car i'ue auui-, iia-, i>y i yu\ eying a false no- tion of them, been productive of such me- thods of treating them, as are diametrically opposite to those which ought lo be pur- sued. A small orifice or outlet from a large or deep cavity, discharging a thin gleet, or sa- nies, made a considerable part of the idea, Ti'hich our ancestors had of a fistulous sore, wherever seated. With the term fistulous, they always connected a notion of callo- sity: and, therefore, whenever they found such a kind of opening yielding such sort of discharge, and attended with any degree of induration, they called, the complaint a fis- tula. Imagining this callosity to be a dis- eased alteration made in the very structure of the parts, they had no conception that it could be cured by any means^ but by re- moval with a cutting instrument, or by de- struction with escharotics: and, therefore, they immediately attacked it with knife or caustic, in order to accomplish one of these ends; and very terrible work they often made. That abscesses, formed near the funda- ment, do sometimes, from bad habits, from extreme neglect, or from gross mistreatment, become fistulous, is certain ; but the majo- rity of them have not, at first, any one cha- racter or mark of a true fistula; nor can, without the most supine neglect on the side of the patient, ortbe most ignorant manage- ment on the part of the surgeon, degene- rate, or be converted into one. Collections of matter from inflammation (wherever formed) if they be not opened in time, andinaproper manner, do often burst. The hole, through which the matter finds vent, is generally small, and not often situ- ated in the most convenient, or most de- pendent part of the tumour : it therefore is unfit for the discharge of all the contents of the abscess; and, instead of closing, contracts itself to a smaller size, and be- coming hard at its edges, continues to drain off what is furnished by the undigested sides of the cavity. When an abscess about the anus bursts, the smallness of the accidental orifice ; the hardness of its edges; its being found lo be the outlet from a deep cavity; the dailv discharge of a thin, gleety,discoloured kind of matter; and the induration of the parts round about, have all contributed to raise, and confirm the idea of a true fistula. Upon this idea was built the old perni- ' ions doctrine of live excision, or us free destruction. Abscesses about the anus present them- -elves in different forms. Sometimes the attack is made with symp- toms of high inflammation; with pain, fever, i i^our, he. and the fever ends as soon as the abscess is formed. In this case, a |ii.n of the buttock near to the anus is considerably swollen, and has a large circumscribed hardness. In a short time, the middle of thj< hardness becomes red, and inflamed; and in the centre of it matter is formed. Vol. i This (in the lHugu,i™e of our l<>r-1 is railed in general a phlrgman ; but when i* appears in this particular part, aphyma. The pain is sometimes great, the fever high, the tumour large, and exquisitely ten- der ; but however disagreeable tbe appear- ances may have been, or however high the symptoms may have risen, before suppura- tion, yet, when that end is fairly and fully accomplished, the patient generally becomes easy and cool; and the matter formed un- der such circumstances, though it may be plentiful, vet is good. On the "other hand, the external parts, after much pain, attended with fever, sick- ness, fcc. are sometimes attacked with con- siderable i nil a m motion, but without any of that circumscribed hardness, which cha- racterized the preceding tumour ; instead of which the inflammation is extended largely, and the skin wears an erysipelatous kind of an appearance. In this, the disease is more superficial; the quantity of matter small, and the cellular membrane sloughy to a considerable extent. Sometimes, instead of either of the pre- ceding appearances, there is formed in this part, what the trench call une suppuration gangreneuse; in which the cellular and adi- pose membrane is affected in the same man- ner,asitis in the disease called a carbuncle. In this case, the skin is of a dusky red or purple kind of colour ; and although harder than when in a natural state, yet it has, by no means, that degree of tension or resist- ance, which it has cither in the phlegmon, or in the erysipelas. The patient has generally, at first, a hard, full, jarring pulse, with great thirst, and very fatiguing restlessness. If the progress of the disease be not stopped, ortbe patient relieved by medicine, the pulse soon chan- ges into an unequal, low, faltering one; and the strength and the spirits sink in such manner, as to imply great and immediately impending mischief. The matter formed under ihe skin, so altered, is small in quan- tity, and bad in quality ; and the adipose membrane is gangrenous and sloughy throughout the extent of the discoloration. This generally happens to persons, whose habit is either naturally ijjd, or rendered so by intemperance. In each of these different affections, the whole malady is often confined to the skin and cellular membrane underneath it; and no other symptoms attend, than the usual general ones, or such as arise from the for- mation of matter or sloughs in the part i.u mediately affected. But italic- often hap- pens, that, added to these effects, the patient is made unhappy by complaints arising from an influence, which such mischief has uti parts in the neighbourhood of the disease ; such as the urinary bladder, tbe vagina, the urethra, the hemorrhoidal vpssels, and the reclura ; producing retention of urine, stran- gury, dysury, bearing down, tenesmus, piles, diarrhoea, or obstinate cosliveness; which complaints are sometimes so pressing, as to all ourattent'-jn. On ••<<> «>•' r-h-.. ;, 216 AflUS. large quantities of matter and deep sloughs are sometimes formed, and great devasta- tion committed on the parts about the rec- tum, with little or no previous pain, tumour, or inflammation. Sometimes the disease makes its first ap- pearance in an induration of the skin, near to the verge of the anus, but without pain or alteration of colour; which hardness gradu- ally softens and suppurates. Tbe matter, when let out, in this c.se, is small in quantity, good in quality ; and the sore is superficial, clean, and well-conditioned. On the con- trary, it now and then happens, that al- though the pain is but little, and the inflam- mation apparently slight, yet the matter is large in quantity, bad in quality, extremely offensive, and proceeds from a deep crude hollow, which bears an ill-natured aspect. The place also where the abscess points, and where the matter, if let alone, would burst its way out, is various and uncertain. Sometimes it is in the buttock, at a distance from the anus; at other times near its verge, or in the perineum, and this discharge is made sometimes from one orifice only, some- times from several. In some cases, there is not only an opening through the skin, ex- ternally, but another through the intestine into its cavity : in others, there is only one orifice, and that either external or internal. Sometimesthe matter is formed at a con- siderable distance from the rectum, which is not even laid bare by it; at others, it is laid bare also, and not perforated : it is also, sometimes, not only denuded, but pierced ; and that in more places than one. All consideration of preventing suppura- tion, is generally out of the question: and our business, if called at the beginning, must be to moderate the symptoms; to for- ward the suppuration ; when the malter is formed, to let it out; and to treat tbe sore in such manner, as shall be most likely to pro- duce a speedy and lasting cure. When there are no symptoms which re- quire particular attention, and all that we have to do is to assist the maturation of the tumour, a soft poultice is the best applica- tion. When the disease is fairly of the phleg- monoid kind, the thinner the skin is suffered to become, before the abscess be opened, the better: as the induration of the parts about will thereby be the more dissolved, and, consequently, there will be the less to do after such opening has been made. This kind of tumour is generally found in people of full, sanguine habits; and who, there- fore, if the pain be great, and the fever high, will bear evacuation, both by phlebotomy, and gentle cathartics: which is not often the casejof those, who are said to be of bilious constitutions ; in whom the inflammation is of a larger extent, and in whom tbe skin wears the yellowish tint of the erysipelas'; persons of such kind of habit, and in such circumstances, being in general seldom ca- pable of bearing large evacuations. When the inflammation is erysipelatous, the quantity of matter formed is small, com- pared with the «ize and extent of the tu- mour; the disease is rather a sloughy, »0 trid state of the cellular membrane, than an imposthumation ; and therefore, the sooner it is opened, the better : if we wait for the matter to make a point, we shall wait for what will not happen ; at least not till after a considerable length of time; during which the disease in the membrane will extend it- self, and consequently, the cavity of the sinus, or abscess, be thereby greatly increa- sed. When, instead of either of the precedin» appearances, the skin wears a dusky, pur- plish-red colour; has a doughy, unresisting kind of feel, and is very little sensible: when these circumstances are joined with an unequal, faltering kind of pulse, irregu- lar shiverings. a great failure of strength and spirits, and inclination to doze, the case is formidable, and the event generally fatal. ' The habit, in these circumstances, is al- ways bad; sometimes from nature, but much more frequently from gluttony, and intem- perance. What assistance art can lend, must be administered speedily; every mi- nute is of consequence ; and if the disease be not stopped, the patient will sink. Here (says Pott) is no need for evacuation of any kind: recourse must be immediately had to medical assistance ; the part affected should be frequently fomented with hot spirituous fomentations, a large and deep incbion should be made into the diseased parts; and the application made to it should be of the warmest, most antiseptic kind. This also is a general kind of observa- tion, and equally applicable to the same sort of disease in any part of the body. Our ancestors have thought fit to call it in some a carbuncle, and in others, by other names: but it is (wherever seated) really and truly a gangrene of the cellular and adipose membrane : it always implies great degene- racy of habit, and, most commonly, end; ill. Strangury, dysury, and even total reten- tion of urine, are no very uncommon attend- ants upon ■ abscesses forming in the neigh- bourhood of the rectum and bladder: more especially if the seat of them be near the neck of the latter. They sometimes continue from tbe nfit attack of the inflammation, until the matter is formed, and has made its way outward and sometimes last a few hours only. The two former most commonly are ea- sily relieved by the loss of blood, and the use of gum arabic, with nitre, &c. But in the last (the total retention,) they who ban not often seen this case, generally have im- mediate recourse to the catheter; hut the practice is essentially wrong. The neck of the bladder does certainly participate, in some degree, in the said in- flammation. But, the principal part of the complaint arises from irritation, and the die6aSexiiS' &trict,y sP^king, spasm* aJ.c- . rJle manner in which an attack o thisi kind b generally made; the very tittle distention which the bladder <>&«. ANUS, 2l»> fillers ; the small quantity of urine some- times contained in it, even when the symp- toms are most pressing ; and the most cer- tain, as well as safe, method of relieving it; all tend to strengthen such opinion. But whether we attribute the evil to in- flammation, or to spasmodic irritation, whatever can, in any degree, contribute to the exasperation of either, must be mani- festly wrong. The violent passage of the catheter through the neck of the bladder (for violent in such circumstances it must be) can never be right. If the instrument be successfully intro- ducd,it must either be withdrawn as soon as the bladder is emptied, or it must be left in it: if the former be done, the same cause of retention remaining, the same effect re- turns ; the same pain and violence must again be submitted to, under (most likely) increased difficulties. On the other hand, if the catheter be left in the bladder, it will often, while its neck is in this state, occasion such disturbance, that the remedy (as it is called) will prove an exasperation of the disease, and add to the evil it is designed to alleviate ; nor is this all; for the resistance, which the parts, wliile in this state, make, is sometimes so great, that if any violence be used, tbe instrument will make for itself a new rout in the neighbouring parts, and lay the foundation of such mischief as fre- quently baffles all our art. The true, safe, and rational method of re- lieving this complaint (says Pott) is by eva- cuation and anodyne relaxation: this not only procures immediate ease, but does, at the same time, serve another very material purpose ; which is that of maturating the ab- scess. Loss of blood is necessary; the quantity to be determined by the strength and state of the patient: the intestines should also be emptied, if there be time for so doing- by a gentle cathartic; but the most effectual relief will be from the warm bath, or semicupium, the application of bladders with hot water to the pubes and perineum, and, above all other remedies, the injection of clysters, consisting of warm water, oil, and opium. There may have been cases which have resisted and baffled this method of treatment ; but Pott has ne- ver met with them. A painful tenesmus is no uncommon at- tendant upon an inflammation of the parts about the rectum. If a dose of rhubarb, joined with a warm anodyne, such as the conf. mitbrid. or such like, does not remove it, Ihe injection of thin starch and opium, or tiuct. thebaic, is almost infallible. The bearing down, in females, as it pro- ceeds in this case, from the same kind of cause (viz. irritation) admits of relief from the same means as the tenesmus. Iu some habits an obstinate costiveness attends this kind of inflammation, accompa- nied, not unfrequently, with a painful dis- tention and enlargement of the hemorrhoi- dal vessels, both internally and externally. While a quantity of hard feces are detained within the large intestines, the whole habit must be disordered ; and the symptomatic fever, which necessarily accompanies the formation of matter, must be considerably heightened. And while the vessels sur- rounding the rectum (which are large and numerous) are distended, all the ills proceed- ing from pressure, inflammation, and irrita- tion, must be increased. Phlebotomy, laxative clysters, and a low, cool regimen, must be the remedies: while a soft cataplasm applied externally serves to relax and mollify the swollen, indurated pibs, at the same time that it hastens the suppu- ration. When the abscesses have formed, and are fit to be opened, or when they have already burst, they may be reduced to two general heads, viz. 1. Those, in which the intestine is not at all interested; and, 2. Those, in which it is either laid,bare, or perforated. In making the opening, the knife or lan- cet should be passed in deep enough to reach the fluid ; and, when it is in, the inci- sion should be continued upward and down- ward, in such manner as to divide all the skin covering the matter. By these means, the contents of the abscess will be dis- charged at once ; future lodgment of mat- ter will be prevented ; convenient |room will be made for the application of proper dressings; and there will be no necessity for making the incision in different direc- tions, or for removing any part of the skin composing the verge of the anus. Notwithstanding all these collections of matter are generally called fistitlce, and are all supposed to affect the intestinum rectum, yet it is very certain that the seat of the ab- scess, is sometimes at such distance from the gut, that it is not at all interested by it; and that none of these cases either are, or can be originally fistulm. In this state of the disease, we have no more necessarily to do with the intestine, than if it was not there ; the case is to be considered merely as an abscess in the cel- lular membrane. Suppose a large and convenient opening to have been made by a simple incision; the contents of the abscess to have been thereby discharged; and a sore or cavity produced, which is to be filled up. The term filling up, and the former opi- nion, that tbe induration of the parts about is a diseased callosity, have been the two principal sources of misconduct in these cases. The old opinion, with regard to hollow and hardness, was, that the former is caused entirely by loss of >ubstance : and the lat- ter, by diseased alteration in the structure of the parts. The consequence of which opinion was, that as soon as the matter was discharged, the cavity was filled and distended, in order to procure a gradual regeneration of flesh, and the dressings, with which it was so filled were most commonly of the escharotic 210 -> AM > Icind., Intended foi? the dissolution of laard- r»e--. The practice is a necessary consequence of the theory. Whoever supposes diseased callosity7; and great loss of substance, will necessarily think himself obliged to destroy the former, and to prevent the cavity, formed by the latter, from filling up too hastily. On the other hand, he who regards the cavity of the abscess as being principally the effect of the gradual distraction and separation of its sides, with very little loss of substance, compared with the size of tbe shid cavity ; aud who looks upon the indu- ration round about, as nothing more than a circumstance which necessarily accompa- nies every inflammation in membranous parts, more especially in those which tend to suppuration ; will, upon the smallest reflection, perceive, that the dressings ap- plied to such cavity ought to be so small in quantity, as to permit nature to bring the >ides of the cavity toward each other, and that such small quantity of dressings ought to coiiM^t of materials proper only to en- fourage easy and gradual suppuration. Suppuration is to be produced and main- tained, not by thrusting in such applica- tions, as by their quantity distend, and by their quality irritate and destroy ; but by dressing lightly and easily with such as ap- pease, relax, and soften. If the hollow, immediately it i« opened, be filled with dressings (of any kind,) the eides of it will be kept from approaching each other, or may even be farther separa- ted. But if this cavity be not filled, or have little or no dressings of any kind introduced into it, the sides immediately collapse; and, coming nearer and nearer, do, in a very short space of time, convert a large hollow into a small sinus. And this is also con- stantly the case, when the matter, instead of being let out by an artificial opening, es- capes through one made by tbe bursting of the containing parts. True, this sinus will not always become perfectly closed ; but the aim of nature is not, therefore, the less'evident; nor the hint, which art ought to borrow from her, Ihe less palpable. In this, as in most other cases, where there are large sores, or considerable cavi- ties, a great deal will depend on the pa- tient's habit, and the care that is taken of it: if that be good, or if it be properly- corrected, the surgeon will have very little Trouble in his choice of dressings ; onlv to take care that they do not offend either in quantity, or quality : but if the habit be bad, or injudiciously treated, he may use the whole farrago of externals, and only waste his own and his patient's time. By light, easy treatment, large abscesses formed in the neighbourhood of the rectum, will sometimes be cured, without any ne- cessity occurring of meddling with the said if. But il much more frequently happens, at the intestine, although it may not have been pierced or eroded by the matter, has yt been «o 'Tripped or decided, that no consolidation of lur t-iuus can be obtained, but by a division; that is, by laying the two cavities, viz. that of the abscess, und thai of the intestine, into one. When the intestine is found to be separa- ted from the surrounding parts by the mat ter, the operation of dividing it had better (on many accounts) be performed at the time the "abscess is first opened, than be de- ferred to a future one. For, if it be done properly, it will add so little to the pain, Which the patient must feel by opening the abscess, that he will seldom be able to dis- tinguish the one from the other, cither with regard to time or sensation ; whereas, if it be deferred, he must either be in continual ei- pectation of a second cutting, or feel one at a time when he does not expect it. The intention in this operatioa is to divide the intestine rectum from the verge of tbe anus up a0 high as the top of the hollow hi which the matter was formed ; thereby to lay the two cavities of the gut and absciss into one ; and by means of an open, in- stead of a hollow or sinuous sore, to ob- tain a firm, and lasting cure. For this purpose, the curved, probe-point- ed knife, with a narrow blade, is the most useful and handy instrument of any. This, introduced into the sinus, while the sur- geon's fore-linger is in the intestine, will enable him to divide all that can ever re- quire division ; and that with less pain to tbe patient, with more facility to the ope- rator, as well as with more certainty and expedition than any other instrument what- ever. If there be no opening in the intes- tine, the smallest degree of force will thrust the point of the knife through, and thereby make one : if there be one already, tbe same point will find and pass through k. In either case, it will be received by the finger in ano; will thereby be prevented from deviating, and being brought out bv the same finger, must necessarily divide all that is between the edge of the knife, and the verge of the anus : that is, must by one simple incision (which is made in the smallest space of time imaginable) lay tbe two cavities of the sinus and of the intes- tine into one. Authors make a very formal distinction betw een those cases iu which the intestine is pierced by the matter, and those in wbieh 1 it is not ; but although this distinction may be useful when the di Cerent states of the j disease are to be described, yet in practice, , when the operation of dividing the gut be- comes necessary, such distinction is of n» consequence at all ; it makes no alteratk* in the degree, kind, or quantity, of pain which the patient is to feel ; the force re- quired to push the knife through the tender gut is next to none, and when its point Is in the cavity, the cases are exactly simile* Immediately after the operation, a nof? dossil of fine lint should be introduced (from the rectum) between the divided lif* i of the incision ; as well to repress biij slight haemorrhage, as to prevent ihe ho- m-d'ite reunion of the =aid lips : and th' ANUS. 221 rest of the sore should be lightly dressed with the same. This first dressing should be permitted to continue, until a beginning nppuration renders it loose enough to come away easily ; and all the future ones should be as light, soft, and easy as possible ; consisting only of such materials as are likely to promote kindly and gradual sup- puration. The sides ot the.abscess are large ; the incision must necessarily, for a few days, be inflamed ; and the discharge will, for some time, be discoloured and sleety : this induration, and this sort of dis- charge, are often mistaken for signs of dis- eased callosity, and undiscovered sinuses ; upon which presumptions, escharotics are freely applied, and diligent search is made for new hollows ; the former of these most commonly increase both the hardness and the gleet; and by the latter new sinuses are sometimes really produced. These occasion a repetition of escharotics, and perhaps, of incisions ; by which means, <-ascs which at first, and in their own nature were simple and easy of cure, are rendered complex and tedious. To quit reasoning, and speak to fact only: In the great number of these cases, which must have been in St. Bartholomew's Hospital, within these ten or twelve years, I do aver, (says Polt) that I have not met with one, in the circumstances before des- cribed, that has not been cured by mere sim- ple division, together with light, easy dress- ings :. and that I have nofj in all that time, vsed fot*this purpose, a single grain ofpraici- pilatc,or of any other cscharolic. The best and most proper method of di- viding the intestine, in the case of a collec- tion of matter formed juxtaanum, we have already described. The intention to be aimed at by incision in the present case, is exactly the same, and ought to be executed in the same man- ner. Let us first suppose the matter to be fairly formed ; to have made its poiut, as it is called ; and to be fit to be let out. Where such point is, that is, where the skin is most thin, and the fluctuation most palpable, there the opening most certainly ought to be made, and always with a cutting instrument, not caustic, as was formerly done. We have supposed the matter of the abscess to have been formed, and collected; but still to have been contained within the cavity, until let out by au incision. We are now to consider it, as having made its own way out, without the help of art. This state of the disease is also subject to mine variety of appearance; aud these different appearances have produced, not only a multiplicity of appellations, but a groundless supposition also, of a variety of essentially different circumstances. When a discharge of the matter bv in- cision is loo long delayed or ut fleeted, it makes its own way out, by burning the ex- t"nial parts «iunewhere n«»ar to the funda- ment, or by eroding and making a hole through the intestine into its- cavity ; or sometimes by both. In either case, the discharge is made sometimes by one orifice only, and sometimes by more. Those, in which the matter has made its escape by one or more openings, through the skin only, are called blind external fistula ; those, in which the discharge has been made into the cavity of the intestine, without any orifice in1 the skin, are named blind in- ternal ; and those, which have an opening both through the skin, and into the gut, are called complete fistula'.. Thus, all these cases are deemed fistulous, when hardly any of them ever are so -/and none of them necessarily. They are still mere abscesses, which are burst without the help of art ; and If taken proper and timely care of, will require no such treat- ment as a true fistula may possible stand in need of. ' , The mostfrequentof allare what are called the blind external; and the complete. The method whereby each of these states may be known is, by introducing a probe into the sinus by the orifice in the skin, while the fore-finger is within the rectum : this will give the examiner an opportunity of knowing exactly the true state of the case, with all its circumstances. Whether the case be, what is called a complete fistula, or not; that is, whether there be an opening in the akin only, ov one there, and another in the intestine, the appearance to the* eye is much the same. Upon discharge of the matter, the external swelling subsides, and the inflamed colour of the skin disappears, tbe orifice, which a,'. first was sloughy and foul, after a day or two are past, becomes clean and contracts in size ; but the discharge, by fretting the parts about, renders the patient still uneasy. As this kind of opening seldom proves sufficient for a cure, (though it sometimes does) the induration, iu some degree, re- mains ; and if the orifice happens not to be a depending one, some part of the matter lodges, and is discharged by intervals, or may be pressed out by the fingers of an ex- aminer. The disease, in this state, is not very painful ; but it is troublesome, nasty, and offensive : the continual discharge of a thin kind of fluid from it, creates heat, and causes excoriation in the parts above; it daubs the linen of the patient; and is, at times, very fetid ; the orifice also- some- times contracts so, as not (o be sufficient for the discharge; and the lodgment of the matter then occasions fresh disturbance. The means of cure proposed and prac- tised by our ancestors, were three, m'z. caustic, ligature, and incision. The intention in each of these is the same, viz. to form one cavity of the sinus and intestines by laying the former into the latter. The two first are now completely and most properly, exploded. * ' Hitherto we have considered the disease either as an abscess, from which the matter ba^ been let out by an incision, m^.c bv a a:\L\- surgeon, or from which tbe contents have been discharged by one single orifice, formed by the bursting of the skin some- where about the fundament. Let us now take notice of it, when instead of one such opening, there are several. This state of the case generally happens when the quantity of matter collected has been large, the inflammation of considera- ble extent, the adipose membrane very sloughy, and the skin worn very thin be- fore it burst.—It is, indeed, a circumstance of no real consequence at all; but from being misunderstood, or not properly at- tended to, is made one of additional ter- ror to the patient, and additional alarm to the inexperienced practitioner: for it is taught, and frequently believed, that each of these orifices is an outlet from, or leads to a distinct sinus, or hollow : whereas in truth, the case is most commonly quite otherwise ; all these openings are only so many distinct burstings of the skin co- vering the matter ; and do all, be they few or many, lead and open immediately into the one single cavity of the abscess : they neither indicate, nor lead to, nor are caused by distinct sinuses ; nor would the appear- ance of twenty of them (if possible) ne cessarily imply more than one general hol- low. If this account be a true one, it will fol- low, that the chirurgie treatment of this kind of case ought to be very little, if at all dif- ferent from that of the preceding; and that all that can be necessary to be done, must be to divide each of these orifices in such manner as to make one cavity of the whole. This the probe-knife will easily and expeditiously do; and when that is done, if the sore, or more properly its edges, should make a very ragged, uneven appearance, the removal of a small portion of such irre- gular ans-ular parts will answer all the pur- poses of making room for the application of dressings, and for producing a smooth, even cicatrix after the sore shall be healed. When a considerable quantity of matter has been recently let out, and the internal parts are not only in a crude, undigested state, but have not yet had time to collapse, and approach .each other; the inside of such cavity will appear large ; and if a probe be pushed with any degree of force, it will pass in more than one direction into the cellular membrane by the side of the rectum. But let not the inexperienced practitioner be alarmed at this, and immedi- ately fancy, that there are so many distinct sinuses . neither let him, if be be of a more hardy disposition, go to work immediately with his director, knife, or scissors: let him enlarge the external wound bv making his incision freely ; let him lay all the separate orifices open into that cavity; let him di- vide the intestine lengthwise by means of his finger in ano ; let bitn dress lightly and easily ; let him pay proper attention to the habit of the patient; and wait, and see what a few'days, under such conduct, will pro- duce. By this he will frequently find, that the large cavity of the abscess will become small and clean ; that the induration round about will gradually lessen ; that the probe will not pass in that manner into the cellu- lar membrane ; and consequently, that his fears of a multiplicity of sinuses were groundless. On the contrary, if the sore be crammed or dressed with irritating, or es- charotic medicines, all the appearances will be different: the hardness will increase, the lips of the wound will be inverted, the ca- vity of the sore will remain large, crude, and foul; the discharge will be thin, gleety, and discoloured ; the patient will be uneasy and feverish : and, if no new cavities are formed by the irritation •( parts, and con- finement of matter, yet the original one will have no opportunity of contracting itself; and may very possibly become truly fis- tulous. Sometimes the matter of an abscess, form- ed junta anum, instead of making its way out through tbe skin, externally near tba verge of the anus, or in the buttock, pierces through (he intestine only. This is what is called a blind internal fistula In this case, after tbe discharge has been made, the greater part of the tuinefrrtion subside?, -md tbe patient becomes easier. If this does not produce a cure, which some- times, though very seldom happens, soma small degree of induration generally remains in the place where the original tumour was, upon pressure on this hardness, a small dis- charge of matter is frequently made per anum ; and sometimes the expulsion of air from the cavity of the abscess into thai of the intestine may very palpably be felt,and clearly beard ; the stools particularly, if hard and requiring force to be expelled, are some- times smeared with matter; arid although the patient, by the bursting of the abscess, is relieved from the acute pain which the collection occasioned, yet he is seldom per- fectly free from a dull kind of uneasiness, especially if he sits for a considerable length of time in one posture. The real difference between this kind of case, and that in which there is an external opening (with regard to method of cure) is very immaterial; for an external opening must be made, and then all difference ceases. In (his, as in the former* no cure can reasonably be expected, until the cavily of the abscess, and that of the rectum, are made one , and tbe only differ- ence is, that in tbe one case we have an on- fiee at, or near the verge of the anus, by which we are immediately enabled to per- form that necessary operation ; in the other ue must make one. We come now to that state of the disease, which ma\ truly and properly be called jit- tubus. This is generally defined, tinuion- gustus, callosus, profundus.- acri sank dify ens; ..r, |.„ I) onis translates it, " Un ulcere prufoudfr caverneux, dont I'entrie est etroilt, fy le fond plus large ; avec issue d'un f** acre fy virulent ; et accompagnt de calif sit is." Various causes may produce or concori" producing sucb a <='nfe of the part? concern AMJS £223 ed aa will constitute a fistula, in the proper sense of the word ; that is, a deep, hollow sore, or sinus, all parts of which are so hard- ened, or so diseased, as to be absolutely in- capable of being healed, while in that state ; and from which a frequent, ordaily discharge is made, of thin, discoloured sanies, or fluid. These are d'wided into two classes, viz. those which are the effect of neglect,distem- pered habit, or of bad management, and which may be called, without any great im- propriety, local diseases; and those which are the consequence of disorders, whose ori- gin and seat are not in the immediate sinus or fistula, but in parts more or less distant, and which, therefore, are not local com plaints. The natures and characters of these are obviously different by description ; but they are still more so in their most frequent event, the former being generally curable by proper treatment; the latter frequently not so by any means whatever. Under tbe former are reckoned all such cases as were originally mere collections of matter within the coats ot tbe intestine rec- tum,orin the cellular membrane surrounding tbe said gui ; but which, by being long neg- lected, grossly managed, or by happening in habits which were disordered, and for which disorders no proper remedies were adminis- tered, suffer such alteration, and get into such state, as to deserve the appellation of fistula. Under the latter are comprised all those cases, in which the disease has its origin and first state in the higher and more distant parts of the pelvis, about the os sacrum, lower vertebrae of tbe loins, and parts adja- cent thereto ; and are either strumous, or the consequence of long and much distempered habits; or the effect of, or combined with, other distempers, local or general ; such as a diseased neck of the bladder, or pros- trate gland, or urethra, he. he. he. Among tbe very low people, who are brought into hospitals, we frequently meet with cases of the former kind: cases, which, at first, were mere simple abscesses; but which, from uncleanliness, from intem- perance, negligence, and distempered con- stitutions, become such kind of sores, as may be called fistulous. In these the Hrt of surgery is undoubtedly, in some measure, and at some time, neces- sary ; but it very seldom is the first or prin- cipal fountain from whence relief is to be sought: the general effects of intemperance, debauchery, and diseases of the habit are first to b corrected aud removed, before surgery cim with propriety, or « itb reason- able pro-peel of advance, be made use of. The surgery required in these cases, con- sists in laying op.-n and dividing the sinu , or sinuses, in sucli manner that there may be no possible lodgment for matter, and that such cavities may be fairly opened length- wise into that of the intestine rectum" if the internal parts of these hollows are hard, »nd do not yield good matter, which is sometimes the ease, more especially where attempts have been made to cure by inject- ing astringent liquors, such parts should be lightly scratched or scarified with the point of a knife or lancet, but not dressed with escharotics; and if either from the multi- plicity of external orifices,or from the loose, flabby, hardened, or inverted state of the lips and edges of the wound near to the fundament, it seems very improbable that they < an be got into such a state as to heal smoothly and evenly, such portion of them should be cut off as may just serve that pur- pose The dressings should be soft, easy, and light; and the whole intent of them to produce such suppuration as may soften the parts, and bring them into a state fit for healing. If a loose, fungous kind of flesh has taken possession of tbe inside of the sinus, (a thing much talked of, and very seldom met w ith) a slight touch of the lunar caustic will reduce it sooner, and with better effect on the sore, than any other escharotic what- ever. The method and medicines, by which the habit of the patient was corrected, must be continued (at least in some degree) through the whole cure ; and all the excesses and irregularities, which may have contributed to i:ijure it, must be avoided. By these means, cases which at first have a most disagreeable and formidable aspect, are frequently brought into such state, as to give very little trouble in the healing. If the bad state of the sore arises merely from its having been crammed, irritated, and eroded ; the method of obtaining relief is so obvious, as hardly to need recital. A patient who has been so treated, has generally some degree of fever ; has a pulse which is too hard, and too quick ; is thirsty, and does not get his due quantity of natu- ral rest. A sore which has been so dress- ed, has generally a considerable degree of inflammatory hardness round about; the lips and edges of it are found full, inflamed, and sometimes inverted; the whole verge of the anus is swollen ; the haemorrhoidal vessels are loaded ; the discharge from the sore is large, thin, and discoloured ; aad all the lower part of the rectum participates of the inflammatory irritation, producing pain, bearing-down, tenesmus, he. Contraria contrariis is never more true than in this instance: the painful, uneasy state of the sore, and of the rectum; is the great cause of all the mischief, both general and parti- cular ; and the first intention must be to alter that state All escharotics must be thrown out, and disused ; and in lieu of them, a sofi digestive should be substituted, in such manner as not to cause any disten- tion, or to give any uneasiness from quantity : over which a poultice should be applied : these dressings should be renewed twice a day ; and the patient should be en- joined absolute rest. At the same time, at- tention should be paid to the general dis- turbance, which the former treatment may 224 AM- have created. Blood should be uraw n off from the sanguine ;. the feverish heat should be calmed by proper medicines; the lan- guid and low should be assisted with the bark and cordials: and ease in the part must, at all events, beVibtaincd by tbe injection of anodyne clysters of starch and opium. If the sinus has not yet been laid open, and the bad state of parts is occasioned by f.he introduction of tents imbued with es- rharotics; or by the injection of astringent liquors, (the one for the destruction of cal- losity, the other for the drying up gleet and humidity) no operation of any kind should be attempted until both the patient and the parts are easy, cool, and quiet: ca- taplasms, clysters, rest, and proper medi- cines must procure that: and when that is accomplished, the operation of dividing the sinus, and (if necessary) of removing a small portion of the ragged edges, may be execu- ted, and will, in all probability, be attended with success. On the contrary, if such ope- ration be performed while tbe parts are in a state of inflammation, the pain will be great, the sore for several days very troublesome, and the cure prolonged or retarded, instead of being expedited. Abscesses and collections of diseased fluids, are frequently formed about the lum- bar vertebrae, under the psoas muscle, and near to the os sacrum ; in which cases, the said bones are sometimes carious, or other- wise diseased. These sometimes form si- nuses, which run down by the side of the rectum, and burst near to the fundament. The chirurgie treatment of such sores and sinuses can have no little influence on the remote situation, where the collection of matter is originally formed. (See Lumbar Abscess.) Fistulous sores, sinuse3, and indurations about the anus, which are consequences of diseases of the neck of the bladder, and urethra, called fistula? in perinaso, require separate and particular consideration. (See Fistula in Perinaio.) Pott may be considered as the source and authority of the foregoing remarks. M. Roux has lately published a sort of critique on the preference, which English surgeons invariably give to Pott's method of operating for the fistula in ano. The chief peculiarity in the French plan, on which he bestows unqualified praise, con- sists in the use of a kind of director, called a gorget, which is usually made of ebony- wood, and intended to he introduced within the rectum with its concavity turned to- wards the fistula. A steel inflexible direct- or, slightly pointed and without a cul-de- sac, is then passed through the fistula till the '.joint comes into contact with the wooden gorget.* A long, narrow, sharp-pointed, :-traight bistoury is :;ow introduced along the groove of'the steel director, till its point meets the groove of the ebony gorget, by cutting upon which all the parts ^re di- vided, which lie between the internal opening of the fistula and the anus. It may he objected to this method, that it is not al- ways easy to make a direi tor passut once through the fistula into the rectum. Thbis acknowledged by M. Richerand, who adds, that, in this circumstance, the point of the director may be forced into the rectum, without lessening the chance of the success of the operation. (Nosogr. Chirurg. T.$, p. 463, 464. Edit. 4.) Why then does it matter so much, that the surgeon sometimes pierces the rectum with the point of hi* curved bistoury ? Surely, this is as good an instrument for making the puncture as the pointed director. Besides, it appears to me, that a flexible silver director is more likely to follow the track of the fistula into the rectum, than an unbending iron instru- ment. I shall say nothing of the awkward- ness of using the other wooden director: the finger of the surgeon can always do the office of all such contrivances, with great- er safety and convenience. M. Roux also censures us for not cramming the wound with charpie ; for he is not content with merely introducing into it a dossil of lint. (See Parallele de la Chir. Angloise, t\t. p. 296, fa.) His countryman Pouteau, bow- ever, knew better long ago: for he has ex- pressed his decided conviction of tbe inuti- lity of cramming the wound with dressing? to its very bottom after the third day, when superficial dressings, and the renewal of them as often as cleanliness requires, will be fully sufficient. For information, relative to former opi- nions concerning^wfuhxinano, referto Cel- sus ; Heisters Surgery; Le Dran's Opera- lions; Sharp's Operations; La Faye's Notes on Dionis. H. Bass, De Fistula Anifelicitrr curanda. in Hallei Disp. Chir. 4, 463 J. I. Petit, Traiti des Mai. Chir. T. land2,p. 113. Petit is an advocate for making on early opening, like Pott, and all the best mi- ters on this disease. In Kirklaml's Medical Surgery, Vol. 2, may be found an account of the opinions and practice of many famet celebrated practitioners. The best modern practical remarks are contained in Pott'i Treatise on the Fistula in Ano. in which he has offered also an excellent critique on tome opinions of Le Drnn, De la Fuye, and Chtsil- den. The reader may also consult with ad- vantage Sabatier's Midecine Opfratoire, Tom. 2; B. Bell's Surgery, Vol.2; Lalta'i Surgery, Vol. 2 ; T. Whately, Cases of Po- lypi, fa. with an rippcndix, describing an im- proved instrument for the fistula in ano, Srn Lond. 1805. J. T. Oetemann, De Fistula dni, 4to. Jenm, 1812. Richerand's Nosogrttph' Chirurgicale. T. Z, p. 446, fa. Edits* Roux. Voyage fait a Londres en lbl4, o« Parallele dc la Chirurgie Angloise arec It Chirurgie Francaise, p. 35"), fa. P^ 1815. Callisens Syst. Chirurgiff Hodietti- Tl, p. 470. Schreger, Chirurgi- tines, p. 360.) It must be confessed, thai few surgeons have entertained sufficiently accurate ideas of the changes, which hap- pen around the wounded, or mortified por- tion of intestine, when an artificial anus \- produced; and though Desault's account was excellent, as far as it went, it was not until the year 1809, when Scarpa published his valuable work on Hernia, that the whole process of nature on such occasions was completely elucidated. The hernial sae, (says he) does not always partake of gan- grene with the viscera contained in a her- nia, and even when it does slough, aina the separation of the dead parts happens on the outside of the abdominal ring, there al most always remains in this situation a por- tion of the neck of the hernial sac perfeietit sound. It may be said therefore, that, » all cases, immediately after the detachment of the mortified intestine, whether it happen within, or on the outside of the ring, the two orifices of the gut are enveloped in the neck of the hernial sac, which, soon becom- rmr adherent f° t^m by the effect of i"- ANU,a, 220 fiammation, serves for a certain time to di- rect the feces towards the external wound, and to prevent their effusion in the abdo- men. In proportion as the outer wound di- minishes, the external portion of the neck of the hernial sac also contracts; but, that part, which embraces the orifices of the in- testine, gradually becomes larger, and at length forms a kind of membranous funnel- shaped, intermediate cavity, which makes the communication between the two parts of the bowel. However, according to Scarpa's investigation, this adhesion of the neck of the hernial sac, round the two orifices of the gut, does not hinder the latter from gradually quitting the ring, and becoming more and more deeply placed in theveavity of the abdomen. The base of the above described funnel-shaped membranous ca- vity corresponds to the bowel, aud its apex tends towards the wound, or fistula. But, in relation to this part of the subject, there are some other circumstances which every surgeon should well understand, and his ignorance of them would not be excu- sable, on the ground of their not having been, like the funnel-shaped membranous cavity, forming the communication between the two orifices of the bowel, only a disco- very of recent date ; for, they were fully explained many years ago. I here allude to the exact position of the two portions of the bowel, with respect to each other, the direction of their orifices, the angle, or ridge between them, and the difference in their diameters. The first of these circum- stances, viz. the position of the two parts of the bowel, as we have seen, is pointed out by Mr. Travers, who represents them as occupying a position nearly parallel, and cites an interesting observation recorded by Pipelet. The patient was a woman, 56 years old; the loop of spoiled gut was from five to six inches long ; the contents of the bowel were discharged through the wound for a considerable time, and an artificial anus was established. Some accidental ob- struction occurred ; a purgative was given, which operated in the natural way, and, in fifteen days, the wound was healed. She lived in perfect health to the age of 82, when she died of a disease not connected with this malady. Pipelet examined the body, and has given a figure representing the union. The line of the intestine form- ed uu acute angle, where it adhered to the peritoneum, opposite to the crural arch. The cylinder is evidently much contracted. Pipelet particularly dwells upon tbe angu- lar position and constriction of the tube at the point of union. Tbe lower continua- tion of the intestinal tube was also remark- ed to be more contracted than the upper Sort ion, a circumstance correctly referred y Mr. Travers. to the undilated state of the bowels, situated between the artificial and the natural anus. (See Mim. de I'Acad. de Chir. T. 4,p. 164, and Tracers on Injuries of the Intestines, p. 364.) The two ends of the bowel, as Scarpa has observed, are always found lying in a more nr less paral- lel manner by the side of each other; the upper, with its orifice open, and directed towards the external wound by the feces, which issue from it, while the lower, which gives passage to nothing, becomes less ca- pacious, and Is retracted further into the abdomen. Hence, the breach in the intes- tinal canal is never repaired by the orifices of the upper and lower portions of the bow- els reuniting, coalescing, and running, as it were, into each other Indeed, they meet at a very acute angle ; the axis of one does not correspond to that of the other; and their orifices never lie exactly opposite each other. It is in short by means of the funnel- shaped cavity,formed by the remains of the hernial sac, that the two parts of the bowel communicate, and the feces, in order to get from the upper into the lower continu- ation of the intestine, must first pass in a semicircular track through that funnel-sha- ped cavity, there being between the orifices of the bowel, directly opposite to the com- munication between the cavity of the in- testine and that of the funnel-shaped mem- brane, a considerable projection, or jutting angle, forming a material additional obstacle to the direct passage of the feces from ihe up- per into the lower portion of the intestinal tube. (Scarpa sull' Ernie Memorie, Anat. Chirurgiche, Milano, 1809.) Desault, after noticing the efficiency of the adhesions between tbe injured part of the bowel and the edge of the opening in the parietes of the abdomen, in preventing extravasation, remarks, that, if such adhe- sions were entire, the abdominal parietes would form a substitute for the portion of the canal, which has been destroyed, and the contents of the bowel would continue to pass, as usual, towards the anus, if the portions of the intestine separated and ad- herent to the neighbouring parts, did not form such an acute angle as obstructs the passage of the intestinal matter. The more acute this angle is, the greater is the ob- struction ; when the two parts of the bowel lie nearly parallel, the entrance into the lower portion of the canal is completely prevented ; but, if they meet at a right an- gle, then more or less of the contents of the upper portion may be transmitted into the lower. The first disposition chiefly happens when a considerable part of the intestinal canal has been destroyed, or when the tube has been completely divided; while tbe second posture is principally remarked in all cases where the injury has been less extensive. And it is plain, that the possibi- lity of a cure depends materially on the kind of angle, at which the two portions of bowel meet, and that the projection of the internal fraenum, or jutting membranous ridge between the two orifices, is always a greater or lesser obstacle to the cure. With respect to the diminution, which occurs in the diameter of the part of the intestinal canal, between the artificial opening and the natural anus, Desault ad- mits the correctness of the observation, but entirely dissents from such author* as have 23Q ANUS. spoken of the change, as sometimes pro- ceeding so far, that an obliteration of that portion of the intestinal tube is the conse- quence. The mucus secreted within it suffices for preventing this obliteration ; a secretion which, in these cases, is copious, and is partly voided from the rectum, in the form of white flakes. And, if any fur- ther proof were needed, that the bowels between the artificial and natural ani re- main pervious, it is furnished by the fact, that, in cases of artificial anus, the lower continuation of the tube frequently becomes inverted, and protrudes. On the other hand, the kind of obliteration, above spo- ken of, has never been demonstrated by dissection : it was not observed by Lecat, in the examination of the body of a person who died twelve years after the entire ces- sation of the passage of feces per anum; nor was it found t<> exist by Desault, when he opened a patient who died of marasmus in the Hotel-Dieu, in consequence of an artificial anus, which communicated with the ileum, and had lasted two years. (02uvr. de Desault, T. 2, p. 354-56.) However proper the formation of an ar- tificial anus may be, in many cases, in which the patient's life depends upon the event, it must be confessed, that the consequence is a most afflicting and disgusting infirmity. This truth cannot be denied, though the feces which are discharged, from not having been so Ions; retained in the bowels, may not be so fetid as those which are evacuated in the ordinary way. As the opening, which gives vent to the excrement, is not endued with the same organization as the lower end of the rectum, and as, in particular, it is not furnished with any sphincter ca- pable of contracting and relaxing itself, as occasion requires, the feces are continually escaping without any knowledge of the cir- cumstance on the part of the patient. Hence the uncleanly state of the parts around the external opening ; and their frequently ex- coriated fungoifs stfrte. Some persons in this state, among the number of those whose histories are on record, have made use of a metal box, in which their excrement has been received. Schenckius relates the case of an officer who was'wounded in the belly, and who allowed his feces to escape into a vessel made for the purpose. Dionis makes mention of a similar case. What occurred to an invalid soldier, says this eminent writer, is too singular to serve as an example in practice, since nature alone preserved him, by making tbe wound of the abdomen serve as an opening for tbe dis- charge of his feces. The intestine has be- come adherent to it, and he daily evacu- ates his excrement through this opening. The matter coming away involuntarily, ne- cessitates him to have a tin box for its re- ception . Moscati also communicated to the Aca- demy of Surgery, the history of a wounded man, in whom an artificial anus took place, inconsequence of a wound in the abdomen below the right hypochondrium. His ei- crement used to be received in atinboi, fastened to him by a belt. The above sue- geon very properly remarks, as rather a sin- gular circumstance in this wound, that it admitted of a leaden cannula being intro- duced, to which cannula the tin box wa- accommodated. Uncleanliness is not the only inconveni- ence of an artificial anus. Persons have been known to be quite debilitated by the affliction, and even ultimately to die in con- sequence of it. This is liable to happen, whenever the intestinal canal is opened very high up, so that the aliment escapes before chylification is completed, and the nutritious part of the food has been takeu up by th* lacleals. In this circumstance, the patient becomes emaciated, and some- times perishes, as Desault had an opportu- nity of observing, and examples of which are also recorded by Hoin and Le Blanc. Iu cases of this description, tbe matter voided has little fetor, and is frequently sourish. In all instances, the matteris eva- cuated involuntarily, because there is no- thing like a sphincter. But, when the opening only interests the lower convolu- tions of the ileum, or, what is more fre- quent, when it has occurred in the large in- testines, the danger is less serious, and |ia- tients, in this state, are often noticed per- forming all their functions very well, and, with the exception of colic, to which they are subject, enjoying as good health as they did previously to their having the present disease. In sueh examples, the matter void- ed is more fetid, its discharge does not fol- low so quickly its introduction into the sto- mach, and it is retained for a longer lime. Many patients, afflicted with an artificial anus, void no feces at all from the rectum; but they occasionally go to the vault, for the purpose of voiding a thick whitish sub- stance, which is the mucous secretion of the portion of the large intestines nearest to the anus. Under certain circumstances, the quantity of this mucus discharged i= more copious. (Desault, Vol. cit. p. 3b9.) The most grievous occurrence, to which persons with an artificial anus are exposed, is a prolapsus of the bowel, similar to what sometimes happens through the anus, with respect to th° rectum. The descent of the bowel is sometimes simple, only affecting a portion of the intestinal canal just above gr below the opening. On other occasions, the complaint is double, the bowel both above and below the opening being pro- lapsed. This descent o£ the intestine forms a tumour, the dimensions of which vary considerably in the different subjects in whom it is observed. When the protrusion is caused by the upper part of the intes- tinal canal, the feces are voided at the ex- tremity of the tumour, and, when the swell- ing consists of the lower portion of the bowel, the excrement is evacuated at tbe base of the prolapsed part. By observing this evacuation, when the tumour i? double ANLs 231 H is eaay to know to which end of the in- testinal canal each protruded portion be- longs. This consequence of an artificial anus is very serious, because it greatly in- creases the inconvenience which the pa- tient suffers. Sometimes, the tumour is exquisitely sensible; and, occasionally, when the eversion of the intestine is consi- derable, a strangulation is produced, which puts the patient's life in danger. I apprehend no well-informed surgeon of (he present day can doubt, thi't formerly the frequency of artificial ani after hernia, was seriously increased by the absurd mea- sures sometimes adopted for the express purpose of preventing ihem : and, as Mr. Travers has rightly observed, the cases re- ported by the old surgeons, if they prove anything, prove this: "that the canal has been very generally restored, when the ar- tificial anus was reckoned upon as inevita- ble, and that where an officious solicitude had been at work to prevent it, showing itself in an active interference with tl e ar- Tangements of nature, the case has termi- nated in artificial anus ; so that the event, either way, has been a matter of surprise to the surgeon. The fear of doing too little, or too much, applies only to the pernicious customs of dilating the stricture, displacing, amputating, and sewing the intestine ; the general adoption of which practice fully accounts to my mind for the number of ar- tificial ani, which are the sequela; of hernia." (Op. cit. p. 367.) The treatment of an artificial anus, is either palliative, or radical. The first con- sists in obviating the habitual uncleanhness, produced by the involuntary discharge of the intestinal matter, and in relieving such bad symptoms, as may arise from the disor- der. » The first indication is fulfilled by the em- ployment of silver, or tin machines, whiuh are either kept applied to the external open- ing by means of a spring, or form recepta- cles placed more or less off the artificial anus, from which the intestinal matter is transmitted through a tube, kept constantly in the opening. In general, says Desault, as elastic gum is supple, light, and capable of takiog any shape, it is the best material for the construction of such instruments, which, however, rarely answer their pur- pose completely, and always give the pa- tient a great deal of trouble. As for the second indication, Richter, with the view of hindering the too quick escape of the intestinal matter, and the death of the patient from this cause, propo- sed covering the opening for a certain time with a piece of sponge, supported by an r-lastic bandage, or truss. But Loeffler found this method objectionable, as it was apt to bring on colic, constipation, and in- flammation, and excoriation of the skin. ,. When the outer opening is disposed to contract too much, and inconveniences arise frdm this change, Sabatier is an advo- cate for preventing such closure by ineaii<: >i' a tent, or skein of silk, introduced fflo the aperture, and changed very often for the sake of cleanliness; while others pre- fer a ring of ivory for the purpose. But the irritation produced by the matter imbibed by this sort of tent, and in particular the liability of the bowel to proti ude, and be strangulated in the opening of the ivory ring, are found strong objections to these practices; and, according to Desnult, the sponge, employed by Richter, also occa- sions a great deal of excoriation by the irritation of the fluid w hich is lodged in it. For tfie purposes of hindering a protru- sion of the gut, of keeping the opening suf- ficiently p< rvious, of relieving any uneasi- ness and tenesmus, of hindering the intesti- nal matter from escaping in the intervals of dressing, and confining it long enough lor the adequate nourishment of the patient, Desault preferred a linen tent, or stop- per, covered by a pad of charpie, com- presses, and a tight bandage. At first, says he, the patient feels some uneasiness from this plan, and slight colics may be the con- sequence of it; but, by degrees, the parts become habituated to their new state, and every thing goes on well. With respect to the employment of tents and plugs, with the views above indicated, I am disposed to think the practice can rarely be advisable, and that any necessity for it may be obvia- ted by attention to diet, and the occasional exhibition of laxative medicines and clys- ters, as will be hereafter noticed. When the gut protrudes, its reduction is to be ef- fected in the same way, as a common pro- lapsus ani; but considerable difficulty will occur when the protruded part is inflamed, thickened, and of considerable size. Sur- geons, indeed, have usually regarded the reduction as being impracticable in these circumstances; but, according to Desault, this is not the case, as compression with a bandage, kept up for some days, will suc- ceed. Care must be taken, however, to leave a sufficient opening for the passage of the feces. Whatever may be the size of the protrusion, Desault argues, that it should be the invariable rule of the surgeon to en- deavour to return the part by the means here suggested. (See OZuvres Chir. de De- sault, T. 2,p. 361, fa.) The radical cure is what is next to be considered. The business of the surgeon is to prevent, if possible, the formation of an artificial anus; but, when the event has oc- curred, and, particularly, when the whole, or the greater part. of the stools is dis- charged in this way, no attempt must be made to stop up the opening, without a great deal of consideration ; for, any effort of this kind, made under circumstances which do not justify it, may be the i. eans of exposing the patient's life to the most alarming danger. Sometimes, indeed, without any interference of the surgeon, the outward opening contracts, and, the' issue of the intestinal matter being ob- structed, pain and tenesmus are excited ; and the same consequences may be produ- ced by any swelling and enlargement of the AM:- projecting mlge, situated between the two portions of the bowel. In two cases, Puy found this swelling take place in such a de- gree, that the patients fell victims to the complete stoppage of the intestinal con- tents. The symptoms which arise, are then similar to those which happen in strangula- ted hernia. Hoin, Le Blanc, and Sabatier, also cite instances, in which the patients lost their lives by gangrene being brought on by this species of strangulation. (De- sault, Vol. cit. p. 360.) There is a period (says Mr. Travels,) at which the function of the lower portion of the canal, with a little assistance, may be restored. The natural order of events, connected with this recovery, has been mis- taken and inverted. Practitioners have closed the wound, instead of conducting I he matter by purgatives and clysters into the large intestines. Now, the wound w ill never fail to heal, when the matter reco- vers its accustomed route; but, this condi- tion cannot be reversed. The restoration is safest, when most gradual; when there is evidence of an existing sympathy between the repair of structure, and the return of function. According to the same gentle- man, there is reason to believe, that the well-timed exhibition of a single purgative might often prove effectual. " If the food is rapid, and little changed, in its passage, it should be pultaceous and nutritive, and given in moderate quantity at short inter- vals ; while injections of the same kind should be administered at least twice in twenty-four hours, and retained as long as possible." He states, that, by such means, patients may be nourished for many weeks. If the discharge is sparing, and does not readily escape, he recommends an occa- sional purgative in less than ordinary quan- tity. He disapproves of other medicines, especially stimulants, and all such food as is difficult of digestion, giving a general preference to animal food in a gelatinous form. He bestows just praise on strict at- tention to cleanliness, and in opposition to Desault and Sabatier, condemns the em- ployment of tents and sponges. (Op. cit. p. 371, 373.) Numerous cases on record furnish abun- dance of proof, that the feces, after being voided for several months from the wound, produced by the operation for hernia, fre- quently resume their natural course. Facts of this kind, which in general may be said to be common where the intestine is with- out loss of substance, are not very rare even where more or less of the bowel has been destroyed by gangrene ; and many illustrations of this remark may be found in Jim writings of Petit, Pott, Le Dran, he. The greater number of these instances of .-access, as already stated, were the result of the most simple, unofficious treatment, or rather of the undisturbed, and very little ns^ed, efforts of nature. In the radical cure of an artificial amis, the following are the general indications laid down by Desault: i. To rec'uce the gut when it protrudes, and is evened. 2. To prevent the issue of the feces from the wound, so that they may be obliged topa-s on towards the rectum, at the same time that the healing of the external opening is to be promoted. 3. To obviate any inter- nal impediments to the passage of the mat- ter into the lower part of the intestinal canal. How tbe first of these objects is to he ac- complished in the case of greatest difficulty. that is, when the parietes of the bowel arc thickened, has been already explained. Experience proves, says Desault, that the second indication cannot be fulfilled by means of sutures. The best thing for thi? purpose he represents to be the linen stop- per, above spoken of as a means for prevent- ing the protrusion of the bowel. Here it answers the double object of hindering such a protrusion, and filling up the fistulous opening, so as to make the contents of the bowel tend towards the anus. Desault ar- gues, that the surgeon need not be appre- hensive of the tent doing harm by keeping the wound from healing. The first aim, he says, should be to determine the feces to take their natural route ; and when this has been done by closing the external opening. tbe tent may be removed, and this openia; will spontaneously close. Howpver, when the internal impediment is too great, it must be overcome, ere such treatment can be successful. According to Desault, the most frequent impediment, here alluded to, is the angle formed by the two portions of the intestine, and it must be enlarged, and rendered less acute, in or- der that the feces may continue their route. This desirable change he recommends to be effected by introducing long dossils of charpie into the two ends of the bowel,nnd gradually altering their direction so as to bring it into one same straight line. When the dilatation is sufficient, and the inneran- gle, or ridge, is effaced, the long dossils need not be continued. The linen tent, with the precaution of not introducing it too deeply, lest it obstruct the course of the feces itself, will then suffice. When this plan is skilfully managed, Desault says, there will be a great chance of its succeed- ing, and its beneficial effect will be denoted by a rumbling in the bowels, and frequent- ly by slight colics. At first, wind is dis- charged from the rectum, and, soon after- wards, the feces begin to come away. On the contrary, if they should not pass with facility, the colic should become violent, and an accumulation happen in the upp^' portion of the intestinal canal, the teat must be withdrawn, and the other cause of obstruction be considered, and, if possible, removed. (Vol. cit.p. 365, fa.) In the preceding columns, I have given. a full explanation of the impediment, mad* to the passage of the feces into the lower orifice of the intestinal canal, by the pro- jecting septum, or ridge between the t*o parts of the bowel, and the matter having to traverse the funnel-shaoed membranous AM-a 233 otvity in quite a icmicircuiar track. A re- presentation of this septum may be seen in Scurpa's work. Tab. 9, Fig. 1. and a!»o in the sixth plate of Mr. Traversa Inquiry. In one example, in which this septum was pluinly visible in the wound, Dupuytren passed into the orifice of the upper part of the bowel a curved needle, and, passing it through the projecting septum, brought it out again through the orifice of the lower portion of the j?ut. Thus, he included a considerable part of the septum in a ligature, which was daily made thicker, with a view of first exciting inflammation in the two layers of this septum, and thus ensuring their adhesion together, and his next plan consisted in making a division through the part embraced by the ligature, whereby, the passage of the feces into the lower portion of the bowel was made quite free. But, as the section, made by the ligature, was too su- perficial, Dupuytren completed the division of the septum with a knife ; but peritonitis and the death of the patient ensued. In another case, this eminent surgeon tried to render the layers of the septum adherent by compressing them between the blades of a pair of forceps of particular construction, and afterwards be effected the division of tbe part by augmenting the compression, by means of a screw, traversing the handles of the instrument. In a case which follow- ed the operation for the bubonocele, attend- ed with mortification of the bowel, Dupuy- tren began with dilating the outer opening with a bistoury, and, after ascertaining the position of the septum between the two orifices of the bowel, he introduced one of the blades of the forceps into each portion of the gut, and clased the instrument with the screw. The part of the instrument, si- tuated externally to the ridge, or septum, he covered with charpie and a compress. The constriction was soon followed by colic pains, and tendency to vomit, which symp- toms, however, were quickly removed by fomenting the belly. They recurred, how- ever, the instrument became loose, and some discharge ensued. On examination, tbe septum was found to be partially divi- ded. After the breadth of the instrument had been lessened, it was applied again ; but when the screw was turned, the patient be- gan to suffer such violent pain over the whole of the abdomen, that it was necessa- ry to diminish the pressure ; and, as the instrument was afterwards separated from the parts in a fit of vomiting, it was with- drawn. A trial was now made to determine the feces towards the rectum by pressure on the external opening; but the plan could not be endured, and the hinderance to the egress of the intestinal matter was so op- pressive, that it was discontinued. As the iorceps used on the foregoing occasion, did not take sufficient hold of the septum, nor divide it properly, the instrument was somewhat altered. Dr. Reisinger has pub- lished three cases, in which it was success- fully employed by Dupuytren. In the first <»f tbe-.e examples when the instrument had Vor ». been applied, it embraced the septum so well, that it could not be displaced from it. The colic attacks, vomiting, thirst, furred tongue, and loss of appetite, which ensued, soon gave way after the belly had been fo- mented ; the constriction was then increa- sed, and found to produce less and less in- dispoMtion. On the 29ih, very little of the feces came out of tbe artificial anus, and, after a short time five natural evacuations took place. The blades of the instrument were now completely closed, and, on taking it out, a slough of membrane was found be- tween the blades ; a proof, that the septum was destroyed. On the 30th, the patient's1 health was undisturbed. Clysters was now administered, with the view of promoting evacuations in the natural manner; and, the next day, the patieirt had a proper mo- tion, without any assistance, and a very small quantity of the feces passed out of the fistulous opening. This aperture was now merely covered with charpie ; but, as some high granulations were rising, the powder of colopbonium was sprinkled upon them, and compresses and a bandage were ap- plied. The use of clysters was also daily continued, though the patient voided his fe- ces in the natural way. On discontinuing the external pressure, the quantity of dis- charge from the fistulous opening increa- sed ; and, therefore, on the 1st of Oetober., the compresses were again applied, and kept on the part with a spring truss. The treatment ended in a perfect cure. In another case, Dnpuytren enlarged the lower angle of the outer opening with a bis- toury, and, after feeling with bis finger, tbat both orifices of the bowel were close to that opening, he applied the forceps. In the evening, the constriction was increased, which was followed by severe colic pains over the whole abdomen. They subsided, however, the following day. From the outer opening, a great deal of slimy excrement was discharged. The constriction was not augmented. On the 5th day,the patient was attacked in the night, with pain and vomit- ing. The following night was also very rest- less. Though the belly was not tense, it could not bear to be touched. On the 11th and 12th days, the patient was nearly free from pain; and, by means of clysters, two natural motions were procured ; and, on the 13th, as the patient was easy, Dupuytren began to make pressure on the fistulous opening. On the 26th, the edges of the aper- ture were touched with lunar caustic ; and, on the 28th, a compress, supported by a spring truss, was applied. The patient was kept constantly in the horizontal posture; the feces began to be voided the natural way regularly, and the opening contracted in the most favourable manner. I think the generality of surgeons will agree with Dr. Reisinger, that the foregoing treatment cannot be indiscriminately adopt- ed, in all descriptions of potients, without danger. It should never be tried too soon after tbe formation of an artificial anus; but time shouU bo allowed for the irritability :!34 A.M.S and sei.su.i.ity of the gul, and t'|tually of the septum, to be lessened by the effect of the air and the pressure of the feces. Nor should the trial ever be made ere it has been fully ascertained, that nature cannot herself bring about the cure. Many other interest- ing observations on this new proposal may be perused in Dr. Reisinger s tract, the title of which is given in the list of works at the end of the present article. In order not to incur the risk of extravasation of the feces in the abdomen, the constriction of the sep- tum should never be increased with impru- dent haste, before the adhesive inflamma- tion has had time to be produced between the layers, of which that part is composed. 1 shall conclude with the relation of an interesting case of artificial anus, complica- ted with prolapsus, as recorded by my friend Mr. Lawrence. «' If the complaint (a mortified hernia) ter- minates in the formation of an artificial anus, we must endeavour to alleviate those dis- tressing inconveniences, which arise from the involuntary discharge of wind and feces through the new opening, by supplying the patient with an apparatus, in which these may be received as they pass off. An instru- ment of this kind, the construction of which appears very perfect, is described by Rich- ter (Anfangsgr. der Wundarzn. vol. 5.) from Ihe 7'rat'fe' des Bandages of Juville. The patient will be best enabled to adapt any contrivance of this sort to the particular circumstances of his own case. It has been found, in some instances, that a common elastic truss, with a compress of lint under tbe pad, has been more serviceable than any complicated instrument (Parisian Journal, vol. 1. p. 193.) in preventing the continual flow of feculent matter from the artificial opening." (Treatise on Hernia, p. 206.) " I know," says Mr. Lawrence, " a pa- tient with an artificial anus, in whom tbe gut often protrudes to tbe length of eight or ten inches, at the same time bleeding from its surface. This is attended with pain, and compels him to lie down; in which position the intestine recedes. Tbe patient has now discharged all his feces at the groin for fif- teen years; and has enjoyed tolerable health and strength during that time. His evacua- tions are generally fluid; but sometimes of the natural consistence. Whenever he re- tains his urine, after feeling an inclination to void it, a quantity of clear, inoffensive mucus, like the white, of an egg, amounting to about four ounces, is expelled from the anus; and this may occur two or three times in the day." (P. 208.) When the protruded intestine is strangula- lated, an operation may become necessary for the removal of the stricture. (Schmucker, Vermisehte Chirurgische Schriften, t. 2.) Two cases which terminated fatally from this cause, are mentioned by Sabatier, in a memoir in tbe 6 torn, de I'Acad. de Chir. Mr. Lawrenee also refers to Le Blanc Precis d'Operations de Chir. torn. 2. p. 445. We should always endeavour to prevent such protrusion?, when a disposition to their for- mation seems to exist by the u»e of a sleel truss, which should, indeed, be worn by the patient, independently of this circumstance. If the tumour has become irreducible by the hand, an attempt may be made to replace it by keeping up a constant pressure on Ihe part, the patient being at the same lime con- fined to bed. By these means, as we have already noticed, Desault, (Parisian Journal, vol. l.p. 178.) returned a very large prolap- sus, and, by pressure on the opening, the feces were made to pass entirely by the anus, although, for four years, they had been void- ed only through the wound. (Lawrence, p. 209,210.) 'In cases of mortified hernia, the wound sometimes closes, except a small fistulous opening, w hich discharges a thin fluid, and cannot be healed. Mr. Lawrence has rela- ted, in his excellent treatise on hernia, a case, in which the feces came from the wound some time after an operation, although the bowel did not appear gangre- nous when this proceeding was adopted. (P. 211.) In the appendix to this work, the author adds some further account of the case of artificial anus, which he has related. (P. 208.) The man is sixty years of age, and appears to be healthy, active, and even younger than he really is. He had hud a scrotal hernia, which ended in mortifica- tion, and involved the testicle of the same side, and a large portion of the integument', in the destruction. It is now nearly seven- teen years since thi3 event, and the feces have, during all this time, been discharged from the groin. He has never made use of a truss, nor taken any step, except that of always keeping a quantity of tow in hii breeches. The prolapsed portion of intestine varies in length and size at different times. It was four inches long when Mr. Lawrence saw it, and the basis, which is the largest part, measured nearly six inches in circumference. The prolapsus never re- cedes entirely, and it has occasionally pro- truded to the length of eight or ten inches, being as large as the forearm, and emitting blood. This occurrence is painful, ana only comes on when the bowels are out ol order. Warm fomentations, and a reenm- bent position, afford relief, and accomplish a reduction of the bowel. The projecting part is of an uniform red colour, similar to that of florid and healthy granulations. The surface, although wrink- led and irregular, is smooth and lubricated by a mucous secretion. It feels firm and fleshy, and can be squeezed and handled without exciting pain. The man has not the least power of retaining his stoob- When these are fluid, they come away re- peatedly in the course of the day, and *Hh considerable force. When of a firmer con- sistence, there is only one stool every <<» or two days, and the evacuation requires much straining. Such feces are not broader than the little finger. When the patient « purged, ihe food is often voided very""1* AOKTA 233 changed. This is particularly the case with cucumber. In th^state, he is always very weak. Ale is sometimes discharged five minutes alter taken, being scarcely at ajl altered. The bowels are strongly affected by slight doses of purgatives.,, * Consult Sabatier, in Mem. de I'Acad. de Chirurgie, t. 5. 4/o. and in Midecine Opera- ratoire, t. 2. L'Encyclogedff Mifhodguc, Parlie Chirurg. Richter's\dnfangsgrAtler Wundarzn. Band. 5. J. R.Tieff&nbach, £hine- rum in intestinis lethalitas occasio^pasus ra- rissimi, quo colon vulneralum, inversum per 14 annosex abdomine propendens exhihripc ; Halleri Disp. Chir. 5. 61. Parisian Cfttfcr- gical Journal, v. 1. CEuvres Chirurg. de De^ vault par Bichat, t. 2. p. 352, fa. Schmuc- ker's Chirurgische Schriften, vol. 2. Law- rence's Treatise on Hernia. Callisen's Sys- tema Chirurgiaz Hodiernal, t. 2. p. 710, fa. Travers, Inquiry into the Process of Nature in repairing Injuries of the Intestines, chap. 8. 8»o. Lond. 1812. Scarpa sull' Ernie Memorie Anatomico-Chirurgiche, fol. Milu- no, 1800. Anzeige einer von dem H. Pro- fessor Dupuytren erfundenen, und mil dem glocklichsten Erfolge ausgefuhrlen Operalion- sweite zur Heilung des Anus Artificialis, nebst Bemerkungen von Franz Reisinger; Augs- burg, 1817. Hennen's Military Surgery, p. 407, tyc ed. 2. Svo. Edinb. 1820. Three cases from gunshot wounds; the cure effected by aiding nature with the exhibition of occa- sional laxatives and clysters. All irritating plans were avoided. Scarpa represents the artificial ani, which follow wounds, as far more difficult of cure, than those, which are the consequence of hernia, with mortification ; yet I have known many of the first descrip- tion of cases cured. * AORTA. Aneurisms of this vessel have already been treated of; but there are a few other particulars, relating to this im- portant artery, which seem to merit notice in a dictionary of surgery. WOUND OF THE AORTA NOT ALWAYS FOL- LOWED BY INSTANTANEOUS DEATH. A case exemplifying this fact, was some time ago recorded by M. Pelletan. In the month of May, 1802, a young militaiyman, of middling strength, applied at the Hotel- Dieu. In a duel, he had been run through with a foil, which penetrated above the right nipple, and came out at the left loin. The most alarming symptoms were appre- hended ; but several days elapsed without any serious complaints taking place. The fmtient was bled twice, and kept on a very ow regimen. Every thing went on quietly for a fortnight, lie now complained of se- vere pains in his loins, and he was relieved by the warm bath. He seemed to be reco- vering, got up, and went to walk in the garden allotted for the sick ; but the pain in his loins quickly returned, attended with difficulty of breathing, constipation, and wakefulness. He now became very impa- firnt, and out of temper with the surgeons for not relieving him. On the 15th of July, two months after" the accident, a deformity of the spine was remaiked, about the eighth dorsal vertebra. The patient grew rapidly worse, and died in the utmost agony, saying that he felt suffocated, and tearing of the shirt, that his chest might be free from the pressure of all kinds of clothing. On the body being opened, the right side of ih& chest w^s found full of blood, coagu- latea in various degrees, and an opening, thadiamete^.oT wb^ch was equal to that of a writing pen, was/tie tec ted in the aorta obqjte the crura of thetdjaphragm. All the adjacent cellularjubstan|g was injected with b^qpd,im4 xhree ot the dorsal ver- tfibsfffi were foiiBjd carious. No mark of injiyy wasj^rcejtible in any of the thoracic or abdominal viscera. (See Pqlletan's Clinique dirurg^c^le^t. l.p. 92—94^»«i ' ■ i '-w __* • THICKENING A^Nl), CONSTRICTION OF THE yOJJTA. *» § Meckel met with two cases, in which the^ aorta was thickened and considerably con- stricted, just below its arch ; yet, in-both subjects, there was every reason to believe, that the abdominal viscera and lower ex- tremities had been duly supplied^ with blood. This fluid, which could only pass from the heart with great difficulty, and in small quantities, had, by regurgitating, lacerated the semilunarvalves. (Mim. de I'Acad. Royal de Berlin, 1756. 06s. 17 and 18.) A similar 4 example is recorded by Stoerk. (Ann. Med. 11. p. 171.) An instance,in which a stricture was met with in the aorta, opposite to the termination of the canalis arteriosus, is des- cribed by Mr. A. Cooper. The little finger could hardly pass through the constricjion, which impeded the course of the blqbd through the heart and lungs, and was at- tended with a considerable dilatation of the right ventricle. (Surgical Essays, vol* LJfc 103, 8ro. Lond. 1818.) OBLITERATION OF TIIF CAV1TT OT Tni: AORTA. ft is observed by Professor Scarpa, that the whole body may be regarded as an anastomosisof vessels, a vascular circle, and he contends, that this remark is so true, that even an obliteration of the aorta itself, immediately below its arch, may take place, without the general circulation of the blood in the body being stopped. Such a disease of the aorta was seen by Paris in the body of a woman. While she lived, the blood, which was expelled from the heart, was transmitted into the trunk of the aorta, be- low the constriction, and it got there by passing through the subclavian, axillary, and cervical arteries, into the mammary, inter- costal, diaphragmatic, and epigastric arte- ries From these latter arteries, the blood passed info the vessels of the thoracic and abdominal visepra, and those of the lower extremities (See Default's Journal, f. 2 f 107. Brasdor, in Recueil Ptriodiqac de la Sve. de Med. I. 3. No. 18.) Dr. Graham, of Glasgow, publish«r*a»7i- other example, in which the aorta w/f com- pletely obstructed, just below th- caiialis, arteriosus. The particulars are Jrtajkd in' the Med. Chir. Trans, vol. 6. p. &7.'9.-m - Dr. Goodison, of Wicklow, in efadfjnirag the dead body of a woman, ki th«*HostliaiFtaie being also rendered impervAqs^dowa jUp if^ ' itf| ,f. 5s of sfc»> a^pfo were ani the rnit»al and ,ed fher^appearances '^e^jxations." The bifurcat half (A ft oLwb senjilnnan considerably eni /t|a4ksjdd vp\\eMr itffers the obliteration of the aorta to the effects of the process, by which an aneu- rism had been spontaneously cured ; in which particular, this case is quite different from those reported by M. Paris, and Dr. Graham. (See Dublin Hospital Reports, vol. 2. p. 293, fa. 8vo. 1818.) Thenextcase which I shall notice,is oneof the most memorable in tbe annals of surgery, since it was nothing less than an operation, in which a ligature was applied tq the aorta of a living subject, under circumstances which, as far as my judgment extends, war- ranted even this desperate attempt to pre- serve life. Mr. A. Cooper had often placed Ligatures round the aorta in dogs, and found that the blood was readily carried by the anastomoses to their posterior extremities. (See Med. Chir. Trans, vol. 2. p. 158.) A porter, aged thirty-eight, was admitted into Guy's Hospital, April 9, 1S17, for an aneu- rism in the left groin, situated partly above, and partly below, Poupart's ligament. The swelling was considerably diffused, and pressure upon it gave a great deal of pain. re a slough had formed. The bleeding rred from time to time, and on the -5th was so much exhausted by loss pf blood that bis feces passed involuntarily, and hb immediate death was only prevented by pressure on the opening. At nine o'clock in the evening, this experienced surgeon made a small incision into the sac abova Poupart's ligament, and introducing hit finger, tried if it were practicable to pass a ligature round the externa! iliac artery, .within the cavity; but the thing was found impossible, as, instead of the vessel, " only a chaos of broken coagula" could be per- ceived. At the moment of withdrawing tbe finger, two students compressed the aorta against the spine, and tJ.ie incision wasthen closed with a dossil of lint ; Mr. A.Cooper now determined to apply a ligature to tbe aorta itself. " 1 made (says lie) an incision three inches long, into the linea alba,givinj; itaslight curve, to avoid the umbilicus. One inch and a half was above, and the remain- der below, the navel," the cut being in- clined towards the left side. " Having di- vided the linea alba, I made a small aper- ture into the peritoneum, and introduced my finger into the abdomen; and then, with a probe-pointed bistoury, enlarged the opening into the peritoneum to nearly the same extent as that of the external wound Neither the omentum nor the intestine* protruded ; and, during the progress of the operation, only one small convolution pro- jected beyond the wound." With his finger nail he scratched through the peritoneum, on the left side of the aorta, and then gent- ly moving bis finger from side to side, be gradually passed it between the aorta and spine, and again penetrated the peritoneum on the right side of the aorta. A blunt aneurismal-needle, armed with a single Ug« ture, was next conveyed under that vessel, and tied, with the precaution of excluding the intestines from the noose. The wound was then closed, by means of tbe quilled suture and adhesive plaster. During tbe operation, the feces were discharged invo- luntarily, and the pulse both immediately, and for an hour after the operation, wa< 144. An opiate was given, and the involun- tary passage of feces soon ceased. The sensibility of the right leg was verv imper- fect. In the night, tbe patient complained of heat in the abdomen ; but he felt nopaifl upon pressure ; and tbe lower extreniities( which had been cold a little while after the operation, were regaining their heat, hot AOR APO 2S7. their sensibility was very indistinct. At six o'clock the following morning, the sen- sibility of the limbs was still imperfect; but at eight o'clock the right one was warmer than the left, and its sensibility returning. At noon, the temperature of tbe right limb was ninety-four ; that of the left, or aneu- rismal one, eighty-seven and a half. At three o'clock an enema was ordered. The heat of the right leg was now ninety-six ; that of the left, or diseased limb, eighty- seven and a half. It is unnecessary, here, to detail all the various circumstances which preceded the patient's death. Vo- miting, pain in the abdomen and loins, in- voluntary discharge of urine and feces ; a weak pulse, cold sweats, he. were some of the most remarkable symptoms. At eight o'clock on the second morning after the operation, the aneurismal limb appeared livid and cold, more particularly round the aneurism ; but the right leg was warm ; and between one and two o'clock, the same day, the patient died. On opening the ab- domen, there was not the least appearance of peritoneal inflammation, except at the edges of the wound ; and the omentum and intestines were of their natural colour. The ligature, which included no portion of in- testine or omentum, was placed round the aorta, about three quarters of an inch above its bifurcation. When the vessel was open- ed, a clot, of more than an inch in extent, filled it above the ligature ; and below the bifurcation, another clot, an inch in extent; occupied the right iliac artery, while the left contained a third, which extended as far as the aneurism. The neck of the thigh- bone was also found broken within the cap- sular ligament, and not united ; an occiden- tal complication. As there were no ap- pearances of inflammation of the viscera, Mr. A. Cooper refers the cause of the man's death to tbe want of circulation in the aneurismal limb, which never recovered its natural heat, nor any degree of sensibility, though the right leg was not prevented from doing so; hence, says this experienced sureeon, "in an aneurism similarly situated, Ihe ligature must be applied before the swelling has acquired any very considerable magnitude." (SurgicalEssays,vol. l.p. 114, fa.) Indeed, the most important conclusions I com this case are—First, that, where no other impediments exist, the circulation will continue in the lower extremities, though the abdominal aorta be tied, or sud- denly obstructed. Secondly, that suffering aneurismal sw ellings to become very large, before the operation is done, exposes (he patient to considerable disadvantage, on account of the pressure of the disease upon the surrounding anastomoses, whereby the continuance of tbe circulation is rendered less certain than it would be, were the ope- ration done at an earlier period. HUPTURK OK TnK AORTA WITHIN THi; PERI- CARDIUBf. The snrgiral writings of Scarpa, in rela- tion to the formation of aneurisms, have now gained extensive celebrity in the world. It is well known, that this author maintains the doctrine, that, in all aneurisms, the in- ternal and muscular coats of the artery are ruptured, and that the aneurismal sac is not formed of these tunics, but of the dilated cellular sheath, which surrounds the vessel. When a large aneurism bursts, there is always a double rupture; one of the artery; another of the aneurismal sac. The last is that, which is the immediate cause of the patient's destruction, by altering the circum- scribed state of the aneurism into the dif- fused. There are some exceptions, however, to the foregoing statement, and Scarpa has not failed to point them out. When the inter- nal and muscular coats of the aorta are ruptured in a situation, where the outside of the vessel is only covered by a thin, tense, closely adherent membrane, such mem- brane may be ruptured at the same time with the proper coats of the artery, and sudden death be occasioned by the effusion of blood in tbe cavity of the thorax. These events are liable to happen, whenever the proper coats of the aorta are ruptured, within the pericardium, where the vessel is only covered by a thin layer reflected from this membranous bag. Walter has recorded one example of this kind, and Morgagni several others. A similar case is related by Scarpa. (Seft Haller Disput. Chir. Tom. 6. Acta Medic. Berlin. Vol. 8, p. 86. Morgag- ni de Sed. et Causis Morb. Epist. 26, art. 7. 17. 21. Epist. -27, Art. 28 Scarpa on Aneurism, trans, by Wishart, p. 81. Also Hodgson on the Diseases of Arteries and Veins.) STEATOMATOUS TUMOURS OF THE AORTA. Two steatomatous tumours were noticed by Stenzel in the body of a male subject. They were situated in the substance of the membranes of the aorta, immediately below its arch. Notwithstanding these swellings rendered the vessel almost impervious, the man had the appearance of strength, and of having been well nourished. Htec corpora fere cor magnitudine mquabant ut omnem propemodum exeunti e sinistri cordis thalamo sanguinispatiumprtocluderent. De Steato- matibus in principio arteriae aortae, he. Wittemb. 1723. This is another striking fact, illustrating the great power of the inosculations to carry on the circulation. APH^ERESIS. (from a$tupta>, to remove.) This term was formerly used in the schools of surgery, to signify that part of the art, which consists in taking off any diseased, or preternatural portion of the body. APONEUROSIS. The expression mpev was applied by Hippocrates and other an-» cient writers to tendons and ligaments era well as nerves, all which parts*seemed to resemble each other in having a white fibrous texture. Matter often collects under aponeuroses in different situations of the body, parti- iUfi APP culariy under the tendinous expansion, which cover the muscles of the thigh, the leg, and the fore-arm. Abscesses are also sometimes met with under the temporal, tbe palmar, and the plantar fasciae; in the tendi- nous thecee, which include the flexor tendons of the fingers; and, occasionally, also, in the aponeurotic sheath, in which the rectus ab- dominis muscle is situated. One particular effect of an aponeurosis, oranyNkindof tendinous expansion, lying between a collection of matter and the skin, is materially to retard the progress of the pus towards the surface of the body. Hence if the case be allowed to take its own course, the quantity of matter increases, the pus spreads extensively under the apo- neurosis in every possible direction, sepa- rates the muscles from such fascia, and the muscles from each other, and the abscess does not burst till a vast deal of mischief has been produced, together with more or less sloughing of the fascia, tendons, he. 'These circumstances cannot happen, with- out a considerable degree of constitutional disturbance, and a permanent loss of the use of certain muscles. Even when a spontaneous opening is formed, and some of the matter escapes, it is often only a very imperfect discharge; for, the aperture ge- nerally occurs, not in a depending situation, nor over the main collection of pus, but, at apart, where the aponeurosis is most thin, and consequently, where the matter had tbe least resistance to overcome in getting to the surface of the body. In all such cases, the chief indication is to make an early and a depending opening with a lancetv so as to prevent the exten- sion of the abscess, and .to let the matter escape as fast as it is formed. If a sponta- neous opening should have occurred in an unfavourable place, a new aperture must be made in a proper situation ; or if the former should be sufficiently depending, and near the principal accumulation of matter, but too small, it must be rendered larger with a curved bistoury and a director. Whenever any black dead pieces of fascia, or tendons, present themselves at the opening, they must he taken hold of with a pair of for- ceps, and extracted. APOSTEME, or APOSTUME. An ab- scess. APPARATUS. This implies the prepa- ration, and arrangement of every thing ne- cessary in the performance of an operation, or in the application of dressings. The ap- paratus varies according to circumstances. Instruments, machines, bandages, tapes, compresses, pledgets, dossils of lint, spon- ges, basins of water, towels, he. he. are parts of the apparatus, as well at any medi- cinal substances used. • It is a rule in surgery to have the appara- tus ready before an operation is begun. All preparations of this kind should be made, if possible, out of the patient's room and pre- sence, as they might agitate and render him timid. We have beenlatelvren«iired bv a Frenrb arc; surgeon, for our too common neglect oi what has been here recommended. '< |„ France (observes M. Roux) we are canful not to let a patient, who is to undergo a serious operation, see any of the requbhV preparations for it. We hasten as much tu possible the immediate preparatory mea- sures, in order not to prolong unnecessarily the restlessness and moral agitation, whici the expectation of an operation, and some- times of the slightest one, always produce? These precautions are neglectea by the English surgeons, at least, by most of those whom I saw operate. They even neglect them in private practice, where, more commonly than in hospitals, we have to deal with pusillanimous individuals, who are easily alarmed, and whose extreme suscep- tibility it is of importance to spare. It was in the very room, where the patient lay, of course under his eyes, that the table, and all the necessary instruments for litho- tomy, were arranged, at an operation, which I saw done in London, during my stay in that capital, by a gentleman at the head of I113 profession." (See Parallele de la Chi- rurgie Angloise avec la Chirurgie Francoist, p. 105 ) M. Roux, in his visit to London, had also too good reason to complain of the slovenly objectionable practice of leavingjthe appli- cation of the tourniquet, and the dressing of the wound after a surgical operation, lo mere novices and students. I entirely co- incide with him, that, in respect to the dressings in particular, a surgeon is bound to extend his attention and solicitude a little beyond the moment, when the operation terminates. APPARATUS MINOR; APPARATUS MAJOR; APPARATUS ALTUS. Three ways of cutting for the stone. (See Litho- tomy.) AQUA PICIS LIQUIDS. Dubl. Take of tar two pints ; water a gallon. Mil them with a wooden rod for a quarter of an bonr, and after the tar has subsided, let the liquor be strained, and kept in well-corkfid bottles. This lotion is often used in cases of per rigo. Ulcers on the legs, are sometime' extensively surrounded with a scorbutic redness, and pimples. In such instance!, the aqua picis, used as an application round the limb, over the dressings, is of great ser- vice. (See Liquor.) \RGENTI NITRAS. {Nitride of ijlw, lunar caustic.) Is the best of the mildest caustics. Its utility for stimulating indolent ulcers, and keeping granulations from rising too high, is well known to every surgeon Mr. Hunter sanctions the use of the ar- gentum nitraturn, on the first appearance oi a chancre, before absorption can be suppo- sed to have taken place. He directs the caustic to be scraped to a point, like a blacklead pencil; so that, when it is applied every part of the surface of the chance may be touched with it; and he advises the repetition of this process, till tbe last slough. which is thrown off. leaves the =ore ftV>': and herilthv ARSENIC 239 J his treatment when the sore is very small, may sometimes be advisable, as a means of lessening the chance of the con- stitution being infected by absorption. In general, surgeons combine with the plan the moderate use of mercury. The important use of the argentum nitra- lum, in the cure of numerous diseases, we shall have occasion to remark in various places of this work ; particularly when we come to the article Cornea, ulcers of; Iris, prolapsus of; Ulcers; Urethra, strictures of, fa. The argentum nitratum is often used in fhe form of a solution, in the proportion of a dram of the caustic to an ounce of distilled water. In general this application ought to be at first more or less diluted with distilled water. Cancerous ulcers ; and sores about the nose and neighbouring parts of the face, being examples of lupus, or noli me tungere, arc often considerably benefited by the ar- gentum nitratum, both in the solid and fluid state. The solution agrees also very well with certain sores, which occur round the roots of the nails of the fingers and toes. The lotion is sometimes applied with a camel-hair pencil; but in general, by dip- ping little soft bits of lint in the fluid, laying them on the part, and covering them with a pledget. ARNICA. Leopardsbane. Amaurosis is the principal surgical case, in which this medicine is now ever employed. Its re- pute in the eure of that disease also chiefly prevails abroad ; for, I believe, in this coun- try, surgeons have no confidence in it, as a remedy for amaurotic disorders. ARSENIC is the chief ingredient in a secret remedy, which has long possessed very great celebrity in Ireland for the cure of cancer, and is now well known among surgeons, by the name of Plunket's caustic. This application consists of the ranunculus acris, the greater crow-foot, the flammula vulgaris, and t!»e lesser crow-foot, in the proportion of an ounce of each, bruised and mixed with a drachm of the white oxide of arsenic, and five scruples of sulphur. The whole is to be beaten into a paste, formed into balls, and dried in the sun. When re- quired for use, these balls are beaten up with yelk of egg, and spread upon a piece of pig's bladder. The use of the ranunculus is to destroy the cuticle, upon which the arsenic would have no effect; for it is to be obser- ved, that Plunket's caustic was employed for the dispersion of tumours, as Well as for the relief of ulcerated cancers. The appli- cation is to remain onHhe part twenty-four hours, at the end of which time, the slough is to be dressed with any simple unirritating ointment. When arsenic was first recom- mended as an application for cancers, itused generally to be blended with opium. When Plunket's caustic is employed, so as to form un eschar over a scirrhous tumour, I conjec- ture, that if it ever do good, it is not by any specific effect of this arsenicul application, hut simply as a slough, or issue, formed "ear the diseasx; in any other manner. It is highly probable,'also, that the swellings, which have been thus dispersed, have never been complicated with the structure charac- teristic of true scirrhi. With respect to cancerous ulcers, Plunket's caustic some- times evidently produces a degree of amend- ment, which, however, rarely lasts for any considerable time ; but, there are many in- veterate ulcerations, and anomalous sores, which derive permanent benefit from the application, and are even completely cured by it. Some examples of lupus, ulcerations about the roots of the nails, and reputed carcinomatous sores of the lips, are of this description. At Paris, an arsenical paste is often used by Dubois, and other surgeons of that capi- tal, for cancerous sores of the penis, and other malignant ulcers. It is composed of 70 parts of cinnabar, 22 of sanguis draconis, and 8 of the white oxide of arsenic, formed into paste with saliva at the time when it id to be employed. " The pain and inflamma- tion that succeed the use of it (says Mr. Cross,) cannot be equalled by the severest operation with the knife." (Sketches of the Medical Schools of Paris, p. 45, Svo. 1815.) Even death may be occasioned by the ab- sorption of the poison, as appears from the two annexed facts, the first of which is re- corded by M. Roux, in his Medecine Opera- toire. "The day after the paste was applied, the patient complained of colic and severe vomiting, and in two days perished in con- vulsions, et les plus vives angoisses. The body went quickly into putrefaction. The internal coat of the stomach and a great part of the intestinal canal, were inflamed, and marked here and there with dark spots. Just before I visited Paris, (adds Mr. Cross,) I dissected in London a woman, who died under similar circumstances, and where the same morbid appearances were presented, he." (Op. cit.) Mr. Juslarnond's applications to cancer, originally suggested by a receipt, said to be preserved in the Earl of Arundel's family, were somewhat varied. They were "ene- rally combinations of arsenic and sulphur. The above receipt directs an ounce of yel- low arsenic, with half that quantity of ar- menjan bole, and sometimes as much red precipitate. Mr. Justamoud also employed a sulphuret of arsenic, and a combination of this sulphuret with crude anttmony. The arsenical preparation, selected for use, was scraped, and laid ou the middle of the sore, the edges of which were moistened with a combinatiou of the muriate of iron and mu- riate of ammonia. In some instances, we learn, that the effects of the treatment were the correction of the fetid smell, melioration of the appearance of the sore, and separa- tion of the cancerous part. In the Pharmacopeia Chirurgica, Mr Justamond's arsenical caustic is directed to be made in the following manner P- Anlimonii pulverizati ^j. Arsenici pulver£ zati ^ij. These are to be melted together in a crucible. The application may be reduced to any decree of mildness by blending with V40 .\KaJiMC. this pulverised caustic a quantity ui opium in the form of powder, which whs also sup- posed load specifically in diminishing pain. The powder of white oxide of arsenic, un- mixed w ilh other substances, has sometimes been sprinkled upon cancerous and other inveterate ulcers; but, (he practice is now abandoned by every judicious surgeon, on account of the violent pain resulting from it, and the not unfrequent fatal consequences of its apsorption. Could I suppose a man, so rash and ignorant as to revive this murderous practice, yet existed in the profession, 1 should feel disposed to lengthen these re- marks : but I am persuaded, that, in this country, at least, more judgment and know- ledge every where prevail. Tbe white ox- ide of arsenic, however, may be applied with more prudence in other forms; either in one of those already specified ; or, as a lotion composed of eight grains of the oxide, and the same quantity of subcarbonate of potash, dissolved iu four ounces of distilled water: or, as an ointment formed by rubbing to- gether one drachm of the oiide, and twelve drachms of spermaceti ointment. (See A. T. Thomson's Dispensatory, p. 51.) Febures celebrated remedy consisted of ten grains of the white oxide of arsenic, dissolved in a pint of distilled water, to which were then added an ounce of the extractum conii, three ounces of the liquor plumbi subacetatis, and a drachm of lauda- num. With this fluid, the cancer was washed every morning. M. Febure like- wise gave arsenic internally; and his pre- scription was two grains of the white oxide, a pint of distilled water, syrup of chichory q. s. and half an ounce of rhubarb. Of this mixture, a table spoonful was given every night and morning, with half a drachm of the syrup of poppies. Each dose contained about one-twelfth of a grain of arsenic; but, in proportion as the patient was able to bear an increased quantity, the dose was gradually augmented to six table spoonfuls of the solution. The arseniate, or rather superarseniate, of potash, is an excellent preparation for in- ternal exhibition. The Dublin Pharmaco- poeia directs it to be made as follows : take of white oxide of arsenic, nitrate of potas- sa, each au ounce. Reduce them separately to powder ; then, having mixed them, put them into a glass retort, and place it in a sand-bath, exposed to a gradually raised heat, until the bottom of the retort becomes obscurely red. The vapours, arising from the retort, should be transmitted through distilled water, by means of a proper appa- ratus, in order that the nitrous acid, extrica- ted by tbe heat, may be disengaged. Dis- solve the residue in four pounds of boiling distilled water, and after due evaporation, set it apart, in order that crystals may form. This preparation has long been known un- der the name of Macquer's arsenical neu- tral salt. It may be given in the following way : ]£ Potassae Supcrarseniatis gr. ij. Aq. Mentha? Sativa? Spirit. ?iv. Vinosi tenuioris 'fj. M. et cola. Dosis drachma} dum ter quotidie. The kali arsenicatum, or, as it ought to he called, the superarseniate of potash, may also be given in the form of the pills, made up with crumb of bread, each of which may contain from one-sixteenth to one- eighth of a grain of the arsenical salt. The following is Dr. Fowler's method of preparing arsenic for internal use : take of the white oxide of arsenic, and pure sub- carbonate of potash, each sixty-four grains. Boil them gently in a Florentine flask, or other glass vessel, with half a pound tf distilled water, until the arsenic is dissolved. To this solution, when cold, add half an ounce of the compound spirit of lavender, and as much water as will make the whole equal to a pint, or fifteen ounces and a half in weight. The dose of this solution, of which the liquor arsenicalis L. P is a new imitation, is as follows: from two years old to four M. ij. or iij to v ; from five to seven M. v. to vij ; from eight to twelve M. vij to x ; from thirteen to eighteen M. x to lii; from eighteen upwards M. xii. These dosea may be repeated every eight, or twelve hours, the medicine being diluted with thick gruel, or barley water. As the pre- paration is decomposed by the infusion aod decoction of cinchona, it should never be ordered with either of these medicines, The white oxide of arsenic may be given in the form of pills, made by mixinu one grain of it with ten of sugar, and then beat- ing up the mixture with a sufficient quantity of the crumb of bread to form ten pills,one of which is a dose. It will only be in my power to specify here a few of the numer- ous surgical cases, in which the internal employment of arsenic has been proposed. The following are particularly worthy ot attention ; tetanic affections; cancer; lupus; elephantiasis ; inert cases of lepra; (See Bateman's Pract. Synopsis of Cutaneous Du- eases, p. 33, Ed. 3.) various unnamed ma- lignant ulcers ; certain forms, or sequels of the venereal disease, or other unintelligible diseases, which cannot be subdued by mer- cury ; different cutaneous affections, hi. A longer list of diseases, for which atrial of arsenic is suggested, may be*seen in some papers published by Mr. Hill. (Edinb. Med. and Surg. Journ. Vol. 5, 6.) Arsenic has also been recommended wf Dr. J. Hunter, for the prevention of hydro- phobia. (See Trans, of a Society for U* Improvement of Med. and Chir. Knowltdj*, Vol. 1.) Later trials of the medicine, however, in this particular case, do not ap- pear to entitle it to any confidence. Dr. Marcet fouud it quite unavailing, though not less than three drops of Fowler's solu- tion were taken every other hour, in tw» drachms of peppermint, or sweetened water. (See Med. Chir. Trans. Vol. I, p. 141, !»•) After the symptoms of hydrophobia ha« once begun, arsenic is decidedly useless* But, although it fails in hydropboM»i some facts published by Mr. Ireland, *• geon to the-60th regiment, make it appear a ?ruly valuable end efficacious remedy ,0" ARHuKlLs. ■2-kl mninteractiug theptn.->u,i of serpents. (See the lower estreiuiiy of tue wounded vea- Med. Chir. Trans. Vol. 2. p. 393.) sel in a sufficient stream to produce an ARTERIOTOMY. (from ofngM, an ar- alarming, aud, in some instances, a fatal he- tery, and Tt//vo, to cut.) The operation of morrhage " (On Diseases of Arteries, fa.p. opening an artery, for the purpose of taking 469) This correct observation is followed away blood for the relief of diseases. (See by a case, in which the bleeding from the Bleeding.) lower end of a divided brachial artery ARTERIES. The process, by which a caused the patient's death. Of course, tbe divided, or punctured artery is healed, is inference is, that both extremities of the particularly considered under the word vessel ought to have been tied directly after Hemorrhage ; while the general principles; the receipt of the wound. With regard ta which ought to be observed in the applica- tying the trunk of an artery in a part of the tion of the means for the stoppage of bleed- limb, where it can be exposed with facility, ing, may be collected partly from the re- when it is difficult to secure its bleeding marks, contained in that part of the work, extremities, as Mr. Hodgson remarks, the and partly from what is stated in the ar- practice " was falsely deduced from a. tides, Amputation, Aneurism, and Ligature, knowledge of the fact, that the ligature of A* the condition of a bleeding patient ad- an artery at a distance from the disease will mits of no delay, and the preservation of effect the cure of an aneurism. But, a his life entirely depends upon proper mea- more intimate acquaintance with the con sures being immediately taken, no man dition of a limb after such an operation, and ought to be suffered to profess surgery, who the processes, by which the cure ofan anen is not competent to the treatment of wound- rism is effected after the modern operation, ed arteries, whether injured by accident, or afford a complete illustration of the ineffi- in a surgical operation. As Langenbeck cacy and danger of this mode of treating a observes, an ignorant practitioner, when wounded artery ; for it is now fully proved, called to a case of serious hemorrhage, is that, when an artery is tied, a stream of thrown into such consternation, as actually blood continues to pass through it below deprives him of the power of rendering the ligature, (p. 471.) This Well-informed prompt assistance. Pale as a corpse, and surgeon is aware, however, that instances trembling, he beholds the jet of blood; and do occur, in which only the upper end of for the sake of appearing to do something, a wounded artery is tied, and yet the pa- perhaps, he applies spirit of wine, or a very tient recovers without hemorrhage from the tight bandage, and cries out for further aid ; lower orifice, which is closed by the natural while simple pressure with the thumb upon processes. a certain point in the vicinity of the injury, In the year 1814, in Holland, I took up Would prevent all this confusion, and a dan- the femoral artery, in the middle of the gerous loss of blood. No part of surgery, thigh, in a case, in which the popliteal ar- in fact, is of higher importance, than the tery had given way, ten days after the pas- treatment of wounded arteries, and it de- sage of a musket-ball through the ham. I serves, Iherefore, to be earnestly studied by employed only one smallish ligature, which every practitioner, whether he move in the was applied with the precaution of not. higher, or the lower sphere of the profes- detaching the artery from its natural con- sion. And, as a proof of the necessity of nexions. The hemorrhage was effectually i ountry surgeons making themselves ac- stopped, and the wound healed in the most quainted with the subject, he recites the favourable manner. Here, no doubt, the in- case of a turf-cutter, who let the instru- flammation in the ham had obliterated the ment with which he worked fall against the portion of the artery immediately below the lower part of his leg, whereby the posterior point at which it had sloughed, or ulcera- tibial artery was wounded. The blood ted, and there might even have been from gushed out profusely, and the surgeon who the same cause some deposition of lymph was sent for, applied a tourniquet to the within the upper portion of the popliteal popliteal artery, and thus stopped the bleed- artery, contributing to the success of the ing for a time ; but, unfortunately, the operation. But, no doubt, it was the dimi- tourniquet was kept so long on the limb, nution of the impulse of the circulation by that the foot mortified, and sloughed away, the ligature of the femoral artery, which (Bibl. far die Chir. B. 1. p. 231,232, Golt. enabled nature to corapletethe obliteration 1806.) From the explanations, delivered of the wounded part of the vessel. Some- in the article Hemorrhage, it will be seen, times, says Mr. Hodgson, when hemorrhage that, in all bleedings from considerable ar- takes place, a few days after the bleeding teries, nothing is equal to the ligature, as from a wounded artery has been stopped by a means for preventing tbe further loss of compression, one extremity of the vessel blood ; and it may be laid down as a stand- will be pervious, whilst the other will have ing rule, that each extremity of the wound- closed by the natural processes. Cases ed vessel should be tied as near as possible have even occurred, in which the upper to the wound in its coats. As Mr. Hodgson end of the artery has been closed by the has remarked, " the necessity of tying both natural processes, whilst those processes ends of a wounded artery is evident from failed in effecting the obliteration of the ihe fact, that the anastomoses in all parts of lower extremity of the vessel, from which the body, are so extensive, as to furnish a a serious hemorrhage took place. (Hodg- supply of blood, which may pa-- through son, Op cit. 17">. and Cr?\rir in l\'»w Men. V'ol.L .31 LI4J vk'ieru:* ond Phys. Journ. Vol. 4, t . W,.) Indeed, in the example in which I took up the fe- moral artery myself, it was impossible to say positively, whether tbe blood came from tbe part of the popliteal artery above, or below the slough in it, as no incision was made into the ham. The principle, respecting tbe application of a ligature to each end of every large divided artery, is to be extended also to punctured arteries, one ligature being placed above, and the other below, the opening in the vessel. * From some observations, introduced in Ihe article Aneurism, p. 150, it will be seen, that, when the impulse of the circulation has been lessened by the ligature of the main trunk of an artery, some distance above the wound, the hemorrhage from the more remote portion of the vessel, may sometimes be effectually restrained by pressure, which, previously to the stoppage of one great current of blood to the part, had proved unavailing. This fact is worth remembering in cases, in which the arteries of the band, or foot, are wounded. Mortification is observed to be more frequent after the ligature of an artery for a wound, than for an aneurism. In wounds, Mr. Hodgson very correctly, I think, refers the difference to tbe frequent injury of the surrounding parls, and particularly of the veins and nerves, and to the loss of blood, and want of quietude, and proper care after the accident. The principal anastomosing vessels are also sometimes divided. (P. 479.) Having given in the article Aneurism, the necessary directions, how to cut down to and tie many of the principal arteries, I shall conclude the present subject with a few instructions how to take up the arte- ries of the fore-arm and leg, as explained by Scarpa, Mr. C. Bell, Mr. Hodgson, aud others. Some directions how to act in a ease of wounded axillary artery are like- wise subjoined. In order to lay bare the radial artery at the upper third of the fore-arm, a finger is to be put on the insertion of the tendon of the biceps. A little below- this insertion, an incision, about two inches and a half in length, is to be made in the integuments, in the oblique direction, denoted by the in- ner edge of the supinator radii longus. Tbe subjacentfasciaisthen to be divided, and the inner edge of the supinator muscle drawn a little from the outer side of the arm : in the space, between that muscle and the flexor carpi radialis, the radial artery im- mediately presents itself, passing over the tendon of the pronator radii teres, and the flexor longus pollicis, and it then runs down between the latter named tendon and the flexor carpi radialis. (See Camper's Anat. Demonsl. Pathol. Lib. 1, Tab. 1, fig. 2.) A branch of the musculo-spiral nerve lies on tbe radial side of tbe artery. At the wrist, the radial artery may be ta- ken up by making an incision a little way from the radial margin of the flexor carpi ulnnris. Here Ihe artery is covered by a:as- cia over which a small branch of the extcr- nal'cutaneous nerve runs ; but the vessel ii now unaccompanied with the musculo-spiral nerve, which quits it, and»passes under the supinator radii longus, a little 'below the middle of the fore-arm. After tbe radial artery leaves the fore part of the wrist, it may be taken up by making an incision '-on the outside of the insertionof the extensor primi internodii policis, and the inside of ihe extensor tertii internodii pollici:. Betwixt these tendons, the artery lies very deep, and over it is the extreme branch of the muscular spiral nerve. We find ihe ar- tery going close to the notch, betwixt the oi scaphoides and trapezium." (C. Bell, Op. Surgery, V. 2. p. 373.) For bringing into view the ulnar artery at the upper third of the fore-arm, (hesitua- tion and breadth of the flexor carpi ulnarii muscle must fkst be ascertained. An incision is then lo be made from above downwardt, beginning two inches below the inner cos dyle of tbe humerus, and following the course of the inner margin of the above muscle to the extent of two inches and a half. The fascia is then to be divided : the lienor carpi ulnaris is to be drawn a little away from the flexor digitorum sublimis Iu this opening, rather under the margin of the latter muscle, the ulnar artery will be felt with the finger, continuing its course over the flexor profundus. The ulnar nerve ii situated on the ulnar side of tbe artery. Below the middle of the fore-arui, the ul nar artery is more superficial, and may easi- ly be taken up by making an incision upon the radial side of the flexor carpi ulnaris, between the tendon of which muscle, and that of the flexor profundus digitoruin,tfae ves- sel is situated. The artery, however, will not be reached until a thin aponeurosis underthe fascia of the fore-arm has been divided. Tin: nerve is rather more underthe tendon of the flexor carpi ulnaris, than the nrtery. When the ulnar artery arises from the brachial above the elbow, it runs above the fascia, and is easily taken up at any part of its course. The anterior tibial artery passes forward between the bones of the leg, about an inch below the upper head of the fibula. In or- der to take up the vessel in this situation, a free cut must be made through the fascia, extended, between the heads of the libiajud fibula. The incision is then to be continued more deeply at the edge of the peronar* longus, following the fascia between tbi- muscle and the origin of the extensor digi" torum communis. The artery will be me' with on the interosseous ligament. (C Bell. V.2, p. 376.) In order to lay bare the anterior tibial ar tery. a little above the middle of the le;. the finger is to be passed along the outer side of the spine of the tibia, and the breadth of the tibialis anticus muscle is'0 be ascertained. Along the outer margin 0l this muscle, an incision is to be nn conceal tbe wound in the artery. An assist- ant must compress the vessel, from above the clavicle, as it passes over the first rib. When the weapon has penetrated, from be- low upward, directly into the axilla, the surgeon is to make a free dilatation of the wound upon a director, or his finger. This must be done lo a sufficient height to ex- pose a considerable portion of the artery, and the precise situation of the wound in it. When the weapon has pierced obliquely, or from above downwards, through a por- tion of the great pectoral muscle, into the axilla, Scarpa advises the surgeon to cut through the lower edge of this muscle, and enlarge the wound, on a director, or his finger, so as to bring fairly into view the in- jured part of the artery. Tbe thoracic ar- teries, divided in this operation, must be immediately tied. The clots of blood are then to be removed, and the bottom of the wound cleaned with a sponge, by which means the opening in the axillary artery will be more clearly seen. As this vessel lies imbedded in the brachial plexus of nerves, the surgeon must take care to raise it from these latter parts with a pair of for- ceps, before he ties it. Two ligatures will be required : one above; the other below the wound of the artery. ASTRINGENTS, (from asiringo, to bind.) In medicine, are those substances which possess a power of making the living fibres become contracted, condensed, and corru- gated. They are employed in the practice of surgery chiefly as external applications, either for restoring diminished tonic power, or checking various discharges. Astringent lotions are usually deemed eligible local re- medies for phlegmonous inflammation. ATHEROMA, (from «6»/«, pap.) An encysted tumour, so named from its pap- like contents. (See Tumours Enn/sted.% B. B >ALSAMUM COPA1V/E. Exhibited by surgeons principally in cases of gonorrhea, gleet, and piles : The common dose is from i en to thirty d nips, two or three times a day. BALSAM!M PERUVIANUM CIM FELLE BOVINO. ft Fellis Bovini 3iij. Balsami Peruv. 3j. M. Dr. H. Smith re- commended this application to be occasion- ally dropped into the ear, when there is a fetid discharge from the meatus auditorius. This passage is also to be washed out every day,by throw ing into it with a syringe warm water alone, or containing a little soap. BAND \r, K (Pefigatio. Fascia.) The u.--e of bandages is to keep dressings, compresses, remedies, he. in their proper situation ; to compress blood-vessels, so as to restrain hemorrhage ; to rectify certain deformities by holding the deranged parts in a natural position ; and to unite parts, in which there is a solution of continuity. As the application of bandages is an important branch of surgery, authors have not neglect- ed it. Muchhasbeen written on the subject, and almost every writatr has devised new- bandages, perhaps without much benefit to the art. Unfortunately, it is next to impos- sible to give very clear ideas of tbe numer- als sorts of bandages by a printed descrip,- 24* UAADAGE. lion of them. The aiirgton can only ac- auire all the necessary instruction and in- irmation from tbe experience and habit re- sulting from practice. Hence, we shall confine ourselves to a general account of the subject. Bandages should be made of such mate- rials, as possess sufficient strength to fulfil the end proposed in applying them, and at the same time, they should be supple enough to admit of being accommodated to the parts, to which they are applied. Bandages are made of linen, cotton, or flannel. If possible, they should be with- out a seam, or selvage, which sometimes causes unequal and painful pressure. There are cases, in which the bandnge should have a degree of firmness, that does not belong to tbe materials usually employ- ed. This circumstance is obvious in cases of hernia, and in all those examples, in which there is occasion for elastic banda- ges. As we have already observed, linen, flannel, and cotton (calico,) are the common materials. The first employment of flannel bandages is imputed to tbe Scotch surgeons, who preferred them to linen ones, in conse- «juence of their being better calculated for absorbing moisture, while, being more elas- tic, they yield in a greater degree in cases requiring this property ; as in the swelling subsequent to dislocations, fractures, he. It has been asserted, that linen |s better than flannel, because more cleanly; but neither one nor the other will continue dean, unless care be taken to change it often enough. \\ here the indication is to keep the parts warm, flannel is of course prefera- ble to linen or calico. Tbe employment of cotton or calico bandages is a more recent method, and many advantages are attributed to the soft- ness and elasticity of this material. In applying a bandage, care must beta- ken, that it be put on tight enough to fulfil the object in view, without running any risk of stopping the circulation, or doing barm in any other way. If it benotsufli- t iently tight to support the parts in a proper manner, it is useless ; if it be too tense, it v^ ill produce swelling, inflammation, and even mortification. In ord.-r to apply a roller skilfully, the part which is to be covered, must be put in its proper situation ; the head of the roller hi hi in the surgeon's hand, and only so much unrolled, as i-> necessary for the com- mencement of the application. In general, the bandage should beapplied in such a manner, as will admit of its be- ing removed with the most ease, and allow the slate of the subjacent parts to be exa- mined, as often as occasion may require. For this reason, in fractures of the leg and thigh, the eighteen-tailed bandage is generally preferred to a simple roller. The former may be loosened and tightened, at pleasure, without occasioning tbe smallest di^urbance nf ihn affected limb ; a thing which could not be done, were a common roller to be employed. As soon as a bandage has fulfilled the object for which it is applied, and it has be- come useless, its employment should be dis- continued ; for, by remaining too long on parts, it may obstruct the circulation, dimi- nish the tone of the compressed fibres and vessels, and thus do harm. Bandages are either simple or compound. They are also sometimes divided into gene- ral and particular. The latter often derive their names from the parts to which they are usually applied. A simple bandage is a long piece of lines or cotton, of an indefinite length, and from three to six inches in breadth. When about to be applied, it is commonly rolled up, and the rolled part is termed its head. When rolled up from each end, it is called a double-headed roller or bandage. The chief of the simple bandages are the circular, the spiral, the uniting,thi retaining, the expelltnt, and the creeping. The circular bandage is the simplest; consisting merely of a tew circles of a roller covering, or overlapping each other. The spiral bandage is the most frequently used of all; for, it is this, which is seen in such common employment on the limbs, in cases of ulcers, varices, &.c. In applying a common roller to the whole of a limo, the bandage must be carried round the part spirally ; for otherwise the whole member cannot he covered. When the leg is the part, the surgeon is to begin by surrounding the foot with a few turns. Then carrying the head of the bandage over the instep, he is to convey it backward, so as to make Ihe bandage unroll, and apply itself just above the heel. The roller may next be brought over the inner ankle ; thence again over the instep, and under the sole; and the surgeon then brings the bandage spirally upward once more to the outer part of the leg. After this, every circle of the roller is to be applied, so as to ascend up the limb in a gradual, spiral form, and so as to cover about one-third of the turn of the roll" immediately below it. The increasing and diminishing diameter of the limb, is one great cause, which brings into view theun- skilfulness of a surgeon in this common operation ; for, it prevents the roller from lying smoothly although spirally applied, unless a particular artifice be dexterously adopted. The plan alluded to, is to double back the part of the roller that would'not be even, were the application to be con- tinued in the common spiral way, without Ibis manoeuvre. When the bulk of the limb increases very suddenly, ittfajsome- times necessary to fold, or, as it is termed. reverse, every circle of the bandage in th' above manner, iu order to make it lie evenly on the limb. It is manifest, that the pres- sure of the roller will be greatest when the duplicatures are situated, and hen«. when it is an object to compress any par"' cular part, the surgeon should contrive to BANDAGE 24A> ;e verse the turns of the bandage just oyer the situation where most pressure is desira- ble. When a roller is to be applied to the fore-arm, it is best to make the few first turns of the bandage round the hand. Care must be taken not to make the ban- dage very tight, if it be intended to wet it afterwards with any lotion ; for it is always rendered still more tense by moisture. Mr. John Bell describes the principal pur- poses for which a roller is employed, as follows : " Although in recent wounds, it is with plasters and sutures that we unite the parts point to point, yet it is with the bandage that we support the limb, preserve the parts in continual and perfect contact with each other, and prevent any strain upon the sutures, with which the parts are immediately joined, and we often unite parts by the bandage alone. (This is called the Uniting Bandage, and will be pre- sently described.) But it is particularly to be observed, that in gun-shot wounds, and other bruised wounds, though it would be imprudent to sew tbe parts, since it is impossible that they should altogether unite, yet the gentle and general support which we give by a compress and bandage, pre- vents them from separating far from each other, unites the deep parts early, and les- sens the extent of that surface, which must naturally fall into suppuration. " In the hemorrhagy of wounds, we can- not always find the artery; we dare not always cut parts for fear of greater dan- gers ; we are often alarmed with bleedings from uncertain vessels, he. or from veins ns well as arteries : these hemorrhages are to be suppressed by the compress ; which compress, or even the sponge itself, is but an instrument of compression, serving to give the bandage its perfect effect. Fre- quently, in bleedings near the groin, or the arm-pit, or the angle of the jaw, wherever the bleeding is rapid, the vessels uncertain, the cavity deep, and the blood not to be commanded by a tourniquet, and where the •:ircumstances forbid a deliberate and sure operation-, we trust to compress and bandage alone. " Bandage is very powerful in suppressing bleeding. At one period of surgery, it took place of every other method , &c. If a compress be neatly put upon the bleeding arteries, if there be a bone to resist the compress, or even if the soft parts be firm below, and the bandage be well rolled, the patient is almost secure. But such a roller must be rolled smoothly from the very ex- tremity of the fingers or toes ; the member must be thoroughly supported in all its lower tarts, that it may bear the pressure above. t is partial stricture alone that does harm, creates intolerable pain and anxiety, or brings on gangrene. Hemorrhagy requires a very powerful compression, which must therefore be very general, he. It must not be made only over the bleeding arteries which is all that the surgeon thinks 0f ;n' funeral, &r " In abscesses, where matter is working downwards along the limb, seeking out, as it were, the weak parts, undermining the skin, andwastingit,insulatingand surround- ing the muscles, and penetrating to the bones, the bandage does every thing. The expelling bandage, the propelling bandage, the defensive bandage, were among the names, which the older surgeons gave to the roller, when it was applied for these particular purposes; and these are pro- perties of the roller, which should not be forgotten." (Principles of Surgery, Vol. 1.) Soon after this description of some of the chief surgical uses of the roller, Mr. John Bell proceeds to explain, in what manner this most simple of all bandages may be put on a limb. li Practice will convince you, that the firmness and neatness of a bandage depend altogether upon these two points.; first, upon the turns succeeding each other in a regular proportion ; and, secondly, upon making reverses, wherever you find any slackness likely to arise from the varying form of the limb. Thus, in rolling from the foot to the ankle, leg, and knee, you must take care, first, that the turns, or us the French call them, doloires, of the roller lie over one another by just one-lhird of the breadth of the bandage ; and secondly, that at every difficult part, as over a joint. you turn the roller in your hand, make an angle, and lay the roller upon the limb, with the opposite flat side towards it; you must turn the bandage so as to reverse it. making, what the Fench call, arenversie of the roller at the ankle, at the calf of the leg. and at the knee. You must be careful to roll your bandage from below upwards, and support the whole limb by a general pressure. That you may be able to sup- port the diseased"part with a particular pres- sure, you must lay compresses upon the hollows and upon the bed of each particular abscess, and change the place of these com- presses from time to lime, so as now to pre- vent matter sinking into a particular hollow, now to press it out from a place where it is already lodged, and again to reunite the surface of an abscess already completely formed, from which the matter has been discharged." (Principles of Surgery, Vol. I.) In the article Joints, we have taken no- tice of the good effects of the pressure of the roller in the cure of some diseases of the knee. Here we shall ju.-t introduce Mr. John Bell's sentiments upon the subject: " In a diseased*bursa, as in a relaxation of the knee-joint, that disease, which, with but a little indulgence, a very little encourage- ment of fomentations, poultices, bleeding. and low diet, would end in white-swelling of the knee, may be stopped even by so simple a matter as a well-rolled bandage. (Vol. 1, p. 127.) The uniting bandage, or spica descendens, used in rectilinear wounds, consists of a double-headed roller, with a longitudinal slit in the middle, of three or four inches Ion? The roller, having one head pa«-erf :>46 BANDAGE through the slit, enables the surgeon to dra v the lips of the wound together. The whole must be managed, so thatthe bandage may act equally. When the wounds are stitched, this bandage supports the stitches, and prevents their tearing through the skin. When the wound is deep, writers advise a compress to be applied on each side, in or- der to press the deeper part of its sides to- gether. VVheu the wound is very long, two or three bandages should be employed, and great care must be taken, that the pres- sure is perfectly equable Henkel and Richter recommend an uni- ting bandage, which allows the surgeon to see the wound, over which only narrow tapes cross. The reader, if he should ever wish to employ this contrivance, may read u description of it in Rees's Cyclopaedia, or :\Iotherby's Medical Dictionary ; though 1 confess I could not understand it from the description in those works, until I looked at the plate in Richter's Anfangsgr. der Wun- darzn. Band 1. When we make use of a single-headed roller, as a retentive bandage only, we should always remember to begin the ap- plication of it on the side opposite the wound. ■ The obvious reason for so doing is to prevent a farther separation of the lips of the wound, as the contrary manner of applying the roller would tend directly to divide them. (Gooch, Vol. \,p. 143.) The intention of the expellent bandage is to keep the discharge sufficiently near the orifice of the wound to prevent the forma- tion of sinuses. In general, a compress of unequal thickness is necessary; the thinner part of the compress being placed next, and immediately contiguous to, the orifice of the wound; the thicker part below. Before the bandage is applied, the pus must be completely pressed out, and the rolling begin with two, or three, circular turns on the lower part of the compress. The bandage must then be carried spirally upwards, but not quite so tightly, as below. It is afterwards lo be rolled downward to the place where it began. The creeping is a simple bandage, every succeeding turn of which only just covers the edge of the preceding one. It is em- ployed in cases, in which the object is merely to secure the dressings, and not to make any considerable, or equable pres- sure. A bandage is termed compound, when se- veral pieces of linen, cotton, or flannel, are sewed together iu different" directions, or when the bandage is torn or cut, so as to have several tails. Such are the T bandage, the suspensary, the capistrum, &:c. The eighteen-tailed bandage is one of tbe most compound. It is now in general use for all fractures of the leg and thigh, some- times for those of the fore-arm, and fre- quently, for particular wounds. Its great recommendations are the facility with which it can be undone, so as to allow the parts to be examined, and it« not creating. on such an occasion, Ihe smallest disturb ance of the disease, or accident. The eighteen-tailed bandage is made by|a Ion. itudinal portion of a common roller, and by a sufficient number of transverse pieces, or tails, to cover as much of the part as is requisite. Each of the cross pieces is to be propor- tioned in length to the circumference of the part of the limb to which it i* to be ap- plied ; so that in making this sort of ban dage for the leg, or thigh, the upper tail* will be twice as long as the lower one.' After laying the long part of the bandage on a table, fix the upper end of it in some way oi another. Then begin laying the upper tails across it, and proceed with placing the rest. Each tail must be long enough to extend about two inches beyond the opposite one, when they are both ap- plied. The tails, being all arranged acros-- the longitudinal band, they are to be stitched in this position with a needle and thread When the bandage is intended for the leg, a piece of the longitudinal part of the roller below, is to extend beyond tbe tails. This is usually brought under the sole of tbe foot, and then applied over the inner ankle in the first instance, after the bandage lias been put under the limb. Then the surgeon lays down the first of the lower tails, and covers it with the next one above. In this way, he proceeds upward, till all the cros« pieces are applied, the uppermost one of which he fastens with a pin. This bandage has a very neat appearance. The tails are said to lie better, when placed across the longitudinal piece a little obliquely. (Pott-} The T bandage is, for the most part, owl for covering parts of the abdomen and back. and especially, the scrotum, periiisum, and parts about the anus. Its name is derived from its resemblance to the letter T, and it is, as Mr. John Bell remarks, the peculiar bandage of the body. If the breast or belly be wounded, we make the trans- verse piece, which encircles the body, very broad, and having split the tail-part into two portions, one of these is to be con- veyed over each side of the neck, aud pinned to the opposite part of the circular bandage, so as to form a suspensory for the latter, and prevent its slipping down. But says Mr. John Bell, if we have a wound,or disease, or operation, near the groui) °t private parts, the tail-part then become1 the most important part of the bandage then the tranverse piece, which is to en- circle the pelvis, is smaller, while the tad- part is made very broad. When the iliseas* is in tbe private parts, perinajum, or anu5 we often split the tail according to circum- stances ; but, when the disease-is in om groin, we generally leave the tail-part of the bandage entire and broad. The linleum scissum, or split-cloth, " ■ bandage applied occasionally to the head, and consists of a central part, and six, or eight tails, or beads, whirb are applied M follow^ BAN DAG! ] 24: v\ ben tbe ciotti has *ix heads, the middle, or unsplit part of the cloth is applied to the top of the head. The two front tails go round the temples, and are pinned at the occiput , the two back tails go also round the temples, and are pinned over the fore- head ; the two middle tails are usually di- rected to be tied under the chin ; but, as Mr. John Bell observes, this suffocates and heats the patient, and it is better to tie them over the top of the head, or obliquely, so as to make pressure upon any particular point. (Principles of Surgery, Vol. l.p. 131.) Tbe old surgeons usually split this middle tail into two parts, a broad, and narrow one. fu the broad one, they made a hole to let the ear pass through. This broad portion was tied under the chin, while Ihe narrow ends were tied obliquely over the head. As Mr. John Bell has observed, though this gave the split-cloth the effect of eight tails, yet, the ancient surgeons did not name it the split- cloth with eight tails. When they split the cloth into eight tails, and, especial- ly, when they tied the eight tails in the fol- lowing particular manner, they called the bandage cancer, as resembling a crab in the number of its legs. The cancer or split- cloth of eight tails, was laid over the head, in such a manner, that four tails hung over the forehead and eyes, while the other four hung over the back of the bead. They were tied as follows ; first, the two outer- most tails, on each side in front, were tied over the forehead, while the two middle tails in front were left hanging over the knot. Then the two outermost, or lateral tails behind, were tied round the occiput. Next the middle tails were tied, the two an- terior ones being made to cross over each other, and pass round the temples to be pinned at the occiput; while the two middle tails behind, were made to cross each other, and pass round the temples, so as to be pin- ned over the ears, or near the forehead. (See John Bell's Principles. Vol. 1. p 132.) The triangular bandage is generally a handkerchief doubled in that form. It is commonly used on the head, and now and then, as a support to the testicles, when swelled. The French term it couvre-chef en triangle. The nodose bandage, called also scapha, is a double-headed roller, made of a fillet four yards long, and about an inch and a half broad. It must be reversed two or three times, so as to form a knot upon the part which is to be compressed. It is em- ployed, when a hemorrhage from a wound is to be stopped, oi, for securing the com- press, after bleeding in the temporal artery. The most convenient bandage in general for the forehead, face, and jaws, is the four-tailed one, or single split-cloth. It is composed of a strip of cloth, about lour inches wide, which is to be torn at each end, so as to leave only a convenient portion of the middle part entire. This un- split middle portion is to be applied to the forehead, if the wound be there, and the two upper tails are carried backward, and tied over the back part of the head, while the two lower ones are lo be lied either over the top of the head, or under the chin, as may seem most convenient. When the wound is on the top of the bead, the middle of the undivided part is to be applied to the dressings. The two posterior tails are to be tied forward, and the two an- terior ones are to be carried backward, so as to be tied behind the head. This is sometimes called Galen's bandage. It is curious, that writers on bandages should use the terms head, and tail, synonymously, and hence this four-tailed bandage is often call- ed the sling with four heads. Such confu- sion of language is highly reprehensible, as it contributes, in a very high degree, to ob- struct the comprehension of any, the most simple subject. If the upper lip be cut, and a bandage needed, which is seldom the case, it is al- most superfluous to say, that this bandage will serve the purpose. It serves also in cuts of the lower lip. though there, also, we trust rather to the twisted suture, than a bandage. The single split-cloth is particularly use- ful in supporting a fractured lower jaw, and in such cases, is the only one employed in modern surgery. This bandage, when used for this particular purpose, namely, sup- porting the lower jaw is named capistrum, or bridle, because it goes round the par* somewhat like a horse's halter. "In some cases, (says Mr. John Bell) the circumstances require us to support the chin particularly, and then the unslit part of the bandage is applied upon the chin with a small hole to receive the point; but, where the jaw is broken, we pr d up the jaw-bone into its right shape, with com- presses pressed in under the jaw, and se- cured by this bandage. When we are hi fear of hemorrhagy after any wound, or operation, near the angle of the jaw, we can give the sling a very remarkable degree of firmness. For this purpose, we tear the band into three tails on each side, and we stitch the bandages at the bottom of each slit, lest it should give way, when drawn firm," &,c. (Principles of Surgery, Vol. 1.) W e have already described one way of applying a handkerchief, as a bandage to the head, when we noticed the triangular one, or couvre-chef en triangle. The other manner of applying the handkerchief, call- ed the grand couvre-chef, is as follows ; You take a large handkerchief, and fold it, not in a triangular, but a square form. You let one edge project about three finger- breadths beyond the other, in order to form a general border for the bandage. You lav the handkerchief upon the head, so as to make the lower fold, to winch the project- ing border belongs, lie text the head ; while the projecting border itself is left hanging over the eyes, till the bandage is adjusted^ The two corners of the outermost fold are first to be tied under the chin ; the project- ing border is then to be turned back, and pinned in a circular form round the face. a;- Bi'.i. w bile tiie coi nets of the fold next the head ore to be carried backward and tied. After ihe outer corners of this bandage h&ve been ' tied underthe chin; after Ihe inner corners have been drawn out and car- r ied round the occiput; and after the bor- der has been lurned back and pinned ; the doubling of the handkerchief over each side of the neck hangs in a loose awkward man- ner. It remains, therefore, to pin this part of the handkerchief up above the ear, as neatly as can be contrived. (See J. Bell's Principles.) The grand couvre-chef has certainly no- thing to recommend it, either in point of utility or elegance. A common night-cap must always be infinitely preferable to it. In the event, how ever, of a cap not being at band, it is proper that the surgeon should know, what contrivances may be substitu- ted to fulfil the objects in view. Having, in tbe numerous articles of this Dictionary, noticed tbe mode of applying bandages in particular cases, and allotted a few separate descriptions for such bandages, as are not here mentioned, but which are of- ten spoken of in books.we shall conclude for the present, with referring the reader for further information to Motherby's Medical Dictionary; Rees's Cyclopaedia; and John bell's Principles of Surgery, Vol. 1. Galen mid Vidus Vidius are reckoned the best of the old writers on the subject; M. Sue, Thillaye, Heister, Juville, Lombard, and Bernstein, of the modern ones. The latter are said however, lobe all too prolix. (Sec Rees's Cyclopadia, art. Bandage) BARK, Peruvian, (See Cinchona.) BELLADONNA. (Deadly Night-shade.) Is violently narcotic. The leaves were first used externally for discussing scirrhous swellings, and they have been subsequently given internally, in scirrhous and cancerous diseases, amaurosis, he. Five grains are reckoned a powerful dose.- one is ac- counted enough to begin with. At present, the extract, as directed by the London Col- lege, is more commonly prescribed. From the power, which belladonna is known to possess, of lowering the action of the whole arterial system, it seems to be a fit medicine in many surgical cases, where that object is desirable, particularly in ex- amples of aneurism. A very peculiar virtue, which belladonna has, is that of causing a dilatation of the pupil, when used as an external application lo the eyebrow and eyelids. The late Mr. Saunders was in the habit of employing belladonna a good deal for this express pur- pose. A little while before undertaking the operation for the congenital cataract, he was accustomed to introduce some dissol- ved extract of belladonna between the eye- lids, or rub the eyebrow and skin about ihe eye freely with the same application. The consequence w as, that if there were no adhesions of the iris lo other parts, a full dilatation of the pupil was produced in kes= than an hour, and the whole of the ca- BLA taraet was distinctly brought into vieu This was unquestionably a considerable im- provement in practice, as the iris was kept out of danger, and the operation material!) facilitated. 1 allude here more particularly to Mr.Saunders's own method, in which he introduced the needle through the cornea, in front of the iris, and then conveyed it to the cataract through the enlarged pupil. Belladonna was also externally applied by Mr. Saunders, after the operation, with the view of preventing tbe edge of the iri< from becoming adherent to the edges of the torn capsule. Stramonium is found to have the same effect upon the iris, as belladonna Some experiments, in which the fart i< clearly proved, were detailed many year< ago, by a namesake of my own in the Uni ted States. (See A Dissertation on the Pro- perties and Effects of the Datura Stramoni- um, fa. by Samuel Cooper, Philadelphia, 1797. C. Himly de la Paralysit dt llrii par une application local de Jusquiame, t/c. 2d Ed. 12mo. Altona , 1805. J. Bailey, Ob- servations relative to the Use of Belladonna in painful Disorders of the Head and Face, Svo. Lond. 1818.) BINOCL'LUS. (from binus, double, at oculus, the eye.) A bandage for keeping dressings on both eyes. Its applicalionwill easily be understood by referring to Mono- cuius. BISTOURY. (Bisloire, Frenck.) Any small knife for surgical purposes. r BLADDER, Puncture of. This is an operation, to which we are obliged to have recourse, after having in vain employed all the other means indicated for preventing the bad, and even fatal consequences of a stoppage of the evacuation of the urine, and distention of th* bladder. Various accidents and diseases, both acute and chronic, may occasion this dangerous state, as will be more particularly noticed in the article Urine, retention of. The bladder, which can conveniently hold about a pint and a half of urine, is no sooner dilated, so as to contain two pint", than uneasy sensations are experienced. The desire of discharging the water now becomes urgent, ana if the inclination be not gratified, and the bladder be suffered to be dilated beyond its natural slate, it lose* all power of contraction, and become* pa- ralytic. The desire, indeed, continues, and the efforts are renewed in painful parox- ysms ; but, the power is lost and the blad- der becomes more and more distended. When this viscus is dilated in the utmost de- gree, and neither its own structure, nor the space in the abdomen, can allow a further distention; either the bladder must be la- cerated, which it never is, so equally is i* supported by the pressure of the surround- ing parts, or its orifice must expand and the urine begin to flow. After the third day of the retention, the urine often really be- gins to flow, and, whatever descends from the kidneys is evacuated in small quantitie<: from time to time, and at this period, the Madder i<- di-tr-nded in a; great a degree:»' BLADDER. ~*» it ever cau be, however long the patient may survive. This dribbling of the urine, which begins, when the bladder is dilated to the utmost, and continues till the eighth, or tenth day, or till the bladder sloughs, has long been understood, and is named by the French. " urine par rigorgement." To practitioners, who do not understand it, the occurrence is most deceitful. The friends felicitate themselves, that the urine begins to flow ; the surgeon be- lieves it; basins, and cloths, wet with urine, are easily produced; but, the patient lies unrelieved. The continued distention of the bladder is followed by universal inflam- mation of the abdomen. The insensibility, and low delirium of incipient gangrene, are inistakru for that relief, which was ex- pected from the flow of urine, till either hiccough comes on, and the patient dies of fever, and inflammation, or the urine gets into the abdomen, through an aperture, formed by mortification. Let no surgeon, therefore, trust to the reports of nurses, and friends, but lay his hand upon the hypogas- tric region, and tap with his finger, in order that he may distinguish the distended blad- der, and the fluctuation of urine. As the bladder suffers no further distention, after the third day, why should it burst? Not from laceration ; for it is supported by the uniform pressure of the surrounding visce- ra; not by yielding suddenly, for it is distend- ed to its utmost on the third day of the re- tention, and yet seldom gives way before the tenth; not by attenuation, for it be- comes thickened. The term laceration was never more wrongly applied, than in this instance; for, when there isa breach iu the bladder, it is found, on dissection, to be a small round hole, such as might be covered with the point of the finger. The rest of the \ iscus, and the adjacent bowels, are red and inflamed, while this single point is black, and mortified ! D«lay is more dan- gerous, than even the worst modes of ma- king an opening Into the bladder, and, while life exists, the patient should have his chance. (See John Bell's Principles of Surgery, Vol.2, Part 1, p. 262, fa.) That many patients die after paracentesis of the bladder is an undoubted truth, aud this circumstance has rather intimidated practitioners against the operation. It ap- pears to me, however, that death may in general be more fairly ascribed to the effects of the disease, than to the puncture of the bladder, and that, if this last measure were not deferred so long, as it often is, tbe re- coveries would be more numerous. Hence, when relief cannot be obtained by the treatment described in the article, Urine, Retention of; when no urine at all has come away, at the end of the third day; or when it only does so in a dribbling man- ner after this period, while the bladder con- tinues distended, and no catheter can be introduced ; the operation should not be delayed. In urgent cases, one should ra- ther operate, as soon as forty-eight hours have elapsed No doubt, a man, who is exceedingly skilful in the use of the catheter, and knows how to practise with science and judg- ment all the other means for relieving the retention of urine, will not frequently find it necessary to have recourse to the opera- tion of puncturing the bladder. This is said to have been so much the case with the eminent Desault, that, iu the course of ten years, he had occasion only once to perform such an operation in the Hotel Dieu, where diseases of the urethra are always extremely numerous. (See (Euvres Chir. de Desault, par Bichat, Tom. 2, p. 316.) When, however, this superior manual dex- terity with the catheter is not the acquire- ment of the practitioner, the timely per- formance of the paracentesis of the bladder should ever be observed. At the present day, the absolute necessity for puncturing the bladder is also rendered a less frequent circumstance, not only by the treatment of diseases of the urethra being belter under- stood, than formerly, but also by the very great perfection, to which the construction of elastic gum catheters is brought, instru- ments, from which the most essential assist- ance may frequently be derived. I shall next treat of the three modes of doing the operation. 1. Puncture through the Perinaium. The first surgeon that ever performed this operation is said to have been M. Tolet, a French surgeon, the author of a valuable treatise, entitled " Traite de Li- thotomie, ou de I'txtraction de la pierre hors de la vessce, Troisieme edition, Paris, 1681." According to Sabatier, it was customary, at the time of Dionis, to make the opening with a narrow-pointed scalpel, about four or five inches long, which was plunged into the bladder, at the place where the incision in the apparatus major terminated. (See Lithotomy.) The escape of the urine indi- cated when the surgeon had reached the bladder. A straight probe was conducted along the knife, and then a cannula was passed along the probe into the bladder, where it was allowed to remain as long as necessary, care being taken to fix it by means of tapes, put through the rings at the broad part of the instruments. The opening was then closed with a linen tent. Some practitioners, however, after intro- ducing a staff as far into the urethra as pos- sible, began an incision in the perineum. Having made an opening into the canal,, they pushed the staff into the bladder, and along this instrument introduced a gorget. With the assistance of the gorget, a cannula was next passed into the bladder, and al- lowed to continue thus introduced. This complicated mode of proceeding, which Sabatier is pleased to term more methodi- cal than that which has been first men- tioned, could only answer in cases, where the obstruction about the neck of the blad- der was inconsiderable, and where in fact the introduction of the catheter was not yet impracticable At least therefore, the me* 250 BLADDER. thod was unnecessary. The other plan of piercing the urethra in several places, and making a passage for the urine through the prostate, says 6abatier, increased the in- flammation, with which this gland was affected, and rendered the disease, if not mortal, at least much more difficult of cure. Sabatier represents Dionis as the first who suggested this method of opening the bladder on one side of the perineum, at the part, where Fr^re Jacques used to perform lithotomy. Dionis conceived, that in this mode of operating, the patient would suffer less pain, because neither the urethra, nor the neck of the bladder, would be injured; but at the same time, he recommended a process to be followed, which was similar to that pursued in making the puncture in the middle of the perineum ; viz. that a nar- row scalpel should first be introduced, so as to make a passage for the probe, along which the cannula was to be guided into the bladder. The idea of substituting for these unsuitable instruments a trocar of con- venient length, was exceedingly simple, and for this improvement, which took place in 1721, surgery is indebted to Juncker, (See Conspectus Chirurgia, Tab. 97, p. 674,) unless the following passage be correct: '• In the year 1717, or 1718, M. Peyronie showed in the King's garden a long trocar, which he had successfully employed in a similar puncture." (Desault's Parisian Chir. Journ. Vol. 2, p. 267.) The patient having been placed in the fame position as for lithotomy, an assistant is to press with bis left band on the region of the bladder, above the pubes, in order to propel that viscus as far downward into the lesser pelvis as possible, while, with his right hand, he supports the scrotum. The sur- geon is then to introduce the trocar at the middle of aline, drawn from the tuberosity of the ischium to the raphe of the perineum, two lines more forward than the verge of the anus. Tbe instrument is first to be pushed in a direction parallel to the axis of the body; and its point is afterwards to be turned a little inwards. Here, according to Bichat, there is no occasion to convey the cannula so far into the bladder, as is done, when the operation is performed above the pubes. The portion of this viscus, that is pierced, being incapable of changing its position, with regard to other parts in the perineum, if the cannula only project a few lines into its cavity, it will not be liable to slip out. It would be wrong, indeed, to carry it in further; for, the pressure of its end against the posterior parietes of the bladder would do harm. Lastly, the can- nula is to be fixed in its place, by means of the T bandage. (See GZuvres Chir. de De- sault, T.3,p. 320.) Some writers recommend the introduc- tion of the left index finger into the rectum, in order to draw this intestine out of the way; but Sabatier thinks it better to use this finger for pressing on the part of tbe perineum, where the puncture is about to be made, so as to make the skin tei.se- and assist in the guidance of the trocar. (Me- decine Operatoirc, T.2,p. 126.) The parts, divided in the puncture, are the skin, a good deal of fat, and cellular substance, the levator ani muscle, and that portion of the lower part of the bladder, which is situated on one side of its neck. The following is the judgment, which Bi- chat has passed upon this method: In the track, which the trocar has to pass, there is no part, the puncture of which must of ne- cessity give rise to bad symptoms. A sur- geon, moderately exercised in tbe practice of this operation, is tolerably sure of piercing the bladder, which is opened in the most depending situation, and at a point, which constantly bears the same relation to the perinajum. But, the position, in which the patient is placed for the operation, is a great deal more disagreeable, than that for tbe puncture above the pubes. Several as- sistants are required to fix him, and one is necessary for compressing the bladder in the hypogastric region. There is a possibility of wounding the vessels of the perineum, and of pricking the nerves whicn accom- pany them. If the point of the trocar be carried too much outwards, it may glide over the external side of the bladder? If it be inclined forwards, it may slip between this viscus and the pubes. If it be turned too much inwards, it may pierce the pros- tate gland. If directed too much back- wards, it may wound the vasa deferentia, the rectum, the extremity of the ureter,and the vesiculae seminales. Also, while the cannula is kept introduced, the patient can neither walk about, nor sit down: but must continually keep himself in bed. Lastly, this mode of operating is frequently counter- indicated, by tumours, or other common diseases, in this part of the body, in conse- quence of retentions of urine. ((Eurret Chir. de Desault par Bichat, Tom. 3, p. 321.) The puncture of the bladder front the pe- rineum is now almost universally aban- doned by British surgeons. " We may es- teem it fortunate," says Desault, ° if tbe trocar penetrates directly into the bWder, after piercing the fat and the muscles, situ- sated between the tuberosity of the ischium and the anus ; and, as this viscus isaobjfct to much variation in its form, the surgeon will often be defeated, unless he be per- fectly clear in his ideas respecting its sitat- tion and figure. This disappointment is not without example, and there issuficient cause to deter a practitioner from perform- ing this operation, independently of the danger of wounding with the trocar the vasa deferentia, vesiculae seminales, ureter, he. (Parisian Chir. Journ. P. 2, P. 267.) If there be now any practitioners^aH>° are averse to the total relinquishaMftoi this method, I think the following cautio»i given by Sabatier, may be of service to tbem : perhaps, the operation would be more safe, if the surgeon were to bnpa with making a deep incision in the peri nenm, as is practised in the lateral war d cuttingforthe st'.ne.and if he were to the cavity of the abdomen. The patient may easily lie on his side, or abdomen, so as to discharge all the urine contained u the bladder. There are here no nerves, nor vessels, of which the injury can be dangerous. No difficulty is experienced in fixing the cannula, and the presence of this instrument does not hinder the patient from sitting, standing up, or even walking about in his chamber. When the cannula, also, is introduced to the fower part of tbe Wani BLADDER. 253 der, this viscus cannot possibly quit it. Lastly, the wound heals with more facility, than that made in any other method." Respecting this advice to push the cannu- la so far into the bladder, it is highly ob- jectionable,for the reason already explained. The writer of the preceding commendation seems to me rather too partial. He has told us of the little thickness of the wounded parts, and, yet a little before bestovying these praises, he has acknowledged, " il est rare, que dans cette ponction, on traverse directcmentlalignc blanche .- on passe presque toujours sur tes cotes, el I'on dirise la pcau, I'apone'urose des muscles largcs du bas-ventre, lesmusclcs droits, quelquefois I'un despyrami- dales, et la parol antirieure de la vessie." (Tom. 3. p. 318.) According to my own judgment, the plan which is about to be described, is the safest and best, when the circumstances of the case afford a choice, and I think, that it would be for the benefit of the afflicted, if the puncture above the pubes were only performed in cases, in which the enor- mous enlargement of the prostate gland, and the disease in the rectum, prevent a puncture from being safely made from the rectum. 3. Puncture from the Rectum. This method is more generally applicable, than either of the two plans above related. It is not, like the puncture in the perineum, liable to the objection, that the wound is made iu diseased or inflamed parts, which afterwards become gangrenous. Nor is it, like the puncture above the pubes, attend- ed with a chance of the urine diffusing it- self in the cellular membrane. It has also the advantage of emptying the bladder com- pletely. Tbe puncture is made sufficiently far from the neck of the bladder not to in- crease any inflammation existing in that situation; and the operation is really at- tended with little pain, since there is no skin, nor muscles to be wounded, merely the coats of the bladder and rectum at a point w here these viscera lie in contact with each other. The enlargement of the prostate gland, and disease of the rectum, are, perhaps, the only solid reason against its being uniformly preferred. When the bladder istobe tapped from the rectum, two fingers should be introduced into the intestine, instead of one, as has been directed. In this manner, the can- nula can be more conveniently guided, and held in a proper position, while the trocar is introduced with the other hand. The stilette, however, must never be introduced into the cannula, except when this is pro- perly placed, wilh its extremity against the part, where it is intended to make the puncture. We read in the Philosophical Transac- tions for 1776, of a case of total retention of urine, from strictures, where the bladder was successfully punctured from the rec- tum. Mr. Hamilton, who did the opera- tion, thought of the plan, in consequence of feeling the bladder exceedingly promi- nent in the rectum, on introducing his fin- ger into the anus. The patient was placed in the same posi- tion as that for lithotomy; a trocar was. passed along the finger into the anus, and pushed into the lowest and most projecting part of the swelling, in the direction of the axis of the bladder. A straight catheter was immediately introduced through the cannula, lest the bladder by contracting should quit the latter, which was taken away, and, as soon as the water was dis- charged, the catheter was also- removed. Notwithstanding the puncture, the bladder retained the urine as usual, until a desire to make water occurred. Then the opening made by the instrument seemed to expand, and the water flowed in a full stream from the anus. The urine came away in this manner, two days, after which it passed the natural way, with the aid of a bougie,which had been passed through the urethra, into the bladder, and which was used, till all the disease in this canal was cured. The method is said to have been origin- ally proposed in 1750, by Mr. Fleurant, sur- geon of the hospital La Chariti, at Lyons; and Pouteau, in 1760, published an account of it, and three cases in which Fleurant had operated- It was also the feel of the blad- der, on the introduction of a finger intra anum, which led the latter surgeon to choose making a puncture in this situation. The urine was immediately discharged, and the cannula supported in its place with the T bandage, until the natural passage was ren- dered pervious again. But the cannula, be- ing allowed to remain in the rectum, be- came incommodious to the patient, when he went to stool, and the inconvenience was vastly increased by the continual drih- bling of the urine from the mouth of the instrument. Hamilton avoided both these inconveniences, by withdrawing the can- nula at first. In another instance, however. Fleurant left the cannula in (he amis and bladder, thirty-nine days, without the least inconvenience. In order to lessen the inconvenience, at- tending the presence of the cannula, Fleu- rant suggested that it would be better to have the tube made of a flexible substance ; a proposal, that seems to merit attention, though, I believe, the inconveniences of wearing the cannula are not in general very serious, and, were a case of this kind to present itself, I should have no hesitation in withdrawing the tube altogether. In the first volume of the Mem. of the Medical Society of London, two cases are related, in which, after tapping the bladdey from the rectum, the cannula was immedi- ately withdrawn, without any bad effect} and a similar fact is recorded in the Medi- cal Communications, Vol. 1. A curved trocar, of sufficient length, is the best for performing the operation, and was recommended by Pouteau. As the trocar with a lancet-point may cut blood vessels, which would bleed freelv, soms 2o4 BLADDER. authors express their preference to one made with a triangular point. (Howship, p- 315.) It should be introduced into the pro- minence made by the distended bladder, a little beyond the prostate gland, exactly in the centre of the front of the rectum ; but not imprudently far up the intestine, lest the peritoneum be injured. For some useful cautions on this head, the profession are indebted to Mr. Carpue, who has very pro- perly adverted to the very low point to which the portion of peritoneum reflected over tbe rectum descends. (Hist, of the High Operation, fa. p. 178, 8ro. Lond. 1819.) By keeping the point of the trocar in the centre of the anterior part of the rec- tum, and not introducing it without first distinctly feeling with the end of the finger, the exact placa into which it is to enter, the vesiculaj seminales, which diverge from each other above, will not be wounded; and even were they so, perhaps no serious consequences would follow. It is not necessary to retain the cannula in the puncture, after the inflammation has consolidated the sides of the wound, and there is no danger of the aperture closing up, till there is another passage made for the urine. Sir E. Home thinks, that, after about thirty-seven hours, the cannula may be properly taken out. (Trans.'of a Soc. for Med. and Chir. Knowledge, Vol. 2.) Indeed, I am not acquainted with any fact, showing the ill effect of removing the cannula at once; for, here the urine has only to pass through a mere opening, without any lon- gitudinal extent, like what remains after puncturing above the pubes. The safety and simplicity of tapping the bladder from the rectum, will always recommend this method to impartial practitioners. The wound is made at a distance from the peri- toneum, passes through no thickness of parts, and is quite unattended with any chance of the urine becoming extravasated i in the cellular substance. Whether the bladder be morbidly contracted and thick- ened ; whether the neck of the bladder be inflamed ; it is equally applicable ; enlarge- ment of the prostate gland, and much dis- ease in the rectum, can alone warrant the puncture above the pubes being ever pre- ferred. I am happy to join the experienced and judicious Mr. Hey with the advocates for this mode of performing the operation, and as his opinion on this subject must have considerable influence, I shall quote the fol- lowing passage from his valuable work, par- ticularly as the observations confirm some other points, adverted to in the present ar- ticle. " It is sometimes impossible, from various causes, to make a catheter pass through the urethra. The puncture of the bladder then becomes necessary, if the re- tention of urine continues. This operation may be performed, either above the pubes, or through the rectum. I have seen it performed in both.these methods; but, give tbe preference to the latter. It is more easy to the surgeon ; and less painful to the patient. Pouteau's curved trocar i- a very convenient instrument; and may be used with safety for puncturing the bladder through the rectum; but, the operator should cautiously avoid wounding an artery which may be felt running toward* tbe anus, where the bladder is most protube- rant. The finger, which is introduced into the rectum to guide the trocar, may be con- veniently placed a little on either side of this vessel. It is not always necessary to leave the cannula in the bladder, as the urine sometimes begins to flow through the penis, within a few hours after tbe bladder is emptied. Perhaps, this event may in the most frequent, when the introduction of the catheter has been prevented by a stricture in the urethra. If the wound be- comes closed, before the power of expel- ling the urine is regained, recourse mutt ba had to a repetition of tbe operation, which gives very little trouble to the patient: nei- ther is he much incommoded by suffering the cannula to remain two or three days in the bladder. This is sometimes necessary, and seldom improper." (Hey's Practical Observations in Surgery, p. 430—431, odii. In the foregoing columns, Lhave briefly adverted to the proposal of cutting into the urethra behind the obstruction, instead of puncturing the bladder. Mr. Grainger, of Birmingham, a few years ago, also recom- mended cutting into the urethra, immedi- ately in front of the prostate, and relieving the bladder by the introduction of a female catheter through the glaqd, or, (if that could not be accomplished) by the division of its substance with a scalpel, (MedLani Surg. Remarks, fa. Svo. Lond. 1816.) Women seldom stand in need of n para- centesis of the bladder; but, when the ope- ration is necessary in them, it is more safely and easily performed from the vagina,than in any other way. If it should be propertu leave the cannula introduced, this must lie long enough to allow its orifice to be situa- ted on the outside of the the labia, whew it must be fixed with a T. bandage. Consult particularly Sharp on the Optra- tions, Chap. 15. and his Critical Inqmr). Ambr. Bertrandi, Trattato delle Optramw di Chirurgia, accresciuto dinote,fa.daiOn- rurghi G.A.Penchienatie G Brugnont,%tt. Torino, 1S02. Bertrandi was an approver »J the puncture from the rectum: so waiU Blanc. Operat. de Chir. T. 1. Melanges it Chirurgie, par Pouteau, Lyon, 1760, P.6D0. L'Encyclopidie Methodique, Parlie Chirurf cale; art. Paracentese de la Vessie. Sekuut- ker, Chir. Wahrnemungen, 2 Th. No. 39- puncture from the rectum. Sabatier's Medi- cine Opiratoire, Tom. 2. Mursinna, Jour* far die Chirurgie, fa. 4, p. 46,67. Casts*! puncture from the rectum, and aboit I* pubes. In illustration of the operation *J puncturing the bladder, Camper's plates *tt the best: See hi* Demonst.Anat. Palhot-Lt* 2. In this work, the danger of letting <*< end of any long instrument, when introduU* press against the inside of Ihe bladder. "P* BLADDER. 255 red by a case, in which llial organ was perfo- rated by the extremity of a catheter, p. 11. Klohss, Diss, de Paracentesi Vesica Urinaria per intestinum rectum, Jen. 1791. A. Bonn, Anat. Chir. Bemerkungen liber die Harnrer- haltung, und den Blasenslich. Leips. 1794, prefers the puncture above the pubes. J. Howship, Pract. Obs. on Diseases of the Uri- nary Organs, p. 214, 8vo. Lond. 1816, thinks the operation from the rectum superior to the other methods. Sir E. Home in Trans, for the Improvement of Med. and Chir. Know- ledge, Vol. 2. Abernethy's Surgical Observa- tions, 1804. John Bell's Principles of Sur- gery, Vol. 2. QZuvrcs Chir. de Desault par Bichat, T. 3, p. 315, fa. W. Schmiduber die Krankheiten der Hamblase, fa. 8vo. Wien, 1806. Richerand's Nosogr. Chir. T. 3, edit. 4. Hey's Practical Observations in Surgery, p. 430, edit. 2. Parisian Chirurgi- cal Journal, Vol. 2. p. 156, and p. 265. S. T. Summering uber die schnell und langsam tod- lichen Krankheiten der Hamblase, fa. Frank- fart, 1809. The author is an advocate for tAe puncture above the pubes, in preference to that through the rectum, which he thinks right only in one case, viz. when the bladder is so contracted, that it does not rise out of the lesser cavity of the pelvis, and the fluctua- tion of the urine can be felt in the rectum, but not above the pubes. In this opinion, he is joined by Langenbeck. (Bibliolhek, 3 B. p. 719.) Callisen's Syslema Chirurgim Ho- diernte, T. i, p. 277, fa. Chirurgischc Ver- suchevonB. G. Schreger, B. 1. Uber den Blasenslich Oberhalb der Schoosfuge, p. 211, fa. 8vo. Nurnberg. 1811, git>e» the prefer- ence to the puncture above the pubes. Ed- ward Grainger, Med. and Surg. Remarks, fa. with Obs. on the different modes of opening the bladder in retention af urine, fa. Svo. Lond. 1815. C. Bell, Surgical Obs. 8vo. Part O.Lond. 1818. Bladder, Tumour extirpated from. Mr. Warner has recorded a case, in which an excrescence, growing from the inside of a young woman's bladder, was successfully- removed. The patient, on the 24th of June, 1747, strained herself in endeavouring to lift a great weight, and she was immediately siezed with a pain in the small of herbaek, and a total retention of urine. In April, 1750, she applied to Mr. Warner, who found, upon inquiry, that she had never been able, from the moment of the- acci- dent, to void a drop of urine without the assistance of the catheter; that she was in continual pain, and had lately been much weakened, by having several times lost con- siderable quantities of blood, occasioned by the force made use of in introducing the instrument into the bladder. Mr. Warner, upon examining the parts with his forefinger, which he had great dif- ficulty in introducing into the meatus uri- narius, discovered a considerable tumour, which seemed to be of a fleshy substance, and took its rise from the lower part of the bladder, near itc neck. When the patient Mrained to make water, and the bladder was foil, the excrescence protruded a little way out of the meatus urinarius; but, upon ceasing to strain, it presently returned. A purgative having been given the day before the operation, and the rectum emp- tied by means of an emollient clyster, Mr. Warner directed the patient to strain, so as to make the bladder project. He then hin- dered it from returning into the bladder, by passing a ligature through it, and endea- voured to draw it further out. The latter object was found impracticable, on account of the size of the tumour. Seeing this, Mr. Warner dilated the meatus urinarius on the right side, by cutting it upwards, about half way towards the neck of the bladder, when, by pulling the swelling forwards, he was enabled to tie its base, which was very large, with a ligature. For three days after the operation, a good deal of pain was felt in the abdomen. On the sixth day, the tumour dropped off. From the first day, the urine came away without assistance, and the patient got quite well. The tumour resembled a tur- key's egg in shape and size. (See Warntr's Cases in Surgey, edit. 5,p. 303.) Perhaps, in this example, tying the tu- mour was preferable to cutting it away, even though its base was large ; for, had the knife been used, there would have been some danger of the bladder becoming filled with blood. Bladder, Hernia of. See Hernia. Bladder, Insects discharged from. The instances, in which worms are stated to have been discharged from the bladder, are very numerous. Many cases of this kind are referred to in Voigtel's Handbuch der pathologischen Anatoinie, b. 3, p. 337—342. A few years ago, an interesting example was recorded by Mr. Lawrence. (See Mtd. Chir. Trans. V. 2. p. 382, fa.) Bladdek, Deficiency of. .Numerous ex- amples, in which this deviation from the natural structure has occurred, are recorded by medical writers. The publications, how- ever, which, as far as I know, contain the most ample information on the subject, are, aGottingen inaugural Dissertation, entitled, " De Vesica: Urinaria Prolapsu Nalivo," bv by Dr. Roose, late professor in Brunswick", and a paper, called " An attempt toioards a systematic account of the appe.irances,connect- ed with that malconformation of the Urinary Organs, in which the ureters, instead of termi- nating in a perfect bladder, open externally on the surface of the Abdomen," by A. Dun- can, jun. in Edin. Med and Surg. Journal, Vol. 1. In this last production, may be seen references to all tbe most noted cases on record, both male and female. (See also Handbuch der Pathologischen Anatomic von J. F. Meckel, 1 B. p. 650, Sro. Ltip. 1S1-U Bladder, Wounds of. See Gunshot Hounds. Many cases of rupture of the bladder from blows or falls are recorded followed by fatal extravasation of urine in the abdomen. Two such instances have been recently detailed by llf. Cusack. (See Dub. Hospital Rep'i:s<; explained in a foregoing article. See Aneu- rism. Cavalline cured the disease by divi- ding tbe vessel, and compression. (Colics. di Casi Chir. t. 2.) TOriCAL BLEEDING.— CCFriNS- This is done by means of a scarificator, and a glass, shaped somewhat like a bell. The scarificator is an instrument contain- ing a number of lancets, sometimes as many as twenty, which are so contrived, that when the instrument is applied to any part of the surface of the body, and a spring is pressed, they suddenly start out, and make the necessary punctures. The instrument is so constructed, that tbe depth, to which the lancets penetrate, may be made greater or less, at the option of the practitioner. As only small vessels can be thus opened, a very inconsiderable quantity of blood would be discharged, were not some method taken to promote the evacuation. This is com- monly done with a cupping-glass, the air within the cavity of which is rarified, by the flame of a little lamp, containing spirit of wine, and furnished with a thick wick. This plan is preferable to that of setting on fire a piece of tow, dipped in this fluid, and put in flic cavity of the glass ; a clumsy expedient, adding unnecessarily to the suf- ferings of the patient, by cauterizing the skin ; doing harm also by rarifying the air more than necessary within the glass, in consequence of which the edges of the cup compress the cutaneous vessels so much as to obstruct the influx of blood. The larger the glass, if properly exhausted, the less pain does the patient suffer, and the more freely does the blood flow." (See Mapleson's Treatise on the Art of Cupping, p. 63—65. 12?no. Lond. 1S13.) When the mouth of the glass is placed over the scari- fications, and the rarified air in it becomes condensed as it cools, the glass is forced down on the skin, and a considerable suc- tion takes place. This professor of the said art says, that when the operation is about to be done, a basin of warm water, a piece of fine sponge, and a lighted candle, should be provided. As many of the cupping-glasses as may be judged necessary are to be put in the basin. If sixteen or twenty ounces of blood are to be taken away, four glasses, of a size adapted to the surface to which they arc to be applied, will generally be required. Each glass is then to be held for an instant over the flame of the spirit-lamp, and immediately placed upon the skin. Upon the quickness with which this is dosae, the neatness and efficacy of the operation will depend. If dry cupping be only in- tended, the glasses may be allowed to re- main on the skin for a few moments, and be replaced five or six times, with a little variation of their position, in order to pre- vent the skin from being hurt by their pres- sure. If the intention be to scarify and take away blood, the glass ought not to remain more than a minute, when the srarificator is to be instantly applied; for by the quick- ness with which the application of tht- srarificator succeeds the removal of the glass, the patient is saved a degree of pain. which he would otherwise suffer from the making of the punctures. When the glasses are so full as to be in danger of. falling of. or the blood is coagulated in them, Aim should be removed, emptied, and applied again. For the sske of neatness, care should be taken to insert the nail under the upper part of the glass, and remove it so as to keep its bottom downwards, the scarifications being at the same time wiped with a sponge, wet in warm water. The glasses also previously to each application. should be rinsed in warm water, but not dried. For these, and some other useful directions, see Mapleson's Treatise, p. CA.i,f Trials have been made of syringes, cal- culated for exhausting the air from cupping- glasses ; but the plan is not found so con venient as that above described. A common pledget, or bit of rag, i.« imusl ly applied as a dressing for the puncture' made with a scarificator. If r little smarting be not minded, Mr. Mnpleson prefers the application of arque- bnsade water, or spirits of wine, as it immediately stops the oozing of blood,and prevents subsequent itching. (P. 69.) LEECHES. Leeches are often preferable to fuppinr, which is attended with more irritation than many surfaces, under particular circum- stances, can bear, especially when the ttpi- cal bleeding is to be frequently repeated; and they can be used in cases in which It would not be safe or convenient to employ the lancet. Formerly medicinal leeches were very abundant in England, but owing to their now being in greater request, and to the draining and cultivation of waste lands, it is necessary to import large tupplies from the continent, chiefly from Bourdeaui and Lisbon. As much imposition prevails m this branch of commerce, it should be understood, that unless a leech be marked with yellow rings, or spots, or with varies*. ted lines, running the whole length of uv back, it will generally be found useless (See A Treatise on the Medicinal Letth, bo J. R. Johnson, p. 133, 8ro. Lond. 181a) When leeches are to be kept in any con- siderable quantity, this gentleman recom- mends them to be placed in a large vessml, provided with a false bottom, so perforated as to allow them a ready passage. Ttos false bottom should be raised from three to six inches above the real bottom, or to soch an extent as will admit of a turf, of nearly equal dimensions, being pluced betw*** them. It should fit closely to the aid* that the earth may not be distnrbed by tb< frequent introduction of fresh water. It* necessary that the vesrel be also farnisher with a stop-cock, in order that th» wate may be drawn off a«= often a>- mav be ron BLELliLNG. 2-j«J r'.Jcred expedient. But previously to our placing the leeches in this vessel, they should be singly examined. If on being handled, they contract, and feel hard and firm, it affords the best indication of their being healthy ; but should they feel flabby, or exhibit protuberances, or white ulcerous specks on the surface, they should be kept in jars by themselves, the water and the turfofwbichshouldbefrequentiv renewed." (Op. cit. p. 138.) Leeches, occasionally, cannot be easily made to fix on the particular part we wish ; but tbey will do so, if the place be first cooled with a cloth dipped in cold water, or if it be moistened with cream or milk, and they be confined in the situation with a small glass. According to Dr. Johnson, the part on Which it is intended they shall fix should be as clean as possible ; it should, therefore, be first washed with soap and water, and afterwards with water alone, which will be more necessary should any liniment or em- brocation have been used. Leeches are often found to bite belter, when removed from the water at least an hour previously to their application. In the common prac- tice of putting as many of them as may be required into a wine-glass, and inverting it upon the part affected, there is the disad- vantage, that they frequently retire to the upper part of the glass, and cannot be got down again, without some risk of displacing those which have already fastened. To remedy this inconvenience, Dr. Johnson re- commends glass vessels of various sizes and figures, but none of them more than an inch deep. But, in his own practice, he prefers applying leeches with his hand. " Bring a leech towards the part whereon you intend to fix it, and as soon as it begins to ext«ud the head, to seek an attachment, endeavour that it may affix itself to the place required." When it evinces no dis- position to bite, a little puncture may be made with a lancet, when the animal will fix itself. " When the patient is fearful of the lancet, and one leech only shall have bitten, where several are required, it may be of use to remove it, which is readily done by inserting the nail of the finger be- tween its mouth and the skin. The blood then flowing from the orifice, will induce the remainder to bite with the greatest avidity. As soon as the leeches are gorged, they drop off; this usually happens within ten or fifteen minutes. Sometimes they re- main affixed a considerable time, and become indolent; but they are quickly roused from mis state by sprinkling them with a few drops of cold water." (Johnson, op. cit. p. 141.) When they fall off, the bleeding may be promoted, if necessary, by foment- ing the part. When the bleeding continues longer than is desirable, a slight compress will usually stop it ; but in more trouble- some cases, the compress must be dipped in brandy, or spirits of wine. In young in- fants, the hemorrhage from the bites of leeches has sometimes proved fatal, and the same thing mjy happen iu adults. An example of each fact is related by Eeau- chene (Gazellede Santi. Sept. 1815.) When the bleeding is very troublesome, Auten- rieth advises pieces of charpie to be pushed into the orifices of the bites ; a method which he assures us, is perfectly effectual. (Tubingen Blatter, B.2. St. l.p. 57.) In order to make a leech disgorge, it is usual to throw a little salt upon it: in a few seconds the blood,is rejected, the leech assumes a coiled form, and is seldom found fit for use again before the end of four or five days. As salt, however, fre- quently" blisters the leech, it has been pro- posed to empty the animal by regular and uniform pressure; but though Dr. Johnson considers this plan better than the other, he admits that it is scarcely practicable, with- out injuring the internal structure of the leech. He says, the best method, and that from which the animal suffers the least in- convenience, is pouring a small quantity of vinegar upon its head. Leeches which have been recently applied should always be kept by themselves, aud allowed to re- tain, for their nourishment, about one-third of the blood which they extract. For a great deal of valuable information respect- ing leeches, see Johnson's work, the title of which is above specified. When leeches are very scarce, their tails may be snipped off, while they are sucking, and the blood will then flow, drop by drop, from the artificial opening, as fast as the animals suck it; or with the same view, an incision may be made with a lancet, close to the tail. (Johnson, Op. cit. p. 144.)j SCARIFICATION WITU A LANCET, Is mostly done in cases of inflamed eyes. An assistant is to raise the upper eyelid, while the surgeon himself depresses the lower one, and makes a number of slight scarifi- cations, where the vessels seem mostturgid, trying particularly to cut the largest com- pletely across. ILL CONSEQUENCES SOHETIAIXS fOLLOWISS BLEEDING IN THE ARM. 1. Ecc/iymosis. The most common is a thrombus, or ecchymosis, a small tumour around the orifice, and occasioned by the blood in- sinuating itself into the adjoining cellular substance, at the time when this fluid is flowing out of the vessel. Changing the posture of the arm will frequently hinder the thrombus from increasing in size, so as to obstruct the evacuation of blood. But, in some instances, the tumour suddenly be- comes so large, that it entirely interrupts the operation, aud prevents it from being finished. In these cases, however, the most effectual method of preventing the tumour from becoming still larger, is to remove the bandage. By allowing the bandage to ieni«in: n vtrrv considerable : v< elliinr mav £80 BLELI>i.\o. be induced, and sum as might be attended with great trouble. If more blood be re- Juired to be taken away, it ought to be rawn from another vein, and what is still better, from a vein in the other arm. The best applications for promoting the absorption of these tumours, are those con- taining spirit, vinegar, or the muriate of ammonia. Compresses, wetted with any lotion of this sort, may be advantageously put on the swelling, and confined there with a slack bandage. 2. Inflammation of the Integuments and sub- jacent Cellular Substance. According to Mr. Abernethy, the inflam- mation and suppuration of tbe cellular sub- stance, in which the vein lies, are the most frequent occurrences. On the subsidence of this inflammation the tube of the vein is free from induration. Sometimes the inflam- mation is rather indolent, producing a cir- cumscribed and slowly suppurating tumour. Sometimes it is more diffused, and partakes ef the erysipelatous nature. On other oc- casions, the affection is of the phlegmonous hind. When the lancet has been bad, so as ra- ther to have lacerated than cut the parts; when the' constitution is irritable, and espe- cially when care is not taken to unite the edges of the puncture, aud the arm is allow- ed to move about, so as to make the two sides of the wound rub against each other, inflammation will most probably ensue. The treatment of this case consists in keep- ing the arm perfectly at rest in a sling, ap- plying the saturine lotion, and giving one or two mild saline purges. When suppura- tion takes place, a small poultice is the best loeal application. 3. Absorbents inflamed. Sometimes, particularly when the arm is not kept properly quiet after bleeding, swellings make their appearance about the middle of the arm, over the large vessels, and on the fore-arm, about the mid-space, between the elbow and wrist, in the integu- ments covering the flexor muscles. The swelling at the inner edge of the biceps is sometimes as large as an egg. Before such swellings take place, tbe wound in the vein often inflames, becomes painful, and suppu- rates, but without any perceptible indura- tion of tbe venal tube, either at this time, or after tbe subsidence of the inflammation. Pain is felt shooting from tbe orifice iu the vein, hi lines up and down the arm, and upon pressing in the course of this pain,, its degree is increased. On examining the arm attentively, indurated absorbents may be plainly felt, leading to the tumour at the side of the biceps muscle. The pain and swelling often extend to the axilla, where the glands also sometimes enlarge. Chordlike substances, evidently absorbents, may sometimes be felt, not only leading from the puncture to the swelling hi the middle of the arm, but also from this latter situation up to the axibaiy giaou>, and from the wound in the vein down i,. the enlarged glands at the mid-space U tween the elbow and wrist, over the fltvit muscles of the hand. Tbe enlarged glands very often proceed to suppuration, and the patient suffers fe- brile symptoms. It may be suspected thai the foregoing consequences arise from the lancet being envenomed, and from the ab- sorption of the virulent matter; but (he frequent descent of the disease to (he inferior absorbents militates against this supposition. When the absorbents become inflamed, they quickly communicate the affection W the surrounding cellular substance. These vessels, when indurated, appear like small chords, perhaps of one eighth of an inch iu diameter: this substance cannot be ibi slender sides of the vessels, suddenly in creased in bulk, but an induration of the surrounding cellular Substance. The inflammation of the absorbents, in consequence of local injury, is deducible from two causes : one, the absorption ol irritating matter ; and the other, the effect of tbe mere irritation of the divided take. When virulent matter is taken up by th* absorbents, it is generally conveyed to the next absorbent gland, where its progress being retarded, its stimulating qualities give rise to inflammation, and, frequently, no evident disease of the vessel, through which it has passed, can be distinguished. When inflammation of the abeorhents happens in consequence of irritation, the part of the vessel nearest the irritating cause, generally suffers most, while the glands, being remotely situated, are not to much inflamed. The treatment of the preceding case con- sists in keeping the arm perfectly quiet ia a sling, dressing the puncture of the vein with any mild simple salve, covering the sUm- tion of the inflamed lymphatics with linen wet with the saturnine lotion, and giving some gentle purging medicine. When the glandular swellings suppurate, poultices should be applied, and if the mat- ter does not soon spontaneously make it* way outward, the surgeon may opea the abscess. (See Abernethy'* Essay m thk subject.) 4. Inflammation of th* Vein. When the wound does not unite, the vein itself is very likely to inflame. Thi* affection will vary in its degree, extent, aaa progress. One degree of inflammaua* may only cause a slight thickening of the venal tube, and an adhesion of its side*. Abscesses, more or less extensive, may re- sult from an inflammation of greater vio- lence, and the matter may sometimes be- come blended with the circulating flautk and produce dangerous consequences, (V the matter may be quite circumscribed, aad make its way to the surface. When tka vein is extensively inflamed, a good dtsi of sympathetic fever is likely to ensu*.Wl BLCED1.V.'. 2Cl merely from Uic excitement, which inflam- mation usually produces, but also from the irritation continued along the membranous lining of the vein towards the heart. If, however, the excited inflammation should fortunately produce an adhesion of the sides of the vein to each other, at some lit- tle distance from the wounded part, this adhesion will form a boundary to the inflammation, and prevent its spreading further. The effect of the adhesive in- flammation in preventing the extension of inflammation along membranous surfaces, was originally explained by Mr. Hunter. In one case, Mr. Hunter applied a com- press to the inflamed vein, above the wounded part, and he thought that he thus succeeded in producing an adhesion, as the inflammation was prevented from spreading further. When the inflammation does not continue equally in both direc- tions, but descends along the course of the vein, its extension in the other direction is probably prevented by the adhesion of the sides of the vein to each other. (See Obs. on the Inflammation of the internal coat* of vein*, by J. Hunter, in Trans, of a Soc. for the Improvement of Med. if Chir. Knowledge, Vol. 1, p. 18, fa.) More information on this subject will be found under the head of Veins. Mr. Abernethy mentions his having seen only three eases, in which an inflammation of the vein succeeded venesection. In nei- ther of these did the vein suppurate. In one, about three inches of the venal tube inflamed, both above and below the punc- ture. The integuments over the vessel were very much swollen, red, and painful, and there was a good deal of fever, with a rapid pulse, and furred tongue. The vein did not swell, when compressed above the diseased part. In another instance, :the in- flammation of the vein did not extend to- wards the heart, but only downward, in which direction it extended as far as the wrist. The treatment is to lessen the inflamma- tion of the vein by the same means, which other inflammations require, and to keep the affection from spreading along the membranous lining of ther4 vessel towards tba heart, by placing a compress over the vein, a little way above the puncture, so as to make the opposite sides of the vessel ad- here together. Mr. Abernethy can conceive a case, in which the vein may even suppurate, and a total division of the vessel be proper, not merely to obviate the extension of the local disease, but to prevent the pus from beco- ming mixed with the circulation. Were such a proceeding deemed right, I think Mr. Brodie's method of cutting the vessel would be best. However, I have never heard of any case, in which the practice has been adopted. As for the scheme of tying the vein above the diseased part of it, the severe effects frequently following this method, must, as Mr. Dunn has reminded H"vi render it Ie*s eligible, than incision. 5. Inflammation of ihe Fascia of the Fore-Arm. Sometimes, in consequence of the in- flammation arising from the wound of the lancet in bleeding, the arm becomes very painful, and can hardly be moved. The puncture often remains unhealed, but with- out much inflammation of the surrounding integuments. The fore-arm and fingers cannot be extended without great pain. The integuments are sometimes affected with a kind of erysipolas; being not very painful, when slightly touched, but when forcibly compressed, so as to affect the inferior parts, the patient suffers a good deal. The pain frequently extends towards the axilla and acromion; no swelling, however, being perceptible in either direction. These symp- toms are attended with considerable fever After about a week, a small superficial col- lection of matter sometimes takes place a little below the internal condyle : this being opened, a very little pus is discharged, and there is scarcely any diminution of the swelling or pain. Perhaps, after a few days more, a fluctuation of matter is distinguished below the external condyle, and this ab- scess being opened, a great deal of matter gushes from the wound, the swelling greatly subsides, and the patient's future sufferings are comparatively trivial. The last opening, however, is often ina- dequate to the complete discharge of the matter, which is sometimes originally formed beneath the fascia, in the course of the ulna, and its pointing at the upper part of the arm depends on the thinness of the fascia in this situation. The collection of pus descends under the lower part of the detached fascia, and a depending opening for its discharge becomes necessary. This being made, the patient soon gets well. In these cases, neither the vein nor the absorbents appear inflamed. The integu- ments are not much affected, and the pa- tient complains of a tightness of the fore- arm. Matter does not always form, and the pliability of the arm, after a good while, gradually returns again. Mr. Watson relates a case, which was fol- lowed by a permanent contraction of the fore-arm. Mr. Abernethy is of opinion, that a similar contraction of the fore- arm, from a tense slate of the fascia, may be relieved by detaching the fascia from the i tendon of the biceps, to which it is naturally connected. Mr. Watson seems to have obtained success in his first case, by having cut this connexion. The treatment of an inflamed fascia, in consequence of venesection, has in it no peculiarity. General means for the cure of inflammation should be employed. The limb should be kept quiet, and the inflamed part relaxed. As soon as tbe inflammation abates, the extension of the fore-arm and fingers ought to be attempted, and daily performed, to obviate the contraction, which might otherwise ensue. (Aberjiithy.) Mr Charles Bell objects to calling the ULEEDIMf. affection an inflammation of the ta.cia, be- cause he sees no proof of this part being inflamed, and he conceives that the symp- toms proceed from the inflammation spread- ing in the cellular membrane, and, passing down among the muscles, and under the fascia. The fascia acts as a bandage, aud from the swelling of the parts beneath, it binds the arm, but is not itself inflamed, and contracted. When necessary to divide the fascia, Mr. Charles Bell thinks it would be better to begin an incision near the inner condyle of the humerus, and to continue it some inches down the arm, rather than per- form the nice, if not dangerous operation, of cutting the fascia, at the point where the expansion goes off from the round tendon of the biceps. When the elbow joint and fore-arm con- tinue stiff after all inflammation is over, Mr. C. Bell recommends frictions with campho- rated mercurial ointment, he. and the urm to be gradually brought into an extended state by placing a splint on the forepart of the limb. (Operatise Surgery, Vol. l.p. 66.) 6. Ill Consequences of a Wounded Nerve. Mr. Abernethy informs us, that Mr. Pott used to mention two cases, in which the pa- tients had suffered distracting pains, follow- ed by convulsions and other symptoms, which could only be ascribed to nervous ir- ritation, arising from a partial division of the nerve, and he recommended its total division, as a probable remedy. Dr.Monro related similar cuses, in which such treat- ment proved successful. Hence, it is highly necessary to know the characteristic symptoms of the case, parti- cularly, as all the foregoing cases would be exasperated by the treatment just now allu- ded to. It is to Mr. Abernethy that we are indebted for several valuable remarks eluci- dating this subject. He informs us, that the two cutaneous nerves are those which are exposed to injury. Most frequently all their branches pass beneath the veins, at the bend of the arm ; but sometimes, al- though the chief rami go beneath these ves- sels, many small filaments are detached over them, which it is impossible to avoid wounding in phlebotomy. Mr. Abernethy thinks the situation of the median nerve, renders any injury of it very unlikely. If, however, a doubt should be entertained on this subject, an attention to symptoms will soon dispel it. When a nerve is irritated at any part, between its origin and termination, a sensation is felt, as if some injury were done to the parts which it supplies. If, therefore, the cuta- neous nerves were injured, the integuments of the fore-arm would seem to suffer pain; if the median nerve, the thumb, and two next fingers would be painfully affected.— (Abernethy,) What are the ills likely to arise from a wounded nerve ? If it were partially cut, would it not, like a tendon, or any other Mibstance, unite ? It seems probable that it would do so. i>s nerves, as large as the cu- taneous ouea oi the arm, are very niiuieiui;< in various situations of tbe body, and irr partially wounded in operations, without any peculiar consequences usually eniuim-. The extraordinary pain sometimes expe- rienced in bleeding, may denote that a cu- taneous nerve is injured. The situation of the nervous branches is such, that they must often be partially wounded in the ope- ration, though they probably unite again, iu almost all cases, without any ill conse- quences. Yet, says Mr. Abernethy, it ii possible that an inflammation of the nerve may accidentally ensue, which would bt aggravated, if the nerve were kept tease, in consequence of its partial division. Mr. Abernethy thinks the disorder, arisen from inflammation of the nerve in common with the other wounded parts. This geiitlenuu supposes, that an inflamed nerve would be very likely to communicate dreadful irri- tation to the sensorium, and that a cure would be likely to arise from intercepting its communication with that organ. The general opinion is, that the nerve is only partially divided, and that a complete division would bring relief. Mr. Pott pro- posed enlarging tbe original orifice. It is possible, however, that the injured nerve may be under the vein, and, if the nerve be inflamed, even a total division of it, at the affected part, would, perhaps, fail in reliev- ing the general nervous irritation, which the disease has occasioned. To intercept the communication of the inflamed nerve with the sensorium, however, promises perfect relief. This object can only be accom- plished by making a transverse incision above the orifice of the vein. The incision need not be large, for the injured nerve must lie within the limits of the original ori- fice, and it need only descend as low asthe fascia of the fore-arm, above which all the filaments of the cutaneous nerves are situa- ted. As the extent of the inflammation of the nerve is uncertain, Mr. Abernethy sug- gests even making a division of the cuta- neous nerve still further from the wound made in bleeding. Examples are recorded, in which not only extrarordinary pain was occasioned by the prick of tbe*iancet; but, erysipelas of the skin ending in gangrene of thewbas* limb, and the death of the patient. (See Richerand's Nosog. Chir. Tom. 2, p. 390, Edit. 2.) A case, in which the greater part of the integuments of the arm, had bees) destroyed by erysipelas, thus produced, 1 lately saw under tbe care of Mr. Vincent, in St. Bartholomew's hospital. In former times, it was customary to refer many of the bad symptoms occasion- ally following venesection, to a ppncuire of the tendon of the biceps ; but, this doe- trine is now in a great measure renounced, the experiments of Haller having com- pletely proved, that tendons and aponeu- roses are. comparatively speaking, pr*1 endued with little or no sensibility. In the foregoing account, the various aH consequences occasionally arising after*** BLEEDING 26i ncsection are represented -eparately ; no doubt, in some cases, they may occur to- gether. See R. Butler's Essay concerning Blood- lelling, fa. Svo. Lond. 1734. M. Martin, Traite de la Phl'.botomie et de VArteriotomie, 8vo. Paris, 1741. Quesnay, Traiti des Ef- fets et de VUsage de la SaignAe, 12mo. Pans. G. Vieusseux, De la Saignie, et de son Usage dans la plupart des Maladies, 8vo. Pa- ris, 1815. J. J. Walbaum, De Veneesectione, Gotl. 1749. (Haller Disp. Chir. 6, 477.) B. Bell's System of Surgery. Essay on the ill Consequencts, sometimes following Vene- section, by J. Abernethy. Medical Commu- nications, Vol. 2. Richerand's Nosographie Chirurgicale, Tom. 2, p. 416, Edit. 4. M. Freteau, Traiti Elemtntaire Sur I'Emploi legitime et methodique des Emissions San- guines, fa. 8vo. Paris, 1816. Mapleson's Treatise on the Art of Cupping, 12mo. Lond. J813; and Dr. J. R. Johnson's valuable Treatise on the Medicinal Leech, including its Medical and Natural History, wiih a des- cription of its Anatomical Structure, and Re- marks upon the Diseases, Preservation, and Management of Leeches, Svo. Lond. 1816. BLEEDING. (See Hemorrhage and Ar- teries.) B L E' N 0 RRII A GI A, or Blinorrhaa. (From iihtrm, mucus, and gtZ, to flow.) A discharge of mucus. SweUiaur, who main- tains, that gonorrhoea is attended with a mucous, and not a purulent discharge, pre- fers the name of blenorrhagia for the dis- ease. However, in treating of gonorrhoea, Ave shall find that this last appellation is itself not altogether free from objections. BLEPHAROPTOSIS. (From £At?«£sv, the eyelid, and Trtuai;, a falling down ) Called also ptosis. An inability to raise the upper eyelid. (See Ptosis) BLEPHARO'TIS. An inflammation of ihe eyelids. BLINDNESS. This is an effect of many diseases of the eye. See, particularly, Amaurosis; Cataract; Cornea, Opacities of; Gutta Serena ; Hydrophlhalmia ; Leu- coma ; Ophthalmy ; Pterygium ; Pupil, clo- sure of; Staphyloma, fa. BLISTERS. Topical applications, which, when put on the skin, raise the cuticle in the form of a vesicle, filled with a serous fluid. Various substances produce this effect on the skin ; but the powder of can- tharides is what operates with most cer- tainty and expedition, and is now invaria- bly made use of for the purpose. The blister plaster is thus composed; f£ Can- tharidum ftj. Emplastri cera fohs. Adipis suillaprap. ftj. The wax plaster and lard being melted, and allowed to become nearly cold, the powdered cantharides are after- wards to be added. When it is not wished to maintain a dis- cbarge from the blistered part, it is sufficient to make a puncture in the cuticle to let out the fluid; but when the case requires keep- ing up a secretion of pu?, the surgeon must remove the whole of the detached cuticle with a pair of «ris<:or', and dn??s tbe exco- riated surface i,i a particular manner. Practitioners used formerly to mix powder of cantharides with an ointment, and dress the part with this composition. But such a dressing not unfrequently occasioned very painful affections of the bladder, a scalding sensation in making water, and roost af- flicting stranguries. An inflammation of the bladder, ending fatally, has been thus exci- ted. The treatment of such complaints con- sists in removing every particle of cantha- rides from the blistered part, which is to be well fomented, and making the patient drink abundantly of mucilaginous drinks. Camphor is now suspected to prove more hurtful than useful. These objections to the employment of salves, containing cantharides, for dressing blistered surfaces, led to the use of meze- reon, euphorbium, and other irritating sub- stances, which, when incorporated with ointment, form very proper compositions for keeping blisters open, without the in- convenience of irritating the bladder, like cantharides. The favourite application, however, for keeping open blisters, is the powder of savine, which was brought into notice by Mr. Crow- ther, in the first edition of his book on the White Swelling. In the last edition, this gentleman remarks, that he was led to the trial of different eschoratic applications, in the form of ointment, in consequence of the minute attention, which caustic issues de- mand ; and among other things, he was in- duced to try powdered savine, from ob- serving its effects in the removal of warts. Some of the powder was first mixed with white cerate, and applied as a dressing to the part, that had been blistered; but the ointment ran off, leaving the powder dry upon the sore, and no effect was produced Mr. Crowther next inspissated a decoction of savine, and mixed the extract with the ointment, which succeeded better, for it produced a great and permanent discharge. At last, after various trials, he was led to prefer a preparation analogous to the ungu- entum sambuci P. L. and he now offers the following formula, as* answering every desirable purpose : ft Sabine recentis con- iurte lbij, Cera flava Ibj, Adipis suilla lbiv. Adipe et cera liquefacla, incoque sabinam et cola. The difference of this formula from that, which Mr. Crowther published in 1797, only consists in using a double proportion of the savine leaves. The ceratum sabina; of Apothecary's Hall, he says, is admirably made : the fresh savine is bruised with half the quantity of lard, which is submitted to the force of an iron press, and the whole is added to the remainder of the lard, which is boiled until the herb begins to crisp; the ointment is then strained off, and the pro- portion of wax, ordered, being previously melted, is added. On the use of the savine cerate, immediately after the cuticle raised by the blister, is removed, it should be ob- served, says Mr. Crow ther, that experience has proved the advantage of ivsjpg the npnli- .264 BOUGIE cation lowered by a half, or two-thirds, of the unguentum cera?. An attention to this direction will produce less irritation and more discharge, than if the savine cerate were used in its full strength. Mr. Crow- ther says also, that he has found fomenting the part with flannel wrung out of warm water, a more easy, and preferable way of keeping the blistered surface clean, and fit for the impression of the ointment, than scraping the part, as has been directed by others. An occasional dressing of the un- guentum resinae flava?, he has found, a very useful application for rendering the sore free from an appearance of slough or rather dense lymph, which has sometimes been so firm in its texture, as to be separated by the probe, with as much readiness, as the cuticle is detached after blistering. As the dis- charge diminishes, the strength of the sa- vine dressing should be proportionally in- creased. The ceratum sabina? must be used, in a stronger, or weaker degree, in propor- tion to the excitement produced on the patient's skin. Some require a greater sti- mulus, than others, for the promotion of the discharge, and this can only be managed by the sensations, which the irritation of the cerate occasions. Mr. Crowther had used ointments, con- taining the flowers of the eiematis recta, the capsicum, and the leaves of the digitalis purpurea. The two first produced no effect: the last was very stimulating ; and Mr. Crowther mentions his intention to take the first convenient opportunity to de- termine its qualities more accurately. lie has also used caustic potassa, mixed with spermaceti cerate, in the proportion of one dram to aii ounce : it proved very stimula- ting, but produced no discharge. He has tried one dram of tlve oxymuriate of mer- cury, blended with two ounces of the above cerate; but the application was so intole- rably painful, that at the end of two hours, it became necessary to remove the dressing; and the patient was attacked with a most severe ptyalism. (Practical Observations on the While Swelling, fa., a new edition, by B. Crowther, 1S0S.) Instead of keeping a blister open, it is frequently a judicious plan to renew the application of the emplastrum lyttae, after healing up the vesication first produ- ced, and to continue, in this manner, a succession of blisters, at short intervals, as long as the circumstances of the case may demand. Where the skin is peculiarly irri- table, and, particularly, in young children, where the emplastrum lyttae sometimes acts so violently as to produce sloughing, or, in any cases, where the plaster produces stran- gury and irritation of the urinary organs, I am informed, that the inconvenience may be avoided, and the cuticle raised very well, if apiece of silk paper be interposed between the plaster and the integuments. Mr. A. T. Thompson recommends for the same purpose a piece of thin gauze, wet with vinegar, and applied smoothly and closely over the plaster. (Dispensatory: p. 717, Ed. 2.) For infanta, a proporlkm .,; opium has sometimes been added to the emplastrum lyttae, in order to render its ac- tion less violent; a proposal made 1 believe, by Mr. Chevalier. BOIL. (See Furunculus.) BOiSES, Diseases of; See Antrum; c*. ries; Exostosis; Joints; Mollifies; .Yuen,. sis; Osteosarcoma; Rickets; and Vtntntl Disease. The following works, relative to the pathology of the bones, deserve notice —F. C. Spoendli, De Sensibilitale Ojrium Morbosa, 4to. Golt. 1814. A. Murray, be Sensibilitale Ossium Morbosa ; (Ludw. Script, Neur. 4.) O. Marray, Diss. Acad, dt fiensiti. litale Ossium Morbosa. (Frank. Del. Op, 12.) J. G. Slurmius, De Vulneribus U> sium. Helmst. 1743. A. Bonn, Tab. Ostium Morbosorum pracipue Thesauri HovianiMl Amst. 1785, 88. C. F. Clcssius, uebtr die Krankheiten der Knochen, 12mo. Tubing. 1799. A. G. Naumann, De Ostiiide, 4io. Lips. 1818. R. Ncsbitt, Human Osteogeny, two lectures on the nature of Ossification, 8r«. Land. 1736. Sandiforl Museum Anatomi- cum Lugduno Batava Descriplum, 2 Volfol. Lugd. 1793. Weidmann, De Necrosi Ouium, fol. Francof. 1793. Brodie on Diseases of Joints, Svo. Lond. 1818. Howship in Med. Chir. Trans, and various other publkationt specified at the end of the article Necrosu. BOUGIE,—Is a smooth flexible instru- ment, which is introduced into the urethra for the cure of diseases of that passage; (See Urethra) and is so named from its ge- nerally containing wax in its composition, and bearing some resemblance to a irai taper, in French, bougie. However, the kinds of bougies are various, and some oi them, employed in modern surgery, so for from having any similitude to a wax taper, are formed altogether of metal. They ad- mit of being divided into those which are solid ; and others, which are hollow, and are more commonly named catheters. (See Catheter.) The exact period when bougies were first used is a doubtful point in the history of surgery. By Andrew Lacuna, a Spanish physician, the invention is ascribed ton Portuguese empiric, and in 1551, the shuik author published what had been comroini- cated to him upon this subject. In the year 1554, Amatus Lusitadus published a work, in which he refers to several wit- nesses to prove, that the empirical practi- tioner, above alluded to, had learned from him the use of bougies, while, on the other hand, he candidly owns, that he hansel/ was indebted to Aldereto, of Salamanca, for a knowledge of these instruments, la 1553, however, Alpb. Ferri, of Naples,W» deavoured to show, that his acqnaint»*P with the utility of bougies reached «4 "' back as 1548, and, of course, that he I*• anticipated Lacuna, and perhaps even Alde- reto. But, instead of representing hi"'-"''' as the original inventor of bougies, henje"; tions that they were known to Alexander of Tralles, which, if true, carries backtab invention to the sixth renturv. A. Ferri) BOLGIE. JCG also, before describing bougies and escharo- tic ointments, mentions various means for examining the state of the urethra, and, among other things, cylinders made of flexi- ble lead, and of different sizes. Escharotic ointments for what were termed carnosilies of the urethra, and bougies were also des- cribed by I'etronius in 1565, and afterwards by A. Tare. The oldest bougies, which were wicks of i.otlou, or thread, covered with wax, and escharotic plasters, were in lime succeeded by those composed of linen smeared with wax. This change was made with the view of letting them have a hollow construction : en improvement, which was first noticed by Fabricius ab Aquapendente. (Op. Chir. 1617.) In the middle of the 17th centuiy, the manner of making and using bougies was well known to Scultetus, as appears from his Armamentarium Chirurg. tab. 13, fig. 9, 10. The making of bougies has now become so distinct a trade, that it may be considered superfluous to treat of the subject in this dictionary. However, though a surgeon may not actually choose to take the trouble of making bougies himself, he shouid un- derstand how they ought to be made. Swe- dinur recommend* the following composi- tion : ft Cera? flava? jfcj, Spermatis ceti 3iij. Cerussa? acetata? 3V- These articles are to lie slowly boiled together, till the mass is of proper consistence. Mr. B. Bell's bougie plaster is thus made : ft Emplastri lylhar- gyri ^iv, Cera? flava? ^iss, Olei Oliva? 3iij- The two last ingredients are to be melted in one vessel, and the litharge plaster in ano- ther, before they are mixed. In Wilson's Pharmacopoeia Chirurgica, I observe this formula: r£ Olei Oliva1 Ibiiss, Cera? flava? Ibj, Minii lbiss. Boil the ingredients toge- ther over a slow fire, till the minium is dis- solved, which will be in about four or six hours. The composition for bougies is now- very simple, as modern surgeons place no confidence in the medicated substances, formerly extolled by Daran. The linen, which may be considered as the basis of the bougie, is to be impregnated with the composition, which is generally wax and oil, rendered somewhat firmer by a propor- tion of resin. Some saturnine preparation is commonly added, as the urethra is in an irritable state, and the mechanical irritation might otherwise increase it. Of whatever composition bougies are made, they must be of different sizes, from that of a knitting- needle to that of a large quill, and even larger. Having spread the composition, chosen for the purpose, on linen rag, cut this into slips, from six to ten inches long, and from half an inch, to an inch, or more in breadth. Then dexterously roll them on a glazed tile into the proper cylindrical form. As the end of the bougie," which is first introduced into the urethra, should be somewhat smaller than the rest, the slips must be rather narrower iu this situation, and, when the bougies are roiled up, that Vol. I. 34 side must be outward, on which the plaster is spread. Daran, and some of the older writers, attributed the efficacy of their bougies to the composition used in forming them. On the contrary, Mr. Sharp apprehended that it was chiefly owing to the pressure, which was made on the affected part; and Mr. Aikin adds, that as bougies of very different compositions, succeed equally well in cu- ring the same diseases in tbe urethra, it is plain, that they do not act from any pecu- liar qualities in their composition-, but by means of some common property, probably, their mechanical form. As the healthy as well as the diseased parts are exposed to the effects of bougies made of very active materials, modern sur- geons always prefer such as are made of a simple uuirritating composition. Plenck recommended bougies of catgut, which may be easily introduced into an urethra, even when it is greatly contracted, their size being small, their substance firm, and dilatable by moisture. It is objected to catgut, however, that it sometimes ex- pands beyond the stricture, and gives great pain on being withdrawn. Formerly, cat- gut bougies were sometimes coated with elastic gum, a valuable material of which I shall next speak. The invention of elastic bougies and ca- theters originated with Bernard, a silver- smith at Paris, who, in the year 1779, pre- sented some instruments of this kind to the Academy of Surgery, which period was prior to the claim made by Professor Pickel of Wurzburgto the discovery. (See Journ. deMed. an. 1785.) For the composition of bougies, elastic resin, or gum, is thought to be very desira- ble, as it unites firmness and flexibility. Mr. Wiison, in his Pharmacopoeia Chirurgia, is inclined to think that the art of making these instruments, consists in finding a suit- able solvent for the indian gum. As this substance, if dissolved in a?ther, completely recovers its former'felasticity, upon the eva- poration of this fluid, it is supposed that a?ther, though rather too expensive, would answer. I find it positively asserted, however, in a modern work of great repute, that the idea of elastic gum, being the substance really employed, is a mistake, as the mate- rial used is nothing more than linseed oil, boiled for a considerable time, and used as a varnish for the silk, linen, or cotton tube, (See Diet, des Sciences Mid. art. Bougie.) Very cheap and good elastic gum bougies are made by Feburier, No. 51, Rue" du Bac at Paris, who has twelve different sizes. His elastic gum catheters are also well made, though, for smoothness and regu- larity, I think they are not equal to some, which are now constructed in London, but I believe, Feburier's smallest size is rather less than any which are made in this city; an advantage which no doubt our artists will soon be able to give their productions. This ingenious mechanic does not employ 266 BRONCHOCELE. •atgut in tbe composition of the elastic gum bougies, for which he is so celebrated. These bougies are most excellent, when you can get them to pass ; for they dilate the stricture with the least possible irri- tation. But, sometimes, they cannot be introduced, when a wax bougie can ; and from the trials which I have made of them, 1 conceive tbis arises from their elasticity and continual tendency to become straight, when they reach the perina?um, so thatthe point presses on the lower surface of the urethra. Hence, when the obstruction is on that side, it must be very difficult to get the end of the bougie over it. A few years ago, Mr. Smyth discovered a metallic composition, of which he formed bougies, to which some practitioners impute very superioi qualities. These bougies are flexible, have a highly polished surface, of a silver hue, and possess a sufficient degree •f firmness for any force necessary in in- troducing them for the cure of strictures in the urethra. The advocates for the metal- lic bougies assert, that such instruments ex- ceed any other bougies, which have yet been invented, and are capable of succeed- ing in all cases, in which the use of a bougie is proper. They are either solid, or hollow, and are said to answer extremely well as eatheters; for, they not only pass into the bladder with ease, but may also be con- tinued there for any convenient space of time, and thus produce essential benefit. (W. Smyth, Brief Essay on the Advantages of flexible Metallic Bougies, 8vo. Lond. 1804.) Tbe greatest objection, which has been urged against them, is, that they are attend- ed with a risk of breaking. I have heard of an eminent surgeon being called upon to cut into the bladder, in consequence of a me- tallic bougie having broken, and a piece of it got into that organ, where it became a cause of the severe symptoms which are commonly the effect of a stone in the blad- der. For the particulars of an interesting •ase, in which a metallic bougie broke in the urethra, the reader may consult London Med. Repository, Vol. 9, JVo.51. It has also been objected to metallic bougies, that, although they are sufficiently flexible, they are quite destitute of elasticity. The bougie, with its application, says Mr. Hunter, is perhaps one of the greatest im- provements in surgery, which these last thirty or forty years have produced. When I compare the practice of the present day, with what it was in the year 1750, I can scarcely be persuaded, that 1 am treating the same disease. I remember, when, about that time, I was attending the first Hospitals in the city, the common bougies were, either a piece of lead or a small wax candle, and, although the present bougie was known then, the due preference was not given to it, nor its particular merit un- derstood, as we may see from the publica- tions of that time. Daran was the first, who improved the bougie, and brought it into general use.— He wrote professedly on the diseases for which it is a cure, and also ol the mannei of preparing it, but, he has introduced much absurdity into his descriptions of the disea- ses, the modes of treatment, and the powers and composition of his bougies. When Daran published his observations on the bougie, every surgeon set to worl to discover the composition, and each con- ceived that he had found it out, fmm the bougies, which he had made, producing the effects described by Daran. It never oc- curred to them, that any extraneous body, of the same shape and consistence, would do the same thing. (See a Treatise on the Venereal Disease, p. 116. Sharp's Critical Inquiry, Ch. 4 ; Aikin on the External Uk of Lead ; Daran Obs. Chir. Sur les Maladies de V Uretre, 12mo. Paris, 1748, and 1768; Olivier, Lettre dans laquelle on dimontrtlu avantages, que Von pent retirerde I'uuge des bougiescreuses, fa. 8vo. Paris, 1750; Dttaull Journ de Chir. T. 2, p. 375, and T. 3, p. 123, 1792; Smyth's Brief Essay on flexible metallic bougies, Svo. Lond. 1804; Did. des Sciences Medicates, T. 3,p. 2*5, fa. 8ro. Pa- ris, 1812.) Of armed bougies, as well as of some other kinds, and of the manner of using bou- gies in general, I shall speak in the article Urethra, Strictures of. BRAIN. (For concussion, compression of, he. see Head, Injuries of; for tbe hernia of, see Hernia Cerebri) BREAST. (See Mammary Abscess; Mam- ma, Removal of; Cancer, fa.) * BRONCHOCELE. (from fytyx«, the windpipe, and tax*, a tumour.) Also call- ed botium, or bocium. The Swiss call the disease gotre, or goitre. Some have called it, hernia gulturis ; guttur tumidum; track- lophyma ; gossum ; exechebronchos; gon- grona ; hernia bronchialis. Heister thought it should be named tracheocele. Prosser, from its frequency on the hilly parts of Der- byshire, called it the Derbyshire neck; and not satisfied respecting the similitude of this tumour to that observed on the necks of wo- men on the Alps, the English Bronchotde. ByAlibert the disease is called Thyrophraxit. 1. The simple bronchocele or tbyroph- raxia, is (he most common form of theira- ease, and is a mere enlargement of tberiby- roid gland. Tbe integuments covering the part, are quite unchanged. Women are observed to be more subject to it than men. It is also well known to be in general fi« from danger, the office of the thyroid gland not being of such importance in the urinal economy, as to be essential to the continu- ance of life. Alibert assures us, however, that he has seen one example, in which tw tumour became cancerous, and destroyed the mother of a family. 2. The compound bronchocele is th"- which presents the greatest variety, and as- tonishes every beholder. Sometimes a more or less voluminous cyat is formed round it, filled with a pultaceous, or puru- lent matter. Sometimes, in compoow bronchoceles, calcareous, and other hete- rogeneous substances are found. Inttfoce* BRONCHOCELE ^es, Alibcrt observed, on the outside of the enlarged gland, a yellow fatty mass; and, in a third instance, the gland itself formed a true sarcoma. (Nosologic Naturelle, T. I, p. 464—465, folio, Paris, 1817.) The term bronchocele, always signifies in this country, an enlargement of the thyroid gland, which, with the disease of the sur- rounding parts, sometimes not only occu- pies all the space from one angle of the jaw to the other, but forms a considerable projection on each side of the neck, advan- cing forward a good way beyond the chin, and forming an enormous mass which hangs down over the\mest. The swelling, which is more or less unequal, in general bus a soft spongy elastic fee), especially when the disease is not in a very advanced state; but, no fluctuation is usually percepti- ble, and the part is exceedingly indolent. The skin retains nearly its ordinary colour; but, when the tumour is of very long stand- ing, and great size, the veins of the neck become more or less varicose. According to Prosser, the tumour general- ly begins between the eighth and twelfth years. It enlarges slowly during a few years, till, at last, it augments rather rapid- ly, and forms a bulky pendulous tumour. Women are far more subject to the disease, than men, and the tumour is observed to be particularly apt to increase rapidly dnring their confinement in childbed. Sometimes bronchocele affects the whole of the thy- roid gland, that is to say, the two lateral lobes, and the intervening portion, and it is in this kind of case, that it is not unusual to remark three distinct swellings, for the most part of unequal size. Frequently, only one lobe is affected; while, in many cases, the three portions of the thyroid gland are all enlarged, and so confounded together, that they make, as it were, only one connected globular mass. Finally, in some dissections, the thyroid gland has been found quite unchanged, the whole of the tumour having consisted of a sarcomatous disease of the adjacent lymphatic glands and cellular membrane. (Posliglionc, p. 21.) When only one lobe of the thyroid gland is affected, it may extend in front of the carotid artery, and be lifted up by each diastole of this vessel, so as to appear to have the pulsatory motion ofan aneurism. (A. Burns"* Surgical Anatomy of the Head and Nick, p. 195, and Parisian Chirurgical Jour. Vol.2,p.292,293.) Alibcrt believes, that he first made the remark, that the right lobe was more frequently enlarged than the left. (Noiol. Nat. T. \,p. 465.) The ordinary seat of bronchocele, as Flnjani remarks, is in the thyroid gland; but sometimes cysts are formed in the cel- lular membrane. (Collez. a' Oss. T.3. p. 277.) And Po*ti;;lione also observes, that the swelling is sometimes encysted, and fill- ed with matter of various degrees of con- sistence, resembling honey, he.; in some cases, it is emphysematous, or filled with air; ami, in other instances, it is sarcoma- tous, having the consistence of a gland, which is enlarged, but not scirrhous.— These different characters, says he, indicaUv that the treatment ought not to be the same in all cases. (Mcmoria sulla Natura del Gozzo, p. 20.) Bronchocele is common in some of the valleys of the Alps, Appenines and Pyren- nees. Indeed, there are certain places, where the disease is so frequent, that hard- ly an individual is totally exempt from it. Larrey, in travelling through the valley of Maurenne, noticed, that almost all the in- habitants were affected with goitres of dif- ferent sizes, whereby the countenance was deformed, and the features rendered hide- ous. (.Wi7i.de Chir. Mil. T. 1, p. 123.)— And Postiglione remarks, that in Savoy, Switzerland, the Tyrol, and Carinthia., there are villages, in which all the inhabi- tants without exception have these swell- ings, the position and regularity of which are there considered as indications of beau- ty. (Mcmoria sulla Natura del Gozzo, p. 22.) In many, the swelling is so enormous that it is impossible to conceal it by any sort of clothing. A state of idiotisin is another affliction, which is sometimes combined with the goitre, in countries where the lat- ter affection is endemic. However, all, who have the disease, are not idiots, nor cretins, as they have been called, and in Switzerland, and elsewhere, it is met with in persons who possess the most perfect in- tellectual faculties. Where bronchocele and cretinism exist together, Fodere, and several other writers, ascribe the affection of the mind to the state of the thyroid gland. (See Traiti sur le Goitre et le Cretinisme, Svo. Paris, an. 8.) This opinion, however, appears to want foundation, since the men- tal faculties are from birth weak, and, in many,the idiotism is complete, where there is no enlargement of the thyroid gland, or where the tumour is not bigger than a wal- nut, so that no impediment can exist to the circulation to, or from the brain. (Burns on the Surgical Anatomy of the Head and Neck, p. 192.) The direct testimony of Dr. Reeve also proves, that, in the countries where cretins are numerous, many people of sound and vigorous minds have broncho- cele. (See Dr. Reeve's Paper on Cretinism, Edin. Med. and Surgical Journal, Vol. 5, p. 31.) Hence,as Mr. A. Burns has remarked,the combination of bronchocele and cretinism must be considered as accidental; a truth, tnat seems to derive confirmation from the fact, that, in some parts of this country, bronchocele is frequent, where cretinism is seldom or never seen. In the valleys of several mountainous countries, particularly Switzerland, Savoy, the Tyrol, Carinthia, Derbyshire, &c. bronchocele is endemic; and it occurs remarkably often in young subjects, and much more frequently in the female than the male sex. Bronchocele is a disease not confined tu Europe : it is met with iii almost every country on the globe. Professor Barton. in his travels among the Indians, settled at Oneida, in the state of New-York, saw BRONCHOCF.I.r.. the complaint in an old woman, the wife of the chief of thattribe. From this woman Barton learned, that bronchoceles were by- no means uncommon among the Oneida Indians, the complaint exi-ting in several of their villages. He found, also, that tbe disease resembled that seen in Europe, in respect to its varieties. He did not indeed himself soc the pendulous bronchocele, which descends over the breast; but, he understood, that it was not uncommon among the women on the banks of the Mohaw k river, who wore a particular dress for its concealment. In North America, bronchocele attacks persons of every age ; but, it is most frequently seen in adults ; a difference from what is noticed in Europe. Bronchocele is said to be frequent in L;>w- er Canada. Boupland, the companion of Humboldt, informed Alibert, that the dis- ease was endemic in .New Grenada, and that it prevailed in such a degree in the lit- tle towns of Hunda and Monpa, on the banks of the Magdalen river, that scarcely any of the inhabitants were free from it.— The blacks, and those who led an active laborious life, however, are reported not to have been affected. Some of the natives of the Isthmus of Darien, are said also to bn terribly disfigured by this disease. (Alibcrt, Nosol.Nat. T. lfp.469.) In European women, bronchocele usual- ly makes its appearance at an early age, generally between the eighth and twelfth year, and it continues to increase gradually for three, four, or five years, and is said sometimes to enlarge more, during the last half year, than for a year, or two previous- ly. It does not generally rise so high as the ears, as in the cases mentioned by Wise- man. Sometimes, however, this happens, as we see in the case of Clement Deserme, of whom Alibert has given an engraving. In this patient, a part of the tumour, as large as a hen's egg. projected into the mouth. (Nosol. Nut. T. \,p. 466.) The swelling ex- tended from the ears to (he mi !e of the breast. A seton produced a part'.ai subsi- dence of it; but, when it was withdrawn, the orifices closed. After two years more, tl:■'. swelling became painful, suppuration took place, and fifteen pints of matter were discharged ; and six ounces every day after the swelling had burst,came away with the dressings for three month*, but," notwith- standing all this suppuration, and more af- terwards, the tumour was only partially les- sened. The disease mostly has a pendulous form, not unlike, as Albueasis says, the flap or detVlap of a turkey cock, the bottom be- ing the largest part of the tumour. Alibert mentions a case, in which the swelling hung down to the middle of the s:ernum, and the large mass, which was quite a bur- den to the patient, used to become hard, "V'ld as it were frozen, in veiycold weather. This author, however, cannot be right, when he adds, thai it wh» an inert body, destitute of vitality.' (Nosol.Nat. T. 1, p. 466.) In another curious instance, the tumour formed a long cylinder, which reached down to the middle of the thigh, the diameter beco- ming gradually smaller downwards. (p.4ti8.) As a modern author has remarked,the com- mon seat of bronchocele is in the thyroid gland ; but, frequently, the surrounding cellular membrane is more or less thicken- ed, and contributes to the swelling. Some- times also the neighbouring lymphatic glands are affected, when its I ase is widen- ed, and extends from one side of the neck to the other. In this circumstance, the swelling gradually loses itself in the sur- rounding parts, and is not circumscribed, as in ordinary instances. (Pusliglione Mem. sulla Natura del Gozzo, p. 20.) It is soft, or rather flabby to the touch, and some- what moveable, but after afew years, when it has ceased enlarging, it becomes firmer, and more fixed. When the disease is very large, it generally occasions a difficulty of breathing, which is increased on the pa- tient's catching cold, or attempting to run. In some subjects, the tumour is so largr,and effects the breathing so much, that a loud w hepzing is occasioned ; but, there are ma- ny exceptions to this remark. Sometime--. when the swelling is of great size, patient! suffer very little inconvenience; while others are greatly incommoded, though the tumour may be small. In general, the in- convenience is trivial. The voice is some- times rendered hoarse, and, in particular cases, the difficulty of speech is very consi- derable. (See Flajani Collez. d'Ots. T. 3, p. 271.) The difficulty of respiration, produced by the pressure of the tumour, and the enlarge- ment of other glands, as this authorremarw, is ihe most dangerous effect of the disease, since by disordering the pulmonary circu- lation, it renders the pulse irregular and in- termittent, and a strong throbbing is tin- ted in the region of the heart, followed by fatal disease of the lungs themselves: con- sequences, often not su:-pectedto have any connexion with the bronchocele, though it is in reality the immediate cause of them, {Vol. Cit. p. 278.) The causes of the bronchocele are little known. To the opinion that bronchocele is caused by the earthy impregnation of wiilur used for drink, the following objec- tions offer themselves. 1. The water of Derbyshire, in districts, where this disease is considered endemic, contains much so- percarbonate of lime; but that in common use about .Nottingham, where the disease i< als\» prevalent,isimnregiiatedwitbsulphate of lime. How ever, that the disease is not produced by water, impregnated with sul- phate of lime, is evident; for,as Alihtrto'1- serves, the waters of Saint-Jean, Saint-Sul- pice, and St. Pierre, where bronchocele is frequent, contain much less of this earth than the watersof L'pper Maurienne, where the disease is hardly ever noticed, though the houses are built upon a vast quarry ol gypsum. The same fact was observed hy Bonpland in New Grenada. (Nosol. J***' BRONCHOCELE. 269 T.l,p. 471.) Nor, as Fodere explained, can the cause of the disease be correctly referred to the use of any particular kind of food. Certain localities, however, seem to contribute to its frequency ; for, this au- thor observed, that the disease is not preva- lent in very high places, nor in open plains ; but, that it becomes mote and more com- mon, as we descend into deep valleys, made by torrents, where there is a good deal of marsh, and abundance of fruit trees. The air is here constantly humid. 2. Abstinence from water unboiled does not diminish, nor interrupt the gradual progress of the disease. 3. Patients are cured of the disease, who still continue to drink water from the same source as before, without taking any pre- caution, as boiling, he. 4. The disease in thiscourtry is less frequently found among men. ^ny instances may be related of aswell nthe neck,sometimesvery pain- ful, ar \ ous advocate for the early performance of bronchotomy, and he has cited several in- stances, in which this operation was Suc- re ssfully performed, both for the relief of BRONCHOTOMY. 2*7? quinsy and extraction of foreign bodies from the trachea. The affections of the larynx, requiring bronchotomy, would seem, indeed, to be more numerous and diversified, than is usually supposed: thus, Mr. C. Bell men- tions the case of a m dical student, who was attacked with shivering, fever, and sore throat, and in three days died of suffo- cation. On dissection, no obstruction in the larynx was observed, but only an in- flammation of its membrane, and a spot like a small pox pustule, upon tbe margin of tbe glottis. (Surgical Obs Parti, p. 14.) 2. The compression of the trachea by foreign bodies lodged in the pharynx, or by tumours, formed outwardly, and of suffi- cient size to compress tbe windpipe, is an equal reason for operating, more or less expeditiously, according to the symptoms. Mr. B. Bell mentions two instances of suf- focation from bodies falling into the pharynx. Respiration was only stopped for a few mi- nutes ; but, the cases were equally fatal, notwithstanding the employment of all the usual means. This author thinks, there was every reason to believe, that bronchotomy would have been attended with the greatest success, if it had been performed in time, before the effects of the suffocation had be- come mortal. The operation should also be done, when the trachea is compressed by tumours. The author of the article Bronchotomie, in VEncyclopidie Mithodique, says, that about twenty years ago, he opened a man, who had died of an emphysema, which came on instantaneously. He had had, for a long while, a bronchocele, which was of an enormous magnitude towards the end of his life. The cavity of the trachea was sp obliterated, that there was scarcely room enough to admit the thickness of a small piece of money. Doubtless, broncho- tomy, performed before the emphysema made its appearance, would have prolonged this man's days. In cases of this last description, Desault would have advised the introduction of an elastic gum catheter into the trachea from the nose, in order to facilitate respiration. This practice, I believe, has not hitherto been attempted by English surgeons, though it has been repeatedly tried in France. (See (Euvrcs Chir.de Desault, T. 2,p. 236,&c.) Habicot successfully performed this ope- ration on a lad fourteen years old, who, having heard, that gold, when swallowed, did no harm, attempted to swallow nine pistoles wrapped up in a piece of cloth, in order to hide them from thieves. The packet, which was very large, could not pass the narrow part of the pharynx ; and here it lodged, so that it could neither be extracted, nor forced down into the sto- mach. The boy was on the point of being suffocated by the pressure, which the foreign body made on the trachea; and his neck and face were so swollen and black, that he could not have been known. Habi- cot, to whose house the patient was brought, attempted in vain, by different means, to dislodge the foreign body. At length, perceiving the patient in evident danger of being suffocated, he resolved to perform bronchotomy. This operation was no sooner done, than the swelling and lividity of the face and neck disappeared. Habicot pushed the pieces of gold down into the stomach with a leaden probe, and. the pistoles were, at different times, dis- charged from the anus, eight or ten days afterwards. The wound of the trachea very soon got quite well. (See Mem. de I'Acad. de Chirurgie, Tom. 12, p. 243, Edit. in 12mo.) In such a case, Desault would have intro- duced an elastic gum catheter into the larynx, instead of performing bronchotomy, which could not answer, were the foreign body low down. (See (Euvres Chirurg. de Desault, Tom. 2, p 247.) 3. Foreign bodies in the trachea, may render it necessary to practice bronchoto- my. Here 1 ought rather to say, perhaps, laryngotomy, which by several modern surgeons is in these cases deemed most ap- plicable. (Desault; C. Bell, Surg. Obs. Part 1, p. 47, Sic.) Louis, in an excellent memoir, on extra- neous substances in the trachea, hasproved, more convincingly than all other preceding writers, the necessity of the operation in circumstances of this kind. The following case fell under his observation. On Monday, the 19th of Vlareh, 1759, a little girl, seven years old, playing with some dried kidney-beans, threw one into her mouth, and thought she had swallowed it. She was immediately attacked with a difficulty of breathing, and a severe con- vulsive cough. The little girl said she had swallowed a bean, and such assistance as was thought proper, was given her. Want of success was the cause of several surgeons being successively sent for, who vainly em- ployed the different means, prescribed by art, for extracting foreign bodies from the oesophagus, or forcing them into the sto- mach. A fine sponge, cautiously fastened to the end of a whalebone probang, was repeatedly introduced through the whole extent o( the oesophagus. The little girl, who made a sign w ilh her finger, that the foreign body was situated in the middle of the neck, thought that she felt some relief, when the sponge was conveyed below the place which she pointed out. She had, every now and then, a violent cough, the efforts attending which produced convul- sions in all her limbs. Deglutition was un- obstructed ; and warm water and oil of sweet almonds had been swallowed with- out difficulty. Two whole days had been passed in sufferings, when the relations called in Louis. The little girl, with all possible fortitude and sense, was several times held in her friends' arms, ready to die of suffocation. Louis, well aware of what had happened, came into the room where the patient was. She wa3 sitting up in her bed, suffering no other symptom than a very great difficulty of breathing. Louis 276 BRONCHOTOMY'. inquired where she felt pain, and she made such a sign in reply, as left no doubt con- cerning the nature of the accident. She put the index finger of her left hand on the trachea, between the larynx and sternum The fruitless attempts which had been made in the oesophagus, w ith a view of dis- lodging the foreign body ; the nature and the smallness of this body, which was not such as would be stopped in the passage for the food ; and the facility of swallowing. were negative proofs, thatthe bean was not in the oesophagus. Respiration was.the only function disturbed ; it was attended with difficulty, and a rattling in the throat The little girl expectorated a frothy fluid, and she pointed out so accurately the painful point where the object producing all her sufferings was situated, that Louis did not hesitate to declare to the relations, from this single inspection, that the bean was in the windpipe, and lhat there was only one way of saving the child's life, which was to make an incision, for the purpose of ex- tracting the. foreign body. He apprised them, that the operation was neither diffi- cult nor dangerous, that it bad succeeded as often as it had been practised, and that the very pressing danger of the case only jusi allowed time to take the opinion of some "other well-informed surgeons, respecting the indispensable necessity for such an ope- ration. Louis thought this precaution ne- cessary, in order to acquire the confidence ofthe parents, and to shelter himself from all reproach, in case the event of the case should not correspond with his hopes. Louis went home to prepare all the requi- sites for bronchotomy, and, ,in two hours, he was informed the surgeons, who were consulted, waited for him. Since Louis went away, the child had become quiet, and was lying on its side asleep. The opinion he had delivered, had been ill-explained by the friends and attendants, and had been dis- cussed, before his return. They, who had been rendering their assistance, on the sup- position, thatthe foreign body was in the oesophagus, evinced surprise at the proposal of extracting, by an operation, a substance, the presence of which, in any part of this tube, was not obvious. Louis explained his advice, in regard to bronchotomy, and he did not expect a doubt to be set up against so positive a fact. The investiga- tion of truth may authorize objections, to which those who make them, only give the value which is due ; but Louis was asked concerning the possibility of the case. It was objected, that a substance as large as a bean could not insinuate itself into-the tra- chea. He brought every one: into bis sen- timent, by a short explanation of cases of this sort, with which he himself was ac- quainted. The little girl was examined; she was better than when Louis saw her before, and a very palpable emphysema was seen above the clavicle, on each side of the neck, a symptom which did not exist two hours previously. This swelling made Louis conclude, that the urgency for the operation was still greater. The friend^ whose confidence hil been shaken bv Us» opposition he had experienced in bringing about unanimity, were in the greatest em- barrassment, when they were told, thatthe child might die of an operation, which be had represented as only a simple incision nee from nil danger. Louis was repeatedly asked, if he would be responsible for the child's life during the operation, and he in vain replied, that if there were any thing to fear during tbe operation, it would be from the accident itself, and not from tbe assist- ance rendered. This distinction was not per- ceived, and Louis withdrew, at the same time refusing bis consent to the exhibition of two grains of emetic tartar, the effect of whieh would be useless, and might be dan- gerous. The medicine was given in the night: the child was fatigued with its ope- ration, and quite unbenefitted. On Tues- day morning, Louis found the little girl very quiet, and they who had paid their visits earlier, found her wonderfully well. ''"he respiration, however, continued to be still attended with a rattling noise, which „ouis had observed in the evening, when ne breathing was much more laborious. The child was nearly suffocated several times in tbe course of the day, and died in the evening, three days after the accident. Bordenave, who had seen the patient, in- formed Louis of the child's death on Fri- day. The body was opened, before a nu- merous assembly of persons. After ranking a longitudinal incision through the skin and fat, along the trachea, between the sterno- hyoidei muscles, Bordenave slit open the trachea, cutting three of its cartilages.— This very instant, every one could seethe bean, and Louis took it out with a small pair of forceps. It was manifest, from the ease with which this foreign body was ex- tracted, thatthe operation would have had, on the living subject, the most salutary ef- fect. The relations had to regret having sacrificed a child, which was dear to them, to an irresolution and a timidity, which the most persuasive arguments could.not re- move. (Mem. de I'Acad. Royale de Chirur- gie, Tom. 12, p. 293, fa. Edit, in 12i».) This case evinces, in the most decided manner, the symptoms which result from the presence of foreign bodies in tbe tra- chea, and shows the only one surgical pro- ceeding which can be of use. But, amon; the phenomena, apparently difficult of ei- planation, is the calm, which, at different intervals, followed the afflicting cough.— Anatomy, however, has dispelled muchaj the doubt on tbi3 matter. It is know* that the whole canal of the trachea is moeh less sensible than the rima glottidis. h foreign body, like a bean, may remainis certain time in that canal without much in- convenience, the passage being only sonie- what obstructed, according to the potiuw of the substance. It may even remain se- veral days, months, or years, without pro- ducing any symptom of its presence, ei- cept a trivial sensation of obstruction, *"o Halle, 1805. Did. des Sciences Med. Art. Bronchotomie, T.3, 1812 Surgical Observations, by C. Bell, Part l.p. \4,fa.$vo. Lond. 1816. Case of Cynanche Laryngea, requiring Tracheo- tomy, and the continued use of a Cannula, ever since the Operation, in Med. Chir. Journ. Vol. 6, p. l.Svo. Lond. 1818. BUBO. (finCa*, the groin.). Modern sur- geons mean, b) this term, a swelling ofthe lymphatic glands, particularly of those in the groin, and axilla. The disease may arise from the mere irri- tation of a local disorder; from the absorp-" tion of some irritating matter, such as the venereal poison ; or from constitutional causes. Of the first kind of bubo, that, which is named the sympathetic, is an instance. Of the second, the venereal bubo is a remarka- ble specimen. (See Venereal Disease.) The pestilential bubo, which is a symptom of the plague, and scrofulous swellings of the inguinal aud axillary glands; may be regarded as examples of buboes from con- stitutional causes. (See Scrofula.) The inguinal glands ofteu become affect- ed with simple phlegmonous inflammation. in consequence of irritation in parts, from which the absorbent vessels, passing lo such glands, proceed. These, swellings ought to be carefully discriminated from others, which arise from the absorption of vene- real matter The first cases are simple in- flammations,and only demand the applica- tion of leeches, the cold saturnine lotion, and the exhibition of a few saline purges ; but thelatterdiseases render the administra- tion of mercury indispensable. Sympathetic is the epithet usually given to inflammation of glands from mere irritation ; and, we shall adopt it, without entering into the question of its propriety. The sympathetic bubo is mostly occasion- ed by the irritation of a virulent gonorrhoea. The pain, which such a swelling gives, is trifling, compared with that of a true venereal bubo, arising from tbe absorption of matter, and it seldom suppurates. How- ever, it has been contended, that the glands in the groin do sometimes swell and in- flame from the actual absorption of venereal matter from the urethra, in cases of gonor- rhoea, and which swellings must eon- 2S6 BURNS sequently be venereal. (Hunter on the Ve- nereal, p. 57.) The manner, in which buboes form from mere irritation, will be better understood by referring to tbe occasional consequences of venesection, in the article Bleeding. The distinguishing characters ofthe vene- real bubo are noticed in the article Vene- real Disease. BUBONOCELE, (from &*&!,, the groin, and h*)ji, a tumour.) A species of hernia, in which the bowels protrude at tbe abdo- minal riiii;. The case is often called an inguinal hernia, because the tumour takes place in the groin. (See Hernia) BURNS are usually divided into three kinds. 1st. In o such as produce an inflammation of the cutaneous texture, but an inflamma- tion, which, if it be not improperly treated, almost always manifests a tendency to re- solution. 2dly. Into burns, which injure the vital powers of the cutis, occasion the separation of the cuticle, and produce sup- puration on the surface of the cutaneous testurc. 3dly. Into burns, in which the vitality and organization of a greater or less portion of the cutis are either immedi- ately or subsequently destroyed, and a soft slough or hard eschar produced. (See Thomson's Lectures on Inflammation, p. 585, 586.) Suppuration is not always an unavoida- ble consequence ofthe vesications in burns; but it is a common and a troublesome one. " In, severe cases, it may take place by the second, or third day ; often not till a later period. It often occurs without any ap- fiearance of ulceration ; continues for a onger, or shorter time ; and is at last stopped by the formation of a new cuticle. In other instances, small ulcerations appear on the surface or edges of the burn. These spreading form extensive sores, which are iu general long in healing, even where the granulations, which form upon them, have a healthy appearance." (Op. cit. p. 595.) Burns present different appearances, ac- cording to the degree of violence, with which the causes producing them have operated, and according to the kind of cause, of which they are the effect. Burns, which only irritate the surface of the skin, are essentially different from those, which destroy it; and these latter have a very different aspect from what others present, which have attacked parts more deeply situated, such as the muscles, tendons, liga- ments, he. Scalds, which are the effect of heated fluids, do not exactly resemble burns, occasioned by the direct contact of very hot metallic bodies, or some combusti- ble substance on fire. As fluids are not capable of acquiring so high a temperature, as many solid things, scalds are generally less violent than bums, in the injairy w bich they produce ; but, in consequence of liquids often flowing about with great ra- pidity, and being suddenly thrown in large quantities over the patient, scalds are fre- quently dangerous on account of their ex- tent. It is well worthy of remark, that the danger of the effects of lire is not less pro- portioned to the size, than the degree and depth of the injury. A burn, that ia to violent, as to kill parts at once, may not be in the least dangerous, if not extensive; while, a scald, which perhaps only raises the cuticle, may prove fatal, if very huge. The degree of danger, however, is to be rated from a consideration both of the size and violence of the injury. The worst burns, which occur in practice, arise from explosions of gunpowder, or inflammable gases, from ladies's dresses catching fire,and from the boiling over of hot fluids, in labo- ratories, manufactories, he. Burns, which only destroy the cuticle, and irritate the skin, are very similar to the effects, produced by cantharides and rube- facients. The irritation, which such inju- ries excite, increases the action of the arte- ries of the part affected, and they effuse a fluid under the cuticle, which becomcseleva- ted and detached. Hence, the skin become? covered with vesicles, or bladders, which are more or less numerous, and large, ac- cording to the manner, in which the cause has operated. But, when the skin, or sub- jacent parts, are destroyed, no vesicles make their appearance. In this circum- stance, a black eschar is seen ; and when the dead parts are detached, there remains a sore, more or less deep, according to the depth, to which the destructive effects of the fire have extended. The parts may either be killed, at the mo- ment of the injury, by the immediate ef- fect of the fire, or they may first inflame, ' and then mortifv. In all cases of burns, the quantity of in- jury depends on the degree "f heat in the burning substance; on the duration.and extent of its application ; and on the sensi- bility of the burnt part. When a large surface is burnt, mortifica- tion sometimes makes its appearance with great violence, and very quickly after the accident; but, in general, the symptom, the most to be dreaded, in such cases, is inflammation. The pain and irritntion often run to such a pitch, that, notwithstanding every means, there is frequently immense trouble in keeping down the inflammation. When the burnt surface is very large, the effects ofthe inflammation are not confined to the part, which was first injured; but, even cause a great deal of fever; and, in cer- tain cases, a comatose state, which may | end in death. M It has been observed, that persons, who M die of sevene burns, seem to experience • remarkable difficulty of breathing, and op- pression of the lungs. These organs, and the skin, are both concerned in separating a large quantity of water from the circulation, and their participating in this function mayi perhaps, afford a reason for respiration be- ing often much affected, when a large sur- face of skin is burnt. However, the kid- neys perform the same office, and they are not particularly affected in burnt patients; =o that the asthmatic symptoms, freqnentfr BURNS. 2s; noticed i» cases of burns, are probably owing to a sympathy between the lungs and skin, or else to causes not at present understood. TREATMENT OF BORNS. Two general methods of treating burns have at all times been followed. One con- sists in the application of substances, which produce a cooling or refrigerant effect; the otlter in the employment of calefacient or stimulating substances. Dr. Thomson is satisfied, that each of these different modes may have its advantages in particular cases. (Led. on Inflammation, p. 588.) The practice mostly resorted to in this country some years since, is explained by Mr. B. Bell. When the skin is not destroy- ed, but seems to suftvr merely from irrita- tion, relief may be obtained by dipping the part affected in very cold water, and keep- ing it for some time immersed. This au- thor states, that plunging the injured part suddenly into boiling water would also pro- cure ease ; an assertion, however, much to be doubted, and a practice not likely to be imitated. In some cases, emollients afford immediate relief; but, in general, astrin- gent applications are best. Strong brandy or alcohol is particularly praised. At first the pain is increased by this remedy ; but an agreeable soothing sensation soon fol- lows. The parts should be immersed in the spirit, and, when this cannot be done, soft old linen, soaked in the application, should be kept constantly on the burn.— The liquor plumbi superacetatis dilutus is recommended. It is said to prove useful, however, only by being a-tringent,as equal benefit may be derived from a strong solu- tion of alum, he. Such applications were frequently made with the view of prevent- ing the formation of vesicles; but, Mr. B. Bell always remarked, that there was less pain, when the blisters had already appear- ed, than when prevented from rising, by remedies applied immediately after the oc- currence of the injury. The applications should be continued as long as the pain remains ; and in extensive burns, creating great irritation, opium should be prescribed. The stupor, with which patients, so situated, are often at- tacked, receives more relief from opium, than any thing else. Some recommend opening the vesica- tions immediately; others assert, that they should not be meddled with. Mr. B. Bell thinks they should not be opened till the pain arisyig from the burn is entirely gone. At this period, he says, they should always be punctured; for, when the serum is al- lowed to rest long upon the skin beneath, it has a bad effect, and even induces some degree of ulceration. Small punctures, not large incisions, should be made. All the fluid having been discharged,a liniment of wax and oil, with a small proportion of the superacetate of lead, is to he applied. On the subjectof opening the vesications in burns, Dr. Thomson believes, that the diversity of opinion arises from the differ- ent effects resulting from the particular manner in which the opening is made. " If a portion of the cuticle be removed, sb as to permit the air to come into contact with the inflamed surface of the cutis, pain, and a considerable degree of general irritation, will necessarily be induced; but if the ve- sications be opened cautiously with the point of a needle, so as to allow the se- rum to drain off slowly, without, at the 9ame time, .allowing the air to enter be- tween the cuticle and cutis, the early open- ing ofthe vesications will not only not oc- casion pain, but will give considerable re- lief, by diminishing the state of tension, with which the vesications are almost al- ways, in a greater or less degree, accompa- nied. When opened in this manner, the vesications often fill again with serum j but the punctures may be repeated as often as is necessary, without any hazard of ag- gravating the inflammation. Great care should be taken, in every instance, to pre- serve the raised portion of cuticle as en- tire as possible," he. (See Lectures on In- flammation, p. 595.) When there is much irritation and fever, blood-letting, and such remedies, as the particular symptoms demand, must be ad- vised. On account of the pulse being fre- quently small, quick and vibratory, bleed- ing is at present not often employed. As Dr. Thomson remarks, however, it may be- come necessary in patients of a strong ro- bust constitution, in whom the symptoma- tic fever assumes an inflammatory type.__ He ha3 often seen a single - bleeding pro- cure great relief in these cases ; and he does not remember a case where bleedin°- was followed by injurious effects. (P. 594.) When the skin ulcerates, the treatment does not differ from what will be described in speaking of Ulcers When burns are produced by gunpow- der, or less destroyed, cooling emollient applications were formerly thought most effectual, and a liniment, composed of equal proportions of lime-water and linseed oil, gained the greatest celebrity. Even at this day, the application is very often employed. Mr. B. Bell advises it to be put on the parts, by means of a soft hair pen- cil, as the application and removal of the softest covering, are often productive of much pain. The same author admits, how- ever, that there are some cases in which Goulard's cerate, and a weak solution of the superacetate of lead, more quickly procure ease, than the above liniment. The sloughs having come away, the sores are to be dressed according to com- mon principles. (See Ulcers.) When burns are produced hy gunpow- der, some ofthe grains may be forced into the skin : these should be picked out with the point of a needle, and an emollient poultice applied, which will dissolve and bring away any particles of gunpowder yet remaining. JiS BLRNS. Burnt parts, which are contiguous, fre- quently grow together in the progress of the cure. The fingers, toes, sides of the nostrils, and the eye-lids are particularly liable to this occurrence which is to be prevented by keeping dressings always in- terposed between the parts likely to be- come adhereut, until they are perfectly healed. The sores, resulting from burns, are, per- haps, more disposed, than any other ulcers, to form large granulations, which rise con- siderably above the level of the surroun I- ing skin. No poultices should now be used. The sores should be dressed with any mode- rately stimulating, astringent ointment: the ung. lapid. calaminaris, or the unguentum resinae with the pulv. hydrarg. nitrat. rub. is now generally preferred : and, if the part will allow of the application of a roller, the pressure of this will be of immense ser- vice in keeping down the granulations, and rendering them more healthy. When these methods fail, the sores should be gently rubbed with the argentum nitratum. In the dry and hot state of the skin, Dr. Thomson is an advocate for diaphoretics. "Laxatives (says he) are often necessary; but, it is in general bert to employ only the gentler sort, on account of the trouble and pain, which moving always gives the pa- tient. Anodynes are often required, not only to procure sleep, but even a tempora- ry alleviation ofthe pungency ofthe pain, which the burn occasions. A mild vegeta- ble and farinaceous diet should be used du- ring the period of the symptomatic fever. Animal food, wine, and other cordials, may be required in the progress of a suppura- ting burn; but. they are not necessary at first, and when given in this stage, are al- most always injurious. (See Lectures on Inflammation, p, 594.) With respect to the topical applications recommended by thisvgentleman, he gene- rally prefers .in cases of superficial burns cooling and refrigerant remedies. When there are vesications, and suppuration takes place without ulceration, he advises us, af- ter refrigerants have ceased to produce be- neficial effects, to use the linimentum aquae calcis. However, where the progress of cicatrization is slow, he recommends, in stead of this liniment, ointments containing lead, or zinc, particularly the unguentum lapid. calaminaris. In the ulcerating state of suppurating burns, he prefers emollient cataplasms.— But, when the discharge contiuues, or be- comes more profuse underthe use of poulti- ces, they are to be left off, and astringent washes employed, such as lime-water, the compound decoction of oak bark; a weak -olution of sulphate of copper, he. Where the parts are destroyed and con- verted into sloughs, Dr. Thomson does not * Iiink it matters much whether vinegar, oily liniments, turpentine, spirits of wine, or emollient poultices, be at first employ- ed. He acknowledges, however, that the '-»mltice is the remedy, under the triplica- tion of which, the separation of the dead parts is most easily and agreeably accom- plished. " The question (says he) at pre- sent most deserving the attention of medi- cal practitioners, with regard to the use of the warm emollient poultice in burns, i.«, whether we should apply it immediately after the burn has been received, or inter- pose for some hours, as has been so strong- ly recommended, dressings with vinegar, spirits of wine, or oil of turpentine. My own experience has not been sufficient to enable me to determine this point to my entire satisfaction. Yet, I think it right to state to you, that, in a number of trials made at different times, I have had occa- sion to see burns, to which common emol- lient poultices had been from the first ap- plied, slough and granulate faster, and in a more kindly manner, than similar burns in the same persons, to which in some instan- ces the Carron oil (lin. aq. calcis.) and, in others again oil of turpentine, were applied at the same time with the poultices.'' (See Lectures on Inflammation, p. 609.) MR. CLEGHORN'S PLAN. This gentleman, who was a brewer at Edinburgh, was induced to pay great atten- tion to the,effects of various modes of treat- ing burns, on account of the frequency of these accidents among his own workmen. His observations led him to prefer the im- mediate application of vinegar, which was to be continued for some hours, by any of the most convenient means, until the pain abated ; and when this returned,the vine- gar was repeated. If the burn had been so severe as to have produced a destruction of parts, these, as soon as the pain had ceased, were covered with a poultice, the application of which was continued about six, or, at most, eight hours, and after its removal the parts were entirely covered with very finely powdered chalk, so as to take away every appearance of moisture on the surface of the sore. This being done, the whole burnt surface was again covered with the poultice. The sam* mode was pursued every night and morn- ing, until the cure was complete. If the use of poultices relaxed the ulcers too much, a plaster, or ointment, containing sub-carbonate of lead, was applied; but the chalk was still sprinkled upon the sore. With respect to general remedies, Mr. Cieghom allowed bis patients to eat boil- ed, or roasted fowl, or in short, any plain- ly dressed meat, which they liked. He did not object to their taking moderate quanti- ties of wine, spirits and water, ale, or por- ter. He never had occasion to order bark, or any internal medicines whatever, and he only once thought it necessaiy to let blood. When the patient was costive, Mr. Cieghom ordered boiled pot-barley and prunes, or some other laxative nouriskiiig food, and sometimes an injection, butnto any purgative, as he remarked that the dis- turbance of frequently going to itool wa< BURN?. 2S9 distressing to a patient with bad sores. Be- sides, he thought that a hurtful weakness and languor were always (more or less) brought on by purgatives. From the ef- fects, too, which he felt- them have upon himself, and observed them to have upon others, they did not seem to have so much tendency to remove heat and feverish symptoms as is generally supposed, and he believed, that they more frequently carried off useful humours than hurtful ones. Diluted sulphuric acid was not found to answer so' well as vinegar, and the latter produced most benefit, when it was fresh and lively to tbe taste. In cold weather, Mr. Cleghorn some- times warmed the vinegar a little, placed the patients near the fire, gave them some- thing warm internally, and kept them, in every respect, in a comfortable situation. His object, in so doing, was to prevent the occurrence of tremblings, and chilness, which, in two instances, after employing cold vinegar, took place in an alarming de- gree. The account of Mr. Cleghorn's plan was published by Mr Hunter. (See Med. Facts and Observations, Vol. 2.) SIR JAMES EARL'S PLAN. Th'i3 gentleman was an advocate for the use of cold water, or rather ice ; and pub- lished several cases of extensive burns, in which this method was employed with the best effect. Cold water was enumerated by Mr. B. Bell, among the applications to burns, and it was not uncommonly used long before Sir James Earle communicated the result of his experience to the public. The method, indeed, is very ancient.— " Cold is a remedy (says Dr. J. Thomson) which has long been employed to diminish the inflammation of superficial burns — Rhazes directs, that, in recent burns, cloths dipt in cold water, or in rose-water cooled with snow, be applied as soon as possible to the parts which have been in- jured, and that these cloths be*renewed from time to time; and Avicenna says, that this practice often prevents the forma- tion of blisters." (Lectures on Inflamma- tion, p. 689.) Sir James Earle's publica- tion, however, had the good effect of draw- ing considerable attention to the subject, and of leading surgeons to try the method in a great number of instances, in which other more hurtful modes of treatment might otherwise have been employed.— The burnt parts may either be plunged in cold water, or they may be covered with linen dipped in the same, and renewed as often as it acquires warmth from thptpart. The application should be continued as long as the heat and pain remain, which they will often do for a great many hours. (See Essay on the Means of lessening the Ef- feds of Fire on the Human Body. 8vo. Lond. 1803.) Some caution, however, in the applica- tion of cold becomes necessary, when a scald is of very large size, or situated upon Vol. I 37 the trunk of the body. In extensive burns, ' superficial as they may be, the patient is liable to be affected with cold shiverings; and these shiverings may be greatly aggra- vated by exposure, and by the application of cold. Perhaps, therefore, in these ex- amples, warm applications ought to be preferred. (Dr J. Thomson's Lectures on Inflammation, p. 591.) BARON LARRET'S PLAN. It seems to me, that, on the subject of burns, there is, even at the present day as much contrariety of sentiment, as in any part of sureery whatsoever. After all the praises, which we have of late years heard of vinegar, cold applications, oil of turpen- tine, he. a French surgeon, whose talents and opportunities of observation, entitle his opinion to the highest attention, has re- cently censured the employment of all such remedies. Larrey, though a military sur- geon, has had occasion to see numerous burns, in consequence of explosions. He declares, that he has been long struck with the bad effects of repellents, such as fresh water with the muriate of ammonia, oxycrate, the aqua vegeto-mineralis, and the solution of opium in ice-water, applica- tions, which are extolled in some modern books, and used in cases of deep burns, by a great number of practitioners ; and he ex- presses his belief, that such ' j iries fre- quently prove mortal, for wa t of more judicious treatment. He recommends dres- sing all deep burns, with fine old linen, spiead with saffron ointment, which, he says, has the quality of diminishing the pain, and preventing irritation by keeping the nervous papillae from coming into contact with the air, or being pressed by the linen and clothes The employment ofthis oint- ment, (or in case good oil cannot be pro- cared for its composition, honey, instead of it) is to be continued till suppuration takes place. When this is established, Larrey employs the ointment of styrax, for the pur- pose of supporting the systaltic power of the subjacent vessels, promoting the de- tachment of the eschars, and checking the extension of the sloughing. As soon as the dead parts have separated, Larrey again has recourse to the saffron ointment, for which he gradually substitutes dry lint, with strips of linen spread with cerate.— When the vessels exceed the level of the edge of the sore, he touches tbem with the argentum nitratum, and he occasionally applies a weak solution of the oxy-muriate of mercury, or of the sulphate of copper. Larrey prescribes emollient and antispas- modic beverages, which are to be taken warm, such as milk of almonds, containing nitre, and properly sweetened ; hydromel; rice ptisan, he. His patients were never deprived of light nourishment, such as broths, jellies, eggs, soups, Sic. His expe- rience had taught him, that soldiers (who it is to be observed were his patients) cannot bear low diet, so well as persons leading an 290 Ul RNS. inactive life. Besides, he remarks, that as these injuries, with loss of substance, are a long time in healing, it would be acting con- trary to the precept of Hippocrates to put burnt patients on low diet. Larrey assures us, that he has found this simple treatment, which he calls soothing and gently tonic, almost always successful. (See Mimoires de Chirurgie Mililaire, Tom. l.p. 93.) dr. kkntish's plan. From what has been stated, it appears, that in cases of burns, cold and hot, irrita- ting and soothing, astringent and emollient applications, have all been outwardly em- ployed without much discrimination. But, the internal treatment has always been of one kind, and both the ancients and mo- derns agree in advising blood-letting, cool- ing purges, and, in short, the v hole of tbe antiphlogistic plan If w e except Mr. Cleg- horn, who condemned purges, and allowed stimulants internally. Dr. Kentish has been almost the only advocate for the latter means. The fanciful theories advanced by Dr. Kentish, lead him to believe, that as burns are injuries, attended with increa-i d action, there are twoindic;tem. In a second essay, Dr. Kentish remarks, that, in the first species of burns, in which the action of the ,/ art is only increased, be has not found any thing better for th< first application, than the heated oleum tere- binthinaa and tbe basilicon ointment, thin- ned with the same. In superficial burns, when the pain has ce sed, he considers it adviseable to desist from this application in nbout four and twenty hours, and use at the second dressing, a digestive, sufficiently thinned with common oil, beginning on the third day, with" the ceratum lap. calami- naris. This author has frequently seen se- condary inflammation excited by tbe re- medy. The most certain remedy, for this unpleasant symptom, is a digestive oint- ment, thinned with oil or a plaster of ce- rate, and over that a large warm poultice. The cerate will finish the cure. Should there be much uneasiness of the system, an anodyde, proportioned to tbe age of the patient, should be given. The growth of fungus, and the profuse discharge of matter, are to be repressed, as already mentioned, by sprinkling pow dered chalk on the surface, and by the use of pur- gatives, in the latter stages. The chalk must be very finely levigated. Dr. Kentish's theories are, as far as I can judge, visionary ; they may amuse tbe fancy, but can never improve ti.e judgment. They are nearly unintelligible ; they are unsup- ported by any sort of rational evidence; and, as being only the dreams of a credu- lous, sportive imagination, they must soon decline into neglect, if i-ot oblivion. Low- ever, in making these remarks, it is far from my intention to extend tbe same ani- madversion to the mode of treatment in- sisted upon by Dr. Kentish, which forms a question which cannot be determined by reason, but by experience. He is a man, who has had superior opportunities of ob- serving this part of practice, and the al- leged succe.-s of his plan of treatment has acquired exte'nsive approbation, although there are still many practitioners, who pre- fer common methods, and the antiphlogistic principles. The cicatrix of a burn is often of great extent, and, on this account, the subsequent absorption of the granulations on which the new skin is formed, (a process by which the magnitude of the scar is after- wards lessened,) is so considerable as to draw the neighbouring parts out of their natural position, and occasion the most un- pleasant kinds of deformity. Thus, barns BUR on the neck are apt to cause a distortion oi the head, or even draw down the chin to the breast bone; and in the limbs inch contractions as fix tbe joints in one immovt> able position Simply dividing these con- tractions again mostly fails altogether, or only produces very partial and temporary relief, as after the cicatrization is completed, the new-formed parts are absorbed, and the contraction recurs. A proposal has been lately made by my friend Mr. Earle, to cut away the w hole of the cicatrix, and then bring the edges of the skin as much towards each other as possible, in the transverse di- rection, with strips of adhesive plaster. In one case, in which " from the forepart of the upper arm, to within about two iache* of the wrist, a firm tense cicatrix, of an almost horny consistence, extended, which kept the elbow immoveably bent to a right angle," this gentleman performed such an operation. After removing the cicatrix, the flexor muscles at first made some resistance to the extension of the limb; but by de- grees they yielded, and the arm was brought nearly to a right line. The whole limb was kept in this position by means of a splint and bandage. In the end, the contraction was cured, and the use of the limb restored. (See Med. Chir. Trans. Vol. 5, p. 96, fa.) Probably, as this patient was a young growing subject, only six years of age, tbe operation would have proved equally suc- cessful, if a simple division ofthe contracted skin had been made, aim tbe arm kept ex- tended for a length of time by the use of a splint. It is hardly necessary to observe, that cutting a Iarire cicatrix entirely away, must always be a severe, and sometimes a dangerous operation : therefore, the avoid- ance of it, if possible, cannot but be desi- rable. (See B. Bell's System of Surgery; Medical Facts and Observations, Vol. 2; J. Stdillol. de Ambuslione Theses, 4lo. Pari' siis 1781. Richter'* Anfangsgrunde der Wundarsneykunst, Band. 1 Earle's Euan on the Means of lessening the Effects of. Fire on the Ih.mun Body, Svo. Lond. 1799. Ken- tish's Two Essays on Bums, the first of which was published in 1798. Hedin, Diss, sittm Observationes circa rulnera ex combuslkme, fa. 4to. Upsalia, 1804. Larrey, Mimovrts de Chirurgie Mditaire, Tom. 1, p. -3—96. Boyers Traiti des Maladies Chir. T. 1, ?■ 160. Nodes Dickinson, Remarks on Burnt and Scalds, chiefly in reference lo the print* pie of treatment at the time of their infliction, suggested by a perusal ofthe. last edilionofaa Essay on Burns, by E. Kentish, M D. 8ro. Lond 1818. Lccturt* on Inflammation, b* Joh- Thomson, p. 585, fa. Edin. 1811 Lassus Pcthologie Chir. T. 2, p. 39J. U- veille, Nouvelle Doctrine ( hir. T. 4, p.Zhh. Pearson's Principles of Surgery, p. HI- Edit. 1808.) Bl'RS/E MUCOSA.—These are small membranous sacs, situated about the joints, particularly the large ones ofthe upper and lower extremities. For the most part, they lie under tendons. The celebrated Dr A. Monro, of Edinburgh, published a very full CESAREAN OPERATION. 293 account of the bursa; mucosae, and also of made to disperse them, by warm applica- their diseases. These parts are naturally tions, friction, (particularly with camphor- filled with an oily kind of fluid, the use of ated mercurial ointment,) or blisters, kept which is to lubricate surfaces, upon which open w ith the savin cerate. But, if these the tendons play, in their passage over tumours should become very painful, and joints. In the healthy state, this fluid is so not yield to the above methods, Dr. Monro small in quantity, that it cannot be seen recommends opening them; a practice, without opening the membrane containing however, which can seldom be really ne- it; but, occasionally, such an accumulation cessary, or proper. This author was con- takes place, that very considerable swell- tinually alarmed at the idea of the bad ings are the consequent e. Tumours of effects of air admitted into cavities of the this sort are often produced by bruises and body, and, hence, iu the operation, even of sprains, and, now and then, by rheumatic opening the bursa; mucosae, he is- very par- affections. These swellings are not often at ticular in directing the incision in the skin, tended with much pain, though, in some not to be made immediately opposite that cases, it is very acute, when pressure is made in the sac. Care must also be taken made with the fingers. The tumours yield, to avoid cutting the tendons^near the swell- in a certain degree, to pressure ; but, they ing. rise again, with an appearance of elasticity, Dr. Monro had seen cases, in which am- not remarked in other sorts of swellings, putation became indispensable, in conse- At first, they appear to be circumscribed, quence of the terrible symptoms following and confined to a small extent ofthe joint; the opening of bursa; mucosae. but, sometimes, th>; fluid, forming them, is On account of such evil consequences, so abundant, that they extend over a great which are imputed to the hir, though they part of the circumference of the limb. The would as often arise, were the same practice skin, unless inflamed, retains its usual pursued in a situation, in which no air colour. could have access at all. it has been recom- In this morbid state of the bursa; mu- mended to pass a seton through the swell- cosa;, they contain different kinds of fluids, ing, and to remove the silk, after it has re- according to. the cause of the disease, mained just long enough to excite inflam- When the tumour depends on a rheumatic mation ofthe cyst, when an attempt is to be affection, the contents are ordinarily very made to unite the opposite sides ofthe ca- fluid. They are thicker, when the cause is vity by pressure. of a scrophulous nature. When the disease I have never seen any swelling of this is the consequence of a bruise, or sprain kind, which could not-be discussed by the the cifused fluid often contains hard con- means usually employed for promoting the cretions, and, as it were, cartilaginous ones, absorption of other tumours. Indeed, the which are sometimes quite loose, and, treatment should be very like that of Hy- more or less, numerous. Such substances drops articuli. (See Joints.) may frequently be felt, when the tumour is Consult Monro's Description of all the examined with the fingers. Bursa Mucosa-, fa. with rer arks on their ac- In practice, such distinctions are not of cidents ve days, and the life of the mother w as saved, after the dead foetus had been extracted by a midwife, was also probably of the same nature: at all events, the want of authentic partieu- lars, and the circumstance ofthe operation having been done by a woman, leave the true nature ofthe case questionable. If therefore, when we speak ofthe Ce- sarean Operation, we mean that, in whieh the parietes of the abdomen and those of the uterus are divided by the sur- geon, *nd the foetus extracted, I believe that, as far as the history of the practice ex- tends iu this country, it cannot be said, that the mother has ever recovered after such a proceeding; though some years ago, a calculation was made, that the ope- ration had been done not less than eighteen times in Great Britain. Ten ofthe chil- dren, however, are stated to have been sa- ved. On the continent, the practice has proved infinitely more successful; for, of 231 cases of this operation, to be found in the records of medicine, 139 are said to have terminated successfully. (Kellie, in Edin. Med. and Swgical Journal, Vol. 8, p. 17.) No doubt, the ill success of the Cav sarean Operation in England was correctly explained by Dr. Hull: "In France, and some other nations upon the European Continent, the Caesarean Operation has been, and continues to be performed, where British practitioners do not think it indicated ; it is also had recourse to early, before the strength of the mother has been exhausted by the long continuance and fre- quent repetition of tormenting, t'ough un- availing pains, and before her life is endan- gered by the accession of inflammation of the abdominal cavity. From thia view of the matter, we may reasonably expect, that recoveries will be more frequent in France, than in England and Scotland, where the reverse practice obtains. And, it is from such cases as these, in w hich it is employed in France, that the value of the operation ought to be appreciated. Who would be sanguine in his expectation of a recovery under such circumstances, as it has generally been resorted to in this coun- try, namely, where the female has laboured for years under malacosteon, (mollUiet osti- um) a disease hiihertoin itself incurable; where she has been brought into imminent danger by previous inflammation of the in- testines ; or other contents of the abdomi- nal cavity; or been exhausted by a labour of a week's continuance, or even longer." Dr. Hull thus refutes the opinion of Mr. W. Simmons, that our ill success wasowing to climate, or some peculiarity in the con- stitutions of the females of this island.— (See Hull's Defence of the Casarean Opera- tion, p. 10.) When the foetus is contained in the womb, and cannot be expelled, by reason ofthe invincible obstacles to which I have al- ready referred, the Cesarean Operation should be practised before the mother and. foetus both perish from the violence of the pains, hemorrhage, convulsions, he. For this purpose it is necessary to make an extensive incision in the integuments ef the abdomen, and in the uterus. Some CESAREAN OPERATION. 297 have thought, that cutting the parietes of the belly would be mortal, while others have believed a wound ofthe uterus equal- ly dangerous. Hence, such persons have condemned the operation on the principle, that religious reasons do not authorize ta- king one life to save another. All the op- ponents of the Caesarean Operation fear the hemorrhage, which, they say, must fol- low. Indeed, if the uterus were not to contract sufficiently, when tbe foetus and after birth had come away, the bleeding would really be perilous. But when, by means of the Caesarean Operation, the foetus is extracted, together with the placenta and membranes, the uterus contracts, just as it does after a natural labour. Besides, even when the mother is alive, the opera- tion is not commonly done, till the uterus evinces a propensity to deliver itself, and begins to contract. The womb being de- livered of its contents, the incision becomes closed, the vessels obliterated, and there is no fear of hemorrhage. The wound must also make so irritable an organ more disposed to contract; but, ^ hatever argu- ments may be adduced, it is enough to say in this case : Artem experientia fecit, exem- plo monstrante viam. Rousset, in 1581, pub- lished a work in French, entitled Hystiro- tomie, ou I'Accouchement Cisarien. This book, in 1601, was translated into Latin, and enlarged with an appendix by the cele- brated Bauhin. Even then, the practice of the Cesarean Operation on the living mo- ther had its defenders. Bauhin relates that, in the year 1500, a sow-gelder performed the Caesarean Operation on his wife, tarn feliciter, ut ea posted gemellos et quatuor ad- huc infantes enixa fueril. This is said to be the first instance, in which the opera- tion was ever done on the living mother with success. Many other cases were af- terwards collected and published. The possibility of operating successfully on the living mother, was proved with great perspicuity and accuracy, by Simon, in the Memoires de I'Acad. de Chirurgie, T. I, 4lo. Here we are presented with a collection of sixty-four Caesarean Opera- lions, more than a half of which had been done on thirteen women. Some of these bad undergone the operation once or twice; others five or six times. There was one woman in particular, who had undergone it seven times, and always with success. This seems to prove, notwith- standing all assertions to the contrary, that the operation for the most part succeeds. But, if the life of the mother should not invariably be preserved, the Caesarean Ope- ration ought not to be rejected on this account: it ought always to be done, when relief cannot be obtained by other means; just as amputation and lythotomy are prac- tised, though they are not constantly fol- lowed by success. Would any thing be more cruel, than to abandon a mother and her child, and leave them to perish, while there is any hope of saving them both ? It is true, that when a pregnant woman dies Vol. I 38 of any inward disorder, and not from the pains and efforts of labour, the foetus is sometimes still alive in the uterus; but, in cases of death after difficult labours, and the great efforts made by the uterus to overcome the obstacles to parturition, the foetus is generally de*d; and the operation therefore is less likely to be availing. (See Bertrandi Traili des Opirations de Chirur- gie, chap. 5 ) It is tbe opinion of the best writers upon this subject, that whenever a woman dies, at all advanced in pregnancy, tbe perform- ance of the Caesarean Operation is highly proper. The propriety of this practice, in such circumstances, was known to the an- cient Romans ; for, by a decree of Numa Pompilius, no woman, who died pregnant, was suffered to be buried, ere her body had been opened, with the view of pre- serving the infant for the use of the state. (Sprengel Geschichte der Chir. Th. l,p. 371.) Experience has proved, that when the foe- tus has not attained the period, at which parturition commonly happens:, it will sometimes survive the operation a consider- able time, and that, wdien it is full grown, its life may be most happily preserved.— Although instances are cited, in which ihe foetus in utero has been found alive upwards of four and twenty hours after the death of the mother, little stress should be laid on such prodigies. The operation ought to be done without any delay. Rven then, we are not certain of savin? the infant's life. In the greater number of instances, the foetus perishes at the same time with the mother, and from the same causes. The cases \vhich are recorded of the foetus be- ing extracted alive, after the death of the mother, are numerous: I shall here only refer to three, two of which rest on the un- impeachable authority of Flajani, who was himself the operator. (Collezione di Os- servadoni, fa. di Chirurgia, T.3,p. 144— 146.) In one of these instances, the ope- ration was done on a woman killed by vi- olence in tbe ninth month of pregnancy: the child lived six hours ; in the other, a foetus was extracted from a woman who had died of typhus fever, in the seventh month, and though the operation was not done till she had been dead about an hour, the child was taken out alive, and continued lo live full ten minutes. A living child was also taken out of its mother by Vesling, after her death from typhus. (Welsch. Obs. Med. Episagm. No 74, p. 47: Sprengel Geschichte der Chir. Th. 1, p. 374.) With respect to the statements of Cangiamila, a Sicilian practitioner. I join Sprengel in considering tbem as incredible exaggera- tions; five instances are given, in which the foetus was taken out of the mother from fifteen to twenty-four hours after her death, and yet continued to live. Cangia- mila says, that at Syracuse, in the course of eighteen years, the operation had been practised twenty times under the same cir- cumstances; that at Girgenti, thirteen children were saved out of twenty-two 298 CESAREAN OPERATION womeu, who had died pregnant; and that, in twent\ -four years at Montereali, twen- ty-one children were preserved in the same manner. (Embryologia Sacra. Venet. 1763. fol.) As Sprengel remarks, one might almost suppose, from this account, that in Sicily pregnancy was generally fa- tal. If the mother should happen to die in labour, and the neck ofthe ulerus were sufficiently dilated, or disposed to be so, an attempt should be made to accomplish delivery in the ordinary way ; for, exam- ples have occurred, in which women, sup- posde to be dead in this circumstance, were in reality alive. Hence, we find, that the senate of Venice in 1608 enacted a law, by which practitioners were liable to punishment, in case they neglected to operate with a.* much caution on a preg- nant woman, supposed to be dead, as on the living subject; and rules to be ob- served were again issued by the same go- vernment, in 1720. (Seb. Melli La Corn- marelevatrice, p. 108, 4/o Venez 1721 ; Per- soni Diss, sopra POperas. Cesar p. 15, 8ro. Venez. 1778.) A law to the same effect was likewise made in 1749, by the king of Sicily, who decreed the punishment of death to those medical men, who omitted to perform the Caesarean Operation on such women as died in the advanced stages of pregnancy. In the Journal de Savans de Janvier, 1749, the following case, confirm- ing the propriety of such caution, was in- serted by Rigaudeaux, surgeon to the Mili- tary Hospital at Douay. This practitioner, having been sent for to a woman, to whose residence he was unable to proceed, till two hours after her apparent death, he had the sheet, with which she was covered, re- moved, and perceiving that the body re- tained its suppleness and warmth, he tried whether the foetus could not be extracted in the ordinary way, which was easily effect- ed as soon as the feet were got hold of. Tbe first endeavours to save the child were very unpromising; but, after a few hours, they had the desired effect. As the woman con- tinued in the same state live hours after- wards, Rigaudeaux recomme d-d that she might not be buried before her limbs were quite cold and stiff. He afterwards had the satisfaction to learn, that she was also restored to life. This remarkable case hap- pened on the 8th of June, 1745, and both the mother and child were living at the pe- riod, when Rigaudeaux published the ob- servation. Supposing, however, delivery in the or- dinary manner, to be impracticable, at all events, the Caesarean Operation ought to be performed, with tbe same cautions, as if the mother were alive, only one incision being made for the purpose of opening tbe uterus. Almost all the insurmountable obstacles to delivery originate from the bad confor- mation of the pelvis, depending upon ra- chitis ; though they are not an invariable consequence of it, since there are women, extremely deformed, in whom no imperfec- tion of the pelvis exists, while it prevails iu others, whose shape is but trivially disfigu- red. An examination ofthe dimensions of the pelvis is the right mode of ascertaining, whether there is really such an impediment to parturition. In order that the dimensions may not be an obstacle to delivery, the dis- tance, between the upper edge of the sacrum and the os pubis, ought to be three inches and a half; and the distances between the tuberosities of the ischium, and between each of these protuberances and the point of the os coccygis, three inches. Women have indeed been known to be delivered, without assistance, although the first of the above distances was only two inches and a half; but, then the heads of the children were so elongated, that the great diameter was nearly ei^ht inches, while that which extends from one parietal protuberance to the other, w a> reduced to two inches five or six lines, and the infants were lifeless. If they are to be born alive, they must be taken out of the womb by the Cssarpan Operation ; but, the latter proceeding should never be adopted, without a certain- ty, that they are actually living ; for, when dead, they may be extracted in a way, that is attended with much less risk to the mother. It is not always an easy matter to ascer- tain with certainty, whethera foetus inutero, be living or dead. If it has entirely ceased to move, after being affected with a violent motion, the probability is, that it is no lon- ger alive. But, to be certain, manualexami- nation is necessary, which may be practised in two ways. One consists in pressing upon the uterus, through the parietes ofthe abdo- men. If the child lives, such pressure makes it move, and the motion can be plainly felt, and distinguished. In the other method, onehand is employed in pressing up- on the uterus externally, while, with tbe fin- gers of the otherhand, passed up the vagina, corresponds<• pressure is also to be made. The uterus is likewise to be allowed to de- scend as far as possible, in order to induce tbe foetus to move. \\ hen no decisive in- dications can be thus obtained, it becomes necessary to rupture the membranes, if they have not already given way, introduce the hand into the uterus, and put a finger into the child's mouth, for the purpose of making it move its tongue. The finger may also be applied to the region of the heart, so as to examine whether this organ is beating; and the umbilical cord may be touched, in order to ascertain whether there is still a pulsation in it. When none of these pro- ceedings furnish unequivocal information, the conclusion is, that the child is dead, and its extraction is indicated, unless the nar- rowness of the parts be such, that the band cannot be passed into the uterus, in which case, the Cesarean Operation is indis- pensable. But, how are we to form a judgment res- pecting the dimensions ofthe pelvis ? And how can we know, whether that diameter, which extends from the upper edge of tbe CESAREAN OPERATION. 2** iacrum to the os pubis, is long enough to allow the passage ofthe child ? The proper confirmation of this part is known, by the roundness and equality ofthe hips, both in the transverse and perpendicular direction ; by the projection of the pubes ; by the moderate depression ofthe sacrum ; by an extent of four or five inches from the mid- dle of this depression to the bottom of the os coccygis ; by an extent of seven or eight inches from the spinous process ofthe last lumbar vertebra to the highest part of the mons veneris, in a woman moderately fat ; and by there being an interspace of eight or nine inches, between the two anterior su- periorspinous processes ofthe ossa ilium. These general calculations, however, are insufficient. In order to ac>i lire more cor- rect opinions, double comp .sses have been employed. The branches ofthe first being applied to the top ofthe sacrum, and middle ofthe mons veneris, three inches are to be deducted from the dimensions, indicated by the instrument ; viz. two inches and a half for the thickness of the upper part ofthe sa- crum, (which is said to be constant in sub jects of every size,) and half an inch for that ofthe os pubis. In women, who are ex- ceedingly fat, some lines must also be de- ducted on this account. Hence, when the total thickness of the pelvis, measured in this direction, is seven inches, there will re- main four for the distance from the upper part ofthe sacrum to the os pubis, or for the extent ofthe lesser diameter ofthe upper aperture of the pelvis. For taking the measurement internally, a kind of sector was invented by Coutouly. It bears a considerable resemblance to the instruments employed by shoemakers for measuring the feet. It is passed into the vagina, with its two branches approximated, until one arrives opposite the anterior and upper part of the sacrum, when the other is to be drawn outward, so as to be applied to the pubes. The distance between the branches, is judged of by the graduations on the instrument. This was named by its inventor a pelvimeter. According to Saba- tier, it is not always easy to place it with ac- curacy ; its employment is attended with some pain ; and there arc particular cases in which it cannot be used. Instead of this contrivance, tbe celebrated Baudeloque recommended a means, which seems to be very safe and simple. The in- dex finger of one hand is to be introduced into the vagina to the upper part of the projection ofthe sacrum. The finger, hav- ing the radial edge turned forwards, is then to be inclined anteriorly till it touches the arch of the pubes. The point of contact being then marked with the opposite hand, the length from the point in question to the end of the finger is to be measured. This length, which indicates the distance be- tween the sacrum and the bottom ofthe symphysis pubis, usually exceeds that of the lesser diameter of the pelvis by about six lines. Baudeloque acknowledges, that this measurement is not exactly accurate ; but, he believes, it will do very well, be- cause, unless the narrowness of the pelvis be extreme, two, or three lines hardly make any difference in the facility of parturition. The following is the description of the pelvis ofthe woman, twice operated upon by Dr. Locher: the ossa pubis, which should be on the same level with the pro- montory ofthe sacrum, were found perpen- dicularly under it; so thatthe child neces- sarily extended the abdominal integuments by its own weight, into a pendulous bag overhanging the thighs. For the same rea- son, nothing could be felt of the child by examination per vaginam. The sacrum, in- stead of closing the pelvis behind, by a semi- circular curve, which forms a kind of con- ductor for the child in parturition, stretched nearly horizontally backwards. A repre- sentation of this pelvis, with a few other particulars, may be seen in a modern publi- cation. (Med. Chir. Tram. Vol. 11, p. 199.) The pelvis may be every where well formed, and yet present an insurmountable obstacle to delivery, in case an exostosis, lessening its dimensions, should exist on one ofthe bones, which compose this part of the skeleton. Pineau met with a case of this description in a woman, who died un- delivered. The tumour originated from one ofthe ossa pubis. A steatomatous swelling situated with the head of the child in tbe up- per aperture ofthe pelvis, might produce the same effect, unless it were detected, and could be pushed out of th« way, so as to make room for the foetus to pass. Baude- loque mentions a swelling of this kind. It was six or seven inches long, and an inch and a half in width. The extremity of it, which was as large as half an hen's egg, had a bony feel, and contained nine well-form- ed teeth, the rest of the mass being steato- matous. It had descended into the lesser pelvis, below the projection ofthe sacrum, and a little to one side. It might have been taken for an exostosis of this last bone. The labour pains continued sixty hours, and the propriety of performing the Caesarean Ope- ration was under consideration. Baudeloque was averse to this proceeding. He recom- mended turningthe child, and extracting it by the feet, because he thought, that the pelvis was sufficiently capacious to admit of deli- very. The event proved, that it was three inches nine lines, from before backward, and four inches nine lines transversely. The foetus was soon easily extracted. The assis- tance ofthe forceps was necessary togetout the head. The child was stillborn. The mother, exhausted with numerous unavail- ing efforts, only survived between 50 and 69 hours. Baudeloque wasofopinion,thatade- fective regimen also tended to occasion hei death. Among the insurmountable obstacles to delivery may be reckoned such a displace- ment ofthe uterus, that this viscus protrudes from the abdomen, and forms a hernia. The records of surgery have preserved some examples of this extraordinary occur- rence. Twice has the Caesarean Operation 300 CESAREAN OPERATION. been performed, and, in one of the cases, the w oman survived so long, that hopes were entertained of her recovery. In- deed, as Sabatier observes, why should not the operation succeed in such a case, w here the uterus is only covered by the integu- ments, and there is no occasion to cut into the abdomen, just as well as other instances, in which it is indispensableto divide the mus- cles, and open the cavity of tbe belly ? In the other case on record, delivery was effect- ed in the ordinary way, either by raising the abdomen, and keepj;ig it in this position with towels skilfully placed, or by making pressure on the uterus, which bad the bene- ficial effect of making this organ resume its proper situation. Having shown the absolute necessity for the Caesarean Operation, under certain cir- cumstances, it remains to consider the pro- per time for performing it, the requisite pre- paratory means, and the method of opera- ting. With regard to the time of operating, practitioners do not agree upon this point ; some advising the operation to be done, be- fore the membranes have burst, and the wa- ters been discharged ; others, not till after- wards. The arguments, in favour of the first plan, are, the facility with which the uterus may be opened without any risk of injuring the foetus, and the hope that the viscus w ill contract with sufficient force to prevent h-morrhage. The advocates for the second mode believe, that, in operating after the discharge of tbe waters, there is less danger ofthe uterus falling into a state of relaxation, in consequence of becoming suddenly empty after being fully distended, and that this method does not demand so extensive an incision. Hence,they recom- mend, as a preliminary step, to open the membranes. Whatever conduct be ndopt- ed, it is essential, that the labour should be urgent and unequivocal, that the cervix ute- ri should be effaced, and that the os tincae should be sufficiently dilated to allow tbe lochia to be discharged ; but, at the same time, says Sabatier, if the operation is not to be done till after the escape of the wa- ters, there ought not to be too much delay, lest the patient's strength should be exhaust- ed, and the violent efforts of labour should bring on an inflammatory state ofthe pari- etes ofthe uterus. The propriety of emptying the rectum and bladder is so evident, that it is unneces- sary to ins'iM upon it. This precaution is more particularly requisite in regard to the latter of these viscera, which has been known to rise so much ovei the uterus, as to conceal the greater part of it. Baudeloque had occasion to remark this circumstance, in a woman, upon whom he was operating. The bladder ascended above the navel, and presented itself through tbe whole extent of the opening made in the parietes of the ab- domen. The instruments, dressings, he. which may be wanted, are two bistouries, one with a convex edge, the other having probe-point; sponges; basins of cold water acidulated with a little vinegar ; long strips of adhesive plaster ; needles and ligatures- lint; long and square compresses ; a baud- age to be applied round the body, with a scapulary, he. For the purpose of undergoing the opera- lion, the patient should be placed at the edge of her bed, well supported ; her chest and head should be moderately rais- ed ; her knees should be somewhat bent and held by assistants, one of whom ought to be expressly appointed to fix the uterus by making pressure laterally, and from above downward, so as to circumscribe, in some degree, the swelling of the uterus and prevent the protrusion of the bowels. These things being attended to, the integu- ments are to be divided with the convex- edged bistoury to the extent of at least six inches. The place, and direction of this incision, differ with different operators. In the most ancient method, it was cus- tomary to make the incision between the outer edge of the rectus muscle, and a line, drawn from the anterior superior spi- nous process of the ilium, to the junction of the bone of the first rib with its cartilage. This cut was begun a little below the umbi- licus, and was continued downward as far as an inch above the pubes. After the inte- guments had been divided, the muscles, aponeuroses, and peritoneum were cut, and the uterus, cautiously opened. The left in- dex finger was then introduced into this viscus, the wound of which was dilated by means of the probe-pointed bistoury. This manner of operating is subject to great inconveniences. The place, where the incision is made, is the situation of mus- cles, the fibres of which have a different direction, and, on contracting, separate the edges of the wound, and make it gape. The considerable blood vessels, which rami- fy there, may be the source of perilous bleeding. Tbe bowels can protrude in that situation more readily, than any where else. When the position of the uterus is oblique, and when, consequently, the edges of this viscus are turned forward and backward, and its surfaces to the right and left, the incision will be made in one of the lateral portions of the uterus, where the trunks of its blood-vessels are known to be situated, and sometimes even the Follapian tube and ovary may be cut. The fibres of the uterus are cut transversely, so that the edges of the incision are apt to gape, instead of being in contact. This last circumstance may the more readily permit the lochia to escape into the abdomen, inasmuch as the uterus is cut nearly through its whole length, and there is no cavity, in which they can accu- mulate, in order to be discharged through the cervix of that organ. The linea alba has been frequently consi- dered the most eligible place for making the incision. As Sabatier informs us, it was the method adopted by Soleyres and De- ileurye, and it has the recommendation of CESAREAN OPERATION. 301 Baudeloque, because there are fewer parts to be cut, and, when the uterus is exposed, an incision, parallel to its principal fibres, may be made in its middle part. Soleyres thought that this plan of operating origina- ted with Plainer and Guerin, a surgeon at Crept en Valois, Platner says ; Incidanlur juxta lineam albam, plagd majore qua ab umbilico ad ossa pubis fere descendit, turn ab- dominis musculi, turn peritonaum, ubi tandem vilandum ne violelur arteria epigastrica. Guerin, in bis case, made an incision, six inches long, which negan a little above the unibiiicus, and extended to within an inch and a half of the pubes. He afterwards di- vided the fat, muscles, and peritoneum, in order to get at the uterus, the anterior part of which was opened, the wound being made rather in the body, than the fundus of that viscus. Deleur\e will not admit, that these writers actually divided the linea alba, because they speak of having cut muscles, which in reality do not exist in that situa- tion ; and he attributes tbe honour of the invention to Varoquier, a surgeon of Lisle, in Flanders ; but, the method was known to Mauriceau, as we may be convinced of by the following passage, extracted from the chapter in which he treats of the Caesa- rean Operation, '• La plupart veulent qu'on incise au cbli gauche du ventre ; mais I'ou- verture sera mieux au milieu entre les musclts droits, car il n'y a '. as found to be attached to the parts just behind, arid near the abdominal ring; but it was easily separated. Govei does not mention whether the mother survived ; but the thing w ould not be very astonish- ing, considering the situation of the foetus. Bertrandi says he was unacquainted with any other example of the Caesarean Opera tion being done in cases of extra-uterine foetuses, so as to save both the mother and infant. This eminent man condemned ope- rating, in ventral eases, on the ground that the placenta could not be separated from the viscera, to which it might adhere, or, if left behind, ft could not be detached, w ithout such inflammation and suppuration as would be mortal. But if, in addition to such objections, says Bertrandi, the opera- tion has been proposed by many, and prac tised by none, we may conclude, that this depends on the difficulty of judging of such pregnancies, and ofthe time when the ope- ration should be attempted. He puts out of the question the dilatations, which have been indicated for extracting dead portions of the foetus, and also Govei's case, who operated without expecting to meet with a foetus at all. (Bertrandi Traili des Opirations de Chirurgie, Chap. 5.) Whenever the Caesarean Operation, or gastrotomy, has been performed, the prac- titioner is not merely to endeavour to pre vent inflammation, heal the wound, and appease any untoward symptoms, which may arise ; he should also prevail upon the mother to suckle the child, in order that the lochia may not be too copious, and, after the wound is healed, she should be ad- vised to wear a bandage, for the purpose of hindering the formation of a ventral hernia, of which, according to surgical writers, there is a considerable risk. Fr. Roussetus; Casarei Partus Assertio Hisloriologica, fa. Svo. Paris, 1590. Fr. Roussetus, Fatus vivi ex malre viva sine al- terutrius periculo Casura. 12mo. Basil. 1591 Theoph. Raynaud, De Ortu Infantium con- tra Naturam per Seclionem Casaream, fa 12wio. Lugd. 1637. A. Cyprianns. Epi*tol« 306 CAL CAL Historitrm exhibens Fat us humani post 21 menses ex uteri tuba, matre salva, ac super- stile, excisi. Svo. Lugd. Bat. 1700. This is the celebrated case related by Albosius at the end of Bauhin's Transl. of Roussel. J. B. Verduc, Traiti des Opirations de Chirurgie; nouvelle Edit. l2mo. Par. 1121. Sabatier's Midecine Opiratoire, T. 1, Ed. 2. Richer- ches sur VOperation Cisarienne par M Si- mon, in Mini, de I'Acad. Royalt de Chirur- gie, Tom. 3, p. 210, fa. and Tom.h,p 317. fa. Edit, in \2mo. Bertrandi Traiti des Opi- rations de Chirurgie, Chap. 5. Boudelocque's Traiti des Acco ichemens, Paris, 1807. Den- man's Introduction to Midwifery, 4to. 1805. Also Obs. on the Rupture of the Uterus, fa. 8vo. 1810. Hull's Defence of Ihe Casarean Operation, Svo. Manchester, 179S. Also kis Letters to Mr. W. Simmons. Haighton's Inquiry concerning the true and spurious Casarian Operation. P. Berlen, De Sectione Sigaultiana el Casarea harumque Sectionum inter se Comparatione .- (Coll. Diss. Lorain. 4, 321.) G. Ruellan, Quastio, fa. An ad servandam pro foztu matrem, obstelricum ha- matile minus anceps et aque insons, quam ad scrvandum cum matre fcetum seclio Casarea. (Haller, Disp. Chir. 3, 525. Pan's, 1744) A. Lindemann, De Partu Prelernaturali quern sine Matris aut Foetus Sectione absol- vere nun licet. 4to. Gott. 1755. Med. Obs. and Inquiries, Vol. 4, p. 274, fa. J. Vaughan, Cases, fa. to which is annexed an Account of the Casarean Section, fa. 8vo. Lond. 1778. P. J. F. Walckiers, de Hyste- rotomolocia, sine Sectione Casarea, Lovan. 1785. Edinb. Med. and "Surgical Journ. Vol. 4, p. 178, Vol. 8, p. 11. Garlhshore's Obs. on Extra-uterine Cases, inserted in the Slh Vol. Lond. Med. Journ. Richter's An- fangsgr. der Wundarzneykunst, B. 7 Kap. "«; Gott. 1804. C. Bell in Medico-Chirurg. Trans. Vol. 4, p. 347, fa.; J. J. Locher, Vol. 9; and J. J. Locher, N. Meyer, F. Spitzbarth, $■ J. Lorinser, in Vol. 11 of the same work. J. F. Freymann, De Partu Casareo. 12mo. Marb. Catt. 1797. G. Josephi, ilber die Sehwangerschaft ausserhalb der Gebiirmutter, fa. 8vo. Rostock, 1803. Flajani Osstrva- zioni, fa. di Chirvrgia, T. p. 3, 144, fa. Ro- ma, 1802. Rhode, Relatio de Sectione Casa- rea feliciter peracta. 4to. Dorpali, 1803- K. Sprengel, Geschichte der Chir. Th. \,p. 369, fa. 8vo. Halle, 1805. M. Baudeloque, Two Memoirs on the Casarean Operation. Transl. ioith notes, fa. by John Hull. Svo. Manches- ter, 1S11. E. L. Heim, Erfahrungen, fa. liber Schwangerschaften ausserhalb der Ge- barmutter, Svo. Berlin, 1812. A. J. A. Ste- vens, De Conditionibus qua apud parturien- tem Sectionem Casaream, vel potius illam Synchondroneos ossium Pubis, postulant. 4lo. Lugd. 1817. Dictionnaire des Sciences Med. T. 17, p. 419, Paris, 1816, and T. 23, p. 293, fa.; IS 18. F. Von Siebold, Journal far Geburtshiilfe, Frauenzimmer und Kin- derkrankheiten, 3 B. 8vo. Francof. 1819. CALCULUS. Calculi form in the ducts of the salivary glands; in the kidneys, bladder, urethra, gall-bladder, &c. A pa- per on calculi formed in the lachrymal sar, has just been published in Graefe's new Journal. (Journ.far die Chir.No. 1, Berlin, 1S20.) For an account of what are com- monly called stones in the bladder, refer to Urinary C dculi. CALCULUS IN THE INTERIOR OF THE EYE. See Eye, fa. CVLLUS, New bme, or the substance which serves to join together the ends of a fracture, and for the restoration of destroy- ed portions of bone. 1. The old surgeons believed callus to be a mere inorganic concrete, a fluid pour- ed out from the extremities of the ruptured vessels, which was soon hardenedf into bone. They always described it as an " e\- udation of the bony juice, and imagined that it oozed from the ends of broken bones, as gum from trees, sometimes too profusely, sometimes too sparingly. The reunion of broken bones, and the harden- ing of callus, they compared with the glue- ing together of two pieces of wood, or the soldering of a broken pot. (A. Pari.) Ihe old surgeons also conceived, that callus sometimes flowed into the joints, so as to form a clumsy, prominent protuberance,— They imagined that callus was a juice, which congealed at a determinate period of time, and they therefore had fixed days for undoing the bandages of each particular fracture. They supposed that its exuber- ance might be suppressed by a firm and well-rolled bandage, and its knobby de- formities corrected by pillows and com- presses ; that it mi^ht be softened by fric- tions and oils, so as to allow the bone lobe set anew. All their notions were mechani- cal ; and their absurd doctrines have been the apology for all the contrivers of ma- chines, from Hildanus down to Dr. Aitken and Mr. Gooeh. 2. By Galen and Duhamel, however, a second doctrine was entertained, which imputed the formation of callus altogether to the periosteum and medullary texture, which were supposed to produce two folid rings round the fracture, the interspace be- tween them being afterwards effaced. 3. A third opinion, maintained by Bor- denave, and the best modern observers, is, that the process of nature, in the production of callus, bears a great resemblance to the changes which take place for the reunion of w ounds of the soft parts. A bone is a well-organized part of the living body ; that matter, which keepaiU earthy parts together, is of a gelatinons nature. The phosphate of lime, to wbieh a bone owes its firmness, is deposited in the interstices of the gluten, undergoing* con- tinual change and renovation. It is inces- santly taken up by the absorbents, and se- creted again by the arteries. It is this con- tinual absorption and deposition of earthy matter, which forms the bone at first, and enables it to grow with the growth of the body. It is this unceasing activity of the vessels of a bone which enables it torene" itself when it is broken or diseased. I" short, it is by various forms of one sent- CALLUS. 301 ting process, that bone is formed at first, is supported during health, and is renewed on all necessary occasions. Bone is a secre- tion, originally deposited by the arteries of the bone, which arteries are continually employed in renewing it. Callus is not a concrete juice, deposited merely for filling up the interstices betwixt fractured bones, but it is a regeneration of new and perfect bone, furnished with arteries, veins, and absorbents by which its earthy matter is continually changed, like that of the con- tiguous bone. Indeed, there could be no connexion between the original bone and callus, were the latter only the inorganic concrete, which it was formerly supposed to be. Notwithstanding the more accurate opi- nions now entertained, concerning callus, the supposition is still very common, that the slightest motion will destroy a callus, which is about to form. But, says Mr. John Bell, it is an ignorant fear, proceeding merely from the state of the parts not ha- ving been observed; for, when callus forms, the perfect constitution of the bone is restored ; the arteries pour out from each end of a broken bone a gelatinous matter; the vessels, by which that gluten is secreted, expand and multiply ia it, till they form, betwixt the broken ends, a well-organized and animated mass, ready to begin anew the secretion of bone. Thus, the ends of the bone, when the bony secretion com- mences, are nearly in the same condition, as soft parts which have recently adhered ; and it is only when there is a want of con- tinuity in the vessels, or when a warn of energetic action incapacitates them from renewing their secretion, that callus is im- perfectly formed. This is the reason, why in scorbutic constitutions, in patients in- fected with syphilis, in pregnancy, in fever, or in any great disorder of th" system, or while the wound of a compound fracture is open, no callus is generated. (Jolvi BeWs Principles of Surgery, Vol. 1, p. 50O, 501.) How far some of the latter statement is cor- rect, or not, will be seen in the article Fracturet. For some time, the secretion of earthy matter is imperfect; the young bone is soft, flexible, and of an organization suited for all the purposes of bone ; but, hitherto delicate and unconfirmed ; not a mere concrete, like a crystallization of a salt, which, if interrupted iu the moment of forming, will never form ; not liable to be discomposed by a slight accident, nor to be entirely destroyed by being even roughly moved or shaken. Incipient callus is soft, fleshy, and yielding; it is ligamentous in its consistence, so that it is not very easily injured ; and, in its organization, it is so perfect, that when it is hurt, or the bony secretion interrupted, the breach soon heals, just as soft parts adhere, and thus the callus becomes again entire, aud the process is immediately renewed. In consequence of the above circumstan- '■r-°. if a limb be broken a second time, when the first fracture is nearly cured, the bone unites more easily than after the first accident; and Mr. J. Bell even asserts, that when it is broken a third, and a fourth time, the union is still quicker. In these cases, the limb yields, it bends under the weight ofthe body, which it cannot support ; but, without any snapping or splintering of the bone, and, generally, without any over- shooting ofthe ends ofthe part, and with- out any crepitation. Callus is found to be more vascular, than the old bone. Mr. John Bell mentions an instance of a bone, which bad been broken twelve years before he injected it, yet the callus was rendered singularly red. When a recently formed callus is broken, many of its vessels are ruptured, but some are only elongated, and it rarely happens that its whole substance is torn. It is easy to conceive, how readily the continuity of the vessels will be renewed in a broken callus, when we reflect on its great vascu- larity ; and the vigorous circulation, excited by the accident in vessels already accustom- ed to the secretion of bone. These rea- sons show, why a broken or bent callus, is more speedily united, than a fractured bone. When bones granulate, says Mr. Wilson, the granulations at first appear exactly simi- lar to those ofthe sofi parts, and, as in the soft parts, take place to restore any loss, which the bones may have suffered, 'ibis- process is very similar to that of the first formation of bone. In the skull, membrane was first formed ; and here also, in the pro- cess of restoration, the granulations change into membrane, and then into bone. In cy- lindrical bones, the granulations first pro- duce a species of cartilage, and this is af- terwards converted into bone. Thus, in the restoration of bone, nature is guided by the same laws, which prevail in its first for- mation. If the granulations, thrown out on the surface of a bone, be viewed in a microscope, they appear to form a number of small points, like villi, the bases of w hich first become similar to cartilage, and then to bone. "The preparations from the sur- face of granulating stumps, show the ex- treme delicacy of the first bony threads, and also their mode of uniting laterally with eaeh other." (J. Wilson's Lectures on the Structure, Physiology, and Diseases ofthe Bones, fa.p. 197, 8ro. Lond. 1820.) And, in another place, he repeats, " I have examined several skulls on the death of the persons, at different periods, from days to years after pieces of bone had been removed, and before the vacancies had been completely filled up ; but, I never could, in any of them, discover the least appearance of cartilage." A membrane here alwavs precedes the formation of bone. (p. 210.) For additional observations on callus, see Fracture. N. M. Midler, De Callo Ossium; 4lo. Norimb. 1707 ; Duhamel in Mim. de I'Acad. Royale des Sciences an. 1741. p. 92, et 222 ; Boehmer, de Callo Ossium i. rubia tinciorum radicispastu infectorum, 4(o. Lips. 1752 ; Delhleef, Diss, exhibens Ossium CaP 308 CAL CA> generationem et naturam per fracta in ani- malibus rubia radice pastis ossa dtmonstra- tam, 4io. Goelt. 1763; A. Marrigues. sur la Formation du Cal. Paris, 1783. A. M'Do- nald, De Necrosi, fa. Edin. 1799. The works of Trojd, David, Blumtnbuch, and Koehler, as specified at the conclusion of the article Necrosi*. J. Wilson, Lectures on the Structure, Physiology, and Diseases of the Bones, p. 208,6ro. fa. Lond. 1820. CALOMEL. (Submuriate of mercury ; hydrargyri submurias. L. P.) Its extensive utility, in numerous surgical diseases, will be conspicuous in a large proportion of the articles in this work. When prescribed, as an alterative, the common dose is a grain once or twice a day ; when ordered as a purgative, from three to eight grains may be given, and when directed, with the view of exciting salivation, one or two grains, con- joined w ith opium, are usually administered night and morning. This medicine, combin- ed with opium, is frequently given, for the relief of what is usually termed spasmo- dic stricture, which is an attendant on se- vere cases of gonorrhoea. CALX CUM POTASSA. This is a strong kind of caustic, chiefly used for making the eschars, when issues are formed in cases of diseased vertebrae, white swellings, morbid hip-joints, i^e. (See / ertebra.) Tbisoaus- tic is also sometimes used, though not so often as it was formerly, for opening buboes and other abscesses. Some are in tbe habit of making it into a paste with soft soap ; they cover the part affected with adhesive plaster, in which there is a hole of the size of the eschar intended to be made ; and into this aperture they press the paste till it touches the skin. A bandage is then appli- ed to secure tbe caustic substance in its situ- ation, till the intended effect is produced. The action of calx cum potassa, in this way, however, is more inert and tedious, and, perhaps, on this account, more pain- ful. Hence, many of the best modern sur- geons never adopt this method ; but, after covering the surrounding parts w itii sticking plaster, rub the caustic on the situation, where it is desired to produce an eschar, till the skin turns brown. The end ofthe caus- tic must first be a little moistened. The calx cum potassa, is sometimes em- ployed also for destroying fungous excres- cences. Before the port-wine injection was found to answer best for the radical cure of hy- drocele, this caustic whs often used as a means of cure. (See Hydrocele.) Mr. Else, a chief advocate for the latter method, used to mix the caustic with powdered opium, by which contrivance, it is said, though not with much appearance of truth, that the sloughs were made with little, or no pain to the patient. Some assert that the potassa alone, acts more quickly, than when mixed with quick- lime. I have not found this to be the fact, and, after trying both, give the preference to the calx cum potassa. CAMPHOR, is used externally, chiefly as a means of exciting the action ofthe ab- sorbents, and thus dispersing many kinds of swellings, extravasations, indurations, fcc. Hence, it is a common ingredient in lini- ments It has also the property of rousing the action of the nerves, and quickening the circulation in parts, on which it is rub- bed For this reason, in paralytic affec- tions, it is sometimes employed." Perhaps, there is no composition, that has greater power in exciting the absorption of any tu- mour, or hardness, than camphorated mer- curial ointment. In cases of delirium, depending on the irritation of local surgical diseases, and in some descriptions of mortification, camphor is occasionally prescribed. It has also been recommended,as singularly useful for tbt re- lief of stranguries, even those depending on the operation of cantharides. Bui, although it may occasionally have succeeded, when given w ith this view, it not only does not always do so, but, it has been known to cause an opposite effect, sometimes produ- cing great scalding in voiding the urine, and sometimes pains like those of labour. (Medi- cal Tiansactions, Vol. \,p. 470.) In chor- dee, its utility is generally acknowledged. CANCER, (derived from cancer,a crab, to which, a part, affected with cancer, and surrounded with varicose veins, wasancient- ly thought to have some resemblance.) Carcinoma. The disease has two principal forms ; one named scirrhus, or occult cancer; the other, ulcerated, or open cancer. According to the usual definition, aa Mr. Pearson ob- serves, an indolent scirrhus is a hard and almost insensible tumour, commonly situa- ted in a glandular part, and accompanied with little, or no discolouration of the sur- face of the skin. But, when the disease has proceeded from the indolent to the ma- lignant slate, the tumour is unequal in its figure, it becomes painful, the skin acquires a purple, or livid hue, and the cutaneous veins are often varicose. (Principle* of Sur- gery, § 331, 343.) The pain is remarked to be acute and lancinating, and its attacks re- cur with more or less frequency. At length, the tumour breaks, and is converted into cancer, strictly so called, or the disease in the state of ulceration. The female breast, and the uteres, are particularly subject to the disease. The breasts of men are but rarely affected The testes, lips, (especially the lower one of male subjects) the penis, the lachrymal gland and eye, the tongue, the skin, (parti- cularly that of the face) the tonsils, the py- lorus, the bladder, rectum, prostate, and a variety of other parts, are recorded by sur- gical writers as having frequently been the seat of scirrhus and cancer. They seem, however, to have comprehended an im- mense number of different malignant disea- ses under one common name, and, in many of the cases called cancerous, there are no vestiges of the true scirrhous structure. CANCER. 3o» OV SCIRRHUS, OR CANCER, NOT IN TBE UL- CERATED STATE. Mr. Abernethy has given a matchless his- !ory of this affection, as it appears in the emale breast, where it most frequently oc- curs, and can be best investigated. Some- times, says this valuable writer, it condenses the surrounding substance, so as to acquire a capsule ; and then it appears, like many sarcomatous tumours, to be a part of new formation. In other cases, the mammary gland seems to be the nidus for the diseased action. In tbe latter case, the boundaries ofthe disease cannot be accurately ascer- tained, as the carcinomatous structure, hav- ing no distinguishable investment, is confu- sed with the rest of the gland. Sir Everard Home also remarks, that when the disease originates by a small portion of the glandu- lar structure of the breast becoming hard, which is very commonly tbe case, it is readily distinguished by the bard part never having been perfectly circumscribed, and giving more the feel of a knot in the gland itself, than of a substance distinct from it. In each of these instances, carcinoma be- gins at a small spot, and extends from it in all directions, like rays from a centre. This is one feature distinguishing this disease from many others, which, at their first at- tack,involve a considerable portion, if not the whole, of the part, in which they occur. The progress of carcinoma is more or less quick in different instances. When slow, it is in general unremitting. Mr. Abernethy thinks, that though the disease may be checked, it cannot be made to recede by the treatment, which lessens other swell- ings. On this point, however, he is not positive ; for, surgeons have informed him, that diseases, which eventually proved to be carcinomatous, have been considerably diminished by local treatment. With great deference to Mr. Abernethy, we may be allowed to remark in this place, that every tumour, which ends in cancer, is not from the first of this nature, though it has in the end become so ; consequently, it may at first yield to local applications, but will not do so after the cancerous action has com- menced. Hence, Mr. Abernethy's opinion, that a true carcinomatous tumour cannot be partially dispersed, at least, remains un- weakened by the fact, that some tumours have at first been lessened by remedies, though they at last ended in cancer. Sir E. Home's observations tend to prove, that any sort of tumour may ultimately become cancerous. Without risk of inaccuracy, we may set down the backwardness of a scirrhous swell- ing to be dispersed, or diminished, as one of its most confirmed features. This obdu- rate and destructive disease excites the con- tiguous parts, whatever their nature may be, to enter into the same diseased action. The skin, the cellular substance, the muscles, and the periosteum, all become affected, if tbey are in the vicinity of cancer. This very striking circumstance distinguishes carcinoma, savs Mr. Aber- nethy, from several other diseases. In what this author calls medullary sarcoma, the disease is propagated along the absorb- ing system ; but the parts immediately in contact with the enlarged glands do not as- sume the same diseased actions. Neither in the tuberculatcd species does the ulcera- tion spread alongthe skin, but destroysthat part only which covers the diseased glands. According to Mr. Abernethy, a disposition to cancer existing in the surrounding parts, before the actual occurrence of the diseased action, was a circumstance noticed by Mr. Hunter. Hence arose the following rule in practice : That a surgeon ought not to be contented with removing merely theindurated, or actually diseased part, but that he should also take away some portion of the surround- ing substance, in which a diseased disposition may probably have been excited In conse- quence of this communication of disease to the contiguous parts, the skin soon becomes indurated, and attached to a carcinomatous tumour, which, in like manner, is fixed to the muscles, or other part, over which it was formed. As a carcinomatous tumour increases, it generally, though not constantly, becomeg unequal upon its surface, so that this ine- quality has been considered as characteris- tic of the disease. A lancinating pain is common ; but it is not experienced in every case, without exception. It is also a symp- tom, attending other tumours, which are unlike carcinoma in structure, and it can- not, therefore, be deemed an infallible cri- terion of the nature ofthe disease. (Aber- nethy's Surgical Works, Vol. 2, p. 69, fa.) A hard and painful glandular swelling, having a disposition to become cancer, says Richter, is the common, but, inade- quate and erroneous definition of scirrhus. The disease is not regularly attended with swelling; sometimes scirrhous parts dimi- nish in size and shrink. Hardness ,s not a characteristic property ; for many tumours, which are not scirrhous, are exceedingly indurated. The disease is not always situa- ted in the gland: it irequently attacks structures, which cannot be called glandu- lar; and hard glandular swellings are often seen, which do not partake of scirrhus___ The disposition to cancer cannot be enu- merated among the marks of scirrhus, since it is not discoverable, till carcinoma has ac- tually commenced. Its termination in open cancer, is not an invariable occurrence- and other tumours become cancerous to' which no one would apply the term scir- rhus. (Anfangsgr. der Wundarzn. B. 1.) Scientific surgeons ought undoubtedly to have a definite meaning when they employ the term scirrhus; the word is generally used most vaguely; and, perhaps, influenced bv its etymology, surgeons call an immense number of various morbid indurations scir- rhous, which are not at all of a malianant or dangerous character. I have always considered scirrhus as a diseased hardness, in which there is a pro- pensity to cancerous ulceration, and a 310 CANCER greater backwardness to recede, than ex- ists in any other kind of diseased hardness, although the skin may occasionally not break during life, and a few scirrhous indu- rations may h'hir. Works, p. 83.) yet, it is now well ascertained, that, in all these instan ces, the changes, which precede cancerous ulceration, bear no resemblance 10 those of a true malignant scirrhus. The puckering of the skin, the dull leaden colour of the integuments, the knotted and uneven feel of the disease, the occasional darting pains in the part, its fixed attach- ment to the skin above, and muscles be- neath, form so striking an assemblage of symptoms, that, when they are all present, there cannot be the smallest doubt, that the tumour is a scirrhus, and that the disease is about to acquire, if it have not already acquired, the power of contami- nating the surrounding parts, and the lym- phatic glands, to which the absorbents of the diseased part tends. As Sir Everard Home has observed, the truly scirrhous tumour,which is known to be capable of changing into the true open can- cer, when allowed to increase in size is known to be hard, heavy, and connected with the gland of the breast ; and, when moved, the whole gland moves along with it. The structure of a scirrhous tumour in the breast, is diflerent in the various stages of the disease ; and a description of the appearances, exhibited in the three princi- pal ones, may give a tolerable idea of what the changes are, which it goes through, previous to its breaking, or becoming, what is termed, an open cancer. When a section is made of such a tu- mour, in an early stage, provided the struc- ture can be seen to advantage, it puts on the following appearance: the centre is more compact, harder to the feel, aud has a more uniform texture, than the rest of the tumour; and is nearly of the consis- tence of cartilage. This middle part does not exceed the size of a silver penny ; and from this, in every direction, like rays, are seen ligamentous bands, of a white colour, and very narrow, looking, in the section, like so many extremely irregular lines, passing to the circumference ofthe tumour, which is blended with the substance of the surrounding gland. In the interstices, be- tween these bands, the substance is differ- ent, and becomes less compact towards the outer edge. On a more minute examina- tion, transverse ligamentous bands of a fainter appearance, form a kind of net- work, in the meshes of which the new- formed substance is enclosed. This struc- ture accords with what Dr. Baillie describes to be the cose in cancerous diseases of the stomach and uterus. In a more advanced stage ofthe tumour the whole of the diseased part has a more' uniform structure ; no central point can be distinguished ; the external edge is more defined, and distinct from the surrounding gland ; and the ligamentous bands, in dif- ferent directions, are very apparent, but do not follow any course, that can be traced. When the tumour has advanced to what may be called cancerous suppuration which, however, does not always happen in the centre, before it has approached the skin, and formed an external sore ; it then exhibits an appearance totally different from what has been described. In the cen- tre is a small irregular cavity, filled with a bloody fluid, the edges of which are ulcer- ated, jagged, and spongy. Beyond these there is a radiated appearance of ligamen- tous bands, diverging towards the circum- ference; but the tumour near the circum- ference is more compact, and is made up of distinct portions, each of which has a centre, surrounded by ligamentous bands, in concentric circles. In some instances, scirrhus has no ap- pearance of suppuration, or ulceration, in the centre, but consists of a cyst, filled with a transparent fluid, and a fungous ex- crescence, projecting into this cavity, the lining of which is smooth and polished — When a large hydatid of this kind occurs, a number of very small ones have been found, in different parts of the same tumour; and, in other cases, there are many very small ones, of the size of pins' heads, with- out a large one. These hydatids arc, by no means, sufficiently frequent in their occur- rence to admit of their forming any part of the character of a cancerous tumour.— (Home's Observations on Cancer, p. 156, fa Svo. Lond. 1806.J In the fourth chapter of this work, the author relates two cases of hydatids found in the breast. In the first, the contents of the cyst were bloody serum ; in tbe second, a clear fluid. These two cases of simple hydatids in the breast, unconnected with any other diseased alteration of structure, led Sir E. Home to consider more particu- larly the nature of such hydatids, as are sometimes found in cancerous breasts; and, he believes, that they form no real part of the cancerous disease, but are accidental complaints superadded to it; and it is this gentleman's belief, that, as they occur in the natura] state of the gland, they are much more likely to do so in disease. (Op. cit. p. 108, 159.) Sir E. Home defines what he means by cancer, as follows: "As cancer is a term too indiscriminately applied to many local diseases for which we have no remedy, though they differ very much among them- selves, it becomes necessary to state what the complaints are which I include under this denomination. The present observa- tions respecting cancer, apply only to those diseased appearances, which are eapable of CANCER 311 contaminating other parts, either by direct communication, or through the m dium of the absorbents ; and when they approach the skin, produce in it small tumours of their own nature, by a mode of contamina- tion, with which we are at present unac- quainted. " There is a disease, by which parts of a glandular structure are very frequently at- tacked, particularly the os tincae, the alae of the nose, the lips, and the glans penis. This has been called cancer, but differs from the species, of which we are now- treating, in not contaminating the neigh- bouring parts with which it is in contact; and neither affecting the absorbent glands, nor the skin at a distance from it. It is, properly speaking, an eating sore, which is uniformly progressive; whereas, in cancer, after the sore has made some progress, a ridge is formed upon the margin, and the ulceration no longer takes that direction. It also differs from a cancer, in admitting of a cure in many instances, and under dif- ferent modes of treatment. ''From the facts which have been sta- ted, (See the cases detailed in this gentle- man's work,) it appears that cancer is a dis- ease which is local in Us origin. In this re- spect the cases (alluded to) only confirm an opinion very generally received among medical practitioners; but, in favour of which no series of facts had been laid be- fore the public, of sufficient force entirely to establish the opinion." (P. 145, fa.) Sir E. Home endeavours to establish a second point, that cancer is not a disease uhich immediately lakes place in a healthy part of the body; but one, for the production of which it is necessary, thai ihe part should have undergone some previous change, con necled with the disease. In proof of this, Sir E. Home adduces the two first cases in his work, and the innumerable instances in which a pimple, small tumour, or wart upon the nose, cheek or prepuce, may re- main for ten, fifteen, or thirty years, with- out producing the smallest inconvenience; but, at the age of sixty or seventy, upon being cut in shaving, bruised by any acci- dental violence, or otherwise injured, as- sumes a cancerous disposition. All the cases of induration of the gland of the breast, or of indolent tumours in it, which have continued for years without producing any symptom, and, after being irritated by accidental violence, have as- sumed a new disposition, and become can- cerous, admit of the same explanation; and are adduced as so many proofs ofthe truth of this latter position. (P. 147, fa.) However, the doctrine that certain tu- mours may change their nature, and change into cancer, is one which is sometimes looked upon with suspicion. "Improper treatment may without doubt exasperate diseases, and render a complaint, which ap- peared to be mild and tractable, danger- ous or destructive; but, to aggravate the symptoms, and to change the form of the disease, are things, that ought not to be confounded. I do not affirm (says Mr. Pearson) that a breast, which has been the 3eat of a mammary abscess, or a gland that has been affected by scrofula, may not be- come cancerous ; for they might have suf- fered from this disease, had no previous complaint existed ; but, these morbid al- terations generate no greater propensity to cancer, than if the parts had always retain- ed their natural condition. There is no ne- cessary connexion between cancer and any other disease ; nor has it ever been clearly proved, that one is convertible into the other." (Pract. Obs. on Cancerous Com- plaints, p 8.) To the latter way of think- ing, Mr. Abernethy also inclines; for, in speaking of the occurrence of cancer in parts previously diseased in another man- ner, he confesses, that his own observa- tions have not led him to believe, that this change is common. "Cases of tumours, which have remained indolent for twenty or more years becoming cancerous at an advanced period of life, are not unfrequent- ly met with ;" but, (says Mr. Abernethy,) the patients " might have been liable to the formation of a cancerous disease, even if no diseased structure had previously exist- ed." A degree of indecision, however, appears to be tbro>vn upon this statement by the admission, that cancer is more likely to begin in parts previously diseased. (Surg. Works, Vol. 2, on Tumours, p. 87.) The following are some of tbe most dis- tinguishing characters of scirrhus. A scir- rhous induration seldom acquires the mag- nitude, to which almost all other tumours are liable to grow, when no steps are taken to retard their growth. .Many scirrhi are attended even with a diminution, or shrunk state, of the part affected. Scirrhi are generally more fixed, and less moveable, than other sorts of tumours; especially, when the latter have never been in a state of inflammation. With the exception of the fungus haema- toides, other diseases do not involve in their ravages indiscriminately every kind of structure, skin, muscle, cellular substance, he. and the integuments seldom become affected before the distention, produced by the size of such swellings, becomes very considerable. In scirrhous cases, tbe skin soon becomes contaminated, discoloured, and puckered. Some few tumours may be harder, and heavier, than a few scirrhi; but, the reverse, is commonly the case As other indurations, and tumours, may assume the cancerous action, and even end in cancerous ulceration ; and, as some true scirrhi, when not irritated by improper treatment may continue stationary for years ; the occurrence of actual carcinoma cannot prove, that the preceding state was that of scirrhus. The only criterion ofthe latter disease is deduced from the assemblage of characters already specified ; for, except the peculiar puckering, and speedy leaden discolouration ofthe skin, no other appear 312 CANCER ances, considered separately, form any line of discrimination. The white ligamentous bands, around a scirrhus, form a very characteristic mark of the complaint, at least as it presents itself in the female breast ; but, these cannot be detected, till the disease has been removed. Hence, how manifestly prudent it must be lo take away a considerable portion of the substance surrounding a scirrhous tumour! Were any of these white bands left, the disease would inevitably recur Mr. Pearson has never yet met with an unequivocal proof of a primary scirrhus in an absorbent gland, and, (says he) " if a larger experience shall confirm this obser- vation, and establish it, as a general rule, it will afford material assistance in forming the diagnosis of this disease. (Pract. Obs. on Cancerous Complaints, p. 5.) SirE. Home, however, has given tbe particulars of one case, which seemed to him to have com- menced in one of the lymphatic glands, situated between the nipple and the axilla. (Obs. on Cancer, p. 161.) The position laid down by Mr. Pearson, that when the disease originates in those glands, it will rarely be found to be of a cancerous nature, may yet be very generally correct. OF CANCER IN THE STATE OF ULCERATION. According to the observations of Mr. Abernethy, the diseased skin, covering a carcinomatous tumour of the breast, gene- rally ulcerates, before the swelling has attained any great magnitude ; a large chasm is then produced in its substance, partly by a sloughing, and partly by an ul- cerating process. Sometimes, when cells, contained in the tumour, are by this means laid open, their contents, which are a pulpy matter of different decrees of consistence, and various colours, fall out,and an excoria- ting ichor issues from their sides. This dis- charge takes place with a celerity, which would almost induce belief, that it can hardly result from the process of secretion. When the diseased actions have, as it were, exhausted themselves, an attempt at reparation appears to take place, similar to that which occurs in healthy parts. New flesh is formed, constituting a fungus of pe- culiar hardness, as it partakes of the dis- eased actions, by which it w as produced. This diseased fungus occasionally even cicatrizes. But, though the. actions of the disease are thus mitigated ; though they may be for some time indolent and station- ary ; they never cease, nor does the part ever become healthy. In the mean while, the disease extends through the medium of the absorbing ves- sels. Their glands become affected, at a considerable distance from the original tu- mour. The progress of carcinoma in an absorbent gland, is the same as that, which has been already described. Tbe disease is communicated from one gland to another, so that after all the axillary glands are affected, those which lie under the collar bone, at the lower part of the neck, aud upper part of the chest, become disordered. Occasionally, a gland, or two, become dis- eased higher up in the neck, and apparently out of the course which the absorbed fluids would take. As the disease continues, the absorbent glands, in the course of the in- ternal mammary vessels, become affected. In the advanced stage of carcinoma, a number of small tumours, similar in struc- ture to the original disease, form at some distance, so as to make a kind of irregular circle round it. The strongest constitutions now sink under the pain and irritation, which the disease creates, aggravated by the obstruction, which it occasions to the function of absorption in those parts, to which the vessels leading to the diseased glands belong. Towards the conclusion ofthe disease, the patient is generally affected with difficulty of breath- ing, and a cough. (See Abernethy's Surgi- cal Works, Vol. 2, p. 72, fa.) In the above species of carcinoma, de- scribed by Mr. Abernethy, the part is pecu- liarly hard, and rarely attains considerable magnitude. He admits, however, that there are varieties, and speaks of another case, iu which the integuments sometimes remain pale and pliant; " and a surgeon, who first sees the breast in this state, may doubt whether the disease be actual cancer, or common sarcoma. The substance of the tu- mour is also much less hard, than in the spe- cimen first described ; yet, it is more com- pact and weighty, than most other diseases of the same bulk, which are not carcino- matous. If the history of the disease ac- cords with that of carcinoma; that is to say, if it began in a small district, and regu- larly and unabatingly attained its present magnitude ; if the surface of the tumour be unequal, having produced in various parts roundish projecting knobs, the disease will almost invariably be found to be carcinoma The skin will soon adhere to one, or more of these prominences ; it will ulcerate and expose the subjacent parts; and the future progress of the disease will accord to that of the harder and smaller specimen," ex- cept that the absorbents are much less liable to be affected. (Vol. cit. 85.) The edges of a cancerous ulcer are hard, ragged, and unequal, very painful, and re- versed in different ways, being sometimes turned upwards and backwards, and, on other occasions inwards. Tbe whole sur- face of the sore is commonly unequal: in some parts, there are considerable risings, whilst, in others, there are deep excavations. The discharge, for the most part, is a thin, dark coloured, fetid ichor; and is often possessed of such a degree of acrimony, as to excoriate, and even destroy, the neigh- bouring parts. In the more advanced stages of the disease, a good deal of blood is often lost from the ulcerated vessels. A burning heat is universally felt over the ul- cerated surface ; and, this is the most tor- menting symptom, that attends the disorder. Those shooting, lancinating pains, which CANCER. 313 are generally very distressing in the occult state ofthe complaint, became now a great deal more so. .Notwithstanding cancerous diseases are not always situated in glandular parts, the situation of such sores affords some assistance in the diagnosis; for, six times as many cancerous affections occur in the lips, and female breasts, as in all the rest of the body together. (B. Bell.) By some of the old writers, the causes of cancer were referred to the presence of worms, which destroyed the parts, and pro- duced all the local mischief. Strange as this doctrine may appear, one very analo- goustoitwasadopted by the late Dr. Adams. (Observations on Morbid Poisons.) When hydatids found their way into a solid sub- stance, he supposed, that the effect would be cancer; and he conjectured, that the success of au operation would depend, in a great measure, upon these animals being < onfined in a common cyst, for then they eould be entirely removed; whereas, if they were unconnected, some ofthe smaller ones would be likely to remain. The ab- surdity of this doctrine, and the eccentric reasoning, by which it is supported, make it quite unnecessary here to fatigue the reader with an explanation of it. Concerning the manner, in which these animals produce the symptoms of cancer, we are told, that " this enlargement of a foreign body in a solid substance, and so extremely sensible, as the breast, cannot but be attended with intense paiu, and frequent inflammation :" a doctrine not far removed, says Mr. J. Burns, from that taught in the humoral schools, which maintained, that the coagu- lation, and inspissation of the fluids, dis- tended the follicles ofthe glands, producing many cavities, and much pain. (J. Burns on Inflammation, Vol. 2.) Though hydatids are occasionally found in cancerous tu- mours, they are not found often enough to make any part of the character of the dis- ease ; and they are met with in cases in which there is not the least vestige of such disorder. After cancer had continued some time, it was believed, that the matter was ab- sorbed into the blood, and that all the hu- mours were speedily assimilated. Hence was explaiued the fatal and rapid progress of relapses, after an apparent cure. The only effect of absorption, however, is on the lymphatic glands, which intervene be- twixt the sore and the heart; for, beyond these, the absorbed matter is changed in its fsji nature and properties. (Bum*.) t In many instances, cancer is evidently produced by the same causes, which are capable of producing simple inflammation. It is, however, a general opinion, that can- cer arises frequently from some unknown md mysterious cause, which we cannot 'efect, and which, therefore, has been re- lived into a constitutional taint. But, as ir as we know, the constitution is perfectly ualthy in the commencement of this dis- lse ; nor i* there the smallest proof, that resembles scrofula, in depending on any Vol. I 40 peculiarity of constitution, before the causes operate. Blows, bruises, he. may give rise to cancer; but, in many instances, there is no evident local cause acting directly on the part. In the breast, cancer frequently commences, without the interference of any topical agent. In these cases, how- ever, there is always an irregularity, or dis- appearance of the menses ; and the affec- tion of the mamma may be supposed to depend on sympathy between it and the uterus. Certain it is, that cancer is very frequent about the time of life, when the menstrual discharge ceases. It is a commonly received opinion, that cancer is an hereditary disease, or observed to prevail a good deal in particular families. Sir Everard Home has endeavoured to re- concile this sentiment to the doctrine of the disease being at first entirely of a local nature ; circumstances, which seem incom- patible : " It is now universally admitted (says be) that children take after their pa- rents in the general structure of their bodies, and therefore will be more or less liable to have the different solids, of which they are composed, disturbed by the same causes f aud when a violence of any kind is committed upon them, it may be produc- tive of the same diseases.—In somefamilies, the venereal disease shall always appear in the form of gonorrhoea [?] ; in others again, rarely or never in that form, but, in that of chancre. [?] Strictures in the urethra are common in some families : they have taken place iu a father, and all bis sons from very slight causes ; such indeed as would not have produced the disease in others. Yet, stricture cannot be called hereditary, because it is a local complaint, arising from a local inflammation differing in different people, according to the natural irritability of the parts, which are affected. In this way, and this only, can cancer run in fami- lies, and be an hereditary disease, he." (Obs. on Cancer, p. 150.) The observations, w hich this gentleman has published respect- ing cancer, are unquestionably some of the most valuable which have yet been collect- ed ; but, I am doubtful about the correctness of one term, which is frequently met with in his work, viz. cancerous poison. At all events, I am not at present acquainted with any facts, which satisfactorily demonstrate the existence of such virus; and, from some circumstances briefly mentioned in vol. X of the 4th edition of the First Lines of the Practice of Surgery, the reality of a poisou of this nature would seem at least question- able. In support of the belief in the ex- istence of a cancerous virus, it has been ob- served, however, " that we scarcely ever see glands diseased out of the course, which the absorbed matter would naturally take, though they are affected in this manner in diseases, which can be propagated by irri- tation." (Abernethy's Surg. Works, Vol. 2, on Tumours, p. 75.) Undoubtedly, cancer is most common iu elderly persons ; but no age is exempt from the disease. Mr. J. Burns has seen it dis- 314 CANCER. tinctly marked, and attended with a fatal event, in children of five years old ; he mentions two instances of the eye being affected in such subjects, though from the late observations of Mr. Wardrop, we may now reasonably suspect, that these exam- ples were really cases of the fungus haema- todes. An instance, in which a cancerous disease of the breast began at the age of fifteen, is related by Sir E. Home. (Obs. on Cancer, fa. p. 50.) TREATMENT OF CANCER. Cancers have sometimes been supposed to be a general disorder of the system ; some- times merely local affections. This is a point of much importance in practice ; for, if cancers are originally only local affec- tions, no objection can be made to extirpa- ting them. They who think, that caucer is a constitutional disease, regard the operation as useless, perhaps hurtful, inasmuch as it may convert a scirrhus into an open cancer, or make the affection occur in some other part. Some ofthe best practitioners ofthe pre- sent day, however, reject the doctrine of cancer depending on constitutional causes; and, we have stated Sir E. Home's senti- ments, in opposition to the opinion. When eancer breaks out again, in the same part, after the performance of an operation, it is often owing to some portion of the disease having been blameably left behind, or to the operation having been put off too long. How likely it is, that some of the can- cerous disease may be left unremoved by the operator, is obvious on considering the manner, in which the white bands, resem- bling ligament, shoot into the surrounding fat; and that, even the fibres ofthe muscles, beneath a cancerous disease, are frequently affected. At the same time, it must be al- lowed, that the disease is sometimes, to all' appearances, so freely and completely re- moved., that its recurrence may be imputed, perhaps w ith equal probability, to the con- tinued operation of the same unknown cause, which originally produced the first cancerous mischief. Until late years, the accounts given of the results of operations for cancers were so unpromising, that they deterred many patients from undergoing a timely opera- tion ; which, for cancerous complaints, is the only remedy to be depended on, with which we are as yet acquainted. As Mr, B. Bell remarks, the great authority of Dr. Alexander Monro must have had no incon- siderable influence even with practitioners, in making them much more backward in undertaking the extirpation of cancers, than they otherwise would have been. " Of near sixty cancers," says he, " which I have been present at the extirpation of, only four patients remained free of the dis- ease, at the end of two years: three of these lucky people had occult cancers in the breast, and the fourth had an ulcerated cancer on the lip." (Edinb. Med. Essays, Vol. 5.) Dr. Monro also observes, that, in those, in whom be saw the dise^e relup.se, it was always more violent, and mude a quicker progress, than it commonly did in others, on whom no operation had been performed. Hence he questions," whether ought cancerous tumours to be extirpated, or ought the palliative method only to be followed ?" and, upon the whole, he con- cludes against their extirpation, except in such as are of the occult kind, in young healthy people, and have been occasioned by bruises, or other external causes. More modern experience, however, ha< afforded a very different result, and given ample encouragement to the early perform- ance of an operation, and even lo making an attempt to cut away the disease, in every instance, both of the occult and ulcerated kind, when such a measure can be so exe- cuted, as not to leave a particle of the can- cerous mischief behind. Mr. Hill, in 1772, published some valuable remarks on the present subject. At this pe- riod, he had extirpated from differ-ut parts of the body eighty-eight genuine cancers, which were all ulcerated, except four; and all the patients, except two, recovered of the operation. Of the first forty-five case>, only one proved unsuccessful; in three more, the cancer broke out again in different parts; and, in a fifth, there were threat- enings of some tumours, at a distance from the original disease. These tumours, how- ever, did not appear, till three years after the operation ; and the woman was carried off by a fever, before they had made any progress. All tbe rest of the forty-five con- tinued well, as long as they lived : or arr so says Mr. Hill, at this day. Oneofthem survived the operation above thirty years, and, fifteen were then alive, although the last of them was cured in March, 1761. Of the next thirty-three, one lived only four months; and, in five more, the disease broke out afresh, after having been once healed. The reason why, out of forty- five cases, only four or five proved unsuc- cessful, and six, out of thirty-three, wasa; follows : " The extraordinary success 1 met with, (says Mr. Hill,) made cancerous pa- tients resort to me from all corners of the country, several of whom, after delaying till there was little probability of a cure by extirpation, or any other means, forced me to perform the operation, contrary both te my judgment and inclination " Upon a survey in April, 1764, made with a view to publication, the numbers stood thus: Total cured, of different ages from eighty downwards, sixty-three; of whom there were then living 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 course of the last two years. So that, upon the whole, after thirty years'practice, thirty-nine, of sixty-three patients, were alive and sound ; which gives Mr. Hill oc- casion to observe, that the different patients lived as long after the extirpation of the cancers, as according to the bills of morta- CANCER 315 iity, they would have done, had they never had any cancers, or undergone any opera- tion. The remaining twenty-five, which com- plete the eighty-eight, were cured since the year 1764. Twenty-two of these had been cured, at least, two years; and some of them, it may be remarked, were seventy, and one ninety years old. In the year 1770, the sum of the whole ' stood thus: Of eighty-eight cancers, extir- pated at least two years before ; not cured, two ; broke out afresh, nine ; threatened wiih a relapse, one ; in all, twelve, which is less than a seventh part of the whole num- ber. At that time, there vyere about forty patients alive and sound, whose cancers had been extirpated above two years before. Mr B. Bell, who was present at many of these cases, bears witness to Mr. Hill's accu- racy; and the former very judiciously slates, that, " from these and many other authenti- cated facts, which, if necessary, might be adduced, ofthe success attending the extir- pation of cancers, there is, it is presumed, very great reason, for considering the dis- ease, in general, as a local complaint, not originally counected with any disorder of the sj stern." With respect to Mr. Bell's opinion, that a general cancerous taint sel- dom, or perhaps never, occurs, but incon- sequence of the cancerous virus being ab- sorbed into the constitution from some local affection, much doubt attends even this sup- position, though the practical inference from it is what cannot be found fault with : viz. iu every case of real cancer, or rather in such scirrhosities, as from their nature, are known generally to terminate in cancer, we should have recourse to extirpation as early as possible; " and if this were done soon after the appearance of such affections, or before the formation of matter takes jiluce, their return would probably be a very rare occurrence." (System, of Sur- gery, Vol. 7.) After comparing the different accounts of success given by Monro and Hill, well might Richter say : " Jure sane dixeris, de uno eodemque morbo hos viros loqui, dubilari ferepotest." (Obs. Chir. Ease. 3.) MEDICINES AND PLANS, WHICH HATE BEEN TRIED FOR THE CURE OF SCIRRHUS AND CANCER. It is a contested point, whether a truly cancerous disease is susceptible of any pro- cess, by which a spontaneous cure can be effected. It appears certain, however, that a violent inflammation, ending in sloughing, may sometimes accomplish an entire sepa- ration of a cancerous affection, and that the sore, left behind, may then heal. Facts, confirming this observation, are occasion- ally exemplified in cases, where caustic is used, and accidental inflammations have led to the same fortunate result, as we may be convinced of by examples recorded by Sir Everard Home, Richerand, he. The latter writer, adverting to the effort, which nature sometimes makes to rid herself of the disease, on the inflammation and bursting of the tumour, takes the opportu- nity to relate the following case. A woman, aged forty-eight, of a strong constitution, was admitted into the hospital of St. Louis, with a cancerous tumour of the right breast. The swelling, after becoming softer, aud af- fected with lancinating pains, was attacked with an inflammation, which extended to the skin of the part, and all the adjacent cel- lular membrane. The whole of the swell- ing mortified, and was detached. A large sore, of healthy appearance, remained after this loss of substance, and healed in two months. (Nosographie Chir. T. 1, p. 381, Edit. 2.) In general, however, it must be confessed, that inflammation, attacking a cancerous disease, renders things worse instead of better, and by converting occult cancers into ulcerated ones, hastens the patient's death, or, at all events, renders his cure more diffi- cult, and forbids any attempts, which, on such a principle, might be made for his relief. Of the general remedies, narcotics, such as cicuta, opium, nightshade, &.c. have been employed with most confidence. Cicuta owed its reputation to the experi- menting talent of Storck, who has written several libelli on this plant. According to him, cicuta possesses very evident powers over cancer, and has cured a great many eases; but, in less prejudiced hands, it has been found much less successful; and even in many of the, instances, adduced by Baron Storck, of its utility, it is by no means proved, that the disease was really cancer. The public have now, with great reason, very little reliance on this medicine. Mr. J. Burns declares, that, in cancerous ulcera- tion, he never knew cicuta to produce even temporary melioration. The common way of exhibiting hemlock is to begin with small doses, and increase them gradually, until they produce vertigo. We may begin with two grains of the ex- tract, or four of the powder, recently pre- pared, twice, or thrice a day, and the quan- tity is'to be gradually increased. In thi» way,'s6me patients have at last been able to takeVWit ounce of the extract daily ; but, says MiR'Buftisj'' if a much less quantity, than this,'prodirde no good effect, we may con- sider jt as usgless to continue a remedy, which!, in ems' dose, must injure the consti- tution every d'ay that it is continued. On the continent, hemlock has been used in the form of a bath ; but, this method is so disa- greeable, that few will submit to it. Belladonna was highly recommended bv Lambergen. During its use, he kept the bowels open with clysters, administered every second day. The dose should be, at first, a grain of the dried leaves, made into a pill. This, in the beginning, is to be given in the morning and evening, and afterwards more frequently. The reputation of bella- donna has not been supported by much success. Hyosciamus has often been tried in can- SI« CANCER. reroiis cases, and was held in great estima- tion by the ancients. Mr. J. Burn- sav-, he has employed it occasionally, but wiih little effect. The common dose at first is three grains ofthe extract. Aconitum has also been given ; and, as it \< a very powerful and dangerous narcotic, a patient usually begins with only half of a grain of the extract night and morning. Solanum dulcamara, Paris epiadrifolia, Phy- tolacca, he. have been recommended ; but, they are now hardly ever employed; which is a sufficient proof of their inefficacy. Mr. J. Iforns tried the hydro-sulphuret of am- monia, without any benefit. Richter pre- scribed the laurns cerasus, but with very little success. The dose of tbe distilled water being uncertain, four or five grains of tbe fresh leaves may be infused in a little water, as a dose. Tbe digitalis diminishes vascular action, and may act on scirrhi, like abstinence, bleeding, he. It has, however, no specific virtue in curing cancerous diseases. Opium isseldom employed, with an inten- tion of curing cancer, although it probably has jnr-t as much power of this kind, as other narcotics, which have been more fre- quently used. For the purpose of lessening the pain of cancerous diseases, opium is very freely employed. 'Ionics may sometimes improve the gene- ral health ; but, as they never produce any effect on the local disease, they are now seldom exhibited. Justamond thought arsenic a specific for cancers. Future experience has not, how- ever, confirmed the truth of this opinion, though there are many practitioners, who continue to think highly of the efficacy of this mineral in certain forms of disease, which have sometimes been classed with cancer, and in many cases of lupus, and malignant ulcers of the tongue, and other parts, it may really possess greater claims to further trial, than perhaps any other medi- cine, yet suggested. It unquestionably cures numerous ill-looking sores, on the face, lips, and tongue, and is one of the best remedies for lupus. Mr. Hill observes: "Experience has furnished me with some substantial reasons for considering,arsenic as a medicine of considerable merit, both with regard to actual cancer and scirrhus, which may one day terminate in that hor- rible species of ulcer; and although I can- not as yet say it will remove the one, or cure the other, as certainly and safely as mercury commonly does a syphilitic swell- ing, or open sore, yet, it will, in a great majority of cases, retard the progress of the true scirrhous tumour, and often prevent its becoming cancer. In some, it has appeared, to dissipate such swellings completely." (See Edinb. Med. and Surgical Journ. Vol. 6. p. 58.) Mercury, in conjunction with decoctions of guaiacum, sarsaparilla, he. has been re- commended ; but, as Mr J. Burns remarks, no fact is more certainly ascertained, than that mercury always exasperates the dis- ease, especially, when in the ulcerated state. Sulphate of copper has been tried ; but, at present, it retains no character, ns a reme- dy for cancer. The same may be said of muriated barytes. The carbonate (rust) of iron was particu- larly recommended by Mr. Carmicharl. Besides the carbonate of iron, he sometime* prescribed the tartrate of iron and potass, and the phosphate, oxyphosphate, and suboxy- phosphate of the metal. Some constitution* can bear these preparations only iu small quantities ; they affect most patients with constipation, and many with headach and dyspnea. These circumstances, therefore, must be attended to in regulating the dosi>. The above gentleman has seldom given le-.* than thirty grains, in divided doses, in a day, or exceeded sixty. He prefers the suboxyphosphate for internal use, and states, that it answers beet in small doses, frequent- ly repeated. It should be blended with white of egg, have a little pine fixed alkMi added, and then be made into pills with powdered liquorice. Aloes is recommended for the removal of costiveness. When half a grain is combined with a pill, containing four grains of carbonate of iron, and taken thrice a day, the constipation will be obvia- ted. When the internal use of iron brings on headach, difficult respiration, a quick. sometimes full pulse, which is also general- ly hard and wiry, excessive languor, lassi- tude, &.c. and such symptoms become alarming, the iron is to be left off, and four grains of camphor given every fifth hour. At the same time, that preparations of iron were internally administered, Mr. Car- michael employed externally, for ulcerated cancers, the carbonate, phosphate, oxyphos- phate, and arseniate of iron, blended with water, to the consistence of a thin paste, which was applied once every twenty-four hours. To occult cancers, the same gentle- man applied a solution of the sulphate of iron, ^j to lbj of water. The acetate of iron, diluted with eight or ten times its weight of water, was aUo used. These lo- tions were put on the part affected by means of folded linen, wet in them, and covered with a piece of oiled silk to prevent injury of the clothes. (See An Essay\ on the effects of the Carbonate and other prepa- rations of iron upon Cancer, fa. by R. Car- michael, 2d Ed. 8vo. Dublin, 180S.) Many remedies have acquired celebrity in cases of cancer, because very bad and malignant diseases, only supposed to be cancers, have got well, under their use Such is probably the case with the carbo- nate of iron. . The only mode of treatment, which Mr. Pearson has ever seen to do any particular benefit to cancer, is that of keeping the pa- tient on a diet, barely sufficient for the sup- port of life, such as barley-water alone, tea, he. Patients, with cancers, receive con- siderable benefit from being kept strictly on a milk diet. The old surgeons commonly dressed can- CANCER 317 cerous sores, with narcotic applications. Vesalius used cloths, dipped in the juice of Ihe solanum ; whilst others employed it mixed with oil of roses, and preparations of lead, and antimony. Others had recourse to the hyosciamus ; but, of late, cicutapoul- tices have superseded most other narcotic applications ; and, in many cases, as Mr. J Bums observes, they have, undoubtedly abated pain, and diminished fetor ; but this is idl which can reasonably be expected ; and even this expectation will not always be realized. This gentleman thinks carrot poultices better than those of hemlock, as they produce as much ease, and more pow- erfully diminish the fetor. The fetor of cancers hdving been thought to resemble that of the sulphuret of potash, (liver of sulphur) and the oxygenated muri- atic acid being the best agent for decompo- sing and destroying such smell, it has been recommended, as an application to cance- rous sores. It may correct the fetor ; but, it will never accomplish a cure. Carbonic acid has been said not only to correct the fetor, but, in some instances, completely to cure the disease. It was long ago proposed, says Mr. J. Burns, by Peyrille, and was again brought forward by Dr. Ewart. Ex- perience, however, has not shown, that the efficacy of carbonic acid, in cases of cancer, is vary great. Fourcroy remarks: " After fhe first applications, the cancerous sore appears to assume a more favourable aspect; the sanies, which flows from it, becomes whiter, thicker, and purer, and the flesh has a redder and fresher colour ; but, these flattering appearances are deceitful, nor do they continue long, for the sore speedily re- turns to its former state, and its progress goes on, as before the application." The best method of applying carbonic acid is, by means of a bladder, the mouth of which is fastened round the sore with adhesive plaster. The air is introduced by a pipe, inserted at the other end. Sometimes the fermenting poultice is employed. Digitalis, as alocal application, is entitled to about as much confidence as cicuta. Tar ointment, gastric juice, absorbent powders, &.c. have been tried ; but, without any evident good. (See J. Burns on In- flammation, Vol. 2.) Mr.Fearon rejected all internal remedies, as inefficient in the treatment of cancer, and in the early stages of the complaint, recom- mended a method of practice, founded on his idea ofthe inflammatory nature of the disease. " Iu the beginning of scirrhous af- fections of the breast and testis, the mode I have adopted of taking away blood, is by leeches repeatedly applied to the parts. In this course, however, I have often been in- terrupted by the topical inflammation, pro- duced by these animals, around the parts where they fastened. In delicate female habits, I have often lost a week, before I could proceed to the re-application of them. V hen the symptoms lead me to suspect the stomach, uterus, or auy of the viscera, to be so affected, that the complaint either is, or, most probably, soon will become can- cerous, I then have recourse to general bleedings. But, whether topical or general, perseverance for a sufficient length of time is necessary. Though the pulse never in- dicated such practice, yet the patients have not suffered by repeated bleedings ; on the contrary, when they passed a certain time without losing blood, they felt a return of their symptoms, and of their own accord, desired to be bled again. To this plan of repeated bleedings, I joined a milk and ve- getable diet, avoiding wine, spirits, and fer- mented liquors." Mr. Fearon used also to keep the belly open, and employ saturnine applications. Of the method of treating cancer by pres- sure, I have spoken in another work. (First Lines ofthe Practice of Surgery, Vol. 1.) and therefore, in this place, I need merely re- peat, that it is a practice, which none of the best modern surgeons think entitled to approbation. From the preceding accounts, we may infer, that scarcely any reliance is to be placed on any known remedy, or plan, in cases of real scirrhi, and ulcerated cancers. The operation is the only rational means of getting rid ofthe disease ; and, to waste time, so as to allow the disorder to increase in a serious degree, merely for the sake of trying a train of unpromising medicines, is conduct, which is unworthy of a wise sur- geon's imitation. Perhaps, in early cases, it may be right to make trial of arsenic, cicuta, or preparations of iron. But, the practitioner should be- ware of devoting too much time to medi- cines, which w ill in all probability prove inadequate to the object for which they are exhibited. Mr. Fearon's method seems also warrantable, together with diet merely enough to support life ; but the punishment, attending a resignation to this last regimen, would be greater, than that of having the disease cut away, while the chance of efn> cacy would be much less. Upon the whole, therefore, the operation is what we should generally adopt, as the surest, and the safest means of getting rid of cancerous diseases. As 1 have before remarked, the operation is always admissible, when every particle of the di. ease can be removed by it. Even large open cancers, if they can be entirely cut away, are often capable of being effec- tually cured. The removal of cancerous disorders even in the slightest and most trivial cases, should always be effected with the scalpel, in preference to caustic; the use of which, though sometimes it may succeed by produ cing a complete destruction ofthe diseased parts, causes severe agony, and, in the event of its not acting sufficiently on all the dis eased parts, often renders the complaint more aggravated, and kills the patient, and this in a very short space of time. In cases of cancer, the irritation generally 318 GANGER. occasioned by every application ofthe caus- tic kind, together with the pain and inflam- mation, which commonly ensue, are strong objections. Plunket's remedy, which is chiefly arsenic, is equally objectionable. Nor can you, at once, -o certainly extirpate every atom of cancerous mischief with any caustic, as you can with the knife : for, with this, you immediately gain an ocular inspection of the surface surrounding the disease, so as to see and feel whether the disordered parts are completely removed, or whether any portion of the disorder re- quires a further employment of the instru- ment. With respect to the pain, that of caustics is infinitely greater, more intolera- ble, and more tedious, than that occasioned by the knife. When caustic also fails in destroying every particle of the disease at once, it almost always tends to enlarge, in a very rapid way, the original boundaries ofthe mischief. For an account of the method of removing scirrhi and ulcerated cancers, see Mamma, Removal of. Much addi- tional information, respecting cancers, is contained in the 4th Fd. of the First Lines of the Practice of Surgery, Vol. 1, Svo. 1819. Le Dran's Operations in Surgery, p. 87, fa. Edit. 2. B. Bell's Surgery, Vol. 2. Juslamond's Account ofthe Methods pursued in the Treatment of Cancerous and Scirrhous Disorders, Svo. Lord 1780; also his Surgical Tracts, fa. 8vo. Lond. 1789. James Hill, Cases in Surgery, Svo. Edinb. 177:2 Vin- dungus ab Hurting, De Optima Cancrum Mammarum extirpandi ratione. Alsdorf, 1720. (Haller, Disp Chir. 2, 609.) /,. Rouppe, deMorbu Navi^nnlium liber, accedit Obs. de Effectu, Extracti cicuta Storkiano in Cancro Svo. Lugd. 1764. G. Dowman, on the Nature, fa. of a Scirrhus, Svo. Lond. A. Storck, An Essay on the Medical Nature of Hemlock, fa. 8vo. Lond. 1760. C. Molina- rius Hisloria Mulieris a scirrho curala, 8vo. Vindob. 1761. G. Tabor, De Cancro Mam- marum, cumque nova extirpandi Methodo, Trajei ti, 1721. C. Perry, Mechanical Ac- count of the Hysteric Passion, fa. with an Appendix on Ca,icer, Svo. Lond. 1755 Sir John Hill, plain and useful Directions for those who are afflicted with Cancers 2d. Ed. 8vo. Lond. G. A. Langguth, Programma de potissimis Cancri Mammarum Causispruden- ter occupandis, Witlemb. 1752. Ph. Fr. flmelin el Achat. Gartner, Specifica Melho- dus recentior cancrum sanandi, fa. Tubinga, 1757. N. Zaffarini, StoriadidueMammelle Demolite nella di cui scirrosa sostanza sono stati trovati nove Aghi. Svo. Venez. 1761. C. Petrus, Dis*. sislens hisloriam rariorem mamma cancrosa, sanguinem menstruum fundenlis, methodo simpliciore sonata.— '(Frank. Del. Op. 10.) W. Beckett, New Dis- coveries, relating to the Cure of Cancers, wherein a method of dissolving cancerous sub- stance is recommended, fa. Svo. Lond. 1711. W. Norford, Essay on the general Method of treating Cancerous Tumours, fa. 12mo. Lond. 1753. R. Guy, An Essay on Scir- rhous Tumoursand Cancers,8vo. Lond. 1759; also. Practical Obs. on Cancers, fa. 8ro. J. Burrows, Practical Essay on Cancers, Sio. Lond. 1767. CAr. C. Lerchc, Obs. de Cancro Mammarum. 4to. Gott. 1777. F. Hopkins, De Scirrho et Carcinomale, 8no. Edinb. 1777. B. Pcyrilhe, Diss, on Cancerous Diseases translated from the Latin, with Notes, 8to. Lond. 1777. ./. Andree, Observations upon a Trenlisi on the Virtues of Hemlock in the Cure of Cancers, written by Or. Storck, of Vienna, wherein the Doctor's Ciucs ,n favour of that vegetable are candidly examineit, and proved insufficient in divers instances; icilh some practical remarks on Cancer in general, fa. 8vo. Lond. 1761. P.J. F De Rameux Scirrho et Cancro, Oeuderghern, lTsa. f. Clerke, Diss de Cancro, Svo. Edinb. 1784. R. Hamilton, on Serophuloas Affections, with Remarks on Scirrhus, fa. 8vo. Lond. 1791 E Kentish, Cases of Lancer ; with Obs. on the Use of t arbonate. of Lime, 8re Newcastle, 1802. C T. Juhnson, a Practical Essay on Cancer, 8vo. Lond. 1810. Fearon on Can- cers with an Account of a new and successful method of operating, particularly in Cancers ofthe Breast, or Testicle, 8vo. Lond. 17.M5. B. Bell on Ulcers. Adams on Cancerous Breasts, Svo. Lond. 1801 ; and on Morbid Poisons, 2d Ed. 1807. Medical Museum, Vol. 1. Med. Trans. Vol. 1. Gooch's Med. Observations, Vol 3. L'Encyclopedic Mitho- dique, Partie Chirurgicale. Article Cancer, in Rees's Cyclopadia. Practical Observations on (anccr, by J. Howard, 8i'o. Lond. 1811. Memoire renj'ermant quelques Vuts Gineralrs sur le Cancer, in (Euvres Chirurgicales de Desault par. Bichat, Tom. 3, p. 406, ^c— Richerand's Nosographie Chirurgicale, Tom, 1 p. 377, fa. Edit. 2. Lambe's Inquiry into the origin and cure of Constitutional Disea- ses, 8vo. Lond. 1805, and Reports ofthe Effects of a peculiar Regimen in Cancerous Com- plaints, Svo. Lond. 1815. Baillie's Morbid Anatomy of some ofthe most important Paris of the Human Body. The Queries ofthe So- ciety for investigating the Nature and Curt of Cancer may be seen in the Edinb. Med and Surgical Journal, Vol. 2, p. 382, fa. Diet. des Sciences Med. art. Cancer. Alibert, Nosol. Naturelle, T.\,fol. Paris, 1817. Consult also, Wardrop on Fungus Hamatodti, in whichmay be seen an interesting comparator view of this last affection and Cancer. Den- man's Observations on the cure of Cancer, 8i*. Lond. 1810; and Carmichael's Essay on the Effects of Carbonate and other preparations of Iron upon Cancers ; with an Inquiry into the Nature of that and other diseases, to which it bears a relation, 2d Ed. Svo. Dublin, 1809. W. Thomas, Commentaries on the Treatment of Scirrhi and Cancer, 8vo. Lond. 1805,1817. S. Young, Inquiry into the Nature, fa- of Cancer, 8vo Lond. 1805. Minutes of Ca- ses of Cancer and Cancerous tendency, torn. Lond 1816; also further Report* of dues treated by the new mode of pressure, 8ro. Lond. 1818. j. Pearson, Practical Obs. on Cance- rous Complaints ; with an Account of some Diseases, which have been confounded with Cancer ; also Critical Remarks on some of the Operations performed in Cancerous Cater, 8vo. Lond. 1793. Ahernethy's Surgical CAP Works, Vol. 2. Lond. 1811. J. Rodman, A. Practical Explanation of Cancer in the Breast, Svo. Lond. 1815. Sir E. Home, Obs. on Can- cer, Svo. Lond. 1805. CANCER SCROTI.----CHIMNEY- SWEEPER'S CANCER. (See Scrotum.) CA'NCRl M ORIS. A deep, foul, irre- gular, fetid ulcer, with jagged edges, which appears upon the inside of the lips and cheeks, and is attended with a copious flow of offensive saliva. According to Mr. Pear- son, this disease is seldom seen in adults; but, most commonly, in children from the age of eighteen months to that of six or seven years. The gums, as well as the lips and cheeks, are sometimes affected, in which circumstance, the teeth are general- ly carious and loose. The ulceration is oc- casionally attended with abscesses, which burst either through the cheek, lip, or just below the jaw. Exfoliations are not unfre- quent, and, when the disease is neglected, extensive sloughing sometimes happens. Living in a marshy situation; unwhole- some food; and inattention to cleanliness; are suspected to be conducive to this dis- order. The causes of the affliction seem not to be understood; but it is remarked, that the disease prevails most in houses, where children are crowded together It is uncertain whether the complaint is con- tagious. Though children are the usual subjects of this disease, grown-up persons do not al- ways escape its attacks. The treatment recommended consists in extracting diseased teeth and loose pieces of bone, directing a milk vegetable diet, with a prudent quantity of fermented li- quors; and prescribing bark, sarsaparilla, and elm bark, with sulphuric acid. The best external applications are, dilu- ted mineral acids ; burnt alum; the decoc- tum cinchona', with sulphate of zinc ; tinc- ture of myrrh; lime-water, with spirit of wine, he. (See Pearson's Principles of Sur- gery, Edit. 2, p. 287.) • CANTHARIDES. (Lytla.) Spanish or French flies, with which the common blis- tering-plaster is made. In surgery, they are also prescribed in incontinence of urine, gleets, he. The tincture is sometimes used as a liniment for stimulating parts. CAPELINA. (from capeline, a woman's hat, or bandage, French.) A double-head- ed roller, above twenty-four feet long, and four inches broad. The middle is applied to the occiput, and, after two or three cir- cular rounds, the rollers intersect each other upon the forehead and occiput; then one roller being reflected over the vertex to the forehead, the other is continued in a circular track. They next cross each other upon the forehead, after which the first head is carried back obliquely towards the occiput, and reflected by the side of the other. The last is continued in a circular direc- tion ; but the first is brought again over the sagittal suture, backward and forward, and so continued, till the whole head is covered. Bv the ancients, this bandage was some- CAR 31$ times applied in cases of hydrocephalus: it has no advantage, however, and is now hardly ever used. CAPILLARY FISSURE. A very minute crack in the skull. The term came into use from the resemblance of such a frac- ture to a hair. CAPISTRUM. (See Bandage.) * CARBUNCLE, (from carbo, a burning coal.) Anthrax. This is a very common symptom in the plague ; but comes on also sometimes as a primary disease. The first symptoms are great beat and violent pain in some part of the body, on which arises a kind of pimple, attended with great itch- ing; below which a circumscribed, but ve- ry deep-seated, and extremely hard tumour may be felt with the fingers. This tumour soon assumes a dark red, or purple colour, about the centre, but is considerably paler towards the edges. A blister frequently appears on the apex, which, as it occasions an intolerable itching, is often scratched by the patient. The blister being thus broken, a brown sanies is discharged, and an eschar makes its appearance. Many such pim- ples are sometimes produced upon one tu- mour, in consequeuce of the patient's scratching the part. (Bromfield's Obs. Vol. I.) Carbuncles have been distinguished into the benign and malignant kinds ; but as far as the disease can be judged of at present in this country, the distinctions are only founded upon tbe different degrees of vio- lence, with which the disease makes its at- tack. Some carbuncles are said to be pes- tilential ; while others are not at all infec- tious. Fortunately, all cases, which are met with in this island are ofthe last sort; for no opportunities of remarking the pestilen- tial anthrax have occurred in England since the deplorable periods of 1665, and 1666. The carbuncle sometimes appears in per- sons affected with typhoid fevers, in which case, it is attended with great weight and stiffness of the adjacent parts ; the patient is restless and pale, the tongue white, or of a deep red, and moist; the pulse low, urine sometimes pale, sometimes very turbid, with all the other symptoms in an exag- gerated degree, which attend typhoid fe- vers. The patient often complains much of his head, either from pain or giddiness. Sometimes he is drowsy ; at other times, he cannot get the least sleep. Occasional- ly, he is delirious. The case is also apt to be attended with chilliness, or rigours, and profuse perspirations. The patient is some- times costive, sometimes afflicted with a profusion of stools; he generally complains of loss of appetite, nausea, and vomiting, takes but little nourishment, complains of difficulty ef breathing, and is extremely low, with palpitations of the heart, and sometimes faintings. (See Bromfield's Ob- servations, Vol. 1, p. 122.) Sometimes a little slough, of a black co- lour, appears in the middle of the tumour. This was supposed by the ancients to be a part ofthe body burnt to a cinder, or hard crust, by the violence of the disease. By some authors, the carbuncle is considered "320 CAR CAR as a sort of gangrenous affection of the cel- lular substance. (Latta.) The progress of carbuncles to the gangrenous state is gene- rally quick, Their size is very various; they have been known to be as large as a plate. Considerable local pain and indura- tion always attend the disease. The skin, indeed, has a peculiar feel, like that of brawn. As the complaint advances, seve- ral apertures generally form in the tumour. Through these openings, there is discharged a greenish, bloody, fetid, irritating matter. The internal sloughing is often very exten- sive, even when no sign of mortification can be outwardly discovered. If attention is paid to the skin in this case, we shall frequently find some miliary eruptions about the clavicles, the breasts, or other parts of the body; and, towards the latter end of the disorder, a different collection of large pimples will sometimes be thrown out, like the small-pox, and sup- purate. Some of these, indeed, are occa- sionally converted into actual carbuncles. It was this species of anthrax, which was called malignant, and certainly, if any ca- ses, seen in this country, demand this epi- thet more strongly than others, it is the in- stance, the description of which we have ju<=t quitted. The constitution is often so low and ex- hausted, that death follows. The carbun- cle, indeed, is most frequent in old persons, whose constitutions have been injured by voluptuous living, and, hence, we cannot be surprised, that the local disease, influ- enced by the general disorder of the sys- tem, should assume a dangerous aspect. The degree of peril may generally be esti- mated by the magnitude and situation of the tumour, the number of such swellings at the same time, the age of the patient, and the state of his constitution. Iu cases of anthrax, the duty of a sur- geon may be described in a few words.— With regard to the local treatment, the grand thing is to make an early, and free incision into the tumour, so as to allow the sloughs and matter to escape readily. As much of the contents as possible is to be at once pressed out, and then the part is to be covered with an emollient poultice. In- deed, until the tumour is opened, no appli- cations are more proper than emollient poultices, and, when an incision has been made, they are far preferable to any de- tersive antiseptic injections, made with bark, tincture of myrrh, he. or to any lo- tions made with the sulphates of copper, and zinc, nitrate of silver, he.; fomenta- tions will also be found to afford considera- ble relief, both before and after an open- ing has been made. As the discharge is exceedingly fetid and irritating, it will be necessary to put on a fresh poultice two or three times a day. The use of the poultice is to be continued till all the sloughs have separated, and the surface of the cavity ap- pears red, and in a granulating state, when soft lint and a pledget of some unirritating ointment, should be applied, together with a compress and bandage. The manner in which the disease is protracted, by not ula. king a proper opening in due time, cannot be too strongly impressed upon tbe mind of every practitioner, and it may justly be re- garded as a frequeut i *iison of tbe fatal ter. minations of numerous cases. Mr. Brom- field forcibly inculcates tbe necessity of making a timely opening for the discharge of the slough6; for, says he, in case von rely on the opening, made by nature, tlin thin matter only will be discharged; tbe sloughy membranes will remain, and the orifice close up. (See Vol. \,p. 128.) It was fon.ierly not an uncommon cus- tom to extirpate carbuncles with the knife, or to destroy them with the actual and po- tential cauteries. The French were very fond of burning the swelling with a hot iron, the employment of which is sanction- ed by Porteau. (See his (Eucrts Pod- humes.) These methods, having been found cruelly painful, and, in no manner advan- tageous, have long been branded with the reproaches of all English surgeons. With respect to the constitutional treatment, \w; should remember that the disease is for the most part met with in bad constitutions, am] in persons who are weak and irritable.— Hence, it is only when there is a full strong pulse, and the complaint is just beginniug, that bleeding is allowable. Bark and cam- phor are the internal medicines most com- monly needed. The diluted sulphuric acid is also highly proper, as well as wine and aromatics. As the pain is very severe, opium is generally an essential remedy.— The constitutional treatment is very analo- gous to that of mortification, and, for this reason, I do not deem it necessary to en- large the present article, by expatiating on this part of the subject. (See Mortification.) In many of the southern parts of Europe, a malignant species of carbuncle, appears to be endemic, contagious, and very often fatal. For an account of this form of the disease, I would particularly advise the reader to consult Richerand's Nosogr. Chir. T.\, p. ccx, fa. Edit. 4, and Larrey't Mi- moires de Chirurgie Militaire, Tom. 1, p. 104, fa. A description of it was likewise in- troduced into the 4th edition ofthe First Lines of Surgery. Bromfield's Chirurgical Ciuti and Observations, Vol. 1. L'Encyclopidie Mitlwdique, Partie Chirurg. art. Anthrax. Pearson's Principles. Richter's Anfangsgr. der Wundarzn. B. I. Boyer s Traiti des Ma- ladies Chirurgicales, T. 2, p. 50, fa. CARCINOMA, (from jm/uuw, a crab.) See Cancer. CARIES, (from mpa, to abrade.) Caries is a disease of the bones, supposed to be very analogous to ulceration of the soft parts; and this comparison is one of great antiquity, having been made by Galen. However, by the generality of the ancieats, caries was not discriminated from necrosis. It was from the surgeons ofthe eighteenth century, that more correct opinions were derived respecting caries. Until this period, writers had done little more, than mention the complaint and the methods of treating it. Some new light was thrown upon the- CARIESr. 321 subject by J. L. Petit, in his remarks upon exostosis and caries. (Mai des Os. T. 2, Chap. 16, p. 27.) But, as he only spoke of the disorder, as one of the terminations of exostosis, he has not entered far into the consideration of it. The best observations on caries were first made by Dr. A. Monro, primu*. (Edinb. Med. Essays, T. 6, art. 25.) This memoir contains the earliest correct ideas of dry caries, or necrosis, which is rightly compared to mortification of the soft parts, and named gangrenous caries. The bones, like other parts of the body, are composed of arteries, veins, absorbent vessels, nerves, and a cellular texture; they are endued with vitality; they are nourished, grow, waste, are repaired, and undergo va- rious mutations, according to the age of the individual; and they are subject to dis- eases analogous to those of the soft parts. To the phosphate of lime, which is more or less abundantly distributed in their texture, they owe all their solidity, and, perhaps, it is to the same earthy substance, that the difference in their vital properties, and in their diseases, from those of the rest of the body, is to be referred. In fact, this parti- cular organization, and inferior vitality of the bones, are generally supposed to account for the small number peculiar character, and slow progress of their diseases. (Did. des Sciences Med. T. 4, p. 80.) All the bones are liable to caries; but those of a spongy texture are more fre- quently attacked, than such as are compact. Hence, the vertebrae ; astragalus, and other bones of the tarsus; those of the carpus; the sternum ; the bones of the pelvis, and the heads of the long bones, are often af- fected ; and the bones of young persons are unquestionably more frequently the seat of canes, than those of old subjects. In necrosis, the bone is entirely deprived of life ; in caries, the vital principle exists, but a morbid action is going on, whereby the texture of the bone is altered, and ren- dered softer and lighter than natural. In the most common species of caries, a loose, fungous flesh grows out of the inter- stices, formed On the surface ofthe diseased bone, and bleeds from the slightest causes. There is generally a sinus in the soft parts, which leads down to the caries, and emits a very fetid, dark-coloured sanies. These symptoms, however, as well as the tendency in the accompanying ulcer or sinus, to pro- duce large fungous granulations, are more constant in cases of necrosis, than in those of caries, some of which may remain a very considerable time unattended with any out- ward sore, abscess, or sinus, as we see illus- trated in the caries produced by various '• diseases of the joints. Aud, indeed, parti- cular forms of caries, (if they deserve that name) are rarely accompanied with suppu- ration : a fact, to which I shall again advert. " The absorption of bone, like that of soft parts (says Dr. Thomson,) may be distin- guished imto interstitial, progressive, and ul- cerative. We have ample proofs of the in- terstitial absorption, or that which is daily. Vnr.l. 41 hourly, and unceasingly taking place from every part of the substance of bone, in the deposition and removal of phosphate of lime, that has been tinged with madder. If too much earth be removed, the quantity of ani- mal matter will be relatively increased, and a disposition given to softness of the bones —a state, which exists in the bones of child- ren in the disease called the rickets, and in the bones of older people in that denomi- nated mollifies ossium, or the rickets of grown people. " I have already had occasion to mention the effects of the progressive absorption of bone, as manifested in the progress of aneu- risms and other tumours to the skin ; but, the formation of pus is by no means a ne- cessary, constant, or even frequent at- tendant on the progress of progressive ab- sorption in bone. Hydatids in the brains of sheep, tumours growing from the pia or dura mater in the human body (see Dura Mater,) or aneurism seated over the cra- nium, or within the cavity of the -chest, are often the cause ofthe whole substance of a bone being removed, layer after layer, by progressive absorption, without the forma- tion of a single particle of pus. (See Aneu- rism.) This state of the bone has often been confounded, but improperly, with that state of the bone, which arises from ulcera- tive absorption, the slate, which is properly denominated caries, and in which, one or more solutions of continuity may be produ- ced upon the surface, or in the substance of the bones. The ulcerations occasioned in bones by the venereal disease, afford by far the best marked examples of the effects and appearances of ulcerative absorption, or ca- ries in bones, he." (See Thomson'* Lec- tures on Inflammation, p. 389.) Caries has been divided into three kinds, according to the nature of its causes: 1, Caries from external causes; 2, from an internal local cause, where no outward in- jury of the bone, and no internal constitu- tional disease, can be suspected to have pro- duced the disorder, and where the affection can be removed by local means. The caries ofthe finger bones from whitlows, is quoted as a specimen of this form of the disease. Perhaps, however, the case is generally ra- ther an instance of necrosis; 3, from a ge- neral internal cause, or constitutional dis» ease, in which cases, besides local reme- dies, it is necessary to employ such medi- cines, as are calculated to obviate the par- ticular affection ofthe system, whence the diseased state ofthe bone has originated. But, in addition to these general divisions ofthe subject, there are many circumstan- ces, in relation to the varieties of caries, which may be said yet to lie in obscurity. If, as a modern writer remarks, the situation ofthe bones, the nature of their organisa- tion, and the slowness of their diseases, would let an attentive observer trace the formal ion, developement, and progress of caries, no doubt, there would be noticed a diversity in its symptoms, corresponding to it" different species ; and, probablv. j; 3i& CARIES tvould be found, that a venereal, or scrophu- lous caries would vary in its origin and pro- gress, as much from a caries, from a purely local cause, as a venereal or scrophulous ul- cer differs from the kind of ulceration, which follows a common abscess. (Did. des Scien- ces Mid. T. 4, p. 84.) The worm-e-ten ca- ries, as it has been termed, w hich pene- trates the whole substance of a bone, and gives it an appearance as if it had been bored in hundreds of places, isa very differ- ent affection from some other forms of the disease, whether cuperficial, or extended to the deeper texture ofthe bone affected. Abscesses situated in the vicinity of bom s, are frequently thought to be the cause both of necrosis and caries. Hence, the rule to open such abscesses at an early period, in order to prevent the honp from being affect- ed. If some abscesses, like those which form over the anterior surface of the tibia, and mastoid process of the temporal bone, be frequently attended either with caries or necrosis, the latter is mostly the cause, and not the effect of the suppuration. Pus, which isa bland, unctuous, inodorous fluid, never attacks the soft parts, with which it is in contact, until its qualities are changed by exposure to the air. When an abscess forms in the anterior part of the parietes of tbe abdomen, the peritoneum of that part, naturally a thin membrane, instead of being destroyed, becomes thick and strong enough to resist the extension of the abscess towards the cavity ofthe abdomen. So also, when an abscess is formed over a bone, not origi- nally diseased, or hurt by the same causes, which produced the abscess,and not injured by being kept exposed, or by astringent es- charotic applications, neither caries, nor ne- crosis, is likely to happen. On the contra- ry, the periosteum, like the peritoneum, be- comes thickened, and granulations are formed over it. The venereal disease is sometimes a cause of caries ; sometimes of necrosis ; and in other instances, of exostosis. When it attacks the bones of the nose, it general- ly renders them carious, and the face sadly disfigured. The bones of the palate are sometimes altered in the same manner ; but, on other occasions, the effect is ne- crosis. In cases of cancer of the breast, the ster- num and ribs are sometimes found carious. I believe, that, in such cases, the disease of the bones has nothing in its own nature, entitling it to be regarded as cancerous It is a mere effect of the original disorder, and if the carious bo. e could be removed tdgether with every particle of the disease ofthe soft parts, a cure would probably fol- low. Or, supposing the carious bone were the only portion of the disease left, it is con- ceivable, that the case might yet end in a cure. Carie?, arising from syphilis, most com- monly affects the tibia, cranium, ossa nasi, ossa palati, and sternum. A caries of the vertebrae is known by pe- culiar symptoms, among which a paralysis ofthe inferior extremities, and lumbar ab- scesses, are the most remarkable. Caries from an external, or from a local internal cause, is less dangerous than that, which proceeds from a constitutional dis- ease, particularly, when the latter is difficult of cure. A caries ofthe spongy part of bones is more difficult to cure, than a similar affec- tion of tin ir coi .,.,(ct parts. Caries of the carpal and tarsal bones is particularly otuti. nate. These bones oemg in close contact, the affec.iion cannot easily be prevented from spreuding from one to the other. Am- putation i> often the only means of cure. The same is freqiu ntly the case, when the spongy heads ofthe long bones forming the large joints, become carious. Kveii this mode of relief is not practicable when the head of the bone lies very deep y, like that of the os femoris Caries ofthe ossa ilium, is also observed to be particularly difficult of ren oval. Caries from scrophula is more difficult of cure, than that from syphilis, and scurvy; for, some efficacious remedies against toe latter diseases are known ; but scrophula cannot be said to be within the reach of medicine. The prognosis is less favourable in old, than young subjects, and much de- pends on the extent of the disease, the pa- tient's strength, and the state of the soft parts. When caries arises from constitutional disease, internal remedies are of course in- dicated. Thus mercurial and sudorific medi- cines put a stop to caries from syphilis; while, vegetable diet, and acids, cure both the scurvy, and the < aries dependent on it. According.^ writers, the indications in the treatment of caries are; either to pro- duce h change in tbe action ofthe diseased portion of bone, whereby it may regain a healthy state ; or to destroy it altogether. In the caries from constitutional causes, the first object seems to be brought about by the operation of such remedies as remove the original disease ; and I should much doubt, whether, in these cases, any very ac tive local treatment is necessary, or free from objection. Of course, this remark is meant to apply only to examples, in which we possess some medicine, or plan, which is known to be a tolerably sure remedy for the general disease. This is not the case in caries from scrophula, and here issues, blis- ters, and other local means are unquestion- ably advantageous (See Joints and Verte- bra A) But, surgeons have proceeded fur- ther, and, not content with issues, blisters, fomentations, he. as means for quickening the action of the. disexsed bone, they have commonly recommended applying directly upon it the stiongest stimulants, a« the tinc- ture of aloes or myrrh, a solution of the argentum nitratum, or d luted muriatic acid. For the destruction of caries, the actual and potential cauteries, and cutting instru- ments, have been employed. CAR • On the continent, and particularly in France, they still adhere to the plan of touching carious parts of bones with the actual cautery after bringing them fairly into view by the previous use of the knife. It is thought, that the burning iron acts, by changing; the caries into a necrosis, irrita- ting the subjacent sound parts, and exciting that action of the vcsspIs. by which the dead or disi-ased part of the bones must be thrown off. Such is the doctrine inculcated by Boyer. Mr. Hey succeeded in cutting away a ca- rious pari of ihe tibia He began the ope- ration by dissecting off the granulations of flesh, which bad arisen from the bone, and then sawed out, by means of a circular headed saw, a wedge of the tibia, two inches in length. The removnl of this por- tion brought into view a caries of the can- celli, almost as ixteusive as the piece already removed. With different trephines, suited to the breadth of the caries, Mr. Hey re- moved the diseased can7.) Pott used to fill the cavity of the wound with lint; but Desault, and all the modern surgeons of this country, bring the edges of the wound together, and endeavourto heal as much of it as possible by the first intention. Some, with this view, use sutures and stick- ing plaster; others, only the latter, aided with compresses and a T bandage; which means, in my humble opinion, are quiet enough. The operation of the compresses and bandages cannot be too carefully attended to, as it is the surest means of preventing hemorrhage from any small arteries in the scrotum, while it conduces to the union of the parts. Care must be taken, however, not to let the pressure hurt tbe sound tes tide. The plan of dressing adopted by Mr. Lawrence, consists in retaining the edges of the skin in apposition with two or three sutures, and then applying a narrow strip of simple dressing. A folded cloth, kept con- stantly damp, is also laid over tbe wound. (Med'Chir. Trans. Vol. 6. loc. cit.) With respect to sutures, some doubt may be en- tertaiued of their utility after this operation, and I have remarked, that considerable irri- tation and an extensive erysipelas some- times follow their employment. Roux also noticed their bad effects in a case, which occurred during his visit to this country. (See Parallile de la Chirurgie Angloise avec la Chirurgie Francaise, p. 121.) i It is somewhat extraordinary, that Larrey should condemn the plan of uniting the wound, though, indeed, we cannot be sur- prised at bis delivering this advice, when we recollect, that he disapproves of healing the stump, after amputation, by the first in- tention. The passage, relative to dressing the wound after castration, seems to be a contrast to the sensible observations which generally prevail in this author's publica- tion : " II ne faul pas, reunir les bords de la plaie, comme font conseiXli quelques prati- dens, parte qu'ils doivent suppurer, et que la suppuration est nieessaire !" -(Mem. de Chi- rurgie Militairc, Tom. 3, p. 426.) Larrey is joined by Roux aud the rest of the French surgeons on this point. The main reasons, stated by the latter writer, for not bringing the wound together, are, that se- condaryhemorrhage cannot be well guarded against, except by filling the p*rt 25.) The same experienced and able surgeon also acquaints us, that he has more than once extricated from trouble, persons who knew not how to stop the bleeding after the operation. He has seen some of them take off the dressings several times, without discovering the wounded vessel. As they imagined, that the only hemorrhage, which could follow castration, must be from the spermatic artery, they contented them* selves with examining the ligature on the chord, and increasing the compression, in order to stop the bleeding; but, finding their attempts fail, they were compelled to seek assistance. On being sent for, M. Petit found, that the blood did not issue from the cord, but from a small artery un- der the skin, at tbe inferior angle of the wound. He easily stopped the hemorrhage, and explained, not only, that the cord bad no share in the accident, but tbat it is ge- nerally suspected without foundation. In- deed, says he, the least constriction will stop the bleeding from the spermatic artery; it is not essential to tie it,—" I a.yself am content with cutting the cord, so as to leave it rather longer than usual, und appl> i't> ligature ; I press it against the os pubis, near the ring of the external oblique; 1 lay over it a linen comr>re<-:. half as thick & CASTRATION. 325 the finger, two inches in length, sufficiently broad to cover the part, and yet narrow enough to be placed entirely within the wound. Over this compress, I put dossils of lint ; I fill the scrotum with plain lint, and then cover the whole with compresses, observing to put one, which is thicker tu.m the rest, above the pubes, immediately over that which I have laid upon tbe cord, so that the bandage may make moderate pressure on this last part, yet sufficient to prevent bleeding." (Op. cit. p. 526, 527.) This quotation is not made with a view of inducing any modern operator to imitate the preceding practice, which, indeed, the advantages of the present mode of dressing the wound entirely forbid,as well as the great- er security of the ligature ; but, the passage is cited, for the express purpose of impress- ing on the mind of the young surgeon, that, in general, after the removal of a dis- eased testis, there is more r-sk of bleeding from the vessels of the scrotum, than those of the cord. I have never seen hemorrhage from the spermatic artery give trouble after the operation, but, have often known sur- geons obliged to take off the dressings on account of bleeding in the scrotum. In every operation, in which a considera- ble portion of skin is to be divided,and par- ticularly in this, and in the amputation of women's breasts, it should always be re- membered, that, as the division ofthe skin (the general organ of sensation) is the most acute and painful part of what is done by the knife, it cannot be done too quickly, and should always be done at once: the scrotum should constantly be dividrdto the bottom, and the circular incision in the skin of a breast always made quite round, before any thing else be thought of. If this be not executed properly, and perfectly, the operation will be attended with a great deal of pain which might be avoided, and the operator will be justly blameable. (Pott.) When the diseased testicle is exceedingly large, or a part ofthe scrotum is diseased, the surgeon should take care to remove the redundant, or morbid portion of the skin, by including the piece, which be designs to take away, within two long elliptical inci- sions, which are to meet at the upper and lower part of the swelling. In this manner, as Mr Samuel Sharp has observed, the be- morrhiijri" will be much less, t e operation greatly shortened, the sloughing ofthe dis- tendeu skin prevented, and the recurrence of cancerous disease rendered less likely. (See Treatise of the Operations, ihap. 10.) Mr. Lawrence concurs with M. de la Faye in thinking it best in this operation always to remove a large piece of the scro- tum with the lestich, by which means tbe surface ofthe wound is lessened. (See Med. Chir. Tran*. Vol. 6, p 196.) If the tumour be of a pyriform figure, per- fectly smooth, and equal in its surface, and free from pain, notwithstanding the degree of hardness may be great, and the surgeon may in his own opinion, be clear that the tumour is not produced by water, but i<; a true scirrhus, let him, immediately previous to the operation, pierce the anterior part with a trocar, in order lo be certain "My reason for giving this advice is, that 1 was once so deceived by every apparent circum- stance of a true, equal indolent scirrhus, that I removed a testicle, which proved upon examination to be so little diseased, that, had I pierced it with a trocar previous to the operation, I could, and certainly should have preserved it." (Pott.) It is well known, that the agony of tying the cord is immensely increased by inclu- ding the vas deferens, ai d, as no good re- sults from so doing, the practice deserves the severest reprobation, notwithstanding the opposite opinion of Mr Pearson, (Pract. Obs outancer,p 74.) and the writer ofthe article Castration in Rees's Cyclopaedia. Cases are even recorded, in which the inclusion of the whole ofthe spermatic cord appears to have occasioned severe and peri- lous consequences, aud these in so great a degree, that it has been found necessary to cut and remove the ligature. Sometimes, says Petit, patients on whom castration has been performed, suffer more or less acute pain in the kidneys. The suffering often be- comes insupportable and highly dangerous, the belly being swelled, tense, and painful; the patient being affected with syncopes, and affections'of the heart, sometimes with vomiting, and retention of urine ; lastly, an universal inflammation ofthe belly,and a vio- lent fever, accompanied with delirium, are occasionally the fatal consequences of this operation. Pet! was required to visit a pa- tient, who had been in this deplorable state for twenty-four hours, after having suffered castration, and this distinguished surgeon could impute the sudden and violent symp- toms to nothing, except the ligature on the spermatic cord ; consequently, he advised the ligature to be removed. 1 he patient re- ceived some slight relief from this step, .ad, after having been bled twice within a s;iort space of time, he found himself a great deal better ; but, as the dressings became wet with blood, apprehension of bleeding began to be entertained. Petit, therefore, had re- course to moderate compression ofthe cord, in the manner above related. No hemor- rhage ensued ; the case afterwards went on well ; and the patient recovered sooner than was expected. (Traiti des Maladies Chir. Tom. 2, ^.527,528.) In the operation of removing a testicle, one caution seems particularly necessary, viz. if the cord shculd be at all enlarged, the surgeon ought carefully to examine, whether the augmentation of its size may not be owing to a portion of intestine, or omentum, ihr.t is contained within it. (See Sabatier's Midecine Opiratoire, Tom. 1, p. 332, Edit. 1.) 1.. one cast of extirpation of the testicle, " after the operation was com- pleted, and the wound dressed, the patient being seized with a fit of coughirg, to the astonishment and dismay of the surgeon, the dress, ngs were forced off by a protru- sion of several convolutions of small inre< •326 CAS CAT tines; from this, it was proved, that the pa- tient had had a hernia ; but, the diseased en- largement ofthe testicle had acted as a truss, and prevented the rupture from coming down. (See Operative Surgery, by C. Bell, Vol \,p. 226, also p. 224) There is another circumstance, which merits attention in the performance of this operation : when there are reasons, which oblige us to divide the cord high up, and this part has not been tied before such di- vision is made, it may be drawn up by the cremaster within the abdominal ring, and some difficulty may be experienced in se- curing the spermatic arteries. Mr. B. Bell saw this happen twice, and the patients lost their lives from hemorrhage. Hence, when it is necessary to cut through the cord near the ring, perhaps it may be best always to apply the ligature first, observing not to include the vas deferens. However, were the cord,' previously to the application of ligatures to its arteries, to happen in any in- stance to be drawn up within the ring, a surgeon would be guilty of most supine neg- lect to Jet the patient die of bleeding ; for, as Mr. C. Bell has remarked, we may follow the cord with perfect safety, even to the origin of the.cremaster, which pulls it up, if attention be paid to the course of the cord, obliquely upward and outward, with- in the.ingunial canal. It sometimes happens, that abscesses form in the remains of the spermatic cord, after the operation of castration. Such suppu- ration may.frequently be prevented by the employment of bleeding directly after the operation, and repeating the evacuation on the first access of the inflammation of the pavtconcerned. Besides venesection, low diet, neutral salts, diluents, &.c. are indica- ted, and the part should be covered with an emollient poultice. When pus is complete- ly formed, the abscess should be opened. When the symptoms subside, says Petit, tbey, who are little versed iu practice, are apt to fancy the abscess cured ; but, they are sometimes mistaken. Tbe matter is not always sufficiently near the surface to be felt, and, in this circumstance, the apo- neurosis ofthe external oblique muscle is so tense, that it hinders the fluctuation from being distinctly felt. Indeed as the matter finds a lodgment under this aponeurosis, following the course of the sheath of the vessels, there is reason to fear, that it may lead to additional inflammation and suppu- ration, and extend up the duplicature of the peritoneum to the loins. In these cases, the abscess occasionally makes its way out- ward, and the dressings are inundated with matter; but, if this should not happen quick- ly, the sooner the tumour is opened the bet- ter. Tbe opening ought unquestionably to be made wherever the fluctuation is plainly distinguishable; but, as Petit has remarked, the tension ofthe aponeurosis ofthe exter- nal oblique muscle makes the undulation of the matter less readily and plainly percepti- ble, than if the abscess were only in the fat. Therefore, in order to avoid mistake, this surgeon advises us to feel at the abdominal ring, as, in general, the pus can be more readily frit here, than in other situations. If matter is felt, and no resistance is experi- enced, Petit advises the finger to be passed into this opening, aud in case tbe seat of the abscess should be found to be under the aponeurosis, we are recommended to di- vide, with a probe-pointed bistoury, the skin and fat immediately covering the ring, then to separate the fibres of this aperture, as it were, without rutting them. (See Traiti d< * Maladies Chirurgicale*, Tom. 2 p. 629—530) No doubt, this surgeon meant, that the division of the tendon ought to be made in the direction of its fibres. Consult Le Dran'* Operations. Sharp's Operations of Surgery, chap. 10. Pott on the Hydrocele, fa. Sabatier, de la Mid. Oper. Tom. 1. Bertrandi Traiti des Opir. de Chi- rurgie, Chap.M. OZuvres Chirurgicalu de Desault par Bichat, Tom 2, p. 449. Larrey Mimoires de Chirurgie Militaire, Tom. 3, y. 423, fa. Pearson on Cancerous Complaints. J. L Petit, Traiti des Maladies Chirurgicales, Tom. 2, p. 519, fa. C. Bell's Operative Sur- gery, Vol. 1. Richerand's Nosographie Chi- rugicale, Tom 4, p. 281, fa. Edit 2, fa. A lona account of the particular sentimentm of several eminent surgeons is to be found in Rees's Cyclopadia, art. Castration. Roux, Parallile de la Chirurgie Angloise avec la Chirurgie Francaise, p. 119. fa. Lawrence in Med Chir. Trans. Vol. 6, p. 196—197. Sketches ofthe Medical Schools of Paris, by J. Cross, p 139, fa. CATAPLASM A \CETI. Made by mix- ing a sufficient quantity of vinegar with either oatmeal, linseed meal,or bread crum. When linseed is employed, it is best to add a little oatmeal, or bread crum, in order to keep the poultice from becoming hard. The vinegar poultice is generally applied cold, and is principally used in cases of bruises and sprains. CATAPLASMA ACETOSjE. SorrelPoul- tice. r\ Acelosa lbj. To be beaten in a mortar into a pulp. CATAPLASMA ALUMINIS. Made by stirring the whites of two eggs with a bit of alum, till they are coagulated. In cases of chronic and purulent ophthalmy, it has been applied to the eye, between two bits of rag, and if has been praised as a good applica- tion to chilblains, which are not broken. CATAPLASMA BYNES. (Malt.) R Farina Bynes, Spuma Cerevisie, q. s. This is applied to cases of gangrene and ill con- ditioned extending sores. It is used in in- stances similar to those, in which the cats- pl.-sma fermenti is employed, and, by giving out carbonic acid gas, is supposed to operate as a gentle stimulus, and as a corrector of fetid effluvia. CATAPLASMA CARBONIS. Made by mixing powdered charcoal with linseed meal ana warm water, and is applied to improve the condition of several kinds of unhealthy sores. CATAPLASMA CEREVISI/E. Made CAT £AT , 327 by stirring some oatmeal, or linseed meal, in strong beer grounds. It is used in the same cases, as the Cataplasma Fermenti, and Cataplasma Bynes. CATAPLASMA CICUTJE. Hemlock Poultice. R Herba cicuta exfoliata £>}. Aquafontana ft>ij. To be boiled, till only a pint remains, when as much linseed meal as necessary is to be added. This is an excellent application to many cancerous and scrofulous ulcers, and other malignant sores; frequently producing a great diminution of the pain of such disea- ses, and improving their appearance. Jus- tamond preferred the fresh herb, bruised. CATAPLASMA DAUCI. Cairo* Poul- tice, rx Radicis Dauci recenlis ft,j. Bruise it in a mortar into a pulp. Some, perhaps, with reason, recommend the carrots to be first boiled. The carrot poultice is employ- ed as an application to ulcerated cancers, scrofulous sores of an irritable kind and va- rious inveterate malignant ulcers CATAPLASMA DIGITALIS. Made by mixing linseed meal w.th a decoction of the leaves of the plant. It is said to hnve great sedative virtues, to be adapted to the same cases as the cicuta poultice, and even to be more beneficial. CATAPLASMA FARINACEUM. The bread and milk poultice, made by putting some slices of bread crum in milk, and let- ting them gently simmer over the fire in a saucepan, till they are properly softened. The mass is then to be mixed and stirred about with a spoon/and spread on linen, in order to be applied. This poultice, which isofthe emollient kind, is with many per- sons the common one lor all ordinary pur- poses. Most surgeons, however, employ, instead of it, the linseed poultice, which is cheaper, more readily made, not apt to turn sour, and in all common cases, quite as ad- vantageous iu every respect. CATAPLASMA FERMENTI. Ferment- ing Poultice. R. Farina I'ritici. Ibj. Cere- visia Spuma, Vest dicta ; ftss. These are to be mixed together and exposed to a moderate heat, till the effervescence begins. In cases of sloughing and many ill-condi- tioned ulcers, this is an application of great repute. CATAPLASMA LI NI. Linseed Poultice. R Farina Lini ftss Aq ferveidis ftiss. The powder is to be gradually sprinkled into the hot water, while they are quickly blended together with a spoon. This is the best and most convenient of all the emollient poultices for common ca- ses, and it has nearly superseded that of bread and milk, which was formerly much more frequently employed. Mr. Hunter speaks in the following terms ofthe linseed poultice and its uses. " Poultices are commonly made too thin; by which means, the least pressure, or their own gravity, removes them from the part ; they should be thick enough to support a certain form when applied. "Tbey are generally made of stale bread *n<\ milk. This composition, in general. makes too brittle an application ; it breaks easily into different portions?from the least motion, and often leaves some part of the wound uncovered, which is frustrating the first intention. " The poultice which makes the best ap- plication, and continues most nearly the same between each dressing, is that formed of the meal of linseed ; it is made at once, and when applied, it keeps always in one mass " The kind of wound to which the above application is best adapted, is a wound made in a sound part, which we intend shall heal by granulation. The same ap- plication is equally proper when parts are deprived of I if.-, arid consequently will slough. It is therefore the very best dress- ing for a gunshot wouild, and probably for most lacerated wounds ; for lint, applied to a part that is to throw, off a slough, will often be retained till 'that slough is separa- ted, which will be for eight, ten, or more days." • ■ , CATAPLASMA MALI MATURI. This is made by roasting a ripe apple, removing the peel and core, and beating the pulp into a soft mass. It is sometimes applied to in- flamed eyes, by means of a little muslin bag. CATAPLASMA MURIATIS SODiE. t\ Pulveris Lini, Mica Panis a. a. partes aqunles, Aq. Soda; Muriata q. s. This is used for diminishing scrofulous tumours and glands. When it excites too much ir- ritation in the skin, a linseed poultice may be substituted for it, until this state has sub- sided. CATAPLASMA PLUMBI SUBACETA- TIS. & Liquoris Plumbi Subacetatis drach. j. Aquae distillatae lib. j. Micae panis q. s.—Misce. Practitioners who place much confidence in the virtues of lead, externally applied, often use this poultice in cases of inflam- mation. CAJAPLASMAQUERCUS MARINE This is prepared by bruising a quantity ofthe marine plant commonly called sea tang, which is afterwards to be applied by way of a poultice. Its chief use is in cases of scrofula, white swellings, and glandular tumours. When this vegetable could not be ob- tained in its recent >tate, a common poul- tice of sea-water and oatmeal was substi- tuted by the late Mr. Hunter and other surgeons of eminence. CATARACT. (From tttr et^eure-te, to con- found or disturb; because the disease con- founds or destroys vision.) y\tuya,fAa., v7ro CATARAC J says Beer, when it happens, the lens always participates in the opacity, much more quick- ly, than occurs in the anterior capsular cata- ract. Hence, the disease can never be ob- served up to its perfect developement. Re- specting the state of the lens, some differ- ence prevails between the statement of Beer and that of Mr. I ravers : the hitter gentleman informs us. that where theopaeity of the posterior caj sule is met with, which he agrees with Beer in considering as vry rare, the lens and anterior capsule are usually transparent; " and when this is not the case, and the cataract escapes with a posterior fold of opaque capsule, it is always accompanied with a considerable discharge of vitreous humour. (Synopsis of the Diseases of the Eye, p. 209.) And, in speaking of the opa- city of the posterior capsule, in another work, he informs us, that he has not ob- served, that, in this case, the lens undergoes any diminution. (Med. Chir. Trans. Vol. 4. p. 286.) Like the anterior capsular cata- ract, it is denoted by a whitish-gray, unequal variegated colour; but no light-coloured, chalk-white spots and streaks are ever dis- cernible, which while the lens retains its transparency may be owing to the distance of the cataract from the pupil. However, the opacity situated behind the pupil, always seems concave, when the eye is inspected, not from before, but from every side ot it. While the posterior half of the capsule is not completely opaque, the lens is not ma- terially affected ; the eyesight is only more or less weakened ; and sometimes, espe- cially with the aid of a magnifying glnss a tolerable degree of vision is enjoyed, not- withstanding the considerable opacity be- hind the pupil. This species of cataract has not itself any influence over the motions of the iris, and after the lens becomes opaque, it is not softened. Though the complete capsular cataract is not the rarest species of genuine cataract, it cannot be said to be very common In addition to the symptoms of the anterior capsular cataract, it presents few, yet de- cided characters, which indicate it pre- viously to an operation: viz. the iris is nearly motionless, the cataract lying close to that organ ; the posterior chamber for the same reason is effaced ; and an inexperienced surgeon might really suppose the anterior portion of the capsule were adherent to the uvea, unless he convinced himself of the contrary,by producingtan artificial dilatation of the pupil with hyosciamus, or belladon- na. Sometimes, the iris even seems thrust out, by this large cataract, towards the cor- nea in a convex form ; and the patient can only perceive the strongest kinds of Ii;:ht. The third species of genuine cataract is the catarada Morgagniana, which some term the milk cataract, and others con found with the purulent cataract. It is one of the rarest forms of the disease ; so rare indeed, that Mr. Travers regards the case as purely hypothetical. (Synopsis of Diseases of the Eye, p. 208.) The following is the form of disease, described by Beer, under this name ; it proceeds irom a total conver- sion of the lens into a milky fluid, or thin jelly, frequently attended with a complete capsular cataract. It^ origin is said to be alwavs (pick, and an immediate effect of chyuiical injuries of the eye, especially those produced by the gases formed when • m tal is oxydated by a mineral acid. The following are the symptoms of the case, while it is uncomplicated with disease of the lens and capsule ; a stab-, which can never continue long. Though the colour is milk-white, it is delicate and thin, like that of diluted milk. The whole pupil seems cloudy, but when- ever the eye-ball moves suddenly and violet tly, or the eyelid is rubbed over the eye, the opaque substances change their shape and position. The posterior cham- ber is nearly annihilated, which may be owing to the quantity of fluid, or gelatinous substance collected. While the lens and capsule are not materially changed, the sight suffers only a diminution, though it is very cloudy, and small objects cannot be distinguished at all. When, however, the lens and capsule become opaque, vision is quite abolished, a certain power of know- ing light from darkness only remaining. Not iiiifreq>> ntly, says Beer, when the lens itself is in a dissolved state, the capsule ■s partially opaque, the eye is kept quiet for a few minutes, and the patient stands orsits in an upright posture, two rows of opaque matter can be plainly seen ; the tipper be- ing the least white of the two; the lower presenting a chalky whiteness. However, as soon as the patient suddenly or violently moves nis eye, or head, or the eyelid is rubbed over the e,e, both these rows of opaque matter disappear, and the colour of the opa- city behind the pupil again seems uniform.. The fourth species ot genuine cataract, described by Beer, is the capsulo lentiadar cataract, to which he conceives the liquor of Morgagni in an altered state, may likewise often contribute, as may be inferred from the prodigious size of this cataract. It is by no means uncommon, and is attended with the following characteristic symptoms, 'he- colour of ihe opacity close to the uvea, h partly chalk white, partly like that of mo- ther-of-pearl, and, in many places, both these colours can be evidently seen dispo^ one over the other, that of raotber-of-pean, howetvr, being always most superficial Exposure of the eye to the most vivid light scarcely causes any motion of the iris, but the pupil is circular, without any angles in it. After the application of the extract of henbane, the iris contracts a^ain exceeding- ly slowly, and the pupil is long in retuninf to its former diameter. Besides the oblite- ration of the posterior chamber the ante- rior one itself is mostly diminished, in con- sequence of the iris being pushed towards the cornea by the very large size of the cataract, and hence, the sensation of light is very indistinct. The capsnlo-lenticular cataract is not un- frequently the consequence of aslowinflar CATARACT 331 matory process in the iris, the lens and its capsule ; and hence, several varieties of this case, and its not unfrequent combination witbaspurious cataract; all which different modifications, says Beer, should be correctly understood previously to an operation, in order to form a just prognosis of its event, and to know what method of operating ought to be adopted Of these varieties the first is the capsulo- lenticular cataract, conjoined with slight de- positions of new matter upon the anterior capsule of the lens. These after-formations ' upon the front layer of the capsule, as Beer calls them, put on very different appear- ances, and accordingly receive various ap- pellations. For instance, the marbled cap- sulo-lenticular cataract, when tbe chalk- white new formed substances upon the an- terior layer of the capsule are so arranged as to resemble the variegated appearance of marble. The window, or lattice capsulo- lenticular cataract, w hen the new-deposited substances cross each other, leaving darker coloured interspaces. The stellated capsulo- ttnticular cataract, when the new matter runs in concentric streaks, to >vards the mid- dle ofthe pupil. The cenlral-capsulo-lenli- cular cataract, when a single, elevated, white, shining point is formed o.i the ante- rior capsule, while tbe rest of this mem- brane is tolerably clear, and the lens not completely opaque. 'Ihe dotted capsulo- lenticular cataract, when the front layer of the capsule presents several distinct uncon- nected dispositions on its surface. The half-cataract, or cataractacapsulolenticularis dimidiata, when one half of the front layer of the capsule is covered with a white de- posit. In all these, and some other exam- ples, says Beer, the lens is found to be con- verted to its very nucleus into a gelatinous, or milk substance. The second variety of the capsulo-lenti- cular cataract, pointed out by Beer, is the encysted, indicated by its snow-white colour; sometimes lying so close to the uvea, as to push the iris forward towards the cornea ; and, at other times, appearing to be at a dis- tance from the uvea. These circumstances, as Beer remarks, almost always depend up- on the position of the head ; for, when this is inclined forwards, the cataract readily assumes a globular form, and projects con- siderably towards the anterior chamber. Frequently, this variety ofthe capsulo-len- ticular cataract constitutes the kind of case, to which the epithets, tremulous or shaking and swimming, or floating, ar ap- plied. According to Beer, the reason of such unsteadiness in the cataract Uowingto the broker:, or very slight connexion of the capsule of the lens with the neighbouring textures The same author has never seen any case of this kind, which had not been preceded by a violent concussion of the eye, or adjacent part of the head. Both layers of the capsule are opaque, and some- times considerably thickened The third variety of the capsulo-lenticular cataract, described by Beer, is tbe pyramidal, or coni- cal, which is one of tbe rarer forms of the disease, and always brought on by violenl internal inflammation ofthe eye, especially affecting the lens, its capsule, and the iris It may be known by a white, almost shi- ning, conical, more or less, projecting new- formed substance, which grows from the centre of the anterior layer ofthe capsule, and is almost in close contact with the pupillary margin of the iris. Hence, the iris is always quite motionless, and the pupil angular. Sometimes, this growth from the capsule extends itself so far into the anterior chamber, as nearly to touch the inner surface of the cornea, and sometimes actually to adhere firmly to it.- a circumstance, says Beer, w hicb is very con- stant in the conical staphyloma of the cor- nea, though not discoverable till the opera- tion is performed. The power of discerning light is feeble and indistinct, and sometimes entirely abolished. The fourth variety of the capsulo-lenticu- lar cataract is that which is covered with a dry shell, or husk. Though principally met with in young children, it is not one of the most uncommon affections in adults, and in the former, it is often falsely regarded as a con- genital complaint. When this cataract is extracted either from children, or grown-up persons, Beer says, that the dried shrivelled capsule is always found round the equally dry nucleus of the lens, like a husk, or shell. In children, however, he says, that the nucleus ofthe lens is often scarcely percep- tible, while, in adults, it is always of consi- derable size, and this may be the reason, why this cataract in children does not pre- sent so bright a yellow-white colour, as it does in grown-up persons. In infants, in which it is frequently seen in the first weeks of their existence, it is manifestly produced by a slow and neglected inflammation of the lens and its capsule, arising from too strong light. In adults, the inflammation, exciting this form of cataract, is always owing to external violence ; yet Beer sup- poses, that a considerable diminution of co- hesion between the capsule and the adjacent textures must likewise have a principal share in bringing on the disease, which, in grown-up persons, is constantly preceded by a concussion of the eye-ball, from the cut of a whip, the lash of a horse's tail, he. Professor Schmidt had never seen this kind of cataract, except in boys and girls, who in their early childhood had been afflicted with convulsions; and hence, he thought, that the cause of the disease was owing to a partial loosening of the cap- sule from its natural connexions by the violence of the convulsive paroxysms. Abhandlung tiber Naclistaar und Iritis nach Slaar. perationen, Wien. 1801, 4to.) How- ever, Beer assures us, that he has seen infants, scarcely two months old, affected with this cataract, which had not been pre- ceded, or followed by any convulsions - while a much larger number of children with the same kind of cataract had fallen under his notice, where more or less severe 332 CATARACT. blows on the head had been received. With respect to the convulsions, spoken ot by Schmidt, he also questions, whether they and the cataract might not be owing to the same cause, viz. the preceding inflamma- tion within the eye ? In children, says Beer, this form of cataract may be known by its light gray, whitish, though seldom very white, colour, its diminutive size, and con- siderable distance from the uvea, and by tbe freedom, with whicb the iris moves, when no adhesions exist at any points between this organ and the cataract, as occasionally happens ; a proof of the previous inflamma- tion of the capsule, lens, and neighbouring textures. The eye-sight is never quite im- peded, but only much diminished. On the contrary, in adults, as Beer has remarked, this cataract invariably presents a dazzling white hue, and only a few points of it are of a smutty yellowish white colour, whence the case has been sometimes termed the gypsum cataract. It is not convex, but ra- ther flat °, it does not approach the iris ; and, when free from adhesions to the uvea, which are more likely to happen in adults, it has no effect on the motion of the iris. Vision is generally entirely lost, with the exception of the power of discerning the fight, and, even this faculty is somefimes destroyed, in consequence of the previous violence done to the eye, whereby not merely the lens and its capsule, but also the retina, have suffered. According to Beer, one of the rarest varie- ties of the capsulo lenticular cataract is ibat accompanied with a cyst of purulent matter. It is indicated by a deep lemon rolour, very slow motion ofthe iiis, manifest Hbolition of the posterior chamber, slight convexity of the iris, trivial perception of light, aud Ihe weak, unhealthy constitution ofthe patient. The purulent cyst, which sometimes con- tains a very fetid mattpr, and was therefore called by Schiferli the putrid cataract, (The oretisch-Praktische Abhandlung fiber den Grauen Staar 8ro. Jena, and Leipz 1797,) may sometimes be taken nut, without being broken, together withth«-whole capsule of the lens, with the aid ofthe forceps, or otaracl- tenaculum, as was first correctly remarked by Professor Schmidt. In one single exam- ple, Beer found the cyst of matter between the lens and the anterior port ion of its capsule. Mr. Travers has likewise seen an example of suppuration vvilhin the capsule,which project- ed through the pupil in a globular form, and was filled with tms. The case happened in a lad, and had been preceded by a severe blow on the eve. (Synopsis of the Diseases ofthe Eye. p. 2<>6.) Tbe sixth, and last variety of the capsnlo- lenticular cataract, mentioned by Beer, is the well-known case, de«nihed b\ the French under ihe name of cataracte barrie, the bar-cataract, ami by Schniidi underthe appellation of the cataract, with a girth or zone. The case, savs Beer, is one of tbe least frequent. The diagnosis is easy ; for, behind the diminished, more or less angular i.yj'.<:[. the cataract can be plainly seen, to which is attached, either in a more or les- perpendicular, or horizontal direction, a chalk-while, generally very shining, and thirkish kind of bar, or girth, which is close- ly adherent at both its extremities to the pu- pillary margin of the uvea, and sometimes ranches, but often only on one side, mors or less towards the ciliary processes. The iris is therefore completely motionless, the uvea not being merely adherent to the substance forming what is termed the bar, or girth, but al«o clos. ly connected with the whole front portion of the capsule. The percep- tion of light is either very indistinct, or quite lost, Hnd, not unfrequently, the «lnbe of ihe eye is somewhat smaller than natural. Beer says, lb t he has never met with (bis variety of cataract, except after violent internal in- flammation of the eye. He df scribestbrsub- stance, composing the bar or girth, as being of various consistence, ani soiui'limes firm and almost cartilaginous. In iwo cataracts of this sort, which he extracted from a boy twelve years of age, hr found the bar. strict- ly speaking, ossified, and the capsule, which was nearly cartilaginous, was adherent to a very small, firm nucleus of the lens, though they were yet capable of separation. In a dead subject, Beer also examined such a ca- taract, in which tbe outer end of the bar scarcely extended to the greater ring of tbe uvea, but the inner end reached over tbe ciliary processes to the ciliary ligament, from which latter part it ivas inseparable (Lfhre von den Augenkr, B. 2, p. 302.) OF SPURIOUS CATARACTS. The most frequent, according to Beer, is what he names the lymph-cataract. It it, without exception, the effectof an inflamma tion, which is chiefly situated in the iris, the lens, and its capsule. Hence, it is frequently combined wi h a genuine cataract. The na- ture of the disease mny be known from the patient's account, that the preseit blindness has been preceded by a painful tedious af- fection of his eye and bead ; and from an examination of the eye itself, in whicb the pupil will be found more or less diminished and angular ; the iris either perfectly mo- tionless, or nearly so; the eyesight, end even sometimes the perception of light, more or less impeded, or lost, and this not merely in proportion to the quantity of Imyph observable immediately behind the pupil, but also in proportion to other mor- bid effects produced in the organ by inflam- mation. Lastly, tbe surgeon may notice directly behind the pupil a plastic lymph, either in the form of a delicate kind of net- work, or of a thick web of a snow--vhite colour. Sometimes, in this variety of spa- rious cataract,though very little coagulating lymph appears upon the anterior portion of the capsule of the lens, and what is effused, as v\ ell as the lens itself, is almost clear and transparent, yet, the eyesight is considera- bly impaired ; and, on more careful exami- nation of the pupil, somethine of a dark- brown colour is perceived, which often pro- CATARACT. 333 jects, at several points behind the pupillary edge of the iris, a good way towards the centre of the pupil. In this substance, one may discern, with a good magnifying glass, new vessels extending from those of the uvea, and formed by the previous inflam- mation, by means of which vessels, this mass, and tbe delicate layer of lymph, are connected with the capsule of the lens. According to Beer's sentiments, it is only the real lymph-cataract, which rightly de- serves the epithet membranous, which is sometimes wrongly applied to the capsular cataract; for, says he, the lymph-cataract alone consists of an adventitious membrane, formed by inflammation of a web of plastic lymph, which may be very thin, and semi- transparent, while the lens and its capsule are nearly quite clear, though the patient may be almost or completely blind, when the,effects of the inflammation have extend- ed to the choroides and retina. The spurious purulent cataract is much less frequent, than the lymph-cataract. In ne- glected cases of hypopium (see this word,) where the*pupil is already quite covered with pus, the greater part of the effused matter is sometimes absorbed, and the pu- il can be seen again, but, immediately ehind it, a quantity of coagulating lymph can be discerned as in the lymph cataract, sometimes even projecting partly into the anterior chamber, but blended with parti- cles of purulent matter, so as to give it a light yellowish tinge, and a clustered ap- pearance. The pupil is always diminished, adherent to the morbid substance, and an- gular ; the motionless iris projects towards the cornea ; and not only the eye-sight, but even the perception of light are completely lost, or the latter at least much diminished. A rare variety of spurious cataract, des- cribed by Beer, is the blood-cataract Either from some considerable injury of the eye, a large quantity of blood is extravasated in the chambers, and, slowly absorbed during tbe ophthalmy caused by the violence, a part of it, however, remaining in the poste- rior chamber in the form of small clots, encysted in the lymph, which was effused during the inflammation ; or else in the course of a more tedious and neglected case of hypopium, blood is effused in the cham- bers of the eye, and, not mixing with the pus, still continues in the same form behind the pupil, after the matter has been absorb- ed. In tbe first example, this cataract looks like a reddish web, interwoven with silvery streaks, or threads; the pupil, though angular, is seldom contracted ; the iris nearly, or quite motionless ; and, not only is the light clearly distinguished, but a partial degree of vision sometimes retained. On the contrary, in the second instance, the opacity behind the pupil is very dense, white, studded with reddish, or brownish points, or specks, having a clustered ap- pearance, and frequently projecting through the pupil into the anterior chamber ; while the pupil itself is very small, and angular, *ho irjs quite incapable of motion, and ?<>• nerally either no perception of light re- mains, or only a very confined indetermi- nate sensation of it. Beer says, that this , cataract may easily be mistaken for lymph, and that its differences can only be made out w ith a good magnifying glass. The dendritic cataract of Schmidt, the arborescent cataract of Richter, or the choroid cataract; as Beer observes is not one of the least frequent of the spurious cataracts, and is invariably the consequence of a vio- lent concussion of the globe of the eye, with, or without a wound, whereby a por- tion of the tapetum of the uvea.is loosened and becomes placed upon the anterior layer of the capsule, more or less resembling in its appearance the arborescent form of the stone termed a dendritis. Immediately af- ter such a concussion of the eye-ball, the patient complains of a serious diminution and confusion of vision. Whoever examines the eye only superficially, will certainly not discern the pieces of the tapetum lying upon the yet perfectly transparent capsule of the lens, for the most careful inspection will be necessary for the purpose, and some- times the aid of a magnifying glass will be requisite. But, as the lens and its capsule are mostly at tfie same time loosened from their connexions, they likewise generally become deprived of their transparency, and as soon as this has happened, the displaced portion ofthe tapetum can be readily seen. When inflammation ensues, the flakes of the tapetum become closely adherent to the f out layer of the capsule of the lens, and even the pupillary edge of the uvea acquires the same kind of connexion, so that the perception of light is diminished. But, says Beer, wrhen inflammation follows, the pu- pillary margin ofthe uvea remains free, the,' iris is perfectly moveable, the light clearly distinguishable though the lens and its cap- sule he entirely opaque, and sometimes the flakes of the tapetum resembling tbe arbo- rescent streaksofthe dendritis alter in shape, size, and position, but never completely disappear, though they may not closely ad- here to the capsule. (Lehre von den Augenkr. B. 2, p. 303, 3(19.) Another classification of cataracts, which is of great importance to an operator, is that which is founded upon their consist- ence ; for, as Beer remarks, this makes not only a great difference in the prognosis, but also in the choice of a method of operating. When the opaque lens is either more in- durated, than in the natural state, or retains a tolerable degree of firmness, the case is termed, a firm, or hard cataract. When the substance of the lens seems to be converted into a whitish, or other kind of fluid, lodged in the capsule, the case is denominated a milky, or fluid cataract. When the opaque lens is of a middling consistence, neither hard nor fluid, but, about as consistent as a thick jelly, or curds, the case is named a soft, or caseous cataract. When the anterior, ■ or posterior, layer of the crystalline capsule becomes opaque, after the lens itself has been removed from this little membranous 334 CATARACT sac, by a previous operation, the affection is named a secondary cataract. The harder the cataract is, the thinner and smaller it becomes. In this case, the disease presents either an ash-coloured, a yellow, or a brownish appearance : According to Beer, its colour is very dark. The interspace, be- twixt the cataract and pupil, is considerable The patient distinctly discerns light from darkness, and when the pupil is dilated, can even plainly perceive lar^e bright ob- jects. In the dilated state of the pupil, a black circle surrounding the lens is very perceptible. The motions of the iris are free and prompt; and the anterior surface ofthe cataract appears flat, without any de gree of convexity. Richter's Anfangsgr. der Wundarzn p. 177. 3 B. Beer, Vol. cit p. 809.) Beer says, that it is only the genuine len- ticular cataract, whicb can be hard, and it is chiefly met with in thin, elderly persons ; but, with respect to the opinion, that all cataracts in old personsare firm, he says, this is frequently contradicted by experience. In cataracts, extracted from thin, aged in- dividuals, the lens is sometimes found dwindled, as hard as wood, nearly of a chesnut-brown colour, and with its two surfaces as flat as if they had been com- pressed. This case has sometimes been denominated the dark-gray cataract, and is very difficult to make out previously to an operation, being liable to be mistaken for an incipient amaurosis. Hence, in order to judge of it effectually, the pupil should al- ways be dilated with hyosciamus. To the firmish, consistent kind, Beer re- fers several capsulo-lenticular cataracts, namely, the encysted, and conical oi pyra- midal cataracts, that to which he apples the epithet dry husked, the gypsum cataract, in particular, and the bar-cataract, w hich at least is always partly f.rm, as well as all the varieties of spurious cataract (Beer, B. 2, p. 309.) The fluid, or milky cataract, has usually a white appearance; and irregular spots and streaks, different in colour from the rest of tbe cataract, are often observable on it. These are apt to change their figure and situation, when frequent and sudden motions of the eyes occur, or when the eyes are rubbed and pressed ; sometimes, also, these spots and streaks vanish, and then reappear. The lower portion of tbe pupil seems more opaque than the upper, probably because the untraiisparent and heavy parts of the milky fluid sink down- ward to the bottom of the capsule. The crystalline lens, as it loses its firmness, commonly acquires an augmented size.— Hence, the fluid cataract is thick, and the opacity close behind the pupil. Some- times one can perceive no space be- tween the cataract and margin of the pu- pil. In advanced case*, this aperture is usually very much dilated, and the iris moves slowly and inertly This happens because the cataract touches the iris, and impedes its action. Tbe fluid cataract is sometimes of such a thickness, that it pro triides into the pupil, and presses the iris so much forward, as to make it assume a convex appearance. Patients, who have milky cataracts, generally distinguish light from darkness very indistinctly, and some- times not at all; partly, because the cata- ract, when it is thick, lies so close to tbe iris, that few or no rays of light can enter be- tween them into the eye; partly, because the fluid cataract always assume-, more or less, a globular form, and therefore has no thin edge, through which the rays of light can penetrate. (Richter's Anfangsgr. oer Wundarz. 3 B 174, 175.) Mr. Travers be- lieves that fluid cataraits are rarely con- tained in a transparent capsule, and his ex- perience has taught him, that this memhnine is partially opaque, presenting a dotted, or mottled surface. The opaque spots arc most distinguishable when viewed laterally. (See Med. Chir Trans. Vol. 4, p. 284.) According to Beer, a fluid cataract is mostly conjoined \*'ith a complete opacity of the capsule; its diagnosis therefore is commonly very difficult, and sometimes its nature cannot be known with certainty, until an operation is undertaken. When tbe capsule is opaque only in some places, he states, that the following circumstances may be noticed The cataract lies close to the uvea, and when the patient inclines his head forwards, the cataract presses the iris towards the cornea, and the anterior chamber becomes evidently smaller; but, when he lies upon his back, the cataract recedes in some d 'gree fioin the uvea. The power of disfin.iuishim the light is de- cided. When the head is kept quiet for a long time, a thick sediment, and a thinner part can be plainly remarked in the cata- ract; during which state, that is. while the two substances are undisturbed, tbe patient can sometimes distinguish large well-lighted objects: as through a dense mist; but, when the head, or eye. is quickly moved, these two substances become confused together again, and the cataract asiain presents an u.iiform white colour. (Vol. cit. p 312.) It cannot be denied, says Beer, that what is called the congenital cataract, and which presents itself in infants soon after birth, when their eyes have been exposed to im- moderate light, is not unfrequently fluid: but in such cases it must not he presumed that the lens is always in this state ; for, in fact, the cataract is often of that sort, vnich Beer describes under the name of dry- husked. Sometimes the opaque hens is of a mid- dling; consistence, neither hard nor fluid, bat about as consistent as thick jelly, curds, or new cheese. Cases of this description are termed soft or caseous cataracts. Thecon- sistence here spoken of, may be confined to the^jy.o, surfaces of the lens, or may ex- ist in its very centre. I he first case is }&e most frequent. The diagnosis is not diffi- cult ; tor, it always has a light gray, firajr- ish white, or seagreen colour. When it is far advanced, it quite impedes the eyesight CATARACT. 33i and sometimes considerably interferes with the .erception of light. (Beer, B 2, p. 31#.) As the lens softens in this manner it com- monly grows thicker and larger, even ac- quiring a much greater size than the fluid. It is not unfrequent to meet with cnseous cataracts of twice t elf. He adds, that he had seen three children, all born of the same parents, who acquired cataracts at the age of three years. (On the different kinds of Cataract, p. 3.) '* During my apprenticeship with the late Mr. Hill, of Barnstaple, I was present when lie operated on two brothers, and a sister, all of whom were adults, and who stated, that three or four others of their family were affected wiih symptoms not unlike those which they had experienced at the i ominencemeiit of the complaint. I my- self recently operated on two gentlemen advanced in years, who informed me, that they had a brother, ou bis return from In- dia, who was similarly affected." (See Adams's Pract. Observations on Ectropium, Artificial Pupil, and Cataract, p. 101. Ijm- don, 1812.) Beer also speaks of families, iu which the cliilda#u all became afflicted w ith cataracts at a certain age ; cases, says he, where an operation, though done by the most skilful practitioner, hardly ever succeeds. (Lelue con der Augenkr. B. 2,p. 331.) Long exposure of the head and eyes to the rays of the sun, together with a bent position of the body, as iu some kiuds of field labour, and the drinking of new acid wines, are reckoned by Beer as causes pro- moting the fortnution of cataracts ou the approach of age ; also hard labour near strong fires, ns near ovens and forgas, in glass houses, he.; and heuce, it is not un- frequent for smiths, cooka, he. when they are advanced iu years, to be afflicted with cataracts. Beer suys, that he has also learned from repeated observation, that exposing the eve to tbe vapour of concentrated acids, nap- thu, und alcohol, will sometimes bring on a cataract; a .statement, which will b- re- ceived iu this country with some hesitation, where the vapour of ether has been occa- sionally recommended for the dispersion of "re.oities eC' i1.' ' •■•- ni-i 'i cap-nle. Tlu- dust of lime is also supposed to be condu- cive to the disease, cataract!* being said to be frequent among the workmen in lime pils and kilns. Wounds of the eye, where tbe weapon has pierced the capsule and the lens, and especially violent concussions of the fore- part of the globe of the eye, though n« wound may erist, are in general followed by a cataract, as an immediate consequence. This is the case, says Beer, even when no inflammation arises from the injury, the ca- taract often occurring in a few hours, and in so considerable a degree as not to admit oi being mistaken. The cause of cataract thus rapidly pro- duced, must depend, in Beer's opinion, upon the complete separation of the lens, from its connexions with the capsule, and not un- frequently in part upon the detachment or the capsule itself from the neighbouring tex- tures ; for, in such cases, this membrane also gradually becomes opaque. According to Beer, cataracts frequently arise from a slow, insidious, inflammatie-n of the lens and its capsule. With respect to the prognosis, it must be evident from what has been premised, that there are many cataracts in which the cure is highly problematical, and others, in which the impossibility of restoring vision, even in the slightest degree, may be predicted with absolute certainty. With the little positive information which surgeons possess concerning tbe causes of cataracts, scarcely any expectation tan ever be entertained of curing opacities of the lens and its capsule, by means of medicine, so as to supersede all occasion for an opera- tion. A possibility of success, as Beer re- marks, can exist only when the cause of the cataract is ascertained, admits of complete removal, and the disease is in an early stage. And he has learned from manifold and re- peated trials, thatthe attempt to cure an incipient cataract will never succeed, except; when some determinate and obvious gene- ral or local affection of a curable nature has had a chief share in tbe production of the disease of the eye ; as, for instance, scrophula in a mildisb form, syphilis (?) and the sudden cure of eruptions, or old ulcers of the legs, (?) or a slow insidious inflam- mation of the iris and capsule of the lens. In some examples of this kind, Beer could only check the further progress of the ca- taract, and, even when the,eye sight wa; improved, it was never rendered perfectly' clear. And when the cataract was far ad- vanced, and quite developed, with the ex- ception of tbe general melioration of the health, and an improved state of the eye, whereby it was put in a better condition for the operation; not the slightest benefit was derived from medicine. (Lehre, fa. B. 2, p 333.) The principal external remedies that bava been tried for the cure of the cataract,'are, bleeding, cupping, scarifying, setons, issues, blisters, und fumigations"; and the chief fo' leviia1. ivmnlir»* «re nrtorn m-. emeu,-- ,-> 338 CA1ARACT. fharties, sudoiifies, eeph&lics, and sternuta- tories. Preparations of eye-bright, mille- pedes, wild poppy, henbane, and hemlock, were some years ago credulously commend- ed as specifics for the disorder. Scultetus asserts, that he checked the progress of a cataract, by applying to the eye the gall of a pike, mixed with sugar; and Spigelius boasted of having success- fully used, for this purpose, the oil of the eelpout (mustcla fluviatilis.) Cataracts are said to have been cured in venereal patients, while under a course of mercury. Probably, however, many such eases might have been mere opacities of tbe cornea, which had been mistaken for cataracts. Wenzel placed no reliance what- ever on the power of any remedies to dissi- pate a cataract, and, as he had remarked their inefficacy in numerous instances, he felt authorized in declaring, that internal remedies, either of the mercurial, or any other kind, are inadequate to the cure of this disorder; and equally so, whether the opacity be in the crystalline, or in the cap- sule, whether incipient, or advanced. Although the late Mr. Ware coincided with Wenzel and Beer, in regard to the un- certainty of all known medicines to dissi- pate an opacity, either in the lens, or its capsule, or even to prevent the progress of such opacity, when once begun, yet accord- ing to his observations, many cases prove, that the powers of nature are often sufficient to accomplish these purposes. The opaci- ties, in particular, which are produced by external vilolence, Mr. Ware had repeated- ly seen dissipated in a short space of time, when no other parts of the eye had been butt. In such cases, the crystalline lens is generally absorbed, as is proved by the be- nefit which is afterwards derived from very convex glasses. In some of these cases, though the crystalline had been dissolved, the greater part of the capsule remained opaque, and the light was transmitted to the retina only through a small aperture, which bad become transparent in its centre. In- stances are also not wanting, in which ca- taracts, formed without any violence, have been suddenly dissipated in consequence of an accidental blow on the eye. The reme- dies which Mr. Ware found more effectual than others, were the application to the eye itself of one or two drops of aether, once or twice in the course of the day, and oc- casionally rubbing the eye, over the lid, with the point of the finger, first moistened with a weak volatile, or mercurial liniment. Eut, as Beer observes, the operation is now regarded almost as the only means afford- ing any rational hope of restoring the eye- sight of patients afflicted with cataracts. Notwithstanding also the perfection to which the operation, with all its different modifications, is really brought, its perform- ance will not always re-establish vision; nay, says Beer, it is frequently counterindi- eated; and, even in favourable ca.«es, the result pf tbe operation is exposed to so many Contingencies, that it is rather a mat- ter of surprise, that, on the whole, ta much success should attend it as is found to hap- pen. When an operation for a cataract is done apparently under favourable circumstances, and its event is uuexpectedly very incom- plete, or quite unsuccessful, surgeons in vain ascribe the failure to the method of opera- ting, which they have hitherto adopted, and uselessly abandon it for another; became none of these methods, including that which ie preferred, brought to the highest state of perfection possible, can be applicable to all cataracts. But, says Beer, the reason of the ill success is generally rather owing to the operation not having been indicated, or to a mode of operating not well calcu- lated for the particular case having been se- lected. He ridicules the idea of adhering exclusively to any one plan of operating; and, whenever the question is put to him, what is his own plan ? he answers, that bis custom is to operate in the manner which appears to him to be best adapted to each particular case, about which he is consulted. A surgeon should be able to distinguish, first, the cases of cataract, in which an ope- ration maybe done with the best chance of success ; secondly, the examples, in which the prognosis is more or less doubtful; and, lastly, the cases, in which there is a great probability, or an absolute certainty, ot the operation failing, in which last circumstance the practice is prohibited. According to Beer, the result of an ope- ration will probably be favourable ; 1. When the cataract is a genuine local com- plaint, perfectly free from every species of complication. 2. When the conformation of the eye and surrounding parts ii such,as to allow whatever method of operating may be most advantageous for the particular case, to be done without difficulty. 8. When the patient is intelligent enough to behave himself, in a manner, which will not disturb the precisian and safety of the requisite proceedings in the operation, or the subsequent treatment. 4. When the operator, not only possesses all requisite medical and surgical knowledge in gentjel, but is capable of judging correctly^/lw method of operating suits the panaculir case ; and when besides he has deri^from nature and acquirements such mental stjd corporeal qualities, as are essential lo a skil- ful operator on the eye ; viz. an acute eye- sight, a steady, but light, skilful hand, ex- cellently qualified for mechanical artifice in general; long, pliant fingers ; a delicate touch ; a certain tenderness in the scientific treatment of this particular organ ; com- plete fearlessness; invincible presence of mind; and proper circumspection. & When the requisite instruments are not too complicated ; but well adapted to the pur- pose, and in right order. 6. When the do- mestic condition of the patient is such as not to occasion any particular disadvantage! during, or after the operation. Yet, say* Beer^even with this fortunate combination of Circumstances, uniform success must uot CATARACT. 33* be expected after operations for cataracts ; for a patient, whose sight is quite prevent- ed by this disease, and who previously to its origin, was already far-sighted, will be still more so after the removal of the disea- sed lens, and in order to see distinctly the most common objects which are near, he will be obliged constantly to employ suita- ble glasses. An individual of this descrip- tion, though the operation be done with great success, is apt not to be satisfied. But, such patients as were short sighted pre- viously to the formation of their cataracts, are more pleased with tbe restoration of vision ; as, before the operation, their eye- sight was much less than what it is now,and, in general, they can lay aside the glasses, which they formerly made use of, with- out having occasion forany others. Lastly, as Beer remarks, although patients, who, before the origin of their cataracts, were neither far nor short-sighted, are sensible ofthe important benefit of an operation, in- asmuch as they now plainly discern all ob- jects again, yet, they are usually obliged to employ spectacles in reading, writing, or doing any kind of fine work. On the other hand, the result of an ope- ration Beer considers always more or less doubtful; 1. When the cataract is only lo- cally complicated, as, for instance, with pterygium, which may not form any abso- lute reason against the experiment. 2. When the conformation ofthe eye and sur- rounding parts, causes several hinderances to the operator ; as is the case, when the eye is small, and deep in the orbit, and the fissure of the eye-lids very narrow. 3. When the patient is either very stupid, and obstinate ; rough mannered ; particularly timid ; or badly fed. 4. When the surgeon knows how to operate only in one way, in which, perhaps, he bos also not had suffi- cient experience, and when possibly he is also deficient in the qualities specified above, as essential to a good operator on the eyes. 5. When the instruments are bad. 6. When in the patient's domestic af- fairs, there are any circumstances which cannot be removed, and are likely to have a bad effect upon the operation, as an un- wholesome, damp room, great uncleanli- ness, &c. 7. When the origin of the cata- ract was attended with repeated, or tedious headach, though this may have subsided a long w hile. 8. When the patient is particu- larly subject to catarrhal and rheumatic com- plaints, especially affecting tbe eyes. 9. When the patient has often had, or still la- bours underan attack of erysipelas, notwith- standing the parts inflamed be remote from theeye. 10. When thepatient's skin is pecu- liarly irritable. 11. When in his childhood, oryouth ,he has been frequently afflicted w ith convulsions, or epileptic fits, though these complaints may have ceased many years. 12. When there is the least tendency to cer- tain constitutional diseases, scrophulu, gout, syphilis, he. Gout, however, does not al- ways make an operation fail, as we learn from Mr. Traver*. who, in three r.a«ei, ex- tracted the cataract from gouty subjects, and, though a smart attack ofthe disease fol- lowed the operation, the eyes were unaffect- ed, and the sight was well recovered. (Sy- nopsis ofthe Diseases of the Eye, p. 297) 13. When the patient's habit is bad, though not affected with any definite disorder. 14. When the patient in his youth has often been troubled with attacks of ophthalmy. 16. When he cannot perceive the different degrees of light,and correctly describe them, while nothing to account for this state caw be detected in the eye itself. 16. The re- sult ofan operation is always very doubtful, when there is the slightest tendency to hys- teria, or hypochondriasis. 17. When the patient is subject to violent mental emo- tions, mania, fcc. 18. When the eye to be operated upon can still discern things, how- ever feebly, a state, which generally produ- ces an involuntary resistance, to the neces- sary measures in the operation. 19. When the cataract is the consequence of a wound, though free from complication. 20. When the putient is in the state of preg- nancy. 21. When one eye has been alrea- dy destroyed by suppuration. 22. And lastly, when one eye has already been ope- rated upon without success, by a man, whose professional judgment, skill, and cau- tion, are unquestionable. According to Beer, the result of the ope- ration will be more or less u; favourable ; 1. When the patient is affected with gutta, or acne rosacea, not the effect of hard drink- ing, but rather of scurvy. 2. When evident traces of some general disease ofthe consti- tution are present. 3. When the patient has been ill, and is only yet convalescent. 4. When any other disease, though not con- stitutional, is present. 5. When the cata- ract is adherent for a considerable extent to the uvea, or an incurable, though not very severe chronic inflammatory affection of the eye-lids, or eye-ball, prevails, as, for in- stance, an habitual inflammation of the Meibomian glands; ectropium of the lower eye-lid ; the remains of a paunus ; or, a strong aversion to light. Lastly, as Beer observes, every operation must fail, when the#cataract is manifestly joined with complete amaurosis, a dissolu- tion of the vitreous humour, dropsy, or atrophy ofthe eye, some species of ophthal- my, glaucoma, or a general varicose affec- tion ofthe blood vessels ofthe eye. The capacity of distinguishing light from darkness, and, in a shady place, w here the pupil is not too much contracted, of per- ceiving bright colours and the shadows of objects, is, as Scarpa has particularly noti- ced, a very important desideratum in every case, selected for operation. The power of distinguishing light from darkness, is even more satisfactory, than motion of the iris. I saw many years ago in St. Bartholomew's and the York hospi- tals, several cases of complete gutta serena in both eyes, in which there was the freest contraction and dilatation of the pupils Had such patients been also afflicted with 310. CAI'XrUrl. cataract (a complication by no means un- frequent) nnc\ a surgeon, induced by the moveable st.ite of the iris, had undertaken an operation, it must of course have proved unavailing, since the r. us of light could only have been transmitted to an insensible, reti- na. Richter. and Wenzel. make mention o:the.-e peculiarities, and the latter refers the phenomenon to the iris deriving its nerves wholly from the lenticular ganglion, while the immediate organ of sight, is con- stituted entirely by another distinct nerve. Hence, motion of "the iris is not an infallible criterion, according to several authors, (Walhen) that the retina is endued with sen- sibility. Relating to this subject, Mr. Lucas has made a curious remark : he attended, iu conjunction with Hey and Jones, five children of a clergyman at Leaven, near Beverley, who were all born blind. He write*," None of them can distinguish light from darkness, and, although the pupil is, in common, neither too much diluted nor contracted, and has motions, yet these do not stern to depend upon the usual causes, but are irregulur." (Med. Obs. and Inq. Vol. 6.) The reciprocal sympathy between the two organs of sight, is so active, that no one, so- licitous to acquire either physiological or pHthological knowledge respecting them ought, for a moment, to forget it. Hence, in the examination of cataracts, it is of the highest importance to keep one eye entirely secluded from the light, while the surgeon is investigating the state of the iris in the other; for, the impression of the rays of light upon one eye, sensible to this stimu- lus, is known to be often sufficient to pro- duce corresponding motions of the iris in the opposite one, although in the state of perfect amaurosis. In other examples of cataract, the pupil may be quite motionless, and yet sight shall be restored after the per- formance of an operation. (Weuzel.) There are two circumstances, however, which may prevent us from ascertaining, whether the retina is sensible to light or not-s the first is, a circular adhesion of tbe crystalline capsnle to tbe iris. Here Richter thought, that some opinion might be formed of the nature of this case, by* observing the dis- tance between the cataract and pupil : in- ferring, that when the space, between the pupil and opaque lens, was inconsiderable, such an adhesion had happened ; and, when the cataract did not seem particularly close to the pupil, and yet the patient could not discern light from darkness, that it was complicated with amaurosis. The second circumstance, sometimes utterly preventing the ingress of any light to the healthy reti- na, is the round bulky form of the cataract. But, although the power of distinguishing light from darkness is more satisfactory, than motion of the iris, it is not an unequivocal test of the retina being perfectly free from disease. While the gutta serena is incom- plete, the patient can yet distinguish light, and the shadows of objects. Dilatationof the pupil is. idMi. a deceitful criterion of the complication of gulta eerena with the cat ft • ract. When thecatuiact is large, or adhe- rent to the iris, the pupil is frequently much dibit cd, however natural and sound the state of the optic nerve may be : tbe pupil often continues quite iindilatcd in a perfect gutta serena. (Richter.) From all this it must be manifest, Im, that the irregularity, and inconstancy ofthe symptoms ot gutta serena, together with the possibility oi particular states of the cata- ract rendering the patient utterly uncon- scious of the stimulus of light, make it ne- cessary for the surgeou to be particularly atteutive to the appearance, and to the his- tory of the origin and progress of the dis- ease, in order to understand the real condi- tion of certain cases. 2d, That when the patient can distinguish light from darkness, though the iris may be motionless, there i« good ground for trying an operatiou. Pos- sibly, in this circumstance, an incipient amaurosis may exist, but, the chance of (lie defect of the iris arising from other causes; the certainty, that the opaque body must, he removed from the axis of sight, (even iftha disease ofthe retina be cured,) ere sight can be restored ; and the improbability, that an operation to cure the cataract, will render the other complaint at all less reme- diable ; fully justify the attempt. Frequent- ly, the patient has a full formed cataract in one eye, which presents the signs of amau- rosis, while au incipient cataract, or one as much advanced, exists in the other, which, at present, is free from these symptoms -. iu this case (says Mr. Travers,) the cataract of the latter should be removed, without de- lay. (Synopsis, fa. p. 314.) The concurrent testimony of almost all writers upon the subject tends to prove that the restoration of sight has sometimes been effected in the most hopeless cases, and I am, therefore, of opinion with Mr. Lucas, that in all doubtful cases, an opera- tion should be tried as a remedy, by ne means violent or hazardous. (Med. Obs. and Inquiries, I ol. C>, p. 267.) I shall conclude this part of the subject, with annexing the sentiment of Mr. Travers, viz. that it would be incorrect to say, that the operation isunadviseable in all cases of cataract, in which the patient has no senie of light ; for, it is possible, that the density of the lens may be such as absolutely to ex- clude the light, and that the mottonsof the iris muy be therefore .suspended ; or from some degree of pressure of the lens, or adhesion of the uvea to the capsule, that the pupil maybe undilated,und the circum- ference of tbe lens permanently covered. But, undoubtedly, says Mr. Travers a ca"- ofthisdescription isunpiomising. "Astroug sense of light, by which at least to know tbe direction, in which it enters the apait- nient, to be sensible of its falling on the eye, and of a shade, as tbe hand for example, in- tercepting it, w ifh a corresponding freedom of motion ofthe pupil, is the most favoura- ble state for the operation." (Synopsis e-flh'. Di./ uses ofthe J'j/r, p. 'JI5.) CATARACT. 341 As it not unfrequently happens, that ca- taracts, produced by external violence,spon- taneously disappear, (Pott, Hey, fa.) the operation should never be too hastily re- commended for such instances. Respecting the question, whether an operation ought to be done, when only one eye is affected with cataract, and the other is sound, I find some difference of opinion prevails. One reason assigned by the condemners of this practice, viz. that one eye is suffi- cient for the necessities of life, is but of a frivolous description ; and, another, that the pntient would never be able to see dis- tinctly after the operation, by reason ofthe difference of the focus in the eyes, is, (I have grounds for believing) only a gratui- tous supposition, inconsiderately transmitted from one writer to another. In support of what I have here advanced, and to prove that success does sometimes, probably in general, (if no other causes of failure ex- ist,) attend the practice of couching, and extraction, when only one eye is affected with a cataract, I shall first adduce a fact from Maitre Jan. (Traiti des Maladies de I'Oeil. Edit. Paris, 1741, 12mo. Obs. sur une Cataracte laiteuse, p. 196.) " Le 17 Octobre de llannee 1785. J'allai a Savierc pour abaiser une cataracte dans I'oeil gauche d'un jeune garcon appellc Nicolas Very, valet de Sebastien Coutan, laboureur. Cette cataracte me paroissoit d'une bonne couleur, la pupil!,; se dilatoit lentement, et beaucoup, et se resserroit de meine, quand je passois lu main entre I'oeil ei le grand jour, le sain itcmt fcrmi.," he. After describing the operation,he continues, " Quelques jours apres je rttournai le voir, et je trouvai que I'.iumeur aqueuse 6toit fort eelaircie, et qu'il distinguoit toutes sortes d'objets: je le vis encore sept ou huit jours apres en passant par 6on village, et je le rencontrai faisant son ouvrage, et entiere- nient gueri, sans qu'il parut qu'il eut jamais etc incommode de cataracte.". Buron Wenzel was iu the habit of extract- ing cataracts with the most successful re- sult, when only one eye was affected with the disease, as may be learnt by referring to the cases here specified. (Cases 6, 13, 16, 19, 22, 25, 29, 30, 31, 34, he. Treatise on the Cataract.) It will be necessary to quote here only two cases, related by this eminent oculist. " Madame Harvey, a tobacconist, at Chalons sur Marne, presented a compli- cated case similar to the preceding. She bad a cutaract in the right eye, combined with an opacity in the anterior portion of the capsule, as appeared by the white spots and inequalities of which I have spoken above, in tbe surface of the cry.-talliue.— Her left eye was sound. I operated on the right eye in the year 1782, he. The patient suffered some pain in consequence of ihe operation, but was soon removed by bleed- ing Jicr in the foot; and notwithstanding this obstacle, the sight was soon recovered to a* great a degree of perfection as was possible after such an operation." . (Wenscl on the Cataract, p. 138, Case 16.) The following case isas explicit as pos- sible on the point under consideration. " A poorwoman.de la Ferle sous Jouarre, who had a cataract in the right eye upwards of ten years, came to consult me in the year 178U. I found all the symptoms ofthe case favourable to an operation," he. (after de- scribing the manner of doing it, he contin- ues ;) " I immediately bound up, not only the eye that hud undergone the operation, but the sound one also ; a precaution, which it is necessary to use after all operations on the eye, even the most simple; it being al- most impossible, that one eye should not follow the motions of the other, he. In u fortnight she was perfectly cured; and, though the pupil remained larger than it was before the operation, or than that iu the left eye, and had much less motion, yet this eye, as well as the other, perceived ob- jects very distinctly.'" (Case 22, p. 166.) In the Medical and Physical Journal for May 1808, I have read au ingenious paper, defending the practice of operating, when only one eye is affected. Inext proceed to notice what Richter has remarked upon this head. He was former- ly convinced, that the advice not to ope- rate, when there is a cataract only in one eye, ought, for several reasons, to be dis- regarded; he reminds us of the wonderful consent between the eyes, so that one is seldom diseased without the other, sooner or later, falling into the same state; and hence he questions whether it may not be possible to prevent the, loss of the sound eye by a timely operation ? An non caveri possit jacturaiutcgii oculi tempestive extra- hendo cataractumprioris ? (Obs. Chir. Fascic. I.) He adverts to the remarkuble case re- lated by St. Ives, where a man was wound- ed in the right eye by a small shot, and, shortly afterwards, had a cataract in it; he then gradually became blind iu the left, but soon recovered his sight in it, after the ca- taract had been extracted from the right one. Here let us notice, that St. Ives (.V«- ladie* des Yeux, Chap. 15, Art. 3,) makes no mention of any confusion in vision, in consequence of the different refracting powers of the two eyes in question. An- other reason, judiciously assigned by Rich- ter, (06*. Chirurg. Fa>cic. 1.) for disregard- ing the above precept, is, that in waiting until a caturact forms in the other eye, the existing one, which is at this moment, per- haps, iu the most favourable state for the operation, may soon change so much for the worse (for instance it may contract such adhesions to the iris,) as either to de- stroy all prospect of relief, or, at most, af- ford but a very precarious and discouraging one. The length of time necessary to wait is also uncertain and tedious. I once saw a man in St. Bartholomew's Hospital, who had had a cataract in one eye fifteen years, during all which time the other continued quite sound; and another case of tweutv 343 CATARACT. years standing has lately been communica- ted to me. It is right to state, that Richter latterly inculcated a contrary opinion to what he formerly espoused, yet, without specifying the particular facts which indu- ced him to revoke his former sentiments. The principal reason stated by him is, that the patient not only does not see much more acutely with the two eyes after the operation, than with one before it, but, he frequently sees more confusedly, because the eye that has been operated on, cannot see well without the aid of a glass, which, perhaps, the sound one does not require. (Anfangsgrunde der Wundarzn. Dritter B. p. 199.) When I remember that no cases are ad- duced by this author to contradict the ra- tionality of his former sentiments; when 1 also reflect upon the facts recorded by Mailre-Jan, St. Ives, and Wenzel; when I contemplate that Callisen mentions, as the feeble ground of his adopting the common opinion, that, in one single instance of this description, he was unsuccessful, without particularizing from what immediate cause the failure arose; there appears to my mind strong cause to believe, that the advice, not to operate, when there is only one ca- taract, and the other eye is perfect, is at least a subject which merits further investi- gation. Warner's objection is similar to that specified by Richter: he writes, " the eye, from which the crystalline lens is re- moved, cannot be restored to a degree of perfection at all equal to that of the sound eye, without the assistance of a convex glass .-" (Description of the Human Eye and its Diseases, p. 85.) but, is not the power of using both eyes at the same time, even with Ihe inconvenience of being necessitated to employ a glass for the purpose, preferable to being blind of one ? The cases quoted, at all events prove, that confusion in vision is not always the result of the practice: whether the fact is concordant with the modern theory of vision, is entirely another consideration; if it should be found in- compatible with it, we must infer, that our knowledge of optics still continues imper- fect ; not that such well-attested axamples as some alluded to, are unworthy of belief. When there is a full-formed cataract in one eye, and vision is retained in the other, Mr. Travers thinks the postponement of the operation wrong. " I am satisfied, (says he) that the cataractous eye, if it be- comes the subject of an accidental inflam- mation, is strongly disposed to go into amaurosis; and, further, that the retina loses its vigour by the permanent exclusion of light, I speak from repeated observation of the fact. The objection to the operation on the ground of inconvenience, arising from tbe difference of focus of the two eyes, when one only is tbe subject of dis- ease, is trivial, and a consideration alto- gether subordinate: such a defect may al- ways be remedied by glasses properly ad- justed. In several cases of amaurosis, en- suing upon cataract, I have been disposed to regard the change in consistence and volume of the lens, us productive of a de- stroying inflammation ; in others, of a par- tial absorption of the vitreous humour."— (Synopsis of Diseases of the Eye, p. 318.) For some decided information on the foregoing interesting question, I have re- ferred to Beer; but he seems not to have entered into its consideration at all. The only instance in whicb he approaches tbe subject, is, when he notices the custom of covering the eye, whicb yet possesses more or less vision, when the other alone has a cataract in a fit state for an operation.— (Lehre von den Augenkr. B. 2, p. 361.) The reason which has induced me to al- lot so much spare for the consideration of the question, whether au operation should be undertaken, when only one eye is affect- ed, is a conviction of the importance ofthe decision made about it. Were I to judge only from what has been said by w rh>rs, I should be confident, that a determination in the negative must be erroneous; but, when I know that my experienced and ju- dicious friend Mr. Lawrence joins in the belief, that the practice is not productive of advantage, the only inference which I venture to make, is, that the subject de- serves further experiment. When there are cataracts in both eyes, most authors are of opinion, that there is no reason why one should not be operated upon immediately after the other. As, how- ever, the ophthalmy is likely to be more severe, cateris paribus, when both eyes are operated upon at the same time, Scarpa, who gives the preference to the needle, dis- approves of this mode of proceeding, and assures us, that, in patients with cataracts in both eyes, his experience has taught him, that it is by no means advantageous to ope- rate upon one immediately after the other; but that it is better to wait till one eye is well, before any attempt is made upon the other. (Saggio dt Osservazioni, fa. p. 26a.) On this point, the following is Beer's sen- timent :—When cataracts are completely formed in both eyes, the patient willing, and every thing promises a favourable re- sult, both eyes may be operated upon at the same time. On the contrary, when any circumstances are present, which render the event of the operatiou very doubtful, it is most adviseable to make the attempt only on one eye, even though the patient abso- lutely wish more to be done, so that if the first operation should fail, but the complica- tion of this cataract afterwards change con- siderably to the advantage of the patient, one eye would still be left for a second more favourable attempt. (Lehre ton den Augenkr. B. 2, p. 350.) Some years ago, it was tbe common doc- trine, that no operation should be underta- ken for a cataract, before the patient had attained the age of docility and reason, and, inapointof view abstracteldy surgical, there can be no doubt of the rectitude of inch advice; but, when it is further considered, how essential sight is to the acquirement of CATARACT. 343 education ; that youth is the condition best adapted for this indispensable pursuit; that when the child's head is steadily fixed, the needle admits of being employed; that, with the aid of an assistant, this object can most effectually be accomplished; that, when the operation is delayed, the cataract may acquire adhesions; that, persons have not only had cataracts successfully depress-^ ed or broken, at a very early age, but with the assistance of a speculum oculi, have even had them extracted, (See Ware's Note, p. 90, of Wenzel's Treatite,) which is universally acknowledged to be afar more difficult process ; and that the pupil of the eye in a young subject, is nearly as large as is an adult; (Warner's Description ofthe Human Eye and its Diseases, p. 34.) I can- not help thinking with Mr. Lucas, that af- ter a child is old enough to bear an opera- tion, the attempt to cure a cataract with the needle may be proper at any age. Sur- geons do not refuse to operate for the hare- lip, as early as two years of age; they do not wait for docility and reason in the pa- tient, to make him munageable, and sensi- ble of the propriety of submitting quietly to the performance of the operation ; they render him tractable by force, and thus they wisely succeed in making perhaps, with more certainty, than reliance upon the fortitude of any human being would af- ford, a very precise incision, such as the nature of the operation demands; and, why should they refuse to attempt the cure of cataracts, in children, when the motives are more urgent, and it is equally in the power of art to substitute means, quite as effectual as docility and reason in surgical patients ? What experienced operator would trust to these qualities, when he undertakes any grand operation, even on the most ra- tional and firm adult ? (Critical Reflection* on the Cataract, 1805 ) Of late years, the attention of surgeons has been much drawn to the subject of ope- rating on the cataracts of children, and the propriety of the practice seems to be now firmly fixed on the basis of experience. It is even ascertained, that the needle may be successfully employed on children ofthe most tender age. The late Mr. Saunders, surgeon to the London Infirmary for curing diseases of the eye, may be said to have had the principal share in promoting the adop- tion of this important improvement. His practice confirmed, what reason had long ago made probable, and the judgment, ten- derness, and skill, with which he operated on the eyes of infants, as well as those of adults, were followed by a degree of suc- cess, whicb had never been previously wit- nessed, and which infused quite a new spirit into this most interesting branch of sur- gery. Subjects from eighteen months to four years old, received most benefit from Mr. Saunder's operations ; and, if any in- termediate time be selected, Dr. Farre (the editor of this gentleman's publication) is inclined to recommendthe age of two years# ■'•' The parts have then attained a degree or resistance, which enables the surgeon to operate with greater precision, than at au earlier period ; yet, thecapsule has not he- come so tough and flexible, as it does at a later period, after the lens has been more completely absorlx-J. " But, this is not the greatest, although a considerable advantage of an early opera- tion ; for, in cases, in which the patient has no perception of external objects, the muscles acquire such an inveterate habit of rolling the eye, that, for a very long time after the pupil has been cleared by an ope- ration, no voluntary effort can control this irregular motion, nor direct the eye to ob- jects with sufficient precision for the purpose of distinct and useful vision. The retina too, by a law, common to all the structures of an animal body, for want of being exer- cised, fades in power. Its sensibility, in many of the cases, cured at the ages of four years, and under, could not be surpassed iu children, who had enjoyed vision from birth; but, at eight years, or even earlier, the sense was evidently less active ; at twelve, it was still more dull ; and from tbe age of fifteen and upwards, it was generally very imperfect, and sometimes the mere perception of light remained. But, these observations do not apply to those congeni- tal cataracts, in which only the centre of the lens and capsule is opaque, the circum- ference being transparent, for, in those, the retina is exercised by a perception, although an imperfect one, of external objects, the motions of the muscles, which direct the globe, are associated, and an absoption of the lens does not take place : therefore, in this variety of the disease, the argument iu fa- vour of an early operation, is not so much a medical, as a moral one—it is preferable for the purposes of education and enjoy. ment." (Saunders on Diseases ofthe Eye, p. 153,155.) Besides Mr. Saunders, several other sur- geons of the present day have become zealous advocates for operating upon the cataracts of children. Even Mr. Ware, before his death, strongly recommended the use of the needle in the congenital cataract of infants and children. His mode of operating I shall hereafter notice. The late Mr. Gibson, of Manchester, likewise urged the propriety of couching young sub- jects, and fixed on the age of six months, as preferable to that of two years. "What- ever objections (says he) have been urged against the safe and effectual use of the couching needle in infants, have always ap- peared to me so slight, and so easily sur- mountable, that, without inquiring particu- larly into the real state of the question, I have long concluded, that the same motives, which would induce an operator to couch a cataract at any period of adult life, would equally lead him to perform that operation at any earlier period, when a cataract exist- ed. Acting upon this presumption, I have operated upon children of all ages, for ten years past." fSee Edinb. Med. and Surgical Journal. Vol.7, p. 394) :i44 I ATARACT. Mr. Gibsons pa|.ier being dated June, 1311, we are of course giveu to understand, I hut he pursued this practice from the year 1801, and he usserts, that his experience had vinbraced a considerable number of cases. •; In performing the operation of couch- ing infants, it bus always appeared to me, isays this gentleman) that the advantages to be gained by restoring vision ot so early a period, are so important, as to bear down any obstacles which may occasionally be opposed to the safe use of the needle. Lven the risk of deranging the figure of the pupil forms no solid objection to its use ; and may always be avoided by steadiness and good management. Should even n slight chunge in its figure be produced, it is seldom in the least detrimental to distinct vision, and enn scarcely be considered a blemish in tl.e eye of any one ; except, per- haps, iu that of ageoinetriciuu ; who iuuy easily reconcile to himself the presence of an ovul opening, where one of a circular form should exist. It may farther be obser- ved, that, if an operator cannot depend upon his management ofthe eye, so us lo render it steady by the introduction of the cocchiug needle, he can avail himself of the assistance of a speculum to restrain its mo- tions. •: The following observations will apply principally to infants under twenty months old. The advantages, which an operator possesses, in operating upon a child of this age, as compared with a child of three years old, or upwards, are important. An infant is not conscious ofthe operation intended : it is free from the fours created by imagina- tion, and can oppose very feeble resistance to the means employed to secure it with steadiuess. At uu early age, it has not ac- quired the power of retracting the eye deep in the socket, 60 that the operator has al- ways a good prospect of introducing the couching needle with ease, by watching a proper opportunity. The eye has not, at this time, acquired tbe unsteady rolling mo- tion, which, ufter a few years, is so common and remarkable in children born blind, or reduced to that state soon after birth. So that this impediment to the easy introduc- tion ofthe needle does not existin infants a lew months old. The operator also has it in his power, to administer a dose of opium, sufficient to render the steps necessary to expose the eye, almost entirely disregard- ed by his patient. With respect lo the state ofthe eye itself, but, particularly, that of the cataract, this is more favourable for the operation, than any future period of life. In infants, the caturacl is generally Jlu'ul, ajd merely requires the free rupture of its con- taining capsule, which is in that case gene- rally opaque. The capsule, however, is ten- der, aud easily removed by the needle, so as to leave an aperture sufficiently large for the admission of light. The milky fluid, w Inch escapes from tbe capsule, is soon re- moved by absorption. If, on the other hand, (says Mr. Gibson) the cataract should be >-oH. it is generally of to pulpy a softuc - (but the tree laceration i.l the milerior |j of its capsule, and the consequent admission of the aqueous humour, ensure its speedy dissolution, and disappearance, without tbe necessity, of a second operation. Should tbe cataract happen to be hard, there will be no more difficulty in depressing it, thxn in an adult. So uniformly favourable is tir state of the cataract to the success of ii;* operation, that I may venture lo pronounce, that nn operator of common experience ai>.) expertness, will seldom foil of sneers*, if hr can, in an adult, depress u hard cataract, i,r rupture the containing capsule, ami brrul, down the substance of a soft, or fluid can ruct when it occurs. ,; Such (continues Mr. Gibson) arc the advantages, derived from the age ofthe pa- tient, and state ofthe eye, which would in- duce au operator to use the couching needle a few months after birth. If, however, a surgeon hid even difficulties to encounter, which do riot occur in adults, surelv t!i>> in- valuable benefit, conferred by cnahiii)^ h.i infant to become an intelligent hr-'w;, like other children, instead of reainiiiiu:; 1.1 u state approaching to idiolisui, wuuM incline him to run s nne risk of failure, and to make more than common exertions, especially as there is little chance of injuring the eye, when proper cautions arc used. Yet so im- portant a consideration appears to have had little influence upon oculists, and hence, many children have been doomed to years of darkness, happv in the estimation ut their parents and friends, if they could di-- tinguish black from white ; or dbcr-rn any perceptible difference between the bright- ness of the sun, and the glimmering of h tallow candle. " These advantages, which an operator will possess, when he attempts the removul of a cataract in a child of a few months old, are peculiar to that period. In proportion as the age of the patient advances, until he arrives at the age of discretion, and can es- timate, in some measure, the value of li^ht, by feeling its loss, the difficulties, opimn-J to the use ofthe couching needle, ini;rea-e His fears of the operation, the unsteadiness of the eye, and his power of retracting it within the orbit, present considerahle, but not insuperable obstacles ; such, however, as everv surgeon would willingly dispense with, if" he had it in his power. " Before an operation,at an early a»e h recommended, the practitioner ought fas ut any other age) to ascertain, that the catarait is not complicated with a defective state01 the retina, or with a complete amaurosi* Such cases are by no meaus uncoiniti" Some years ago, I recollect to have seen l:v or six children, the families of two sivn- who were all totally blind, and in an ill"'" state, with cataracts accompanied by .ta.j;i- rosi.s." (Gibson Op. ct loco cit.) I find also in this gentleman's paper, sornr arguments, which have been repeated ■" Mr. SaunJer's work. " Few praeiitioii'1!-, at all conversant with cases with bliudin'-- lroui birth-, will d-.-ny. tr: •'.: < \\'<-'>h r:- CATARACT. 34« able, that the eye may lose a considerable part of its original powers, from the mere circumstance of its having so long remained a passive organ. Hence, probably it hap- pens, that, in some cases of congenital cata- ract, the only benefit conferred on the pa- tient, by an operation, is that of enabling him to find his way in an awkward manner, and to discriminate the more vivid colours. Such patients have never been able to dis- cern small objects, or to judge in any useful degree, of figure or magnitude ; I am well aware, however, says Mr. Gibson, that, in some rare instances, such a defective state ofthe eye exists from birth. " Another circumstance, which must have attracted the attention of oculists, is, that in a few years, the eye of a patient born blind, acquires a restless and rolling motion, which is at length so firmly established by habit, that he has little control over it. This motion unfortunately continues, for a con- siderable time, after sight has been restoredr to such a person, and is a very material ob- stacle to the early attainment of a know- ledge of the objects of vision. He cannot fix his eye steadily upon one point for a mo- ment, and the inconvenience which arises from this unsteadiness, is, to such a person, occasionally as great a bar to tbe distinct view of an object, as the unsteady motion ofthe same object would be to one, whose vision is perfect. This inconvenience any one can appreciate, and, as far as 1 know, it is completely avoided by restoring sight at an early age. •As a motive for operating on infants, Mr. Gibson also comments on the loss of those years, whicb ought to be spent in education. (See Edinb. Med. and Surgical Journal, Vol. 7, p. 394, 400.) When once it is decided to operate upon a cataract, the sooner the operation is gen- erally done, the better, because the anxiety ofthe patient increases, as Beer says, with every day, nay, with every hour. Just be- fore tbe operation, care must be taken not to let the patient eat a great deal, nor load his stomach with substances difficult of di- gestion ; and, if the stomach and bowels should already be disordered by what they contuin, their contents ought to be carefully removed previously to the operation. In the same manner, if the surgeon wish to keep off much inflammation, and the patient should.be constipated, this state must be ob- viated by*\uitable medicines. And, lastly, when, at the request of the patient himself, the operation is deferred for a few days, the greatest caution must be used not to let him expose himself to any causes, likely to bring on catarrhal or rheumatic complaints. (Beer, B. 2, p. 344J The following advice deliver- ed by Scarpa, with respect to the prepara- tion of patients for operations on the eye with the needle, is valuable: In ordinary cases, there is not the least occasion for any preparatory treatment previous to the ope- ration ; all that prudence requires is, that the patient should abstain from animal food,* and fermented liquors, for a few days, be- Vol. L 44 fore submitting to it, and should take one dose of a gentle purgative. But, this, like every other general observation, is liable to particular exceptions. Hypochondriacal men, hysterical women, and patients subject to affections of the stomach and nervous sys- tem, should take, for two or three weeks before the operation, tonic bitter medicines, particularly the infusion of quassia, either with or without a few drops of the aether vitriolicum to each dose ; or, in other cases, 3J of Peruvian bark, with j)j of valerian, may be administered two or three times a day with particular benefit. It is observed by the most accurate writers upon this sub- ject, that, in such persons, the symptoms consequent to operations upon the eyes, are often much more violent than in common cases ; and it therefore seems proper to en- deavour, previously, to meliorate their con- stitutions. When the patient is timid, it is very adviseable to give him, half an hour be- fore the time of operating, about fifteen drops of the tinctura opii, with a little wine. Some patients, besides being afflicted with cataracts, have the edges of the eye- lids swollen and gummy, with relaxation, and chronic redness of the conjunctiva. In this case, before undertaking to couch, it is adviseable to apply a blister to the nape of the neck, and to keep it open for two or three weeks, by^neans of the savin cerate, and to insinuate every morning and evening, between the palpebral and globe of the eye, a small quantity of the unguentum hydrarg. nitrat. mitius, prepared according to the pharmacopoeia of St. Bartholomew's Hospi- tal, increasing its strength gradually. (I£. Unguenti hydrargyri nitrati, ^iv. Adipis Suillae ^viij. Olei Oliva?, ^ij.) In obstinate cases, when this ointment does not produce the desired effect, an ointment recommended by Janin, (Memoires sur 1'Oeil,) should be substituted : it consists of |ss of hog's lard, 3ij of prepared tutty, 3'j of armenian bole, and 3j ofthe white calx of quicksilver. At first, care should be taken to use it lowered, with twice or thrice its quantity of lard. In the day time, a collyrium, composed of ?iv of rosewater, ^ss of the mucilage of quince seeds, and gr. v. of the sulphate of zinc, may also be frequently used with con- siderable advantage. By such means, the morbid secretion from tbe Meibomian glands, and membranous lining of the eye- lids, will be checked, and the due action of the vessels, and natural flexibility of the eye-lids, will be restored. (Saggio di Osser- vazioni, fa. suite principali malaltie degli occhi, Venez. 1802.) There are three different operations prac- tised for the cure of cataracts, viz. one termed coughing, or depression, of which the method, c&Uedreclination, is a modification, as will be hereafter explained; another, named extraction ; and a third denominated keratonyxis, which consists in puncturing the cornea with a needle, the point of which is to be conveyed through the pupil, so as to reach the cataract which is to be *>46 CATARACT gently broken into u.-i ^mmis. As Beerob- jerves, each of these modes has, iu particu- lar cases, mantfest advantages over the other two ; butjno single method will ever be exclusively preferred, and invariably followed, by any man of experience and judgment. In every operation for a cata- ract, the position of the patient, assistants, and surgeon, is of great importance. .In order to enable the assistant who stands behind the patient, to be conveniently near the head of the latter, Beer pre- fers letting the patient sit on a stool, which has no back. However, as I shall ■ presently notice, some eminent surgeons have urged good reasons in favour of em- ploying a chair, which is completely per- pendicular. When tbe left eye is to be ope- rated upon, the same assistant is to apply his right-hand underthe patient's chin,and press the head ofthe latter against his breast, at the same time that he inclines it and himself more or less forward towards the operator, who sits upon rather ahigh stool, in front of the patient. In this country, a music-stool is commonly preferred, the height of which can be regulated in a mo- ment, by simply turning the seat round to the right, or left, whereby the screw, with which it is connected, is made to rise, or descend, as may be found most desirable. The same assistant then places his left-hand flat upon the left side of tbje patient's fore- head, with the points of the fore and middle fingers, somewhat under the edge of the upper eye-lid ; and, with the fore-finger, he is now to raise the edge of this eye-lid, as much as possible, following that finger immediately with the middle one, so as to fix the eye-lid with greater certainty. The ends of these fingers, how ever, must be so applied, as not to touch the globe of the eye in the-slightest manner, much less make any pressure upon it, yet, so that the upper part of the eye-ball and cornea may be gently resisted by them, when theeye rolls upwards away from the instrument about to be introduced, whereby this position, which is extremely convenient to the ope- rator, may be immediately rectified. The patient should also sit obliquely opposite a clear window, so that a sufficient light may fall obliquely upon the eyes, without any rays being reflected to the cornea, and be- coming a hinderance to the operator. Nor should light from any other quarter be ever allowed to fall upon the eyes. 'The sur- geon should sit in front of the patient, whose head ought to be directly opposite the operator's breast, whereby the latter will be enabled to see from above, with the Sreatest correctness, every thing in tbe eye uring the operation, and will not be under the necessity of raising his arms too con- siderably. Supposing it to be the left eye, which is to be operated upon, he next ef- fectually draws down the lower eye-lid with the left fore-finger, the end of which must be placed over the edge of the eye-lid, towards the globe of the eye, just like those of the assistant, who supports the upper eye-lid. The middle linger is then to be ap- plied in a similar way over the caruncula lachrynkdis. The operator now takes in his right-hand the requisite instrument for tbe operation, viz. the needle, or knife, which is to be held, like a pen, between the thumb and the fore and middle fingers. By this particular arrangement of the fingers ofthe assistant and operator, which,indeed, is partly ineffectual where the fissure of the eye-lids is very narrow, and the eve- ball is diminutive and suuk in the orbit, the restless eye of the timid patient is fixed ; for a point of the finger is disposed on every side, to which the eye. can possibly turn . away from the instrument about to be in- troduced, and when the cornea is gently touched with the extremity of the finger, the wronged position, which the eye is about to take, is immediately prevented This method of fixing the eye, says Beer, u not merely indispensable for youug ope- rators, but is the oqly perfectly unobjec- tionable one, which Can be employed on this delicate organ, since all mechanical inventions for this purpose, like the specu- lum oculi, which keeps the eye steaJv, by considerable pressure, orothercontriv ances, like Rumpelt's instrument, which does the same thing by means of a short-pointed in- strument attached to a kind of thimble, and with which the sclerotica is pierced, and held motionless, are found by experience to be worse than useless. And, as a proof of this fact, Beer adverts to the numerous pa- tients, who come out of the hands of such operators as employ these instruments, witli a more or less# hurtful loss of the vitreous humour, and other ill consequences-, a statement, which nearly agrees with the observations of Wenzel and Ware. Baron Wenzel considers all instruments, for fixing the eye, quite unnecessary : they render the operation more complicatesjL more dreadful to the patient, more tmbar- s, rassing to the operator, and are very liable to irritate and wound the eye. If he could approve of any kind of speculum, be should give the preference to Rumpelt's thimble, at -the end of which is a sharp- pointed instrument, like the pique of Pa- rhard. The thimble is placed 0^1 the mid- dle finger of the operator, audi it has the advantage of not obstructing the; use ofthe fore-finger, but leaves it at liberty to keep down the lower'eye-lid. » * The pressure, occasioned by ail contri- vances for fixing the eye, is a seridus objec- tion to their employment, as it ds apt to cause a sudden protrusion of great part of the vitreous humour. (Wenzel.)' The late Mr. Ware coincided with Wen- zel, respecting the general objections to specula. At the same time, be remarks, that, in some instances, of children bom with cataracts, he had Ivsen obliged to fix the eye with a speculum ; without the aid of which, he found it totally impracticable lo make the incision through the cornea, with any degree of precision, or safety. His speculum is an oval ring, the longejt CATARACT. 347 diameter of which is about twice as long ns the diameter of the cornea, and the shortest about half as long again as this tunic. Annexed to the upper rim of the speculum is h rest, or shoulder, to support-the upper eye-lid, and by its lower rim, it is fixed to a handle of such « length, and bent in such a wa v, as may render it convenient to be held. (IV tire.) * Nor does Beer entertain a higher opinion of other inventions, made for the purpose of enabling surgeons to operate on both eyes with the right hand ; for, says he, the right eye should always be operated upon with the left-hand, and the left with the right, and he who cannot learn to be equally skilful with both bis hands, must always remain a bungler. (Lehre von den Augenkr. B.2,p. 347— 350.) Mr. Alexander, whose great skill in ope- rations on the eye' is universally acknow- ledged, employs no assistant for raising the upper eye-bd, or fixing ij# ; eye, which ob- jects he accomplishes Himself; and, in Germany, this independent mode of pro- ceeding has been particularly commended by Borth. (Etwas Uber die Ausziehung des grauen Staare,fnrdengeubten Operaleur, Svo. Wien. 1797 ) The preceding directions,* respecting the position of the assistant, the scats for the patient and surgeon, and the mode of fixing the eye, are chiefly those of Professor Beer. Whether these instructions are in every re- spect better than the following, which combine the sentiments of some other wri- ters of experience, the impartial reader must judge for himself. The patient should be seated rather low, opposite a window where the light is not vivid, and in such a manner, that the rays may fall laterally upon the eye about to be couched. The other eye, whether in a healthy or diseased state, ought always to be closed, and co- vered with a handkerchief, or any thing convenient for the purpose ; for, so strong is the sympathy between the two organs, that the motions of the one constantly pro- duce a disturbance of the other. The sur- geon should sit upon a seat, rather higher than that upon which the patient is placed ; and, in order to give his hand a greater de-S gree of steadiness in the various manoeuvres ofthe operation, he will find it useful to place bis elbow upon his knee, which must be sufficiently raised for this purpose, by a stool placed under the foot. The chair, on which the patient sits, ought todiave a high back, against which his head may be so firmly supported, that he cannot draw it backward during the operation. The back of the chair must not slope backward, as that of a common one, but be quite perpen- dicular, in order that the patient's head may not be too distant from the surgeon's breast. (Richter's Anfangsgr.der Wundarzn. p. 207, 3 B.) The propriety of supporting the patient's head rather upon the back of the chair, on which he. sits, than upon an assistant's breast, as Bisrhoff has observed, is founded upon a consideration, that the least motion ofthe assistant, even that necessarily occa- sioned by respiration, causes, also, a syn- chronous motion of the part, supported ou his breast, which cannot fail to be disadvan- tageous, hoth in the operation of extraction, and of coughing. Hence, Callisen and Richter, both recommended the method of " supporting the patientfs head gainst the perpendicular back of the chair. But, as this is not at present the common practice, possibly the inconvenience of having the back of the chair between tbe assistant and ^ patient^may more than counterbalance i;tageous. vv In certain cases, where the muscles ofthe eye and eye-lids, arc incessantly affected with spasm; or, where the eyf is peculiarly- diminutive, and sunkasit were,in the orbit, the elevator for the upper eye-lid, invented by Peflier, and approved by Scarpa,, may possibly prove serviceable : in* young sub- jects, I think it might contribute much to facilitate the operation. The particular sentiments of Wenzel and Ware, concerning the mode of fixing the eye, will be further explained in the des- cription of the extraction of the cataract. OF COUCHING, OR DEPRESSION OF THE CA- TARACT, AND RECLINATION. The operation of couching was once sup- posed to cjfisist altogether in removing the opaque lens out of the axis of vision, by means of a needle, constructed for the pur- pose ; but, it is well known to be frequently effectual on another principle, even when the nature aud consistence of the' cataract do not admit of tile depression of the opaque body. In short, experience fully proves that the diseased lens, when broken and disturb- ed with the needle, and especially when freely exposed to tbe contact of the aqueous humour by a proper laceration of its capsule, is gradually dissolved and removed by tha action of the absorbents. , M However, when a surgeon spemes of de- pression, he always means the operation of pushing the cataract nearly perpendicularly, and to a sufficient depth below the pupil in- to the vitreous humour, so as to prevent the opaque substance from being an impediment to vision. WViters of the highest reputation and greatest experience differ so widely about the merits of this operation, tltat, I think it fuir to conclude, that, on each side, strong prejudices and exaggerations have been suf- fered to enter the question. In general, it w'ill be observed, that oculists, and others, who seek for a name in this branch of sur- gery, decry tbe operation of depression ; and, if it were designed to make the use of the needle an exclusive practice, then I believe the results of modern experience would com- pel every impartial surgeon to enter a pro- test against tbe decision. In this respect, the doctrines of Pott, Callisen, Hey, and Scarpa, are undoubtedly wrong, though their sentiments are blended with many valuable ■M* i ATMfVCT. and important truths. Beer, who is by no means a great advocate for depression, ad- mits its utility in particular cases. It is easi- ly comprehensible, says he, that in this way, a firm and large cataract, either cannot be removed without injuring the retina, and the attachment of the corpus ciliare to the vitre- ous humour, or not far enough to prevent the opaque*body from rising again at tbe first opportunity. Hence, the former com- plaints about the frequent return of the ca- taract, and other ill consequences, unappeas- able vomiting, suddenly produced amauro- sis, and severe inflammation, he. But,- while Beer acknowledges the frequency of these ill effects of depression, he condemns the universal rejection of it, attempted at tbe present day, aVd the unlimited substitution for it of reclination, which consists in apply- ing tbe needle in a certain manner to the an- terior surface ofthe cataract, and depressing the opaque body into tbe vitreous humour, in such a way, that the front surface of the cataract is now the upper one, its back sur- face the lower one, its upper edge back- wards, and its lower edge forwards; a change, which Beer says, cannot be made without an extensive destruction ofthe cells of the vitreous humour. Hence, with few exceptions, this author thinks the common mode of depression should be preferred. (Lehre von den Augenkr. B. 2, p.352.) And, in this sentiment, be is joined by Mr. Tra- vers, who remarks, that the real objection to couching is the breaking up«of the fine texture ofthe globe ofthe eye, by the forci- ble depression of the lens. " Whether it be depressed edgeways or breadthways, makes no difference in tbe result; it must still oc- cupy a breach in the cells ofthe vitreous hu- mour, and must derange and disorder that delicate texture, and those connected with it. A slow insidious inflammation marked by a gradual developement of the symptoms of disorganization, viz. congestion of vessels, turbid humours, flaccid tunics, and palsied iris, is too often the consequence. Tbe sight, instead of improving, when the imme- diate effects of the injury are passed away, remains habitually weak and dim, or de- clines and fades altogether. The advocates for reclination seem to forget, that the prin- ciple, which is the same in both operations, is the real ground of objection. As to the position of the lens, I suspect less mischief is done by the old method of depression, as less force is required to break a space for the vertical, than the horizontal lens, pro- vided the depression be carried to no great- er extent, than is necessary to clear the in- ferior border of the pupil." (Synopsis ofthe Diseases ofthe Eye, p. 318.) Beer divides both the operations of couch- ing and reclination into three stages: the first is that in which the needle is introduced into the eye ; tbe second that, in which it is passed into the posterior chamber and placed across the anterior surface of the cataract; the third is that, in which the operator ac- complishes the act of depression, or reclina- tion There are two couching needles, which now seem to be generally preferred; name- ly, that which was used by the late Mr. Hey; and that recommended by Scarpa. The length of Mr. Hey's needle is some- what less than an inch. It would be suffi- ciently long if it did not exceed seven- eighths of an inch. It is round, except near the point, where it is made flat by grinding two opposite sides. The flat part is ground gradually thiner to the extremity of the nee- dle, which is semi-circular, and ought to be made as sharp as a lancet. The flat part ex- tends iu length, about an eighth ofan inch, and its sides are parallel. From the part ' where the needle ceases to be flat, ils diam- eter gradually increases towards the handle. The flat part is one-fortieth of an inch in di- ameter. The part which is nearest the han- dle, is one-twentieth of an inch. The han- dle, which is three inches and a half in length, is made of light wood, stained black. It is octagonal, and has a little ivory inlaid in the two sides, which correspond with the edge of the needle. Mr. Hey describes the recommendations of this instrument in tbe following terms: 1. "It is only half the length of the com- mon needle ; and this gives the operator a greater command over the motions of it-. point, in removing tbe crystalline from its bed, and tearing its capsule. It is also of some consequence, that the operator should know how far the point of his needle has penetrated the globe of the eye, before be has an opportunity of seeing it through the pupil ; as it ought to be brought forwards when it has reached the axis of the pupil. Now he may undoubtedly form a better judgment respecting this circumstance, when the length of his needle does not much ex- ceed the diameter of the eye, than when he uses one of the ordinary length, winch is nearly two inches. The shortness of the needle is peculiarly useful, when the cap- sule is so opaque that the point cannot be seen through the pupil. 2. " As this needle becomes gradually thicker towards the handle, it will remain fixed in that part of the sclerotis, to which the operator has pushed it, while he employs its point in depressing and removing the ca- taract. But the spear-shaped needle, by making a wound larger in diameter, than that part of the instrument, which remains in tbe sclerotis, becomes unsteady, and is with difficulty prevented from sliding for- wards against the ciliary processes, while the operator is giving it those motions which are necessary for depressing the cataract. " On the sunie account the common spear- shaped needle may suffer some of the vitre- ous humour to escape during tbe operation, whereby the iris and ciliary processes would be somewhat displaced, and rendered flac- cid ; whereas the needle which I use, mak- ing but a small aperture in the sclerotis, aod filling up that aperture completely during tbe operation, no portion ofthe vitreous humour can flow out so as to render the iris and cili- ary processes flaccid. CATARACT 349 3. " This needle iris no projecting edges; but the spear-shaped needle, having two sharp edges, which grow gradually broader to a certain distance from its point, will be liable to wound the iris, if it be introduced too near the ciliary ligament, with its edges in a horizontal position. I have been in- formed, that, in an operation performed by one of the most eminent surgeons in the me- tropolis, now deceased, the iris was divided as far as the pupil. If tbe operator, in order to avoid this danger, introduces his needle with its edges in a vertical position, be will divide tbe fibres of the sclerotis transversely, and, by thus enlarging the wound, will in- crease the unsteadiness of the instrument. Besides, however the needle be introduced, one of its sharp edges mu-t be turned to- ward the iris in the act of depressing the ca- taract ; and, in the various motions which are often necessary in this operation, tbe ci- liary processes are certainly exposed to more danger than when a needle is used which lias no projecting edge. 4. " It has no projecting point. In the use of the spear-shaped needle, the opera- tor's intention is lo bring its broadest part over the centre of the crystalline. In at- tempting to do this, there is great danger of carrying the point beyond the circumference of tne crystalline, and catching hold ofthe ciliary processes, or (heir investing mem- brane, the membrana nigra. This accident is the more probable, as the point of the needle must unavoidably be directed oblique- iy forwards, and this motion, if carried too far, brings the point into contact with the ciliary processes, as they surround the cap- sule of the crystalline. " A needle, (recommended by Mr. Hey,) will pass through the sclerotis with ease. Ii will depress a firm cataract readily, and break down the texture of one that is soft. If the operator finds it of use to bring the point of the needle into the anterior cham- ber of the eye, (which is often the case,) he may do this with the greatest safely, for the edges of the needle will not wound the iris. In short, if the operator, in the use of this needle, does but attend properly to the mo- tion of its point, he will do no avoidable in- jury to the eye, and this caution becomes the less embarrassing, as the point does not project beyond that part of the needle by whicb the depression is made, the extreme part of Ihe needle being used for this pur- pose." (Hey.) Scarpa employs a very slender needle, possessing a sufficient firmness to enter the eye without hazard of breaking, and having a point, which is slightly curved. The curv- ed extremity of the needle is flat upon its dorsum, or convexity,sharp at its edges, and has a concavity, constructed with two ob- lique surfaces, forming in the middle a gen- tle eminence, that is continued along to the very point of the instrument; there is a mark on the side of tbe handle, which cor- responds to the convexity ofthe point. The surgeons of the Leeds Infirmary have had one advantage in the needle, which they have used in imitation of Baron Hilmer; I mean, having it made of no greater length, than the purposes of the operation demand. A couching needle is sufficiently long when it does not exceed, at most, an inch in length: this affords (he operator a greater command over the motions of the point, and enables him to judge more accurately, how far it has penetrated the globe of the eye, before he has an opportunity of seeing it through the pupil. To the needle, there- fore, so much recommended by Scarpa, aud so successfully used by him, and Dr. Morigi, principal surgeon ofthe hospital at Piacenza, and one of the most expert operators ofthe present day in Italy, it seems proper to unite Ihe improvement of having it made no lon- ger than is necessary. The needle, here de- scribed, will penetrate the sclerotic coat as readily as any straight one, of the same dia- meter, and, by reason of its slenderness, will impair the internal structure of theeye less in its movements, than common couching needles. When cautiously pushed in a trans- verse direction, till its point has reached the upper part ofthe opaque lens, it becomes si- tuated with its convexity towards tbe iris, and its point in an opposite direction ; and, upon the least pressure being made by its convex -urfai.-e, it removes the cataract a lit- tle downward, by which a space is afforded at the tipper part of the pupil, between the cataracl and the ciliary processes, through which the instrument may be safely convey- ed in front of the opaque body and its cap- sule, which it is prudent to lacerate in the operation. In cases of caseous, milky, and membranous cataracts, tbe soft pulp of the crystalline maybe most readily divided, and broken peice-meal by the edges of its curv- ed extremity; and the front layer of tbe capsule lacerated into numerous membra- nous flakes, which, by turning the point of the instrument towards the pupil, may be as easily pushed through this aperture into the anterior chamber, where Scarpa finds ab- sorption takes place more quickly, than be- hind (he pupil. I ought to mention, however, that Beer, and a few other skilful operators, still give the preference to a straight spear-pointed needle -, and, if such an instrument be se- lected, I do not think a better one can be devised, than that described by Scarpa, but made quite straight. As Mr. Travers has observed, in all cases of operation with the needle, the employ- ment of a solution of the extract of bella- donna in an equal part of distilled water, is a point of the first importance. " The space, included between tbe eyebrow and lasb, should be thickly painted w ith the solution once, or oftener, in the twenty-four hours, and this varnish should be preserved moist for a period of half an hour, in order to ad- mit of its absorption. The frequency ofthe application must be determined by its ef- fect upon the pupil. The preternatural dila- tation should not be permanently maintain- ed; for, if it be, (be pupil will in all proba- bility be mis-shapen," when the use of the 350 CATARACT. belladonna is suspended, and the iris reco- vers its power. (Synopsis of the Diseases of the Eye, p. 322.) The couching needle (if the curved one be used) is to be held with its convexity forward ; its point backward; and its handle parallel to the patient's temple. The sur- geon, having directed the patient to turn the eye towards the nose, is to introduce the instrument boldly through the sclerotic coat, at the distance of at least one line and a half from the margin of the cornea, for fear of injuring the ciliary processes. Most authors advise the puncture to be made at about one line, and some even at the minute distance of l-16th of au inch (Hey) from the union of the cornea with the sclerotica; but, as the ciliary processes ought invariably to be avoided, and there is no real cause to dread wounding the apo- neurosis of the abductor muscle, as some have conceived, the propriety of punctu- ring the globe of the eye, at the distance of one line and a half, or two, from the margin of the cornea, as advised by Petit, Platner, Bertrandi, Beer, he. must be sufficiently manifest. A'or is it a matter of indifference, at what height the needle is introduced, if it be desi- rable to avoid, as much as possible, effusion of blood in the operation. Anatomy re- veals to us, thut the long ciliary artery pur- sues its course to the iris, along the middle of the external convexity of the eye-ball, between the sclerotic and choroid coats; and hence, in order to avoid this vessel, it is prudent to introduce the instrument a full line below the transverse diameter of the pupil, as Dudell, Guntz, Bertrandi, Beer, Scarpa, he. have directed. If the couching needle were introduced higher than the track of the long ciliary artery, it would be inconvenient for the depression of the ca- taract. The exact place, where the point of the needle should next be guided, is, no doubt, between the cataract and ciiiary processes, in front of the opaque lens, and its capsule: but, as I conceive, the attempt to bit this delicate invisible mark, borders upon im- possibility, and, with a straight pointed needle, might even endanger the iris, I can- not refrain from expressing my dissent to the common method of passing a coughing needle at once in front of the cataract. On the contrary, it seems safer to direct the extremity of the instrument immediately over tha opaque lens, and, in the first instance, to depress it a little downwardly means of the convex flat surface of the end of the needle, in order to make room for the safe conveyance of the instrument, be- tween the cataract, and corpus ciliare, in front of the diseased crystalline and its capsule; taking care, in this latter step of the operation, to keep the marked side of the handle forward, by which means the point of the needle will be in an opposite direction to the iris, and will come into contact with the diseased body, and the membrane binding it down in the fossula of the vitreous humour. When this has been done, and the case is a firm cataract, the in- strument wdi be visible through the pupil; and now we are to push its point trans- versely, as near as possible the margin of the lens, on tbe .'ide next the internal angle of the eve, tatfo'C strict care to keep it continually turned backward. The opera- tor is then to fowline the handle of the in- strument towaids himself, whereby its point will be directed through the capsule, into the substance of the opaque lens ; and, on making a movement of the needle, descri- bing the segment of a circle, at the vune instant incliningit downward und backward, he will lacerate the former, and convey it, in the generality of cases, with the latter, deeply into the vitreous humour. Beer, as I have explained, gives the pre- ference to a spear-pointed straight needle, one flat surface of which, at the period of its first introduction into the eye, is turned upwards; the other, downwards; one edge, directed towards the nasal, the other, to- wards the temporal canthus; mid the point towards the centre of the eyeball. Beer prefers this mode of proceeding, in order to avoid moving the lens too soon out of its natural situation, whereby the subsequent manoeuvres of depression or reclination, he thinks would be rendered very unccrtaiu and incomplete. He also recommend* the surgeon to support his hand in some measure1 on the patient's cheek by means of the little finger, so as to have it in his power to check the too sudden and deep entrance of tli« instrument into the eye, liable to happen when the broadest part of the spear- point has passed through the sclerotica. (Lehre, fa. B 2, p. 354.) It happened, unfortunately for the credit of the operation of depression, that Petit admonished surgeons to beware of wound- ing the anterior layer of the crystalline capsule: he had an idea, that, when this caution was observed, the vitreous humour would afterward fill up the space, pre- viously occupied by the lens, and that thus the refracting powers of the eye might be- come as strong as in the natural state, and the necessity for using spectacles be consi- rably obviated. But, we are now apprized, that leaving this very membrane, from which Petit anticipated such great utility, even were it practicable to leave it con- stantly uninjured in its natural situation, would be one of the worst inculcations that could possibly be established ; for, in many cases, where extraction proves fruitless, in some, where depression fails, the want of success is owing to a subsequent opacity of the crystalline capsule ; in short, bliiidne* is reproduced by tbe secondary membranous cataract. It seems more than probable, that, in some of the instances, where the opaque lens has been said to huve risen again, nothing more has happened, than tbe dis- easeinquestion. Therefore,notwithstanding the whole capsule in the m ijority of cases may be depressed with the lens out of the axis of vision, as it is not a constant occur- 1 CATARACT. 351 rence, I cannot too strongly enforce the propriety of extirpating, as it were, every source and seat of the cataract ia the same operation, and, in imitation of the celebra- ted Scarpa, who is entitled to the honour of having first pointed out the great impor- tance, of this practice, I shall presume to recommend, as a general rule in couching, always to lacerate the front layer of the capsule, whether in an opaque or transpa- rent state. The capsule of the crystalline lens may retain its usual transparency, while the lens itself is in an opaque state. In this case, an inexperienced operator might, from the blackness of the pupil, suppose, not only that he had removed the lens, but also the capsule from the axis of sight; and, having depressed the cataract, be might un- intentionally leave this membrane entire in its natural situation. Therefore, if there should be any reason for suspecting, that the anterior layer of the capsule has es- caped laceration ; if, in other words, the resistance made to moving the convexity of the instrument forward, towards the pupil, should give rise to such a suspicion ; for the sake of removing all doubt, it is proper to communicate to the needle a gentle rota- tory motion, by which its point will be turned forward, and disengaged, through the transparent capsule, opposite the pupil : then, by repeating a few movements down- ward and backward, it will be so freely rent with the needle, as to occasion no fu- ture trouble. If a straight, slender, spear-pointed nee- dle be used, bke that ot Beer, and the se- cond stage of the operation be completed by the introduction of the extremity of the instrument into the posterior chamber, then, according to the directions given by the same writer, when depression is indicated, the needle is to be immediately carried to the uppermost part of the cataract, with its point directed somewhat obliquely down- wards ; and with that surface, which in the first instance, was applied to the front of the lens, now placed upon its superior edge; then the opaque body is to be pushed ra- ther obliquely, downwards antl outwards, so far below the pupil, that it can no longer be distinguished. After this has been done, the needle is to be gently raised, in order to see whether the cataract will continue depressed, and if it be.found to do so, the needle is to he withdraw n in the same di- rection, in which it was introduced. On the other hand, says Beer, when re- clination is to be practised, the needle af- ter being applied to the front surface ofthe cataract, is not to be moved further out of the position ofthe second stage of the ope- ration, but its handle is merely to be raised diagonally forwards, whereby the cataract will be pressed downwards and out- wards to the bottom ofthe vitreous humour, and turned in the manner already specified. Beer has delivered what appears to me one valuable piece of advice for operators on the eye with the needle: whether depres- sion, or reclination, is to be done, says he, a surgeon can only use this instrument with- out injurious consequences on the principle of a lever; and every attempt to press with the whole length of the instrument is not on- ly ineffectual, with respect to tbe progress of the operation, but so hurtful to the eye, that bad effects must follow, as may be readily conceived, when it is recollected how vio- lently the ciliary nerves must be stretched. As for the modifications of the manoeu- vres, rendered necessary by the varieties of cataracts, they are (says Beer) so unimport- ant in all cases of depression, that a young operator will easily understand them him- self. But, things are far otherwise in the practice of reclination; for, when the case is a completely formed capsular-lenticular cataract, and the opaque capsule is so thin, as to be torn during the turning of tbe lens, the latter body will indeed be placed in the intended position at the bottom ofthe eye, but the capsule itself, which has merely been lacerated, must form a secondary ca- taract, unless the surgeon, with a sharp dou- ble-edged needle, immediately divide it in every direction, and remove it as fur as pos- sible from the pupil. When, during recli- nation, a softisk lens, or one which is pulpy to its very nucleus, breaks into several pieces, it is necessary, iu order not to have afterwards a considerable secondary lenti- cular cataract, to put the larger fragments separately in a state of reclination, while the smaller ones may either be depressed, or (if the pupil be not too much contracted) they may be pushed into the anterior cham- ber, where they will soon be absorbed. When the cataract is partially adherent to the uvea, Beer recommends an endeavour to be first made, with the edge of the needle, (which is to be introduced flat between the cataract and the uvea, above or below the adhesion) to separate the adherent parts be- fore the attempt at reclination is made. Should it be a cataract, which always rises again as soon as the needle is taken from it, though the instrument has not pierced it at all, the case is termed the elastic cataract, in which the lens is not only firmly adherent to its own capsule, but this also to the mem- brana hyaloidea. Here Beer thinks, that the best plan is first to carry the needle to the uppermost point of the posterior surface of the lens, and by means of perpendicular movements of the cutting part of the instru- ment, to endeavourcompletely to loosen this preternatural adhesion of the cataract to the vitreous humour, when reclination may be tried againy and will perhaps succeed. But, says Beer, when the continual rising ofthe cataract is caused by the operator's running • the needle into it, the instrument must ei- ther be withdrawn far enough out*bf the eye to let it be again properly brought into the posterior chamber, when reclination may be effectually repeated ; or, if the ca- taract be firmly fixed on the needle at the bottom of the eye, the instrument should uot be raised again, but previously to bein<* withdrawn, it should be rotated a couple of CATARACT. times on its axis, whereby the pierced lens will be more easily disengaged from the needle, and at last continue depressed. (Lehre von den Augenkr. B. 2, p. 366—358.) In addition to Beer's directions for couch- ing and reclination, the following observa- tions seem to me to merit attention. When the case is a fluid or milky cataract, the operator frequently finds, that, on pass- ing the point of the couching needle through the anterior layer of the capsule, its white milky contents instantly flow out, and, spreading like a cloud over the two cham- bers of the aqueous humour, completely conceal the pupil, the iris, and the instru- ment, from his view ; who, however, ought never to be discouraged at this event. Al- though it seems to me most prudent, lo postpone the completion of operations with the needle, in the example of blood concealing the pupil, in the first step of couching, and not to renew any attempt before the aqueous humour has recover- ed its transparency ; I am inclined to adopt this sentiment, chiefly because, the species of cataract is, in this circumstance, gene- rally unknown to the operator, consequent- ly he must be absolutely incapable of em- ploying that method of couching, which the peculiarities of the case may demand. Speaking of this case, however, Beer says, " the surgeon must hasten the completion of extraction, or reclination, though possibly the operation may not always admit of be- ing continued, or, if gone on with, it must be done, as it were blindfold." (Lehre, fa. B. 2. p. 361.) When a milky fluid blends itself with the aqueous humour, and pre- vents the surgeon from seeing the iris and pupil: this event itself is a source of infor- mation to him, inasmuch as it gives him a perfect insight into the nature of the cata- ract, which he is treating; and instructs him what method of operating it is his duty to adopt. The surgeon, guided by bis ana- tomical knowledge of theeye, should make the curved point of (he needle describe the segment of a circle, from the inner, to- ward the outer canthus, and in a direction backward, as if he had to depress a firm ca- taract. (Scarpa.) Thus be will succeed in lacerating, as much as is necessary, tbe ante- rior layer of the capsule, upon which, in a great measure, the perfectjsuccess of the ope- ration depends; and, not only in the milky, but almost every other species of cataract. In regard to the extravasation of the milky fluid in the chambers of tbe aqueous hu- mour, numerous observations, from the most creditable authorities, prove, that it sponta- neously disappears very soon after the ope- ration, and leaves the pupil of its accus- tomed transparency. " In twelve cases of a dissolved lens, on which I have operated," says Latta, " the dissolution was so com- plete, that, on entering the needle into the capsule of the lens, the whole was mixed with the aqueous humour, and all that could be done, was to destroy the capsule as completely as possible, that all the milky matter might be evacuated. In ten of these cases, vision was almost completeiy re- stored in four weeks from the operatiou Mr. Pott, in treating of this circumstance, viz. the effusion ofthe fluid contents of tho capsule into the aqueous humour, observes, that so far from being an unlucky one, and preventive of success, it proves, on the con- trary, productive of all the benefit whicb cau be derived from the most successful de- pression or extraction, as he has often and often seen. \\ hen the cataract is of a soft, or caseous description, the particles of which it is com- posed will frequently elude all efforts made with the needle to depress them, and will continue behind the pupil in the axis of vi- sion. This has been adduced as one in- stance lhal baffles the efficacy of couching, and may really seem to the inexperienced, an unfortunate circumstance. Ii often hap- pens in the operation of extraction, that fragments of opaque matter are unavoidably overlooked and left behind ; yet Kichter confesses, that such matter is frequently removed by the absorbents. Supposing a caseous cataract were not sufficiently bro- ken, and disturbed in the first operation, and that, consequently, the absorbents did not completely remove it, such a state might possibly require a reapplication of the in- strument ; but this does not generally or. cur, and is the worst that can happen. It is quite impossible to determine a priori, what effect will result from the most trivial disturbance of a cataract; its entire absorp- tion may, in some instances, follow, while in others, a repetition of the operation be- comes necessary for the restoration of sight. Even where the whole firm lens'hai reascended behind the pupil, as L»tla and Hey confirm, the absorbents have supersed- ed the necessity for couching again. Tbe disappearance of the opaque particles of cataracts was, in all times, and in all ages, a fact of such conspicuousness, that, as ap- pears from the authority of Barbette and others, it was recorded", even previous to (he discovery ofthe system of lymphatic vessels in the body. Indeed the modern observations of Scarpa and others, so strongly corrobo- rate the account which I have given of the vigorous action ofthe absorbents, in the two chambers of the aqueous humour; and par- ticularly, in the anterior one, that, from the moment the case is discovered to be a soft, or caseous cataract, it seems quite unneces- sary to make any further attempt to depress it into the vitreous humour. Mr. Pott some- times, in this circumstance, made no attempt of this kind, but contented himself with a free laceration of tbe capsule, and, after turning tbe needle round and round, be- tween his finger and thumb, within the body of the crystalline, left all the parts in their natural situation, where he hardly ever knew them fail of dissolving so entirely, a» not to leave the smallest vestige of a cats-.. ract. This eminent surgeon even practised i occasionally what Beer sanctions, and Scar- y pa so strongly recommends at this day; tor he sometimes pushed the firm part of such CATARACT. 3a3 cataracts through the pupil into the anterior chamber, where it always disappeared, with- out producing the least inconvenience ; we must, at tbe same time add, that he thought tbis method wrong, not on account of its inefficacy, but an apprehension that it would be apt to produce an irregularity of the pupil, one of the worst inconveniencies at- tending the operation of extraction. But the deformity of the pupil, after extraction, seems to proceed either from an actual la- ceration of the iris, or a forcible distention of the pupil, by tbe passage of large cata- racts through it, a kind of cause that would not be present in pushing the broken por- tions of a caseous lens into the anterior chamber. Hence, it does not seem warrant- able to reject this very efficacious plan of treatment. It is well deserving of notice, (bat Mr. Hey, who has several times seen the whole opaque nucleus and very fre- quently small opaque portions fall into the anterior chamber, makes this remark: "In- deed, if the cataract could, in all cases, be brought into the anterior chamber of the eye, without injury to the iris, it would be ihe best method of performing the operation." What the same author also observes in the subsequent part of bis work, is strikingly corroborative of the efficacy of Scarpa's Siractice. The practice of the Italian pro- essor consists in lacerating the anterior porlioti of the crystalline capsule, to the extent of the diameter of the pupil in a mo- derately dilated state ; in breaking (he pap- py substanee of the diseased lens piecemeal; and in pushing the fragments through the pupil into the anterior chamber, where they are gradually absorbed. One great advantage of couching, insist- ed upon by Scarpa, depends upon its gene- rally removing the capsule, at the same time with the lens, from the passage of the rays of light to the retina. Sometimes, how- ever, this desirable event, by whieh tbe pa- tient is extricated from the danger of a se- condary membranous cataract, does not take place even in the operation of depression ; and, when the lens included in its capsule is extracted from the eye, by the other me- thod, it may always be considered as rather an uncommon circumstance. What most frecuently constitutes the secondary mem- branous cataract, is the anterior half of the capsule, which not having been remov- ed, or sufficiently broken, in a previous ope- ration, continues more or less entire iu its natural situation,afterwards becomes opaque, and thus impedes the free transmission of the rays of light to the seat of vision. Some- times tbe secondary membranous cataract presents itself beyond the pupil, in the form of membranous flakes, apparently floating in the aqueous humour, and shutting up the pupil : at other times it appears in the form of triangular membranes, with their bases affixed to tbe Membranu Hyaloidea, and their points directed towards the centre of the Cupil. When there is only a minute mem- ranous flake suspended in the posterior chamber, Scarpa thinks it by no means ne- cessary for the patient to submit to another Vor. C 1.-, operation ; vision is tolerably perfect, and the small particle of opaque matter will, in time, spontaneously disappear. But when the secondary membranous cataract consists of a collection of opaque fragments of the cap- su!e,accumulatedsoas either in a great degree or entirely to close tbe pupil ; or when the disease consists of tbe whole anterior half of tbe opaque capsule, neglected in a prior operation, and continuing adherent in its natural situation, it is indispensable to ope- rate again ; for, although in tbe first case, there may be good reason to hope, that the collection of membranous fragments might, in time, disappear, yet it would be unjustifi- able to detain the patient for weeks and months in a state of anxiety and blindness, when a safe and simple operation would restore him, in a very short space of time, to tbe enjoyment of this most useful of the senses. In (be second case, says Scarpa, it is absolutely indispensable: for while the capsule remains adherent to its natural con- nexions, the opacity seldom disappears, and may even expand itself over a larger portion of the pupil. He advises tbe operation lo be performed as follows: when the aper- ture in the iris is obstructed by a collection of membranous flakes, detached from the membraua hyaloidea, the curved needle should be introduced, with the usual pre- caution of keeping its convexity forward, its point backward, until arrived behind tbe mass of opaque matter; the surgeon is then lo turn the point of the needle towards the pupil, aud is to push through tbis opening, regularly one after another, all the opaque particles into the anterior chamber, where, as we have before noticed, absorption seems to be carried on more vigorously than be- hind tbe pupil. All endeavours to depress them into the vitreous humour, Scarpa has found it to be in vain; for scarcely is the couching needle withdrawn when they all reappear at the pupil, as if, (to use his own phrase) carried thither by a current: but when forced into the anterior chamber be- sides, being incapable of blocking up the pupil, they lie without inconvenience, at tbe bot- tom of that cavity, and in a few weeks are entirely absorbed. When the secondary membranous cataract consists of the whole anterior layer of the crystalline capsule, or of several portions of it connected with the membraua hyaloidea, Scarpa, after cautiously turning the point of the needle towards the pupil, pierces the opaque capsule : or, if there be any inter- space, he passes the point of the instrument through it; then, having turned it agaia backward, he conveys it, as near as possible, to the attachment of the membranous cata- ract, and after piercing the capsule, or each portion of it successively, and sometimes carefully rolling the handle of the instru- ment between his finger and thumb, so as to twist the capsule round its extremity, he thus breaks the cataract, as far as it is prac- ticable, at every point of its circumference. Tbe portions of membrane, by this means separated from their adhesions, are next cautiously pushed, with the point of the- oj4 CATARACT. couching needle turned forward, through the pupil, into the anterior chamber. In these niano'uvres the operator must use the utmost caution not to injure the iris, and ciliary processes, for upon this circumstance depends the avoidance of bad symptoms after the operation, notwithstanding its du- ration may be long, and the necessary movements of the needle frequently repeat- ed. If a part of the membranous cataract be found adherent to the iris, (a complica- tion, that will be indicated when, upon moving it backward, or downward with tbe needle, the pupil alters its shape, and from being circular becomes of an oval, or irre- gular figure,) even more caution is required than iu the foregoing case, so as to make repeated, but delicate movements of tbe ii'-edle, to separate the membranous opacity, without injuring the iris. Beer's mode of proceeding in such a case, I have already described. Scarpa does not deem it necessary to vary the plan of operating above explained, if occasionally the cataract be formed of the posterior layer of the capsule. And ac- cording to this author, the same plan also succeeds in those rare instances where the substance itself of the crystalline wastes, and is almost completely absorbed, leaving Ihe capsule opaque, and including, at most, only a small nucleus, not larger than a pin's head. Scarpa terms it the Primary Mem- branous Cataract, and describes it as being met with in children, or young people un- der the age of twenty; as being character- ized by a certain transparency, and simili- tude to a cobweb; by a whitish opaque point, either at its centre or circumference ; and, by a streaked and reticulated appear- ance : he adds, that whosoever attempts to depress such a cataract is baffled, as it reap- pears behind the pupil, soon after tbe ope- ration ; he recommends breaking it freely with the curved extremity of the couching needle, and pushing its fragments into the anterior chamber, where they are gradual- ly absorbed in the course of about three weeks. No other topical application is generally requisite, after the operation, but a small compress of fine linen; and the patient ought to be kept in a quiet, moderately dark- ened room. On the following morning, a dose of some mild purgative salt, such as (he sulphate of soda, or magnesia, may usually be administered, with advantage. 1 shall not enlarge upon the method of treat- ment, when the inflammation,subsequent to couching, exceeds the ordinary bounds ; in hypochondriacal, hysterical, and irritable constitutions, this is more frequently met with, and I have already touched upon the propriety of some preparatory measures before operating upon these unfavourable subjects. Beer remarks, that, although after extrac- tion, very cautious trials of the sight are in- dispensable, they are by no means proper after the depression or reclination of a vntaract ; for, the action of the muscles of the eye in the inspection ol objects at v«. rious distances, is very liable to make the opaque body rise again. Hence, as soon as the pupil is clear, Beer recommends co- vering both eyes (even when one only has been operated upon) with a plaster, and simple linen compress, which last is to be fastened on the forehead with a common bandage. The same experienced operator also enjoins perfect quietude of the body and head for some days. The patient, he says, may either lie iu bed, or sit in an arm- chair, as may be most agreeable, care being taken to avoid ull sudden motions. Tbe most proper food for the patient is such as is easily digested, not too nutritious, aud does not require much mastication. Every thing must be avoided which has n tenden- cy to excite inflammation in the eye. On the third or fourth day the eye should he opened, and afterwards be merely protect- ed by a green silk eye screen, which should also be gradually dispensed with. The pa- tient should be careful to do whatever is agreeable to the eye which has been opera- ted upon, and as carefully avoid every thing which irritates it, or causes a disagreeable sensation in it, a difficulty of opening the eyelids, or keeping them open, u discharge of tears, or a redness of the white of the eye, he. Of the thrombus under the conjunctiva, sometimes caused by the prick ofthe needle, and of the readily bleeding granulations which occasionally shoot up at the punc- ture, 1 need not here particularly speak — For relieving the obstinate vomiting, some- times excited by injury ofthe ciliary nerves, or that of the retina, Beer recommends castor, musk, and opium, except when the eye is in a stale of inflammation, in which circumstance, the antiphlogistic treatment is preferable. Such vomiting, Beer joins other writers in believing, is often produ- ced by a firm lens being depressed too far, so as to injure the retina ; a case, however, which is usually combined with a suddenly produced, complete, or incomplete amau- rosis. Here, unless the position of the len« can be changed by a sudden movement ot the head, the above class of medicines will be of no use. This kind of amaurosis may also take place without any vomiting, and, as Beer has had opportunities of remarking, it will not always subside, even though the cataract be made to rise again. The seme amaurotic affection may also result from the surgeon hurting the retina by pushing the needle too deeply against this mem- ^ bi-ane. According to Beer, the ophthalmy, ij liable to happen in these cases, as well as after extraction and kexatonyxis, is always \ most severe in the iris and neighbjDiiring textures, (louden Augenkr. B. 2, p. 361— m 63.) 1 I cannot help remarking how judicious ft it is never (o attempt too much at one time VJ in any mode of couching. It happens HfcrlJji this, as iu most other branches of operativejD* surgery, that celerity is too often mistaken"*""] for skill; the operator should nut only he ion CATARACT slow and deliberate in achieving his pur- pose ; he should be taught to consider that a repetition of couching may, like the punc- ture of a vein, be safely and advantageously put in practice again and again ; and with far greater security, than if, for the sake of appearing expeditious, or avoiding the tem- porary semblance of failure, a bolder use of the couching needle should be made, than the delicate structure of the eye war- rants. We read, in Mr. Hey's Practical Ob- servations on Surgery, that he couched one eye seven times, before perfect success was obtained; had he been less patient, and en- deavoured to effect by one or two rough applications of the instrument, what he achieved by seven efforts of a gentler de- scription, it is highly probable, that the structure of the eye would have been so impaired, as well as the consequent oph- thalmy so violent, as to have utterly pre- vented the restoration of sight. All the various methods of couching ha- ving now been described, I subjoin (he -en- (iineutsof Beer, respecting the circumstan- ces by which the choice of depression'or reclination ought to be regulated. Accord- ing to this author, when the cataract is very firm, or moderately so, wiih a scabrous siirfa'-p, or the case is what has been already described under the name of encysted cata- ract, or when the cataract consists of any tough membrane, both depression and re- clination cau only be a palliative remedy, for, says he, none of these cataracts after the operation can be dissolved and absorbed, but must remain in the eye, as a foreign un- organized body, ready at every opportunity to rise again, and partially or completely blind the patient anew. Beer assures us, that he has carefully examined tbe eyes of persons after death, on whom depression or reclination bad been practised, iu some in- stances, twenty or more years previously ; but, iu almost all the examples, (he lens was found firm and undissolved, or at most only diminished, with, or without its cap- sule,. Membranous cataracts were very tri- vially lessened ; though they had quite lost their- tough consistence, and were changed "^truo a firniish white mass. In a living per- son, Beer says he saw an instance, in which a cataract rose again after it had been de- pressed by Hilmer thiny years previously : it was small, angular, and, when the pupil was dilated, it floated from one chamber of (he eye into the oilier. When extracted, which was done with complete success, it was found to be almost ossified. In 1805, Beer extracted from a woman, forty years of age, a very large, hard, yellowish, white lenticular-cataract, which had beun in the an- terior chamber twenty-six years. The lens had been thus displaced by a blow received on the eye from the branch of a tree. Nor has Beer ever yet seen a case, in which a cataract of a semi-firm consistence was dis- '•"**»10lvedand absorbed. (Vonden Augenkr. B. 2, p. 363.) Had Beer confined his state- ments to what happens to certain cataracts, on which depression, or reclination. s'lietlv so called, had been practised, 1 should have been disposed to accede to the general as- sertion, respecting the great length of time, which a firm or tough capsular cataract re- mains iu the vitreous humour undissolved and unabsorbed. But, if he mean that the same thing is generally the case with cata- racts broken piecemeal, und placed in the aqueous humour, we know, that such a re- presentation is contradicted by the expe- rience of an infinite number of the highest authorities in surgery. Nay, notwithstand- ing the case adduced of a bony lens having remained in the aqueous humour twenty- six years, I am disposed to think, that Beer himself does not intend to question the absorption of the fragments of cataracts in the aqueous humour, particularly as at p. 357, B. 2, he sanctions pushing the frag- ments of semi-firm cataracts through the pupil into the anterior chamber, where, he confesses, that they are soon absorbed. Beer thinks that, in general, depression and reclination are indicated only in cases, in which extraction is absolutely impracti- cable, or attended with too great difficulty, as will be better understood when this ope- ration is considered. As examples of this kind, Beer specifies au extensive adhesion of the iris to the cornea ; a very flat cor- nea, and, of course, so small an anterior chamber, that an incision of proper size in the cornea cannot be made ; a broad arcus senilis ; an habitually contracted pupil (in- capable of being artificially dilated ;) an eye much sunk in the orbit, with a small fissure between the eyelids ; eyes affected with incessant convulsive motions ; a par- tial adhesion of the cataract to the uvea; unappeasable timidity in the patient; and an impossibility of managing him during and after the operation, in consequence of his childhood or stupidity. With regard to the question, whether de- pression or reclination should be preferred, Beer is of opinion, that the first method is indicated only when the dimensions of the cataract are small, and consequently, when there is room enough for it to be placed be- low the pupil, without the ciliary processes being torn from the annulus ciliaris. Such cases are the dry-husked, capsulo-lenticular cataract, (the primary membranous cataract, of Scarpa,) when perfectly free from adhe- sions to the uvea; the true lenticular secon- dary cataract, produced by the small but firm fragments of the feus having been left, or risen again ; and the genuine secondary membranous, or capsular cataract. On the other hand, reclination is to be preferred when, together with the above objections to extraction, the surgeon has to deal with a fully formed, very hard lenticular, or cap- sulo-lenticular cataract; or with a c=>se of the latter kind, complicated with partial adhesions to the uvea; or when the case is a secondary capsular cataract, similarly cir- cumstanced ; a secondary cutarad of lymph ; a gypsum-cataract ; or there is reason to apprehend a considerable tendency in the blood-vessels of ih* interior of the eve to 35« TATAR \r:T become varicose. (Lehre ron den Augenkr. B. 2, p. 365.) The manner of operating with the needle upon the congenital cataract? of children, will be hereafter explained. EXTRACTION OF TUT CATARACT. As soon as it was fully proved that the true cataract was an opacity of the crystal- line lens ; that the loss of sight would not be occasioned by the removal of this body ; that the cornea might be divided without danger; and that when the aqueous hu- mour had been discharged, it would be quickly regenerated ; the mode of cure, by extracting the cataract out of the eye, na- turally presented itself. (Wenzel.) Freytag first made an attempt to extract the cataract, about the close of the 17th century. After bim, Lotterius of Turin performed this operation, a good descrip- tion of which was first given by Daviel; and the ingenuity and industry of Wenzel afterwards brought this mode of operating considerably nearer to perfection. (Bram- billa, Instrumentarium Chir. Austriacum, 1782, p. 71.) With the valuable instructions which Ware and Beer have still more recently fur- nished, the extraction of tbe cataract may now be regarded as brought to the highest state of improvement. According to Beer, the extraction of the cataract usually ad- mits of division into three stages, the first of which, as in depression and reclination, is the most important, because, unless it be performed exactly as it ought to be, the ope- ration will be very liable to fail, and it is exceedingly difficult to make amends for any fault committed in this early part of the proceedings. The first stage consists in making an effectual opening in the cor- nea with a suitable knife. The second, in dividing the anterior layer of tbe capsule, which, says Beer, should not be merely punctured, or torn with a bluntish instru- ment, but cut with a sharp two-edged lance- pointed needle, and, as much as possible, annihilated. In the third stage, the expul- sion of the cataract from the eye is effected either by the well-regulated action of the eye-ball itself, or by the assistance of art. But, as Beer remarks, they who have learn- ed the manner of effectually and skilfully cutting the cornea, will frequently have the pleasure to find the two last stages benefi- cially converted into one, and the opera- tion in general soon and expeditiously com- pleted. (Von den Augenkr. B. 2, p. 366.) The knives, used by Richter, Wenzel, Ware, and Beer, are all of them more or less different; but, they agree in the com- mon quality of completely filling up the wound, as it is extended, so that none of the vitreous humour can escape before the division of the cornea is finished Wenzel's knife resembles the common lancet employed in bleeding, excepting that its blade is a little longer, and not quite so broad. Its edges are straight, and the blade is an inch and a belt" (eighteen lines) long, and a quarter of an inch (three lines) broad, in the widest part of it, which is at the bai«e. From this part it gradually be- comes narrower towards the point; so thai this breadth of a quarter of an inch ex- tends only to the space of about one-third ofan inch from the base ; and, for the space of half an inch from the point, it is no more than one-eighth of an inch broad. The knife, employed by the late Mr. Ware, is, in regard to its dimensions, not un- like the instrument employed by Wenzel. The principal difference is, that Mr. Ware'i knife is less spear-pointed; in consequence of which, when this latter instrument has pierced through the cornea, its lower, or cutting edge will sooner pass below the in- ferior margin of the pupil, than the knife used by Wenzel. On this account, Mr. Ware believed that the iris would he less likely to be entangled under the knife, which he recommended, than under Wen- zel's, when the instrument begins to cut its way downwards, and the aqueous humour is discharged. Mr. Ware particularly ndvi- ses great care to be taken to let the knile increase gradually in thickness from the point to the handle; by which meant, if it be conducted steadily through the cornea, it will be next to an impossibility, that any Eart of the aqueous humour can escape, efore the section is begun downwards; and, consequently, during this time, the cornea will preserve its true convexity.— But, if the blade should not increase in thickness from the point; or if it be in- curvated much in its back, or edge, tbe aqueous humour will unavoidably escape, before the puncture is completed; and the iris, being brought under the edge of the knife, will be in great danger of being wounded by it. But, a better knife than any other which has yet been proposed, is that employed by Beer, a representation of which 1 have given in Vol. 1, of Iht First Lines of Surgery, plate 7, fig. 3. Tbe senti- ments of Richter, Scarpa, Beer, and others, about tbe position of the patient in the operation, and the mode of fixing the eye, have been already noticed in a foregoing section. Baron Wenzel determined to run no risk of bad consequences from undue pressure on tbe eye, made no endeavour to fix this organ at all at the period of cutting the cor- nea. The late Mr. Ware did not approve of this plan of leaving the eye unfixed. Tbe danger likely to arise from undue pressure, he observes, can only take place, bfterthe instrument has made an opening into tbe eye : but tbe pressure which Mr. Warr ad- vises, in order to fix the eye, is to be remo- ved the instant the knife is carried through the cornea, and before any attempt is made to divide this tunic downwards. To under- stand this subject better, however, the reader should know, that Mr. Ware divided the incision of the cornea into two distinct proceMP* : the firrt of which may be called CATARACT. 3»> 7 punctuation, and the second section. So long, says Mr. Ware, as the knife fills up the aperture in which it is inserted, that is, until it has passed through both sides of the cornea, and its extremity has advanced some way beyond this tunic, the aqueous humour cannot be discharged, and pressure may be continued with safety. The punc- tuation of the cornea being completed, the purpose of pressure is fully answered ; and, if such pressure be continued, when the section of the cornea begins, instead of be- ing useful, it will be hurtful. To avoid all bad effects, Mr. Ware recommends the cor- nea to be cut in the following way. The operator is to place the fore and mid- dle finger ofthe left hand, upon the tunica conjunctiva, just below, and a little on the inside of the cornea. At the same time, the assistant, who supports the head, is to apply one, or, if the eye projects sufficient- ly, two of his fingers, upon the conjunctiva, a little on the inside and above the cornea. The fingers of the operator and assistant, thus opposed to each other, will fix the eye, and prevent the lids from closing. The point of the knife is to enter the outside of the cornea, a little above its transverse di- ameter, and just before its connexion with tile sclerotica. Thus introduced, it is to be pushed ou slowly, but steadily, without the least intermission, and in a straight direc- tion, with its blade parallel to the iris, so as to pierce the cornea towards the inner an- gle of tbe eye, on the side opposite to that which it first entered, and till about one- third part of it is seen to emerge beyond the inner margin ofthe cornea. When the knife has reached so far, the punctuation is completed. The broad part of the blade is now between the cornea and the iris, and its cutting edge below the pupil, which of course is out of all danger of being wound- ed. As every degree of pressure must now be taken off the eyeball, the fingers, both of the operator and his assistant, are in- stantly to be removed from this part, and shifted to the eyelids. These are to be kept asunder by gently pressing them against the edges ofthe orbit; and the eye is to be left entirely to the guidance of the knife, by which, says Mr. Ware, it may be raised, depressed, or drawn to either side, as may be found necessary. The aqueous humour being now partly, if not entirely evacuated, and the co-n^a of course rendered flaccid, the edge of the blade is to be pressed slowly downward, till it has cut it* way out, and separated a little more than half the cor- nea from tbe sclerotica, following the semi- circular direction, marked out by the at- tachment of the one to the other. (Ware.) As soon as the point of thp knife had ar- rived^ opposite the pupil, Wenzel used to incline it gently backward, and thus punc- ture the capsule of the crystalline. But, Mr. Ware very properly objects to this method of opening the capsule w ith the in- strument used for cutting the cornea, and at the same time. The pb.n may exhibit dexterity : but is of no use. and \* often at- tended with considerable danger of wound- ing the iris. In the eyes of some persons, the iris is convex, and it is almost impossible to com- plete the section of the cornea, without en- tangling the iris under the edge of the knife, unless a particular artifice be adopt- ed. Wenzel, in this circumstance, recom- mends gently rubbing the cornea downward with the finger; one ofthe most important directions, according to Mr. Ware, in the Baron's whole book. Wenzel imputed several advantages to the oblique manner in which he used to .divide the cornea. The best modern occu- lists, however, do not imitate this method. If the edge of the knife should incline too much forward, and its direction be not altered, the incision in the cornea will be too small, and terminate almost opposite the pupil. In tbis case, there will be great difficulty in extracting the cataract, and the cicatrix afterw ards will often obstruct sight. If. on the contrary, the edge of the instru- ment be inclined too much backward, and its direction be not changed, tbe incision will approach too near the part where the iris and sclerotica unite, and, there will be great danger of wounding them. These accidents may be prevented by gently roll- ing the instrument between the fingers, un- til the blade takes the proper direction.— (Wenzel.) Mr. Ware has seen operators, through a fear of wounding the iris, introduce and bring out tbe instrument at a considerable distance before the union of the cornea and sclerotica; in consequence of which, the incision from one side of the cornea to the other has been made too small to allow the easy extraction of the cataract, although from above downward, it wa« fully large enough for this purpose. Mr. Ware has also sometimes observed, that though the punctuation of the cornea from side to side has been properly conducted, and its sec- tion afterwards, to all appearance, effectual- ly completed, yet, on account of the fric- tions, employed to disengage the iris from the edge of the instrument, the knife, in cutting downward, has been carried be- tween the layers of the cornea, and, conse- quently, though the incision has appeared externally, to be of its proper size; inter- nally, it has been much too small for allow- ing the cataract to be easily extracted. In this case, the incision must be enlarged, by means of a' pair of curved blunt-pointed scissors, which should be introduced it the part where the knife first entered the cor- nea. (Ware.) Beer subdivides the first stage of this ope- ration into four, each of which, he says, claims the utmost attention, if it be wished to make the incision in the cornea in eve- ry respect proper: the first is the introduc- tion of the knife through the cornea into the anterior chamber; the second is direct- ing the knife towards the place where its point is to be brought out again ; the third is bringing out the point, and guiding the 3oS CATARACT. knife in continuing the incision in the cor- nea; and the fourth is the finishing of that incision. As Beer states, a completely well- made incision in the cornea, must, in the first place, be of sufficient size to let the cataract escape from the eye without the slightest impediment; and it will be large enough, if care be taken to open one half of the cornea near its edge. Secondly, it must be of a proper shape, its margin not being triangular, nor notched, but evenly ronnded. In general, says Beer, no greater disadvantage can happen than that of having too small au incision in the cornea; for, even when the cataract is pressed out of such an opening, portions of it are al- ways left behind, which afterwards cannot be extracted without trouble; and though the sight may be at the moment restored, it will be fortunate if the eye be not after- wards spoiled by the effects of inflamma- tion. When the incision is triangular, or notched, its edges cannot be put smoothly together so as to be healed by the first inten- tion, which, however, is highly necessary, and tbe consequence is a white ugly scar, which is slowly produced with inflamma- tion, and forms a greater or lesser perma- nent impediment to vision downwards, though the patient be capable of seeing the smallest objects, which are straight before him. According to Beer, when the knife is to be introduced, its point should enter the cornea, about one-eighth of a line from its edge, and one-fourth of a line above its transverse diameter, directed obliquely to- wards the iris, with its edge turned down- wards, by which means, the point will pass immediately into the anterior chamber. As soon as it has arrived there, which is indica- ted partly by the bright extremity of the knife being seen within the space in ques- tion, and partly by the tactus erudilus, such a direction is to be given to the instrument, that its point may project from the place of its entrance nearly in a direct line to- wards the intended place of its exit out of the cornea, but a little higher; while the posterior surface of the blade is to be con- veyed across the anterior chamber exactly parallel to the iris. The knife is to be cau- tiously pushed on, neither too quickly nor too slowly, with its point contiuually direct- ed somewhat upwards above the part, where it is to pass out again, until the point arrives near the inner edge of the cornea ; but, in the transverse passage of the knife, its edge should not be suffered either to go nearer to, or further from, the iris, as every turn of the blade backwards or forwards, opens the upper angle of the wound, when the aqueous humour immediately escapes, and the iris not only falls close against the posterior surface of the blade, but, some- times even under the edge, so as to throw the young operator into the greatest embar- rassment. If the point of the knife has now been favourably brought out, the surgeon is to continue to push it on, without pressing it downwards, or making a sawing motion with it, until the last stage of the operation, viz. that iu which the incision is finished. However, as soon as the point of the knife has passed out of the cornea, and niched the inner canthus, attention must be paid first, to that part of the blade which i vet in the anterior chamber, so that the "iris may not fall under its edge, and the knife may not take au erroneous direction ; se- condly, to the point of the knife, which continually projects more a.id more, ,(, that the inner canthus may not be wound- ed, which accident, though trivial in ii.self would make the unprepared patient sudden' . ly and involuntarily draw back his head. The only way of preventing this injury, says Beer, is regularly to incline the handle more backwards and downwards, in proportion as the point passes further out of the ante- rior chamber. Thirdly, at the period, when the last piece of the cornea is to be cut the knife should be pushed-on very slowly! for otherwise the lens, and w ith it a pari!.;' the vitreous humour may be discharged, us now the muscles of the eye are acting, and compressing this organ with the greatest force, and in old persons especially, the loose conjunctiva, after the cornea is cut through, comes against the knife, and is apt to be wounded. At the time, when the ope- rator finishes the incision in the cornea, the assistant is to let the upper eyelid cover the eye, and a tew seconds are to be allowed for the patient to recover from his fright. In the second stage of the operatiou, Beer directs the assistant again steadily to hold the patient's head in the same manner, as during the cutting of the cornea; but, the upper eyelid, he says, must be carefully and effectually raised, without touching the eye- ball in the least, or letting the ends of tbe fingers project beyond the edge of the tar- sus. The operator is to depress the lower eyelid with his forefinger, which is not to be removed away from the eye, but gently applied to the lower part of it with the in- tervention of the eyelid, by which means, the cataract-lance, or capsule-needle, may be more readily and easily introduced uader the flap of the cornea into the pupil, while the gentle pressure, and the projection of the cataract thereby produced, considera- bly enlarge the pupil, and facilitate the pro- per division of the capsule. Iu order to complete the latter object, the surgeon in- troduces one of the sharp edges of the cap- sule-needle, with the point directed towards the inner canthus, between the cornea and the iris, the wound in the former of these membranes being opened as little as possi- ble, lest the atmospheric air enter the eye, a circumstance, of which Beer entertaimi great apprehension. After the capsule needle has been cautiously passed to the inferior margin of the pupil, its lower sharp edge is to be applied to the capsule of the lens with its point directly upwards, and one of it* flat surfaces towards the inner; nod the r other, towards the outer canthus. The oj>e- rator is now strictly to cut through the capsule, by making at small distances from CATARACT. 3-79 one another repeated perpendicular strokes with the edge of the needle. Then the han- dle of the instrument is to be half turned round on its axis, and similar strokes are to be made with its edge in a somewhat ob- lique direction, by which means, the ante- rior layer of the capsule will be cut into many squarish fragments, some of which, in the third stage of the operation, are ta- ken out of the eye together with the cata- ract, and the risk of a secondary cataract of the anterior layer of the capsule is in a great measure removed. When the cap- sule-needle has done its business, it is to be withdrawn from the eye in the same posi- tion in which it was introduced, and the se- cond stage ofthe operation is thus finished. (Beer, B. 2, p. 369.) I believe no better instructions, than the foregoing, can be delivered, respecting the most advantageous method of dividing the capsule. They are infinitely better than those given by Wenzel and Ware. As soon as the point of the cornea knife had arrived opposite the pupil, Wenzel used to incline it gently backward, and thus puncture the capsule ; but, Mr. Ware very properly ob- jected to this plan, which, however it might serve to exhibit the dexterity of the opera- tor, was attended with no advantage to the patient, and could not be so efficient and safe as the mode of making the division of the capsule a distinct part of the operation. Indeed, Wenzel himself did not recom- mend opening tbe capsule ofthe crystalline, in every instance, at the. time of cutting the cornea. In cases, where the pupil is much contracted, and where the muscles of the eye and eyelids are easily thrown into con- vulsions, it is improper, says he, to puncture the capsule when tbe section ofthe cornea is making. This is also improper when the space, between the crystalline, and the iris, termed the posterior chamber, is large. In all such cases, Wenzel acknowledged, that it is better simply to divide the cor- nea iu the first instance, and then to puncture the capsule w ith a different instru- ment. Wenzel and his father used to employ, for this purpose, aflat needle, one line, that i*, one-twelfth part ofan inch in diameter, having its cutting extremity a little incurva- ted. This needle, which they advised to be made of nealed gold, in order that its plia- bility may allow the operator to bend it in different directions, as occasion requires, is fixed in a handle, two inches and a half in length, and similar to that of the cornea knife. At the other extremity of the same handle, a small curette, or scoop is fixed, made also of nealed gold, which is of use for extracting the cataract. The late Mr. Ware's method of opening the capsule will be hereafter noticed. When the incision in the cornea has been completed, and the capsule effectually divi- ded, the cataract, as Beer observes, advan- ~ ces into the pupil immediately behind the capsule-needle, and, if there be the least ac- tion in the eye itself, it is generally at once discharged. Lnder these very favourable circumstauces, however, it sometimes hap- pens, that a portionof the gelatinous or scab- rous surface of the cataract is detached at the margin ofthe pupil, as the opaque body is passing out, and, therefore, in the second stage of the operation, Beer recommends having Daviel's scoop always readyv which is to be substituted for the capsule-needle, and employed for preventing the loose frag- ments from falling back into tbe posterior chamber in the following manner : as soon as the operator remarks, that, in the passage ofthe cataract out ofthe pupil, a portion of it will be scraped off by the edge of that opening, he should introduce the scoop at the lower and outer edge, of the cataract upwards, between the cornea and tie iris, so as to be able to keep the part of the ca- taract, which is ready to break off, close up behind the rest of it, and bring the whole out ofthe eye. But, says Beer, when the third stage of the operation, viz. the removal ofthe cata- ract from the eye, cannot be so readily ac- complished, a circumstance, not always owing to an imperfection in the incision iu the cornea, or in the division ofthe capsule, but sometimes proceeding from a want of proper action in the eye itself; the opera- tor, if he feels convinced that the fault does not lie in the first or second stage of the operation, (in which case, it would be ne- cessary to endeavour to rectify what is wrong,) bhould assist in promoting the dis- charge of the cataract. There are two man- ners of doing this, and it is not a matter of indifference which is selected ; for, the se- cond should be adopted only, when the first will not answer. Hence, says Beer, the operator, like a skilful accoucheur, must first trust to the action of the organ itself, which he should in a certain degree excite, and not proceed immediately to the use of a scoop, hook, or forceps. The eye is to be suffered to turn quickly a few times up- wards, and in general, during these move- ments, the surgeon will perceive, that the lower edge ofthe cataract advances further through the pupil, and at length, slips out of the eye, without the aid of instruments. If at this period, a portion of the cataract were found to be likely to break off, the em- ployment of Daviel's scoop, in the way al- ready explained, would be proper. On the other hand, if, during the protracted move- ments of the eye upwards, this organ evince little energy of its own, the cataract will not enter the pupil, or scarcely do so, much less pass out ofthe eye, and the operator is underthe necessity of resorting to manual assistance, and with the end of the finger used for keeping the lower eyelid depressed, be is genlly to press the lid against the low- er part ofthe e\ eball. Such pressure should be gradually increased, until the greatest diameter of the cataract has passed into the pupil, at which moment, the pressure mu-t not be discontinued, before tbe cataract is completely out ofthe eye, which object may be promoted by supporting the lower pai"? 360 CATARACT. of the lens with Daviel's scoop, and then the pressure is to be diminished in the same gradual way, in which it has been previously augmented. Immediately the cataract is completely out of the eye, and the surgeon has paid due attention to the removal of any fragments left behind, the assistant is to let the upper eyelid descend, the patient is to be desired to keep both his eves shut and perfectly still, and his head and eyes are to be covered with a clean white piece of linen, so that the effect of the light may be moderated. When the patient has recovered from the alarm, which, according to Beer, the pas- sage of the cataract outwards, especially when it is large and firm, always produces in a greater or lesser degree, be is to be placed with bis back towards tbe window, and the linen is to be raised a little from the eye, which is to be very slowly opened, while the other eye, which has not been operated upon, is to be kept welt covered. Beer says, that the patient should then be shown some objects, not of a shining, or very bright description, at different distan- ces ; and, if he is able to see them plainlyj the surgeon may proceed to apply the dressings without delay. Beer confesses, that, if possible, it would be better to dispense altogether with making any trials of (he power of the eye, which has just been operated upon, because such attempts must tend to increase the subse- quent inflammation in the organ ; yet, he is of opinion, that these trials of the eyesight are necessary after extraction of the cata- ract. First, because the capability of see- ing immediately, is a thing always expected by the patient and his friends, and leaving them in ignorance on this point, would keep up an anxiety, likely to have a bad effect in rendering the ophthalmy more severe. Se- condly, Beer urges, as a stronger motive for the custom, the circumstance of the patient seeing, when his eye is first opened, all, even the smallest objects, though he sudden- ly loses the faculty of distinguishing them at all, or sees them very obscurely ; and, now, if he be half turned with his face to- wards the window, one will find in the pu- pil, which directly after the passage of the cataract was perfectly clear, some soft or firm fragments of the lens, which are first dislodged from within the capsule by the variations in the eye, produced by the in- spection of different objects at different dis- tances, and which, without these trials of vision, would be long in being loosened by the aqueous humour, and might form a se- condary lenticular cataract; which will not now be the case, as the surgeon can and ought at once to remove them. (Lehre von den Augenkr. 2 B. p. 373.) The preceding mode of operating, as Beer observes, will not answer for every case of cataract, adapted to extraction ; but, the plan sometimes requires to be modified ac- cording to circumstances. Thus, according to the same writer, when the eye is very prominent, and particularly when at the same time the fissure of the eyelid* is ei- tremely narrow, the incision in the cor- nea must not be made horizontally, but ob- liquely outwards ; for otherwise the edge of the lower eyelid will retard the healing of the wound, and an ugly cicatrix, more or lr»« injurious to the eyesight, be the conse- quence. When tbe cataract is of middling consist- ence, neither very hard, nor soft. Beer as- sures us, that the attempt ought to be mad* to extract the cataract and the capsule to- gether at the same time, as formerly recom- mended by him. (Melhode den graven Staahr sammt der Kapsel aussuziehen, fa Wien. 1799.) In such a case, he says, the experiment will mostly succeed, if properly conducted, and, if it should not, it cause* not the slightest detriment to the eye, nor the least obstacle to the effectual comple- tion of the operation. In order to accom- plish what is desired, the capsule-needle is to be introduced into the pupil, as in the se- cond stage ofthe operation, and its point is then to be slowly pushed, as far as its great- est diameter, into the centre of the lens, so that one surface of the needle may be up- wards, the other downwards ; one of it* cutting edges turned towards the inner can- thus, the other towards the outer one. And now the needle, with the impaled catarc-t, is to have sudden, but short perpendicular jerks communicated to it, by which mean*, the upper and lower connexions ofthe cap- sule with the neighbouring textures will he in part loosened. '1 be needle is next lo be suddenly rotated, without withdrawing it from the cataract, so that one of its flat sur- faces may face the inner canthus, the other, the outer one ; and one of its edges maybe turned upwards, the other, downwards; and then the short sudden jerks of the needle in the horizontal direction may be repeated, for the purpose of breaking, as muoh as pos- sible, (be lateral connexions of the capsule. Lastly, the capsule-needle is to be quickly withdrawn from the eye, when it is mostly followed by the lens and the capsule, or the cataract comes away fixed on the point of the instrument, at which moment the pu- pil becomes perfectly clear and black. When the cataract does not follow the withdraw- ing of the needle, the surgeon is to proceed with the usual cautions to the third stage of the operation. Great as the advantage would always be of extracting the cataract, toge- ther with its capsule, it is plain, thatythe at- tempt is not practicable when the case is a very hard lenticular cataract, because the capsule needle cannot be effectually intro- duced into the body of such a lens, situated upon the yielding vitreous humour. Nor would the plan answer, if the cataract were very soft, as the movements of the needle in it could have no effect in breaking the connexions of the capsule. In the case described by Beer unde" the name oiencysied cataract, the capsule; must, not be opened ; but after properly opening the cornea, if the cataract does not escape of it-elf at this moment from the eye, th" CATARACT 361 operator must iniinedialefy introduce the small cataract-tenaculum, with its point turned downwards, between the cornea and the iris, into the pupil. The cataract should then be firmly taken hold of with the hook, and slowly and steadily drawn out of the eye with its thick, tough capsule. Beer says, that extraction should be performed in the same way in the dry-husked capsulo- lenticular cataract of children and adults, except that, in allthese cases, a fine, elastic, sharp, silver, or golden spatula, fixed at the lower part of Daviel's curette or scoop, should be ready at hand to assist in se- parating the cataract from the vitreous hu- mour, immediately the opaque substance is disponed to pass out ofthe eye. Also in the completely fluid cataract, when the capsule is partially opaque and thickened, a circum- stance easily known by appearances, the same mode of extraction must be attempted. But, if the hook should tear its way out, and the capsule empty itself, the extraction must be performed altogether with the forceps. The latter instrument is to be cautiously in- troduced in the same manner as the capsule- needle into the pupil, one ofthe largest and thickest portions of the capsule are then to be taken hold of, and.suddenly drawn out towards the opposite side, by which means, generally the whole anterior layer, and sometimes also the posterior layer of the capsule will be detached, and the pupil im- mediately cleared. On the contrary, in what Beer has called the bar cataract, which, he says, is seldom fit for an opera- tion, as soon as the cornea has been opened, the bar must first be separated, by means of the capsule-needle, from the uvea, in what- ever way is found most practicable, and then it is to be extracted with the small ca- taract-tenaculum, or teeth forceps ; when this has been done, the cataract itself must be taken out of the eye in the same manner as the encysted cataract. (B. 2, p. 377.) When extraction has been completed, the next object is to dress the eye; while the patient turns his eye upwards, the lower eye- lid is to be drawn downwards from the <-ye with the fore-finger, and steadily held so, un- til the patient has shut his eye as much as possible. At this moment, Beer applies a small strip of adhesive plaster, perpendicu- larly over the fissure of the eyelid, a practice very properly not imitated in this country ; and then a doubled piece of fine linen, which is fastened on the forehead with a common bandage. Both eyes he dresses in the same manner, even when only one has been ope- rated upon. Mr. Ware found, that a'dossil of lint, steep- ed in plain water, or brandy and water, and covered with the spermaceti, or saturnine cerate, and removed once every day, is the most easy and convenient dressing, that can be applied after the operation. The cerate over the lint prevents the latter, when im- pregnated with the discharge, from becom- ing stiff, and irrituling the lids • Mr. Ware thought the mode of applying the compress and bandage over the eve, a circumstance Vol I 46 of no small importance, became, if tooloose, the dressings are very apt to slip off, and, consequently, to press unequally and inju- riously on the eye; and, if too tight, tbe un- due pressure will excite pain and inflamma- tion, and even force out some ofthe vitreous humour. Mr. Ware's compress is made of soft linen, folded, two or three times, wide enough to cover both eyes, and sufficiently long to extend from the upper part of the forehead to the lower part of the nose. This be pins at the top of the patient's night-cap ; and its lower part, which is divided in the middle, to allow the nose to come through it, he lays loosely over the eyes. The ban- dage, also made of old linen, and as broad as six fingers, he carries round (he head over the compress, and pins to the side of the night-cap moderately tight. A slip of linen is afterwards carried under the chin, and pinned at each end to the side ofthe band- age, so as to prevent it from slipping up- wards. (Ware.) Beer recommends the p*a- tient to lie upon his back, with his head not too low, and in a chamber whicb is not too light, and to remain in this way at least un- til the wound in the cornea is closed. As, during the first two days after the operation, the doubled piece of linen, which Beer pla- ces over the eye, is repeatedly wet through with the discharged aqueous humour, it is to be changed several times a day. care being taken to let the fresh pieces of linen be well aired and warmed. With respect to the after treatment. Beer also enjoins the obser- vance of every thing, which has been alrea- dy pointed out as proper afier depression and reclination ; and,in particular, while the wound in the cornea is not fiimly healed, and tiie eye cannot be kept open, the jmtie :■< must refrain from taking snuff and smoking tobacco. According to the same author, i,o thoughts should be entertained of opening (he eye at lin, till two or Ihree days after tbe discharge of the aqueous humour bas completely ceased ; a circumstance always indicated by slight prickings in the eye it- self, by a burning, though not verj severe, pain, attending the escape of that fluid from the inner canthus, and in irritable, nervous, debilitated subjects, even by the sensation of transient luminous appearances There- fore, Beer says, the eye should seldom be opened before tbe 5th, or 6th day. When this is first done, the light should be very moderate, and the patient placed with his back towards it, all unnecessary lateral light being kept from tbe eye by the linen attach- ed lo tbe forehead, while Ihe daily trials of the newly recovered powers of the eye should be made with the utmost precaution. On the 8tb,9th,or at latest, on the lOib day, Beer recommends leaving Ihe eye open, but screened above by a green eye-shade, in a half darkened chamber; and he is after- wards to be treated, until his eye is perfectly well, according to the rules already laid down as proper to be observed after couch- ing. And, especially when the patient has had cataracts in both eyes, Besr 'hinks if as well to apprize him, in order to preventun- 362 CA'i'AUaCT. necessary alarm, that, upon first going out into the open air particularly in the even- ing, he will be for some moments almost blinded, and then begin to see again, but every object will now appear covered with a white, shining circle, which at lengih goes off; though, inthe open air, it will some- tiroes continue for several days. (B. 2. p. 380.) The late Mr. Ware published an inquiry into the ciuses preventing Ihe success of extraction of the cataract. The first, which he considers, is making the incision through the cornea too small. In this circumstance a degree of violence will be required to bring the cataract through the wound : and, if the cataract be not altered in its figure, tbe wound will be forcibly dilated, and the edge of the iris compressed between the cornea and the cataract. In (his way, either some of its fibres may be ruptured, or it may be other- wise so much injured,as to excite a consi- derable degree of inflammation, and even induce, in the end, a closure ofthe pupil.. This accident may arise from the opera- tor's cutting the cornea, without being able lo see exactly the position of this mem- brane, in consequence of the eye having turned inward, owing to its not eing pro- perly fixed. The fault may also proceed from tbe incision having been begun below the transverse diameter of the cornea. In this manner, nine-sixteenths, or rather more than half of the circumference of this mem- brane, will not be divided ; which extent the incision ought always to occupy, in or- der to allow the cataract to be extracted with facility. When however the cornea is remarkably flat, and tbe iris projects unusually forward in the anterior chamber, Mr. Ware recom- mends including only one-third of Ihe cor- nea in the first incision, and afterwards en- larging the aperture, on the outer side, by means of curved scissors. Taking care to fix the eye in Mr. Ware's way, is represented by this author as being of great consequence in hindering the wound in the cornea trom being made too small. Whenever the wound in tbe cornea is- made too small, it should always be enlar- ged before proceeding further in the opera- tion ; and, according to Mr. Ware, this can be best accomplished with a pair of curved blunt-pointed scissors, on the outer side of the cornea, where the knife first made its entrance. For doing this, Beer recommends the use of Daviel's scissors, which are to be intro- duced with their concavity towards the ope- rator, and their point directed towards the pupil. Beer also introduces tbe point of tbe inner blade into tbe middle of tbe wound of the cornea, underthe flap already made, and passes it somewhat higher th-m the place to which it is necessary to enlarge the in- cision. Then he first conveys the instru- ment to tbe inner or outer angle of the wound, where the dilatation is to be made, keeping the blade which is within the cor- nea, not paraiiei to the iris, but iu an Ouliqiw position with respect to it, for otherwise the best scissors will fail lo make a clear divi- sion. Tbe scissors also must not be opened more, than is absolutely necessary, and they should be very quickly shut, and in such a manner, that the outer blade ought only to move towards that within the cornea, lest the eye suffer injury. Beer says, that it n hardly ever necessary to enlarge the inci- sion in the cornea at both its angles; and, in these cases, he confesses, that all idea of shaping the wound altogether as it ought to be, must be renounced. (Lehre von den Augenkr. R. 2, p. 282.) Wounding the iris with the cornea-knife, is the second accident, which Mr. Ware considers. The principal cause seems to him to be a discharge of tbe aqueous hu- mour, before the knife has passed through the cornea low enough (o hinder the lower part ofthe iris, which forms the inferior rim ofthe pupil, from getting beneath tbe edge of the instrument. According to Mr. Ware., the escape of the aqueous humour may be owing to some inaccuracy in the shape of the knife, or unsteadiness in introducing it. The falling of tbe lower part ofthe iris un- der the edge ofthe knife, Mr. Ware believes, cannot always be prevented by the utmost skill, or precaution of the operator. Hap- pily, however, says he, we have been taught, that the iris may be reinstated, after it has been thus displaced, and without suffering any injury, by making gentle frictions on the cornea, with the pointof the finger. By unsteadiness in passing tbe knife, Mr Ware means, that the knife may not only be suffered to make a punctuation through this tunic, but, that its edge may, at the same time^be unintentionally pressed downward, so as to make au incision likewise ; in con- sequence of which downward motion of tbe knife,an aperture must unavoidably be left in the cornea, through which the aqueous humour will escape. If (he cornea knife in- crease through its whole length, both in width and thickness, and if it be merely pushed through the cornea, no space will be left, through whicb any fluid can escape According to Beer, tbe escape of the aqueous humour, as the knife passes across the anterior chamber, may happen with, or without any fault on the part of tbe ope- rator, and the iris fall not merely against the posterior surface of the knife, but even project under its edge, and over its back. When this happens, Beer joins Ware in re- commending the end of the middle finger, situated at the inner canthus, to be gently pressed without delay upon that part of the cornea, which is in front of the knife, and, at the moment, when this is done, the iris will recede from the edge ofthe instrument, and the operator, by being very quick, may proceed again without any risk of injuring that part of the eye. But, if tbe iris should be found to project again above and below tne knife immediately the point of tbe lin- ger is removed from the cornea, such remo- val should not be made, and the knife be OATARACT 3G3 boldly pushed oo until its point pierces the other side ofthe cornea; ar, if the point has already passed some way out of the cornea towards the inner canthus, the blade is to be pushed on so far, that no protrusion of the iris is possible. For, says Beer, while tbe finger continues to make gentle pres- sure upon the cornea, the iris w ill not fall nnder the knife. Should the eye chance to withdraw itself from the knife, after this has penetrated the anterior chamber; a circum- stance, which may easily happen in restless timid patients, the greater part or the whole of the aqueous humour is immediately dis- charged, and the iris conies in contact with the empty cornea. In this case, Beer says, that the operator should find out the wound with another knife, and with a wriggling motion of the instrument, conduct it be- tween the iris and the cornea, twisting and turning the point about until it has success- fully passed beyond the external, then be- yond the inner pupillary margin of the iris, and has finally come out of the cornea again. Now tbe incision in the cornea may be properly finished, in doing whicb, it is always necessary to keep the middle finger applied to this membrane, in consequence of tbe disposition of the iris to fall against the knife. Beer mentions it as a curious feet, that most ofthe patients, who are rest- less and unmanageable at the first introduc- tion ofthe knife, and who themselves cause that disagreeable occurrence now spoken of, are, on the contrary, very quiet during the foregoing manoeuvres. (Lehre von den Au- genkr. B. 2,p. 381.) The third accident, noticed by Mr. Ware, is the escape of the vitreous humour. The common occasion of this occurrence is tbe undue application of pressure. It may take place, either when the incision is made through tbe cornea, or at tbe time of ex- tracting tbe cataract. Some eyes are sub- ject to spasm, which renders them much more liable to this accident. To prevent it, Mr. Ware recommends every kind and degree of pressure to be taken from (he eye, before the knife has completely cut its way through the comeu. And, as soon as the knife has proceeded sufficiently low to se- cure the iris from being wounded, the opera- tor Should not only take heed, that bis own fingers do not touch the eye,but should also direct the assistant, who supports (be upper lid, to remove his fingers entirely from tbis part. The assistant seldom need make any pressure on the globe ofthe eye : however, when there is room for one of his fingers to be placed on the inner and upper part ofthe globe, without interfering with those ofthe operator, the method may be followed, in order to make the eye still more fixed. But immediately the punduation of the cornea is completed, tbe assistant's finger should always be entirely removed both from the eyelids and eye itself. Notwithstanding the upper lid is left thus free, there will be sufficient space between it and the lower lid, to allow the progress of the knife (0 be fcen : and. in finishing the wound, the operator should depress the low- er lid with great gentleness. The vitreous humour may also be lost, in consequence of opening the capsule of the lens nearer the circumference, than the cen- tre of the pupil. As the crystalline is both thinner and softer at (hat part, the instru- ment will be liable to pass through both sides of (he capsule, and enter the vitreous humour. Tbis humour having no longer any barrier to its escape, is liable to be forced out by the action of tbe eyelids alone ; and, when pressure is afterwards made, to bring the cataract through, a much greater quan- tity will be lost, and the cataract, instead of coming forward, will recede from the pu- pil. The only way to extract it now, is, by letting the upper lid be gently raised by an assistant, (a rare instance, in which tbis is necessary after cutting the cornea) while the operator, either with the fore-finger of the left-hand, or with the blunt end of the curette, applied beneath the incision in the cornea, prevents the cataract from sinking further. Then, with bis right-hand, let him introduce a hook under the flap of the cor- nea, and with its point carefully entangle the cataract, and bring it away. To prevent, however, such difficulties, Mr. Ware never attempted to puncture tbe capsule, until the whole pupil was in view. He was in the habit of opening the capsule with a gold-pointed needle, arched towards its extremity. Wenzel's needle, for this purpose, was flat in its extremity: Mr. Ware's pointed ; and (his is their only dif- ference. The latter introduced bis instru- ment under the flap of the cornea, with its arched part uppermost, until its point was on a level with the centre ofthe pupil. The end of the instrument was then turned in- ward, and gently rubbed on the capsule of the crystalline, until it pierced it. In a few instances, Mr. Ware found the capsule so tough, that the point of the gold needle would not enter it, and he was obliged to use a sharp steel instrument, of the same shape as that with a gold point. As already explained, Beer was much bolder with the capsule than Ware, and there can be little doubt, that both his capsule-needle and mode of usins it are better, than those of Wenzel and Ware. The vitreous humour may also be lost, at the time of extracting the cataract, and the usual cause is an undue application of pres- sure. All violent pressure is quite unne- cessary for forcing out the cataract, when the wound in the cornea is sufficiently large. When the wound is too small, it should be enlarged as above directed. If pressure be continued at all after the cataract is extract- ed, tbe capsule ofthe vitreous humour will certainly be ruptured, and some of this part of the eye protrude. Pressure may even rupture the capsule of the vitreous humour, before the cataract is brought through the incision in the cornea; the same conse- quences will ensue ; and the same practice be necessary, as in the case, in which the operator has unskilfully opened the capsule 3*>4 CATAHACT. of the vitreous humour with the needle, in attempting to open that of the lens. In taking away fragments of opaque mat- ter from the pupil, by means of the curette, jreatcare is requisite to avoid wounding the posterior part of the capsule of the crystal- line with tbe end of the instrument, so as to open a way for the escape.of the vitreous humour. Tbe vitreous humour may, indeed, be for- ced out, after tbe extraction ot the cataract, merely by a spasmodic action of the eyelids. On this subject, Mr. Ware, after hinting his suspicion, that, in a case of this kind, which he saw, the assistant's keeping up the lid contributed to the event, repeats his advice, " that the upper eyelid should be raised sole- ly by tbe. fingers ofthe left-hand oi the ope- rator," after cutting tbe cornea. Mr. Ware seems to think, that more evil has resulted from the operator's being de- terred, by the readiness, with which tbe vitreous humour continues to start out, from ascertaining, that all the fragments of the cataract are removed, and that the whole of the iris has resumed its position, than from the mere loss ofthe vitreous humour, which ii quickly regenerated. When a portion of the vitreous humour protrudes, Beer thinks, that the safest prac- tice is not to meddle with it, though he owns, that, in this circumstance, the wound heals slowly, and i6 always followed by a more or less perceptible, whitish scar, the pupil being generally drawn towards it, nud de- formed, while tbe iris aud the partly emp- tied membrana hyaloidea become adherent to the edges of the incision in the cornea. But, says Beer, the eyesight will be but little, or not at all impaired, notwithstanding one- eighth or one-fourth of the vitreous humour may be lost. However, he observes, that when one-third or half of it has escaped, a good degree of vision afterward cannot be expected ; and when more than half has been lost, the operation will have a still less successful result. He states also, that, when two-thirds have been lost, though the eye may recover its natural form, tbe pupillary edge of the iris will remain contracted round the empty, light-gray membrana hyaloidea, which projects into the anterior chamber, consequently, the pupil will be closed, and that state of the iris ensue, which is aptly termed a sinking of the pupil, subsidentia pupillte or synicesis. Mr. Ware notices the accident of extract- ing only a part ofthe cataract, and leaving the remainder behind. He is an advocate for removing all opaque substances from the pupil, except an extreme degree of irritabili- ty, to which some eyes are subject, should render the introduction of every sort of in- strument, after the cataract is extracted, dif- ficult and dangerous. Mr. Ware usually removed opaque portions of the cataract by means of acurette ; and, occasionally; when the opaque substance was large, and adhe- rent to the capsule, he was obliged to ex- tract it with small forceps. Before finishing tbe operation. Mr. Ware approves of always rubbing the end of the linger gently on the forepart of the eye, over the eyelids; which proceeding tends to bring into view any opaque matter, which may previously lie behind the iris. Mr. Ware relates a case. proving, that such opacities, as cannot be re- moved iu the operation, are capable of be- in j: absorbed. When, notwithstanding the observance of the directions laid down by Beer, as explain- ed in the previous columns, some of the pul- taceous. or scabrous surface ofthe cataract is detached, and continues behind in the posterior chamber, Beer says, that it ought to be immediately removed, lest the patient be left with a secondary lenticular cataract, which, he observes, is not always so certain of being dissolved and absorbed, as some imagine. The fragments may be removed in two ways ; and, first, the experiment of rubbing the upper eyelid over the eye should be made, because it not unfrequently brings the remains, especially when they are gela- tiuous, completely through the pupil, and out of the incision in the cornea. But, if such manoeuvre should not be effectual, Beer recommends cautiously introducing Daviel's curette to the outer pupillary edge of the iris, with its concavity towards the inner surface ofthe flap of the cornea, with- out raising this flap unnecessarily high, and then the operator is to endeavour to scoop out at once as much of tbe opaque matter as he can, and bring it to the inner surface of the cornea. He says, that it will rarely be necessary frequently to repeat the in- troduction of the curette. (B. 2, p. 387.) According to Mr. Ware, an opacity of the capsule can be the only reason for removing it. The anterior part, he says, can alone be- come the object of the operator's attention: its posterior part is necessarily hidden, while the cataract remains in the eye, and afterward, if discovered to be opaque, it is so closely connected with the capsule of the vitreous humour, that Mr. Ware believes it cannot be removed by any instrument, without hazarding a destructive effusion of this humour. When, however, the opaque lens is ac- companied with an opacity in the front part of the capsule, Mr. Ware recommends the following plan. After cutting the cor- nea, as usual, a fine pointed instrument, somewhat smaller in size than a round couching-needle, and a little bent towards the point, should be introduced under the flap of the cornea, with its bent part upward, until its point is parallel with tbe aperture of the pupil. The point should then be turned toward the opaque capsule, w hich is to be punctured by it, in a circular direction, as near to the rim of the pupil »s the instrument can be applied, without hurt- ing the iris. Sometimes, the part included within the punctures, may be extracted on the point ofthe instrument; and, if this can- not be done, it should be removed with a small pair of forceps. The lens, whether opaque or transparent, should next be ex- tracted, by making a slight pressure w i'h CATA the curette, either above, or below, the cir- cumference of the cornea. On the preceding subject, Beer remarks, that when none of the lens itself is left be- liind, but there is a slight degree of opacity in the anterior layer of the capsule, easily distinguishable from tbe cut flakes, and pro- ducing the least obstacle to vision, the opaque membrane should be taken away with the forceps, in the manner described in the preceding pages; for, otherwise a secondary capsular cataract will follow, which will become of a snow-white colour, and if only a trivial degree of iritis take place after the operation, it will become ad- herent to the iris, and the pupil become con- tracted and disfigured. (B. 2, p. 388.) Beer does not agree with Ware in con- demning all attempts to remove the poste- rior layer of the capsule, when found opaque, after the extraction of the lens. The case, he says, is indicated by the light grayspeckled appearance of the whole pupil, and by the patient seeing nothing at all, or objects only indistinctly in a thick mist. Beer advises a cataract-tenaculum to be passed into the pupil, in the same way as the capsule-needle is introduced in the se- cond stage of extraction, directing its point downwards as it enters, and upwards when it is brought out again. After it has en- tered the pupil, it is to be made to divide and annihilate, by repeated turns ofthe te- naculum, the hack layer of the capsule, and also the membrana hyaloidea, directly be- hind it, which, in such a case, is always ad- herent, ami opaque. Of these membranes a considerable part, closely wound round the book, may be taken out of the eye, though never withoutsome slight loss ofthe vitreous humour. In cases of this kind, the patient ought to be informed, that,though his sight will be restored, a part ofthe cataract must be left, and will be visible behind the pupil, particularly when it is dilated ; for, other- wise, suspicions may arise, that the opera- tion has been badly done, and a relapse ap- prehended. (B. 2,p.388.) Mr. Ware has considered the bad conse- quences of allowing foreign bodies of any kind, after the operation, to press unequally on the globe of the eye ; comprehending, under this head, the intervention of the edge ofthe lower eyelid between the sides ofthe divided cornea ; the inversion of the edge of the lower eyelid ; and the lodgment of one, or more, loose eyelashes on the globe of the eye. To prevent the first accident, every ope- rator, before applying the dressings, should carefully depress the lower eyelid; and, before he suffers the lid to rise, should take care that the flap of the cornea be accurate- ly adjusted in its proper position; and,that the upper lid be dropped, so as completely to cover it. After this, the eyelids should not be opened again, for three or four days, that is, until there is a good reason to suppose the wound in the coruea closed. (Ware.) The inversion ofthe lower eyelid is hurt- le ACT. 366 ful, in consequence of its making the eye- lashes rub against the eye. These should be extracted the day before the operation. For the mode of effecting a permanent cure, see Trichiasis. Besides the danger, to which the eye is exposed, from the inversion of the edee of the lid, the evo may receive injury from the improper position of the eyelashes alone ; one or more of which, during the operation, may happen to bend inwards; or, becoming loose, may afterward insinuate themselves between the inside ofthe lid and the eye. An eyelash bent inward, should be rectified ; if broken off and loose, it should be removed. Mr. Ware lastly considers prematurely ex- posing the eye to a strong light. He cen- sures the plan of opening the eyelids, within the first two or three days after the opera- tion, because the stimulus of the light in- creases the ophthalmy, and the method is apt to disturb tbe wound in the cornea, before it is closed. Mr. Ware, however, wishes it not to be inferred, that he is an advocate for long confinement after the operation. His mode is to keep the patient wholly in bed, and to direct him to move his head as little as possible for the first three days after the operation. During this time, a dossil of wet lint i» kept on his eyes, covered with a saturnine plaster, compress, and bandage, as already described. The dressing is renew- ed once every day, and tbe outsides of the eyelids washed with warm water in winter and cold in summer. At each time of dress- ing, the skin of the lower lid is drawn gently down, to prevent any tendency to an inversion. Animal food is prohibited and the patient enjoined not to talk much! On the fourth day, he is permitted to sit up for two or three hours, and, if he has hail no stool since the operation, a mild openin°- medicine is now administered. On the fifth, the time of his sitting up is len°then- ed, and, presuming that the wound ?n the cornea is now closed, Mr. AVare usually ex- amines the state of the eye. After this, no dressings need be applied in the daytime care being taken to defend it from a strom' lgbt, by a pasteboard hood, or shade, and by darkening the room, so that no inconve- nience is felt. The patient may now also look, for a short time, at large objects. The following part of the treatment need inter- fere very little with the wishes of the pa- tient, unless unexpected accidents should occur. (Ware.) As Beer, observes, if the patient be very restless, make frequent attempts to open his eye in the lea=t, and partly "lie upon the eye or if in changing the compresses the great- est caution be not used, the eye will perhaps be roughly pressed upon, and the iris pro- trude between the displaced and half-open- ed edges of the incision in the cornea, to which it will become adherent during a slow and very seldom violent inflammation lrom the moment when the iris thus inter- poses itself between the sides ofthe wound, the aqueous humour begins to collect, an J at length pushes the iris considerable fo- 866 CATARACT. wards. In tbis case, Beer recommends carefully opening the eye in a very mode- rate light, and adopting the expedients for- merly mentioned, for the purpose of making the iris recede. The dressings should be re- applied, and the eye kept closed and very quiet for at least eight or ten days, so as to hinder a recurrence of this disagreeable ac- cident. But if the iris should be already adherent to the edges of the wound in the cornea, the eye incapable of bearing light, and the aqueous humour more or less ac- cumulated in the anterior chamber, Beer eays, every thing must be left to time, while the eye is kept lightly covered for about a fortnight, and the existing inflammation pro- perly treated. Then, if the protrusion or staphyloma of tbe iris should not be dimi- nished, by the means calculated for lessen- ing the inflammation, caustic, or the knife must be employed. (Beer, B. 2, p. 391.) The same causes which have been above specified as conducive to a protrusion of the iris, may also produce a discharge of the vitreous humour. The following observations by Beer are interesting : when the dressings have been unskilfully applied ; when the incision in the cornea has been made horizontally upon a large prominent eye ; when the" fissure of the eyelids is exceedingly narrow ; or the patient is restless ; a proper cicatrization of the wound in the cornea may not follow. Though tbe aqueous humour may collect in Ihe anterior chamber, the partially united lamellae of the cornea may be incapable of duly resisting the distention of that fluid, and consequently protrude in the form of a light-gray, semi-transparent, oval vesicle, extending nearly the whole length of the wound in the cornea, and being most pro- minent in the centre. The patient com- plains of an annoying sense of pressure in the eye, as in cases of protrusion of the iris; but tbe discharge of * he aqueous hu- mour has completely stopped, and there- fore the anterior chamber presents its natu- ral appearance, and the pupil its regular round shape, though the edges of the wound in the cornea are whitish and swollen. This case was formerly regarded as a prolapsus of the membrane of the aqueous humour; but Beer considers it as a sort of hernia of the cornea, termed ceralocele. Merely puncturing, or cutting away the cyst is of no service; for, though the aqueous hu- mour immediately flows out, the wound soon closes again, and the tumour reap- pears, attended also with some risk of the iris falling into the cyst, and becoming ad- herent to it. Effectual relief cannot be ob- tained, unless the tumour be removed with Daviel's scissors, as close as possible to the wound ; the dressings skilfully arranged ; and the eye kept closed and quiet for eight days, or a fortnight. In f^uch a case, a whitish scar is always permanently left. (Beer, B. 2, p. 393.) Beer observes, that when the pupil con- tracts very considerably after the incision in the cornea is made, and the cataract at the same time remains at some distance from the uvea, too small an opening has generally been made, and it ought to be en- larged. But if the cataract cannot be forced through the pupil, without making pressure on the lower part of the eyeball, and the closure of the pupil should still continue, the circumstance proceeds from the loss of the aqueous humour, and the second stage of extraction must be deferred a little while until the pupil dilates again, and (he opera- tion must then be finished in a very mode- rate light. When, in the second stage of the opera- tion, the anterior layer of the capsule has been properly divided, and yet the cataract will not pass into the pupil, though the eye itself acts with energy, Beer savs, that it U indispensably necessary to make pressure upon the lower part of the eyeball, as al- ready advised, and to continue it either un- til the cataract with its lowermost edge ef- fectually projects through the pupil and out of the eye, or until it is moved so far direct- ly upwards, (without entering the pupil,) that its lower margin is brought into view, and quite a black semilunar interspace i-. seen between it and the inferior pupillary edge of the iris. At this moment the ope- rator, without increasing the pressure ofthe finger on tbe eyeball, lest the vitreous hu- mour burst, and a great part of it be lost, and without lessening the pressure, lest the cataract sink back into the eye, should in- troduce Daviel's curette into the above in- terspace, with its hollow surface applied against the back surface of the cataract. which is to be gently pushed out of the eye. In doing this, Beer owns that a small part of the vitreous humour is almost always lost. but the quantity is not at all comparable to what is lost when the hyaloid membrane gives way before Daviel's curette is intro- duced, which can then only be passed into the eye through the protruded vitreous hu- mour for the purpose of pushing out the ca- taract. Beer notices the occasional protrusion of the iris, in the third stage of the operation. more or less between the edges of the in- cision in the cornea, immediately after the exit of the cataract. Here, says Beer, the iris should be reduced without the least de- lay, and the pupil, which is completely oval, made round again ; a thing which the ope- rator may easily perform, by applying his hand flat upon the patient's forehead, letting the latter shut his eye, rubbing tbe upper eyelid quickly, yet gently with the thumb, and ,then suddenly opening the eye, by which means a moderate light, will all at once strike it, and induce an expansion of the iris. In all patients who have been operated upon for cataracts, the edges of the eyelids become glued together with mucus on the first night after the operation ; yet, accord- ing to Beer, in individuals particularly sub- ject to copious secretions of mucus, it is not unusual for the puncta Iachrymalia and lachrymal ducts to be blocked up with thick- CATARACT, 367 r.ned mucus, whereoy tiie tears are prevent- ed from duly passing down into the nose, so that from time to time they are discharged from the inner angle of the eye, and collect under the eyelids. In this case the patient soon begins to complain of a violent, conti- nual, and increasing sense of pressure on tbe eye, and the upper eyelid swells, unattend- ed with any redness. Irritable persons also experience a stupefying dull headach. These inconveniences may be immediately removed by clearing away the mucus with a little lukewarm milk from the inner can- thus, and letting a stream of clean water fall over the check. Care must also be taken to hinder a recurrence of the circumstance again, and to remove it if it should happen. The inflammation, consequent to extrac- tion, chiefly affects the iris and neighbour- ing textures. Beer refers its origin princi- pally to the entrance of air into the interior of the eye ; which, owing to the size ofthe wound, be says, is not entirely to be pre- vented. But another cause is the introduc tion of different instruments into the eye, and hence the inflammation is generally se- vere, when it has been necessary to remove fragments of the cataract with Daviel's cu- rette, or to take away the capsule with for- ceps, or destroy it with the lenaculum- needle. However, Beer is of opinion, that a surgeon, who knows how to operate well in every mode, will not find the inflamma- tion, under these circumstances, more vio- lent after extraction, than other methods, and therefore, he thinks, that when no con- siderable impediment exists, it should be preferred. Beer, who considers extraction as a radical mode of removing a cataract, thinks, that when there are no great and in- surmountable obstacles to its performance, and the operator can execute it as well as all other methods, and with the requisite skill, it ought to be preferred. But when he is deficient in skill, he is himself the greatest impediment to the success of the operation. The particular cases, in which the methods of depression and reclination are indicated, have been already specified, and in these, of course, extraction is not advantageous. There are also some exam- ples, as Beer remarks, in which tbe latter operation must be hazardous for a beginner, and therefore, in respect, to such an opera- tor, by no means eligible, as in cases of bar- cataract, and capsulo-lenticular cataracts with a cyst of purulent matter. (Beer, B. 2, p. OP KERATONYXIS. The etymology and meaning of this term will be found in its place in this dictionary. This operation requires the pupil to be first artificially dilated. It admits of being di- vided into two stages; first, the introduc- tion of the needle through the cornea and pupil as far as the cataract; and, secondly, the breaking of the lens to pieces, and the division und laceration of its capsule, tor hose purposes, Beer prefers a common, straight, spear-snaped, sharp-edged couch- ing-needle to any curved-one, however fine it may be made ; first, because it pierces the cornea, with greater facility ; secondly, because Doth a soft cataract and the capsulo can be more ettectually cut with it, a larger opening being made, through which the aqueous humour may flow over the frag- ments of the lens, and the dissolution of the cataract be thus rendered more certain ; whereas, with a curved needle, Beer says, the lens can only be disturbed, and the cap- sule torn, under which circumstances, in- flammation and a secondary capsular cata- ract is likely to be produced. He directs the instrument to be introduced either at the lower, or at the external part of the cornea, one line and a half from its margin, the point being directed obliquely towards the pupil, and the capsule is to be effectually cut by moving the extremity of the needle laterally in various ways; and, above all things it is necessary at ihe time of breaking the lens piecemeal, not to let the instrument continue always within this body, but, at every stroke, to lift it completely out of the lens and capsule, and then introduce it into them again in different directions. As Beer observes, this metnod of opera- ting must soon have been found as little adapted to all cataracts, as any other mode ; for, otherwise, the suggestion would not have been made to practise reclination through the cornea. To this form of recli- nation, however, Beer adduces great objec- tions; for, he says, that, in this manner, either the cataract cannot be properly turned, if the iris be duly spared; but it will continue to lie obliquely, being always quite evident below the pupil, and very apt to rise again from the slightest cause; or it is indeed depressed far enough towards the bottom of the eye, but, however much the pupil may be artificially dilated, the pupil- lary edge of the iris is more or less injured, especially with the convexity ot a curved needle. In addition to these considerations, Beer urges against this method all the objec- tions, which apply to tbe practice of reclina- tion through the sclerotica. Afier the lens and capsule have been ef- fectually cut in pieces, tbe same light mode of dressing and the same after-treatment are proper, wbich are adopted in cases of de- pression and reclination. Beer also particu- larly objects to any trials being immediately made ot tbe eyesight. At tbe same time, he assures us, that he has not met with any of the instances, so frequently mentioned in books, of persons, on whom keratonyxis has been done, seeing perfectly well, and hav- ing quite a clear pupil in a few days; under the most favourable circumstances, several weeks, and sometimes as many months, elapsed, before the pupil became quite trans- parent According to Beer, keratonyxis is not lia- ble to many accidents. Sometimes, says he the artificially dilated pupil contracts, assooii as the needle has pierced the cornea, and reached the cataract: in this ciruuntance. 36S CATARACT. the operator must wait quietly, until the pu- pil gradually expands again, a change, which may be promoted by screening the eye with the hand. If the operation were to be con- tinued without delay, either the pupillary edge of the iris would be seriously and dan- gerously hurt by the needle, or the cataract could not be effectually divided. When, contrary to expectation, (he nucleus of the cataract is too hard to be broken piecemeal, reclination and depression should be done through the cornea, as well as circumstances will allow, and these objects can be more easily effected with a part, than with the whole, of the lens. When the lens is found completely fluid- but the capsule opaque on- ly at some points, Beer, with a view of pre- venting a secondary capsular cataract, re- commends cutting the membrane in all di- rections, and annihilating it as much as pos- sible. Keratonyxis may be followed by the same evils, which occasionally take place af- ter depression and reclination, and which will require similar treatment. But, according to Beer's experience, one of the most frequent consequences is a secondary capsular cata- ract, which often ensues even though the pu- pil was quite clear at the time of the opera- tion, and though it may not quite blind the patient, it considerably lessens his power of vision, and renders the operation very in- complete. When the sole object of keratonyxis is to break and cut tbe cataract and its capsule piecemeal, and the fragments are to be left to dissolve and to be absorbed, the operation can be indicated only where this division, breaking, dissolution, and absorption of tbe cataract, can be successfully wrought. Hence, Beer sets down the method as not calculated for firm, hard, lenticular cataracts; nor for (hose which are softish and scabrous only upon their surface; and, be says, that it is not suited for capsulo-lenticular cata- racts, nor for any cases, termed false cata- racts, which are of a membranous nature. Keratonyxis, he observes, may be expected to answer only in fluid or gelatinous cata- racts, when the capsule is either little or not at all opaque aud thickened, and of course can be easily opened and cut to pieces, as in the case described underthe name of en- cysted cataract. For the above reasons, the method is well adapted for children and young subjects, in whom the origin aud ge- neral complications of a cataract involve the case in suspicious circumstances. Langenbeck, who has practised kerato- nyxis to a considerable extent; thinks extrac- tion preferable to it only when the whole cataract can be brought out at once, by means of gentle pressure on the eye, and with the aid of Daviel's curette, as in the case of a firm cataract; while he represents keratonyxis as most advantageous, where, by tbe manoeuvre of opening the capsule, the mass of the cataract would be so divided by the instrument as not to admit of being ex- tracted altogether; but, would require the use of a scoop, forceps, or hook for bringing out the fragments, aa in examples of soft, milky, and capsular cataracts. Langenbrc* also urges, as a reason against extracting soft cataracts, their greater size, whereby in their passage through (be pupil in an entire stote, they may injure the iris. (Neue Bi- bliothek for die Chir. 1. B. p. 461.) Valua ble information on keratonyxis has been pub- lished by the same author in (be 4th vol. of his first Bibliothek, in the 1st vol. of his new Bibl. p. 1, die. \S)'> ; and mi a tract entitled, '• Prfifungder Keratonyxis einer Methodeden grauen Staar dureh die Hornhaut au reclini- ren. oder zu serstuckeln nebst erlaulernden Operations geschichlen. Gottengen. 1811. See also G. H. Buchorn's Diss, de Keratonyx- ide; Hala. OF THE CONGENITAL CATARACT, AUD OPE- RATING UPON CHILDREN. I shall not stop here to inquire, whether the expression c.ongential cataract is general ly used with strict propriety; but, it is worth noticing, that the term is reprobated by Beer, as being in general incorrectly applied. So much has been already said in a pre- ceding section of (bis article, concerning the propriety and striking advantages of opera- ting for the cataracts of children, that to es- patiate further upon this point would be a mere waste of time. We have noticed the case, which Scarpa terms the primary membranous cataract, and which is mentioned by Ihnt distinguished professor, as being met wilb in children, or young people, under the age of twenty, the substance of the crystalline itself being a! most entirely absorbed, while the capsule is left in an opaque state, including, at most. only a small nucleus, not larger than a pin's head. This disease is described by Scarpa as being exceedingly rare, and characterized by a certain transparency, and similitude to a cobweb; by a whitish opaque point, either at its centre, or circumference ; and by a streaked and reticulated appearance. Now, this example, which is represented by Scarpa as being rare, appears, from the ex- perience of Mr. Saunders, to be by no means uncommon, since, at tbe London Infirmary for curing diseases of the eye, it has been found, that the majority of conge- nital cataracts are capsular, or membranous. This last statement is also at variance with that of the late Mr. Gibson, who has asserted, that, in infants, the cataract is generally fluid. (Edinb. Med. and Surgical Journal, Vol. 7, p. 397.) Mr. Ware also asserts, that, in children, born with cataracts, the crys- talline humour has generally, if not always, been found either in a soft, or fluid state (Obs. on the Cataract, and Gutta Serena, Vol 2, p. 380.) However, as Mr. Saunders must have had the most experience in these par- ticular cases, I believe, we must consider his account as the most accurate. We learn from this last gentleman's publication, that, in the congenital cataract, after the crys- talline lens is converted into an opaque substance, it is gradually absorbed ; and, in proportion to the progress of absorption- CATARACT. 3uy tbe anterior lamella of the capsule ap- proaches the posterior, until they form one membrane, which is while, opaque, and very elastic. This process is commonly completed long before the eighth year, and the operator will now find a substance, which he will in vain endeavour either to extract or depress. But, there is one form of the congenital cataract, in which the ab- sorption of the lens does not proceed, viz. when the centre ofthe crystalline is opaque, and its circumference is perfectly transpa- rent. Should the capsule and lens be pene- trated, however, with any instrument, the opacity soon becomes complete, and from this moment, the substance of the lens begins to be absorbed. The experience of Mr. Saunders proves, that, iu the congenital cataract, the lens may be either solid, soft, or fluid, but, that more frequently it is partially, or completely absorbed, and the cataract is capsular. The following table of forty-four cases is given in Mr. Saunders's work,forthepurpose of showing in what proportion each spe- cies of cataract has been found to prevail in congenital cases. Solid opnque lens, with or without opacity of the capsule. Three single, two double cataracts ....... Solid lens, opaque in the centre, transparent in the circumference, with cap- sule iu the same state. Five double .... Soft opaque lens, with, or without opacity of the capsule. Two single, two double Soft opaque lens, with solid nucleus. One single, two double Soft opaque lens, with dotted capsule, the spots white, the spaces transparent Two double ....... nt. } Fluid cataract, with opacity of the capsule. Two-single Fluid cataract, with opacity of the capsule, and closed pupil. Two double Opaque and thickened capsule, the lens being completely absorbed, or the re- mains of it being thin and squamose. Six single, twelve double Opaque and thickened capsule, with only a very small nucleus of the lens un- absorbed in the centre. Two single Opaque and thickened capsule in the centre, remains of the lens in the cir- cumference. One double ...... 18 Here the corresponding character of con- genital cataracts in the eyes of each indivi- dual is exhibited by the number of double cases, and we are informed, that the same character was preserved in the cataracts of several children of the same family. (Saun- ders on Diseases of the Eye, edit, by Dr. Farre, p. 136, 13*5) The congenita- cataract appears frequent- ly to afflict several children of the same pa- rents In the course of the present article, I have already had occasion to advert to two striking examples of this fact The first is related by Mr. Lucas, who attended five children of a clergyman at Leaven, near Beverley, all born "with cataracts. (See Med. Obs. and Inquiries, Vol. 6.) The se- cond is mentioned by Mr. Gibson, who some years ago, saw five or six children, the fa- milies of two sisters, who were all totally blind, and in an idiotic state, having cata- racts accompanied with amaurosis. (Edinb. Med. and Surgical Journal, Vol. 8, p. 398.) Several instances occurred to the late Mr. Saunders In one family, two brothers were thus afflicted. In a second family, two brothers, twins, became blind with cata- racts at the age of twenty-one months, each within a few days of the other. It is re- Vot. I. 47 markable, that the four cataracts had pre- risely the same character. In a third fami- ly, a brother and two sisters were born with this disease The eldest sister was affected with it only in one eye, the brother and youngest sister in both eyes. In a fourth family, three brothers and a sister had all congenital cataracts. (Saunders on the Dis- eases ofthe Eye, p. 134," 133.) Children with congenital cataracts pos- sess various degrees of vision; but, when they are totally blind, their eyes not being attracted by external objects, volition is not exercised over the muscles of these organs, which roll about with an irregular, rapid, and trembling motion. I shall now proceed to speak of the man- ner of operating upon children. Until the time of Mr. Pott, the intention of surgeons, in couching, or depressing the cataract, (as indeed tbe expression itself implies,) was to push the opaque crystalline downward, away from the pupil. Mr. Pott, conscious that the cataract often existed in a fluid, or soft state, was aware that it could not then be depressed ; and, therefore, in such cases, he recommended using the couching nee- dle for the express purpose of breaking down the cataract, and of making a large 370 CATARACT aperture in the capsule, so that the aqueous humour, which he believed to be a solvent for the opaque crystalline, might come into immediate contact with this body. This operation, subsequently to Mr. Pott, has been strongly and ably recommended by Mr. Hey, of Leeds, and Professor Scarpa, of Pavia. In the cases of children, it even received the approbation of the late Mr. Ware, who informs us, that he and his son had performed a similar operation on a con- siderable number of infants and young per- sons with uniform success. (On the Opera- tion of Puncturing the Capsule of the Crys- talline Humour, p. 9 ) But, notwiths anding the utility and effi- cacy of lacerating the front layer of the crystalline capsule had been so much in- sisted upon by Scarpa and others, their ob- servations were confined to the cataract in tbe adult subject, and, before the example Get by the late Mr Saunders, no one (except- ing, perhaps, Mr. Gibson of Manchester) ventured to apply, as aregular and successful practice, such an operation to the eyes of infants and children. Indeed, itseems highly probable, that even Mr Gibson himself would have remained silent upon the sub- ject, had not his attention been roused by the reports of the London Institution for curing diseases of the eye, which repdrts, he says, were dispersed and exhibited in the public news rooms of Manchester. For the creation and perfection of this benefi- cial practice, therefore, I am disposed to five the memory of Mr. Saunders great onour. The propriety of operating for the cataracts of children had lon^ ago been insisted upon by a few writers, and the attempt even now and then made ; but, the the method never gained any ground, until Mr. Saunders led the way. It only remains for me to describe the plans of operating, as executed by Mr. Saun- ders, Mr. Gibson, and Mr. Ware. Tbe principle, on which Mr. Saunders proceeded in his operations on the congeni- tal cataract, was founded on the opinion, that the only obstacle to the absorption of the opaque lens is the capsule ; and that as the latter also is most generally opaque," the business of art is to effect a permanent aper- ture in the centre of this membrane. This applies to every case of congenital cataract, which can occur." Mr. Saunders used to overcome the difficulty of operating upon children, by fixing the eyeball with Pellier's elevator, having the patient held by four or five assistants, dilating the pupil with bella- donna, and employing a very slender needle, armed with a cutting edge from its shoulders to its point, and furnished with a very sharp point, calculated to penetrate with the utmost facility. Before the operation, the extract of bella- donna, diluted with water to the consistence of cream, is to be dropped into the eye, or, to avoid irritation, the extract itself may be smeared in considerable quantity, over the eyelid and brow. In less than an hour, if there be no adhesions, it produces a full dila- tation of the pupil, exposing to view nearly the whole anterior surface of the cataract. The application should then be washed from the appendages of the eye. In using the needle, Mr. Saunders most carefully abstained from doing any injury to the vitreous humour, or its capsule, and it was an essential point with him to avoid displacing the lens In directing the extre- mity of the instrument to the centre of the capsule, he passed it either through the cornea, near tbe edge of this membrane, (the operation now called keratonyxis,) or through the sclerotica a little way behind the iris. By the first, which is called tbe anterior operation, Mr. Saunders conceived, that less injury would be inflicted, and less irritation excited, than by introducing tbe needle behind the iris, through all the tunics of the eye. In every case, the first thing aimed at was the perm inent destruction of the central portion of the capsule to an ex- tent equal to that of the natural size of the pupil. If the capsule contained an opaque lens, Mr. Saunders used next to sink the needle gently into the body of the crystal- line, and moderately open its texture; cau- tiously observing not to move the lens at all out of its natural situation. When the case was a fluid cataract, Mr. Saunders was content in the first operation with simply lacerating the centre of the capsule, being desirous of avoiding to in- crease the irritation following the diffusion of the matter of the cataract in tbe aqueous humour. When the cataract was entirely capsular, Mr. Saunders acted with rather more free- dom, as he entertained in this case less fear of inflammation : but, in other respects, he proceeded with the same objects in view, which have been already related, and of which the principal consisted in effecting a permanent aperture in the centre of the cap- sule, without detaching this membrane at its circumference ; for then the pupil would have been more or less covered by it, aod the operation imperfect, "because this thick- ened capsule is never absorbed, and the pen- dulous nap is incapable of presenting a suf- ficient resistance to the needle to admit of being removed by a second operation." (P. 145.) I have already explained, that Mr. Saun- ders found, that the greatest success at- tended the operation between the ages of eighteen months and four years. One ope- ration frequently accomplished a cure; as many as five were seldom requisite. The only particularity, in Mr. Saunders's treatment ofthe eye after the operation, was that of applying the belladonna externally for tbe purpose of making the pupil remain dilated till the inflammation had ceased,so as lo keep the edge of the iris from contracting adhesions with the margin of the torn cap- sule. In leaving tbis part of the subject, I must advise every surgeon to read the in- teresting account of Mr. Saunders's practice, published by his friend and colleague, Dr. Farre. Many minute particulars will be CATARACT 37J iound in this work, highly worthy of the practitioner's attention and imitation. Mr. Gibson appears to have been un- acquainted with the usefulness of tbe extract of belladonna in preparing the eye for the operation. A few hours before operating, he was in the habit of ordering an opiate, sufficient to produce . considerable degree of drowsiness, so that the infant generally allowed its eyelids to be opened, and pro- Eerly secured without resistance, and was ttle inclined to offer any impediment to the introduction of the couching needle ; but, on the contrary, presented the sclerotica to view, naturally turning up the white of its eye. If the infant was more than" a year old, and whenever it was necessary, Mr. Gibson used to introduce its body and arms into a kind of sack, open at both ends, and furnished with strings to draw round the neck, and tif sufficiently tight round the legs, so that its hands were effectually secured and the assistants had only to steady its body, and fix its head, whilst the child was laid on a table, upon a pillow. Mr. Gibson never found it necessary to use a speculum, having uniformly experienced, that, after the couching needle was in- troduced, he had no difficulty in command- ing the eye, aided by a slight decree of pres- sure upon the eyeball w ith the index and middle fingers of" his left-hand, which were employed in depressing the lower eyelid. He admits, however, th;it the speculum can easily be applied, if an operator prefer it. He generally used Scarpa's needle, because, in infants, the free rupture of the capsule of the lens ought commonly to be aimed at, in order thatthe milky cataract may escape, and mix with the aqueous humour; or, if the cata- ract be soft, that the aqueous humour may be freely admitted to i(s pulpy substance which has been previously broken down with tbe needle. He thinks that no peculiarity is necessary in depressing :he hard cataract of infants. Before Scarpa's needle was known in this country, Mr. Gibson used Mr. Hey's, which was generally effectual, and, as he conceives, possesses the recommendation of being less liable to have its point entan- gled in the iris. He says, that, when a milky cataract has been thus evacuated, it renders the aqueous humour turbid ; but, that, within the space of two days, the eye generally acquires its natural transparency, and vision commences. When the capsule and substance of the soft cataract have been broken down, and the aqueous humour has come into contact with the lens, the solu- tion and disappearance ofthe cataract, in all the cases, upon which Mr. Gibson has opera- ted, have uniformly taken place in a short time. The experience of Mr Gibson curi- ously differs from that of Mr. Saunders in one respect: he assures us, that although he has met with cataracts in infants hard enough to bear depression, yet that he has never met with a simple membranous cataract; though this is no uncommon occurrence in patients at the age of eight, or ten, as well as in adults, who have been blind from birth. (See Edinb. Med. and SurgkalJouy- nal, Vol. 8, p. 398, 399.) For the purpose of fixing the eye, Mr. Ware considered Pellier's elevator requisite in operating upon infants. When the pa- tient, however, had advanced"beyond the age of infancy, Mr. Waie sometimes fixed the eye by means of the fingers alone. For the purpose of puncturing the capsule, and breaking down the cataract, this gentleman gave the preference to an instrument, which resembles one recommended by Cheselden, for the purpose of making an artificial pupil; but it is somewhat narrower. Its blade indeed is so narrow, that it nearly resem- bles a needle, its extremity is pointed, and it cuts on one side for the space of about the eighth of > n inch, the other side being blunt. It is perfectly straight; is an inch long in the blade ; and forms a complete wedge through its whole length. Upon one side of the handle is a coloured spot, by attending to which, the operator may always ascertain the position ofthe instrument in the eye. Mr. Wsfre dilated the pupil with the ex- tractum belladonna?, softened with a little water, and applied about half an hour be- fore the time of operating. This gentleman believed, that in operating upon infants, the surgeon might perform the operation with more composure, if the patient were laid upon a table, with the head properly raised on a pillow. The bent end of Pellier's ele- vator should be introduced under the upper eyelid, and the instrument committed to the care of an assistant. If the right eye is to undergo the operation, and the surgeon operate with his right hand, he must of course sit or stand behind the patient; and, in this case, he will himself manage the speculum with his left-hand. The eye being thus fixed, Mr. Ware passed the point of the narrowed-bladed knife above mentioned through the sclerotica, on the side next to the temple, about the eighth ofan inch from the union of that membrane to the cornea, the blunt edge being turned downwards. The instrument was pushed forwards in the same direction, until its point had nearly reached the centre of the crystalline. The point was then brought forwards, until it had passed through the opaque crystalline and its capsule, and was plainly visible in the anterior chamber. If the cataract was fluid, and the anterior chamber became im- mediately filled with the opaque matter, Mr. Ware deemed it adviseable to withdraw the instrument and defer further measures until the matter was absorbed, which ab- sorption'usually took place in the course of a few days, and sometimes of a few hours. If no visible change were produced in the pupil, the point and cutting edge of the in- strument were applied in different direct tions, so as to divide both the opaque crystal- line and its capsule into small portions, and if possible, bring them forwards into the anterior chamber. This may require the instrument to be kept in the eye for a minute or two ; but, if the operator preserve his steadiness, he may continue it there a much 372 CA PARACT longer time without doing the least injury to the iris, or to any other part. If the ca- taract be found of a firm consistence, (though this rarely happens in young per- sons,) it may be adviseable to depress it below the pupil; and in such a case parti- cular care should be taken to perforate largely the posterior part of the capsule, and to withdraw the instrument immediately after the cataract has been depressed in order to hinder it from rising again. If the opacity be in the capsule the instrument will not act so easily upon it as it does on the opaque crystalline; but, notwithstanding this, the capsule as well as the crystalline, may be divided by it into larger or smaller portions, which, when thus divided, will be softened by the action of the aqueous hu- mour ; and though in the first operation on such case, says Mr. Ware, it may not be possible to remove the opacity, yet, on the second or third attempt, the divided portions may be brought forwards into the anterior chamber, in which place, they will then be gradually absorbed, and soon disappear. After the operation, Mr. Ware seldom found it necessary to take away blood from chil dren, or persons under the age of twenty. He continued a cooling antiphlogistic treat- ment a few days. After this, if any opaque matter remained, he expedited its absorp- tion by dropping a small portion of pow dered sugar into the eye once or twice a day. When, at the end of a week or ten days, the inflammation was over, and the pupil obstructed with opaque matter, Mr. Ware advised a repetition of the operation. After a similar interval, the operation, he says, may be requisite again. In most cases, Mr. Ware was obliged to operate twice ; in a few instances, once proved suf- ficient ; and only in three, out of the last twenty, did he find it necessary-to operate a fourth time. (On the Operation of Punc- turing the Capsule of the Crystalline Hu- mour.) I think any impartial man, who considers the practice ofthe three preceding opera- tors, will find great cause to admire the su- perior gentleness and skill, which predomi- nate in the operations ofthe late Mr. Saun- ders. For my own part, I am so fully con- vinced of the mischief, which has been done to the eyes, by tbe rash boldness, awk- wardness, and unsteadiness of numerous operators, that, it appears to me, the incul- cation of gentleness and forbearance in all operations for the cataract, is the bounden duty of every man, who has occasion to write upon the subject. Great manual skill, and invariable gentleness, indeed, seem to me to have had more share in rendering Mr. Saunders's operations successful, than any particularity either in his method or his instrument. I have no hesitation in de- claring my own partiality to the principles, on which his practice was founded, and my belief, that they are well calculated to im- prove most materially this interesting branch of surgery. Consult particularly Oelsus De Re Mcdica. J. H. Freytag, De Cataracta, Argent. 1721. J. B. Boye< Quastio, fa. q<< deprimenda Cataracts expectanda matura- tio ; Paris, 1728. A. Ferrein, Quastio, fa. Quinam sint preicipui, quomodo explicentur etcurentur, leniis crystal!irnc Morbi. Monsp. 1732. A. F. L. Col. de Villart Quastio, fa. An Oculi Pundio Cataradam praeateal, Pa- ris, 1740. J. F. Henckel. De caturucia • rys- tallina Vera, Francof. ad Viadn 1774. J. P. Schnitzlein, De Suffusionis Naiura et C'u- ratione, Lips. 1750. J U- Thuranl, Quastio, fa. An in Cataracta potior le lis Cryttalli- na Extradio per Incisianem in Cornea, qnam Depressio per Acum, Paris, 17.V2. (Haller, Disp. Chir. 2,166 ) C /. Jos. Gtntil, Quteslio, fa. An in deprimenda Cataracta iptius Cap- sula inferne postice imprimum stcanda est, Pa- ris, 1752. D. Mauchart, De Extraclwne Ca- taracta ultra ptrficienda Tub. 1752. J. R. Tenon, De Cataracta Theses ex Anutomia et Chirurgia, 4to. Paris, 1757. A Petit, Leitre, dans laquelle il dimontrc'quc le Cryttallin est fortpres del'Uvie, et rapporte dt nuuvella Preuves, qui concernenl I Opiration de la Cataracte. (Haller, Disp. Chir. 5,670.) D. Colombier, Diis. de Suffusione. seu Cataracta Oeuli. Paris, 1765 J. F. Reidienbach, Cautela et Observationes circa Extractionem Cataracta, novum methodum Synisesin. oper- andi sislentes. Tub. 1767. Chalibert, A Diss. upon the Gutta Serena, and the Progress of Cataracts, $«. Svo. Lond. 1774. C. F. Lud- wig, De Suffusionis per acum curaliont. L. Heister, De Cataracta, fa. tract. Alt. 1713; Vindicia de Cataracta. fa. All. 1713; and Apologia et Uberior illuslraiio Syslemati* sui de Cataracta, Glaucomate, et Amaurosi, 12mo. Altorf. 1717. Pott's Remark* on the Cataract, Vol. 3, of hit Chirurgical Works. Daviel sur une Nouvelle Miihode de Guirir la Cataracte par I'Extraction du Cryttallin, in Mim. de I'Acad de Chirurgie, Tom. b, p. 369, Edit. 12mo. A. Bischoff, A. Treatise on the Extraction of the Cataract, 8ro. Lond. 1793. Wensel's Treatise on the Cataract, by Ware, 8vo. Lond. 1791. W. II. J. Buchhorn, Die Kemtmiyxis. Eint neue gefahrlostrt Mc- thode den grauen Staar zu operiren, fa. 8ro. Hala Magd. 1811. Richter's Treutue on the Extraction nfthe Cataract, Transl. Sto. Lond. 1791 ; and Anfangsgr. der Wundarzneylnmsl. Band. 3. Jon. Wathen. A Diss, on the Theo- ry and Cure of the Catarad, in which the Practice of Extraction is supported, fa Svo. Lond 1785. R. Muter Practical Observa- tions on various novel modes of operating on Cataract, t,c.8vo. Wisbeach, 1811. Kupfer, Diss, de Utilittte Belladonna in sananda con- strtctione mmia iridis ; Erlanga, 1&03- Himlay, Ophthalmologische, Bibl. I, B. 2,No. 3. lAe Use of Hyosciamus for dilating the Pu- pil proposed. J. Sterenson, Prod. Trtatist on the Cataract, Svo. Lond. 1813. J Wathen, A New, fa. Method of Curing the Fistula La- chrymalis, fa. with an Appendix on the Treat- ment after the operation for the Cataract, Svo. Lond. 1792. J. A. Schmidt, in Abhandlvm- gen der K. K Josephs Acad. 2. B. p. 209, 273, ^ Leber Nachstaar und Iritis naeh Staar- operationen, 4to. Wien. 1801; one of tht most valuable Works ever published on D>■■■•■ CATHETER. 613 loses of the Eye. Ware's Chirurgical Obser- vations on the Eye, 2 Vol. Edit. 3. Scarpa's Observations on the Principal Diseases ofthe Eyes, Edit. 2. Critical Reflections on several important Practical Points relative to the Ca- taract, by the Author of this Dictionary. Hey's Practical Observations in Surgery, Edit. 2. G. Ch. Conradi Bemerkungen tlber einige Gegenst/indt des Grauen Staars, Leipz. 1791. Saunders on Diseases of the Eye, by Farre, Edit. 3. G. J. Bee's Practische Bio- bachtungen nber den grauen Staar, fa. Wien. 1791. Sir J. Earle, An Account of a new Mode of Operating for the removal of Cata- ract,Svo. Lond. 1801. Beer, Melhode den grauen Staar sammnt der Ka/isel auszvsiehen, Wien, 8vo. 1799 ; and Lehri von Den Augenkr. B. 2, Wien, 1817. Lassus, Patho- logic Chirurgicale, Tom. 2,p 504, fa. Edit. 1809. Karl. Aug. Weinhdd'* Anleitung zur Reclination des Grauen Staar* mil der Kap- sel, 1809 ; a Work of great merit. Gibson's Practical Observations on the Formation of an Artificial Pupil, and Remarks on the Ex- traction of Soft Cataracts, fa. 8vo. Lond- 1811. C. J. M. Langenbeck, Prafung der Keratonyxis, einer Melhode den grauen Staar dureh die Hornhaut zu recliniren oder zu strstuckcln nebst erluuternden operation ges- chichten, 8vo. Gott. 1811 ; end several Pa- pers in his Bibliothek of later date. Travers in Medico-Chiurgical Transactions, Vol. 4 and 5 A Synopsis of the Diseases of the Eye, Svo. Lond. 1802. W. Adams Practical Observation* on Ectropium, Artificial Pupil, and Cataract, 1812; and his later Work on Cataract. J. Wardrop, Essays on the Morbid Anatomy of the Human Eye, 2 Vol. 8»o. Lond. 1818. J. Vetch, A Practical Treatise on the Diseases of the Eye, p. 109, fa. 8vo. Lond. 1620. CATHETER, (from **0«y/<, to thrust into.) A tube which is introduced through the ure- thra into the bladder, for the purpose of drawing off the urine. (See Urine, Retention of.) Of course, there are two kinds of ca theters ; one, intended for the male, the other, for the female urethra. With respect to catheters, three things are to be consider- ed : 1st, the instrument itself; 2d, the man- ner of introducing it; and 3d, the conduct to be pursued after its introduction. Catheters were anciently composed of copper : Celsus knew of no other kind. As these, however, had the inconvenience of becoming incrusted with verdigris, they at length fell into disuse, and others, made of silver, were substituted for them. This change, which was made as early as the time ofthe Arabian practitioners, still re- ceives the approbation of the best modern surgeons. The common catheter is a silver tube, of such a diameter as will allow it to be introduced with ease into tbe urethra, and of various figures and lengths, according as it is intended for the young or adult, the male or female, subject. For an adult fe- male subject, it should be about six inches long ; and, for young girls, four or five. For men, the length ought to be from ten inches and a half to eleven iuches. But, as the instrument need not enter far into the bladder, Mr. John Bell's advice to avoid too great a length, merits observance. (Pnn~ ciples of Surgery, Vol. 2, p. 193.) As the urethra in some instances is narrow, and, in others wide, surgeons should be furnished with catheters of different diameters. The choice of the instrument, in re-pect to its width, is likewise determined very much by the nature ofthe disease of the urethra. (Langenbeck, Bibl. B. 1, p. 1177) For a woman, the diameter ought to be at least two lines ; and, for girls, a line and a half. For male adult subjects, Desault recom- mends the thickness of two lines and one- third ; and, for boys, that of a line and a half. In general, whenever the urethra is pefvious, it is better to follow the advice of Desault, and employ a largish catheter, which will enter the passage more easily, and not be entangled in the folds of the in em bran ous lining of the canal, while it will afford a more ready outlet for the urine. On the other hand, small catheters should be preferred, when there are obstructions in the passage. Catheters also differ in shape : those which Desault used for male subjects, had only a slight curvature of one- third of their length; a curvature, which began insensibly from their straight part, and was continued to the very end of their beaks. The curvature was also regular, so as to form the segment of a circle six French inches in diameter. As the course of the urethra in the male subject is regular, the caprice evinced by surgeons in the different curvatures of their catheters, cannot be founded on any correct anatomical princi- ples, and tbe bend of the instrument, (at least for subjects'of the same age and sta- ture,) should generally not vary at all, but be strictly adapted, as Langenbeck remarks, to the natural track of the urethra. (Bibl. 1, p. 1177.) The female catheter, however, has only a slight curvature towards its beak; a shape adapted to the direction of the meatus urinarius. Desault also improved silver catheters, by causing them to be made with elliptical openings, or eyes, at tbe sides ofthe beak, with rounded edges, instead of the longitudinal slits previously in use, in which the lining of the tirethra wasfrequent- ly entangled, pinched, and lacerated, so that acute pain and profuse hemorrhage were the consequences. With the view of pre- venting these evils, he also filled up the openings with lard. (See OHuvres Chir.de Desault, T. 3, p. 118.) Besides silver, or inflexible catheters, sur-. geons now frequently employ flexible ones, made of elastic gum. These last, indeed, are of so much importance, that they may be said to constitute one of the greatest im- provements in modern surgery. I shall not ■ here inquire, whether they were first invent- ed by Theden, Pickel of Wurzburg, or Ber- nard of Paris; this is a point, which the Germans and French must settle themselves. Imperfect attempts bad been made by others at earlier periods to invent catheters, possessing the property of flexibility. Van 374 CATHETER. Belmont proposed the use of catheters, made of horn ; but, this substance was found to be too stiff, and to be very quickly coated with depositions from the urine. Fabricius ab Aqiiapendente employed leather cathe- ters, which were objectionable, inasmuch as they were soon softened by the urine and mucus ot the urethra, when they shrivelled, and became impervious Other flexible ca- theters were also formerly tried, composed of spiral springs of silver-wire, covered with the skins of particular animals. These last, however, were very quickly spoiled by putrefaction ; and when left in the urethra any considerable time, the beak sometimes entirely separated from the rest of the in- strument, and was left behind in the bladder. The elastic gum-catheters, now in use, are liable to none ofthe preceding inconvenien- ces : they are formed of silk tubes, woven for the purpose, and covered with a coat of elastic gum ; they are sufficiently flexi- ble to accommodate themselves to the dif- ferent curvatures of the urethra ; they are not softened by the urine ; and they con- stantly remain with their cavity unoblitera- ted. Their smooth and polished surface makes them continue a long while free from incrustations deposited from the urine. Sometimes, they are introduced with astilet, or wire, which is passed into their canal, in order to ^ive them a certain curvature, and a greater degree of firmness ; but, in gene- ral, it is withdrawn as soon as the tube is in the bladder. Elastic catheters are less irritating to the urethra, and less apt to become covered with calculous incrustations, than silver tubes : they can also be frequently introduced, when a metallic one will not pass The selection of good bougies and cathe- ters, especially in operations upon the male subject, is a business of the first-rate impor- tance, for. by employing such as are dispo- sed to break, " many a practitioner has doomed his patient to years of dreadful, and, perhaps, hopeless suffering, and brought down irreparable disgrace upon his own head." (Med. Chir. Journ. Vol. 5, p. 76.) M. IS'icod, in performing the operation of lithotomy upon a male found the stone, which was very brittle, one inch and a half long, and eight or nine lines thick, travers- ed in the direction of its greater diameter, by a piece of elastic gum catheter, which had acted as a nucleus for the deposition of calcareous mutter. (See Obs. sur le dan- ger d'employer de mnuvaises sondes de gomme elastique ; Journ. de Midecine, par Leroux, Oct. 1816.) The best elastic catheters used to be fabri- cated at Paris, by Bernard. At the present time, the best maker in France is Feburier, orfevre, in the Rue du Bac No. 61, at Paris; but the elastic gum catheters now made in London are in some respects better than French, being generally much smoother and more regular, though I believe our smallest size is not yet so small, as what Feburier makes. The gum catheters are made at Pa- rrs of twelve different sizes, which corres- pond to twelve holes in a plate of bra." "Each catheter, therefore, (says a late intel- ligent visiter to that capital) has its size de- signated by its number, which greatly faci- litates the ascertaining of the progress of the ci-se towards a cure. Numbers 1 and 2 are smaller than can be procured in Eng- land, and are so slender, that I thought there might be danger of their breaking, until I was convinced by seeing the method of ma- king them, that there is no reason for fearing any such thing. A firm tissue of silk is woven upon a brass stilet, of tbe size ofthe cavity of the instrument to be made. In weaving this tissue, the orifice or eye is left, and the whole therefore consists of one' entire thread. The successive layers of varnish are deposited on the ouler surface ofthe silken tissue, their number depending on the size of the instrument; and each coating of varnishing undergoes a long pro- ce-s of scouring before the next is put on, for whicb purpose women are employed by Feburier." (See Sketches of the Medical Schools of Paris by J. Cross, 1815, p. 122, 123.) According to this gentleman, however, the English gum-catheters possess advan- tages : " they retain their curve better without the stilet, are less liable to crack, and have eyes more smooth and better formed." (P. 124.) Bernstein, in his Dic- tionary of Surgery, gives the following ac- count of this instrument, as it is fabricated in Germany: One of the most U3efu! in- ventions which have been made, with re- spect to these instruments, is to construct them of elastic gum. and the merit of this invention is to be ascribed, without doubt, to Theden. (Neue Bemerkungen u. Erfah- rungen, fa. Th. 2. Berlin, 1782, p. 143.) They were afterward improved by a silversmith at Paris, of the name of Ber- nard, who did not apply the dissolved elastic gum to a wire cylinder, as Theden bad done, but to one made of knitted silk ; and these catheters certainly deserve to be re- commended in preference to all other*. But, with respect to their price, the elastic catheters formerly prepared by Pickel, of Wurzburg, (Richter'* Chir. Bibliothek.B.6.p. 512,) deserve particular recommendation. These consist of silk cylinders, plaited or worked upon a probe, and afterwards co- vered with the following varnish: three parts of white-lead, minium, or sugar of lead, with boiled linseed oil, which is the com- mon varnish used by cabinet-makers, mixed with one part of melted amber, and the same quantity of oil of turpentine. With this varnish the silk cylinders are covered, and the same thing is repeated three timed, as soon as each coating has been dried in the open air The catheters are then put in a baker's oven twenty-four hours, when bread has been baked in it the last time, and when it retains the temp, of 60.70. Reaum. Here they are to remain ten or twelve hours. When the catheter has been taken out of the oven, the inequalities are to be nibbed off with a little pumice-stone; CATHETER 375 the end is to be sewed up ; the oblong la- teral aperture is cut in it ; and it is to be coated twelve or fifteen times more with varnish. The catheter must be always well dried in the open air, before the varnish is spread upon it again, and after every third coating which it has received, it must be put in the oven again, so that it must in all have received from fifteen to eighteen coat- ings with varnish, and have been laid five or six times in the oven. The end is smoothed off with oil. (Cyclopadia by Rees, Art. Catheter.) When the object of passing a catheter is merely to empty the bladder, without any design of leaving the instrument afterwards in the passage, Langenbeck always prefers an inflexible one, made of silver. (Bibl. far die Chir. B.l, p. 1176.) Sometimes spasm about the perinaeum renders the introduction of a catheter diffi- cult. In this case, a dose of opium should be administered, before a second attempt is made. When inflammation prevails in the passage, the introduction may often be fa- cilitated by a previous bleeding. The operation of introducing the catheter may be performed, either when the patient is standing up, sitting, or lying down, which last posture is the most favourable. In order to pass a catheter with ease and dexterity, the following circumstances must be ob- served : the instrument must be of suitable shape and size ; a just idea of the perineum and curvature of the urethra must be en- tertained ; tbe catheter must be introduced with the greatest care and delicacy; and the relaxation ofthe abdominal muscles has been insisted upon, (Langenbeck, Bibl. I, p. 1177,) though, I confess, that it does not appear to me, how this circumstance is of importance. One of the most important maxims is, never to force forward tbe instrument, when it is stopped by any obstacle If there are no strictures, the stoppage of the catheter is always owing to one of the following circumstances. Its beak may be pushed against the os pubis. This chiefly occurs when the handle of the instrument is pre- maturely depressed. Here the employment of force can obviously do no good, and may be productive of serious mischief The beak of the catheter may take a wrong di- rection, and push against the side of the urethra, especially at its membranous part, vvhich it may dilate into a kind of pouch. In this circumstance, if force were exerted, it would certainly lacerate the urethra, and occasion a false passage. The end of the catheter may be entangled in a fold of the lining of the urethra, and here force would be equally wrong. Lastly, the point of the instrument may be stopped by the prostate gland, in which case force can be of no ser- vice, and may do great harm. Hence, it is always proper to withdraw the instrument a little, and then push it on gently in a differ- ent position. There are two methods of introducing a male catheter, viz. with the concavity turned towards the abdomen ; or with the conca- vity directed downwards in the firsfstage of the operation. Off course, the latter plan requires the instrument to be turned, so as to place its concavity upwards, as soon as the beak has arrived in the perineum ; and hence, the French surgeons call this method the " tourde maitre." The operation may be divided into three stages. In the first, tbe catheter passes, in the male subject, that portion of the urethra which is surrounded by the corpus spongi- osum ; in the second, it passes the membra- nous part of the canal, situated between the bulb and the prostate gland; and in the third, it enters this gland, and the neck of the bladder. In the first stage, little trouble is usually experienced ; for the canal is here so sup- ported by the surrounding corpus spongi- osum, that it cannot easily be pushed into the form of a pouch, in which the end of the instrument can be entangled. When the catheter is to be introduced with its concavity towards the abdomen, and the patient is in the recumbent posture, the thighs are to be separated, and the legs moderately bent. The surgeon is to draw back the prepuce, and to bold the penis be- tween the thumb and fore-finger of his left- hand, which are to be applied on each side of the corona glandis, and not at all to the under surface of the penis, so as to avoid pressing upon the commencement of the urethra. After the catheter has been well oiled, its handle is to be held between the thumb and fore-finger of the right-hand, and to rest with the back of the little finger upon the patient's abdomen, in the vicinity of the navel. Now, while the handle is parallel to the axis of the body, the beak is to be introduced into the urethra; the penis being extended, and drawn forwards, as it were, over tbe instrument, while the latter is gently pushed on, until its beak has reached the arch of the pubes. When the penis cannot be drawn further over the ca- theter, the beak has arrived in this situation, where it stops in front ofthe arch, and is press- ing against the posterior siue of the urethra. At this particular moment, the handle is to be depressed towards the patient's thighs, and the manceuvre, well managed, generally directs the end of the catheter, at once through the prostatic portion of the urethra into the cavity of tbe bladder. In short, as soon as the beak of the instrument has passed under the arch of the pubes, and the surgeon very slowly brings the handle for- wards, or downwards, the beak is elevated, and glides into the bladder. In this stage of the operation, the penis must be allowed to sink down,and not be kept tense, as this would only render the passage of the instru- ment more difficult. Ihe operation, however, is not always successfully accomplished in this manner. The beak of the cetheter may be stopped by the os pubis ; it may take a wrong direction, so as to push the membranous part of the urethra to one side or the other; or it may be 3/u CATHETER. stopped by a fold of the' lining of the pas- sage. The first kind of impediment is best avoided, by not depressing the handle of the catheter, too soon ; that is, before tbe point has passed beyond the arch of the pubes. When the membranous part of the urethra is pushed to one side or the other, the instrument ought to be withdrawn a little, and then pushed gently on in a differ- ent direction ; but, if this expedient is un- availing, the index finger of the left-hand may be introduced into the rectum, for the purpose of supporting the membranous part of the urethra, and guiding tbe extremity of the catheter. The passage of the cathe- ter through the membranous part of the urethra, and especially the attempt to hit the entrance of the prostate, are the most difficult things in the operation, and also the only ones attended with risk of mischief, which is frequently produced by rough, un- skilful surgeons, when they use violence, and rupture this yielding weak portion of the canal. When the prostate gland is enlarged, the urethra makes a more sudden turn upwards, just as it approaches the bladder, than is natural. The e*nd of the catheter, there- fore, should be more bent upward, than in other cases. In. the third stage of the operation, the beak of the instrument has to pass the prostate gland and neck of the bladder. The principal obstacles to its passage, in this situation, arise from spasm of the neck of the bladder, and muscles in the perineum, and from tbe instrument being pushed against the prostate gland, instead of into the continuation of the urethra through it. The first impediment may generally be ob- viated by waiting a few moments, and gently rubbing the perineum, before at- tempting to push the catheter further into the passage. The hinderance, caused by the prostate, is best eluded by using an instru- ment the point of which is more curved, than its other part. Sometimes the surgeon himself presses the prostate towards the os pubis, by means of his finger in the rectum, and thus prevents tbe passage of the cathe- ter, by increasing the sudden curvature at this part ofthe urethra. Hence, as Richter observes, it is a very important maxim, never to introduce the finger so far into the rectum, as to press on the prostate gland itself. When the catheter has turned round the pubes, and is just about to enter the neck of the bladder, is the critical moment, in which may be seen, whether a surgeon can or can- not manage the operation w ith skill; for, if he knows how to pass the instrument, he suddenly, but not violently changes its di- rection. He depresses the handle with a particular kind of address, and raises the point, which, as if it had suddenly sur- mounted some obstacle, starts into the neck of the bladder, and the urine bursts out in a jet from the mouth of the catheter. They, who are unskilful, press the tube forward, and persist, as they had begun, in drawing np the peuis, en the supposition that by stretching tbis part they lengthen the urethra, and make it straight, whereas they elongate only that part of the canal, along which the catheter has already passed! (John Bell's Principles of Surgery, Vol. 2 « 213.) e' When the catheter is to be introduced with its concavity downwards, or by the 11 tour de maitre," the beak is to be passed into the urethra, and the penis drawn over it, as it were, as in the foregoing method. Iu other words, the instrument well oiled, is to be introduced, with its convexity upper- most, as far as it can be, without using force. As soon, however, as the end of the catheter has reached the point, at which the canal begins to form a curve under the pu- bes, the surgeon is to make the penis and the instrument perform a semicircularmove- ment, by inclining them towards the right groin, and then towards the abdomen. In the execution of this manoeuvre, care is to be taken to keep the beak of the catheter stationary, so that it may be the centre of the movement, and simply revolve upon itself. This part ofthe operation, the object of which is to turn the concavity of the ca- theter upwards, ought to be done very slowly, a large sweep being made with the handle, while particular care is taken not to retract, nor move the beak from its posi- tion. The handle is then to be depressed, and the operation finished exactly in the same manner, as when the first plan is pur- sued. As Desault properly observes, the only circumstance, in which tbe two me- thods differ, is, that, in one, the same thing is performed by two movements, which is done in the other by one ; so that the ope- ration is rendered more difficult and pain- ful. Hence, many judicious modern sur- geons never practise the " lour de maitre," except when their patients are very corpu- lent or placed in the position usually chosen for lithotomy, when other modes df intro- ducing the catheter would be less con- venient. The depth to which the catheter has en- tered, the cessation of any feeling of resist- ance to the motions of the beak, when re- volved upon its axis, and the issue of the urine, are the circumstances, by which the surgeon knows, that the instrument has passed into tbe bladder. According to the experience of Desault, the practice of gradually letting out a part of tbe urine, after the catheter has been in- troduced, is by no means advantageoos^— He also disapproves of running into the op- posite extreme that is to say, of letting trie urine flow out of the catheter, as fast as it- is secreted ; for, then, the bladder is kept constantly relaxed, and the detrusor muscle will not be likely to recover its tone. When the bladder is continually empty, it is liable to come into contact with the end of the catheter; a circumstance which has some- times caused considerable irritation, pain, and even ulceration of that viscus. Besides these inconveniences, there are some others; the catheter is sooner obstructed with m»- CATHETER, 37? cus, and covered with incrustations, than When it is closed with the stilet. The pa- tients arc likewise obliged to remain in bed, where they are either wet with their urine, or compelled to have incessantly a pot for its reception. The best practice, therefore, seems to be that of letting out all the urine, as soon as the catheter is introduced, and then closing the instrument until the bladder has become moderately distended again ; for experience proves, that such moderate distention and relaxation of the muscular fibres of the bladder, alternately kept up, have the same good effects upon that organ, as moderate exercise has upon other parts of the body. When a catheter is to be left in the urethra, it should always bet, properly fixed with a narrow piece of tape, or else it is apt to slip out, or even pass foo far into the passage. For this purpose, some sur- geons use cotton-thread, which theyfasten to the rings, or round the external end of the catheter. The two extremities of the thread are then carried some way along the dorsum of the penis, when they are tied together, and afterwards conveyed in oppo- site directions round the part, till they meet underneath it, where they are tied in a bow. When a silver catheter is employed, a tape, or narrow riband is passed through each of the rings, and conveyed to each side of the elvis, where it is fastened lo a circular andage. Mr. Hunter remarks, that the common bag-truss for the scrotum answers extremely well, when two or three rings are fixed on each side of it along the side ofthe scrotum, and the ring of the cannula is fastened to any of them with a piece of tape. (On the Venereal Disease, Ed. 2, p. 159.)— He also notices another method: when the catheter (says he) is fairly in the bladder, the outer end is rather inclined downwards, nearly in a line with the body. To keep it in this position, we may take the common strap, or belt part of a bag-truss, with two thigh straps, either fixed to it, or hooked to it, and coming round each thigh forwards by the side of the scrotum, to be fastened to the belt, where the ears of the bag are usually fixed. A small ring, or two, may be fixed to each strap just where it passes the scrotum or root of the penis ; and with a piece of small tape, the ends ofthe cathe- ter may be fixed to those rings, which will keep it in the bladder. It seems Mr. Hun- ter did not, like Desault, disapprove of leaving the catheter unclosed, and he adds, therefore, " a bit of rag, about four or five inches long, with a hole at the end of it, passed over the exterior end ofthe catheter, and the loose end allowed to hang in a basin placed between the thighs, will catch the water, which cannot disengage itself from the catheter, and keep the patient dry; or, if another pipe is introduced into the cathe- ter, it will answer the same purpose. (Op. cit. p. 191.) But, there are numerous modes of fixing a catheter, which need not be spe- cified ; for, although they are of importance, the principles which should be observed in adopting them, are the main things to be Vot I. 48 understood. These are, first, never to fix a catheter in such a way, that too much ot the instrument projects into the cavity of the bladder ; and, secondly, to be careful that the thread or tape, which is applied, will not chafe and irritate the parts. Mr. Hey has offered some good practical remarks on the introduction of the catheter. If, says he, the point of the catheter be less turned than the urethra, the point will be pushed against the posterior part ofthe pas- sage, instead of following the course of the canal. The posterior part of the urethra has nothing contiguous to it which can sup ' port it; and no considerable degree of force will push the point of the catheter through that part between the bladder and the rec- tum. If this accident is avoided, still the point will be pushed against the prostate. and cannot enter the bladder. Mr. Hey tells us, that the truth of this is illustrated by the assistance which is derived, when- ever the catheter stops at the prostate, from elevating the point of the instrument with a finger introduced in the rectum. Mr. Hey takes notice of the impropriety of pushing forwards the point of the cathe- ter, before its handle is sufficiently depress- ed, as the point would move in a horizontal direction, and be likely to rupture the poste rior side of the urethra. The difficulty arising from the inflamed and dry state of the passage, (which difficul- ties I should conceive can never be great,) Mr. Hey says, may be obviated by the pre- vious introduction of a bougie, well covered with lard. In order to pass tbe catheter, Mr. Hoy places his patient on a bed, in a recumbent posture, his breech advancing to, or project- ing a little beyond the edge of the bed. If the patient's feet ca:mot rest upon the floor, Mr. Hey supports the right leg by a stool, or by the hand of an assistant. The patient's head and shoulders are elevatedby pillows ; but the lower part of the abdomen is left in a horizontal position. Mr. Hey commonly introduces the catheter with its convexity towards the abdomen, and having gently pushed down the point of the instrument, till it becomes stopped by the curvature of the urethra, under the symphysis pubis, he turns the handle towards the navel, pressing at the same time its point. In making the turn, he sometimes keeps the handle at the same distance from the patient's abdomen, and sometimes makes it gradually recede ; but, in either method, he avoids pushing forwards the point of the catheter any far- ther than is necessary to carry it just beyond the angle of the symphysis pubis. When be feels that the point is beyond that part, he pulls the catheter gently towards him hooking, as it were, the point of the instru- ment upon the pubes. He then depresses the handle, making it describe a portion of a circle, the centre of which is the angle of the pubis. When the handle of the cathe- ter is brought into a horizontal position, with the concave side ofthe instrument up- wards, he pu?hes foiwards the point, keep* 378 CATHLl'ER. ing it close to the interior surface of the symphysis pubis; for when passing in this direction, it will not hitch upon the pros- tate gland, nor injure the membranous part of the urethra. If the surgeon uses a flexible catheter, covered with el istic gum, it is of great con- sequence to have the stilet made of some firm metallic substance, and of a proper thickness. Mr. Hey always makes use of brass wire for the purpose. If the stilet is too slender, the catheter will not preserve the same curvature during the operation ; and it will be difficult to make the point pass upwards behind the symphysis pubis in a proper direction. If the stilet is too thick, it is withdrawn with difficulty. When the stilet is of a proper thickness, this instrument has one advantage over the silver catheter, which is, that is curvature may be increased while it is in the urethra, vvhich is often of great use when tbe point approaches the prostate gland. In all cases, where an elastic gum catheter is preferred, care must be taken that it does not pass un- necessarily far into the bladder; and, if it be too long, a part of it ought to be cut off, or a shorter one employed. When the proper manoeuvres with a silver catheter do not succeed, the surgeon must change it, taking a bigger or more slender one, with a greater or less curve, according to such observations as he may have made in his first attempt. But, if the catheter has been of a good form or commodious size, yet has not passed easily, he should, instead of choosing a rigid catheter of another size Or form, take a flexible one for his second attempt. The flexible catheter is generally Slender, and of sufficient length, and its shape may be accommodated to all occa- sions, and to all forms of the urethra ; for, having a stiff wire, we can give that wire either before or after it has passed into the catheter, whatever shape we please; and what is still of greater importance, we can introduce the instrument without, or with the wire, as circumstances may require ; or what is more advantageous, we can intro- duce the wire particularly so as not quite to reach the point of the catheter, but only to within two inches or a little more of this part, by which contrivance the point, if previously warmed, and wrought in the hand, has so much elasticity, that it follows the precise curve of the urethra, and yet has sufficient rigidity to surmount any slight resistance. If this too fail, and especially, if there be the slightest reason to suspect, that the resistance is not merely spasmodic, but arises from stricture near the neck ot the bladder in a young man, or swelling of the prostate in an old one, we may take a small bougie, turn up the extremity of it with the finger and thumb, so as to make it incline towards the pubes, and allowing no time for the wax to be softened, pass it quickly down to the obstruction, turn it with a vertical or twisting motion, and make it enter the constricted part. On withdraw- '■'•? it in about ten minutes or a quarter of an hour, the urine generally escapes, or the catheter may now be introduced. (John Bell's Principles of Surgery, Vol. 2, p. 215.) Mr. Hey has found, that, in withdrawing the stilet of an ela-tic gum catheter, the in- strument become- more curved ; and he has availed himsell of this information by with- drawing the -tih-t, as .e is introducing the catheter beyond the arch of the pubes, by which artifice the point is raised in the due direction Mr. Hey says you may sometimes, though not always, succeed in introducing an elas- tic gum catheter by using one which has acquired a considerable degree of curva- ture and firmness, by having had a curved stilet kept in it a lon« while. Introduce this without the stilet, with its concavity towards the abdomen, taking care not to push on the point of the instrument, after it has reached the symphysis pubis, until its handle is de- pressed into a horizontal position. When it is necessary to draw off the urine frequently, and the surgeon cannot attend often enough for this purpose, a catheter must be left in the urethra, fill an attend- ant, or the patient himself, has learnt the mode of introducing the instrument. (Hey.) Mr. Hey imputes the formation of a false passage, or the rupture of the membranous part of the urethra, generally to the method of pushing forwards the catheter, before its handle has been depressed In this manner, the course of the instrument crosses that of the urethra, and the point of the catheter pressing against the posterior side of the membranous part of the urethra, is easily forced through the coats of that canal. The want of due curvature in the catheter, and of sufficient bluntness in its point, greatly contribute to facilitate this injury. In this case, the point of the instrument passes more readily into the wound, than onward along the urethra against the symphysis pu- bis. Without this pressure, the point is apt to recede, and not readily enter the mem- branous part of the urethra. ^ Mr. Hey surmounted a difficulty of this kind, by bending upwards the point of a silver catheter, so as to keep it more closely in contact with the anterior part of the ure- thra, and thereby pass over the wound made in the posterior side of the canal. In the instance alluded to, as it was necessary to leave an elastic gum catheter in the urethra, Mr. Hey procured some brass wire of a proper thickness, with which he made a sti- let, and, having given it the same curvature as that of the silver catheter, he introduced it about four hours after the preceding ope- ration, and fixed it by tying it to a bag truss. Mr. Hey sometimes succeeded by partly withdrawing the stilet, at the moment when he wished to increase the curvature of the catheter. In an instance, in which the urethra had suffered a violent contusion, Mr. Hey drew off the urine with a silver catheter of unu- sual thickness, after he had failed with in- struments of a smaller bore. He suspected that the urethra was ruptured, and wasobli- • CATHETER. iil9 gtd to raise the point of the catheter by a linger introduced into the rectum, and to use bleeding, purgatives, the warm bath, and opium, before it could be made to pass. The elastic gum catheter was afterwards employed. It is an unsettled point, whether it is best to leave the catheter in the urethra, until the power of expelling the urine is re- gained, or to draw off the urine tw ice a day, and withdraw the catheter after each opera- tion. Mr. Hey thinks that no general rule can be laid down; some patients cannot bear the catheter to remain introduced ; others seem to suffer no inconvenience from it. On the w hole, however, Mr. Hey commonly prefers removing the catheter. In this manner, he is of opinion, that the power of expelling the urine again is soon- est acquired. The preceding question is often determi- ned by the nature of the disease, and, as Mr. Hunter observes, in cases of debility of the bladder, and where a catheter passes with difficulty, or with great uncertainty, as well as in other instances, in which it must be used frequently, and for a length of time, it will be necessary to keep it introduced, so as to allow the water to pass freely through it. (On the Venereal Disease, Edit. 2, p. 191.) In France, a conical silver catheter (sonde conique) is frequently employed in difficult cases by Boyer, Roux, he. This instru- ment has a very slight curvature, and an ex- tremity almost pointed. By force, regularly applied, it is introduced into the bladder, in spite of all opposition. Care is taken to keep it in the centre ofthe passage, und the direc- tion of its point is judged of by the position ofthe lateral rings. The rule mentioned by Boux, for commencing the great depression of the outer extremity of the instrument, is, when, by the finger in the rectum, the point can be felt to have reached the apex of the prostate. (See Sketches of the Medical Schools of Paris, by J. Cross, p. 112.) In bad cases, the conical catheter is usually allow- ed to remain introduced three or four days, and on being withdrawn, a small flexible gum catheter generally admits of being used. The forcible manner in which the French surgeons employ the conical silver catheter, must often do great and dangerous mischief. Thus, in two examples, which were witness- ed and examined by Roux himself after the decease of the patients, a false passage had been made, no flexible gum catheter could be passed, the urine was effused in the cellular membrane, and the parts were gan- grenous. (Seep. 116 of the above work) According to the observation of Mr. Cross, the French surgeons employ the conical silver catheter with too little discrimination, and "in their practice they seem to make no nice distinctions between impediments to the flow of urine from spasm, irritable and inflamed state of the canal, disease ofthe prostate gland, and cartilaginous stricture of long duration. If the conical catheter be admissible at all, it is in the last of these rases, particularly, when combined with fistula in perinaeo ; and here all surgeons, who are familiar with the treatment of dis- eases ofthe urethra, occasionally use means, which approach very closely to the forcing method of the French. I have heard of in- stances, in which John Hunter employed great force with the silver catheter, and o\ ercame the obstruction. I have seen Mr. Pearson, (who generally treats strictures as mildly, and, I need hardly say, as success- fully as any man) take a steel sound, and pass it gradually and forcibly on into the bladder, at the same time feeling his way, as it were, by keeping one finger in the rec- tum : the relief of the patient, and the ulti- mate cure of tbe disease, were the resultsof this practice." (P. 118.) It appears further that the conical silver catheter has been used by Mr. A. Cooper. Without altogether condemning the occasional employment of this instrument, I perfectly coincide with Mr. Cross, that it is one, with which young men, of little caution and no experience, may do more harm in the first few cases they meet with, than the rest of their life will af- ford them opportunities of doing good. Mr. Hunter refers to instances, in which the common cathether had been pushed through the projecting part of the prostate gland into the bladder, and the water then drawn off; but, " in one patient, the blood from the wound passed into the bladder, and increased the quantity of matter in it. The use of the catheter was attempted a second time; but, not succeeding, I was sent for. I passed the catheter till it came to the stop, and then suspecting, that this part of the prostate projected forwards, I in- troduced my finger into the anus, and found that gland very much enlarged. By de- pressing tbe handle of the catheter, which of course raised the point, it passed over the projection ; but, unfortunately the blood had coagulated in the bladder, which filled up the holes in the catheter, so that I was obliged to withdraw it, and clear it repeat- edly. This I practised several days; but, suspecting that the coagulum must in the end kill, I proposed cutting him (the patient) for the stone ; but he died before it could be conveniently done, and the dissection, after death, explained the case, &c." (On the Venereal Disease, Ed. 2, p. 172.) To one acquainted with anatomy, the in- troduction ofthe female catheter is exceed- ingly simple. From motives of delicacy to the sex, the instrument should always be passed without any exposure. The surgeon should hold the catheter in his right hand, while he introduces the fore-finger of his left-hand between the nymphae so as to feel upon the upper surface of the passage the little papilla, which surrounds, and denotes to the touch, the precise situation ofthe ori- fice of the meatus urinarius. Holding the concavity of the catheter forward, the sur- geon, guided by the foro-finger of his left- hand, is then to introduce the instrument upward into the bladder. A female cathe- ter should always be furnished with some contrivance for preventing its slipping com MO < At < ER pletely into the bladder: the following case, mentioned in a respectable periodical work, fully proves the truth of this remark. Some years ago, a surgeon, practising in the country, was required to introduce the catheter for a lady labouring under reten- tion of urine. During the operation, he was observed to exhibit signs of confusion, and to quit his patient in considerable em- barrassment. The same day, he abruptly left his home, and was never seen after- ward. The lady passed several years of dreadful suffering, attributed by herself and the professional gentleman, on whom the treatment of the case devolved, to aggrava- tion ofthe original complaint. At length, an abscess presented itself in the sacral region, and the surgeon punctured it,when his instru- ment came in contact with some unusually hard substance imbedded in the centre of the abscess. With a pair of forceps, he now ex- tracted to his utter astonishment a blackened female catheter. From this period, the lady's sufferings all terminated. A similar accident nearly happened in the practice of another gentleman. (See Medico-Chir. Journ. Vol. 5, p. 76, Lond. 1818.) (See Urine, Retention of,) J. Hunter, Treatise on the Venereal Disease, Ed. 2, in various pla- ces. Hey's Practical Observations in Surge- ry, Ed. 3. John Bell's Principles, Vol. 2. Ware on Ihe Catheter. Sketches of the Medi- cal Schools of Paris, by J. Cross, p. Ill, fa. Jos. MlSweeny, Observations on the Catheter, Edinb. Med. and Surgical Journ. No. 58, p. 52. Richter's Anfangsgr. der Wundarzney- kunst. Rees's Cyclopadia, Art. Catlieter. Langenbeck, 1 Bibl. fur die Chir. B. 1, p. 1175, 12mo. Gott. 1806. Desault, CEuvres Chir. T. 3. The Observations on the Cathe- ter, by Desault, Richler, J. Hunter, and Hey, are the bed, with which lam acquainted. CATLING, often spelt in surgical books, catlin, is a long, narrow, double-edged, sharp-pointed, straight knife, which is chiefly used in amputations of the leg and fore-arm, for dividing the interosseous ligaments and the muscles, he. situated between the two bones. Tbe catling is frequently made too wide and large, so that it cannot execute its office with the right degree of ease. CAUSTICS, (from t*iu>, to burn.) Medi- cines, which destroy parts by burning, or chymically decomposing them. The potassa fusa (kali purum,) the potas- sa cum calce (calx cum kali puro,) the anti- monium muriatum, the argenti nitras, the bydrargyri nitrico-oxydum. tbe acidum sul- phuricum,aud the cupri sulphas, are the caus- tics in most frequent use among surgeons. CAUTERIZATION, (from nxurn^a,, to eauterize.) The act of burning any part with a cautery. CAUTERY, (from kmu, to burn.) Cau- teries are of two kinds, viz. actual and po- tential. By the first term, is implied a heat- ed iron ; by the second, surgeons under- stand any caustic application. The high opinion which the ancients en- tertained of the efficacy of the actual caute- ry, may be well conceived from the follew- ing passage. " Quoscumque morbus inedica- menta non sanaut, ferrura sanat; quos fer- rum non sanat ignis sanat; quos vero ignis non sanat, insonabilesexistimare opportet" (Hipp. Sect.8,Aph. 6.) The actual cautery has been employed for the stoppage of bleeding, where the vessels could neither be tied, nor compressed. It has been also era- ployed for the destruction of carcinomatous tumours and ulcers ; fistula: ; polypi, and a vurietyof fungous diseases. Whoever looks over the writings of Hippocrates, will dis- cover that the actual cautery was a prin- cipal means of relief in several chronic af- fections, as dropsies, diseased joints, he. In modern times, the actual cautery has been more and more relinquished, in pro- portion assurgery has attained a higher state of improvement. On the continent, how- ever, it still retains advocates. In France, all the professors recommend and employ it in particular cases. The hospital gangrene, a peculiar disorder, which is much more frequently seen in foreign hospitals, is said to be little affected by any internal reme- dies. '- yegetable and diluted mineral acids are the local means employed with effect in mild cases. I have, (says Mr. Cross,) alrea- dy alluded to a case of Pelletan's, where carbon was applied, and the progress of the disease impeded. But, the actual cautery is the only means, that has been found effec- tual, in stopping the fatal progress of bad ca- ses of hospital ulcer, and the iron is applied red-hot, so as to produce an eschar on every point of the surface of the sore." (Sec Sketches of the Medical Schools of Paris, by J. Cross, p. 84.) Desault often employed the actual caute- ry to destroy fungous tumours ofthe antrum. (See Antrum.) The same practice is still followed by Pelletan and other eminent sur- geons in France. Mr. Cross saw it adopted in one such case with good effeet. (P. 86.) That part of the fungus, which can be cut away, is to be so removed, and the deeper portion, out of the reach ofthe knife, is to be cauterized. If there be any case in sur- gery, justifying the use of a red-hot iron, it is a fungus of the antrum. But, even in this instance, I should prefer any other certain mode of destroying the root of the disease. CERATOTOME. (from «§»?, a horn, and , to cut.) The name given by Wenzel to the knife, with which he divided the cornea, or horny coat of the eye. CERATUM CALAMINE. (L.) A good simple dressing. CERATUM CETACEI. (L.) The sper- maceti cerate. A mild, unirritating salve, for common purposes. CERATUM CONII. fr. Unguenti Conii Ibj. (See Unguentum.) Cetacei ^ij. Cer& Alba, ^iij- M. One of the formula at St. Bartholomew's Hospital, occasionally ap- plied to cancerous, scrofulous, phagedenic, herpetic, and other inveterate sores. CERATUM HYDRARGYRI SUBMURI- ATIS. ft. Hydrarg. Submuriatis, Ji. Cerati Lapid. Calamin. %ss. M. Some practitioners pre partial to this as adre5?ing forchan«re« CER CERATUM LYTTjE. (L.) This, which was lately called tbe cerate of cantharides, was once much used for stimulating blister- ed surfaces, in order to maintain a discharge. The ceratum sabinm, however, which an- swers much better, and is not attended with danger of bringing on strangury, inflamma- tion of the bladder, he., has almost superse- ded the ceratum lyttae. CERATUM PLUMBI SUPERACETA- TIS. (L.) An eligible, mildly astringent, unirritating salve. CERATUM PLUMBI COMPOSITUM. (L.) An excellent, unirritating, gently as- tringent salve, for common purposes. CERATUM SABINE, ft. Sabina Re- centis Contusa, Cera Flava, sing. lbj. Adipis Suilla, lbiv. Mix the savin with the melted wax and hog's lard, and strain the composi- tion. This is the common application for keep- ing open blisters, on the plan recommended by Mr. Crowther. (See Blisters.) CERATUM SAPON1S. (L.) ft. Plumbi oxydi semivitrei lib. j. Aceti cong. j. Saponis une. viij. Olei oliva, Cera flava, sing, lib j. This is the soap cerate of St. Bartholo- mew's Hospital. In preparing it, the ut- most caution must be used. The three first ingredients are to be mixed together and boiled gently till all the moisture is evapora- ted ; after whicb, the wax and oil, previously melted together, must be added. The whole composition, from first to last, must be incessantly and effectually stirred, with- put which the whole will be spoiled. This formula was introduced into practice by Mr. Pott, and is found to be a very con- venient application for fractures, and also as an external dressing for ulcers ; being of a convenient degree of adhesiveness, and at the same time possessing the usual proper- ties of a saturnine remedy. In applying this cerate, spread on linen, in fractures of the leg or arm, one caution is necessary to be observed, namely, that it be in two distinct pieces; for if, in one piece, the limb be encircled by it, and the ends overlap each other, it will form a very inconvenient and partial constriction ofthe fractured part, in consequence of the sub- sequent tumefaction. (Pharm. Chirurg.) CERU'MEN AUBIS. A degree of deaf- ness is frequently produced by the lodg- ment of hard dry pellets of this substance in the meatus auditorius. The best plan, in such cases, is to syringe the ear with warm water, which should be injected with mo- derate force. In some instances, deafness seems to de- pend on a defective secretion of the ceru- men, and a consequent dryness of the meatus. Here, a drop or two of sweet oil may now and then be introduced into the ear, and fomentations applied. CERUSSA ACETATA. Sugar of lead. Acetite of lead. This preparation, which is now named by Hu: college plumbi supcrace- tas, is well known as an ingredient in a va- riety of lotions and collyria. It has the qualities of preparations of lead ineeneral, CHE v»' being highly useful for diminishing inflam- mation. CHALAZIUM. (from £*m«£i, a hail- stone.) A little tubercle on the eyelid which has been whimsically supposed to resemble a hailstone. It is the same as the hordeolum or stye. (See Hordeolum.) CHAMOMILE. The flowers, which are bitter and aromatic, are used in surgery, for making fomentations. CHANCRE, (from xagwof, cancer vene- reus.) A sore which arises from the direct application of the venerea] poison to any part of the body. Of course it almost always occurs on the genitals. Such vene- real sores, as break out from a general con- tamination of the system, in consequence of absorption, never have the term chancre applied to them. (For an account of the nature and treatment of chancres, see Ve- nereal Disease.) CHEMOSIS. (from #ura>,to gape.) When ophthalmy or inflammation of the eye, is exceedingly violent, it frequently happens, that one or more vessels become ruptured on the side next the eyeball, and a quantity of blood is infused into the cellular mem- brane, which connect*, the conjunctiva with the anterior hemisphere of the eye. Hence, the conjunctiva becomes gradually elevated upon the eyeball, and projects towards the eyelids, so as to conceal within it the cornea, which appears as if it were depressed. (Scarpa.) In this way, the middle of the eye assumes the appearance of a gap, or aperture. According to the late Mr. Ware, when blood is extravasated under the tunica con- junctiva, there cannot be an easier or more effectual remedy than aether. A few drops are to be poured into the palm of the hand, and diffused over it. which may be immedia- tely done by pressing the other hand against it. The hand is then to be applied to the eye, and kept close to it, while the spirit is evaporating. By this means, the action of the absorbent vessels for the dispersion of the blood is excited, and quickened. In a few instances of cbemosis, in which the swelling and inflammation of tbe con- junctiva have been great, the same author found the following application particularly beneficial, after free evacuations : ft. In- teriorium foliorum recentium Lactuco? Sissilis, ~iij. Coque cum Aq Pur. ^ss. In balnea inuria pro semiliora; tunc exprimatur succus, et applicetur paululum ad oculos et ad palpe bras, sape in die. ( Ware.) Ophthalmy, attended with chemosis, de- mands the most rigorous employment of the antiphlogistic treatment. Both general and topical bleeding should be speedily and co- piously put in practice, with due regard, however, to the age and strength of the pa- tient. Leeches should be applied to the vicinity of the eyelids, or, what is prefera- ble, the temporal artery should be opened. When chemosis is very considerable, the distention of the conjunctiva may be re- lieved by making an incision in it, near its junction with the cornea, f See Ophthalmy.) CHL CHI CHEVASTER or Cheva'stre. A double- headed roller, the middle of which was ap- plied to the chin ; the bandage then crossed at the top of the head, and passed on each side to the nape of the neck, where it crossed again. It was next carried up to the top of the head, and so on, till all the roller was exhausted. CHIA'STRE. A bandage for stopping he- morrhage from tbe temporal artery. It is double-headed, about an inch and a half wide, and four ells long. The middle ofthe roller is applied to the unwounded side of the hand ; the bandage is carried round to the bleeding temple, and there made to cross over a compress on the wound. The roller is then continued over the coronal suture, and under the chin, care being taken to make the bandage cross upon the com- press. In this way, the roller is applied round the bead, till the whole is spent. CHILBLAINS are the effect of inflamma- tion, arising from cold. A chilblain in its mildest form, is attended with a moderate redness of the skin a sensation of heat and itching, and more or less swelling, which symptoms, after a time, spontaneously dis- appear. The intolerable itching aud sense of tingling, accompanying the inflammation of tbe milder description of chilblains, are observed to be seriously aggravated by ex- posure to heat. In a more violent degree, the swelling is larger, redder, and sometimes of a dark blue colour; and the heat itching, and pain, are so excessive, that the patient cannot use the part. In the third degree, small vesicles arise upon the tumour, which burst anil leave excoriations. These often change into ill-conditioned sores, which sometimes penetrate even as deeply as the bone, discharge a thin ichorous matter, and generally prove very obstinate. As Dr. John Thomson has remarked, " when the serum contained in tbe vesications is let out by a small opening, a portion of new cuticle is usually formed to supply the place of that, which has been separated; but, when the inflammation is severe, and the affection neglected, or improperly treated, the parts, which are the seat of vesication, are liable to pass into the state of viiated ulcers. In this state, they yield a thin, ichorous, or sanious discharge, and are in general brought, only after a longtime, and with much diffi- culty,to a healthy suppuration. In neglected cases, these ulcers not unfrequently become covered with foul sloughs. Ulceration often supervenes, and the soft parts covering the bones, are destroyed." (On Inflammation,p. 638.) The worst stage of chilblains is at- tended with sloughing. Chilblains are particularly apt to occur in persons, who are in the habit of going im- mediately to the fire, when they come home in winter with their fingers and toes very cold; they are also frequent in persons, who often go suddenly into the cold, while very warm, t Hence, the disease most com- monly affects parts of the body, which are peculiarly exposed to these sudden transi- tions : for instance, the nose, ears, lips, toes, heels, and fingers Richter remarks, that they are still more frequently occasioned, when the part, suddenly exposed to cold, is in a moist perspiring state, as well as Warm. Young subjects are much more liable to this troublesome complaint than adults; and females brought up in a delicate manner, are generally more afflicted, than the other sex. The most likely plan of preventing chil- blains is to accustom the skin to moderate friction ; to avoid hot rooms and muking the parts too warm ; to adapt the quantity and kind of clothing to the state of the con- stitution, so as to avoid extremes, both in summer and winter ; to wash the parts fre- quently with cold water ; to take regular exercise in the open air in all weathers, and to take particular care not to go suddenly into a warm room, or very near the fire, out of the cold air. Although chilblains of the milder kinds are only local inflammations, yet they have some peculiarity in them ; for they are not most benefited by the same antiphlogistic applications, which are most effectual in the relief of inflammation in general. One ofthe best modes of curing chilblains of the milder kind is to rub them with snow, or ice cold water, or to bathe them in the latter, several times a day, keeping them immersed each time, till the the pain and itching abate. After the parts have been rubbed or bathed in this way, they should be well dried with a towel, and covered with flannel or leather socks. This plan is perhaps as good a one as any; but it is not that which is always congenial to the feelings and caprice of patients; and with the constitutions of some it may even disagree. In such cases, the parts affected may be rubbed with spirit of wine, iinimentum suponis, tincture myrrhs, or a strong solution of alum, or vinegar. A mixture of oleum terebinthina? and balsamum copaiva?, in equal parts, is a celebrated ap- plication. A mixture of two parts of cam- phorated spirit of wine, and one of the liquor plumbi subacetatis has also been praised. Mr. Wardrop speaks highly of one part of the tincture of lytta?, with six ofthe soap liniment. (Medico-Chir. Trans. Vol.o p. 142.) With respect to vesications, " their oc- currence is always hastened, and the in- flammation, upon vvhich they depend,greatly aggravated by the action of external heat; and, hence, the propriety of continuing cold applications to frost-bitten parts,so long as their temperature continues above the natural standard, or the inflammation ex- cited seems to retain an acute character. From the tendency, which the inflamma- tion excited, has to pass into gangrene, the more stimulating applications, such as spirit of wine, diluted ammonia, or oil of turpen- tine may be required. But, should these applications prove too stimulating, their strength may be weakened by additions of greater or less portions of the Iinimentum CHi ex-aqua calcis." (ThomsononInflammation, p, 648.) When chilblains have suppurated and ul- cerated, the sores require stimulating dress- ings, such as lint dipped in a mixture of the liquor plumbi, subacetatis dilutus,and liquor calcis ; tinctura myrrba*, or warm vinegar. If a salve be employed, one which cont ins the hydrargyri nitrico-oxydum is best. Ul- cers of this kind frequently require to be touched with the nitrate of silver, or dressed with a solution of it. Chilblains,attended with sloughing, should be poulticed, till the dead parts are detached. The sores should then be first dressed with some mildly stimulating ointment, such as the unguentum resinae flava?. With this, in a day or two, a little of the hydrargyri nitri- co-oxydum maybe mixed ; but the surgeon should not venture on the employment of very irritating applications, till he sees what the parts will bear, and whether such will be requisite at all; for, were he too bold, immediately he leaves off the poultices he might bring on sloughing again. The reader may find a long lisl of applica- tions for chilblains in Rees's Cyclopadia, ar- ticle Chilblains. See also Richter's Anfangsgr. der Wundarzn. Band. 1. Thomson's Lec- tures on Inflammation ;p. 637, fa. Lassus, Pathologic Chirurg. T. 2. p. 388, fa. Liveilli Nouvelle Doctrine Chir. T. 4, p. 352, fa. Callisen's Systema Chirurgia Hodierna, Vol. 1. p. 304, fa. Edit. 1798. Pearson's Principles of Surgery, p. 153, fa. Edit. 1808. CHIMNEY-SWEEPER'S CANCER.— See Scrotum. CHORDEE. (French, from ^cgJVi, a cord ) When inflammation is not confined merely to the surface of the urethra, but affects the corpus spongiosum, it produces in it an extravasation of coagulable lymph, as in the adhesive inflammation, which uni- ting the cells together, destroys the power of distention of the corpus spongiosum urethra?, and makes it unequal in this res- pect to the corpora cavernosa penis, and therefore a curvature takes place at thetime of an erection, which is called a chordee. The curvature is generally in the lower part of the penis. When the chordee is violent, the inner membrane of the urethra is so much upon the stretch, that it may be torn, and a profuse bleeding from the urethra ex- cited, that often relieves the patient, and even sometimes proves a cure. This is the inflammatory chordee ; there is another kind, which has been named spas- modic. In the beginning of the inflammatory chordee, bleeding from the arm is often of service ; but it is more immediately useful to take blood from the part itself by leeches ; for, we often find, that when a vessel gives way, and bleeds a good deal, the patient is greatly relieved. Exposing the penis to the steam cf hot water frequently gives great re- lief. Poultices have also beneficial effects ; and both fomentations and poultices will often do most good when they contain cam- phor. Opium,given internally,is ofsingu- CHO 383 lar service ; and if it be joined with cam- phor, the effect will be still greater. Wh-n the chordee continues after all in- flammation has terminated, no evacuations are required ; for, the' consequences of the inflammation will cease gradually by the ab- sorption of the extiavasated coagulating lymph. Mercurial ointment, rubbed on the part, will considerably promote this event. When the common methods of cure are un- availing, hemlock is sometimes very useful. Electricity may be of service. A chordee is often longer in going off, than any other consequence of a gonorrhoea, but, in the end, it disappears. For bringing about the removal ofthe ex- travasated lymph, camphorated mercurial ointment is better, than the simple unguen- tum hydrargyri. According to Mr. Hunter, the spasmodic chordee is much benefited by bark. (See his Treatise on the Venereal Dis- ease, Ed. 2.) CICATRIX. A scar : the mark left after the healing of a wound, or ulcer. CICATRIZATION. The process by which wounds and sores heal Granulations having been formed, the next object of na- ture is to cover them with skin. The parts which had receded by their natural elastici- ty, in consequence of the breach made in them, now begin to be brought together by the contraction of the granulations. The contraction takes place at every point, but principally from edge to edge, which brings tbe circumference ofthe sore towards the centre, so that the sore becomes smaller and smaller, even although little, or no new skin is formed. The contracting tendency is in some de- gree proportioned to the general healin°- disposition of the sore, and looseness of the parts. When granulations are formed upon a fixed surface, their contraction is mecha- nically impeded ; as, for instance, on the skull,the skin, he. Hence, in all operations on such parts, as much skin should be saved as possible. When there has been a loss of substance making a hollow sore, and the contraction ofthe granulations has begun, and made a good deal of progress, before they have had time to rise as high as the skin, then the edges ofthe skin are generally drawn down and tucked in by it, in the hollow direction ofthe surface ofthe sore. The contraction of the granulations con- tinues, till the healing is complete ; but it is greatest at first. That there is a mechani cal resistance to such contraction, is proved by the assistance, which may be given to the process by the application of a bandage Besides the contractile power ofthe gran- ulations, there is also a similar power in the surrounding edge of the cicatrizing skin which assists the contraction ofthe granu' lations, and is generally more considerable than that of the granulations themselves draw ing tbe mouth of the wound together' like a purse. The contractile power of the skin is confined principally to thevery ed»e where it is cicatrizing, and, as Hunter be- 384 CINCHONA. lieved, to those very granulations, which have already cicatrized ; for, the natural or original skin, surrounding this edge, does not contract, or at least not nearly so much, as appears by its having been thrown into folds and plaits, while the new skin is smooth and shining. The uses of the contraction of granu- lations are various. It facilitates the heal- ing of a sore, as there arc two operations going on at the same time, viz. contraction and skinning. It avoids the formation of much new skin, the advantage of vvhich is evident ; for it is with the skin as with all other parts of the body, viz. that such as are originally formed are much fitter for the purposes of life, than those which are newly formed, and not nearly so liable as ulceration. When the whole surface of a sore has skinned over, the substance, the remains of the granulations, on which the new skin is formed, still continues to contract, till hard- ly anything more is left than what the new skin stands upon. This is a very small part, in comparison with the first formed granula- tions, and it in time loses most of its appa- rent vessels, becoming white and ligamen- tous. All newly healed sores are at first redder than the common skin, but in time, they become much whiter. As the granulations contract, the surround- ing old skin is stretched to cover the part, which had been deprived of skin. When a sore begins to heal, the surround- ing old skin, close to the granulations, be- comes smooth, and rounded with a whitish cast, as if covered with something white. This, Mr.Hunter supposed to be a beginning cuticle, and it is as early and sure a symp- tom of healing as any. While the sore re- tains its red edge all round, for perhaps a quarter, or half an inch in breadth, we may be certain, that it is not in a healing state. Skin is a very different substance, with respect to texture, from the granulations upon which it is formed ; but it is not known, whether it is anew substance form- ed by the granulations, or a change in the surface ofthe granulations themselves. The new skin -most commonly takes its rise from the surrounding old skin, as if elongated from it; but not always. In very large sores, but principally old ulcers, in which the edges of the surrounding skin have but little tendency to contract, and the cellular membrane underneath to yield, or the old skin to become drawn over the ul- cerated surface, the nearest granulations do not acquire a cicatrizing disposition. In such cases, new skin forms in different parts of the ulcer, standing on the surface of the granulations, like little islands. Whatever change the granulations under- go to form new skin, they are generally guided to it by the surrounding skin, which gives this disposition to the surface of the adjoining granulations. The new-formed skin is never so large as the sore was, on which it is formed, owing to the contraction of the granulations, and the yielding of tue surrounding old skin. It the sore is situated where the adjoining skin is loose, as in the scrotum, then the contrac- tile power of the granulations being quite free from obstruction, a very little new skin is formed ; but, if the sore is situated where the skin is fixed or tense, the new skin is nearly as large as the sore. The new skin is at first commonly on the same level with the old. This, however, is not the case with scalds and burns, which frequently heal with a cicatrix, higher than the skin, although the granulations may have been kept from rising higher than this part. The new-formed cutis is neither so yield- ing nor so elastic as the original is ; it is also less moveable. It gradually becomes, how- ever, more flexible and loose. At first, it is very thin and tender, but it afterwards be- comes firmer and thicker. It is a smooth continued skin, not formed with those in- sensible indentations, which are observed in the natural or original skin, and by vvhich the latter admits of any distention, which the cellular membrane itself will allow of. This new cutis, and indeed all the sub- stance which had formerly been granula- tions, is not nearly so strong, nor endowed with such lasting and proper actions, as the originally formed parts. The living princi- ple itself is less active ; for when an old sore breaks out, it continues to yield, till almost the whole of the new-formed matter has been absorbed, or has mortified. The young cutis is extremely full of ves- sels ; but these afterwards disappear, and the part becomes white. The surrounding old skin, being drawn toward the centre by the contraction of the granulations, is thrown into loose folds, while the new skin itself seems to be upon the stretch,'having a smooth shining appearance. I he new cuticle is more easily formed from the cutis, than the cutis itself from granulations. Every point of the surface of the cutis is concerned in forming cuticle, so that this is forming equally every where at once ; but the formation of the cutis is principally progressive from the adjoining skin. The new cuticle is at first very thin, and rather pulpy than horny. As it becomes stronger, it looks smooth and shining, and is more transparent than the old cuticle. The rete mucosum is later in forming than the cuticle, and in some cases never forms at all. In blacks who have been wounded, or blistered, the cicatrix isa considerable time before it becomes dark ; aud in one black, whom Mr. Hunter saw, the scar of a sore, which had been upon his leg when young, remained white when he was old. Many cicatrices of blacks, however, are even dark- er than any other parts ofthe skin. (Hun- ter on the Blood, Inflammation, fa. The. read- er may also consult Thomson'* Lecture* on Inflammation, p. 399, fa.) CICUTA. See Conium Maculaium. CINCHONA. As one of the designs of this dictionary is to embrace tbe pubjects- CINCHONA. l?Ai oi a surgical pharmacopoeia, peruvian bark, which is administered in a multiplicity of surgical cases, cannot be passed over in silence. Its great repute for its virtues in stopping mortifications, and -iccelerating the separa- tion of tbe sloughs, every person, whe- ther of the medical profession or not, has frequently heard of. Indeed, so high is the character of the medicine, that many practitioners order it in some stage, or another, of almost every distemper, often prescribe it when it is totally useless, give it when it actually does harm, and make their patients swallow such quantities as operate perniciously, when smaller doses would ef- fect striking benefit. Some men are credu- lous enough to think, that from the peruvian bark vigour and strength are directly extri- cated, and infused into the constitution, in exact proportion to the quantity of the medicine, vvhich the stomach will keep down and digest. While a doctrine of this sort prevails, we must expect to see indiscriminate and erro- neous practice. The generality of diseases will always be attended with an appearance of languor and weakness, and, certainly, while there exists a supposition that a drug is at hand, possessing the quality of evolving and communicating strength, it would be absurd to fancy, that so important an article will not be largely exhibitedin a multiplicity of surgical cases. I shall not presume to * hazard an idea of the powers of the peruvi- an bark in the practice of physic ; but, I have not the least doubt, that they have been unwarrantably*exaggerated in surgery, so as to blind aud prejudice many a prac- titioner of good abilities, and lead him to adopt injudicious and hurtful methods of treatment. Under particular circumstances, bark has undoubtedly tbe quality of increasing the tone of the digestive organs ; and, of course, w henever the indication is to strengthen the system by nourishing food, and the appetite fails, this medicine may prove of the highest utility, provided it is given in moderate do- ses, and it appears to agree with the stomach and bowels But, the plan of making the patient swallow as much of the medicine as can be got into his stomach, must, in my opinion, be invariably followed by bad, in- stead of good effects. How can it be rea- sonably expected, thatthe stomach, which is already out of order, can be set right by having an immoderate quantity of any drug whatever forced into it ? In fact, if the ali- ' mentary canal were in a healthy state, must not such practice be likely to throw it into a disordered condition ? Bark is an excellent medicine, when ju- diciously administered ; but, like every other good medicine, in bad hands, it may be the means of producing the worst consequen- ces. ' How much good does mercury effect in an infinite number of surgical diseases, when prescribed by a surgeon of understand- ing ; what a poison it becomes under the direction of an izuorant practitioner ! Vqi f M) With re'spect to cases of mortification, bark is often most strongly indicated, when the sloughing is not surrounded with active in- flammation, when the patient is debilitated, and his stomach cannot take nutritious food. I have always regarded tbe notion of giving bark, a< a specific forgangrane, as totally un- founded and absurd. I have watched its effects in these cases, and could never dis- cern that it had the least peculiar power of operating directly upon the parts, which are distempered. Whatever good it does, is by its improving the tone of the digestive or- gans, and making them more capable of conveying nourishment, and, of course, strength into the constitution. I should feel myself guilty of a degree of presumption in speaking thus freely upon this subject, were not my sentiments in some measure supported by those of certain sur- gical writers, the remembrance of whom will always be hailed with unfeigned vene- ration and esteem. Mr. Samuel Sharp was not bigoted to bark, and, while he allowed it to possess a share of efficacy, he would not admit that it was capable of miraculous- ly accomplishing every thing, which tbe ignorant or prejudiced alleged. " I know,'' says he, "it will be looked upon by many as a kind of scepticism to doubt the efficacy of a remedy $o well attested by such an h> finity of cases, and yet, I shall frankly own, I have never clearly to my satisfaction, met with any evident proofs of its. prefer- ence to the cordial medicines usually pre- scribed ; though I have a long time made experiment of it with a view to search into the truth. Perhaps it may seem strange, thus to dis- pute a doctrine established on what is called matter of fact; but, I shall here observe, that in the practice of physic and surgery, it is often exceedingly difficult to ascertain a fact. Prejudice, or want of abilities, sometimes misleads us in our judgment, where there is evidently a right and a wrong; but, in certain cases, to distinguish how far the remedy, and how far nature operate, is probably above our discernment. In gan- grenes, particularly, there is frequently such a complication of unknown circumstances, as cannot but tend to deceive an unwary ob- server. Mortifications arising from mere cold, compression, or stricture, generally cease upon removing the cause, and are, therefore, seldom proper cases for proving the power of the bark. However, there are two kinds of gangrene, where internals h^ve a fairer trial; those are a spreading gangrene from an internal cause, and a spreading gangrene from violent external accidents, such as gunshot wounds, com- pound fractures, &,c. Yet, even here we cannot judge of their effect with absolute certainty ; for, sometimes, a mortification from internal causes is a kind of critical disorder. There seems to be a certain por- tion of the body destined to perish, and no more ; of this we have an infinity of ex- amples brought into our hospitals, where the gangrene stops at a particular point. 386 Ut: i IR without the least assistance trom art. Tbe same thing happens in the other species of gangrene from violent accidents, where the injury appears to be communicated to a cer- tain distance, and no farther; though by the way, I shall remark in this place, con- trary to the received opinion, that gangrenes from these accidents, (where there has been no previous straitness of bandage,) are as often fatal, as those from internal causes. " As I have here stated the fact, we see how difficult it is to ascertain the real effi- cacy of this medicine ; but, had bark in any degree those wonderful effects iu gangrenes, which it has in periodical complaints, its pre-eminence would no more be doubted in the one case, than in the other. What, in my judgment, seems to have raised its Character so high, are the great numbers of Single observations published on this sub- ject, the authors of which not having fre- quent opportunities of seeing the issue of this disorder, under the use of cordials, &.c and some of them, perhaps, prejudiced with the common supposition, that every gan- grene is of itself mortal, have therefore as- cribed a marvellous influence to the bark, when the event has proved successful.— (Sharp's Crit. Inq. chap. 8, on Amputation.) Some further remarks on this subject w ill be reserved for tbe article Mortification. According to Mr. Bromfield, bark is a specific for old ulcers, where the inflamma- tion seems circumscribed at the distance of an inch round the sore, the surface of the ulcer looks glossy, and the discharge is ex- tremely thin and very offensive, with little or no sleep, from the violence of the pain. He further observes, that the addition of opium, as circumstances may require, will often be found necessary. (Chirurgical Ob- servations and Cases, Vol. l,p. 132.) Bark i3 given so extensively in the prac- tice of surgery, that there are few impor- tant cases, in which, in certain circumstan- ces, and at some period or another, it is not indicated. When persons have been weakened by a course of mercury, or by the effects of any disease whatsoever, mo- derate doses of bark will frequently be found of great service. But, it only becomes so on the principles above suggested, and, as far as my judgment extends, tbis medi- cine should never be prescribed in any sur- gical cases in excessive and unreasonable quantities. The yellow bark, or tbe cortex cinchona; cordifolia? of the new pharmacopoeia, is said to possess more efficacy, than the other kinds. CINNABAR ARTIFICIAL. (Hydrar- gi/ri Sulphuretum rubrum.) Is chiefly em- ployed by surgeons for fumigating venereal ulcers. An apparatus is sold in the shops for this purpose. The powder is thrown upon a heated iron, and the smoke is con- ducted by means of a tube to the part af- fected. CIRCUMCISION, (from circumeido, to cut round.) Tbe operation of cutting off a circular piece of the prepuce, sometimes practised in cases of phymosis. (dee Pity* mosis.) CIKSOCELE. (from iu^toc, a varix, and *mxh, a tumour.) (irsocele is a varicose dis- tention and enlargement of the spermatic vein; and whether considered on account of the pain, which it sometimes occasions, or on account of a wasting of the testicle, whicb now and then follows, it may truly be called a disease. It is frequently mis- taken for a descent of a small portion of omentum. The uneasiness which it occa- sions, is a dull kind of pain in tbe back, generally relieved by suspension of the scrotum. It has been resembled to a col- lection of earth-worms; but whoever has an idea of 8 varicose vessel, will not stand in need of an illustration by comparison. It is most frequently confined to that part of the spermatic process, which is below the opening in the abdominal tendon; and the vessels generally become rather larger, as they approach the testis. Mr. Pott never knew any good effect from external applica- tions of any kind. In general the testicle is perfectly uncon- cerned in, and unaffected by, this disease; but it sometimes happens that it makes its appearance very suddenly, and with acute pain, requiring rest and ease; and some- times after such symptoms have been remo- ved, Mr. Pott has seen the testicle so wasted as hardly to be discernible. He has also observed the same effect from the injudi- cious application of a truss to a true cirso- ' cele ; the vessels, by means of the pressure, became enlarged to a prodigious size, but the testicle shrunk to almost nothing. (Pott'i Works, Vol. 2.) Morgagni has remarked, that the disease is more frequent in the left, than the right spermatic cord ; a circumstance which he refers to the left spermatic vein terminating in the renal. (De Sedibus et Caus. Morb. Epist. 43, art. 34.) Cirsocele is more frequently than any other disorder, mistaken for an omental hernia As Mr. Astley Cooper remarks, when large, it dilates upon coughing; and it swells in an erect, and retires in a recumbent pos- ture of the body. There is only one sure method of distinguishing the two com- plaints; place the patient in a horizontal posture, and empty the swelling by pressure upon the scrotum; then put the fingers firmly upon the upper part of the abdomi- ,nal ring, and desire the patient to rise; if it is a hernia, the tumour cannot reappear, as long as the pressure is continued at the ring; but if a cirsocele, the swelling returr* with increased size, on account of tbe re- turn of blood into the abdomen being pre- vented by the pressure. (A Cooper on In- guinal Hernia.) Cirsocele canfor the most part only be palliated, and seldom radically cured. When th • complaint is attended with pain, cold saturnine, and alum, lotions may be applied to the testicle and spermatic cord. At the same time, blood should be repeatedly ta- ken away by means of leeches; the bowel? COL CON 387 should be kept gently open ; the patient should be placed in a horizontal posture; and the testicle should be supported in a bag- truss. In general, the patient only finds it ne- cessary to keep up the testicle by this kind of suspensory bandage. Gooeh, and other writers, have related cases of cirsocele, iu which the pain was so intolerable and incurable, that nothing but castration could afford the patient any re- lief. (J. A. Murray de Cirsocele, Upsal, 1784. Pott on Hydrocele, fa Richter in Nov. Com- ment. Goetl.No.4, and in Obs. Chir. Fasc. 2, p. 22. Gooch Chir Works. Most, Diss, de Cirsocele, Hala, 1796.) CIRSOPHTHALMIA (from X'i^i a va- rix, and oodxK/uioc, the eye.) A general vari- cose affection of tiie blood-vessels of the eye. CLAP. (See Gonurrhaa.) COLLYRIUM ACIDI ACETICI. ft. Aceti Dislillati ^j. Spiritus Vini lenuioris ^ss. Aq. Rosa- ?viij. Misce. The strength to be diminished or increased, as circum- stances may require. This collyrium is re- commended for weak watery eyes, and sometimes for the scrofulous ophthalmy.— (See Wilson's Pharm Chir. p. 66.) COLLYRIUM ALUMIMS. ft. Alumnus purif. 3j. Aq. rosae ?vj. This is a good as- tringent collyrium, employed at Guy's Hos- pital. COLLYRIUM AMMONTiE ACETATE. ft. Liq. amnion, acet. Aq. rose, sing. ?j. M. COLLYRIUM AMMONLE ACETATE CAMPHORATUM.ft.Collyriiammon.acet. Misturae camphorate sing. ?ij M. COLLYRIUM AMMOM.E ACETATE OPIATUM. ft. Collyrii ammon. acet. §iv. Tinct opii. gutt. xl. M. COLLYRIUM CUPRI SULPHATIS CAMPHORATUM. ft. Aq. Cupri sulphatis camphorate 3'j- Aq. distillate 3iv. M. Recommended by Mr. Ware, for the puru- lent ophthalmy of children. COLLYRIUM HYDRARGYRI OXYMU- RIAT1S. ft. Hydrarg. oxy-muriatis gr.ss. Aq. distillat. ^iv M. Tbis collyrium is fit to be employed, after the acute stage of the ophthalmy has for some time subsided, and it will disperse many superficial opacities of the cornea. COLLYRIUM OPIATUM. ft. Opii Ex- tracti gr. x. Camphorae gr. vj. Aquae dis- tillate ferventis ^xii. Beat the two first in- gredients together in a mortar, aid mix the hot water gradually, and strain the fluid. This collyrium is recommended in some ophthalmia, attended with great pain and swelling. (See Wilson's Pharm, hir. p. .0.) COLLYRIUM PLUMBI At ETA I IS.— ft. Aquae rosae ?vj. Plumbi acetatis. 3ss. Misce. or, ft. Aq. distillat v *iv. Liq. plum- bi acetatis. gutt. x. M. This is a good ap- plication to the eyes, when one of a gently astringent, cooling quality is indicated. COLLYRIUM Z1NCI JULPHAT1S.--- Zinci sulphatis gr. v. Aq. distillate ^iv. M. This is the most common collyrium of all .- i« may be made gradually strouger COLLYRIUM ZINCI SULPHATIS CUM MUCILAGINE SEMINIS CYDOMI MALI. ft. Aq. plantaginis .^iv. zinci sulphatis gr. V. et mucil. sem. cydon. mal. ^ss. M. In order to check the morbid secretion from the eyelids, in cases of fistula lachry- malis, or what Scarpa calls it flusso palpe- br ale purif or me, this celebrated Professor re- commends a few drops of the, above colly- rium to be insinuated between the eyelids and the eye. COLPOCELE. (from xnKim, the vagina, and knK», a tumour.) A tumour, or hernia, situated in Ihe vagina. COLPOPTOSIS. (from no\iro;, the vagina, and ictiwlo, to fall down.) A bearing or fall- ing down of the vagina. (See Vagina, Pro- lapsus of.) COMA, (from xm, or kuo, to lie down.)— Anciently any total suppression of the pow- ers of sense ; but now it means a lethargic drowsiness. It is a symptom of several surgical disorders. COMMINUTED, (from comminuo, to break in pieces.) A fracture is termed com- minuted, when the bone is broken into seve- ral pieces. COMPRESS, (from comprimo, to press upon.) Folded linen, lint, or other mate- rials, making a sort of pad, vvhich surgeons place over those parts of the body on which they wish to make particular pressure, and for this purpose a bandage is usually applied over the compress. Compresses are also frequently applied to prevent the ill effects, which the pressure of hard bodies, or tight bandages, would otherwise occasion. COMPRESSION OF THE BRAIN. (See Head, Injuries of.) CONCUSSION OF THE BRAIN. (See Head, Injuries of.) CONDUCTOR, (from conduco, to guide.) A surgical instrument for directing the knife in certain operations. It is more com- monly called a director. CONDY LOMA. (from iw»2 ; p 17-1.) 1 have sometimes pre->cribed as an altera- tive with manifest benefit in several surgi- cal diseases, a pill containing three grains of extractum conii, one of hydrargyri sub- murias (calomel,) and one of antiinonii sal- phuretum precipitutum. (F. Hoffman, of Hemlock 8vo. Lond. 1763. A. Slftck, Libtl- lus, quo demonstratur cicutam non solum usu intemo tutissimi cxhiberi, ted et esse simul remedium valdt) utile, fa.; Lililio altera, 8co. Vindob. 1761. Also Supplimcntum Ne- cetsarium de Cicuta, Svo. Vindob. 1761. J. Pearson, On various Articles of the Materia Mcdic.a, dye. 2d Edit. 8n<. Lond. 1807.) CONTUSED WOUNDS (See Wound*.) CONTUSION, (from contundo, to bruise.) A bruise. Slight bruises seldom meet with much at- tention ; but, when they are severe, very bad consequences mav ensue, and these are the more likely to occur, when such cases are not taken proper care of. In all severe bruises, besides the inflam- mation which the violence necessarily oc- casions, there is an instantaneous extrava- sation, in consequence of the rupture of many of the small vessels of the part. In no other way can we account for those very considerable tumours which often rist im- mediately after injuries of this nature, i'hi black and blue appearance instantly follow- ing many bruises, can only be explained by there being an actual effusion of blood from the small arteries and veins, which have been ruptured. Even largish vessels are frequently burst in this manner, and con- siderable collections of blood are the con- sequence. Blows on the head very often cause a large effusion of blood under the scalp. I have seen many ounces thus e.v travasated. Btiides the rupture of an infinite number of -•'. all vessels and extravasation, which attend all bruises in a greater or less degree, the tone of the fibres and vessels, which have suffered contusion, is considerably dis- ordered. Nay, the violence may have been so great, that the parts are from the first de- prived of vitality, and must slough. Parts at some distance from such as are actually struck, may suffer greatly from the violence of the contusion. This effect is what the French havenamed acontrecoup The bad consequences of bruises are not invariably proportioned to the force which has operated ; much depends on tbe nature and situation of the part. When a contu- sion takes place on a bone, vvhich is thinly covered with soft parts, the latter always suffer very severely in consequence of be- ing pressed, at the time of the accident, be- tween two hard bodies. Hence, bruises of tbe shin *o frequently cause sloughing and CORNEA. 389 'roublesome sores. Contusions affecting the large joints, are always serious cases; the inflammation occasioned is generally obstinate, And abscesses and other diseases, which may follow, are proper grounds for serious alarm In the treatment of bruises,- the practi- tioner has three indications, which ought successively to claim his attention. Tbe first is to prevent and diminish in- flammation, which, from the violence done, must be expected to arise. The bruised parts should be kept perfectly at rest, and be covered with linen, constantly wet with the liquor plumbi acetatis dilutus. When muscles are bruised, they are to be kept in a relaxed position, and never used. ]{ the bruise should have been very vio- lent, it will be proper to apply leeches, and this repeatedly, and even in some cases, particularly when the joints are contused, to take blood from the arm. In every in- stance, the bowels should he kept well open with saline purgatives. A second object in the cure of contusions, is to promote the absorption of tbe extra- vasated fluid by discutient applications.— These may at once be employed in all or- dinary contusions, not attended with too much violence ; for then nothing is so bene ficial as maintaining a continual evaporation from the bruised part, by means of the cold saturnine lotion, and, at the same time, re- peatedly applying leeches. In common bruises, however, the Lotto ammonia muria- tes (see this article,) is an excellent discu- tient application ; but most surgeons are in the habit of ordering liniments for all ofdi- nary contusions, and certainly they do so much good in accelerating the absorption of the extravasated blood, that the practice is highly praiseworthy. The Iinimentum sa- ponis, or the Iinimentum cainphore, are as good as any that can be employed. (See Linimentum.) In many cases, unattended by any threat- ening appearances of inflammation, but in which there is a good deal of blood and fluid extravasated, bandages act very bene- ficially, by the remarkable power which they have of exciting the action of the lym- phatics, by means ofthe pressure which they produce. A third object in the treatment of contu- sions, is to restore the tone of the parts.— Rubbing tbe parts with liniments has a good deal of effect in this way. But, notwith- standing such applications, it is often ob- served, that bruised parts continue for a long while weak, and even swell, and be- come o'dematous, when the patient takes exercise, or allows them to hang down, as their functions in life may require. Pump- ing cold water two or three times a day, on a part thus circumstanced, is the very best measure which can be adopted. A bandage • should also be worn, if the situation of the part will permit. These steps, togetherwith perseverance in the use of liniments, and in exercise gradually increased, will soon Srinf every thing into its natural state again. CORNEA TUNICA, (from cornw.a horn.) The anterior transparent convex part of the eye, which in texture is tough like horn. It has a structure peculiar to itself, being com- posed of a number of concentric cellular lamelle, in the cells of which is deposited a particular sort of fluid It is covered ex- ternally by a continuation of the conjunc- tiva, which belongs to the class of mucous membranes ; and it is lined by a membrane, the tunica humoris aquei, which seems to belong to the serous class. FLESHY EXCBESCENCES OF THE COKNEA. Mr. Wardrop, in his Essays on the Mor- bid Anatomy of the Human Eye, has pub- lished an excellent chapter on this subject. Besides pterygia, which are treated of in another part of this dictionary, Mr. Ward- rop states that the cornea is subject to two kinds of caruncles, or fleshy excrescences. One appears at birth, or soon after it, and resembles the nevi materni so frequent on the skin of various pat ts of the body. The second is described as having a greater ana logy to the fungi, which grow from mucous surfaces, and being in general preceded by ulceration. Of tbe congenital excrescence of the cor- nea, Mr. Wardrop has seen two remarkable instances. Tbe first was in a girl, eight or ten years of age, on whose left eye there was a conical mass, the base of which grew from about two-thirds of the cornea, and a small portion of the adjoining sclero- tic coat. The second example occurred in a patient upwards of fifty years old The tumour had been observed from birth, was about as large as a horse-bean, and only a small portion of it seemed to grow from the cor- nea. The other part was situated on the white ofthe eye, next the temporal angle of the orbit. From the middle of the excres- cence, upwards of twelve long firm hairs grew, and hung over the cheek. Air. Wardrop acquaints us, that a similar tumour, with two hairs growing out of it, was seen at Lisbon by Dr. Barron, of St. Andrews. Mr. Crampton also mentions, that he once saw a " tuft of very strong hairs proceeding from the sclerotica." (Es- say on Ihe Entropeon, p. 7.) And De Ga- zelles met with an instance in which a sin- gle hair grew from the cornea. (Journ. dc Midecine, Tom. 24.) According to Mr. Wardrop, this species of excrescence of the cornea greatly resembles thespots, covered with hair, which are frequent on various parts of the surface of the body. \\ ith regard to the second kind of tumour growing from the cornea, a fungus, proceed- ing from an ulcer of this part of the eye, is stated to be very uncommon. However, it is said, that, when a portion of the iris pro- trudes through an ulcer of the cornea, the growth of a large excrescence from the pro- jecting part is not so unusual. Of such a disease, Air. Wardrop has cited examples from Maitre Jean's Traiti des Maladies des 390 CORNEA. yeaux, Voigtel, Beer, and Plaichner. Ex- crescences, growing from the cornea, are alsoquoted from tbe following works ; Hand- buch der Pathologischen Anatomie, Von F. G. Voigtel, Halle, 1804. Praktische Beobach- tungen uber den grauen Staar und die Krank- heiten der Hornhaut, von Joseph Beer, Wien, 1791. Plaichner's Dissertatio, de Fungo Oculi. (See Wardrop'* Essays on the Mor- bid Anatomy of the Human Eye, Vol. 1, chap. 4.) Others are likewise described by Mery, in Mim. de I'Acad. des Sciences, 1783; by Dupri in Phil Trans Vol. 19 ; and Home in the same Work, Vol. 81. The only treatment which excrescences of the cornea admit of, is to remove them with a scalpel and a pair of forceps, or to destroy them with caustic. ABSCESSES OF TBE CORNEA. The following description of abscesses of the cornea, is taken from Mr. Wardrop's va- luable work on the Morbid Anatomy of the Eye. When the matter is collected between the lamellae ofthe cornea, it first appears like a small spot; and, instead of resembling a small speck in colour, it is of the yellow hue of common pus. As the quantity of the matter increases, this spot becomes broader, and it does not alter its situation from the position of the head. If it be situated among the external layers ofthe cornea, or imme- diately below the corneal conjunctiva, a tumour is formed anteriorly, and, if touched with the point of a probe, the contained fluid can be felt fluctuating within, or if the eye be looked at sideways, an alteration in the form of the cornea may be readilyper- ceived. When the matter collects between the in- terior lamella;, it does not produce any evi- dent alteration, in the external form of the cornea; but, if it be touched with the point of a probe, a fluctuation can be more or less distinctly perceived, and the spot alters its form, and becomes somewhat broader. Such collections of matter appear on every part of the cornea. Sometimes they alter their situation by degrees, and sink downwards; and sometimes they change both their situation and form. They very seldom cover more than one-fourth or one- third of the cornea. When the quantity of matter is small, it b often completely absorbed during the abatement of the inflammatory symptoms, and it generally leaves no vestige behind it. In other cases, the cornea is eroded ex- ternally, producing an ulcer, and subse- quent opacity. In some few instances, the internal lamella? of the cornea gives way, and the matter escapes into the anterior chamber. When __ an artificial opening is made, the matter often does not readily flow out; and it is sometimes so tenacious, and contained in a cavity so irregular, that it neither escapes spontaneously, nor can it be evacuated by art. It is particularly to the cases, in which matter collects between the layers oi the cornea, that the terms unguis, and onyx, are applied. (See Wardrop's Essays on the Morbid Anatomy of the Human Eye, Vol. 1. chap. 6.) According to a late writer, these words should be restricted to what be names " crescentic interlamellar depositions. "— (Trover*'* Synopsis of the Diseases of the Eye, p. H5.| Where the cornea is affected wiih onyx, this gentleman commends antiphlo gistic treatment. (P. 278.) And with re. spect to a large collection of matter in tbe cornea, whether the puriform onyx, or cen- tral abscess, he observes that it requires "a supporting constitutional treatment, mild cathartics, and the application of blisters:" calomel should be avoided, and tbe < ornea can seldom be punctured to advantage (P. 280.) OPACITIES OF THE CORNEA. Opacity of the cornea is one of the worst consequences of obstinate chronic ophthal- my. Ihe term opacity is used, when the loss of transparency extends over the whole, or the greater part of the cornea; while other cases of a more limited kind are nam- ed srecks. The d'*tinction, as Iieer observes, is chiefly important in respect to the prog- nosis. (Lehre von den Augenkr. B. 2, p. 77.) Scarpa distinguishes the superficial and recent species of opacity from the albugo and leucoma, (see these words,) which are not in general attended with inflammation, assume a clear pearl colour, affect the very substance of the cornea, aud form a dense speck upon tbis coat of the eye. The ne- bula or slight opacity, here to be treated of, is preceded and accompanied by chronic ophthalmy ; it allows the iris and pupil to be discerned through a kind of cloudiness, and consequently does not entirely bereave the patient of vision, but permits him to distin- guish objects, as it were, through a mist. The nebula is an effect of protracted or ill treated chronic ophthalmy. The veins of the conjunctiva, much relaxed by the long continuance of the inflammation, become preternaturally turgid and prominent; after- wards they begin to appear irregular and knotty, first in their trunks, then in their ra- mifications, near the union of the cornea with the sclerotica, and lastly, in their most minute ramifications, returning from the de- licate layer of the conjunctiva, spread over the cornea. It is only, however, in extreme relaxation of the veins of tbe conjunctiva, that these very small branches of the cornea become enlarged. When this happens, some reddish streaks begin to be perceptible, in the interspace of which, very soon afterwards, a thin milky albuminous fluid is effused, which dims the diaphanous state oi tbe cornea. The whitish, delicate, superficial.'speck, thence resulting, forms precisely what is termed, nebula, or the kind of opacity here to be considered. And since this extravasation may happen only at one point of the cornea, or in more places, the opacity may be in one *peck. or cornea. an in several distinct ones, but which altogether diminish, more or less, the transparency of this membrane. The cloudiness of the cornea which some- times takes place in the inflammatory stage of violent acute ophthalmy, especially differs from the species of opacity expressed by the term nebula. The first is a deep extravasa- tion of coagulating lymph in the internal cellular texture of the cornea, or else the opacity proceeds from an abscess between the layers of this membrane about to end in ulceration. On the other hand, the nebula forms slowly upon superficies ofthe cornea, in long protracted chronic ophthalmy; is preceded first by a varicose enlargement of the veins in the conjunctiva, next of those in the delicate lamina of this tunic, conti- nued overthe frontof the cornea; and finally it is followed by an effusion of albuminous lymph in the texture of this thin layer, ex- panded over the transparent part ofthe eye. This effusion never elevates itself in the shape of a pustule. Wherever the cornea is affected with nebula, the part of the con- junctiva, corresponding to it, is constantly occupied by a net-work of varicose veins, more knotty and prominent than other ves- sels of the same description, and though the cornea be clouded at more points than one, there are distinct corresponding fasciculi of varicose veins in the white ofthe eye. Scar- pa injected an eye affected with chronic ophthalmy,and nebula,and he foundthat the wax easily passed, both into the enlarged veins of the conjunctiva, and those of that part ofthe surface ofthe cornea where the opacity existed ; the inosculations all round the margin of the cornea were beautifully variegated, without trespassing that line, whicb bounds the sclerotica, except on that side, where the cornea was affected with the species of opacity. Mr. Travers does not adopt precisely the same definition of nebula, as Scarpa; for, he describes it as a thickening of the con- junctiva, and an effusion of adhesive mat- ter bet een it and the cornea, or between the lamella ofthe latter, commonly the pro- duct of acute strumous ophthalmy. (Synop- sis, fa. p. 118.) " According to Scarpa, the superficial opa- city, which alone he calls nebula, demands, from its very origin, active treatment; for, though at first it may only occupy a small portion of the cornea, when left to itself, it advances towards tbe centre of this mem- brane, and the ramifications of the dilated veins upon this coat, growing still larger, at length convert the delicate continuation of the conjunctiva upon the surface ofthe cor- nea, into a dense opaque membrane, ob- structing vision. The curative indication in this disease is to make the varicose vessels resume their natural diameters, or if that be impracti- cable, to cut off all communication between the trunk of the most prominent vari- cose veins of the conjunctiva, and the ra- mifications coming from the surface of the cornea, the seat of the opacity. The first mode of treatment is executed by means of topical astringents and corroborants, espe- cially Janin's ophthalmic ointment, and suc- cess attends it, when the opacity is in an early state, and not extensive But when advanced lo the centre ofthe cornea, the most infallible treatment is the excision of the fasciculus of va- ricose veins near their ramifications, that is, near the seat of the opacity. By means of this excision, the blood retarded in the di- lated veins of the cornea is voided ; the va- ricose veins of the conjunctiva have an op- portunity to contract and regain their tone, no longer having blood impelled into them ; and the turbid secretion effused iu the tex- ture of the layer of the conjunctiva conti- nued over the cornea, or in the cellular sub- stance, connecting these two membranes, becomes absorbed. The celebrity, with which the nebula disappears, after this ope- ration, is surprising, commonly in twenty- four hours. The extent, to which the exci- sion of the varicose veins of tbe conjunctiva must be performed, depends upon the extent ofthe opacity ofthe cornea. Thus, should there be only one set of varicose vessels, corresponding to an opacity of moderate extent, it is sufficient to cut a portion of thern away. Should there appear several dim specks upon the cornea, with as many distinct sets of varicose vessels, arranged round upon the white ofthe eye, the surgeon must make a circular incision into the con- junctiva, near the margin ofthe cornea, by which he will certainly divide every plexus of varicose vessels. But let it be observed, that a simple incision through the varicose vessels is not permanently effectual in de- stroying all direct communication between the trunks and ramifications of these vessels upon the cornea, after such an incision made, for instance, with a lancet; though it be true that a separation of the mouths of the divided vessels follows in opposite direc- tions, it is no less true, that in the course of a few days after the incision, the mouths of (he same vessels approximate each other, and inosculate, so as to resume their former continuity. Hence, to derive from this ope- ration all possible advantage, it is essential to extirpete with the knife a small portion of the varicose plexus, together with the adhe- rent particle of the tunica conjunctiva. The eyelids are to be separated from the affected eye by a skilful assistant, who is, at the same moment, to support the patient's head upon his breast. The surgeon is then to take hold of the varicose vessels with a pair of small forceps, near the edge of the cornea, and to lift them a little up, which the lax state ofthe conjunctiva renders easy; then, with a pair of small curved scissors^ he is to cut away the plexus of varicose ves- sels, together with a small piece ofthe con- junctiva, making the wound of a semilunar form, and as near as possible to the cornea. If it should be necessary to operate upon more than one plexus of varicose vessels si- tuated at some distance apart, the surgeon must elevate them one after the other with the forceps and remove them. But, when 31B CORNEA they are very close together, and occupy every side of the eye, he must make an un- interrupted circular incision in the conjunc- tiva, guiding it closely to the margin of the cornea all round, so as to divide with the conjunctiva, all the varico»e vessels. This being done, he may allow the cut vessels to bleed freely; even promoting the hemorrhage by fomenting the eyelids, until the blood discontinues to flow Scarpa then covers the eye with an oval piece of the emplastrum saponis, and a retentive band- age. The eye ought not to be opened till twenty-four hours after the operation, when, usually, the opacity of the cornea will be found completely dispersed ; and, during the ensuing days, the patient is to be en- joined to keep the eye shut, and covered with a bit of fine rag. A collyrium of milk and rose-water warm, may be applied two or three times a day. When the inflamma- tion of the conjunctiva happens, about the second or third day after the operation, par- ticularly in cases in which the incision is made all round, while the greater part of the sphere ofthe eye reddens, a whitish cir- cle, in the pHce of the incision, forms a line of boundary to the redness vvhich does not extend further upon the cornea. This inflammation of the conjunctiva, with the aid of internal antiphlogistic remedies, and topical emollients, abates in a few days, and then pus is secreted along the track of the incision in the conjunctiva. Tbe wound contracts, and growing smaller and smaller, soon cicatrizes. Bathing the eye with warm milk and rose-water is the only local treat- ment necessary in tbis stage of the com- plaint. Thus, not only the transparency of the cornea is revived, but also the preternatural laxity of the conjunctiva is diminished, or even removed. When the conjunctiva sub- sequently appears yellowish and wrinkled, the use of topical astringents and corrobo- rants, and of Janin's ophthalmic ointment, may be highly beneficial, in preventing the recurrence of the varicose state of the'ves- sels. (Scarpa sulle malattie degli occhi, c. 8.) According to the experience of Dr. Vetch, Scarpa's plan of removing the plexus of-va- ricose vessels, together with a portion ofthe conjunctiva, produces no good effect, " ex- cept in cases of great relaxation of tbe mem- brane covering the eye." He asserts, that new vessels immediately appear in the room of those removed, and ihe sood derived from tbe bleeding does not compensate for the irritation produced by the operation. (A Practical Treatise on Ike Diseases of the Eye, p. 86.) However, when it is reflected, that Scarpa advises tbis practice only for advanced cases, and particularly recom- mends topical astringents for the more re- cent stages of tbe disease, he nearly agrees with Dr. Vetch, as far as this point is con- cerned. But, Scarpa's account of the dis- ease and its treatment is left imperfect by the omission of any notice ofthe connexion frequently existing between opacity of the cornea, and a rough scabrous granulated state of the lining of tho eyelids. Vei per- haps, Scarpa was not to be expected to treat of this combination in bis chapter on nebula, because his definition of this super- ficial opacity will not altogether suit the affection of the same membrane, referred* to in the following observations. It h re- marked by Dr. Vetch, that, after the com- plete cessation of conjunctival ophthalmia, as far as regards that portion of the mem- brane," which covers the eye, tbe villous plongation of the vessels of the lining of the eyelids, instead of recovering their na- tural state, acquire a further increase of size so as to produce u rough, scabrous or granu- lated surface, with a secretion of puriform matter. The irritation of this unequal sur- face gradually induces an inflammatory state of the sclerotic vessels, and, consequently, a greater flow of blood towards the cornea : the superficial vessels become varicose ; the conjunctiva assumes a dusky and loaded ap- pearance ; and the cornea becomes opaque, not partially, but throughout the whole extent of its structure. This affection, sayi Dr. Vetch, is essentially different from those nehulous, or partial opacities, which take place in primary sclerotic inflammation, and vvhich consist in slight extravasations, ac- companied by intolerance of light, and in vv bicb any affection of the palpebral linings isa secondary, instead of a primary circum- stance. The cornea is of the green colour, presented by a broken gun-flint; and while it is sufficiently diaphanous to permit the perception of light, it is yet too opaque to allow tbe patient to discern external objects, except by their shades. Nor can the colour of the iris, and limits of ihe pupil be seen. Dr. Vetch also describes Ihe conjunctiva as being sometimes so much relaxed, and its vessels so generally loaded, as to give it a dusky appearance similar to that of tbe cor- nea ; and, in other instances, without much alteration of its thickness, or transparency, it is said to lose for a considerable extent its close attachment to the subjacent lamina of the cornea. Along with the opaque state of the cornea, there is more generally an enlargement of individual vessels, which penetrate almost to its centre, increase as (hey come outwards, and terminate id trunks, which run to the duplicative of the conjunctiva. Dr. Vetch represents this dis- ease of the palpebre as consisting at first in a highly villous Mate of their membranous lining. This state, if not rectified by proper treatment, gives birth to granulations, whicb, in time, become more deeply sulcated, hard, or warty, accompanied by an oozing of pu- rulent matter. Dr. Vetch has explained, that the use of the actual cautery, excision, and friction, for the purpose of curing the diseased state of the eyelids, •may be traced back to Hippocrates, who prefers escharo- tics. Dr. Vetch ascribes their first employ- ment in these cases to St. Ives. Mr. Saun- ders, he observes, took an early and a just view of the relations, existing between tbe diseased conditions of the palpebral linings. and tbe opaque state of the cornea: and b<- CORNEA 39» succeeded in establishing the cure of the latter by the removal of the former. In short, Dr. Vetch admits, that, in tbe case, which more especially formed the claim of Mr Saunders to the discovery of the nature of the disease, the practice of excision was attended with complete success. Dr. Vefch contends, however, that tbis method is for the mo»t part inadequate to the cure of the disease , and that there are very few cases, in which the more certain and consistent process of gradually repressing the diseased surface by escharotic substances will not produce a more complete and permanent cure. After giving a fair trial to a great variety of escharotics, made into ointments, and applied to tbe inside of the upper eyelid, Dr. Vetch found tbe direct application of the escharotic substances themselves was preferable. When there is too much increa- sed action in the vessels of the sclerotic coat, Dr. Vetch recommends the use of escharotics to be preceded by cupping the temples : or, where there is any risk of a slough, tbe application of a leech to tbe inside of the lower eyelid. Whatever will bring on a determination of blood to the head is to be avoided, and a low regimen observed. The escharotics, preferred by Dr. Vetch, are the sulphate of copper and nitrate of silver, scraped in the form of a pencil, and fixed in a portcrayon^ In this way, Dr. Vetch says, they should be applied, not as some have conceived, with the view of pro- ducing a slough Over the whole surface, but, with great delicacy, and in so many points only, as will produce a gradual change in the condition and disposition of the part. As long as there is any secretion of pus, the above application may be materially assist- ed by tbe daily use of the undiluted liquor plumbi acetaiis. When the disease resists these remedies, and its surface is hard and warty, Dr. Vetch applies to the everted sur- face powder of verdigris, or burnt alum, finely levigated; or even lightly touches the diseased surface with the kali purum. In employing these remedies, he enjoins confining their operation to the point of contact, so as to prevent them from hurting the eye. Hence, they are to he applied in very minute quantities with a fine camel's hair pencil, and to be washed off with an elastic gum syringe, before the eyelid is re- turned. Of the employment of astringent collyria, in conjunction with escharotics, Dr. Vetch disapproves. (See A Practical Treatise on the Diseases of the Eye, p. 67, fa.) With respect to the treatment by ex- cision as first practised by Mr. Saunders with scissors, and afterwards by Sir W. Adams with a knife, the principle of cure does not appear to me different from that aimed at with escharotics, unless these lat- ter be supposed not always to destroy, but sometimes to cause an absorption of the fungous granulations. For tbe purpose of cutting away tbe redundant diseased mem- brane,' the eyelids should be everted over a probe. For the form of disease, termed by Mr. Vol. I. 50 Travers ,: strumous nebula, with vessels overshooting the cornea," this gentleman recommends ptyalism. He says, that "the hydrargyrus cum creta, or oxy-muriate, in small, but frequent doses, will sometimes succeed better in this case, than the other forms of mercury, and the combination of calomel with antimony, better than that with opium." When (he internal exhibition of mercury either disorders the bowels, or has no effect on the constitution, frictions are to be preferred. (Synopsis of the Dis- eases of the Eye, p. 282.) In the particular form of opacity, to which he alludes, he disapproves of dividing the vessels of the conjunctiva, before the inflammation has declined. (P. 285.) From some observations, published by Mr. Wardrop, iT would appear, that certain opacities of the cornea are produced by an increase in the quantity of the contents of the eyeball, and nut by tbe deposition of an albuminous fluid in the texture of the cornea, as takes place in the common speck. He considers this fact proved by cases, in which the cornea regained its transparency the instant the aqueous humour was evacua- ted. Some cases are detailed by this gen- tleman, with the view of recommending the practice of puncturing the cornea, and discharging the aqueous humour, for the re- lief of the kind of opacity to which we have here alluded. (See Med. Chir. Trans. Vol. 4, p. 180, fa.) For other opacities of the cornea, refer to Albugo, Leucoma, and Staphyloma. ULCERS OF THE CORNEA. An ulcer is a common consequence ofthe bursting of a small abscess, which not un- frequently forms beneaih the delicate layer ofthe conjunctiva continued over the cor- nea, or in the very substance of tbe cornea itself, after violent ophthalmy. At other times, the ulcer is produced by the contact of corroding matter, or sharp-pointed bodies insinuated into the eyes, such as quicklime, pieces of glass, or iron, (horns, he. As Dr. Vetch has observed, ulceration of the cornea is a very frequent con-equence of purulent ophthalmy The little abscessof the cornea is attended with the same symptoms, as the severe acute ophthalmy; especially with a troublesome sensation of tension in the eye, eyebrow, end nape of the neck; with ar- dent heat; copious secretion of tears ; aver- sion to light ; intense redness of the con- junctiva, particularly near the point of sup- puration. The inflammatory pustule, com- pared with similar ones, in any other part of the body, is slow in bursting after matter is formed. Scarpa deems it improper, how- ever, to puncture the small abscess; for, though it assumos the appearance of being perfectly maturated, the matter contained in it is so tenacious, and adherent to the substance of the cornea, that not a particle issues out of the artificial aperture, and the wound exasperates tbe disease, increases the opacity of the cornea, and often occa- sions another small abscess to form in the aw CORNEA vicinity of tiie first. Indeed, if the obser- vations of Mr. Travers be correct, " the ulcer of the cornea begins, not in abscess, but, in a circumscribed deposit of lymph, or in pure ulcerative absorption without pus." (Synopsis of the Diseases of the Eye, p. 106.) And Dr. Vetch takes notice, that the observalion, with respect to fluid matter never forming in the cornea, he invariably found true in several cases, where the whole of the eyeball had been destroyed by inflam- mation. (Pract. Treatise on ihe Diseasesofthe Eye, p 52.) This author differs from Scurpa, however, respecting the question of opening pustules, or abscesses of the cornea; for he remarks, that, whenever the matter, or slough is removed, the ulcer, however deep and extensive, will fill up without leucoma being the consequence. By a little address, he says, it may, in most instances, be remo- ved in a mass upon the point of a lancet, or couching needle. (Op. cit. p. 50.) This re- mark applies both to cases where lymph, or tenacious matter more or less protrudes, and to instances, in which it is quite confi- ned between the lamella? of the cornea. Scarpa thinks that the safest plan is to tem- porize, until the pustule spontaneously bursts, promoting it by means of frequent fomentations, bathing the eye with warm milk and water,and applying emollient poul- tices. The spontaneous bursting of the little abscess is usually denoted by a sudden increase of all the symptoms of ophthalmy; particularly by an intolerable burning pain at the point of'the cornea, where the abscess first began, greatly increased by motion of the eye, or eyelid. The event is confirmed by ocular inspections and at the spot where the white pustule existed, a cavity appears, as may best be seen, when the eye is view- ed in the profile. Extraneous bodies in the eye, which have simply divided a part of the cornea, or lodged in it, when soon ex- tracted, do not in general cause ulceration, as the injured part heals by the first inten- tion. Those which destroy or burn the surface of this membrane, or which, when lodged, are not soon extracted, excite acute ophthalmy, suppuration at the injured part, and at length ulceration. As Dr. Vetch has observed, the appear- ance of ulceration varies according to the degree of apostemation, ortendency towards it, in the surrounding cornea: when this part is clear, the case is doing well, but when opacity comes on, the ulcer is increasing. The soft middle lamina, he says, is destroyed with great rapidity, when the inflammation is violent, but as soon as tbe ulcer reaches the internal coat, its progress often proceeds no further. (Practical Treatise on Diseases ofthe Eye, p. 52.) The ulcer of the cornea, as Scarpa re- marks, has this in common with all solutions of continuity in the skin, where this is deli- cate, tense, and endowed with exquisite sensibility, that, at its first appearance, it is of a pale ash-colour; has its edges high and irregular; creates sharp pain'; discharges, instead of pus, an acrid »erura. and tends to spread widely and deeply. Such is the pre- cise character of ulcers upen the cornea, and such is the nature of those upon the nip- ple of the mainme; the glans penis; lips; apex ofthe tongue ; the tarsi; the entrance ofthe meatus auditoriuse.Mernus; nostrils; &c. Ulcers of this description, neglected, or ill treated, speedily enlarge, mute their way deeply, and destroy the parts in which they are situated. If they spread superfi- cially upon the cornea, the transparency of this membrane is destroyed; if they pro- ceed deeply, and penetrate the anterior chamber of the aqueous humour, tbis fluid escapes, and a fistula of tbe cornea may en- sue ; and if it should form a larger opening in it, besides the exit ofthe aqueous humour, it occasions another more grievous malady than the ulcer itself, namely, a prolapsus of a portion of the iris ; an escape of the crys- talline lens and vitreous humour; in short, a total destruction of the whole organ of sight. It i« therefore of the highest import- ance, as soon as an ulcer appears upon the cornea, to impede its growing larger, as much as the nature of it will permit; the morbid process should be converted into a healing one, and the surgeon must exert his skill with more attention, the more extensivo and deep the ulceration has proceeded. According to Scarpa, the cicatrix of a larger ulcer impairs the texture of the cornea so much, that the injury is irreparable. Yet, Dr. Vetch assures us, that when a slough covers an ulcer of considerable extent, and is taken off with great caution, so as not to wound the inner tunic pf the cornea; or when it cannot be removed, if it be slightly scarified, and divided ; the cornea may re- cover its transparency after two-thirds of it have been in this state. (Prad. Treatise on the Diseases ofthe Eye, p. 51.) They who inculcate, that no external ap- plication can be adopted with benefit, for the cure of this disease, before the acute oph- thalmy has been subdued, or, at least, dimi- nished, are, in Scarpa's opinion, deceived. Experience teaches, that local remedies ought, in the very first instance, to be ap- plied to the ulcer, such as are appropriate to lessen the increased morbid irritability, and stop the destructive process going on; afterwards such means should be taken, as will cure the ophthalmy, if it does not sub- side gradually, as the ulcer heals. It is a fact, confirmed by repeated observation, that it is the ulcer which keeps up the oph- thalmy, not the ophthalmy the ulcer. The case, however, is to be excepted, in which the ulcer makes its appearance in the height of a sev ere ophthalmy. Here the first indi- cation is to abate inflammation, before at- tempting to heal the sore. It is true, that when the little abscess of the cornea breaks, the symptoms of acute ophthalmy are aggravated ; the redness of the conjunctiva is increased, as well as tbe turgid state of its vessels ; but it is equally certain, that it happens from no other cause, than an increased inflammation in the part. in consequence ofthe augmented sensibility CORNEA 395 iu the ulcerated spot ofthe cornea. As soon as this increase of sensibility in the ulcer of the cornea ceases, or abates in violence, the ophthalmy retreats with equal speed, and finally, when the ulcer heals, the inflamma- tion disappears gradually, or, at most, re- quires only the use of an astringent, and corroborant collyrium, for a few days. Ana- logous examples every day occur in practice, in ulcers of other parts, besides the cornea ; particularly in little foul ulcers on the inside of the lips, on the apex of the tongue, on the nipples, on the glans penis, which, as was described above, at their first appearance, assume an ash-coloured surface, excite in- flammation of the part in which they are seated, and cause a very troublesome itching and ardent heat in the part affected. To subdue this inflammation, we do nothing more, and the vulgar do the same, than re- pel the excessive irritability in these ulcers, and convert the ulcerative process into cica- trization : this done, the surrounding inflam- mation immediately disappears of itself. Such speedy and good effects may be ob- tained by caustic. It immediately destroys the naked extremities of tbe nerves in the ulcerated part, and soon removes the dis- eased irritability in the part affected ; it con- verts the ash-coloured surface of the ulcer, and the serous discharge upon it, into an eschar and scab, which, as a kind of epider- mis, moderates tiie contact of the neigh- bouring parts upon the ulcer, and at length converts the process of ulceration into that of granulation and cicatrization. For cauterizing the ulcer of the cornea, the caustic, to which Scarpa gives the pre- ference, is the argentum nitratum. It must be scraped to a point like a crayon pencil, and the eyelids being opened perfectly, and the upper eyelid suspended, by means of Pellier's elevator, the ulcer of tbe cornea is to be touched with the apex sufficiently to form an eschar. Should any of the caustic dissolve in the tears, the eye must be co- piously bathed with warm milk. At the in- stant the caustic is applied, the patient com- plains of a most acute pain ; but this aggra- vation is amply compensated, by the ease experienced a few minutes after the opera- tion ; the burning heat in the eye ceases, as it were by a charm; the eye and eyelids become capable of motion without pain; the flux of tears and theturgidityof the ves- sels of the conjunctiva decrease ; the patient can bear a moderate light, and enjoys re- pose. These advantages last while the es- char adheres to the cornea. On the separation of the eschar, some- times at the end of two, three, or four days after the application of the caustic, the pri- mary symptoms of the disease recur, espe- cially the smarting and burning pain at the ulcerated part of the cornea ; the effusion of tears ; tbe restraint in moving.the eye aud eyelids; and the aversion to light; but all these inconveniences are less in degree than before. At their recurrence, the sur- geon, without delay, must renew the appli- • atinn of the argentum nitratum. making a good eschar, as at first, upon the whole sur- face of the ulcer, vvhich will, as before, be followed by perfect ease in the eye. The application of the caustic is, if required, to be repeated a third time, that is, if upon the separation ofthe eschar, the extreme irrita- bility in the ulcer is not exhausted, and its progressive mischief checked. When the case goes on favourably, it is a constant phe- nomenon in the cure of this disease, that, at every separation of the eschar, the diseased sensibility of the eye is decreased ; the ulcer also, abandoning its pale ash-colour, as- sumes a delicate fleshy tint, a certain sign that the destructive process vvhich prevailed is turned into a healing one. The turgid state of the vessels of the conjunctiva, and the degree of ophthalmy, disappear, in pro- portion as the ulcer draws near to a cure. At this epoch, when the formation of gra- nulations has begun, tbe surgeon would act very wrongly, were he to continue the use of the argentum nitratum ; it would now reproduce pain, effusion of tears, and in- flammation in the eye ; and the ulcer would take on that foul ash-coloured aspect, with swelled and irregular edges, which it had in the beginning. Platner has noticed this fact. Necesse est, ut hoc temperata manu, nee crebrius fiat, ne nova inflammatio, novaque lachryma hie acrioribus concitetur. Inst. Chi- rurg. § 314. As soon as ease is felt in the eye, and granulations begin to rise, whether after the first, second, or third application of the caustic, the surgeon must refrain from the use of every strong caustic, and use only the following collyrium. JJ Zinci Sulphatis gr. iv. Aq. Rosa %iv. mucil. Sem. Cydon. mali ^ss M. This to be used every two hours, the eye, in the intervals, being de- fended from the air and light, by means of a slight compress, and retentive bandage. When, besides the ulcer of the cornea, a slight relaxation ofthe conjunctiva remains, Janin's ointment, towards the end of the treatment, introduced between the eye and eyelids, morning and evening, proves ser- viceable. It must be adapted in strength and quantity to the particular sensibility of the patient. To cure those superficial excoriations of the cornea, which make no excavation in the substance of this membrane, and which, in reality, are only a detachment of the cu- ticle, covering the layer of the conjunctiva continued over the cornea, the use of caus- tic is not requisite. The same collyrium, combined with mucilage, is sufficient. The symptoms which accompany such slight ex- coriations, or detachments of the cuticle, are unimportant, and when the patient takes care to bathe his eye, every two or three hours, with the solution of sulphate of zinc, and to avoid too much light, and ex- posure to the air, they soon get well. According to Dr. Vetch, when the ulcera- tive process is likely to destroy the mem- brane, which lines the cornea, it can only be checked by measures, calculated to subdue the inflammation, upon which it depends. " As long, therefore, as *here is an anpP8»- 396 CORNEA. ance of activity in the disease, or recurrence of pain, local blood-letting, by cupping, or leeches, must be steadily adhered to. The indication of the ulcer healing is easily seen in the diminished activity of the inflamma- tion, relief from pain, and the clean aspect ofthe ulcerated part. The injection of ve- getable, tepid astringent infusions may be used, or milk and water only. When called upon in extreme cases, where the imme- diate perforation of the inner membrane is threatened, we may, with great propriety, resort to the operation of puncturing the cornea at a plai e as remote as possible from the ulcer- Next in importance to a diminu- tion of the action, on which the ulcer de- pends, is the removal by scarification of any slough thrown out from its surface, or imbed- ded in the adjoining part of the cornea. Sometimes, but always subordinate to these indications, we may add some topical ap- plications to the ulcer; a solution of nitrate of silver, the infusion of tobacco, or calo- mel, in powder, applied with a camel's hair pencil." (Practical Treatise on Diseases of the Eye,p.o7.) In incipient protrusions of the inner membrane of the cornea, this au- thor decidedly condemns the use of the ar- gentum nitratum in the free manner propo- sed by Scarpa ; observing, that, " if the caustic touches by accident the edge of the ulcer, or any part but the apex of the pro- jecting vesicle, it will often produce much mischief." Thus far of ulcers of the cornea, and the best mode of curing them inordinary cases. However, sometimes, says Scarpa, in con- sequence of ill-treatment, the ulcer, already very extensive, assumes the form of a fun- gous excrescence upon the cornea, appear- ing to derive its nourishment from a band of blood-vessels of the conjunctiva ; and, on this account, it occasions, not unfrequently, a serious mistake in being taken for a real pterygium. Left to itself, or treated with slight astringents, it produces, in general, a loss of the whole eye. It requires the speedy adoption of some active and effica- cious plan, to destroy all the fungus upon the cornea, to annihilate tbe vessels of the conjunctiva tending to it, and to impede the progress of ulceration. This consists first in cutting away the fungus, w ith a pair of small scissors, to a level w ith the cornea, continuing the incision far enough upon the conjunctiva, to remove, with tbe excres- cence, that string of blood-vessels, from which it seems to derive its supply. Ha- ving effected this, and allowed the blood to flow freely, Scarpa applies the argentum nitratum to all the space of the cornea, which appears to have been the seat of tbe fungus, so as to make a complete eschar; and if, upon its separation, the whole morbid surface should not be destroyed, he repeats the caustic until the ulcerative process changes into a healing one. To execute commodiously such a lull application of the caustic, it is not in general enough to have the upper eyelid raised by an assistant, and the lower one depressed; it is also further requisite, that the operator, by means of g spatula, introduced between the upper eye- lid and the eyeball, should hold tne same elevated with his own left-hand, while, with the right, he applies the caustic, so as to form a strong deep eschar. The action of the caustic cannot always be calculated with precision, and therefore a portion of the whole tbicknes* of the cornea may be destroyed with the fungus, which never fails to be followed by a pro- lapsus of part of the iris, through the aper- ture made in the cornea. This accident may seem grievous, yet it is not irreparable, a* will be shown in the article hit, Prolapsus of; and when the surgeon tan produce a firm cicatrix at the point, where the excres- cence was situated, which prevents a repro- duction of the fungus, and a total destruc- tion of the eye, he has fulfilled the indica- tions required. (Scarpa suite Malaltie degli Occhi.) Iu a late publication, two cases of ulcer of the cornea are recorded, which were be- nefited by Mr. Wardrop's operation of punc- turing the cornea and discharging the aqueous humour. In ihe first example, there was an ulcer on the central part of the cornea, and a cluster of blood-vessels pass- ing towards it. The w hole eyeball was also much inflamed. The puncture was madeat the place where tbe vessels pa-sed. The pa- tient's severe headach "wu9 relieved, and under tbe use of fomentations, and the vinous tincture of opium, all the other symptoms rapidly subsided. In the second case, there were two or three erosions, with a good deal of muddiness of the cornea, headach, he. The obscurity of this mem- brane instantly disappeared, and the head- ach subsided, upon the aqueous humour being discharged.. With the help of bleed- ing and fomentations, the symptoms abated, the ulcer healed in a few days, and tbe eye recovered. (See Med. Chir. Trans. Vol.4, p. 186—187.) In superficial ulcers of the cornea, attend- ed with much inflammation of the conjunc- tiva, Mr. Travers recommends opium, com- bined so as to operate upon the skin, and keeping the bowels well open. Here he differs from Scarpa, in specifying the use of the nitrate of silver, as the best local treat- ment. Warm fomentations, he says, afford temporary relief, and where the inflamma- tion of the sclerotica is intense, he advises the exhibition of mercury (Synopsi* tf the Diseases ofthe Eye, j>. 218.) With regard to the treatment of indolent, and deep sloughing ulcers ofthe cornea, Mr Travers praises, in addition to the employ- ment ofthe nitrate of silver, the occasional use of leeches, and the administration of tonics and sedatives. The same author has also noticed chronic interstitial ulcers, where the cornea is trans- parent, " but indented, like a bonce, when struck upon a marble hearth, or pitted, ac- cording as tbe ulcers are diffused, or circum- scribed." These are said to succeed acute inflammation, wheu large quantities of blood CORNEA 39; have been lost, and to occur frequently in children imperfectly nourished, or in adults, who are very debilitated. With the aid of good diet, tonics, and moderate topical stimulants, like the vinum opii, or the zinc collyrium, they become hazy, which de- notes the commencement of the adhesive inflammation. (Op. cit. p. 117.) OS6IF1CATIOS OF THE CORNEA. Mr. Wardrop has seen only one instance of ossification of the cornea; and, in that case, the whole eye was changed iu its form, and the cornea had become opaque. On macerating the latter part,* a piece of bone, weighing iwo grains, oval-shaped, hard, and with a smooth surface, was found between its lamellae. A piece of bone was also found between the choroid coat and retina. The same gentleman informs us, that Walter had, in hismusuem, a piece of cor- nea, taken from a man sixty years of age, containing a bony mass, which was three lines long, two bro*d, and weighed two grains. In Mr. Wardrop's publication, there is also recorded a curious case, in which a portion of bone was formed, either in the substance of the cornea, or immediately be- hind it, and which was extracted from the eye by Mr. Anderson, surgeon at lnverary. The patient was a woman thirty-one years of age, and the formation of the bony sub- stance, which was about half as large as a sixpence, is said to have been occasioned by a fall against the root of a tree, fifteen years before the operation, by which acci- dent the eye was struck, though not cut. (See Wardrop's Essays on the Morbid Anato- my ofthe Human Eye, Vol. 1, chap. 10.) ALTERATION IN THE FORM OF THE CORNEA. This is the last subject which I shall take notice of in tbe present article. It is well known, that the convexity ofthe cornea va- ries in different persons, and in the same in- dividual at different periods of life, this part of the eye being naturally most convex in young subjects. It appears, also, from the experiments of the late Mr. Ramsden, and those of Sir E. Home, that the sphericity of the cornea is altered according to the dis- tance at which objects are viewed. Sometimes the cornea projects, or col- lapses so considerably, without its transpa- rency being affected, that sight is much im- paired, or quite destroyed. The first case has been called by some authors, the Sta- phyloma pellucidum; the second Rhytidosis Leveillfe, the French translator of Scarpa's book on the diseases of the eye, has descri- bed a case, in which the cornea of both eyes became of a conical form.' Mr. War- drop met with two examples of a similar disease ; but only one eye was affected in each of them. In both cases, the conical figure of the cornea was very remarkable, and the apex in the cone was in the centre of the cornea. When the eye was viewed laterally, the apex resembled a piece of solid crystal, and when looked at directly opposite, it had a transparent sparkling ap- pearance, which prevented the pupil and iris from being distinctly seen. One of these cases occurred in a lady up- wards of thirty years of age, and the changes produced in her vision were very remarka- ble. At the distance ofan inch, or an inch and a halt, she could plainly distinguish small objects, when held towards the tem- poral angle of the eye, although it required consideraide exertion ; but the sphere of vision was very limited. On looking through a small hole in a card, she could distinguish objects held very close to the eye, and could even read a book. At any distance greater than two inches, vision was very indistinct; and, at a few feet, she could neither judge of the distance, nor the form ofthe object. When she looked at a uist.-nt luminous body, such as a candle, it was multiplied five or six times, and all the images were more or less indistinct. She could never find any glass sufficiently concave to as- sist her vision. She did not remark this complaint in her eye, until she was about sixteen years of ane, and sbe does not think it has undergone any change since that time. In Mr. Wardrop's publication may be read a letter from Dr. Brewster, giving an expla- nation of the phenomena of the foregoing case. It appears, that Mr. Phipps has had op- portunities of watching the progress of seve- ral cases, in which the cornea had become conical, aud that he never saw the disease in persons underthe age of fourteen or six- teen. The same gentleman also observes, thai when the cone is once complete, tbe disease seldom makes any further progress, except that the apex sometimes becomes opaque. Burgman saw a remarkable case, where the cornea of both the eyes of a person, who had been hanged, were so prodigious- ly extended, that they reached down to the mouth, like two horns. (Haller, Disputa- tiones Chirurg Tom. 2.) The chapter by Mr. Wardrop on the preceding subject wij.1 be found highly iuleresting to such as are desirous of further information concerning this curious disease of the eye. (See War- drop's Essays on the Morbid Anatomy of the Eye, Vol. 1, chap, la.) For information^ relative to diseases of the cornea, see M. Geiger, De Fistula Cornea, Tub.1742. C. F. Gifftheil, De Ulceribus Cornea, Tub. 1744. / W. Baury, De Maculis Cornea, fa. Tub. 1743. G. H. Volgcr, De Maculis Cornea, 4to. Gott. 1778. A G. Richter, An- fangsgr. der Wundarzn. B.3, Kap. 4, Svo. Gott 1795. An!. Scarpa, Trattato delle Ma- luttie degli occhi,lEd. 8vo. Pavia, 1816,chap. 8, 10. J- Beer, Praktiscfie beobacht. fiber den grauen Staar, und die Krankheiten, Der Hornhaut, Wien. 1799, und Lehre von den Augpikr. 2 B. Wien. 1817. M. J. Chelius, Uebn die durclisichlige Hornhaut de* Auges, 39s CORNS. ihre Fund.on, und ihre Krankhaflen Veran- derungen. Svo. Karsrulie, 1818. A. Clemens, Diss, sistens Tunica Cornea et Humoris Aquei Monographiam Physiologieo-paihologi- cam, 4to. Gott, 1816. J. Wardrop's Essays on the Morbid Anatomy of tht Human Eye, Vol. 1, 8ro. Edit. 1808. B. Travers, Synop- sis of the Diseases of the Eye, 8»o. Lond. 1820. J. Vetch, a Practical Treatise on the Diseases of the Eye, 8vo. Lond. 1820. Ihe sections of this work on opaque cornea, and ulceration ofthe cornea, are highly interest- ing. CORNS. (Clavi, Spina Pedum, Colli, Condylomata, fa.) A corn, technically call- ed clavus, from its fancied resemblance to the head of a nail, is a brawn-like hardness of the skin, with a kind of root sometimes extending deeply into the subjacent cellular substance. When this is the case, the indura- ted part is fixed ; but while the hardness is more superficial, it is quite moveable. Some corns rise up above the level of the skin, in the manner of a fiat wart. They are hard, dry, and insensible, just like the thickened cuticle, vvhich forms on the soles ofthe feet, or on the hands of labouring people. Corns are entirely owing to repeated and long-continued pressure. Hence, they are mostfrequentlyin such situations as are most exposed to pressure, and where the skin is near bones, as on tbe toes, soles of the feet, &c. However, corns have occasionally been seen over the crista ofthe ilium, from the pressure of stays, and even on the ears, from the pressure of heavy ear-rings. Corns ofthe feet are usually owing to tight shoes, and, consequently, they are more common in the higher classes, and in women, than other subjects. In females, indeed, the ridiculous fashion of wearing high-heeled shoes, was very conducive to this affliction ; for, certainly, it merits the appellation. In shoes thus made,the whole weight of the body falls principally on the toes, which become quite wedged, and dread- fully compressed in the end ofthe shoe. Though some persons, who have corns, suffer very little, others occasionally endure such torture from them, that they are quite incapable of standing or walking. Doubt- less the great pain proceeds from the irrita- tion of the hard corn on the tender cutis beneath, which is frequently very much in- flamed, in consequence of the pressure. It is observed, that every thing which accele- rates the motion of the blood, which heats the feet, which increases the pressure of the corn on the subjacent parts, or the de- termination of blood to the feet, or which promotes its accumulation in them, exaspe- rates the pain. Hence, the bad effects of warm stockings, tight shoes, exercise, long standing, drinking, &c. The pain in warm weather is always much more annoying, than in winter. If a person merely seeks temporary relief, it may be obtained by pulling off his tight shoes, sitting down, placing his feet in a horizontal posture, and becoming a Jittle cool : the prominent portion of the corn should be cut off, as far as if can be done, without exciting pain, or bleeding, and the feel should be bathed in warm water. The radical cure essentially requires the avoidance of all the above causes, and, par- ticularly, of much walking, or standing. Wide, soft shoes, should be worn. Such means nre not only requisite for a radical cure, but they alone very often effect it. How many women become spontaneously free from corns in childbed, and other con- finements ! Though the radical cure is so easy, few obtain it, because their perseve- rance ceases as soon as they experience the wished-for relief. When business, or other circumstnnces, prevent the patient from adopting tbis plan, and oblige him to walk or stand a good deal, still, it is possible to remove all pres- sure from the corn. For this purpose, from eight to twelve pieces of linen, smeared with an emollient ointment, and having an aperture cut in the middle, exactly adapted to the size of the corn, are to be laid over each other, and so applied to the foot, that the corn is to lie in the opening, in such a manner that it cannot be touched by the shoe, or stocking. When the plaster ha* been applied some weeks, the'corn com- monly disappears, without any other means Should the corn be in tbe sole of the foot, it is only necessary to put in the shoe a felt- sole wherein a hole has been cot, corres- ponding to the situation, size, and figure, of the induration. A corn may also be certainly, permanent- ly, and speedily eradicated, by the following method, especially when the plaster< and felt-sole wifh a hole in it, are employed at the same time. The corn is to be rubbed twice a day with an emollient ointment, such as that of marshmallows, or with tbe volatile liniment, which is still better; and, in the interim, is to be covered with a soft- ening plaster. Every morningand evening, the foot is to Joe put for half an hour in warm water, and, whilst there, the corn is to be well rubbed with soap. Afterward, all the soft, white, pulpy outside of the corn, is to be scraped off with a blunt knife ; , but, tbe scraping is to be left off, tbe mo- ment the patient begins to complain of pain from it. The same treatment is to be per- sisted in, without interruption, until the corn is totally extirpated, vvhich is generally ef- fected in eight or twelve days. If left off sooner, the corn grows again. A multitude of other remedies for curing corns are recommended. They all possess, more or less, an emollient and discutient property. The principal are green wax, soap, mercurial, and hemlock plasters, a piece of green oil-skin, &.c. Thev are to he applied to the corn, and renewed as often as necessary. An infallible composition consists of two ounces of gum ammoniacum, the same quantity of yellow wax, and six drams of verdigris. In a fortnight, if the corn yet remain, a fresh plaster is to be ap- plied. Tt is frequently difficult, and hazardous fo CRE <.ut out a com. The whole must be com- pletely taken away, or else it gr vvs again ; and the more frequently it is partially cut away, the quicker is its growth rendered When the skin is moveable, and, conse- quently, the com not adherent to the subja- cent parts, its excision may be performed with facility and safety, but not without pain. But, in the opposite case, either leaving a piece of the corn behind, or wounding tbe parts beneath, can seldom be avoided. The latter circumstance may ex- cite serious mischief. A person, entirely cured of corns, is sure to be affected with them again, unless the above-mentioned causes be carefully avoid- ed. Some subjects are, indeed, particularly disposed to have tbe complaint. Tbere are persons, who for life wear tight shoes, and take no care of their feet, and yet are never incommoded with corns. On the contrary, others are constantly troubled with them, though they pay attention to themselves. Many are for a time vexed with corns, and then become quite free from them,.though they continue to wear the same kind of shoes and stockings. Mr. Wardrop recommends cutting, or tearing away as much of the corn as can be done with safety ; then keeping the toe for some time in warm water ; and, after the adjacent skin has been well dried, rubbing the exposed surface of the corn with the ar- gentum nitratum, or wetting it, by the means of a camel-hair pencil, with a solu- tion ofthe oxy-inuriate of mercury in spirit of wine. Either of these applications, two or three times repeated, he says, will mostly effect a cure. (See Med. Chir. Trans. Vol. 5, p. 140.) However, the use of caustic for the cure of corns is not a new proposal. (See Callisen's Syst. Chir. Hodierna, Part. 2, 200.) The above account is chiefly taken from Richter's Anfangsgrunde der Wundarzney- kunst, B. 1. COUCHING. The depression of the ca- taract, or the introducing of an instrument into the eye, for the purpose of pressing the opaque crystalline lens downward, out of the axis of sight. (See Cataract.) COUVRE CHEF. The name of a band- age. (See Bandage.) CRANIUM. For an account of its frac- tures, see Head, Injuries of. CREMOR LITH\RGYRI ACETATI. ft. Cremoris lactis 3jj. Liq. Plumbi. acet. CUR 399 3j. M. Employed by Kirkland in ophthal- mies, and other inflammations. CREPITATION. The crackling noise made in cases of emphysema, when the air is passing from one part of the cellular membrane into another. CREPITUS, (from crepo, to make a noise.) This term is applied by surgeons to the grating sensation, occasioned by the, ends of a fracture, wheu they are moved, and rubbed against each other. A crepitus is one of the most positive symptoms of the existence of such an accident. 41 CUBEBiE. (Cubabah, Arab.) Piper caudatum. Cumamus. Cubebs. The dried berries of the Piper Cubeba of Linnaeus :— foliis oblique ovatis, seu oblonges venosis acu- tis,spica solitaria pedunculata oppositifolio fructibus pedicellatis. They are of an ash brown colour, generally wrinkled, and re- sembling pepper, but furnished each with a slender stalk. They are a warm spice, of a pleasant smell, and moderately pungent taste, imported from Java ; and may be exhibited in all cases where warm spicy medicines are indicated. Great encomium has been passed upon this article as a reme- dy in gonorrhoea, and is considered under that head in the Appendix. CUt'PlNG. (See Bleeding.) CUPRI SULPHAS. (Sulphate of Cop- per.) Is an escharotic, and an ingredient in several astringept fluid applications, lo- tions for ulcers, collyria for the eyes, and injections for the urethra. CURETTE. (French.) An instrument, shaped like a minute spoon, or scoop, in- vented by Daviel, anchised in the extraction of the cataract, for taking away any opaque matter, which may remain behind the pupil, immediately after tbe crystalline has been taken out. CURVATURE OF THE SPIJVE. (See Vertebra, Disease of.) CYSTITOME. (from nunc, and rtava, to cut.) An instrument made on the same principle as the pharyngotomus, and invent- ed by M. de la Faye, for opening the cap- sule of the crystalline lens. CYSTOCELE. (from Kvtri;,the bladder, and mKn, a tumour.) A hernia, formed by a protrusion of the bladder. (See Hernia.) CYSTOTOMf A. (from mtk the bladder, and ttf/im, to cut.) Making an opening into the bladder for the extraction of a stone or calculus. (See Lithotomy) . D. JDaCRYOMA. (from cicucgiMi, to weep.) An impervious state of one, or both the puncta lachrymalia, preventing the tears from passing into the lachrymal sac. DAUCUS. The carrot, when boiled, and beaten to a pulp, is used in surgery as a poultice, which is often applied to malignant and phagedenic ulcers. (See Cataplasma Dauci.) DECOCTUM CHAMtEMELI. R. Flo rum Chamcemeli |ss. Aquae Distillatae lbj Boil ten minutes, and strain the liquor. A common decoction for fomentations. (See Fomtnlum.) DECOCTUM DULCAMARA. R. Dal- -luO DEC DIP camarse Caulis Concisa> unciam, Aquw uc- tarium cum Semisse. Decoque ad octarium, et cola. The decoction of bittersweet, or woody nightshade, is recommended for some cuta- neous diseases, proceeding from scrofula, lepra, and lues venerea. Tbe dose is one or two table spoonfuls, three times a day. An aromatic tincture should be added. DECOCTUM HELLEBORI ALBI.— (Now the Decoclum Veratri.) ft. Pulveris Radices Hellebori Albi ^j. Aqua? Distilla- tae lbij. Spiritus Vinosi Rectificati |ij. Boil the «ater and powder, till only one half the fluid remains, and when cold, add the spirit. This is used as a lotion for curing psora, porrigo, and some herpetic affections. DECOCTUM LOBELIA. (Blue Cardi- nal Flower of Virginia.) ft- Radicis Lobe- lia; Syphilitica; Sicca? Manipj. Aqua; Dis- tillate? lb. xii. This is to be boiled till only four quarts remain. The lobelia once gain- ed repute as an antivenereal, though little reliance is now put in it. The patient is at first to take half a pint twice, and afterwards four times a day. It operates, however, as a purgative, and the doses must be regula- ted according as the bowels appear to bear them. DECOCTUM MEZEREI. £. Cortlcis Radicis Mezerei Recentis 3U- Radicis Glycirrhizae Contuse ^j. Aquae Distillatae tbiij. Boil the mezereon in the water, till only two pints remain ; and, when the boil- ing is nearly finished, add the liquorice root. The decoction of mezereon has been much prescribed for venereal nodes and nocturnal pains in the bones, in doses of from four to eight ounces, three times a day. DECOCTUM PAPAVERIS. ft. Papa- veris Somniferi Capsularum Concisarum |iv. Aquae Ibiv. Boil for a quarter of an hour, and strain. In cases attended with great pain and inflammation, this decoction is used as a fomenting fluid. DECOCTUM QUERCUS. ft. Quercus Corticis ?j. Aqua lbij. Boil down to a pint, and strain tbe fluid. This decoction forms a very astringent injection, vvhich is sometimes used for stop- ping gleets from tbe vagina. It also makes a lotion, which is of considerable use in ca- ses of prolapsus ani. It may be applied to some slight rheumatic white swellings, which it will sometimes cure, particularly, when a little alum is put into it. DECOCTUM SARSAPARILL^E. ft. Sarsaparilla Radicis Concisee ^iv. Aquae Ferventis, Ibiv. The sa* saparillae is to be macerated for four hours, near the fire, in a vessel lightly closed. The root is then to be taken out. bruised, and put into tbe fluid again. The maceration is to be continued two hours longer, after which the liquor is to be boiled till only two pints remain. Lastly, it is to be strained. DECOCTUM SARSAPARILLA COM- POSITUM. ft. Decocti Sarsaparillae fer- ventis Ibiv. Sassafras Radicis Concisae, Guaiaci Ligni Rasi, Glycyrrhizae Radicis Contuse, Singuloruro §j. Mezerei Rudicuj Corticis 3'ij- These are to be boiled to- gether for a quarter of an hour, and then strained. This, and the preceding decoction of sar- saparillce, are much prescribed by surgeon* in cases of venereal nodes and pains; but, while some surgeons bold them in high re- pute, in such cases, others entertain an op- posite opinion of them. They are also com- monly given in several cutaneous diseases, and in scrofula. The simple decoction is frequently direct- ed for the restoration of the constitution after a course of mercury, sometimes mix- ed with an equal quantity of milk. The common dose of both the decoction; is from four to eight ounces, three times a day. . The compound one possesses similar aualitics to those ofthe famous Lisbon diet rink, for which it is now generally pre- scribed. DECOCTUM ULMI. ft. Ulmi Corticis Recentis Contus. ?jiv. Aqua; lblv. Boil to two pints, and then strain the liquor. Tbe decoction of elm bark is often pre- scribed in cutaneous diseases. Its operation is frequently promoted by giving with it the hydrargyri submurias. DECOCTUM VERATRI. (See Decoc- turn Hellebori Albi.) DEPRESSION OF THE SKULL. (See Head, Injuries of.) DEPRESSION OF THE CATARACT (See Cataract.) DETERMINATION. When the blood flows into a part more rapidly and copious- ly than is natural, it is said, in the language of surgery, that there is a determination of blood to it. DLERESIS. (from J«u;u to divide.) A division of substance ; a solution of conti- nuity. This was formerly a sort of generic term, applied to every part of surgery, by which the continuity of parts was divided. DIGESTION, (from digero, to dissolve.) By the digestion of a wound, or ulcer, the old surgeons meant bringing it into a state, in which it formed healthy pu3. DIGESTIVES. Applications which pro- mote this object. DIORTHROSIS. (from ?0go», to di« rect.) One of the ancient divisions of sur- gery -. it signifies the restoration of parts to their proper situations DIPLO'PIA. (from cTwrx»f, double, • and o»f. the eye, or wrlajuaj, to see.) Visu* duph- catus. This i- one of the most unusual dis- eases of the eyes, and it is of two kinds. For instance, the patient either sees an object double, treble, he. only when he is looking at it vvitb both bis • yes, and no sooner is one eye shut, than the object is seen single and right; or else, he sees every object double, whe- ther he surveys it with one, or both his eyes. The disorder is observed to affect persons in different degrees. Patients seldom see the two appearances, which objects present with equal distinctness; but generally, discern one much more plainly and perfectly, than the other. The first dh'inct shape, which DIPLOPIA. 401 strikes the eye, is commonly that of tbe real object, while the second is indistinct, false, and visionary. Therefore, patients labour- ing under this affection, sel om make a mis- take, but almost always know which is the true and real object. However, (here are cases in which tne pa1 ient sees wiih equal clearness, the (wo appearances which things assume, so thai he is incapable of distinguish- ing the real object from what is false and only imaginary. The disorder is sometimes transitory and of short duration, and may be brought on in a healthy eye by some accidental cause, gene- rally an irritation affecting the organ. Some- times, the complaint is continual; some- times periodical. In particular instances, the patient only sees objects double, when he has been straining his sight for a consider- able lime, as for example, when be has been reading a small print for a long while by can- dlelight. In this case, the disorder becomes lessened by shutting the eyes for a few mo- ments. There arealso instances, in which the objects only have a double appearance at a par- liculardistance, and not, either w hen they are nearer or furtheroff. Sometimes the p itient sees objects, double only upon one side, as, for example, w hen he turns hi* eyes 10 the right hand, while nothing of this sort is experien- ced in looking in any other direction. In certain ca-es, objects appear double, in what- ever way the eyes are turned and directed. The causes of double vision may be divi- ded into four classes. Namely, the object which the patient looks at, may be repre- sented double upon the retina, which is the effect of the first class ot causes. Or, the object may be depicted in one eye differently from whut it is in the other, in regard to size, position, distance, clearness, he.; this is the effect of the -i-cond class of cau-es. Or, the object may appear to one eye to be in a different place from that which it seems to the other to occupy: tbe effect of the third class of causes. Or, lastly, tbe sensi- bility of the optic nerves is defective, so that the image of an object, though it may appear single to one eye as well as tbe other, yet in one identical situation will seem double to both of them. When the complaint origi- nates lrom causes of ihe first and fourth class, the patient sees things double, whether be is using only one, or both eves; but, wheu it proceeds from (he second and third class of causes, the patient sees objects double only when he is looking at them with both eyes, and, no sooner does he shut one, than objects put on their natural, single ap- pearance. The following are the chief causes of the first class of a single object being depicted upon the retina as if double. 1. An uneven- ness of the cornea, which is divided into two, or more convex surfaces. There are cases, which show, that such an uneven shape may actually be the cau.-e of double vision. (Haller Element. Physiol. Tom. 5, p. 85.) According 10 Beer, Ibis conformation of the cornea is mostly a result of several prece- ding ulcers of that membrane, in which cir- Vot. I 51 cumstance the patient sees with the affected eye not merely double, l>ut treble, and quad- ruple, ol which facts Beer has met with some examples. (Lehre von den Augenkr. B. 2, p. 31.) However, it must not tie dissembled, that in a far greater number of instances, such unevenness of the cornea, though equally considerable, does not occasion this defect of sight. We have principally an op- portunity of observing cases of this sort after Ibe operation of extracting tbe cata- ract. Hence, it would seem, that the in- equalities must be of very particular shape to produce double vision. The diagnosis of this cause is ea-v enough ; but, the re- moval of it is impracticable : for. how is it possible to restore the original shape of the cornea ? On this case, however, Beer de- livers a more favourable prognosis than Richter, for he states, that when the pa- tient is not decrtpil, Ihe double vision, from altered shape of the cornea, will gradually disappear of itself when proper care is taken of the constitution, and in particular of the eye. (B. 2, p. 32.) 2. An inequality of the anterior surface of the crystalline lens, whereby the same is divided into several distinct surfaces, it is suggested, may also be the occasion of diplopia. Sucti an inequali- ty may possibly produce the disorder ; but, it is exceedingly doubtful wheiher any case of this sort has ever been met with, and, as Richter properly remarks, the investigation is not worth undertaking, as the diagnosis and cure would be equally impracticable. The only possible method of cure would be the extraction, or depression, of the crystal- line lens ; yet, with (he uncertainty respect- ing the nature of the cause, what man would be ju-rified iu performing an operation, in which the patient is not wholly exempt from the danger of losing hi> sight altogether? A double aperture in the iri-, or as the case is termed, a double pupil, aid a deviation of the pupil from its natural position, have been enumerated as causes of diplopia. (Bau- mer in Act. Soc. Hassiac. 1, No. 27.) How- ever, Richter deems the reality of the first of these causes doubtful; for, cases have been noticed, where double vision was not the effect of there being two openings in the iris. (Janin Mim. sur I'Oeil.) But, were the disorder actually to originate in this way, it would not admit of a cure. The causes of the second class, by the effect of which-the object is represented, in regard to its size, position, di-tance, he. dif- ferently in one eve from what it is in the other, are for tbe most part rather possible, than such as have been actually observed. Tbe causes, which make objects assume an appearance contrary to tbe real one, may sometimes be confined lo one eye, to which, things are depicted diversely from what they are to the other healthy eye, so that the patient sees, as it were double. Thus, for example, there may be a stronger refrac- tion of the rays of light in one eye than the other ; the patient may be a myo'ps with one eye, and a presbyops with the other; and then the object will seem to one eye large, 4tftl DIPLOPIA to the other small, to one eye distant, to the other plainly near. This,state of the sight, indeed, is said to have occurred after ope- rating upon a cataract in one eye. (Heuer- mann.) However, that this is not a common consequence of operating upon a cataract in one eye, while the other is perfect, is uf- ficiently clear, from what has been said upon the subject, in a foregoing part of ibis work. (See Cataract.) In particular examples, ob- jects which are perpendicular seem to the patient to have a sloping posture. When it is considered, tha^ only one eye is thus affect- ed, and that to it things will appear sloping, and to the other straight, double vision must be tbe effect. A few remarks connected With this subject will be introduced hereafter. (See Sight, Defects of.) When both eyes are so directed to an ob- ject, that it becomes situated in the axis of vision of each of these organs, such object is represented in both at the same place, that is, it is depicted upon that part of the retina, on which the axis of sight falls. Thus tbe object seems to both eyes to be in the same place, and, though the two organs discern the thing, it only communicates a single ap- pearance. But, when one eye is turned to any object in a different direction from that of the other; that is to say, when one eye is turned to an object in such a wiy, that tbe object is situated in the axis of vision of this eye, while the opposite eye is so turned, that the same object is placed on one side of its axis of vision ; in other words, when a person squints ; the object is depicted in one eye upon n different part of the retina from what it is in the other ; consequently, the object appears to the two respee'ive or- gans to be differently situated, and the pa- tient is affected with diplopia. This is the third species of this disorder, which arises from strabismus as a third kind of occasional cause. Such patients naturally see objects double only when tbey behold them with both eyes. A person, who squints, usually has one eye stronger than the other, and the weak- ness of one of these organs is the common cause of the strabismus. Such a person does not see objects double, because be only sees with one eye well, and with the other so faintly and imperfectly, that scarcely any impression is made. Hence, every case of strabismus is not necessarily combined with diplopia; indeed, tbe common kind of squint- ing is not joined with it. A person, affect- ed with strabismus, only sees double, when the sight of each eye is equally strong, and when tbe squinting does not depend upon *ay weakness of one of the eves, but upon some other occasional causes. The princi pal causes of the latter sort are of a spasmo- dic nature, viz.: an irritation affects some muscle of the eye in such a manner, that the patient is incapacitated from moving both Biseyea according to bis will, and from direct- ing tbem to any object, so that such object may be at once in tbe axis of vision of both. On this case, the observations of Sir E. Home are interesting, who has made many accurate reflections on the rtlect oi an irre- gular action of the straight muscles of the eye in producing double vision. fP/ti7. Trans, 1797.) Richter states, that, in the majority of cases, the irritation alluded to is seated in Ihe ga-uic organs, though he thinks, that, any other species of irritation may operate upon the eyes in a -iindar manner. This kind of diplopia is frequently attendant on other spasmodic diseases as a symptom. It often accompanies hypochondrii-is. Sometimes, it is the consequence of violent pain. Rich- ter informs us of a man, who saw double and squinted, during a severe headach. lie states, that another was affected in Ihe same way during a toolhach. Sometimes, the diplopia is owing to a paralysis of .>ne of the muscles of the eye; (Morgagni de Sedi- bus et Causis Morborum, Epist. l;s. art. 20; a paralysis of the abductor muscle) some- times, to a tumour in the orbit. I lie diag- nosis of this kind of diplopia is free from difficulty ; the patient having been affected with squinting ever since things appeared double to him. The views which Sir E. Home took of diplopia from irregular action, spasm, or weakness, of any particular muscle of tbe eye, led him to propose a plan of treat- ment, the principle of which is to keep the muscle affected for a time, perfectly at rest, which is eaany done, by covering the eye wiii a bandage, and not allowing the organ to be at all employed. The fourth class of causes are such irrita- tions as act upon the optic nei res, changing their sensibility in such a way, thai objects do not make that sort of impression upon them, which tbey ought to do. Thus, things sometimes have the appearance of being coloured, when they are really not so ; im- moveable objects seem in motion, straight objects appear oblique, and in the c.ses, which we are now treating of, single things seem to tbe eye double, treble, fee This faulty kind ot sensibility may also be pro- duced by irritation in eyes, whicb are per- fectly sound; but it is most readily occa- sioned in eyes, which are pre.ernaturally weak and irritable. In these very tiivial and inconsiderable irritations will often excite it In the treatment, the couunou judication is to discover and remove whatever irritation conduces to this effect > bm, the attempt fre- quently fails. In irritable eyes, the disorder is often brought on by very •light irritations, which cannot always be dimiuisbed, or re- moved. Here, the grand indication is to cure the weakness and irritnbility of tbe or- gans. According to Richter, the fourth class of causes ol diplopia is the mosl irequent. The irritations are of various kinds, and general- ly seated in tbe abdominal viscera. Diplo- pia is sometimes the ton e.pje.ice ol in- ebriety, foulness of the stomach, intermitting fevers, hypocbondri sis, wor.ns, &c. How- ever, tbe complaint is occasion-illy excited by other sorts of irritation. It has frequent ly followed a violent fright. It may be con- DIPLOPIA. 40* nected with spasmodic and painful diseases of several kinds. Severe keadacns and tootbachs are sometimes joined with this affection of the sight. Richter mentions a boy, who, be'me in the wood?, was struek by the bough of a tree over the eye, and, in consequence of the accident became affect- ed with diplopia. He informs us of a man, who rode a journey on horseback, along a snowy road on a very sunshiny day, and was affected in the same manner. This af- fection of the eyes is sometimes the effect of injuries of the head. (See Hill's Cases in Surgery,p. 108. Schmucker, Med Chir. Be- merk, 1 B. No. 26. Hennen's Principles of Military Surgery, p. 345, Ed. 2.) Persons who have weak eyes, are apt to become double-sigh'ef', whenever Ihey look atten- tively for a long while at any light shining objects. Patients ii. fev: rs are also -omelimes double-sighted. (Gooch's Cases, fa Vol. 2.) The irritation, productive of diplopia, may lead to other serious complaints of the eye, when it operates with great violence. In- deed, it frequently happens, that diplopia terminates in some other disorder of the eyes, and is often the forerunner of Ine worst diseases of these organs, particularly the gutta serena. The difficulty, or ease of the cure, partly depends upon the nature of the remote cause, and partly upon the con- dition of the eye. Some of the causes are easy, others difficult of removal. V\ hen the eye is very weak and irritable, the disorder frequently continues, notwithstanding the irritation has been removed. Also, when the complaint is relieved, it is exceedingly difficult to prevent a relapse, for on very ir- ritable eyes, slight irritations, which cannot be hindered, are apt to produce a return of the affection Therefore, the indication is to rem.ive the existing defect of sight, and take means for the prevention of its return, or the commencement of any other. The weakness and preternatural irritability of the eye should be removed, as well as every sort of irritation, things which are often dif- ficult of accomplishment. The chief business of the surgeon in the treatment of this kind of diplopia, consists in endeavouring to find out and remove the irritation occasioning the disorder. The majority of such irritations are of the same nature as those, which give rise to the gutta serena. (See Amaurosis ) Indeed, both the complaints are often only different effects of the same cause, and of course require a similar mode of treatment. The boy whom Richter has mentioned, as having become double-sighted in consequence of being struck over the eye with the bough of a tree, was cured by the external use of the infu- sum radicis Valerianae and spiritus vini cro- catus, with which the eyelids and adjacent parts were rubbed several times a day. A diplopia, which followed a violent fright, was cured by valerian, preceded by a few doses of cream of tartar. The case report- ed by Dr. Hennen, as proceeding from a gunshot wound of the soft parts, covering fbe root of the nose and right eyebrow. yielded to abstinence, occasional emetics, and cold collyria. (Principles of Mil. Sur- gery, Ed. 2, p. 345.) A hypochondriacal patient got rid of the disorder by means of the warm bath. \ diplopia, supposed to arise from disorder of the biliary secretion, was cured by means of pills made of gum- galbanum, g :aiacum, rhubarb, and Venice soap, assisted with emetics and purgatives. When the irritation, exciting the disor- der, is only of temporary duration, as for instance, looking at shining objects; when the disorder continues after the removal of the irritation ; or, lastly, when the irritation cannot be well detected; the surgeon is to endeavour, by means of nervous and sooth- ing medicines either to remove the impres- sion which the irritation has left upon the nerves; or to render the nerves insensible to the continuing irritation. According to Richter the following remedies have proved useful in cases of diplopia: hartshorn, drop- ped into the hand, and held before the eyes; the external use of the spiritus vini croca- tus ; warm bathing of the eye, particularly iu a decoction of white poppy heads; bath- ing the eye in cold collyria ; the internal administration of bark, valerian, small do- ses of ipecacuanha, flowers of zinc, and oleum cajeput. In one instance, in which it was impossible to detect the cause, Rich- ter states, that soluble tartar with ox's gall and castoreum was found of service ; that, in another similar case, rhubarb, ox's gall, and assafoetida ; and, in a third, liquor am- monia; acetatae with ox's gall, proved use- ful. This author further observes, that, in all cases, in which the particular cause of the disorder cannot be precisely determi- ned, we may conjecture that such cause has its seat in the abdominal viscera; and that much benefit may often be derived from mild resolvents, evacuants, and anodyne medicines. (Richter's Ansfangsgr. der Wun- darzn. B. 3 Kap. 15.) According to Beer, the diplopia, which is not an effect of the continuance of another disease after inflammation of the eye, but probably depends upon injury ofthe retina, caused by such inflammation, usually di- minishes, without the assistance of art, if the eye be not abused. (Lehre von den Au- genkr. B. 2, p. 32.) Fen- the foregoing ac- count of diplopia I am chiefly indebted to Richter. See also A Voter et J. C. Heinitke, Visus Vilia duo rarissima; alteruth duplicati, alterum dimidinli fa. Witlemb. 1723. (Hal- ler Diss, ad Morb. 1, 305.) J. J. Klauhold de Visu duplicato, 4to. Argent. 1746. Buchner de Visione simplici et duplici, 4to. Argent. 1753. Eider, Richerches Physiques sur la diverse rifrangibiliti des rayons de lumiire; Mim.deI'Acad. des Sciences, fee; Berlin,p. 200, 1754. Klinke de Diplopia, 4to. Goett. 1774. Sir E. Home's Obs. on the straight Muscles of the Eye, and the structure of the Cornea, in Phil. Trans, for 1797; B. Gooch, Chir. Cases, fa Vol. 2, p. 42, fa. 8vo. Lond. 1792. Keghellini, Letter a sopra V off era della cistainuna Donna, fa. 8vo. Venet. 1749; an instance of Diplopia from double pv-pil. Dirt. 404 DISLOCATION des Sciences, Med. T.9,p. 497. J. Wardrop, Eissays on the Morbid Anatomy of the Human Eye, Vol. 2, p. 216, fa. 8vo Lond. 1818. DIRECTOR, (from dirigo, to direct.)— One of the most common instruments of surgery; it is long, narrow, grooved, and made of silver, in order that it may be bent into any desirable shape Its use is to direct the knife, and pro eel the parts un- derneath from the edge or point of the lat- ter instrument. The surgeon introduces the director under the parts, whicb he means to divide, and then either cuts down, along the groove of the instrument wiih a com- mon bistoury, or cuts upward with a nar- row, curved, pointed bistoury, the point of which is turned upwards, which lie careful- ly introduces along the groove. This instru- ment and the crooked bistoury are com- monly employed for opening sinuses, for cutting fistula in ano, and fistula; in other situations, and for dilating the stricture in cases of hernia. DISLOCATION. (fromdwZoce, to put out of place.) A Luxation. When the articu- lar surfaces of the bones are forced out of their proper situation, the accident is termed a dislocation or luxation. Mr. Astley Cooper has justly remarked, that, of the various accidents which happen to the body, there are few which require more prompt assistance, or in which the re- putation ei the surgeon is more at stake, than cases of luxation ; for, if much time be lost prior to the attempt at reduction, there is great additional difficulty in accom- plishing it, and it is often entirely incapable of being effected. If it remains unknown, and consequently unreduced, the patient be- comes a living memorial of the surgeon's ig- norance or inattention. Hence, this experi- enced surgeon forcibly inculcates the careful study of anatomy ; the want of *n accurate knowledge of the structure of the joints being the chief cause of the many errors, which happen in the diagnosis and treat- ment of dislocated bones. The following passage cannot be too deeply impressed upon the surgeon's mind: "A considerable share of anatomical knowledge is required to de- tect the nature of these accidents, as well as to suggest the best means of reduction ; and, it is much to be lamented,that ourstu- dents neglect to inform themselves suffi- ciently of the structure of the joints. They often dissect the muscles of a limb with great neatness and minuteness, and then throw it away, without any examination of the ligaments, the knowledge of whicb, in a surgical point of view, is of infinitely greater importance ; and from hence arise the numerous errors of which they are guilty, when tbey embark in the practice of their profession ; for, the injuries of the hip, elbow, and shoulder, are scarcely to be detected, but by those who possess accurate anatomical information. Even our hospital surgeons, who have neglected anatomy, mistake these accidents; for, I have known thepullies applied to an hospital patient, in case af a fracture ofthe neck of the thigh- bone, which had been mistaken for a dislo- cation, and the patient cruelly exposed, through the surgeon's ignorance, to a vio- lent and protracted extension. It is there- fore proper, that tbe form of the ends of tbe bones, tiieir mode of articulation, the liga- ments by which they are connected, and the direction in which the larger muscles act, should be well understood." (Surgical Essays, Part I,p. 2) ihe most important differences of luxa- tions are,—1. With respect to the articula- tion, in which tnese accidents take place;— 2. The extent of the dislocation;—3. The direction in which tbe bone is displaced ;— The length of time the displacement has ntinued,—6 The circumstances which accompany it, and which make the injury simple or compound ;—6. And lastly, with respect to the causes of the accident. 1. Every kind of joint is not equally lia- ble to dislocations Experience proves, in- deed, that, in the greater part of the verte- bral column, luxations are absolutely im- possible, the pieces of bone being articula- ted by extensive, numerous surfaces, va- rying in their form and direction, and so tied together by many powerful, elastic means, that very little motion is allowed. Experience proves, also, that the strength of the articulations of the pelvic bones can scarcely be affected by enormous efforts, unless these bones be simultaneously frac- tured. Boyer has therefore set down luxa- tions of joints with continuous surfaces as impossible. (Traiti des Maladies, Chirurg. T. 4. p. 17.) And, Mr. A. Cooper observes, that, in the spine, the motion between any two bones is so sma 1, that dislocations hardly ever occur, except between the first and second vertebra;, although the bones are often displaced by fracture. (Surgical Essays, p. 14.) In the articulations with contiguous sur- faces, the facility with which dislocations happen, depend? upon the extent and varie- ty of motion in such joints. Thus, in the short bones of the carpus, and particularly of the tarsus, and af the carpian and tarsian extremities of the metacarpal and metatarsal bones, where flat broad surfaces are held to- gether by ligaments, strong, numerous, and partly interarticular, and where only an ob- scure degree of motion can take place ; dis- locations are very unfrequent, and can only be produced by uncommon violence. The loose joints, which admit of motion in every direction, are those in which dislo- cations most frequently occur; such is that of tbe humerus with the scapula 0b the contrary, the ginglymoid joints, which al- low motion only in two directions, are, com- paratively speaking, seldom dislocated.— The articular surfaces of the latter are of great extent, and, consequently, the heads of the hones must be pushed a great way in order to be completely dislocated ; and the ligaments are nuirrerous and strong. 2. With respect to the extent of the dis- location, luxations are either complete or in- complete. The latter term is applied when DISLOCATION. 403 the articular surfaces still remain partially in contact. Incomplete dislocations only occur in ginglymoid articulations, as those of the foot, knee, and elbow. In these, the luxation is almost always incomplete ; and very great violence must have operated, when they are completely dislocated. In the elbow, the dislocation is partial, with respect both to the ulna and radius. In the orbicular articu- lations, the luxations are almost invariably complete. However," the os humeri some- times rests upon the edge of tbe glenoid ca- vity, and readily returns into its socket "— (A. Cooper, Essays Pari 1, p. 14) The lower jaw is sometimes partially dislocated in a manner differentirom what is common- ly meant by this expression, viz. one of its condyles is luxated, while the other remains in its natural si uation. As Mr. \. Cooper has explained, a partial dislocation sometimes occurs at the ankle joint. " An ankle (says be) was dissected at Guy's, and given to the collection of St. Thomas's, which was partially dislocated: the end of the tibia rested still in part upon the astragalus, but a large portion of its sur- face was seated on the os naviculare, and the tibia, altered by this change of place, had formed two new articular surfaces, with their faces turned in opposite directions to- wards the two bones. The dislocation had not been reduced." 3. In the orbicular joints, the head of the bone may be dislocated at any point of their circumference ; and the luxations are named accordingly upward, downward, forward, and backward. In the ginglymoid articulations, the bones may either be dislocated laterally, or forward or backward. 4. The length of time a dislocation has existed, makes a material difference. In ge- neral, recent dislocations may be easily re- duced ; but, when the heads of the bones have been out of their places, for several days, the reduction becomes exceedingly difficult, and in other cases, very often im- possible. The soft parts, and the bone itself, have acquired a certain position ; the muscles have adapted themselves in length to the altered situation ofthe bone, to which they are attached, and sometimes, cannot be lengthened sufficiently to allow the bone to be reduced. Desault and Boyer believe, that frequently the opening in the capsular ligament soon becomes closed, and binders the return of the head of the bone info its original situation ; a statement, which does not coincide with the sentiments of Mr A. Cooper. (Surgical Essays, Part 1, p. 18.) Lastly, the luxated bone may become ad- herent to the parts on which it has been forced. 6 The difference is immense, in regard to the danger of the case, arising from the circumst ance of adislocation being attended or unattended, with a wound, communica- ting, internally with the joint, and externally with the air. When there is no wound of this kind, the danger is generally trivial, and the dislocation is termed a simple one . when fbere is snch a wound, together with tbe dislocation, the case is denominated com- pound, and is frequently accompanied with the most imminent peril. Indeed, the lat- ter kind of accident often renders amputa- tion proper. 6. The causes of dislocations are exter- nal and internal. A predisposition to such accidents may depend on circumstances natural, or accidental The great latitude of motion, whicb the joint admits of; the little extent of the articular surfaces ; the looseness and fewness of the ligaments; the lowness of one side of the articular cavity, as, at the interior and inferior part ol the acetabulum; and the shallowness of the cavity, as of that of the capsula ; are na- tural predisposing causes of luxations. A paralytic affection of the muscles of a joint, and a looseness of its ligaments, are also predisposing causes. When the deltoid muscle is paralytic, the mere weight of the arm has been known to cause such a length- ening of the capsular ligament of the shoul- der joint, that the head of the os brachii descended two or three inches from the glenoid cavity. Two cases, strikingly illustrative of the tendency to dislocation from a weakened, or paralytic state of the muscles, are re- corded by Mr. A. Cooper. The first is that of a junior officer of ah India ship, who, for some trifling offence, had been placed with his foot upon a small projection on the deck, while his arm was kept forcibly drawn up to the yard-arm for an hour. " Wheu he returned to England, he had the power of readily throwing that arm from its socket, merely by raising it towards his head ; but, a very slight extension reduced it. The muscles were wasted, also, as in a case of paralysis." The other example happened in a young gentleman, troubled with a paralytic affection of his right.side from dentition. " The muscles of the shoulder were wasted, and he had the power of throwing his os humeri over the posterior edge of the glenoid cavity of the scapula, from whence it became easily reduced." In these cases, Mr A. Cooper observes, that no laeeration of the ligaments could have occurred, and they show the influence of the muscles in preventing dislocation, and in impeding reduction. (Surgical Essays, Part \,p. 10.) the looseness ofthe ligaments sometimes makes the occurrence of dislocations so easy, that the slightest causes produce them, Some persons cannot yawn or laugh, with- out running the*risk of having their lower jaw luxated. On this account, collections of fluid within the knee, causing a relaxa- tion of the ligament of the patella, are often followed by a dislocation of that bone. And, w henever a bone has been once dis- located, it ever afterwards has a tendency to be displaced again by a slighter cause, than what was first necessary to produce the accident, this tendency, indeed, in- creases with every new displacement. Such diseases, as destroy the cartilages ligaments, and articular Cavities of the 4"G DISLOCATION bones, may give rise to a dislocation. The knee is sometimes, but not frequently, par- tially luxated in consequence of a white swelling ; the thign is often dislocated in consequence of the acetabulum and liga- ments being destroyed by what is commo.ily named the disease of .he hip-joint. Such dislocations are termed spontaneous. In the anatomical collection at St. Tho- mas's Hospital, there is a preparation of a knee, dislocated iu consequence of ulcera- tion, and anchylosed, the leg forming a right angle with the femur directly for- wards. (See A. Cooper's Surg. Essay*, Part l,p. 11.) An enarthrosis joint can only be disloca- ted by external violence, a blow, a fall, or the action ofthe muscles, when the axis of the bone is in a direction, more or less oblique, with respect to the surface with which it is articulated. Any external force may occasion a dislo- cation (generally incomplete) in the gingly- moid joints ; but, in the ball and socket arti- culations, the action of th:-. muscles con- stantly has a share in producing tbe accident. So, when a person falls on his elbow, while his arm is raised outwards from his side, the force, thus applied, will undoubtedly contribute very much to push the head of the os brachii out of the glenoid cavity, at the lower and internal part. Still, the sud- den action ofthe pectoralis major, latissimus dorsi, and teres major, which always takes place from tbe alarm, will also aid in pulling downward and inward the head of tbe bone. Under certain circumstances, tbe violent action of the muscles alone may produce a dislocation, without the conjoint operation of any outward force. But, w hen the patient is aware in time of the violence, which is about to operate, and his muscles are prepared for resistance, a dislocation cannot be produced without the greatest difficulty, (A. Cooper, op. cit. p. 15.) unless the posture of the member it the moment be such as to render the action of the strongest muscles conducive to the displace- ment, instead of preventive of it, as is fre- quently the case in luxations of the shoulder. Dislocations are constantly attended with more or less laceration or elongation of the ligaments: and, in the shoulder and .hip, the capsules are always torn, when the acci- dent has been produced by violence. Some instances, in which the ligaments are only- lengthened and relaxed, I have already quoted. SYMPTOMS OF DISLOCATIONS. As Boyer justly observes, there is not any dislocation, which does not produce pain and incapacity in the limb; but, these symptoms are ouly equivocal, and caunot distinguish the case from a fracture; nor even from a simple contusion. He divides the symptoms of dislocations into those which may be collected from the circum- stances attending tbe occurrence of the ac- cident ; and into others, which he calls pre- sent, or positive. In order that a dislocation may happen, there must be a particular attitude of the limb during the action of the exter- nal violence. Indeed the displacement can hardly occur from the direct action of the cause on the articulation itself. The action of the luxating cause is the more efficient, the further it is from the joint, and the lunger the lever is, which it affects. Thus, in a fab on the side, when the arm, raised considerably from the trunk, has had to sustain all the weight of the body on a point at its inner side, the probability of a dislocation is evident, and even that the head of the bone baa been forced through the lower portion of The capsular ligament. But, the symptoms, which Boyer terras positive, or actually present, are numerous and clear: 1. In dislocations of orbicular joints, and complete taxations of ginglymoid joints, the articular surfaces are not at all in contact, and the point, where the dislocated bone h lodged, cannot be upon the same level with the centre of the cavity, from which it has been forced Hence, a change in the length of the limb. In the ginglymoid joints, such alteration can only be a shorten- ing proportioned to the extent of the dis- placement ; for there is then an overlapping of tbe bones, similar to that of the frag- ments of a fracture, longitudinally dis- placed. But in the orbicular joints, the bone may be displaced and carried above, or be- low, the articular cavity, so that, in the first event, a shortening, in the second, an elon- gation of the limb, will be produced. But, as the direction of the member is at the same time altered, it is not always practica- ble to place the limbs parallel together, nor to bring them near the trunk, for the purpose of judging whether they are lengthened or shortened. A comparison, however, made without this advantage, will generally enable the surgeon to form a cor- rect opinion. The proper length of a dislo- cated limb cannot be restored, except by putting the bone back into the cavity, from which it has slipped. In general, tbis can- not be accomplished without considerable efforts, while a slight exertion is usually sufficient to obtain the same effect in cases, where the shortening of the limb depends upon a fracture. It is also particularly worthy of notice, that, when once the na- tural length of the limb has been restored in dislocations, it remains, while there are a great many fractures, in which tbe shorten- ing of the member recurs after it has been made to disappear. The surgeon must also recollect, that an elongation of the limb can never happen in cases of fracture, as it does in certain dislocations. 2. In almost all complete luxations, the direction of the axis of the limb is unavoida- bly altered. This circumstance arises from the resistance of that portion of the articu- lar ligaments, which has not been ruptured. as well as from the action of tbe muscles In complete lateral dislocations of gingly- moid joints, the direction ofthe axis of the DISLOCATION 407 iunb is not altered, on account of the total rupture ofthe ligaments, and even of a part of the surrounding muscles. Neither is tbis observable in incomplete dislocations of such articulations, on account of the extent of the articular surfaces. But, it is strongly marked in complete luxations of these joints, where the displacement b:is happened in the direction of the articular movements, al- though in cases of this description the liga- ments must be totally ruptured. The mus- cles, which have suffered less, are in a state of extreme tension, and must neces- sarily alter the axis of the limb. Tbe ten- sion of certain muscles, and the preservation of some of the ligaments, especially in the orbicular joints, are also a cause of a rota- tory movement of the dislocated limb at the moment of the displacement, and which it afterwards retains. Thus, in luxations of the thigh, the toes and knee are turned outward, or inward, according as the head of the thigh bone happens to be situated at the inside, or outside of the joint. These two kinds of alteration in the direction of the limb are permanent when they depend upon a dislocation ; a circumstance quite different from what is observable in frac- tures, where the same changes occur, but can be made to cease at once without any- particular effort. 3. The absolute immobility of a limb, or, at least, the inability of performing certain motions, is among the most characteristic symptoms of a dislocation. In some com- plete luxations of particular ginglymoid joints, the dislocated limb is absolutely, or very nearly incapable of any motion. Thus, in the dislocation of the fore-arm back- wards, the particular disposition of the bones, and the extreme tension of the ex- tensor and flexor muscles, confine the limb in the half-bent state, and at the same time resist every spontaneous motion, and like- wise almost every motion which is commu- nicated. In the orbicular joints, the painful tension of the muscles, which surround the luxated bone, nearly impedes all spontane- ous movements, but, in general, analogous motions to that, by which the displacement was produced, can be communicated to the limb, though not without exciting pain. Thus, in the dislocation of the humerus downward, the elbow hardly admits of'be- ing put near the side, nor of being carried forward, and backward; but it can be raised up with ease. In the dislocation of the acromial end of the clavicle, the pa- tient can bring the arm towards the trunk, separate it a little from the side, or carry it forward or backward ;,for he cannot raise it in a direct way. Lastly, in complete lateral dislocations of such joints, as have alternate motions, the patient has the power of performing no motion of the part; but, the complete destruction of all the means of union allows the limb to obey every species of extraneous impulse, and this symptom, which is besides never single, makes the na- ture ofthe case sufficiently manifest. Sometimes, as Mr. A. Cooper has re- marked, a considerable degree of motion continues for a short time after a disloca- tion : thus, in a man brought into Guy's Hos- pital, whose thigh bone had just been dislo- cated into the foramen ovale, a great mo- bility of the femur still remained; but, "in less than three hours it became firmly fixed in its new situation by the contra' tion of the muscles " (Surgical Essays, Part 1, p. 3.) 4. In dislocations with elongation ofthe displaced limb, the general and uniform ten- sion of all tbe muscles arranged along it, gives to these organs an appearance as if they lay nearer the circumference of the bone, and the limb were smaller than its fellow. The muscles, however, which be- long to the side, from which tbe dislocated bone has become more distant, appear more tense than tbe others, and form externally a prominent line. This is very manifestly the case with the deltoid muscle, when the arm is luxated downward. On the contrary, in dislocations where the limb is shortened, the muscles are relaxed ; but, being irrita- ted, they contract and accommodate them- selves to the shortened state of the limb.__ Hence, the extraordinary swelling of their fleshy part, and the manifest tumefaction of the portion of the member, to which they belong:. We have a striking example of this in the dislocation of the thigh upward and outward, where the muscles at the^nsideof the limb form a distinct oblong tumour. The parts, which surround the affected joint, also experience alterations in their form, whenever muscles, connected with the dislocated bone, occupy that situation. Thus, in dislocations of the thigh, the but- tock on tbe same side is flattened, if the bone is carried inward ; but, it is more pro- minent, when the thigh bone is carried out- ward ; and its lower edije is situated higher or lower, than in the natural state, accord- ing as the luxation may have taken place up- ward or dow nward. In the complete luxa- tion of the fore-arm backward, the triceps is tense, and forms a cylindrical promi- nence, owing to the displacement of the olecranon backward, in which displacement it is obliged to participate. 5. The circumference of the joint itself presents alterations of shape well deserving attention, and. in order to judge rightly of this symptom, correct anatomical know- ledge is iif high importance. The form of the joints principally depends upon the shape of the heads of the bones Hence, the natural relation of the bones to each other cannot be altered without a change being immediately produced in the external form of the joint. The changes, vvhich the muscles, passing over the luxated joint, at he same time undergo in their situ- ation and direction, contribute likewise to the difference of shape, by destroying the harmony of what may be called the out! lines of the limb. enarthrosis, has slipped out of the cavitv instead of theplum'pness, which prevfousfv 408 DISLOCATION". indicated the natural relation of parts, the head of 'he dislocated bone may be distin- guished at some surrounding point of the articulation, while at the articulation itself may ne remarked a flatness, caused by one of the neighbouring muscles stretched over the articular cavity, and more deeply may be perceived the outline and depression pro- duced by this cavity itself. The bony emi- nences, situated near the joint, and whose outlines were gradually effaced in the gene- ral form of the member, are rendered much more apparent by the displacement, and project, in a stronger degree, than in the natural state. On this part of the subject, Mr. A. Cooper is particularly correct, when he observes, that the head of the bone can generally be felt in its new situation, ex- cepting in some of the dislocations of the hip, and its rotation is often the best crite- rion of the accident. The natural promi- nences of bone near the joint, either disappear, or become less conspicuous, as the trochanter at the hip-joint. Sometimes the revi rse oc- curs; for in dislocations of the shoulder, the acromion projects more than usual. (Surg. Essays, Part 1, p. 4.) The lines, made by the contour of the limb and the natural relation of the bones, are so manifestly broken in dislocations of ginglymoid joints, that, when there is no inflammatory swelling, the case is intelligi- ble in an instant. More certain knowledge, however, and more correct information, respecting the kind of displacement, are to be obtained by attentively examining the changes of position, which the bony promi- nences, forming the termination of the bones articulated together, have undergone, and which are the more obvious in these joints, inasmuch as they give attachment to the principal muscles. The natural rela- tions of these processes being known, the least error of situation ought to strike the well-informed attentive practitioner. Thus, in the elbow joint, a considerable differ ence in the respective height, and in the distances between the olecranon and inter- nal and external condyles, can be easily dis- tinguished. But, tne thing is less easy when the surrounding parts are so swelled and tense, as to make the bony projections deeper from the surface, and less pbvious to examination. Even then, however, a good surgeon will at least find something to make him suspect the dislocation, and the suspi- cion will be confirmed when be again exa- mines the part on the swelling beginning to subside. It is of the utmost consequence to make out what the case is as early as pos- sible ; for, the unnatural state, in which the soft parts are placed, keeps up the swelling a long while ; and if the surgeon watt till this has entirely subsided, before he ascer- tains that the bones are luxated, he will have waited till it is too late to think of reducing them, and the patient must remain for ever afterward deprived of the free use of his limb. (Boyer, Traiti des Maladies Chir T. A,p. 45, fa.) It is not only the inflammato- ry swelling, which may tend to conceal the state of the ends of the bone ; sometimes a quicker tumour arises from the effusion of blood in the cellular membrane, and causes an equal difficulty of feeling the exact posi- tion of the heads of tbe bones. Dislocations are also, sometimes, attended with particular symptoms, arising altogether from the pressure caused by tbe bead ofthe luxated bone on certain parts. I he sternal end ofthe clavicle has been known to com- press the trachea, and impede respiration. the head of the humerus may press upon the axillary plexus of nerves, and produce a paralytic affection of the whole arm. Id one instance, cited by Mr. A. Cooper, a dis- located cluvicle pressed upon the oesopha- gus, and endangered life. (Surg. Essays, Parti, p. 4.) As Kirkland has observed, there are some luxations, which are far worse injuries than fractures: of this description, ore disloca- tions of the vertebrae, cases which, indeed, can hardly happen without fracture, and are almost always fatal; dislocations ofthe long bones, with protrusion oftheir ends through the muscles and skin, and severe inflammation,extensive abscesses, attended with great risk of being followed by large and tedious exfoliations, and not unfre- quently gangrene. According to Mr. A. Cooper, young sub- jects rarely experience dislocations; their bones break, or their epiphyses give way much more frequently than the articular sur- faces are displaced. (Surg. Essays, Part 1, p. 16.) Suspected luxations of the hip in children commonly turn out to be disease of the joint, one instance of which is given by the preceding author, and an example of which I was lately consulted about ray- self. Also, when a dislocation of the elbow is suspected in a child, because the bone appears readily to return into its place, but directly to slip out of it again, Mr. A. Cooper says, that the case is an oblique fracture of the condyles of the humerus. PROGNOSIS. In general, every unreduced dislocation, must deprive the patient more or less com- pletely of the use of the limb; for, nature cannot in any of these cases re-establish the natural relations which are lost. There is indeed an effort made to restore some of the motions, and tbe use of the limb in a certain degree: but, it is always very im- perfectly accomplished, and in the best ca- ses, only a confined degree of motion is re-established. Nature cannot in any way alter the lengthened or shortened state of the limb ; and she can only correct in eve- ry imperfect manner its faulty direction.— There are even some cases, in which na- ture can effect no amendment whatsoever; as, for instance, complete dislocations of ginglymoid joints in the direction of the ar- ticular movements : here so great an alte- ration would be requisite in the surfaces in contact, and so extensive an elongation of the muscles, that the dislocated part mu5*. continue nearly motionless. DISLOCATION los There are, however, a lew exceptions to this general rule. The arthrodia joints are seldom extensively displaced; and as, in the natural state, their motions are very limit- ed, the loss of these motions, in conse- quence of the natural relations not having been restored, is of less importance.— Thus, the bones of the carpus, those of the tarsus, and the acromial end of the clavicle, may be dislocated, and be reduced either imperfectly, or not at all, without the func- tions of tbe limb, to which they belong, be- ing materially impaired. (Boyer, Traiti des Maladies Chir. T. 4, p. 54.) Dislocations of enarthrosis are generally much less dangerous, than those of gingly- moid joints ; for, the action of the muscles has a great share in producing the former; the violence done to the external parts is less; and the laceration of the soft parts is not so considerable. Even in the same kind of joints, the seriousness of the case depends on the largeness of the articular surfaces, and the number and strength of the muscles and ligaments. Dislocations of the ginglymoid joints, however, are more easily reduced than those of enarthrosis articulations, the mus- cles of which are frequently very powerful, and capable of making great resistance to the efforts of the surgeon. This is fre- quently seen in luxations of tbe shoulder and thigh. It maybe said, however, of the luxations of enarthrosis joints, that, if they happen the most easily, they are attended with less injury; and that, although their reduction may require considerable efforts, yet it can be accomplished, and the accident leaves no ill effects. On the contrary, in dislocations of ginglymoid joints, the same reason which renders them more unfrequent, makes them also more serious. The solidity of these joints prevents the uniting means from be- ing destroyed, except by great violence ; and the extent of the articular surfaces does not permit a considerable displacement, es- pecially a complete one, without extensive injury of the ligaments, and surrounding soft parts. It is for these reasons, no doubt, that compound luxations and protrusions of the heads of the bones, are most commonly seen iu the ginglymoid articulations. Still it must be allowed, that the incom- plete dislocations of these joints, unattend- ed with much displacement, are not at all serious accidents. The more recent a luxation is, the more easy it is to reduce, and therefore, caleris paribus, the less grave is the injury. In this point of view, dislocations of ginglymoid joints are tbe most serious, because they soon become irreducible. Simple dislocations are much less danger- ous, than those which are complicated with contusion, the injury of a large nerve, or blood-vessel, inflammatory swelling, frac- ture, wound, and, especially, a protrusion of one of the articular surfaces. (Boyer, Traili dts Maladies Clr'r. T 4 p. 55, 56.) Voi. I 52 Dislocations from ulceration and suppura- tion in joints, termed spontaneous luxations, cannot admit of reduction : when they arise from the hip-disease, it is not merely in con- sequence of tbe ligaments being destroyed, the brim of the acetabulum ifseif is often annihilated However, there are other.spon- taneous dislocations from preternatural loose- ness of tbe ligaments, where reduction may be accomplished with the greatest facility; though in these instances, the displacement generally recurs from the slightest causes. TlItATMENT OF DISLOCATIONS IN GENERAL Mr. Pott observes :—By what our forefa- thers have said on the subject of luxations, and by the. descriptions and figures vvhich they have left us of the means they used, of what they call their organs and machinema- ta, it is plain, that force was their object, and that whatever purposes were aimed ai or executed by these instruments or ma- chines, were aimed at and executed princi- pally by violence. Many, or most of them, are much more calculated to pull a man's joints asunder, than to set them to rights.— Hardly any of them are so contrived as to execute the purpose for which they should be used, in a maimer most adapted to the nature or mechanism of the parts on which they are to operate. The force or power.of some of the instruments is not always de- terminable as to degree, by the operator, and consequently may do too little or too much, according to different circumstances in the case, or more or less caution or rash- ness in the surgeon. If in the diagnosis of these accidents, an exact knowledge of the ligaments is of the highest importance, a familiar acquaintance witn the muscles is not less essential in the treatment. In dislocations, as in fractures, says Pott, our great attention ought to be paid to the muscles belonging to the part affected. These are the moving powers, and by these the joints, as well as other moveable parts, are put into action j while the parts to be moved are in right order and disposition, their actions will be regular and just, and generally determinable by the will of the a^ent, (at least in what are called voluntary motions,) but when the said parts are dis- turbed from that order and disposition, the action or power of the muscles does not therefore cease ; far from it, they still con- tinue to exert themselves occasionally, but instead of producing regular motions, at the will of tbe agent, they pull and distort the arts they are attached to, and which by eing displaced, cannot perform the func- tions for which they were designed. " Hence principally arise the trouble and difficulty which attend the reduction of luxa- ted joints. The mere bones composing the articulations, or the mere connecting liga- ments, would in general afford very little opposition ; and the replacing the disloca- tion would require very little trouble or force, was it not for the resistance of (he muscles and tendons attached !o and con- 410 DISLOCATION nected with them: tor by examining the fresh joints ofthe human body, we shall find, that they not only are all moved by muscles and tendons, but also, that although what are called the ligaments of the joints do really connect and hold them together, in such manner as could not well be executed without them, yet in many instances, they are, when stript of all connexion, so very weak and lax, and so dilatable and distrac- tile, that they do little more than connect the bones and retain the synovia; and that the strength as well as the motion of the joints, depends in great measure on the mus- cles and tendons connected with and pass- ing over them; and this in those articula- tions which are designed for the greatest Suantity, as well as for celerity of motion. [ence it must follow, that as the figure, mo- bility, action, and strength of the principal joints, depend so much more on the mus- cles,and tendons in connexion with them, than on their mere ligaments, that the for- mer are the parts which require our first and greatest regard, these being the parts which will necessarily oppose us in our at- tempts for reduction, and whose resistance must be either eluded or overcome ; terms of very different import, and which every practitioner ought to be well apprised of." (See Pott's Chir. Works, Vol. 1.) That the muscles are the chief cause of re- sistance is strongly evinced by cases, in which the dislocation is accompanied with injury of any vital organ ; for then the bone may be reduced by a very slight force. Thu3, in a man, who had an injury of his jejunum, and a dislocation of his hip, the bone was most easily replaced. (A. Cooper, Surgical Essays, Part 1, p. 20.) In short, any thing which produces faintness or weak- ness, facilitates the reduction of dislocated bones, as intoxication, nausea and sickness, paralysis, he. The following, which are some of the principles laid down by Mr. Pott, merit at- tention.— 1. Although a joint may have been luxa- ted by means of considerable violence, it does by no means follow, thatthe same de- gree of violence is necessary for its reduc- tion. 2. When a joint has been luxated, at least one of the bones of which it is composed, is detained in tbat unnatural situation by the action of some of the muscular parts in connexion with it; whicb action, by the immobility of the joint, becomes as it were tonic, and is not under the direction of the will of the patient. 3. That all the force used in reducing a luxated bone, be it more or less, be it by bands, towels, ligatures, or machines, ought always to be applied to the other extremity of the said bone, and as much as possible to that only. Mr. Pott argues, that if the ex- lending force were applied to a distant part of the limb, or to the bone below or adjoin- ing, it would necessarily be lost in the arti- culation which is not luxated, owing to the ■ 'elding nature of the ligammt-. and be of little or no service, in that which is dulo- cated. This remark, though made by Pott, and generally received as true, is very in- correct; for, it t« i.ds to state, that if you pull at the ankle, or wrist, the force does not operate on the hip, or shoulder. 4. That in the reduction of such joints, as are composea u( a round bend, received into a socket, such as those of the shoulder and hip, the whole body should be kept as steady as possible. 5. That in order to make use of an extend- ding force with all possible advantage, and to excite thereby the lea^t pain and incon- venience, it is necessary that all parts serv- ing to the motion of the dislocated joint, or in any degree connected with it, be put into such a state as to give the smallest possible degree of resistance. 6. That in the reduction of such joints as consist of a round head, moving in an ace- tabulum or socket, no attempt ought to be made for replacing the said head, until it has by extension been brought forth from the place where it is, and nearly to a level with the said socket. This will show us, says Mr. Pott, a fault in the common ambi, and why that kind of ambi, which Mr. Freke called his commander, isa much better instrument than any of them, or indeed than all; be- cause it is a lever joined to an extensor; and that capable of being used with the arm, in such position as to require the least exten- sion, and to admit the most; besides which it is graduated, and therefore perfectly under the dominion of the operator.. It will show us, why the old method by the door or lad- der, sometimes produced a fracture of the neck of the scapula; as Mr. Pott saw it do himself. Why if a sufficient degree of ex- tension be not made, the towel over the surgeon's shoulder, and under the patient's axilla, must prove an impediment rather than an assistance, by thrusting the head of the humerus under the neck of the scapula. instead of directing it into its socket. Why the bar, or rolling-pin, under the axilla, pro- duces the same effect. Why the common method of bending the arm (that, is, the os humeri) downward, before sufficient exten- sion has been made, prevents the very thing aimed at, by pushing the head of the bone under tbe scapula, which the continuation of the extension for a few seconds only would have carried into its proper place. To the observation, that mere extension only^draws the head of the bone out from the axilla, in which it is lodged, but does not replace it in the acetabulum scapula?, Mr. Pott replies that, when the head of the os humeri is drawn forth from tbe axilla, and brought to a level with the cup of the scapula, it must be a very great and very unnecessary addi- tion of extending force, that will or can keen it from going into it. All that the surgeon has to do, is to bring it to such level; the muscles attached to the bone will do the rest for him, and that whether he will or not. *■ 7. Another of Pott's principles is, that whatever kind or degree of force may b« DISLOCATION. 411 lound necessary for the reduction of a luxa- ted joint, that such force be employed gra- dually ; that the lesser degree be always first tried, and tbat it be increased gradatim. (See Pott's Chir. Works, Vol 1.) The supposition of the reduction being sometimes prevented by the capsular liga- ments, Mr. A. Cooper considers as quite er- roneous : he assures us, that in dislocations from violence, those ligaments are always extensively lacerated ; and that the idea of the neck of the bone being girt, or confined, by them, is altogether untrue. (Surg. Es- says, Part \,p. 18.) But, in addition to the resistance of the muscles, there are in old dislocations three circumstances, pointed out by Mr. A. Cooper as causes of the diffi- culty of reduction. 1. The extremity ofthe bone contracts adhesion to the surrounding parts, so that in dissection, even when the muscles are removed, the bone cannot be reduced. 2. The socket is sometimes filled up with adhesive matter. 3. A new bony socket is sometimes formed, in which the head ofthe bone is so completely confined, that it could not be extricated without break- ing its new lodgment. (Surgical Essays, Pari 1, p. 21.) Dislocations in general cannot be reduced without trouble ; but, after the reduction is accomplished, it is easily maintained. On the contrary, fractures are for the most part easy of reduction; but cannot be kept in tbis desirable state without difficulty. The moment extension is remitted, the muscles act, the ends ofthe broken bone slip out of their proper situation with respect to each other, and the distortion of the limb recurs. As a modem writer has observed, the reduc- tion is only a small part of the treatment of fractures -. the most essential point of it is the almost daily care, which a fracture de- mands during the whole time requisite for its consolidation. The contrary is the case in luxations. Here, in fact, the reduction is every thing, if we put out of consideration the less frequent cases, in which the dislo- cation is complicated, and attended with such grave circumstances, as render it in- dispensably necessary to continue for a length of time the utmost surgical care. But, even'then, the protracted treatment is less for the dislocation itself, than for the extra- ordinary circumstances, with which it is ac- companied. (See Roux, Parellele de la Chi- rurgie Angloise avec la Chirurgie Francaise, p. 207.) All the ancient writers recommend the extending force to be applied to the luxated bone ; for instance, above the knee in dislo- cations of the thigh-bone, and above the el- bow in those of the humerus. We have stated, that Pott, advised this plan, and the same practice, which is approved by J. L. Petit, Duverney, and Callisen, is almost ge- nerally adopted in this country. How ever, many of the best modern sur- geons iu France, for instance, Fabre, D'Apouy, Desault, Boyer, Richerand, and Leveille, advise the extending force not to be applied on fhehixnted bone, but on that with which it is articulated, and as far as possible from it. It is said that this plan has two most important advantages: first, the muscles, which surround the dislocated bone, are not compressed, nor stimulated to spasmodic contractions, which would resist the reduction ; secondly, the extending force is much more considerable, than in the other mode ; for, by using a long lever, we obtain a greater degree of power. In Pott's remarks, we find even him, in- fluenced by tbe prevailing prejudice against the above practice, that part of the extend- ing force is lost on the joint, intervening be- tween the dislocation, and the part at which the extension is made. This notion is quite unfounded, as every man who reflects, for one moment, must soon perceive. When extension is made at the wrist, the ligaments, muscles, he. which connect the bones ofthe fore-arm with the os brachii, have the whole of the extending force operating on them, and they must obviously transmit the same degree of extension, which they re- ceive, to the bone above, to which they are attached. Indeed, this matter seems so plain, that I think it would be an insult lo the read- er's understanding to say any more about it, than that such eminent surgeons, as have contrary sentiments, can never have taken the trouble to reflect for themselves on this particular subject. Wheteerthe force, ne- cessary to be exerted in some instances, would have a bad effect on the intervening joint, may yet be a question ; but, as De- sault's practice was very extensive, and he did not find any objection of this kind, per- haps, we have no right to conclude, that such a one would exist. If, however, the common objection to Desault's plan of applying the extending force be unfounded, the question still re- mains to be settled, whether this practice is most advantageous on the grounds above specified ? This is a point, which, perhaps, cannot be at once peremptorily decided al- together in the negative, or the affirmative, since what may be best in one kind of dislo- cation, may not be so in another. Thus, Mr. A. Cooper states, that, as far as he has had an opportunity of observing, it is gene- rally best to apply the extension to the bone, which is dislocated; but, that dislocations of the shoulder are exceptions, in which he mostly prefers to reduce the head of the bone by placing his heel in the axilla, and drawing the arm at the wrist in a line with the side of the body, whereby the pecto- ralis major and latissimus dorsi are kept in a relaxed state. (Surgical Essays, Part 1, p. 25.) Extension may either be made by means of assistants, who are to take hold of nap- kins, or sheets, put round the part, at which it is judged proper to make the extension ; or else a multiplied pulley may be used. In cases of difficulty, Mr. A. Cooper thinks the pulley should always be preferred. " When assistants are employed, their exertions are sudden, violent, and often ill-directed, and the force is more likely to produce, laeet-ft- 112 DISLOCATION. tion of parts, than lo restore the bone to its situation. Their efforts are also often un- combined, and their muscles are necessarily fatigued, as those of the patient, whose re- sistance they are employed to overcome." In dislocations of the nip joint, and in those of the shoulder which have been long unre- duced, pulleys should always be employed. (A. Cooper, Surgical Essays, Part 1, p. 24.) But, whether pulleys be used, or uol, nothing more need be added to what Mr. Pott has stated, concerning the propriety of using moderate force in the first instance, and in- creasing the extending power very gra- dually. The extension should always be first made in the same direction, in which the disloca- ted bone is thrown; but, in proportion as the muscles yield, the bone is to be gra- dually brought back into its natural position. Thus* the head of the bone becomes dis- engaged from the parts, among which it has been placed, and is brought back to the articular cavity again by being made to fol- low the same course, vvhich it took in esca- ping from it. Extension will prove quite unavailing, un- less the bone, with which the dislocated head is naturally ;arliculate*d, be kept mo- tionless by counter-extension, or a force at least equal to the other, but made in a con- trary direction. The mode of fixing the scapula and pelvis, in luxations of the shoulder and thigh, will be hereafter described. In dislocations of ginglymoid joints, ex- tension and counter-extension arc only made, for the purpose of diminishing the friction of the surfaces ofthe joints, so as to be enabled to put them in their natural situation. When the atfempts at reduction fail, the want of success is sometimes owing to the extension not being powerful enough, and the great muscular strength of the patient, which counteracts all efforts to replace the bone. In the latter case, the patient may be freely bled, and put into a warm bath, so as to make him faint. The opening in the vein should be made large, because a cer- tain evacuation of blood is more likely lo produce weakness and swooning, than a gradual discharge of it; and the pe.tient, for the same reason, may be bled as he stands up. In very difficult cases, tbe expedient of intoxication has been recommended, as when the patient is in this state, his muscles are incapable of making great resistance to reduction. Under these circumstances, opi- um is also frequently administered, with ad- vantage. When tbe mu;cles make consi- derable opposition, Mr. A. Cooper, instead of bleedin? and tbe warm bath, has some- times given nauseating doses of tartarized antimony ; a practice, which has been occa- sionally adopted bv others. The medicine should be exhibited in repeated doses, until nausea is excited ; but, it is not necessary to make the patient vomit; for, as soon as the nauseating eliect is produced, "the mus- cles lose their tone, and dislocations can be reduced with comparatively less effort, and at a more distant time from the acci- dent, than can be effected in any other way." (A. Cooper, Surgical Essay*, Part 1. p. 22.) In cases of unusual difficulty, this method, together with the warm bath and bleeding, seems rational and judicious: but. except in cases of that description, 1 should prefer long-continued, unremitting, not loo violent, extension, which will at last over- come the muscles of the most athletic man. Sometimes, the resistance made to reduction by such muscles, as act in obedience to the will, may be eluded by the patient's atten- tion being suddenly taken from the injured part, at which moment the action of those muscles is suspended, and a very little effort on the part of the surgeon will reduce the bone. A case, illustrating tbis circumstance, is recorded by Mr. A. Cooper. (Part 1 p. 26.) Dislocations of orbicular joints can sel- dom be reduced, after a month, though De- sault used to succeed, with great violence, at the end of three or four. Dislocations of ginglymoid articulations generally become irreducible in twenty, or twenty-four day*, in consequence of anchylosis. The reduction of a dislocation is known by the limb recovering its natural length, shape, and direction, and being able to per- form certain motions, not possible while tbe bone was out of its place. The patient ei- periences a great and sudden diminution of pain ; and, very often, the head of the bone makes a noise at the moment when it re- turns into the cavity of the joint. In order to keep the bone from slippingoat of its place again, we have only to hinder the limb from moving. When splints can act powerfully in steadying the joint, they are very often used, as in dislocations of tbe ankle, wrist, fcc. As the humerus cannot be luxated, except when at some distance from tbe body, a return of its dislocation will be prevented by confining the arm close to the side in a sling. The spica ban- dage, applied after such an accident, is more satisfactory to the patient, than really effica- cious. \\ batever bandage is used to keep the arm from moving, should be put ou the lower end of tbe bone, as far as possible from the centre of motion. COMPOUND DISLOCATION. Compound Dislocations are those, which are attended w ith a wound communicating with the cavities of the injured joints. In most instances, this opening in the skin is caused by the protrusion of the bone, but sometimes by tbe part having struck against some hard, or irregular body These acci- dents are frequently attended with great danger ; and the same nicety of judgment is requisite in determining, whether amputa- tion ought to be immediately petformed, or an effort made to preserve the limb, as in cases of compound fractures, and bad gun- shot injni ie? ; Bnd many of the observation' DISLOCATION. Aid which I shall have to offer upon tbe latter subjects, will for the most part, be applica- ble to the present. The luxation of a large joint, being con- joined with an external wound, leading into the capsular ligament, is a circumstance, that has a particular tendency to increase the danger of the accident. In many cases, we see injuries of this description followed by violent and extensive inflammation, abscesses and mortification, fever, delirium, and death. When the patient is much ad- vanced in years, is much debilitated, or of an unt ealtby irritable constitution, com- pound luxations, especially if attended with much contusion and other injury of the soft parts, and wrongly treated, very often have a fatal termination. This, however, is not the general event of compound dislocations, and whatever may have happened in former times, we now know, that, in the present improved state of surgery, these accidents mostly admit of cure. This statement may be made, without any censure being cast upon every instance of amputation per- formed in such cases. I know,that this ope- ration is sometimes indispensable directly after tbe accident, and I am equally aware, that it may become necessary in a fu- ture stage, when extensive abscesses, or sloughing, joined with threatening constitu- tional symptoms, have taken place. My only design is to recommend the endeavour to cure the generality of compound luxa- tions. But, if a case were to present itself, attended with serious contusion and lacera- tion of the soft parts, I should be as earnest an advocate for amputation as any surgeon. Mr. Hammick, surgeon to the Royal Na- val Hospital, Plymouth, in speaking of com- pound dislocations of the ankle, advises am- putation, " where the lower head3 of the tibia and fibula are very much shattered ; where, together with the compound disloca- tion of these bones, some of the tarsal bones are displaced and injured ; where any large vessels are divided, and cannot be secured without extensive enlargement of the wound, and disturbance ofthe soft parts; where the common integuments, with the neighbouring tendons and muscles are con- siderably torn ; where the protruded tibia cannot by any means be reduced; and where the constitution is enfeebled at the time of the accident, and not likely to en- dure pain, discharge, and length of confine- ment." (A. Cooper's Surg. Essays, Pari 2, p. 146.) Perhaps, as general remarks, these may not be inaccurate ; but, there are ex- ceptions to them. Thus, we find in Mr. A. Cooper's publication several cases, in which compound dislocations of the ankle termi- nated well, notwithstanding the displace- ment and removal of the astragalus, other instances of which kind of success are to be found in the records of surgery. (See Laumonier, in Fourcroy, Mid. eclairie; Percy, in Journ. de Med. continui Nov. 1811, p. 348.) However, if the ends of the tibia and tarsal bones, especially the astragalus and ** calcb are broken, the operation of amputation is recommended on high autho- rity. (A. Coopers Surg. Essays, Part 2, p. 181.) But, with regard to the division of large blood-vessels, Mr. A. Cooper states, that he would not at once proceed to am- putation on that account. " The case from Mr. Sandford of Worcester, sent me by Mr. Cardeu, clearly shows, that the division of the anterior tibial artery does not, if it be well secured, prevent the patient's recovery. 1 also once saw a compound fracture, close to the ankle-joint, accompanied by a divi- sion of that artery ; and, although the pa- tient was in the hospital, and a brewer's servant, who possess-d the worst constitu- tion to struggle against severe injuries, yet this man recovered without amputation." Nor in Mr. A. Coopera opinion, would all hope be precluded, even if the posterior tibial artery were injured. (Voc. cit. p. 186.) For the method of securing these vessels, see Arteries. The following are the circumstances, which Mr. A. Cooper has known to give rise to the necessity for amputation in compound dis- locations of the ankle. 1. The advanced age of the patient. 2. A very extensive la- cerated wound. 3. Difficulty of reducing the ends of the bones he considers rather as a reason for sawing them off, than for amputation. 4. The extremely shattered state of the bones. 5. Dislocations of the tibia outwards cause greater injury of the bones and soft parts, than those inwards. and more frequently require amputation. 6. Sometimes the bone cannot be kept re- duced, owing to the tibia in the dislocation outwards being obliquely fractured. 7. Di- vision of a large blood-vessel, attended with extensive wound of the soft parts. 8. Mor- tification. 9. Excessive contusion. 10. Ex- tensive suppuration. 11. Necrosis, where the sequestra do not admit of removal. 12. Very great and permanent deformity of the foot. 13. When tetanus comes on, Mr. A. Cooper does not approve of the operation. The treatment of a compound dislocation requires the reduction to be effected with- out delay, and with as little violence and disturbance as possible. If any difficulty of reduction should arise from the bone being girt by the integuments, the opening in them should be dilated with a scalpel. The limb is then' to be placed in splints, with the necessary pads, eighteen-tailed bandage, he. Mr. A. Cooper judiciously recommends the portions of this bandage not to be sewed together, " but passed under the leg, so that one piece may be removed when it be- comes stiff;" and by fixing another to its end, before it '.s withdrawn, the fresh piece may be applied, without any disturbance of the limb. (Surg. Essays, Part 2, p. 120.) The wound is to be freed from any dirt, clots of blood, or other extraneous matter, and its lips are to be accurately brought to- gether with strips of adhesive plaster. Mr. A. Cojper considers lint dipped in the blood. which oozes out, the best kind of first dress- ing. The johit is to be covered with linen kept constantly wet with the liquor plumbi acetatis dilutus. or with what i* better. 414 DISLOC AllON. spirit of wine and water ; the bandage is to be loosely laid down, and the splints fast- ened on the limb with their proper straps, or pieces of tape, and the limb is to be kept perfectly at rest in an eligible posture. The patient, if strong and young, is to be bled. This last practice may be more freely adopted iu the country, than in London, or large hospitals. An anodyne, tbe first night, or two, will be highly proper. Saline draughts, ant'unon.als, and a low re./.nen, are also indicated d.iring the first few days of the symptomatic fever, which co.ninonly follows so serious an accident. According to Mr. A. Cooper, purgatives should be used with the utmost caution ;" "for, (says he,) there cannot be a worse practice, when a limb has been placed in a good position, and adhesion is proceeding, than to disturb the processes of nature by the frequent changes of position, which purges produce ; and I am quite sure, that, in cases of compound fracture, I have seen patients destroyed by their frequent administration. That which is to be done by bleeding and emptying tbe bowels, should be effected within au hour, or two, after the accident, before the adhesive inflammation arises." (Surgical Essays, Part 2, p. 121.) Here the fracture bed, invented by .Vlr. Earle, would allow purgatives to be used, without any disturbance of the limb. If the case takes a favourable course, the constitutional fever will not be excessive, nor will the pain and inflammation of the limb be immoderate. Sometimes, the wound unites, more or less, without suppuration ; a circumstance particularly desirable, as tending more than any thing else to lessen the danger, by changing the case, as it were, from a compound into a simple one. In other cases, the wound is not united; but the inflammation and suppuration are not violent, nor extensive ; the constitution is not dangerously disturbed; and hopes of ultimate success may be reasonably enter- tained. When the w ouud is disposed to heal favourably, adhesive plaster, with or with- out lint, or a pledget of soft soap cerate, is the best dressing. In other instances, while the suppuration is copious, and the parts are tense and painful, emollient poultices are the most eligible. When the symptomatic fever, and first in- flammatory symptoms, are over, and much discharge prevails, attended with marks of approaching weakness, the patient is to be allowed more food, and directed to take bark, cordials, porter, wine, &.c. If his nights are restless, he must have opiates ; if he sweats profusely, sulphuric acid ; and, in short, all such medicines, as his particu- lar complaints may require, are to be pre- scribed. When the inflammation of a compound dislocation is violent, or extensive, general bleeding, the application of leeches, and the use of fomentations, and poultices, are tbe most likely means of lessening the mischief. Yet- it is only in strong habits, that venesec- tion to any extent can be prudently practised in large cities, or crowded hospitals. The following are the instructions, deli- vered by Mr. A. Cooper, on the subjeet of dressings. " If the patient complain of con- siderable pain, in tbe part in four or five days. the bandage may be raided to examine the wound ; and, if there be inuch inAamiixtion, a corner ot the lint (or other dressing) should be lifted from the wound, to give vent to any matter, winch may have formed; but, this ought to be done with great circumspec- tion, as there i- danger of disturbing (he ad- hesive process, if that be proceeding without suppuration. By this local tieatment, it will every now and then happen, that the wound will be closed by adhesion ; but, if in a few days it be not, and suppuration take place, the matter, should have an opportuni- ty of escaping; and the lint being removed, simple dressings should be applied. Altera week, or ten days, if there be suppuration, with much surrounding inflammation, poul- tices should be applied upon the wound, leeches in its neighbourhood, and upon the limb at a distance, the evaporating lotion should still be employed ; but, as soon as the inflammation is lessened, tbe poultices should be discontinued." (Surgical Essays, Part 2, p. 121.) In certain examples, the most skilful treat- ment is unavailing. The joint and limb be- come affected with considerable pain and swelling; the fever runs high; delirium comes on ; and the patient may even perish from the violence of the first sjmptoras, the limb being generally at the some time attack- ed by gangrene. If these first dangers are avoided, the wound may yet not heal favour- ably ; the inflammation inny be considerable, or of an erysipelatous nature ; large absces- ses under the fascia? may be formed; the bones may be affected with necrosis; and the hectical symptoms, and sinking state of the patient, may make the only chance of recovery depend upon amputation. But, even this operation is sometimes deferred till too late, and the patient must be left to hi? miserable fate. Whoever gives the smallest reflection to the nature of compound fractures, will per ceive, that it is often a matter of the highest importance, to make a right decision ut the very beginning, whether amputation should be immediately done, or whether an attempt to save the limb ought to be made. In some instance-., the patient's sole chance depends upon the operation being performed at once, without tbe least delay, and the opportunity of doing* it never returns. The surgeon should take off the limb as soon as be has seen the nature of the injury, and not wait till a general tendency to swelling and gan- grene has spread through the member, and every action in the system is disturbed. Am- putation, under these circumstances, is un- doubtedly done with a very diminished chance of success; and, until certain facts were adduced by Baron Larrey, Mr. Law- rence, Mr. A. C. Hulchinsnn, and others, vvai DISLOCATION. 415 ol late years altogether prohibited. (See Amputation and JV/orfi/ica/ton.) But besides this first critical period, the sur- geon often has to exercise a nice degree of judgment in a future stage ofthe case; I mean. when the suppuration is copious, the wound open, the bones carious, and the health im- paired. Here the practitioner may some- times err, iu taking off a limb that might be saved; or, be may lommil a worse fault, and make the patient lose bis life, in a fruit- less attempt to save the member. No pre- cepts can form tbe right practitioner in this delicate part of surgery ; genius alone can- not do it; the opportunity of making obser- vations, and the talent of profiting by them, are here the things which make tbe consum- mate surgeon. It should ever be recollected, in regard to bad compound dislocations, that in young subjects, and in a salubrious'air, many cases will do well, which in old persons, and in the polluted atmosphere of London, and crowded hospitals, would be fatal without amputation. The constitutions of some individuals are so irritable, that whether an attempt be made lo save the limb, or amputation be at once performed, the case has a rapid and fatal ter- mination. According to Mr. A. Cooper, persons who are much loaded with fat, " are generally very irritable, and bear important accidents very ill; indeed, says he, they generally die, whichever plan of treatment be pursued." However, he adds, that such corpulent people as take a great deal of exercise, form exceptions to tbe foregoing remark." (Surgical Essays, Part 2, p. 195.) There is a practice, in regard to compound dislocations, which, I think oughtatall events to be adopted only in a very few cases; I mean tbe plan of sawing off the head of tbe luxated bone. According to Leveille, this method is recommended by Hippocrates as a means of accelerating and perfecting the cure. (Nouvelle Doctrine Chirurgicale, Tom. 2, p. 44.) However, it seems not to have done sufficient good, iu ancient times, to ob- tain a lasting reputation. In fact, when it was mentioned by the late Mr. Goocb, it had sunk into such oblivion, that it w as re- ceived as an entirely new proposal. " Com- pound luxations (says this author) are of a more dangerous nature, than compound frac- tures, for very plain reasons ; but, if a sur- geon should judge it adviseable to attempt saving a limb under such threatening cir- cumstances. / am intlined to think, from what I have observed, he will be more likely to succeed, by sawing off the head ofthe bone, especially if it has long been quite out and exposed to the air." Mr. Goocb afterward takes notice of a case in which Mi Cooper of Bung»y sawed off the heads of the tibia and fibula, *nd preser- ved the limb, the patient being able to walk and work for bis bread for many years af- terward. Other examples are also briefly mentioned, in which the lower head of the radius was sawn off, and the head of the se- cond bone of 'he thumb. The late Mr. Hey of Leeds, was induced to make trial of this plan in a compound luxation of the ankle. The example, how- ever, vvhich he published, is decidedly high- ly unfavorable to the practice, as the fol- lowing passage will show : " I was in hopes, that this patient would have been able to walk stoutly ; but, in this, I was disappoint- ed. He walked indeed without a crutch ; but, his gait was slow, his leg remaining weak, and his toes turning outwards, which rather surprised me, as his leg was very straight, when I ceased attending him." Mr. Hey did not recite this case, with the view of recommending a similar practice in all cases of this accident; for, he had not always adopted it, nor was he of opinion, that the same mode of treatment, whether by replacing the bones, sawing off their ex- tremities, or amputating the limb, ought to be universally practised. When the lacera- tion of the capsular ligament and integu- ments is not greater, than is sufficient to permit the head of the tibia to pass through them ; and when, at the same time, the joint, or contiguous parts, have suffered no other injury ; Mr. Hey recommends the re- placing of the bone, and an union of the integuments by suture, with the treat- ment adapted to wounds of the joints.— (Practical Observations in Surgery, Chap. 11, Edit. 2.) That in a few cases, recorded by Mr. Gooch,and Mr. Hey, the patients recovered with a new sort of joint, only proves to my mind, the great resources and activity of nature, and her occasional triumph over the opposition she meets with from bad and in- judicious surgery. A limb so treated, must ever afterward be shorter than its fellow, and consequently the patient be more or less a cripple. We have seen, that, in the only instance, published by Mr. Hey, con- siderable deformity was the consequence of the practice. 1 cannot help adding my be- lief, that this gentleman would have experi- enced more success in the treatment of compound dislocations, had he relinquished the objectionable method of sewing up the wound. In such accidents, every kind of irritation should be avoided as much as possible, and that the wound may be con- veniently closed with sticking plaster, the observation of numerous cases in St. Bar- tholomew's Hospital has perfectly convin- ced me. In this munificent institution, un- der the disadvantage of the air of London, a,id an hospital, compound luxations used, at the period when I was an apprentice there, to be treated with marked success ; and, I feel warranted in ascribing the cir- cumstance to the mode of treatment, which was conducted on the principles explained in this section of the dictionary. The most ingenious arguments, which have vet been urged in behalf of the prac- tice of sawing off the ends ofthe bones, in compound dislocations of the ankle, are those recently published by Mr. A. Cooper. However, he does not advise the plan, without restrictions. If the dislocation ,'«ay«: 416 DISLOCATION" he) can be easuy rtuun-j, without sawing off the end of the bone ; if it be not too obliquely broken to remain firmly upon the astragalus after being reduced ; if the end of the bone be not shattered, for then tbe small loose pieces of bone should be remo- ved, aud the surface of the bone be smooth- ed by the saw ; if the patient be not ex- cessively irritable, and the muscles, affected with violent spasms, impeding reduction, and causing a displacement of the bones after they have been reduced ; Mr. A. Cooper advises the immediate reduction of the parts, and uniting tbe wound by adhe- sion. In the opposite circumstances, rather than amputate the limb, he would saw off the ends of the bones. (Surgical Eissays, Part I,p. 164.) The only case, in which tbe plan of saw- ing off the head of the bone can be at all proper, is when a compound dislocation oannot be reduced, notwithstanding the en- largement of the wound in tbe skin, and every other possible means. There is no other mode of preventing the formidable symptoms, which would ensue, were the bone left in a state of protrusion through the integuments ; nor is there any better way of alleviating such symptoms after they have actually begun. M. Roux gives much praise to the English surgeons for the judi- cious boldness, which they have evinced in cases of this description. Although Fab- ricius Hildanus, Ferrand, Desault, Laumo- nier, and several other French surgeons, have, like many British practitioners, ventu- red to remove the whole ofthe astragalus, when this bone was totalty separated from the scaphoides, and protruded,in compound luxations, yet M. Roux acknowledges, that the bold practice of sawing off the lower end of the humerus, the lower end of the radius, the lower end of the tibia, and also of the fibula, at the same time, originated with, and was first executed by English surgeons. (Parallele de la Chirurgie Ang- loise avec la Chirurgie Francoise, p. 208— 209.) DISLOCATIONS OF THE LOWER JAW. The lower jaw can only be luxated for- ward and either one, or both of its condyles may become displaced in this direction. Every dislocation, except that forward, is rendered impossible by the formation of the parts. The lower jaw cannot even be dislocated forward, unless the mouth, just before the occurrence of the accident, be very much open. Whenever the chin is considerably depressed, the condyles slide from behind forward, under the transverse root ofthe zygomatic processes. The car- tilaginous cap, which envelopes the con- dyles, and follows them in all their motions, still affords them an articular cavity ; but, the depression of the bone continuing, the liguments give way, the condyles glide be- fore the eminentue arliculares, and slip un- der the zygomatic arches. Hence, a dislo- cation mostly happens,while the patient is 'aituhing, gapiiii, he. A blow on the jaw. when the mouiu is wiueopeii, may etuii) cause the accident. The case has occasion- ally arisen from the exercise of great force in drawing out the teeth. Whenever the jaw has once been dislocated, the same causes more easily reproduce the occur- rence. In certain individuals, the ligaments are so loose, and the muscles so weak, that a dislocation is produced by any slight at- tempt to yawn, laugh, or (as Lnmotte lias observed) to bite any substance, which is rather large. (Leviilli, Nouvelle Doctrine Chirurgicale, Tom. 2. p. 54.) There have been persons, who could scarcely ever laugh heartily, without their lower jaws being luxated. But, of all the causes of this occurrence, yawning alone, even with- out the combination of any external force, is by far the most common. When the jaw is depressed, and its an- gles, to the external sides of which the raas- seters are attached, are carried upwards and backwards, if these muscles contract, the greater part of their force is employed to bring the condyles into the zygomatic de- pression. (Boyer.) Dislocations of the lower jaw are at- tended with a great deal of pain, which Boyer imputes to the pressure produced by the condyles on the deep-seated temporal nerves, and those going lo the inasscters, which nerves pass before the roots of the zygomatic process. 'I be mouth is wide open, and cannot be shut. It is more open in recent dislocations, than in those, which have continued for some time. An empty space is felt before the ear, in the natural situation ofthe condyles. The coronoid pro- cess forms under the cheek bone a promi- nence, which may be felt through the cheek, or from within the mouth. The cheeks and temples are flattened by the lengthening of the temporal, masseter, and bnccinator muscles. The saliva flows in large quanti- ties from the mouth, the secretion of which fluid is greatly increased by tbe irritation of the air. The arch, formed by the teeth of the lower jaw, is situated more forward than that formed by the teeth of the upper jaw. During the first five days after the ac- cident the patient can neither speak, nor swallow. (Boyer.) When only one con- dyle is dislocated, the mouth is distorted, and turned towards the opposite side, while the fellow-teeth of the jaws do not corres- pond. However, Mr. Hey asserts, that fre- quently the position of the chin is not per- ceptibly altered. (Practical Observations, p. 322.) When the accident has remained unre- duced for several days or weeks, the symp- toms are not so well marked. In such in- stances, the chin becomes gradually approx- imated to the upper jaw ; the patient reco- vers by degrees the faculty of speaking and swallowing; but, he stammers, and the sa- liva dribbles from his mouth. The suffer- ings, induced by a dislocated jaw, are cer- tainly great enough to be sometimes fatal, if the case continue unrectified; but, we are not to believe Hippocrates when h* DISLOCATION. 417 positively declares ttie accident mortal, if not reduced before the tenth day. Monteggia attended a man, two months after such a luxation, which had not been understood, and Fabricius ab Aquapendente assures us that he bad never seen the prog- nostic of Hippocrates verified, though he had had many pafients of this sort under his care. (Leviilli, Nouvelle Doctrine Chir. T.2.p. 58.) Dislocations of the lower jaw are to be reduced in the following manner: The sur- geon is first to wrap some linen round his thumbs to keep them from being hurt by the patient's teeth, and then introduce them in- to the mouth, as far as possible on the grind- ing teeth. At the same time, he is to place his fingers under the chin and base of the jaw, and while he depresses the molares with his thumbs, he raises the chin with his fingers, by which means the condyles be- come disengaged from their situation under the zygomas ; at which instant the muscles draw those parts so rapidly back into the articular cavities again, that the surgeon's thumbs might sometimes be hurt, did he not immediately move them outward between the cheek and the jaw. The reduction being accomplished, a fresh displacement is to be prevented by applying a four-tailed bandage, as recommended for the fractured jaw. The patient should for some time avoid eating food which requires much mastication. The ancients used to place two pieces of stick betw een the grinding teeth, and, while they used these as levers to depress the back part of the bone, they raised the chin by means of a bandage. John de Vigo has des- cribed this method from Salicetus,Lanfranc, and Guido di Cauliaco; but, it is not pre- ferable to the modern plan, in regard to ef- ficacy ; and it has the disadvantage of ex- posing the teeth to injury. DISLOCATIONS OF THE VERTEBRAE. The lurge surfaces, with which these bones support each other ; the number and thickness of their ligaments; the strength of their muscles; the little degree of motion which each vertebra naturally has ; and the vertical direction of the articular process- es ; make dislocations of the dorsal and lumbar vertebra; impossible, unless there be also a fracture of the above-mentioned processes. Of these cases I shall merely re- mark, that they can only result from im- mense violence ; that the symptoms would bean irregularity in the disposition ofthe spi- nous processes, retention or incontinence of the urine and feces, paralysis and a motion- less state of the lower extremities, the ef- fects of the pressure, or other injury, to which the spinal marrow would be subject- ed. Similar symptoms may also arise, when the spinal marrow has merely under- gone a violent concussion, without any fracture or dislocation whatever A and it is certain, that most of tbe cases mentioned by authors as dislocations of the lumbar and Vol. I 53 dorsal vertebra:, have only been concus- sions of the spinal marrow, or fractures ot such bones. Tbe cervical vertebra?, however, not ha- ving such extensive articular surfaces, and having more motion, are occasionally luxa- ted. The dislocation of the head from the first vertebra, and of the first vertebra? from the second, particularly the last accident, is the most common ; but luxations of the cervical vertebra lower down, though very rare, are possible. Indeed, according to Boyer, many examples have happened, in which one of the inferior oblique, or articu- lar processes of a cervical vertebra has been dislocated, so as to cause a permanent in- clination of the neck towards the side op- posite to that of the displacement. (Trait* des Mai. Chir. T.4,p. 114.) Whether the case, published by Mr. C. Bell, under the name of a subluxation ofthe spine, ought to be received as an unequi- vocal specimen of a displacement ofthe last cervical from the first dorsal vertebra, I cannot pretend to determine. This author speaks of an evident loosening between these two bones ; of a considerable space between them ; of the destruction of the intervertebral substance ; and of an im- mense quantity of pus around the injured part ofthe spine ; as circumstances seen in the dissection. " On the backnart, the pus had extended under the scapulae, and on the forepart was bounded by tbe oesopha- gus," and, in the spinal canal, it had de- scended through the whole length of the sheath to the cauda epuina. (C. Bell, Surg. Obs. Vol. l,p. 148.) DISLOCATION OF THE HEAD FROM THE FIRST VKHTEBRA, OR ATLAS. The os occipitis, and first cervical verte- bra are so firmly connected by ligaments, that there is no instance of their being luxa- ted from an external cause, and, were the accident to happen, it would immediately prove fatal by the unavoidable compression and injury of the spinal marrow. Five examples of displacement of the atlas by disease are in the Museum at Ley- den, and are described by Sandifort. Boy- er has seen one at la Charit6 ; and a very interesting description of a similar case, illustrated by engravings, has been recently published by Schupke (De Luxatione Spon- tanea Atlantis el Epistrophei, 4to Berol. 1816.) In this tract is collected from the writings of J. P. Frank, (Delect. Opusc. Vol. 5.) from those of Reil, (Feiberlehre, B 2, § 102 ;) and of Rust, &,c. an exact detail ofthe symptoms oi the disease; an important topic on which Boyer confesses his inability to give any information. These spontaneous displace- ments of the atlas may depend upon caries and scrophulous disease of its articular sur- faces, or upon an exostosis of its transverse process, or a similar t'imour growing from the neighbouring portion of the os occipi- tis. or petrous portion of the temporal bone. By these causes, the anterior, or posterior lie UISL0CA1I0.V iireh, or one ot tbe sides of the atlas, has been made to intercept a third, the half and even two-thirds of the diameter of the foramen magnum. Notwithstanding the very remarkable constriction of the medulla spinalis, thus occasioned, it is noticed by Boyer, that life may be carried on, and tbe nutritive functions performed sufficiently well to afford time enough either for the exostoses to attain a large size, or for the anchylosis, binding together the head and most of the cervical vertebrae, to acquire great solidity According to the same au- thor, the atlas is never found free and dis- tinct, when thus displaced, but is confound- ed at least with the os occipitis, and mostly with five or six of the subjacent vertebrae. And, another interesting fact is, that, in cases of this description, the joint between the atlas and occiput is never the only one, which is displaced and deformed, unless the disease be very slightly advanced ; for, the articulation ot the processus dentatus with the atlas, and sometimes that ofthe point of the same process with the occiput, are con- siderably affected. Sometimes, the proces- sus dentatus and the occiput retain their na- tural positiou with respect to each othpr, and the atlas alone jeems to be displaced between them Sometimes the second vertebra i* out of its place with respect to the os occipitis in the same direction as the atlas, but not in quite so great a degree. Lastly, in some other instances, the two vertebrae are twisted in opposite directions, a*, for instance, one to the left, the other to the right; or vice ver>a. In one of the rases recorded by Sandifort, this kind of lateral displacement in opposite directions was *o extensive, that an interspace, only six lines in breadth, was left between their approximated annular margins. An instance was seen by Duverney, where the displace- ment of the two vertebrae was from before backward, and where the processus dentatus was approximated to the posterior arch of the atlas to the extent of two-thirds of the annular opening in tbis vertebra. In these cases, nothing can be more obvious, than that there must be a destruction, or at all events a thoroughly diseased state, of the ligaments between the atlas and dentatus, and of those connecting the dental process to the occiput. (Boyer, Vol. cit. p. 105.) As for the treatment of the preceding forms of disease, experience has hitherto furnished little satisfactory knowledge. But, as an analogy is seen between these cases, and the scrophulous and carious affections of other joints, blisters, setons, and issues have been proposed and tried. Rust found these remedies only capable of retarding the progress of the disease, and of producing an abatement of the symptoms. The pain often reaching from the back of the head to the forehead, was rendered less severe; and the difficulty of swallowing was considera- bly lessened. But, the means here specified were not found adequate to arrest the mor- bid change in the bones. However, Rust thinks that z rater benefit might lie expect- ed, if a case were to present its-ell arising altogether fiom a local cause, without its origin being connected with constitutional disease. (Salzburger, Med. Chir. Zeitvng Jahrgang. 1813, B. 3, p. 108.) DISLOCATIONS OF IHE FIRST CERVICAL VERTEBRA FROM THE SECOND. The rotatory motion of the head is chiefly performed by the first vertebra moving on the second. When this motion is forced be- yond it* proper limits, the ligaments which tie the processus dentatus to the edge of the foramen magnum are torn, and, supposing the head to be forced from the left to the right, the left side of the body of the verte- bra is carried before its corresponding arti- culating surface, while the right side falls behind its corresponding surface. Sometimes the processus dentatus, whose ligaments are ruptured, quits the foramen formed for it by tbe transverse ligament and the anterior arch of the first vertebra, and presses on the medulla oblongata. But, according to Boyer, th« processus dentatus may be dis- placed in t>*'o ways: 1st, It may be carried directly backwards, the transverse and other ligaments being broken. This mode of dis- placement Boyer considers as the most diffi- cult and uncommon, as it can hardly take place, except from a fall from a great height upon the back of the head, while the spine is bent forwards. (Traiti des Mai. Chir. T. 4, p. 109.) However, the accident may happen in another manner, as was the case in Mr. C. Bell's instance, where the misfor- tune occurred from a fall with the chin upon the curb-stone. (Surg. Obs. Vol. 1. p. 150.) 2dly, In a violent rotation, in which the face is carried sideways beyond the proper limits, the lateral and accessory ligaments of tbe processus dentatus may be stretched and twisted spirally round this process. The force operates entirely upon them, and not a' all upon the transverse ligament. Now when the lateral and accessory liga- ments of the processus dentatus have given way, and an effort to incline the head to one side is kept up, one of the sides of the space, bounded by the tranverse ligament, may present itself near the point of the proces- sus dentatus, which may then pass below the transverse ligament without rupturing it. In children where the processus dentatus is not fully developed, and the ligaments are weaker than in the adult, a perpendicular impulse may break the lateral and acces- sory ligaments, and then force the processus dentatus under the transverse ligament, without rupturing this latter part ; as Boyer conceives must have been the case In the child, which J. L. Petit mentions as having been instantaneously killed by being lifted up by the head. Lastly, it is asserted, that, when the tram verse, lateral, and other ligaments are capa- ble of making very great resistance to force, which tends to rupture them all, and to throw the processus dentatus directly back- ward?, this process, if a' all more *\*r\Cs- DISLOCATION 4I« than common, may be broken near its base, and the lateral articulations between the two first vertebra' be instantly destroyed. (Boyer, Vol. cit. p. 110.) Patients can hardly be expected to sur- vive mischief of this kind in so high a si- tuation ; when the transverse ligament is broken, and the processus dentatus is thrown directly backward against the medulla ob- longata, the effect must be instant death, as happened in the case lately recorded by Mr. C. Bell. (Surg. Obs. Vol. l,p. 150.) According to surgical writers, the causes which may produce this formidable accident, are various : a fall on the head from a high place ; the fall of a heavy body against the back of the neck ; a violent blow ; a forcible twist ofthe neck ; tumbling ; standing upon the head; the rash custom of lifting chil- dren up by the head, he. Louis found that the first vertebra was dislocated from the second in the malefactors hanged at Lyons, at which pUce,the executioner used to give a sudden twist to the body, at the moment of its suspension, and then bear with all his weight upon it. Under such circumstances, Boyer conceives that the processus dentatus would pass under the transverse ligament, without this ligament being ruptured. Dislocations of the cervical vertebrae are said not to be always fatal, as when they occur at the third, fourth, fifth,or sixthof these bones, and only one articular process is luxated. In these instances, the vertebral canal is not so much lessened as to com- press the spinal marrow, and occasion im- mediate death. With regard to the prognosis and treat- ment of all luxations in vvhich the processus dentatus is displaced, the reader need only hear, that such cases are immediately fatal. Mistaken notions have been entertained upon this point, in consequence of particu- lar dislocations of the neck having been successfully treated. A mother brought her child to Desault, with its neck bent, and its chin turned to- wards the right shoulder. The accident had been a consequence of the head having been fixed on the ground, while the feet were up in the air. A surgeon happened to be with Desault at the time, and they agreed to make an attempt to reduce the luxation, and to apprise the mother, that though the child might be cured, there was a possibility of its perishing under their hands. Being permitted to do what they judged proper, they fixed the shoulders, and the head was gently raised, and gradually turned into its natural position. The mother was rewarded for her courageous resignation ; the child could now move freely; the pain ceased, and a considerable swelling in the situation of the luxation alone remained, and it was dispersed by the application of emollient poultices. (Leviilli, Nouvelle Doctrine Chir. T. 2. p. 62.) Another alleged instance of the reduc- tion of a dislocation of the neck is also re- corded by Dr. Settin, in vol. 1 of Schmuc- {.-ivV Vermiscbte Chirurgische Schriften However, both in tbis case, and that related of Desault, there can now be little, or no doubt, that the accident was not a disloca- tion of the dentata from the atlas, but only a luxation of one of the oblique processes of one of the cervical vertebrae lower down. Wheneverthe processus dentatus is suddenly displaced, or fractured, the effects on the medulla spinalis are inevitably fatal. Fo- more information respecting dislocations of I be vertebrae, consult T. E. Schmidt, De Luxaiione Nucha, Haller, Disp. Chir. 2. 351, Tub. 1747. S. T. Soemmering, Bemerkun- gen ilber Verrenkung und Bruch des Ruck- graths, 8vo. Berlin, 1793. Boyer, Traiti de- Mal. Chir. T. 4, p. 100, fa. 8vo. Paris, 1814. A. E. Schupke, De Luxaiione Spontanea At- lantis et Epistrophei, 4to. Berol. 1816. C. Bell, Surgical Obs. Vol. I, p. 145, 149, fa. Svo. Lond. 1816. DISLOCATIONS OF THE CLAVICLE. These are much less common, than frac- tures, which are said to occur six times more frequently. The clavicle may be luxated at its sternal extremity, forwards, backwards, and up- wards, but never downwards, on account of the situation of the cartilage of the first rib. The luxation forward is the most fre- quent, and almost the only one ever met with. It may arise from the other end of the clavicle being forced very much back- ward. Dislocations backwards and upwards are very unusual. To cause the first sort of accident, the shoulder must be violently driven forwards, and at the same time de- pressed with great force- The dislocation backwards is more rare, than that upward? If the dislocation be forwards, a hard cir- cumscribed tumour is felt, or even seen, on the front and upper part of the sternum. When the shoulder is carried forward and outward, this tumour disappears, and pre- viously there was a vacancy where the head of the clavicle ought to be. When the luxation is upwards, the dis- tance between tbe sternal ends of the clavi cles is diminished. When the dislocation is backwards, there is a depression where tbe end of the clavi- cle ought to be, and the bead of the bone forms a projection at the front and lower part of the neck, which, as J. L. Petit re- marks, may compress the trachea, oesopha- gus, jugular vein, carotid artery, and nerves. The head is inclined towards the side, on which the accident itself is situated. In reducing these dislocations of the ster- nal end of the clavicle, we are to make a lever of the arm, by means of which the shoulder is brought outwards; and when thus brought outwards, it is to be pushed for- wards, if the dislocation be in that direction; backwards, if the dislocation be behind; and upwards, if the dislocation be above. It is as difficult to keep the bone reduced, as it is easy to reduce it, so smooth and ob- lique are the articular surfaces. The same position of the arm, and the h!0 IiJSl.OC.VtION same apparatus, as in fractures ofthe clavi- cle, are to be employed. The end of the clavicle, however, can never be kept from rising a little, and this would be the case even were the tourniquet used, which was proposed by Brasdor, for making pressure • >u the end of the bone. The dislocation of the capsular end of the clavicle from the acromion is much less common, 'ihe luxation upwards i> almost the only one that ever occurs. It ispossible, however, for the accident to fake place downwards, and for the end of the clavicle to glide under the acromion. The rarity of dislocations of the capsular end of the clavicle is owing to tbe strength of the liga- ments tying the clavicle and acromion to- gether. A fall on the top of the shoulder may cause the dislocation upwards. J he scapu- lar end of the clavicle then slides upwards on tbe acromion, and the shoulder is drawn inwards by the muscles which approximate the arm to the body. The violent action of the trapezius muscle, in pulling upward tbe clavicle, may tend to produce the accident. Pain at the top of the shoulder, and a pro- jection at tbe end of the clavicle, under the skin covering the acromion, are symptoms, indicating w hat has happened. Tbe patient also inclines bis brad to the affected side, and avoids moving his arm or shoulder. This dislocation is reduced by carrying the shoulder outwards, putting a cushion in the axilla, and applying Default's bandage for fractures of the clavicle, (See Fractures,) making the turns ascend from the elbow to the shoulder, so as to press the luxated end of tbe bone downward, and keep it in iti due situation, ut the same time that ihe el- bow is confined close to the side, and sup- ported in a sling, by vvhich means the shoulder will be kept raised and inclined outwards. This plan, which is advised by Boyer, is more efficient than the common practice, which consists in applying a com- press, the figure of 8 bandage, and support- ing the arm in a sling. However, the exact muintenanceof the reduction by any appara- tus whatever, is found to be a matter of tbe greatest difficulty, though it is agreeable to know, that notw itbstanding this disadvan- tage, the cases always have a favourable ter- mination. In the course of my time I have seen several cases in proof of this statement, and one example was shown me last suu mer by Mr. Vincent, in St. Bartholomew 'sHosdi- tal. F DISLOCATIONS OF THE OS BRACH1I. iVature, which varies according to the ne- cessities of different animals, the number of their joints, has also been provident enough to vary the structure of these parts, accord- ing to the use of the different portions of their economy. To great moveableness some unite considerable solidity; for in- stance, the vertebral column. Others are very strong, but only admit of a slight yielding motion, as we observe in the car- pns, tarsus, ha. Lastly, other joints admit of a great latitude of motion; but their strong., is easily overpowered by the action of ex ternal bodies. Such are, in man, the shoul- der-joint, and that between the sternum and clavicle. The last kinds of articulation are parti- cularly subject to dislocation, and, of all, not one is so often luxated as the shoulder- joint. Bichat mentions, that it appears, from <■• comparative table,that in some years, this accident, at the Hotel-Dieu, has been as frequent, and even more so, than dislo- cations of all the other bones taken collec- tively. Here every thing seems to facilitate the escape of the bone from its natural cavity. An oval shallow cavity, surrounded by u margin of little thickness, receives a semi- spherical head, which is twice as broad as the cavity in the perpendicular direction, and three times as extensive from before backward. With respect to the ligaments, the joint is only strengthened by a mere capsule, which is thin below, where nothing opposes a dislocation ; but thicker above, where the acromion, coracoid process, and triangular ligament, form an almost insur- mountable obstacle to such an accident. With regard to the muscles, and motions of this joint, strong and numerous fasciculi surround the articular surfaces, make them easily move in all directions, and pushing the head of the os brachii against the different points of the capsule, dis- tend this ligamentous bag, and when their power exceeds the resistance, actually lace- rate it. As for external bodies, what bone is more exposed than the os brachii, to the effect of their force ? Thus subjected to the influence of these predisposing causes, the os brachii would be m continual danger of being dislocated, if the scapula, which is as moveable as itself, did not furnish a point of support for it, by accompanying all its motions. This point of support accommodates itself to the varia- tions in the position of the head ot the os brachii, so that to the moveableness of the articular surfaces, their strength is, in a great measure owing. The shoulder-joint, which is very liable to luxations in a general sense, is not equally so at all points. There are some, where a dislocation cannot occur; there are others where, though possibly such an ac- cident has never been observed. Hence, before examining the mechanism of disloca- tions of this joint, it is essential to deter- mine with precision tbe directions, in which they may take place. Here, indeed, authors diner iu a very singular manner. Some- times, they employ different terms to express the same thing; and sometimes, the same words to signify different things. In- variably agreed about certain kinds of dis- locations, they entertain opposite sentiments concerning others; and, in the midst of these differences, the perplexed surgeon olten cannot decide on what basis to found his practice. Several former writers speak of four kind? DISLOCATION 421 ijl dislocations of the shoulder; many of three ; some acknowledge only two : while others allow the possibility of only one kind. By those, who enumerated the different directions, in which the bone might be luxa- ted, four cases were particularly noticed. Ihe dislocations were termed upward,down- ward, forward, and backivard. Such was the opinion of the predecessors of Hippo- crates, who sufficiently demonstrates its in- accuracy. Others divided dislocations of the shoulder into such as take place downward, upward, outward, and forward. This divi- sion is adopted by Galen, who, however, only cites an example of the luxation for- ward, and does not illustrate what he means by dislocations upward, and inward ihe second class of writers, among whom was Oribasius, distinguished disloca- tions into those which occur downward, for- ward, and backward. Sometimes, they named the luxations downward,outward,arid inward. Paul of jEgina followed this plan, and, no doubt, his meaning is the same as that of Oribasius, only expressed in differ- ent terms. Sometimes, they called the dis- locations downward, forward, and upward. Albucasis did so, and thought the latter case exceedingly uncommon. The third set believed, that when the head of the os brachii was displaced, it could be carried only downward into the armpit, a very common case ; or forward, an accident less frequent. Celsus is almost the only one, who has established this differ- ence : be remarks, Humerus modo in alam cxcidit, modo in partem priorem Lastly, the fourth body of writers only believed in the dislocation downward; which was the sentiment of Hippocrates, who had seen no other sort of case in his practice. At verb humerus inferiorem in par- tem excidit; aliam in partem excidere non audivi. The moderns borrowed from the ancients their divisions of dislocations of the shoul- der-joint, and, at first,liketheirpredecessors, they only determined in a vague manner the precise situations of the head of the bone. However, they afterward fixed it with more determination, in proportion as they became enlightened by anatomy, and, in particular, took notice of the essential difference between primitive and consecu- tive luxations. Petit admits four kinds of dislocations. 1. Downward on the inferior costa of the sca- pula, very rarely met with. 2. Outward, under the spine of this bone; a case, which as a primitive one, can only occur with difficulty. 3 Inward, into the armpit. 4. Forward, between the coracoid process and the clavicle. Heister, like this eminent prac- titioner, acknowledged four dislocations; but with a difference both of expression and meaning. One is downward, iu the axilla; one forward, under the great pec- toral muscle ; another backward, under the scapula, and a fourth outward, under the snine of this bone. According to Duverney, primitive luxations never occur in any di- rection but downward ; the others being all the effect of muscular action. DIVISION ADOPTED BV DESAULT. In the midst of these very confused ways of viewing a very simple subject, Desault judged it necessary, iu order to acquire deter- minate ideas, to divide dislocations of the humerus into primitive, which are the sud- den effect of external violence, and into consecutive, vvhich follow the first, by the in- fluence of causes presently to be explained. Let the oval surface ot the glenoid cavity be included within four lines; one repre- senting its upper edge ; another its lower; a third its inner edge ; and a fourth its exter- nal one. It is manifest, that the head of the hu- merus cannot be displaced towards the up- per edge. There, are situated the acromion and coracoid process, the triangular liga- ment stretched between them, the tendons of the triceps, supraspinatus, and the fleshy portion of the deltoid, insurmountable ob- stacles to the luxation of the head of the bone, propelled by any force up- ward. Besides, what power could this be ? Supposing there were such a force, the head of the bone must necessarily be driven out- ward as well as up*' ard, ere its head would be displaced. This is impossible, because the trunk prevents the lower part of the arm from being directed sufficiently inward to produce this effect. On the contrary, at the other margins, there is little resistance. At the inferior one, the long portion of the triceps ; at the internal one, the tendon of the subscapular ris; and at the external edge, those of the infra-spinatus, and teres minor, will readily yield to any power directed against them, and allow primitive luxations to take place, downward, inward, or outward. Down- ward, between the tendon of the long por- tion of the triceps, and the tendon of the subscapularis, which last, according to Mr. Cooper, is ruptured; (Surg Essays, Part X, p. 7.) inward, between the fossa subscapu- laris, and muscle oi this name ; outward, be- tween the fossa infraspinata, and infraspina- tus muscle. After being pushed out of its cavity, aud first placed in one of these three directions, the head of the humerus often changes its position; and then, to a primitive luxation, downward, or inward, a consecutive one suc- ceeds. But, a consecutive could neverfol low a primitive dislocation outward, were this ever met with, as the spine of the sca- pula would form an obstacle. A consecutive luxation inward may suc- ceed a primitive one dow nward: indeed nothing resists the nead-of the humerus, in the course which it then follows to get be- tween the fossa subscapularis and the mus- cle similarly named On the contrary, should it tend outward, it is opposed by the' tendon of the triceps, and notwithstanding what Petit has written, Desault believed ■41^ DISLOCATION that a consecutive dislocation in this direc- tion never happens. Sometimes, after the head of the bone has escaped from the internal or inferior part of the capsule, it is carried behind the clavicle. forming a case of consecutive dislocation upward; a specimen of which was pre- served in Desault s museum. But, here, the secondary displacement only takes place slowly, and, when it occurs, a reduction can rarely be effected, on account of tbe strong adhesions, contracted by the surfaces of the bone. Thus, in the specimen referred to,a new cavity was formed behind the clavicle, and the humerus adhered by new kinds of ligaments to the surrounding parts. The humerus then is subject to four kinds of dislocation. 1. Downward. 2. Outward. In these two directions the accident is al- ways primitive. 3. Inward, which is some- times primitive, sometimes consecutive. 4. Upward ; a case which can never occur ex- cept as a consecutive one. The second and fourth cases are so very rare in comparison with the others, that they alone claim attention. CAUSES. The action of external bodies, directed against the arm ; bnt, particularly, falls, in which tbis part is forced against a resisting body, gives rise to primitive dislocations, and then the different species ofthe accident are determined, by the particular position ofthe humerus at the instant, when tbe in- jury takes place. Should this bone be raised from the side, without being carried either forward or backward; should the elbow be elevated, and tbe fall take place on the side, then the weight of the trunk, almost entirely sup- ported by tbis bone, forces downward its upper part which stretches and lacerates the lower part of the capsular ligament. Thus a luxation downward is produced, and ifs oc- currence may also be facilitated by the com- bined action of the latissiinus dorsi, pecto- ralis major, and teres major, muscles, as Fabre has judiciously remarked ; for being at this period involuntarily contracted to support the trunk, they act with the power of a considerable lever; the resistance being the head of the bone, which they draw downward, while the fixed point isthe lower end of the bone, resting against the ground. Some authors also consider, as tbe imme- diate cause of a dislocation downward, the strong action of the deltoid, which is sup- posed to depress th£head of the bone, and push it downward through the capsular liga- ment. Certain observations seem incou- testably to establish this mode of disloca- tion. Bichat mentions the well-known case of a notary, who luxated his arm downward, in lifting np a register. The rationale of the primitive luxation inward differs very little from that ofthe pre- ceding case. The elbow is both separated from the side, and carried backward: in foiling, the weight of tbe body acts on the humerus, the front part of t,ic capsule is la- cerated, and a luxation takes place in this direction. The dislocation outward is produced in the same sort of way The elbow is carried forward, towards the opposite shoulder; the capsule is stretched outward, and if a suffi- cient force act on the limb, it is lacerated. But, bow could such a force arise ? In a tall, the arm being pushed against the trunk, and kept there, cannot move extensively enough to cause such a laceration. Hence, a luxa- tion outward must necessarily be exceed- ingly rare, and Desault, in all his experience, never saw such an accident. Besides, when, in a fall, the arm is raised from the side, and inclined forward or backward, tbe weight of the body only operates upon it obliquely, and the limb is very little exposed to the action ofthe latissiinus dorsi, pectoralis ma- jor, and terres major muscles. A few in- stances of a dislocation of the bead of the humerus outward, however, have been re- corded. In a dead subject, Boyer remarked a singular inclination of the glenoid cavity backwards, its articular surface, also, pre- senting on this side an extraordinary elonga- tion, and the humerus readily slipping under the spine of the scapula. (Traiti des Mat. Chir T. 4, p. 176.) In the patient whose history was publish- ed by M. Fizeau, and in whom a dislocation of the humerus outwards and backwards, was seen both by that gentleman and Boyer, there was also the particularity, that the lux- ation was readilv reproduced. (Journ. dt Med par. < orvisa'rt, fa T. 10, p. 380.) Hence, Boyer suspects, that this very rare kind of displacement must have been facili- tated by some preternatural disposition of the articular surfaces, especially that of the glenoid cavity. No dislocation must occur more frequently, than that downward, in which the influence of the weight of the body, and of the action of the muscles is di- rect. The luxation, inward, however, is common, and a multitude of cases, seen by Desault, confirm the reality of this kind of primitive dislocation, though doubted by se- veral modern authors, who are disposed to think with Hippocrates, that all dislocations at first take place downward. The capsule may only be stretched in a primitive luxation, and then the articular surfaces lose their relations but imperfectly; though most frequently, it is lacerated, and the head of the bone passes through the rup- ture. Indeed, in all primitive dislocations from violence, and not from paralysis of tbe deltoid, and a gradual yielding ofthe cap- sule, I believe the latter part is always ex- tensively lacerated. In general, authors have paid too little attention to this circum- stance, which dissections have repeatedly demonstrated to practitioners, and to Desault m particular This eminent surgeon had two specimens made of wax ; one, of a dis- location inward ; the other of one down- ward; both of which were met with in sub- jects, who died at the Hotel Dieu. Bell also makes mention of similar facts, and another DISLOCATION. 423 English surgeon, says Bichat, has observed the same occurrence. 1 suppose Bichat here alludes to Mr. Thompson, wholongago noticed the laceration of the capsule, and particularly called the attention of surgeons to the subject, in the Medical Observations and Inquiries. Desault conceives that the capsule may be sufficiently torn to let the head of the bone escape ; but that the opening may after- ward form a kind of constriction round the neck of the humerus, so as to prevent the return of the bead of the bone into the place, which it originally occupied. The correctness of this statement, however, is positively denied by Mr. A. Cooper, who remarks, that they who entertain this be- lief, must forget the inelastic structure of the capsular ligament, and never witnessed by dissection the extensive laceration which it suffers in dislocations from violence. (Surgical Essays, Part. 1, p. 18.) When a consecutive luxation follows a primitive one, several causes may concur in producing it. If a fresh fall should happen, while the arm is separated from the trunk, the head of the humerus, which nothing confines, obeys, with the utmost facility, the power displacing it in this manner, and is again pushed out of the situation whicb it accidentally occupies. A man in going down stairs, meets with a fall, and dislocates the humerus down- ward ; he immediately sends for Desault, who defers the reduction till the evening. In the mean time, the patient in getting upon a chair, slips and falls again. The pain was more acute, than when the first ac- cident occurred, and Desault, on his re- turn, instead of finding the head of the hu- merus as it was in the morning, in the hol- low ofthe axilla, finds it behind the pectora- lis major muscle. The action of muscles is a permanent cause of a new dislocation. When the hu- merus is luxated downward, the pectoralis major, and the deltoid draw upward, and inward, the upper part of this bone, which, only making a weak resistance to their ac- tion, changes its position, and takes one in the above double direction. The various motions imparted to the arm, may also produce the same effect, accord- ing to their direction. Thus, in conse- quence of unskilful efforts to reduce the bone, a luxation inward frequently follows one downward. SYMPTOMS. In general, the diagnosis of dislocations of the humerus is attended with no difficul- ties. Whatever may be the mode and situation ofthe dislocation, there always exists, as Hippocrates has remarked, a manifest de- pression under the acromion, which forms a more evident projection, than in the natu- ral state. Almost all the motions ofthe arm are painful; some cannot be performed in wv degree ; and thev ore all very limited. The arm cannot move without the shoulder moving nlso, because the articulation being no longer able to execute its functions, both hand the shoulder form, as it were, one body. To these symptoms, generally character- istic of every sort of dislocation of the hu- merus, are to be added such as are peculiar to each particular case. When the luxation is downward, the arm is a little longer, than in the natural state ; it is capable of being moved a little outward : but, an acute pain is the inevitable consequence of moving it either forward or backward. The elbow is more or less removed from tbe axis of the body by the action of the deltoid, and the long head ofthe biceps, and supraspinatus muscles, are stretched, contract and tend to draw the bone outward. The pain, which arises from this position, compels the patient to lean towards the dislocated limb, to keep the forearm half bent, and the elbow sup- ported on his hip, in such a way, that the arm, having a resting place, may be shelter. ed from all painful motion, and stretching ofthe muscles. By this posture alone, De- sault was in the habit of detecting a luxa- tion downward, and his diagnosis was sel- dom found to be erroneous. Thus, in a frac- ture ofthe clavicle, the leaning posture of the patient is often, at the first glimpse, characteristic ofthe accident. In the axil- la, a prominence, formed by the head of the humerus, may constantly be felt. With the general symptoms of disloca- tions of the humerus, a luxation inward has the following : the elbow, separated from the axis of the body, is inclined a little backward ; the humerus seems to be directed towards the middle of the clavicle ; motion backward is not very painful, but that forward is infinitely so; there is a manifest prominence under the great pectoral muscle ; the arm is very little longer than in the natural state ; and the posture is the same, as in the foregoing case. Were a dislocation outward to present it- self, it would be particularly characterized by a hard tumour under the spine of the scapula ; by the direction ofthe elbow for- ward ; by its separation from the trunk ; and by the somewhat increased length of the arm. A projection behind the clavicle ; a mani- fest shortening of the arm ; and its direc- tion ; would clearly denote a dislocation upward. Frequently, nothing is more difficult, than to determine, whether the case is a primi- tive dislocation inward, or a consecutive one ; the same symptoms being observable in both cases. An accurate history of the case, by representing the order in which the symptoms occurred, can alone throw light on this point, which is the more interesting, as in the two cases, tbe means of reduction should vary. In the first, the head of the bone returns, through a short track, into its natural cavity ; in the recond, it has to t"? 424 DISLOCATION. verse a much greater distance to arrive there. If, as Petit has pretended, there are dislo- cations backward, sometimes primitive, sometimes consecutive, this remark would be equally applicable to them. Some analogous symptoms between dis- locations ofthe humerus, tbe fracture of its neck, and luxations of the scapular e.d of the clavicle, might here create an uncer- tainty, if, in the latter case, the absence of a tumour in the armpit, and of a depression underthe acromion, did not prevent an er- ror. Uncertainty might arise, if iu the frac- ture of the neck of the humerus, the proper symptoms of a fracture did not prevent a most detrimental mistake, which tbe occa- sional direction of the humerus, and a kind of prominence formed by the lower end of the fracture in the axilla, might otherwise cause. (See Fracture of ihe Neck of the Humerus.) Inflammatory symptoms seldom follow dislocations ofthe humerus. AUny authors, particularly B. Bell, speak of an cedema- tous swelling of the whole upper extremi- ty, as a frequent consequence of a disloca- tion inward, and it is referred to the com- Eression ofthe axillary glands. Experience as not often demonstrated this occurrence at the Hotel Dieu, except iu very old luxa- tions ; and when the thing has occurred, very beneficial effects have been obtained, in certain instances, by applying for a few days, a moderately tight bandage from tbe fingers up to the axilla, after the reduction has been accomplished. Bichat relates a case, in which tbe oedema did not disappear with the cause, but even rather iucreused ; but the day after a bandage had been appli- ed, the swelling was found diminished by one half. There is another consequence, to which authors have paid but little attention ; though it was known lo Vvicenna, and was several times observed by Desault. This is a palsy ofthe upper extremity, arising from the pressure, made by the bead of the bone, when dislocated inward, upon the axillary plexus of nerves. This consequence some- times resists every means ot relief. Indeed, when the nerves have been a long time compressed, the affection is very diffi- cult of cure. Desault several times applied the moxa above the clavicle. The success, which he first experienced on some patient*, did not follow invariably in otiiers. But, when the head of the humerus has only made, as it were, a momentary pres- sure on the nerves, and the reduction has been effected, soon after the appearance of the symptoms, the paralytic affection often goes off of itself, and its dispersion may always be powerfully promoted by the use of volatile liniments. OF THE REDUCTION. We may refer to two general classes, the infinitely various number of means, propo- sed for the reduction of a dislocated hume- rus. The first are designed to push back, by some kind of mechanical lorco, tn» head of the bone, into the cavity from which it is displaced, either with, or without ma- king previous extension. The others are merely intended to disengage the head of the bone from the place which it accident- ally occupies, leaving it to be put into its natural situation by the action of the muscles. By the first means, art effects every thing; by the second, it limits its interfe- rence to the suitable direction of the powers of nature. In the first method, the force externally applied always operates on the bone iu the diagonal of two powers, which resist each other at a more or less acute an- gle ; in the last the power is only in one direction. Here it is only necessary to state, that all the means, intended to operate iu the first way, act nearly in the following manner. Something placed under the axilla, serves as a fulcrum, on whicb the arm is moved as a lever, the resistance being produced by the dislocated head of the humerus, while the power is applied either to the low- er part of this bone, or the wrist. The con- dyles of the humerus being pushed down- ward and inward, tiie head of the bone is necessarily moved in tbe opposite direction, towards the glenoid cavity, into which it slips with more or less facility. Thus operated the machine, so celebra- ted among the ancients and moderns, under the name of the ambi of Hippocrates ; whether used exactly in the form described by him, or with the numerous corrections devised by Paul of ^Egina, Ambrose, Fare, Duverney, Freke, he. By this machine, a double motion is communicated to the head of the humerus, as above explained. The extension usually moves the bone from its unnatural situation, and is executed in different ways. Sometimes, tbe weight of the body on one side, und the dragging of the end of the dislocated bone on tbe other, tend toproduce this effect. Such was the action of the ladder, door, he. described in Hippocrates's Treatise on Fractures, and re- peated in modern works. Sometimes, the trunk is fixed in an unchangeable manner, while the arm is powerfull. extended, as is practised in employing the machine of Oribasius, and was one of the methods for- merly adopted in the public places, where wrestlers combated. Sometimes, no extension is sensibly exe- cuted, aud while the end of the humerus is pushed outward by a body placed under the axilla, the surgeon pushes it upward into the glenoid cavity. We shall not here inquire into the incon- veniences peculiar to each of these methods. Petit and B. Bell have already done so. We shall only point out the objections, com- mon to all of them. The exit of the head of the bone, through the lacerated capsule, is not necessarily at- tendant on the dislocation. Nor is it even possible to know with precision the situa- tion of this opening. Why then should we DISLOCATION 426 make use of an artificial force to direct the bead ofthe bone towards this opening ? However covered the body placed under the axilla may be, to serve as a fulcrum, there is always a more or less inconvenient chafing, frequently dreadful stretching and laceration of parts, in consequence of its application, when the trunk is suspended upon it, as in the instance of the door, Sic. In this way, Petit has seen a fracture of the neck of the humerus produced, and even a laceration and aneurism of the axillary ar- tery. Few surgeons have ready at hand the different kinds of apparatus. Hence, trouble and loss of time in getting them ; time, which is of so much moment in the reduc- tion ; this being always the more easy, the sooner it is accomplished. When the luxation is consecutive, how can mechanical means bring back the head ofthe boue, through the track it has taken ? For instance, if to a dislocation downward one inward has succeeded, the head of the bone must necessarily be brought down, before it can be replaced in its cavity. The above artificial means often act repugnantly to the action of the muscles, which is a chief and essential agent in the reduction. If the dislocation should be upward, they would obviously be ineffectual. Perhaps, however, they might be advan- tageously employed, when a primitive lux- ation downward is quite recent, and when the head of the bone is very near its cavi- ty. Then the inferior costa of the scapula presents an inclined plane, along which the end ofthe bone can easily glide, when pro- pelled by any kind of external force. No doubt, it is to this tendency of the head of the bone to be replaced, that we must at- tribute the success, certainly exaggerated, but in part real, on whicb the inventor of such machines endeavours to establish the superiority of his plan. But, in this case, it is useless to multiply artificial powers, when natural means suf- fice, and when we can accomplish the re- duction with the hands more effectually, because we can vary the motions with more precision. Thus Desault very often employed the following method with great success. The patient being seated upon a chair of mode- rate height, be took hold ofthe hand on the affected side, placed it between his knees, which he moved downward and backward, in order to make the extension and disen- gage the head of the bone, while an assist- ant held back the trunk to effect the coun- ter-extension. This was sometimes execu- ted by the weight of the body, and effort of the patient. At the same time, the sur- geon's hands being applied to the arm, in such a way, that the four fingers of each were put in the hollow of the axilla, and the thumbs on the outer part ofthe arm, pushed upward, and a little outward, the head of the humerus, which usually returned with ease into its natural cavity. Petit explains i;i. The:-e i iii;t also be two bandage. DISLOCATION ouc made ol linen, several times doubled, four inches wide, and eight or nine feet long; the other a towel, folded in tbe same way, but not always wanted. The patient may either sit in a chair of moderate height, or lie down upon a table, which is firmly fixed, and covered with a mattress. Desault, for a long while, used to put the patient in the first of these positions, which, indeed, is generally preferred. In it the arm may be advantageously drawn in a transverse direction ; but if, as is often the case, there be occasion to make extension upward or downward, the assistant is then obliged to rise up, and depress himself, has not sufficient power, finds himself obstruct- ed, and cannot vary, at the pleasure of the purgeon, the direction in which the arm is to be extended. This position is also much more fatiguing to the patient, than one in which the trunk is equally supported upon n horizontal plane. Hence, Desault, in the hitter years of his practice, abandoned the first position, and invariably adopted the last. The patient being put in the proper posi- tion, the linen compress is applied to the oxilla, on tbe side affected, and upon this compress the middle of the first extending bandage is placed, the two beads of which t>internal condyle, are never so obscured, that the dis- tance between them cannot be felt to be in creased. It is true, that the rubbing of the coronoid process and olecranon against the humerus, may cause a grating noise, similar to that of a fracture ; and some attention is certainly requisite to establish a diagnosis between a fracture of the head of the radius and a dislocation ofthe fore-arm backwards! As Boyer observes, when we consider the extent of the articular surfaces, and the great distance which they must be thrown ere they cease to be in contact, it is evident that a luxation backward must be attended with serious injury of the surrounding soft parts. The lateral ligaments are also constantly rup- tured, and sometimes the annular ligament of the radius. Probably the lower insertions of tbe biceps and brachialis internus would likewise be more frequently lacerated, by the violent protrusion of the head of hume- rus forwards, were it not, that their attach- ments are at some distance from the foint. This mischief, however, occasionally 'takes Elace, and then the fore-arm is observed to e readily placed in any position, and not to retain one attitude, as is generally the case in dislocations. The lower end of the hu- merus, indeed, has been known not only to lacerate these muscles, but to burst the integu- ments, and present itself externally; an in- stance of which is recorded by Petit, and two such cases I saw myself during my ap- prenticeship at St. Batbolomew's. Boyer justly remarks, that it is difficult to conceive how, under these circumstances, the brachial artery and median nerve can escape. In fact, tbis vessel has sometimes been ruptured and mortification of the limb been the con- sequence ; but, this injury of the artery and the laceration of the muscles and skin are rare occurrences. ( Traiti des Mai. Chir 430 DISLOCATION. T. 4, p. 215.) Nor, if the arlery were wound- ed, would gangrene be invariably the result; for, if my memory is correct, an instance in which the limb was saved, notwithstand- ing such a complication, is mentioned by Mr. Abernethy in his lectures, though, no doubt the risk would be great. The following method of reducing the case, is advised by Boyer:—The patient being firmly seated, an assistant to take hold of the middle part of the humerus, and ronke counter-extension, while another assistant makes extension at the inferior part ot the fore-arm- The surgeon, seated on the out- side, grasps the elbow with his two hands, by applying the fore-fingers of each to the anterior part ofthe humerus, and the thumbs lo the posterior, with which he presses on tbe olecranon, in a direction downwards and forwards. This method will in general be successful. If the strength of the pa- tient, or-the long continuance of the luxa- tion, render it necessary to employ a greater force, extension is to be made with a towel applied on the wrist, aud a cushion is to be placed in the axilla, and the arm and trunk fixed, as is done in cases of luxation of the humerus- A bandage may afterwards be applied, in the form of a figure of 8, and the arm kept in a sling. The laceration, which always takes place, is invariably followed by more or less swelling, which is to be combated by antiphlogistic means. At the end ol seven or eight days, when the inflammatory symptoms are nearly gone, the articulation is to be gently moved, and the motion is to be increased every day, in order lo prevent an anchylosis, to which there is a great tendency. In this luxation, tbe annular ligament which confines the head of the radius to tbe extremity of the ulna, is sometimes torn, and the radius passes before the ulna. In such cases pronation and supination are difficult and painful, though tbe principal luxation has been reduced. The bead of the radius may be easily replaced by pressing it from before backwards, and it is to be kept in its place by a compress, applied to tbe superior and external part of the fore-arm. The bandage and compress are to be taken off every two or three days, and reapplied- This is adviseable, on account of the necessity of moving the articulation to prevent an- chylosis. If the luxatioD be not soon reduced, it be- comes irreducible ; the heads of the radius and ulna grow to the backpart of the hu- merus, and the patient can neither bend nor extend his arm. However, in certain cases, especially in young persons, some motion is in time acquired; the beads ot the radius aud ulna forming for themselves cavities in the humerus, in which they perform some motions, but always imperfectly. In a modern publication, an instance of a dislocation of the beads of the radius and ulna backward is related, where the lower end of the humerus protruded through the integument?, and as it could not be reduced, it was sawn off. The patient, a boy, recoJ vered the full use of his arm. (Evans, Pract. Obs. on Cataract; Compound Disloca- tions, fa.p. 101, Wellington, 1815.) A luxation forwards should be treated as a fracture of the olecranon, with which it would be inevitably accompanied. Here, on account of the great Injury done to the soltparts.it would also be right to bleed the patient copiously, and put him on the anti- phlogistic regimen. As to lateral luxations, either inwards or outwards, they are always incomplete, and easily discovered. They are reduced by ex- tending the humerus and fore-arm, and at the same time pushing the extremity of tbe humerus, and the two bones of the fore-arm in opposite directions. These luxations cannot be produced with- out considerable violence; but when the bones are reduced, theyluV easily kept in their place. It will be sufficient to pass a roller round the purt, lo put the fore-arm in a middle state, neither much bent nor extend- ed, and to support it in a sling. But much inflammation is to be expected from tbe in- jury done to the soft parts. In order to pre- vent, or at least mitigate it, the patient is to be bled two or three times, and put on a low diet, and the articulation is to be covered with the lotio plumbi acet. or an emollient poultice. It is scarcely necessary to repeat, that the arm is to be moved as soon as the state of the soft pans will admit of it. (Bo- yer, sur les Maladies des Os, T. 2.) A dislocation ot ihe tore-arm backward, is said to occur ten times as frequently as lateral luxations ; and those forward arc so rare, that no comparison whatever can be drawn. (Qluvres chir. de Desault, T. 1.) An incomplete lateral luxation may be produced by a blow, which drives the upper part of the fore-arm violently outward, or inward. A fooiman, says Petit, in falling from a coach, had bis nrm entangled in the spokes of a wheel, and a dislocation out- ward was the consequence. Another man luxated his fore-arm inward, by falling from his horse and driving bis arm against an uneven place. When the ulna is pushed into Ihesituation of tbe radius, the space between the olecranon and internal condyle is much greater than natural, and the radius cunnot be easily ro- tated, nor the fore-arm bent and extended, in a perfect manner. The dislocation inward must be uncommon, as the fotm of the bones is almost an insur- mountable obstacle to such an accident. It may happen, however, as the authority of Petit confirms. All recent dislocations of tbe elbow are easily reduced, and as easily maintained so; for a displacement is prevented by the reciprocal manner in which the articular biirlaies receive each other, and by their mutual eminences and cavities. This con- sideration, however, should not lead us to omit the application of a bandage in the form of a figure 8, and supporting the arm in a s!inuch cases sufficiently evident. Recent dislocations of the wrist, particu- larly such as are incomplete, are easy of reduction ; but when the displacement has been suffered to continue some time, more difficulty is experienced, and in a few days, all attempts are generally unavailing. This observation applies to all dislocations of gin- glymoid joints; and I cannot, therefore, too strongly condemn the waste of time in trials to disperse the swelling of the soft parts, ere the bones are replaced ; an absurd plan, which I am sorry to say, is sanctioned by Boyer. (Mai. Chir. T. 4, p. 260.) For the purpose of reducing the dislo- cated bones, gentle extension must be made, while the two surfaces of the joint are made to slide on each other in a direction con- trary to what they took when the accident occurred. In dislocations of the wrist, numerous ten- dons are always seriously sprained, andmany ligaments lacerated; consequently a good deal of swelling generally follows, and the patient is a long time in regaining the per- fect use of the joint. Hence, the propriety of bleeding, low diet, and opening, cooling medicines ; while the hand and wrist should be continually covered with linen wet with the lotio plumbi acetatis and the fore-arm Vol. I &> and hand kept in splints, which ought to ex- tend to the end of the fingers, so as to pre- vent a return of the displacement. The limb must also remain quiet in a sling. When the ruptured ligaments have uni- ted, liniments will tend to dispel the re- maining stiffness and weakness of the joint. Sometimes the lower head of the radiu3 is driven through the skin at the inside of the wrist, between the radial artery, and the mass formed of the flexor tendons of the wrist and fingers. Cases of this description, when well managed, generally have a fa- vourable termination, as we see in the case reported by M.Thomassin. (Journ. de Med. T. 39.) If the smallness of the opening in the skin cause an impediment to reduction, the inte- guments should be divided with a knife. DISLOCATIONS OF THE CARPUS, METACARFCS, FINGERS AND THUMB. A dislocation of the carpal bones from each other seems almost impossible. The 03 magnum, however, has been known to be partially luxated from the deep cavity formed for it in the os scaphoides and os lunare. This displacement is produced by too great a flexion of the bones of the first phalanx on those of the second, and the os magnum forms a tumour on the back of the hand. (Chopart; Boyer; Richerand.) Chopart once met with a partial luxation of the os magnum in a butcher. Baron Boyer has seen several examples of the ac- cident, which, he says, is more common in women than men ; a circumstance, which he imputes to the ligaments being looser in females, and to the bones of the carpus in them having naturally a greater degree of motion. The tumour increases, when the hand is bent, and diminishes, when it is ex- tended. The case does not produce any serious inconvenience. If the wrist be ex- tended, and pressure be made on the bead of the os magnum, the reduction is easily accomplished; though a renewal of the displacement cannot be prevented, unless the extension and compression be kept up by means of a suitable apparatus, during the whole time, requisite for the healing of the torn ligaments. As the inconveniences of the accident are slight, few patients will submit to any tedious, irksome treatment; and sometimes the surgeon is never con- sulted, till it is too late to think of replacing the bone. In general, therefore, the sur- geon is obliged to be content with treating the case as a sprain, or contuson. The connexion of the metacarpal bones with one another, and with those ofthe car- pus, is so close, and the degree of motion so slight, that a dislocation can hardly take place. The first metacarpal bone, which is articulated with the os trapezium, and ad- mits of the movements of flexion, extension, abduction, and adduction, is capable of be- ing luxated ; but the accident isuncommon for reasons explained iu my other work +64 LIoLUC ATIoN Although from the nature ofthe joint, be- tween the first metacarpal bone and the tra- pezium, one might infer, that a dislocation is possible in the four directions, backwards, forwards, inwards, and outwards, yet, if we are to believe Boyer, the first case is the only one which has been observed. The accident is produced by the application of external force to the back of the metacar- pal bone, which is suddenly and violently thrown into a state of flexion, the case usually arising from a fall on the outer edge of the hand. In this circumstance, the upper head of the bone is forcibly driven backwards, the capsular ligament is lacerated, the ex- tensor tendons of the thumb are pushed up, and the head of the bone slips behind the trapezium. For an account of the symptoms and treat- ment of this accident, I must refer to the 4th Ed. ofthe First Lines ofthe Practice of Sur- gery, Vol. 2, p. 4(59. The first phalanges of the fingers may be dislocated backwards off the heads of the metacarpal bones. A luxation forwards would be very difficult, if not impossible, because the articular surfaces of the metacarpal bones extend a good way forwards, and the palm of the hand makes resistance to such anaccident. The first phalanx ofthe thumb, in particular, is often dislocated backwards, behind the head ofthe first metacarpal bone, in which case it remains extended, while the second phalanx is bent. These dislocations should be speedily re- duced ; for, after eight or ten days, they be- come irreducible. In a luxation ofthe first bone of the thumb, which was too old to be easily reduced, and where the part was thrown behind the head of the metacarpal bone, Desault proposed cutting down to the dislocation, and pushing the head of the bone into its place with a spatula. Even in cases, which are quite recent, this kind of dislocation frequently cannot be reduced without the utmost difficulty ; and the dif- ferent proposals which have been made, respecting this particular accident, by Mr. Evans, the late Mr. Hey, Mr. C. Bell, and Boyer, are highly deserving the notice of the surgical practitioner, who will find them explained in my other work. Dislocations of the thumb and little finger inwards, and that of the thumb outwards, (which are possible cases) and luxations of the first phalanges ofthe other fingers back- wards, are all reduced by making extension on the lower end ofthe affected thumb, or finger, and at the same time pressing the head of the bone towards its natural situa- tion. After the reduction, the thumb, or finger, affected, should be rolled with tape, and surrounded and supported with pasteboard, till the lacerated ligaments have united ; care being taken to keep the hand and fore- arm quiet in a sling. The luxation of the first phalanx of the thumb, behind the meta- carpal bone requires peculiar treatment) as I »r ve f-K-where explained, DISLOCATIONS OF 1H£BONES OF 1 HE PELVi ■ Experience proves, that the bones of the pelvis, notwithstanding the vast strength of their ligaments, may be dislocated by vio- lence ; thus, the os sacrum may be driven forwards towards the interior of the pelvis ; the ossa ilium may be displaced forwards and upwards ; and the bones of the pubes may be totally separated at the symphysis, and an evident degree of moveableness oc- cur between them. For the production of these accidents the operation of enormous force is requisite ; and, in fact, their usual causes are falls from a great height; the fall of a very heavy body against the sa- crum, at a period when the body is fixed ; and the pressure of the pelvis, between a wall, or post, and the wheel of a carriage, or wagon. Hence, the dislocation is gene- rally the least part of the mischief occa- sioned by such kinds of violence, and the case is commonly attended with concussion of the spinal marrow, injury of the sacral nerves, extravasation of blood in the cellu- lar substance of the pelvis, or cavity of the peritoneum, injury of the kidneys, and frac- ture of one, or more, ofthe bones ofthe pelvis. As Mr. A. Cooper has remarked, some of these cases, complicated with frac- ture, are liable to be mistaken for disloca- tions of the thigh: When, says this gentle- man, a fracture ofthe os innominatum hap- pens through the acetabulum, the head of the femur is drawn upwards, and the tro- chanter somewhat forwards, so that tbe leg is shortened, and the knee and foot are turned inwards. Such a case, therefore, may be readily mistaken. If the os inno- minatum is disjointed from the sacrum, and the pubes and ischium are broken, the limb is slightly shorter than the other; but, the knee and foot are not turned inwards. These accidents may generally be detected by a crepitus perceived in the motion of the thigh, when the surgeon applies his hand to the crista ofthe ilium, and there is greater motion, than in a dislocation of the thigh. (A. Cooper, Surgical Essays, Part 1, p. 49.) In addition to the complications which may attend a dislocation of the bones ofthe pelvis^and arise immediately from the ex- ternal ^Pence, the case is always followed by inflammation, which may be very seri- ous, not only on account of the extent ofthe articular surfaces affected, but because such inflammation may extend to the peritoneum, and viscera ofthe abdomen and pelvis, as I have myself seen in two or three instances. Lewis relates a case, in whicb the os ilium of the right side was found separated from the saerum, so as to project nearh- three inches behind it. This accident wa\ caused by a heavy sack of wheat falling on a labourer. (Mem. de I'Acad, de Chir. T. 4, 4lo.) In a case, recorded by Mr. A. Cooper, the posterior part of the acetabulum was broken off, and the head of the thigh-bout had slipped from its *ockc( ; the fracture DISLOCATION. 43o extended across the innomatum to the pubes, the bones of which were separated at the symphysis nearly an inch asunder. The ilia were separated on each side, and the left os pubis, ischium, and ilium broken. (Surgical Essays, Part. 1, p. 50.) In the same work may also be perused another rase of fracture of the body of the os pu- bis and ramus of the ischium, combined with a luxation of the right os innominatum from the sacrum, and laceration ofthe liga- ments of the symphysis of the pubes: When these cases do not prove fatal from the direct effect ofthe great violence com- mitted on many parts, or from peritonitus, the same unpleasant event sometimes fol- lows rather later from suppuration of the articular surfaces takingplace, and abscess- es forming in the cellular membrane of the pelvis. (Boyer, Traiti des Mai. Chir. T. 4, p. 147.) A case, in which a dislocation of the left os innominatum upwards had a successful termination, was attended by Enaux, Hoin, and Chaussier, and is published in a modern work. (Mem. de I'Acad. des Sciences de Di- jon.) As the reduction could not be ac- complished at first, antiphlogistic treatment was followed for some days, when new at- tempts to replace the bone were made, but could not be continued, as they caused a re- currence of pain and other bad symptoms. A third trial, made at a later period, was not more effectual ; and all thoughts of re- duction were then abandoned. After the patient had been kept quiet some time, though not so long as was wished, he quit- ted his bed, and began to walk about on crutches. I do not understand, however, as is asserted, how the weight of the body could now bring about the reduction, which had been previously attempted in vain. Be this as it may, the result was the patient's recovery. The fact clearly proves, as Boy- er observes, that, in cases ofthis description, the most important object is not to aim at the reduction, but rather to oppose, by every means in our power, inflammation and its consequences. Frequently, the use ofthe catheter is necessary, and, sometimes an incontinence of urine, or the involuntary discharge of the feces, demands the strict- est attention to cleanliness. In these cases, if the patient live any time, there is also another source of danger, consisting in a tendency to sloughing, in the soft parts, on which (he patient lies, and which, when they have been bruised, require still greater vigilance. The os coccygis is not so easily disloca- ted as fractured. Boyer, however, has seen it displaced in a man, who was greatly ema- ciated by disease. This subject had consi- derable ulcerations about the coccyx, and the bone itself was bare. There was an in- terspace of nearly two inches, between the sacrum and base of the os coccygis. In proportion as the man regained his strength, the bone recovered its right position, and, at length united to the os sacrum, notwith- j-tanding the artion of the levatores ani, which are inserted into it. (Boyer.) This case, however, was not an accidental luxa- tion ; and it clearly arose from the destruc- tion ofthe ligaments by disease. Authors mention two kinds of, disloca- tion, to which the os coccygis is liable; one, inward; the other, outward. The first is always occasioned by external vio- lence ; the second, by the pressure of the child's head in difficult labours. Pain, diffi- culty of voiding the feces and urine, tenes- mus, and inflammation, sometimes ending in abscesses, which interest the rectum, arc symptoms said to attend and follow disloca- tions of the os coccygis. The best authors now regard all schemes for the reduction useless, as the bone will spontaneously return into its place as soon as the cause of displacement ceases ; and the introduction of the finger within the rectum, and handling ofthe painful and in- jured parts, are more likely to increase the subsequent inflammation, and produce ab- scesses, than have any beneficial effect. In short, the wisest plan is to be content with enjoining quietude, and adopting antiphlo- gistic measures. DISLOCATION OF THE RIBS. J. L. Petit was silent on this subject, as he thought such cases never occurred. Since his death, a French surgeon, Buttet, has related an iustance, which he supposed to be a dislocation ofthe posterior extremi- ty of the rib from the vertebra? ; but Boyer clearly proves, that there were no true rea- sons for this opinion, and that the case was only a fracture of the neck, or end ofthe bone, near the spine. (Traiti de Mai. Chir. T. 4, p. 123.) Ambrose Pare, Barbette, Juncker, Plat- ner, and Heister, not only admit the occur- rence of luxations of the ribs, but describe different species of them. Lieutaud also ex- tended the term luxations to cases, in vvhich the head of the rib is separated by- disease, the pressure of aneurisms, he. In a modern work may be read the par- ticulars of a case, where all the ribs are said to have been dislocated from their cartila- ges. The accident arose from (he chest being violently compressed between the beam of a mill and the wall. In such a case, there is no means of reduction, except the effect produced by forcible inspirations ; nor are there any modes of relief, but bleed- ing, and the application of a roller round the chest. (See C. Bell's Surg. Obs. p. 171.) DISLOCATIONS OF THE THIGH-BONE. The head of the thigh-bone may be dislo- cated upwards on the dorsum of the ilium ; upwards and forwards on tbe body of the os pubis ; downwards and forwards on the foramen ovale ; and backwards on the is- chiatic notch. The dislocation upwards and backwards, and that downwards and forwards, are tire most frequent. V&. DISLOCATION. The common kind of dislocation of the thigh-bone upwards, or the dorsum of the ilium, is attended with the following symptoms. The thigh is shorter than its fellow, a little bent, and carried inwards. The knee inclines more forwards and in- wards than the opposite one ; the leg and thigh are turned inwards, and the foot points in this direction : the toe resting, as Mr. A. Cooper remarks, against the tarsus of the other foot. (Surgical Essays. Port. 4, p. 27.) There is an approximation of the tro- chanter major to the anterior superior spi- nous process of the ilium, and at the same time it is elevated and carried a little for- wards. It is also less prominent, than that on the opposite side, and the natural round- ness of the hip has disappeared. The natu- ral length of the limb cannot be restored, without reducing the luxation : the foot, cannot be turned outwards, and any at- tempt to do so causes pain ; but, the incli- nation ofthe foot inwards may be increased. (Boyer.) When an attempt is made to draw the leg away from the other, it cannot be ac- complished ; but the thigh may be slightly bent across its fellow. A dislocation on the dorsum of the ilium is generally at once readily discriminated from a fracture of the neck of the thigh- bone, within the capsular ligament, by the rotation of the limb inwards ; a position, which is unusual in a fracture of any part of the os femoris. "In a fracture of the neck ofthe thigh-bone (says Mr. A. Cooper) the knee and foot are generally turned out- wards ; the trochanter is drawn backwards : the limb can be readily bent towards the abdomen, although with some pain ; but, above all, the limb, which is shortened from one to two inches by the contraction ofthe muscles, can be made of the length ofthe other by a slight extension, and when the extension is abandoned, the leg is again shortened. If, when extended, the limb is rotated, a crepitus can often be felt, which ceases when rotation is performed under a shortened state of tbe limb. * Tbe fractured neck of the thigh bone, within the capsular ligament, rarely occurs but in advanced age, and it is the effect of the most trifling accidents, owing to the absorption, which this part of the bone undergoes at advanced periods of life. Fractures external to the capsular ligament occur at any age ; but, generally in the middle periods of life ; and these are easily distinguished by the crepi- tus, which attends them, if tbe limb is rota- ted, and the trochanter is compressed with the hand. The position is the same as in fractures within the ligament. The propor- tion of fractures of the neck of the thigh- bone, which I have seen, is at least four ca- ses to one of dislocation." (A. Cooper, Surg. Essays, Part 1, p. 28.) To reduce this dislocation, the patient should be placed on his opposite side upon a table firmly fixed, or a large four-posted «£ateav' A snePt» fo,ded longitudinally, is brst to be placed under the perineum, and one end being carried behind the patient, the other before him, they are to he fastened to one of the legs, or posts of the bed. Tim* the pelvis will be fixed, so as to allow the necessary extension ofthe thigh-bone to be made. Great care must be taken during the extension to keep the scrotum and testicles, or the pudenda in women, from being hurt by the sheet passed under tbe perineum. The patient must be further fixed by the as- sistants. The best practitioners of the present day in France, advise the extending force to be applied to the inferior part ofthe leg, in or- der to have it as far as possible from the parts, which resist the return ofthe head of the bone into its natural situation. In this country, surgeons generally prefer making the extension by means ot a sheet, or the strap of a pulley, fastened round the limb just above the condyles of the os femoris. The direction in which Mr. A. Cooper makes the extension, is in the line made by the limb, when it is brought across the other thigh a little above the knee. As soon as the head of the bone has been brought on a level with the acetabulum by the assistants, who are making the extension, the surgeon is to force it into this cavity by pressing on the great trochanter; or by rotating the knee and foot gently outwards, as practised by Mr. A. Cooper. The extension should always be made in a gradual and unremitting manner: at first, gently ; but afterward more strongly; ne- ver violently. The difficulty of reduction arises from the great power and resistance of the muscles, especially the glutei and tri- ceps, which will at length be fatigued, so as to yield to the extending force, if care be taken, that it be maintained tbe necessary time, without the least intermission. Some- times, when there is difficulty in bringing the head of the bone over the lip of the acetabulum, Mr. A. Cooper raises it by placing his arm under it near the joint. The disappearance of all the symptoms, and the noise made by the head of the bone, when it slips into the acetabulum, denote, that the reduction is effected. This noise, however, is not always made when pulleys are used. The bone is afterward to be kept from slipping out again, by tying the pa- tient's thighs together with a bandage placed a little above the knees. The patient should be kept in bed at least three weeks; live low, and rub the joint with a camphorated liniment. Due time must be given for the lacerated ligaments to unite, and tba sprain- ed parts to recover; premature exercise may bring on irremediable disease in the joint. Mr. Hey gives the following description of the way, in which he reduced a case of this kind. " The extension of the limb must be made in a right line with the trunk of the body ; and, during the extension, the head of the bone must be directed outwards as well as downwards. A rotatory motion of the o« femoris on its own axis, towards the spine, DISLOCATION. 437 (the patient lying prone) seems likely to ele- vate the great trochanter, bring it nearer to its natural position, and direct the head of the bone towards the acetabulum. These circumstances led to the following method. A folded blanket was wrapped round one of the bed-posts, so that the patient, lying in a prone position, and astride of the bed-post, might nave the affected limb on tbe outside of the bed. The bed was rendered immove- able, by placing it against a small iron pil- lar, which had been fixed for the purpose of supporting the curtain rods. The leg was bent to a right angle with the thigh, and was supported in that position by Mr. Lucas, who, when the extension should be brought to a proper degree, was to give the thigh its rotatory motion, by pushing the leg inwards, that is, towards the other inferior extremity. Mr. Jones sat before the patient's knee, and was to assist in giving the rotatory motion, by pushing the knee outwards at the same moment. I sat by the side ofthe patient, to press the bead of the bone downwards and outwards during the extension. Two long towels were wrapped round the thigh just above the condyles, one towel passing on the inside of the knee, the other on the out- side. Three persons made the extension; but when we attempted to give the thigh its rotatory motion, we found it confined by the towel which passed on the inside of tbe knee and leg. We therefore placed both the towels on the outside ; and in this posi- tion the extending force concurred in giving the rotatory motion. The first effort that was made, after the towels were thus placed, had the desired effect, and the head of the bone moved downwards and outwards into the acetabulum." (Hey's Practical Observa- tions, p. 313.) For the purpose of facilitating the reduc- tion, many surgeons endeavour to produce a temporary faintness by a copious vene- section, immediately before the extension is begun; a practice, which, when tbe pa- tient's state of health does not forbid it, is advisable, as lessening very materially the resistance of the muscles. Mr. A. Cooper gives it bis general approbation, as well as the warm bath, and nauseating doses of tar- tarized antimony. After taking away from twelve to twenty ounces of blood, this gen- tleman places tbe patient in a bath heated to 100 degrees, and gradually raised to 110 degrees, until a faintness is induced. While in the bath, the patient is also to take a grain of tartarized antimony every ten minutes, until nausea is excited, when he is to be removed from the bath, put in blankets, and placed between two strong posts, in each of which a staple it fixed, or he may be placed on the floor, into whicb two rings may be screwed. The manner in which Mr. A Coo- per performs the reduction with pulleys, having been detailed in the 2d vol. of the First Lines of Surgery, I shall not here re- peat it. In all cases of difficulty, the above- mentioned debilitating means, the intoxi- cating effect of a liberal dose of opium, and the use ot pulleys, for the reduction, ap- pear to me to deserve commendation. Luxations of the thigh bone, downwards and forwards upon tbe obturator foramen, are the next in frequency to those upon the dor- sura of the ilium. The accident is facilitated by the great extent, to which the abduction of the thigh can be carried; by the notch at the inferior and internal part of the ace- tabulum ; by the weakness of the orbicular ligament on this side ; and by the ligamen- tum teres not opposing, nor being necessa- rily ruptured by H; that is to say, it is only broken, when the head of the femur has been carried with great violence, further from the acetabulum than common. The head of the bone is thrown between the ob- turator ligament, and obturator externus muscle. The symptoms are as follows: the injured limbjs longer than its fellow, the bead ofthe femur being situated lower than the aceta- bulum ; the trochanter major, which is less prominent than natural, is removed to a greater distance from the anterior superior spinous process of the ilium, and the thigh is flattened, in consequence of theelongationof the head of the muscles. A hard round tu- mour, formed by the femur, is felt at the inner and superior part of the thigh, towards the perineum. The leg is slightly bent; and the knee and foot, I believe, are generally turn- ed outwards. However, according to Mr. A. Cooper's experience, the foot, though widely separated from the other, is gene- rally turned neither outwards, nor inwards; but, he has seen a little variation in this res- pect, in different instances. Hence, he pre- fers a3 the diagnostic symptoms, the bent position of the body, the separated knees, and the increased length of the limb. (Es- says, Part 1, p. 37.) The latter symptom alone is a sufficient indication of the acci- dent not being a fracture. Dislocations on the obturator foramen, are very easy of reduction. The pelvis having been fixed, the extension is to be made downwards and outwards, so as just to dislodge the head of the bone. The mus- cles then generally draw it into the aceta- bulum, on the extending force being gra- dually relaxed, if the upper part of the bone be pulled outward, with a bandage, and the ankle be at tbe same instant inclined in- wards. Thus, the limb is used as a lever, with very considerable power. Mr. Hey says, that " In this species of dis- location, (downwards and forwards,) as the head of the bone is situated lower, than the acetabulum, it is evident, that an extension made in a right line with the trunk of the body, must remove the head of the bone farther from its proper place, and thereby prevent, instead of assisting, reduction. The extension ought to be made with the thigh at a right angle,, or inclined somewhat less than a right angle, to the trunk of the body. When the extension has removed the head of the bone from the external obturator muscle, which cover? the great foramen of 43S DISLOCATION. the os innominatum, the upper part of the os femoris must then be pushed or drawn outwards; which motion will be greatly as- sisted by moving the lower part of the os femoris, at the same moment, in a contrary direction ; and, by a rotatory motion ofthe bone upon its own axis, turning tbe head of the bone towards the acetabulum.'' (Hey, 316.) The ensuing case illustrates Mr. Hey's practice. " The lower bed-post, on the right side of the bed on which the patient lay, was placed in contact with a small immoveable iron pillar (about an inch square in thickness,) such as in our wards are used for supporting the curtain rods of tbe beds. A folded blan- ket being wrapped round the bed-post and pillar, the patient was placed astride of them, with his left thigh close to the post, and his right thigh on the outside of the bed. A large piece of flannel was put between the blanket and the scrotum, that the latter might not be hurt during the extension. " The patient sat upright, with his abdo- men in contact with the folded blanket which covered the bed-post. He supported himself by putting his arms round the post, and an assistant sat behind him to prevent him from receding backwards. He was also supported on each side. " Two long towels were put round the lower part of the thigh, after the part bad been well defended from excoriation by the application of a flannel roller. The knot which the towels form, was made upon the anterior part of the thigh, that the motion: intended to be given to the leg might not be impeded by the towels. " The thigh being placed in a horizontal position, or rather a little elevated, with the teg hanging down at right angles to the rhigh, I sat down upon a chair, directly fronting the patient, and directed a gentle extension to be made by the assistants stand- ing at my left side. This was done with the view of drawing the head ofthe bone a lit- tle nearer to the middle of the thigh, and the extension had this effect. I then placed the two assistants, wbo held the towels, at my right side, by which means the exten- sion would be made in a direction a little inclined to the sound limb. Mr. Logan stood on the right side of the patient, with his hands placed on the upper and inner side of the thigh, for the purpose of drawing the head of the bone towards tbe acetabulum, when the extension should have removed it sufficiently from the place in which it now lay. " I desired the assistants to make the ex- tension slowly and gradually; and to give a signal when it arrived at its greatest degree. At that moment, Mr. Logan drew the upper part of the bone outwards, while I pushed the knee inwards, and also gave the os femo- ris a considerable rotatory motion, by push- ing the right leg towards the left. By these combined motions, the head of the os femo- ris was directed upwards and outwards, or, n other word?, directly towards the aceta- bulum, into winch it entered at our first at- tempt made in this manner. " The scrotum, as the patient assured me. was not hurt in the least by the extension. (Hey, p. 318.) The thigh-bone is sometimes luxated up- wards and forwards on the pubes. The whole limb is turned outwards, and shorten- ed by one inch ; the trochanter major is nearer the anterior superior spinons process of the ilium than natural; the head of the bone forms a tumour in the groin above the level of Poupart's ligament, on the outer side of the femoral artery and vein ; and, pressing on the anterior crural nerves, causes great pain, numbness, and even pa- ralysis ; and the knee is generally carried backwards. In the account of the position of the limb, however, authors vary; and, in opposition to what Boyer has stated, Mr. A. Cooper remarks, that there is a slight flexion for- wards and outwards. (Surgical Essays, Part 1, p. 45.) The head of the bone felt in the groin. and the impossibility of rotating the limb inward distinguish this case from a fracture of the neck of the bone. In reducing this dislocation, Mr. A. Coop er recommends the extension to be made in a line behind the axis of the body, so as to draw the thigh-bone backwards; and, when such extension has been continued some time, a napkin is to be put under the upper part of the bone, und its head lifted over the.pubes and edge of the acetabulum. The last dislocation of the thigh remain- ing to be spoken of, is that backwards. In this case, according to the valable des- cription of it given by Mr. A. Cooper, the head of the thigh-bone is placed on the pyriformis muscle, between the edge of the bone which forms the upper part of the iscbiatic notch and thesacrosciaticligament, being behind the acetabulum, and a little above the level ofthe middle of that cavity. The limb is generally not more than half an inch shorter than its fellow; and the knee and foot are turned inwards, but not nearly in so great a degree as in the dislocation on the dorsum of the ilium. The thigh inclines a little forward, the knee is slightly bent, and the limb is so fixed, that flexion and ro- tation are in a great measure prevented. Mr. A. Cooper considers tbis dislocation as the most difficult, both to detect and re- duce : difficult to detect, because the length of the limb, and the position of the knee and foot, are but little changed ; difficult to re- duce, because the head of the bone is placed deeply behind the acetabulum, and requires to be drawn over the edge of the socket, as well as towards it. In thin subjects, a hard tumour is felt at the posterior and inferior part of the buttock, and the great trochan- ter is removed further from the spine of the ilium. The pelvis being fixed, the extension is to be made downwards and forwards, across the middle of the other thigh, so as to dis- lodge the head of the bone, while the «=ur- DISLOCATION 430 gcou, with a napkin, placed just below the trochanter minor, pulls the upper part of the femur towards the acetabulum. In this case, pulleys are preferable for making the extension. DISLOCATIONS OF THE PATELLA. This bone may be luxated outwards, or even inwards, when violently pushed in this direction. The luxation outwards is the most frequent, because the bone more easily slips in this direction off the outer condyle of the femur, than inwards. The assertion made by some authors, that the dislocation inwards is the most common, is quite erroneous, as I have elsewhere more particularly considered. (See First Lines of Surgery, Vol. 2.) In confirmation of what has been here observed, I may mention, however, the opinion of Mr. A. Cooper, who states, that the bone is most frequently thrown on the external condyle, where it produces a projection ; and this circum- stance, with an incapacity of bending the knee, is evidence of the nature of the injury (Surgical Essays, Part l,p. 6*6.) The gene- rality of cases are easily reduced by pres- sure, when the extensions of the leg have been completely relaxed; but, owing to a lax state of the ligament of the patella, or other predisposing causes, the bone is some- times difficultly kept in its proper situation, unless a roller be applied. The inflamma- tory affection of the joint is to be opposed by bleeding, purging, and the use of the lotio plumbi subacetatis. The joint must be kept quiet a few days, and then gently moved in order to prevent stiffness. DISLOCATIONS OF THE KNEE. The tibia may be luxated forward, back- ward, or to either side; accidents, which may be complete, or incomplete. As Boyer observes, complete dislocations of the upper head of the tibia are exceedingly rare, be- cause the articular surface of the condyles of the femur is so extensive, that the tibia cannot be entirely removed from it, with- out a prodigious laceration of the ligaments, tendons, and all the rest of the soft parts. The condyles of the femur are disposed in such a manner, that, in the extreme flexion of the leg, the articular cavities of the upper head of the tibia are still in contact with those bony eminences ; and this cir- cumstance, together with the resistance made by the ligament of the patella, the pa- tella itself, and the tendon of the extensor muscles of the leg, renders a sudden dislo- cation of the tibia backwards so difficult, that Boyer seems even to question the pos- sibility of the accident, notwithstanding the case recited by Heister. (Traiti des Mai. Chir. T. 4, p. 366.) That this acci- dent, however, sometimes really happens, no longer admits of dispute : the case is no- ticed by Mr. A. Cooper as producing the fol- io w ing appearances; a shortened state ofthe limb ; a projection of the condyles of the os femoris; a depression in the situation of the ligament of the patella ; and a bending of the leg forwards. This latter statement, I conceive, must be a mistake ; and my sus- picion is corroborated by Boyer, who de- clares, that, in the dislocation of the head of the tibia backwards, the leg is bent to a very acute angle, and cannot be extended again. (Mai. Chir. T. 4,p 369.) It appears further, from the particulars of the example of this accident seen by Dr. Walshman, that the dislocation may even be complete, the head of the tibia being thrown behind the condyles of the femur into the ham. The tendinous connexion of the patella to the rectus muscle was ruptured ; and, probably, without a laceration of that tendon, or of the ligament of the patella, such a degree of displacement could scarcely have happened (Surgical Essays, part 2, p. 74.) But, if a sudden dislocation of the tibia from the femur backwards is uncommon, the same remark cannot be made respecting a displacement in that direction, gradually produced by the effects of disease. Seve- ral cases of the latter kind have fallen under my own observation. A dislocation of the head of the tibia forwards, from the condyles of the femur, cannot happen without the greatest difficul- ty ; for the accident must be attended with a laceration of the lateral, crucial, and ob- lique, or posterior ligaments, all which tend to prevent the leg from being too far ex- tended ; and, in addition to all this injury, Boyer, calculates, that the heads of the gas- trocenemius, the popliteus, and the exten- sor tendons of the leg, would be immode- rately stretched, and even torn. An exam- ple of this luxation was seen in Guy's hospi- tal in 1802. According to Mr. A. Cooper, while the tibia projects forward the thigh- bone is depressed, and thrown somewhat laterally, as well as backwards. The os fe- moris makes such pressure on the popliteal artery, as to prevent the pulsation of the anterior tibial artery on the instep ; and the patella and tibia are drawn forwards by the rectus muscle. (Surgical Essays, part 2, p. 73.) Dislocations inwards or outwards, though more frequent than the foregoing cases, are still to be considered as rare, and are always incomplete. In the dislocation inwards, the condyle of the os femoris is thrown upon the external semilunar cartilage, and the tibia projects at the inner side of the joint, so as at once to disclose the nature of the accident; and a depression may be felt un- der the external condyle. In the luxation of the head of the tibia outwards, the con- dyle of the os femoris is thrown upon the inner semilunar cartilage, or, as Mr. A. Cooper says, rather behind it. In both these cases, this gentleman thinks, that the tibia is rather twisted upon the os femoris, so that the condyle of the latter bone is thrown somewhat backwards, as well as outwards, or inwards. I have stated, that lateral luxations of the libia from the temui' are almost always in- 44<» DISLOCATION. dislocation inwards seem- to be established by the 402d Obs. of Lamotte. Whenever the tibia is dislocated from the femur, the accident has generally happened either while some force was operating upon that bone, at a period when the femur was fixed and immoveable, or else while the thigh- bone was propelled, or twisted with great violence, while the leg itself wasfirmly fixed. The bones of the leg are sometimes twisted outward, and the internal lateral ligament ruptured; but this may happen without the crucial ligament being broken. On the other hand, when the bones of the leg are violently twisted inward, the crucial ligaments, and external lateral ligament, must inevitably be ruptured. These accidents are all most easily re- duced, by making gentle extension, and pushing the head of the tibia in the proper direction. The grand object, after the re- duction, is to avert inflammation of the knee, and promote the union of the torn liga- ments. The first demands the rigorous ob- servance of the antiphlogistic plan—bleed- ing, leeches, low diet, opening medicines, and a cooling evaporating lotion ; both re- quire the limb to remain perfectly motion- less. With respect to splints, I conceive, that their pressure would be objectionable. As soon as the ligaments have grown to- gether, and the danger of the inflammation is over, which will be in about three weeks, the joint should be gently bent and extended every duy, in order to prevent stiffness. Liniments will now also be of service. In this section, we must notice the cases, which were first described by tbe late Mr. Hey, and are named by Mr. A. Cooper par- tial luxations of the thigh-bone from the se- milunar cartilages. Mr. Hey observes, that the disorder muy happen either with, or without contaion. When no contusion has occurred, or the effects of it are removed, the joint, with respect to shape, appears un- injured. If there is any difference from its usual appearance, it is that the ligament of the patella seems rather more relaxed than that of the sound limb. The leg is readily bent, or eitended by the bands of the sur- geon, and without pain to the patient: at most, the degree of uneasiness, caused by this flexion and extension, is trifling. But, the patient himself cannot freely bend, nor perfectly extend the limb in walking; and he is compelled to walk with an invariable and small degree of flexion. Yet, though the leg is stiff in walking, it may be freely moved, while the patient is sitting down. Mr. Hey ascribes this complaint to any causes which had the effect of hindering the condyles ofthe os femoris from moving truly in the hollow formed by the semilunar cartilages, and articular depressions of the tibia; an unequal tension of the lateral, or crucial ligaments ; or some slight derange- ment of the semilunar cartilages. (Pract. Obs. p. 333, ed. 2.) Mr. A. Cooper savs, the most frequent cause of the accident is the point of the foot, while everted, stri- »t:ig a^ain^t anv [>>oV,-ion, when pain ii immediately fou m the knee, and the pa- tient becomes incapable of perfectly ex- tending the leg. He has also known the case produced by a person's suddenly turn- ing in bed, and the clothes not suffering the foot to turn as quickly as the rest of the body. A. sudden twist ofthe knee inwards may also displace tbe semilunar cartilages. Mr. A. Cooper gives the following expla- nation of the case. The semilunar cartila- ges are united to the tibia by ligaments, which, when relaxed, allow the cartilages to be easily pushed from their natural situa- tion by the condyles of the femur, which then come into contact with tbe head of the tibia; and now, upon an attempt being made to extend the leg, a complete move- ment of this kind is prevented by the edges of tbe semilunar cartilages. (Surgical Essays, Part 2, p. 76.) In several examples recorded by Mr. Hey, a cure was effected by placing the patient upon an elevated seat, extending the joint, while one hand was placed above the knee, and then sud- denly moving the leg backwards, so as to make as acute an angle with the thigh as possible. (Pract. Obs. p. 337.) This manoeu- vre seems to have the effect of restoring the semilunar cartilages to their natural posi- tion. Sometimes, however, it will not answer; and, in one such case, mentioned by Mr. A. Cooper, the patient used to ac- complish the reduction by sitting upon the ground, and then bending the thigh in- wards and pulling the foot outwards. A knee-cap laced tightly, and furnished with a strong leather strap just below the patella, was requisite in this instance for preventing a return of the displacement. In another case, subject to frequent relapses, these were at length hindered by a bandage with four rollers attached to it, which were tightly applied above and below the patella. (A. Cooper, Surgical Essay*, Part 2,p. 77.) Compound dislocations of the knee are generally deemed cases demanding amputa- tion. DISLOCATIONS OF THE FIBULA. J According to Mr. A. Cooper, luxations of the upper head of the fibula, from relaxa- tion of the ligaments, are more frequent than those from violence. The head ofthe bone is thrown backwards. The bone is easily replaced, but immediately slips behind the tibia again. When the case is attended with disease, repeated blisters are recom- mended ; and, afterwards, a strap to confine the bone in its natural situation. (Surg. Essays, part 2, p. 106.) In other instances, a roller, a compress applied over the head of the fibula, and a splint along this bone, would be proper. (Boyer, Mai. Chir. T. 4, p. 374.) The latter author has seen a dis- placement of the whole fibula upwards, accompanying a dislocation ofthe foot out- wards. This case must be exceedingly un- frequent, as it is resisted not only by the ligaments of the upper joint ofthe fibula, but also by those very strong ligamentous ' ompl'.-'e • bur, the possibility of a compb*> DISLOCATION. 441 lmndi, which bind the malleolus externusto the astragalus and os calcis. In all the ca- ses which I have seen, the pressure of the nstragalus, when driven outwards, has bro- ken the fibula. In the instance mentioned by Boyer, the double luxation ofthe fibula was readily reduced, by rectifying the posi- tion ofthe foot, and bringing the astragalus into its proper place again with respect to the tibia. DISLOCATIONS OF T«E FOOT. The tibia may be dislocated from tho as- tragalus inwards or outwards ; forwards or backwards ; and either of these luxations may be complete or incomplete. The dis- location inwards is the most common ; tbe foot being thrown outwards, and its inner edge resting upon the ground, while the fibu- la is broken about two or three inches above the ankle. Upon dissection, as Mr. A. Cooper observes, the end of the tibia is found resting upon the inner side of flic as- tragalus, and, if the accident has been pro- duced by a jump from a considerable height, the lower end ofthe tibia, where it is con- nected to the fibula by ligament, is split off, and remains attached to the latter bone. The broken end of the fibula itself is carried down upon the astragalus, occupying the natural situation of the tibia. The malleo- lus externus remains in its natural situation, with two inches ofthe fibula, and the piece of the tibia, which is split off. The capsu- lar ligament, attached to the fibula, and the three strong fibular tarsal ligaments, are un- injured. (Surgical Essays, Part 2, p. 107.) One thing, very essential to be understood in this case, i3, that the fracture ofthe fibu- la is here the first mischief, without which the dislocation could not have happened. The fibula may easily be fractured without any luxation of the foot, but the above-de- scribed dislocation can never take place unpreceded by a fracture ofthe fibula; and, grave and serious as the displacement of the joint is, it is always a secondary event. (Dupuytren, Annuaire Med. Chir. 1819, p. 3.) It was to this particular case, joined with Ihe fracture of the fibula, that Mr. Pott drew the attention of surgeons, as affording a striking example of the benefit derived from relaxing the muscles ; the instance in which, " by leaping or jumping, the fibula breaks within two or three inches of its lower extremity. When this happens, the inferior fractured end of the fibula falls in- ward towards the tibia, that extremity of (he bone which forms the outer ankle is turned somewhat outward and upward, and the tibia having lost its proper support, and not being of itself capable of steadily pre- serving its true perpendicular bearing, is forced off from the astragalus inwards; by which means the weak bursal, pr common ligament ofthe joint, is violently stretched, if not torn, and the strong ones, which fas- ten the tibia to the astragalus and os calcis, are always lacerated ; thu= producing, at Vol. I. 56 the same time, a perfect fracture and a par- tial dislocation, to which is sometimes add- ed a wound in the integuments, made by the bone at the inner ankle. By this means, and indeed as a necessary consequence, all the tendons vvhich pass behind or under,or are attached to the extremities of the tibia and fibula, or os calcis, have their natural direction and disposition so altered, that, instead of performing their appointed ac- tions, they all contribute to the distortion of the foot, and that by turning it outward and upward." When this accident is accompanied, as it sometimes is, with a wound of the integu- ments ofthe inner ankle, and that made by the protrusion of the bone, the danger and difficulties of the case are seriously increa- sed. " By the fracture of the fibula, the dilata- tion of tbe bursal ligament of the joint, and the rupture of those which should tie the end of the tibia firmly to the astragalus and os calcis, the perpendicular bearing of the tibia on the astragalus is lost, and the foot becomes distorted ; by this distortion the direction and action of all the muscles al- ready recited are so altered, that it becomes (in the usual way of treating this case) a difficult matter to reduce the joint ; and, the support of the fibula being gone, a more difficult one to keep it in its place after re- duction. If it be attempted with compress and strict bandage, the consequence often is a very troublesome, as well as painful ulce- ration ofthe inner ankle, vvhich very ulce- ration becomes itself a reason why such kind of pressure and bandage can be no longer continued ; and if the bone be not kept in its place, the lameness and deformi- ty are such as to be very fatiguing to the patient, and to oblige him to wear a shoe" with an iron, or a laced buskin, or some- thing of that sort, for a great while, or per-1 haps for life. " All this trouble, pain, difficulty, and in- convenience, are occasioned by putting and keeping the limb in such position as neces- sarily puts the muscles into action, or into a state of resistance, which in this case is the same. This occasions the difficulty in reduction, and the difficulty in keeping it reduced ; this distorts the foot, and by pull- ing it outward and upward makes that de- formity which always accompanies such accident; but if the position of the limb be changed, if by laying it on its outside, with the knee moderately bent, the muscles form- ing the calf of the leg, and those which pass behind the fibula, and under the os calcis, are all put into a state of relaxation and non-resistance, all this difficulty and trou- ble do in general vanish immediately; the foot may easily be placed right, the joint re- duced, and by maintaining the same dispo- sition of the limb, every thing will in gene- ral succeed very happily, as I have many times experienced." (Pott.) I think the profession are much indebted to Air. A. Cooper, for his application of trnis t" dislocations ofthe ankle*, which 442 DISLOCATION are liable to no mistake or confusion. Thus, when he speaks of a dislocation of the tibia inwards or outwards, backwards or for- wards, the case spoken of is immediately known. On the contrary, when authors write about dislocations of the ankle, or foot, in any named direction, their meaning may be various and misinterpreted. We find this exemplified in Dupuytren's valua- ble memoir on fractures ofthe lower end of the fibula; for, instead of terming the above case, a dislocation of the foot out- wards, as the generality of writers have done, he thinks it should be named a dislocation of the foot inwards, on account of the direc- tion in which the astragalus is carried. (Annuaire Med. Chir. p. 3, 1819.) With respect to the treatment of the pre- ceding case, Dupuytren admits, that Pott's method easily effects a reduction, though incapable of maintaining it; but, as I have endeavoured in the 2d Vol. of the First Lines of Surgerv, to explain the practice re- cently proposed" at the H6tel-Dieu, it would be useless repetition to enter into the sub- ject again- Mr. A. Cooper appears to pre- fer the mode of treatment on Mr. Pott's principles; but gives one very essential piece of advice, which is, that the splint, upon which the outer part ofthe limb rests, may have a foot-piece, " to give support to the foot, prevent its eversien, and preserve it at right angles with the leg. If much in- flammation succeeds, leeches are to be ap- plied to the parts, and the constitution will require relief by taking blood from the arm." (Surgical Essays, Part 2, p. 108.) When the tibia is dislocated outwards, the internal lateral ligaments are always ruptured, or pulled away from the bones, and the inner malleolus broken, previously to the fracture of the fibula. On a part of this statement, however, Dupuytren and Mr. A. Cooper differ, as the latter mentions, thatthe deltoid ligament remains unbroken. In some cases, according to Mr. A. Cooper, the fracture is not confined to the malleolus, but passes obliquely through the articular surface of the tibia, which is thrown for- wards and outwards upon the astragalus, in front ofthe malleolus externus. Sometimes, the astragalus is fractured, and the lower extremity of the fibula broken into several splinters. He states, also, that, when the fibula is not broken, the external lateral ligaments are ruptured. The foot is thrown inwards, its outer edge resting upon tbe ground ; while a considerable projection is made by the malleolus externus under the skin. The accident is generally caused by the passage of the wheel of a carriage over the leg, or a violent twist of thefoot inwards in jumping, or falling. (A. Cooper, Vol. cit. p. 113.) The reduction is accomplished by relax- ing the muscles of the calf, making exten- sion in the axis ofthe leg, and pressing the lowtr head of the tibia inwards towards the astragalus. « The limb is to be laid upon its outer side, resting "upon a uplint with a foot-piece, and a pad is to be placed upon the fibula just above the outer angle, and extending a few inches upwards, so as in some measure to raise that portion ofthe leg, and prevent the tibia and fibula slipping from the astragalus, as well as lessen the pressure ofthe malleolus externus upon the integuments. (Surg. Essays, Part 2. p. 113.) Mr. A. Cooper also enjoins paying the strictest attention to hindering the foot from being twisted inwards, or pointed down- wards. Dupuytren's manner of treating this case, is described in the second Vol. ofthe First Lines of Surgery. A complete dislocation ofthe lower head of the tibia forwards cannot happen, with- out the fibula being first broken, and either the base ofthe malleolus internus fractured, or its point torn away. The foot being then acted upon by the extensor and flexor mus- cles, and unretained by the malleoli and their ligaments, yields to the powerful ope- ration ofthe muscles of the calf, the astra- galus passing behind the tibia, while tbis projects forward under the tendons and skin of the instep. (Dupuytren, Annuaire Med. Chir. p. 187,4to. Paris, 1819.) The foot of course is much shortened, the heel length- ened, and firmly fixed, and the toes point downwards. Upon dissection the tibia is found to rest upon the upper surface of the os naviculare, and os cuneiforme internum. The anterior part of the capsular ligament is torn through ; the deltoid ligament is only partially lacerated ; and the three ligaments of the fibula remain unbroken. (A. Cooper, Vol. cit. p. 109.) This case is much more difficult of reduc- tion, than the instance in which the foot is thrown inwards ; and the cause is owing to the powerful manner, in which the muscles resist the extension of the parts, and placing them in their natural position again. As Dupuytren observes, it is true, that such resistance may be lessened by relaxing the muscles, and drawing the patient's atten- tion from his limb, plans which folly an- swer for the reduction of the other above- mentioned case ; yet, in that now under consideration, tbey are insufficient, and here a greater effort is required to bring the foot from behind forwards, and to place the astragalus under the tibia. And, a still greater difficulty is to keep the parts redu- ced during the time necessary for the fibula and torn ligaments to be firmly united. In fact, the upper surface of the astragalus, which is convex from behind forwards, is so slippery, that it is hard to make the tibia rest securely on the articular pulley of that bone, which is itself incessantly acted upon by the extensor muscles of the leg, so as to have a tendency to slip behind the lower head of the tibia. In addition therefore to the bent posture, Dupuytren deems it ne- cessary hereto employ an apparatus, which Kropels the foot forward, and the lower ead of the tibia backwards. (Annuaire Med. Chir.p. 189.) A* this apparatus ha< DISLOCATION. 443 been described in the second Vol. of the First Lines of Surgery, I need not explain it again. Mr. A. Cooper prefers keeping the limb upon the heel, resting upon a pillow. A splint, with a suitable pad, and a foot-piece, is to be applied to each side of the leg, care being taken to keep the foot well support- ed at a right angle with the leg. (Surgical Essays, Pari 2, p. 110.) Besides the complete dislocation of the tibia forwards, a partial case is sometimes met with, where one-half of tbe articular surface of the bone rests upon the os navi- culare, and the other on the astragalus. According to Mr. A. Cooper, the fibula is broken ; the foot appears but little shorten- ed ; nor is there any considerable projection ofthe heel. The foot points downwards ; it cannot be put flat on the ground, and is nearly stiff; and the heel continues drawn up. The accident, if not detected and rec- tified in its early stage, afterwards admits of no relief, the change in the state of the muscles, and the position in which the fibu- lu has united, not suffering any reduction, even though great force be employed. Dislocations forwards or backwards, of the tibia, are not common: during fifteen years, Dupuytren has scarcely met with two, or three cases ; though he has seen some hundreds of lateral dislocation. It must be obvious to every body, says he, that when the foot is violently bent, or ex- tended, many powerful muscles resist the movement in question, and prevent the mis- chief, with which the articulation is threat- ened. (Annuaire Med. Chir. de Hospitaux de Paris, p. 34.) A luxation ofthe tibia from the astragalus backwards, Mr. A. Cooper has never had an opportunity of observing; a proof ofthe rarity of the accident. A luxation of the astragalus, either simple or complicated, with a laceration ofthe in- teguments, as Mr. Hey has remarked, is an accident, which does not often occur. Above, the astragalus is articulated with the tibia and fibula ; below, it is united, by means of a capsular ligament, to the os cal- cis ; while, in front, it is connected to the os naviculare by a capsular, and broad in- ternal lateral ligament, thus situated, it is evident, that its displacement is not likely to happen with great frequency ; and yet, this observation must be received only as a comparative one ; for, the cases ot dislo- cation of the astragalus, now upon record, are rather numerous. When a dislocation of the lower head of the tibia is combined with one of the as- tragalus from the os calcis, and os navicu- lare, and the ligaments, which kept these bones together, are nearly destroyed, while a considerable portion of the astragalus it- self protrudes through the wound in the in- teguments, if it be judged prudent to attempt the preservation ofthe limb, it is best per- haps to imitate Desault, Ferrand, Trye, and Evans, and extract the astragalus altogether. A luxation of the astragalus, unattended with a wound in the skin, is a serious and embarrassing accident; for, in general, the reduction is so difficult, that it is not many years since the case was deemed a ground for amputation. (See Gooch's Chir. Cases, fa.) When the displacement in question happens, the astragalus is generally thrown forwards upon the os naviculare, forming a tumour on the instep, and inclining a little either to the outer, or inner side of the foot. In many cases of this description, the reduction is found to be impracticable. Here, as Boyer observes, the impediment does not depend upon the head of the bone being constricted in the narrow opening of the capsule ; but rather upon the impossi- bility of making the extending force, and the pressure ofthe surgeon's hands, operate with much effect upon the displaced bone. However, an example is recorded by De- sault ; where the reduction was accom- plished by dividing the skin, and then ex- tending the incision through a part of the ligaments. In the Journal de Chir. another case is also related of a simple dislocation of the astragalus from the os calcis, and os naviculare, where the reduction was easily performed by common means. Boyer con- ceives it probable, that, in these cases, most of the ligaments, uniting the astraga- lus to the os calcis, and os naviculare were ruptured, and that the first of these bones was therefore sufficiently moveable to ad- mit of being replaced by the pressure ofthe fingers. But, the luxated astragalus may be so wedged between the tibia, os caicis, and os naviculare, that its reduction is impossi- ble, as Boyer has actually seen. In the case, here referred to, things were left to take their course, except that every possible means was employed to keep offinflamrna- tion. The result was, that the skin, cover- ing the projection of the astragalus at the inner and upper part of the foot, sloughed, and amputation was at length deemed ne- cessary. (Mai. Chir. T. 4, p. 400.) In another case, recorded by Mr. Hey, pressure was made with a tight bandage on the pro- minence ofthe astragalus, and the soft parts over it became gangrenous; yet, a recovery followed without amputation, all the pro- jecting portion of the astragalus having gradually come away in fragments. (Hey's Pracf. Obs. p. 384, Ed. 2.) In an instance, recently published by Dupuytren, a person dislocated the astragalus by alighting with great violence upon the heel, the bone be- ing driven forwards by the pressure, which it had sustained between the tibia and os calcis, so as to form a proturberance under the skin of the instep. As the reduction was found impracticable, a cut was made down to the displaced bone, with the inten- tion of extracting it; but, Dupuytren found, that he could not remove it so readily as be expected ; nor yet could he replace it; and, it was not till after a tedious operation, that he succeeded in taking it away. The difficulty arose from the upper surface of the bone being turned downwards, while the back projection of what was naturally the lower part of it took hold of the tibia Dis DhB in tlu' Kiapnri»of a hook. {Antmai/e Med. '':>/-. des Hopitatrx de Paris, 1819, p. 28.) In another modern valuable publication, two cases of dislocation ofthe astragalus are related. One was a simple luxation of the astragalus inwards, the os calcis, and the rest of the foot being thrown outwards. The reduction was easily performed by fixing the knee, then extending the foot gently and directly from the leg, by laying hold of the heel with one hand, and placing the other on the dorsum of the foot; and lastly, by pressing the foot inwards, whilst counter- pressure was made with the knee upon the opposite side ofthe lower extremity of the tibia. Tbe other instance, alluded to, was a compound luxation, in vvhich the astragalus was displaced outwards, and the other tarsal bones thrown inwards. Beduction was ac- complished first by bending the leg so as to relax the muscles, and then by extending the foot, as above explained, and rotating it outwards. (A. Cooper, Surgical Essays, Part 2, v. 207.) By heavy weights falling upon the foot, a dislocation is sometimes produced at the transverse joint between the astragalus and os calcis behind, and the os naviculare and os cuboides in front. Mr. \. Cooper has twice seen the os cu- neiforme internum dislocated, and, in both ea^-es, the head of the bone naturally con- nected to the os naviculare, projected in- wards and somewhat upwards, being drawn in this direction by the action ofthe tibialis antir-ns muscle. In neither instance was the reduction accomplished ; and, in one, the patient had so trivial a lameness, that the functions of the foot were expected to be in time perfect again. (Surgical Essays, Part 2, p. 209.) The phalanges of tbe toes are sometimes dislocated, and the first bone of tbe great toe is frequently luxated from the first meta- tarsal bone ; but I am not aware, that these cases are attended with any particular diffi- culty in the reduction, like some dislocations ofthe thumb. On the subject of Dislocations consult A. Flach.de. fyixatione Ossis femoris rariore, frequentiore collifradura, Disp.Argent. 1723. H. Lingutt, Qutestio, fa. Anin Humeriluxa- tione ambe potius quam scala, Janua, Poly- spastusque iterato r novata ? Paris, 1732. G. C. Rcichel, Dis. de Epiphysium ab Ossium Diaphysi Diducliane, Lips. 1759. J. L. Petit, Traiti des Maladies des Os, 1725, et Traili des Mai. Chir. 17S3; Duverney Traiti des Maladies des Os. Lecons sur les Maladies des Os ridigies en un Traiti complet de ces Ma- ladies par Richerand, Tom. 2. Richerand No- sographie Chirurgicale, Tom. 3, p. 193, fa. Edit. 4. tXuvres Chir. Desault, par Bichat, Tom. 1. Pott's Remarks on Fractures and Dislocations, 1775; Kirkland's Observations upon Mr. Pott's General Remarks on Frac- tures, fa. White's Cases in Surgery. Medi- cal Observations and Inquiries, Vol 2. Brom- field's Chirurgical Cases and Observations, 1773. J. F. P. Castella, Sur les Fracture fin PCrone; Landshut, 1808. C. Bell. A System of Operative'Sur^ecy, 1809, J ffoie- SL'p, Pract. Obs. in Surgery, e, when there is an opening in th# skull. Then n hardness, felt from the very first at the cir- cumference of the tumour, denotes that it comes from within. When the swelling in carefully handled, such a crackling sensa- tion is perceived, as would arise from touch- ing dry parchment stretched over the skin. On making much pressure, pain is occasion- ed, and sometimes a numbness in all the limbs, stupefuction, and other more or less afflicting symptoms. The tumour, in some measure, returns inward, especially, when not very large, and gradually rises up out- ward again, when the pressure is disconti- nued. Sometimes, there is puin ; at other limes, there is none ; which may be owing to the manner in which the tumour is affect- ed by the edges of the bone, through which it passes. The pain is often made to go off by compression, but returns as soon as this is taken off. The tumour has an alternate motion, derived from the pulsation of tbe brain, or of the large arteries at its base. This throbbing motion has led many practi- tioners to mistake the disease for an aneu- rism, as happened in the second case related in the memoir of M. Louis. When the tu- mour is pushed sideways, and the finger carried between it and the edge of the bone, through which the disease protrudes, the bony edge may be felt, touching the base of (he swelling, and more or less constricting it. This symptom, when distinguishable, added to a certain hardness and elasticity, and sometimes a facility of reduction, forms a pathognomonic mark, whereby fungous tumours of the dura mater may be discri- minated from hernia? ofthe brain, external fleshy tumours, abscesses, exostoses, and other affections, which at first sight resemble. them. Probably, however, some variety in the symptoms prevails in different instances; for, in the cases recorded by Walther, there was no pulsation, strictly so called, but merely an obscure movement, or an alternate dis- tention and flaccidity, arising from influx of blood into the vessels ofthe diseased mass ; the tumours could not be pushed within the cranium in the slightest degree ; nor did the attempt cause any ofthe effects usually ob- served to proceed from pressure on the brain. No aperture could be felt in the skull, much less could the irregular edges of the bone around the tumour be distinguish- ed. (Journ. fur Chir. B. I, p. 67—61, fa. Svo. Berlin, 1820.) Whatever movements also were percepti- ble in the swellings, Walther is convinced could not be communicated to them by the pulsations of the subjacent brain ; because they were wedged, as it were, in an apert-ire in the skull, and adherent to the dura mater beneath them, and to the superincumbent periosteum, so that, even in the dead sub- ject, they did not admit of being pushed in the least more outwards without difficulty, and the employment of strong pressure. (Vol. cit. p. 57.) Indeed, this tight constriction of the ru- DURA MATER. 447 mour not only explains why stupor, paraly- sis, &c. were not brought on in these parti- cular examples by external pressure, but also why the edges of the hole in the skull could not be felt; and the small size of the same opening, in relation to the magnitude of the swelling, fully accounts in my opinion for the circumstance of the swellings not sinking inwards under pressure. But, I am far from being convinced with Walther, that fungi of the dura mater are in their nature always irreducible, (see Vol. cit. p. 82 ;) a belief, which he grounds upon the connexion of the diseased mass with the vessels of the diploe ; its constriction by the bone ; and its expansion under, as well as above, the cra- nium. Here, I think Walther is as wrong in saying, that none of these fungi can pos- sibly be reduced, as others would be in as- serting that it is their invariable character to be reducible. These differences must chiefly depend upon the size of the swelling, in re- lation to that of the aperture in the skull. Generally speaking, fungous tumours of the dura mater are very dangerous, as well on account of their nature, as of the diffi- culty of curing them in any certain manner, and of tbe internal and external disorder, which they may occasion. Such as have a pedicle, the base of which is not extensive ; which are firm in their texture, without much disease in the surrounding bone, are movea- ble, not very painful, and in persons, who are in other respects quite well, are in gene- ral reputed to be the least perilous. These arc the cases, in which a cure may be at- tempted, with a hope of success, though the event is always exceedingly doubtful. When the contrary of what has been just related occurs, when the disease is of long continuance, and the brain already affected, nothing favourable can be expected. Compression is the most simple means of cure, and that vvhich has naturally occurred to such practitioners, as have mistaken the disease for an aneurism, or a hernia cerebri. The efficacy of this method has been further misconceived, because the tumour, when not very large, has sometimes been partly, or even wholly reduced, without any bad consequences. This had no little share in leading to errors, concerning the true cha- racter of the disease. But, as might be con- ceived, this reduction, only being attended with temporary success, and having no effect whatever on the original cause of the affec- tion, the symptoms returned, and the tumour rose up again, the moment the compression was discontinued. There is a fact in the me- moir of M. Louis, which seems to evince, that good effects may sometimes be produ- ced by compression judiciously employed. A woman, brought to the brink ofthe grave by the symptoms, occasioned by a tumour of the above kind, having rested with her bead, for some time, on the same side as the tumour, found the swelling so suddenly re- duced, without any ill effects, that she thought herself cured by some miracle. Compression artfully kept up, by means of a piece of tin, 1 t-tened lo her cap, prevented the protrusion of the tumour agaiu. The pressure, how ever, not having been nlways very exact, the symptoms every now and then recurred, while the tumour was in the act of being de- pressed again, and they afterward ceased, on the swelling having assumed a suitable position. The symptoms were, doubtless, occasioned by the irritation, which the tu- mour suffered, in passing the inequalities around the opening, through which it pro- truded. The patient lived in this state nine years, having every now- and then trances, in one of which, attended with hiccough and vomiting, she perished. As compression cannot be depended upon, (be following safer method may be tried. It consists in exposing the tumour with a knife, which is certainly preferable to caustics, the action of which is very tedious and painful, and can never be limited or extended with any degree of precision. A crucial incision may be made through the scalp covering the tumour, and the flaps dissected up and reflect- ed, so as to bring all the bony circumference into view. Then with trephines repeatedly applied, or with what would be better, Mr. Hey's saws, all the margin of the bone should be carefully removed. Now, if it be true, that the vessels of the diploe are chiefly concerned in the supply ofthe diseased mass, we see that this source of its growth must be destroyed by the foregoing proceeding. The tumour, thus disengaged on all sides, may be cut off with a scalpel; and such ar- teries as bleed much should be tied. Then, in- stead of applying caustic, as sometimes ad- vised, perhaps, it would be better to remove every part of both layers of the dura mater immediately under the situation of the ex- crescence. By this means, and the removal of the surrounding bone and diploe, all chance of the regeneration of the tumour would be prevented. In attempting the excision of a fungus ofthe dura mater, it is certainly an interesting point to know, whether the tumour has an intimate vascular connexion with the diploe,and pericranium, as asserted by Siebold, Walther, and some other respectable authorities; though the importance of the information on this sub- ject to the practitioner is somewhat lessened by his being aware, that it is necessary always to begin with sawing away the bone in the immediate vicinity of the diseased mass. In the dissection of one case, Wal- ther found the pericranium thickened for a considerable extent around the disease, and closely connected with the tumour by ves- sels. (Vol.cit. p. 100.) When the tumour is sarcomatous, and its pedicle small and narrow, as sometimes happens, one should not hesitate to cut it off. This method is preferable to tying its base with a ligature, a plan which could not be executed, without dragging, and seriously injuring the dura mater. The excision is also preferable to caustics, which cause great pain, and very often convulsions. In performing the extirpation, we should re- move the whole extent of the tumour, and, if posrible; its roof, <■•■'f.n though it may ex- -l-l«i EAR fend as deepiy as tiie iiitc-raal layer of the dura mater. This step must not be delayed, for tbe disease will continue to increase, so as to affectihe brain, become incurable, and even mortal. It is to such decision, that we must impute the success, which attended the treatment of the Spaniard Avalos, of whom Marcus Aurelius Severinus makes mention. The above nobleman was afflicted with intolerable headachs, which no re- medy could appease.' It was proposed to him to trepan the cranium, an operation to which he consented. This proceeding broughtinto view, under the bone,a fungous excrescence, the destruction of which proved a permanent cure of the violent pains, which the disease had occasioned. It is not mentioned in this case, whether the internal layer of the dura mater was healthy or not; but, there is foundation, for believ- ing, that if the extirpation of these tumours be undertaken in time, and bold measures be pursued, as in the instance just cited, success would often be obtained. Indeed, reason would support this opinion; for, when the disease is not extensive, it is ne- cessary to expose a much smaller surface of the dura mater. It appears to me, however, that trepan- ning can never be warrantable, unless the disease be indicated by some external ( hanges. I saw my late master, Mr. Rams- den, trepan a man for a mere fixed pain in one part of the head, on the supposition, that there was a tumour under the bone; but no tumour was found, and tbe operation caused inflammation of the dura mater, aud proved fatnl. l*io doubt, in somj cases, lue hemorrhage will be considerable, as was exemplified in the instance in vvhich Walther made an incision at the base of one of these fungi, in order to ascertain its nature : two pints of blood being lost from several vessels of very large size ere they could be secured ; aud the further use of the knife discontinued. M. Louis has described other tumours, which grow from the surface of the dura mater, when this membrane has been de- nuded, as after the application of the tre- phine. They only seem to differ from the preceding cases in not existing before the opening was made in the skull. These cases are not to be confounded with the hernia cerebri. (See this Article.) See on the preceding subject, Mimoire sur les Tumeurs fongueusesde la Dure-Mere,par M. Louis, in Mim. de I'Acadimie de Chirurgie, Tom. 5, 4to., or Tom. 13, 12mo. Encyclopidie Mi- thodique, Parlie Chirurgicale, art. Dure-Mere. J. P. Kaufmann, de Tumore Capitis fungoso post Cariem Cranii exorto. Helmsl. 1743. Lassus, Pathologic Chirurgicale, Tom. 1, p. 497. Edit. 1809. J.andC. Wenzel, uber die Schwammigen Auswuchse auf der aussern Hirnhaut. Fol. Mainz. 1811. In this work, the sentiments ofM. Louisare espoused. Ph. v.' Walther in Journ. fur Chirurgie von C Grafe, fa. B. 1, P. 55, fa. 8vo. Berlin. 1820. The latter writer criticises the opinions of the Wenzels, and, of course, differs considerably from Louis on several points, some of which t have noticed in the foregoing pages. For an account of inflammation of the dura mater, See Head, Injuries of. E. KATt, DIsLAaES Ol. _l\_N organ, so valuable and necessary to the perfection of our existence, as the ear, should have all the resources of surgery exerted for the preservation of its integrity, and the removal of the diseases, with which it may be affected. What, indeed, would have been our lot, if nature had been less liberal, and not endued us with the sense of hearing ? As Leschevin has observed, we should then have been ill-qualified for the receipt of instruction ; a principal inlet of divine and human knowledge would have been closed ; and there being no reciprocal communication of ideas, our feeble reason could never have approached perfection. Even our life itself being as it were depend- ent upon all such bodies as surround us, would have been incessantly exposed to dangers. The eyesight serves to render us conscious of objects, which present themselves before us, and. when we judge them to be hurtful, vve endeavour to avoid them. But, to say nothing of our inability of looking on all sides at once, our eyes become of no ser- > ice to u«. whenever we happen to be en- ■^foped in (Jyi'-Ties;. The hearing is then the only sense that watches over our safety. It warns us, not only of every thing which is moving about us, but like- wise of noises, which are more or less dis- tant. Such are the inestimable advantages which we derive from this organ. Its im- portance, when healthy, makes it worthy of the utmost efforts of surgery, when diseased. (Leschevin, in Mimoires sur les Sujetspro- posis pour le Prix de I'Acad. Royale de Chi- rurgie, Tom.9,p. Ill, 112.£dtr. 127no.) It is not many years since the diseases of the ear were a subject, on which the greatest ignorance and the most mistaken opinions prevailed ; and, indeed, how could any correct pathological information be ex- pected, while anatomists had not given a complete and acurate description of the organ itself? Also, notwithstanding wbat has now been made out, respecting disorders of the ear, it is generally admitted, that they still require further investigation, and re- newed industry. Tfiough Duverney, Val- salva, Morgagni, &.c. dispelled some of the darkness, which covered this branch of surgery, they left agreat deal undone. Since their time, science has been enriched with the valuable discoveries of Colunni, Meckel, LAR. MO Scarpa, and Comparcui; the two first of whom demonstrated, that the labyrinth is filled with a limpid fluid, and not (as was pretended) with confined air; while the two last distinguished anatomists favoured the public with the first very accurate des- cription of the parts composing the laby- rinth, especially the -emicircular canals. In 1703, the French Academy of Surgery offered a prize for the best essay on diseases of the ear, and, two yeara afterwards the honour was adjudged to that of Leschevin, senior surgeon of the hospital at Rouen. This memoir is still of great value, few mo- dern treatises being more complete. The most useful contributors to our stock of in- formation on the Pathology of the ear, sub- sequently to M. Leschevin, have been Krit- ter, and Lentin (Ueber das Schwere Gehoer. Leipz. 1794;) Trampel (Arneman'* Magaz. B.2,\79S;) Pfingsten (Vieljahrige Erfah- rung ueber die Gehoerfelder, Kiel, 1802;) Alard (sur le Calarrhede I'Oreille, 8vo. Paris, 1807, 2d Edit.) Mr. A. Cooper, (Phil. Trans. 1802.) Portal (Anat. Med. 1803.) J. C. Saunders, (Anat. and Dis. ofthe Ear, 1806.) Baron Boyer (Mai. Chir. T. 6.) Saissy, in an essay, which received the approbation of the Medical Society of Bordeaux ; and Pro- fessor Rosenthal in a short but sensible tract on the pathology of the ear. (See Journ. Complem. T. 6, 1820.) But, notwithstanding the laudable endea- vours of so many men of eminence, the pathology of the internal ear, and the treat- ment of its diseases, are far, 1 may say, very far from a high state of improvement. To further advances, indeed, some dis- couraging obstacles present themselves: the auditory apparatus is extremely complica- ted ; the most important parts of it are en- tirely out of the reach of ocular inspection ; the anatomy of the organ is perhaps not yet completely unravelled; the exact uses and action of several parts of it, anatomi- cally known, are still involved in mystery ; the opportunities of dissecting the ear in a state of disease are neither frequent, nor duly watched, and even when they are taken, and when vestiges of disease, or im- perfection, are traced to particular parts of the organ, the utmost difficulty is expe- rienced in drawing any useful practical con- clusion, because the natural uses of those parts, and the precise manner in which they contribute to the perfection of the ear, are not known to the most enlightened physio- logists. We are here nearly iu the same helpless dilemma, as a watchmaker would be, were he, in examining the interior of a watch, to find parts broken and out of order, the exact uses of which, in the perfection of the instrument, he had not first studied and comprehended. In fact, the physiology of the ear is but very imperfectly under- stood ; and, as Rosenthal remarks, (Journ. Complem. T. 6, p. 17) if, notwithstanding the progress made in optics, and the com- plete knowledge ofthe structure of the eye, a perfect explanation has not yet been given of the phenomena of this organ, as an Vol. I. 57 instrument of vision, we cannot wonder, that, with far more circumscribed informa- tion about acoustics, and the greater diffi- culty of unravelling the structure of the ear, so little progress should have been made in the physiology of the latter organ. Were it practicable in acoustics to arrive at that'precision and certainty, which would enable us to establish laws in the theory of sound, as fixed as those which relate to light, this void in physiological science might perhaps be obviated. But, Rosenthal justly argues, that hitherto the approach to per- fection has not been made, and this notwith- standing the learned and valuable labours of Chladni. (Akustik. 4to. Leipz. 1802.) Some facts, however, are admitted to be well as- certained, and the researches of Autenrieth and Kerner (Rcil's Archir. fur die Physiol. T. 9, p. 313—376.) are honourably mentioned; for, though they only elucidate the function of the conductor-part of the ear, they are of unquestionable importance to the medi- cal practitioner. It is clearly proved, that the difference in the length and breadth of the meatus auditorius, the form of the membrana tympani, and the make of the cavity ofthe tympanum, modify sound; that is to say, that the differences of structure of the auricle and meatus auditorius externus, which merely receive and concentrate the sonorous undulations, as these emanate from a vibrating body, can only influence the degree of force, or weakness of the sound ; while, on the contrary, the differences of structure in the membrane and cavity of the tympanum are not limited to this effect, but the greater or less tension of the one, and the more or less considerable capacity of the other, appear to alter in greater or lesser degree the particular character of the sound. (Journ. Complem. T. 6, p. 20.) I. Wounds and Defects of theExlemal Ear. The external ear, which is a sort of instru- ment calculated for concentrating the undu- lations or waves of sound, may be totally cut off, without deafness being the conse- quence. For a few days after the loss, the hearing i3 rather hard ; but the infirmity gra- dually diminishes, the increased sensibility of the auditory nerve compensating for the imperfection of the organic apparatus. (Ri- cherand Nosogr. Chir. T. 2, p. 122, Edit. 2.) Dr. Hennen says, that he has met with a case, where the external ear was completely removed by a cannon shot, and yet the sense of hearing was as acute as ever. (Principle* of Military Surgery, p. 348, Ed. 2.) Another case, recorded by Wepfer, also proves, that a total loss of the auricle may not cause any material injury of hearing, for the patient of whom he speaks had had the whole of the external ear destroyed by ulceration, and yet could hear as well as before the loss. (Kritter und Lentin Ueber i'as schwere Gekoer, p 19, Leipz. 1794.) However, if we are to credit the statement of other writers, the recovery is generally far \< sscomplete. Thus Leschevin notices, that they who have lost the external ear, or have it naturally too flat, loo EA or ill shaped, have the hearing less fine. The defect can only be remediea by an ar- tificial ear, or an ear trumpet, which, re- ceiving a large quantity ofthe sonorous un- dulations, and directing them towards the meatus auditorius, thus does the office ofthe external ear. (Prix, dt I'Acad. Royale de Cur. T. 9, p. 120. Edit. 12mo.) Wounds are not the only causes, by which the external ear may be lost: its separation is sometimes the consequence of ulceration, and sometimes the effect of the bites of horses and other animals. In cold climates, it is frequently frozen, and afterwards at- tacked with inflammation and sloughing. When the external ear is not totally separa- ted from the head, the surgeon should not despair of being able to accomplish the re- union of it. This attempt should always be made, however small a connexion the part may have with the skin ; for, in wounds of this kind, the efforts of surgery have occa- sionally succeeded beyond all expectation. Wounds of the external ear, whatever may be their size and shape, do not require dfferent treatment from that of the generality of other wounds. The reunion of the divi- ded part is the only indication, and it may be in most instances easily fulfilled by means of methodical dressings. Such writers, as have recommended sutures for wounds of the ear, (says Leschevin,) have founded this advice upon the difficulty of applying to the part a bandage, that will keep the edges ofthe wound exactly together. The crani- um, however, affords a firm and equal sur- face, against which the external ear may be conveniently fixed. Certainly, it is not more easy to secure dressings on the nose than the ear; and yet, cases are recorded, in which the cartilaginous part of the nose was wounded, and almost entirely separated, and the union was effected without the aid of suture". (See Mem. de M. Pibrac surl'Abus des Sulures,in Mem. de I'Acad.de Chir.Tom.3.) In wounds ofthe ear, then, we may con- clude, that sutures are generally useless and unnecessary. As examples may occur, how- ever, in which the wound may be so irregu- lar and considerable as not to admit of be- ing accurately united, except by tbis means, it should not be absolutely rejected. An enlightened surgeon will not abandon alto- gether any curative plans; he only points out tbeir proper utility, and keeps them within the right limits. When sticking plas- ter, simple dressings, and a bandage, that makes moderate pressure, appear insuffi- cient for keeping the edges of a wound of the ear in due contact, the judicious prac- titioner will not hesitate to employ sutures. When a bandage is applied to the external ear, it should only be put on with moderate tightness, since much pressure gives con- siderable uneasiness, and may induce slough- ing. In order to prevent these disagreeable effects, Leschevin advises us to fill the space behind the ear with soft wool or cotton, against which the part may be compressed without risk. (Op. cit. p. 119.) Karon Boyer remembers a medical stu- dent, who was compelled by an ulcer on the sacrum to lie for a long time on bis side, in vvhich posture the pressure on the ear caused a slough ofthe antihelix, and after the separation of tbe dead part, an aperture, large enough to receive the end of the little finger, was left in the pinna or auricle. In the application of sutures to the ear, the ancients caution us to avoid care- fully the cartilage, and to sew only the skin. They were fearful that pricking the carti- lage would make it mortify, " ce qui est sou- tenle-fois arivi," says Pare. But notwith- standing so respectable an authority, as Les- chevin has remarked, the moderns make no scruple about sewing cartilages. In wounds of the nose, Verduc expressly di- rects the skin and cartilage to be pierced at once, and the success of the plan is put out of all doubt by a multitude of facts. The same treatment may also be safely ex- tended to the ear. Celsus, lib. 8, c. 6, speaks of fractures of the cartilage of the ear ; but, such an acci- dent seems hardly possible, unless the part be previously ossified. Leschevin and Boy- er have never met with such a case, either in practice, or in the works of surgical writers. In this section, a few malformations of the external ear require notice. Sometimes the orifice of the meatus auditorius is dimi- nished by the tragus, antitragus, and antihe- lix being depressed into it. Here the exci- sion of these wrongly-formed eminences has been recommended, as a surer means of perfecting the sense of hearing, than the use of any tube, or dilating instruments. The tragus has been known to projec^con- siderahly backwards, and to apply itself most closely over the orifice of the meatus, which was also a mere slit, instead of a round opening. In one case of this descrip- tion, relief was obtained by the introduction of tubes, calculated to maintain the tragus in its proper position. (Did. des Sciences Med. T. 38, p.28.) Sometimes the outer ear is entirely want- ing. Thus Fritelli has given an account of a child iu this condition, whose physiogno- my at the same time strongly resembled that of an ape. (Orteschi Giorn di Med. T. 3, p. 80.) Oberteuffer has also recorded an ex- ample of a total deficiency of the auricles in an adult, who yet heard very well. (Stark's Neues Archiv. B. 2, p. 638. J. F. Meckel Handbuch der Pathol. Anat. B. i, p. 400, Leipz. 1812.) Many years ago, I remember a child, which was shown to several medical gentlemen in London, as a curiosity ; it was entirely des- titute of all appearance of external ears, and no vestiges of the meatus auditorii could be seen,these openings being completely cover- ed by the common integuments. Yet the child could hear a great deal, though the sense was certainly dull and imperfect. I remember thatthe circumstance ofthe pa- tient hearing so well as he did, was what excited considerable surprise. I am sorry I do not more particularly recollect, at the EAR. 451 present time, the degree in which this sense was enjoyed, and several other circumstan- ces, such as the child's age, power of speech, he. The example, however, is interesting, inasmuch as it proves, that even a deficien- cy ofthe auricles, combined with an imper- forate condition of both ears, may be unat- tended with complete deafness, provided the internal and more essential parts of these organs are sound and perfectly formed. Baron Boyer attended a young man, tbe lobule of one of whose ears extended in a very inconvenient manner over the cheek : the redundant portion was removed with a pair of scissors, and the wound soon healed. The auricle, not being a very irritable part, is not often inflamed, and when it is so, the affection is generally of an erysipelatous character. Portal has seen the part nearly an inch thick ; and he takes notice of the prodigious thickness, which the lobe of the car sometimes acquires in women, who wear very heavy ear-rings, which keep up constant irritation. Small encysted and adi- pose swellings occasionally grow under the skin of the external ear, and demand the same treatment as swellings ofthe same na- ture in other situations. (See Tumours.) Lastly, the external ear is frequently the seat of scrofulous, and other ill-conditioned ulcers. These cases generally require clean- liness, alterative medicines, and to be dressed with the ung. hydrarg. nitrat. or a solution of the nitrate of silver; and sometimes when the sores resist for a long time the effects of medicine and the usual dressings, they will soon heal up, if the treatment be assisted with a blister, or seton, kept open on the nape of the neck. (See Diet, det Sciences Med. T.38, p. 28, 29.) 2. Ofthe Meatus Auditorius, and its Imperfec- tion. This is the passage, which leads from the cavity of the external ear, called the concha, down to the membrane of the tympanum. It is partly cartilaginous, and partly bony, and has an oblique winding direction, so that its whole extent cannot be easily seen. There are circumstances, however, in which it is proper to look as far as possible into the passage. Such is the case, when the surgeon is to extract any foreign bqdy, to remove any excrescence, or to detect any other occasion of deafness. Fabricius Hilda- nus gives a piece of advice upon this subject, not to be despised ; namely, to expose the ear to the rays of the sun, in order to be enabled to see the very bottom ofthe mea- tus auditorius externus. The surgical operations practised on the meatus auditorius are confined to opening it, when preternaturally closed, extract- ing foreign bodies, washing the passage out with injections, and removing excrescences, which may form there. The case which we shall next treat of, is the imperforatiou of the meatus auditorius externus, a defect with which some children are born. When the malformation exists in both ears, it generally renders tbe subject dumb, as well as deaf, for, as he is incapable of imitating sounds, which he does not hear, he cannot of course learn to speak, although the organs ofspeech may be perfect, and in every respect rightly disposed. In this case, the surgeon has to rectify the error of na ture, and, (to use the language of Lesche- vin,) he has to give by a double miracle, hearing and speech to an animated being, who, deprived of these two faculties, can scarcelybe regarded in society as one of the human race. How highly must such an ope- ration raise the utility and excellence of sur- gery in the estimation ofthe world ! When the meatus auditorius externus is merely closed by an external membrane, the nature of the case is evident, and the mode of relief equally easy. But, when the membrane is more deeply situated in the passage, near the tympanum, the diagnosis is attended with more difficulty, and the treatment with greater trouble. If the preternatural membrane is external, or only a little way within the passage, it is to be divided with a bistoury ; the small flaps are to be cut away ; a tent, of a suit- able size, is to be introduced into the open- ing ; and the wound is to be healed secun- dum arlem, care being taken to keep it con- stantly dilated, until the cicatrization is completed. When the obstruction is deeply situated, we must first be sure of its existence, vvhich is never ascertained, or even suspected, till after a long while. It is not till after chil- dren are past tbe age, at which they usually begin to talk, that any defect is suspected in the organ of hearing, because until this pe- riod, little notice is taken, whether they hear or not. As soon as it is clear, that this sense is deficient, the ears should al- ways be examined with great attention, in order to discover, if possible, the cause of deafness. Sometimes, the infirmity depends upon a malformation of the internal ear, and the cause does not then admit of detec- tion. The most convenient method of ma- king the examination is to expose the ear, which is about to be examined, to the light ofthe sun. In this situation, the surgeon will be able to see beyond the middle of the bony part of tbe meatus, if he places his eye opposite the orifice of the passage, and takes care to efface the curvature of the cartilaginous portion ofthe canal, by draw- ing upward the external ear. If the passage has been carefully cleansed, before the ex- amination, the skin, forming the obstruction, may now be seen, unless it be immediately adherent to the tympanum. When the preternatural septum is not closely united to tbe tympanum, its destruc- tion should be attempted, and hopes of ef- fecting the object, either suddenly, or gra- dually, may reasonably be entertained. Ac- cording to Leschevin, the particular situa- tion ofthe obstruction is (he circumstance, by vvhich the surgeon ought to be guided in making a choice ofthe means for this ope- ration. If the membranous partition is >,. 4o2 EAB- far from the tympanum, that it can be pler- eed without danger of wounding the latter part, there can be no hesitation in choosing the plan to be adopted. In the contrary state of things, Leschevin is an advocate for the employment of caustic, not only on account of the risk of injuring the tympa- num with a cutting instrument, but, also, because, if the puncture were ever so well executed, a tent could not be introduced in- to it, so as to prevent it from closing again. In the first case, a very narrow sharp- pointed bistoury should be used : after its blade has been wrapped round with a bit of tape to within aline ofthe point, it is to be passed perpendicularly down to the preter- natural membrane, which is to be cut through its whole diameter. The instru- ment being then directed first towards one side, then the other, the crucial incision is to be completed. As the flaps, which are small and deeply situated, cannot be remo- ved, the surgeon must be content with keep- ing them separated by means of a blunt tent. Tbe wound will heal just as favour- ably as that occasioned in removing the im- perforation of the concha, or outer part of the meatus auditorius. (Prix de I'Acad. de Chir.p. 124—126, T. 9.) In the second ease, that is to say, when the risk of wound- ing the tympanum leads us to prefer the em- ployment of caustic, the safest and most commodious way of putting the plan in execution would be that of touching the obstruction, as often as circumstances may require, with the extremity of a bougie armed with the argentum nitratum. In theintcrvals ofthe applications, no dressings need be introduced, except a bit of clean soft cotton, for the purpose of absorbing any discharge, which may take place within the passage. It is manifest, that if the whole, or a con- siderable part of the meatus auditorius ex- ternus were wanting, the foregoing mea- sures would be insufficient. The following observations of Leschevin merit attention : '•' I do not here allude to cases, in which a malformation of the bone exists. I know not, whether there are any examples of such an impcrforation ; but, it is clear, that it would be absolutely incurable. I speak of a temporal bone perfectly formed in all its pnrts, and the meatus auditorius of which, instead of being merely lined by a membrane, as in the natural state, is block- ed up by the cohesion of the parietes of this membrane throughout a certain extent of the canal ; ju^t as the urethra, rectum, or vagina, is sometimes observed to be not simply closed by a membrane, but by a true obliteration of its cavity. " Such a defect in the ear may be con- genital, and it may also arise from a wound, or ulceration, of the whole circumference of the meatus auditorius externus, this canal having become closed by the adhesion of its parietes, on cicatrization taking place. " Such an imperforation, whether con- genital or accidental, must certainly be n;ore difficult to cure, than tbe example* treated of above ; but, (avs Leschevin) I do not for this reason believe, that the case ought to be entirely abandoned. Yet, I would not have the cure attempted in all sorts of circumstances. For instance, if the defect only existed in one ear, and the otherwere sound, I would not undertake the operation, because, as the patient can hear tolerably well on one side, the advantages which he might derive from having the en- joyment of the other ear, would not coun- terbalance the pain and bad symptoms occa- sioned by such an experiment, the success of vvhich is extremely uncertain. I would not then run the risk of making a perfora- tion, except in a case of complete deafness; and I propose this means only as a dubious one upon the fundamental maxim, so often laid down, that it is preferable to employ a doubtful remedy, than none at all. 11 With respect to the mode of executing this operation," says Leschevin, " the tro- car seems the most eligible instrument. I would employ one, that is very short, and the point of which is blnntish, and only projects out of a cannula ns little as possi- ble. This construction would indeed make the instrument less adapted to pierce any thing ; but, still, as the parts to be perfora- ted are firm, their division mightbe accom- plished sufficiently well ; and the inconve- nience of n trivial difficulty in the introduc- tion of the trocar is comparatively much less, than that which would attend the dan- ger of wounding with a sharper point the membrane of the tympanum. I would plunge the point of the instrument into the place, where tbe opening ofthe meatus au- ditorius externally ought naturally to be, and which would be denoted, either by a slight depression, or at all events by attend- ing to the different parts of the ear, espe- cially the tragus, which is situated directly over this passage. I would push in the tro- car gently, in the direction of the canal formed in the bone, until the point of the instrument felt as if it had reached a vacant space. Then, withdrawing the trocar, and leaving the cannula, I would try whether the patient could hear. I would then intro- duce into the cavity of the cannula itself a small, rather firm tent, ofthe length of the passage, or a small bougie. By means of n probe, I would push it to the end of the cannula, vvhich I would now take out, ob- serving to press upon the tent, which is to be left in. The rest of the treatment con- sists in keeping the canal pervious, making it suppurate, and healing it with common applications. One essential caution, how- ever, would be that of keeping the part dila- ted long after it had healed : otherwise, it might close ngain. and a repetition of the operation become necessary. This hap- pened to Heister, as he him-elf apprizes us, and it occurred to Roonhuyscn in treating imperforations ofthe vagina. '•If the cohesion of the pari-tes of the meatus auditorius externus were to extend to the tympanum inclusively, the operation would be fruitless ; but. n* it is irnno=Mble EAR. 4JJ3 to ascertain this circumstance, before the attempt is made, the surgeon would incur no disgrace by relinquishing the operation, and giving up the treatment of an incurable disease. If, then, after the trocar weie in- troduced to about the depth of the tympa- num, the situation of which must be judged of by our anatomical knowledge, uo cavity were met with, the operation should be aban- doned ; and, if in these circumstances, any one were to impute the want of success to theinefficacy of surgery, orthe unskilfulness of the surgeon, he would act very unfairly, " It is also plain, that such an operation could cure a congenital deafness, only inas- much as it might depend upon the imperfo- ration ; for, if there should exist,at the same time, in the internal ear, any malformation, destructive ofthe power of the organ, the remedying of the external defect would be quite useless." (Leschevin, in Prix de I'Acad. de Chirurgie, Tom. 9, p. 127, 132.) We find, that this author entertains a great dread of wounding the tympanum, and cer- tainly he is right in generally insisting upon the prudence of avoiding such an accident. It will appear, however, in the sequel of this article, that under certain circumstan- ces, puncturing the tympanum has been successfully practised, as a mode of remedy- ing deafness. The operation, however, de- mands caution ; for, if done so as to injure the connexion ofthe malleus with the mem- brana tympani, the hearing must ever af- terward be very imperfect. 3. Unusual smallness of the Meatus Audito- rius Externus. Iinperforation is not the only congenital imperfection of the meatus auditorius ; this passage is occasionally too narrow for the admission of a due quantity of the sonorous undulations, and the sense is of course weakened. Leschevin mentions, that M. de la Metrie found this canal so narrow in a young person, that it could hardly admit a probe. What has been observed, concern- ing the imperforation, is also applicable to this case. If it depends upon malformation ofthe bone, it is manifestly incurable ; but, if it is owing to a thickening of the. soft parts, within the meatus, hopes may be in- dulged of doing good by gradunlly dilating the passage by tents, which should be in- creased in size from time to time, and, last- ly, making the patient wear for a consider- able time, a tube, adapted to the part in shape. (Leschevin, in Prix de I'Acad. de Chirurgie, Tom.9,p 132.) Mr. Earle has lately published a case, in which the diameter of the meatus auditori- us wns considerably lessened by a thicken- ing of the surrounding parts, and especially of the cuticle, attended with a discharge from the passage, and great impairment of hearing. A cure was effected by injecting into the passage a very strong solution of the nitrate of silver, vvhich in a few days, was followed by a detachment of the thick- ened portions of cuticle. This evacuation wne assisted by throw ing warm water into the passage. See Med. Chir. Trans. Vol. 10, p. 411, Sre.) Boyer was consulted for a deafness, which arose from a malformation, which consisted of a flattening of the mea- tus, its opposite sides being for some extent in contact. The patient was advised to wear in the ear a gold tube of suitable shape, by which means be was enabled to hear perfectly well. 4. Faulty shape of the Meatus Auditorius Externus. Anatomy informs us, that this passage is naturally oblique, and somewhat winding ; and natural philosophy teaches us the ne- cessity of such obliquity, which multiplies the reflections of the sonorous waves, and thereby strengthens the sense. This theory, says Leschevin, is confirmed by experience ; for, there are persons, in whom the meatus auditorius is almost straight, and they are found to be hard of hearing. If there is any means of correcting this defect, it must be that of substituting, for the natural cur- vature of the passage, a curved and conical tube, which must be placed at the outside of the organ, just like a hearing trumpet. The acoustic instrument, invented by Deck- ers, which is much more convenient, might also prove useful. (Op. cit. p. 133.) 5. Extraneous Substances, Insects, fa. in the. Meatus Auditorius Externus. Foreign bodies met with in this situation are inert substances, which have been in- troduced by some external force ; insects, vvhich have insinuated themselves into the passage ; or tbe cerumen itself, hardened in such a degree as to obstruct the trans- mission of the sonorous undulations. Worms, which make their appearance in the meatus auditorius, ate always produced subsequent- ly to ulcerations in the passage, or in the in- terior of the tympanum, and, very often, such insects are quite unsuspected causes of particular symptoms. In tbe cases of surgery, published in 1778, by Acrel, there is an instance confirming the statement just offered. It is the case of a woman, who, having been long afflicted with a hardness of hearing, was suddenly seized with violent convulsions, without any apparent cause, and soon afterward complained of an acute pain in the ear. This affection was followed by a recurrence of convulsions, which were still more vehement. A small tent of fine linen, moistened with a mixture of oil nnd laudanum, was introduced into the meatus auditorius, and, on removing it the next day, several small round worms were observed upon it, and, from that peri od, all the symptoms disappeared. To this case, we shall add another from Morgagni. A young woman consultedValsalva, and told him, that when she was a girl, a worm had been discharged from her left ear; that another one, about six months ago, had also been discharged, very much like a small silkworm in shape. This event took place after very acute pain in the same ear, the forehead nnd temples. She added, that 4M LAR. .Mnce this, she bad been tormented with the same pains, at diflerent intervals, and so se- verely, that she often swooned away for two hours together. On recovering from this state, a small worm was discharged, of the same shape as, but much smaller than, the preceding one, and she was now afflict- ed with deafness and insensibility on the same side. After hearing this relation, Val- salva no longer entertained any doubt of the membrane of the tympanum being ul- cerated. He proposed the employment of an injection, in order to destroy such worms as yet remained. For this purpose, distilled water of St. John's wort, in which mercury had been agitated, was used. In order to prevent a recurrence of the incon- venience, Morgagni recommends the affect- ed ear to be closed up when the patient goes to sl^ep, in autumn and summer. If this be not done, flies, attracted by the sup- puration, enter the meatus auditorius, and, while the patient is inconscious, deposit their eggs in the ear. Acrel, in speaking of worms, generated in the meatus audito- rius observes, that there is no better reme- dy for them, than the decoction of ledum palustre, injected into the ear, several times a day. However, as this plant cannot al- ways be procured, an infusion of tobacco in oil of almonds may be used, a few drops of whicb are to be introduced into the ear, and retained there by means of a little bit of cotton. This application, which is not inju- rious to the lining ofthe passage, is fatal to insects, and especially to worms. It will an- swer in cases where caterpillars, ants, earwigs and other insects have insinuated themselves into the meatus auditorius; though it is generally considered better first to endea- vour to extract them. A piece of lint, smeared with honey, often suffices for this purpose, and when they cannot be extracted by this simple means, they may be taken out with a small pair of forceps. The latter method serves also for the ex- traction of cherry-stones, peas, or other seeds which have been introduced into the meatus auditorius. If such substances should make too much resistance, forceps with stronger blades for breaking the extraneous bodies must be employed, and then the fragments are to be extracted piecemeal. But, in these cases, before attempting the extraction, a little oil of almonds should be injected. The presence of foreign bodies in the ear often occasions the most extraor- dinary symptoms, as we may see in the fourth observation of Fabricius Hildanus, Cent. 13. After four surgeons, who had been succes- sively, consulted had in vain exerted all their industry to extract a bit of glass from the left ear of a young girl,the patient found herself abandoned to the most excruciating pain, which soon extended to all the side of the head, and which, after a considerable time, was followed by a paralysis ofthe leftside, a dry cough, suppression of the menses, epileptic convulsions, and, at length, an a'-opby of tiie foff arm. Hildanus cured her, by extracting the piece ol glass, which had remained eight years in her ear, and had been tbe cause of all this disorder. Although the extraction must have been very difficult, it does not appear that Hilda- nus found it necessary to practise an inci- sion behind the ear, as some authors have advised, and among them, Duverney, who has quoted the foregoing case. We must agree with Leschevin, that such an incision does not seem likely to facilitate the object very materially; for, it must be on the outside of the extraneous substance, which is in the bony part of the canal. The in- cision enables us, in some measure, to avoid the obliquity of the passage, as Duverney has observed ; but it is not such obliquity of the cartilaginous portion of tbe canal, that can be a great impediment ; for, as it is flexible, it may easily be made straight, by drawing upwards the external ear. Hence, Fabricius ab Aquapendente rejected this operation, first proposed by Paulus iEgineta ; and it is justly disapproved of by Leschevin. (Prix de I' Acad, de Chir. Tom. 9, p. 147, Edit. 12wio.) Sabatier relates a case, in which a paper ball, which had been pushed into the mea- tus auditorius, made its way by ulceration into the cavity of the tympanum, where an abscess formed, which communicated with the interior of the cranium. (Diet, des Sci- ences Med. T. 7, p. 8.) 6. Meatus Auditorius obstructed with thick- ened, or hardened Cerumen. The cerumen, secreted in tbe meatus au- ditorius by the sebaceous glands, frequently accumulates there in large quantities, and becoming harder and harder, at length ac- quires so great a degree of solidity as en- tirely to deprive the patient of the power of hearing. Galen has remarked, i numero eorum qua meatum obsiruunt, sordesesse qua in auribus colligi solent. This species of deafness is one of those kinds, which are the most easy of cure, as is confirmed by observers, especially Duverney. Formerly frequent injections, either with simple olive oil, or oil of almonds, were recommended. The injection was retained by a piece of cotton, and when there was reason to be- lieve thatthe matter was sufficiently soften- ed, an attempt was made to extract it by means of a small scoop-like instrument. Various experiments were, made by Hay- garth, at Chester, in 1769, from which "it appears that warm water is preferable to oil. The water dissolves the mucous mat- ter, which connects together the truly ce- ruminous particles, and which is the cause of their tenacity ; other applications only succeeding by reason of the water which they contain. The lodgment of hard pellets of wax, if neglected, may ultimately produce ulcera- tion of the tympanum, and other serious mischief. Thus, in one case, Ribes and Chaussier found the handle ofthe malleus separated from its bead, partly destroyed, and covered with tbe hardened cerumen tba* EAR. ■iio had made its way into the tympanum. t^See Did. des Sciences Med. T. 38, p. 30.) " The symptoms (says ^r. Saunders) which are attached to the inspissation of the cerumen are pretty well known. The patient, besides his inability to hear, com- plains of noises, particularly a clash or con- fused sound in mastication, and of heavy sound;, like the ponderous strokes of a ham- mer. " The practitioner is led by the relation of such symptoms to suspect the existence of wax ; but he may reduce it to a certainty by examination. " Any means capable of removing the inspissated wax may be adopted ; but syrin- ging the meatus with warm water is the most speedy and effectual, and the only means necessary. As the organ is sound, the patient is instantaneously restored." (Anatomy ofthe human Ear, with a Treatise on its Diseases, by J. C. Saunders, 1806, p. 27, 28.) In order to throw an injection into the ear with effect, a large syringe, capable of holding, at least, six or eight ounces, should be employed ; and the fluid should be in- jected with a good deal of force, care be- ing taken to let it enter in the natural direc- tion, and not against one of the sides ofthe passage. The surgeon must also avoid pressing the pipe too deeply into the ear, so as to hurt the tympanum. As the fluid regurgitates with considerable rapidity, a small basin is to be held close up to the ear at the time of using the syringe, so as to catch the water, and hinder it from wetting the patient's clothes ; for the surer preven- tion of which a napkin is also to be laid over the shoulder. In general it is neces- sary to throw the water into the ear six or seven times, or more, ere the pellets of wax are loosened, and entirely brought out; and, sometimes, the injections will not completely succeed the first day on which they are employed. The evening before the syringe is to be used, it may oc- casionally be best to drop a little sweet oil into the ear. 7. Discharges from the Meatus Auditorius. Purulent discharges from the ear either come from the meatus auditorious externus itself, or they originate from suppuration in the tympanum, in consequence of blows on the head, abscesses after malignant fevers, the small-pox, or the venereal disease. In such cases, the little bones of the ear are sometimes detached, and escape externally, and complete deafness is most frequently tbe consequence. However, in a few in- stances, total deafness does not always fol- low even this kind of mischief, as I myself have witnessed on one or two occasions. There is greater hope when the disorder is confined to the meatus ; as judicious treat- ment may now avert the most serious con- sequences. In Acrel's surgical cases, there is a case relative to the circumstance «f which we are speaking. Suppuration took place in the meatus auditorius externus, in consequence of acute rheumatism, which w-as followed by vertigo, restlessness, and a violent headach. The matter discharged was yellowish, of an aqueous consistence, and acid smell. The meatus auditorius was filled with a spongy flesh. On introducing a probe, our author felt a piece of loose rough bone, which he immediately took hold of with a pair of forceps, and extracted. From the time when this was accomplished, Ihe discharge diminished ; and, with the aid of proper treatment, the patient became perfectly well. The meatus auditorius, like all other parts of the body, is skibject to inflammation. This is frequently produced by exposure to cold. It is hardly necessary to say, that generally topical bleeding and antiphlogis- tic means are indicated. The meatus audi- torius should also be protected from the cold air, particularly in the winter season, by means of a piece of cotton. Mr. Saunders observes, " When the means employed to reduce the inflammation have not succeeded, and matter has formed, it is generally evacuated, as far as I have observed, between tbe auricle and mastoid process, or into the meatus. If it has been evacuated into the meatus, the opening is most commonly small, and the spongy granulations, squeezed through a small aperture, assume the appearance of a poly- pus. Sometimes the small aperture, by which the matter is evacuated, is in this manner even closed, and the patient suffers the inconvenience of frequent returns of pain from the retention of the discharge. When the parts have fallen into this state, it will be expeditht to hasten the cure by making an incision into the sinus, between the auricle and mastoid process. " It occasionally happens, that the bone itself dies, inconsequence of the sinus being neglected, or the original extent of the sup- puration. The exfoliating parts are the meatus externus of the os temporis or the external lamina of the mastoid process, rP. 24, 25.) 8. Excrescences in the Meatus Auditorius. Though the membrane, lining the meatus auditorius, is very delicate, it is not the less liable to become thickened, and to form polypous excrescences. This case, how- ever, is not common. As such tumours are ordinarily firmer in their texture than poly- pi of the nose, they are sometimes not so easily extracted with forceps. When they are situated near the external orifice, and admit of being taken hold of with a small pair of forceps, or a hook, they may easily be cut away, when drawn outward, and this without any reason for fearing hemor- rhage. This indeed, is usually very trivial. When the tumours are more deeply situated, Mr. B. Bell recommends the use of a liga- ture. Here the same plan may be pursued as will be explained in the article Polypus. But, it sometimes happens, that the excres- cences cannot be removed in this manner ; a* instead of being adherent by a narrow •liti EAR neck, they have a broad base, which occu- pies a considerable extent of the passage. In such cases, the use of escharotics has been absurdly proposed ; but, as these ap- plications cannot be used without risk of injuring the membrane of the tympanum, it is better to have recourse to another method. (Encyclopidie Mithodiqui ; Par- tie Chirurgicale, Art. ^Auditif conduit.) Mr. B. Bell recommends dilating the passage with bougies ; but it is obvious that the pressure of such instruments would also be very likely to irritate and inflame the mem- brane of the tympanum. 9. Herpes of the Meatus Auditorius. An herpetic ulcerous eruption sometimes affects tbe meatus auditorius and auricle, producing considerable thickening of the skin, and so great an obstruction ofthe pas- sage, that a good deal of deafness is the consequence. Mr. Saunders remarks, that, in this case, " the ichor, w hich exudes from the pores of the ulcerated surface, inspis- sates in tbe meatus, and not only obstructs the entrance of sound, but is accompanied with a great degree of fcetor. This disease is not unfrequent. I have never seen it re- sist the effect of alterative medicines," the use of injections containing (he oxymuriate of quicksilver, and the application of the unguentum hydrargyri nitrati. Mr. Saun- ders exhibited calomel as the alterative, and, in one instance, employed a solution of the argentum nitratum, as an injection. (Page 25, 26.) When the disease is obsti- nate, a seton should be made on the nape of the neck, or a blister be applied behind the car. 10. Affections of the Tympanum. The ear is sometimes affected with a pn- riform ichorous discbarge, attended with a loss of hearing, proportionate to the degree of disorganization which the tympanum has sustained. Frequently, on blowing the nose, air is expelled at the meatus auditorius ex- ternus ; and, when this is the case, it is evi- dent, that the discharge is connected with an injury, or destruction of the membrana tym- pani. However, when the Eustachian tube is obstructed with mucus, or matter, or when it is rendered impervious, and perma- nently closed by inflammation, the mem- brana tympani may not be perfect, and yet, it is clear, no air can in this state be forced out ofthe external ear in the above manner. An examination with a blunt probe, or with the eye, while the rays of tbe sun fall into the passage, should therefore not be omitted. If the membrane have any aper- ture in it, the probe will pass into the cavity of the tympanum, and the surgeon feel that his instrument is in contact with the ossicula. In this manner, the affection may be dis- criminated from an herpetic ulceration of the meatus auditorius externus. The causes are various: In scarlatina maligna, the mem- brana tympani occasionally inflames, and sloughs; all the ossicula are discharged, *nd, if the patient live, he often continues quite deaf. An earach, in other word.-', acute inflammation ofthe tympanum is the most common occasion of suppuration in this cavity, iu which, and the cells of the mastoid process, a good deal of pus collects. At length the membrana tympani ulcerates, and a large quantity of matter is discharged ; but, as tha-secretion of pus still goes on, the discharge continues to ooze out of the ex- ternal ear. Instead of stimulating applications, in- flammation of the tympanum demands the rigorous employment ofantiphlogistic means. Unfortunately, it is a too common practice, in this case, to have recourse to acrid spiri- tuous remedies. Above all things, the re- peated application of leeches to the skin be- hind the external ear, and over the mastoid process, should never be neglected. As soon as the inflammation ceases, the degree of deafness occasioned by it, will also disap- pear. This, however, does not always hap- pen. When an abscess is situated in the cavity ofthe tympanum, Mr. Saunders thinks, that the membrana tympani should not be allow- ed to burst by ulceration, but be opened by a small puncture. (P. 31.) However, un- less there were the strongest ground for be- lieving, that the Eustachian tube were im- pervious, this advice, I think, ought not to be followed, more especially as the symp- toms are generally too vague to afford any degree of certainty in the diagnosis. Sometimes the disease, of which we are treating, is more insidious iu its attack: slight paroxysms of pain occur, and are relieved by slight discharges. The case goes on in this way, until, at hut, a contiuual discharge of matter from the ear takes place. The dis- order is destructive iu its tendency to the faculty of hearing, and it rarely stops until it has so much disorganized the tympanum and its contents, as to occasion total deaf- ness. Hence, Mr. Saunders insists upon the propriety of making attempts to arrest its progress,—attempts which are free from danger ; and he censures the foolish fear of interfering with the complaint, founded on the apprehension, that bad constitutional effects may originate from stopping the dis- charge. If the case be neglected, tbe tympanum is very likely to become carious; before which change, the disease, says Mr. Saunders, is mostly curable. Mr. Saunders divides the complaint into three stages: 1. A simple puriform dis- charge. 2. A puriform discharge compli- cated with fungi and polypi. 3. A puriform discharge with caries ofthe tympanum. As the disease is local, direct applications to the parts affected are chiefly entitled to confi- dence. Blisters and setons may also be ad- vantageously employed. Mr. Saunders's practice consisted in administering laxative medicines and fomenting the ear, while in- flammatory symptoms lasted, and afterward injecting a solution of the sulphate of zinc, or cerussa acetata. In the, second stage, when there were Ear. 437 iungi, he .emuved or destroyed them with forceps, afterward touched their roots with the argentum nitratum, or injected a solu- tion of alum, sulphate of zinc^ or argentum nitratum. Writers describe a relaxed state of the membrana tympani, as a cause of deafness. If, says a late author, after a discharge from the meatus auditorius externus, or cavity of the tympanum, or a dropsy of the latter ca- vity, the hearing remains hard, there is rea- son to suspect, that the infirmity may de- pend upon relaxation of the membrane of the tympanum, or paralysis of the internal muscle ofthe malleus. This suspicion will be strengthened, if the deafness should in- crease in damp, and lessen in dry weather; and particularly, if it be found, that the hear- ing is benefited by introducing into the ear dry warm tonic applications, such as the smoke of burning juniper-berries, or other astringent vegetable substances. The de- coction of bark, used as an injection, is also said to have done good. The relaxation ofthe tympanum, alleged to proceed from a rupture of the muscle of the maleus, is deemed incurable; but it is not so with the case, which depends upon paralysis of this muscle. Here tonic injec- tions into the tympanum, through the Eus- tachian tube, are recommended. (Did des Sciences Med. T. 38,p. 50.) Electricity, sti- mulating liniments and gargles, and a blister, might also be tried. Imperfect hearing is supposed sometimes to arise from preternatural tension of the membrane of the tympanum, indicated by the patient hearing better in wet than dry weather, and by his hearing what is spoken in a low tone, near his ear, bettef than any thing said in a loud manner. The opinions, delivered by writers on the causes of this affection, are only uncertain conjectures. The local treatment recommended, consists of injecting into the meatus auditorius, emol- lient decoctions, or warm milk, or introdu- cing into the passage a dossil of soft cotton, dipped in oil of sweet almonds. Nothing certain is known respecting the proper con- stitutional treatment, as must be clear from our ignorance of the causes of this form of disease of the ear. Hardness of hearing appears sometimes to be caused by a chronic thickening of the membrane of the tympanum ; and it is al- leged, that there are casesof this description, which proceed from syphilis, and require mercury. An issue in the arm nearest the affected ear, .. nd emollient and slightly sti- mulant injections, are likewise commended. When the tympanum was so considerably thickened, that there was no chance of re- storing it to a healthy state, Portal question- ed whether it might not be adviseable to make a small opening in it ? (Prkcis de Chir. Pratique, T. 2, p. 480.) This operation, which is said to have been first suggested by Cheselden, will be considered in the ensuing section. Morgagni found the cavity ofthe tympa- num intersected by numerous membranes, Vor. 1 58 which iiupeueu the movements of the ossi- cula. (Epist. an. 6, § 4.) Meckel does not mention any example of a deficiency of all the ossicula. (Handb. des Pathol. Anat. B.\,p. 402.) Mersanni,how- ever, found the incus wanting. (Bonet Se- pulch. T. 1, sect. 19, Obs. 4, § 1.) Caldani, the malleus and incus. (Epist. ad Haller, T. 6, p. 142.) The latter case was unattended with any bad effect on the hearing; the first with deafness. In a deaf child, three years of age, Bailly found the ossicula of only 1-3 their proper size. (Bonet Sepulcr. T. 1, sect. 19, Obs. 4, § 3.) In an example, where the fenestra rotunda was obstructed, Cotun- ni found tbe ossicula twice as large as natu- ral. (De labyrinthi auris contenlis, § 72, and Meckel's Handb. des Pathol. Anat. B. 1, p. 402.) A case, in which all the ossicula were wanting, is now on record. (See Did. des Sciences Med. T.38,p. 114.) 11. Obstruction of the Eustachian Tube. This is often a cause of a considerable de- gree of deafness, because it is necessary for perfect hearing, that air should be conveyed from tbe mouth through this passage into the cavity of the tympanum, which now can no longer happen. A degree of deafness generally attends a severe cold, whicb is accounted for by the Eustachian tube being obstructed with thick- ened mucus. Mr. Saunders tells us, that the obstruction most frequently arises from syphilitic ulcers in the throat, or sloughing in the cynanche maligna. The deafness comes on when such sores are healed, that is, when the obstruction is complete. The descent of a nasal polypus into the pharynx, and enlarged tonsils, have also been known to close the tube. (P. 42.) When the Eustachian tube is obstructed, the patient cannot feel the membrana tym- pani crackle, as it were, in his ear, on blow- ing forcibly with his nose and mouth stop- ped. Previous ulceration, or disease, of the throat will sometimes facilitate the diagno- sis. When the Eustachian tube is obstructed with mucus, it has been proposed to employ injections, which are to be thrown by means of a syringe and catheter, into the guttural orifice of that canal. This operation, how- ever, is alleged to be always attended with trouble, and, when the os spongiosum info- rms happens to be situated near the floor of the orbit, the introduction of any instrument, like a female catheter, would be impractica- ble. (Richerand Nosogr. Chir. T.2,p. 131, edit. 2.) Mr. A. Cooper had noticed, that hearing was only impaired; not lost, when suppura- tions in the tympanum had injured, and even destroyed the membrana tympani, and that the degree of deafness by no means equalled what resulted from an obstruction of the Eus- tachian tube. Hence, when the tube was per- manently obliterated, he conceived, that a small puncture of the membrana tympani might be the means of enabling the patient to hear. This gentleman reports four cases, 46* lML. in which tbe experiment was made with success. Tbe operation consists in introducing an instrument, resembling a hydrocele trocar, but curved, into the meatus auditorius ex- ternus, and pushing it through the anterior and inferior part of tbe membrana tympani; a place rendered most eligible, on account of the situation of the chorda tympani and manubrium of the malleus, parts vvhich should be left uninjured. The instrument must not be introduced far, lest it wound the vascular lining of the tympanum, and cause a temporary continuance of the deafness by an effusion of blood. When the puncture is made, in proper cases, and in a judicious manner, hearing is immediately restored. A small hole in the membrana tympani now conveys the air into the cavity of the tym- panum, answering the same purpose as the Eustachian tube. The surgeon will be able to operate with more ease, if he take care to lessen the cur- vature of the meatus auditorius by drawing upward the external ear. There is some chance of a relapse iu con- sequence of the opening closing up. This consideration led Richerand to propose making the aperture with caustic, so as to destroy a part of the membrane. (Nosogr. Chir. T. 2, p. 132, edit. 2.) The suggestion is not likely to be adopted, on account of the inconveniences of applying caustic with- in the ear. Mr. Saunders is an advocate for making the opening large. This gentle- man instantaneously restored the hearingof one patient who had been deaf thirty years, In consequence of a destruction of a part of his palate by syphilis. (P. 45.) In an in- stance where a young man had been deaf for eight years, apparently from obstruction of the Eustachian tube by swellings and disease about the throat. Paroisse also re- stored the hearing directly, by perforating the anterior and inferior part of the tympa- num. (Opuscules de Chir.p. 309, 8vo. Paris, 1806.) Tbe practice has also been success- fully adopted by Michaelis in one case, and Hunold has tried it in a vast number of ex- amples, two-thirds of which succeeded. (Did. des Sciences Med. T. 38, p. 63 Mr A. Cooper's cases are in the Phil. Trans, for 1802.)' Puncturing the membrana tympani has been attended with some degree of success in France, where it has been tried by hard, Celliez, and Maunoir, he. It is not to be dissembled, however, that it is liable to fail- ure. Dubois performed the operation in four instances, without success. (Richerand Nosogr. Chir. T. 2, p. 132.) In most cases, the patients benefited are said to have experienced pain just after the trochar was withdrawn. The organ, not being accustomed to sound, had become so extremely sensible, that it could bear the gentlest impression of the sonorous vibra- tions, and the patient's first request after the perforation had been made, was, that persons near him might speak softly. This excessive tenderness of tbe sense gradually subsides. The two principal objections made to the foregoing practice, are the risk of injuring that part of the tympanum, which is con- nected with the malleus, and the tendency of tbe puncture to heal up again. (See Did. des Sciences Med. T 38, p. 67 ; Maunoir in Journ. de Med. T. Ii; Sabatier, Traiti d'Anatomie, T. 2, p. 186.) The author of the article Oreille in the latter dictionary, who cannot, however, be deemed at all partial to the operation, delivers the follow- ing judgment concerning it :—1. It is the-only operation, which is likely to answer, where the tympanum is cartilaginous or ossified, and the rest of the organ is sound. 2. It will be attended with some success, where the Eustachian tube is closed, and this de- fect cannot be otherwise removed. 3. It will be useless where the cavity of the tym- panum is filled with matter, which is too thick to escape through the puncture. 4. When deafness depends on paralysis of the auditory nerve. 6. When the infirmity arises from inflammation ofthe ear or ner- vous irritation. 6. From fevers, the Eusta- chian tube being pervious. The limits of this work will not allow me to introduce the directions given by various authors for injecting fluids into the Eustachi- an tube. Wathen, Baron Boyer, and the latest surgeons, who have considered thjs operation,seem to agree, that it is more easi- ly performed by passing the tube through one of the nostrils, than the mouth. Wathen's instruments are described in Phil. Trans 1794; those of Baron Boyer in Traite des Mai. Chir. T. 6, p. 391 ; and those of another modern advoca'e for this operation, in Diet. des Sciences Med. T 38, p. 108. The lat- ter author, after stating how his tubes, which are four French inches in length, and shaped somewhat like an italic S, are intro- duced, enumerates the following as the ad- vantages derived from their employment. 1. Fluid applications may be conveyed into the Eustachian tube, the cavity of the tym- panum, and the mastoid cells, and deeply- seated obstinate ulcerations within these parts cured. 2. The same parts can be cleared from any mucus with which they are obstructed. 3. Blood extravasated with- in the tympanum, from blows on the head, can be washed out. 4. Chalky substances, which sometimes form in the tympanum, may be brought out in the same manner. 6. Through the tube a stilet can be passed into the Eustachian tube, so as to perforate a congenital septum, or any cicatrix, ob- structing the entrance of that passage. 6. When the sensibility of the auditory nerve is dull, the effect of fluids thrown into the tympanum, can be tried. 12. Of perforating the Mastoid Process. Of all the cases of deafness, for which Arneman and others have recommended this operation, that attended with an abscet- and caries of this process is the only one, ir: which the practice Is now at all sanctioned EAfc, 459. An instance is related by Jasser, in which the carious surface of the right mastoid pro- cess was exposed by an incision, and an opening detected with a probe An injec- tion was thrown into the aperture with a syringe, when, to the astonishment of Jas- ser and his patient, the fluid gushed out of the right nostril. The plan was repeated for a few days, and, at the end of three weeks, the part was healed, and the hearing greatly improved. This success induced Jasser to make a perforation in the left mas- toid process, the ear on that side being deaf, and to employ the injection, which was also discharged from the left nostril. The hearing, however, was not so completely restored in this as it had been in the right ear ; but the wound healed up, without any exfoliations. (Journ. de Med. Fev. 1793.) The idea of perforating the mastoid process was suggested long before the time of Jasser. Riolan, in various parts of his works, suggests the propriety of making a small perforation in several cases of deaf ness, and tinnitus aurium, attended with ob- struction of tbe Eustachian tube. Rolfin- cius also advised a similar opening to be made in the mastoid process with a trocar, in cases of dropsy of the cavity of the tym- anum and of the mastoid cells. Jasser, owever, was the first who actually made the experiment, and his example was follow- ed by Hagstroem, whose attempt did not succeed, the completion of the operation having been interrupted by profuse hemor- rhage, and no benefit done to the hearing. The injections also appear to have caused, in this instance, alarming symptoms, violent pain in the head, loss of vision, sense of suffocation, and syncope. The fluid enter- ed the mastoid cells, without any of itissuing, either by the nostrils or mouth. (Op. cit.) The operation was successfully tried by Loffler. The injection did not pass into the mouth, yet the hearing was restored, though it was lost again when the wound closed. Hence, a new opening was made, and kept from healing by means of a piece of cat-gut. The patient was afterward able to hear when his mouth was open- The perforation of the mastoid process was not approved of by Morgagni ; indeed, it must often fail, as both Morgagni and Hagstroem have observed, on account of complete bony partitions preventing all communications between the mastoid cells ; and sometimes the mastoid process, instead of being cellular, is perfectly solid, an in- stance of which is recorded by A. Murray. 13. Diseases of the Labyrinth. These are much more diversified than might, at first, be supposed, and, if we ad- mit the two doubtful cases, said to depend upon the state of the lymph of Cotunni, there are not less than seven different spe- cies of disease affectingthe labyrinth:—1. Disease of the fenestra ovalis, and fenestra rotunda, as ulceration, thickening, he. 2. Malformation of these apertures. 3. Mai- formation of the labyrinth. 4. Inflamma- tion of the nervous membrane, which lines its cavities. 5. Alteration of the liquor of Cotunni. 6 Deficiency of the same fluid. 7. Affections ofthe nerve of hearing. No doubt deafness (and that kind of it which so frequently foils the most skilful men) often arises from an insensible state of the portio mollis of the auditory nerve, or ofthe surfaces, on which its filaments are spread. This affection is analogous to the amaurosis, or gutta serena, in vvhich, though every part of the eye may seem to possess its natural structure, sight is lost, because the rays of light only strike against a para- lytic, or insensible retina. Mr. Saunders dissected the ears of two deaf patients, with the greatest care, but could not discover the least deviation from the natural struc- ture. In the commencement of deafness from a paralytic affection of the auditory nerve, Mr. A. Cooper remarked, that the secretion of cerumen was diminished, and, when the deafness became worse, was to- tally suppressed. And another particular symptom of paralysis of the auditory nerve, pointed out by the same author, is the pa- tient's inability to hear the sound of a watch placed between the incisor teeth. With respect to the causes of a paralytic affection of the auditory nerve, they are mostly buried in great obscurity, and some of them probably depend upon congenital imperfection of the nerve, or brain itself. It seems, however, that a part of the causes, to which we allude, act mechanically, as an extravasation of blood, a steatoma, or an exostosis; while others operate upon the ear by sympathy, as is the case w hen deaf- ness is produced by the presence of worms in the bowels. Mr. Saunders remarks, that all the disea- ses of the internal ear may be denominated nervous deafness; the term, in this sense, embracing every disease, the seat of which is in the nerve, or parts containing the nerve. Nervous deafness is attended with various complaints in different cases, noises in the head of sundry kinds, the murmuring of water, the hissing of a boiling kettle, rustling of leaves, blowing of wind, &c. Other patients speak of a beating noise, cor- responding with the pulse, and increased by bodily exertion, in the same degree as the action ofthe heart. (Saunders, p. 47.) According to this author, there is a syphili- tic species of nervous deafness, attended with a sensation of some ofthe above pecu- liar noises : and one case is related, in vvhich the hearing was completely restored, in five weeks, by a mercurial course. Mr. Saunders relieved several cases of nervous deafness by confining patients to low diet, giving them calomel freely, re- peated doses of sulphate of soda, magnesia, sometimes twice, sometimes thrice, a week, or according to circumstances, and applying blisters behind the ears at intervals of a week. The plan requires perseverance. Electricity has been highly recommend- ed for the cure of nervous deafness, though the prospect of benefit from it most entirely 460 EAR. depend upon the nature ofthe cause of the infirmity- It is allowed to be sometimes useful in cases of incomplete paralysis of tbe auditory nerve ; but, it cannot be of any service w here the Eustachian tube, the cavi- ty of the tympanum, ortbe mastoid cells, are obstructed. It is set down as hurtful, when the patients are very irritable, and subject to vertigo, bleeding from the nose, great determination of blood to the head, &c. (Did. des Sciences Med. T. 38, p. 124.) The evidencej in favour of the efficacy of galvanism, is still more scanty and question- able. Whether in certain cases of deafness from torpor of the auditory nerve, the introduc- tion of tonic injections into the cavity of the tympanum, through the Eustachian tube, will answer in the manner stated by a late writer, future experience must deter- mine. (Diet, des Sciences Med. T. 38, p. 120—121.) This article, I think, may be usefully con- cluded with a few general, but sensible ob- servations on the various kinds of deafness, made by a modern writer. According to Professor Rosenthal, all the disorders of the sense of hearing may be comprised under three principal forms. 1. Deafness (Surditas, Cophosis) in which the faculty of hearing articulated sounds is completely annihilated. 2. Hardness of hearing (Dysacia) in which this faculty is so diminished, that ar- ticulated sounds cannot be heaid, without the assistance of a particular apparatus. 3. Alteration, or diminution of hearing (Paracusis) in which the faculty of hearing articulated sounds, in the natural way, is imperfect for want of precision. 1. Deafness, Rosenthal distinguishes into two degrees, the first of which is marked by an absolute impossibility of hearing at all ; the second, by a power of still distinguish- ing certain sounds, as whistling, the vowels, &.c. The first is usually congenital, and a cause of dumbness. The discrimination of these two degrees, Rosenthal considers of great importance in practice, and especially in institutions for the deaf and dumb; because the exceeding- ly fine sense of touch, with which deaf per- sons are sometimes gifted, is apt to be mis- taken for the faculty of hearing. This fact. is illustrated by some interesting experi- ments made by Pfingsten on deaf and dumb persons. (Vieljaehrige Erfahrung ueber die Gehoerfehler der Taubstummen, Kiel. 1802,p. 32.) A deaf and dumb girl, who was at needlework in a room near Ihe house-door, regularly gave notice when- ever it was opened or shut. As the door was furnished with a little bell, which rung loud enough whenever the door moved to be plainly beard in the neighbouring room, and, with the exception of this noise, no other impulse nor shock could be distin- guished, Pfingsten was surprised at the cir- cumstance. Desirous of ascertaining how the girl really knew about the movements ofthe door, he caused the bell to be rung with great force without the door being opened : the child was perfectly uncon- scious of the noise. The bell was after- ward kept still, while a person opened and shut the door so softly, that Pfingsten him- self could not bear it ; yet, the child instant- ly gave warning, that somebody had enter- ed. The inference was, that the chair, on which she sat, communicated to her legs and back a certain impulse, which made her con- scious of the motioii of the door. The dissection of the ears of deaf and dumb persons has evinced some facts, expla- natory of the cause of the loss of hearing. Among other things, it appears, that com- plete deafness, whether congenital, or acqui- red, more frequently depends upon morbid alterations of the soft parts, than upon anv irregularity in the formation of the bones. Thus, in the body of a person, who had been deaf und dumb while living, Hoffmann found the auditory nerve diminished in siee, while every other part of the organ was perfectly natural. Arnemann found the nerve harder th m common. Dr. Heighten met with an instance, in which the vestibuium was filled with a caseous -ubsUnce. (A case of origi- nal deafness, in Mem. of the Med. Society, Vol. 3, p. 1—15.) Duverney and Sandifort found the auditory nerve strongly compress- ed by a steutoma. In one case, Itard found every part of the ear apparently so natural, that the deafness could not be ascribed to paralysis of the nerve. In another, the in- firmity depended upon obstruction of the pas-ages. In a third, the cavity of Ihe tym- panum, and the vestibuium, contained small portions of calcareous matter. He has also seen the tympanum filled with a thick yel- low lymph, or a thin fluid enclosed in mem- branous cells. In the dissection of the body of a deaf and dumb person, Rosenthal no- ticed, among other remarkable circumstan- ces, a greater hardness of the auditory, than of the facial nerve, and preternatural firm- ness of the medulla oblongata. Thickening of tbe membrane of ihe tympanum. Tbe bony roof of the cavity of the tympanum not thicker than paper, and just over the junction of the malleus with the incus, the bony substance was so absorbed, that an appearance like that of membrane alone re- mained. The mastoid cells, cavity of the tympanum, and the Eustachian lubes con- tained a limpid yellow fluid. In the tym- panum, the periosteum was thickened,form- ing small cells around the ossicula, which were of their natural structure. Nothing particular was remarked in the labyrinth. In a small proportion of instances, the above degree of deafness has been traced to anomaly in the structure of tbe solid parts. Thus, Mundini found the cochlea composed of only one circle and a half. (Opusc. Acad. Bonon, 1791, T. 7, p. 422.) Valsalva found the stapes adherent to the fenestra ovalis. (De Aure Humana, cap. 11;) and Reimarns the ossicula entirely wanting. (Kunstriebe der Thiere,p. 57.) In the first degree of deafness above de- scribed which when congenital) mnst excite suspicion of serious malformation of the organ, ana abolition of the nervous influence, and when acquired indicates a complete injury of the functions of the nerve, the prognosis, as Rosenthal observes, must be unfavour- able. Nor tan it be otherwise in the second congenital degree of the disease, though only a partial imperfection of th» organ and nerve can here be supposed. On the other hand, when the latter-degree is acquired, there is more prospect of relief, because merely a partial alteration in the soft parts is to be suspected. 2. Hardness of hearing. Rosenthal also distinguishes several degrees of, what is termed, hardness of hearing. In the first, the patient cannot hear a distant noise, and especially high tones; but, he can perceive, though it is true not in a very distinct man- ner, articulated sounds, when the voice is a good deal raised. In tbe second decree, he hears and distinguishes both high and low tones very well, and also words, but only when the voice is somewhat raised. These two cases are better undnrstood, inasmuch as it is tolerably well ascertained, that the immediate cause of tbe infirmity is some alteration in that part of the organ, which serves as a conductor for the vibra- tions of sound, or else an increased sensibi- lity of the nerve, all the internal ear being in other respects right. Among alterations of tbe conducting parts of the organ, Rosenthal comprehends : 1. A total obliteration of tbe meatus audi- torius externus, its imperforation or com- plete absence. These cases may almost always be detected by a superficial examina- tion, the patient only bearing when some solid bodies are placed between bis teeth, while his dull perception of sounds does not appear to be much lessened wheu tbe ear is covered. 2. Diseases of the cavity of the tympa- num, as inflammation of its membranous lining, caries of its parietes, or collections of blood, pus, or other fluid, in its cavity. Rosenthal thinks there can be no doubt, that inflammation and suppuration iu the tympa- num are much more frequent than is gene; rally supposed, the former aflvction being often mistaken for a slight attack of rhetf- malism. In dissecting aged subjects, tic has frequently found the membrane of the tym- panum thickened and opaque, and he could only impute this appearance to previous in- flammation. After detailing a case, illustrative of the symptoms of inflammation within the tym- panum, and a few observations on caries, and collections of fluid in that cavity, Ro- senthal notices the hardness of hearing, con- nected with nervous irritability, in the treat- ment of whicb case, he insists upon the ad- vantage that would result from a knowledge of the particular species of morbid excite- ment prevailing in the patient. But, as nothing very certain can be made out on this point, and only conjectures can follow some dissections of bodies, that the affection consists either in a determination of blood \R. 461 to the part, or in a partial paralysis of the auditory nerve, the exact nature and form of which are quite incomprehensible, it is ab solutely necessary to attend solely to the diagnosis of the nervous affection in gene- ral. This diagnosis will be facilitated', 1st- If the patient has been previously very sen- sible to the impression of certain tones, or sound in general. 2dly. If the power of hearing has been lost all on a sudden, with- out any mark of inflammation. 3dly. If the affection coincides with other nervous disorders. 3. Alteration, or Diminution of Hearing. Between the most perfect hearing, congeni- tal or acquired, and this point of diminu- tion of the faculty of hearing, Rosenthal ob- serves, there are a great many degrees, the cause of which is the more difficult to com- prehend, as Ihe circumstances of structure, which enable every part to perform its func- tions with freedom and perfection, are not yet made out. If, says he, it were in our power to determine what is truly the regular structure of each part, we should then be furnished with a means of judging correctly of the anomalies of function, the changes in which would be indicated quite as clear- ly as in the eye, by shades of organization, absolutel) in the same way, as we jidge of the modifications, vvhich tbe image of ob- jects must undergo at the bottom of the ocular mirror, by the greater or less convex- ity of the cornea, or lens, or the consistence of the other humours. In the present state of physiological and pathological knowledge of tbe ear, there- fore, Rosenthal conceives, that little can be attempted with respect to a scientific classifi- cation of these cases of altered, or diminish- ed hearing. As the cavity of the tympanum and its contents are the parts, which have principal influence over the intensity of sound, and a great share in the propagation of articulated sounds, their faulty condition must here be chiefly the subject for consi- deration. And, among their numerous de- fects, traced by dissection, and already spe- cified in the foregoing columns, Rosenthal particularly calfs the attention of the reader, 1. To alteraiions of the membrane of the tympanum, whether proceeding from con- genital malformation, or situation, or from thickening, ossification, perforation, or la- ceration of the same part. 2. The lodgment of some fluid in the cavity of the tympanum, more frequently produced, than is commonly supposed, by obstruction of the Eustachian tube. In most new-born infants, Rosenthal has also found the cavity of tbe tympanum filled with a thick, almost gelatinous fluid, vvhich for some days is not absorbed, and is proba- bly tbe cause of the indifference, evinced by new-born children, to sounds, which are even so intense as to be offensive to the ears of an adult. 3. Alterations of the membrane of the fenestra rotunda, such as its imperfect forma- tion, or erroneous siluation, its thickened state, fee 462 ECC EC1 But, it is remarked by Rosenthal, that as the difference in the intensity of sound may occasion a modification in the sensations of the ear, the merely conducting part- of the auditory apparatus must not he forgotten, as the external ear and the meatus auditorium externus, which regulate I lie quantity of sonorous waves, whicb strike the auditory nerve. However, the malfoimations of the meatus, and the state of the ceruminous se- cretion within it, are observed by Krilter and Lentin (Ueber das Schwere Gehoere, L. 19, Leipz. 1794.) to have more effect on the hearing, than defects of the auricle itself, the whole of whicb, as we have stated, may be lost without any material deafness being produced. Lastly, Rosenthal calls our atten- tion to the nervous action, or influence, which, whelher-too much r ised, or depress- ed, may equally render tbe hearing dull; and some useful information may for the most part be derived from attending to the patient's general sensibility. (See Journ. Complem T. 6, p. 21, 4*- Duverney de I'Organe de VOuie, \2mo. 1633; P. Kenne- dy, A Treatise on the Eye, and on some of the Diseases of the Ear, Svo. Lond. 17 Li. A. D. Dienert, Quastio, fa. an absque Mem- brana Tympani apcrtura lopica injiciin con- cham possint, Paris 1748. Mimuirc sur la Thiorie des Maladies de I'Oreille, et sur les moyens que la Chirurgie peut employer pour leur curation, in prix de I'Acad. de Chir. T. 9, p. Ill, 4^- Edit. 12m©. I. D. Arnemann, Bemerkungen nber die Durchborung des Pro- cessus Mastoideus in gewissen Fallen der Taubheit, Svo. Gott. 1792. G. R. Trampel ron den Krankeiten des Ohres in Arnemann's Magazin far die Wundarzneiwisienschaft, B. 2, p. 17, fa. Svo. Gait. 1798. Richerand, No- sogr Chir. T. 2, p. 135, fa. Edit. 4. A. Cooper, in the Phil. Trans, for 1802 ; Saun- ders on the Anatomy and Diseases of the Ear, 1806. Desmonceaux, Traiti des Maladies des Yeux et des Oreilles, 2. Tom. 8ro. Paris, 1806 Lassus, Pathologic Chirurgicale, T. 1, p. 84, Edit 1809. W. Wright, An Essay on the Human Ear, its Anatomical Structure, and incidental Complaints, Svo. Lond, 1817. Diet. des Sciences Med. art. dreille, T. 38, 8vo. Paris, 1819. Rosenthal, Essai d'une Patho- logic de I'Organe de I'Ouie, in Journ. Com- plemenlaire du Did. des Sciences Mid. T. 6, p. 17, Svo. Paris, 1820. For an account of malformations of the organ, see Meckel's Handbuch der Pathol. Anat. B. l,/>.400, fa. Svo. Ltipz. 1812.) ECCHYMOSIS. (from *%v», to pour out) A superficial, soft swelling, attended with a livid or blue colour of the skin, pro- duced by blood extravasated in the cellular substance. The causes of ecchymosis are falls, blows, sprains, he. whicb occasion a rupture of the small vessels on the surface of the body, and a consequent effusion of blood, even without any extern.il breach of continuity. Ecchymosis is one of the symptoms of a contusion. (See Contusion.) A considera- ble ecchymosis may originate from a very slight bruise, when the nip'ured vessels are capable of pouring out a large quantity of blood, and particularly when the parts con- tain an abundance of loose, cellular sub- stance. In general, ecchymosis does not m-ike its appearance immediately after the blow, or ^prnin,and sometimes not till unve- ra! hours after the application of the vio- lence : at least, it is not till ibis lime (hat the black, blue, and livid colour of the skin is most conspicuous. A black-eye, which is only an ecchymosis, is always most dis- figured six or eight hours after the receipt of the blow. In Ihe article Bleeding, we have noticed how an ecchymosis may arise from the blood getting out of the vein inio the adjacent cel- lular substance. Common cases of ecchymosis may gene- rally be easily cured, by applying discu- tient lotions, and administering one or two doses of any mild purgative salt. The best topical applications are vinegar, the lotio muriatis ammonia?; spirit, vin. campb. and th« liquor amnion, acet. The object is to avert inflammation, and to promote the absorption of the extravasated fluid. In casesof ecchymosis, I have seen such success attend the practice of dispersing rollections of extravasated blood, by means of absorption, that the plan of evacuating it by an incision, seems to me to be seldom necessary. When an opening is made, and air is admitted, the portion of blood, which cannot be pressed out, soon putrefies, and extensive inflammation and suppuration, are tbe too frequent consequences. The quick and powerful action of the ab- sorbent vessels in removing extravasations of blood, can now' be no longer called in question, when we daily see it proved in modern practice, (bat the largest aneurismal swellings are thus speedily diminished and removed, after the operation of tying the arteries, from which such tumours arise. I wish, however, the preceding observa- tions merely to convey a general condemna- tion of the practice of opening swellings containing extravasated blood; for, no sur- •geon is more assured, than I am myself, that there are particular exceptions, in which the plan is highly proper and necessary. Thus, whenever a case of extensive ecchymosis, or a large tumour of extravasated blood, either excites suppuration, or creates exces- sive pain from distention, it is better to prac- tise a free opening. So it sometimes hap- pens, in cases of aneurism, that the skin breaks after the artery has been tied, and some of tbe blood escapes ; but the remain- der putrefies, and soon becomes blended with purulent matter in the sac. Here the making of a free incision for the discharge ofthe irritating contents ofthe swelling, with due attention to every caution, delivered in the article Aneurism, will often be followed by beneficial effects. ECTROPIUM. (from nClfpru, to divert.) A turning out, or an eversion ofthe eyelids. It is remarked by Scarpa, that just as ex- re^ive relaxation ofthe skin nflhe evelide. ECTROPIUM. 463 and a morbid contraction of their lining, near the edges, in consequence of ulcera- tions and cicatrices, occasion a faulty incli- nation of the tarsus and eyelashes against the eye ; so, sometimes, an elongation and swelling of the membranous lining of the eyelids, or too great a contraction and short- ening of the skin of the eyelid itself, or neighbouring parts, produce an opposite dis- order to trichiasis, viz. an eversion of the eyelids, termed ectropium. Of course, in respect to causes, there are two species of this disease; one produced by an unnatural swelling of the lining of the eyelids, which not only pushes their edges from the eyeball, but also presses them so forcibly, that they become everted; the other, arising from a contraction of the skin covering the eyelid, or of that in the vicini- ty, by which means the edge of the eyelid is first removed for some distance from the eye, and afterward turned completely out- ward,together with the whole ofthe affect- ed eyelid. The morbid swelling of tbe lining of the eyelids, which causes the first species of ec- tropium, (putting out of present considera- tion a similar affection incidental to old age) arises mostly from a congenital laxity of this membrane, afterward increased by obstinate chronic ophthalmies, particularly of a scrofulous nature, in relaxed, unhealthy subjects ; or else the disease originates from the small-pox affecting the eyes. While the disease is confined to the lower eyelid, as it most commonly is, the lining of this part may be observed rising in the form of a semilunar fold, of a pale red colour, like the fungous granulations of wounds, and in- tervening between the eye and eyelid, which latter it in some measure everts. When the swelling is afterward occasioned by the lining of both eyelids, the disease assumes an annular shape, in the centre of which the eyeball seems sunk, while the circumference ofthe ring presses, and everts the edges of the two eyelids so as to cause both great un- easiness and deformity. In each of the above cases, on pressing the skin of the eye- lids with the point of the finger, it becomes manifest that they are very capable of being elongated,and would readily yield, so as en- tirely to cover the eyeball, were they not prevented by the intervening swelling of their membranous lining. Besides the very considerable deformity which the disease produces, it occasions a continual discharge of tears over the cheek, and, what is worse, a dryness ofthe eyeball, frequent exasperated attacks of chronic oph- thalmy, incapacity to bear the light, and, lastly, opacity and ulceration of the cornea. The second species of ectropium, or that arising from a contraction of the integu- ments of the eyelids, or neighbouring parts, is not unfrequently a consequence of puck- ered scars, produced by the confluent small- pox ; deep burns ; or the excision of can- cerous, orencysted tumours, without saving a sufficient quantity of skin; or, lastly, the disorder is the effect of malignant carbun- cles, or any kind of wound attended with much loss of substance. Each of these causes is quite enough to bring on such a contraction ofthe skin ofthe eyelids, as t» draw these parts towards the arches of the orbits, so as to remove them from the eye- ball, and turn their edges outward. No sooner has this circumstance happened, than it is often followed by another one equally unpleasant, namely, a swelling of tbe inter- nal membrane of the affected eyelids, vvhich afterward has a great share in completing the eversion. The lining of the eyelids, though trivially everted, being continually exposed to the air, and irritation of extrane- ous substances, soon swells, and rises up, like a fungus. One side of this fungus-like tumour covers a part of the eyeball; the other pushes the eyelid so considerably out- ward, that its edge is not unfrequently in contact with the margin of the orbit. The complaints induced by this second species of ectropium, are the same as those brought on by the first; it being noticed, however, that in both cases, whenever the disease is inve- terate, the fungous swelling ofthe inside of the eylids becomes hard, coriaceous, and, as it were, callous. Although in both species of ectropium, the lining ofthe eyelids seems equally swol- len, yet the surgeon cm easily distinguish to which ofthe two species the disease be- longs. For, in tbe first, the skin of the eye- lids, and adjoining parts, is not deformed with scars, and by pressing the everted eye- lid with the point of the finger, the part would with ease cover the eye, were it not for the intervening fungous swelling. But, in the second species of ectropium, besides tbe obvious cicatrix and contraction of the skin of the eyelids, or adjacent parts, when an effort is made to cover the eye with the everted eylid, by pressing upon the latter part with the point of the finger, it does not give way so as completely to cover the globe, or only yields, as it ought to do, for a cer- tain extent; or it does not move in the least from its unnatural position, byreason ofthe integuments of the eyelids having been so extensively destroyed, that their margin has become adherent to the arch ofthe orbit. According to Scarpa, thi cure of this die- Case cannot be accomplished with equal perfection in both its forms, the second spe- cies being, in some cases, absolutely incu- rable. For, as in the first species of ectro- pium, the disease only depends upon amor- bid intumescence ofthe internal membrane of the eylids, and the treatment merely con- sists in removing the redundant portion, art possesses many efficacious means of accom- plishing what is desired. But, in the second species of ectropium, the chief cause of which arises from the loss of a portion ofthe skin ofthe eyelids, or adjacent parts, which loss no known artifice can restore, surgery is not capable of effecting a perfect cure of the malady. The treatment is confined to remedying, as much as possible, such com- plaints as result from this kind of eversion and this can be done in a more or less snti; 4bH ECTROPIUM. factory manner, according a» the loss of skin of the eyelid is little or great. Cases, in which so much skin is deficient that the edge of the eyelid is adherent to the margin of the orbit, Scarpa abandons as incurable. Si nimium palpebra deest, says Celsus, nulla id restituere curatio potest: (lib. 7. cap. 7.) In the second species of ectropium, Scarpa thinks, that the degree of success attending the cure may always be estimated by re- marking to what point the eyelid admits of being replaced, on being gently pushed with the end of the finger towards the globe of the eye, both before and after the employ- ment of such means as are calculated to effect an elongation of the skin of the eye- lid ; for, it is to this point, and no further, that art can reduce the everted part, and permanently keep it so replaced. When the first species of ectropium is re- cent, the fungous swelling of the lining ofthe eyelid not considerable, and, consequently, the edge of the eyelid not much turned out, and in young subjects (for in old ones the eyelids are so flaccid that the disease is irre- mediable.) Scarpa prefers destroying the fungous surface of the internal membrane of the eyelid by the repeated application ofthe argentum nitratum. In recent cases, where the patient is weak and irritable, (or a child) Beer commences the treatment with simply applying every day the tincture of opium, which, after a time, is to be strengthened by the addition of naptha. To the relaxed con- junctiva he afterward applies escharotic eyesalves, and, last of all, the nitrate of silver, and muriate of antimony. Where the part is hard and callous, he precedes tbe employ ment of caustic by scarifications. (Lehre, fa. B. 2, p. 136.) For remedying the considerable and inve- terate form ofthe first species of the disease, the quickest and surest plan is to cut away the whole of the fungous swelling closely from the muscular substance, on tbe inside ofthe eyelid. This is the advice both of Beer and Scarpa. And, indeed, even in most cases which are not so slight, as to yield to mere astringent applications, this practice is now commonly preferred in this country to the use of caustic, the action of which is more tedious and painful, and less under control. The following is Scarpa's description ofthe operation.. Thepatientbeing seated, with his head a lit- tle inclined backward, the surgeon, with the index and middle finger of his left hand, is firmly to keep the eyelid everted, and hold- ing a small pair of curved scissors, with con- vex edges, in his right, he is completely to cut off the whole fungosity of the internal membrane of the eyelid, as near as possible to its base. The same operation is then to be repeated on the other eyelid, should that be affected with tbe same disorder. If the excrescence should be of such a shape that it cannot be exactly included within the scissors, it must be raised as much as possi- ble with forceps or a double-pointed hook, and dissected off at its base, by means of a *mal! bistoury with ;• convex edge. This last mode is prelerred by Beer to the use of scis- sors, and I confess that it has always appear- ed to me the most convenient. The bleed- ing, which seems, at the beginning of the operation as if it would be copious, stops of itself, or as soon as the eye is bathed with cold water. Tbe surgeon is then to apply the dressings, which are to consist of two small compresses, one put on the upper, the other on the lower arch of the orbit, and over these the uniting bandage, in the form ofthe monoculus, or so applied as to com- press and replace the edges of the everted eyelids, in order to make them cover the eye. On the first removal of the dressings, which should take place about twenty-four or thirty hours after tbe operation, the sur- geon will find the whole, or almost the whole, of the eyelid in its natural position. The treatment should afterward consist in washing the ulcer on the inside of the eyelid twice a day with simple water, or barley water, and mel rosae, until it is completely well. If towards the end of the cure, the wound should assume a fungous appear- ance, or the edge of the eyelid seem to be too distant from the eyeball, the wound on the inside of the eyelid must be rubbed seve- ral times with the argentum nitratum, for the purpose of destroying a little more of the membranous lining, so that, when the cicatrization follows, a greater contraction of it may take place, aud the edge of the eyelid be drawn still nearer the eye. Pro- per steps must be taken, however, foi resist- ing the principal cause on which the ectro- pium depends, particularly chronic ophthal- my, a relaxed and varicose state of the con- junctiva, he. (See Ophthalmy.) In the second species of ectropium, or that produced by an accidental contraction of the skin of the"eyelids, or neighbouring parts, the curative indication does in no respect differ from what it is in the foregoing instance. If a contraction of the integu- ments has proved capable of everting the eyelid, the excision of apiece ofthe internal membrane of Ihe part, andthe cicatrix which will follow, must also be capable, for the same reason, of bringing back the eyelid into its natural position. But, since nothing can restore the lost skin, the shortened state of the whole eyelid, in whatever degree it ex- ists, must always continue, even after any operation the most skilfully executed. Hence, the treatment of the second species of ectropium will never succeed so perfect- ly as that of the first, and the replaced eye- lid will always remain shorter than natural, in proportion to the quantity of integuments lost. It is true, that in many cases the ever- sion seems greater than it actually is, in re- gard to the small quantity of skin lost or de- stroyed : for, when the disease has once be- gun, though the contraction ofthe skin may be trivial, in consequence ofthe little quan- tity of it deficient, still the swelling of the lining of the eyelid, which never fails to in- crease, at last brings on a complete eversion ofthe part. Iu these cases, the cure may be accomplished with such success, as is sur ECTROPIUM. 46s prising to the inexperienced ; for, after the fungous swelling of the internal membrane ofthe eyelid has been cut off, and the edge ofthe part approximated to the eyeball, the shortening of the eyelid, remaining after the operation, is so trivial, that it may be con- sidered as nothing in comparison with the deformity and inconvenience occasioned by the ectropium. Whenever, therefore, the retraction of the skin of the everted eyelid, and the consequent shortness of it, are such as not to prevent its rising again and cover- ing the eye, if not entirely, at least mode- rately, the surgeon should cut away the internal membrane ofthe everted eyelid,as already explained, so as to produce a loss of substance on the inside of the everted eyelid. This may be done most conveni- ently, either with the convex-edged curved scissors, or small convex-edged bistoury. In inveterate cases of ectropium, in wdiich the tumid lining ofthe eyelids has become hard and callous, it is best to apply to the everted eyelid, for a few days before the operation, a soft bread and milk poultice, in order to render the part flexible, and more easily separated than it could be in its former rigid state. The division ofthe cicatrices, which have given rise to the shortening and eversion of the eyelid, as Scarpa observes, does not procure any permanent elongation of this part, and consequently it is of no avail in the cure ofthe present disease. We see the same circumstance occur after deep and ex- tensive burns ofthe skin ofthe palm ofthe hand and fingers : whatever pains may have been taken, during the treatment, to keep the hand and fingers extended, no sooner is the cicatrization thus completed, than the fingers become irremediably bent. The same thing happens after extensive burns of the skin of the face and neck. Fabricius ab Aquapendente, who well knew the inutility of making^*semilunar cut in the skin of the. eyelids, for the purpose of remedying their shortening and eversion, proposes, as the best expedient, to stretch them with adhesive plasters, applied to them and the eyebrow, and tied closely together. Whatever advantage may result from this practice, the same degree of benefit may be derived from using, for a few days, a bread and milk poultice, afterward oily embro- cations, and, lastly, the uniting bandage, so put on as to stretch the shortened eyelid in an opposite direction to that produced by the cicatrix ; a practice which Scarpa thinks should always be carefully tried, before re- sorting to the operation. The patient being seated, if an adult, or placed on a table with his head a little ele- vated, and held by proper assistants, if a child, the surgeon, with a small convex- edged bistoury, is to make an incision of sufficient depth into the internal membrane of the eyelid, among the tarsus, carefully avoiding the situation of the puncta lachry- malia. Then he should raise with a pair of forceps, the flap of the divided fungous membrane, and continue to detach it with Vor. I. 59 the bistoury, from the subjacent parts, all over the inner surface of the eyelid, as far as where the membrane quits this part, to be reflected overlhe front of the eye, under the name of conjunctiva. Tbe separation being thus far accomplished, the membrane is to be raised still more with the forceps, and cut off with one, or two strokes of the scissors, at the lowest part of the eyelid. The compresses and bandage, to keep the eyelid replaced, are to be applied, as above directed. On changing the dressings, a day or two after the operation, the eyelid will be found, in a great measure, replaced, and the disfigurement, vvhich the disease caused, greatly amended. The operation is rarely followed oy bad symptoms, such as vomit- ing, violent pain, and inflammation. How- ever, should they occur, the vomiting may be relieved by means of an opiate clyster, and as for the pain and inflammation, at- tended with great tumefaction ofthe eyelid operated upon, these complaints may be cured by applying a poultice, or bags filled with emollient herbs, at the same time em- ploying internal antiphlogistics, until the in- flammation and swelling have subsided, and suppuration has commenced on the inside ofthe eyelid, on which the operation has been done. After this, the treatment is to consist in washing the part, twice a day, with barley-water and mel rosa?, and, lastly, in touching the wound a few times with the argentum nitratum, in order to keep the granulations within certain limits, and to form a permanent cicatrix, proper for main- taining the eyelid replaced. (Scarpa sulle Malattie degli Occhi.) In cases, in vvhich the eversion is consi- derable, Sir. W. Adams has never found the simple incision of the fungus, as practised by Scarpa, sufficient to effect a radical cure, and he therefore tried a ne* mode of ope- rating. In his first attempts, he employed a very small curved bistoury, the point of which he carried along the inside of the eyelid, at its outer angle, downwards and outwards, as far as the point of reflection of the conjunctiva would admit. He then pushed it through the whole substance of the everted eyelid and its integuments, and cut upwards through the tarsus, making an incision nearly half an inch in length. With a curved pair of scissors, he next snip- ped off a piece of the edge of the tarsus, about one-third ofan inch in width, and he afterward removed with the same instru- ment, tbe whole of the diseased conjunctiva. When the bleeding had ceased, Sir W. Adams passed a needle and ligature through the whole substance of the two divided portions, and brought them as accurately into contact as possible. Finding, however, that too much integument had been left at the lower part of the incision, he employ- ed, in future operations, instead of toe scalpel, a pair of straight scissors, with which he cut out an angular piece of the lid, resembling the letter V. Latterly, Sir W. Adams has found it advantageous to leave about a quarter ofan inch ofthe lid adjoin 466 LcZ ing its external angle, and after shortening the part as much as necessary, he brings the edges of the incision together with a suture. (See Practical Observations on the Ectropium, fa. by W. Adams, p. 4 and 5, Ijond. 1812.) On tbe subject of the foregoing proposal M. Roux observes ; " What Sir W. Adams says, with a view of enhancing the value of his own method, about the frequent recur- rence of ectropium, when the conjunctiva is simply cut out, is a gratuitous assertion, contradicted by experience. I have already, in a very great number of cases, undertaken the cure of ectropium in the common way : the operation always succeeded as much as the degree, or other circumstances, of the disease allowed ; and I have not yet observed an instance of a relapse. (Voyage fait & Londres en 1814, ou Parallile de la 'Chirurgie Angloise avec la Chirurgie Fran- roue, p. 291.) If this new operation, how- ever, will cure the ectropium, caused by the contraction of cicatrices, as its inventor de- scribes, or produce great improvement, as the experience of Mr. Travers confirms, (Synopsis ofthe Diseases of the Eye, p. 235.) it is clear, that, though it may not be neces- sary in ordinary cases, its usefulness will not be entirely lost. The contracted scar must of course be divided, in addition to the other proceedings. E. C. Keck de Edropio, Tubing. 1733. Scarpa's Osservazioni sulle Malattie degli Occhi, Ed. 5, cap. 6. to which writer I am chiefly indebted for the preceding account of Ihe Disease. Richter's Anfangsgr. der Wun- darsueykunst, Band 2, p. 473, fa. Wenzel* Manuel de I'Occuliste. Pellier,Recueil d'Obs. sur les Maladies des Yeux. Sir W. Adams, Pract. Observ. on Ectropium, or Eversion of the Eyelids, with a description of a new opera- tion for the curt of that Disease; on the modes of forming an artificial pupil ; and on Cata- ract, Svo. Lond. 1812. M. Bordenave, "Mi- moire dans lequcl on propose un nouveaux procidi pour Ir alter le renversement des Pau- pieres," in Mem. de I'Acad. Royale de Chi- rurgie, T. 13, p. 156 et seq. Edit. 12mo. It was in (his memoir, that the proposal of remo- ving aportion of 'theinside of the eyelidfor the cure of ectropium was first made, and its effi- cacy illustrated by facts. Here may also be found the best historical account ofthe differ- ent methods of treatment, which have prevail- ed from the earliest periods of surgery. Con- sult also Parallile de la Chirurgie Angloise avec la Chirurgie Francaise, par P J. Roux, p. 289—292 ; Paris, 1815. G. J. Beer, Lehre von den Augenkrankheiten, B. 2, p. 133, fa. Svo. Wien. 1817. Benj. Travers, Synopsis ofthe Diseases of the Eye, p. 234, 356, fa. 8vo. Lond. 1820. ECZEMA, or Ecze'sma (from ugtce, to boil out,) is characterized by an eruption of small vesicles on various parts of the skin, u:ually close, or crowded together, with lit- tle or no inflammation round their bases, and unattended by fever. It is not conta- gious. (Bateman's Synopsis, P. 260, Ed. 3.) There are several varieties of this disease, 1.1.1. the most remarkable of which is the eczema rubrum from the irritation of mercury. This form is attended with quickened pulse and a white tongue; but the stomach and sensorium are not materially disturbed (See .Wercury.) EFFUSION, (from rffundo, to pour out.) In surgery, means the escape of any fluid out of the vessel, or viscus, naturally con- taining it, and its lodgment in another cavi- ty, in the cellular substance, or in the sub- stance of parts. Thus, when the chest is wounded, blood is sometimes effused from the vessels into the cavity of the pleura ; in cases of false aneurisms, the blood passes out of the artery into the interstices of the cellular substance ; in cases of fistula in perinaeo, the urine flows from the blad- der and urethra into the cellular membrane of the perineum and scrotum ; and, when great violence is applied to the skull, blood is often effused even in the very substance of the brain. Effusion also sometimes signifies the na- tural secretion of fluids from the vessels : thus surgeons frequently speak of the coa- gulable lymph being effused on different sur- faces. (See Extravasation.) ELEGTRICITY. Among the aids of sur- gery, electricity once held a conspicuous and important situation. It has, however, met with r fate, not unusual with remedies too much cried up and too indiscriminately employed ; that of having fallen into an un- deserved degree of neglect. Whatever its effects may be on the sys- tem, it certainly possesses this advantage over other topical remedies, that it may be made to act on parts very remote from the surface. Electricity, as a topical remedy for surgi- cal diseases, is chiefly used in amaurosis, deafness, some chronic tumours, and ab. scesses, weakness io^m sprains, or contu- sions, paralysis, he.' In cases of suspended animation, electri- city is sometimes an important auxiliary for the restoration of the vital functions. (See J. Curry's Obs. on Apparent Death, fa. Ed. 2, 1815.) ELEVATOR. An instrument for raising depressed portions of the skull. Besides the common elevator, now gene- rally preferred by all the best operators, several others have been invented ; as, for instance, the tripod elevator, and another, which was first devised by M. J. L. Petit, and afterward improved by M. Louis. The common elevator is an exceedingly simple instrument, being a mere lever, the end of which is somewhat bent, and made rough, in order that it may less readily slip away from the piece of bone, whicb is to be raised. This instrument may be used by for- ming a fulcram for it, either in the band, whicb holds it, or upon the fingers of the other hand; ortbe operator may make a fixed point for it on the edge of the opening made with the trephine, or of that which the arcidcntal violence bn« occasioned. KMPHVZEMA. 4t>: One piece of the tripod elevator consists of three branches uniting above in one com- mon trunk. The latter part is pervaded by a long screw, having below a kind of hook, and above a sort of handle for turning it. It was by means of the hook, drawn up by turning the screw, that the depressed por- tion of bone was elevated. The inventors of tbe tripod elevator were certainly very well acquainted with the im- perfections ofthe common one ; and they endeavoured to obviate them, by procuring a firmer fulcrum, and a greater degree of power. But it was necessary to change tbe situation of their elevator, as often as there was occasion to raise a different portion of bone ; and the hook being connected with an inflexible piece of steel, the direction of which was always the same as that of the instrument, it became troublesome and difficult to place the hook under the piec;e of bone, which stood in need of being raised. These inconveniences induced J. L. Petit to contrive a new elevator, vvhich consisted of a lever, mounted on a handle, and straight throughout its whole length, except just at its very end, which was slightly cur- ved, in order that it might be more conveni- ently put under the portion of bone, vvhich wa9-about to be elevated. The lever was pierced at various distances from its bent end, with several holes, intended for the re- ception of a little kind of moveable screw- peg, which was fixed upon the top of a sort of bridge. This latter part ofthe instrument consisted of an arch, the ends of which were long and covered with small pads, while, on its centre, was placed the little screw-peg already mentioned. It was the intention of Petit, that the peg should be joined to the bridge by means of a hinge ; and as he found that it was frequently ne- cessary to elevate several different pieces of bone, he thought, that the peg should not be completely fastened in the hole, but that it should be capable of being moved about in any wished-for direction. With this construction, however, it was found, thatthe peg would only allow the lever to be applied with its edge obliquely, under the bone about to be raised, wrhen the part of the cranium was situated to the right or left. Louis conceived, that it wrouldbe a great improvement ofPetit's elevator, if a sort of pivot were substituted for the fiinge. Tbe kver would then admit of being readily moved in every direction, and put under any point of bone, without any occasion to alter the position ofthe bridge or fulcrum. I have only to add, respecting elevators for fractures of the skull, that all the best modern surgeons content themselves with the common one, which is the most simple, and, in the hands of a surgeon, who knows how to use it, is found to answer every de- sirable purpose. ELYTROCELE. (from o.vl^r, the va- gina, and K»ty- a tumour.) \ hernia in the EMBROCATIO ALUMINIS. ft. Alu- minis ^ij. Aceti spiritus vinosi tenuioris, sing. Jbss. For chilblains and diseased joints. EMBROCATIO AMxMONLE. ft. Liq. ammon. ^i. Etheris sulphurici ?ss. Spir. Lavandula? ^ij. M. For sprains and bruises. EMBROCATIO AMMONLE ACETA- TE CAMPHORATE. ft. Linim. Camph. Liq.aminon. acet. sing. 3vj- Liq. Ammon. ^ss. M. For sprains,bruises, and chilblains, not in a state of suppuration. EMBROCATIO AMMONIA ACETA- TE, ft. Liq. ammon. acet. Lin. sapon. sing. ?j. M. For bruises, with inflammation. EMBROCATIO LYTTE CUM CAM- PHORA. ft, Tinct. Lyttae Spirit, camph. sing. 3j- M- This may be used in any case, in which the object is to stimulate the skin. It should be remembered, however, that the absorption of lyttae will sometimes bring on strangury. EMBRYOTOMY, (from t^un, a foe- tus, and , to cut.) The operation of cutting into the womb, in order to extract the foetus. (See Casarean Operation.) EMPHYSEMA. (t/uKpua-n/ua. from pvS,5 KMI'HVSEMA body is in an upright posture, or he is sit- ting a little inclined forward. The counte- nance becomes red and swollen. The pulse, at first, weak and contracted, becomes afterward irregular. The extremities grow cold, and, if the patient continue unrelieved, he soon dies, to every appearance suffoca- ted. The emphvsematous swelling, whereso- ever situated, is easily distinguished from oedema, or anasarca, by tbe crepitation, which occurs on handling it, or a rioise, like that which takes place on compressing a dry bladder half filled w ith air. (Encyclo- pidie .Wi'.hodique ; Parlie Chirurgicale, Art. Emphysema.) Tbe tumour is colourless and free from pain. It does not of itself descend into de- pending parts, though by pressure it may be made to change its situation. It is elastic, that is to say, it may be pressed down, but it rises up again as soon as the pressure is discontinued. The swelling never retains the impression of the end ofthe finger, or, in the language of surgery, never pits. The part affected is not heavy. The tumour first makes its appearance in one particular place ; but, it soon extends itself over the whole body, and causes an extraordinary distention ofthe skin. (Richter's Anfangsgr. der Wundarzn. B. l,p. 451.) The wound of the pleura and intercostals may sometimes be too small to suffer the air to get readily into the c< llular membrane, and inflate it, but may confine a part of it in the cavity of the thorax, so as to com- press the lungs, prevent their expansion, and cause the same *ymptoms of tightness of the chest, quick breathing, and sense of suffocation, vvhich water does in the hydrops pectoris, or matter in the empyema.— (Hewson.) To understand, why the air passes at all out of the w ound of the lungs, we must ad- vert to the manner in which inspiration and expiration are naturally carried on. It is well known, that in the perfect state, the surface of the lungs always lies in close contact with the membrane lining the chest, both in inspiration and expiration. The lungs themselves are only passive organs, and are quite incapable, by any action of their own, of expanding and contracting, so as to maintain their external surface always in contact with the inside of the thorax, whicb is continually undergoing an alternate change of dimensions. Every muscle, that has any share in enlarging and diminishing the capacity of the chest, must contribute to the effect of adapting the volume of the luni;s to the cavity, in which they are con- tained, as long as there is no communication between the cavity of the pleura, and the external air. In inspiration, the thorax is enlarged in every direction, the lungs are expanded in the same way, and the air en- tering through Ihe windpipe into the air cells of these organs, prevents the occur- rence of a vacuum. But, in cases of wounds, when there is a free communication between the atmos- phere and inside of the chest, no sooner n this cavity expanded, than the air naturally enters it at the same time, and for the same reasons, that the air enters the lungs througb the trachea, and the lung itself remains proportionally collapsed. When the tho- rax is next contracted, in expiration, the air is compressed out of the lung, and also out ofthe bag of the pleura, through the exter- nal wound, if there be a direct one, in which circumstance, the emphysematous swelling is never extensive. But, in the case of a fractured rib, attend- ed with a breach in the pleura costalis, pleu- ra pulmonalis, and air-cells of the lungs, there is no direct communication between the cavity of the chest and the external air; in other words, there is no outward wound in the parietes of the thorax. There is, how ever, a preternatural opening form- ed between the air-cells of the lungs and the cavity of the chest, and also another one between the latter space, and the gene- ral cellular substance of the body, through the breach in the pleura costalis. The con- sequence is, that when the chest is expand- ed in inspiration, air rushes from the wound in the surface of the lungs, and insinuates itself between them and the pleura costalis. The lungs collapse in proportion, and the place, vvhich they naturally occupied, when distended, is now occupied by the air. When, in expiration, the dimensions of the chest are every where diminished, the air, now lodged in the bag ofthe pleura, cannot get back into the aperture in the collapsed lung, because this is already full of air, and is equally compressed on every side, by that which is confined in the thorax. Were there no breach in the pleura costalis, this air could not now become diffused ; the muscles of inspiration would next enlarge the chest, remove tbe pressure from the sur- face of the wounded lung, more air would be sucked out of it, as it were, into the space between the pleura costalis and pleu- ra pulmonalis, and this process would go on, till the lungs of the wounded side were completely collapsed. But, in the case of a fractured rib, or narrow stab, in which there is also a breach in the pleura costalis, without any free vent ontvvard, for the air, which gets out of the lung into the cavity of the pleura, as soon as the expiratory powers lessen the capacity of the chest, this air, not being able to pass back through the breach in the collapsed lung, is forced through the laceration, or wound, in the pleura costalis, into the common cellular substance. It is through the communicating cells of this structure, that the air becomes most extensively diffused over the whole body, in proportion as the expiratory muscles continue in their turn to lessen the capacity of the chest, and pump the air, as it were, through the breach in the pleura costalis, immediately after it has been drawn out of the wound ofthe lung, in inspiration. (See John Bell on Wounds of the Breast, and Hal- lidayon Emphysema, 1807 ' EMPHYSEMA. -169 To prove that the confinement of air in the chest is tbe eause of the dangerous symptoms attending emphysema, Hewson adverts to the histories ot some remarkable cases, published by Littre, Mery, W. Hun ter, and Cheston. (See Jlfem. de I'Acad. Royale des Sciences, for 1713, Med. Observa- tions and Inquiries, Vol. 2, and Pathological Inquiries.) In Littre's case, tbe patient, who had been wounded in the side with a sword, could not breathe, without making the most violent efforts, especially during the latter part of his disease: he died on the fifth day. In Mery's instance, the fourth and fifth true ribs were broken by a coach passing over the chest; the patient's respiration was much impeded from the first, and be- came more and more difficult till he died, which was on the fourth day after the accident. In Dr. Hunter's case, the patient had re- ceived a considerable hurt on his side by a fall from his horse. He had a difficulty of breathing, vvhich increased in proportion as tbe skin became elevated and tense ; it was laborious as well as frequent. His in- spiration was short, and almost instantane- ous, and ended with a catch in the throat, which was produced by the shutting of the glottis : after this he strained to expire for a moment without any noise, then suddenly opening the glottis, he forced out his breath with a sort of groan, and in a hurry, and then quickly inspired again ; so that his endea- vours seemed to be to keep his lungs always full ; inspiration succeeded expiration as fast as possible. He said, his difficulty of breathing was owing to an oppression or tightness across his breast, near the pit of the stomach. He had a little cough, which exasperated his pain, and he brought up blood and phlegm from his lungs. He was relieved by scarifications, and recovered. In Mr. Cheston's case, tbe man had re- ceived a blow on the chest. He had a con- stant cough, bringing np, after many ineffec tual efforts, a frothy discharge, lightly tinc- tured with blood ; he seemed to be in tbe greatest agonies, and constantly threatened with suffocation. His pulse was irregular, and sometimes scarcely to be felt, his face livid, and, when he was sensible, which was only now and then, he complained of a pain in his head. On passing a bandage round his chest, with a proper compress to prevent the discharge of air into the cellular mem- brane, and to confine the motion of the thorax, the patient cried out that he could not suffer it. A strong compression by the hand alone affected him in the same way. Notwithstanding bleeding, repeated scarifi- cations, and other means, his sense of suf- focation, and difficulty of breathing increa- sed. On the fourth day, the air no longer passed into the cellular membrane, when on a sudden inclining his head backward, as it were, for the admission of more air than usual, his breathing became more dif- ficult and interrupted, he turned wholly insensible, and soon afterwards died. Littre, Mery, and Cheston, opened their patients after death. Besides a wound of the lungs and frac- tured rib, Littre found a considerable quan- tity of blood in the cavity of the thorax, and was sensible of some fetid air escaping, on his first puncturing the intercostals and pleura. The wounded lobe was bard and black, and the other two of the same side were inflamed. Iu Mery's patient, no blood was extrava- sated, nor was there any thing preternatural, except the fractured ribs, the wound of the pleura, and that of the lungs. Cheston found a fracture of the tenth and eleventh ribs, and a wound of the lungs. The lungs below the wound were livid, and more compact than usual; but every thing else was natural, no extravasation, no in- flammation, no internal emphysema. Hewson made several experiments on animals, tending to prove, that air in their chests produced great difficulty inbreathing, such as occurs in cases of emphysema ; and, in one case, which he examined after death, air was actually discharged on puncturing the thorax. The object of Mr. Hevvson's paper is to recommend making an opening in the chest for tbe purpose of giving vent to the air confined in that cavity, just as is done for the discharge of pus, in cases of empyema, or of water, in those of hydrops pectoris. In wounds of the lungs, says this author, whether occasioned by fractured ribs, or other causes, when symptoms of tightness and suffocation come on, so far should we be from dreading the emphysematous swell- ing of the cellular membrane, that we should rather consider it as a favourable symptom, showing that the air is not likely to be confined in tbe thorax; and so far should we be from compressing the wound to prevent the inflation, or emphysema, that we should rather dilate it (if not large enough already) or perform the paracentesis thoracis. We may judge of the necessity of this operation from the violence of the symptoms, such as the oppressed breathing, Sic. For when these are not considerable, and the air passes out of the chest with sufficient freedom, the operation is then un- necessary. If the disease is on the right side, the best place for performing the operation, says Mr. Hewson, will be on the forepart of the chest, between the fifth and sixth ribs ; for, there the integuments are thin, and, in the case of air, no depending drain is required. But, if the disease is on the left side, it will be more adviseable to make tbe opening be- tween the seventh and eighth, or eighth and ninth ribs, in order that we may be sure of avoiding the pericardium. As large penetrating wounds are inconvenient on ac- count of the air entering by the aperture in such a quantity, as to prevent the expansionof the lungs, a small wound will be eligible, especially as air does not require a large 4~tQ EMPHYSEMA one for its escape. Mr. Hewson recom- mends dissecting cautiously with a knife, in preference to the coarse and hazardous method of thrusting in a trocar. There is one error prevailing in Mr. Hew- son's paper, for which he has been justly criti- cised by Mr. John Bell; viz. the idea that it is possible and proper to make the collapsed lung expand by making an opening in the chest. Bromfield and B. Bell have both imbibed the same erroneous opinions, and proposed plans for exhausting the air and expanding the lung. It is very certain that it is impracticable to make the collapsed viscus expand, until the breach in it is closed, and this closure is greatly promoted by the quiet state, in which the collapsed lung remains; a state, also, the most favoura- ble for the stoppage of any bleeding from the pulmonary vessels. The true object then of making an open- ing into the thorax, when the symptoms of suffocation are violent, is not to obtain an expansion of the lung on the affected side, nor to take the pressure of the air from it; but, to remove the pressure caused on the opposite lung by the distention of the me- diastinum, and, at tbe same time, to diminish the pressure of the air on the diaphragm. The lung on the affected side must continue collapsed, and it is most advantageous that it should do so. The opposite lung is that, which for a time must of itself carry on re- spiration, and it is known to be fully ade- quate to this function, provided the quan- tity of air, on the other side of the chest, does not produce too much pressure on the mediastinum, and diaphragm. Mr. John Bell concludes his remarks on this subject, with advising the following practice:— 1st. When the crackling tumour begins to form over a fractured rib, small punctures should be made with the point of a lancet, as in bleeding; and if the point be struck deep enough, the air will rush out audibly. But, as (supposing the lung is not adherent to the inside of the chest) this air was in the thorax, before it came into the cellular substance, it is plain, that the thorax is still full, and that the lung of that side is already collapsed and useless, and must continue so. The purpose, therefore, of making these scarifications, and especially, of making them so near the fractured part, is not to re- lieve the lungs, but merely to prevent the air spreading more widely beneath the skin. 2d. If the air should have spread to very remote parts of the body, as to the scrotum, and down the thighs, it will be easier to make small punctures in those parts, to let out the air directly, than to press it along the whole body, till it is brought up to the punctures made on the chest, oyer the wounded part. 3d. If, notwithstanding free punctures, and pressing out the air in this way, you should find by the oppression, that either air, or blood, is accumulating within the cavity of thp thorax, so a* to oppress not the wounded lung only, whicn was of course collapsed and useless from the *rst, but the dia- phragm, and through the diaphragm to affect also the sound lung; then a freer incision must be made, through the skin and muscles, and a small puncture should be cautiously made through the pleura,in order to let out the air, or blood, confined in the thorax.—(John Bell, Op. cit. p. 278.) In all these cases, copious and frequently repeated venesection is generally proper. After a few days, the wound, in the col lapsed lung, is closed by the adhesive in- flammation, so that the air no longer passes out of it into the cavity of the chest, and the outer wound may therefore be healed. What air is already there is ultimately ab- sorbed, and the lung, expanding in propor- tion, resumes its original functions. The application of a bandage round the chest is sometimes practised in cases of emphysema, and its utility, when the ribs are broken, has been highly spoken of by Mr. Abernethy. " Pressure by bandage (says he) not only hinders the air from diffu- sing itself through the cellular substance, but serves to prevent it from escaping out of the wounded lung, and, of course, faci- litates the healing of the wound, which would be prevented by the constant trans- mission of air. Its early application, there- fore will often prevent a very troublesome symptom, whilst, at the same time, by keep- ing the fractured bones from motion, it greatly lessens the sufferings of the patient." (Ahernethy's Surgical Works, Vol. 2, p. 179.) Where emphysema is complicated with a fractured rib, the latter injury is unquestion- ably a reason in favour of a bandage. Bulj whether the pressure of the roller will be useful, or hurtful, with respect to the em- physema itself, or the state of the lungs, and respiration, may be questionable. As for its tendency to resist the diffusion of air in the common cellular membrane, tbis circumstance does not appear to me im- portant, because the air, thus diffused, much as it disfigures the patient, is nearly harm- less, at least as long as the interlobular tex- ture of the lungs remains uninflated ; a dan- ger, also, which no bandaging, as far as I can judge, has any tendency to prevent. Neither will a bandage have so much effect in hindering the diffusion of air, as scarifica- tions, with this important additional con- sideration, that punctures, or small incisions, made over the broken rib, prevent the spreading of the air by letting it escape, while a bandage can only do so by more or less resisting its escape from the cavity of the pleura, which mode of operation in some cases would dangerously interfere with the continuation of respiration by the lung of the opposite side. At the same time, 1 believe, that where the air extravasated within the injured side' of the chest is not in such quantity, as to oppress the sound lung, and a rib is broken, a bandage will generally afford great relief. Indeed, it is but justice to Mr. Abernethy to state, that he does not recommend the employment of a bandage L.MPl.i'oEMA. •in in all cases of emphysema. ,; Patients (says he) will not always be able to wear a band- age, when one lung is collapsed, particu- larly if any previous disease has existed in the other, as it equally confines the motions of the ribs on both sides, and as every pos- sible enlargement of the chest becomes ne- cessary for the due admission of the air into the lung, which still executes its functions. Under these circumstances, if the emphy- sema continues, (and its continuance must always denote that the wound in the lung is not closed,) I should esteem it the best practice to make a small opening into the chest, so that the external air might have a free communication with that cavity ; and then the injured lung must remain motion- less till its wound is healed, and the medias- tinum, will, in every state of the thorax, preserve its natural situation.'' (Abernethy, Vol. cit.p. 183.) Emphysema has been known to arise from the bursting of a vomica and ulcera- tion of the surface of the lungs; but, the air whicb escapes, in this instance, cannot find its way into the cavity of the thorax, because the inflammation, which precedes the abscess and ulceration of the aircells, closes those which are adjacent, and pro- duces an adhesion of the edges of the vo- mica, or ulcer, to the inner surface of the chest, so as entirely to separate the two ca- vities. We are not acquainted with any in- stance of the symptoms, imputed to the confinement of air in the chest, originating from suppuration and ulceration of the sur- face ofthe lungs ; but, Palfyn, Dr. Hunter, and the author of the article Emphysema, in the Encyclopedic Methodique, Partie Chirurgicale, have seen cases, in which em- physema originated from abscesses of the lungs, attended with adhesion to the pleura, and ulcerations in the situation of such ad- hesion. In these instances, the pus having made its way through the pleura and inter- costal muscles, the air escapes also through the same track, so as to pass into the cellu- lar membrane on the ouside of the chest. A violent effort of respiration has, some- times, produced a certain degree of emphy- sema, whicb first makes its appearance about the clavicles, and afterward spreads over the neck and adjacent parts. The efforts of labour have been known to occa- sion a similar symptom ; but, no bad con- sequences followed. (Medical Communica- tions, Vol. l,p. 176; Blackden in Med. Facts and Experiments, Vol. 2, and Wilmer's Obs. in Surgery, p. 143.) Louis has described an emphysema of this sort, which, on account of its cause, and the indication which it furnishes to the practi- tioner, is highly important. This famous surgeon had occasion to remark it in a young girl, who died suffocated, from a bean falling into her windpipe, and he con- siders it, as a pathognomonic symptom of such an accident, concerning the existence of which it is so essential not to commit any mistake. (See Bronchotomy.) This emphy- sema made its appearance on both sides of 'lie neck, above the clavicles, and came on suddenly, on the third day alter the acci- dent. The inspection of the body proved, that the lungs and mediastinum were also in an emphysematous state. The retention of the air, confined by the foreign body, produced, says Louis, at each attempt to ex- pire, and, especially, when the violent fits of coughing occurred, a strong propulsion of this fluid towards the surface of the lung, into the spongy substance of this viscus. Thence, the air passed into the cellular tex- ture, which unites the surface of the lung to tbe pleura pulmonalis; and, by communi- cations from cells to cells it caused a prodi- gious swelling of the cellular substance, between the two layers ofthe mediastinum. The emphysema, increasing, at length made its appearance above the clavicles. This tumefaction of the lung, and surrounding parts, in consequence of air getting into their spongy and cellular texture, is an evi- dent cause of suffocation, and the swelling seems so natural an effect of the presence of a foreign body in the trachea, that one can hardly fail to think it an essential symptom, though no author has made mention of it. (Mim. de I'Acad. de Chir. Tom. 4, in 4to.) The emphysematous swelling, sometimes formed in the axilla, in the reduction of a dislocated shoulder, (See Dislocation) was accounted for by Desault and Bichat, on the same principle as. the foregoing case, viz. a rupture of one of the air-cells, by the pa- tient's efforts to hold his breath during the reduction of the bone. How far the expla- nation of the cause may be true, has been questioned. (See Did. des Sciences Med. T. 12, p. 15;) the fact itself admits of no doubt, and is both curious and interesting. An emphysematous swelling ofthe head, neck, and chest, has also been noticed in typhoid fevers. Dr. Huxham relates an in- stance of this sort, in a sailor of a scorbutic habit. (Medical Observations and Inquiries, Vol. 3, Art. 4.) A case of spontaneous em- physema has likewise been described by Dr. Baillie. (See Trans, of a Soc. for the Improvement of Med. and Chir. Knowledge, Vol. l,p.202.) A curious example of what has been call- ed a spontaneous emphysema, is recorded by Mr. Allan Burns: " The patient was a strong athletic man, who, about six years previous to his application at the Royal In- firmary, had received a smart blow on the neck, from the keel of a boat. This injury was soon followed by the formation of a firm tense tumour on the place which had been hurt. The swelling increased very slowly, during the five years immediately succeeding its commencement; but, during the sixth, it received a very rapid addition to its bulk. At this time, it measured nearly six inches in diameter, seemed to be con- fined by a firm and dense covering, and the morbid parts had an obscure fluctuation. From the first to the last, the tumour bad been productive of very little pain. "Judging from the apparent fluctuation, that the tumour was encysted, it was re- solved, at a consultation, to puncture the swelling, draw off its contents, and then pas? 472 EMP EMP a seton through it. By plunging a lancet into it, only a very small quantity of blood, partly coagulated, and partly fluid, was dis- charged,—a quantity so trifling, that, after its evacuation, the size of the tumour was not perceptibly reduced. A seton was pass- ed through the swelling. At this time the man was in perfect health. " About ten hours after the operation, the patient was seized with extremely violent ri- gours, followed by heat, thirst, pain in the back, excessive pain in the tumour, and op- pressive sickness. " An emetic was prescribed, but, instead of producing vomiting, it operated as a ca- thartic. To remove the irritation tbe seton was withdrawn. The pain in the tumour, however, and the general uneasiness con- tinued to increase, and thirty hours subse- quent to making tbe puncture, air began to issue from the track of the seton ; and, af- terward the cellular membrane ofthe neck, and of the other parts of the body in suc- cession, became distended with a gaseous fluid. In the course of a few hours, after the commencement of the general emphy- sema, the man died. " Twelve hours after death, when the body was free from putrefaction, it was in- spected. The emphysema was neither in- creased, nor diminished since death, and some idea may be formed of its extent, when the scrotum was distended to the size ofthe head of an adult. Even the cavities of the heart, and the canals of the blood- vessels, contained a considerable quantity of air. We could discover no direct com- munication between the tumour and the trachea or lungs, although such was careful- ly sought for." (A. Burns on the Surgical Anatomy of the Head and Neck, p. 51—53.) From such cases, we may infer, with the preceding writer, that from tbe mere rup- ture of a few of the bronchial cells, occa- sioned by irregular action of the lungs, or by some other internal cause, a spontaneous diffusion of air may take place in the cellu- lar texture ofthe body. Such examples are dependent on the same cause as the emphy- sema from injury of tbe lungs ; only the rupture of the bronchial cells in the former eases is less obvious. Surgeons often observe a partial emphy- sema in cases of gangrene. Here, however, it is hardly necessary to observe, the air is the product of putrefaction, and the disor- der has not tbe smallest connexion with any injury, or disease of the air-cells of the lungs. The reader may consult with advantage, PEncyclopidie Mithodique, Parlie Chirurgi- cale. C. C. Puysch, De Emphysemate (Haller. Disp. Chir. 2. 567, Halo-., 1733. H. A. Nies, De Miro Emphysemate, 4lo. Duisb. ad Rhen. 1751 Hcicson's Paper in Medical Observa- tions and Inquiries, Vol. 3. Mim. de I'Acad. Royale des Sciences, for 1713. Dr. Hunter, in Medical Observations and Inquiries, Vol. 2, Cheston, in Pathological Inquiries. Aherne- thy's Surgical Works, Vol. 2. Richter von der Windgetehwulst, in Anfangsgr. der Wundarz- neykunst, Band 1, p. 461, fa. John Bell on Wounds, Ed. 3. Edinb. 1812. Halliday on Emphysema, 1807. Allan Burns on the Sur- fical Anatomy ofthe Head and Neck, p. 62, c. Trans, of a Society for the Improvement of Medical and Chir. Knowledge, Vol. 1, p. 262 Wilmer's Observations in Surgery, p. 143. F. C. Waitz, De Emphysemate, 4lo. Lips. 1803. Richerand Nosographie Chirur- gicale, Tom. 4, p. 164, Edit. 2. Lassus Pa- thologic Chirurgicale, Tom. 2, p. 321, fa. Edit. 1809. Did. des Sciences Mid. T. 12, p. 1, fa J. Hennen, Principles of Mil. Surgery, p. 376. Ed. 2, 8vo. Edinb. 1820. C. Bell, Surgical Obs. Vol. l,p. 161, 4"". EMPLASTRUM AMMONIACI CUM ACETO. ft. Ammoniaci purif. ^ij. Acidi Acetici ?iij. Ammoniacum in aceto lique- factum evapora in vase ferreo ad emplastri crassitudinem. EMPLASTRUM AMMONIACI SCIL- LITICUM. ft. Gumm. ammoniaci ?j. Ace- ti Scillitici, q. s. ut fiant emplastrum, quo pars affecta tegatur. Mr. Ford found this last plaster useful in some scrofulous affections. It may be ren- dered more stimulating by sprinkling it with squills. (Ford on the Hip-joint, p. 59.) It was recommended by Swediaur; LondonMc- dical Journal, Vol. l,p. 198. EMPLASTRUM AMMONIACI CUM HYDRARGYRO. Discutient. EMPLASTRUM AMMONIACI CUM CICUTA. ft. Gum. ammon ^iij. Extracti Conii 3'j- Liq Plumb, acet 3j- Dissolve the ammoniacum in a little vine- gar of squills, then add the other ingre- dients, and boil them all slowly to the con- sistence of a plaster. Discutient. EMPLASTRUM AMMONLE. ft. Sa- pon.^ij. Emplastr. Plumbi. ^ss. Ammon. mur. 3j. The two first articles are to be melted to- gether, and when nearly cold, the murialed ammonia, finely powdered, is to be added. This plaster stimulates the skin, excites the action ofthe absorbents, and disperses many chronic swellings and indurations. EMPLASTRUM CANTHARIDIS. (See Blister.) EMPLASTRUM GALBANl COMPOSI- TUM. L.P. (Olim emplastrum lithargyri comp.) Properties discutient. EMPLASTRUM HYDRARGYRI. L. P. (Olim emplastrum lilharg. cum hydrargyro.) Properties discutient. EMPLASTRUM LYTTiE L. P. (See Blister.) EMPLASTRUM PLUMBI. L. P. (Olim emplastrum litharguri, or diacholon plaster) EMPLASTRUM RESINS. L. P. Olim emplastrum lithargyri c urn retina.) The com • mon adhesive, or sticking plaster. EMPLASTRUM SAPONIS. The plaster commonly used for fractures. It is also frequently applied to bruised parts, and to many indurations of a chronic nature. EMPYEMA, (from ct, within, and mnv, pus, or matter.) A collection of purulent matter in the cavity of the chest. The ancients made use ofthe word, "em- EMPYEMA. 473 pyeiiia" to express every kind of internal suppuration. It was ./Etius who first re- stricted the term to the collections of matter, which sometimes form in the cavity of the pleura, or membrane lining the chest; and all the best modern surgeons invariably at- tach this meaning alone to the expression. The operation for empyema properly means the making of an opening into the thorax, for the purpose of giving vent to the matter, collected in the cavity of the pleura, though the phrase with several writers de- notes making an incision into the chest, in order to let out any effused, or confined fluid, whether matter, blood, an aqueous fluid, or even air The necessity for having recourse to such an operation, however, does not often present itself. I would not wish to be supposed to assert, that inflam- mation of the lungs, pleura, mediastinum, diaphragm, and even of the liver, does not sometimes terminate in suppuration. Cer- tainly, the latter event is occasionally pro- duced ; but, when it does happen, the mat- ter does not always make its way into the cavity ofthe chest: frequently external ab- scesses form, or the pus is either coughed up, or discharged with the stools. Acute and chronic abscesses not unfre- quently form in the cellular substance, be- tween the pleura and the ribs and intercos- tal muscles. A swelling occurs between two of those bones; the skin does not un- dergo any change of colour; a fluctuation is distinguishable, and sometimes an extensive oedema is observable. With respect to abscesses, formed in the cellular substance, connecting the pleura costalis to the intercostal muscles, they rarely burst into the chest, the pleura always being considerably thickened. However, in order to keep them from spreading ex- tensively, as well as to obviate any possi- bility of their breaking inwards, the best rule is to make an early, and, if possible, a depending opening. The motions of respi- ration then both promote the exit of the matter, as well as. the contraction ofthe cavity, in which it was lodged ; and the disease, if unattended with caries, generally terminates favourably. It often happens, however, that the ribs are carious, and then the cure is more tedi- ous and difficult. A modern writer, indeed, informs us, that, when the inside of the rib is extensively carious, or when the caries is near the junction of the bone to the spine, the fistula is incurable. (Lassus Patfwlogie Chirurgicale, Tom. 1, p. 128, Edit. 1S09.) On the other hand, another surgeon of vast experience recommends us to, endeavour to separate the diseased bone, either by cutting it away, or employing the trepan. (Pelle- tan Clinique Chir. T. 3, p. 253.) Were a part of a diseased rib to admit of being sawn away, Mr. Hey's convex saw would be a more proper instrument for the purpose, than a trepan. An abscess of the preceding kind may be so situated, and attended with such a pulsation, as greatlv *o resemble an aneu- Voi.I. K<> rism ofthe origin ofthe aorta. An interest- ing case of this description is detailed by Pelletan. (Clinique Chir. T. 3. p. 254,) and another was seen by Baron Boyer. (Traite des Mai. Chir. T. 7, p. 333.) When the surface ofthe lungs and that of tbe pleura costalis have become adherent to each other, in the situation of the abscess, so as to constitute what is termed encysted empyema, the pus, disposed by a law of na- ture to make its way to the surface of the body, generally occasions ulceration of the intercostal muscles, and collects on the outside of them. An abscess of this kind comes on with a deep-seated pain in the part affected : an oedematous swelling, which retains the impression of the finger; and a fluctuation, which is at first not very dis- tinct, but, from day to day, becomes more und more palpable, and, at length, leads the surgeon to make an opening. If this be not done when the fluctuation becomes perceptible, the abscess may pos- sibly insinuate itself into the cavity of the pleura, in consequence of the adhesion be- ing in part destroyed by ulceration. Saba- tier affirms, tbat the case may take this course, even when the abscess has been punctured, and while a free external open- ing exists; and this experienced surgeon has adduced a fact in confirmation of such an occurrence. (See M-'.dicine Opiratoire, Tom. 2, p. 249.) In a few instances, the surface of the lung ulcerates, and the matter is voided from the trachea. But in the majority of exam- ples, the pus makes its way outwards, through the pleura costalis. If inflamma- tion occurs in the anterior mediastinum, and ends in suppuration, the abscess may possibly burst into neither of the cavities of the chest; but, make its way outward, after rendering the sternum carious, as happened in the example recorded by Van Swieten. (Comment, on Boerhaave's 895th Aphorism.) But, though collections of matter in tbe anterior mediastinum are influenced by tbe general law, whereby abscesses in general tend to the surface of the body, and though it be true, that they rarely burst inwardly into the cavity ofthe pleura, the contrary may happen, as is proved by the 9th case in La Martiniere's memoir on the operation of trepanning the sternum. Here the event was the more extraordinary, as there was already an external opening in the abscess. External injuries, such as the perforation of the sternum with a sword, (Vanderwel, Obs. 29, Cent. 1.) a contusion, a fracture, or a caries of this bone, may give rise to an abscess in the anterior mediastinum. Galen has recorded a memorable example, where the abscess was the consequence of a wound of the forepart of the ehest. After the in- jury, which was in the region ofthe sternum, seemed quite well, an abscess formed in the same situation, and being opened healed up. The part, however, soon inflamed and sup- purated again. The abscess could not now be cured. A consultation was held, at which Galen attendee! A* the sternum wa« 414 EMPYEMA obviou>l\ carious, and the puliation of the heart was visible, every one was afraid of undertaking the treatment of the case, since, it wus conceived, that it would be necessary to open the thorax itself. Galen, however, engaged to manage the treatment, without making any such opening, and he express- ed his opinion, that he should be able to ef- fect a cure. Not finding the bone so exten- sively diseased, as was apprehended, he even indulged considerable hopes of suc- cess. After the removal of a portion ofthe bone, tbe heart was quite exposed (as is al- leged,) by reason of the pericardium having been destroyed by the previous disease. After the operation, the patient experienced a speedy recovery. J. L. Petit met with nn abscess in the an- terior mediastinum, in consequence of a gun- shot wound in the situation of the sternum. The injury had been merely dressed with some digestive application ; no dilatation, nor any particular examination of the wound had been made The patient, after being to all appearances quite well, and joining his regiment again, was soon taken ill with ir- regular shiverings, and other febrile symp- toms. Petit probed the wound, and found the bone affected. As there was a difficulty of breathing, he suspected an abscess either in the diploe, or behind the sternum, and, consequently, he proposed laying the bone bare, and applying a trepan. This opera- tion gave vent to some sanious matter, and, a3 soon as the inner part of the sternum was perforated, a quantity of pus was discharged. The patient was relieved, and afterward recovered. (Petit, Traili des Mai. Chir. T. l,p. 80.) Another instance, in which an abscess be- hind the sternum was cured by making a perforation in that bone opposite the lower part ofthe cavity, in vvhich the matter col- lected, is recorded by De la Martinicre. (Mim. de I'Acad. de Chir. T. 12, Ed. 12mo.) When, in consequence of inflammation, an absccs forms deeply in the substance of the lungs, the pus more easily makes its way into the air-cells, and tends towards the bronchia?, than towards the surface of the lungs. In this case, the patient spits up pu- rulent matter. When the opening, by which the abscess has burst internally, is large, and the pus escapes from it in considerable quan- tity at a time, the patient is in some danger of being suffocated. However, if the open- ing be. not immoderately large, and the pus, which is effused, be not too copious, a reco- very may ensue. Abscesses in the substance of the diaphragm, and collections of matter in the liver, may also be discharged by the pus being coughed up from the trachea, when the parts affected become connected with the luna;s by adhesions, and the ab- scesses of the! iver are situated on its convex surfuce. When the collection of matter in the liver occupies any other situation, the abscess frequently makes its way into the * colon, and the pus is discharged with the ?tools. Several cases of this kind are re- '.?'»d by authors . Sabatier bus recorded I wo in his Medecine Operatoire , Le Dran makes. mention of others ; and Pemberton, in his book on the Diseases ofthe Abdominal Vis- cera, p. 36, relates additional instances of a similar nature. I shall now proceed to the consideration of empyema strictly so called. Sometimes it is a consequence of a penetrating wound of the chest; occasionally it proceeds from the bursting of one or more vomicae ; in a few examples, it arises from the particular way, in which abscesses of the liver burst; (Journ. de Med. T. 3, p. 47. Morgagni, Epist. 30, art. 4.) but in the greater number of in- stances, it originates from pleuritic inflam- mation, especially that of the chronic kind. (Boyer, Traiti des Mai. Chir. T. 7, p. 352.) Empyema very rarely takes place in both sides of the chest, but isalmost always limit- ed to one cavity of the pleura. According to Baron Boyer, when empye- ma arises from thoracic inflammation, pleu- ritis, or pneumonia, the symptoms, charac- terizing it, are always preceded by those of the disease, of which the effusion of pus upon the diaphragm is the effect. Inquiry must therefore be made, whether the patient has pleurisy, or peripneumony, the symp- toms of which have lasted longer than a fortnight; and whether, after a transient amendment, there have been frequent shi- verings, followed by a low continued fever, with nightly exacerbations. Now, these first circumstances justify the belief, that the inflammatory disorder has terminated in suppuration, and that the symptoms after- ward experienced, depend upon effusion of matter in the chest. Some of these arise from the mechanical action of the pus upon the lungs, heart, and parietes of the chest, and belong also to other effusions in the tho- rax ; the rest may be said to be the effects of ulceration and suppuration ofthe parts on the animal economy, and therefore, particu- larly belong to empyema. First, of the common symptoms, respira- tion is difficult, short, and frequent; tbe pa- tient suffers great oppression, and expe- riences a sense of suffocation, and of weight upon the diaphragm. He cannot move about, even for a short time, without being quite out of breath, and threatened withsyn- cope. He has an almost incessant, and very fatiguing cough, which is sometimes dry, sometimes attended with expectoration. (Boyer, Traiti des Mai. Chir. T. 7, p. 366.) No surgical writer, with whom I am ac- quainted, has treated with more discrimina- tion, than Mr. Samuel Sharp, of the symp- toms produced by collections of matter in the chest. He remarks, that it has been al- most universally taught, that, when a fluid is extravasated in the thorax, the patient can only lie on the diseased side, the weight of the incumbent fluid on the mediastinum be- coming troublesome, if he places himself on the sound side. For the same reason, when there is fluid in both cavities of the thorax, the patient finds it most easy to lie on his back, or to lean forwards, in order that the fluid may neither pre-^ upon the media.-*: EMPYEMA 475 ;iini), nor the diaphragm. But, it is noticed by Mr. Sharp, that, however true this doc- trine may prove in most instances, there are a few, in which, notwithstanding the extra- vasation, the patient does not complain of more inconvenience in one posture than another, nor even of any great difficulty of breathing. (See Le Dran's Obs. 217, and Marchelli, 65.) On this account, observes Mr. Sharp, it is sometimes less easy to determine, when the operation is requisite, than if we had so exact a criterion, as we are generally supposed to have. But, says he, though this may be wanting, there are some other circum- stances, which will generally guide us with a reasonable certainty. He states, that the most infallible symptom of a large quantity of fluid in one of the cavities of the thorax, is a preternatural expansion of that side of the chest, where it lies ; for, in proportion as the fluid accumulates, it will necessarily elevate the ribs on that side, and prevent them from contracting so much in expiration as the ribs on the other side. This change is said to be most evident, when the surgeon views the back of the chest. (Boyer, Vol. cit. p. 357.) Mr. Sharp also refers to Le Dran's Obs. 211, vol. 1, in order to prove, that the pressure of the fluid on the lungs may sometimes be so great, as to make them collapse, and almost totally obstruct their function. When, therefore, says Mr. Sharp, the thorax becomes thus expanded, after a previous pulmonary disorder, and the case is attended with the symptoms of a suppura- tion, it is probably owing to a collection of matter. The patient, he observes, will also labour under a continual low fever, and a particular anxiety from the load of fluid. Besides this dilatation of the cavity by an accumulation ofthe fluid, the patient will be sensible of an undulation, which is some- times so evident, that a bystander can plain- ly hear it in certain motions of the body. Mr. Sharp adds, that this was the case with a patient of his own, on whom he performed the operation ; but the fluid in this instance, he says, was very thin, being a serous mat- ter, rather than pus. Sometimes, when the practitioner applies his ear close to the pa- tient's chest, while this is agitated, a noise can be heard, like that produced by shaking a small cask, not quite full of water. (See Dr. Archer's Case in Trans, ofthe Fellows, fa. of the King's and Queen's College of Physi- cians in Ireland, Vol. 2, p. 2.) In this in- stance, the fluid resembled whey. According to the same author, it will also frequently happen, that though the skin and intercostal muscles, are not inflamed, they will become oedematous in certain parts of the thorax ; or, if they are not oedematous, they will be a little thickened ; or, as Boyer" states, the intercostal spaces are widened, and, when the empyema is considerable, in- stead of being depressed, as they are in thin persons, they project beyond the level of tbe ribs. (Mai. Chir. T. 7, p. 357.) These symptoms, joined with the enlargement of p. ad Morb. 2, 4031.) Gerardus le Maire, Diss. de Empyemate, 4lo. Lugd. 1735. Sharp's Critical Inquiry into the Present Slate of Surgery, sect, on Empyema Lc Dran's Ob- servations in Surgery. J. L. Petit, Traiti des Maladies Chirurgicales, Tom. 1. Chap. 3. DesPlaics de la Poitrine. Warner's Cases in Surgery, Chap. 6. Edit. 4. Memoire sur VOpiration du Tripanau Sternum,par M.de la Marliniirc in Mim. de I'Acad. Royale de Chirurgie, Tom. 12, p. 342, Edit. 12mo. L. G. Van Malcotc, De Empyemate, Tenera- mvnd. 17«3. Sabatier, Midecine. Opiratoire, Tom. 2. p. 247, 4-c. Edit 1. A. 0'Flaherty, De Empyemate, Montp. 1774. Andouarddr VF.mpyeme, Cure Radicale Obtenuepar I'Opi- ration, fa. Svo. Paris. 1808. CaJHixcn, Sys- tema Chirurgia Hodierna, Vol. 2, p. 363, Edit. 1798. Flajani Collezione d'osserva- zioni, fa di Chirurgia, T. 3. p. ]85,fa.Svo. Roma, 182d. Richera-.d, Nosogr. Chir T. 4, sect, des Maladiis de I'Appareil respiratoire. Ltviilli,Nouvelle Doctrine Chir. T. 2 p. 575, fa. Hey's Practical Observations in Surgery, Ed. 3. Lassus Pathologic Chirurgicale, T 1, p. 122, fa Larrey, Mimnires de Chirurgie Militaire, T. 3. p. 442, et T. 4. p. 356, fa. Pelletan, Clinique Ch.r. T. 3, p. 236, fa. J. Hennen, Principles of Military Surgery, p. 384, fa. F.d. 2. iivo. Edinb. !82u. Boyer, Traiti des Mai. Chir. T. 7.p. 351, fa. Svo. Paris, 1S21. ENCANTHIS. (from tv, and asuSs?. the angle of the eye ) The encanthis, at its commencement, is notbingmoresays Scarpa, than a small, soft, red, and sometimes rather livid, excrescence, which grows from the caruncula lachrymalis, and, at the same time, from the neighbouring semilunar fold of the conjunctive. The inve- terate encanthis is ordinarily of considerable magnitude; ifs roots extend beyond the1 caruncula lachrymalis, and semilunar fold, to the membranous lining of one or both eye- lids. The putient experiences very serious inconvenience from its origin, and interposi- tion between the commissure of (he eyelids, vvhich it necessarily keeps asunder, on the side towards the nose. The encanthis keeps up a chronic ophthal- my, impedes theaction of the eyelids, and in particular, prevents the complete closure of the eye. Besides, pnrtly by comp'essing, and partly by displacing the orifices of the puncta Inchrymulia, it obstructs the free pas- sage of the tears into tbe nose. According lo Scarpa, this eserescenrp, on its first appearance, is commonly granulated, lik( a mullieny, or is of a ragged and fringed structure. Alterwiird, when it had acquired a certain size, one part of it represents a granulated tumour, while the rest appears like a smooth, whitish, or ash-coloured sub- stance, streaked with varicose vessels, sonic- times advancing as far over the conjunctiva, covering the side of the eye next to the nose, as where the cornea and sclerotica unite. In Ibis advanced state, theeitcanthis constantly interest* the caruncula lachrymalis, the val- vula semilunaris, and the membranous lining of one, or both e>elids. In addition to the roots, which in such circumstances connect the excrescence with the caruncula lachryma- lis, the semilunar fold, and the conjunctiva ol the globe of the eye, the encanthis emits an appendage, or prominent, fii m elongation, along the inside of the upper, or lower eyelid, in the direction of its edge. The middle, or body, of ihe enennthis. divides near the cor- nea, as it were, like a swallow's tail, to form two appendages,or elongations, one of whicb extends along the inner surface of the upper eyelid by the margin of which it is covered, while the othershoots in a direction from the ENCANTIll,- internal towards the external angle, along the inside of the lower eyelid, which also conceals it benentb its edge. The body of the encanthis, or that middle portion of the whole excrescence which reaches from the caruncula lachrymalis, and s-emilutiar fold, inclusively, over the con- junctiva aim st to the junction of the scle- rotica with ti.e cornea, sometimes forms a prominence, as large as a small nut, or ches- nut. At other time3, it is of considerable size, but depressed and broken down, as it were, at its centre. Still, however, the bo- dy of the encanthis preserves that granula- ted appearance which prevailed nt first; while one or both the appendages, on the inside of the eyelids, appear rather like a fleshy than a granulated substance. On turning out the inside of the eyelids, these appendages, or elongations of the en- i anthis, form a prominence projecting for- ward. When both eyelids are equally affect- ed, and turned inside out, the appendages conjointly represent, as it were, a ring, the back of which rests on the globe of theeye. Sometimes, the encanthis assumes a can- cerous malignancy. This character is evin- ced by the dull-red, leaden, or (as Beer says) ihe bluish red colour of the excrescence ; by its excessive hardness, and the lancina- ting pains which occur in it, and extend to the forehead, the whole eyeball, and the temple, especially when the tumour has men slightly touched. It is also evinced by the propensity of the excrescence to bleed, by the partial ulcerations on its surface, which emit a fungous substance, and a thin and exceedingly acrid discharge. The dis- ease is constantly attended with epiphora, and preceded by a scirrhous induration of the caruncle. The eyeball and neighbour- ing bones, which are of a spongy texture, are said to participate very soon in the dis- i\i«e, the lower eyelid also becoming evert- ed. (Beer, Lehre von den Augenkr. B. 2, p. 187, 1S8.) Tbis form of encanthis only ad- mits of palliative treatment; unless, indeed, nn effort be made to extirpate it entirely, to- gether with the whole of what is contained in the orbit; and even then the event is du- bious. Beer joins Scarpa in the statement, that the operation rarely proves successful, and adds, that it is always followed by an incu- rable weeping, and a considerable eversion ofthe lower eyelid. (Vol. cit. p. 1S9.) For- tunately, the truly cancerous encanthis is uncommon: and Mr. Travers, who was a •nrgeon to the London' Eye Infirmary seve- ral years, never met with an instance of it. (Synopsis of Diseases of Ihe Eye, p. 103.) The benign encanthis, how large soever it may be, is always curable by extirpation. Those instances which are small, incipient, and granulated, like a mulberry, or of a frin- ged structure, which originate either from the caruncula lachrymalis, or the semilunar fold of the conjunctiva, or from both these parts together, and even in part from the in- ternal commissure of the eyelids, may be eai?ed by means of a pair of forceps, and cut off from the whole ot their origin, closely to their base, with the curved scissors with convex edges. In the performance of thfc operation, it is unnecessary to introduce a needle and thread through this little excres- cence, as some are wont to do, for the pur- pose of raising it, and destroying more accu- rately all its origins ana adhesions. The same object is fulfilled by means of forceps, without inconveniencing the patient with a puncture of this kind, and drawing a thread through the part, in order to make a noose. However, irr cutting out an encanthis of this small size, care should be taken not to re- move, together with that portion of the ex- crescence which originates from the carun- cula lachrymalis, any more of tbis latter body than what is absolutely necessary for the precise eradication ofthe disease, in or- der that no irremediable weeping may be occasioned. When the little excrescence has been de- tached from all its roots, says Scarpa, the eye must be washed several times with cold water in order to cleanse it from the blood, and then it is to be covered with a piece of fine linen and a retentive bandage. On the 6th, 6th, or 7th day, the inflammation ari- sing from the operation entirely ceases, and the suppuration from the wound is accom- panied with the mucous appearance already described. The little wounds are then to be touched with a piece of alum, scraped to a point like a crayon, and the vitriolic colly- rium, containing the mucilage of quince seeds, is to be injected into the affected eye several times a day. If these means should not bring about the vvished-for cicatrization ; but, on the contrary, the small wounds situa- ted on the caruncula, and internal commis- sure of the eyelids, should become stationa- ry, and covered with proud flesh, the argen- tum nitratum ought to be applied to them. The conjunctiva, however, should be avoid- ed as much as possible, especially if at all wounded. When the fungous granulations have been destroyed, the cure may be per- fected by the collyrium already mentioned, or rather by introducing, thrice a day, be- tween the eyeball and internal angle ofthe eyelids, the powder of tutty, and the arme- nian bole. Bidloo extols very much pow- dered chalk, either alone or in conjunction with burnt alum. (Exercit. Anat. Chir'. De- cad. 2.) ', .xcision is equally applicable to the invete- rate encanthis, which is of considerable size, and broken down at its body, or which forms a prominence as large as a nut, or t-hesnui, with two fleshy appendages extend- ing along the inner surface of one or both eyelids. The application of a ligature to such an excrescence ought never to be re- garded as a method of cure ; for the large inveterafe encanthis never has a sufficiently narrow neck to admit of being lied. On the contrary, when the tumour is voluminous, its roots invariably extend to tbe caruncula lachrymalis, the semilunar fold, and the conjunctiva covering the eyeball, oftentimes pearly as far ;** iant;ty of the substance of this part, i prevent the tears from dropping over the qheck after (he wound h healed. ihe t ye is to be repeatedly washed with cold water. The rest of the treatment, consequent to the extirpation of a laige encanthis, is almost the same as what was explained in speaking ofthe small incipient case. Bathing the eye very frequently in the lotion of mallows, and employing anodyne, detergent collyria, are the best local means, until the mucous appearance, preceding suppuration, has ta- ken place onthe surface of the v ound. Then we may have recourse to mild astringent ointments and collyria. The mildest topi- cal applications are generally the best, both in tbe first stage of suppuration, as vv ell as afterward, particularly when, together with the encanthis, we have removed a consider- able piece of the conjunctiva, which cover- ed the eyeball towards the nose, and was intimately connected with the body of the excrescence. Consult Scarpa tulle Mallallie degli Occhi. Ed. 5, Cap. 12; Richter, Anfangsgr. der Wundarzn. Band 2, p. 473, fa Edit. 1802. G J. Beer, Lehre von den Augenkr. B. 2, P. 187, 8do. Wein. 1817. On the whole, I con- sider Scarpa's observations the most correct and valuable, and they hove therefore been freely employed in the foregoing article. ENCEPHALOCELE. (from «j,jm**A9», the brain, and mttot, a tumour.) A hernia of the brain. (See Hernia Cerebri.) ENCYSTED TUMOURS. (See Tumours Encysted.) ENEMA, (from impi, to inject.) A clyster. The following are some of the most use- ful clysters employed in the practice of sur- gery. Cathartic. ft. Decocti Hordei Ibj. Soda? Muriatis ^j.—Misce. ft. Decocti Avenae ffej. Olei Oliva? ^ij. Magnesias Sulphatis ~j.—Misce Anodyne. ft. Mucilaginis Amyli, Aqua? distillatat sing. ?ij. Tincture? Opii guttas xh. —Misce. ft. Olei Oliva? jiv. Tinctura? Opii gut- tas xr..—Misce. The two latter clysters are particularly useful in cases in vvhich there is great irri- tation about the rectum, bladder, or urethra. They have great effect in diminishing spas- modic affections of this canal aud the neck of the bladder. Tobacco. Employed in cases of strangulated Hernia. ft. Nicotiana? 3j- Aq. ferventis jfoj. The plant is to be macerated ten minutes, and the liquor then strained for use. One half should be first injected, and soon after- ward the other, unless the clyster should operate with dangerous violence, as it some- times does in particular constitutions. ENTEROCELE. (from p/???a, the bowels, and vihH, a tumour.) A hernia, in vvhich th' ronter.ts ofthe tumour are intesUne. -130 EP1 EPI ENTERO-EPIPLOCELE. (from a',^a, the bowels, errrxw, the omentum, and jwxd a tumour.) A hernia, in which the contents of the swelling are both intestine and omen-. turn. ENTROPIUM. (from *to, lo turn.) An inversion of the eyelids. (Sec Trichiasis.) EPIGLOTTIS SHOT AWAY The prac- tice of Baron Larrey furnishes a curious ex- ample, in which the epiglottis of a French soldier was shot off at the battle of Alexan- dria, on the 21st of March, 1801. Tbe ball entered at the angle of the jaw, crossed the throat obliquely, and came >ut at the oppo- site side of the neck. The base of the tongue was grazed, and the epiglottis shot away; the patient spit it up after the accident, and showed it to the surgeon, who first saw him. One may be convinced of the fact by an ac- count of the symptoms. I he patient was not in much pain ; but bis voice was hoarse, feeble, and scarcely audible. When he. first attempted to swallow, he was seized with a convulsive suffocating cough, attended with vomiting. Annoyed by thirst, which the extreme heat of the weather and the irritation ofthe wound ex- cited, he incessantly repeated his attempts to drink ; but always with the same result. Four days were passed in this deplorable condition. He already experienced violent complaints at bis stomach; continual loss of sleep; he had a small accelerated pulse, and was beginning to look thin. Such was the state of this wounded sol- dier, when Larrey saw him on the fifth day. After making a few inquiries about what had passed after the accident, attempting to make the patient drink, a>>d examining the interior ofthe mouth, Larrey was convin- ced, that the paroxysms of suffocation, and the inability to swallow depended upon the permanent opening of the glottis, the lid of which had been shot away. Tbe prognosis of the injury was exceedingly unfavourable, and there can be no doubt, that, if the pa- tient had been abandoned to the resources of nature, he would have died in the course of a few days. The indications were equally difficult to fulfil : the most urgent was to appease the hunger and thirst, with which this poor soldier was afflicted. Lar- rey fortunately, was provided with an elas- tic gum tube, constructed for the oesopha- gus. This instrument was introduced with the usual precautions, into the pharynx, and by means of it, the patient was given some drink, which relieved him much, and afterward some rich broth. The patient wasted in this manner for six weeks, at the end of which time, he was able, without the assistance of the tube, to swallow thick panado, and thickened rice, made into little balls. The powers of speech and degluti- tion in time became much more perfect ; in consequence, as Larrey imagines, of an enlargement of the arytenoid cartilages, and an expansion of that part of the base of rbe t6ngue ■<• V-eh lie; next to the glottis. baviug formed a sort of substitute for the epiglottis. (Mimoiresde ChirurgieMititaire, T. 2, p. 145—149.) The foregoing case illustrates, in a con- vincing manner, the importance and utility of elastic gum tubes for conveying nourish- ment and medicines down the cesophaguH in wounds about the throat. All practi- tioners, and, especially, military surgeons, should be duly impressed with the necessity of having such an insti mient always at hand. The patient, whose case is above recited, owed his preservation altogether to this means, without which he must have been starved to death. In the fourth vol. of Ihe above work, P. 247, is recorded another case, in which n gun-shot wound,thattook away the epiglot- tis, and broke the os hyoides, was success- fully treated. EPIPHORA, (from »rio. Lond. 1819, and Beer Lehre von den Augenkr. B. 2.) EPIPLOCELE. (from tiri7rxoov, tbe omen- tum, and »t>i», a tumour.) A hernia, formed by a protrusion of the omentum (See Hernia.) EPULIS, (from &ri, upon, and *a*, the gums.) A small tubercle on the gums. It is said sometimes to become cancerous. The best plan of cure is to extirpate it with a knife. ERETHISMUS. (from eg«9***», to irri- tate.) The state of irritation, attending the early stage of acute diseases Mr. Pearson has-described a state of the constitution, produced by mercury acting on it as a poi- son. He calls it the mercurial erethismus, and mentions, that it is characterized by great depression of strength, anxiety about the pracordia, irregular action of the heart, frequent sighing, trembling, a small, quick, sometimes intermitting pulse, occasional vomiting, a pale contracted countenance, a sense of coldness ; but the tongue is sel- dom furred, nor are the vital and natural functions much disturbed. In this state, any sudden exertion will sometimes prove fatal Mr. Pearson advises, with a view of preventing the dangerous tendency of this affection, the immediate discontinuance of the use of mercury ; and exposing the pa- tient to a drv cool a'«: The inninien' ERYSIPELAS. ■181 i.retuismus may otteu be averted by the camphor mixture with large doses of the volatile alkali, if mercury be also left off. Sarsaparilla is also beneficial, when the stomach will bear it. (Pear on Lues Verwra, page 156, fa. Edit. £.) ERYSIPELAS, (from tnt*, to draw, and vriheic, adjoining.) St. Anthony's fire ; so called, from its tendency to draw the neigh- bouring parts into the same stale, or, in other words, from its propensity to spread. Erysipelas may be defined to be an in- flammatory, cutaneous, and trivially eleva- ted swelling, attended with a redness, which disappears, and leaves a white spot for a short time after being touched with the end of the finger, and the affection, which is not like phlegmon regularly circumscri- bed, is characterized by a remarkable pro- pensity to spread. The part is generally of a bright red co- lour, clear, and shining. Tbe tumour is not accompanied by throbbing, and a burn- ing heat and tingling are felt, rather than acute pain. In many instances, vesications arise; a circumstance, vvhich led Dr. Wil- lan to include the disease in the order Bulla;. However, if we mean this arrange- ment to extend to what is named local, or accidental erysipelas, as well as to the idio- pathic forms of the disorder, there cannot be a doubt of its inaccuracy, many examples -of erysipelas from local irritation being cha- racterized neither by fever, nor vesications. The Greeks,.admitting into their theories of medicine the metaphysical principles of philosophy, and the superstitious ideas of the Pythagoreans, respecting numbers, agreed in the existence of four elements, four radical qualities, four temperaments, and consequently four humours and four species of tumours, produced by stagnation, or a diseased alteration of the humours above mentioned. Phlegmon, according to their theory, was formed by the blood, erysipelas by the bilious, cedema by the pituitous, and scirrhus by the melancholic or atrabilious temperament. But as this theory was often contradicted by observation, they were obliged to have recourse to the supposition of a mixture of the humours, by means of which tumours of a mixed description were formed ; whence, no doubt, we derive the distinction of simple or true erysipelas, (produced merely by extravasation and de- posit of the bilious humour, underthe skin :) from the compound or spurious, which took its name from the humour at the time most prevalent ; hence the names of phlegmo- nous, oedematous, scirrhous, erysipelas, he. In order to have just ideas respecting the various forms of erysipelas, tbe first thing is to establish ah eligible classification of them. Desault prefers the division of ery- sipelas into phlegmonous, bilious, and local ; (Chir. Journ. Vol. 2.) an arrangement which seems founded on experience and correct observation. Mr. Pearson also divides the complaint into three forms, viz. the phlegmo- ■".ous, the ademalous. and gangrenous; (Prin-. Voj I 6) ciples of Surgery, Chap, x.) Buiserius noti- ces, 1. The idiopathic, or primitive erysipe- las, or that which arises spontaneously from an internal cause, unpreceded by any other disease. 2. Symptomatic, or secondary ery- sipelas, depending on another affection, bv which its progress is completely influenced. 3. Accidental erysipelas, or that vvhich h casually excited'by some external manifest cause, (tnslit. Med. Prac. T. 2. C. 2. Svo. Lips. 1798.) In the bilious erysipelas, which would be classed, as an idiopathic case, the swelling is trifling, and often imperceptible, the skin of a rose-colour, generally a little verging towards yellow. The sensation, which the patient experiences is neither that of ten- sion nor pulsation, but a painful smarting, similar to what results from the application of hot water, or from exposure to the burn- ing rays of the sun. Towards the period of the invasion of this disease, and often several days pre- viously, the appetite is lost, the mouth bit ter, the tongue moist, and covered with a yellow mucus. Nausea and sometimes bilious vomitings come on. The patient becomes weak and dejected, and is affected with wandering pains and considerable heat; without any particular dry ness of the skin or violent sense of thirst. Sometimes the disease begins with fever, more or less violent, preceded by shivering and violent pain in the head. In the phlegmonous erysipelas, the skin i- more raised than in the preceding species, the swelling harder and deeper, aud of a darker colour. There is generally a slight degree of tension ofthe integuments, with pungent pain, and occasionally a sensation of throbbing. On the first days of the at- tack,there is neither bitterness in the mouth, nor nausea, tbe skin and tongue become dry, and are accompanied with a violent sense of thirst; the pulse is full and hard, indicating plethora. Tbis form of erysipe- las most frequently occurs in the face, usu- ally affecting only one side of it; some- times it seizes one ofthe extremities ; and, in both cases, it is ushered in by a smart feverish attack. (Bateman, Synopsis of Cu- taneous Diseases, P. 126, Ed. 3.) At the expiration of a few days, parlicu- larly when the disease has been treated by bleeding and an antiphlogistic regimen, the tongue becomes foul and moist at its edges. bitterness of tbe mouth and nausea super- vene, and the disease, in its progress, pre- sents little difference from bilious erysipelas. (Parisian Chirurgical Journal, Vol. 2, p 24, fa.) The following is a description of phleg- monous erysipelas, as it sometimes appears when it attacks the bead. The attack is mostly preceded by shiver-' ings, complaints about the region of the heart, and other symptoms very similar to those which indicate the approach of an in- termittent fever. Tbe heat is often accom panied with a little delirium, and almost always w;'h drowsiness of a more or !<•«* fo^ ERYSIPELAS evident kinu. i»e swelling generally makes its appearance on the second night, or third day of the fever, attacking tbe fore- head, the cheeks, the nose, or eyelids. This swelling is elastic and smooth ; but It is not distinctly circumscribed, and it gra- dually spreads over such parts ofthe face as were not at first affected. The skin becomes of a bright red colour; occasionally having a tendency to a livid hue ; in other instances having a mixture of yellow. These colours disappear when pressure is made on the part affected, but very soon reappear when such pressure is discontinued. The patient experiences a burning heat, and a disagree- able pricking in the part, rather than any acute pain ; sometimes ho complains of a very troublesome itching. The surface of the tumour is shining, and, as it were, semi- iranspareut; but without hardness, tension, or any sensation of throbbing. Tbe eyelids are often so swollen that the patient cannot see. and the whole countenance is exceed- ingly disfigured. On more or less of the erysipelatous tumour vesications arise on ;he fourth, or fifth day ; they are filled with a transparent serous fluid, and bear a great resemblance to those which are occasioned by boiling water. They commonly burst, or subside on tbe fifth, or sixth ; the fluid, vvhich is discharged, sometimes excoriating the neighbouring parts. Frequently, there is even a slight ulceration At their base, which ulceration, in the werst sort of cases, assumes a gangrenous appearance, and falls rapidly into a state of complete mortifica- tion. When the disease takes amore favour- able course, the fever now begins to abate ; the vesications dry up ; and, atrthe end of eight or twelve days, tbe cuticle peels of, and the scabs, situated in places which were occupied by tbe vesications, fall off. The degree of danger depends materially on the delirium and other symptoms indicating an affection of the brain. When phlegmonous erysipelas attacks the face, the termination of tbe disorder in suppuration is very rare. (Bateman, Vol. cit. p. 127.) According to several writers, the seat of erysipelas in the greater number of cases is the very surface of the cutis ; its most vas- cular and nervous part. (Dict.de* Sciences Med. T. 13, p. 255.) And, perhaps, it may be true, that the disorder here commences, and is most intense. Yet, there cart be no doubt, that the affection generally extends more deeply, aud affects tbe subjacent cel- lular membrane, particularly in cases of phlegmonous erysipelas. The affection of the cellular membrane, however, is very different from what happens in phlegmonous inflammation. In true erysipelas, healthy pus is rarely found enclosed in a circum- scribed cavity ; and when there is any se- cretion of purulent matter, a feel is commu- nicated, on compressing the part, almost lik.e that which a ' onge would give. In sucft cases, tbe cellular substance is frequent- ly grangrenous. It does not appear to me, that anv very *sact information has vet been established respecting the causes ot erysipelas. We absolutely know nothing about the im mediate cause ; the prevailing ideas concern- ing the predisposing causes are vague ; and only those causes, termed exciting, appear entitled to much confidence. They are : 1. Violent passions, such as anger, acute grief, he. 2. Exposure to the heat of the «un, or that of the fire, too long continued. 3. The impression of cold damp air. 4. The action of various vegetable, mi- neral, and animal poisons. 5. Wounds, contusions, fractures, the stings of insects, he. In most cases, erysipelas would seem to be intimately dependent on the state of the constitution. Thus, persons in the habit erf drunkenness, and other kinds of intemper- ance, and who, in a state of intoxication, meet with local injuries, often have erysipela- tous inflammation in consequence of them. Other subjects, who lead more regular lives, experience, when they meet witb similar injuries, healthy phlegmonous inflammation. The opinion of Hippocrates und Oaten, with respect to the origin of this disorder from a congestion of the bile, is univer- sally known to all initiated in the profession of Surgery. This old doctrine has been, in some measure, revived by Tissot, and many- other believers in the humoral pathology, who attribute the cause of erysipelas to an acrid humour, commonly a bilious one, dif- fused through the mass of the blood. But, much as I despise the absurdity of this theory, observation obliges me to confess, that the complaint seems frequentlyto.be connected with a wrong state of the chy- lopoietic viscera, and especially of the liver. A further proof, that erysipelas is mostly dependent on constitutional causes, is, that the affection most frequently happens in autumn, or in any season, when hot weather is succeeded by cold and wet. Erysipelas frequently attacks both sexes ; but women are thought to be rather more subject to it than men, and the reason for this circumstance, generally mentioned, is the greater delicacy and tenderness of the skin in females. But, it would be quite as rational to suspect their weaker and more irritable constitutions, and their sedentary mode of life. In lying-in hospitals, and other charites for the reception of children, new-born infants are often afflicted with a species of erysipelas, which begins in the umbilical region, and thence extends to the pudenda. This case, which sometimes ter- minates in gangrene, aud proves fatal, has been ascribed by some writers to injury- done to the navel-string during labour, and by others to tbe bad air frequently allowed to accumulate in establishments of the above description ; a cause, which too often renders complaints, which are at first trivial, ultimately fatal. Sometimes, the complaint is scarcely cured in one place, when it makes its appearance in another, and when this tendency is evinced in a great de:rree;the case is tevme*' ERYSIPELAS 4SK erysipelas ambulans, vel erraiicum. La Motte has published a striking instance of this form of the disease. A child, between nine and ten years of age, was attacked with erysipelas of the scalp, forehead, and ears, which afterward extended to the neck, and then to the shoulders, while the scalp and face became free from it: in proportion as the disease spread downwards, all the upper parts got well, so that, in the end, there was no portion of the surface of the body, which had escaped, even down to the fingers and toes, the parts last of all affected. (Obs. Chir.) A very uncommon variety of disease is an universal erysipelas. No disorder is more subject, than the present, to relapses ; but a remarkable thing, sometimes attending the return of the complaint, is its being some- times strictly periodical. In chlorotic wo- men,the erysipelatous attack is occasionally made every month just at tbe period when the menses should take place. (Hoffman.) This periodical nature of erysipelas has been observed in men: Lorry knew two male patients, one of whom used to be attacked with erysipelas twice a year at the time of the equinox ; the other had only one attack annually, which was wont to happen in the beginning of the spring. My friend, Mr. Maul of Southampton, lately informed me of an erysipelas, which was both periodical and universal, affecting a lady several times, at intervals of two years. A doctrine has been started, that erysipe- las is sometimes propagated by contagion. (Wells, in Trans, for the Improvement of Med. and Surg. Knowledge, Vol. 2, Art. 17,1800.) But, as Dr. Bateman has truly remarked, suchjcasesare, at all events,extremely rare, and perhaps never happen in well-ventilated and cleanly houses. (Synopeis, fa. p. 131.) In places of an opposite description, the in- fection of many individuals together might be explained by the operation of the same exciting causes upon them all, without any supposition of contagion. The characters which distinguish erysipe- las fromjjhlegmon are: 1. The inflammatory swelling, which takes place in the former, is not so elevated as in the latter, and is never plainly circum- scribed. 2. In most cases, the surface of the skin seems as if it were burnt. 3. The redness, though of a bright de- scription, disappears on pressure. 4. The sense of throbbing, and darting pain, attendant on phlegmon, is not obser- vable. 5. The inflamed part is free from ten- sion, and appears,as if it were affected with osdema, or rather with emphysema; only one can perceive no crepitation. It must not be inferred from these differ- ences, that erysipelas is to be considered as a disease essentially distinct from those, which are called inflammatory, as it has some characters in which it manifestly ap- proaches them. Like phlegmonous inflam- mations, it may be excited by any local irritation. Like other inflammations, it may end in suppuration, though of alessperfec< sort, than that in which phlegmon ends, and rarely contained in a circumscribed cavity. The pulse, in phlegmonous erysipelas, is frequent, hard, sometimes full; and when the patients are bled, their blood has the same appearance, and is covered with the same kind of inflammatory crust, as blood taken away in other kinds of inflammation. It is proper, however, to notice, that practitioners are not universally agreed with respect to the nature of the pulse in erysipe- las : it is, according to some, particularly Mr. Pearson, soft, frequent, and often irre- gular. But, if due attention be paid, this difference will be found to depend on parti- cular circumstances. In the phlegmonous erysipelas, the pulse will always be fuller than in the bilious. In the impure air of hospitals, and in all places, where the air is impregnated with carbonic acid gas, and other noxious gases, we find, that various affections decidedly inflammatory, espe- cially those which are attendant on wounds, affect the body, and the sanguiferous system in particular, in a very different manner from what is observed when the patients are living in a more salubrious air. All inflam- mations assume a character more or less unfavourable, in consequence of the in- fluence of bad air. This is particularly- striking in cases of erysipelas. In such in- stances, living in an impure atmosphere has a singular effect in augmenting the sense cm weakness and dejection, which patient-; always experience in a certain degree ; and, in these cases, it may even go so far as to produce a total alteration of the state of the pulse. But, if attention be paid to the dis- ease in a situation where the atmosphere is not impregnated with putrid effluvia, it will be found to put on a very different shape. The symptoms of dejection, of nervous irritation, and of cerebral disturbance, are much less conspicuous, and the state of the ulse, especially in patients who have not een previously debilitated by other dis eases, bears a great resemblance to that which takes place in an inflammation of the chest. Besides bad air,manyother circumstances, which do not even belong to the nature of erysipelas, may have a share in producing an alteration of its symptoms. Thus, while inflammations of another kind, such as pleu- risy and acute rheumatism, particularly affect robust persons, in whom the vital principle exists with a great deal of energy, erysipelas is prone to attack persons who are aged, or of delicate and depraved con- stitutions. The latter is also seen making its appearance a? a symptom, in weakened parts, which have in a certain degree been deprived of their tone, as is the case with oedematous parts. It is not surprising, that, in these different cases, in which tbe tone of the system has already suffered, the state of thepnbe. in persons affected with erv=: 154 ERYSIPELAS. pelas, should seem different from what it is in individuals, who are more healthy and ro- bust. Treatment of Erysipelas. The treatment of idiopathic erysipelas varies according to the causes, symptoms, complications, and anomalies ofthe disease, and may be divided into internal and exter- nal. That the mode of relief must be very different in phlegmonous erysipelas from what it is in other varieties of the disorder, must be plain to every body, who has the least knowledge pf the nature of diseases in ge- neral. Common casesof acute, or phlegmonous ery- sipelas, yield to mild purgatives, and a light v egetable diet, with which remedies practi- tioners usually conjoin diaphoretics and the saline mixture. Whether bleeding is right or not in tbis species of erysipelas, is a point, on which different sentiments prevail. I believe, however, that venesection in the milder forms of the complaint is now pretty generally allowed to he unnecessary, nor is it necessary to repeal bleeding in any case of erysipelas so frequently as isdone iu other in- flammatory diseases. We ought to be guided, however, in this respect, by tbe state of the pulse, and other symptoms, never forgetting the patient's age, strength, and other impor- tant considerations. Ca?teris paribus, the pa- tient will bear bleeding better in the coun- try, and in an open, pure air, than in a large city, and especially in an hospital. And, as has been truly remarked, unlets there be a considerable tendency to delirium, or ceiua, blood-letting can seldom be re- peated with advantage, at least in large towns. (Pearson's Principles of Surgery; Bateman's Synopsis, p. 132, Ed. 3.) Instead of this practice tbe latter author judiciously recommends local bleeding and blistering, but not upon, or very near the diseased surface, whereby he avoids producing the trouble- some sores, the frequency of which in former times, after taking blood from erysi- pelatous parts, led Mr. B. Bell to pronounce a general condemnation of the method. Alexander of Tralles, and Par6 had a high opinion of the beneficial effects of plenty "f fresh, cool air in cases of erysipelas, and the truth of this sentiment is acknowledged by all the best physicians and surgeons of the preset.t day. Care should be taken also, 'hat the patient be not covered with too much clothing; a piece of advice delivered by tbe first of the two preceding writers. Cullen, whose theories induced him to regard erysipelas as a species of putrid fever, combined with evacuants the use of bark, wine, and other antiseptics. Bui, as Dr. Bateman correctly observes, the adminis- tration of cinchona and opium, in cases of ftcute or phlegmonous erysipelas, is certainly unnecessary, and appears to be pf equivocal safety. In the bilious erysipelas, whatever degree of heat or fever might exist, Desault gave, ;rn ths first instance, a grain of tartarized antimony dissolved in a considerable quan- ity of fluid; and the symptoms generally diminished as soon as tbe effects of the me dicine had ceased. He had seen them en- tirely subside, although the medicine pro- duced no other sensible alteration, in the animal economy, than an increase of the insensible perspiration and urine: some- times the symptoms resisted these evacua- tions, and he was obliged to have recourse once or twice, or even more frequently, to the use of the emetic drink. When the erysipelas was cured, and the bitterness in the mouth and fever had subsided, two or three purges of cassia and manna, with a grain of emetic-tartar, were exhibited; du- ring the cure, the patient was ordered to drink freely of a diluting ptisan, acidulated with oxymel : and as soon as the symptoms were mitigated, the diet of the patient was allowed to be more nourishing and gene- rous; for, when it was too spare, the case was remarked never to proceed so favour- ably, particularly in hospitals, where the air, generally speaking, is unhealthy. In the bilious erysipelas, Desault obseived, that the cases of the patients, who had been bled previously to their admission into tbe hospital, were invariably the most serious and obstinate, particularly, when the bleeding had been frequently repeated In cases of bilious erysipelas, many mo- dern practitioners would be bolder with antimonials than Desault, first, by imitating Richter, and giving an emetic at the com- mencement of the attack, and then by ex- hibiting more freely either antimonial pow- der, or tartarized antimony, with a dose or two of calomel. In phlegmonous erysipelas, Desault was an advocate for bleeding in the beginning of the disorder, and, this practice he followed up by the administration of tartarized anti- mony and evacuants. In cases of idiopathic erysipelas, whether phlegmonous or bilious, external applications have been deemed useless, or hurtful, by a large proportion of practitioners, among whom is Desault. In the early stage of the disease, Dr. Bateman has found powdery substances, like flour, starch, chalk, &.c. in- crease the heat and irritation, and afterward when tbe fluid of the vesications oozes out, such substances produce additional irrita- tion, by forming w ith the concreting fluid hard crusts upon the tender surface. This practice is also condemned by Mr. Pearson. The only plan, perhaps, which is unobjec- tionable, as a means of allaying the irrita- tion produced by the discbarge from the vesication, is that advised by Dr. Willan, and which consists in fomenting, or washing the part3 from time to time with milk, bran and water, or a decoction of elder-flowers and poppy-heads. In the early stage of the inflammation, Dr. Bateman has found great relief derived from moderate tepid washing, or the application ofthe diluted liquor am- mon . acet. (Synopsis of Cutaneous Diseases, p. 133, Ed. 3 ) Though Desault forbids local remedies in cases of idiopathic erysipelas, he does net extend the prohibition to examr>!p<;. either ERYSIPELAS. 480 ci bilious or phlegmonous erysipelas, from a contusion, wound, or an ulcer; regimen and internal medicines, according to De- sault, here being insufficient, unless topical applications are employed to abate the lo- cal irritation, and excite suppuration. With this view, he commends cataplasms, but he deems one caution essential, viz. that the application of the poultice should not ex- tend much below the contused surface, or the edges of the wound. If any application is permitted on the rest ofthe erysipelatous surface, he tbinks,that it should be the liquor plumbi acetatisdilutis made weak. (Parisian Chirurg. Journ. Vol. 2.) Mr. Pearson prefers mild warm cata- plasms, composed of the powders of anni- seed, fennel, camomile flowers, &c. mixed with a fourth part, or an equal quantity, of bread, and a proper quantity of milk. Lin- seed powder, he says, may sometimes prove a convenient addition. Little more need be said, respecting the treatment of secondary, or symptomatic ery- sipelas. Generally less important than the other disease, with which it is associated, its management is quite subordinate to that of the latter affection. Thus, when erysipe- las makes its appearance round a wound, or ulcer, the practice only requires to be some- what modified according to the circumstan- ces, state, and nature of the injury, or sore. As for what is termed accidental erysipe- las, or that caused by casual local irritation, applied directly to the skin, as from acrid substances, heat, friction, the sting of in- sects, he. the removal of the cause, the em- ployment of cold, or even ice-cold lotions, and other antiphlogistic means, are tbe only measures essentially necessary. Cases of universal erysipelas have been successfully treated by warm-bathing, aperi- ent medicines, and small doses of the ace- tate of potassa. (Did. des Sciences Med. T. 13, p. 266.) In the azdemalous erysipelas, perhaps, bleeding is never admissible. The loss of even a very small quantity of blood may have the most fatal consequences. One should also be exceedingly sparing of other evacuations. A determination to the skin should in particular be kept up by antimo- nials, and irritation and pain soothed by ad- ministering tbe a?thersulphuricus, camphor, opium, he. When the disorder seems to shift its situation to- any internal part, and particularly to the brain, blisters should be applied between the shoulders, to tbe head or legs, without the least delay And, it is in the oedematous erysipelas more espe- cially, that the patient's strength should be supported by tonic remedies, wine, bark, and cordials. In casesof phlegmonous erysipelas, if the inflammation continues in an unabated form beyond the seventh, or eighth day, suppu- ration is to be apprehended. Here Boyer recommends the employment of emollient applications, and immediately a fluctuation i« rlMinsuishable for even what be terms " un empatement purulent") he advises the surgeon to make such incisions as may be necessary for the discharge of the matter. He also states, that the incisions should be made at several depending points. (See Boytr's Traiti des Maladies Chirurgicales, T. 2, p. 22.) It appears from the observations of Mr. A. C. Hutchison, late surgeon to the Naval Hospital at Deal, that seafaring men are veiy liable to phlegmonous erysipelas of the extremities, particularly of the legs. The cause is ascribed to the irritation of the salt water, and the friction of their loose coarse trowsers. In this description of pa- tients, the disease frequently proceeds ra- pidly to the gangrenous state, and the con- sequence is the loss of many lives and limbs. Even when the danger of mortification is avoided,abscesses often occur, which spread between the muscles and under the integu- ments to a surprising extent: " from the ankle to the trochanter, and over the glutaei muscles." In the first few cases, which came underthe care of Mr. Hutchison, this gentleman's plan of treatment, in addition to the usual medical means, consisted of lo- cal bleeding by means of cupping glasses, fol- low ed by fomentations. Subsequently, however, he adopted Ihe method of making several free incisions with a scalpel on the in- flamed surface, in a longitudinal direction, through the integuments, and down to the mm- cles, as early in the disease as possible, and be- fore any secretions have taken place. These incisions may be about an inch and a half in length, two or three inches apart, and vary in number from six to eighteen, according to the extent of surface which the disease is found to occupy. Mr. Hutchison states, that these incisions will yield between fif- teen and twenty ounces of blood, and give relief to the tense skin, at the same time that they form channels for the escape of fluid, and the prevention of bags of matter. Af- ter the operation, fomentations, or saturnine lotions, are employed. By the preceding kind of treatment Mr. Hutchison thinks the fatal termination of the disease may be rendered less frequent, and gangrenous mischief wholly prevented. He supports this assertion with observing, that he never lost a case in the Deal Hospi- tal for the last five years, during which the practice was followed. (See Med. Chir. Trans. Vol. 5, p. 278, fa.) On the proposal of this new treatment, I shall make very little comment, because I have never seen it tried. But, I shall ven- ture to state, that I have not much opinion of it. What.' are all the principles of sur- gery now so changed, and is the nature of the human body and constitution so altered, that inflamed parts are to be soothed by maiming and wounding them, or to use the author's words, by making " from six to eighteen incisions" in them ? I would beg leave to ask, whether from six to eighteen deep cuts down to the muscles could ever be made in an uninflamed part, without produ- cing inflammation ? It is to be remarked, however, thut formerly Mr Hutchison, be- 486 EXAi EXF tore his adoption of this plan, used to apply to the part affected cupping glasses, which every surgeon knows will often of them- selves irritate so much by their pressure, in- dependently of the scarifications, as to make the sound skin inflame, and sometimes slough. We must not wonder, therefore, that his early treatment of phlegmonous ery- sipelas did not answer. As we have mention- ed above, on the authority of Boyer and other eminent surgeons, incisions may undoubted- ly become necessary in erysipelas, but, not before there is matter to be discharged. When once its existence is ascertained, the employment of the knife cannot too speed- ily follow. With regard to the treatment of the gan- grenout erysipelas, nothing more need be said than what is contained in the article on mortification. Consult Desault's Parisian Chirurgical Journal, Vol. 2. Also CEuvrts C'.irurgicales de Desault par Bichat, T. 2, p. 681, fa. En- cyclopidie Mithodique, Partie Chirurgicale, art. Erysipile. Cullen's First Lines of the Practice of Physic, Vol.1. Pearson's Prin- ciple* of Surgery. Some Ports of Hunter's Treatise on the Blood, Inflammation, fa. Richerand, Nosogr. Chir. T. 1, p. 118, fa. Edit. 2. Lassus, Pathologic Chir. Tl,p. 8, fa. Edit. 1B09. Traiti des Maladies Chir. par M. le Baron Boyer, Tom. 2, p. 6, et seq. A. C. Hutchison in Med. Chir. Trans. Vol. 6, p. 278, fa. and Practical Obs. in Surgery, 1816. T. Bateman, A Practical Synopsis of Cutaneous Diseases, p. 125, 4"*- Ed. 3. Diet. des Sciences Med. Vol. 13, p. 253, fa. ERYTHEMA, (from tgi/659c, red.) A redness of any part. A mere rash or efflo- rescence, not accompanied by any swelling, vesication, or fever, circumstances whicb, according to Dr. Bateman, distinguish it from erysipelas. (Synopsis of Cutaneous Diseases,p. 119, Ed. 3.) Its six varieties are described in the latter work. For the ery- thema mercuriale, see Mercury. The term is often wrongly applied to eruptions, at- tended with redness, and distinct papular and vesicular elevation, as we see in the in- stance of mercurial erythema, which Dr. Bateman says should be named eczema. ESCHAR, (from tr^et^ou, to form a scab, or crust.) This term is applied to a dry crust, formed by a portion of the solids deprived of life. When any living part has been burnt by the actual, or potential cau- tery, all that has been submitted to the ac- tion of tbis application, loses its sensibility and vital principle, becomes bard, rough on the surface, and of a black, or gray colour, forming what is properly named an eschar, a slough, producedby caustics, or actual fire. ESCHAROTICS. (from t^ogoa, to form a crust over.) Applications, which form an eschar, or deaden the surface on which they are put. By escharotics,however, surgeons commonly understand the milder kinds of caustics, such a9 the hydrargyri nitrico-oxy- dum, subacetate of copper, he. EXiERESIS. (from t^euetu, to remove.) One. ofthe divisions of ctirgery adopted by the old surgeons ; the term implies the ie« moval of parts. EXCORIATION, (from excorio, to take off the skin.) A separation of the cuticle ; a soreness, merely affecting tbe surface of the skin. EXFOLIATION, (from exfolio, to cast the leaf.) The separation of a dead piece of bone from the living, is termed exfo- liation. One part of abone is never separated from another by the rotting ofthe dead part, for that which comes away is as firm as it ever was. Exfoliation takes place with most ex- pedition in bones, which have the fewest cells, and whose texture is the elosest. Be- fore any part of a bone can be thrown off by exfoliation, it must be dead. But, even then till the process of exfoliation begins, the bone adheres as strongly as ever, and would remain for years, before it could be separated by putrefaction alone. The hu- man bones are composed of two substances, viz. a true animal matter, and an earthy one, the phosphat of lime, which are only mixed with each other. A dead bone acts on the system, in the same manner, as any other extraneous body. It stimulates tbe adjacent living parts, in consequence of which, such a process is begun, as must terminate in its being thrown off. The effects of this sti- mulus are, first, thatthe living adjacent bone becomes more vascular ; a circumstance, which always takes place, when a part has more to do, than is just sufficient for the support of life. Secondly, that the earth ofthe living part, where it is in contact with the dead bone, is absorbed; and there the bone becomes softer, and adheres by its animal matter only. As Mr. Wilson lias stated, " before any mark of separation is seen on the surface, the living bone sur- rounding the dead, for the extent of a mere line, has become as soft as if it had been steeped in acid." (On the Skeleton and Diseases of the Bones, p. 281, 8vo. London, 1820.) Thirdly, that the living animal part is at last absorbed along the surface of con- tact : this part of the process commences, however, long before the last is finished; and both of them begin at the surface ; though, in their course, they do not every where take place in an equal degree at the same time. Fourthly, in proportion to the waste made by the last part of the process, granulations arise from the living surface, and fill up the intermediate space, so that there is no vacuum. These different stages together constitute ulceration. When any part of a bone is once loose, it is pushed to the surface in the same^. manner, as most other inanimate bodies would be, and this stage is partly mechanicaij"and partly a con- tinuation of ulceration. A proof of the third stage, above mentioned, may be deri- ved from cases, in which people die, while exfoliation is going on. A small groove, or worm-eaten canal, can then be discovered, which becomes gradually deeper, and fol- lows the irregularities of the living and dead surfaces. After the application of the tr«»- EXFOLIATION 4»> pan, a circular piece ot bone is frequently thrown off, which is always less than the space from which it came. This, as Mr. Hunter observed, would never be the case were there not a loss of substance. " Although (says Mr. Wilson) in general the absorption takes place in the living bone, it still appears, that, under peculiar circum- stances, the absorbing vessels have the pow- er of acting on and removing the substance of dead bone. This happens after the dead part has been separated from the living, and when from its shape, and the form of the living surrounding bone, it is prevented from obtaining a passage to the surface of the bo- dy ; as in exfoliations of the cranium, when the inner table of the exfoliated part is broader and wider than the outer table." ( 07i the Skeleton, fa. p. 282.) In very hard bones, the colour of the dead, exfoliating portion is generally white; but, in softer bones, it is yellow, dark, and sometimes black. ( Wilson, op. cit.) It was anciently believed, that whenever a bone was denuded, the exposed surface must necessarily exfoliate, and, this being taken for granted, the old surgeons used to put immediately in practice whatever they thought best calculated to bring on an exfo- liation as quickly as possible. For this pur- pose, the actual cautery was usually applied to the part of the bone which was uncover- ed, and as, under such treatment, a portion of tbe bone was of course killed, and then exfoliated, the prejudiced practitioner be- lieved, that he had only accelerated a pro- cess which must of necessity have followed in a more slow and tedious manner. According to Mr. Hunter, neither caus- tics nor the actual cautery hasten exfolia- tion ; they only produce death in a part of the bone, which is the first step towards ex- foliation, and if they ever hasten exfoliation, when the bone is already dead, it must be by producing inflammation in the adjacent living bone ; a change that makes it exert a power of which it was previously incapable. Exfoliation is not a necessary conse- quence of a bone being laid bare, and depri- ved of its periosteum. If the bone be in other respects uninjured, healthy,and enjoy- ing a vigorous circulation of blood through its texture, granulations will Le generated on the surface of such bone, which will co- ver and firmly adhere to it, without the smallest exfoliation being thrown off, espe- cially in young subjects. But if caustic, sti- mulating, or drying applications be made use of, or the bone be left for a considerable time exposed, the circulation in the superfi- cial portion of it will necessarily be disturb- ed and destroyed, and that part of the sur- face, through vvhich the circulation ceases to be carried on, will be separated and cast off by the process of exfoliation. If any application to an exfoliating por- tion of bone be at all efficacious, it must be one which will stop the mortification in the affected bone, and promote the absorption of those particles of phosphate of lime, •loch form the connexion between that which is living and that which is actually dead. And as the bone dies from the same causes as the soft parts mortify, we should at least follow in practice the same princi- ples which we adopt in the latter instance ; and though, from the inferior vascularity, and vital power of bones, we cannot expect surgery to have as much control over their affections as over those of the soft parts, yet every good will thus be obtained whicb it is possible to acquire. Attention to such prin- ciples will at least teach us to refrain from making the death of part of a bone more ex- tensive than it would be, if the cautery, caustics, and strong astringents, were not employed. The best mode of attempting to prevent an exfoliation from occurring at all in a bone that has been exposed by a wound, is to cover the part again, as soon as possible, with the flesh, which has been detached from it. This, as I shall hereafter notice, (see Head, Injuries of,) may generally be practised with advantage, when the scalp has been detached from the cranium, pro- vided the flap have still even the most limit- ed connexion with the rest of the integu- ments. When the exposed bone cannot be cover- ed, it shouhl be dressed with the mildest artd simplest applications, with plain lint, or lint spread with the unguentum cetaceum. Tbe dead pieces of bone, when very tedi- ous in exfoliating, when wedged in the sub- stance of the surrounding living bone, and when so situated as to admit of being safely sawn, or cut away, may sometimes be ad- vantageously removed in this manner. (See Caries and Necrosis.) In such operations, Mr. Hey's saws may be employed with great convenience ; and where these are not ap- plicable, that invented by Mr. Machell, and described in Mr. A. Cooper's Surgical Essays, or another devised by Graefe, and explained by Schwalb (De Serru Orbiculari, 4to. Berol- 1819,) deserve to be recollected. In speaking of necrosis, I shall have occa- sion to notice the efficacy of blisters, kept open with the'savin cerate, in quickening the process by which dead portions of bone are loosened, as particular!v pointed out by the late Mr. Crowther, in his work on the white swelling. Tenon published three Memoirs on the Exfo- liation of Bones. The two first are inserted at pages 372, and 403 Mem. de I'Acad. des Sciences, 1758 ; the ihird at p. 223 of the same Work, for 1760. P. Poissonier, An recenti vulnere nudatis ossibus exfoliatis ? conclusio negans, 4to. Parisii, 1760. Journ. de Mid. par M. Roux, T. 31, p. 801, T 32, p. 181, T. 33, p 168, T 36, p. 537, T 38, p. 153, T. 39, p. 432. Theden, Neue Bermerkungen, fa. kap. 3, 8vo. Berlin, 1782. Trans, for the Jm- provement of Med. and Chir. Knowledge, Vol. 2, p. 277, fa. Wiedman in his excellent. book, entitled " De Necrosi Ossium," has gi- ven an account of the various opinions of se- veral distinguished writers, concerning the way in which a dead portion of bone is sepa- ro'rd from the living part:. and he has refu- 4&b EXOPHTHALMIA ted many erroneous doctrines set up by Hippo- crates, Van Swieten, B. Bell, fa. See p. 23, et seq. op. cit. Did. des Sciences Mid. art- Exfoliation. J. Thompson's Lectures on In- flammation, p. 394, 398. P. Boulay sur VExfoliation des Os, 41 o. Paris, 1814. J. Wilson on the Structure and Physiology of the Skeleton, and on the Diseases of the Bones, fa. p. 230, 4-c. 8vo ' Lond. 1820. EXOMPHALOS. (from i£ out of, and tj* EXOPHTHALMIA. trusion is occasioned. Suppuration and ridge of the os froiuis gone, as well as the fungous tumours in the antrum must be exophthalmia, and derangement of vision. treated according to directions lard down in Some sharp bony irregularities, however, the article Antrum. After the cure of such could now be most plainly felt, projecting diseases, the antrum is often reduced to its in front of the diminished swelling. natural dimensions, and in this circumstance, In a lute publication, a memorable case of the orbit may become so wide, that the eye- exophthalmia is related by Mr. Travers : the ball will return into it again. Should this globe of the eye appears to have been gra- not happen, the extirpation of the organ will dually forced upwards and outwards, and to be proper. The induration and swelling of have had its motions considerably impeded, the cellular-substance in the orbit, may in consequence of the orbit being partly oc- be sometimes dispersed by means of mer- cupied by two swellings, which were of the cury.—(Louis, sur Plusieurs Maladies du nature ofthe aneurism by anastomosis.—(See Globe dc I'CEil, in Mim. del'Acad. Royale de Aneurism.) The swellings could uot have Chirurgie, T. 13, Ed. 12mo.) When such been removed, without at the same time ex- treatment fails, we are recommended to ex- tirpating the eye. Mr. Travers was there- tirpatetheeye. (RichterAnfangsgr. der Wun- fore induced to try, whether applying a li- darzn, B. 3, p. 413.) Exostoses, situated in gat tire to the carotid artery would have the the anterior part ofthe orbit, may some- effect of checking and curing the disease; rimes be removed. Tbe continental sur- an expectation, which was warranted by geons generally advise us to expose the tu- analogous instances, in which the growth of mour by an incision, and to apply caustic, swellings, and their dispersion, are brought or the actual cautery to it, in order to kill about by lessening the quantity of blood de- the protuberant part ofthe bone, and make termined to them. The experiment corn- it exfoliate. In this eountry, most practi- pletely succeeded ; the swellings in the vi- tioners would prefer the employment of cut- cinity of the eye subsided ; the patient was ting instruments for removing such exosto- freed from several grievous complaints, to ses. When,however,thetumourliesdeep!y which she had been previously subject; and in the orbit, it ennnot be got at, and if it among other benefits, a cure of the exoph- should resist the effect of mercurial medi- thalmia was one result, which most interests cines and mezereon, we are directed to ex- us in the present place. The case is also tirpate the eye. (Richter op. et loco cit.) highly important on other accounts, and Abscesses in the orbit ought to be opened, more particularly, as confirming the fact, and after this has been done, the eye gene- that the carotid artery may he tied, without rally returns into its proper position. (Pel- any dangerous effects on the brain, and as licr.) When encysted tumours in the orbit proving, that in cases of aneurism, the sur- admit of being extirpated in the customary geon should not be afraid of proceeding to manner, the plan should be adopted ; but, such an operation. (See Med. Chir. Trans. when this cannot be done, Richter's advice Vol. 2, Art. 1.) The judgment and decision, may be followed, which is to open them, with which Mr. Travers acted in this case, press out the contained matter, and after- appear to me highly meritorious. ward extract the cyst. Considerable diffi- The carotid artery has also been tied by culty, however, frequently attends every Mr. Dalrymple, surgeon at Norwich, in a effort to remove the whole cyst, and unless case very similar to the preceding, and with this be done, a permanent cicatrization can- equal success. (See Med. Chir. Trans. Vol. not be expected. (See Tracer's Synopsis, 6,p. Ill, fa.) P- 225.) ^ When the causes of exophthalmia have On account of the vicinity of the brain, been removed, the eye must be put into its and the communication between the parts natural situation. If the organ has been within the orbit and the dura mater, the longdisplaced,thesurgeon often finds the ful- extirpation of tumours from that cavity is filment of this indication attended with diffi- not exempt from risk of fatal consequences, culty. Indeed, he is frequently obliged to as two cases recently published by Langen- employ methodical bandages forthe purpose beck, fully prove. (JV'eue Bibl. B. 2, p. 241 of promoting the gradual return of the eye —244.) A young lady was referred to Mr. into the orbit. Yet, even in such cases, the Lawrence and myself this spring, (1821,) by eyesight is often regained ; but, if this should Mr. Maul of Southampton, for advice, re- not happen spontaneously, stimulants and specting a tumour occupying the inner and tonics are to be tried. (See Amaurosis.) upper portion of the orbit, and attended with Fab. Ilildan centur. 6, obs. 1. Vander Wiel, a degree of exopthalamia, constant exacer- centur. 2 obs. 9. Paw, obs. anat. 23. Tulpius bation at the period of the menses, and oc- lib. 1, cap. 28. Hope, in Phil. Trans for casionally double vision. (See Diplopia.) 1744. Louis sur plusieurs Maladies du Globe We refrained from advising any immediate de I'CEil, fa. in Mim. de I'Acad. de Chirur- attempt at extirpation, the swelling being so gie, T. 13, in l2mo. Brocklesby, in Medical firm and immoveable, that the disease was Obs. and Inquiries, Vol. 4, p. 371. Wltite's suspected to be partly of a bony nature. Cases in Surgery, p. 131__135, fa. Warner's However, on seeing this case about a fort- , Crises in Surgery, p. 108. Edit. 3. Lassus night afterward, I was surprised to find the Pathologic Chir. T. 2, p. 144, Edit. 2. Riche- tumour not more than half its former size, rand, Nosogr. Chir T.2,p. 117, Edit. 2. Med and all the firm and (what was conceived to Chir. Trans. Vol.2, art. 1, Vol. 4, v. 316 be) b'"iy induration befow the superciliary end Vol. 6, p. 111. •&•<:. tt'-'i)er''s A.>' EXOSTOSIS 491 fangsgr. der Wundarzn. B. 3, p. 406, fa., Gott. 1795. The matter in this last Work forms the basis of the foregoing observntions. Langenbeck, Neue Bibl. B. 2. Petitbeau, in Journ. de Mid. par Corvisart, T 14. EXOSTOSIS. (From «£, out, and cj-mv, a bone.) An exostosis is a tumour formed by an exuberant growth of bony matter on the surface of a bone, or as Boyer says, it is formed by the more or less considerable en- largement of a part, or the whole of a bone. (Traiti des Mai. Chir. T. 3, p. 541.) If bones resemble the soft parts ofthe body in their structure, they must resemble them in their diseases, and of course be liable to various kinds of tumours. Nay, an extraor- dinary increase ofthe size and density of all the bones of an individual has been ob- served, which affection ought probaly also to be classed with the disease, to which sur- geons usually apply the term exostosis. The generality of writers, even the most modern, have admitted many diseases among exostoses, which ought to be considered in a very distinct light: I need only instance the spina ventosa. One division of exostoses is into true and false; the former being of a truly osseous consistence, the others being more or less hollow, spongy expansions of the bones, sometimes containing a quantity of fleshy, fungous matter within the shell ofthe disease. Periostoses, or mere thickenings of the pe- riosteum, are also classed among the false exostoses. (Did. des Sciences Med. T. 14, p. 218.) According to Mr. A. Cooper, exosto- ses have two diflerent seats: by periosteal exostosis, this author means an osseous de- position seated between the external sur- face of the bone, and the internal surface of the periosteum, and firmly adherent to both; by medullary exostosis, he signifies a similar formation originating in the medullary mem- brane, and cancellated structure of a bone. The same experienced surgeon makes two other general divisions of exostoses into the cartilaginous and fungous, the first being " preceded by the formation of cartilage, which forms the nidus for the ossific de- posit," while the second is a tumour softer than cartilage, yet firmer than fungus, in other parts of the body, containing spicula of bone, being of a malignant nature, and depending " upon a peculiar state of consti- tution and action of vessels." It is a disease similar to " fungus haematodes, but some- what modified by the structure of the part in vvhich it originates." (Surgical Essays, Part 1, p. 156 ) This last form of exostosis is probably the disease treated of in another part of this dictionary, under the title of Osteosarcoma. Exostoses differ very much in respect to size. Those of the cranium are generally small and circumscribed. Exceptions oc- cur, however, for we learn, that Sir Eve- rard Home removed a very large tumour, which had a bony base, and was situated on the head. (A. Cooper, Surgical Essays, Part I, p. 156.) The largest true exostoses met with are such as are formed upon the long bones. In the history of surgery may be found numerous case3 of enormous exosto- ses ; but it is worthy of notice, that these were nearly all of them of the species term- ed false, and many of them were situated in the jaw, the clavicle, or the extremities ofthe long bones. Observations of this kind are abundant in l'Historie de I'Acad. des Sciences; les Mem. de I'Acad. de Chir. ; the Sepulchrfctum Anatomicum ; the writings of Morgagni, he. (Did. des Sciences Med. T 14, p. 219.) The bones most frequently affected with exostosis, are those ofthe cranium, the low- er jaw, sternum, humerus, radius, ulna. bones of the carpus, and particularly the fe- mur, and tibia. There is, however, no bone of the body, which may not become the seat of this disease. It is not uncommon to find all the bones of the cranium affected with exostosis, and the ossa parietalia some- times an inch thick. According to Mr. A. Cooper, the exostosis, whicb forms between the outer table ofthe skull and the pericranium, is ofan extreme- ly hard consistence, and generally attended with little pain, while the J'ungous exostosis, springing from the diploe of the skull, is less firm, and more vascular. It is described as being of a malignant nature, making its way through the inner table, and occasion- ing disease of the dura mater, and fatal ef- fects on the brain. (Surgical Essays, Part I, p. 156.) Sometimes as Boyer remarks, the tumour is confined to a small part of the affected bone, composing a mass superadded to its surface, and of various shapes. Sometimes it rises insensibly, having no very distinct limits, and resembling a more or less regu- lar portion of a sphere. In some instances its figure is styloid, and it projects in a great- er or less degree. On other occasions, its base is rendered distinct by a pedicle, ox contraction, which varies in breadth and length in different cases. In particular in- stances, the exostosis, though limited to the surface of a bone, occupies the whole ex- tent of it. Thus, the whole external surface of one of the bones of the skull has been found occupied by an exostosis, while the cerebral surface ofthe same bone was in the natural slate. The whole circumference of the femur sometimes acquires an enormous size, at the same time that the medullary surface of the same boqf continues entirely unchanged. These are the periosteal exos- toses of Mr. Cooper. In other examples, on the contrary, ihe two surfaces and the whole thickness of the bone are deformed by an augmentation of bulk; and when this happens in a cylindrical bone, the medullary cavity is more or less reduced, or even to- tally obliterated. There are a few extreme- ly uncommon coses, in which the substance of a bone acquires great solidity, and a hard- ness compared to that of ivory, without any material increase of bulk. An exostosis rarely occupies the whole extent and thick- ness of a bone ; but when this happens in n EXOSTOSIS y lindrical bone, the articular surfaces gene- rally remain in their natural state. The structure and consistence of exosto- ses present great differences. Sometimes. especially when the tumour is not very large, and it is situated on the surface of a cylin- drical bone,one may trace with the eye the diverging of the osseous fibres, in the inter- space of which one would say, that there is deposited a new bony substanqg, the orga- nization of which is less distinct. Some- times the tumour is entirely cellular, and formed of a few broad laminae, intercepting extensive spaces, which are filled with mat- ter different from the medulla, and of va- rious quality. This case is denominated ihe laminated exostosis. Sometimes the enlar- ged portion of bone makes a sort of hollow sphere, with thick hard walls, and the cavi- ty of which is filled with fungous granula- tions more or less extensive and indolent. According to Boyer, this variety of tbe dis- ease differs essentially from osteosarcoma, notwithstanding external appearances. The case here alluded to, I conclude to be the aame as that vvhich Mr A.Cooper ha.* named the cartilaginous exostosis of the medullary membrane. "In this case, the shell of the bone becomes extremely expanded, or ra- ther the original shell is absorbed, and a new one deposited ; and within this ossified cavity, thus produced, a very large mass of cartilage is formed, elastic, firm,and fibious." It is not malignant, but often ends in a very extensive disease. (A. Cooper, Surgical Essays, Part l,p. 173.) In other instances, the tumour is perfectly solid, exceeding in consistence that of the hardest bones, and equalling that of ivory. Here, the surface is sometimes smooth, and like that of the bone in its natural state; sometimes irregular, full of little projections, and in some degree stalactitical. It is very uncommon to find a large portion of an exostosis converted into a pultaceous sub- stance ; but it is not at all unfrequent to see this substance composing part ofthe tumour. Lastly, it very often happens, that tbe same exostosis presents an assemblage ofthe ivory substance, and of the cellular laminat d sub- stance, the cavities of which are partly filled with a pultaceous matter, and partly with a sort of gelatinous substance When an exostosis is not very large, it hardly affects the surrounding soft parts; but when it has made considerable progress, the muscles become stretched and emacia- ted, the cellular substance is thickened, and, its layers being adherent together, a kind of confusion is produced among all the adja- cent parts. Exostoses not of considerable size may, however, seriously interrupt the functions of certain organs. The action of the flexor muscles of the leg has been known to be obstructed by an exostosis in the vi- cinity of the knee. A similar tumour aris- ing near the symphysis pubis need not be very large to impede considerably the func- tions ofthe urethra, as experience has pro- ved. An exostosis in the orbit has been known to displace the eye and destrov vi- sion. Lastly, exostoses, when situated neat- certain important organs, and of large size, may affect with different degrees of gravity tbe functions of these parts, as the brain, the the lungs, he. (See Boyer, Traiti des Mai. Chir. T. 3, p. 541—544.) Mr. A. Cooper has related a case, in which the eyes were pushed out of their sockets by two exostoses, which grew from the antra, and one of which destroyed the patient by making its way to the brain through the orbitar process ofthe os frontis. (Surgical Essays, Part 1, p. 167.) In one instance, reported by the same author, an exostosis from the sixth or seventh cervical vertebra abolished the pulse at the wrist, by pressing upon the subclavian artery. (P. 159.) In another, a cartilaginous exos- tosis of the medullary membrane of the lower jaw extended so far back that it press- ed the epiglottis down upon the rima glotti- dis, and caused such difficulty of respiration, aud so much irritation, that the patient was destroyed. (P. 175.) Venereal exostoses, or nodes, are observed to arise chiefly on compact bones, and such of these as are superficially covered with soft parts, as for instance, the bones of the cranium, and the front'surface ofthe tibia. The causes of exostosis do not seem to be at all understood. Most writers impute the disease to internal causes, such as scrofula and lues venerea. That the latter affection is the cause of nodes, which are certainly a species of exostosis, no one will deny ; but, that scrofula is ever concerned in producing any of the other kinds of exostosis must not be admitted, at least, before some evidence is adduced in supportof the doctrine. Boyer, however, and all the surgeons of the conti- nent adopt the opinion, that scrofula is sometimes a cause ofthe disease. Hydatids are occasionally found within exostoses, in which circumstance the former are supposed to be tbe cause of the enlarge- ment ofthe bone. A remarkable specimen of sneb a disease in the tibia is mentioned by Mr. A. Cooper. (Surgical Essays, Part 1, p. 163.) He refers also to a humerus, in the museum of St. Thomas's Hospital, where the shell of the bone is considerably expand- ed, the periosteum over it thickened, and in the seat ofthe cancellated structure,several hydatids, supposed to have been the cause of the enlargement ofthe exterior surface of the bone, as well as of the increase of its cavity. (Vol. cit.p. 161.) A most interest- ing case of a bony tumour on the forehead, containing hydatids, has likewise been re- cently published by Mr. R. Keate. (jlfetf. Chir. Trans. Vol. 10, p. 278.) The ease with which bony tumours form in some persons, is a curious and remarka- ble fact, and renders it probable, that con- stitutional causes here have great influence Thus, such a blow, as in the generality of persons, would hardly excite notice, will, in others, bring on swellings of the bone, which is struck. Mr. A. Cooper adverts to a young friend of his, in whom an exostosis, which wns undoubtedly rau^d by a blow, EXOSTOSIS 493 is growing on the metacarpal bone of the little finger, (loc. cit.) I remember, that Mr. Abernethy mentions, in his lectures, bis having seen a boy from Cornwall, who was so excessively afflicted with an apparent predisposition to exostoses or an exuberant deposition of bony matter, that a very tri- fling blow would occasion a bony swelling on any bone of his body. His ligainentum nuchae was ossified, and prevented the mo- tion of bis neck ; the margins of his axilla; were also ossified, so that he was, as it were, completely pinioned. Besides all this, the subjectin question had numerous other exos- toses on various parts of his body. Mr. Abernethy gave, in this case, muriatic and acet:c acids, with a view of dissolving the lime, which this gentleman thought might be too abundant in the system ; but, even if this theory had been correct, and the acids capable ofthe chymical action in- tended, after passing into the circulation, how could they be expected to dissolve only the redundant depositions of [ihosphat of lime, and at Ihe same time leave the skeleton itself undissolved ? When an exostosis depends upon lues venerea, it is almost always preceded by an acute pain, which in the beginning ex- tends to nearly the whole of the affected bone, but afterward becomes fixed to the point where the exostosis forms, and it is most severe in the night-time. When an exostosis is caused by scrofula, says Boyer, the pain is duller, or rather it is quite incon- siderable. It is the same vvitn V e exostosis, which succeeds a blow, or contusion, with- out any manifest general cause. In the lat- ter example, the pain immediately excited by the accident subsides in a few days, and the swelling occurs so slowly, that no notice is taken of it till it has attained some mag- nitude. (Traili des Mai. Chir. T. 3, /.. 545.) An exostosis constantly feels hard ; but its size is various, and it may be indolent, or painful. By these signs, and its firm adhe- sion to the bones, it may be always distin- guished from other tumours. Some exosto- ses cannot be ascertained before death. Such was the case in which the parietal bone was found, after death, to be three times thicker than natural. Such also was the example related in the memoirs of the Academy at Dijon, in which a person died from an exostosis on tbe internal side ofthe os pubis, which tumour prevented the dis- charge ofthe urine, or the introduction of a catheter, by its pressure on the neck ofthe bladder. Exostoses may be either acute or chronic, in their progress. In the first case, which, according to Boyer, happens most common- ly iu the cellular exostosis, described by authors under the name of laminated, the appearance and formation of the tumour are quick ; the swelling rapidly acquires a considerable size ; and it is always preceded by, and accompanied with, continual violent pain, which the external and internal use of opium has little effect upon, and the inten- sify of which is not increased by pressure The pain is sometimes so severe that it occa- sions a good deal of symptomatic fever. Beyer, who seems not to be aware of the origin of what he terms the cellular, and what Mr. A. Cooper has named fungous ex- ostosis, from the medullary membrane, finds difficulty in accounting for (he rapid growth, and ^reat sensibility of ihe tumour, consider- ing (he natural density of ihe bones, and the little energv ot their vital properties. In thi haidest kinds of exostosis, says Boyer, the tumour is preceded by no pain, or, if any, it is very slight ; the tumour grows slowly , and, although it sometimes attains a considerable size, its increase is attended with no particular sensibility, and no disturbance of th- animal economy. (Boyer, op. cit. T. 3, p. 546.) On, ignorance of the pathology of exosto- ses, particularly their causes, accounts for tbe imperfection ot our trealmeut of them. With the except ion of the venerealexostosis,or node, there is no species of this affection, for which it can be said, that we have any one medicine of efficacy. Buyer, and other writers on tbe diseases of the hones, seem to regard some exostoses us a perfectly inorganic mass of lime, and, consequently tiny entertain no idea, that the ab-orbent vessels can possibly take away the panicles of the tumour, just us the secreting arteries have laid them down. Such writers, however, are well aware, that nodes are ca- pable of being diminished, and this can only be effected by tbe action of the absorbent systun. Boyer does acknowledge, indeed, that he has s indeed, equally, and, with regard loethe eye, more formidable and fatal, than cancer, but distinguished from it by peculiar characters, which not being confined to age. sex. or part 49£ EVE of the body, auatKs the eyeball both of the infant and adult. (Scarpa, Trans, by Briggs, P. 502. Ed. 2.) According to Scarpa, and indeed, the sentiments of several other surgeons of the present day, cancer is always preceded by scirrhus, or a morbid induration of the part affected. As tbe disorganization increases in this hard scirrhous substance, an icho- rous fluid is formed in cells within it, and afterward extends towards the external surface of the tumour, causing ulceration ofthe investing parts. The compact, and apparently fibrous mass is then converted into a malignant fungous ulcer, of a livid, or cineritious colour, with edges everted, and irregularly excavated, and with a dis- cbarge of acrid, offensive sanies. The schirrus, composing the base of the malig- nant fungus, instead of increasing in size, now rather diminishes, but retains all its original hardness, and, after rising a certain way above tbe ulcerated surface, is de- stroyed at various points by the same ulce- rated process, from which it originated. And, if any part of the livid fungous sore seem disposed to heal, it is a deceitful ap- pearance, as, in a little time, the smooth points are again attacked by ulceration. To relate in this place all the differences between cancer and fungus haematodes of (he eye, would be superfluous, as the sub- ject is considered in a future article (See Fungus Hamalodes;) but, I may briefly ad- vert to a few remarkable points of diversity; 1st. The primary origin of fungus hasma- todes is generally in the retina, especially, that point at which the optic nerve enters the cavity of the eye. 2dly. True cancer ofthe eyeball, when it begins on any part ofthe organ itself, instead of commencing as fungus haematodes at the deepest part of the eye, originates on its surface in the con- junctiva; and, as far as present evidence extends, if we except the lachrymal gland, this membrane is the only texture, connect- ed with the eye, ever primarily affected with carcinoma. (Scarpa on Diseases of the Eye, p. 526, Ed. 2 ; and Travers, Synopsis of the Diseases of the Eye, P. 99.) 3dly. Cancer of the eye, as Scarpa truly observes, is less destructive than fungus htematodes, and that for two important reasons. In the first place, because carcinoma begins on the exterior parts of the eye, so that whatever relates to the origin and formation of the disease is open to observation ; and se- condly, because the cancerous fungus of the eye, on its first appearance, is not actu- ally malignant, but becomes so in process of time, or from improper treatment, pre- viously to which period goed surgery may be employed with effect. In this light, Scarpa views many excrescences on the conjunctiva and anterior hemisphere ofthe eye, which appear in consequence of a straphyloma of the cornea, long exposed to the air and ulceration ; those which arise from relaxation and chronic inflammation ofthe conjunctiva ; from ulceration of the cornea, neglected or improperly treated ; from violent ophthalmy, not of a contagion* nature, treated in the acute stage with astringent and irritating applications ; from suppuration of the eye, rupture ofthe cor- nea, and wasting of the eyeball; or from blows, or burns on the part. Nothing, says Scarpa, is more probable, than that all these ulcerated fungi were, on their first appearance, not of malignant character, or certainly not cancerous, and that many of them were not actually so at the time of a successful operation being done. Now, in the opinion ofthe same valuable author, there is no criterion as yet known of the precise time, when a sarcoma of the eye changes from tbe state of a common ulcerated fungus to that of carcinoma ; for, the exquisite sensibility, darting pains, ra- pidity of growth, colour, and ichorous dis- charge, are not an adequate proof of can • cer. The symptom, however, on which he is inclined to place the greatest dependence, as a mark of the change in question, is the almost cartilaginous hardness of the malig- nant ulcerated fungus, which induration, he asserts, is not met with in the benign fun- gus, and never fails to precede the forma- tion of cancer. (See Scarpa on the Eye, Transl. by Briggs, Ed. 2, p. 511—513.) 4thly. The last difference of fungus hav malodes from cancer of the eye, here to be noticed, is the pulpy softness of the whole of the diseased mass, in the first of these diseases ; a character completely opposite to the firm, almost cartilaginous consistence of the carcinomatous fungus. Before describing the operation of remo- ving an eye, affected with malignant disease, the following corollaries, drawn by Scarpa, should be recollected. 1. The complete extirpation of the eye, for the cure of fun- gus haematodes, although performed on the first appearance of the disease under the form of a yellowish spot, deeply seated in the eye, is useless, and rather accelerates the death of the patient. 2. The exterior fungous excrescence of the eye, commonly called carcinoma, be- ginning on the conjunctiva, and anterior hemisphere, while it is soft, flexible, and pulpy, although accompanied with symp- toms, similar to those of carcinoma, is not actually this disease, nor does it become malignant, and strictly cancerous, until it is rigid, hard, coriaceous,v>arty, and, hi every respect, scirrhous. 3. The inveterate fungous excrescence, hard to the touch in all its parts, covered with ulcerated warts, which has involved the whole ofthe eyeball, optic nerve, and sur- rounding parts, and rendered the bones of the orbit carious, and contaminated the lymphatic glands behind the angle of the jaw, and, in the neck, is incurable. 4. On the contrary, the partial, or total extirpation of tbe eye will succeed, when attempted before the external fungous ex- crescence has changed from the state of soft- ness to that of a scirrhous, warty, and carci- nomatous hardness. (Vol. cit. p. 626.) The operation of removing the eye wa« first performed in the sixteenth century by Bartisch, a German practitioner, who employed a coarsely constructed instru- ment, shaped like a spoon, with cutting edges, and by means of which the eye was separated from the surrounding parts, and taken out of the orbit. This instrument wustoo broad to admit of ready introduc- tion to the deep contracted part of the orbit, so that, when it was used, either a part of the disease was likely to be left behind, or the thin bones of the orbit to be fractured in the attempt to pass it more deeply into that cavity. Fabricius Hildanus became acquainted with these inconveniences by experience, and, in order to avoid them, devised a sort of probe-pointed bistoury ; a better instrument, but not free from ob- jections, and forgotten for near a century afterward ; surgeons continuing to use sometimes the cutting spoon, sometimes various kinds of hooks. Muys, Bartholine, &c. afford examples of operations so per- formed. Bidloo made use of scissors, and a pointed bistoury. A lancet seemed to Lavauguyon sufficient for extirpating the eye, and he is the first French surgeon who has spoken of this operation. All the surgeons of that coun- try considered the operation as useless, cruel, and danger us, until St. Ives men- tioned, that he had done it with success. Heister preferred operating with the bis- toury alone. Several English surgeons have used a sort of curved knife, an engra- ving of wrhich is given in B. Bell's system ; but, in dissecting the tumour, this instru- ment was regarded by Louis as less conve- nient than a straight bistoury. Thus far the plans of operating, advised by authors, were not guided by any fixed rules. Louis endeavoured to lay down such rules, and for n long while his method was mostly adopted in France. It consists in dividing the attachments of the eye to the eyelids ; then those ofthe small oblique muscle ; next, those of the great oblique muscle ; then those of the levator palpe- bral superioris, varying, according to their insertions, the manner of holding the knife. The eyeball is afterward detached, and the four straight muscle3, and optic nerve, di- vided with a pair of scissors. This way of" operating, founded upon ana- tomical principles, seems at first glimpse to offer a method, in whicb, as Louis re- marks, each stroke ofthe instrument is gui- ded by the knowledge of the parts. But, it is to be noticed, that these parts, being altered by disease, most commonly do not present the same structure and relations, which they do in the natural state; and (hat the flattened, lacerated, destroyed muscles, on their being confused with the eye itself, cannot serve, as in lithotomy, for the foun- dation of any precept relative to the opera- tion. Besides, why use both tbe knife and scissors ? The latter instrument is obviously useless, though Louis seems to think the operation cannot be done without it. The jnclinntion ofthe outer side ofthe orbit will E. 495 always allow a bistoury to be carried to the bottom of this cavity, so as to divide from above downwards, the optic nerve, and muscular attachments. Guided by the above principles, Desault, after having practised, and taught the me- thod of Louis, returned to Heister's advice, who directs only a bistoury to be employed. To have an exact idea of the mode of ope- rating, vvhich is always easy and simple with this one instrument, we must suppose the carcinoma to be in three different states. 1. When the tumour hardly pro- jects out of the orbit, so that the eyelids are free. 2. When it is much larger, pro- jects considerably forward, and pushes in this direction the healthy eyelids, which are in contact with it, together with a portion ofthe conjunctiva, vvhich invests them, and is now detached from them. 3. When, in a much more advanced period, the eyelids participate in the cancerous state. In the first case, the eyelids must be separated from the eye, by cutting through the con- junctiva, where it turns to be reflected over the globe of the eye. In the second In- stance, the eyelids and conjunctiva, vvhich are in contact with the diseased eye, must be dissected from it. In the third, these parts must be cut away, together with the eye. (tEuores Chir. de Desault, T. 2.) After the above observations, and the additional information on the subject con- tained in the 1st vol. of the 4th Edition of the First Lines of the Practice of Surgery, I shall conclude this article with a few brief directions. When the eyeball is exceedingly enlar- ged, it is necessary to divide the eyelids at the external angle, in order to facilitate the operation. The surgeon can in general operate most conveniently when he em- ploys a common dissecting knife,and when his patient is lying down with his face ex- posed to a good light. In cutting out a dis- eased eye, it is necessary to draw the part forwards, regularly as its surrounding at- tachments are divided, in order that its connexions, which are still more deeply situated, may be reached with the knife" This object cannot be very well accom- plished with the fingers, or forceps, and_, therefore, most surgicul writers recommend us, either to introduce a ligature through the front of the tumour, (see Travers, Sy- nopsis, p. 308.) or to employ a hook, for the purpose of drawing the part in any direc- tion, during the operation, vvhich the ne- cessary proceedings may require. When the eyelids are diseased, they must be re- moved ; but, if prudence sanctions their being preserved, this is an immense advan- tage. The eye must not be drawn out too forcibly, before the optic nerve is divided, and care must be taken not to penetrate any of the foramina, or thin parts of the orbit, wilh the point of the knife, for fear of injuring the brain. Great care should also be taken to leave no diseased parts behind, in the orbit. The hemorrhage mav be stopped by filling the orbit with «rr»U( d FEVERS lint, and applying a compress and bandage. It is constantly adviseable to remove the lachrymal gland, as this part seems to be particularly apt to be the source of such inveterate fungous diseases, as too often follow the operation. Mr. Travers, with a straight double-edged knife, freely divides the conjunctiva and oblique muscles, so as to separate the eye- ball and lachrymal gland from the base of the orbit. Drawing the eye then gently forwards with the ligature, he introduces a double-edged knife, " curved breadthwise" at the temporal commissure of the lids, for the purpose of dividing the muscles, vessels, and nerves, by which the globe remains at- tached. The hemorrhage he represses with a small bit of fine sponge put into the or- bit, and a light compress, applied over the eyelids, and supported with a bandage. The sponge, he says, should not be suffered to remain longer than the following day, when a soft poultice in a muslin bag may be substituted for the compress. He ap- proves of giving an opiate at bed-time, and joins the late Mr. Ware in condemning the practice of cramming the orbit with lint, or charpie, and leaving it to be discharged by suppuration. (Synopsis of the Diseases of the Eye, p. 308.) For a few days after the operation, anti- phlogistic treatment is proper. Sometimes fungous granulations continually form in the orbit, notwithstanding they are repeatedly destroyed; and sometimes the disease in the orbit extends even to the brain, and pro- duces fatal consequences. When malignant fungous excrescences grow from the cornea alone, it is clearly unnecessary to extirpate the whole eyeball. For information relating to the subjects of this article, consult particularly Mimoire sur plusieurs Maladies du Globe de I'CEit; ou I'on examine particulierement les cas qui "rigent I'rxtirpation de eel organe, et la Me- thode d'y proctder; par M. Louis, in Mim. de I'Acad. de Chirurgie, Tom. 13, p. 262, Edit. in \2mo. C. F. Kultchmcid, Programma de oculo ulcere canccroso laborante ftliciter extir- pato, fa. Jena. 1748. J. G. G. Voit, Oculi Humani Anatomia et Pathulogia ejus demque in statu morboso Extirpatio, 8to. Norimb. 1810. Bertrandi, Traiti de* Opirations de Chirurgie, p. 519, Edit. 1784, Paris. Saba- tier, de la Midecine Opiratoire, Tom. 3, p. 64, Edit. 1. Richter. Anfangsgr. der Wumiare. B. 3 p. 415 Gott. 1795. Mimoire sur ('Ex- tirpation de I'CEil <. arcinomatoux in tAEuvres Chir. de Desault par Bichat, T. 2, p. 102. Richerand, Nosographie Chir. T. 2. p. 103, fa. Edit. 2 Ware, in Trans, ofthe Medical Society of London, Vol. I,part 1 p. 140, fa. Lassus, Pathalogie Chir. T. 1, p. 450. Edit. 1809. Wardrop on Fungus Hamotodes, p. 93, fa. Scarpa on the principal Diseases of the Eye, chap. 21, Ed. 2, transl. by Briggs, Svo. Lond. 1818. B. Travers, A. Synopsis of ,the Diseases of the Eye, Sec. 4, 8vo. Lond. 1820.' EYE, DISEASES OF. See Amaurosis ; Cataract; Cornea; Encanthis; Exophthal- mia ; Fungus Ha mat odes ; Gutla Serena; Hemeralopia; Iris; Hydropthalmia ; Hy- popium ; Leucoma ; Nyctalopia ; Ophthalmy ; Pterygium ; Pupil, Closure of; Staphyloma, fa. fa. EYELIDS, DISEASES OF. See Ectro- pium ; Lagophthalmus; Hordeolum; Pto- sis; Trichiasis; and Tumours Encysted. In the examination ofthe interior of the upper eyelid, a modern very convenient plan is now pursued, which is to evert the part over a probe, which is to be placed just across the upper edge of the cartilage of the tarsus, which is then to be suddenly inclined out- wards when the whole inner surface of the lid will be exposed, the part continuing in this everted^ state until replaced by the sur- geon. F. F, EVERS, SURGICAL. Under this head may be comprehended two species of fever, viz. tbe inflammatory and the hectic, which are particularly interesting to surgeons, be- cause frequently attendant on surgical dis- orders. In treating of inflammation, I have men- tioned, that a febrile disturbance of the con- stitution is attendant on every considerable inflammation. In the present article, some account will be offered of the particulars of this disorder. The fever about to be described is known and distinguished by several names; some calling it inflammatory ; some symptomatic ; and others sympathetic. It is sometimes idio- pathic ; that is to say, it occasionally origi- nates at the same time with the local inflam- mation, and fiom the same causes. (Burns.) Jn other instances, and indeed we mav sav in all ordinary surgical cases, it is symptoma tic ; or, in other words, it is produced, not directly by the causes which originally pro- duced the inflammation,but in consequence of the sympathy of the whole constitution with the disturbed stale of a pait. The idiopathic inflammatory fever is said to be always preceded by chilliness. The symptomatic, or sympathetic inflammatory fever, sometimes takes place so quickly, in consequence of the violence of the exciting cause, or ofthe local inflammation, that no preceding coldness is observable. If, how- ever the local inflammation be more slowly induced, and consequently operate more gradually on the system, then the coldness is evidently perceived. The symptomatic fever, induced by scalding, or burning a part, is quickly produced, and we have very little time to attend to the earliest period of its formation. On the other hand, the sympto FEVERS. 501 matic fever, induced by wounds, is excited more slowly, and the period of its formation is longer. This fever is net produced, when the inflammation only affects parts in a slight degree ; but it makes its appearance if the local inflammation be considerable, or if it affect very sensible parts. (Burm.) The degree in which this fever is excited does not altogether depend upon the abso- lute quantity or violence of the inflamma- tion ; but in a great measure upon the de- gree of tbe local inflammatory action, com- pared with the natural power and action of the part affected. Parts in whicb the action is naturally low, are extremely painful when inflamed,and the system sympathizes greatly with them. Hence, the constitution is very much affected when tendons, bones, or liga- ments, are the parts inflamed. Severe in- flammation of alarge joint, every one knows, is apt to excite the most alarming, and even fatal derangement of the system. When very sensible parts are inflamed, as for in- stance the eye, the symptomatic fever is ge- nerally more considerable than it would be were it to arise from an equal quantity and degree of inflammation in a less sensible organ. In common parts, as muscles, cellular membrane, skin, he. the symptoms will be acute; the pulse strong and full, and the more so if tbe inflammation be near the heart; but, perhaps not so quick as when the part is far from it. Ihe stomach will sym- pathize less, and (he blood will be pushed farther into tbe small vessels. (Hunter.) If the inflammation be in tendinous. ligamentous, or bony parts, Ihe symptoms wirt be less acute, the stomach will sympa- thize more, the pulse will not be so full, but perhaps quicker ; there will be more irritabi lity, and the Mood not being propelled so well into small vessels, it will forsake the , skin. (Hunter.) It seems to be a material circumstance, whether the inflammation is in the upper, or lower extremity ; that is. far from, or near the heart, for the symptoms are more violent, the constitution more affected, and tbe power of resolution less, when the part in- flamed is far from the source of the circula- tion, than when near it, even when the parts are similar, both in texture and use. (Hun- ter.) If the heart, or lungs, are inflamed, either immediately, or nffected secondarily, by sympathy, the disease has more violent ef- fects upon the constitution than the same quantity of inflammation would have if tbe part affected were not a vital one, or one with which the vital parts did not sympa- thize. If the part be such as the vital ones readily sympathize with, then the sympa thetic action of the latter will affect the con- stitution, as in an inflammation of the testi- cle. (Hunter.) In such cases, the pulse is much quicker and smaller, and the blood is more sizy than if the inflammation were in a common part, such as muscle, cellular membrane, and skin. (Hunter.) When the stomach is inflamed, the pa- tient feels an oppression and dejection through all the stages of the inflammation ; the pulse is generally low and quick, and the pain obtuse, strong, and oppressing; such as the patient can hardly bear. If the intestines are much affected, the same symp- toms take place, especially if the inflamma- tion be iu the upper part of the canal; but if only the colon be affected, the patient is more roused, an j the pulse is fuller than when the stomach alone is inflamed. When the uterus is inflamed, the pulse is extremely quick and low When the inflammation is either in the intestines, testicle, -or uterus, the stomach generally sympathizes. In in- flammation of the brain, the pulse varies more than in the same affection of any other part; and perhaps we must, in this instance, form a judgment of the complaint, more from other symptoms than the pulse. (Hunter.) When inflammation is situated in a part, not very essential to life, and occasions the ge- neral affection of the system, called inflam- matory lev er, the pulse is fuller and stronger than common, and the blood is pushed far- ther into the extreme arteries than when the inflammation is in a vital part. Tbe patient, after many occasional rigours, is at first rather roused. The pulse is as above described, wheu the constitution is strong and not irri- table ; but if this be extremely irritable and weak, as in many women who lead sedenta- ry lives, the pulse may be quick, hard, and small, at the commencement of the inflam- mation, just as if vital parts were concerned. The blood may also be sizy; but it will be loose and flat on the surface. (Hunter.) We may set down the ordinary symptoms of the inflammatory feverf occurring in con- sequence of local inflammation in common parts and in a healthy habit, as follows: Tbe pulse is frequent, full and strong; all the secretions are diminished ; the patient is vigilant and restless; the perspiration is obstructed, and the skin is hot and dry; the urine is high-coloured, and small in quan- tity; the mouth is parched, and the tongue furred ; an oppressive thirst is experienced; with disturbance of the ner1 ous system; loss of appetite and sleep; and in some cases, delirium. treatment of inflammatory fever. Up6n this part ofthe subject very little is to be said ; for as in almost every in-tance the febrile disturbance ofthe system is pro- duced, and entirely kept up by.the local in- flammation, it must be evident, that the means employed for dim uisbin- the exciting cause, are als>. the best for abating the con- stitutional effects. Hence it very seldom happens that any particular measures arc adopted expressly for the fever itself; as this affection is sure to subside in proportion as the local inflammation is lessened or resol- ved. But when the febrile disturbance is considerable, aud the inflammation itself is also considerable, the agitated state of the system may have in its turn a share in keep- US FEVERS- ing up, and even increasing the local affec- tion, and should be quieted as much as pos- sible. However, in these very instances, in all probability we should be led to a more rigorous adoption of the antiphlogistic plan of treatment, by an abstract consideration of the state of the local inflammation itself, without any reference to that of the consti- tution. Indeed the increased action of the heart and arteries, and the suppression of the secretions, require the employment of antiphlogistic means, and antimonials. the very same things which are indicated for the resolution of the local inflammation itself Bleeding, purging, cold drinks, low diet.; the exhibition of the antimonium tar- tarizatum, James's powder, or the common antimonial powder; and bathing the feet and body in warm water,are measures which have the greatest efficacy in tranquillizing the constitutional disturbance implied by the term inflammatory fever. But I think it right to repeat, that it is hardly ever neces- sary to have recourse to such an evacuation as general bleeding, merely on account of the fever; as this is only an effect vvhich in- variably subsides in proportion as the local cause is diminished. As Dr. Thomson has remarked, "the in- flammatory fever, succeeding to external injuries or to chirurgical operations, under- goes a kitid of natural crisis by the appear- ance of suppuration. In these instances therefore, unless when the patient is strong and in full health, when the disease is seat- ed in an organ of much importance to life, or is in danger of spre .ding, as is the case in all inflammations of the membranes lining the tbree great cavities of the body, the lan- cet ought to be used with caution. For we may, by too fret a detraction of blood, pro- duce a sudden sinking ofthe powers of life, and convert the existingconstitutional symp- toms into fever of a different type or cha- racter. But in all cases of inflammation, in which any doubt arises with regard to the farther general detraction of blood, it may, I believe, be laid down as a general rule, that it is safer to employ local than general blood- letting." (Lectures on Inflammation, p. 170.) hectic fever. The sympathetic, or symptomatic fever, al- ready described, is an immediate affection of the constitution, in consequence of some local disorder; hectic fever is a remote ef- fect. When hectic fever is a consequence of local disease, it has commonly been prece- ded by inflammation and suppuration ; but there is an inability to produce granulation and cicatrization : and the cure, of course, cannot be accomplished. The constitution may now be said to be oppressed with a local disease, or irritation, from which it cannot deliver itself. A distinction should be made between hectic fever, arising entirely from a focal complaint in a good constitution, which is only disturbed by too great an irritation, and hectic fever, arising principally from the badness of the constitution ; which docs not dispose the parts to heal. In the first species, it is only necessary to remove the part (if removeable,) and then all will do well; but in the second, nothing is gained by a remo- val ofthe part, unless the wound, made in the operation, is much less, and more easy put into a local method of cure; by reason of which, tbe constitution sinks less, under this state and the operation together, than under the former disease. Here the nicest discrimination is requisite. (Hunter.) Owing to a variety of circumstances, hec- tic fever comes on at very different periods after the inflammation, and commencement of suppuration. Some constitutions having less powers of resistance than others, must more easily fall into this state. Hectic fever takes its rise from a variety of causes, which have been divided into two species, with regard to diseased parts ; viz. parts called vital, and others not of this na- ture. Many of the causes of hectic fever, arising from diseases of the vital parts, would not produce this constitutional affection, if they were in any other part of the body; such, for instance, is the formation of tu- mours, either in. or so as to press upon, a vital part, or one whose functions are im- mediately connected with life. Scirrhi in the stomach, and mesenteric glands ; dis- eased lungs, liver, he. very soon produce hectic, fever. When hectic fever arises from adisease of apart that is not vital, it commences sooner or later, according as it is in the power of the part to heal, or continue the disease. If the part be far from the source of the circu- lation, the lever will come on sooner, with the same quantity of disease. When the disease is in parts which are not vital, and excites hectic fever, it is generally in situa- tions where so much mischief happens, as to affect the constitution, and where the powers of healing are little. This is the case with diseases of many of the joints. We must also include parts which have a tendency to such specific diseases, as are not readily cured in any situation. Although hectic fever commonly arises from some incurable local disease of a vital part, or of an extensive disease of a com- mon part, yet it is possiide for it to be an original disease in the constitution, without any local cause whatever, that we know of. Hectic is a slow mode of dissolution : the general symptoms are those of a low, or slow fever, attended with weakness. But there is rather weak action, than real weak- ness ; for upon the removal of the hectic cause, the action of strength is immediately produced, and every natural function is re- established, however much it may have been previou-ly impaired. The particu'ar symptoms are debility ; a small, quick, and sharp pulse; the blood forsakes the skin; loss of appetite ; frequent- ly, a rejection of all aliment from the sto- mach ; wasting; a great readiness to be thrown into sweats; spontaneous perspira- tions, when the patient is in bed ; pale-eo- FEVERS 503 loured, and very copious urine ; and often a constitutional purging. Hectic fever has been imputed to the ab- sorption of pus into the circulation ; but no doubt, much exaggeration has prevailed in the doctrine, which ascribes to this cause many of the bad symptoms, frequently at- tacking persons who have sores. When suppuration takes place in particular parts, especially vital ones, hectic fever almost constantly arises. It also attends many in- flammations before suppuration has actually happened, as in cases of white swelling of the large joints. The same quantity and species of inflammation and suppuration in any ofthe fleshy parts, especially such as are near the source of the circulation, have in general no such effect. Hence, in the first instances, the fever is only an effect on the system, produced by a local complaint, that has a peculiar property. The constitution sympathizes more rea- dily with diseases of vital organs, than with those of any other parts; their diseases are also in general more difficult of cure, than the same affections of parts, which are not vital. All diseases of bones, ligaments, and tendons, affect the constitution more rea- dily, than those of muscles, skin, cellular membrane, he. When the disease is in vital parts, and is such as not to kill, by its first constitutional effects, the system then becomes teazed with a complaint, which is disturbing the neces- sary actions of health. In the large joints, a disease continues to harass the constitution, by attacking parts which have no power, or rather, no disposition to produce salutary in- flammation and suppuration. Thus, the system is also irritated by the existence of an incurable disease. Such is the theory of the cause of hectic fever. If the absorption of matter always pro- duced the symptoms above described, how could any patient who has a large sore, pos- sibly escape hectic ; for there is no reason to suppose, that one sore can absorb more readily than another. If absorbed matter occasioned such violent effects as have been commonly ascribed to it, why does not ve- nereal matter do the same ? We often know that absorption is going on, by the progress of buboes. A large one, just on the point of bursting, has been known to be absorbed, in consequence of a few days' sea-sickness. The person continued at sea for four and twenty days afterward ; yet no hectic symp- toms followed, but only the specific consti- tutional effects, vvhich were of a very dif- ferent description. When the cavities of veins are inflamed, matter is sometimes formed within these ves- sels, and cannot fail to get into the circula- tion ; yet, hectic symptoms do not arise. Also very large collections of matter, pro- duced without visible inflammation, as many abscesses of the scrophulous kind, are wholly absorbed, in a very short time, but no bad symptoms are the consequence, (Hunter.) We may conclude, therefore, that the ab- sorption of pus has no share in occasioning hectic fever. Many arguments might be adduced to expose the absurdity of the doc- trine ; but, here it will be sufficient to re- fer the reader to what Mr. Hunter has sa^l farther on the subject, in his work on inflam- mation. It is much more probable, that hectic fever arises from the effect, which the irrita- tion of a vital organ, or other parts, such as joints, has on the constitution, when either incurable in themselves, or are so for a time to the constitution. (Hunter.) treatment of hectic fever. There is no method of curing the conse- quences above related. All relief must de- pend on the cure of the cause, (viz. the local complaint) or on its removal. Tonic medicines have been recommend- ed, on account of the evident existence of great debility. Antiseptics have also been given, in consequence ofthe idea that, when pus is absorbed, it makes the blood disposed to putrefy. For these reasons, bark and wine have been exhibited. In most cases, bark will only assist in supporting the con- stitution. Until the cause is removed, how- ever, there seems no prospect of curing a disorder of the constitution. It is true, to- nic medicines may make the system less susceptible of the disease, and also contri- bute to diminish the cause itself, by dispo- sing the local complaints to heal. When, however, the hectic fever arises from a spe- cific disease, such as the venereal, though bark may enable the constitution to bear the local affection better, than it otherwise could do, yet, this medicine can never re- move the syphylitic mischief. (Hunter.) No medicine, not even bark itself, has any direct power of communicating strength to the human constitution. All that can be done, in the treatment of hectic fever, when it is thought inexpedient, or impracticable, to remove the morbid part, is to combat particular symptoms, and to promote diges- tion. It is by bringing about the latter ob- ject that bark in these cases is useful. The infusion of cinchona being more likely to agree with the stomach, than the decoction, or powder, should generally be preferred. Nourishing food, easy of digestion, should bo frequently taken, in small quantities at a time. Nothing is more prejudicial to a weak constitution, than overloading the stomach Wine may also be given, but not too freely, and, not at all, if it should create heartburn, as it sometimes does in hectic patients. Madeira is less apt, than port, to have this disagreeable, effect. In these cases, it is likewise often found useful to adminis- ter gentle cordial aromatic draughts. But, of all medicines, opium is perhaps the most valuable to those who are afflicted with hectic fever ; it alleviates pain, procures sleep, and checks the diarrhoea, which so frequently contributes to hasten the patient's dissolution. When the local complaint,connected with 504 FINGERS. this fever, is totally incurable, it must, if possible, be remov- d by a manual operation. Thus, when a diseased joint keeps up hectic fever, and seems to present no hope of cure, amputation must be performed. But, when the local disease is attended with a chance of cure, provided the state of the constitu- tion were improved, the surgeon is to endea- vour to support the patient's strength. Great discretion, however, must be exercised, in deciding how long it is safe to oppose the influence of an obstinate local disease over the system, by the power of medicine ; for, although some patients, in an abject state of weakness, have been restored to health by a removal of the morbid part, many have been suffered to sink so low, that no future treatment could save them from the grave. Clemency in the practice of surgery does not consist so much in delaying strong and vigorous measures, as in boldly deciding to put them in execution, as soon as they are indicated. When hectic fever arises from local dis- eases in parts, which the constitution can bear the removal of. the morbid part should be taken away, if it cannot be cured, con- sistently with the advice already given. When the disease arises from some incurable disease in au extremity, and amputation is performed, all the aboveirentioned symp- toms generally cease, almost immediately after the removal of the limb. Thus, a hec- tic pulse, at one hundred and twenty, has been known to sink to ninety in a few hours after the removal of the hectic cause. Persons have, been known to sleep soundly the first night afterward, who had not slept tolerably for several preceding weeks. Cold sweats have stopped immediately, as well as those called colliquative. A purging has immediately ceased, and the urine begun to drop its sediment. (Hunter.) FICAIIO, or FICUS (a fig.) A tu- bercle about the anus, or pudenda, resem- bling a fig. FINGERS, ABSCESSES OF. See Whit- low. Fingers, Amputation of. See Amputation. Fingers, Necrosis of. In these cases, the surgeon is to endeavour to extract tbe ex- foliating portions of bone, immediately they become loose. For this purpose he is justi- fied in making such incisions, as will enable him to fulfil the object in view. Until the process of exfoliation is sufficiently advan- ced, he can do little more, than apply sim- ple dressings, and keep the part in a clean quiet state. When the separation ofthe dead pieces of bone will certainly destroy tbe utility of the finger, and convert the part into an in- convenient, stiff appendage to the hand ; or, when the patient's health is severely impair- ed by the irritation of the disease, the ter- mination of which cannot be expected, within a moderate space of time, amputa- tion is proper. It is a truth, however, that many fingers are amputated, which might be preserved, and surgeons ought to consi- der well, before presuming to remove parts, which, when curable, may become ol' the greatest consequence, in regard lo the per- fection of the head. The bread of many persons, it is well known, depends on the unmutilated state of certain fingers. These remarks are offered, because I have seen several surgeons, fond of sensing every op- portunity of cutting their fellow-creatures, remove fingers, which might have been usefully saved, either by allotting a little more time for the exfoliation or by making incisions, and cutting out the dead piece of bone. Fingers, Dislocations of. See Dislocation. Fingers, Fractures of. See Fracture. Fingers supernumerary. The instances of children born with a smaller number of fingers, than natural, are more rare, than cases in vvhich the number is greater, than usual. Of the latter malformation, exam- ples were noticed in times of great anti- quity. Thus, in the 1st Book of Chronicles is the following notice of such an occur- rence : " There was war at Gath, where was a man of great stature, whose fingers and toes were four and twenty, six on each hand, and six on each foot." (Chap. xx. Verse 6.) Ann Boleyn, so celebrated for ber beauty, and her misfortunes, had six fingers on her right had. Pliny, the natura- list, speaks of two sisters, who had six fingers upon each of their hands. In the Memoirs of the Royal Academy of Sciences for 1743, is the account of a child, which was shown at one of the meetings, andlhad six toes on each foot, and the same number of fingers on each hand. In each foot, there was six metatarsal bones, and the left band an equal number of metacarpal bones, but in the right hand, there were only five, the outer one of which had two articular surfaces, one for the little, and the other for the supernumerary finger. In the Copen- hagen Transactions, T. Bartholine has in- serted the description of a very curious skeleton: on the right hand, there were seven fingers; on the left six; and besides these circumstances, the thumb was double. On the right foo«, there were eight toes; on the left, nine ; the right metatarsus consisting of six bones; the left, of seven. Saviard speaks of a still more curious case : he saw a new-born infant at the Hotel Dieu at Paris; which had ten fingers on each hand, and ten toes on each foot : the phalanges seemed, as if they were all in a broken imperfect state. (Obs. de Chir.) The example of the greatest number of fingers and toes is re- corded by Voight; including the thumb, there were thirteen fingers on each band, and twelve toes on each foot (Mag. far dasneuste der Naturkunde, 3 B,p. 174.) In- dividuals are occasionally born with two thumbs, on the same hand. (Panarolus. Pentec. 3, Obs. Obs. 4—8.) Since allowing the redundant number of fingers to remain would keep up deformity, and create future inconvenience, the sur- geon is called upon to amputate them. The redundant fingers are sometimes with, some- times without a nail: are seldom more nu FIS F1S 505 tnerous than one upon each hand ; are gene- rally situated just on the outside of the little fingers; and, as fai as my observation ex- tends, are incapable of motion, in con- quence of not being furnished, like the rest ofthe fingers, with muscles. Ihe phalanges are also mostly imperfectly formed, or defi- cient. The best plan is to cut off supernu- merary fingers with a scalpel, at the place where they are united to the other part of the hand. The operation should be per- formed, while the patient is in the infant state, that is to say, before the superfluous parts have acquired much size, and while the object can be accomplished with the least pain. The incisions ought to be made, so as to form a wound with edges, which will admit of being brought together with strips of adhesive plaster. As soon as the dressings are applied, the hemorrhage will almost always cease, without a ligature. FISSURE, (from findo, to cleave asunder.) A very fine crack in a bone is so called. FISTULA, in surgery, strictly means a sore, which has a narrow orifice, runs verv deeply, is callous, and has no disposition to heal. The name is evidently taken from tbe similitude, which the long cavity of such an ulcer has to that of a pipe or reed. A fistula commonly leads to the situation of some disease keeping up suppuration ; and from which place the matter cannot readily escape. No technical term has been more misapplied than this ; and no misinterpre- tation of a word has had worse influence in practice, than that of the present one. Many simple, healthy abscesses, with small openings, have too often been called fistu- lous ; and, being considered as in a callous state, the treatment pursued has in reality at last rendered them so, and been the only reason of their not having healed. FISTULA IN ANO. See Anus. FISTULA LACHRYMALIS. In correct language, this term can be applied only to one case, viz. that in which there is an ulce- rated opening in the lachrymal sac, unat- tended with any tendency to heal, and from vvhich opening a quantity of puriform fluid is from time to time discharged, espe- cially when the lachrymal sac is compressed. Such has been the confusion, however, pre- vailing respecting the nature of the diseases of the lachrymal passages, and so great has been the force of ancient custom, that down to the present time, the generality of British, as well as foreign surgeons, imply by the expression, fistula lachrymalis, several forms of disease, totally different from each other, and to only one of which the name is at all applicable. In order not to assist in perpetuating this absurd and erroneous plan, from which nothing but mistakes and ignorance can result, I shall follow the ex- ample, pointed out by Beer, Schmidt, and our countryman, Mr. M'Kenzie, and consi- der the various forms of disease, to which the lachrymal passages are subject, not un- der the head offistula lachrymalis, but under tbe more sensible title, Lachrymal Organs, Diseases of the Vol. I r>4 "FISTULjE IN PERINJSO. As Mr. A. Cooper has justly observed, incisions in the urethra generally heal with great facility; a fact, amply proved by the common result of the lateral operation ; but, when apertures are formed in the urethra, either from dis- eased states of the constitution and the part together, or of the latter alone, and when they are accompanied with any con- siderable destruction of the sides of the urethra, and of the corpus spongiosum, they are mostly very difficult of cure. (Sur- gical Essays, Part 2, p. 211.) When the methods recommended for the removal of strictures (See Urethra, Slrio tures of) have not been attempted, or not succeeded, nature endeavours to relieve her- self by making a new passage for the urine, vvhich, although it often prevents immediate death, yet, if not remedied, is productive of much inconvenience and misery to the pa- tient through life. The mode, by which nature endeavours lo procure relief, is by ulceration on the inside of that part of the urethra which is enlarged, and situated be- tween the stricture and tbe bladder. Thus the urine becomes applied to a new surface j irritating the part, and occasioning the for- mation of an abscess, into wbich the urine has access; and when the matter is dis- charged, be it by nature, or by art, the urine passes through the aperture, and generally continues to do so, whilst the stricture re- mains. (A. Cooper, Surgical Essays, Part 2, p. 212.) The ulceration commonly begins near, or close to the stricture, although the stricture may be at a considerable distance from the bladder. The stricture is often included in the ulceration, by which means it is re- moved ; but, unluckily, tbis does not con- stantly happen. The ulceration is always on the side of the urethra, next to the ex- ternal surface. The internal membrane and substance of the urethra having ulcerated, the urine readily gets into the loose cellular mem brane of the scrotum and penis, and diffuses itself all over those parts ; and as this fluid is very irritating to them, they inflame and swell. The presence of the urine prevents the adhesive inflammation from taking place ; it becomes the cause of suppuration , wherever it is diffused, and the irritation is often so great that it produces mortification, first in all the cellular membrane, and after- ward in several parts of the skin; all of which, if the patient live, slough away, making a free communication between the urethra and external surface, and producing what are termed fistula in perinao, though it is plain enough to every surgeon, who knowsthecorrectmeaningof the word fistu- fo,that a recent opening, produced in the pe- rineum by ulceration or sloughing, ought not to be called a fistula, immediately it is formed, and at least, not until it has ac- quired some of the characters, specified in our explanation of the term fistula. According to Mr. Hunter, when ulcera- tion takes place further back, than the por 506 FISTULJE IN PERINjEO. tion of tbe urethra, between the glans penis and membranous part of the canal, the abscess is generally more circumscribed. The urine sometimes insinuates itself into the corpus spongiosum urethras, and is im- mediately diffused through tbe whole, even to the glans penis, so as to produce a morti- fication of ail those parts. A fatal instance of this kind is reported by Mr. C. Bell. (Surgical Obs. Vol. l.p. 98.) Although the ulceration of the urethra may be in the perinamm, yet the urine ge- nerally passes easily forwards into the scro- tum, which contains the loosest cellular substance in the body ; and there is always a hardness, extending along the perinaeum to the swelled scrotum, in the track of the pus. (Hunter.) Mr. A. Cooper is of opinion, that, as soon as the absces. -:, which are the fore, tinners of the fistula? can be plainly felt to contain a fluid, it is the best practice to open them with a lancet ihe extensive destruction of parts by ulceration, will thus be pre- vented; the piace not unfrequently then heals up expeditiously without any fistulous orifice being left, and a tendency to those dangerous extravasations of urine is also prevented, which, if the abscesses are not opened early, often prove destructive to life. (A. Cooper, Vol. cit. p. 212.) Ulceration can only be prevented by de- stroying tbe stricture ; but when the urine is diffused in the cellular membrane, the re- moval of the stricture will generally be loo late to prevent all tbe mischief, although it will be necessary for tbe complete cure. Therefore, an attempt should be made to pass a bougie, for perhaps the stricture may have been destroyed by the ulceration, so as to allow this instrument to be introduced. When this is the case, bougies must be almost constantly used, in order to procure as free a passage as possible. In these cases, Mr. A. Cooper expresses a preference to metallic bougies, the size of whicb is to be gradually increased, until their diameter ex- ceeds the natural diameter of the passage. In some instances, however, he says, that it will be necessary to introduce a pewter catheter, of large size, and to allow it to re- main in the bladder, so as at once to act 0 upon the stricture, and hinder tbe urine from passing through the preternatural opening. In this manner a permanent cure may often be effected. Although this experienced sur- geon agrees with most surgeons of the pre- sent day, respecting the general inexpe- diency of employing caustic for the re- moval of a stricture, under the preceding circumstances, yet he admits, that instances do present themselves, in which, from long neglect, the urethra, and the parts, sur- rounding the stricture, are so altered in structure, that no instrument can be passed through the obstruction, without danger, and where the slower action of caustic is safer, than the use of a metallic bougie. (Surgical Essays, Part 2, p. 213.) The ex- erience of modern surgeons tends to prove, owever, that there are some cases which form exceptions to the plan ot employing bougies, or catheters, though a fistulous opening may have occurred in the passage. These cases are the examples, in vvhich the apertures in the urethra are the con- sequence of ulceration and abscess, unac- companied by stricture, and taking place in a bad constitution, and perhaps only pre- ceded by a slight discharge from the urethra. Here bougies would increase the tendency to ulceration, and aggravate the local and constitutional irritation. (A. Cooper,p. 216.) While we are attempting to cure the stricture, antiphlogistic measures, particu- larly bleeding, are to be adopted. The parts should be exposed to the steam of hot water; the warm bath made use of; opium and turpentine medicines given by the mouth, and in clysters; with a view of di- minishing any spasmodic affection. But, as Mr. Hunter observes, all these proceedings are often insufficient; and, therefore, an immediate effort must be made, both to un- load the bladder, and to prevent the further effusion of urine, by making an opening in the urethra, somewhere beyond the stricture, but the nearer to it the better. Introduce a director, or some such in- strument, into the urethra, as far as the stric- ture, and make the end of it as prominent as possible, soasto be felt; which, indeed,is often impossible. If it can be felt, it must be cut upon, and the incision carried on a little farther, towards the bladder, or anus, so as to open the urethra beyond the stricture. This will both allow the urine to escape, and destroy the stricture. If the instrument cannot be felt, at first, by the finger, wo must cut down towards it; and, on after- ward feeling it, proceed as above. When the stricture is opposite the scro- tum, as the opening cannot be made in this situation, it must be made in the perinaeum, in vvhich case there can be no direction given by an instrument, as one cannot pass suffi- ciently far, and the only guide is our anato- mical knowledge. The opening being made, proceed as directed in the cure of a false pas- sage. (See Urethra, False passage of.) In whichsoever way the operation is done, a bougie, or a catheter, which is better, must afterward be introduced, and the wound healed over it When the inflammation, from the extra- vasation of urine is attended with suppura- tion and mortification, the parts must be freely scarified, in order to give vent both to the urine and pus. When there is slough- ing, the incisions should be made in the mortified parts. Sometimes, when the urethra is ulcerated, and the cellular membrane of the penis and prepuce is so much distended, as to produce a phymosis, it is impossible to find the orifice ofthe urethra. Frequently the new passages for the urine do not heal, on account ofthe stricture not being removed: and even when this has been cured, they often will not heal, but become truly fistulous, and produce fresh inflammations and suppurations, which often Fib burst by distinct openings. Such new ab- scesses and openings often form, in conse- quence of the former ones having become too small, before the obstruction in the urethra is removed. Such diseases sometimes bring on inter- mittent disorders, which do not yield to bark; but cease as soon as the fistula? and disease of the urethra have been cured. In order to cure fistulae in perinaeo, unat- tended with the above described urgent symptoms, the urethra must be rendered as free as possible, and this alone is often enough ; for, the urine finding a ready pas- sage forwards, is not forced into the internal mouth of the fistulae, so that these heal up. The cure of the strictures, however, is not always sufficient, and the following opera- tion becomes indispensable. Tbe sinuses are to be laid open in tbe same manner as other sinuses, which have no disposition to heal. In doing this, as little as possible of the sound part of the urethra must be opened. Hence, the sur- geon must direct himself to the inner orifice of the fistula?, by means of a staff, introduced (if possible) into the bladder, and a probe passed into one of the fistulous passages. The probe should be first bent, that it may more readily follow the turns of tbe fistula?. When it can be made to meet tbe staff, so much the better; for then the operator can just cut only what is necessary. When the fistula' is so straight, as to ad- mit of a director being introduced, this in- strument is the best. When neither the probe nor the director, can be made to pass as far as the staff, we must open the sinuses as far as the first instrument goes, and then search for the continuation of the passage, for the purpose of laying it open. The difficulties of this dissection, however, in the thickened, diseased state of the parts in the scrotum and perina?um, are such as can only be duly appre- ciated by a man who has either made the attempt himself, or seen it made by others. I have myself seen one ofthe first anatomists in London fail in two instances to trace the continuation of the urethra, and baffled in the endeavour, therefore, to pass an instru- ment from the orifice of that passage into the bladder. The difficulty and confusion, arising from the hardened, enlarged state of tbe parts, which are to be cut, have been well depicted bv Mr. C. Bell. (Surgical Obs. Vol. I. p. 129.) Having divided the fistula? as far as their termination in tbe urethra, a catheter should be introduced, and worn, at first, almost constantly. This is better than a bougie, which must be frequently withdrawn to al- low the patient to make water, and it often could not be introduced again without be- ing entangled in the wounds. In many cases, the employment ofthe ca- theter should not be continued after a cer- tain period. At first, it often assists the cure ; but, in the end, it may obstruct the healing, by acting at the bottom of the wound, as an extraneous body. FOM 507 Hence, when the sores become stationary, let the catheter be withdrawn, and introdu- ced only occasionally. And even after the sores are well, it will be prudent to use the bougie, in order to determine whether tbe passage is free from disease. ' When fistula? in perina?o have been laid open, the wounds are to be at first dressed down 'o the bottom as much as possible, which will prevent the reunion ofthe parts first dressed, and make the granulations shoot from the bottom, so as to consolidate the whole by one bond of union. (Hunter onthe Venereal Disease, Edit. 2.) Addition- al observations upon this subject, and, in particular, the opinions of Desault, will be found in the article Urinary Abscesses and Fistula. Mr A. Cooper's practice in cases, where a considerable portion of the urethra has been destroyed, will be hereafter noti- ced (See/Urethra.) FISTULA, SALIVARY. (See Parotid Duct.) FLUCTUATION, (from fludo, to float.) the perceptible motion communicated to any collection of purulent matter, or other kind of fluid, by applying the fingers to the s irface of the tumour, and pressing with them alternately, in such a man- ner, that the fingers of one hand are to be employed in pressing, or rather in briskly tapping upon the part, while those of the other hand remain lightly placed on another side of the swelling. When the ends of one set of fingers are thus delicately applied, and the surgeon taps, or makes repeated pres- sure with the fingers ofthe other hand, the impulse, given to the fluid, is immediately perceptible to him, and the sensation, thus received, is one of the principal symptoms, by which practitioners are enabled to disco- ver the presence of fluid in a great variety of cases. Great skill in ascertaining by the touch the presence of fluid in parts, or being endued with the tactus eruditus, a3 it is termed, distinguishes the man of experience as remarkably, perhaps, as any quality that can be specified. When the collection of fluid is very deep- ly situated, the fluctuation is frequently ex ceedingly obscure, and sometimes not at all distinguishable. In this circumstance, the presence ofthe fluid is to be ascertained by the consideration of other symptoms. For example, in cases of hydrops pectoris and empyema, surgeons do not expect to feel the undulation of the fluid in the thorax with their fingers; they consider the pa- tient's difficulty of breathing, the uneasiness attending his lying upon one particular side, the cedema of the parietes of the chest, the dropsical affection of other parts, the more raised and arched position ofthe ribs on the affected side, the preceding rigours, fever, and several other circumstances, from which a judgment is formed, both with regard to the presence and the peculiar nature ofthe fluid FOMENTATION. By a fomentation^ surgeons commonly mean the application of flannel or towels, wet with warm water, or ?orae medicinal decoction. In the practice 508 FOR FRA of surgery, fomentations are chiefly of use in relieving pain, and inflammation, and in promoting suppuration, when this is desira- ble. Some particular decoctions, however, are used for fomentations, with a view of affecting by means of their medicinal quali- ties, scrofulous, cancerous, and other sores, of a specific nature. I shall merely subjoin a few of the most useful fomentations in common use. FOMENTUM AMMONITE MURIATE. R. Fomenti Communis ifcij. Ammon. Mur. |j. Spirit. Camph. ?ij Just before using the hot decoction, add to it the ammonia muriata, and spirit. Said to be of service to some indolent ulcers; and, perhaps, it might be of use in promo- ting the absorption of some tumours, and suppuration in others. FOMENTUM CHAM/EMELL ft. Lin. contusi ?j. Chamaemeli ^ij. Aq. Distillat. Ibvj. Paulisper coque, et cola. A fomen- tation in very common use. FOMENTUM CONII. ft. Fol. Conii. recent. ft>j. vel. Fol. Conii. exsiccat. ^iij. Aq. Comm. Ifei'j- Coque usque reman. jfoii. et cola. Sometimes applied to scrofulous, cancerous, and phagedenic uclers. FOMENTUM GALL^E. Galla? Contusa? ^ss. Aq. Ferventis Jfeij. Macera per ho- ram. et cola. Used for the prolapsus ani, and sometimes employed, as a cold applica- tion, in cases of hemorrhoids. FOMENTUM PAPAVERIS ALBI. R Papav. Alb. Exsiccati ^iv. Aq.Pur. Jbvj. Bruise the poppies, put them in the watei, and boil the liquor, till only a quart remains, which is to be strained. This fomentation is an excellent one, for very painful inflam- mations ofthe eyes, and for numerous ulcers, and other diseases, attended with intolerable pain. FORCEPS, an instrument much employ- ed in surgery for a variety of purposes, and having accordingly various constructions. The general design, however, of surgical forceps is to take hold of substances, vvhich cannot be conveniently grasped with the fingers; and, of course, the instrument is always formed on the principle of a pair of pincers, having two blades, either with, or without handles, according to circumstances. The smallest forceps is that which is era- ployed in the operation of extracting the cataract, and which is useful for remov ing any particles of opaque matter from the pupil, after tbe chief part of the crystalline lens has been taken away. Another forceps of larger size, is that used for taking up the mouths of the arteries, when these vessels require a ligature, in cases of hemorrhage. This instrument is also frequently employed for taking dress- ings off sores, removing pieces of dead bone, foreign bodies from wounds, and, particular- ly, for raising the fibres, which are about to be cut, in all operations, where careful dis- section is required. This forceps resembles thai which is contained in every case of dissecting instruments, and is often called the artery, or dissecting forceps, from itt- more important uses. Neither of the foregoing forceps is made with handles ; each opens by its own elas- ticity ; and the ends of the blades only come into contact, when pressed together by tbe surgeon. The following kinds of forceps are con- structed with handles, by means of vvhich they are both opened and shut: 1. The common forceps, contained in every pocket-case of surgical instruments, and used for removing dressings from sores, extracting dead pieces of bone, foreign bodies, he. 2. Larger forceps, employed for extract- ing polypi. 3. Forceps of different sizes and construc- tions, used in the operation of lithotomy, for taking the stone out of the bladder, or for breaking the calculus, when it is too large to be extracted in an entire state. •FRACTURE. (from frango, to break.) Is a solution of continuity of one, or more bones, produced in general by external force; but occasionally, by the powerful action of muscles, as is often exemplified iu the broken patella. The subject of fractures is so interesting a branch of surgery, and the accidents them- selves so frequent and important, that the little vvhich English surgeons have done for the improvement of this part of their profes- sion cannot but cause equal surprise and re- gret. Mr. Pott, it is true, made many excel- lent observations on the treatment of frac- tures in general; and his remarks on com- pound fractures in particular are in some respects the best whicb are extant; but what surgeon will now presume to defend the weak arguments upon which he has founded the doctrine of paying unqualified attention to the relaxation of the muscles, as if this were an object which should constantly su- persede every other consideration, and in- variably regulate the posture of the limb ? I have no hesitation in declaring my own belief, that the doctrine and practice re- commended by Mr. Pott, in regard to frac- tured thighs, have done considerable harm, and the more so, as coming from a man who was deservedly looked upon as one of the best and most experienced judges of surgical practice. Many a surgeon in this country implicitly believed every thing which was asserted by so able a master, and the very observations, which some years ago w ere here considered to be the glory of their author, and the pride of English sur- gery, are now exposed by the surgeons of neighbouring countries, as specimens of our wrong precepts and bad practice. M. Roux, in fact, has had but too much room for ani- madyersion upon this subject. We have not only not made a single improvement of con- sequence in the treatment of any particular fracture, but the generality of our surgical writers have given the most faulty and im- perfect account of the diagnosis, and every thing else relating to these accidents. What is worse, a view of our practice con- FRACTURES. oVkf ■veys no better opinion of this part of our surgery. Observe the care and neatness, with which a French surgeon applies tbe bandages, and splints, and consider how well every indication is accomplished by his apparatus, and you will find great cause both for admiration and imitation. On the other hand, see the slovenly way, in which an English surgeon generally puts on the splints and roller, aud the unscientific me- thod, in which he usually treats a fractured thigh, or clavicle, and you cannot fail to be ashamed of the comparison. This was a matchless opportunity for M. Roux to draw a parallel in favour of French surgery, and of course he has not neglected it, many pages of his work being devoted to an ex- planation of the many improvements De- sault made ; the little, or rather the nothing, which we have done ; and the errors to which we unfortunately still adhere. (See Voyage fait a Londres en 1814, ou Parallile de la Chirurgie Angloise avec la Chirurgie Francoise,p. 173,4^) R is to be hoped, however, that the period has now arrived, when we shall give to the study of fractures the time, the attention, and the importance, which it claims ; and when even the young hospital pupil will not be convinced, that his lecturer by one or two cursory discour- ses can have done justice to the subject. In this article, my plan is to follow the arrangement pursued by Boyer, in his " Traite des Maladies Chirurgicales, T. 3." I shall first speak of fractures in general, and allot separate sections to the consider- ation of, 1. Their differences; 2. Their causes ; 3. Their symptoms; 4. Their prog- nosis ; 5. Their treatment; 6. The for- mation of callus. The subject will then conclude with a full account of the sympt ins, causes, and treatment of the fractures of particular bones. 1. Differences of Fractures. The differences of fractures depend upon what bone is broken ; what portion of it is fractured ; the direction of the fracture ; the respective position of the fragments ; and, lastly, upon circumstances accompa- nying the injury, and making it simple, compound, or variously complicated. 1. In respect to the bone affected. Some- times it is one of the broad bones, as the scapula, the sternum, or the os ilium.— .Sometimes it is a short bone, like the os calcis ; but, far more commonly it is one of the long bones. The situation and func- tions of the broad bones render their frac- tures unfrequent. The bones of the skull are the only exception to this remark, for they are often broken; bufv 'here the as- sistance of the sureeon is required less for the solution of continuity itself, than for the affection of the brain, and the extrava- sation of blood, with which the case is apt to be combined. Fractures of the short bones are still more unusual, because these bones, being nearly equal in their three di- mensions, are capable of greater resistance, and are*ot much within the reach of ex- ternal violence. Besides, most of them are but little exposed to the operation of out- ward force, by their situation, or functions. Hence, unless limbs are crushed, fractures of short .bones are generally caused by the action of the muscles, which also frequently breaks the patella, olecranon, and os calcis. The long bones, which serve as pillars, or arches of support, or levers, are by the very nature of their functions, particularly liable to fractures. 2. In respect to the part ofthe bone broken. Bones may be fractured at different points of their length. Most commonly, their middle portion is broken, and, in this cir- cumstance, they usually break like a stick, which has been bent beyond its extensibility by a force applied at each end of it. Some- times the fracture occurs more or less near the extremities of the bone, which is always an unfavourable event, as will be explained in considering the prognosis. Lastly, the bone is sometimes broken in several places, and the injury may be produced by two different causes, which have operated suc- cessively, or simultaneously, upon the bro- ken parts of the bone ; or it may be occa- sioned by one single cause, which has acted at the same moment upon several points of it. These distinctions of fractures, deduced from their particular situation, tsays Boyer) are not merely scholastic refinements ; they have truly an important influence over the prognosis and treatment, as will be hereafter seen. 3. In respect to the direction, in which the bone is broken. A bone may be fractured in various ways, and the fracture receives different names, according to its direction in regard to the axis of the bone. Thus, fractures are distinguished into transverse and oblique. The obliquity renders the sur- face of the injury larger, and materially in- creases the difficulty of maintaining the ends of the bone in contact, after they have been set. Oblique fractures are subject to consi- derable variety, which depends upon the decree of their obliquity, and whether they are partly oblique and partly transverse. VV hen a bone is broken in different p aces ' at once, and divided into several fragments, or splinters, the fracture is termed commi. nuted. Duverney admitted another class of frac- tures, viz. longitudinal. (See Traiti des Maladies des Os, T. I, p. 167.) But J. L. Petit regarded this species as only imagi- nary, because he conceived that any blow which was capable of breaking a bone lon- gitudinally, would much more readily cause a transverse fracture. Forthe same reason, Louis absolutely rejected the possibility of longitudinal fractures, and this sentiment has been the prevailing one up to the present day. The following case, however, is related by Leveille, in order to prove the possibility of longitudinal fractures. This surgeon ampu tated the thigh of an Austrian soldier who was put under his care in the year 1800, in VIO FRACTURES consequence of being struck by a ball in the lower tnird of the leg, at the battle of Ma rengo. The soldier had walked several miles after receiving the injury, before he arrived at Pavia. Tbe wound appeared simple, and likely to heal as soon as the in- jured portion of the tibia bad exfoliated. Tiie event turned out otherwise, and the thigh was amputated. Leveille bas preserved the tibia, upon which the impression of the ball may be dis- tinguished, and from this point, run sevn-t! longitudinal and oblique hues, which ex- tend from the lower third towards the up- per head of the tibia, and pass through the whole thickness of the parietes of the me- dullary canal. They are acknowledged to be really lougitudinul fractures, by Dubois, Chaufrier, Dumeril, Deschamps, and Roux, who were appointed by me Ecole de Mede- cine to inquire into the fact. (Leviilli, Nouvelle Doctrine Chir. T. 2, p. 158.) In a foregoing article of this dictionary, I mentioned that, in -everal of the casesof fractured thigh bones from gun-shot vio- lence, which were under the care of Dr. Cole and myself in Holland, the bone was split longitudinally to the extent of seven or eight inches. (See Amputation.) The fact, however, that bullets and other balls do produce longitudinal fractures, is now universally admitted ; and w ere there any doubt upoii the subject, a specimen sent to England by my friend Dr. Cole would soon remove it. Boyer. who a few years ago denied the possibility of longitudinal frac- tures, in his late work remarks:—•' On trouve nianmoins, a la suite des plaies d'armes a feu, les os fendus suivant leur lon- gueur, jusques dans lews articulations,"-—but he is correct w ben he adds, that such in- stances afford no proof of the possibility of a simple longitudinal fracture. (See Traiti des Mai,tdies Chir T. 3, p. 10.) 4. In regard to the respective position of the fragments. These differences are highly important to be understood, because, as Boyer remarks, the treatment of fractures consists almost entirely in remedying, or preventing the displacement of the frag- ments. It is not to be supposed, however, that such displacement is an absolutely es- sential symptom of oil fractures, for it sel- dom exists in members composed of two bones, when only one of ti.em is broken. Neither does it constantly happen in every fracture of the neck of a bone, as is exem- plified in certain fractures of the neck of the thigh-bone, the fragments of which sometimes change their relative situation only wheu the patient tries to walk, or the limb is imprudently m-ved about. Frac- tures of the leg are also observed, in which there is neither a displacement of the frag- ments, nor an alteration in the shape of the limb, especially when the tibia alone is frac- tured near its upper part, where it is very thick. When the ulna alone is broken at its upper part, there is hardly ever any dis- placement. The corresponding surfaces of the fragments having a large extent cannot be separated, or can only be to with diffi- culty. The fibula also resists the causes, which teud to produce displacement. But it is a symptom which almost invariably oc- curs when both bones of the leg, or fore-arm, are fractured together; as also in fractures of limbs which contain only one bone, on account of the little extent ofthe surfaces of the fracture, and the great number of mus- cles, which tend to displace them. The displacement may happen in respect to tbe diameter, length, direction, or circum- ference, of the bone. In respect to the diameter. Transverse fractures are the only cases, in which this kind of displacement is observed. The two fragments may either be in contact at a part ol their surfaces, or they may not be in contact at all. In the latter circumstance, the limb is shortened by the ends of the fracture slipping over each other. In respect to length. This mode of dis- placement. :i\ which the ends ofthe broken bone ride more or less over each other, con- stantly occurs in oblique fractures, and sometimes in transverse ones, when the dis- placement in the direction of the diameter of the bone has been such that the surfaces of the fracture are no longer in contact. It will be hereafter explained, that whenever the limb is shortened in fractures of the ex- tremities, it is the lower fragment which is displaced. We may refer to the species of displace- ment here spoken of, that which takes place in fractures ofthe patella, olecranon, and os calcis; but with this difference, that the fragments, instead of riding over each other, separate from each other in the direction of the length of the bone, and continue separa- ted by an interspace more or less consi- derable. In respect to the direction of the bone. In this kind of displacement, the two fragments form an angle more or less prominent, and the bone appears arched. It is principally observed in comminuted fractures. It may also happen in simple fractures; for in- stance, in the leg, when the limb in a strait posture does not lie upon a surface exactly horizontal, and the heel is lower than the rest of the leg. The angular projection is then anterior. Dn the contrary, it would be posterior if the heel were too much raised. In respect to the circumference of the bone. This displacement occuts when the lower fragment performs a rotatory movement, while the upper one continues motionless. Thus, in fractures of the neck of the femur, if the foot is badly supported by the appara- tus, its weight, together with that of the limb, and the action of the muscles, inclines it outward, and turns the lower fragment in the same direction. Besides tbe simple displacements above described, there are others of a more com- plicated' nature, which happen in several directions at once. For example, such is the^ displacement which is observed in a fracture of tbe thigh-bone, when the lower FRACTURES. 511 tragment is drawn upward and inward, while the foot is turned outward. Let us next consider the causes producing the displacement of fractures. The bones being only passive instruments of loco-motion, possess not, in their own organization, any cause of the change of situation vvhich takes place ; but yield to the impulse of external bodies, the weight of the member, and the action of the muscles. The displacement may be produced by an external force, either at the moment when the fracture happens, and by the very action of the fracturing cause itself; or it may be caused by the weight of the body when the fracture precedes the fall; or lastly, it may be brought on by some other ex- ternal force, acting on tne fragments, soon- er or later, after the occurrence of the in- jury. The outward violence, which is productive of a fracture, operates sometimes directly on the situation of the breach of continuity ; sometimes on parts more or less distant from this place. In both cases, tbe action of the force is not confined to the production of the fracture, but is partly spent in causing a dis- placement of the fragments. Falls are the most usual causes of fractures. But sometimes, the fall does not happen till after the leg, or thigh, is actually broken. The weight of the body then produces the displacement, by pushing the upper fragment against the soft parts, which are more or less lacerated. This is what happened to Am- brose Pare. This celebrated surgeon, being kicked by a horse, endeavoured to get out of the way ; but he instantly fell down, and the two bones of his left leg, which had been fractured, being impelled by the weight of the body, not only passed through the skin, but even through his stocking and boot. Boyer has seen a case nearly similar in a young man about twenty years of age, who, in a standing posture, was struck on the mid- dle of the thigh with the pole of a carriage, which fractured the femur. The patient fell down, and in the fall the upper fragment was not only driven through the muscles and in- teguments, but also through his breeches. The weight of the limb itself may pro- duce displacement according to the direction, or circumference of the bone, as already de- tailed. The disturbance of the limb, also, in lifting the patient, and carrying him to bis bed, may sometimes alter the relative situation of the fragments, and cause them to be displaced. But of all the causes of the displacement of fractures, the action of the muscles is the common and most powerful one. Among those muscles vvhich surround a fractured bone, some are attached to it throughout its whole length, and arc equally connected with both the fragments. Some arise from the bone above, and are inserted either into that, which is articulated with the lower fragment, or into the lower fragment ii self. Lastly, there are others, which come from a point more or less distant, and terminate in the upper fragment. The muscles round the thigh bone furnish examples of these three arrangements. The triceps is attached to the bone its whole length. The biceps, semi-membranosus, and semi-tendinosus, come from tbe pelvi^, and are inserted into the leg, a part, with wh'ch ihe lower frag- ment is articulated, and all the motions of which it follows. The great bead of the bi- ceps is inserted into this fragment itself. Lastly, the iliacus, psoas, pectineus, he. i ome from the loins and pelvis, and are at- tached to the femur, not far from its upper end. The muscles which are attached to both fragments, contribute very little to their dis- placement. They may, however, draw tbera to the side on which they are situated, and thus change (he direction of tbe limb The triceps, especially its middle portion, acts in this manner in fractures of the femur, and renders the thigh convex anteriorly. The corar.o-brachiaiis tends to produce the same effect, when the humerus is broken below its middle. The displacement is principally owing to such muscles as are affixed to the lower fragment, or part with which this fragment is articulated. Suppose the humerus to be broken between its upper end and the in- sertion of tbe great pectoral Tbis muscle, aided t>y the latissimus dorsi and teres major, will draw the lower fragment inward, and displace it by drawing it to the inner side of the upper fragment, which remains motion- less. In fractures of the neck of the thigh bone, the upper fragment, included within the capsular ligament, affords attachment to no muscle. All those, which are affixed to the lower fragment, pull it ujtvard and backward, in which direction the displace- ment is inevitable. In all fractures, the lower fragment follows every movement made by the part of the limb with whicb it is articulated, and, consequently, the mus- cles which are attached to tbe bones of this last part of the limb, become a powerful cause of displacement. Thus, in a fracture of the Ihigh bone, the biceps, semi-tendino- sus, and semi-membranosus, draw the leg, and with it the lower fragment, upward, in- ward, and backward, so as to make the lower end of the fracture ascend at the in- side of. and rather behind tbe upper one, the extremity of whicb then projects forward and outward. Iu a fracture of the leg, the gastrocnemius, soleus, and peronei muscles, acting upon the foot, pull the lower frag- ments of tbe tibia and fibula, and draw them to the outer and posterior side of the upper fragments. For, here, as well as every where else, the strongest muscles, in pro- ducing tbe displacement, draw towards tbeir own side the end of (he fracture, on which they operate. And as the posterior muscles of the leg are far more numerous and power- ful than those on the front of tbe limb; while those on its outside are not antagoni- zed by any others ; the displacement roust happen in the direction backward and out- ward. Whenever therefore a bone is frac- tured at a given point, an anatomical know- ahi FRACTURES. ledge of the muscles will enable one to de- termine a priori in what direction the dis- placement will occur, if no means be taken to impede it, and it proceed altogether from this particular cause. Lastly, the muscles, which are attached only to the upper fragment, may sometimes displace it. In a fracture of the (high, situ- ated immediately belo.v the little trochanter, the psoas and iliacus muscles together carry forward the extremity of the upper fragment, which elevates the integuments, and forms a more or less considerable projection near the fold of tbe groin. But, it is to be observed, that, in general, the displacement of the up- per fragment is not common, and that it is the lower one which is drawn out of its pro- per position The manner in which the displacement of fractures is effected by the action of mus- cles, explains one circumstance, which fre- quently attends these cases, especially frac- tures of the thigh, clavicle, and leg. This is arising, a projection of the upper fragment, or that vvhich is nearest the trunk. One might believe, at first sight, that such pro- jection is formed by the upper fragment, which, abandoning its natural situation rises over the lower one. But on the least re- flection, it becomes manifest, that the upper end of the fracture projects only because the lower one is displaced and drawn to- wards that side on which tbe strongest mus- cles are situated. Thus, in practice, in order to make the rising end of the bone, (as it was termed) disappear,, it is only necessary to reduce the lower fragment into its natural place. If instead of doing this, pressure is made on ^je projecting part, the design fails; and n the plan be still more forcibly pursued and continued, inflammation and sloughing of tbe integuments and other soft parts, are likely to be the unfortunate consequences. 5- In respect lo circumstances, with which fractures are accompanied. The most impor- tant division of fractures is into simple and compound. By a simple fracture, surgeons mean a breach in the continuity of one or more bones, without any external wound, com- municating internally with the fracture, and caused by the protrusion of the ends of the broken bone, or bones. By a compound fracture, they signify the same sort of injury of a bone, or bones, attended with a lacera- tion of the integuments, vhich laceration is produced by the protrusion of one, or both ends ofthe fracture. The dangerous nature of compound fractures will be fully explained in the sequel of this article, and we have already adverted to the subject in speaking of Amputation. Fractures are said to be complicated, when they are attended with diseases, or accidents, which render the indications in the treat- ment more numerous, and require the em- ployment of different remedies, or the practice of sundry operations for the accom- plishment of tbe cure. Thus, fractures may be complicated with severe degrees of contusion, wounds of the soft parts, the injury of large blood-vessels, a dislocation, or disease, such as the scurvy, rickets, lues venera, he. which are said to retard the formation of callus, and render the cure more backward. The complication of fracture with dislo- cation happens but seldom, and it cannot oc- cur, unless the luxation has taken place first, or (has been produced at the same time with tbe fracture, and by the same cause. When once the fracture has happened, the frag- ments are not sufficiently within the grasp of external force, and are too moveable to admit of the bone being dislocated. A patient with fracture may be attacked by an acute disease, which may render the treatment more troublesome, and the cure slower. 2. Causes of Fractures. The causes of fractures are divided into predisposing and remote. In the first class are comprehended, the situation and functions of the bones, the age of the patients, and their diseases. Su- perficial bones are more easily fractured than those which are covered by a consider- able quantity of soft parts. The functions of some bones render them more liable to be fractured than others; thus the radius, which supports the hand, is more liable to be fractured than the ulna. The clavicle, which serves to keep the shoulder in its proper position, and support on its arched extremity all the motions of the upper ex- tremity, is particularly subject to be broken. The gradual increase of the quantity of the phosphate of lime, in the structure of tho bones, makes them brittle, in proportion as we advance in years, and in old age, the proportion of the inorganized to the orga- nized part is so great, that the bones are fractured by the slightest causes. In child- hood, the fibrous and organized part bears a greater proportion to the earth, and the bones being, consequently, more elastic and flexible, are not so easily broken, as in old age. Lues venerea, arthritis, cancer, rachitis, scurvy, and scrofula, says Lev6ill6, predis- pose to fractures. B. Bell mentions two ve- nereal patients, of whom the hardest and largest bones were completely broken by the ordinary action of the muscles of the limb. Fabricius Hildanus quotes from Sa- razin, a physician of Lyons, the case of a gouty patient, sixty years of age, who, in putting on his glove, broke his arm ; the fracture having been ascertained three days afterward to be situated above the elbow. Desault used often to speak of a nun of Sal- petriere, whose arm was broken as a person was handing her out of a carriage. LouiS, who was vexed that no union took place, was not a little surprised to find her thigh bone experience the same fate one day as she was changing her posture in bed. It was then that Louis learned that this lady had a cf>neer in ber right breast. Leveilfo r« FRACTURES ->13 sures us, that he has observed similar cases in the H6tel Dieu. According to this last writer, the history of two girls is related by Buchner, one of whom died rickety at the age of sixteen, having broken the femur a short time before her death ; and the other, after taking the breast very well for two years, and thriving for a time, became affected with rachitis, and met with the same accident as she was merely running along the street. (Nouvelle DodrineChir Tom.2,f> 163.) Many extraordinary instances of fractures from the morbid softness and fragility of the bones are upon record. Suffice it here, to refer to the Philosophical Transactions; Mem. de I'Acad. Royale des Sciences ; Act. Hafniens.; Ephem. Nat. Cur. Dec. 1, Ann. 3, Obs. 112; Gooch's Chirurgical Works, Vol. 2; Saviard's Observations Chirurgicales, p. 274. &.c. (See also Fragilitas and Molli- ties Ossium.) On the subject of fractures, produced by the scurvy, Lcveille recommends us to pe- ruse Marcellus Donatus ; Saviard's Observa- tions ; Heyne de Morbis Ossium; Poupart's Works inserted in the Mem. de I'Acad. de Sciences, 1699 ; and the Treatise published at Verona, in 1761, by Jean de Bona. Pare, Plattier, Callisen, and several other writers, set down cold, as a predisposing cause of fractures. This doctrine has origi- nated from these injuries being more fre- quent in Ihe winter time, and is quite errone- ous, since, in cold countries, the greater number of falls, which happen in winter, is a circumstance that fully explains why frac- tures are then more common than in sum- mer. The remote cause of fractures is external force, variously applied, in falls, blows, he. In particular instances, the bones are broken by tbe violent action of the muscles attach- ed to them; this is almost always the case with the fractured patella. The olecranon and os calcis have likewise been broken by a violent contraction of the muscles inserted inio them. With respect to the heel, Petit records two instances, one of which was communicated to him by Poncelet, and the other seen by himself in Madame La Presi- dentede Boissire, who met with the accident in walking a gentle pace in the court of the Hft'.el de Soubise. When the injury happens in leaping, or falls from a high situation, Leveille thinks it more probable, that a por- tion of the os calcis is torn off by the power- ful action of the muscles of the calf, than that it is broken by any blow immediately on the part. He states, that Desault used frequently to cite two examples of this kind, one of which is recorded in his (Euvres Chirurgicales. Whether the long bones can be fractured by the mere action of the muscles, is yet an unsettled point. In the Philosophical Trans- actions, a fracture of the humerus is ascribed to this cause, and Botentuit saw the same accident produced by striking a shuttle- cock with a battledore. According to De- beaumarchef- as a man was deseendiug a Vol. I ** ladder at a quick' rate, his Ueei got entangled in an opening, and he made a violent exer- tion to avoid falling. The consequence was a fracture of the lower third of the leg. Curet informs us, that a cabin-boy, aged seventeen, made a considerable effort to keep himself from being thrown down by the rolling of the ship, as he was making water. The femur was fractured by the powerful action ofthe muscles of the thigh. The lad had no fall, and, with some diffi- culty, supported himself on the other limb; till he received assistance. We are told, says Laveille, by Poupee Des- portes, that a negro, about twelve or thirteen years old, was seized with such violent spasmodic contractions of the mus- cles of the lower extremities, that the feet were turned backward, and the neck of each thigh bone was fractured, the ends ot the broken bones also protruding through the skin upon the outside of the thigh. A cure was effected, after an exfoliation. We read also, in the Melanges des Curieux de la Nature, that, during a fit of epilepsy, a child, ten years old, hud its left humerus and tibia broken, and that upon opening the body, other solutions of continuity were observed. Doctor Chamseru recol- lects having assisted, at his father's house, iu dressing a child, eleven or twelve years old, that had broken the humerus in throw- ing a stone a considerable distance. (Le- viilli, Nouvelle Doctrine Chir. T. 2, p. 164, 166.) .Richerand, however, positively denies, that a long bone, when healthy, can ever be broken by the mere contraction of the muscles. (Nosogr. Chir. J'. 3, p. 12, Edit. 4.) For my own part, making all due allow- ance for the inaccuracy of some of the re- ports made by writers, I think the possibility of the long bones being broken by the violent action of the muscles is sufficiently proved. I have never seen but one example of the occurrence ; but, it was a very un- equivocal one. I once attended for the late Mr. Ramsdens, an exceedingly strong man. at Pentonville, who broke his os brachii in making a powerful blow, although he missed his aim and struck nothing at ail. The whole limb was afterward- affected with vast swelling and inflammation. This man, 1 remember, was also visited by Mr. Welbank, of Chancery-lane. According to Nicod, the greater number of fractures of long bones, by mere muscular action, are preceded by pains in the broken limbs, and, in one of the cases, published by this author, not only was this circumstance re marked, but an abscess and exfoliation of a portion of the fractured humerus ensued. In another instance, reported by this gentleman, the clavicle, in a state of preter- natural fragility from disease, was fractured in an effort to carry the arm far behind the back. After the reunion of the fracture, an abscess took place, and a piece of the bone exfoliated. (Annuaire Med. Chir. des Hopitaux de Paris, p. 494—98, fa 4f» Paris. 1819.'* :>W FRACTURES. 3. Symptoms of Fractures. Some of the symptoms of fractures are equivocal. The pain, and inability to move the limb, commonly enumerated, may arise from a mere bruise, a dislocation, or other cause. The crepitus: the separation and inequalities of the ends of the fracture, when the" bones is superficial; the change in the form of the limb ; and the shortening of it; are circumstances, communicating the most certain information ; and the cre- pitus, in particular, is the principal symptom to be depended upon. The signs of frac- tures, however, are so exceedingly various,. according to the bones, which are the sub- ject of injury, that it cannot be said, that there is any one, which is invariably at- tendant on such cases, and characteristically confined to them. The writers of systems of surgery usually notice loss of motion in the injured limb, deformity, swelling, ten- sion, pain, he. as forming the general diag- nosis of fractures. However, it is easily comprehensible by any one, acquainted with anatomy, that numerous fractures can- not prevent the motion of the part, nor oc- casion outward deformity ; and every sur- geon must know, that though, at first, there may be pain in the situation of a fracture, no swelling and tension take place till after a certain period. When, therefore,a limb is broken, and the event is not manifest from the distortion of the part, it is proper to trace, with the fingers, the outlines of the suspected bone : if it be the tibia, let the surgeon examine withfhis fingers, whether any inequality can be dis- covered along the anterior surface, and along the sharp front edge of that bone. If it be the clavicle, let him trace the superficial course of the bone, in the same attentive manner. Whether any unusual pain occurs, or any unnatural irregularity appears, let him try, if a grating, or crepitus, cannot be felt, on endeavouring to make one end of the suspected fracture rub against the other. When the humerus, or the os femoris, is the subject of inquiry, a crepitus is felt almost as soon as tbe limb is touched, and, in the case of the broken thigb, there isa consider- able shortening of the extremity, except in a few cases of fractures, completely trans- verse. But, when there are two bones, as in the leg and the fore-arm, and only one is broken, the other continues to prevent the limb from being shortened, and thrown out of its natural shape, so that a crepitus can only be felt by a very careful examination with the fingers. The difficulty of the diag- nosis is increased, when the surgeon is con- sulted late, and great swelling has come on. Where is the surgeon- says Boyer, that has not sometimeshesitated to deliver an opinion in certain cases of this description ? (I'raiti des Malad. Chir. 3, p. 27.) When the injured limb is shortened, the surgeon, before pronouncing that such change proceeds- from the riding of the "ragments over each other, must be sure, '.hat the bones are not dislocated, and that 'be linflb is not naturally shorter, than the other, or in consequence of a previous frac- ture, that has been badly set. In comparing the length of the lower ex- tremities, one should place the pelvis in an horizontal position, and put the two ante- rior superior spines of the ossa ilium in-the same line ; for, if these processes are not on a level, the limb, towards which the pel- vis inclines, will seem longer than the op- posite member. Tbe practitioner, who is well acquainted with the conformation of the limbs, and par- ticularly with the mutual relations of the eminences of the bones to each other, will readily perceive the alterations produced by a fracture. Whenever, in consequence of a fall, or a blow, a limb becomes concave at a part, where it ought to be convex; or straight, et vice versa ; the change of shape and direction must proceed from a fracture with displacement. The inner edge of the great toe, when the leg rests on an horizon- tal surface, should correspond with the inner edge of the knee-pan. If this natural rela- tion be altered ; if the inner edge of the great toe correspond with the outer edge of the knee-pan, there can be no doubt of the existence of a fracture of both bones of the leg. (Boyer, Vol. cit. p. T. 3, p. 25.) I am aware, that considerable harm, and great unnecessary pain, have been occa- sioned in the practice of surgery, by too much solicitude to feel the grating of frac- tured bones, and, whenever the case is suf- ficiently evident to the eyes, the practitioner who gives way to this habit, at the expense of- torture to the unfortunate patient, ought, in my opinion, to be severely censured. A fracture is an injury, necessarily attended with a great deal of pain, aud followed by more or less swelling and inflammation ; and to increase these evils by roughly, or unnecessarily handling the part, is ignorantly cured, (if I may use the expression) unsur- gical. In some kinds of fractures, the broken bone is so surrounded with thick fleshy parts, that it is difficult to feel a crepitus, or ascertain the existence of the injury. Some fractures of the neck of the thigh bone, un- attended with much retraction of the limb, are instances illustrative of this observation. 4. Prognosis of Fractures. The Prognosis of fractures varies, ac- cording to the kind of bone injured, what part of it is broken, the direction of the breach of continuity, and what other mis- chief complicates the case. Fractures of bones, which have many strong muscles in- serted into them, are more difficult of cure, than those of other bones, which have not so many powers attached to them, capable of disturbing the fragments. A fracture of the middle part of the long bone, is less dangerous, than a similar in- jury .near a joint. Fractures near joints may occasion a false anchylosis. Thus, in a fracture of the thigh-bone, near the con- dyles, the inflammation and swelling extend to the knee-joint, vvhich is affected with a FRACTURES &br» degree of stiffness that continues for a long while, and sometimes cannot be entirely cured during life. Besides, the inflamma- tion of the joint is attended with more se- vere symptoms, in consequence of the con- tusion having been more violent. In a fracture near an articulation, it is to be ob- served, also, that the splints have no com- mand over the short fragment, so that it is often difficult to prevent displacement. Hence, a fracture of the neck of the thigh- bone is considered a worse case, than a similar injury of the body of the bone. When a bone is fractured in several places, the case is more serious, and the difficulty of cure much augmented. But, the accident is still worse, when a limb is fractured in two different places at once; as, for instance, in the thigh and leg. Here it is almost im- possible to reduce the fracture of the thigh, and maintain the reduction well, so as to preserve the natural length of the limb. (Boyer, Traiti des Mai. Chir. T. 3. p. 29.) Oblique fractures are more troublesome, and difficult of cure, than transverse ones, because an oblique surface does not resist the retraction of the lower portion of the broken bone, and consequently it is very difficult to keep the ends of the fracture duly applied to each other. Fractures complicated with violent contu- sion of the soft parts, or with a wound ren- dering them compound, are much more dan- gerous, than others free from such accidents. The bad symptoms, which render com- pound fractures so dangerous, are of many kinds : hemorrhage ; violent and extensive inflammation ofthe limb, with extreme pain, delirium, and fever; large abscesses; gan- grene ; he. Fractures of the leg are gene- rally more serious, than similar injuries of the upper extremity. Tbe wound of a large artery may add considerably to the danger of a fracture. In a debilitated old man, a fracture is less likely to end well, than in a healthy child, or strong young subject. In extreme old age, the cure of a fracture is always more difficult, and sometimes impossible. (Boyer, T. 3, p. 32.) The scurvy certainly retards the formation of callus ; but, it is not true that jpregnancy always prevents the union of fractures. Some years ago, I attended for Mr. Ramsdens, a woman in a court, leading out of St. Paul's Church-yard, who broke both bones of her leg, when she was seven months gone with child. Her preg- nancy, however, did not appear to be at all unfavourable to the cure, as she got quite well in tbe usual time. " It is not generally settled," says a modern writer, " whether pregnancy should be accounted a complica- tion. I have, as well as some other practi- tioners, seen a pregnant woman get well of a simple fracture in the ordinary time." (Leviilli, Nouvelle Doctrine Chir. T. 2, p. 159.) And in another place he says, " Con- tre I'opinion de Fabrice de Hitden, I'expi- rience m'aprovvi que, chez les femmesgrosses, le cal ilait aussi prompt a se former, que chez fovle autre personve" (Op. dt. Tom. 2. p. 172.) The experience of Boyer aico tends to prove, that pregnancy is not unfavourable to the union of fractures. (See Traiti des Mai. Chir. T. 3, p. 32.) The cases in which fractures remain dis- united, will be considered in a future section ofthe present article. 5. Treatment of Fractures in general. The general treatment of fractures em- braces three principal indications. The first is to reduce the pieces of bone into their na- tural situation. The second is to secure and keep them in this state. And the third is to prevent any unpleasant symptoms likely to arise, and relieve them when they have come on. The first indication is only applicable to cases attended with displacement; for when the fragments are not out of their relative position, the surgeon must strictly retrain from all avoidable disturbance of the limb. His interference should then be limited to putting up the fracture, resisting the acces- sion of all unfavourable symptoms, and re- moving them, if possible, after they have taken place. 6. Of the Reduction of Fractures. The means employed for the reduction of fractures in general, are chiefly three, viz extension; counter-extension; and coapta- tion, or setting. But as Boyer remarks, these means should vary according to the species of displacement; and surgical writers have generalized too much in representing them nil three as necessary for the reduction of every kind of fracture. In fact, there are several cases, in vvhich extension and coun- ter-extension are positively useless : of this nature are fractures of the patella and ole- cranon, where the displacement consists of a separation of the fragments. Here the reduction may be accomplished, by putting the limb in a position, in which the muscles attached to the upper part of the bone are relaxed, and then pushing the upper frag- ment into contact with the lower. Extension signifies the act of pulling the broken part in a direction from the trunk, with a view of bringing tbe ends of the frac- ture into their natural situation. By coun- ter-extension, surgeons imply the act ol making extension in the opposite direction, in order to hinder the limb, or even the whole body, from being drawn along by the extending power, which would then be una- vailing. It was formerly recommended to apply the extending force to the lower fragment, and the counter-extension to the upperone. Such practice, indeed, was advised by Mr. Pott, and is still generally preferred in this country ; but upon the continent, it has been abandoned. The objections alleged against it by Boyerare; first,that itis frequent ly difficult and sometimes impossible, to take hold of the two fragments; as, for example. when the neck ofthe thigh-bone is broken. Secondly, that by applying the extension and rnnnW-evtensinn tn ,,lf> hroken b'vie- 516 I'RACTLRE- itself, most of the muscles, which surround it, are compressed, and such compression produces in these organs a spasmodic con- traction, which often renders the extension and counter-extension useless, and some- times even hurtful. (Traiti des Mai. Chir. T. 3, p. 34.) The French surgeons, there- fore, apply the extending force to that part ofthe limb, which is articulated with the lower fragment, and the counter-extension to that which is articulated with the upper. For instance, in a fracture of the leg, the extending means act upon the foot, and the counter-extending upon the thigh ; and in a fracture of the thigh, the extension is applied to the leg, while the counter-extending power fixes the pelvis. One circumstance must here occur to the mind of the surgical reader. In tbis coun- try, it is properly inculcated, that one of the first principles lo be attended to in the reduction of fractures, is to put the limb in such a position as will relax the most power- ful muscles connected with the broken bone; because these muscles principally impede the reduction, and disturb the ends of the fracture. But in the French mode of mak- ing the extension and counter-extension, how can this grand principle be observed ? If the extending and counter-extending means arc not to be applied to the broken bone itself; but to others, which are articu- lated with it, the limb must of necessity be kept in a straight posture at the time of re- ducing the fracture ; for, were the member placed in a half-bent state, the extension and counter-extension, as practised by the continental surgeons, would not be in the samejline. If, therefore, it be advantageous lo bend the limb at the time of reducing a frac- ture, the French mode of practising extension and counter-extension must be relinquished. I am not, however, one of those surgeons, who are entirely blinded with the idea of the possibility of relaxing the whole ofthe muscles, connected with the broken bone, by merely bending the limb. On the con- trary, I am perfectly convinced with De- sault, that in general, what is gained by the relaxation of some muscles, is lost by the tension of other*. But where it is possible to relax by a certain posture the set of mus- cles most capable of preventing the reduc- tion and disturbing the coaptation of a frac- ture, that posture I would select- Thus, in a fracture of the leg, the strong muscles of the calf undeniably possess this power, and the bent position, which relaxes them, ap- pears to me therefore the most judicious and advantageous, not only during the re- duction, but during the whole treatment of the case. A few years ago, I had under my care, in tbe military hospital at Canibray, a fracture of the tibia and fibula, which was at first treated in the straight posture. The gentlemen who assisted me, reduced the fragments,and made themlie tolerably well. But every time the bandage was opened, the bones were always found displaced again. Finding that this inconvenience went on for two or three weehs. we re- ;o'ved to lay the limb on its outside, in the bent position. Not the least trouble wasa: terward experienced in keeping the frag- ments reduced. Unless, therefore, the i tuation of a wound, abscess, or some parti- cular reason indicate an advantage or con- venience from the straight posture, 1 always reduce a fractured leg in the best position, which will be hereafter described. Here, therefore, I consider tbe French mode of making the extension and counter-exten- sion as generally inadmissible. I was also formerly of opinion, that the bent position ofthe limb on its side, as ad- vised by Mr. Pott, was the best for fractured thighs; but this sentiment has subsequently appeared to me erroneous, and it gives me pleasure to have this opportunity of decla- ring my entire conversion to the principles and practice adopted in these cases by De- sault, and other eminent continental sur- geons. Tbe considerations which have led me to this change, will be related in speak- ing of fractured thighs. If then the straight posture be advantageous in cases of broken thighs, I think it will be universally allowed, that the parts of the limb, recommended by the French surgeons for the application of tbe extension and counter-extension, are the most proper. The evils and difficulties formerly encoun- tered in setting fractured limbs, undoubtedly proceeded inagreat measure from the violen' extension and counter-extension practised by our ancestors. As they were ignorant of the utility of relaxing the muscles, which displaced the ends ofthe broken bone, they had no means, but the employment of actual force, to effect the reduction. Since, how- ever, the excellent instructions, contained in Mr. Pott's remarks on fractures, have re- ceived all the attention due to them, practi- tioners have generally been careful, in the reduction of fractures, to incapacitate thf: muscles as much as possible by relaxing them, and thus the necessity for the employ- ment of violent extension and counter-ex- tension is effectually removed. It is difficult to lay down rules, respecting the precise degree of force which should be used in making extension ; for it must vary- in different cases, according to the species of displacement, and the number and power of the muscles concerned in producing it. In transverse fractures, displaced only ac- cording to the diameter of the bone, a very- moderate extension suffices, as it is merely practised with a view of lessening the fric- tion of the surfaces of the fracture, which are always more or less rough. But what- ever be the direction of thelracture, when the fragments ride over each other, the ex- tension and counter-extension must con- stantly be such as to remove the shortening of the limb, and overcome the force of those muscles, which, after all attention has been paid to their relaxation, still oppose the re- duction. Extension, however, ought never to be practised in a violent and sudden way ; but in as gradual a manner as possible, the utmost care being taken not to shake, not- even move the limb any more than can be avoided. When the practitioner emends n FRACTURES 517 broken member all at once violently, he excites the muscles to strong spasmodic ac- tion, and there is some danger of lacerating them, because their fibres are not allowed tbe requisite time to yield to the force, which elongates them. The extension is to begin in the direction of the lower fragment, and be continued in that, which is natural to the body ofthe bone. In every case of fracture with displace- ment, as soon as the necessary extension has been made, the surgeon is to endeavour to place the ends of the broken bone in their natural situation : this is termed coaptation, or setting. This operation is to be underta- ken in different ways, according to the spe- cies of displacement, and the practitioner can almost always execute it byaclingupon the lower fragment, without applying his fingers directly to the fracture itself, in order to regulate the contact of the extremities of the bone. When, however, it is judged ne- cessary for this purpose to touch the broken part itself, it should be done with the utmost gentleness, so as to avoid pressing the soft parts against .the points and splinters of bone. Although the reduction of fractures may in general be accomplished with tolerable facility, it sometimes happens, that the first attempts fail. This is occasionally ascriba- ble to (heemployment of too much force,and too little management, in making the exten- sion ; so that the muscles are irritated, and act so powerfully, thatthe design of the sur- geon is completely frustrated. Here, the grand means of success is putting the limb into such a position, as will relax the most powerful muscles, which oppose the reduc- tion. Sometimes,however, the irritable and convulsive state of the muscles is not the ef- fect of any wrong mode of proceeding on the part of the surgeon ; but arises from the alarm, pain, and injury, caused by the acci- dent itself. Here relaxing the muscles as much as possible is also tbe most likely me- thod of removing the difficulty. In short, now that the utility of paying attention to this principle is universally known in the profession, a fracture is hardly ever met with, which cannot be immediately reduced; particularly if a copious bleeding be premi- sed when the patient is a strong muscular subject. This evacuation, indeed, will also prove for other reasons highly beneti-ial, where the limb is much contused and swol- len, and the tendency to inflammation is great. 7. Of the means for keeping Fractures reduced. After the bones have been put into their natural situation, time alone would complete their cure, were there not in the muscles a continual propensity to displace the ends of the fracture again. In cases of fracture, these organs are often affected with involun- tary spasmodic action, by which the broken part wrould certainly be displaced, were no measures taken to maintain the extremities of the broken bone in contact. Besides, the patient in easing himself, coughing, sneez- ing, he. must unavoidably subject the limb to a degree of motion by whicb the coapta- tion would be altogether destroyed. Hence, the necessity of employing means for fixing the broken limb so effectually, that it may continue perfectly motionless during the whole time requisite for the union of the fracture. Tbis second indication is some- times troublesome and difficult, and, as Boy- er observes, it is in this part of the treat- «ent, that the surgeon has an opportunity evincing his skill and experience. The means employed for the fulfilment of this in- dication are, an advantageous position ; quietude ; bandages ; splints ; and various kinds of apparatus. In the treatment of all fractures, the posi- tion of the part, and indeed of the whole body, is a thing of material importance. Whenever the case is a fracture of the lower extremities, the patient should lie strictly in bed, until the callus is completely formed. It is likewise an advantage not to have the bed much more than a yard wide, because the surgeon and assistants cau then more conveniently get at any part of the limb. Feather beds are a great deal too soft and yielding -. a horsehair mattress is far prefera- ble. Boyer, indeed, is so impressed with the utility of letting the patient lie upon a surface, which will not sink, that he recom- mends two mattresses to be used, and a board to be laid under the upper one, from the hip to beyond the patient's foot. ( Traiti des Mai. Chir. p. 39, Vol. 3.) The most favourable position for a fractu- red limb, is that, in whicb all tbe muscles, passing over the fracture, and extending either to the lower fragment, or to that part of the limb which is articulated with it, are equally relaxed. The :<:;ired limb should also have firm support at every point, and its position ought to be regulated so tbat not only this object be carefully fulfilled, but at the same lime the chance of displacement from (he action of the muscles, or the v*. eight of the body, or part itself, may be diminished as much «:> possible. Tbe natural, or rather the most easy posi- tion of tbe limb, is (hat which is usually chosen oy a person who reposes himself, or who is sleeping; for then ail motion is sus- pended, and every j ~\r\ assumes tha( posture which is most congenial to it. In ih's con- dition, the limbs are not extended, nor yet entirely bent; but only in a moderate state of flexion. Hence, Boyer remarks, that a half-bent position of the limbs, i that vhicb is most natural, and that in which all the mus- cles enjoy an equal degree of relaxation, and, consequently, that it is, gei.erally speak- ing, the best for fractures. This posture, as Boyer observes, which was recommended by Hippocrates and Galen, has been highly ex- tolled by Pott, who appears to hove exagge- rated its advantages. Considered in a gene- ral way, it is without contradiction prefera- ble to every other position of the limb ; but its employment should be liable to excep- tions, as will be noticed in treating of parti- 518 FRACTURES. cular fractures. (See Boyer, Traiti des Mai. Chir. T. 8, p. 40.) In whatever position a broken limb is placed, (says this writer,) it should bear throughout its whole length equally and per- pendicularly upon the surface on vvhich it lies, and not be only partially supported*. When, for example, only the extremities of a frac- tured limb rest upon the bed, tbe weight of the limb itself will make it bend in the situa- tion of tbe fracture. Tbe limb will also qj rendered crooked, if the broken part be sup- ported, while the extremities of the limb (especially the inferior) sink lower by their own weight. The displacement of the frac- ture is not the only inconvenience arising from the limb being laid upon a surface where it is not every where equally well supported. The parts which do bear on this surface, experience a painful degree of pressure, which, if long continued, is apt to produce inflammation, and even sloughing of the integuments. Thus, in fractures of tbe leg, gangrene of the heel has sometimes arisen entirely from this cause. Such incon- veniences may be prevented by laying a fractured limb on a surface of correspond- ing form ; that is to say, on a surface vvhich is depressed where tbe limb has projections, and rises where il presents depressions. The surface should not be so hard as to annoy the patient, but yet it ought to be sufficiently firm not to yield to (lie weight of the litnh and apparatus. According to Boyer, the best pillows for tbe support of broken limbs, are stuffed with chaff of oats, a substance which he describes as far preferable to feathers, be- cause it more readily admits of being push- ed from the place where the limb is promi- nent to another situation w here the member presents a depression, or hollow ; and it has the advantages of being less heating than feathers, and less apt to spoil. In whatever position fractured limbs are placed, they ought to be kept perfectly quiet during the whole lime requisite for the union. If the broken bone be moved while the callus is forming, the surfaces of the frac- ture rub against each other, and (be process is disturbed ; aud, indeed, sometimes by re- peatedly moving the limb, the consolidation of fractures is entirely prevented, or, at least, rendered very slow and difficult. In order to maintain the limb in the right position, and in a state of quietude, and to preserve the fragments in proper contact with respect to each other, tbe surgeon is to cau- tion the patient to avoid moving at all more than can be helped, aud every cause likely to subject the limb to any kind of shock, or concussion, is to be removed. But, in parti- cular, it will be necessary to apply a reten- tive apparatus, usually consisting of some appiicatiou to the skin itself, bandages, splints, tapes, straps, ad buckles, soft pads, 8ic. (See Boyer, Traiti des Mai. Chir. T. 3, p. 42.) Upon the subject of the dressings, band- ages, he. whicb ought to be applied to frac- tures, no surgeon has written better than Mr. Pott, '■ The intention (says he; in applying any kind of external medicine to a broken limb, is, or ought to be, to repress inflammation, to disperse extravasated blood, to keep the skin lax, moist, and perspirable, and at the same time to afford some, though a very small degree of restraint or confinement to the fracture, but not to bind or press ; and it should also recalculated as much as possible to prevent itching, an herpetic eruption, or an erysipelatous efflorescence. At St. Bar- tholomew's hospital, We use a cerate made by a solution of litharge in vinegar, which, with soap, oil, and wax, is afterward formed into such consistence as just to admit being spread without warming. " This lies very easy, repels inflammation, is not adherent, comes off clean, and very seldom, if ever, irritates, or causes either herpes or erysipelas. But let the form and composition of the application made to tbe limb be what it may, one thing is clear, viz. that it should be put on in such manner, as that it may be renewed and shifted as often as may he necessary, without moving the limb in any mannei : it being certain, that when once a broken thigh or leg has been properly put (o rights and has been deposited properly on the pillow, it ought not ever to be lifted up or moved from it again without necessity, until the fracture is perfectly uni- ted ; and it is true, that such necessity will not very often occur." Such application having been made as the surgeon thinks right, the next thing to be done is to put on a proper bandage.—That former- ly used was what is commonly called a roller. This was of different lengths according to the smgeon's choice, or as it was used in the form of one, two, or more pieces. " By such kind of bandage three intentions are aimed at, and said to be accomplished, viz. to confine the fracture, to repress or pre- vent a flux of humours, and to regulate the callus, (see Duverney:) but whoever will reflect seriously on this matter, will soon be convinced, that although some sort of band- age is necessary in every simple fracture, as well lor preserving some degree of stea- diness to the limb, as for the retention of the applications, yet none, nor either of these three ends can be answered merely, or even principally, by bandage of any kind what- ever : and therefore, if this should be found to be true, that is, if it should appear, that whatever kind of deligation be made use of, it cannot be a principal, but only an accessa- ry kind of assistance, and that in a small de- gree, and very little to be depended upon, it will follow that such kind of bandage as is most difficult to be applied with justness and exactitude, such as is soonest relaxed and out of order, such a- stands most frequently « in need of renewal, and, in such renewal, is most likely lo give pain and trouble, must be more improper and less eligible, than one vvhich is more easily applied, less liable to be out of order, and which can be adjusted without moving the limb, he. " The best and mo»t useful bandage for a simple fracture of the le? or thigh, is what i« FRACTURES. 519 commonly knowu by the name of the eighteen-tailed bandage, or rather one made on the same principle, but with a little dif- ference in tbe disposition of the pieces. The common method is to make it so, that the parts which are to surround the limb make a right angle with that which runs lengthways under it; instead of which, if (hey are tai k ed on so as to make an acute angle, they will fold over each other in an oblique direction, and thereby sit more neatly and more se- curely, as the parts will thereby have more connexion with and more dependence on each other. In compound fractures, as they are called, every body sees and acknowledges tbe utility of this kind of bandage prefera- bly to the roller, and for very obvious and convincing reasons, but particularly because it does not become necessary to lift up and disturb the limb every time it is dressed, or every time the bandage loosens. " Tbe pain attending motion in a com- pound fracture, the circumstance of (be wound, and the greater degree of instability of parts thereby produced, are certainly very good reasons for dressing such wound with a bandage which does not render motion ne- cessary ; but I should be glad to know what can make it necessary, or right, or eligible, to move a limb in tbe case of simple frac- ture ? what benefit can be proposed by it ? what utility can be drawn from it? When a broken bone has been well set, and the limb well placed, what possible advantage can arise from moving it? surely none ; but, on the contrary, pain and probable mischief. Is it not the one great intention, to procure unition ? Can moving the limb every two or three days contribute to such intention ? must it not, on the contrary, obstruct and retard it ? Is not perfect quietude as necessary to- ward tbe union of the bone, in a simple as in a compound fracture ? It is true, that iu the one there is a wound which requires to be dressed, and the motion of the limb may in general be attended with rather more pain than in the other; but does motion in tbe simple fracture give ease, or procure more expeditious union ? " Every benefit then which can be sup- posed (o be obtained from the use of the common bandage or roller, is equally attain- able from the use of that vvhich I have just mentioned, with one additional, and, to the patient, most invaluable advantage, viz. that of never finding it necessary to have his leg ortbigh once, during tbe cure, removed from the pillow on which it has been properly de- posited. In short, to quit reasoning and speak to fact, it is (be constant practice at St. Bartholomew's, and attended with all possible success. We always use the eighteen- tailed bandage ; and never move the limb to renew or adjust it." (Pott's Remarks on Fractures, fa.) In France, an universal preference is given to Scultetus's bandage in every instance where we employ the eighteen-tailed one, from which it chiefly differs in being com- posed of separate pieces admitting of remo- val, so that when a part of the bandage is soiled, it can be taken away, without disturb- ing the whole of tbe dressings. The clean pieces are firs* stitched to those which are about to be removed, and then they are drawn under the part. In cases of com- pound fracture, where the bandage is soiled with the discharge in a very short time, and must be often removed, certainly Scultetus's bandage is the best, particularly as it pos- sesses all tbe recommendations peculiar to that of the eighteen-tailed kind. (Boyer, Traite des Mai Chir T.3,p.46.) With respei-l to the general objects and uses of bandages in cases of fracture, I ought to notice one design of them, which is strong- ly inculcated in the modern French schools : namely, thai of '' benumbing the irritability of the muscles" by the compression result- ing from their regular and even application to the whole of the member. In describing the treatment of particular fractures, I shall have occasion to advert to the examples in wbir.h a moderate general compression of the muscles may be attended with utility. " The parts of tbe general apparatus for a simple fracture, which come next in order, (observes Mr. Pott,) are the splints ;" which are unquestionably the most efficient of all the applications made to a broken limb, with a view of keeping the ends of the fracture steady and in a proper state of contact. Without them, the surgeon would in vain endeavour to maintain the reduction. " Splints," says Pott, " are generally made of pasteboard, wood, or some resisting kind of stuff, and are ordered to be applied length- ways on the broken limb; in some cases three, in others four; for the more steady and quiet detention of the fracture. " That splints, properly made and judi- ciously applied, are very serviceable, is be- yond all doubt; but their utility depends much on tbeirsize, and tbe manner in which they are applied. " The true and proper use of splints is to preserve steadiness in the whole limb, with- out compressing the fracture at all. By the former they become very assistant to the cu- rative intention ; by the latter they are very capable of causing pain aud other inconve- niences ; at the same time that tbey cannot, in tbe nature of things, contribute to the steadiness of the limb. "In order to be of any real use at all, splints should, in the case of a broken leg, reach above the knee and below the ankle ; should be only two in number, and should be so guarded with tow, rag, or cotton, that they should press only on the joints, and not at all on tbe fracture. " By this they become really serviceable : but a short splint, which extends only a little above and a little below the fracture, and does not take in the two joints, is an absur- dity, and, what is worse, it is a mischievous absurdity. " By pressing on both joints, they keep not only them but the foot steady ; by press- ing on the fracture only, they cannot retain it in its place if the foot be in the smallest degree displaced ; but they may, and fre- 62U FRACTURES. quently do, occasion mischief, by rudely pressing the parts covering the fracture against the edges and inequalities of it. " In the case of a fractured os femoris, if the limb be laid in an extended posture, one splint sbould certainly reach from the hip to the outer ankle, and another, (somewhat shorter) should extend from the groin to the inner a.ikfo. In the case of a broken tibia and fibula, there never can be occasion for more than two splints, one of whicb should extend from above the knee to be- low the ankle on one side, and the other splint should do the same on the other side. (See Remarks on Fractures and Dislocations, in Pott's Chirurgical Works, Vol. 1, p. 298, fa. Edit. 1808.) Assalini strongly disapproves of the em- ployment of all tight bandages, and of cover- ing the whole of a broken limb with splints. He was called to a gentleman of rank at Pa- ris, who had broken the knee-pan trans- versely. He laid the limb upon a concave splint, which was adapted in shape lo the under surface of a part ofthe leg and thigh. No bandage was used, merely two leather straps, which crossed upon the knee, and included the fractured bone. A perfect bony union was thus easily effected. As- salini afterward extended the use of a concave splint, applied under the limb, to fractures of the leg and thigh In the first of these cases, however, only the thi^h is received in the hollow splint, and from this two branches, or lateral splints, go along the leg. The apparatus has also a kind of sole for the support of the foot. As this simple contrivance is fastened with a very few straps, and no plasters or bandages are used, the surgeon has constantly a view of the whole front ofthe limb, and ofthe frac- tured part of it, which Assalini thinks a great advantage. In compound fractures, he puts no other dressings on the wound but linen compresses, which are kept continually wet with cold water. (Manuale di Chirurgia, parte prima, 1812.) For further observations on the subject, see Splint. In oblique fractures of the thigh, and sometimes even in those of the leg, the dif- ficulty of accomplishing by the ordinary means a cure free from deformity, and espe- cially without a shortening ofthe limb, has led to the idea of employing continual ex- tension. This expression implies the ope- ration of a bandage, or machine, vvhich con- tinually draws the fragments of the broken bone in contrary directions, at the same time that it restrains them from gliding over each other, and maintains them in contact during the whole time necessary for their union. In England this practice has long been relinquished. It appears to have been chased away by the dazzling theory of re- laxing every muscle in such manner as to render it incapable of displacing an oblique fracture; a theory with which the surgeons of this country were but too much blinded by the persuasive eloquence ofthe late Mr. Pott. Desault saw at once, how ever, every inconsistency in the doctrine of relaxing ' Sur la Gangrene Traumatiqut,n which was published a few years ago by Baron Larrey, contains the inof.t de- cisive facts in regard to the propriety of such practice. (See his Mim. dt Chir. Mitituire, T. 2.) And the experience of Mr. Lawrence tends also to confirm the truth of Larrey's Observations. (See Med. Chir. Trans. tot. fs/>. HM.fo) enable me to judge, or as I may from thence be permitted to dictate, / would advise thdt such attempt should never be made ; but, the first opportunity having been neglected, or not embraced, all the power of the chirur- gie art is to be employed in assisting nature to separate the diseased part from the sound; an attempt which now and then, under par- ticular circumstances, has proved successful, but which is so rarely so, as not to be much depended upon. " If the parts are so bruised and torn, that the circulation through them is rendered impracticable, or if the gangrene is the im- mediate effect of such mischief, the conse- quence of omiting amputation, and of at- tempting to save the limb is, as I have al- ready observed, most frequently very early destruction : but, if the gangrenous mischief be not merely and immediately the effect of the wounded state of the parts, but of high inflammation, badness of general habit, im- proper disposition of the limb, he. it is sometimes in our power so to alleviate, cor- rect, and alter these causes, as to obtain a truce with the disease, and a separation of the unsound parts from the sound. The means whereby to accomplish this end must, in the nature of things, be varied ac- cording to tbe producing causes or circum- stances: tbe sanguine and bilious must be lowered and emptied ; the weak and debili- tated must be assisted by such medicines as will add force to the vis vitce; and errors in the treatment ofthe wound or fracture must be corrected ; but it is evident to common sense, that for these there is no possibility of prescribing any other than very general rules indeed. The nature and circumstan- ces of each individual case must determine the practitioner's conduct. " In general, inflammation will require phlebotomy and an open belly, together with the neutral antiphlogistic medicines; pain and irritation will stand in need of anodynes, and the Peruvian bark, joined, in some cases and at some times, with those of tbe cooling kind, at others with «he cordi- al, will be found necessary and useful. So also tension and induration will point out the use of fomentation and warm relaxing eataplasms, and the most soft and lenient treatment and dressing." Mr. Pott then offers many just observa- tions against stimulating antiseptic applica- tions to the wound and scarification of the limb, as practised while the gangrene is forming. The custom of using stimulating dressings to bad compound fractures first began in cases produced by gunshot, and had its foundation in the opinion, that gun- shot wounds were poisonous, and that the mortification in them was the effect of fire ; a doctrine and practice now completely ex- ploded. " A gunshot wound (says Pott) whether with or without a fracture, is a wound accompanied with the highest de- gree of contusion, and with some degree of laceration ; and every greatly contused and lacerated wound requires the same kind of treatment which a gunshot wound doc*. &2S FRACTURES. as far as regards the soft parts. The inten- tion in both ought to be to appease pain, irritation, and infl mmation." " Scarification, in the manner, and at the time, in which it is generally ordered and performed, has never appeared to me to have served any one good purpose When the parts are really mortified, incisioas made of sufficient depth will give discharge to a quantity of acrid and offensive ichor; will let out the confined air, which is the effect of putrefaction : and thereby will con- tribute to unloading the whole limb; and they will also make way for the application of proper dressings. But while a gangrene is impending, that is, while the parts are in the highest state of inflammation, what the benefit can be which is supposed or expected to proceed from scratching the surface of the skin with a lancet, I never could ima- gine ; nor, though I have often seen it prac- tised, do I remember ever to have seen any real benefit- from it. If the skin be still sound, and of quick sensation, the scratching it in this superficial manner is painful, and adds to the inflamed state of it; if it be not sound, but quite altered, such superficial in- cision can do no possible service ; both the sanies and the imprisoned air are beneath the membrana adiposa; and merely scratch- ing the skin in the superficial manner, in which it is generally done, will not reach to, or discharge either. " From what has been said, it will appear, that there are three points of time, or three stages, of a bad compound fracture, in which amputation of the limb may be necessary and right; aud these three points of time are so limited, that a good deal of the ha- zard or safety of tbe operation depends on the observance or nonobservance of them. "Tbe first is immediately after the acci- dent, before inflammation has taken posses- sion ofthe parts If this opportunity be ne- glected or not embraced, the consequence is either a gangrene or a large suppuration, with formation and lodgment of matter. If the former of these be the case, the opera- tion ought never to be thought of, til', there Is a perfect and absolute separation of the mortified parts.* If the latter, no man can possibly propose tbe removal of a limb, un- til it be found, by sufficient trial, that there is no prospect of obtaining a cure without; and that, by not performing the operation, the patient's strength and life will be ex- hausted by the discharge. When this be- comes the hazard, the sooner amputation is performed the better. In the first instance, the operation ought to take place before inflammatory mischief is incurred ; in the second we are to wait for a kind of crisis of * Compound fractures are cases of external violence. Now as tbe mortification proceeds from tbe injury, and may not be connected with any internal cause, it is an example of what Larrey ca'lsthe "Gungrene Trnuma- tigut, and the question whether the surgeon ought to be governed by the old majimof delaying amputation, until the spreading of the mortification has ceased, yet remains unsettled. Wore tbe patient of a sound con- stitution, and not too far gone, I should not fear to imi- tate Larrey, aud amputate though the mortification »vere aotiraltv in a spreading state such inflammation ; in the third, the pro|>oi'-' tional strength and state of the patient, compared with the discharge and state of the fracture, must form our determination." (Pott's Remarks on Fractures.) 6. Of the Formation of Callus, the Consoli- dation of Fractures, and of the Case* in which they remain without t'mon. In the treatment of fractures, the whole business of the surgeon consists in putting the displaced extremities of the bone into their natural situation again; in keeping them in this situation by means of a suita- ble apparatus ; in endeavouring to avert un- favourable symptoms, and in adopting mea- sures for their removal, when they have actually occurred. The consolidation of a broken bone is (strictly speaking) the work of nature, and is effected by a process, to which a state of perfect health is above all things propitious. This consolidation of a broken bone, which is analogous to the union of wounds of the soft parts, is termed the formation of the cal- lus, and the new uniting bony substance it- self is named callus. 1. Of the Time requisite for the Formation of the Callus, and of general circumstances, which favour, retard, or even completely prevent it. Surgical writers have been absurdly anx- ious to specify a determinate space of time, which should be allowed for the formation of the callus, as if this process always went on in diflerent cases with the same uninter- rupted regularity. Forty days were often fixed upon as necessary for the purpose. This prejudice is not only false, but danger- ous, inasmuch as patients have been there- by induced to suppose themselves cured, before they were so in reality, and have consequently moved about too boldly, and thus run the risk of occasioning deformity, or a new fracture. As Boyer observes, it is impossible to determine precisely, and in a general way, the period requisite for the cure, because it differs according to a vari- ety of circumstances. All we know is, that the callus is usually formed between the twentieth and seventieth day, sootier or la- ter, according to the age and constitution of the patient, tbe thickness of the bone, the weight which it has to support, the state of the patient's health, he. 1. Age. Fractures are consolidated (cate- ris paribus) with more, ease and quickness in young subjects, than in adults, or old per- sons In general, also, the callus forms more speedily in proportion as the individu- al approaches to infancy. In two children, whose arms had been broken in difficult la- bours, De la Motte saw the humerus united in twelve days, by a very simple apparatus. In fact, at this period of life, every part has a tendency to grow and develope itself, and the vitality of the bones is more active, their vascularity greater,theirgelatinoussubstance more abundant. On the contrary, in advan- ced age, the parts have lost all disposition fo developement,the vascularity of the bonef vvhich are preserved in my museum." (Boyer, T. 3, p. 94.) And in another pbue, ihe same Professor, speaking of these false joints, re- marks: '' I repeat that I have never found, in their structure any thing which could be compared with an articulation ; neither cap- sular ligament, nor smooth cartilaginous sur- faces. On the contrary, I have invariably found in the false joints ol the thigh-bone and humerus, which I have had opportuni lies of dissecting, a fibrous ligamentous sub- stance extending from one fragment to the other, and it is very probable, that, with some modifications, it is the same with all the other cases vvhich I have not seen. " But in the fore-arm, the ends of the frac- ture may assume a structure which bears a greater resemblance to an articulation. This is what happened in an example, vvhich was L-omttuiniraied lo Bayle by Sylvestre, in (he Republiqne des Letlres, Juillei 1685 p. 718, ^c. A similar case is recorded by Fab-icius Hildanus. Obs. 91 Centur. 3." (Boyer, Traiti des Mid. Chir. T. 3, p. 101—103.) On this subject, Langenbeck observes, that the edges of the fragment heal, and resem- ble those of a harelip. " When the parts are incessantly moved, the end of on«- fragment becomes excavated in the form ot an articu- lar cavity, i have in my poj-ession (says he^ a lower jaw, and an olecranon, the fra<> 534 FRACTURES tures of whicb are not united. For the con- necting medium, nature has provided a white substance, resembling ligament. In a male patient, I have also seen an articular con- nexion established in ihe body of the thigh- bone, subsequently to a fracture." (Neue Bibl. B. 1, p. 93) When a capsule is lorm- ed, it is alleged not to be of a ligamentous nature. (Bichat, Anatomic Ginirale, T. 3, p. 191.) In the Hunterian Collection may be seen a false joint in the bones oi the fore-arm, where the resemblance to a natural articulation was greater than what Boyer has seen in other situations. A valuable dissertation on false joints has been published by Reisseisen, entitled " De Articulationibus analogis, quafraduris ossi- um superveniunt;" but I am sorry lhat it has not been in my power lo meet with a copy of it. A false joint in the arm, or fore-arm, does not absolutely prevent the motion of tbe limb, which may yet be of considerable use ; but when the disease is in the thigh, or leg, the member Ci-nnot support the weight ofthe body, and the patient is unable to walk with- out crutches. The-diversity of causes which may be con- cerned in preventing the union of fractures, plainly shows, that the treatment should be different in different cases. When the wai-t of union is ascribable to the ends of the fracture not being in a state of coaptation, and to their having been moved about loo frequently, the obvious in- dications are, to set the lracture belter, and to take adequate measures for keeping its extremities in contact and perfectly motion- less. If the union has been prevented by a por- tion n ples-of which accident have been re> emlv published. (A. Cooper's Surgical Essays. Part l.p. 49, &,.-.) During my apprenticeship at St. Bartholo- mew's Hospital, several instances occurred, in which the os ilium, os ischium, and os pu- bis, were found fractured on opening the bo- dies after death ; and, when the great vio- lence necessary to produce the accident is considered, we cannot wonder that the inju- red state of the pelvic, viscera should fre- quently prove fatal. Fractures ofthe ossa in- nominata are unavoidably attended with more or less contusion of the soft parts on the outside of the pelvis, and when the vio- lence has been very great, the pelvic viscera may be seriously bruised, crushed, or lace- rated ; and the large nerves, contained in the pelvis, or the spinal marrow itself, inju- red : hence, extravasation of blood in the cellular membrane of the pelvis, ecchymo- ses deeply situated even in the substance of the muscles, or other organs, injury of the kidneys ; complete loss of motion, a paraly- sis of the lower extremities ; discharge of blood, or a black bilious matter by vomiting, or stool either immediately, or at more or less distant periods from that of the acci- dent ; retention of urine; fever; painful tension of the abdomen, from inflammation of the peritoneum and bowels ; the forma- tion of abscesses, which are sometimes of great extent; sloughing ; and death. (Boy- er, Traiti des Mai. Chir. T.3,p. 154.) As the same author has observed, the vio- lence, occasioning a fracture of the ossa innominata, may produce a displacement of the fragments, and carry them more or less away from their natural situation When the pubes, orischium.is broken, tbe splinters may be propell d hito the canal of the ure- thra, or even through the bladder, and give rise to extravasation of the urine, or by merely compressing these organs, this may cause more or less interruption of their func- tions. But, unless the fragment- be displa- ced by the same force, which caused the fracture, they can hardly be drawn out of their place by any other circumstance, since they are retained by the muscles being at- tached to both fragments, and by surround- ing ligamentous expansions. Owing to the deep situation of fractures of the pelvis, and to there being no displace- ment, nor mobility of the fragments, the di- agnosis is sometimes attended with great difficulty. A suspicion of the accident may be entertained, when the pelvis has suffered great violence, the pati-nt experiences great agony, and all motion of the trunk and low- er extremities is difficult and painful. Un- der these circumstances, if the fracture should be in tbe ilium, especially its upper and front portion, or in the os pibis, the mo- bility of the fragments, or even a crepitus, may be distinguished in a thin subject, if when he is lying horizontally, with histh;ghs and legs bent, and his head and chest eleva- ted, the projecting part of the os innomina- tum be taken hold of, and an attempt be made to move the fragments in opposite di- rections. In this business, however, one caution is given by Boyer, viz. not to mis- take the crepitation ofan emphysema, often attending large extravasations of blood, for the grating of the fractured bone. In cases, in which the fracture affects a part of the os innominatum very deeply pla- ced, and it is limited to a single point «»f the os pubis, or the ischium, so that no detached moveable fragment has been produced the exact nature of the case is rarely made oat with certainty, before the patient's death, and the dissection of the parts. Fractures of the ossa innominata may be generally deemed cases, accompanied with serious danger. When the fragments are displaced, and do not admit of being recti- fied again, the disorder arising from thid cause, may have fatol consequences. And. 542 FRACTURES. as Boyer observes, even when such displace- ment does not exist, these fractures are not the less to be apprehended, on account of the injury, which the spinal marrow and the nerves, vessels, muscles, and viscera within the pelvis are likely to have sustain- ed. These complications, which are almost inseparable from the fracture, may prove indeed directly fatal, or destroy the patient at a period more or less remote from the time of the accident Sometimes, howe- ver, the fracture is not extensive, and the vio- lence, which produced it, has not caused any very serious injury of the soft parts : but examples of this kind are uncommon. In these last cases, w bich are the most sim- ple, a cure of the fracture may be easily ef- fected by means of rest; a position in which all the chief muscles attached to the pelvis, are relaxed; discutieni applications; and a roller, or T bandage. (Boyer, Traiti des Mai. Chir. T. •>, p. 156.) Ihe grand indication is to obviate tbe consequences of inflamma- tion ofthe parts within the pelvis, and even ofthe peritonaeum and abdominal viscera. by copious and repeated blood-letting. Any complaints, respecting the evacuation of the urine and feces, must also receive immediate attention. When there is great contusion, and the bones are very badly broken, the patient cannot move nor go to stool, with- out suffering the most excruciating pain. To afford some assistance in such circum- stances, Boyer, in a particular case, passed a piece of strong girth web under the pelvis, and, collecting the corners into one, fasten- ed them to a pulley suspended from the top of the bed. This enabled the patient to raise himself with very little efforts, so that a flat vessel could be placed under him. It appears to me, that a bed, constructed on the principles recommended by the late Sir James Earle, mi/ht be of infinite service in these cases, as well as in many others, par- ticularly compound fractures and paralytic affections from diseased vertebrae. (See Ob- serrations on Fractures of the Lower Limbs; to winch is added, an account of a -ontrivance to administer cleanliness and comfort lo the bed ridden; by Sir J. Earle, 1807.) Mr. Earle has also exerted his mechanical inge- nuity with great success in the invention of a bed, admirably well calculated for the treatment of fractures, and other cases, in which it is an object of high importance, to enable the patient to empty the bowels with- out changing his position. Sometimes, notwithstanding the rigorous adoption of antiphlogistic measures, absces- ses ca.■■.not be prevented from forming in the pelvis ; particularly, when there are detach- ed splinters driven inwards These collec- tions of matter should be opened, as soon as a distinct fluctuation can be felt. The splint- ers may wound the urethra or bladder, and cause an extravasation. f urine. Desault ex- tracted a splinter, which had had this effect, from the bottom of a wound made forthe dis- charge of the effused urine. In these cases, a catheter should be kept introduced, in or- der to prevent the urine from collecting in the bladder, and afterward insinuating itself into the cavity of the abdomen. (Chopart.) The possibility of mistaking a fracture of the acetabulum for a dislocation ofthe thigh- bone, and the differences of these cases, as explained by Mr. A. Cooper, have been mentioned in the article Dislocation. FRACTURES OF THE THIGH. The os femoris is liable to be broken at every point, from its condyles to its very head ; but it is at tbe middle third of this ex- tent, that fractures mostly occur. The frac- ture is sometimes transverse, but more fre- quently oblique. The latter direction of the injury makes a serious difference in tbe difficulty of curing the case, without future deformity or lameness. Sometimes the fracture is comminuted, the bone being bro- ken in more places than one; and some- times the case is attended with a wound, communicating with the fracture, and ma- king it what is termed compound. As Petit re- marks, however, the thigh-bone is less sel- dom broken into several pieces, than other bones more superficially situated. A fractured thigh is attended with the fol- lowing symptoms ; a local acute pain at the instant of the accident ; a sudden inability to move the limb ; a preternatural mobility of one portion of the bone ; sometimes a very distinct crepitus, when the two ends of the fracture are pressed against each other ; deformity, in regard to the length, thickness, and direction, of the limb. The latter change, viz. the deformity, ought to be accurately understood ; for, having a con- tinual tendency to recur, especially in ob- lique fractures, our chief trouble in the treat- ment is to prevent it. (Desault, par Bichat, T. 1, p. 181.) Almost all fractures of the thigh are at- tended with deformity. When this is con- sidered, in relation to length, it appears, that, in oblique fractures, the broken limb is al- ways shorter than the opposite one ; a cir- cumstance denoting, that the ends of the fracture ride over each other. We may also easily convince ourseUes, by examination, that the deformity is owing to the lower end of the fracture having ascended above the upper one, which remains stationary. What power, except the muscles, can com- municate to the lower portion of the fractu- red bone, a motion from below upwards ? At one end, attached to the pelvis, and, at the other, to this part ofthe bone, the patel- la, the tibia, and fibula, they make the for- mer insertion their fixed point, and draw ing upward the leg, tbe knee, anil the lower por- tion ofthe thigh, they cause directly, or in- directly, the displacement in question. In producing this effect, the triceps, semitendi- nosus, serai-niambranosus, rectus, gracilis, sartorius, he. are the chief agents. Forthe purpose of exemplifying the pow- er ofthe muscles lo displace the ends ofthe fracture, mention is made, in Desault's works by Bichat, of a carpenier, who fell from a scaffold, and broke bis thieh. The FRACTURES. o43 limb, the next day, was as long as the other; but the man had a complete palsy of his lovy- er extremities, and could not discharge his urine. The moxa was applied, the muscles soon regained their power, and then the shortening of the limb began to make its ap- pearance. Besides the action of muscles, there is another cause of displacement. However firm the bed may be, on which the patient is laid, the buttocks, more prominent than the rest of the body, soon form a depression in the bedding, and thence follows au incli- nation in the plane on which the trunk lies, which, gliding from above downward, push- es before it the upper end of the fracture, and makes it ride over the lower one. The muscles, irritated by the points of bone, in- crease their contraction, and draw upward the lower part of the bone ; and, from this double motion of the two ends of the frac- ture in opposite directions, their riding over each other results. (Desault, par Bichat, T. l,p. 183, 184.) Transverse fractures are less liable to be displaced in the longitudinal direction of the bone, because, when once in contact, the ends of the fracture form a mutual resist- ance to each other ; the lower end, drawn upward by the muscles, meets with resist- ance from the upper one, which being itself inclined downward by the weight of the trunk, pushes the former before it, and thus both retain their position in relation to each other. The deformity of a fractured thigh, in the transverse direction, always accompanies that which is longitudinal : but, sometimes, it exists alone. This is the case, when, in a transverse fracture, the two ends of the bone lose their contact ; one being carried out- ward, the other in ward ; or, one remaining in its place, while the other is separated. The upper end of the fracture is not now, as in the foregoing instance, motionless in regard to the muscular action ; the contraction of the pectineus, psoas, iliacus internus, and up- per part of the triceps, draws it from its na- tural direction, and contributes to displace it. The deformity of the limb, in regard to its direction, is either the consequence of the blow, which produced the fracture, or, what is more common, of the ill-directed ex- ertions of persons who carry the patient. Thus we see, that an injudicious pos'ture bends the two portions, so as to make an angle. Whatever may be the kind of deformity, the lower end of the fracture may retain the natural position in which it is placed, or else undergo a rotatory motion on its axis out- ward, which is very common, or inward, which is more unusual. This rotation al- ways aggravates the displaced state of the fracture, and should be attended to in the reduction. (Desault, par B.chal, T. 1, p. 185.) Every one at all initiated in the surgical profession knows, that there are two very different methods of treating fractured thighs. Tn one, which was recommended and prac- tised by Desault, and is still universally pre- ferred in France,the limb is kept in a straight extended position. In the other, the limb is laid upon its side, with the knee bent, a mode, which was extolled by the celebrated Mr. Pott, and since his time has found many partisans in tbis country. To these two po- sitions for fractured thighs may now be add- ed that, in which the patient lies upon bis back, with his thigh and leg in the bent po- sition, supported on two oblique planes, or surfaces, the apex, or angle of which is be- neath the ham. This last position, howe- ver, has been more particularly recommend- ed for fractures of the neck of the femur, though, if it be advantageous for them, I see no reason for not giving it a fair trial in other fractures of that bone. That Mr. Pott has lost sight of certain ad- vantages of the straight position ; that he was blind to the imperfections of the bent posture ; and that he exaggerated the power, which we have of relaxing all the muscles of a limb bv position ; few reflecting sur- geons of the present day will be inclined to deny. Were we to resign the privilege of think- ing for ourselves, and implicitly to mould our opinions, according to any authority, however high, we should often fall into very avoidable errors. Were we to believe the literal sense of several passages in Mr Pott's remarks upon fractures, we should suppose it possible and practicable to relax at once, by a certain posture ofthe limb, every mus- cle connected with a fractured bone. In the first vol. of his works, page 389, edit. 1783, he observes, in speaking of whit must best answer the purpose of incapacitating the muscles from displacing the fracture: " Is it not obvious, that putting tbe limb into such position as shall relax the whole set of muscles, belonging to, or in connexion with, the broken bone, must best answer such purpose?" and,in the next page," What is the reason why no man, however superfi- cially acquainted with his art, ever finds much trouble in setting a fractured os hu- meri ? is it not because both patient and surgeon concur in putting the arm into a state of flexion, that is, into such a state as relaxes all the muscles surrounding the broken bone ?" Also in page 393, he con- tinues, " Change of posture must be the remedy, or rattier the placing the limb in such manner as to relax all its muscles." That to have all the muscles relaxed in cases of fracture would be desirable, were it also practicable, every one will admit; but the possibility of accomplishing it, so long as different muscles have different uses, differ- ent situations, and different attachments to the bones, every one must grant to be no more than visionary. For instance, do not the patient and surgeon, in the ease of frac- tured os humeri, adverted to above, rather concur in putting the fibres of the triceps and anconeus into a state of tension, at the same moment that they relax the biceps and brachialis internus r The position of .the fractured os frvnori.<» 541 FRACTUKFs says Mr. Pott, should be on its outside, rest- ing on the great trochanter, the patient's whole body should be inclined to the same side ; the knee thould be in a middle state between perfect flexion, orextension, or half bent; the leg and foot, lying on their out- side' also, should be well supported by smooth pillows, and should be rather higher in their level than the thigh ; one veiy broad splint of deal, hollowed out and well cover- ed with wool, rag, or tow, should be placed und- r the_thigh, from above the trochanter quite below the knee; and another some- what sh'rter should extend from the groin below the knee on the inside, or rathetin this posture on the upper side. The bandage should be of the eighteen tail kind, and when the bone has been set, and the thigh 'well placed on the pillow, it should not without necessity, (which necessity in this method will seldom occur) be ever moved from it again, until the fracture is united ; and this union will always be accomplished, In more or less time, in proportion as the limb shall have been more or less disturbed. (Pott.) Here only two splints are mentioned; the surgeons ofthe present day usually employ four. After placing Hie patient in a proper position, the necessary extension is to be made. Then the under-splint, having upon it a broad soft pad, and an eighteen-tailed bandage, is to be laid under the thigh, from the great trochanter to the outer condyle. The surgeon, before applying the soap plas- ter, laying down the tails of tbe bandage, and putting on the other three splints, is to take care that the fracture lies as evenly as possible. In the position for a fractured thigh, Mr. Pott, we find, directs the leg and foot to be rather higher in their level than the thigh ; with what particular design, I have not my- self been able to make out. Whoever me- ditates upon the consequence of elevating the leg and foot above the level of the thish, in the bent position, will know, that it is to twist the condyles of the os femoris more outward than is natural When a patient is placed, according to Mr. Pott's direction, upon a common bed, the middle soon sinks so much that the leg becomes situated very considerably higher than the thigh, and t am disposed to think that this is one cat s", vv hy so many broken thighs are united in so de- formed a manner, that tbe foot remains permanently distorted outw.ard. The great propensity of the triceps, and other muscles to produce this effect, may also serve to ex- plain the frequency of the deformity. It is not merely the depression of the middle ofthe bed vvhich is disadvantageous: as the weight of the patient's body falls more upon one side of the bed, than the other, in.the bent position ofthe limb, unless the sacking be tight and . te mattress very firm, it hap- pens, that suc;( a declivity is formed, as to render it exceedingly difficult, if not imprac- ticable, to make the patient continue duly upon his side. It cannot be enjoined too forcibly, the* fractured thighs should alwavs be laid upon beds not likely to Milk mua, When this happens, no rational dependence can be put in the efficacy of the bent posi- tion, and, as Desault has explained, the same thing is hurtful also in the straight posture. The most enthusiastic advocates for the bent position must allow, that it leaves the leg and foot too moveable and unsupported, and that though it may relax the muscles, whicb have the most power to disturb the coaptation of a fractured thigh, it yet leaves a mass of muscle unrelaxed, quite sufficient to displace the ends of the bone. Hence, practitioners should endeavour to improve the apparatus employed, so that it may make a permanent resistance to the action of the muscles, and in tbe straight position such resistance may certainly be practised with most effect and convenience. The whole tenor of Mr. Pott's observa- tions on fractures would lead one to suppose, that from the moment a muscle is partially relaxed, it becomes incapable of acting on, or displacing a fracture. But, if this were correct, (which it cannot be) we should not have the power of completely bending, or extending our limbs ; for as soon as the set of muscles, designed for this purpose, were partly relaxed by the half-flexion, or balf- extension of the joint, they would be de- prived of all further power. Therefore, in addition to the arguments to be brought against the bent posture, arising from its not actually relaxing all the muscles connected with tne broken bone, we are also to take into the account the fact, that the partial relaxation of any muscle by no means inca- pacitates it from acting. In the earlier editions of this Dictionary, I expressed a preference to. Mr. Pott's me- thod of treating broken thighs. More ma- ture reflection, however, and subsequent experience, have made me a convert to the sentiments of Desault on this subject. The terrible compound fractured thigbs, which I had under my care in the campaign in Holland in the year 1814, could not have been at all retained by any apparatus put merely upon the thigh itself. Ihe superio- rity of lone splints, extending the whole length of the limb, was in these cases parti- cularly manifest With such splints which maintain steady the fracture itself, the knee, leg, ankle, and foot, your patient may, in fact, even be removed upon an emergency from one place to another, without any considerable disturbance of the broken part. But, how could this be done in the bent position, with short splints, merely applied to the thigh, affording no support to the leg, and not confining the motions of the knee, and foot ? There are some excellent remarks on the treatment of fractured thighs in Les (Euvrcs Chirurgicales de Desault par Bichat. It is observed, that, if we compare the natural powers of displacement with the artificial resistance of almost every apparatus, we shall find, that the disproportion between such forces i.= too grcft to Iff the form*"- FRACTURES 545 yield to the latter. The action ofthe mus- cles, however, which is always at first very strong, may afterward be gradually dimi- nished by the extension exercised on them. A power incessantly operating can effect, what another greater power temporarily applied, cannot at once accomplish, and the compression of circular bandages tends also to lessen the force ofthe muscles. Desault cured in the Hotel Dieu an im- mense number of fractured thighs, without any kind of deformity. It was particularly to the well-combined employment of exten- sion and compression of the muscles, that such success was owing." The advantage of keeping the muscles a long while extended, in order to diminish (heir power, is especial- ly evident in the reduction of certain dislo- cations, as those ofthe shoulder, in which we often cannot succeed till the muscles have been kept on the stretch for a greater or lesser time. The fracture of the patella and olecranon equally demonstrates the uti- lity of compression for the same purpose; as when the muscles are not compressed by the bandage, they draw upward the frag- ment of bone with double or triple force. Against reducing fractured thighs in the bent posture, Desault entertained the follow- ing objections: the difficulty of making the extension and counter-extension, when the limb is so placed; the necessity of then ap- plying them to the fractured bone itself, in- stead of a situation remote from the fracture, as, for example, the lower part of the leg ; the impossibility of comparing with preci- sion the broken thigh with the sound one, in order to judge of the regularity of its shape ; the irksomeness of this position long continued, though it may at first seem most natural; the inconvenient and painful pres- sure of a part of the trunk on the great tro- chanter of tbe affected side; the derange- ment, to which the limb is exposed when the patient has a motion; the difficulty of filing the leg firmly enough to prevent the effect of its motion on the thigh-bone; the manifest impossibility of adopting this me- thod, when both thighs are fractured ; lastly, experience in France having been little in favour of such posture. Also, what is gained by the relaxation of some muscles, is lost by the tension of others. For such reasons, (certainly strong ones,) Desault abandoned the bent position, and always employed the straight one, which was advised by Hippocrates, and all the Greek physicians. Petit, Heister, and Duverney, recom- mend applying the extending means just above the condyles of the os femoris. Du- pouy was one of the first to remark, that this practice rendered it necessary to em- ploy very great force, and that it would be better to make the extension from the foot. Fabre takes into consideration also the in- convenience of the pressure, made on the muscles, which, irritating and stimulating them to action, multiplies the obstacles to setting tho fracture. For nearly similar motives, Desanlt espoused their doctrine, VnT>. J. *> introduced it at the Hotel Dieu, and tbe success which he experienced from the practice, contributed materially to its more extensive adoption. Desault, as we have stated, preferred the straight posture, and laid his patients on surfaces, not likely to sink with the weight ofthe body. The feather beds, formerly in common use at the H6tel Dieu, had this in- convenience ; for these, in cases of frac- tures, Desault substituted a firm, tolerably hard mattress, which did not allow the con- tinual change of posture to occur, which a soft bed does. The object of every appara- tus being to keep the ends of the fracture from being displaced, the mechanism of every contrivance, for this purpose, should be directed against the causes of the dis- placement. These are, 1. the action ofthe muscles, drawing upward the lower end of the fracture; 2. the weight of the trunk propellingdownwardthe upper end. Hence, every apparatus, intended to prevent dis- placement of a thigh fractured obliquely, should, 1 draw and keep downward the lower end of the fracture ; 2. carry and maintain upward the upper end of the frac- ture, and the trunk, which is above it. This principle is of general application, and only subject to a few exceptions in transverse fractures, attended merely with displace- ment in the direction of the diameter of the limb, or else none at all. 3. There must also be in the apparatus a resistance to the rota- tion of the lower portion ofthe broken bone, so as to keep the limb steady, even.in case of any sudden motion. If we compare the operation of the dif- ferent pieces of our apparatus with thl above indications, we shall find, that without per- manent extension, they are not very effec- tual. With regard to bandages, whether a roller or eighteen-tailed bandage, be used, they all have one common mode of opera- ting; they press the muscles towards the ends of the fracture, so as to make them form a kind of natural case for the fracture, and thus they make lateral resistance against the parts. In this manner, bandages mate- rially aid in preventing displacement side- ways, and are particularly useful in trans- verse fractures. But, what is there to hindes the two inclined surfaces of an oblique frac- ture from slipping one over the other? What power is there to keep the limb from receiving the effects of accidental shocks'. Is the pelvis kept back ? Is the action of tbe muscles resisted P The latter is indeed some- what diminished by the pressure, and this is the chief use ofthe bandage : but, will such compression be enough to prevent the lon- gitudinal displacement of the broken bone, especially, if the bandage be applied slackly, as some advise ? These remarks apply also to compresses; petit moyen contre une grande cause. Splints are useful in firmly fixing the limb, and guarding it from the effects of accidental shocks, or of contractions of the muscles They operate more powerfully than ban dages, in preventing: latere! displacement. 646" FRACTURE*. and hence, they s-uttace for transverse frac- tures, without permanent extension. They also resist the rotation of the thigh outward, Or inward. But when the breach of dohti- nuity is oblique, will they hinder the ends of the bone from gliding over each other, and the consequent shortening of the limb? They obviously could only do so, by the friction of the different pieces of the appara- tus, especially the tapes, vvhich fasten it, and then, to make the resistance effectual, tbey must be tied so tightly as to create danger of mortification. Will the splints prevent the trunk from descending, and propelling before it the upper end of the fracture ? Will they hinder the action of tbe muscles on the lower end? Will tbey, in short, fulfil all the above indications? Their chief use is to prevent lateral displacement, and keep the limb steady. Hence, they should ex- tend along the leg, as well as the thigh, which cannot fail to be disturbed whenever the lower part of the limb is allowed to move. The pads serve principally to keep the limb from being galled by the splints, and their action in preventing displacement of the fracture must be but trivial. According to Desault, the ordinary pieces of apparatus, which do not execute any per- manent extension, may suffice for trans- verse fractures ; but they are always inef- fectual, when tbe division is oblique, be- cause they do not fulfil the twofold indica- tion of drawing downward the lower end of the fracture, and keeping the other one upward. Desault ascertained that the object parti- cularly to be aimed at, was such a disposi- tion that.tbe foot, leg, thigh, and* pelvis, should constitute but one w hole ; so lhat, though the different parts thereof might be drawn in different directions, yet they would still, with respect to one another, preserve the same mutual relation. He invented the following apparatus to answer these pur- poses. A strong splint, long enough to extend from the ridge ofthe os ilium to a certain length beyond the sole of the foot, is a prin- cipal part of this apparatus: this splint should be two inches and a half broad, each of its extremities being pierced in the form of a mortice, and terminating in a semi- circular niche. It is applied to the exterior side of the thigh, by means of two strong linen bands, each being more than a yard long. The middle part of one of these bands is to be applied to the inside of the thigh, at its upper part; its ends are brought to the exterior side of the thigh, passed through the mortice, and knotted on the semicircu- lar niche. Compresses are to be previously placed under the middle part of the band, in order to prevent any disagreeable pres- sure ; as well as on the tuberosity ofthe is- chium, which Desault considered as the principal point of action of this band. The inferior part of the leg is next covered with compresses, On which the middle part ofthe second band is placeu -. tne extremities ot this band cross on the instep and upper part of the foot, then on the sole, after which they are conveyed outward, and one end passed through the mortice and knotted with the other on the niche, with such a degree of force as to pull the inferior portion of the femur downward, and push the splint up- ward, and by this means, the pelvis, andsu: perior portion of the fractured bone. On the internal side of the limb is placed a se- cond splint, which extends from the superior part of the thigh, to a certain distance be- yond the foot. A third is placed on the anterior part ofthe limb from the abdomen to the knee. The superior extremities ofthe anterior and exterior splints are fixed by means of a bandage passed round the pel- vis. A band, the middle part of vvhich is placed under the sole of the foot, and the extremities crossed on its superior surfacpj and fastened to the splints, operates with them in preventing the foot from moving. Before applying the apparatus, Desault covered the whole limb with compresses, wet with a solution of the acetite of lead. Over these, Scultetus's bandage was put, and a roller round the foot, all wet with the same lotion. For more particulars, the reader is referred to the Parisian Chirurgi- cal Journal, Vol. 1 ; QZuvres Chir. de Desault par Bichat, T. 1; Rosalino Giardina Memo- ria sulla Fratture, con alune Modificazione all' Apparato di Desault. Svo. Palermo, IS 14 Boyer, Traiti des Maladies Chir. T. 3; Richerand, Nosogr. Chir. T 3, Edit. 4. Boyer's apparatus for fractured thighs is de- scribed in the 2d vol. of the First Lines of the Practice of Surgery, ed. 4. Instead of the position advised by Pott, or that recommended by Desault and Boy- er, Mr. C. Bell prefers the posture, in which the patient lies upon his back, with the limb supported in the bent attitude by means of a wooden frame. This machine is simple enough, consisting of boards, ten or eleven inches in breadth, one reaching from the heel to the ham, the other from the ham to the tuberosity of the ischium. Under the knee-joint, they are united at an angle, while a horizontal board connects their lower ends together. Thus they form two sloping surfaces, to which cushions are adapted, and over which the limb can be placed in an easy bent position. Near the edge of the inclined boards, holes are made, furnished with pegs. After the bone has been set, a long splint is applied from the hip to the side of the knee, and another along the inside of the thigh. (See Opera- tive Surgery, Vol. 2, p. 189.) 1 entertain a very favourable opinion of this mode of placing fractured thighs. However, the foregoing apparatus does not sufficiently se- cure the leg and foot from motion, though with the aid of a roller and afoot-board, this advantage might easily be obtained. The fracture apparatus, devised by my friend Mr Earle, isexcellently calculated for this mode of treatment, with these additional recom- mendations, that the obliquity of the two FRACTURES. 547 surfaces, on which the limb reposes, can be altered as occasion may require; there is a foot-board for the support of the foot, and a contrivance, by which the patient is ena- bled to have stools, without moving him- self or changing his posture in the slightest degree. Fractures ofthe Neck ofthe Thigh-bone. These accidents are infinitely more fre- quent, than dislocation of the thigh-bone, and are divisible into two kinds » first, that iu which the neck of the bone is broken within the capsular ligament; and second- ly, that in which the fracture happens exter- nally to this ligament, either through the root of the neck of the bone, or through the trochanter major. (A. Cooper, Surgical Es- says, Part 2, p. 30.) The neck of the thigh-bone may be frac- tured either by a fall on the great trochanter, the sole of the foot, or the knee. According to^ Desault, the first accident produces the injury much more frequently, than the two latter. Of thirty cases, which were seen by Desault, four-and-twenty arose from falls on the side. All those inserted by Sabatier in his interesting Memoir, were the result of a similar accident. These statements, how- ever, do not exactly coincide with the ex- perience of Mr. A. Cooperj who observes, that in London, the accident is most com- monly produced by a person slipping off the edge of the foot pavement. According to this eminent surgeon, a fracture of the neck ofthe thigh-bone, within the capsular ligament, seldom happens but at an ad- vanced period of life, and the reason of the facility, with which the injury takes place in old persons, he ascribes to the interstitial absorption, vvhich that part of the femur un- dergoes in individuals past a certain age, whereby it becomes shortened, and altered in its angle with the shaft of the bone. Ivlr. A. Cooper admits, however, that the acci- dent is frequently caused by a fall upon the trochanter major. (Surgical Essays, Part 2, p. 35, 36. Also Larrey, Journ. Complim. T. 8, p. 98,8vo Paris. 1820.) Fractures of the neck of the thigh-bone are said to be more common in women, than men. (J. Wilson on the Skeleton, fa. p. 245.) The division is seldom oblique, almost al- ways transverse ; the neck being sometimes, in the latter case, wedged in the body of the bone, as Desault found in several in- stances ; a model of one of which, in wax, is preserved in the collection of L'Ecole de Sanli, and the natural specimen of which was in the possession of Bichat. The frac- ture of the neck of the thigh-bone is some- times complicated with that of the trochan- ter major. The diagnosis is occasionally so difficult, that the best informed practitioners cannot always detect the accident with certainty. At the instant of the fall, an acute pain is felt, (sometimes a crack is distinctly heard) and a sudden inability to walk occurs ; and the patient cannot raise himself from the ground. The latter rirrnmstanre, however. is not invariable. In the fourth vol. of the Mem. de I'Acad. de Chirurgie, a case is re- lated, in which the patient walked home after the accident, and even gotupthenexf day. Desault published a similar example. The locking of one end of the fracture in the other, may offer an explanation of this circumstance. The dissections made by Dr. Colles, have recently led to another dis- covery, viz. that sometimes the solution of continuity does not extend completely through the neck of the femur. (See Dub- lin Hospital Reports, Vol. 2.) Three cases proving this are there adduced; a fact, which at once explains the ability of some patients to walk directly after the injury, and the absence of all retraction of the limb. A shortening of the limb almost always takes place ; but this symptom is more or less striking, according as the breach of continuity is out of the cavity of the orbi- cular ligament, which then cannot keep the bone from being retracted ; or as the extre- mity of the fracture is confined by this liga- ment. The action of the muscles drawing upward the lower end of the fracture, the weight ofthe trunk in propelling downward the'pelvis and upper end of the fracture, are the two causes ofthe shortening of the limb. In general, a slight effort suffices for the re- storation of the natural length of the limb; but the shortness recurs almost as soon as ihe extension ceases. <• This evidence of the nature of the accident continues," as Mr. A- Cooper correctly remarks, " until the muscles acquire a fix?d contraction, vvhich enables them to resist any extension, which is not of the most powerful kind." (Surgi- cal Essays, Part 2, p. 31.) Goursault and Sabatier remark, that sometimes tbe short- ening of the member does not take place t ii a long while after the accident. In op- position to the common belief, that the limb is shortened, Baron Larrey asserts, that the member is at first actually lengthened. (Journ. Complim. T. 8, p. 99.) This state- ment I have never seen confirmed, and it is contradicted by daily experience. And to prove how widely Larrey differs from Mr. A. Cooper, the following passage, will suffice " In order to form a still more de- cided judgment of this accident (says the latter writer) after the patient has been ex amined in the recumbent posture, let him be directed to stand by his bed-side, sun ported by an assistant, so as to bear his weight upon the sound limb. Immediately he does this, the surgeon observes most dis- tinctly the shortened state of the injured leg, the toes resting on the ground, but the heel not reaching it, the everted foot and knee, and the diminished prominence ofthe hip." (Surgical Essays, Part 2, p. 34.) A swelling is observable at the upper and front part of the thigh, always proportioned to the retraction, of vvhich it appears to be an effect. The projection of the great trochanter is almost entirely effaced. Directed upwards ?»nd backwards, tin? eminer'f becomes an- j4t FRACTURES. proximated to the crista of the os ilium ; but, if pushed in the opposite direction, it readily yields; and, when it has arrived at its natural level, the patient becomes capa- ble of moving his thigh. The knee is a little bent. Abduction of the limb always occasions acute pain, and it is noticed by Mr. A. Cooper, that the rota- tion inw ards is particularly painful, because the broken extremity of the bone then rubs against the capsular ligament. (Vol. cit. p. 33.) If, while the hand is placed on the great trochanter, the limb is rotated on its axis, this bony projection may be felt re- volving on itself, as on a pivot, instead of describing, as in the natural state, the seg- ment of a circle, of which the neck of the femur is the radius. This symptom, which was particularly noticed by Desault, is very manifest when the fracture is situated at the base of the neck, less so when at its middle; and it is not very perceptible when the breach is near the head of the bone. In the rotatory motions, the lower fragment, rub- bing against the upper one, produces a dis- tinct crepitus, which, however, is not an in- variable symptom, as Larrey would lead one to suppose. As Mr. A. Cooper observes, no crepitus can be felt while the patient is lying upon his back with the limb shortened ; but, if the leg be drawn down, it may sometimes be distinguished, especially when the limb is ro- tated inwards. (Surgical Essays, Part 2, p. 34.) The toes are usually turned outward ; a position whicb Sabatier considers as tbe inevitable effect of the fracture, though Pare and Petit noticed, that it did not constantly occur. Two cases, adduced by these illus- trious surgeons, were not credited by M. Louis ; but the experience of Desault fully confirmed the possibility of tbe limb not being always rotated outwards. And, as Mr. A. Cooper has remarked, three or four hours generally elapse before the turning of the limb outward is rendered most obvious by the fixed contraction of the muscles. (Surgical Essays, Part 2, p. 32.) The position of the toes outward is com- monly, and I believe correctly, imputed to the rotator muscles. Bichat conceived, however, thatif this doctrine were true, such position ought always to exist; and he re- minds us, lhat all the muscles, which pro- ceed from the pelvis to the trochanter, are, with the exception of the quadratus, in a state of relaxation, by the approximation of tbe femur to their point of hisertion ; and that the contracted muscles would not allow jlhe foot to be so easily turned inward again. Hence, Bichat thought it probable, that the weight of the foot itself may pull the limb into the position, in which it is commonly found. On the other hand, it is remarked by Mr. A. Cooper, that any one may satisfy himself, that the rotation of the limb out- wards is in part owing to the muscles, by feeling the resistance, which is made to rota- tion inwards, which resistance, however, he thinks may in some measure depend upou the length of the portion of the neck of the femur, which remains attached to the tro- chanter major, and rests against tbe ilium. (Surgical Essays, Part 2, p. 32.) It follows from the preceding account, that none of the symptoms of a fracture of the neck of the thigh-bone are exclusively characteristic , that each, considered sepa- rately, would be insufficient, and that their assemblage can alone throw light on the diagnosis. In every instance of doubt, ho-.v ever, the safe course must be pursued, and the apparatus applied, whicb, though useless, is not dangerous, should the injury not exist, and is indispensably necessary when it does. (Desault, par Bichat, T.l,p. 219—226.) It was at one time supposed, that fractures of the neck of the thigh-bone could not be cured, without some shortening of the limb, and lameness. Ludwig, Sabatier, and Louis, broached tbis doctrine, and imputed tbe cir- cumstance to the destruction of the neck of the Tjone. That this sometimes happens has been well ascertained. A late Surgical visiter to Paris informs us, that, in several specimens, which he examined in different museums, whether imperfect union, or no union at all, had followed the fracture, this absorption of the neck of the bone had taken place to a great extent, and in some to so great an extent, that the articulating surface of the bone, which plays in the acetabulum, rested between the trochanters, consolidated to the body of the bone by ligamentous union, and the thickening of the surrounding parts, whilst all the inter- vening neck of the bone was absorbed. (See Sketches of the Medical School of Paris, by J. Cross, p. 90.) M.Roux has also nearly always found the neck of the femur short- ened and deformed after its reunion. (Pa- ralille de la Chir. Angloise avec la Chir. Francoise, p. 178.) Desault, however, is said to have rarely met with instances of lameness from such a cause in his prac- tice. A question, that has lately been much agi- tated, is, whether reunion by bone ever follows cases, in which the fracture is entirely within the capsule, and the head of the bone insulated, except at its attachment to the acetabulum by the round ligament ? The French surgeons decide in the affirmative, and pretend actually to demonstrate the fact by preparations in their museums. M. Roux, indeed, vv as good enough to send over a specimen to Mr. A. Cooper, with the hope of producing conviction ; but, this eminent surgeon still remains unconvinced, because the traces of reunion in the preparation ap- pear to him to indicate a sort of fracture, where the internal fragment still retained some connexion with the capsular ligament. (Roux Parallele de la Chirurgie Angloise, fa. p. 179, 180.) In fact, it was a case, in which the fracture bad happened at the junction of the cervix with the trochanter. And Mr. A. Cooper in his last valuable pub- lication distinctly states, that, in all the exa- FRACTURES. 549 initiations which he has made of transverse fractures of the cervix femoris, within the capsular ligament, he has never met with a bony union, or of any which ajd not admit of motion of one bone upon the other. (Surgical Essays, Part 2,p. 39 ) By this eminent sur- geon, the want of bony union is referred to the fragments not being in contact and duly- pressed against each other and to the little action in the head of the bone separated from the cervix, " its life being supported solely by the ligamentuni teres, which has some few vessels ramifying from it to the head of the bone " For tbe particular ap- pearances found in the dissection of these cases, I must refer to the statements of Dr. Colles. (Dublin Hospital Reports, Vol.2.,) and to Mr. < ooper's own account, from which it seems, that " no ossific union i* produced ; thai nature makes slight attempts for its production upon the neck of the bone, and upon the trochanter major ; but scarcely any upon the head of the bone; and that, if any union is produced, it is by ligament only." (Vol. cit. p. 46.) Mr. Wil- son's observations are all in confirmation of the same explanation ; (On the Skeleton, p. 247.J and he adverts to two preparations, in tbe museum of the College of Surgeons, which have been supposed to be proofs of a bony reunion of the neck of the femur, sub- sequently to a fracture within the capsular ligament ; but (says Mr. Wilson) " I have very attentively examined these two piepa- tions, and cannot perceive one decisive proof in either of the bone having been actually fractured." One of these cases is that, which was published last year by Mr. Liston in tbe Ed.nb. Med. and Surgical Journ. Lastly, Dr. Colles of Dublin dissected several cases, in which the neck of the femur had been broken : in one, where the injury was within the capsular ligament, "no effort of nature had been made to create a reunion between the two pieces of the frac- ture, and the stability of the limb had de- pended upon the strength of those ligamentous bands, by which each piece was connected with the capsular ligament of the joint, aided, no doubt, by the extraordinary thickness, which the capsular had acquired." (Dublin Hospi- tal Reports, Vol. 2, p. 336.) In the two first instances, reported by this author, " The broken surfaces moved on each other, and were converted into a state approaching to ivory. No attempt had been made lo re- unite the fracture, and the pieces of bone were held in apposition only by new liga- mentous productions from the capsular liga- ment, which were inserted into the external surfaces of each piece. In No. 3, there had been a slight attempt made at reunion. In No. 7,8,and9,we observeduphanomenon,which, 1 believe, is now for the first time mentioned, a fracture of only part of the bone No 6 presented us with that mode of reunion, which some have supposed the most per- fect, of which this fracture is susceptible. While No. 10 and 11 exhibit a mode of re- union, very little inferior to callus in point of firmness, but very different in its na- ture, and which I conceive is peculiar to Ihe fracture of the neck of the femur." Dr. Colles also found, that, in all these cases (except, perhaps, No. 5) the capsular liga- ment was not lacerated. In every instance, however, there was an increased thickness of the capsule, and a removal of alt, or the greater part of the neck of the bone. "■ Al- though the ligamentous bauds seem, in a ma- jority oi instances, to have proceeded from the capsular ligament, yet, it is evident from .No. 6, that these may arise merely from the broken surfaces ot the bo;:e ; for, in this case not a sin le fibre was attached to the capsular ligament, the new bond of union beint; covered by the reflected portion of the synovial membrane or periosteum ofthe neck. We have an illustration of this in Ruysch. Tab. 1, i hes. 9." In No. 10 and 11, the fragments were united by a cartila- ginous substance. In No. 7, 8, and 9, the unbroken portion of the neck was so soft- ened, that it more resembled cartilage than bone, and, in tbis state, " it was laid down upon the fractured surface, and united to it." (Dr. Colles in Dublin Hospital Reports, Vol. 2, p. 353—355.) In the museum of the Ecole de Medecine at Paris, there are some preparations, which the professors exhibit at their lectures, in oii;er to prove, that bony union may succeed a fracture ofthe neck of the femur. These specimens were carefully examined by Mr. Cross ; but, none of them proved to him, that bony union ever follows where the head of the bone becomes insu- lated, except its attachment to the pelvis by theligamentum teres. (Sketches of the Medical Schools at Paris, p. 93.) On the other hand, Boyer observes, that experience fully proves the possibility of uniting such fractures of the neck of the thigh bone, as are situated within the capsular ligament; but, he ac- knowledges, that there are certain circum- stances, which may prevent this desirable event. " F. oni all that has been hitherto said on the prognosis of a fracture of the neck of the femur, we may conclude, (says Boyer) that this fracture is more serious,than that of any other part of the same bone, be- cause the difficulty df keeping it reduced is greater. That it may in general be reunited, especially in young healthy subjects; but, more easily, when it is situated near the base o: the neck, than near the head of the bone. Tl at the languid vitality of one of the fragments and the impossibility of ascer- taining whether the coaptation be exact, make the cure slow, and tbe time necessary for their consolidation uncertain. That the neglect of means adapted to maintaining the lunb in its proper length, and natural straightness and the fragments sufficiently motionless, may cause them to unite by an intermediate substance. Lastly, that the si- tuation of the fracture near the hear of the femur; the complete laceration of he elon- gation of the capsule investing the neck of tbe bone ; the great age of the patient; and, particularly, the constitution labouring under some diathesis, w hich affects the osseous system ; may render the cure absolutely im- 550 FRACTURES. possible ; that, in this'circumstance, one of the fragments is more or less destroyed by the friction of the other against it, and in the joint a disease is formed, vvhich tends to carry off the patient." (Boyer, Traiti des Maladies Chirurgicales, T. 3 p. 284.) This professor lays much stress on the complete laceration of the continuation of the capsuls over the neck of the bone, as an occurrence preventive of union. But, he thinks it does not frequently happen, because the capsular ligament hinders much displacement of the fragment. (Op. cit. p. 278) As for Baron Larrey, he appears to entertain no doubt of the possibility of uniting fractnres of the neck of the femur within the capsular liga- ment, and concludes his tract on this subject with the case of General Fririon, who was perfectly cured, after a supposed injury of this description. (See Journ. Complim. Tom. S,p 118.) How is this discordance between tbe most experienced French and English surgeons to be reconciled and accounted for ? After the very numerous and careful dissections, which have been performed by Mr. A. Cooper and Dr. Colles, with the view of as- certaining the state of the joint, after frac- tures of the neck of tbe thigh-bone, little doubt can be entertained, that, w here the fracture is transverse and within Ihe capsular ligament, a bony reunion, if not absolutely im- possible, is at least so rare an occurrei.ee as not to be calculated upon. Tbe difference of the French surgeons upon tbis question is to be ascribed to their not having duly discrimi- nated from the foregoing kind of case, either fractures extending more or less in the di- rection of the axis of the neck of the bone, or other fractures external to the capsular ligament. How much, however, the safety of the practitioner's reputation will depend upon the prognosis which is given, must be quite evident: for in the transverse fracture within the capsule, lameness is sure lo follow, though its degree cannot at first be exactly es- timated. (A. Cooper, Surgical Essays, Part 2,p.ol.) Tbe following circumstances are enume- rated by this author, as forming a criterion of the fracture being external to the capsular ligament. 1. The injury frequently happens in young persons; indeed, it is said, that, when the patient is under fifty, the fracture is generally on the outside of the capsule, and capable of ossific union. 2. Whilst the internal fracture happens from very slight causes, this is produced by severe blows, falls from considerable heights, or by the passage of a carriage-wheel over the pelvis. 3. The crepitus is in general more readily felt, in conscqueiice-of (heir being less retrac- tion of the limb 4. The trochanter is dis- placed forwards nearer the spine of (he ilium, than natural. 5. The pain of the accident is greater, than when the fracture is within the capsule. 6. The limb is generally less shortened. 7. The limb admits of being ro- tated with greater facility, there being no remnant of the cervix capable of making re- sistance by coming in contact with the ilium. (Vol. cit.p. 53.) Having spoken of tbe nature of fractures of the neck of the thigh-bone, within and without the capsular ligament, I come next to the consideration of the proper practice to be adopted. In the first description of the injury, as no osseous union can be ex- pected, ought we to endeavour to keep the fragments as nearly in a state of apposition as possible, and subject tbe patient to rest and confinement, with tbe view of promo- ting tbe other modes of union, so well point- ed out in Dr. Colles's paper ? Or should we, as Mr. A. Cooper does, avoid confining the patient to any long, or continued extension, " as being likely to be productive of ill- health, without the probability of producing union ?" Yet it appears both from this gen- tleman's own statements, and from those of Dr. Colles, that, though a bony union cannot be effected, other connecting means may be established, and the more perfect these are, the less will be the subsequent lameness. As long, therefore, as these facts are incon- trovertible, I should be disposed to recom- mend surgeons to do every thing in their power to keep tbe limb quiet, and in a de- sirable posture, for a due length of time. Whether for this purpose, Boyer's apparatus, with the limb in the straight posture; or the apparatus with two inclined surfaces, with tiie limb in the bent position, and the patient on his back ; or lastly, Hagedorn's ingenious and scientific treatment, as explained in the second vol. of the First Lines of Surgery, should be preferred, time and experience must determine. Mr. A. Cooper merely places one pillow under tbe whole ! ;'igth of the limb, and puts another across under the patient's knee, so as to keep the limb in an easy bent position. In a fortnight, or three weeks, the patient is allowed to sit upon a high chair, and in a few more days, he begins to take exercise upon crutches. After a time, these are laid aside, a stick substituted for them, and iu a few months this assistance may be dispensed with. At the end of the treatment, a shoe must be worn with a sole of equal thickness to the diminished length of the limb. (Surgical Essays, Part 2, p. 60.) In tbe treatment of such fractures of the neck of tbe femur, as are situated on the out- side of the capsular ligament, Mr. A. Cooper prefers the position in which the patient lies on his back, with the injured limb in a bent posture, supported on what is termed the double inclined plane, the kind of instru- ment already spoken of as being sometimes employed by Mr C. Bell. When the limb has been placed over this machine, in an easy bent position, a long splint, reaching above the trochanter major, is applied to the outer side of the thigb, and fastened to the pelvis with a strong leather strap, so as lo press one portion of bone tow ards the other. The lower part of the splint is also fastened to the outside of tbe knee with a strap. The limb is to be kept as quiet as possible for eight weeks, at tbe end of which time the patient may leave his bed- if tbe attemp FRACTLRE5 ,351 should not cause too much pain; but the splint is to be continued another fortnight. (Surgical Essays, Part 2, p. 59.) Desault's apparatus has been described in the forego- ing columns, and those of Boyer and Hage- dorn are explained and represented in the 2d Vol. of the First Lines ot Surgery. Larrey, who disapproves of the plan of continued extentioo, has lately proposed a particular apparatus for fractures of the neck of the femur: but as it appears to me very inferior to other methods already mentioned, I shall here merely refer to the Journ. Compl. T. 8, p. 116, where a description of it may be found. I am glad to find the number of advocates for Pott's method of treatment annually di- minishing. Indeed, the bad effects and pain- ful consequences of having the whole weight of the trunk operating upon the fractured ends of the bone, which are often not pro- perly in contact, are too obvious to need any comment. Yet this injudicious pressure is made in the bent position, which also for- bids the use of long effective splints, and all assistance from moderate continued exten- sion. A fracture of tbe neck of the thigh-bone may be complicated with a dislocation of the head of tbe bone. (See J. G. Haase, De Fractura colli Ossis Femoris, cum Luxaiione Capitis ejusdem ossis conjunda, Lips. 1798.) For further information relative to fractures of the neck of the femur, the following au- thors may be consulted. C. G. Ludwig de Collo Femoris ejusque Fractura Programma, Lips. 1765. Bellocq, in Mim. I'Acad. de Chir. T. 3. Ailken's and Goodie's machines are described in B. Bell's Surgery, Vol. 4. Sa- batier, in Mim.de I'Acad. de Chir. T.4. Du- verney, Traiti des Mai. des Os., T. 1. Unger, in Richter's Bibl. B. 6, p. 520. Theden, Neue Bemerkungen, fa. Th. 2. Brunning- hausen ueber den Bruch des Schtnkelbeinhal- ses, fa. Wurzb. 1789. Van Gescher uber die Entstellungen des Ruckgrats, und uber der Verrenkungen und Bruche des Schenkelbeins. au* d. Holland. Hedenus, in Bernstein's Darstellung des Chir. Verbandes, Tab. 42, fig. 82 and 83. M. Hagedorn uber der Bruch des Sehenkelbeinhalses, fa. Leipz. 1808. J. N. Sauter, Anweitung die Beinbrilche der Glied- massen, vorzuglich die complicierten, und den Schenkelbeinhalsbruch nach einer neuen, fa. Melhode, ohne Schienen sicher zu heilen, 8vo. Konstanz. 1812. J. Wilson on the Structure and Physiology of the Skeleton, he. p. 243, fa. 8vo. Lond. 1820. Dr. Colles, Dublin Hospital Reports, Vol. 2. A. Cooper Surgi- cal Essays, Part 2. Boyer, Traite des Mai. Chir. T. 3. OBLIQUE FRACTURES OF THE EXTERNAL, OR INTERNAL CONDYLE OF THE FEMUR INTO THE JOINT. In these cases, Mr. A. Cooper prefers the straight position, because the tibia presses the extremity of the broken condyle into a line with that which is not injured. Tbe limb is to be put in the extended pos- 1'ire upon a pillow, and evaporating lo- tions and leeches are to be used for the re- moval of the swelling and inflammation, " When this object has been effected, a roller is to be applied around Ihe knee, and a piece of stiff pasteboard, about sixteen inches long, and sufficiently wide to extend entirely under the joint, and to pass on each side of it, so as to reach to the edge of the patella, is to be dipped in warm water, and applied under the knee, and confined by a roller. When this is dry, it has exactly adapted itself to the form of the joint, and this form it afterward retains, so as best to confine the bones. Splints of wood or tin may be used on each side of the joint; but they are apt to make uneasy pressure! In five weeks, passive motion of the limb may be gently begun, to prevent anchylosis.'' (Surgical Essays, Part 2, p. 101.) This au- thor afterward describes a compound frac- ture of the external condyle, a portion of which was after a time extracted, and the case ended so favourably, that the patient, who was a boy, was able to bend and extend the leg without pain. For fractures just above tbe condyles, Mr. A. Cooper recommends the bent position, without which, he says, deformity is sure to follow. He advises the limb to be placed over the double inclined plane, and a roller applied round the lower portion ofthe femur (p. 103.) FRACTURES OF THE PATELLA. This bone is most frequently broken trans- versely, and the accident may be occasioned either by the action of external bodies, or by that of ihe extensor muscles. In the latter case, the fall is subsequent to the frac- ture, and, as Camper has remarked, it is most- ly only an effect of it. For instance, the line of gravity of the body is, by some cause oranother.inclined backward; the muscles in front contract to bring it forward again ; the extensors act on the patella; this breaks, and the fall ensues. That it is the action of the muscles, and not the fall, which usually breaks the knee-pan, is well ascertained. Sometimes the fracture occurs, though the patient completely succeeds in preventing himself from falling backward, as we find exemplified in two cases lately reported by Mr. A. Cooper. (Surgidal Essays, Part 2, p. 85.) A soldier broke his patella in endea- vouring to kick his Serjeant; the olecranon has been broken in throwing a stone. la the operating theatre of the H6tel Dieu both the knee-pans of a patient were broken by the violent spwsms ofthe muscles, which fol- lowed an operation for the stone. The force of the muscles occasionally ruptures (he common tendon ofthe extensor musclej, or what is more frequent, tbe ligament of the patella. Of these cases, Petit, Desault, and Sabatier, met with examples. When the pa- tella is broken longitudinally, the cause is always outward violence. (CEuvres, Chir de Desault T. 1, p. 252.) A transverse fracture of the patella may also originate from a blow, or fall, on the 652 FRACTURES, art; but, in common cases, it is produced y the violent action of the extensor mus- cles of the leg. It is only of late years, how- ever, that the true mode, in which tbe bone is usually broken, has been understood. As Boyer observes, for the production of a trans- verse fracture of the knee-pan, the extensor muscles of the leg need not act with a con- vulsive force, their ordinary action being strong enough to produce the effect in ques- tion, when the body is inclined backward, and the patient is in danger of falling upon his occiput. In this state, the thigh being bent, the extensor muscles of the leg con- tract powerfully, in order to bring the body forwards, and prevent tbe fall backwards ; and the patella, whose posterior surface then rests only by a point against the forepart of the condyles of the femur, is placed between the resistance of the ligament binding it to the tibia, and the action of the extensor muscles. A fracture now happens the more easily, because, by tbe flexion of the knee, the line of the extensor muscles, and that of the ligament of the patella, are rendered oblique, with respect to the vertical axis of tbis bone, which is bent backwards at the point, where it rests upon the condvles. (Traiti de* Mai. Chir. T. 3,p. 322. C. Bell's Operative Surgery, Vol.2, p. 201, 8ro Lond. 1809. A. Cooper's Surgical Essays, Part 2, p. 86.) By violent spasmodic action of the extensor muscles, however, the patella may be broken transversely, while the limb is perfectly straight. A very singular case is mentioned by Mr. A. Cooper, where a pa- tella, which had been formerly broken, and united by ligament, was again divided into two portions, in consequence of the de- struction of the uniting medium by ulcera- tion. (Vol. cit. p. 100.) A case is also on record, where the ligamentous uniting sub- stance was so incorporated with tbe skin, that when the latter happened to be lacera- ted, the knee-joint was laid open, and ampu- tation became necessary. (C Bell, Op. Surgery, Vol. 2, p. 204.) In transverse fractures, there is a conside- rable separation between the two fragments of the bone, very perceptible to the finger, when the hand is placed on the knee. This separation is not occasioned equally by both portions; the upper one, embraced by the extensor muscles, is drawn upward very for- cibly by these powers, vvhich the patella no longer resists; while the inferior portion, being merely connected with the ligament below, is not moved by any muscle, and can only be displaced by the motions of the leg, to which it is attached. Hence, the se paration is least when the limb is extended, being then only produced by the upper frag- ment ; greatest, when the limb is bent, be- cause both pieces contribute to it; and it may be increased, or diminished, by beading the knee more or less. As Boyer has particularly noticed, the Ulceration, or not, of the tendinous expan- sion, upon the front of the patella, makes a material difference in these cases, because H. is a part of great importance in the cure According to this author, a portion of it in simple fractures of the patella generally es- capes laceration, and the separation of the fragments is then not very considerable ; but violent action of the extensor muscles, the fall subsequent to the fracture, or bend- ing the knee too much, may separate the pieces of bone far from each other, and rup- ture the tendinous expansion. (Traiti des Mai. Chir T. 3, p 328.) According to Mr. A. Cooper, " when the ligament is but lit- tle torn, the separation will be but half an inch ; but under great extent of injury, tbe bone is drawn five inches upwards, the cap- sular ligament, and tendinous aponeurosis covering it, being then greatly lacerated." (Surgical Essays, Part 2, p. 84.) The upper portion of bone may be moved transversely, and pain is thus exci- ted, but no crepitus can be felt, as the two pieces of bone are not sufficiently near eacb other. When the swelling of the knee, con- sequent to fractures of tiie patella, is very great, the symptoms of the injury may be more or less obscured. However, in con- sequence of the inability of the extensor muscles to move the leg, except in a few cases where the fracture is very low, the pa- tient cannot stand without difficulty, and is nearly quite unable to walk. In tbe treatment of a fractured patella, the chief indications are to overcome the action of the extensor muscles of the leg, and to keep the fragments as near each other as possible, partly by a judicious posi- tion of the limb, and partly by mechanical means. The first indication is fulfilled by relaxing the above-mentioned muscles ; 1st, by extending the leg ; 2dly, by bending the thigh on the pelvis, or, in other words, rai- sing the femur, so that the distance between the knee and anterior superior spinous pro- cess ofthe ilium may be as little as possible, which object, however, will also require the body to be raised, and the pelvis some- what inclined forwards. In short, as Rich- ter long ago advised the patient should be almost in a sitting posture, the trunk form- ing a right angle with the thigh. (Bibl. Chir. B 6, p. 611, Gottingen, 1782.) 3dly, The muscles are to be compressed with a roller. The second indication, or that of placing and maintaining tbe fragments in contact, or as nearly so as circumstances will allow, is in a great measure already an- swered by the above recommended position of the limb and trunk ; but it is not per- fectlv fulfilled, unless the upper portion of th* bone be also pressed towards the lower fragment, and mechanically held in this situation by the pressure of an apparatus or bandage. And. in pushing the upper frag- ment towards the lower one, the surgeon should always be careful that the skin be not depressed and inched between them Having described the principles whieb ought to be observed, I do not know that any great utility would result from a detail of the various methods of treating a broken patella preferred by different surgeons. In tbe 2d vol. of tbe Fir>t Lines of Surgery FRACTURES may be found a description ofthe plan and apparatus employed by Baron Boyer. De- sault's practice, which was related in the last edition of this Dictionary, I now omit, as not being exactly such as modern sur- geons would adopt; not from any of his principles being erroneous, but because his apparatus is more complicated than ne- cessary. After putting the patient in bed upon a mattress, and in the desirable posture, with the limb confined, supported, and raised, as above directed, upon a w ell-padded hollow splint, Mr. A. Cooper applies at first no bandage to the knee, but covers it with linen wet with a lotion composed of liq. plumbi acet. dilut. ^v.and spir. vin. ^j. If, on the succeeding day or t\vo,tbere be much tension, or ecchymosis,,leeches should be applied, and the lotion continued; but the employ- ment of a bandage is not to commence un- til the tension has subsided ; for Mr. A. Cooper assures us, that he has seen the greatest suffering, and such swelling as threatened gangrene, produced in these cases by the too early use of a roller. In- stead of a circular bandage, placed above and below the broken bone, and drawn to- gether with tape, he. so as to bring the upper fragment towards the lower one, this expe- rienced surgeon prefers the following me- thod. A leather strap is buckled round the thigh, above tfo- broken ant elevated portion of bone, and from this circular piece of lea- ther, another strap passes under the middle of the footrthe leg being extended, and the foot considerably raised. This strap is brought up to each side of the patella, and buckled to the leather band already applied to the lower part ofthe thi^b. It may also be fastened to the foot or any part of the leg, with tapes, i he limb is lo be confined in this position five weeks, if the patient be an adult, and six if advanced in years. Then a slight passive motion is to be begun, and to be gently increased, from day to day, until the flexion ofthe knee is complete. (Sur- gical Essays, Part 2, p 91.) But, although the impropriety of making any constriction of the knee with a bandage, while the skin is swelled and inflamed, must be obvious, the surgeon ought tobe apprised, that such swelling and inflammation ought not to oc- casion the least delay in placing the limb in the right posture, and pressing the upper fragment towards the lower one. Mohren- heim ascribes the lameness so frequent for- merly after this fracture, partly to the cus- tom of not thinking of bringing the pieces of bone together until the swelling had sub- sided, and partly to the fashion of bending the joint too soon, with a view of preser- ving its motion. But, says he, nothing can be clearer than that it is most advantage- ous to attend to the union of the fracture first, and to the flexibility ofthe joint after- ward. (Beobachlungen, 2 B. Svo. 1783.) Boyer has likewise remarked, that the uni- ting substance is apt to yield, and become lengthened by bending the knee too early, and he therefore never allows this motion Voi f 7<» to be performed before the end of two months. When the ligamentous substance is long, and the patient very slow in regain- ing the use of the extensor muscles, he should sit every day on a table, and endea- vour to bring them into action, and as this increases, a weight may be affixed to the foot, as Hunter, Sheldon, he. recommend. Nothing keeps the leg more surely extend- ed than a long, broad, excavated splint, with a suitable pad applied to the posterior part ofthe thigh and leg, and fixed there with a roller, while the thigh itself is tobe bent by raising the whole limb, from the heel to the top of the thigh, with pillows, vvhich, of course must form a gradual ascent from the tuberosity of the ischium to the foot. The broken patella is almost always uni- ted by means of a ligamentous substance, in- stead of bone. However, that an osseous union may fol- low a transverse fracture of the patella, and still more frequently a perpendicular one, is a fact of which there is now not the slight- est doubt. Thm, Lallement has published an unequivocal specimen of a transverse fracture united by bone, with the history of the case, and the appearances after the death of the patient from some .other affection. (Boyer, Traiti des Mai. Chir. T. 3, p. 355, fa.) In the collection of Dr. William Hun- ter, there is one well-marked instance of the bony union of a transverse fracture of the patella, and other examples have been seen in the dead subject by Mr. Wilson. (On Ihe Structure, Physiology, fa.of the Ske- leton, p. 240.) The reason why transverse fractures of the patella, do not commonly unite by callus, is not owing to the want of power in this bone to produce an osseous connecting substance; for, as Larrey has several times noticed, if the fragments are kept in perfect contact by means of a suita- ble apparatus, their bony reunion become; so complete, that scarcely any vestige ol the injury can afterward be traced. (Journ. Complim. T. 8, p. 114.) Indeed, it is a fac! on which Larrey dwells, as affordinga proof that callus is produced not by the perios- teum, but by the vessels of the bones them- selves. And what must add strength to the purport ofthe foregoing remarks is, the con- sideration that perpendicular or longitudiual fractures of the patella, which are not liable to any displacement from the action of the extensor muscles of the leg, readily adrnk of bony union. (Wilson on the Structure. and Physiology, fa. of the Skeleton, p. 239.1) This is a statement which, I think, could not be rendered doubtful by any experiments made on animals, without the advantages of quietude and proper treatment. Yet. there are other faels related, which prove that both in longitudinal and transverse frac- tures a ligamentous union is generally pro- duced, when the fragments are separated; but if these are not drawn asunder, an os- seous union takes place. Thus, in one case, reported by Mr. A. Cooper, one-third of the patella was separated from the rest of this bone, and bad united by ligament, a free •3*4 FRACTURE* motion being lett between the fragments. (Surgical Essays, Part 2, p. 94.) The same gentleman divided the patella longitudinally in a dog, without extending the division into the tendon above, or the ligament be- low, so that the fragments could not be sepa- rated. In three weeks, a close bony union was the result. (P. 95.) A case i3 also re- lated, in which a gentleman fractured the patella transversely, and the lower portion likewise perpendicularly. The transverse fracture united, as usual, by ligament; tbe perpendicular one, by bone. (P. 96.) The incorrect notions, formerly entertain- ed, respecting the inconveniences ofan ex- udation and projection ofthe callus into ihe joint after a fracture of the patella, and espe- cially when the fragments are kept in con- tact, were long ago refuted by Pott and Sheldon. (Poll's Chir. Works, Vol. 1, p. 332, Ed. of 1808. Sheldon's Essays on the Fracture of the P telln, fa. 8vo. Lond. 1789.) On the contrary, as Mr. A. Cooper particu- larly remarks, " the internal articular sur- face of the bone preserves its natural smoothness." (Essays, Part 2. p. 86.) How such doctrine of a superabundant callus could ever be reconciled with the doubts about a bony union ever being possible, appears difficult of explanation. Pott, and some others, thought that there being commonly an interspace afterward between the two pieces ofthe patella, with a certain length of the connecting substance, might be advantageous in the motion ofthe joint; but Desault, Boyer, Mr. A. Cooper, Sir J. Earle, and others, have always found fhat the greater the distance between the two pieces of the bone, the greater is the difficulty afterward in walking up a rising, or over an unequal ground. In the treatment of a longitudinal, or per- pendicular, fracture of the patella, tbe leg should be kept extended, leeches used, and a cold lotion applied. After a few days, a roller is to be put round the limb, and then a laced knee-cap, with straps buckled round the limb above and below the patella. {A. Cooper, Vol. cit. p. 96.) The experience of Dupuytren confirms the fact, that a longitu- dinal fracture ofthe patella is soon well con- solidated. (Annuaire Med. Chir. de Paris, p.98,4to. Paris, 1819.) Compound fractures of the patella frequently terminate in the death of the patient, unless amputation be done early. The injury, however, does not invariably lead either to the loss of life or limb. I saw a case in St. Bartholomew's hospital last summer (1820,) under Mr. Vincent, where the patella was broken to pieces, and the opening so extensive, that the fingers readily passed into the joint; yet. after a tedious confinement, the formation of abscesses, and the separation of several fragments of bone, the patient recovered with a stiff joint. In general, however, I believe, with Mr. A. Cooper, that in com- pound fractures ofthe patella, if the lacera- tion be extensive, or the contusion very considerable, amputation will be required but, if the wound be small, the patient not irritable, aud no sloughing of the integu- ments, or ligament, likely lo occur, it will be best to try to save the limb. (Vol. cit. p. 99.) The wound should be reunited as speedily as possible, and advantage taken of evaporating lotions, perfect rest in a desira- ble posture, a very low regimen, leeches, venesection, and saline opening medicines. Since writing the above remarks, I have seen another case of bad compound fracture ofthe patella in St. Bartholomew's hospital, where it has been about a month. No frag- ments of bone have yet been removed, but a good deal of matter issues daily from the wound. The case must be regarded as in a very precarious state, though if hectic symptoms should not lower the patient too much, the limb will probably be saved. In addition to the works already cited, consult D. H. Meibomius de Patella Osse, ejusque Lasionibus, et Curalione, Franck. 1697. P. Camper, Diss, de Fracturd Patella, et Olecrani, 4to. Haga Comit. 1789. Buirer in v. Siebold Chiron. 3, 1, p. 64. FRACTURES OF TIIE LEG May be transverse or oblique. The first case is alleged to be most common in chil- dren. Experience proves, that the two bones of the leg are much more frequently broken together, than singly ; a fact ascribed by Boyer to tbe strength of the knee and ankle joints. (Traiti des Mai. Chir. T. 3. p. 360.) The direction of an oblique fracture ofthe tibia is found to be pretty constantly from below upwards, and from within out- wards, the end of the upper fragment mostly presenting itself under the skin at the front and inner part of the leg. In these cases, the longitudinal displacement of the fracture is less constant, than the horizontal and an- gular. However, when it does happen, the inferior fragments are drawn outward and backward, whilst the superior project inter- nally and forward. The angular displace- ment may be produced either by the action of the posterior muscles of the leg, or the weight of the body, and, in both cases, the angle projects forwards. But it may be di- rected posteriorly, if the heel be too much raised. A rotatory displacement, most com- monly happening in the direction outwards, is produced by the inclination of the foot, and if this be turned too much inwards the rotatory displacement will be in that direc- tion. A longitudinal displacement cannot take place i.. transverse fractures, on ac- count ofthe considerable extent of the sur- faces of bone ; but, in oblique fractures, the inferior fragments are almost always drawn upward by the action of the posterior mus- cles of the leg, in which position of the parts, the lower ends of the superior frag- ments project forwards, and may be felt by the hand. Sometimes, however, when the solution of continuity is obliquely downward and outward, the anterior projection will be produced by the lower pieces. In both kinds of displacement, thp pointed ends rr* FRACTURES. 555 Lie bones may tear and penetrate the integu- ments, and cause a compound fracture. The usual symptoms, denoting a fracture of both bones of the leg, arc a change in the direction and shape ofthe limb, pain, and in- capability of walking or bearing upon the limb, mobility of the fractured pieces, and a distinct crepitus. Fractures near the knee are not very sub- ject to displacement, on account ofthe thick- ness of the tibia at that part ; but they are more dangerous than those ofthe middle of the bone, because often followed by anchy- losis of the knee-joint. Fractures, close to the ankle, are still more dangerous. Oblique fractures are very difficult of management, and when their displacement is upward and outward, the integuments are in danger of being torn by the projecting points of the superior portion ofthe tibia. (Boyer.) To bad compound fractures of the leg most of the observations are applicable, already deli- vered on compound fractures in general. When the size of the tibia is compared with that of the fibula, and the close con- nexion of these bones to each other is re- membered, an opinion might be formed, that the first could never be broken without the second. Experience, however, proves the Contrary. And reasons for this fact, as Boyer remarks, may be deduced from the consideration, that the tibia is the bone which supports the weight of the body, and that it is situated at the forepart of the limb, simply covered by the skin, and much ex- posed to the effects of violence. (Traiti des Mai. Chir. T. 3, p. 373.) When the tibia alone is broken, the fracture is said to be ge- nerally transverse. If the injury happens near the knee, the great extent of the fractured surfaces pre- vents any considerable displacement of the fragments; and the fibula acting as a sup- port on the external side, contributes also to this effect. Boyer, however, has seen one instance, in which the tibia was broken by the kick of a horse, and the fragments dis- placed in the direction of the axis of the bone, which displacement could not be rec- tified, so that the bone remained permanent- ly arched at the part. The absence of displacement often ren- ders the diagnosis of fractures of the tibia very difficult, and the difficulty is further in- creased by the little pain and inconvenience produced by such a fracture, with which persons have been known to walk. Whenever there is reason to suspect the accident, in consequence of a blow or a fall on the leg, the part should be minutely exa- mined. The fingers are to be moved along the anterior side of the tibia, the slightest inequality in which may be easily perceiv- ed, on account of its being covered only by the skin ; and the motion of the pieces may be perceived, by grasping the opposite ends of the bone, and pushing thein in contrary directions. However, this motion, and the crepitus, are very indistinct, on account of tiie fibula not allowing the fractured por tions to be sufficiently moved ou one an other. In a review of the position and strength of the two bones of the leg, it will appear that the tibia supports alone the whole weight of the body, every shock directed in the axis of the limb, and mauy kinds of force applied also in the transverse direc- tion, without operating upon any particular point. Hence, the frequency of fractures of the tibia ; and if the fibula is generally bro- ken at the same time, the latter injury is but subsequent to the other, and takes place because this slender bone is not capable ot bearing the weight of the body, the impulse of external violence, and even the action of the muscles, after the tibia has given away. (Dupuytren Annuaire Med. Chir. des Itospi- taux de Paris, p. 15. 4fo. Paris, 1819.) On the other hand, as the same distinguished surgeon remarks, the fibula being principal- ly designed as a support for the outside of the foot, it is particularly when this func- tion is to be executed, and its lower end has to make resistance to efforts made in tbat direction, that it is fractured; and if the lower part of the tibia is also sometimes broken by the same force, it is almost al- ways consecutively, and not by the effect of a direct and 'simultaneous action upon the two bones. (P. 17.) All fractures of the fibula, however, are not caused in the pre- ceding manner; and Dupuytren concurs with Boyer, Mr. C. Bell, and all the best writers on this subject, in dividing these cases into two kinds; first, those in which the force is applied directly to the bone it self; secondly, the more important and se- rious cases, in which the force operates up- on the fibula, through the medium of the foot. With respect to the first class of cases, the situation of the fibula on tbe outer side of the leg, a situation which would seem to expose it much to external violence; its slenderness ; the interspace left between it and the tibia at the middle part of the leg; and the way in which each eiid of it rests upon the laiter bone; would lead one to ex- pect that its middle portion must often be broken; yet the case is less frequent than might be apprehended. And, as Dupuytreii observes, there are two reasons for this fact; viz. the protection which the fibula receives from the peronati muscles, and the rarity of circumstances capable of producing a frac- ture by a direct cause. These fractures, which are usually attended with deformity, and iu some cases, even do not hinder the patient from bearing upon the foot, cannot for the most part be ascertained, unless at- tention be paid to the manner iu which the accident was produced, and to the presence of ecchymosis, and of more or less pain in the part which has been struck, or pressed upon; together with a degree of irregularity ofthe fibula, perceptible by the fingers, and a more or less distinct moveableness and crepitus ofthe ends ofthe fracture. The usual causes of this sort of fracture are blows on the fibula, gunshot wounds, the fall of heavy bodies on the outrid* of th*- 556 FRACTURES. leg, or the passage of them over the same part. The foot is generally twisted, neither Inwards nor outwards, and in most instances, the accident is easily cured by means of rest, without being accompanied by any of the symptoms so often complicating other frac- tures of the fibula, produced by distortion of the foot. (Dupuytren, Vol. cit. p. 4o.) A stri- king analogy may be remarked between fractures of the central part of the fibula and those of the corresponding portion of the ulna, and this in respect to causes, symp- toms, treatment, and consequences. Frac- tures of the middle of the ulna, like those of the body ofthe fibula, are always occasion- ed by blows or falls on the fractured part, or by violence applied directly to the bone. Such fractures are scarcely eve1-, "°nded vvitn any deformity in the l':rr-.: inc city of moving it, or displacement of ti ■ frag- ments ; and just as some individuals are able to walk w ith a broken fibula, others, not- withstanding a fracture of the ulna, are found capable of using their fore-arm nearly as well as if it were free from injury. The latter case, like that of a fracture of the fibu- la, can only be known by tbe recollection of the way in which the hurt was received, the pain, ecchymosis. irregularities, motion, and crepitus, vvhich last effect" are also not very obvious so high up tbe bone. Like fractures of the body of the fibula, those of the body of the ulna only require rest and discutient applications, and very seldom the bandages, &c. necessary in the treatment of fractures of both bones of the fore-arm, or those of the radius alone. (Vol. cit. p. 50.) Fractures of the fibula from an indirect cause may happen from the foot being violent- ly twisted,either inwards or outwards. In both instances, the cause ofthe fracture is a change in the direction of the line, in which the weight of the body h transmitted. In the first case, the said line, instead of following, as it commonly does, the axis of the tibia, and falling upon the astragalus, crosspsthe lower end ofthe tibia, and the ankle joint, oblique- ly from within outwards, and After passing across the malleolus externus, extends to the outside ofthe member. The parts then sup- porting the weight of the body are the mal- leolus externus, and the lower end of the tibia, besides which state of parts, the same malleolus is subjected to the traction of the external lateral ligaments, which operate ivith great force in consequence of those ligaments being now nearly as a right angle with the lower end of the fibula, while this process itself is iu contact with the astraga- lus, which is propelled from within outwards by tbe tibia. The latter bone, b. ing thicker and stronger than the fibula, generally re- sists, and if the malleolus internus sometimes happens to break, it is secondarily, as an ef- fect of the displacement of the foot out- wards. In the other example, where the foot is twisted outwards, the centre of gravity of the body, instead of following its usual course, obliquely crosses the lower end of ♦be fibula.the ankle-joint, and the malleolus internus, and falls on tbe ground at a greater or lesser distance from the inner edge ofthe foot. On the one side, the internal lateral ligaments and malleolus, and on the other, the lower end of the fibula, are then the parts which have to bear the weight of the v hole body, and the force of the muscles; and they are also the parts which are torn and fractured ; first, the internal lateral liga- ments, or tbe malleolus ; and 'secondly, the h-wer portion ofthe fibula. (Annuaire, Mid. Chir. de Paris, 1819, p. 66 67.) i-ome of the -ymptoms of a fracture of the fibula, from an indirect cause, depend upon the fracture of hat bone, and others upon the dislocation of the foot. They are divided by Dupuytren into two kinds; viz. presump- tive, and characteristic. The first are, the way in which the patient received his hurt; a noise, or sort of rrack heard by him at the instant of the injury ; a fixed pain at the lower part of the fibula; a difficulty, or ina- bility of walking; more or less swelling round the ankle, especially about the mal- leolus externus, and lower portion of the fibula. The characteristic symptoms are, an irregularity and unnatural moveableness of some point of the lower end of the fibula; a crepitus, which can be more or less dis- tinctly felt by pressing upon and moving the part; mobility of the whole foot trans- versely, or horizontally ; a facility of bring- ing the lower end of th»* fibula towards the tibia by pressure ;■ a change in the point of incidence of the axis of the limb upon the foot; distortion of the foot outwards, and sometimes backwards; rotation of the same part upon its axis from within outwards; an angular depression, more or less manifest at the outer and lower part of tbe leg; pro- jection of the internal malleolus; disap- pearance of almost all these symptoms, as soon as reduction is effected by a force ap- plied to the foot; and their immediate re- currence when such force is discontinued, particularly if the limb be in the extended posture. (Vol. cit. p. 68.) In considering the varieties of simple frac- ture ofthe fibula, the first to which Dupuy- tren adverts, is that in which the bone is broken more than three inches above the ex- tremity of the malleolus externus; a case, nei- ther accompanied nor followed by any displace- ment of the foot, and almost always produced by the direct application of violence to the broken part ofthe bone. A second variety of simple fractures of the fibula is when the bone has been broken, either by direct or indirect force, within three inches from the end- of the malleolus externus, and when the foot is not displaced, though much displacement is possible, and, indeed, often arises from the slightest effort' or movement made by the patient. The most frequent point of injury is about two inches and a half aboVe tbe extremity of the outer malleolus. This is generally the place of a fracture, caused by a twist ofthe foot outwards; but, the accident may happen lower down, as is commonly seen, when »hr FRACTURES. 'ractuie is occasioned by a twist of the foot inwards. These fractures of the fibula, abstractedly viewed,are not of much importance in them- selves ; but, with reference to the manner in which they facilitate the dislocation of the foot, they are very serious. Among the most frequent complications of fractures ofthe fibula, are the rupture of the internal lateral ligaments, the detach- ment of the point of the inner malleolus, and fracture of the lower part of the tibia. When these injuries originate from a violent twist of the foot outwards, they precede the fracture of the fibula; but, when they are caused by a twist inwards, they follow the breaking of that bone. (Dupuytren, Vol. cit. p. 96.) Besides distortion of the foot outwards, or inwards, as attending certain fractures of the fibula, another complication may be dislocation of the foot backwards, produced by the action of the muscles of the calf, and not by the same causes which broke the bone. However, whenever tbe malleolus internus has not given way, the dislocation is incomplete, and the foot is inclined out- wards as well as backwards. In the com- plete luxation, as Dupuytren remarks, the bent posture is found exceedingly advan- tageous, though he admits, that it will not always answer for maintaining the reduc- tion. TREATMENT OF FRACTURES OF THE LEG. As in cases of fractured thighs, the practi- tioner may adopt either a bent or a-straight position of the limb; in this country, sur- geons mostly follow Mr. Pott's advice, and select the first one, of which alone I shall treat. That the bent position is, generally speaking, the most advantageous for a bro- ken leg, I am well convinced. The strong muscles ofthe calf of the leg are the powers, whicb tend to displace the ends of the fracture, and their relaxation is a thing of the first-rate importance. It is quite dif- ferent in the thigh, where the muscles are so numerous, that the attempt to relax by any position of the limb, all such as have the power of displacing the fragments would be in vain. I am ready to acknowledge, how- ever, that in the bent posture, the apparatus is defective, inasmuch as it does not keep the knee-joint from moving; but yet it n certain that such motion has not so injurious an effect upon fractures of the leg, as it has upon those ofthe thigh. When the case is complicated with a wound, which cannot be dressed in the bent posture ofthe limb, without great disturbance of the fracture, the straight position ought unquestionably to be preferred. With respect to one of Mr Pott's objections to this position, viz. that it makes the knee stiff for a long while afterward, I suspect, that we should not lay much stress upon the circumstance, be- cause, as Boyer has correctly observed, it i- alvvays the joint situated below the fracture., fbat is thus affected. " In the fracture ot the fibula only, (says Pott) the position is not of so much conse- quence ; because bv the tibia remaining en- tire, the figure of the leg is preserved, and extension quite unnecessary ; but still, even here, the laying the leg on its side, instead of on the calf, is attended with one very good consequence, viz. that the confinement ofthe knee, in a moderately bent position, does not render it so incapable of flexion and use afterward, as the straight or extend- ed position of it does and consequently, that the patient will be much sooner able to walk, whose leg has been kept in the for- mer posture, than he whose leg has been confined in the latter. " In the fracture of both tibia and fibula, the knee should be moderately bent, the thigh, body, and leg, being in the same po- sition as in the broken thigh. If common splints be used, one should be placed un- derneath the leg, extending from above the knee to below the ankle, the foot being properly supported by pillows, bolsters, &,c. and another splint of the same length should be placed on the upper side, comprehending both joints in tbe same manner ; which dis- position of splints ought always to be ob- served, as to their length, if the leg be laid extended in the common way, only chan- ging the nominal position of them, as the posture of the leg is changed, and calling what is interior in one case, exterior in the other; and what is superior in one, in the other inferior. " If Mr. Sharp's splints be made use of, there is iu one of them a provision for the more easy support of the foot and ankle, by an excavation in and a prolongation oi the lower or fibular splint, for the purpose of keeping the foot steady." (Poll.) The strong muscles of the leg being re laxed by placing the limb in the bent posi- tion, as advised by Pott, the surgeon is to make such extension as seems requisite, for bringing the ends of the fracture into even apposition. Then he is carefully to raise the leg a little way from the surface of the bed, by taking firmly bold of the limb, above and below the fracture, and ele- vating the broken bones together, in such a way as shall keep both the upper and lower portions as nearly as possible on the same level. At this moment, an assistant should put, exactly beneath the leg, the under splint, which has been previously made ready by covering it with a soft pad, and laying over this an eighteen-tailed bandage. The limb is now to be gently depressed, till it rests on the apparatus. The surgeon, be- fore proceeding further, must once more observe, that the ends of the bones are even- ly in contact. Being assured of this impor- tant point, he is to apply a piece of soap plaster, and lay down the tails of the ban- dage. Another soft pad, well filled with tow, is next to be put over the upper surface o' the leg, and over that the other splint, when the straps are to be tightened. Mr. Pott's method of treating fractures of the fibula, complicated with luxation of the 558 FRACTURES. tibia, is described in the article Dislocation, and Dupuytren's practice in the 2d vol. of the First Lines of the Practice of Surgery. In an oblique fracture of the head of the tibia, extending imo the knee joint, Mr. A. Cooper recommends the straight position, in which the femur has the good effect of keeping the articular surfaces of the tibia even. A roller is to be used for pressing one fragment towards the other; a paste- board splint is also to be applied with the same view ; and early passive motion ofthe joint is to be practised in order to prevent anchylosis. When the fracture is oblique, but does not reach into the joint, the same author prefers placing the limb on the double-in- clined plane. (Surgical Essays, Part 1, p. 103.) FRACTURES OF THE SCAPULA. As Boyer correctly observes, fractures of the scapula are not very common, a circum- stance explicable by the deep and covered position ofthe greater part of this bone, and its great mobility. Nor can these accidents arise withoi.t considerable direct violence. However, there, are some parts of the sca- pula, whicn being more superficial, and of a form more likely to be acted upon by ex- ternal bodies, are more frequently fractured; such are the acromion, and inferior angle of the bone. Fractures of the coracoid pro- cess, and even of the neck of the scapula, are also mentioned ; but, the instances of such accidents are not common; and though these parts of the bone may appear in the skeleton likely to be often broken, their deep situation in the living subject generally saves them. Indeed, as Boyer says, tbey generally require great violence to break them, and then the contusion of the soft parts is a worse injury than the fracture itself: thus, this author has seen the coracoid process broken by the blow of the pole of a carriage, and the patient lost his life from the violence at the same time in- flicted upon all the soft parts about the shoulder (Traiti des Mai. Chir. T. 3, p. 161.) When the acromion is broken, the weight ofthe arm, and the contraction of the del- toid muscle, draw it downward, while the trapezius and levator scapula? draw the rest ofthe bone upward and backward. When the lower angle is broken, the serratus ma- jor anticus draws it forward, while the rest of the scapula remains in its natural situa- tion ; or, if the angular portion be consider- able, the teres major, and some fibres ofthe latissimu? dorsi, contribute to its displace- ment fo-.vard and upward. When tbe coracoid process is fractured, the pectoralis minor, coraco-brachialis, and short head ofthe biceps, concur in drawing it forward and downward. When the neck ofthe scapula is fractured, the weight of the arm makes it drop down so considerably, as to give the appearance of a dislocation ; but, the facility of lifting the os brachii upward, the crepitus, and the falling of the limb downward again, imme- diately it is unsupported, are circumstances clearly marking, that the case is not a dislo- cation. Sometimes great pains, and a cre- pitus, are experienced, on moving tbe shoul- der joint, after an accident; and yet the spine, the neck of the scapula, and all the above parts are not broken. In this cir- cumstance, it is to be suspected, either that a small portion of the bead of the os brachii, or a little piece of the glenoid cavity of the scapula, is broken off; which latter occur- rence, I think, is not very uncommon. Fractures of tbe acromion are attended with pain, which is increased by the motion of the arm ; the form of the shoulder is changed ; and the broken part which has descended, may be raised, by bringing up the elbow close to the side. When the inferior angle is broken, the part remains motionless, while the rest of the scapula is moved; and it is so separa- ted, that no mistake can be made. (Boyer.) Fractures of the spine and body of the bone, are all attended with a crepitus ; and, in the first cases, an irregularity of the inju- red part may generally be felt. The prognosis of fractures of the scapula varies according to the situation of the injury, and tbe attendant circumstances. Fractures of the body of the bone, what- ever may be their direction, are generally very simple, and readily cured. Those of the acromion and lower angle are more troublesome to keep right; but the most serious cases are fractures of the coracoid process and neck of the bone, which cannot be kept right without great difficulty, and are said to be frequently followed by a con- siderable stiffness of the arm, inability to raise it, its atrophy, and even paralysis. In other respects, the danger of fractures of the scapula depends less upon the solution of continuity in the bone, than the contusion of the soft parts, or injury of the thoracic viscera. However, when the fracture is comminuted, and the splinters are forced in to the subscapularis muscle, abscesses may form under the bone, and, according to Bover, require a perforation to be made in it;' (Mai. Chir. T. 3, p. 165.) a proceeding, which I cannot bring myself to think would ever be judicious, as making a depending opening in the soft parts must be far better practice. In military surgery, the scapula is often injured by sabre-cuts; but, as Dr. Hennen remarks, this bone, when preserved from motion, is found in these cases to unite with great readiness, and without fu- ture inconvenience. (Principles of Military Surgery, p. 48, Ed. 2.) According to Boyer, when the scapula is fractured longitudinally, or transversely, it is merely necessary to fix the arm to the side by means of a bandage, which includes the arm and trunk, from the shoulderto the elbow. Thus, the motions of the shoulder, which are only concomitant with those of the arm, are prevented. When the inferior angle is broken. anr< FRACTURES. g&o, drawn downward and forward by the serra- tus major anticus, the scapula must be push- ed toward the fragment, by pushing the arm itself inward, downward, and forward, where it is to be kept with a roller. The fragment is also to be kept backward, as much as pos- sible, with compresses and a roller, and the arm is to be supported in a sling. The fractured acromion requires the arm to be so raised, that the head of tbe 03 bra- chii will push up the acromion, while an as- sistant pushes the scapula forward and down- ward, in a contrary direction to that of tbe arm. To maintain this position, a circular bandage is to be applied round the arm and body. Desault used to apply also a small pillow under the axilla, before putting on the ban- dage, in order to make the bead of the os brachii project more upward, on bringing the arm near the side. Compresses are to be placed on the scapula, which, by this means, and a roller, is to be kept downward and forward. When the coracoid process is fractured, the muscles attached to it are to be relaxed, by bringing the arm forwards towards the breast, and confining it there in a sling; while the shoulder is kept downward and forward, and a compress confined just un- der the broken part with a roller. The treatment of a fracture of the neck of the scapula consists in raising the shoulder to its proper height; in completely taking off the weight of the arm, by means of a proper sling, which always supports the limb from the elbow to the fingers ; and in entirely preventing all motion of the arm by binding it to the trunk with a roller. FRACTURES OF THE CLAVICLE. This bone being long and slender, unsup- ported at its middle, and protected externally only by the integuments, is very often bro- ken. Its serving to keep the scapula at a proper distance from the sternum, and as a apoint d'appui for the os brachii, every im- pulse of which it receives, makes its frac- tures still more common. It may be broken at any part; but its middle, where the curvature is greatest, is most frequently the situation of the injury. It is not very often fractured at its scapiilary extremity. However, a direct force, falling on the shoulder, may break any part of the clavicle, on which it immediately acts. The soft parts, in this kind of case, will also be contused, or even lacerated. A comminuted fracture maybe thus occa- sioned, and if the violence be very great, the subclavian vessels and nerves may be torn. 1 he fall of a heavy body on the shoulder often gives rise to a paralysis of the arm. When the fracturing force is applied to the ends of the bone, as by a fall on the point of the shoulder, or on the hands, while the arms are extended, the clavicle may be very much bent, and fractured so obliquely. that the broken portions protrude through the skin. Fractures of this bone are usually attend- ed with displacement of the broken ends, except when the injury takes place at the scapulary extremity,and within tbe ligament, tying together the clavicle and coracoid process. The external portion of the clavicle is al- ways that which is displaced. The internal part cannot be moved out of its natural si- tuation, by reason of the costo-clavicular li- gaments, and of its being drawn in ; pposite directions, by the sternocleido-mastoideus, and pectoralis major, muscles. Tbe exter- nal portion, drawn down bothjby tbe weight of the arm, and the action of the deltoid muscle, and forward and inward by the pec- toralis major, is carried under tbe internal portion which projects over it. The broken clavicle no longer keeping tbe shoulder at a due distance from the sternum, the arm falls forward towards the breast. The patient finds it impossible to put his hand to his forehead, because this act makes a semicir- cular motion of the humerus necessary, which cannot be done while that bone has not a firm point d'appui. The shoulder and upper extremity may be observed to be nearer the breast, than those of the opposite side. The motion of the pieces of bone on one another may be lelt, as well as the pro- jection of the end of the internal portion. When the shoulder is moved, a crepitus may also be perceived ; but this is productive of great pain, and the diagnosis is so obvious, that it is quite unnecessary. The ancients, and many moderns, have supposed, that, in order to set a fracture of the clavicle, the shoulder must be drawn back, and fixed in that position. The pa- tient w as placed on a low stool, so that an assistant might put his knee between the shoulders, which he drew back at the same time with both hands, while the surgeon ap- plied the bandage, w hich w as to keep the parts in this position. But when the shoul- ders are thus drawn towards one another, the scapula is obviously pushed towards the sternum, and with it the external portion of the clavicle, which passes under the internal fragment. The figure of 8 bandage has commonlv been used for maintaining the parts in this position. While the assistant keeps back the shoulders, as above described, the sur- geon is to apply one end of a roller to the arm-pit on the side affected, and then make it cross obliquely to the opposite shoulder, round which it is to pass, and from this to the other shoulder, about which it is to be applied in the same manner, and afterward repeatedly crossed before and behind. The tightness, with w hich it is necessary to ap- ply this bandage, produces a great deal of excoriation about the arm-pits, and the ef- fect is to make the ends of the fracture over- lap each other, the very thing which it is wished to avoid. Boyer remarks, that the iron cross proposed by Heister, the corslet described bv Brasdor in the Mem. dc I'Arerd 660 FRACTURES. de Chir. and the leather strap recommended by Brunninghaussen, are only modifications of the figure of 8 bandage, and are not at all better. Desault advised extension to be made, by means ofthe limb, vvhich is articulated with the fractured bone. This is done by con- verting the humerus into a lever, by carry- ing its lower end forward, inward, and up- ward, pushing the shoulder backward, up- ward, and outward, and putting a cushion in the arm-pit to serve as a fulcrum. Desault used to put in the arm-pit a hair or flo< k cushion, five or six inches iong, and three inches and a quarter thick at its base. Two strings are attached to the corners of the base placed upward, which cross the back and breast, and are tied to the shoulder of tbe other arm. The cushion being thus placed in the arm-pit, and the fore-arrn bent, Desault used to take hold of the patient's elbow, and carry it forward, upward, and inward, pressing it forcibly against the breo3t. By this manoeuvre, the humerus carries the shoulder outward, (be ends of the fracture become situated opposite each other, and all deformity is removed. An assistant is to support the arm in this position, while the surgeon, having a single- headed roller nine yard*- long, is lo place one end of it in the arm-pit of the opposite side, and thence apply (he bandage over the upper part of the arm, and across the bark to the same situation. Tbe arm and trunk are to be covered wiih such circles of tbe roller, as far down as the elbow, drawing the bandage more tightly, the lower it descends. Conipres>es, dipped in camphorated spirit, are next to be placed along the fractured bone. Desault then took a second roller, of the same length as the first, and put one end of it underthe opposite arm-pit, whence it was carried across the breast over the com- press and fracture, then down bihind the shoulder and arm, and, after ha <\n: passed under the elbow, upward on tbe breast. De- sault next brought it across to the sound shoulder, under and round which he passed it, for the purpose of fixing the first turn. He then conveyed the roller across the back, brought it over the compresses, carried it down in front of tbe shoulder and arm, under the elbow, and obliquely behind the back to the arm-pit, where the application began. The same pl«n was repeated, until all the roller was spent. The apparatus was secured by pins, wherever they promised to be useful, and the patient's hand was kept in a sling. Boyer has invented an apparatus for frac- tured clavicles, which is more simple than that employed by Desault. The cushion is to be applied under the arm. Tbe apparatus consists of a girdle of linen cloth, which passes round the trunk on a level with the elbow. It is fixed on by means of three straps, and as many buckles. At an equal distance from its extremities are placed externally on each side two buckles, two before and two behind the arm. On tbe V>wer part of the arm. is to be laced a piece of quilted cloth, five or six fingers broad. Four straps are attached to it, which corres- pond to the buckles on the outside of the girdle, and serve both to keep the arm close to the trunk, and from moving either back- ward or forward. Certainly, the methods recommended by Desaub und Boyer are very judicious and scientific They are not, however, much adopted in this country, perhaps in conse- quence of 'he general aversion among Eng- lish surgeons to every apparatus which is not exceedingly simple. It is to be hoped, at the same time, that, in the treatment of fractured clavicles, they will always attPnd to the principles which Desault and Boyer- have in- culcated. If they understand why the posi- tion of the arm should be such as these emi- nent surgeons point out, they will have no difficulty in doing what is proper, and with u cushion, sling, and a couple of rollers, they will easily maintain the proper posture. I cannot quit this subject without caution- ing surgeons never to fall into tbe error of supposing the rising end of a broken clavicle to be tbe end which is displaced. This is the one which is truly iu its right situation, and which has often been made by injudicious pressure to protrude through the integu- menls, as I myself have seen. FRACTURES OF THE OS BRACHII, OR HUMERUS. This bone may be fractured at any point of its length : at its middle, either of its ex- tremities, or above the insertion of the pec- toralis major, lutissimus dorsi, and teres major. The last case is termed fracture of the neck of Ihe humerus; but that denomination has not the m rit ot being strictly anatomical. It is possible, however, that what is strictly called (he neck of (be humerus may be fractured, particularly by a gunshot wound. By neck of the humerus, we understand that circular narrowing, which separates the tuberosities from the head. The fractures of this bone may be trans- verse or oblique, simple or compound. Transverse fractures of its middle part, be- low ihe insertion of the deltoid muscle, are attended with but little displacement; for the brachialis iuternus and the triceps, being attached posteriorly and anteriorly to both fragments, counteract one another, and ad- mit only a slight angular displacement. Wutn the fracture takes place above the in- sertion of the deltoid muscle, the inferior portion is first drawn outward and then up- ward on the external side of the superior. Fractures of the humerus, near its lower end, such particularly as are transverse, are not subject to much displacement : a circum- stance to be attributed to (he breadth of the fractured surfaces; to their being covered posteriorly by the triceps muscle, and ante- riorly, by the brachialis internus, which admit only a slight angular displacement, by the inferior portion being drawn a little forward. Oblique fractures are always attended with displacement, whatever be the part of the FrUCTcKE none broken. The inferior portion being drawn upward by the action of tbe deltoides, biceps, coraco-brachialis, and long portion of the triceps, glides easily on the superior, and passes above its lower extremity. Finally, fractures of the neck of the humerus are al- ways attended with displacement, produced by the action of the pectoralis major, latissi- mus dorsi. and teres major, which being at- tached to the lower portion near its superior extremity, draw it first inward and then up- ward, in which last direction it is powerfully urged by the biceps, coraco-brachialis, and long portion of the triceps. In this case, the superior portion itself is directed a little out- ward by the action of the infraspinatus, su- Eraspinatus, and teres minor, which make the ead of the humerus perform a rotatory mo- tion in the glenoid cavity. The shortening and change in the direction of the limb, the crepitus, which mi;y be very distinctly perceived by moving the broken pieces in opposite directions, the pain, and impossibility of moving the arm, he. joined lo the history ofthe case, render the diagno- sis sufficiently plain. Fractures of the neck of the humerus, however, are not so easily ascertained, and for want of attention, have been frequently confounded with luxations of that bone. Yet, the diagnostic symptoms of these two affections are very different. When the neck of the humerus is frac- tured, a depression is observed at the upper part and external side of the arm, very dif- ferent from what accompanies the luxation of that bone downward and inward. In the latter case, a deep depression is found, just below the projection of the acromion, in the natural situation of the head of the hu- merus ; whereas, in fracture of the neck of that bone, the shoulder retains its natural form, the acromion does not project, and the depression is found below the point of the shoulder. Besides, on examining the arm-pit, instead of finding there a round tumour, formed by the head of the humerus, the fractured and unequal extremity of that bone will be easily distinguished. The mo- tion of the broken portions, and the crepi- tus, thus produced, serve still further to es- tablish the diagnosis. (Boyer.) In a simple fracture of the body ofthe hu- merus, the prognosis is generally favoura- ble ; but fractures near tbe elbow are liable to be followed by more or less stiffness of the joint, often very difficult of removal. In ordinary fractures of the os brachii, it is usual to apply two pieces of soap-plaster, which together surround the limb, at the si- tuation where the accident has happened. Extension, if necessary, being now made by an assistant, who at once draws "he lower portion of the bone downward and bends the elbow, the surgeon is to apply a roller round the limb. The external splint is to extend from the acromion to the outer con- dyle, und beiug lined with a soft pad, the wood cannot hurt the limb by pressure The internal splint is to reach from the mar ■,-ins of the axi'lu to a little '" 'ow the inner v, , t 'i condyle, and is lo be welt gu.nded with a pad, filled with tow, or any other soft mate rials. Some surgeons are content with the ap- plication of two splints ; butthoughthe two, above described, are those on which we are to place the greatest reliance, yet, as the cylindrical form of the arm conveniently allows us complelely to incase this part of the limb in splints, I consider the employ- ment of four better; one on the outside, one in the inside, one on the front, and another on the back of the arm. These are to be carefully fixed in their respective situations by means of tape. Throughout the treatment, the elbow and whole of the fore-arm are to be quietly and effectually supported in a sling. FRln'CKE OF THE HEAD, OH NECK OF 1 III OS BRACHII. , Chirurgical language here differs from that adopted by anatomists, and underthe name of fracture of the neck of the humerus, is not meant, that of the circular, hardly per- ceptible depression, vvhich separates the head from tbe tuberosities of this bone. By this expression, surgeons imply the fracture of that contracted part of the humeri!?, which is bounded above by the e tuberosi- ties ; which below is continuous with the body of the bone ; which has the tendons of the pectoralis major, luti-sinius dorsi, and teres major inserted below it; and Which many practitioners extend even as low a- the insertion of the deifoid muscle. Indisputable facts, however, prove tin; possibility of the anatomical neck of the bone being fractured and C. Larbaud show- ed Bichat the humerus of a young man, aged 17, the bead of which bone was accu- rately detached from its body, by a division which had obliquely interested the upper part of the tuberosities. An instance of tbis kind, I think, was pointed out to me this spring (1821) in St. Bartholomew's hospital. The patient was a boy, whose elbow had been strongly kept up, on the supposition.. that the case was a fracture of the neck o! the scapula, and consequently, the irregular end of the humerus formed a remarkable projection in front of the acromion, yet ca- pable of being pushed back, where, howe- ver, it would not remain. When tiie acci- dent is produced by a direct blow or fall on tbe fleshy part of the shoulder, the deltoid is sometimes confused and affected with ecchymosis. Even blood may be effused from some of the ruptured articular veins or arteries, and form a collection, which De- sault recommended to be speedily opuned. though" the reason of such practice, ai a ge- neral thing, must be questionable, because large extravasations of blood about the shoulder arc usually very soon absorbed. The counter-fracture arises from a fall on the elbow, when tins part is separated from the trunk, or else from a fall on the ham', which a ticmiral i,;-'iu'-i moke- u. ,.\ L.OJ FRACTURES tend, with the arm and fore-arm, to protect ourselves at the time of falling. The whole of the symptoms of a fracture of the neck ofthe humerus sufficiently de- note its existence ; but it is not always an easy matter tr s»- this whole, and here more difficulties occur in the diagnois than in any other fracture ofthe humerus. An acute pain is experienced at tl.e mo- ment of tbe fall; sometimes the noise of something breaking is heard. There is always a sudden inability lo move the limb, which, left to itself, remains motionless. But, on external force being applied to the member, this readilyyields, and admits of being moved with the greatest ease, in every direction. An acute pain attends such motion, which, carried too far, may cause bad consequences, as has been observed in patients in whom the fracture has been mistaken for a dislo- cation. Below tba acromion a depression is re- markable, always situated lower down than that which attends a dislocation. If we place one hand on the head, while the lower part of the bone is moved in various direc- tions with the other hand ; or, if while ex- tension is made, an assistant communicates to the bone a rotatory motion, the following circumstances are perceived. 1. The head of the humerus remains motionless. 2. A more or less distinct crepitus is felt, arising from the two ends of the fracture rubbing against each other. These two symptoms are characteristic of the accident; but the swelling of the joint may prevent us from detecting them. Sometimes there is no displacement of the ends of the fracture, and then, as most ofthe symptoms are absent, tbe diagnosis is still more difficult. In general, bowever, the ends of the fracture are displaced, and in this circumstance, it is the lower one, which is out of its proper position, and not the upper one, which is of little extent, and is not acted upon by many muscles. The displacement is generally not very perceptible, in regard to'length, unless the fracture be very oblique, and its pointed spiculae irritate the muscles, aud make them contract with increased power; or unless the blow, which was very violent, continued to operate after the bone had been broken, and forced the ends of the fracture from their state of apposition. In this way, the body of the humerus has been drawn or dri- ven upward so as to protrude Ihrough the deltoid muscle, and integuments, far above (he height of the head of the bone. But commonly, as Petit observes, the weight of the limb powerfully resists the ac- tion of the muscles, and the displacement of the fracture is more liable to be trans- verse. In this circumstance, tbe lower end of the fracture is displaced outward or in- ward, and rarely in any other direction. In the most frequent case, the elbow is sepa- rated from the trunk, and cannot be brought near it without pain ; and in the instance of the bone being displaced outward, the limb has a tendency to the opposite direction. A fracture of the neck of the humerus is not a serious event, and if, as Heister re- marks, prope caput, fractura pejor, et diffici- lius curalur, it is less on account ofthe na- ture and situation of the disease, than of the difficulty experienced in maintaining the endsof the fracture in contact. The reduction usually presents but few difficulties, and the multiplicity of means formerly employed for its accomplishment, serve only to exhibit the uselessness of such resources. Most of the machines, designed for re- ducing dislocations of the humerus, were applied to this kind of fracture. To such machines succeeded the use of pulleys, weights suspended to the limb, he. useless plans, as their only tendency was to inr rease the natural power, which was always more than sufficient. Petit proposes to reduce the fracture, by first placing the arm at a right angle with the body ; and then making extension with the hands ofan assistant, applied above the elbow ; while the counter-extension is made by another assistant, who is to take hold of the fleshy part of the shoulder. This me- thod is liable to three inconveniences It fatigues and even pains the patient; it les- sens the extending powers by bringing them near the moveable point ; and it irritates such muscles as proceed from above to the lower end of the fracture, and thus increases their disposition to contract. Hence, diffi- culties sometimes attended the reduction, which is always simple, when the trunk be- ing fixed, gentle extension is made on the fore-arm half bent. Desault used toaccom- plish the reduction in the following way. The patient may either sit upon a chair, or tbe edge of a bed. The arm is to be a little separated from the trunk, and carried somewhat forward. An assistant is to fix the trunk by drawing towards him the arm of the opposite side. T his mode of making extension is prefera- ble to that commonly employed, and which is effected by applying the hands to the up- per part ofthe affected shoulder. The other being more distant from the resistance, there is no need for exerting so much power; and the patient's body being quite uncover- ed, the surgeon can conveniently apply the bandage, without disturbing the extension. A second assistant extends the fore-arm half bent, which he makes use of as a lever, placing one hand behind the wrist for the purpose of a fulcrum. The other hand, ap- plied to the front and middle part of the fore-arm, and making pressure upon it from above downward, represents the power. The ends of the fracture, which are to be placed in apposition, form the resistance. The relaxation of muscles, produced by the half flexion ofthe fore-arm, and the po- sition of the arm a little raised from the side, are peculiarly favourable to this mode of extension, recommended by the ancients and English. This method has also the ad FRACTURES. 56a vantage of leaving uncovered every part of the limb, to which the apparatus is to be ap- plied. The reduction takes place of itself, on employing a very little force, methodically directed, according as the fracture is dis- placed inward or outward If the surgeon put his hands on the situation of tbe fracture, it is rather to examine the state of the ends ofthe broken bone, than to accomplish a thing seldom required, namely, what is im- plied by the term coaptation. Every apparatus for the cure of fractures being only resistances, made by art to the owers causing the displacement of the bro- en part, it follows, that the whole should act in an inverse ratio to such powers. We have seen, that these consisted ; 1. Ofthe action of external bodies, favoured by the extreme mobility ofthe arm and shoulder; 2. Ofthe action ofthe latissiinus dorsi, pec- toralis major, and terres major, which draw inward the lower end of the fracture, or, what is more common, ofthe deltoid, which pulls it outward ; 3. Of the contractions of the muscles ofthe arm, which tend to draw the end of the fracture a little upwards. Hence, 1. to render tbe arm and shoulder immoveable; 2 to bring either outward, or inward, the lower end ofthe fracture ; 3. to draw downward the same; are the three in- dications, which every bandage, destined for a fracture of the neck of the humerus ought to fulfil. The last object merits less attention, than the two others, because the weight of the arm is alone almost sufficient for the purpose. Desault used to employ the following apparatus for the cure of frac- tures of the neck of the humerus. 1. Two bandages, one about five or six ells long; the other eight or ten ; both about three inches wide. 2. Three strong splints, of different lengths, and between two and three inches broad. 3. A cushion or pillow, three or four inches thick at one of its ends, terminating at the other in a nar- row point, and long enough to reach from the axilla to the elbow. 4. A sling to sup- port the fore-arm. 5. A towel to cover the whole of the apparatus. The reduction is to be effected as above explained, and the assistants are to continue the extension. Then the surgeon is to take the first roller, which is to be wet with the liq. plumbi acet. dil. and he is to fix one of its heads by applying two circular turns to the upper part of the fore-arm. The ban- dage is now lo be rolled moderately tight round the arm upward, making each turn overlap two-thirds of that which is imme- diately below it. When the roller has reached the upper part of the limb, it must be doubled back a few times to prevent the folds, which tbe inequality of the part would create. The bandage is afterward to be carried twice under tbe opposite axilla, and the rest of it, rolled up, is to be brought up to the top of the shoulder, and commit- ted to the care of an assistant. The first splint is to be placed in front, reaching from the bend of the arm as high as the acromion. The second, on the outside from the external condyle to the same height. The third, behind, from the olecra- non to the margin of the axilla. The pillow, interposed between the arm and thorax, serves as a fourth splint, which becomes use- less. An assistant applies these parts of the apparatus, and holds them on by applying his hands near the bend of the arm, in order not to obstruct the application of the re- mainder of the bandage. The surgeon takes hold of the bandage again, and applies it over the splints with moderate tightness, and the bandage ends at the upper part of the fore-arm, where it be- gan. While the assistants continually keep up the extension, the surgeon is to place the pil- low between the arm and trunk, taking care to put the thick end upward, if the fracture be displaced inward ; but downward, if this should be displaced outward, which is most common. It is to be attached by two pins to the upper part of the roller. The arm is to be brought near the trunk, and fixed upon the pillow, by means of the second roller, applied round the arm and thorax. The turns of this bandage should be rather tight below, and slackish above, if the fracture be displaced inward; but if out- ward, they should be slack below, and tight above. The fore-arm is to be supported in a sling, and the whole of the apparatus is to be en- veloped in a napkin, which will prevent the bandages from being pushed out of their places. If the effect of the above apparatus in fulfilling the indications above specified is considered, we shall easily see, lhat they are very well accomplished. The arm, firmly fixed against the trunk, can only move with it, and then nothing displaces the lower end ofthe fracture, which is equally motionless. The shoulder cannot communicate any mo- tion to the upper end of the fracture. The pillow, differently disposed, according fo the direction, in vvhich the lower extremity of the fracture is displaced, serves to keep this part in the opposite position. Should this part of the bone project in- ward, the thick end of the pillow will re- move it further from the chest. The bone will be kept at its distance from the side by the turns of the bandage, which, being very- tight downward, will act upon the limb as n lever, the fulcrum for which will be the pil- low, and the resistance, the action of the pectoralis major, latissiinus dorsi, and teres major. Thus the bandage will have the effect of bringing the elbow nearer the trunk, and move the lower end of the frac- ture in the opposite direction, so that it may' be here considered as an artificial muscle, directly opposing the natural ones. When the lower end of the fracture is drawn outw'ard, vvhich is most commonly the case, the contrary effect will be pro- duced, both from the pressure exercised by the bandage on the upper end of the dis placed portion of the bone, and from tit*: u>l>i FRACTURES. situation of the elbow; which is kept out- ward by the thick parts of the pillow. The outer splint will also prevent the lower end of the fracture from being displaced out- ward, both by its mechanical resistance to the bone, and by compressing the deltoid muscle, which is the chief cause of such displacement. Ail displacement , of the lower end of the fracture, forward, or back- ward, is prevented by the bad. splints ; and as for the longitudinal displacement, which is already prevented by the weight of the limb, it is still more effectually hindered by the compression of the muscles of the arm, both by the splints and roller. (See LEuvres Chir. de Desault, pur Bichat, T. 1.) THACTURES OF THE LOWER END OF THE OS BRACHII, WITH SEPARATION OF THE CONDYLES. Fractures of the os brachii, with detach- ment of its condyles, seem to have escaped tiie notice of most authors, who have writ- ten on the diseases of the bones. The an- cients have left us nothing upon the subject. Heister only mentions the fracture of the lower end of this bone, with a view of ma- king an unfavourable prognosis, ihe acci- dent, however, is not uncommon, and De- sault, in particular, had frequent occasion to meet with it. Whatever its causes may be, the two con- dyles are usually separated from each other by a longitudinal division which, extending more or less upward, is bounded by another transverse, or oblique division, which occu- pies the whole thickness of the bone. Hence, there are three different pieces of bone, and two fractures. Sometimes, the division is more simple. Then, taking a direction outward, or inward, it crosses obliquely downward the lower end of the os brachii, terminates in tbe joint, and only detaches one of the condyles from the body of the bone. In the first case, the deformity is greater, and the fractured part s m' re moveable. When pressure is made, either before or be- hind, on the track of the longitudinal frac- ture, the two condyles becoming further se- parated from each other, leave a fi sure be- tween them, and the fractured part is widened. Tbe fore-arm is almost always in a state of pronation On taking hold of the condyles, and moving them in different di- rections, a distinct crepitus is perceived. In the second case, the separation of the condyles from each other is not so easy; but, a crepitus can always be distinguished, on moving the detached condyle. In one case, in which the external condyle was the only one broken, De*.iult found the limb always supine: a position, which tbe mus- cles inserted into this part are, doubtless, concerned in producing. In both cases, an acute pain, the almost inevitable effect of bending, or extending the fore-arm ; an habitual half-bent state of this part of the limb, and sometimes a sub- sequent swelling of it, together with more or less tumefaction round the joint, are ob servable. When the blow has been very violent, or a pointed piece of the bone pro- trudes through the flesh, these accidents may be complicated with a wound, splinters of bone, &c. Former writers consider the communica- tion of a fracture with a joint, a fatal kind of complication. Swelling and inflamma- tion of tbe adjacent parts; continuance of pain after the reduction ; large abscesses ; even mortifiratiot of the soft parts, and caries of the bones, are, according to such authors, the almost inevitable consequences of these fractures, and anchylosis the most favourable termination. Pure, Petit, Heister, Duverney, all give this exaggerated picture. However, analogous fractures of the olecra- non and patella prove, that this representa- tion is magnified beyond truth. Modern ob- servation has dispelled the ancient doctrine of the effusion of callus into the joint, and with it one of the principal causes, assigned by authors for the symptoms so much dreaded. The communication of the cavity of the joint with the externul air might be thought to have more real influence ; but, this can only occur in compound fractures, and De- sault had often learned from experience, that the contact of air is not so dangerous, as has been supposed. The general cause of all the ill consequences, seen in former times, was erroneous treat- ment, as may be inferred from the success which attended the extensive practice of Desault. The detached condyles, being drawn in opposite directions by the muscles of the arm and forearm, commonly remain unmoved between these two powers, and are but little displaced. External force may, however, [iut them out of their proper situation, and they may then be displaced forward,or back- ward, or they may separate from each other sideways, leaving an interspace between them. Hence, the apparatus should resist them in these four directions, and this object is easily accomplished by means if four splints, kept on with a roller ihe two late- ral splints are particularly necessary, when the condyles are separated from tbe body of „ ihe bone, with an interspace between them. If one nf (hem be still continuous with the humerus, no splint on this side will be re- quisite. The apparatus need not extend as high as when the arm is fractured higher up. Of what avail in steadying the fractured part, are the circles of the bandage,applied to tbe body of the bone, so much above (he injury ? Their only utility would consist in restrain- ing the action of tbe brachialis and triceps, by compressing these muscles. On the other hand, tbe roller should be continued oyer the fore-arm, in order that (he joint, according to the judicious precept of Paulus JEfmeta, may correspond to the middle of the bandage, which should here be firmer than any where else. This method is also of use in producing a gentle com FRACTURES. 555 pression of tbe muscles implanted into the condyles. Desault recommends having the front and back splints flexible at their middle parti which should be applied to the bend of the arm and elbow. (LEuvres Chir.de Desault, par Bichat, T. 1 ) Tbe detail ot the reduction ofthe fracture and application of the roller and splint-, be- comes useless alter what has been said. A further account maybe found in the wotk mentioned in (he preceding paragraph. The arm is to be kept in the bent position in a sling, .'ind perfectly quiet, until itisjud^e>i advisable to begin to move the joint for the purpose of preventing an anchylosis. FRACTURE OF THE FORE-ARM. The fore-arm is more frequently broken than the arm, because external force ope- rates more directly upon it than the latter part, especially in fills on the hands, which are frequent accidents—Bichat, in bis ac- count of Desault's practice, mentions, that fractures of the fore-arm often held (he first place in the comparative table of such cases, kept at tbe H6tel Dieu. We know that the fore-arm is composed of two bones, Ihe ulna and radius. The lasl is much more liable lo fractures than the first, because it is articulated with the hand by a large surface All Ihe shock- received by the latter pari, are communicated to the ra- dius. The situation of this bone more im- mediately exposes it to such causes as may break it; a circumstance vvhich we may readily convince ourselves of on the first in- spection. Both bones of the fore-arm may be broken at the same time, or one alone may be fractured. FRACTURES OF BOTn BONES May occur at the extremities, or middle of the fore-urm. They are frequent at (he mid- dle ; very common below; but seldom hap- pen at the upper part of the fore-arm. where the numerous muscles, and the considerable thickness cf the ulna, resist causes which would otherwise occasion the accident. The bones are usually broken in the same line; but sometimes in two different directions. The fracture is almost always single ; but in a few instances it is double, and Desault, in particular, was one day called to a patient, over whose fore-arm (lie wheels of a carl had passed, so as to break the bones, at the mid die and lower pari, it.to six distinct portions. The middle ones, notwithstanding they were quite detached, united very well, with hurdly any deformity. These accidents are most commonly oc- casioned by direct external violence ; but sometimes ihey are produced by a counter- stroke, which is generally the case when the patient falls on his hand. But in this instance, as the hand is principally connected with the lower broad articular surface of the radius, tiris bone alone has ♦•> sustain a'mesr tbe whole shock of the blow, and hence, is usu- ally the only one broken. The symptoms indicating fractures of the fore-arm, are not bkely to lead the surgeon into any mistake : motion at a par' of the limb, where it was previously inflexible; a crepitus, almost always ensi>y telt ; some- times * distinct depression in the situation of the fracture ; a projection of the ends ofthe fracture beneath the -kin. but a b■«< common symptom ; pa'n on moving the part ; a noise sometimes audible 10 the patient at the mo- ment of the accident ; an inability lo per- lonn the motio'i of pronation and supina- tion ; and • n almost constant hail bent state of tbe fo e-arm. There is one case, however, in which the fracture being very near the wrist-joint, similar appearances to those of a dislocation of this part may arise. But, attention to whether the styloid processes are above, or below, the deformity, will discover whether the case be a fracture or dislocation. In a fracture, the part is also more moveable, and there is a crepitus. (LEuvres Chir. de Desault, par Bichat, T. 1.) Accord.ng to Boyer, the two cases may be distinguished by simply moving the hand, by which motion, if there be a luxation without fracture, the styloid processes of the radius and ulna will not change their situation ; hut, if o fracture ex- ist, they will follow the motion of the hand. The connexion of the two bones of the fore-arm, by the interosseous ligament, wbicb occupies the interspace by w hich they are separated, and the manner in which the muscles attached to both, are inserted into them, render any displacement of tbe broken pieces in the longitudinal direction very difficult ; and in reality, such displace- ment is seldom observed, and never in any considerable degree. When it does take place it is to be ascribed to tbe cause of tbe fracture, rather than to muscular con- traction. On the contrary, iu the transverse displacement, the four | ieces approach one another, and the interosseous space is di- minished or entirely obliterated near the seat of the fracture ; attended with evident deformity of the part. I here is an angular displacement, which the fracturing cause always produces, either forward or back- ward, according to its direction. Boyer gives the following account of the treatment of the fracture of both bones of the fore-arm. The fore arm is to be bent to a right angle with the arm, and the hand placed in a po- sition between pronation and supination. The fore-arm and hand being thus placsd. an assistant tikes hold ofthe four fingers ofthe patient, and extends the fractured parts, while another assistant makes counter-ex- tension by fixing the hu nerus with both his hands. By these means, the operator is enabled to restore the bones to their natural situation, and to push the soft parts into the interosseous space, by a gentle and gradua- ted pressure on tbe anterior and posterior sides of the arm. The bone* are kent ;n fheir place by an 566 PRACTURES. plying first on tbe anterior and posterior sides ofthe fore-arm two longitudinal and gra- duated compresses, the base of which is to be in contact with the arm. I he depth of these compresses should be proportioned to tbe thickness of the arm, increasing as the diameter of the arm diminishes In the next place, the surgeon takes a single headed roller about six yards long, and makes three turns of it on the fractured part; he then descends to the hand by circles partially placed over one another, and envelopes the band by passing the bandage between the thumb and index finger ; the bandage is next carried upward in the same manner, and reflected wherever the inequality ofthe arm may render it necessary. The com- presses aud bandage being thus far applied, the surgeon lays on two -plints, one anteri- orly, the other posteriorly, and applies the remainder of the bandage over them. The compresses and splints should be of the same length as th ; fore-arm. It would be useless to employ lateral splints in this case, unless (what is scarcely ever to be expected or met with) a displacement should have ta- ken place in that direction. Lateral splints would counteract the compresses and two other splints, by lessening tbe radio-cubital diameter of the arm, and with the action of the pronators lend to push the ends of the fracture into the interosseous space. The surgeon's attention should be particularly di- rected to preserve the interosseous space ; for, if this be obliterated, tbe radius cannot rotate on the cubitus, nor the motion of pronation or supination be executed; and this object may be obtained with certainty by applying the compresses and splints in such a manner, thatthe fleshy parts may be forced into, and confined in the interosse- ous space, and by renewing the bandage every seven or eight days. If the fracture be simple, and the contu- sion inconsiderable, the patient need not be confined to bed ; but may walk about with his arm in a sling. FRACTURES OF THE RADIUS Are the most frequent of those ofthe fore- arm. The radius being almost tbe sole sup- port of the hand, and placed in tbe same line with the humerus, is for both these reasons more exposed to fractures, than the ulna. Fractures of the radius, whether trans- verse or oblique, near its middle part or ex- tremities, may be caused by a fall or blow on the fore-arm, or, as happens in most ca- ses, by a fall on the palm of the hand. When likely to fall, we extend our arms, and let the hands come first to tbe ground ; in which case, tue radius, pressed between the hand on the ground, and the humerus, from which it receives (he whole momem- turn of the body, is bent, and, if the fall be sufficiently violent, broken more or less near its middle part. When, after an accident of this kind, pain, and difficulty of perform- ing the motions of pronation and supination, supervene, the probability of a fracture of the radius is very strong. Tbe truth is fully ascertained by pressing with the fingers along the external side of the fore-arm. Also, in endeavouring to perform supination or pronation of the hand, a crepitus and a motion of the broken portions will be per- ceived. When the fracture takes place near the head ofthe radius, the diagnosis is more difficult, on account of the depth of soft parts over that part of the bone. In this case, the thumb is to be placed under the external condyle of the os humeri, and on the superior extremity of the radius, and at the same time the hand is to be brought into the prone and supine positions. If, in these trials, which are always painful, the head of the radius rests motionless, there can be no doubt ofthe bone being fractured. Here the causes of displacement are the same as in fractures of the fore-arm ; it can never take place, except in the direction of the di- ameter of the bone, and is effected princi- pally by the action of the pronating muscles. The ulna serves as a splint in fractures of the radius; and the more effectually, as these two bones are connected with one another throughout their whole length. In general, when only the radius is frac- tured, no extension is requisite. During the treatment, the elbow is to be bent, and the hand put in the mid-state, between prona- tion and supination ; that is to say, the palm ofthe hand is to face the patient's breast. Having reduced the ends of the fracture, when they appear to be displaced, the soap plaster is to be applied, and over this a slack roller. This bandage is, indeed, of no utili- ty ; but, it makes the limb seem to the un- knowing by-standers more comfortable,than if it were omitted, and, as it does no harm, the surgeon may honestly apply it. How- ever, no one can doubt, that tight bandages may act very perniciously, by pressing the radius and ulna together, causing them to grow to each other, or, at all events, making the fracture unite in an uneven manner. Only two splints are necessary ; one is lo be placed along the inside, the other along the outside, of the fore-arm. Soft pads must always be placed between the skin and the splints, in order to obviate the pressure of the hard materials, of which the latter are formed. The inner splint should extend to about the last joint of the fingers; but, not completely to the end of the nails ; for, many patients, after having had their fingers kept, for several weeks, in a state of perfect extension, have been a very long time in be- coming able to bend them again. Sometimes, it may be proper to apply a compress just under the ends of the fracture, to prevent their being depressed toward the ulna too much, the consequence of which has occasionally been tbe loss of the prone and supine motions ofthe hand. In setting a tractured radius, the hand should be inclined to the ulnar side of the fore-arm. FRACTURES OF THE ULNA. Fracture* of this bone are less frequent, FRACIURES. 567 than those of the radius, and takes place ge- nerally at its lower extremity, which is most slender, and least covered. A fracture of this bone is almost always the result of a force acting immediately on the part fractu- red ; as, for instance, when, in a fall, the in- ternal side of the fore-arm strikes against a hard resisting body. On applying the hand judiciously to the inside ofthe fore-arm, this fracture is easily ascertained by the depres- sion at that part, in consequence of the in- ferior portion being drawn toward the radius by the action of the pronator radii quadra- tus. This displacement, however, is less considerable than what takes place in frac- tures of the radius. The superior portion ofthe ulna remains unmoved. (J. L. Petit.) In this case, the assistant, who makes whatever little extension may be necessary, should incline the hand lo the radial side of the fore-arm, while the surgeon pushes the flesh between the two bones, and applies the apparatus, as in the preceding case. In all fractures of the bones of the fore-arm, and, particularly, in those which are near the head of the radius, a false anchylosis is to be apprehended, and should be guarded against by moving the elbow gently and frequently, wheu the consolidation is in a certain de- gree advanced. Fractures ofthe fore-arm always require the part to be kept quietly in a sling. FRACTURES OF THE OLECRANON. The olecranon may be fractured either at its base, or its extremity; but, the first oc- currence is the most frequent. The division is almost always transverse, though occa- sionally oblique. The accident is very rare- ly produced by the action of the muscles, but almost always by external violence, di- rectly applied to the part in a blow, or fall upon the elbow. With regard to symptoms, the contraction of the triceps, being no longer resisted, by any connexion with the ulna, draws upward the short fragment, to which it adheres, so as to produce, between it and the lower one, a more or less evident interspace. This in- terspace is situated at the back part of the joint, and maybe increased or diminished at will, by augmenting the flexion ofthe fore- arm, and putting the triceps into action, or else extending the limb. Another symptom, is the impossibility of spontaneously extend- ing the fore-arm, the necessary effect of the detachment of the triceps from the ulna The fore-arm is constantly half bent, the bi- ceps, and brachialis having no antagonists. Tbe olecranon is, more or less conspicuous- ly, drawn up higher than the condyles of the os brachii, which latter parts, on the con- trary, are naturally situated higher than the olecranon, when the fore-arm is half bent. The upper piece of bone may be moved in every direction, without the ulna participa- ting in the motion. Besides these symptoms, we must take into the account, the consi- derable pain experienced, the crack some- times distinctly heard by the patient, and tiie crepitus which is frequently perceptible. The indications are to pusti downward the retracted portion of tiie olecranon, and lo keep it in this position, at the same time that the ulna is made to meet it, as it were, by extending the fore-arm. According to Desault, however, the fore-arm should not be completely extended, as when the pieces of bone touch at their back part, they leave a vacancy in front, which is apt to be fol- lowed by an irregular callus, prejudicial to the free motion of the elbow. Hence, it was his practice to put the arm between the half bent stale and extension. This posture, however, would soon be changed, if perma- nent means were not taken to maintain it. Desault, with this view, applied a splint along the forepart of the arm. But, as po- sition evidently operates only on the lower part of the olecranon, the upper one re- quires to be brought near the former, and fixed there, which is, doubtless, the most difficult object to effect, because the triceps is continually resisting. Desault used to adopt the following me- thod : the fore-arm being held in the above position, the surgeon is to begin applying a roller round the wrist, and to continue it as high as the elbow. The skin, covering this part, being wrinkled in consequence of the extension of the limb, might insinuate itself between the ends ofthe fracture, and con- sequently it must now be pulled upward by an assistant. The surgeon is then to push the olecranon towards the ulna, and confine it in this situation with a turn of the roller, with which the joint is then to be covered, by applying it in the form of a figure of 8. A strong splint, a little bent, just before the elbow, is next laid along the arm and fore-arm, and fixed by means of a roller. The apparatus being applied, the whole limb is to be evenly supported on a pillow. The cure of the fractured olecranon is seldom effected by the immediate reunion of its fragments : there generally remains a greater or lesser interspace between them, which is filled up by a substance not of a bony consistence. It is true, such inter- space is smaller when the fore-arm has been kept extended ; but, this advantage does not at all counterbalance the unpleasant stiff- ness of the joint, which is the inevitable consequence of a posture so unfavourable to the functions of the limb. (Boyer, Traiti des Maladies Chir T. 3, p. 226.) This au- thor cites several facts, which prove, that when the fractured olecranon is entirely neglected from the case not being under- stood, the fragments are still united by a ligamentous substance, and that when an interspace of half an inch is thus left be- tween them, the strength and motion ofthe elbow become perfect. Camper laid great stress upon the inutility of keeping the arm perfectly extended : he found patients recover sooner and better, when the elbow was kept half bent, and the joint gently exercised at as early a period as possible. " Agglutinationem scilicet motiri non debet chinirgus, sed sublatis tumore a<- iri& i rt.-v. Fh^t: inflammatione quiete et remedus aptis, cu- bitum quotidie prudenter movere, ut unio pertricipitis tendinem,seu per concretionem membranosam formetur, et os ossi non ad- moveatur. Verbo quemadmodum C. Celsus in Med. Lib. S c. 10, § 4. p. 537, de cubito frarto praecepit. Quod si ex summo cubito qui 1 fractura sit, glutinare id vinciendo ali- enum est, fit enim brachium immobile, ac, si nihil aliud quam dolori occurrendum est, idem qui fuitejususus est." (Camper de Frac- tura Patella, p. 66, Haga. 1789.) The late Mr. Sheldon, however, does not concur >\ ith Desault and Camper, respecting the position ofthe limb during tbe treatment, but insists upon the utility of keeping the fore-arm perfectly extended. The main objection to tbe endeavour to effect a close bony union, is the general impossibility of doing this in such a manner, that the extremity of the olecranon will afterward adapt itself precisely to the hollow designed for its re- ception at the back of the humerus. On an average, the olecranon becomes firmly united about the twenty-sixth day. (Desault par Bichat.) FRACTURES OFTHE CVRPAL AND METACAR- PAL BONES, AND PHALANGES OF TIIE FINGERS. The bones of the carpus, when broken, are usually crushed, as it were, between very heavy bodies, or the limb has been en- tangled in powerful machinery, or suffered gunshot violence It must be obvious, therefore, that, as the soft parts are also se- riously injured, these cases are generally followed by severe and troublesome symp- toms, and sometimes require the perfor- mance of amputation, either immediately, or subsequently. When an attempt is to be made to save the part, the chief indications are to extract splinters of bone, and prevent inflammation, abscesses, and mortification The parts may at first be kept wet with a cold evaporating lotion, any wound present being lightly and superficially dressed, but, afterward, as soon as all tendency to bleed- ing is over, emollient poultices may be ap- plied over tbe dressings, instead of the lo- tion. The dressings themselves, however, should not be removed for the fir3t three or four days, all unnecessary disturbance o; the crushed parts being highly injurious. Should abscesses form,- early openings should be practised, so as to prevent the matter from extending up the fore-arm. Duly supporting the hand and fore-arm in a sling is of the greatest importance. The metacarpal bones of the little finger and thumb are more fiequently broken, than tbe other three. A fracture of a metacarpal bone is generally produced by violence ap- lied directly to the part, as no force, capa- le of causing the accident, can well act upon the two ends of the bone -o as to break it. The fracture may be simpie, but, more commonly it is compound, the soft parts being wounded, and lacerated by the rarne violence, which has injured the bone. In most cases, also, unless Ihe force aa. operated by a very limited surface, more than one metacarpal bone is fractured. At first the same kind of treatment is requisite. as in the preceding cases, and after the in- flammation has subsided, a hand-board, or splint maybe employed. When the hand if very badly crushed, amputation is indicated. In fractures ofthe finger bones, the treat- ment consists in applying a piece of soap- plaster, rolling the part with tape, incasing it in pasteboard, sometimes placing the hand on a flat splint, or finger-board, and always keeping the hand, fore-arm, and el- bow, well supported in a sling. For Fractures of the Cranium, see Head, Injuries of For information on fractures consult par- ticularly, J. L. Petit, Traiti des Maladies de* Os; Duverney, Traiti des Maladies des Os. Jonathan Wathen, the Conductor and Con- taining Splints; or a Description of Two New invented Instruments, for the more safe Con- veyance- as well as the more easy and perfect Cure of Fractures of the Leg, 2d Ed. &vo. Lond 1767. W. Sharp in Vol. 57, of the Philosophical Trans, part 2, 1767 An Ac- count of a new Method of treating Fractured Legs. Pott's Remarks on Fractures, and Dis- locations. T. Kirkland, Obs. upon Mr. Pott's general Remarks on Fractures, fa. Svo. Lond 1770; also Appendix lo the same, 8vo. Lond, 1771. Cases in Surgery, by C. White, Edit. 1770. J. Aitken, Essays on several Important Subjects in Surgery, chiefly on the Nature of Fractures ofthe Long Bones ofthe Extremi- ties, particularly those of the Thigh and Leg, Svo. 1771. Boyer, Lecons sur les Maladies des Os, redigies en un Traiti complet de ces Maladies, par Richerand, or the English Translation by Dr. Farrell; also, Boyer, Traiti des Mai. Chir. T. 3. Encyclopidie Methodique, Partie Chir. Art Fracture, Cuis- se, Omoplate Ilium, fa. fa. LEuvres Chir. de Desault, par Bichat, T. 1. Parts of the Pa- risian Chirurgical Journal. Sir J. Earle, A [jCtter containing some Observations on the Fractures of the lower limbs ; to which is added an Account of a Contrivance to administer Cleanliness and Comfort to the bed-ridden, or persons confined to bed by age, accident, sick- ness, or other infirmity. 8vo. Lond 1807. Richerand, Nosographie Chir. T.3. Edit. 4. Leviille, Nouvelle Doctrine Chir T. 2, 181.:. Assalini^Manuale de Chirurgia. Parte Prima, Milano, 1812. Dupuytren, des Fractures ou Courbures des os des Enfans, in Bulletin dc la Faculli de Med. Paris, 1811 Idem sur la Faclure de I'Extrimili infirieure du pironi, les luxations, et les ac0aens qui en tont lu suite, in An:iuaire Med. Chir. de Paris, -ui,. Paris, 1819. Roux, Relation d'un Voyage fait a Londres en 1814, oil ParalRle de la Chirurgie Angloise avec la Chirurgie Vro.i, coise, p. 173, fa. Paris, 1815. Med. Chi, Trans. Vol. 2, p. 47, fa.: Vo,. 5, p. 358, fa. -. Vol 7, p. 103 Sketches of the Medical School* of Paris, by J. Cross, p. 87, fa. I RjENUM LINGUA. In infants, ti.e tougue is sometimes too closely tied down by reason of the fra num. being extre-uelv FRJE FRA 569 s>hort, or continued too far forwards. In the latter case, the child will not be able to use its tongue with sufficient ease in the action Of sucking, swallowing, &c. in consequence of its point being confined at the bottom of the mouth. Though this affection is not un- frequent, it is less common than is generally supposed by parents and nurses. When the child is small, and the nurse's nipple large, it is common for her to suppose the child to be tongue tied, when, in tact, it is only the smallness ofthe child's tongue thaf prevents it from surrounding the nipple, so as to enable it to suck with facility. Mothers also commonly suspect the existence of such an erroneous formation whenever the child is long in beginning to talk. The reality of the case may always be easily ascertained by examining the child's mouth. In the natural state, the point of the tongue is always capable of being turned Upward, towards the palate, as the fraenum does not reach along about a quarter of an inch of the lower part of the tongue from the apex. But, in tongue-tied children, by looking upon one side, we may see the fraenum extending from the back part to the very point, so that the whole length of the tongue is tied down, and unnaturally confined. The plan of cure is to divide as much of the fraenum as seems proper for setting the tongue at liberty. The incision, however, should not be carried more extensively back- ward, than is necessary, lest the raninal ar- teries be cut; an accident, that has been known to have proved fatal. For the same reason, the .scissors used for this operation, should have no points I think the follow- ing piece of advice, offered by a modern author, may be of service to practitioners, who ever find it necessary to divide the fraenum linguae : " It is not tbe relations of the trunk ofthe lingual artery alone which the student ought to make bimself acquaint- ed with. He will do well to study the po- sition of the arteria ranina in respect to the frafnilm linguae. This information will teach him the impropriety of pointing ihe scissors upward and backward, when snipping the fraenum, an operation, by tbe by, oftener performed than needed. He will learn, that the ranular artery lies just above the attach- ment of the fraenum ; so that if he would avoid it, he must turn the points ofthe scis- sors rather downward ; if he do not, the ar- tery will probably suffer." (A. Burns, Surgi- cal Anatomy ofthe Head and Neck, p. 239.) When an infant has the power of sucking, this proceeding should never be resorted to, even though the fraenum may have the ap- pearance of being too short, or extending too far forwards. (Fab. Hildanus, centur. 8, Obs. 28 ; Petit, Traiti des Mai. Chir. T. 3, p. 265, Edit. 1774.) Although the operation of dividing the fraenum linguae is for the most part done without any bad cousequences, surgeons should remember well, that it is liable to dangers, especially when performed either •innecessarily, or unskilfully Besides the fatal events, which have oc* casionally resulted from wounding the ra- ninal arteries, the records of surgery furnish us with proofs, that the mere bleeding from the raninal veins, and the small vessels of the fraenum, may continue so long, in con- sequence of the infant's incessantly sucking as to produce death. In such cases, the child swallows the blood, as fast as it issues from the vessels, so that the cause of death may even escape observation. But, if the body be opened, the stomach and intestines will be found to contain large quantities of blood. (See Dionis, Court d' Operations de Chirurgie, 7e Demonstration; Petit, Traite des Maladies Chir. T. 3, p. 2S2, fa.) Another accident, sometimes following an unnecessary, or too extensive a division of the freenum, consists in the tongue becom- ing thrown backward over tbe glottis into the pharynx, where it lies fixed, and causes suffocation. The observations of Petit ou this subject are highly interesting. (See Op. cit. T. 3, p. 267, fa.) Lastly, it should be known, that an in- fant's inability to move its tongue, or suck, is not always owing to a malformation of the fraenum. Sometimes the tongue is ap- plied and glued, as it were, to the roof of the mouth, by a kind of mucous substance, and in this case, it should be separated with the handle of a spatula. By this means, infants have been saved, which were unable to suck during several days, and were in im- minent danger of perishing from want of nourishment. (See Mimoirs de I'Acad. de Chirurgie, T. 3, p. 16, Edit. 4to.) See particularly Petit, Traiti des Maladies Chir. T. 3,p. 260, fa. Dionis Cours d'Opira- tions, 7e Demonstr. Sabatier, Midecine Opiratoire, T. 3, p. 132, fa. Lassus, Patholo- gic Chir. T. 2, p. 454. Richerand, Nosogr. Chir. T.3,p. 284. Ed. 2. Richter, Anfangsgr'. der Wundarzn. B 4, Kap. 2, p. 11, Ed. 1800.) FRAGILITAS OSSIUM. A morbid brit- tleness ofthe bones. Boyer imputes molliiies ossium to a defi- ciency of lime in their structure ; fragilitas ossium to a dejiciency of the soft matter naturally entering into their texture. He states, that a certain degree of fragilitas os- sium necessarily occurs in old age, because the proportion of lime in the bones naturally increases as we grow old, while that of the organized partdiminishes. Hence,the bones of old persons more easily break than those of young subjects, and are longer in uniting again. As Mr. Wilson observes, however, they never are found so friable and fragile. as to crumble like a calcined bone, but on the contrary, they contain a large quantity of oil, a fact particularly noticed by Saillant, (see Hist.de la Societe de Med. 1776, p. 316,) and after death dry so greasy, that they are unfit to be preserved as preparations. Their organized vascular part is diminished, but their oily animal matter is increased. (On the Skeleton and Diseases of Bones, p. 258.) In persons who have been long afflicted with enncerous diseases, the bone* are so-ir? -Tv> Fl'lsoCS. to become sometimes as brittle, as if tbey had been calcined. Saviard and Louis re- late cases of this description. (Obs. Chir. et Journ. de Sarans, 1691. 06s. et Remarques sur les effelsdu Virus Cancreux, Paris, 1751). Ponteau QZuvres Posthumcs, T. 1.) , Louis mentions a nun who broke her arm by mere- ly leaning on a servant; and iu the London Medical Journal an account is given of a person, who could not even turn in bed, without breaking some of his bones. In the latter stage of syphilis, the bones are alleged to be sometimes remarkably brittle. (Ephem. Nat. Cur. Dec. I. Ann. 3, Obs. 112. Walther, Museum Anat. T. 2, p. 29.) In bad cases of scurvy, tbe bones occa- sionally become so brittle, that tbey are bro- ken by the slightest causes, and do not grow together again. (Boettcher von den Krankh. der Knochen. p. 68.) The fragilitas ossium of old age is incura- ble ; that which depends on some other constitutional disease can only be relieved by a removal of the latter. (See Boyer on Diseases of the Bones, Vol. 2.) This author, in one of his lust works, ex- {iresses his opinion, that tbe doctrine of mol- ities and fragilitas ossium being distinct dif- ferent diseasi s, is by no means sufficiently proved by a due number of accurate obser- vations. (Traiti des Mat. Chir. T. 3, p. 607, 608.) Consult also Waldschmidt, Diss de Fractura Ossium tine Causil riulenta externa. Kilon. 1721. AcrcL Chir. Vorfillt 2, p. 136. Courtial, Nouretlcs Obs. Anat. sur les Os, p 64, 12mo. Paris, 1706. Marcellus Donalus, Lib. 5, c. 1, p. 528. Walther, Museum Anat. Vol. 2, p. 29. Schmucker, Vermisehte Schiifl- en, 1 B. p. 365. Kentish, in Edinb. Med. Comment. Vol. I. Hist, de I'Acad. des Sci- ences, 1765, p. 65. Hist, de la Soc. Royale d* Medecine, 1777 and 1778, p. 224 Journ. de Med. T. 77, p. 267, T. 84, p. 216. Isen- fiam. Pract. llemerk. uber Knochen. p. .^68, 415,466. Fabricius Hildanus, Cent. 2. Obs. 66, 67, 68, Cent. 5, Obs. 89. D'Aubenton, Description du Cabinet du Roi, T. 3, Ossa Veneorum sponte fracta. Meckren. Obs. Med. Chir. p. 341, Amst. 1682. Wiedmann de Ne- crosi Ossium, p. 2, Francofurti, 1793; and the writings of Duverney. Petit, and Pringle. J. Wilson on the Skeleton, fa. p. 258, Svo. tond. 1820. FUNGUS. Any sponge-like excrescence. Granulations are often called fungous when they are top high, large, flabby, and un- healthy. FUNGUS HiEMATODES. (fromfungus, and eu/ua, blood.) The Bleeding Fungus. Spongoid Inflammation. Soft Cancer. Car- r.inome Sanglante. Medullary Sarcoma. This disease, which has been accurately described only of late years, was formerly generally confounded with cancer. The public are indebted to Mr. J. Burns, of Glas- Sow, for the first good account of it; and le subsequent writings of Mr. Hey, of Leeds, Mr. Freer, of Birmingham, Mr. J. Wardrop, Mr. Langstaff, and others. hav<» made us still better acquainted with the suu- ject. It is unquestionably one of the most alarm- ing diseases, incidental to the human body, because we know of no specific, remedy for it; and an operation can only be useful at a time, when it is very difficult to persuade a patient to submit to it. Indeed, when the diseased partis extirpa- ted at an early period, a recovery hardly ever follows ; for experience proves, that it is not a disease of a local nature, but al- most always extends to a variety of organs and structures at the same time, either to the brain, the liver, or lungs, he. It is of the utmost consequence to be aware of this fact, since we should otherwise be induced to attempt many hopeless operations, and deliver a prognosis, that might cause disap- pointment and censure. In a large propor- tion of patients, afflicted with fungus haema- todes, the general disorder of tbe system is indicated by a peculiarly unhealthy aspect; a sallow, greenish yellow colour of the skin, which is frequently covered with clammy perspiration ; constant troublesome cough ; difficulty of breathing, he. Fungus Hamatoucs, is the name used by Mr. Hey. Mr. J. hums has called the dis- ease spongoid inflammation, from the spongy elastic feel, whicb peculiarly characterizes it, and w hich continues even after ulceration takes place. The fungus hamiatodes has most frequently been seen to attack the eye- ball, the upper aud lower extremities the testicle, and the mamma. But, the uterus, ovary, liver, spleen, brain, lungs, thyroid gland, hip, and shoulder joints have also been the seat of the disease. A distemper, which presents itself in so many parts, must be subject to variety in its appearances. FUNGUS H£UAT0D£S OF THE EYE. 1. When it attacks the eye, the first symp- toms are observable in the posterior cham- ber, an appearance, likethatof polished iron, presenting itself at the bottom of the eye. (Scarpa on Diseases of the Eye, p. 505, Ed. 2.) The pupil becomes dilated and immove- able, and, instead of having its natural deep black colour, it is of a dark amber, and some- times of a greenish hue. The change of colour becomes gradually more and more remarkable, and, at length is discovered to be occasioned by a solid substance, which proceeds from the bottom of the eye towards the cornea. The surface of this substance is generally rugged and unequal, ; nd ramifi- cations of the central artery of the retina may sometimes be seen running across it. The front surface of the new mass,at length advances as far forwards as the iris, and the amber, or brown appearance of the pupil, has, in this stage, been known to mislead surgeons into the supposition of there being a cataract, and make them actually atfempt couching. Tbe disease continuing to in- crease, the eyeball loses its natural figure tnd assumes an irregular knobby appear FUNGUS. 57 J ance. Tbe sclerotica also loses its white colour, and becomes of a dark blue, or livid hue. Sometimes, matter now collects be- tween the tumour and the cornea. The lat- ter membrane in time ulcerates, and the fun- gus shoots out. In a few instances, it makes its way through the sclerotica, and is then covered by the conj.inctiva. The surface of the excrescence is irregular, often covered with coagulated blood, and bleeds profusHy from slight causes. When the fungus is very large, the most prominent parts slough away, attended with a fetid sauious discharge. In the course of the disease, the absorbent glands, under the jaw, and about the paro- tid gland, become contaminated. On dis- section, a diseased mass is found extending forwards from the entrance of the optic nerve, the vitreous, crystalline, and aqueous humours being absorbed. The retina is an- nihilated, and the choroid coat propelled forwards, or quite destroyed. The tumour seems to consist of a sort of medullary mat- ter, resembling brain. The optic nerve is thicker and harder than natural of a brown- ish ash-colour, and destitute of its usual tu- bulur appearance. In other cases, the nerve is split into two or more pieces, the inter- spaces being filled up with the morbid growth. (Wardrop.) Nay, as Mr. Travers has stated, tbe optic ganglion, tractus opti- ma, and thalamus, have been repeatedly found diseased, and tbe surrounding adipose substance in the orbit affected to a consider- able extent in places also where there was no direct communication w ith the diseased contents of the globe. (Synopsis of the Dis- cuses of the Eye, p 221.) Even the brain has been observed to share in the disease, sometimes dark red spots appearing on the dura mater ; sometimes small spots, con- taining a fluid like cream, being found be- tween the pia mater, and tunica arachnoides. Mr. Travers has a preparation, exhibiting a genuine example of the disease affecting Ihe anterior right lobe ofthe cerebrum, and pro- truding the eye from its socket, while the eye itself was perfectly free from disease. (Op. cit. p. 223.) When the lymphatic glands at the angle of the jaw are enlarged, as they frequently are, they are also found converted into a kind of medullary matter, similar to that which composes the diseased mass in the eyeball. When the skin bursts over a diseased absorbent gland, a sloughy ulcer is produced ; but, no fungus is emit- ted, unless the affection of the gland with fungus haematodes be primary. Fungus hae- matodes of theeye has been erroneously re- garded as cancer by the best writers. We learn from Bichat, that more than one-third of the patients on whom Desault operated for supposed carcinoma of the eye, were un- der twelve years of age. Twenty out of twenty-four cases of fungus ha:matodes of the eye, with which Mr. Wardrop has been acquainted, happened to children under twelve years of age. Now, as cancer is rather a disease of aged, than young persons, and we find, from Mr. Wardrop, that fungus haematodes of the eye mostly affects persons under twelve years of age, it is tolerably certain, tln.t most of Desault's cases, report- ed to be cancers of the eye, were in fact the equally terrible disease now engaging our consideration. According to Mr. Travers, the only parts of the eye and it* appendages, subject to be primarily attacked by cancer, are the lachrymal gland, conjunctiva, and eyelids ; while the evidence of many cases has assured him, that fungus baimatodes may originate in any texture of the eye, with the exception of the lens and cornea. (Synopsis ofthe Diseases of Ihe Eye, p. 216, 222, and 421.) This account, however, differs from that delivered by Mr. Wardrop and Professor Scarpa, who describe the disease as first commencing in the retina, and particularly at the point, where the optic nerve enters the eye. " For, (says the latter author,) on the first appearance of tire yellowish or greenish spot, the retina on examination is found to be entirely deficient, or in other words, to have degenerated into the malig- nant fungus. It is also found, that tbe cho- roid membrane, while the fungus haematodes is in its incipient state, does not appear to have suffered any remarkable alteration in its texture, and that is only at a more advan- ced period ofthe disease, that this membrane becomes thickened, and separated from its coniiuexion with the sclerotica. The cho- roid membrane even in the most advanced stage of the disorder, preserves more than all others, its natural texture." (Onthe Prin- cipal Diseases ofthe Eyes, p. 507, Ed. 2.) In cases of fungus haematodes, the sight of young subjects is generally destroyed, before the attention of parents is excited to the dis- temper. Frequently, however, a blow, fol- lowed by ophthalmy, precedes the growth of the diseased mass. When no external violence has occurred, the first symptom is a trivial fulness of the vessels of the con- junctiva, the iris becoming, at the same time, extremely vascular, and altered iu colour, and the pupil dilated and immove- able. There is seldom much complaint made of pain ; but, the child is sometimes observed to be languid and feverish. In adults, fungus haematodes of the eye gene- rally comes on without any apparent cause, though sometimes in consequence of a blow. At first, tbe tunica conjunctiva is slightly- reddened, and vision indistinct. The red- ness and obscurity of sight increases slowly, and an agonizing nocturnal headach is ex- perienced, the eye bursts, and the humours are discharged. With regard to the cure of the fungus hae- matodes of the eye, the only chance of ef- / ferting this desirable object depends upon the early extirpation of the diseased organ It must be acknowledged,however, that most of the operations, in which the morbid eve has been removed, have hitherto proved un- successful, owing to a recurrence of the dis- ease. The reason of such ill success may be imputed to the optic nerve and other parts being almost always in a morbid state, be- fore an attempt is made to remove tbe eye. One case, however, described by Mr. Tra- 5.7S FUNGUS. yers, as having its seat in the cellular tex- ture connecting the conjunctiva to the cor- nea, was operated upon, and no recurrence pfthe disease had occurred a twelvemonth afterward. No other texture was affected more, than the contiguity and extent of the disease explained. (Synopsis of the Diseases of the Eye, p. 413.) The operation has al- ways been found to fail, when the disease is advanced so far, that the posterior chamber is filled by the fungous mass. Since no in- ternal medicines, nor external applications, afford the least hope of checking any form of the fungus haematodes, it is manifest, that when the distemper of the eye exceeds cer- tain bounds, the miserable patient is placed beyond the reach of any effectual aid from surgery In a case, however, which I saw in April, 1821, in the London Eye Infirmary, the disease formed a diseased mass »s large as an orange, accompanied with enlarged lymphatic glands over tbe parotid. The pa- tient was an infant. In this instance, Mr. Lawrence used as a local application, the li- quor opii sedativus, prepared by Mr Battley, which was found to lessen considerably the child's sufferings. (See parti ularly War- drop's Obs. on Fungus Hamatodes. Scarpa on the Principal Diseases ofthe Eye, chap. 21. Some Cases in Saunders's Treatise on Diseases of the Eye ; and B. Travers's Synopsis of the Diseases of the Eye, 8vo. Lond. 1820.y FUNGU3 HJSMATODES OF TIIE LIMBS 2. In the extremities, the disease begins with a small colourless tumour, vvhich is soft and elastic, if there be no thick cover- ing over it, such as a fascia; but otherwise it is tense. At first, it is free from uneasi- ness ; but, by degrees, a severe acute pain darts occasionally through it more and more frequently, and at length, becomes inces- sant. Foi a considerable time, the tumour is smooth and even ; but afterward, it pro- jects irregularly ot one, or more points ; and the skin at this place becomes of a livid red colour, and feels thinner. In this situa- tion, it easily yields to pressure, but instant- ly bounds up again. Small openings now form in these projections, through which is discharged a thin bloody matter Almost immediately after these tumours burst, a small fungus protrudes, like a papilla, and this rapidly increases, both in breadth and height, and has exactly the appearance of a carcinomatous fungus, and frequently bleeds profusely. The matter is thin, and exceed- ingly fetid, and the pain becomes of the smarting kind. The integuments, for a little way round these ulcers, are red, and tended-. After ulceration takes place, the nei hbour- ing glands swell, ai.d assume exactly the spongy qualities of tbe primary tumour. If the patient still surv ive the disease in its pre- sent advanced progress, simijartuinoursform in other parts of the body, and the patient dies hectic. After death, or amputation, the tumour is found to consist of a soft substance, some- what like the brain, of a grayish colour, and greasy appearance, with thin mcmbrane-biii; divisions running through it, and cells, or abscesses, in different places, containing a thin bloody matter, occasionally in very considerable quantity. There does not seem uniformly to be an entire cyst, surrounding the tumour; for it very frequently dives down betwixt the muscles, or down to the bone, to vvhich it often appears to adhere. The neighbouring muscles are of a pale co- lour, and lose their fibrous appearance, be- coming more like liver, thai' ir.u.-cle. The bones air always carious in the vicinity of these tumours. The distemper is sometimes caused by ex- ternal violence, though in general there is no evident cause whatever. (Dissertations pn Inflammation by J. Burns, Vol- 2.) Mr. Hey has given several cases of the fungus haematodes. If I notice the most particular circumstances, relative to one of these, it will suffice to inform the reader of the form, in which this terrible affliction has presented itself in this gentleman's practice. A young man, aged twenty-one. two years before applying to Mr. Hey, perceived a small swelling on tbe inside of the right knee, not far from the patella. This tu- mour was moveable, and did not impede the motion ofthe joint: it was not discoloured, but was painful, when moved, or pressed upon. It continued in this state half a year, and then the man having hurt his knee against a stone, it gradually increased in bulk, but did not exceed tbe size ol an egg. The skin was now discoloured with blue specks, which were taken to be veins. He could still walk with ease, and follow hij business. Two months before his admission into the Leeds Infirmary, he met with a fall, and violently bent his knee, but did not strike it against any thing. The tumour began im- mediately to enlarge; and within a few hours, it extended half way up tbe inside of his thigh. About a fortnight after this acci- dent, the skin burst at the lowest part of the tumour, and discharged some blood. A dark-coloured fungus, about the size of a pigeon's egg, here made its appearance, and a few weeks afterward, the skin burst at another part ofthe large tumour, and some blood was aga.n discharged. From the fis- sure arose another fungus, which had in- creased, in the course ofthe last week, to the size of a small melon, and now measu- red eight inches from one side of its base to the other. The base of the fungus frequently bled, especially when the man allowed his limb to hang down. The whole tumour was now of an enor- mous size, being nineteen inches ;.cross, when the measure was carried oyer the last mentioned fungus. From its highest part in the thigh to the lowest part, just below the knee, it measured seventeen inches, without including the fungus. The base of the hi- mour at the knee, exclusive of that part, which ran up the thigb, measured twenty- four inches in circumference. The tumour was situated on the inner side of tbe limb, FUNGUS. **;;•* and was distinctly defined. The skin co- vering the disease, was in some places livid, and had several fissures and small ulcera- tions upon it; but had not burst asunder, ex- cept in the two places above described. The tumour was soft, and gave a sensation of some contained fluid, when gently pressed with the hands alternately in opposite direc- tions. The patient said he had walked w ith- out pain in his knee, a week.before his ad- mission into tbe Infirmary; and he had lost very little blood iu his journey to Letds. He complained of ihe greatest uiiea-irn ss in the highest part of the tumour. It bad be- come hot and painful in the night-time, for some days past. His pulse was 114 iu a mi- nute ; his tongue was clean ; ;.ncl his appe- tite had been good, till the last few days. He had never felt any pulsation in the tu- mour. In a consultation it was determined, that the tumour should be laid open, by cutting off a portion of the distended integuments; and that after removing the contents, if the sac should be found in a sound state, the dis- ease should be treated as a simple wound ; but if in a morbid state, amputation of the limb should be immediately performed. A large oval piece of the integuments be- ing removed, the tumour was found to con- tain a very large quantity of a substance, not much unlike coagulated blood; but more nearly resembling the medullary part of the brain in its consistence and oily nature. It was of a variegated reddish colour, in some parts approaching to white, and as blood is- sued from it, Mr. Hey conceived it w as or- ganized. This mass was partly diffused through the circumjacent parts in innume- rable pouches, to which it adhered, and was partly contained in a large sac of an aponeurotic texture, which was connected with the capsule of the knee-joint. There was a great and universal effusion of blood from the internal surface of the sac, and from the pouches, containing this morbid mass. Amputotion of the limb was immediately performed, on finding such to be the nature of the case. Mr. Hey, unfortunately, how- ever, left a portion of the diseased surface behind on tbe inner part of the thigh, aud hoping that a small narrow portion of the upper part ofthe sac would soon become a clean sore, and not impede the cure, he made the circular incision two inches be- low its higher part. On examining the amputated limb, the vastus internus was found to be brown,-and much softer than th" other must les, which were healthy. There were many small por- tions of blood extravasated in the substance of this muscle. The sac was formed on the aponeurotic covering of the muscle, and ended below where this aponeurosis begins to cover the capsular ligament of the knee. The two fungous substances, above descri- bed, appeared to have been only extensions of the morbid mass, where this had made its Hvay through the sac and the integuments. The joint of the knee, and muscles of the leu, were perfectly sound. I need not detail all the particulars after the operation. Suffice it to say, the man suffered a great deal of constitutional disor- der. After a few weeks, the granulations upon the stump became good, and the cica- trization was nearly completed at the end of the sixth week, after the amputation. At this period, the small and superficial portion of the upper part of tiie great sac, which Mr. Mey had unfortunately left, was now healed ; but a tumour, now about four inches in length,and between two and three in breadth, had gradually risen at the lower and under part ofthe thigh, beneath the ci- catrix. This contained a soft substance, ex- actly similar as far as the touch could dis- cover, to that vvhich had filled the large sac. This tumour became painful, and sometimes discharged a bloody serum, some- times dark-coloured blood, through four op five small openings in the cicatrix. Mr. Hey laid open the tumour, and re- moved its contents ; but no advantage was gained by this proceeding. The interior surface was found to be too much diseased to produce good granulations. Blood con- tinued to ooze out of the wound for a few days Then the inner surface became co- vered with a blackish substance, which gra- dually extended itself, and formed a new fungus. A variety of escharotics were ap- plied to destroy the fungus and morbid sur- face of the wound; but to no purpose, the growth of the fungus always exceeded the quantity destroyed Undiluted oil of vitriol, applied freely , had very little effect. An attempt was once more made to cut away the disease; but on examining the wound carefully, after the contained sub- stance was removed, the muscular substance was found degenerated into a hard mass, vvhich felt somewhat like cartilage. The adipose membrane was also diseased, and formed into large cells, vvhich had contain- ed the fungous substance. Hence, another amputation se med the only resource. After this operation, the whole surface of the stump seemed sound, except the princi- pal artery, which was filled with a some- what stiff matter, resembling coagulated blood, which prevented its bleeding. The inside of the vessel, on being touched with the scalpel, felt hard, and communicated a sensation, like that of scraping bone. I he man was sent home, as soon as his state would admit of it; hut he died con- sumptive about six months .d'terward. Be- sides this instance in Ihe thigh, Mr. Hev re- lates cases of fungus haematodes, situated in the female breast, in the leg, iu the neck (ex- tending from_thf jaw to the clavicle, and produc n^ suffocation,) on the back part of the neck, on the back part of the shoulder and at the extremity of the fore-arm, near the wrist. " If I do not mistake, fsays Mr. Hey,) this disease not unfrequently affects the globe of the eye, causing an enlargement of it, with the destruction of its internal organint 574 FUNGUS. lion. If the eye is not extirpated, the scle- rotis bursts at the last, a Moody sauious mat- ter is discharged, and the patient sinks under the complaint." (P 283.) Besides some cases, in similar situations, to those mentioned by Mr. Hey, one is re- lated by Mr. Bums, in which the hip-joint was the seat ol this terr-ble affection, After detailing the progiess ->f the case to (he poor man's death, this author states that he found on dissection, the hip-j int completely sur- rounded with a soft matter, resenibl.ng the brain, enclosed in thin cells, and here and there ceils full of thin bloody water; the head of tbe thigh bone was quite carious, as was also the acetabulum. The muscles were quite pale, and almost like boiled liver, having completely' lost their fibrous appear- ance, uud muscular properties. Ihe same sort of morbid mischief was also found with- in the pelvis, most of tbe inside ofthe bones, on the affected side, being quite carious. An attempt h»d been made, before the putient died, to tap the bladder; but the trocar had only entered a cell, filled with bloody water, and situated in a mass of the soft brain-like substance. I havt- already said enough, to render the description of the dreadful nature of the fungus haematodes tolerably complete. Lit- tle can be said oi the treatment ; for we know not of one medicine, that seems to have the least power of putting a st. *p to the disease, and we have no reason to believe, th^t r ere is ever the smallest cliaure even of any spontaneous amendment, much less of such a cure. We h ve seen, that when the chief part of a fungus haematodes is cut nwny, and only a small portion of its cyst is left behind, that the fungus is m produced from this part, and soon becomes as formidable, nay more formidable, than it was before, and this not- withstanding tiie application of tbe most powerful escharotics. Neither the hydrar- gyrum nitratus ruber, the hydrargyrus muria- tus, tbe antimonium mtinaium, nor the undi- luted vitriolic acid, have always been able to repress ihe growth of such fungus. (Hey.) There is no remedy that has the power of checking, or removing the complaint. Fric- tion, with anodyne balsams, sometimes gives relief in the early stages; but it does not re- tard the progress of tbe disease. In short, (be ouly chance of cure consists in extirpating the whole of tbe distempered parts, removing not only the soft, brain-bke, fungous substance, but every particle of ihe cysts, sacs, or pouches, in which it may be contained. An operation of tbis kind, how- ev*-.-, is only advi-eahle in (he early stages, while the diseas*- is entirely local, if it ever be so, a circumstance much to be doubted ; for after the neighbouring glandshave becomeaf- fecled, Ihe chance of recovery is almost de- stroyed. Il is sometimes difficult, however, to persuade patients at an early period to submit to amputation, or extirpation, because the pain and inconveniences are inconsider- able ; but the operation ought to be urged with all tbe force which a conviction of"its absolute necessity, and the fatal peril of de- lay, ought to inspire. The attempts to cure the disease, by cutting it away, have been attended with such ill success, that some surgeons deem it advisea- ble not to follow this method, but amputate •he limb at once. The annexed views of the mailer appear to me to be most judicious and rational. First that if an attempt be made to cut sway the tumour, and save tbe limb, the surgeon must be careful to remove, at the same time, a considerable quantity of the soft parts in the circumference of the swell- ing. Secondti, lhat the earlier this is done, the more likely is it to succeed. Thirdly, that, alter (he tumour is taken out, an atten- tive examination of (he surface of the wound should be made, and every suspicious part or fibre be cut away. Fourthly, that, should the disease still recur, amputation ought to l>p instantly performed. Fifthly, that caus- tics should never be applied to this disease Sixthly, lhat, even when one of these ope- rations effectually extirpates the distemper of the limb, (be patient's entire recovery is al- ways rendered exceedingly uncertain, by u-.-on of the viscera, and other invisible pails, being frequently affected, at the time of Ihe operation, with the same sort of dis- ease. FUNGUS HJF.MATODES OF THE TESTICLE. 3. Fungus haematodes of the testicle some- times begins in its glandular part, sometimes in th epididymis. Its progress is slow, aud the pain generally not severe. Nor i- there, at tir-t, any inequality or hardness of the dis- eased part, nor change in (he scrotum. When (he testicle has become exceedingly large, il feels rem rkably soft and elastic, as if it contained a fluid. H nee, tbe case has often been mistaken for a hydrocele, and punctured with .i trocar. (Wardrop; Earle in Med. Chir. Trans. Vol. 3, p. 60.) Occa- sionally, when the tumour is large, it is in some places hard, in others soft. The hy- drocele may be known by tbe water begin- ning to collect at tbe bottom of the scrotum, and then a*, ending towards (he spermatic cord,and by Ihe swelling being circumscribed towards the1 abdominal ring; whereas the fungus haematodes begins with a gradual en- largement of the testicle itself, followed by a fulness, which extends up the spermatic cord. It is not in the slightest degree diapha- nous, and is much heavier than a similar bulk of water. (Earle, op. cit.) As the disease advances, ab-cesse- form, and the scrotum ulcerates; but no fungus shoots out. When the inguinal glands become contaminated, they often acquire an immense size ; and when ihe skin over them bur-is, l.irge por- tions of them slough away. Fungus haema- todes of ihe testicle is said (o afflict young, more frequently than old subjects. On dis- section, the substance ofthe diseased testicle is found to present a medullary, or pulpy ap- pearance, generally of a pale brownish co- lour, though sometimes red. In most cases, (he tunica vaginalis and tunica albuginea are FURUNCULUS. adherent together; occasionally there is fluid between them. In an example, dissected by Mr. Law- rence, the swelling uf tbe testicle consisted of cellular septa, filled with pulpy matter. Nu- merous tubercles of the disease were found in the omentum, and about tbe pelvis, inter- mixed with recently effused coagula. A mass of soft matter, equal in size to a man's head, lay on the spine, behind tbe aorta and vena cava; Which last vessel was closed for some ex- tent. The spermatic vessels could not be found. (See Med. Chir. Trans. Vol. 8, Part i,arl. 13.) The only chance of a cure must be deri- ved from a very early performance of castra- tion, before the disease has extended to Ihe inguinal glands, or far up the spermatic cord. Indeed, very little hope should be placed in the removal of the testicle; for fungus hae- matodes appears to be rather a constitutional than a local disease. Nearly every case on record has terminated fatally, and upon dis- section, either the liver, the lungs, the brain, the mesenteric glands, or other internal parts, have been found affected with the same disease. In one case, dissected by Mr. Lawrence, tubercles of a similar structure to the disease in the axilla, were found in tbe lungs, heart, and, in short, in nearly all (he thoracic and abdominal viscera, though (he contents ot (he skull wre free irom disease. (See Cases recorded by teardrop. Earle, Law- rence, and Langstaff, in Med. (. hir. Trans. Vol. 3 and 8.) We shall quit this subject with stating some of the princip.il differences between two dis- eases, which have been commonly confound ed. A scirrhous tumour is, from its com- mencement, hard, firm, and incompressible, and is composed of two substances ; une hardened and fibrous, the other soft and in organic. The fibrous matter is the most abundant, consisting of septa, which are paler than the soft substance between them. A scirrhous tumour, situated in a gland, is not capable of being separated from the lat- ter port, so much ure the two structures blended. A scirrhus in another situation, sometimes condenses the surrounding cellu- lar substance, so as to form a kind of cap- sule,and assume a circumscribed appearance. When a scirrhous swelling ulcerates, a thin ichor is discharged, and a good deal of (be bard fibrous substance is destroyed by tbe ulce- ration ; other parts become affected, and the patient dies from the increased ravages ot the disease, and its irritation on t e constitu- tion. Sometimes, though not always, after a Sciirhus has ulcerated, it emits a fungus of a very bard texture. Such excrescence, bow- ever, is itself ut last destroyed by the ulce- ration. Cancerous sores, also, frequently put on, for a short timte, an appearance in some places of cicatrization. On the other hand, the fungus haematodes, while of mode- rate size, isa soft elastic swelling, with an equal surface, and a deceitful feel of fluctuation. It is, in general, quite circumscribed, being included within a capsule. The substance ">f tbe tumour, instead of being for the most part hard, consists of a soft, pulpy, medulla- ry matter, which readily mixes with water. When ulceration occurs, the tumour ia not lessened by ibis process, as in si.in bus; but a fungus is emitted, cud tee whole swelling grows with increased rapidity. Cancerous diseases are mostly met with in persons of advanced age, while fungus htr-mato es ge- nerally afflicts young subjects. (Wardrop.) Many dissections have row proved, that Ihe substance of fungus hamiatodes may contain cellular septa, which include the pulpy, me- dullary matter. In cases of external cancer, the viscera are not in general affected at the same time with cancerous disease ; but in the majority of examples of fungus haematodes, tbis dis- temper is found Bffecting in the same sub- ject a variety of parts. In addition to the outward tumour, we find swellings of a si- milar nature, perphaps, in the liver, the lungs, the mesenteric gland', or even in the brain. Yet M Roux will have it, that cancer and fungus haematodes are the same disease ; or, at least, that the latter is only a species of (he former, and thai in bolb cases the same peculiar diathesis > -r»-v«i!s. (Roux, Parallele de la Chirurgie Angloise avec la Chirurgie Franqoiscp 216,217) See Dissertations on Inflammation, by J. Burns. Vol. 2. Hey's Practical Observations in Surgery, ed. 3. Freer on Aneurism. Ob- servations on Fungus Hamatodes, or Sojt Can- cer, by James Wardrop Svo. Edin. 1809. This last publication is highly deserving of the attention of the surgical practitioner, the dis- ease in different organs being well described, and Us character discriminated from that of cancer. A case of this disease is related in Vol. 5 of the London Medical Journal. Il was the consequence of 'in attempt to cure a ganglion by means of a selon. and it proved fatal. A case is also related by Mr. Abernethy, in Sur- gical Obstrvations, 1804, p. 99. bee also a Case of diseased Testicle, accompanied with Disease ofthe Lungs and Brain, by H. Earle, in Medico-Chirurg. Trans. Vol. 3.p. 59, fa. in which Vol. four other cases are recorded by Mr. Lawrence, p. 71, et seq. and one by Mr. Lang- st'ff, p. 277, which last I remember visiting in company with this gentleman and Mr. Law- rence, a short time before the patient died. See also Langslnff's Cases and Observations in the 8th and 9'h Vol. ofthe same work. Voyage fait a Londres en 1814, on Parallile de la Chirugie Angloise avec la • hirurgie Eraucoise p.2\\,fa. On Fungus Hama- todes ofthe Eye, there are some valuable ob- servations in ihe last edition of Scarpa's Trea- tise on the Diseases of that organ. See also Saunders on Diseases of the Ey•-, and B. Tra- vers's Synopsis of Diseases of the Eye, Svo. Lond. 1820. Respecting medullary sarcoma, whicb is generally considered as the same affection as fungus haematodes, some further observa- tions will be delivered hi Ihe article, Tu- mours. FURUNCULUS. (from faro, to rage.> 576 PURUNCULLS- A boil, so named from the violence of the heat and inflammation attending it. A boil is a circumscribed very prominent, hard, deep-red, inflammatory swelling, w hirh is exceedingly painful, and commonly termi- nates in a slow and imperfect suppuration. The figure of the tumour is generally that of a cone, the base of which is considerably below the surface. Upon the most elevated point of (he boil, there is usually a whitish, or livid pustule, which is exquisitely sensible, and immediately beneath this is the seat of tbe abscess. Tbe matter is mostly slow in forming, is seldom very abundant, and never heal'hy at first, being always blended with blood. Tbe complaint is seldom attended with fever, except when the tumour is very large, situated on a sensible part, or when several of these swellings occur at the same time indifferent places. In (he last circum stance, they often occasion in children, and even in irritable adults, restlessness, loss of appetite, spasms, he. They rarely exceed a pigeon's egg in size, and they may originate on'any pari of the body. Boils commonly arise from constitutional causes. Young persons, and especially sub- jects of full plethoric habits, are most subject to them. Ihe disease is also observed to oc- cur wi h most frequency in tbe spring. (Las- sus, Pathologic Chir. T. I, p. 16.) Accord- ing to Richerand, ihe origin of boils depends upon a disordered state of the gastric organs. (Nosographie Chir. T. l.p 124, edit. 2.) The suppuration attending a boil is never perfect, and ih* matter which lorms is not only tinged with biood, but surrounded with a sloughy substance, which m st generally be discharged belore the pari affected will suppurate kindly, and the disease end. Rich- ter compares the slough with a kind of bag, or cyst, and the whole boil with an inflamed encysted tumour. Tbe best plan is mostly to endeavour lo make boils suppurate as freely as possible, by applying external emollient remedies. This seems to be the natural course of tbe dis- ease in its progress to a cure, and, indeed, all endeavours to discuss turunctilous tu- mours commonly fail, or succeed very im- perfectly ; only removing the inflammation, and leaving behind an indolent hardness, which occasions various inconveniences, ac- cording to its situation, every now and then inflames anew, and never entirely disappears, until a free suppuration has been established. In a very fe»v cases, perhaps, il may be proper to try lo discuss boil*. For tbis pur- pose, besides bleeding, gentle evacuations, and n low diet, which are requisite in this as well as other local inflammations, some p,e- scribe as external applications honey strong- ly acidulated with sulphuric acid; alcohol; or camphorated oil. But in Ihe generality ot instauces, suppu- ration must be promo(ed by the use of einol - lient poultices. The tumour, when allowed to burst, generally does so at its apex How- ever, as the opening is generally long iri forming, and too small to allow the sloughy cellular substance to be discharged, it is al- ways best, as soon as aiat'er is known to exist in the tumour, to make a free opening with a lancet, and immediately afterward to press out as much of the matter and sloughs, as can be prudently done. Tbis having been accomplished, and tbe rest of the sloughs pressed out, as soon as it is practicable, healthy pus will be secreted, und the part will granulate and heal. Until the suppura- tion becomes of a healthy kind, and the sloughy substances are entirely discharged, an emollient linseed poultice is the best ap- plication ; and when granulations begin to fill up the cavity, plain lint, and a simple pledget, are (he only dressings necessary. Where there is reaton to suppose the gas- tric organs to be in a disordered state, an emetic should be given in the early part of the treatment, and afterward small repeated doses of any of the mild purging salts. When an indolent hardness continues, after tbe inflammatory, and suppurative state of boils has been cured, the part should be rubbed with a camphorated mercurial oint- ment. Besides the above acute boil, authors de- scribe a chronic one, w hick is said frequently to occur, in subjects who have suffered severely from the small-pox, measles, lues venerea, scrofula, and in constitutions which have been injured by the use of mercury. The chronic boil h commonly situated upon the extremities, is of tbe tame size as the acute one, has a hard base, is not attended with much pain, nor any considerable disco- loration of the skin, until suppuration is far advanced, and the matter is seldom quite formed before ihree or four weeks. This, like the former, sometimes appears in a con- siderable number at a time. The discharge is always thinner than goo I pus, and when tbe boil is large, and has been long in suppu- rating, a great deal of sloughy cellular mem- brane must be cast off, before tbe sore will heal. The principal thing requisite in the local treatment of all furunculous, and carbuncu- lai tumours, is to make an early free opening into ihem, and to press out the matter and sloughs, employing emollient poultices, till all the mortified parts are detached and re- moved, and afterward simple dressings. (See Pearson's Principles of Surgery. Richter, Anfangsgrunde der Wundarzn, B. 1. Lassus, Palhologie Ch>r. T. 1 p 15 Richerand/ Nosographie Chir. T.\,p. 123, edit. 2. ".AiNGLIO.N >77 G. VTANGLION, (yxlyum.) In surgery, a tumour on a tendon, or aponeurosis. A ganglion is an encysted, circumscribed, moveable swelling, commonly free from pain, causing no alteration in the colour of the skin, and formed upon ten Ions in diffe- rent parts ot the body, but most frequently upon the back of the hand, and over the wrist. A French gentleman consulted me, who had one upon the upper part of his foot, which created a great sensation of weakness in the motion of the foot, and I have taken notice, that ganglions occur particularly often just below the kneepan, in housemaids, who are in the habit of kneeling a great deal in order to scour rooms.. A curious example has been lately recorded, in which a ganglion, situated exactly over the arteria radialis and the arteria superficialis volae, was at first sup- posed tobe an aneurism (See Edinb. Med. and Surg. Journ. for April, 1821.) These tumours, when compressed, seem to possess considerable elasticity. They often occur unpreceded by any accident; fre- quently they are the consequence of bruises and violent sprains. They seldom attain a considerable size, and ordinarily are not painful, though every now and then there are instances to the contrary. When opened, they are found to be filled vilha viscid trans- parent fluid, resembling white of egg. If they do not disappear of themselves, or are not cured while recent, by surgical means, they, in some cases, become so large, that they cause great inconvenience, by obstruct- ing the motion of the part, and rendering it painful. Discutient applications sometimes succeed in curing ganglions, and, in this country, friction with the oleum origani is a very common method. I have often seen such tumours very much lessened by this plan of treatment, but seldom cured, and no sooner has tbe friction been discontinued, ti.a.i the fluid iu the cyst has in general accumulated again. Compression is usually more effectual than discutient liniments. Persons with ganglions, have been recommended to rub ihem strong- ly with their thumb, several times a day. After this has been repeated very often, the tumour has sometimes disappeared. But the best method is to make continual pressure on ganglions, by means of a piece of sheet-lead, bound upon the part wiih a bandage. There is no objection, however, to using once or twice a day, in conjunction with this treat- ment, frictions with the oleum origani, or camphorated mercurial ointment, provided these measures together do not seem likely to make ibe tumour inflame, an event, vvhich should aliays bs carefully uvo-ded. Gan- glions, when irritated too much, have been known to become most malignant fungous diseases. Setons have been recomraeuded to be m- \ ol I. ~3 troduced through ganglions, with a view of curing them. This method, however, is not an eligible one ; for, it is by no means free from danger, as the records of surgery fully prove. Cancerous diseases, and even a ma- lignant fatal fungus, (Med. Jour. Vol. 5.) have arisen from the irritation of a seton passed through a ganglion. Frequently, when a ganglion inflames and ulcerates, the cyst throws out a fungus, which is of a very malignant nature. Hence, the practitioner should avoid making an opening into the swelling, or doing any thing which is likely to occasion sloughing, or ulceration of the disease. Ganglions may be cured by pressure of such force as to rupture the cyst} and some authors have recommended putting the hand affected upon a table, and then striking the ganglion several times with the fist, or a mallet. The cyst of a recent gan- glion may also be burst, by compressing it strongly with the thumbs, with or without the intervention of a piece of money ; the fluid is effused into the adjacent cellular mem- brane ; and, pressure being now employed, the opposite sides of the cavity become uni- ted by the adhesive inflammation, and the recurrence of the disease is prevented. (See VEncyclopedic Mithodique, Partie Chir. art. Ganglion; Lassus, Pathologic Chir. T. l,p. 400, fa. ; Leveilli, Nouvelle Doctrine Chir. T. 3, p. 7.) In almost every instance, a ganglion may be cured by pressure and friction, and if not actually cured, the disease may be ren- dered so bearable by these means, that few patients would choose to have the tumour cut out. Under this plan, Ihe swelling be- comes very much diminished, and should it enlarge again, the mode of relief is so sim- ple, and the case so little troublesome, that patients generally content themselves with every now and then wearing a piece of lead on the part. But when ganglions resist all attempts to disperse or palliate them ; when they become extremely inconvenient, either by obstruct ing the functions of a joint, or causing pain; they should be carefully dissected out, by first making a longitudinal incieion in thi skin covering them, then separating the cyst on every side from the contiguous parts, at.d lastly cutting every particle of it off th<» sub- jacent iendon or fascia. The greatest care must be taken not to make any opening in the cyst, so as to let out its contents, and make it collapse; a circumstance, which would render the dissection of it much mora difficult. The operation being accomplished, the skin is to be brought together with slicking pl.vf ler, and a compre3S placed over the situa- tion of (he tjmour. v.. ith a view of healing the wound and the cavity by adhesion. When the ganglion has burst, or is ulcera- ted, it is best to remove the diseased skin, to- 578 GAN gether with the cyst, and of course the inci- sion must be oval or circular, as may seem most convenient. The grand object is not to a'low any particle of the cyst to remain behind, as it would be very likely to throw out a fungus, and prevent a cure. In War- ner's Cases of Surgery, is an account of two considerable ganglions, which this gentle- man, iu imitation of Celsus and Paulus ./F.gineta, thought it right to extirpate. These had become adherent to the tendons of the fingers. Iu the operation, he was obliged to cut (he transverse ligament of the wrist, and Ihe patients, who before could not shut their hands, nor close their fingers, perfectly re- gained the use of these parts. Mr. Gooch relates a case of the same kind, which had been occasioned by a violent bruise, three or four years before. The tumour reached from tbe wrist to the middle of the hand, and created a great deal of pain. Mr. Gooch extirpated it, and I hen restored the position of the hand, and free motion of the joint, by tbe use of emollient applications, and suit- able pressure, made with a machine con- structed for the purpose. Other cases con- firming the safety of cutting out ganglions, are recorded iu the London Medical Journal, for 1787, p. 154 ; by Eller, in Mim. de I'Acad. des Sciences de Berlin, T. 2, ami. 1746; Schmucker in Chir. Walirnehmungen, 1. B. p. 332 ; Girard Lvpiologie. The ganglions, vvhich occur just below the knee, I have seen cured by a little blister ap- plied over them, and kept open with the savin cerate. Camphorated blisters, indeed, have been proposed as a mean? of dispersing other ganglions. (Jaeger, Chir. Cauielen, 2 B.) For information relative to ganglions, consult Warner's Cases in Surgery. Chi- rurgical Works of B. Gooch, Vol. 2, p. 376. Heister's Surgery. B. Ball's Surgery Laltu's System of Surgery. VEncyclopidie Mitho- dique, Parlie Chir. art. Ganglion. Richter, Anfangsgr. der Wundarzn. B. 1. Lassus, Pathologic Chir. T. 1, p. 399; Diet, des Sciences Med. T. 17, p. 311. GANGRENE, (from youvu, to feed upon.) An incipient mortification, so named from its eating away the flesh. Authors have generally distinguished mor- tification into two stages; the first, or inci- pient one, (hey name gangrene, which is at- tended with a sudden diminution of pain in Ihe place affected; a livid discolouration of the part, which from being yellowish be- comes of a greenish hue; a detachment of the cuticle, under which a turbid fluid is ef- fused; lastly, tbe swelling, tension, and hardness, of the previous inflammation, sub- side, and on touching tbe part, a crepitus is perceptible, owing to the generation of air in tbe gangrenous parts. Such is the state, to which the term gan- grene is applied. When the part has become quite cold, black, fibrous, incapable of moving, and des- titute of all feeling, circulation, and life ; this b the second stage of mortification, termed ipha&hu. Gangrene, however, is frequently GAS used synonymously with the word mortifica- tion. (See Mortification.) GASTROCELK (from >«-*{, the sto- mach, and Jo»A.», a tumour.) A hernia of the stomach. GASTROR4PHIA, or gastroraphe. (from >*r*g, the belly, and £*$», a suture.) A sutu'e of the belly, or some of its con- tents. Although the term gastroraphe, in strict- ness of etymology, signifies no more than sewing up any wound of the belly, yet Mr. S. Sharp informs us, that in bis time, the word implied, that ihe wound of the abdo- men was complicated with another of the bowels. The moderns, I think, seem to limit the meaning of the word to the operation of sewing up a wound in the parietes of the ab- domen. What was formerly meant by gastroraphe could scarcely ever be practised, because the symptoms laid down for distinguishing when an intestine is wounded, do not with any certainty determine in what particular part it is wounded; which want of information, makes it absurd to open the abdomen in order to get at it. Hence, the operation of stitch- ing the bowels can only take place when they fall oul of the abdomen, and when we can see where the wound is situated. And, indeed, even in these circumstances, the employment of sutures is a practice, the propriety of which is questionable, as will be further considered in the article Wounds. The circumstances, making the practice of sew ing up a wounded intestine proper, are so rare, that Du Verney, who was the most eminent surgeon in the French army a great many years during the wars, and fashion of duelling, declared, that he had never had a single opportunity of practising gastroraphe, according to the former acceptation of that word. Gastroraphe, or merely sewing up a wound ofthe parietesof the abdomen, may be done, as Mr. Sharp explains, with the common in- terrupted suture, (see Suture) or with the quilled one, vvhich is better, as follows : A ligature, capable of splitting into two, has a needle attached to each end of it. The lip of the wound is to be pierced, from within outw ard, about an inch from its edge. The other needle is to be passed in the same way through the opposite lip. Then the two needles are to be cut off. As many such sutures must be made, as the extent of the wound may require. The sides of the wound are next to be brought together, and the ligatures tied, not in a bow, in the way of the interrupted suture, because the continual action of the abdo- minal muscles might make the ligatures cut their way through the parts. On the con- trary, it is better to divide each end of the ligatures into two portions, and to tie these over a piece of bougie laid along the line at which the ligatures emerge from the flesh. This is to be done to all the ligatures on one side first. Then the wound being closed, another piece of bougie is to be placed along GAS the other lip of the wound, and the opposite ligatures tied over it, with sufficient tight- ness, to keep the sides of the wound in con- tact. This suture is certainly preferable to the interrupted one, because a great deal of its pressure is made on the two pieces of bougie, and of course it is less likely to cut its way out. Its operation is to be assisted with compresses laid over each side of the wound, and the uniting bandage. Every thing that puts the abdominal muscles into action, drags the suture, irritates the wound, and creates a risk of the threads cutting their way through the part, in w hich they are introduced ; consequently, it must be avoid- ed. In order to prevent, as much as possi- ble, the exertion of the muscles, the bowels should be kept open with clysters. Saline draughts with opium are most likely to stop the vomiting, sometimes attendant on wounds of the abdomen, and producing very injurious effects. In about a week, the sutures may gene- rally be removed, and sticking plaster alone employed. As to what more relates to these particular cases, we must refer to Wounds of the Abdomen. It is generally allowed, that sutures are violent means, to which we should only re- sort, when it is impossible to keep the lips of a wound in contact by the observance of a Eroper posture, and the aid of a methodical andage. M. Pibrac believes such circum- stances exceedingly uncommon, and in his excellent production, in the third volume of the Memoirs of the Royal Academy of Sur- gery, relative to the abuse of sutures, cases are related, which fully prove, that wounds of the belly readily unite by means of a suitable posture and a proper bandage, with- out having recourse to gastroraphe. These, however, are less decisive and convincing, (if possible to be so) than the relations of the Caesarean operation, the extensive wound of which has oftentimes been healed by these simple means, after the failure of sutures. It is not only possible to dispense with gastroraphe in the treatment of wounds of the abdomen, it has even been manifested, that this operation has sometimes occasioned very bad symptoms. Under certain circumstances, however, it may be essentially necessary to practise gastroraphe. For instance, were a large wound to be made across the parietes of the abdomen, a suture might become indispensa- bly requisite to prevent a protrusion of the bowels. Yet, even in this case, the sutures should be as few in number as possible. A bandage of tbe eighteen-tailed kind, might prove very useful in a. longitudinal wound of the abdomen, and do away all occasion for gastroraphe. (See Sutures.) We shall conclude this article with a fact, perhaps, more curious, than instructive, related by M. Bordier, of Pondicherry, in the Journal de Medecine, vol. 26,538. An Indian soldier, angry with his wife, killed her, and attempted to destroy himself by giving bimself a wound with a broad kind of dagger in the abdomen, so as to cause a protrusion GLA 579 of the bowels. A doctor of the country, being sent for, dissected between the mus- cles and skin, and introduced a thin piece of lead, which kept up the bowels. The wound soon healed up, the lead having pro- duced no inconvenience. The man was afterward hung, and M. Bordier, when the body was opened, assured himself more par- ticularly of the fact. Indeed, numerous cases prove, that lead may lodge iu the living body, without occasioning the incon- venience, which results from the presence of almost any other kind of extraneous body. See Le Dran, Opirations de Chirurgie. Sharp's Treatise on the Operations of Surgery. L'Encyclopedic Mithodique, Parlie Chirurgi- cale, art. Gastroraphe; Sabatier, Midecine Operatoire, T. 1. GASTROTOMIA. (from y?r»§, the belly, and Te,uva', to cut.) The operation of opening the abdomen and uteres. The Caesarean operation. GLAUCOMA (from yxxuitos. bluish green,) is now defined by modern surgeons to be a greenish, or gray opacity of the vitreous hu- mour, attended with the loss, or a consi- derable impairment of sight (Weller on Diseases of the Eye, Trans, by Monteath, Vol. 2, p. 27.) Professor Beer considers the sub- jects of glaucoma and the cataracta viridis, or glaucomatosa, together in the same chap- ter. He observes, that these diseases occur rather frequently, not only as true effects of inflammation of the eye, but sometimes quite un preceded by this affection. Although glaucoma may continue for a long time as the only disorder, without the crystalline lens being changed in the slightest degree, yet Beer has never seen the case reversed, and the lens become altered as it does iu glaucoma first, and the vitreous humour afterward. In what this author describes as gouty ophthalioy, glaucoma is said to come on with the following symptoms. The iris is not observed to expand, but ra- ther to become contracted ; the pupil is not equally dilated, but extends more towards the canthi, the iris at length becomingscarce- ly perceptible towards each angle ofthe eye, especially the outer one, and the pupil oi course assuming something of tbe appear- ance which is seen in the eye of a rumina- ting animal. In a case, however, which I lately saw in the London Eye Infirmary un- dei Mr. Lawrence, it was particularly re- marked, that the diameter of the pupil was not greatest in the transverse direction; a circumstance, vvhich Beer's account would lead us to expect as constant. And, it parti- cularly merits notice, that as the iris shrinks towards the margin of the cornea, its pupil- lary edge is inverted towards the lens, so that its smaller circle completely disappears. In this very dilated state of the pupil, a gray greenish opacity is perceived, seeming to be very deep, and arising from a real loss of transparency in the vitreous humour. At this period, the lens evidently becomes opaque, acquiring a sea-green hue, and the cataracta viridis, or glaucomatosa, now swells and appears to project forwards into &S0 GLEE'l. the anterior chamber. The pain then be- comes more incessant and violent; the vari- cose affection of the eyeball seriously in- creases ; and the eyesight, which began hourly to diminish from the moment when the pupil was first observed to be in any de- gree expanded and opaque, and the iris mo- tionless, is now so entirely destroyed, that not the slightest perception of external light remains, though the patient may vainly con- gratulate himself on discerning luminous ap- pearances produced within the eye itself, in the form of a fiery, shining circle, especially when the organ is gently pressed upon. An eye in this condition (says Boyer) lias really a look, as if it were dead, the cornea being as flaccid, and void of lustre, as in a co'-pse. Finally, when these symptoms have attained their utmost pitch, an atrophy of the eyeball follows, and the painful sensations about the organ cease. In corpulent individuals, how- ever, they still continue with greater violence. Sooner, or later, the other eye is also either attacked with arthritic iritis, or ophthalmy, or becomes affected with glau- coma, vvhich is ushered in by violent and in- cessant headach. (Beer, Lehre von den Augenkrankheiten, B. 1, p. 681, fa. Svo. Wien. 1813.) According to this author, glaucoma and the green cataract, are never the consequences of any description of oph- thalmy, but what he terms arthritic. (B. 2. p. 255, Wien. 1817.) Both these affections, after they are conjoined with a general vari- cose disease of the eyeball, he sets down as generally incurable. According to Heller, when the vitreous humour first begins to be muddy, the disease may sometimes be checked. (On Diseases of ihe Eye. Vol- 2. p. 29.) The means of relief, depended upon in Germany, are frictions on the eyebrow with tine, opii croc, or liniment, ammon.; the avoidance of cold ; camphorated I'ags of aromatic herbs applied over the eye, b it the effect of which must be rather insignificant; issues; setons; rubbing the antimonial oint- ment over the spine, or behind the ears, he. (Vol. cit. p. 22.8 ) Otherauthorsrecommend applying blisters and giving internally the extract of cieuta, calomel, and soap. (Encyclopidie Mitho- dique, Partie Chir.) The topical use of a-ther might be tried ; but, from the history of the disease, the chances of cure must evidently be nearly hopeless. (See also Tr. G. Bene- dict de Morbis humor is Vitrei, 4to. Lips. 1809.) GLAUCOSIS, same as Glaucoma. GLEET. By the term gleet, we commonly understand a c>" inued running, or discharge after the inflammatory symptoms of a clap for some time have ceased, unattended with pain, scalding in making water, he. Mr. Hunter remarks, that it differs from a gonor- rhoea in being uninfectious, and in the dis- charge consisting of globular bodies, con- tained in a slimy mucus, instead of serum. He says, that a gleet seems to take its rise from a habit of action, which the parts have contracted. The disease, however, some- times stops of itself, even after every me- thod has been ineffectually tried. This pro- bably depends upon accidental changes in' the constitution, and not at all upon the na- ture of the disease itself. Mr. Hunter had asuspici-n, that some gleets were con- nected wifh scrofula. Certain it is, the sea- bath cures more gleets, than the common cold bath, or any other mode of bathing; and a cure may sometimes, but not always, be accomplished by an injection of diluted sea-water. Gleets are often attended with a relaxed constitution. They also sometimes arise from other affections of the urethra, besides gonorrhoea. A stricture is almost always accompanied with a gleet; and so some- times is disease of the prostate glaud. It is remarked by Mr. Hunter, that if a gleet does not arise from any evident cause, and cannot be supposed to be a return of a former gleet, in consequence of a gonorrhoea, either a stricture or diseased prostate gland is to be suspected : an inquiry should be made whether the stream of urine is smaller than common, whether there is any difficulty in voiding it, and whether the calls to make it are frequent. If there should be such symptom, a bougie, rather under the com- mon size, should be introduced ; and, if it passes into the bladder with tolerable ease, the disease is probably in the prostate gland, which should next be examined. (See Urethra, Strictures of; and Prostate Gland.) Balsams, turpentines, and the tinctura lyttae, given internally, are of service, espe- cially in slight cases; and wb -i they are useful, they prove so almost i jn.t iiately. Hence, if they had neither lessened nor re- moved the gleet in five or si> days, Mr Hunter never continued them longer. The same observation applies to cubebs, • o cele- brated of late as a remedy for gonorrhoea and gleet, and the common dose of which is 3ij in any e .i.venient fluid three times a day. As *.ie discrirge, when removed, is alsi ipt to ; cur, such medicines shouh ' ° continued for s >rne time alter the symptoms have dis- appeared. Wh> i the v imle constitution is weak, the cola lath, sea-bath, bark ind steei ay be given. The astringei gums, ; nd salt of steel, given as interna astringents, have little power. With regard to local applications, the as- tringents, commonly used, are, the decoction of bark, sulphat of zinc, alum, and prepara- tions of lead. The aqua vitrt .ica c.aerulea, of the London Dispensaloi v, diluted with eight times its quantity of water, makes a very good injection. Irritating applications consist either of in- jections, or bougies, simple or medicated with irritating medicines. Violent exercise may be considered as having the same effect. Such applications should never be used till the other methods have been fully tried, and fou.d unsuccessful. They at first increase the discharge, and, on this account, are sometimes abandoned too early. Two grains of the oxymuriate of mercury dissolved in eight ounces of water, are a very good irri- tating injection. In irritable habits, such an CON GO!* 581 application may do great harm, and there- fore, if possible, the capability of the parts to bear its employment, should first be made out. Bougies sometimes act . >olenliy, but Mr Hunter thought them more efficacious, than injections. A simple unmedicated one is generally sufficient, and must be used a month or six weeks, before the cure can be depended upon. Those iredicated with camphor, or turp- itine, need not be used so long. The bougie should be under the common size. Mr. Hunter has known a gleet disappear on the breaking out of two chain.. on the glans. Gleets have also been cure'' a blister on the under side of the urethr. « d, by electricity. In every plan of cure, rest, or q detness, is generally of great consequence ; be I after the failure of the usual moles, riding- on horseback will sometimes immediately eliect a cure. Regularity and moderation in diet are to be observed. Intercourse with women often causes a return, or increase of gleet; and, in such cases, it gives suspicion of a fresh infec- tion ; but the difference, betw-een this and a fresh infection, is, that here the return .s almost immediately after the connexio Gleets in women, are cured nearly he same manner as those of men. Turpe:.tin°s, however, have no specific effect on tl.e va- gina ; and the astringent injections user* may also be stronger than those intended for male patients. See 1 Treatise on the Venereal Disease, by John Hunter, Ed. 2. Alt' Swediaur's Prac- tical Observations on Venereal Co .plaints. GLOSSOCATOCHUS. (from yKaxrcct, the tongue; and x«T6^«, to depress.) The ancient glossocatochus wis a sort of forceps, one of the blades of wb'u •* served to depress the tongue, while the other was applied un- der the chin. GOITRE. See.Bronch -ele. * GONORRHOEA. (Jr. .yen', the semen; and e*u>, to flow.) Etyiii.logically, an invo- luntary discharge of the semen ; but always, according to modern surgery, a discharge of a purulent infectious matier, from the ure- thra in the male, and from the vagina and surfaces of the labia, nympha.-, clitoris, &.c. in the female subject. Dr. Swedviur, afW censurirgthe etymolo- gical import, as co eying ^n erroneous iuea, says, if a Greek i e is to be reta:r,ed, he would call it blennorrhagia, from 0\met, mu- cus, and gtu, to flow. However, as most of the moderns consider the discbarge as pus, not mucus, the etymologic 1 import of blen- norrhaea is as objectional as that of gonor- rhoea. In English, the disease is commonly called a clap, from the old French word cla- pises, which were public shops, kept and in- habited by single prostitutes, and generally confined to a particular quarter of the town, as is even now the case in several of the great towns in Italy. In German, the dis- order is named a tripper, from dripping ; and in French, a chaudipisse, from the heat and scalding in making water. (Swediaur.) We shall first present the reader with some of Mr. Hunter's opinions, concerning the nature of gonorrhoea, its symptoms, and treatment; and, lastly, take :iotice of the observations of some other writers. When an irritating matter of any kind is applied to a secreting surface, it increases that secretion, and changes it from its natu- ral slate to some other. In the present in- stance, it is changed from mucus to pus. Till about the year 1753, it was generally supposed, that the matter from the urethra, in cases of gonorrhoea, arose from ulcers in the passage ; but, about that time, it was as- certained, that pus could be secreted with- out a breach of substance. It was first ac- cidentally proved, by dissection, that pus could be formed in the bag of Ihe pleura, without ulceration ; and Mr. Hunter after- .'are °j. mined the urethra of maleiactors and . thers, who were executed, or died, whi'e known to be affected with gonor- rhoea and demonstrated, that the canal was entirely free from every appearance of ulcer. The time when a gonorrhoea first appears, after infect:"n, is extremely various. It ge- nerally comes on sooner than a chancre. Mr. Hunter had reason to believe, that in some instances, the disease began in a few hours; while in others, six weeks previous- ly elapsed; but he had known it begin at all the intermediate periods. Ho \ ever, it was his opinion, that about six, eight, ten, or twelve days after infection, is the most common period. The surface of the urethra is subject to in- flammation and suppuration, from various other causes besides the venereal poison; and sometimes discharges happen sponta- neously, when no immediate cause can be assigned. Such may be called simple gonor- rhoea, having nothing of the venereal infec- tion in them. Mr. Hunter knew of cases, in which the urethra sympathized with the cutting of a tooth, and all the symptoms of a gonorrhoea were produced. This happened several times to the same patient. The urethra is known to be sometimes the seat of the gout; and Mr. Hi 'ter wras acquainted with instances of its being the seat of rheumatism. When a secreting surface has once re- ceived the inflammatory action, its secre- tions are increased and visibly altered. Also, vv'.oti irritation has produced inflammation, anu an ulcer iu the solid parts, a secretion of matter takcsplace, the intention of which, in both, seems to be to wash away the irri- tating matter. But, in inflammations, ari- sing from specific, or morbid poisons, the irritation cannot be thus got rid of; for, al- though the first irritating matter be washed away, yet, the new matter has the same quality as the original had ; and therefore, upon the same principle, it would produce a perpetual source of irritations, even if the venereal inflammation, like many other spe- cific diseases, were not what it really is,. 562 GONORRHOEA. kept up by the specific quality of the inflam- mation itself. This inflammation seems however, to be only capable of lasting a li- mited time, the symptoms, peculiar to it, va- nishing of themselves by the parts becoming less and less susceptible of irritation ; and the subsequent venereal matter can have no power of continuing the original irrit .tion ; for otherwise there would be no end to tbe disease. Tbe time, which the susceptibility ofthe irritation lasts, must depend upon the difference in the constitution, and not upon any difference in the poison itself The venereal disease only ceases sponta- neously, when it attacks a secreting sur- face, and produces a mere secretion of pus, without ulceration. Such were some ofthe sentiments of the late Mr Hunter, who was a firm believer in the identity of the poisons of syphilis and gonorrhoea ; but this idea and the hypothesis, about the impossibility ot any spontaneous cure of venereal sores, are now very generally relinquished. SYMPTOMS OF GO»0RUH(EA. The first symptom is generally an itch- ing at the orifice of the urethra, sometimes eitendingover the whole glans. A little ful- ness ofthe lips of the urethra, the effect of inflammation, is next observable, and soon afterward a running appears. The itching changes into pain, more par- ticularly at the time of voiding the urine. There is often no pain till sometime after the appearance of the discharge, aud other symptoms; and in many gonorrhoeas, there is hardly any pain at all, even when the discharge is very considerable At other times, a great degree of soreness occurs long before any discharge appears, fhere is generally a particular fulness in the penis, and more especially in the glans. Ihe glans bas also a kind of transparency, espe- cially near the beginning of the urethra, where the skin being distended, smooth, and red, resembles a ripe cherry. The mouth of the urethra is, in many instances evi- dently excoriated. The surface ofthe glans itself is often in a half excoriated state, con- sequently very tender ; and it secretes a sort of discharge. Tbe canal of the urethra becomes narrower, which is known by the stream of urine being smaller than common. This proceeds from the fulness of the penis in general, and from the lining of the ure- thra being swollen, and in a spasmodic state. The fear of the patient, while void- ing his urine, also disposes the urethra to contract; and the stream of urine is gene- rally much scattered and broken, as soon as it leaves tbe passage. There is frequently some degree of hemorrhage from the urethra, perhaps from the distention of the vessels, more especially when there is a chordee, or a tendency to one. Small swellings often occur, along the lower surface of the penis, in the course of the urethra. These, Mr. Hunter suspected to be enlarged glands of the passage. They occasionally suppurate, and burst outwardly, but now aad then in the urethra itself. Mr. Hunter bas also sus- pected such tumours to be ducts, or lacunae of the glands of the urethra distended with mucus, in consequence of the mouth ofthe duct being closed, in a manner similar to what happens to the duct leading from the lachrymal sac to the nose, and so as to in- duce inflammation, suppuration, and ulcera- tion Hardness and swelling may also oc- cur in the situation of Cowper's glands, and end in considerable abscesses in the peri- neum. The latter tumours break either internally or externally, and sometimes in both ways, so as to produce fistula? in pe- rinaeo. A soreness is often felt all along the un- der side ot the penis, frequently extending as far as the anus. The pain is particularly great in erections; but the case differs from chordee, the penis remaining straight. In most cases of gonorrhoea, erections are fre- quent, and even sometimes threaten to bring on mortification : as opium is of great service, Mr. Hunter thought, that there was reason to suppose them of a spasmodic na- ture. The natural slimy discharge from the glands of the urethra is first changed, from a tine transparent ropy secretion, to a watery whitish fluid; and the lubricating fluid, which the passage naturally exhales, be- comes less transparent: both these secre- tions becoming gradually thicker, assume more and more tbe qualities of common pus. The matter of gonorrhoea often changes its colour and consistence, sometimes from a white to a yellow, and often to a greenish colour. These changes depend on the in- crease and decrease of the inflammation, and not on the poisonous quality of the matter itself; for any irritation of these parts, equal to that produced in a gonorrhoea, w ill produce the same appearances. The dischurge is produced from the mem- brane lining tbe urethra, and from the la- cuna , but, in general, only for about two or three inches from the external orifice. Mr. Hunter says, seldom further, than an inch and a half, or two inches at most. This he terms the specific extent of the inflt-.mma- tion. Whenever he had an opportunity of examining the urethra affected with gonor- rhoea, he always found the lacunae loaded with matter, and more visible, than in the natural state. Before the time of this cele- brated man, it was commo'nly supposed that the discharge arose from the whole surface of the urethra, and even from Cow- per's glands, the prostate, and vesiculae se- minales. But, if the matter were secreted from all these parts, tbe pus would collect in the bulb, as the semen does, and thence be emitted in jerks; for, nothing can be in the bulbous part of the urethra, without stimu- lating it to action, especially, when in a state of irritation and inflammation. When the inflammation is violent, some of the vessels of the urethra often burst, and a discharge of blood ensues. Sometimes GONORRHOEA. 533 such blood is only just enough to give the matter a tinge. In other instances, erec- tions cause an extravasation, by stretching the part. When the inflammation goes more deep- ly than the membranous lining, and affects the reticular membrane of the urethra, it produces in it an extravasation of coagula- ble lymph, the consequence of which is a chordee. (See Chordee.) Mr. Hunter suspected, that the disease is communicated or creeps along from the glans to the urethra, or, at least, from the lips of the urethra to its inner surface, as it is impossible, that the infectious matter can, during coition, get as fai as the disease ex- tends. He mentions an instance, in which a gentleman, who had not cohabited with any woman for many weeks, to all appear- ance caught a gonorrhoea from a piece of plaster, which had adhered to his glans pe- nis, in a necessary abroad: the infection is accounted for by supposing that some per- son, with a clap, had previously been to this place, and had left behind some of the dis- charge, and that tbe above gentleman had allowed his penis to remain iu contact with the matter, till it had dried. Many symptoms, depending on the sym- pathy of other parts with the urethra, some- times accompany a gonorrhoea An uneasi- ness, partaking of soreness and pain, and a kind of weariness, are every where felt about the pelvis. The scrotum, testicles, perinaeum, anus, and hips, become disagree- ably sensible to the patient, and the testicles often require to be suspended. So irritable, indeed, are they in such cases, that the least accident, or even exercise, which would have no effect of this kind at another time, will make them swell. The glands of the groin are often affected sympathetically, and even swell a little, but they do not sup- purate, as they generally do when tbey in- flame from the absorption of matter. Mr. Hunter has seen the irritation of a gonor- rhoea so extensive as to affect with real pain the thighs, buttocks, and abdominal muscles. He knew one gentleman, who never had a gonorrhoea without being im- mediately seized with universal rheumatic pains. When the disorder, exclusive of the affec tions from sympathy, is not more violent than has been described, Mr. Hunter termed it a common, or simple venereal gonorrhoza; but, if the patient is very susceptible of such irr'nation, or of any other mode of action, which may accompany the venereal, then the symptoms are in proportion more vio- lent. In such circumstances, we sometimes find the irritation and inflammation exceed the specific distance, and extend through the whole urethra. There is often a consi- derable degree of pain in the perinaeum; and a frequent, though not a constant symp- tom, is a spasmodic contraction ofthe acce- leratores urinae, and erectores muscles. In these cases, the inflammation is sometimes considerable, and goes deeply into the cel- lular membrane, but without producing any effect except swelling. Iu other instances, it goes on to suppuration, often becoming one of the causes of fistulae in perinaeo. Thus, Cowper's glands may suppurate, and the irritation often extends even to the blad- der itself. When the bladder is affected, it becomes more susceptible of every kind of irritation. It will not bear the usual distention,"and, therefore, the patient cannot retain his wa- ter the ordinary time; and, the moment the desire of making water takes place, be is obliged instantly to make it, with violent pain in the bladder, and still more in the glans penis, exactly similar to what happens in a fit of the stone. If the bladder be not allowed to discharge its contents immedi- ately, the pain becomes almost intolerable; and even when the water is evacuated, there remains, for some time, a considerable pain both in the bladder and glans. Sometimes, though rarely, when tbe blad- der is much affected, the ureters, and even the kidneys, sympathize; and Mr. Hunter had reason for suspecting, that the irritation might be communicated to the peritoneum, by means of the vas deferens. Mr. Hunter mentions a case, in which, while the inflammatory symptoms of a go- norrhoea were abating, an incontinence of urine came on ; but, in time, got spontane- ously well. A very common symptom, attending a gonorrhoea, is a swelling of the testicle.) See Hernia Humoralls.) Another occasional consequence of a go- norrhoea, is a sympathetic swelling of the inguinal glands. (See Bubo.) A hard chord is sometimes observed, lead- ing from the prepuce along the back of the penis, and often directing its course to one of the groins, and affecting the glands. At the part of the prepuce, where the chord takes its rise, there is most commonly a swelling. This sometimes happens when an excoriation and a discharge from the pre- puce or glans penis exist. From the above account, the symptoms of gonorrhoea, in different cases, seem to be subject to infinite variety. The discharge often appears without any pain ; and the coming on of tbe pain is not at any stated time after the appearance of the discharge. There is often no pain at all, although the discharge is in considerable quantity, and of a bad appearance. The pain often goes off, while the discharge continues, and will re- turn again. In some cases, an itching is felt for a considerable time, which is sometimes succeeded by pain ; though, in many cases, it continues to the end ofthe disease. On the other band, the pain is often trouble- some, and considerable, even when there is little or no discharge. The neighbouring parts sympathize, as the glands ofthe groin, the testicle, the loins, and pubes, the upper parts of the thighs, and the abdominal mus- cles. Sometimes the disease appears a few hours after the application of the poison ; sometimes six weeks elapse first. Lastly, it is often impossible to determine whether 534 GONORRHOEA. the case is a venereal, or only an acci- dental discharge, arising from some un- known cause. GONORRHEA IN WOMEN. The disorder is not so easily ascertained in them as in men, because they are subject to a disorder called fluor albus, which re- sembles gonorrhoea. A discharge simply from women, is less a pi oof of tne existence of a gonorrhoea, than even a discharge with- out pain in men. The kind of matter does not enable us to distinguish a gonorrhoea from a fluor albus ; for in the latter affection, the discharge often puts on all the appear- ance of venereal matter. Pain is not neces- sarily present, and therefore forms no line of distinction. The appearance of the parts often gives us butbttle information ; " for," says Mr. Hunter, " I have frequently exa- mined the parts of those who confessed all the symptoms, such as increase of discharge, pain in making water, soreness in walking, or when the parts were touched, yet I could see no difference between these and sound parts. I know of no other way of judging, in cases where there are no symptoms sen- sible to the person herself, or where the pa- tient bas a mind to deny any uncommon symptoms, but from the circumstances pre- ceding the discharge ; such as her having been connected with men supposed to be unsound, or her being able to give the dis- order to others ; which last circumstance, being derived from Ihe testimony of another person, is not always to be trusted to. for obvious reasons." But, though there may sometimes be great difficulty in forming a judgment of some of these cases, tbe sur- geon may frequently come to a right con- clusion by recollecting, as Mi. Dunn has reminded me, that, besides the difference depending on the suddenly severe symptoms of gonorrhoea, fluor albus may be known by the great debility ; the sinking of the sto- mach ; the weariness of the limbs ; the pain of the back always increased by the erect posture; the severe heaiiucus; the painful menstruation, together with the very gra- dual increase of the disease. From the manner in which the disease is contracted, it must principally attack the va- gina, a part not endowed with much sensa- tion. In many cases, however, it produces a considerable soreness on the inside of the labia, nymphae, clitoris, carunculae myrtitor- mes, and meatus urinarius. In certain cases, these parts are so sore, that they will not bear to be touched ; the person can hardly walk; the urine gives pain in its passage through the urethra; and when it comes into contact with the above-mentioned parts. The bladder sometimes sympathizes, and even tbe kidneys. The mucous u'laD '.s, on the inside of "the labia, often svv«;l, and sometimes suppurate, forming small ab- scesses, which open near the orifice of tbe vagina. According to Mr. Hunter, the venereal matter from the vagina sometimes runs down the perinaeum to tbe anus, and pro- duces a gonorrhoea, or chancre, in that situ- ation. The disease in women may proba- bly wear itself out, as in men ; but it may exist in the vagina for years, if the testimony of patients can be relied on. TREATMENT OF GONORRHOEA. As every form of the venereal disease arises from the same cause, and as we have a specific for some forms, we might expect that this would be a certain cure for every one ; and, therefore, that it must be no dif- ficult task to cure the disease, when in tho form of inflammation and suppuration in the urethra. Experience teaches us, how- ever, that the gonorrhoea is the most variable in its symptoms, while under a cure; and the most uncertain, with respect to its cure, of any forms of the venereal disease, (if it be a form of this disease at all) many cases terminating in a wc-.lc. while others conti- nue for months, under the same treatment. The only curative object is, to destroy the disposition and specilic mode of action in thr> solids ofthe parts, and as they become changed, the poisonous quality of the mat- ter produced will also be destroyed. This effects the cure of the disease, but does not always remove the consequence. Gonorrhoea is incapable of being conti- nued beyond a certain time in any consti- tution ; and, when it is violent, or of long duration, it is owing to the part being very susceptible of such irritation, and readily retaining it. As no specific remedy for go- norrhoea is known, it is fortunate that time alone will effect a cure. It is worthy of consideration, however, whether medicine can be of any service. Mr. Hunter is in- clined to think it not of the least use, in nine cases out often. But even this would be of some consequence, if the cases capa- ble of being benefited could be distin- guished. The means of cure generally adopted are of two kinds, internal remedies and local applications ; but, whatever plan is pursued, we are always fo attend more to the nature of the.constitution, or to any attending dis ease in the parts themselves, or parts con- nected with them, than to the gonorrhoea itself. When the symptoms are violent, but of the common inflammatory kind, known by the extern of the inflammation not exceed- ing the specific distance, the local treatment may be either irritating or soothing. In these cases, irritating applications are less dangerous than when irritable inflam- mation is present, and they may alter the specific action ; but, to produce this effect, their irritation must b>; greater than that of the original injury. The parts will afterward recover of themselves, as from any other common inflammation. Mr llmter believes, however, that in tbe beginning, the soothing plan is the best. If the inflammation be great, and of the irrita- GONORRHOEA 5 85 hie kind, no violence is to be used, for it would only increase the symptoms; and nothing should be done that can tend to atop the discharge, as it would not put a stop to the inflammation. Tbe constitution is to be altered, if possible, by remedies adapted to each disposition, and reducing the disease to its simple form. If the con- stitution cannot be altered, nothing is to be done, and the action is to be allowed to wear itself out. When the inflammation has abated, the cure may be attempted by infernal reme- dies or local applications, which do not ope- rate violently, whereby the irritation might be reproduced. Gentle astringents may be applied. But if the disease has begun mildly, an irritating injection may be used, in order quickly to get rid of the specific mode of action. This application will increase the symptoms for a time; but when it is left off they will often abate, or wholly disappear; and after such abatement, astringents may be used, the discharge being now the only thing to be removed. When itching, pain, and other uncommon sensations are felt for some time before the discharge appears, Mr. Hunter diffidently expresses his inclination to recommend the soothing plan instead of the irritating one, in order to bring onthe discharge, which is a step towards the resolution of the irrita- tion ; and he adds, that to use astringents would be bad practice, as, by retarding the discharge, they would only protract the cure. When there are strictures, or swell- ed testicles, astringents should not be used ; for, while there is a discharge, such com- plaints are relieved. Mr. Hunter thus expresses himself in re- gard to the effect of mercury in gonorrhoea : " I doubt very much of mercury having any specific virtue in this species of the disease ; for I find that it is as soon cured without mercury as with it, he. So little effect, in- deed, has this medicine upon a gonorrhoea, that I have known a gonorrhoea take place while the patient was under a course of mercury, sufficient for the cure of a chancre. Men have been also known to contract a gonorrhoea when loaded with mercury for the cure of a lues venerea; the gonorrhoea, nevertheless, has been as difficult of cure as «n ordinary cases." Mr. Huuterdoes not say much in favour of evacuants, diuretics, and astringents, given internally. He allows, however, that astringents, which act specifically on the parts, as the balsams, conjoined with any other medicine, which may be thought right, may help to lessen the discharge in propor- tion as the inflammation abates. Local applications may be either internal to the urethra, external to the penis, or both. Those vvhich are applied to the urethra seem to promise most efficacy,because they come into immediate contact with the diseased parts. They may be either in a solid or fluid form. A fluid is only a very tempo- rary application- T'o solid ones, or bou- gies, may remain a long while, but In gene- ral irritate immediately, from their solidity alone: and Mr. Hunter says, the less bougies are used, when the parts are in an inflamed state, the better, though he never saw any bad effects from them, when applied with caution. The fluid applications, or injections, in use, are innumerable ; and as gonorrhoea frequently gets well with so many of various kinds, we may infer that such complaints would, in time, get well of themselves. How- ever, there cannot be a doubt, that injec- tions often have an immediate effect on the symptoms, and hence must have power ; though the injection, which possesses the greatest power, is unknown. As injections are only temporary applications, they must be used often, especially when found useful, and not of an irritating kind. Mr. Hunter divides injections into four kinds, the irritating, sedative, emollient, and astringent. Irritating injections, of whatever kind, act in this disease upon the same principle ; that is, by producing an irritation of another kind, which ought to be greater than the ve- nereal ; by which means the venereal is de- stroyed and lost, and the disease cured, al- though the pain and discharge may still be kept up by the injection : effects, however, which will soon go off, when the injection is laid aside. In this way bougies also perform a cure. Most of the irritating injections hajyc an astringent effect, and prove simply astrin- gent when mild. Irritating injections should never be used when there is already much inflammation : especially in constitutions which are known to be incapable of bearing much irritation ; nor should they be used when the inflamma- tion has spread beyond the specific distance ; nor when the testicles are tender ; nor when, upon the discharge ceasing quickly, these parts have become sore ; nor when the pe- rinaeum is very susceptible of inflammation and especially if it formerly should have sup- purated ; nor when there is a tendency in the bladder to irritation, known by the fre quency of making water. In mild cases, and in constitutions which are not irritable, such injections often sue ceed, and remove the disease almost imme diately. The practice, however, ought to be attempted with caution, and not, per- haps, till milder methods have failed. Two grains ofthe hydrargyrus muriatus, dissolved in eight ounces of distilled water, form a very good irritating injection ; but an injec tion of only have this strength may be used, when it is not intended to attempt a cure so quickly. If, however, the injection, even in (hat proportion, gives considerable pain in its application, or occasions a great increase of pain in making water, it should be fur ther diluted. Sedative injections will always be of ser- vice, when the inflammation is considera- ble, and they are very useful in relieving the pain. Perhaps, the best sedative is opium, as well when given by the mouth, or aini".' 5H(i GONORRHOEA. as when applied to the part affected, in the form of au injection. But even opium will not act as a sedative in all constitutions, and parts ; but on the contrary, often has oppo- site effects, producing great irritability. Lead may be reckoned a sedative, so far as it abates inflammation ; while, at the same tiiiW, it may act as a gentle astringent. Four- teen grains of acetate of lead, in ?viij. of distilled water, make a good sedative astrin- gent injection. Drinking freely of diluting liquors may, perhaps, have a sedative effect, as it in part removes some of the causes of irritation, by rendering the urine less stimulating to the bladder, when the irritation i3 there, and to the urethra in it? passage through it. Dilu- ting drinks may possibly lessen the suscepti- bility of irritution. The vegetable mucilages of certain seeds and plants, and the emollient gums, are recommended. Mr. Hunter docs not entertain much opinion of their efficacy, though some of his patients told him, that they experienced less uneasiness in making water, when their drink was impregnated with mucilaginous substances. Emollient injections me the most proper, when the inflammation is very great; and they probably act by first simply washing away the matter, and then leaving a soft ap- plication to tbe part, so as to be singularly serviceable, by lessening the irritating effects of the urine. Indeed, practice proves this; for a solution of gum arubic, milk and water, or sweet oil, will often lessen the pain, and other symptoms, when the more active in- jections have done nothing, or seemed to do harm. The irritation at the orifice of the urethra is frequently so great, that the point of the syringe cannot be suffered to enter. In this case no injection should be used till the in- flammation has abated ; hut in the mean while, fomentations may be employed. Astringent injections act by lessening the discharge. They should only be used to- wards the latter end of the disease, when it has become mild. But if the disease should begin mildly, tbey may be used at the very beginning ; for by gradually lessening the discharge, wilhout increasing the inflamma- tion, we complete the cure, and prevent a continuance of the discharge called gleet. They will have an irritating quality7, if used strong, and hence increase the discharge, in- stead of lessening it. Mr. Hunter's experi- ence did not teach him, that one astringent was much better than another. The astrin- gent gums, as dragon's blood,.the balsams, and the turpentines, dissolved in water; the juices of many vegetables, as oak bark, Pe- ruvian bark, tormentil root, aud perhaps all the metallic salts, as green, blue, and white vitriols ; the salts of mercury, and also alum : probably all act much in the same way; though the mere changing of an injection is often efficacious. The local use of the ni- tric acid, properly diluted, has been com- mended by Vigaroux, Toepelmann, and 6thers, as a safe remedy for the stoppage of gonorrhoea. (See Pearson on the effects of various Articles in the cure of Lues Venerea, p. 205,Ed. 2, and Neucre Erfahr. uber zweckm. Behdl. venerisch. Schleimausflnsse, fa. Leipz. 1809.) The external applications are poultices and fomentations, which can only be useful when the prepuce, glans, and orifice of the urethra, are inflamed. Since Mr. Hunter's time, many surgeons have been in the habit of keeping the penis, in the incipient inflammatory stage of gonor- rhoea, covered with linen, continually wet with the liquor plumbi acetatis dilutus; a practice which is certainly both rational and beneficial. Mr. Abernethy, in his Lectures on Surgery, speaks in favour of this method. And )sorac surgeons, among whom is my intelligent correspondent, Mr.Dunu, of Scar- borough, have seen great relief derived from the use of a suspensor scroti, or double hand- kerchief, vvhich, combined with rest and the elevation of the penis, the last mentioned practitioner has frequently found, indeed, of more service than any thing else. When the glands of the urethra are enlarg- ed, mercurial ointment may be rubbed on the part; but this will probably be of most service after tbe inflammation has subsided. TREATMENT OP GONORRHOEA IN WOMEN. This is nearly the same as that of the dis- ease in men, but is more simple When tho disorder is in the vagina, injections are best; and after their use, (he external parts should be w ell washed. If is almost impossible for the patient to throw an injection into the urethra, when it. is affected. The same in- jections are proper as for men ; but they may be made doubly strong. When the glands of the vagina suppurate, and form abscesses, these should be opened, and dressed; but the practice of smearing the parts with mer- curial ointment, as advised by Mr. Hunter, is now entirely abandoned. CONSTITUTIONAL TREATMENT 0¥ GONORRHOEA. In many strong plethoric constitutions, the symptoms are violent, and there is a great tendency to inflammatory fever. In such instances opiate clysters, though at first productive of relief, sometimes occasion in the end fever, and consequently aggravate all the symptoms. In these cases, the balsam of capivi also sometimes increases the in- flammatory symptoms. In a constitution of this kind, the treatment consists chiefly in evacuations, the best of which are bleeding, and gentle purging. The patient must live sparingly, and above all, use little exer- cise. In a weak and irritable constitution, the symptoms are frequently violent, the inflam- mation extending beyond the specific dis- tance, running along the urethra, andeve.•■ affecting the bladder. Here the indication is to strengthen ; and according to Mr. Hun- GONORRHOEA. ter, bark alone has been known to effect a cure. All evacuations are hurtful. A fever has been known to stop the dis- charge, relieve the pain in making water, and finally cure the disease. On other occa- sions, Mr. Hunter has seen all the symptoms of gonorrhoea cease on the accession of a fever, and return when the fever was sub- dued. In other examples, a gonorrhoea mild at first, has been rendered severe by the coming on of a fever, and upon its subsi- dence, the gonorrhoea has ceased. Although a fever does not always cure a gonorrhoea, yet, as it may do so, nothing should be done while it lasts If the local complaint should continue after the fever is gone, it is to be treated according to symptoms. A gonorrhoea may be considerably affect- ed by the patient's manner of living, and by other diseases attacking the constitution. Most things which hurry or increase the cir- culation, aggravate the symptoms ; such as violent exercise, drinking strong liquors, eating strong indigestible food, some kinds of which act specifically on the urethra, so as to increase the symptoms more than sim- ply heating the body would do; such as pepper, spices, and spirits. In cases which have begun mrldly, in vvhich the inflammation is only slight, or in others in which the violent symptoms have subsided, such medicines as have a tendency to lessen the discharge may be given, toge- ther with the local remedies before mention- ed. Turpentines are the most efficacious, particularly the balsam of copaiva, and cu- bebs. (See Edin. Med. and Surgical Journ. for January 1818, and -for the-, same month, 1819 ; also H. Jeffrey's Pract. Obs. on Cubebs; Svo. Lond. 1821.J Of the latter medicine 3ij may be given tnrice in the 24 hours; but with respect to these and all other remedies, which act upon the disease through the me- dium of the urine, if they succeed at all, it is always within a week, or ten days, from the beginning of their use ; and therefore, if no amendment takes place in this time, they should not be continued. Cantharides, the salts of lead and copper, and alum, have also been recommended. Mr. Hunter advises small doses of mercu- ry, in consequence of the possibility of ab- sorption, and with a view of preventing lues venerea. 1REATMENT OF OCCASIONAL SYMPTOMS OF GONORRHOEA. Bleeding from the Urethra is sometimes re- lieved by the balsam capivi. Mr. Hunter did not find astringent injections of use. Painful erections are greatly presented by taking t enty drops of tincture opii at bed- time. Cicuta has also some power in this way; and many surgeons. iiC, wiich 1 o.tght to have mentioned in former editions, its a common means of lessening (he pain and inconvenience of erections in the inflammatory slage of go- norrhoea. Chordee. See this word. Bladder affected. Opiate clysters, the warm bath, and bleeding, if the patient is of full habit, are proper. Leeches may be applied to the perinaeum. When this affection lasts a considerable time, and is not mitigated by common methods, Mr. Hunter advises try- ing an opiate plaster on the pubes, or the loins, where the nerves of the bladder origi- nate ; or a small blister on the perinaeum. In another place he mentions bark, cicuta, sea air, and sea bathing, among the proper means. Swelled Testicles. See Hernia Humoralis. For a more full account of Gonorrhoea, according to the above doctrines, see a Trea- tise on the Venereal Disease, by John Hunter, from page 29 to 90. ON THE QUESTION, WHETHER GONORRHOEA IS REALLY A FORM OF THE VENEREAL DIS- EASE. The foregoing remarks, and others in Mr. Hunter's work, would lead one to believe that the poison of gonorrhoea and the/vene- real virus are the same. Here it is my duty impartially to state the arguments, which have been urged for, and against, this im- portant doctrine. Mr. Hunter assures us, that he has seen all the symptoms of lues venerea originating from gonorrhoea only; that he had even produced venereal chancres by inoculating with the mailer of gonorrhoea ; and that he afterward repeated these experiments in a manner in which he could not be deceiv- ed. (P. 293, et seq.) Mr. Hunter's experiments, it is true, have been repealed with a different result; but, as a late writer has remarked, can we wonder at this, when we consider from how many- causes gonorrhoea may arise, and bow im- possible it is to distinguish the venereal from any other? (Obs. on Morbid Poisons, by J. Adams, M.D.p.9], Ed, 2.) Another argument, adduced by Hunter, in favour of the poisons of gonorrhoea and chancre being the same, is the probability, that the Otaheiteans had the venereal dis- ease propagated to them by .European sai- lors, who were affected with gonorrhoea; for these can hardly be supposed to have had a chancre during a voyage of five months, without the penis being destroyed. It is impossible, however, to say'what time may elapse, between the application of the venereal poison to the penis, and the commencement of ihe ulceration. There- fore, Bougainville's sailors, alluded to by Mr. Hunter, might have contracted the in- fection at Rio-de-la-Plata ; but actual ulcers on the penis might not have formed till about five months afterward, when the ship arrived at Otaheite. In attempting to explain, why a gonor- rhoea, and a chancre do not equally produce lues venerea, and why the medicine which almost universally cures cbnncre, ha* less io have been made respecting the trunk of the vessel being wounded, or opened, while in fact only a branch of it was concerned. As a qualifica- tion, therefore, of any inferences, which might be drawn from the partial success of applying one ligature only in cases of large wounded arteries, I annex the following re- marks, published some little time ago in an ulily conducted periodical work. "It ap- pears to us, that some of the cases, which M. Roux bas »iven, as the most favourable lor the operation of Hunter, are the least so; for example, be performs it in the cases where aneurism has formed in consequence of the wound of the artery. In support of this, he gives two cases, wh< re, upon the authority of ,\1. Mirault, of Angers, the liga- ture ofthe artery above the wound was suf- ficient. In one case, the humeral was the artery said to be wounded ; in the other, the femoral. We doubt if the femoral were really wounded in this case; for, on refer- ring to the report, we do not find sufficient evidence of that fact; it appears more pro- bable, that a branch only was wounded. We have seen the operation of Hunter per- formed unsuccessfully in two cases of aneu- rism, consequent upon a wound of the ar- tery; and we have seen the preparation of a third case, where the same operation was performed and failed ; that is to say, the inosculations were so free, lhat hemorrhage returned by the lower orifice. In the first case, the popliteal artery was ruptured by a spicubi of bone. The second was a wound of the femoral artery by an iron spike : and Ihe third was a stab of the femoral arte- ry by a knife. In each of these cases, tbe hemorrhage returned by the lower part of the artery. There is in the Bulletins de la Faculle de Medecine, for 1813, a case by the same Mirault, ofan aneurism of the fe- moral artery, in consequence of a wound some considerable time before. Mirault operated according to the method of Hun- ter, that is, he tied the artery above tbe aneu- rism. The sac burst, two hemorrhages en- sued, and the second carried off the patient op the fifteenth day after the operation (N. B. Here, however, it is proper lo remark. that, if the case had been a true aneurism, and the sac had burst, while a stream of blood was yet passing through it, as always happens for some days after tbe ligature of the artery, above the tumour, hemorrhage would have occurred just as it did in the pre- sent case of false aneurism. The premature bursting of the tumour, in fact, converted tbe case directly into one, analogous to a wounded artery, the blood having a pas- sage outwards.) It is rather curious that the first case, which occurred to M. Roux, after his return from England, should be one, which forms a strong argument against performing the operation of Hunter for a wounded artery. " The case, here alluded to, was that of a wound of the femoral ar- tery with a knife, a little below the middle of the thigh, where M. Roux immediately cut down to the vessel some way above the in- jury, and there applied two ligatures, besides a reserve ligature. On the tenth day, he- morrhage came on, when the tightening of the latter ligature having no effect, M.Roux exposed the artery higher up, and applied fresh ligatures immediately below the pro- funda. This stopped the heinorrhage from the upper end of the vessel, but on the fol- lowing morning fresh bleeding took place from the lower end of the artery, and it be- came necessary to lay open the artery below the wound, and also apply ligatures there. No further bleeding took place. (See Quar- terly Journ. of Foreign Medecine, Vol.1,p. 14, 8ro. Lond. 1819.) The tenor of the prece- ding observations is unquestionably correct, inasmuch a3 wounded arteries and recent false diffused aneurisms are concerned; but with respect to cases of false cir- cumscribed aneurisms, of some standing, without any external opening in the skin, they are examples, to which the same prin- ciples should not always be applied, which are so properly recommended to be observed with regard to the other instances. In these latter, the blood may either escape from the lower end of the vessel out of the external wound, or into the cellular membrane after the ligature is applied above the aperture in the artery ; but, no sooner is a false aneurism encysted, than these dangers are prevented. When the ball moves with little velocity, the mischief is generally less ; the bones are not so likely to be fractured ; the parts are less deadened, Sic. However, when the velocity is just great enough to splinter a bone, which is touched, the splintering is generally more extensive, than if the im- petus of the ball had been much greater, in which case, a piece is more likely to be taken out. When the ball moves slowly, it is more likely to be turned by any resistance it may encounter in its passage through parts, and hence the wound is more apt to take a winding course. When a ball enters a part with great velo- city, but is almost spent, before it comes out again, in consequence of the resistance it has met with, there may be a good deal of sloughing about the entrance, and little or GUNSHOT WOUNDS. 597 Done about the exit, owing to the different degrees of celerity with which the ball traversed the parts. (See Hunter.) Gunshot wounds may have either one, or two apertures, according as the ball has lodged, or passed quite through the part. In some cases, the openings are diametrically opposite each other ; in others they are not so, the direction of the ball having been changed by the resistance, which it has met from a bone, cartilage, tendon, he. Thus a ball has been known to enter just on the in- side of the ankle, and come out near the knee, to enter the fore-head and come out at the temple, Sic. (Richerand, Aosographie Chir. T. 1, p. 219, Edit. 2.) Dr. Hennen mentions an instance,in which a ball entered near the potnuin Adami, and after running completely round the neck, was found in the very orifice, at which it had entered. " This circuitous route is a very frequent occurrence, particularly when balls strike the ribs, or abdominal muscles ; for they are turned from the direct line by a very slight resistance indeed, although they will at times run along a continued surface, as the length of a bone, along a muscle, or a fascia, to a very extraordinary distance." Dr. Hennen refers to cases, in vvhich tiie ball traversed almost the whole extent of the body and ex- tremities. " In one instance, which occur- red in a soldier, with his arm extended in the act of endeavouring to climb up a scaling ladder, a ball, which entered about the centre of the humerus, passed along the limb, and over the posterior part of the tho- rax coursed among the abdominal muscles, dipped deep through the glutaei, and pre- sented on the forepart ofthe opposite thigh, about midway down. In another case, a ball, which struck the breast of a man standing erect in the ranks, lodged in the scrotum.'' (Principles of Military Surgery, p. 34, Ed. 2.) The opening, wbere the ball enters, is always smaller than that from which it escapes, and its margin is forced in- wards, while the circumference of the other aperture is quite prominent. The contusion and injury, which the parts suffer, are also greatest about the entrance of the ball, owing to the more considerable impetus, with which it moves. The yellowish livid hue, around gunshot wounds, is a sort of ecchymosis, or extravasation of blood. Ihe injured member is often benumbed and slu- pified, and, when mortification occurs, it spreads with extraordinary rapidity. When the whole constitution is thrown into this kind of torpor, the most fatal consequences are to be apprehended. " C'est dans cet, etat, (says Richerand) que mourut le chevauleger, dont parle Quesnay; I'etat d'h6b6tude etait tel, que cet individu a qui Ton proposa I'amputation de la jaiube, re- pondit que ce n'etait pas son affaire." (Nosographie Chirurg. Tom. 1, p. 221, Edit. 2.) In cases of gunshot wounds, sudden shiverings, syncope, and nervous symptoms, are not unfrequent. Such occurrences, with other bad effects, made the ancients suspect, that something poisonous was carried info the wound ; an opinion, which is now well known lo be erroneous. When there is only one opening, we may infer, that the wound contains a foreign body. An exception to this observation occurs, however, when a ball, instead of tearing the clothes, or linen, carries a por- tion of them in the form of a sac, into the wound, and when such portion of the clothes is withdrawn, the ball falls out, and if this circumstance be not noticed, tbe pre- sence of a single opening may lead to the idea, that the bullet is lodged in the part An instance of this kind is cited by Pare for the purpose of refuting the former notion, that the ball burnt the parts. A case, in which a piece of a shirt was carried in this mannerfour inches into the flesh is mentioned by Mr Gu- thrie. (P. 20, Ed. 2.) It is possible also for a ball to be stopped immediately it has en- tered tbe body, and then to be ejected by the elasticity of the. parts, against which it strikes, as the cartilages of the ribs. (Gu- thrie, p. 19. Ed. 2.) When there are two apertures made by one shot, the ball has escaped; but pieces of the clothes, Sic. may still be lodged in the part. Care must be taken, however, not to confound with these cases others, in which the plurality of openings has been made by different balls. As a modern writer has accurately ex- plained : ' It is no uncommon thing for a hall in striking against the sharp edge of a bone, to be split into two pieces, each of which takes a different direction. Some- times it happens, that one of the pieces re- mains in the place, vvhich it struck, while the other continues its course through ne body. Of a ball, split by the edge of the patella, 1 have known one half pass through at the moment of the injury, and the other remain in the joint for months, without its presence there being suspected. In the same manner, I have known a ball divided by striking against the spine of tbe scapula, and one portion of it pass directly through (he chest, from the point of impulse, while the other moved along the integuments, till it reached the elbow-joint. But, the most frequent examples of the division of bullets, which we had occasion to see, were those which were produced by balls striking against the spherical surface of the cranium. It sometimes happens, that one portion of the ball enters the cranium, while the other either remains without or passes over its external surface. Not unfrequently, in in- juries of the cranium, the balls are lodged between its two tables, in some instances much flattened, and altered in their shape, and, in other instances, without their form being changed." From these facts, it must be evident, lhat even when a gunshot wound has two orifices, the surgeon cannot be certain, that the bullet has not been divi- ded, and that no portion is lodged, unless the entire ball itself happen to be found. (See Thomson's Reports of Obs. in Military Hospitals in Belgium, p. 37, he.) As the ends of the torn vessels are contu- sed and compressed, gunshot wound« have 598 GUNSHOT WOUNDS. less propensity to bleed at first seriously, than most other wounds, unless vessels of importance happen to be injured. There mav even be little hemorrhage at first though a considerable artery be so hurt, that it after- ward sloughs and a dangerous, or a fatal bleeding arises. Thus (as I have already mentioned) in one of my own patients, who had received a musket ball through the ham, the popliteal artery gave way about ten days after the injury, and compelled me to take up the femoral artery; and, in the Eliza- beth Hospitals at Brussels, among the pa- tients under the care of my friend Mr. Collier and myself, about a week after the battle of Waterloo, the cases of hemorrhage, on the looseniHg of the sloughs, were tole- rably numerous not at all coinciding with a recent calculation, that the proportion of such examples, requiring the ligature of ar- teries, is only three or four' iu 1000. (Gu- thrie on Gunsho' Wounds, .p. 8, Ed. 2.) In Holland, the truth of .Mr. Hunter's observa- tion upon this point uppeared to me tobe equally confirmed. It has long been known, that a limb may be torn, or shot off. even near to the trunk of the body, and hardly any liemorrh.tee arise. We hud numerous proofs of this fact after thp battle of Waterloo. I had under my care a man of tbe rifle brigade, whose arm was shattered to pieces as his/h as the shoulder, yet there was no hemorrhage. 1 amputated the ihigh of a Dutch soldier, whose leg had been completely shot off by a cannon ball; but there was no hemor- rhage before the operation. At Merksam, in 1814, I saw a case, in which the greater part of the clavicle, scapula, and many adjacent parts, had been carried away by a cannon- ball ; and yet no bleeding of consequence occurred. 80111611016=, after these violent injuries, the laree arteries do not bleed iu amputation. " We saw a man, (says Dr. Thomson) whose leg had been shot off by a cannon-ball; in amputating his limb above tbe knee, the ar- teries of the thigh were not perceived to bleed ; nor did any of them afterward re- quire to be lied. A case, similar to this, also presented itself, in vvhich the arm had been shot away close to the shoulder-joint." Sometimes the contusion, produced by a cannon-ball, or tbe passage of a bullet in the vicinity of a large artery, seems to cause a laceration of the inner coat of the vessel, and a subsequent obliteration of its cavity by the effusion of coagulable lymph. Facts, in proof of this statement, are re- corded by Dr. Thomson. (See Reports of Observ in the Military Hospitals in Belgium, p 34. 35.) Angular uneven bodies, such as pieces of iron, cut lead, he. produce far more danger- ous wounds, than round even bodies, like leaden bullets. Wounds occasioned by a small shot, are frequently more perilous, than others produced by larger balls; be- cause their track is so narrow-, that it cannot be traced, nor consequently the extraneous body itself extrarted. Such a <-hot often in- jures a viscus, when there is not the smallest external symptom ofthe occurrence. Some- times a great part of the danger, also, arises from the number of the shots which have entered. TREATMENT OF GUNSHOT WOUNDS. The first thing in the treatment of a gun- shot wound in one of the extremities, is lo determine, whether it is most adv iseable to amputate the limb immediately , or to under- take the cure of the wound. When n bone, especially ut a joint, is very much shattered; when the fleshy parts particularly the great blood-v essels and nerves, nre lacerated; when the whole limb has suffered a violent concussion, and is cold and senseless ; there is no hope of preserving it. In this case, it is the surgeon's duty to amputate at once. and not to delay till inflammation, fever. and a tendency to mortification come on. But, besides this violent degree of .injury, in which the propriety of amputation is ob- vious, there are several lower degrees, iu which it is often a difficult thine to decide whether the operation is necessary or not. Here the surgeon must look not only to the injury, but also to the patient's constitution, and even to external circumstances, such as tbe possibility or impossibility of procuring good accommodation, rest, attendance, and pure air. But it is impossible to determine the necessity of amputation by general rules. In every individual case, the surgeon must consider maturely the particular circum- stai.ces, before he ventures to decide. The grounds against the operation are ; tbe pain which it causes at a period when the whole system is disordered by a terrible injury ; the privation of a limb ; and frequent examples, in which nature, aided by judicious sur- gery, repairs the most horrible wounds. The following are the reasons in favour of the operation. By it the patient gpfs rid of a dreadful contused wound, which threatens the greatest peril, and which is exchanged,as it were, for a simple incised one. The pain of amputation is not of more moment than the pain which the requisite incisions, and the extraction of foreign bodies, would cause in case the operation were abandoned. In cases of gunshot wounds, the loss of the limb cannot be taken into the account, for, the surgeon only undertakes the operation where be designs to save the patient'3 life by that privation, and anticipates that tbe part itself cannot be preserved Even, if he should deprive the patient of a limb, that perhaps, might have been preserved, there is this atonement, that he can furnish him with an artificial leg, which often proves far more serviceable than the lost limb would have proved, had it been pre3erved. Should the operation be fixed on, it is to be immedi- ately performed above the wound. (Richter, Anfangsgr. der Wundarzn. B. 1.) When amputation is de&med unneces- sary, the surgeon, according to precepts formerly in vo^rue, is to dilate the wound by one or more incisions. !\bmv of be GUNSHOT WOUNDS. 599 missile weapous employed by the ancients, when received into the body, required in- cisions before they could be extracted ; and this was the case, not only with re- gard to darts and arrows, but also with regard to bits of stone, pieces of iron, and leaden bullets, which were thrown by means of slings. Celsus mentions the ne- cessity of enlarging the orifices, through which these bodies had entered, and may therefore be justly regarded, as the first who recommended the practice of dilatation in the treatment of wounds made by leaden bullets. (Thomson's Reports of Obs. in the Military Hospitals of Belgium, p. 39.) Such a dilatation has been said to have nu- merous advantages ; to facilitate the ex- traction of foreign bodies ; to occasion a to- pical bleeding, and afford'an outlet for the extravasated fluid in the circumference of the wound ; to convert the fistulous form of the track of the ball into an open wound ; and, lastly, to divide ligamentous aponeuro- ses, which otherwise might give rise to spasmodic and other untoward symptoms. More modern experience proves, how- ever, (Hunter, p. 529.) that the utility of such incisions has been overrated ; that they ge- nerally increase the inflammation, which, in these cases, is so much to be apprehend- ed ; that wounds which are not dilated, commonly heal more speedily than others which are ; and that there are only a few cases, in which incisions are beneficial. In fact, as Dr. Hennen has correctly stated, the knife is now rarely, if ever employed in the first instance by English surgeons, except for the purpose of extracting balls, splinters of bone, and other extraneous bodies, or for facilitating the application of ligatures to bleeding vessels. (See Principles of Military Surgery, p. 49, Ed. 2.) The injuries, arising from the practice of indiscriminate dilatation, (says Dr.Thomson) were very early pointed out by Botallus ; and it is singular, how much the opinions of this author, with regard to this point in mili- tary surgery, coincide with those of Mr. Hunter. (Op. cit. p. 40.) The cases of gunshot wounds are various. Sometimes the track of the ball lies superfi- cially under the skin, and only has one open- ing. When it lies in soft parts, and the ball has neither touched a bone, nor a considera- ble blood-ves3el, all incisions are useless, let the wound have one or two apertures. Though dilating the wound has been practi- ced with a view of giving vent to matter, eschars, and foreign flbdies, and even its whole track has been laid open, when su- perficial ; yet, experience proves the inutility of such steps. As, when a ball has passed with great force, there is often a real loss of substance in the skin, a portion of which is driven inward before the ball, it follows, that the opening of a gunshot wound must be more capacious than that of a punctured one. By the separation of sloughs, the wound becomes still more dilated, so that not only matter, but foreign bodies, which approach the skin, easily find an exit. Re- sides incisions commonly close again very soon, and in a few days, the wound falls into the same state, as if no dilatation at all had been made. (Hunter, p. 532.) Ligamentous fibres, and fasciae, are often situated about the orifice of agunshot wound, and some surgeons,have made it a rule al- ways to divide them completely, lest, when the wound inflames, the tension and confine- ment of parts should cause violent spasms and nervous symptoms, and afterward im- pede the discharge of matter and foreign bo- dies. When they obviously have the first ef- fects, the propriety of dividing them cannot be doubted; but. with a mere expectation of the other evils, 1 consider the practice in- judicious. Here, as Mr. Hunter wisely re- marks, the method would be very good, if tension and inflammation were not a conse- quence of wounds, or, if it could be proved, that the effects of dilating a part, that is al- ready wounded, were different from those of the first wound ; but the employment of the knife, being only an extension of the first mischief, must be contradictory to com- mon sense, and common observation. (On Gunshot Wounds,p. 534, 4lo.) The extraction of foreign bodies ranks as one of the most urgent motives for the dila- tation of the wound, and no doubt it is right lo remove, at first, as many of them as pos- sible. Their lodgment irritates the wound, causes violent nervous and inflammatory symptoms, and copious suppuration ; cir- cumstances, vvhich tbe timely extraction of them may prevent. Yet, let it be remember- ed, that the extraction of foreign bodies is frequently attended with immense irritation, and that, while they lie too firmly fixed in parts, it is often a matter of impossibility. After the sloughs have separated, and the wound has become widened, suppuration frequently does not prevail long before the extraneous substances become loose, spon- taneously approach the skin, and easily ad- mit of removal without any dilatation. Hence, it is generally-prudent to extract, at first, only such foreign bodies, as are near the external opening, quite loose, and re- moveable without much irritation ; or such as press on parts of importance, and, thereby excite dangerous symptoms. The surgeon should avoid interfering with those which are deeply and firmly lodged in the wound. He should await suppuration, and the de- tachment of sloughs, and when the foreign bodies become moveable and apparent, he should extract them, with or w ithout an in- cision, as circumstances may demand. The examination of the wound ought to be made as much as possible with the finger, vvhich irritates less, and feels more distinctly than a probe. A great variety of instruments have been devised, either for ascertaining the position of balls, and other foreign bo- dies in gunshot wounds, or for extracting them. But, however numerous and diversi- fied bullet-drawers may be, they all admit of being divided into three kinds. The first are constructed on the principle of a pair of forceps. Others are shaped more or lec«i dOU GLNSHOT WOUNDS like spoons. And a third description are made on the plan of a cork-screw or worm. These last are only designed for cases, in which the ball is fixed in the substance of a bone, and is quite immoveable ; for, if it were lodged in the soft parts, the pressure requisite for introducing the screw into it, would injure and lacerate the parts at the bottom of the wound. Bullet-drawers, con- structed on the plan of forceps, have the in- convenience of not being adapted for seizing the ball, unless their blades are expanded, which always stretches the wound, and cre- ates a great deal of irritation. Forceps have been contrived with blades, which may be introduced separately, and then joined to- gether with a screw. When a ball lies su- perficially, the fingers, or a small pair of for- ceps, will extract it most conveniently. And, with respect to bullet-extractors, as Dr. Hennen has justly observed, they are completely superseded by the common for- ceps, or that of Baron Percy, though unfor- tunately the aid of instruments is most re- quired in tortuous deep passages, where we can least make use of them. (Principles of Military Surgery, p 76, Ed. 2.) The event ofthe treatment above recom- mended, is various. Extraneous substances remaining in the wound, either loosen gra- dually, and come into view so as to be easily rcmoveable ; or they continue concealed, prevent the cure, and give birth to a fistu- lous ulcer. In some instances, the wound closes, aud the foreign bodies remain in the limb during life, without inconvenience ; and in other cases, after a time, they bring on a renewal of inflammation and suppura- tion. Sometimes a foreign body varies its situation, sinking down, and afterward ma- king its appearuice at a different part, where it may excite inflammation and suppura- tion. When the ball lodges in the wound, it is usually difficult to trace it, as the parts col- lapse after its passage, and leave an opening in the skin much smaller than the ball itself. The ball does not regularly take a straight di- rection through the injured part, but often a very tortuous one, particularly wheu the ball is nearly spent. In every case, in which it is not easily discoverable, all pain- ful examinations should be abandoned, and the foreign body left in its situation, until its place is better known, and the first inflam- mation is over. Sometimes, the ball may be both easily found and extracted. At other times, it lodges on the opposite side of the limb, closely under the -kin. According to Mr. Hunter, if the integuments, under which the ball is lodged, should be so contused that they will probably slough, they are to be considered as already dead, and an opening is to be made in them for the extraction of the ball. But, when the ball lies so remote- ly from the skin that it can only just be felt, and the skin itself is quite uninjured, no counter-opening ought to be made. The wound heals better when the ball is left in, •»nd far le-^ inflammation takes place in the vicinity of thia extraneous bony, tbuu about tbe orifice of the wound. \ counter-open- ing always renders the inflammation at the bottom of the wound, as great as at its ori- fice. It is better to let the wound heal up, and extract the ball afterward. (See Hunter, p. 541.) To the justness of this advice, Mr Gu- thrie does not assent, who assures us, that he has cut out a great number of balls, which were not more than an inch from the surface, and never found any inconve- nience ensue. But when the ball lies three or four inches from the surface, and cannol be distinctly felt, he thinks that no incision should at first be made with the view of ex- tracting it. (On Gunshot Wounds, p. 94) 95, Ed. 2.) Sometimes, the ball penetrates the spongy part of a bone, and lodges firmly in it. When it has only entered superficially, it may sometimes be loosened and extracted, by means of an elevator with a thin and somewhat curved extremity, and when it is more firmly fixed, a screw bullet-drawer will sometimes serve for its removal. Should the attempt fail, the employment of a tre- pan for the removal of the ball is recom- mended by some writers ; while others, fearful ofthe irritation, difficulty, and effects of such an operation, and recollecting that balls have sometimes remained fixed in bones for many years, without any serious inconvenience, condemn that practice. On the contrary, Mr. Guthrie lays it down as a general rule, subject to a few exceptions, that a ball should never be allowed to re- main in a bone ; for, says he, " if a ball lodge in the head of a bone, and is not re- moved, it generally causes caries of the bone, disease of the joint, amputation, or death. If in the shaft of a long bone, ne- crosis for the most part follows, with months and years of misery. On a flat bone, caries is equally the result, and if it be surrounded by large muscles, sinuses form in various di- rections, contractions ofthe limb take place, and the patient drags on for years, careless of life, and ready to submit to any thing to obtain relief." (On Gunshot Wounds, p. 91 —93, Ed. 2.) In many of these cases, one thing deserves to be recollected, however, that the necrosis, abscesses, and sinuses are less the effect of the lodgment of the ball, than ofthe violence originally committed on the parts, against which it has struck. Al- though Baron Larrey only sanctions the attempt to remove balls with a trephine, when they actually produce dangerous ef- fects, (Mim. de Chir. Mil. T. 4, p. 185,) I am disposed to believe, that wheneverthe situa- tion of the ball is such, that it can be re- moved at once from a bone with tolerable certainty, and without too much irritation, the practice is commendable. This branch ofthe treatment of gunshot wounds appears to me still to require further elucidation, for though experience has been abundant, the right rules and principles of practice are not yet laid down in the bc-t modern works. GUNSHOT WOUNDS 601 Ai soon as the requisite incisions are made, and foreign bodies extracted, the prime objects in the treatment of gunshot Wounds are accomplished, and tbe rest is, in reality, not different from the surgery of other wounds. With regard to probing gunshot wounds ; when it is evident that the shot has passed out, and no particular object can be fulfilled with the probe, it is often better to dispense with such examination, at least till suppura- tion has come on. Introducing any instru- ment is generally productive both of pain and irritation. But when the ball, or any other extraneous substance, has lodged in tbe wound, and its situation is not imme- diately evident, it will often be adviseable to search for it at once, in order that it may be extracted, if its situation will allow, before inflammation begins. The surgeon, there- fore, considering all the circumstances which can assist him in forming a reasona- ble conjecture of the course of the wound, must give to a probe that curvature or form, which he thinks' most likely to pass readily along it, and must then proceed to make the examination. But, when this is very pain- ful, and the course ofthe wound obscure, it Will often be better to desist, and renew the search when suppuration has taken place, in which stage it can be undertaken with more ease, and a greater prospect of success. When gunshot wounds are inflamed, the tenderness and swelling of the parts are pe- culiarly strong reasons against painful pro- bings, or efforts to extract foreign bodies, as long as this state lasts. (See Chevalier's Trea- tise on Gunshot Wounds, p. 67, 68, Edit. 3.) There is no fact in the practice of surgery better established, than that the cramming of narrow stabs and gunshot wounds with lint, is particularly hurtful. The only possible reason for doing so in the latter cases must be to keep the orifice of tiie wound from healing up, and confining extraneous bodies, matter, he. The apprehension of this hap- pening at first is quite unfounded; for the inside of the mouth of the injured part is often lined with a slough or eschar, which must necessarily be detached before the parts can heal. The first dressings, therefore, should be quite superficial, and of a mild unirritating nature. On the field of battle) indeed, it would be well for many of the wounded, if the surgeon were to content himself with applying simple pledgets, and covering the part with linen wet with cold water. This method would prove much more beneficial, than the hasty and indis- criminate use of adhi-sive plasters, sutures, and tight bandages, from the bad effects of which thousands of soldiers have lost limbs, or lives, which, under more judicious treat- ment, might have been saved. Hunter used to employ fomentations, pledgets of simple ointments, and fiequently over the latter an emollient poultice. In the suppurative stage of gunshot wounds, poultices are ge- nerally allowed to be the best applications. Possessing these ideas, I cannot altogether approve the following directions, though Vor. ! 7o they are certainly better than are given in many surgical books. " A small bit of soft lint may be placed lightly between the lips of the wound, in order to keep it from closing. In some instances, it should be introduced a little beyond the lips, in order to conduct off the fluids effused, and to prevent irregular adhesions from forming near the surface dur- ing the inflammatory stage ; as these would impede the direct exit of the discharge. But the wound is not to be filled with lint- much less crammed with it. A pledget of some simple ointment being then laid on, with tow or cloths to receive the discharge, and these prevented from coming off by a bandage loosely applied, the patient may be put to bed, and so placed, if possible, as to keep the orifice of the wound dependent." (Chevalier, p. 125, 126.) The reasons for what I consider objectionable, namely, in- troducing lint on first dressing the wound, are too frivolous to need comment. In considering the effects of poultices and Cold applications upon gunshot wounds; Mr. Guthrie expresses his decided preference to the use of cold water:—" The inflammation is, in some instances, materially prevented, in many greatly controlled, and, in almost all, very much subdued by it, whilst the suppurative process is not impeded in the generality of cases, in a degree sufficient to interrupt the subsequent one of granulation. In all simple cases of gunshot wounds, that is to say, flesh wounds, in persons of a healthy constitution, a piece of lint, which has been dipped in oil, or on which some ointment has been spread, is the best appli- cation at first to prevent irritation, with two slips of adhesive plaster placed across to re- tain it in its situation. A compress, or some folds of linen, wetted with cold water, are then to be applied over it, and kept con- stantly wet and cold, even by the use of ice, if it can be obtained, and be found com- fortable to the feelings of tbe patient. A roller is of no use, except to prevent the compress from changing its position during sleep, and is, therefore, at that period use- ful ; but as a surgical application, it is use- less, if not positively, injurious, because it binds a part, vvhich ought, to a certain, ex- tent, to swell, and by-pressure causes irrita- tion. Rollers ought not' to be applied sur- gically until after som.e days have elapsed; and it is inexpedient to employ them in the field of battle, even if they were useful, ex- cept where some parts are to be kept in po- sition ; because, when they arc applied iu the first instance, they soon become stiff and bloody, are for the most part cut, and are seldom preserved after the first dressing, so as to become useful at the period, when the surgical application of a roller isindispensa ble." To this just censure of the wrong employment of rollers, Mr. Guthrie annexes some remarks, in which he enters into a ge- neral condemnation of poultices, as appli- cations to gunshot wonnds, believing, that in many instances, cold water maybe employed with the best effect, during the whole pro- gress of the cure. These remarks are tem ii(>2 GUNSHOT WOUNDS pered vv itii the following admission :—" Cold water is not, however, an infallible, or even always an advantageous remedy : there are many persons, with whom cold applications do not agree; there are more, with whom they disagree after a certain period ; and, in either case, they should not be persisted in. Cold does no good in any stage of in- flammation, when the sensation accruing from the first application of it is not agreea- ble to the feelings of the patient; when, in lact, it does not give relief; for, if it pro- duces a sensation of shivering, or an uncom- fortable feeling of any kind, with stiffness of the part, it is doing harm, and a change to the genial sensation of warmth will not only prove more agreeable, but more advanta- geous. This occurs in general about the pe- riod when suppuration has taken place; and cold, in such cases, is preventing the full effect of the action, which warmth encou- rages. Fomentations are then proper ; and, if a poultice be preferred for convenience, by day or by night, an evaporating one of bread will be found sufficient. In the spring ofthe year, the marshmallow makes an ex- cellent poultice, und so do turnips, gourds, carrots, Sic. independently of oatmeal, lin- seed-meal, Indian-meal, and other farinace- ous substances. In all those cases where a poultice is resorted to, as much attention is to be paid lo the period of removing, as of applying it. It is used (o alleviate pain, stiffness, swelling, the uneasiness arising from cold, and to encourage the commen- cing, or interrupted action of ihe vessels to- wards the formation of matter; and, as soon as the effect intended has been gained, the poultice should be abandoned, and re- course again had to cold water, with com- press and bandage." (P. 62—67. Ed. 2.) Although I fully coincide with Mr. Guthrie, respecting the general advantage of cold wa- ter, the dangers of tight bandages, and the bad effects of continuing poultices too long, I do not join him in many of the sentiments which he has expressed about these last in- valuable applications. On the contrary, I appreciate them as ihe btst means, wherever a slough is to be throw i- off, or matter is de- cidedly forming, and as ibesr . ffocts are very frequent in cases of gunshot waunds, my own opinion of the utility of cold applications is limited to the first three or four days after the receipt of tho, injury. Nor ought cold applications ever to be continued, where the torpor, low temperature, and languid circu- lation in the limb, indicate a risk of gangrene. Hence, when a principal artery is tied, their employment is always wrong and hazardous. At the same time, I have no hesitation in declaring my firm belief, that fifty times more mischief has been done by tight rollers applied to recent gunshot wounds, than by either poultices, or cold applications. Formerly, when the track of the ball had two apertures, a seton was sometimes drawn through it, with the view of preventing a premature closure of the wound, and intro- ducing proper applications. The seton was, also, imagined to give free vent to pus. and to promote the evacuation of foreign bodies But a gunshot wound is little inclined to close prematurely, and while a seton rather obstructs the exit of pus, it may as easily push foreign bodies more deeply into the limb, as out of it. There are preferable modes of applying the necessary remedies, and, ns a seton is an extraneous substance itself, its employment cannot fail to be highly perni- cious. Gunshot wounds generally demand the employment of antiphlogistic means, just as other cases, attended with equal inflamma- tion. When they are in the inflamed state, the application of leeches is highly proper. In these cases, bleeding is recommended, and in such a manner as if it were of more service iu them, than wounds in general. But tbe necessity for the practice is really not greater than in other wounds, which have done the same degree of mischief, and from vvhich the same quantity of inflamma- tion and other consequences are expected. Bleeding is certainly proper here, just as it is in all considerable wounds attended with a strong full habit, and great chance of exten- sive inflammation, and much symptomatic fever. In every instance, however, the prac- titioner must take particular care not to be too bold in the practice of bleeding: for when the patient is reduced below a certain degree, his strength is inadequate to support the large and long-continued suppurations which often cannot be avoided. (See Hun- ter, p. 563, 564.) As the orifices of the vessels torn by the ball are compressed, and, as it were, oblite- rated, sometimes no hemorrhage of impor- tance is remarked at first. But, as I have already stated, after some days, and frequent- ly ut a very late period, when the sloughs separate, copious hemorrhages may occur, w'ticb are the more dangerous as they come on unexpectedly,and often when the suppura- tion has already induced great debility. The surgeon himself may occasion the bleeding, by removing the dressings carelessly. Hence, in every case, where, from the situation of the wound, there is reason to apprehend inju- ry of some considerable vessel, the patient must be constantly and attentively watched, and every thing necessary for the immediate stoppage of hemorrhage provided. Another kind of hemorrhage, still more dangerous than the former, particularly oc- curs in such gunshot wounds as have long been in a state of copious suppuration. The blood does not issue from one individual ves- sel, but from the whole surface of tbe wound, as from a sponge, and is so thin ej to resem- ble blood and water. This hemorrhage is very dangerous, because it is particularly apt to exhaust the patient, who is already debili- tated, and its causes are difficult of removal. The case demands the exhibition of bark, and diluted sulphuric acid ; tbe decoction of bark, with a proportion of muriatic acid, be- ing applied to the wound. (Richter.) Gunshot wounds, in crowded military hos- pitals, especially when they are established in unhealthy, low rituations, and due alien- GUNSHOT WOUNDS. 603 tion is not paid to ventilation, cleanliness, and fumigations with nitric acid gas, are of- ten attacked with hospital gangrene, a very serious aud dangerous complication, of which 1 shall speak underthe head of Hospital Gan- grene. The plan of removing the first dressings too soon is as injurious in gunshot wounds as other cases, by creating a premature dis- turbance of the parts. This observation is particularly true, where dry lint has been used, and it is adherent to the wound. Un- less tbe occurrence of bleeding, severe pain, or other untoward symptoms, were to render a different line of conduct necessary, I think such dressings should rarely be removed be- fore the end of the fourth day. And, if cold water has not been continually applied over the lint, so as to keep it moist, or if such lint has not been spread with some mild salve, or dipped in oil, 1 deem it a good rule to ap- ply an emollient poultice over it the even- ing preceding the morning on which the dressings are to be first changed. By this means, they will be loosened, and admit of being taken away without pain or irritation. With the same view, plenty of warm water should be squeezed from a sponge, and al- lowed to fall upon tbe dressings. Pledgets of oil, or ointment, should generally be taken off earlier than dry lint, for they are less ad- herent, and in warm weather, soon become rancid and irritating. For the first days, the matter seldom as- sumes a healthy appearance ; but as soon as the sloughs separate, it then becomes of a proper quality, and the wound is to be treat- ed as a simple abscess. Sometimes the healing process does not commence, though suppuration has prevail- ed a considerable time. On the contrary, notwithstanding tbe exhibition of tonics, and a generous diet, the suppuration ceases to proceed favourably, and the wound becomes unhealthy, and the matter thin. The bones show no disposition to unite, and the patient, reduced by hectic symptoms, is rapidly ap- proaching dissolution- In this state, life may sometimes be preserved by amputation ; the anceps, but unicum remedium. We ought never to be deterred from undertaking tbe operation by tbe fever and weakness, whicb frequently soon disappear when the local cause is removed. OF AMrUTATION IN CASES OF GUNSHOT WO ON OS. The 2d edition of tbis dictionary, publish- ed in 1813, contained all the valuable obser- vations of Baron Larrey, in favour of im- mediate amputation in every instance in which the operation is considered indispen- sable. Since then, the public have been fa- voured with several good practical books, iu which the propriety and necessity of early or immediate amputation in such cases arc urgently inculcated, and the truth of the doctrine is illustrated by additional facts. It is to be observed, however, that for nearly two hundred years past, there have always been some advocates for this judicious prac- tice. " Du Chesne (says Dr. J. Thomson) is the first writer on military surgery, in whose works I have found the recommen- dation to amputate in the severer injuries of the extremities; and it is worthy of remark, that he directs lite operation to be performed before inflammation and other constitutional symptoms shall have supervened." (See TraiU de la Cure generate et particuliire des Arcbusades. Par Jos. Du Chesne; Paris. 1625, p. 143; and Thomson's Report, fa. ;t. 160.) Wiseman not only recommended and practised immediate amputation ; but the same thing was not unfrequently done by the military surgeons of his time. (Chirurgical Treatises, by R. Wiseman, 3d Edit. London, 1696, p. 410.) The celebrated Le Dran, in his excellent little manual of military surge- ry, declared himself an advocate for imme- diate amputation in all cases, in which that operation from tbe first appears to be indis- pensable. Le Dran has at the same time stated briefly, but most distinctly, the com- parative advantages of that practice, with those which may be expected by delay. (See Traili oh Reflexions tiries de la Pratique- sur les Plaics d'Armes a feu. Par II. F. Le Dran; a Paris, 1737.) Ranby, who was Ser- jeant surgeon to King George II. entertain- ed similar opinions to (hose of Le Dran, with regard t,: the utility of immediate am putation. In order to give immediate rebel lo Ihe wounded, and to facilitate tbe per- formance of (he necessary operations, Ran- by proposed, that the surgeons, during battle, should be collected into small bodies, and stationed in the rear of the army. (See the Method of treating Gunshot Wounds. By John Ranby. Edit. 3, p. 29. London, 1781.) After the battle of Fontenoy, in the year 1756, the Royal Academy of Surgery in France offered a prize for the best disserta- tion on the gunshot injuries requiring imme- diate amputation, and on other cases of Ihe same nature, where the operation, though deemed inevitable, might be delayed. L'am- putation itanl absolument nicessaire dans [em- ployes compliquies de fracas des os, et princi- palement cellis qui sont fuilespar amies a feu, diterminer les cas ou il faut faire Poperaliou sur le champ, et ceux ou il convicnt de la dij- firer, et en donner les raisons." ' The priae was adjudged to (he dissertation of Iti Faure, the main object of whose paper whs to recommend delaying the operation. The side of tbe question espoused by M. Faure has found some modern advocates of distin- guished talents and celebrity. Suffice it to mention the names of Hunter, Baron Percy, and Lombard. It is, however, only justice to M. Faure to state in this place, that, though he regarded immediate amputation as full of danger, be admitted, that there were several kinds of injuries of the extremities, iu which it was indispensably and immediately requi- red. " The enumeration (says Dr. Thom- son) which this author has given of these in juries, is more full and distinct than uuv vvhich had been published before bis time and, what may appear singular, it docs im: StM GUNSHOT WOUNDS. differ, in any essential respect, from ihe enu- meration given by later writers, who, in com- bating his opinions, have represented him as an enemy to amputation in almost all inju- ries of the extremities." (See Report of Ob- servations made in the Military Hospitals in Belgium, p. 169.) In 1792, Baron Percy, who was a few years ago at the bead of the medical de- partment of the French army, published a book, in which he gives a preference to de- laying amputation at first, even in cases where it is certain ihat the operation cannot ultimately be dispensed with. (See Manuel de Chirurgien d'Armie.) Even as late as 1804, Lombard, Professor in the Military Academy of Strasburg, defended the doc- trines of M. Faure. (^ee Clinique Chirur- gicale des Plaits faites par amies a feu.) Although, in France, the academy of sur- gery thought proper to decree tbe prize to M. Faure, whose doctrine thus received tbe highest approbation, yet, in that country, very opposite tenets were set up by some men of distinguished talents and extensive military practice. Thus Le Dran, consulting surgeon to the French army, in his work on gunshot wounds, published in 1737, express- ly states, " That when the amputation of a limb is indispensably necessary in the case of a gunshot wound, it ought to be done without delay." (Aphorism 9.) De La Mar- tinicre in particular also wrote some excellent arguments in reply to Bilguer ; arguments which, I tbink, would do honour to the most accomplished surgeon of (he age in which we live. (See Mimoire sur le Traitemcnt des plaies d'armes a feu, in Mim de I'Acad. de Chirurgie, T.U,p. 1, Edit. inl2mo.) M. Boucher, of Lisle, was an advocate for the same side of the question. (Sen Obs. sur des plaies, d'armes a feu, fa. in Mim. de PAcad.de Chirurgie, Tom. 5,p. 27^- fa. Edit. in 12mo.) Schmucker, who was many years surgeon-general to the Prussian armies, pub- lished in 1776, an essay on amputation, in which he particularly mentions, that, during his stay at Paris in 1738, the surgeons of the Hdtel Dieu had been in tbe habit of perform- ing immediate amputation in severe injuries erf the extremities. He also declares himself an advocate for operating immediately, in all casts in which amputation from the first ap- pears to be necessary, and insists, iu a particu- lar manner, on the increased danger which be had seen arise from the operation during the second period. He gives (as Dr. J. Thomson has observed) a minute and cir- cumstantial enumeration ol those injuries, both of the upper and lower extremities, in which he conceived amputation to be neces- sary, and in many of which he bad actually performed it with great success. Schmucker appears to Dr. Thomson to have given a bet- ter account than any preceding military sur geon of the injuries of the thigh; and from the results of his experience, he was led to believe, that ihough compound fractures of the lower part of the thigh-bone might, in fa- vourable circumstances, be cured without am- nuiirtior. yet that this operation is peculiarly necessary in all cases, in tohich the fracture is situated in, or above, the middle of that bone. (J. L. Schmucker, Vermisehte Chirurgischt Schriften, B. 1. Berlin, 1785.) With the foregoing high authority we have to join one of not less celebrity, namely, that of Baron Larrey. who has provt d most convincingly, that when amputation is lo be done in cases of gunshot wounds, nothing is so pernicious as delay. (See Mimoires de Chirurgie MM- taire, Tom. 2, p. 451, he.) It becomes me here to state, also, that the principles inculcated by Baron Larrey, are, in point of fact, the same as those which were so strenuously insisted upon by Mr. Pott, whose principal remarks on the neces- sity of amputation in certain cases, are de- tailed in another part of tbis publication. (See Amputation.) Mr. Pott, indeed, wai not an army surgeon, and what he says was not particularly designed to apply lo milita- ry practice ; but he hits represented, as well as any body can do, the propriety of imme- diate amputation for injuries which leave no doubt that such operation cannot be dispen- sed with, Mr. John Bell, among the moderns, ap- pears to me likewise to have much merit for (he able manner in which he defended the propriety of early amputation, long before tbe sentiments of later writers were ever beard of. He distinctly stales, that " ampu- tation should, in those cases where the limb is plainly and irrecoverably disordered, be performed upon the spot." (See Discourse* onthe Nature, fa. of Wounds, p. 488, Edit. 3.) In short, not withstanding all the modern pretentions to novelty upon this interesting topic, we must acknow ledge, with Dr. Thom- son, that the evidence in favour of tbe ad- vantages of immediate amputation, has al- ways preponderated over lhat for delay. (See Report of Obs. made in Ihe Military Hos- pitals in Belgium, p. 225.) The strongest body of evidence upon this matter, is undoubtedly adduced by Barou Larrey, whose situation at (he head of the medical department ofthe French armies af- forded him most numerous opportunities of judging from actual experience. " Upon this subject, (says he,) now that twenty years of continual war have carried our art to tbe highest pitch of perfection, there can only be one opinion. It is after having incessantly directed the medical service all this time, in quality uf head surgeon and inspector-gene- ral of the armies, that I proceed to discuss the different opinions delivered in the aca- demy, and to settle definitively this great question, which I regard as the most im- portant in military surgery. " If we are to be told, thatthe amputation of a limb is a cruel operation, dangerous in its consequences, and always grievous for the patient, who is thereby mutilated ; that, consequently, there is more honour :n saving a limb than in catting it off with dexterity and success ; these arguments may be refu- ted by answering, that amputation is an ope- ration of necessity, which offers a chance of preservation to the unfortunate, whose death GUNSHOT WOUNDS. 605 appears certain under any other treatment; and that if any doubt should exist of ampu- tation being absolutely indispensable to the patient's safety, the operation is to be defer- red till nature bas declared herself, and given a positive indication for it. We are also justified in adding, that this chance of preservation is at the present day much greater, tbanat the epoch of the academy of surgery. We learn from M. Faure, (hat, of about three hundred amputations performed after the baltle of Fontcnoy, only thirty were followed by success, whilst, on the con- trary, says Baron Larrey, we have saved more than three-fourtbs of the patients on whom amputation has been done, and some of whom also had two limbs removed. This improvement is ascribed by Larrey, 1st, To our now knowing better how to take advan- tage of the indication and favourable time for amputating. 2. To the better method of dressing. 3. To (he mode of operating being more simple, less painful, and more expedi- tious, than that formerly in vogue." To the preceding authorities against delay- ing amputation, in cases of gunshot wounds requiring such operation, I hdve to add Mr. Guthrie, deputy inspector of military hospi- tals, whose opportunities of observation, during the late war in Spain, were particu- larly extensive. In his work, he has detail- ed tbe opinions of many eminent foreign and British surgeons, respecting the propriety, or impropriety, of tbe doctrine of immediate am- putation ; and he has introduced some good criticisms, particularly on Bilguer's statement of the success which was experienced in the Prussian hospitals, from not performi; ^ :h>. operation. Mr. Guthrie, however, does not recommend amputation to be done immedi- ately, if 'he patient be particularly depress- ed by the shock of the injury directly after its receipt; a piece of advice, which 1 be- lieve has in reality been at all times follow- ed, not only in respect to amputations in cases of gunshot wounds, but all other severe local injuries. " I believe it to be (says Mr. Guthrie) a stretch of fancy in those surgeons who conceive, thai if the knife followed the shot in all cases, the patient would have the best chance of success. No one will deny, that if the shot performed a regular amputa- tion, it would not be better lhan to have it to do afterward ; but if they mean to say tbe ope- ration should in general be performed imme- diately after the injury, I can only oppose to them the facts above stated, and tbe ge- neral result of my experience, which is de- cidedly in favour of allowing the first mo- ments of agitation to pass over before any thing be done ; a period extending from that to one, six, or eight hours, according to the difference of constitution, and the different injuries that have been sustained. Em from one lo three hours will in most cases be found sufficient." (On Gunshot Wounds, p. $26, Edit.2, Lond. 1820.) In the fi.-t edition of this gentleman's book, some little want of precision rather concealed his exact mean- ing, with respect lo the period of time which should generally be allowed to transpire be- tween the receipt ofthe injury and the per- formance of amputation; but after all the disposition to controversy upon this point, it appears there is little to fight about, as there is rather a misunderstanding, than a difference of opinion. All acknowledge the advantage of doing the operation imme- diately, when the patient is not foint and depressed by the shock of the accident; all admit the prudence of deferring the use of the knife in other cases until the constitution has revived sufficiently to be capable of bearing the removal of the limb. (See A. C. Hutchinson, Pract. Obs. in Surgery, Svo. Lond. 1816; and his further Observations on the proper period for amputating in Gunthot Wounds, 1817. Qjuarrier, in Med. Chir. Trans. Vol. 8; and Dewar, in Med. Chir. Journ. April, 1819.) As far as my experience goes, when th© necessity of amputation is undoubted, all de- lay is improper beyond the short period, dur- ing which the faintness immediately arising from the injury usually lasts. In the campaign in Holland, 1814, the most successful ampu- tations were those done in the field hospitals directly after the arrival of tbe patients, or rather, as Dr. Hennen has expressed it, with as little delay as possible. " While hundreds are waiting for the decision of the surgeon, he will never be at a loss to select indivi- duals, who can safely and advantageously bear to be operated upon, as quickly as him- self, or assistants, can offer their aid ; but he will betray a miserable want of science in- deed, if, in this crowd of sufferers, he indis- criminately amputates the weak, the terri- fied, the sinking, and the determined. While he is giving his aid to a few of the latter class, encouragement and a cordial will soon make a change in the state of the weakly, or the terrified ; and a longer period, and more active measures, will render even the sinking proper objects for operation.' (On Military Surgery, p. 45, Ed. 2.) It ap- pears from some returns, collected by Mr. Guthrie, that in the peninsula, the compara- tive loss in secondary or delayed operations, and in primary, or immediate amputation?. was as follows :— Secondary. Primary. Upper extremities . . 12 to . . 1 Lower extremities . . 3 to . . 1 The great success attending amputation on the field of battle was also convincingly proved after the battle of Toulouse. Here of 47 immediate amputations,38 were cured, while of the 51 delayed operations, on that occasion, 21 had fatal terminations. (P. 42— 44, Ed. 1.) After the attack on New Or- leans, out of 45 primary amputations, 38 pa- tients recovered, while only 2 of 7 seconda- ry amputations terminated in the preserva- tion of the patients. (Op. cit. p. 294, Ed. 2.'\ OF IMMEDIATE AMPUTATION. When a limb, that has received a gunshot wound, cannot be saved, amputation should be immediately practised The first four and twenty hours, Baron Larrey observes, are the only time that nature remains tranquil. .606 GUNSHOT WOUNDS. (I should say, she does not remain quiet so long,) and we must hasten to take advantage of this period, in order to administer the ne- cessary remedy. In the army, a variety of circumstances make the urgency for amputation still greater. 1. The inconvenience attending the transport of the wounded from the field of battle to the military hospitals, in carriages badly suspended, the jolting of which would produce such disorder in tbe wound, and in the whole body, that most patients would die in the journey, especially if it were long, and the weather either extremely hot or cold. 2. The danger of a long continuance in the hospitals; a danger, which amputation materially diminishes, by changing a gun- shot injury into a wound, that may be spee- dily healed, and reducing the causes of fever, and the hospital gangrene. 3. The cases, in which there is a necessity for abandoning the wounded. In this cir- cumstance, it is of importance to have am- putated, for after the operation, the patients may remain some days without being dress- ed, and the dressings are afterward more easy. Besides, it might often happen, that these unfortunate objects would not meet with surgeons of sufficient skill to do the operation; a circumstance, says Larrey, that we have seen happen among certain nations, whose caravans, for the medical service of the army (ambulances,) are not constructed like those in use with the French. OF CASES, IN WniCH AMPUTATION SHOULD BE DONE IMMEDIATELY. First case. A limb carried away by a can- non-ball, or the explosion of a howitzer, or bomb, requires amputation without any loss of time: the least delay puts the pa- tient's life in danger. In this case, the necessity of the practice is inculcated by M. Faure himself, as well as by Schmucker, Richter, Larrey, Dr. Thomson, and every modern writer up- on gunshot wounds. When a cannon-ball has torn off a limb, amputation ofthe stump should be perform- ed, in order to procure the patient an even, smooth incision, instead ofan irregular, jag- ged, and highly dangerous wound. As the limb has commonly suffered a violent con- cussion, is almost bereft of sense, and power of motion, and the bone frequently has a fis- sure extending some way upward, the ampu- tation is sometimes recommended to be done, if possible, above the nearest joint. Were the operation not done, this kind of injury would require large and free incisions, for the ex- traction of foreign bodies, the shortening of projecting muscles and tendons, aud the dis- charge of abscesses; and as these incisions are likely to occasion at least as much irri- tation as amputation itself, without being productive of equal good, the avoidance even of pain cannot be urged as a reason against the practice. The occasional heal- \nz of such wounds only prove*, that it i« not altogether impossible, in certain in- stances, to effect a cure without amputa- tion. The surgeon can the more readily make up his mind to amputate, as in this case, the operation does not occasion the loss of a limb. As for the place of the inci- sion, no one would be justified in amputa- ting above the knee, when the limb is inju- red at the foot or ankle. The skin has been violently stretched and lacerated ; the muscles have been ruptured and irregularly torn away ; the tendons and aponeuroses lacerated ; the nerves and ves- sels divided and forcibly dragged ; lastly, the bones broken and smashed to a greater or lesser extent. These first effects are fol- lowed by a general, or partial commotion ; by a kind of torpor in the injured part, and a good way above the wound ; by a painful trembling in the remains ofthe member, an event that is singularly afflicting to the pa- tient ; and by a local swelling preceding the erethismus, which quickly shows itself. The hemorrhage, says Baron Larrey, an ac- cident much more to be apprehended than has been supposed, often comes on a few moments after the injury, and if prompt succour were not afforded, would put a pe- riod to the patient's existence. " I can even declare, that had it not been forthe activity of the train of flying surgical carriages, (am- bulances volantes) by means of which the wounded have always been dressed upon the field of battle, many soldiers would have perished from this accident alone." If the operation is not speedily done, pain commences, fever occurs, and the functions of the system become disordered; the irri- tation then increases, and convulsive mo- tions take place. If the patient should not be a victim to these first symptoms, gangrene ofthe stump follows, the fatal consequences of which it is extremely difficult to prevent. After this short exposition, it is ea3y to see, that in this case, amputation ought to be practised immediately, and to delay the operation, and merely apply simple dress- ings, would be affording time for the pre- ceding accidents to arise. At Strasburgh, during the bombardment ofthe fort of Kell, in 1792, three volunteers, says Baron Larrey, had limbs shot off by the explosion of shells: one, an arm ; another, a fore-arm ; and the third, a leg. They were conveyed to the hospital forthe wounded in that town, which was superintended by M. Boy. Several days were suffered to elapse before the amputation was performed; not one of the patients escaped. At Mentz, after the retreat from Frank- fort, several ofthe wounded, who had had limbs shot off, did not have amputation done till some time afterward, and not one of them recovered. At Nice, after the taking of Saourgio, two amputations were practised at the Hospital, No. 2; one of the fore-arm, tbe other of the arm, nine or ten days after the receipt of the injuries : both the patients died. Ar Perpignan, Baron Larrey visited two soldiers, on whom amputation had been done, seven or eirrht days after the receint oUNSHOT WOUNDS. 00? of gunshot injuries in the action of the 14th of July, 1794. One had had a leg shot off, and the other his right arm. Notwithstand- ing Larrey' - utmost cave, he could not save their lives: one died of tetanus; the other of gangrene. In the month of August, 1805, two can- noniers of the guards, in discharging the ar- tillery, had each a hand shot away, and all the forepart of their bodies burnt. These were the two men whose office it was to charge the gun. At the moment when they had just rammed down the wadding on the cartridge, a spark, that had been left unextin- guished, from the neglect to keep the touch- hole closed, set fire to the powder: the ram- rod was violently repelled by the explosion, together with every thing that was situated in ffont of the charge. The rigbt hand of one of the cannoniers was completely torn off, between the (wo phalanges of the car- pus, and thrown more than two hundred paces. The counter shock even threw the man down into the. ditch of the square of the Hdtel des Invalides. The left hand of the other cannonier was torn^way, together with the fore-arm of the^roow-joint, and also forced to a considerable distance. The tendons and muscles sustained vast injury, and the worst symptoms would have occur- red if amputation had not been instantly performed In one case, amputation was done at the wrist ; and in tbe other at the lower third of the arm. The two operations were followed by complete success, although the burns upon the face and chest, in both the patients, were serious and extensive. Second case. When a body, propelled by gunpowder, strikes a limb in such a manner as to smash the bones, violently contuse, la- cerate, and deeply tear away the soft parts, amputation ought to be immediately per- formed. If this measure be neglected, all the injured parts will soon be seized with gangrene: and besides, as Larrey has ex- plained, the accidents which the gravity of the first case produces, will also here be ex- cited. It is only doing justice to the memo- ry of M. Faure lo state, lhat this second case was one which he also particularly instanced as demanding the immediate performance of amputation. (See Prix de I'Acad. Royale de Chirurgie, T. 8, p. 23, Edit. 12mo.) Third case. If a similar body were to car- ry away a great mass of the soft parts, and the principal vessels of a limb, (of tbe thigh, for instance,) without fracturing the bone, the patient would be in a state demanding immediate amputation ; for, independently of the accidents vvhich would originate from a considerable loss of substance, the limb must inevitably mortify. Mr. Guthrie also says, " a cannon-shot destroying (he artery and vein, on the inside (of the thigh) with- out injuring the bone, requires amputation." (P. 185.) When, however, the femoral ar- tery, or vein, is injured by a musket-ball, or small canister-shot, this gentleman recom- mends tying the vessel above and below the wound in it, if the nature of the case be evinced bv bemor-hage. But he believes, that when both vein and artery are injured, amputation is necessary. (P. 186.) With respect to bleeding from the femoral vein, as it may easily be stopped by moderate pressure, the propriety of using any ligature at all is questionable. " An injury of the femoral artery, (ob- serves Mr. Guthrie) requiring an operation, accompanied with fracture of the bone of- the most simple kind, is a proper case for immediate amputation ; for, although many- patients would recover from either acci- dent alone, none would, I believe, surmount the two united, and the higher the accident is in the thigh, the more imperious is the necessity for amputation." (Guthrie on Gunshot Wounds, p. 187.) Fourth case. A grape-shot strikes the thick part of a member, breaks the bone, divides and tears the muscles, and destroys the large nerves, without, however, touching the main artery. According to Larrey, this is a fourth case, requiring immediate ampu- tation. Mr. Guthrie seems to coincide on this point with Larrey: " If a cannon-shot strike the back part of the thigh, and carry away the muscular part behind, and with it the great sciatic nerve, amputation is necessary, even if the bone be untouched, he. In this case, I would not perform the operation by the circular incision, but would preserve a flap from the forepart, or sides, as I could get it, to cover the bone, which should be short." (Guthrie on Gunshot Wounds of the Extremities, p. 184.) Fifth case. If a spent cannon-shot, or one that has been reflected, should strike a mem- ber obliquely, without producing a solution of continuity in the skin, as often happens, the parts which resist its action, such as the bones, muscles, tendons, aponeuroses, and vessels, may be ruptured and lacerated. The extent of the internal disorder is to be examined ; and if the bones should feel, through the soft parts, as if they were smash- ed, and if there should be reason to suspect, from the swelling and a sort of fluctuation, that the vessels are lacerated, amputation ought to be immediately practised. We learn from Larrey, that this is also the ad- vice of Baron Percy. Sometimes, however, the vessels and bones have escaped injury, and the muscles are almost the only parts disordered. In this circumstance, we are enjoined to follow the counsel of De La Martiniere, who recommended making an incision through the skin. By this means, a quantity of thick blackish blood will be discharged, and the practitioner must await events. According to Larrey, such incision is equally necessary in the preceding case, before amputation, in order to ascertain the extent of the mischief vvhich the parts have sustained. It is to such injury, done to internal or- gans, that we must ascribe the death of many- individuals, which was for a long while attri- buted to the commotion produced in the air. (See Ravaton, Traili des Plaies d'Amie*, h Feu 1 (Sua GUNSHOT WOUNDS Although, says Larrey, this opinion has been sanctioned by surgeons of high repute, we may easily convince ourselves of its falsity, if we carefully consider, 1st, the di- rection and course of solid hard bodies, and their relation to the air, through which they have to pass; 2dly, the internal disorder, observable in the dead bodies of persons, whose death is imputed to the mere impres- sion of the air, agitated by the ball; 3dly, the properties of the elastic substances, such as the integuments, cellular substance, he. struck by the shot. It is universally agreed among philoso- phers, that a solid body, moving in a fluid, only acts upon a column of this fluid, the base of which column is nearly equal to the surface which the solid body presents. (See Le Vather sur quelques particularitis con- cernant les playes faites par armes h feu, in Mim. de I'Acad. de Chirurgie, T. 11, p. 34, Ed. 12mo.) Thus a cannon-ball, in traversing a space equal to its diameter, can only displace a portion of air, in the relation of 3 to 2, com- pared with the size of the shot. This fluid, in consequence of its divisibility and homo- genealness with the ambient air, is disper- sed in all directions, and confounded with the total mass of the atmosphere. The effects of this aeriform substance amount to no- thing, and not a doubt can be entertained, that if there is the slightest solution of con- tinuity of any part of the body, it must de- pend upon the direct action of the ball itself. Tf, besides, the quickness of tbe motion of a ball be considered, which quickness is known to diminish in an inverse ratio to the squares of the distance, it will be seen, that the space through which the shot has pass- ed, before striking the object against which it was directed, will already have materially lessened the celerity ofthe projectile, while the motion of the column of air must be totally lost. The different movements which the ball describes in its course, and the elasticity of the skin, enable us to explain how internal injuries are produced, without any external solution of continuity, and often even with- out ecchymosis. The motion, communica- ted to the ball by the power which projects it, is, for a giv«n space, rectilinear If, at this instance, it strikes against the body, it carries the part away to an extent propor- tioned to the mass with which it touches the part. But the ball, after having traversed a certain distance, undergoes, in consequence ofthe resistance of the air, and the attrac- tion of gravity, a change of motion, and now turns on its own axis, in the diagonal direction. If the shot should strike any rounded part of the body, towards the end of its course, it will run round a great portion ofthe cir- cumference of the part, by the effect of its curvilinear movement. It is also in this manner, observes Larrey, that the wheel of a carriage acts in passsing obliquely over the thigh, or leg, of an individual stretched upon the ground. In this case, the results are the same as those of vvhich we have been speak- ing. The most elastic parts yield to the im- pulse of the contusing body ; while such as offer resistance, as, for instance, the bones, tendons, muscles, and aponeuroses, are fractured, ruptured, and lacerated. For the same reason it sometimes happens, that the viscera are similarly injured. At first sight, all the parts appear to be entire ; but a careful examination will not let us remain long in doubt about the inter- nal mischief. In this case, an ecchymosis cannot manifest itself outwardly, because the vessels ofthe skin, which communicate with the internal parts, are ruptured, be- cause the extravasation of blood naturally takes place in the deep excavations occa- sioned by the rupture of the muscles and other parts, and because this fluid cannot make its way through the texture of the skin. Such extravasations can only be de- tected by the touch. The foregoing reasoning is supported by experience. How often, says Larrey, have we not seen thpjfrall carry away pieces of helmets, hats, CTn-tridge-boxes, knapsacks, or other parts of the soldier's dress, without doing any other injury ? The same ball, perhaps, takes off his arm, often at a time when it is closely applied to the body of his comrade, and yet the latter does not re- ceive the slightest harm. The shot may pass betwixt the thighs, and these mem- bers hardly exhibit an ecchymosis at the points, which are gently grazed; the only example in vvhich ecchymosis does occur. In other instances, the hall severs the arm from tbe trunk, and the functions ofthe tho- racic viscera are not at all injured. Baron Larrey then relates the following case, which is analogous to one which I saw near Antwerp, and have already men- tioned in the foregoing columns. M. Me- get, a captain, marching in the front of a square of men, in the heat of the battle of Altzey, 30th March, 1793, had his right leg almost entirely carried away by a large can- non-shot, without the contiguous limb of his lieutenant, who was as close as possible to him, receiving the least injury. The vio- lent general commotion excited, and the ex- treme severity of the weather, made this officer's condition imminently perilous. The progress of the symptoms, however, was checked by amputation, which was instantly performed. M. Meget was then capable of being conveyed to the hospital at Landau, fifteen leagues from the field of battle, where he got quite well. Larrey declines relating numerous other analogous Amputations, which he has been called upon to practise under the same cir- cumstances. M. Buffy, a captain of the ar- tillery of the army of the Rhine, was struck by a howitzer, his left arm being injured, and his head so nearly grazed, that the cor- ner of his hat, vvhich was placed forwards over his face, was shot away as far as the crown. This officer, the skin of whose nose was even torn off. was not deprived of hi-- GUNSHOT WOUNDS. 609 senses, and be was actually courageous enough to continue for some minutes com- manding his company. At length he was conveyed to Larrey's ambulance, who am- putated his arm.- in about a month, the pa- tient was well. Larrey expresses his belief, that what have been erroneously termed wind contusions, if attended with the mischief above specified, require immediate amputation. The least delay makes the patient's preservation ex- tremely doubtful. The internal injury of the member may be ascertained by the touch, by the loss of motion, by the little sensibility retained by the parts, which have been struck; and lastly, by practising an inci-jion, as already recommended. In order to confirm the principle which he endeavours to establish, in opposition to mar.y writers, Larrey indulges himself with the follow ing digression. At the siege of Roses, two cannoniers, having nearly similar w ounds, were brought from the trenches to the ambulance, which Baron Larrey had posted at the village of Palau. They had been struck by a large shot, which, towards the termination of its course, had grazed posteriorly both shoul- ders. In one, Larry perceived a slight ecchymosis over all the back part of the trunk, without any apparent solution of continuity. Respiration hardly went on, and the man spit np a large quantity of frothy vermilion blood. The pulse was small and intermitting, and the extremities were cold. He died an hour after the acci- dent, as Larrey had prognosticated. This gentleman opened the body in the presence of M Dubois, inspector of the military hos- pitals ofthe army of the eastern Pyrenees. The skin was entire; the muscles, aponeu- roses, nerves, and vessels of the shoulders were ruptured and lacerated, the scapulae broken in pieces, the spinous processes of the corresponding dorsal vertebrae, and the posterior extremity of the adjacent ribs fractured. The spinal marrow had suffered injury; the neighbouring part of the lungs was lacerated, and a considerable extrava- sation had taken place in each cavity of the chest. The second cannonier died of similar symptoms, three quarters of an hour after bis arrival at the hospital. On opening the body, the same sort of mischief was disco- vered as in the preceding example. In the German campaigns of the French armies, Larrey met with several similar cases, and accurate examination has invariably convinced him of the direct action of a spherical body, propelled by means of gun- powder. Sixth case. According to Baron Larrey, when the articular heads are much broken, especially those vvhich form the joints of the foot, or knee, and the ligaments, which strengthen these articulations, are broken and lacerated by the fire of a howitzer or a grapeshot, or other kind of ball, immediate amputation is indispensable. The same in- dication would occur, were the ball lodged l7!>r L in the thickness of the articular head of a bone, ov were it so engaged in the joint, as not to admit of being extracted by simple and ordinary means. (See also Guthrie on Gunshot Wounds, p. 197.) Fractures extending into the joints, and accompanied with great laceration of the li- gaments, were cases of gunshot injuries pointed out by M Faure, as indispensably requiring immediate amputation. (See Prix de I'Acad. de Chir. T. 8.) Thus we see, that this author was not so averse to early ampu- tation as several modern writers have repre sented. It is only in tbis manner that the patients can be rescued from the dreadful pain, the spasmodic affections, the violent convul- sions, the acute fever, the considerable ten- sion, and the general inflammation of the limb, which, Larrey observes, are the inva- riable consequences of bad fractures of the large joints. But, adds this author, if the voice of experience be not listened to, and amputation be deferred, the parts become disorganized, and the patient's life is put in to imminent peril. It is evident, says he, that, in this case, if we wish to prevent the patient from dying of the subsequent symptoms, amputation should be performed before twelve, or at most twenty-four hours, have elapsed: even M. Faure himself professed this opinion in regard to certain descriptions of. injury (Mim. de Chir. Militaire, T. 2.) With respect to wounds of the knee, the sentiments of Mr. Guthrie nearly coincide with those of Larrey. " I most solemnly protest (says Mr. G.) I do not remember a case do well, in which I knew the articula- ting end of the femur, or tibia, to be frac- tured by a ball that passed through the joint, although I have tried great numbers, even to the last battle of Toulouse. I know- that persons, wounded in this way, have lived; for, a recovery it cannot be called, where the limb is useless, bent backward, and a constant source of irritation and dis- tress, after several months of acute suffering, to obtain even this partial security from im- pending death ; but, if one case of recovery should take place in fifty, is it any sort of equivalent for the sacrifice of the other forty- nine ? Or is the preserving of a limb of this kind an equivalent for the loss of one man - (On Gunshot Wounds, p. 196.) In the attack of the village of Merksam near Antwerp early in 1814, a soldier of the 95th regiment was brought to our field hos- pital, having received a musket-ball through the knee-joint. The staff surgeons on duty, and Mr. Curtis, surgeon of the 1st guards, were preparing to amputate the limb, when a surgeon, attached to the 95th, urgently re- commended deferring the operation. Su- perficial dressings were applied, and the pa- tient sent to the rear. He lived several months after the accident, at times affording hopes of a perfect recovery ; but, in the end. he fell a victim to hectic symptoms. Indeed such is th" gener?! unfortiina'i 610 GUNSHOT WOUND* result of these cases, that, Dr. Hennen lays it down as a law of military surgery, tbat no lacerated joint, particularly the knee, ankle, or elbow, should ever leave the field un- amputated, where the patient is not obvi- ously sinking. (On Military Surgery, p. 41, Ed. 2) According to Mr. Guthrie, fractures of the patella, without injury of the other bones, admit of delay, provided the bone is not much splintered. Seventh case. Larrey observes, that if a large biscayen, a small cannon-shot or a piece of a bomb-shell, in passing through the substance of a member, should have ex- tensively denuded the bone, without break- ing it, amputation is equally indicated, al- though the soft parts may not appear to have particularly suffered. Indeed, the violent concussion, produced by the accident, has shaken and disorganized all the parts; the medullary substance is injured, the vessels are lacerated, the nerves immoderately stretched, and thrown into a state of stupor; the muscles are deprived of their tone ; and the circulation and sensibility in the limb are obstructed. Before we decide, however, Buron Larrey cautions us to observe atten- tively the symptoms, vvhich characterize this kind of disorder. The case can be sup- posed to happen only in the leg, where the bone is very superficial, and merely covered at its anterior part with the skin. The following are described as the symp- toms : the limb is insensible, the foot cold as ice, the bone partly exposed, and on careful examination, it will be found thai the integu- ments, and even the periosteum, are exten- sively detached from it. Ihe commotion extends to a considerable distance; the functions of the body are disordered ; and all tbe secretions experience a more or less palpable disturbance. The intellectual fa- culties arc suspended, and th> circulation is retarded. The pulse is small and concen- trated ; the countenance pale ; and the eyes have a dull moist appearance. The patient feels such anxiety, that he cannot lona re main in one posture, and requests, tbat his leg may be quickly taken off, as it incom- modes him severely, and he experiences very acute pain in the knee. When all these characteristic symptoms are conjoined, says Larrey, we should not hesitate to am- putate immediately -. for, otherwise the leg will be attacked with sphacelus, and the pa- tient certainly perish Larrey adduces several interesting cases in support of the preceding observations. Eighth case. When a large gynglimoid articulation, such as the elbow, or especially the knee, has been extensively opened with a cutting instrument, and blood is extrava- sated in the joint, Larrey deems immediate amputation necessary. In these cases, the synovial membranes, the ligaments aii-J apo- neurosis inflame, the part swells, and erethismus rapidly takes place ; and acute pains, abscesses, deep sinuses,caries, febrile symptoms, and death, are the speedy conse- quences. Larrey has seen numerous sub- jects die of such injuries, on account ot the operation having been postponed through a hope of saving the limb. In his Memoires de Chirurgie Militaire, Tom. 2, some of these are detailed. Although a wound may penetrate a joint, yet, if it be small and unattended with ex- travasation of blood, M. Larrey informs us, it will generally heal, provided too much compression be not employed. This gentle- man believes in the common doctrine of the pernicious effect of the air on the cavities of the body ; yet, in this place, a doubt seems to affect him : speaking of the less danger of small wounds of joints, be says ; " a quoi tientcette diffirence,puisque Pair pinilre dan* I'articulation dans Pun comme dans I'autre cas f" When two limbs have been at the same time so injured, as to require amputation, we should not be afraid of amputating them both immediately, without any interval. We have, sp.ys Larrey, several times per- formed this double amputation, with almost as much success, as of the amputation of a single member. He has recorded an excel- lent case in confirmation of this statement. (Mini, de Chir. Militaire, T. 2, p.478.) When a limb is differently injured at the same time in two places, and one of the wounds requires amputation, (suppose a wound of the leg with a splintered fracture of tbe bone, and a second of the thigh, done with a ball, but without any fracture of the os femoris, or other bad accident) Lar- rey recommends us, first to dress the simple wound of the thigh, and amputate the leg immediately afterward, if the knee be free from injury. When it is necessary to am- putate above this joint, ihe less important wound need not be dressed, till after the operation, provided it can be comprehended in the section of the member, or be so near the place ofthe incision as to alter the indi- cation. When the wound, demanding am- putation, is the upper one, the operation of course is to be done above it, without pay- ing any regard to the injury situated lower down. Ninth case. To the foregoing species of gunshot wounds, pointed out by Baron Lar- rey as urgently requiring immediate amputa- tion, my own experience, and the observa- tions of Dr. Thomson, justify me in adding compound fractures of the thigh from gun- shot violence. I am particularly glad, that the latter gentleman has devoted a proper degree of attention to these cases , for, the opportunities which I had of judging when abroad, incline me to believe, that military surgeons are hardly yet sufficiently impress- ed with the propriety of immediate amputa- tion in gunshot fractures of the thigh. There were brought into my hospital at Ouden- bosch in 1814, about eight of such cases, all in the worst state for an operation, because several days had elapsed after the receipt of the injuries. All these patients died, es> cepting one, whose fracture was not far above the condyles, and I do not know, that he ever regained a very useful limb. An- GUNSHOT WOUNDS. 611 other had indeed been rescued by amputa- tion from the dangers of the injury; but was unfortunately lost by secondary hemor- rhage about three days after the operation. The bleeding was almost instantly suppress- ed ; yet, such was the weakness of tiie pa- tient, that the irritation of securing the ves- sel, and the loss of blood together destroyed at once every hope of recovery. Were I to judge, then, from my own personal observa- tions in the army, and from some other cases, which I saw under my colleagues, I should without hesitation recommend immediate amputation in all cases of compound frac- tures of the thigh, caused by grape-shot, musket balls, he. If there are any excep- tions to this advice, they are such as are specified in the article Amputation. " Gunshot fractures of the thigh (says Dr. J. Thomson) have been universally allowed to be attended with a high degree of danger ; indeed, till of late years, very few instances have been recorded of recovery from these injuries. Ravaton acknowledges, that, in his long and extensive experience, he had never seen an example of recovery from a gunshot fracture of the thigh ; and Bilguer, in his calculations, with regard to those, who recover from gunshot fractures, sets aside those of the tbigb-bone, as being of a nature altogether hopeless. In the present im- proved state of military surgery, instances not unfrequently occur of recovery from this fracture : but, of these, the number will be found, I believe, to be exceedingly small, in comparison with those who die, particu- larly when the fracture has had its seat above the middle of the bone," he. According to the observation of Percy, scarcely two of ten recover of those, who have suffered gunshot fractures of the thigh- bone. Mr. Guthrie, who seems to have paid greater attention to this subject, than any preceding author, says, that " upon a review of the many cases, vvhich I have seen, I do not believe, that more than one- sixth recovered, so as to have useful limbs; two-thirds of the whole died either with or without amputation ; and the limbs of the remaining sixth, were not only nearly use- less, but a cause of much uneasiness to them for the remainder of their lives." (See Guthrie on Gunshot Wounds, p. 19.) " In fractures by musket bullets of the lower part of the thigh-bone (says Dr. Thomson) recovery not unfrequently takes place ; and both Schmucker and Mr. Guth- rie conceive, that they are injuries in which amputation may be delayed with safety It would be very agreeable, that this opinion should be confirmed by future ex- perience ; but, it appears to me, that before it can be received as a maxim in military surgery, much more extensive and accurate observation, than we yet possess, will be re- quired with regard to the proportion of those who recover without amputation, or after secondary operations, and of those who recover after primary amputation. Of those who had suffered this injury, we saw, comparatively, but a small number recover- ing jn Belgium, and they had been attended with severe local and constitutional symp- toms." See Report of Observations made in the Military Hospitals in Belgium, p. 247, et seq. !n the article Amputation, I have descri- bed the manner in which balls produce fis- sures of several inches in length in the thigh- bone This state ofthe bone, observes Dr. Thomson, must be very unfavourable to re- covery, and his conclusion is. that, in gene- ral, even in fractures of the lower part of the thigh-bone a greater number of lives will be preserved, in military practice, by immediate amputation, than by attempting the cure without that operation. " When the bone appears on a careful examination, to be broken without being much splintered, and when the patient can be removed easily to a place of rest and safety, it may be right. to attempt to preserve the limb; but if the bone be much splintered, or if the con- veyance is to be long, or uncertain, it will, in most instances, I am convinced, be a much safer practice, even in fractures of this part of the thigh-bone, to amputate without delay. " Musket bullets, in passing through the femur, near to the knee-joint, produce fis - sures of the condyles, which generally communicate with the joint. These cases, like those in which the bullets have passed directly through the joint, require immedi- ate amputation. "The writings of military surgeons con tain but few histories of cases, in which the thigh bone had been fractured above its middle by the passage of musket bullet?. These are cases, I believe, which have gene- rally had a fatal termination ; and the dan- ger, attendant upon the amputation, vvhich they require, seems long to have deterred surgeons from attempting to ascertain what advantages might be derived from the em- ployment of that operation. Schmucker re- commends, and states, that he had practised with success, immediate amputation in those cases, in vvhich a sufficient space was left below the groin for the application of the tourniquet. It is curious to remark, in the history of amputation, how long surgeons were in discovering the ease and safety, with vvhich the femoral artery maybe compressed by the fingers, or pads, in its passage over the brim of the. pelvis. Boy, from the im- mediate danger, protracted suffering, and ultimate want of success, which be had ob- served to follow this kind of injury, urges strenuously- tbe propriety of immediate am putation : Mr. Guthrie's opinion, with re- gard to the dangerous nature of these in- juries, and the advantages to be derived in them from immediate amputation, coincides in every respect with those of Schmucker and Boy He observes, that, those whose thigh bone has been fractured in its upper part by a musket bullet, generally die with great suffering, before the end of the sixth, or eighth week ; and that few even of those escape, in whom that bone has been frac- tured in its middle part. Of the few whom r»12 GWNSHOT WOUNDS. we saw, who had survived gunshot fractures in the upper part of the thigh-bone in Bel- gium, scarcely any one could be said to be in a favourable condition. In all, the limbs were much contracted, distorted, and swol- len, and abscesses had formed round and in the neighbourhood of the fractured extremi- ties of the bones. In some instances, these abscesses had extended down the thigh ; but, more frequently, they passed upwards, and occupied the region of the hip-joint and buttocks. In several instances, in which incisions had been made for the evacuation of matter, the fractured and exfoliating ex- tremities of the bones sometimes comminu- ted, and sometimes forming the whole cy- linder, could be felt bare, rough, and exten- sively separated from the soft parts, which sorrounded (hem. In other instances, these extremities were partially enclosed in depo- sitions of new bone, which, from the quan- tity thrown out, seemed to be present in a morbid degree. It was obvious, that, in all of these cases, several months would be required for the reunion of the fractured ex- tremities; that, in some, much pain and misery were still to be endured from the processes of suppuration, ulceration, exfolia- tion, and ejection of dead bone; that in some cases, the patients were incurring great danger from hectic fever, and from diarrhoea; that the ultimate recovery in most of them was doubtful, and that of those in whom this might take place, there was but little probability, that any would be able to use their limbs! The sight of these cases (says Dr. Thomson) made a deep im- pression upon my mind, and has tended to increase my conviction, that this is, of all others, the class of injuries, in which imme- diate amputation is most indispensably re- quired." (See Report of Obsenmtions made in the Military Hospitals in Belgium, p. 254— 258.) Dr. Thomson adds, that what has been said ofthe danger of fractures, produced by musket bullets, in tiie upper part of tbe fe- mur, is true in a still greater degree of those which have their seat in the neck or head of that bone. In such instances, Dr. Thom- son joins the generality of modern army surgeons in strongly recommending ampu- tation at the hip-joint; a subject, of which I have already spoken. (See Amputation.) PF GUNSHOT WOUNDS, IN WHICH AMPUTA- TION MAY BE DEFERRED. If, says Baron Larrey, it he possible to specify the cases, in which amputation ought to be immediately performed, it is impossi- ble to determine a priori those, which will require (he operation subsequently. One gunshot wound, for example, will be cured by ordinary treatment, while another, that is at first less severe, will afterward render amputation indispensable, whether this be Owing to the patient's bad constitution, or the febrile complaints, which are induced. However this may be, the safe rule for ful- filling the indication, that presents itself, is to amputate consecutively only in circum stances, in which every endeavour to save the limb is manifestly in vain. Upon this point, Larrey's doctrine differs from that of Faure. The latter practitioner admits cases, which he terms cases of the second kind, in which he delays amputation, not with any hope of saving the limb, but in order to let the first symptoms subside. The operation, done between the fifteenth and twentieth day, ap- pears to him less dangerous, than when performed immediately after the receipt of the injury. At the above period, according to M. Faure, the commotion, occasioned by the gunshot injury, is dispelled; the patient can reconcile himself to amputation, the mere mention of which fills the pusillani- mous with terror in a greater or lesser de- gree ; the debility ofthe individual is no objec- tion ; and it is laid down as an axiom " that the consequences of every amputation, done in the first instance, are in general extremely dangerous." In support of this theory, M. Faure adduces ten cases of gun- shot injuries, in which, after the battle of Fontenoy, the operation was delayed, in order that it might afterward be performed with more success : a plan, which, accord- ing to the author, proved completely suc- cessful. (See Prix de I'Acad. de Chirurgie, Tom. 8, Edit, in 12mo.) This division of the cases for amputation in two classes, not consistent with nature, Larrey conceives, has been the cause of a great deal of harm. Very often the parti- sans of M. Faure have not dared to resort in the first instance to amputation, the dan- gers of which they exaggerate; while on other occasions, they amputate consecu- tively without any success. Larrey, after arguing that the effects of commotion, instead of increasing, gradually diminish and disappear after the operation, ventures into some hypothesis about the proximate cause ofthe ill effects of commo- tion, which, as being wild and unsatisfac- tory, I shall not here repeat. Baron Larrey will not even admit, that the patient's alarm ought to be a reason for postponing the operation ; because the pa- tient, just after the accident, will be much less afraid ofthe risk, which he has to en- counter, than at the expiration of the first four and twenty hours, when he has had time to reflect upon the consequences ofthe injury, or of amputation; a remark made by the illustrious Pare. " Experience, agreeing with my theory, (says Baron Larrey) has proved both to the army and navy surgeons, that the bad symptoms which soon follow such gunshot injuries, as must occasion the loss of a limb, are much more lo be dreaded, than those of immediate amputation. Out of r vast num- ber of the wounded, who suffered amputa- in the course of the first fonr and tr-enty hours after the memorable Lattle of the first of June, 1794, a very fe> lost their lives. This fact bas been attested by several of om GUNSHOT WOUNDS. 613 colleagues, and especially by M. Fercoc, surgeon of the ship le Jemmappe. The following is said to be an extract from one of his letters. ft After the naval engagement on the first of June. 1794, «: great number of amputa- tions were done immediately after the re- ceipt of the injuries. Sixty of the patients, whose limbs had been thus cut off, were taken to the naval hospital at Brest, and put under the tare of M. Ouret. With the ex- ception of two, who died of tetanus, all the rest were cured; and there was one, who had both his arms amputated. The surgeon ofthe Timiraire, which ship was captured byth-j English, >vas desirous, in compliance with the advice of their medical men, to defer the operation, which many of the wounded stood in need of, till his arrival in port; but, he had the mortification to see them all die during the passage, he." Larrey next acquaints us, that, when he was sent to the army of Italy, in 1 796, he had also the pain of seeing, in the hospitals, great numbers of the wounded fall victims to the confidence, which many of the sur- geons of that army placed in the principles of M. Faure. General Bonaparte saw that the ambulance volante was the only thing, that, in the event of fresh hostilities, could prevent such accidents, and, in conse- quence of his orders, Larrey formed the three divisions d'ambulance which are des- cribed in his Memoires de Chirurgie Mili- taire. Since this period it has always been cus- tomary in the French armies, on the day of battle, to make every preparation for per- forming amputation as speedily as possible. The mere sight of these ambulances, (always attached to the advanced guard,) says M. Larrey, encourages the soldiers, and inspires them with the greatest courage. On this occasion, the following anecdote is cited from Ambroise Pare. This famous surgeon having been urgent- ly sent for by the Duke de Guise besieged in Metz, to attend the wounded of his army, who were in want of assistance, Ambroise Pare was shown to the frightened soldiers at the breach. Upon this, they immediately filled tbe air with shouts of the most lively joy, and cried out: " Nous ne pouvons phis mourir, s'il arrive que nous soyons blessis, puisque Pari est parmi nous." Their cou- rage revived, and their confidence in this skilful surgeon, contributed to the preserva- tion of a place, before which a formidable army was destroyed. Larrey desires us to interrogate the inva- lids, who have lost one or two of their limbs, and nearly all will tell us. that they suffered amputation a few minutes after the accident, or in the first four and twenty hours. " If Faure now retains any partisans," says Larrey, *' I recommend them to repair to the field of battle, the day after an lction ; they would then soon be convinced, that, without the prompt performance of amputa- tion, great number of soldiers must inevita- bly lose their lives. In Egypt, tbis truth was particularly manifested." The following communication upon this point was made to Baron Larrey by M. Masclet, a French surgeon on duty at Alex- andria. " In the naval hospital of this port, I have seen eleven soldiers, or sailors, who were wounded in the naval action off Aboukir, and who had suffered amputation in the first four and twenty hours. In five of these cases, the operation hud been done on the arm ; in two. on the thigh; and in three others on the leg. All these men are reco- vering. In the army hospital, there have been only three thigh amputations, which we performed seveji or eight days after the battle, and these three patients died a few days after the operation, although the opera- tion was done methodically, and no grave symptoms prevailed at the time of its per- formance. You see, sir, experience has, in this instance, quite confirmed your princi- ples." In 1780, during the American war, we are informed by Larrey tbat the surgeons of the French army performed a great number of amputations, according to the opinion then generally adopted in France, that the operation should not be undertaken till after the subsidence of the first symp- toms. Almost all tbe patients, thus treated, died after the operation. On the contrary, the Americans, who had the boldness to amputate immediately (or in the first twen- ty-four hours) upon many of their wounded countrymen, lost only a very few. Yet, M. Dubor, at that time surgeon to the Artois dragoons, and from whom Larrey has col- lected this fact, relates, that the situation of the hospital for the French wounded was, on many accounts, the most advantageous. (Dubor These Inaugurate soutenue 16 Sept. 1803, a I'Ecole de Slrasburg.) Admitting that, by a concurrence of for- tunate circumstances, which are not always to be calculated upon, some patients escape the danger ofthe first symptoms, as Larrey remarks, this proves nothing in favour of doing the operation afterward : it must be seen what nature will do towards the event. ofthe case. If, at the end of twenty, or thirty days, the prognosis is as bad as it was previously, amputation cannot be avoided. Thus all the sufferings, which the patient has endured, have been undergone for nothing, and the operation will now be attended with con- siderable risk, inasmuch as tiie patient may lie in a dangerously weakened state. If nature revives at all, no doubt the suc- cess of the operation becomes more proba- ble ; but, in this case, the surgeon, instead of having recourse to amputation, should redouble his efforts to preserve the limb. CASES DEMANDING AMPUTATION CONSECl • TIVELY. Upon this subject Larrey gives us the an nexed information. 614 GUNSHOT WOUNDS. First case. A spreading Mortification. If the disorder be owinj; to an internal and general cause, it would then be rashness in the surgeon to amputate before nature had put limits to the disease. Larrey describes this kind of gangrene, as being distinguished from that, vvhich is named traumatic, by the symptoms which precede and accompany it. These- symptoms are similar to those which are observed in nervous ataxia, or adynamia. Here the operation ought to be deferred, and endeavours made to combat the general causes with regimen and inter- nal medicines. But, when the gangrene is traumatic, Larrey advises (be limb to be immediately cut off above the disorganized part Several facts in support of this doctrine, are related by this experienced surgeon in his Mimoire sur la Gangrene Traumatique. (See Mortifi- cation.) In that part of the dictionary will be found several additional observations, in favour of the practice adopted and recommended by Larrey, which is so opposite to that incul- cated by Sharp, Pott, and the generality of writers. In the article Amputation, I have noticed a particular case of g-ngrene, which has been pointed out by Mr. Guthrie, as demand- ing the early performance of amputation, and a deviation from the old rule of waiting till the mortification ha ceased to spread. (See Guthrie on Gunshot Wounds of the Extremi- ties, p. 63, ^ c.) Second case. Convulsions of the wounded Limb. It is one ot Larrey's doctrines, (though of a very questionable description,) that amputation of the member, performed immediately the fir«t symptoms of tetanus manifest themselves, interrupts all communi- cation between ihe sourci- of the disorder. and the rest of Ihe body. H<- stales, that (he operation unload- the vesseU, and ihus puts a stop to the tension of the nerves, and to the convulsions of the muscles. These first effects, be says, are followed by h general col- lapsus, whicb promotes ihe excretions, sleep, and tbe equilibrum of every part of the sys- tem. H" argues, thai the whole of the mo- mentary pain cause.I by the operation, can- not increasethetxistiug irritation: besidrsthe sufferings of tetanus rendt-r those of amputa- tion more bearable, and lessen their intensi- ty, especially when the principal nerves of the limb are strongly compressed. So;ne observations will be made on this proposal in the article Titanus. Third cai>e. Bad State of the discharge. It olti-u happens, that in gunshot wounds, complicated wiih fractures, notwithstanding the most skilful treatment, ih<- dis. harge be- comes of a bad quality ; (h- fragmt nts of bone lie suirounded with the matter and have not the least tendency (o unile ; (he patient is attacked with hectic fever, and a colliquative diarrhoea. Under these circum- stances, life may sometimes be preserved by amputation. Forth case. Bad State of the Stump. In hospitals, as Baron Larrey observes, the cure of amputations is sometimes prevented by a fever of a bad character. The stump swells, the integuments become at first retracted, and then reverted and diseased a good jvay upward. The wound changes into a fungous ulcer, the cicatrization of which is hindered by the deep disorder of the bone, and the ulceration of Ihe soft parts. The extremity of the bone projects. In order to remedy this last evil, it has been proposed to snvv off the projecting part of the bone, and with this, even to amputate all the flesh beyond the level of the skin. Larrey condemns such practice, as unnecessary and dangerous, nnd he recommends giving nature time to effect the exfoliation of the diseased pro- jecting part of the bone, and hi al the wound. (See Memoires de Chir. Militaire, T. 2.) GUNSHOT WOUNDS OF THE ABDOMEN. These cases may be divided into two kinds; one only penetrates the parietes of the belly, without hurting tbe contained parts; the other does mischief also to the viscera. The event of these kinds of wounds is very different. In the first, little danger is to be expected, if properly treated ; but, in the second, the success will be extremely uncertain, for in many instances, nothing can be done for the patient, and on other occa- sions, a good deal of art may be employed with advantage. It is observed by Mr. Hunter, tbat such wounds of the abdomen, as do not injure parts like tiie stomach, intestines, bladder, ureters, gall-bladder, large blood-vessels, he. all which contain particular fluids, will gene- r dly end well. But he adds, that there will be a great difference, when the bHI hus pass- ed with immense velocity, as a slough will be produced ; whereas, when the ball bas moved with less impetus, there will not be so much sloughing, and the parls will, in some degree heal by the first intention. Even when tbe ball occasions a slougb, the wound frequently terminates well, (he ad- hesive inflammation taking place on the pe- ritoneum, all round (he wound, so as to ex- clude the general cavity of the abdomen from taking part in the inflammation. Such is often the favourable event, when the ball, besides entering the abdomen, has wounded parts like the omentum, mesentery, he Bnd gone .|uiie through the body, (Hunter on Inflammation; Gunshot Wound*, fa. p. 543.) In gunshot wounds of (he belly, an extra- vasation is apt to lake place on (he sloughs becoming loose, about eit-hl, ten, twelve, or fourteen days alter ihe accident ; but, says Mr. Hunter, although (his new symptom is in general ve■•> disagreeable, naost of (he danger i^ usuallv over, heiore if can appear. In the article Wounds, I have detailed at large the general principles, which should be observed in the treatment of wounds of the the belly; consequently, it would be super- fluous here to go over the vvho'e of this ex- tensive subject again. As a modern writer observe^. " In their (reafnient. the violence GUNSHOT WOUNDS 615 of symptoms is to be combated more by general means, than by any of the mechani- cal aids of surgery. The search fiorextrane- ous bodies, unless superficially situated, is altogether out of the question, except they can be felt by the probe, as in Ravaton'* case, (Chir d'Armie, p. 241)y) or in other cases of lodgment in the bladder, where they may become the object of secondary opera- tions. Enlargement, or contraction of the original wound, as the case may require, for returning the protruded intestine, securing the intetine itself, and promoting the adhe- sion of the parts, are all thai the surgeon has to do in the way of operation ; and even in this, the less be interferes the belter Nature makes wonderful exertions to relieve every injury inflicted upon her, and they are often surprisingly successful, if not injudiciously interfered with. In a penetrating wound of the abdomen, whether by gunshot, or by a cutting instrument, if no protrusion of in- testine take place, (and this it must be ob- served, in musket or pistol wounds rarely occurs,) the lancet, with its powerful conco- mitunts, abstinence and rest, particularly in the supine posture, are our chief dependence. Great pain and tension, vvhich usually ac- company these wounds, must be relieved by leeches to the abdomen, (if they can be pro- cured) by topical application of fomenta- tions, and the warm baih ; and, if any inter- nal medicine is given as a purgative, it must, for obvious reasons, be of the mildest na- ture. Tbe removal of the ingesta, as a source of irritation, is best effected, by frequently- repeated ole ginous clysters -," (see Hen- nen's Principles of Military Surgery, p. 401. Ed. 2.) and with respect to dressings, as the same author has observed, concerning cases, in which a ball has passed directly through tbe abdomen, the mildest applications should be employed, and no plugging with tents, nor introduction of medicated dressings thought of. (P. 406.) In this publication may be found cases, in which musket balls were passed by stool; (p. 404,) in which an artificial anus was formed ; (p. 407, fa.) or the kidneys, liver, (p. 430—432,) diaphragm, (p. 437,) and other viscera, injured. The following case exhibiting the possi- bility of recovery, though the small intes- tine be completely severed with a ball, is in- teresting, particularly as rases of this kind have been regarded as positively fatal. The success was also obtained, notwithstanding the treatment appears to have been rather too officious, especially in regard to four in- cisions made in the end of the bowel, when one would have removed the constriction spoken of. At the assault of Cairo, 1799, M. N. was shot in the abdomen with a ball, which divi- ded the muscular parietes of this cavity, on the right side, and a portion of Ihe ileum. Laney being upon the field of battle, gave him the first assistance. The two ends of the intestine protruded in a separated and infla- ted state. The upper end was everted, in such a way that its contracted edge, like the prepuce in a case of paraphymosis, strangula- ted (he intestinal tube. The course of the feces was thus obstructed, and the contents of (he bowel accumulated above the con- striction. Although the patient's recovery was nearly hopeless, both from the nature of Ihe wound, and from the debility and cholera morbus, which had already seized him in the short period thai he remained without succour in one of the entrenchments, Larrey was de- 'irous of trying what could be done for so singular a rase. He first made four small cuts, through the constricted part of intes- tine, with a pair of curved scissors, and put the bowel into its ordinary state. He passed a ligature through the piece of the mesen- tery, corresponding to the two extremities of the bowel. Tbjse be reduced as far as Ihe margin of the opening which he had taken care to dilate, and the dressings having been applied, he awaited events. The first days were attended with alarming symptoms, i\ hich, however, afterward subsided. Those which depended upon the loss of the alimen- tary matter, successively abated ; and, after two months, the ends of the ileum were op- posite, lo ea< h other, and disposed to become connected (ogether. Larrey seconded the efforts of nature, and dressed tbe patient with a tampon, or sort of tent, that was oc- casionally employed for two months. Tbe patient was then discharged from the hospi- tal quiie cured. In several instances, says Larrey, the sig- moid flexure of the colon was injured, and yet the wounds were cured without any fe- cal fistulas. At tbe siege of Acre, three ex- amples occurred ; and at lhat of Cairo, two. Larrey dilated the entrance and exit of the bdl. Clysters, made of the decoction oi linseed, and emollient beverages were fre- quently exhibited; and the patienls were kept on a low diet, and in the most quiet state. Sword wounds, and those made with the bayonet, or lance, may injure some part of the bladder, or even pass through both sides of this organ. In the latter case, the injury is usually fatal, as the urine escapes from the inner wound into the abdomen, and imme- diately excites mortal inflammation. Baron Larrey dressed on the field of battle several soldiers, whose bladders were thus complete- ly transfixed, and who all perished of inflam- mation and gangrene, within tbe first forty- eight hours. However, he observes, that if the weapon enter the bladder at that part of its fundus, which is not covered by the peritoneum, the case is curable, unless com- plicated with too much internal hemorrhage. The surest criterion of these cases is the escape of the urine from the external wound ; and its discharge may either be momentary, occasional, or continual; differences to be accounted for by tbe situation of the wound, and the change- which happen in the bladder. When the bladder is full, and its upper part is pierced, tbe urine will issue only just at the moment of the accident, and, as soon as it is discharged, the edges of the wound will come together, and permanently close, espe 616 bUNsHOT WOUNDs. cially if the urine can pass freely through tbe natural channel. But when this favour- able condition i- absent, the bladder becomes enormously distended again, tbe wound is opened f new, and the urine discharged once more from tbe external opening. The same things might happen, if one were to with- draw too soon the elastic gum catheter, which has been introduced ; and by introdu- cing the instrument again, the urine might be diverted from the wound, and its natural course re-established. Lastly, Larrey ob serves, that when the wound is situated ut one of tbe lowest points of the bladder, the discharge of urine may be incessant, and be of more or less duration. When the track of: bese punctured wounds is extrusive, and not direct, abscesses form at different points were the urine passes. These abscesses, Larrey directs to be imme- diately opened, and their recurrence prevent- ed by the introduction of an elastc gum catheter through the urethra ; one of the chief means of relief in all wounds of tbe bladder. Together with this treatment, he recommends the warm bath, the application of camphorated oily liniments to the belly, antispasmodic cooling medicines, frequent clysters, and sometimes cupping in the vici- nity of the wound, or bleeding. (See Mem. de Chir. Mil. T. 4, p. 286, 287.) On the last means of relief, it would have been bet- ter if Larrey had laid more stress; for, next to the catheter, tbey are unquestionably the most essential. Baron Larrey informs us, that the gunshot wounds of the bladder, which occurred in Egypt, had for the most part a favourable termination. The most remarkable case was that of F. Chaumelte, a light horseman, who was wounded at the battle of Tabor. The ball passed across the hypogastriuni, about one finger breadth above the pubes, to the point of the left buttock, which cor- responds to the ischiatic notch. The direc- tion of the wound and tbe issue of feces and urine from the two orifices left no doubt, that the bladder and rectum were injured. M. Milioz, who directed the surgical affairs of the division of the army under Kleber, diligently pursued the same kind of treat ment which he had seen Larrey adopt at the siege of Acre. During tbe suppurative stage, the patient was affected with fever; and, after the sloughs were detached, the dis- charge was very copious. A catheter, that was passed into the bladder, prevented an extravasation of the urine, and at the same time, promoted the union of the wound of that viscus. This was healed the first, and the patient, upon his return to Cairo, was quite cured. Larrey has recorded several other inte resting cases of wounds, either of the blad- der alone, or of it and the rectum together, to which I must content myself with refer- ring. (See Mim. de Chir. Militaire, T.2,p. „ 160—165. T. 3, p. 340, fa. T. 4, p. 296, fa.) A ball may go through both sides of ihe bladder, and then either perforate tbe neigh- bouring parts, and escape externally, or bury itself deeply in the flesh. When it has gone quite through the bladder, and after- ward passed out of the body again, urine, blended with blood, immediately issues from one or both apertures, according to their situation. The flow of urine through the urethra is either lessened, or completely suppressed; but through this passage, the patient generally voids more or less blood. Acute and incessant pain is felt in the course of the wound, together with a frequent painful desire to make water, nausea, some- times actual vomiting, and extreme anxiety, and restlessness. Either in its passage in- wards, or its course outwards, the ball may have injured, or perforated the rectum, in which case, the urine passes into this bowel, and mixing with the feces, is discharged from the anus. When a part of the bladder, towards the cavity ofthe abdomen, is injured, as for in- stance, its posterior surface which is covered by the peritoneum, the urine is generally extravasated within the belly, and inflam- mation of the preceding membrane is the immediate consequence. This inflammation spreads with rapidity, and attacks all the viscera, producing vast distention of the ab- domen, fever, coma, and other bad symp- toms, soon terminating in gangrene and death. (Larrey, Mim de Chir. Mil. T. 4, p. 292. 93.) During the first four and twenty hours, very little urine escapes from gunshot wounds ofthe bladder, in consequence of the swell- ing, which almost instantly affects the lips' of the wound. When the bladder \-> full, this fluid is discharged only at the moment of the accident, and mostly only from the wound, by which the ball has made its exit. An extravasation is prevented by the thick slough, which fills all the track of the in- jury, and it is not till the deadened parts be- come loose, tbat any effusion can happen. Hence, it is of the highest importance to introduce an elastic gum catheter into the urethra, where it should be kept, and the instrument should be large enough to fill exactly this canal; for, according to Baron Larrey's observations, if at the period, when the sloughs are detached, the urine has not a ready passage outward, it passes through the wound, and is extravasated the more readily, inasmuch as the separation of the sloughs has occasionally many openings, by vvhich the fluid may insinuate itself into the cellular membrane. Hence, gangrenous mischief aud death. On t w o points, my own experience would not lead me to join in the sentiments of Larrey : first, in opposition to his statement, I am sure, there is risk of extravasation of urine earlier than the period which he spe- cifies, havrrg known thisaccident commence as it '.\.'-i .vithin a few hours after the re- ceipt of the wound ; aud therefore, I should not depend upon the sloughs leing always at first a complete barrier to extravasation of urine, (indeed, their formation throughout the whole track of a gun^'ic wound is bv GUNSHOT WOUNDS. 617 no means a regular occurrence,) but inva- riably pass a catheter as soon as possible, for the more certain prevention of this dan- gerous consequence. Secondly, the period of the separation of sloughs may, indeed, often be contemporary with the first appear- ance, or symptoms of extravasation, particu- larly in cases where the employment ofthe catheter is for some time deferred, as in Baron Larrey's practice, because then a partial extravasation ofthe urine, soon after the injury, and previous to the introduction of the catheter, will cause rapid sloughing, and actually prevent the adhesive inflamma- tion from closing up the cavities of the cel- lular membrane in time to prevent a fatal extension of that irritating fluid among the surrounding parts. Were it not for the par- tial early effusion of urine, no doubt the ad- hesive inflammation would, in these cases, soon have the same effect, in obviating (he danger of urinary extravasation, which it has after lithotomy, or paracentesis of the bladder. (See Bladder.) It is the practice of Baron Larrey to dilate tbe wounds, in order to facilitate the escape of the urine, which might otherwise lodge in the track of (he ball; and perhaps, here the method may frequently be right though I should conceive its propriety must usually depend upon whether the urine has a ten- dency to continue to flow out through the wounds, or not, and upon the presence of obstruction,or not. And in confirmation of this opinion, I may cite Dr Hennen's de- claration, that in these cases, he has very rarely found it necessary to enlarge the wound, when the catheter and proper dress- ings have been employed. (On Military Surgery, p. 421, Ed. 2.) And as soon as possible, a large elastic gum catheter should be introduced, and left in the urethra, taking care to withdraw it, and pass in a clean one every two or three days, so that no incrus- tations may occur. Sometimes, however, the passage of a catheter is very difficult, as is the case, when there are splinters of bone in the urethra, or the parts about the neck of the bladder are inflamed. (Mim.de Chir. Militaire, T. 4, p. 294.) Emollient clysters, and acidulated demulcent drinks are to be prescribed, and the patient is to be kept upon a very low regimen, and in the most quiet state. The dressings are to be light and simple, and cleanliness observed. (Op. cit. T.2,p. 165—170.) Instead of camphor- ated embrocations to the abdomen, another means commended by Larrey, it appears to me, that this author's directions would have been more complete and judicious, had he advised in these cases bleeding, both topical and general. From the injury of arterial ramifications, or varicose vessels, blood is sometimes ex- travasated within the wounded bladder, and causes deep-seated irritation. According to Baron Larrey, the case is indicated by the symptoms of retention of urine, and those of inflammation, with a small pulse, pallor of the countenance, and dryness of the wounds. (T. 4, p. 295.) A more decided Vor.. I 7P criterion, I should think, would be the partial escape of urine mixed with blood, a symp- tom, which could deceive only where the urethra it-elf had been injured. Larrey states that blood, extravasated in the blad- der, rarely coagulates, because blended with urine, and hence, he advises its discharge to be facilitated by means of a catheter, and tepid, emollient, anodyne injections. ('/'. 4, p. 295 ) Sometimes balls carry before them into the bladder, fragments of bone, small coins, pieces of buttons, he. or bits of bullets break off, and lodge in that viscus. When these extraneous bodies are not above a certain size, they are frequently voided through the urethra, (see Cases in Dr. Hennen's Work, p. 419, 422, 424, fa. Ed. 2,) and their eva- cuation may be materially facilitated by the introduction ofan elastic gum catheter, the size of which is to be increased gradually, until the largest can be passed, when the foreign substances will readily enter the tube, or pass out through the dilated urethra. In this way, Baron Larrey has saved gravel patients from a vast deal of suffering. (Mim. de Chir. Mil. T. 1, p. 302.) When the ball is too large to be taken out iu this manner, the lateral operation is to be performed, and it ought to be done before the bladder falls into au ulcerated, or gangrenous state from the pressure and irritation of the foreign body. However, as wounds of tbis organ frequently give rise to dangerous inflamma- tion, Larrey recommends this operation, (and not that above the pubes, as is stated by mistake in Dr Hennen's valuable book, p. 428, Ed. 2,) to be done either before its attack, or not till after its subsidence. (Vol. cit. p. 309.) In fact, almost all the opera- tions of this kind on record have been done some considerable time after tbe receipt of the wound, and to this practice my own judgment would lead me to give a general preference. In one case, however Larrey operated on the fourth day after the receipt of the wound, and with success. After the battle of Waterloo, I was not a little surprised to find in tbe St. Elizabeth hospital at Brussels, a considerable number of cases, in vvhich either the intestines, the stomach, the omentum, or the bladder, pro- truded. I think we had in the division un- der Mr. Collier and myself, not less than three protrusions of the bladder. An order, which I received to join the army in the field on the 27th of June, deprived me of the opportunity of witnessing the progress and termination of these interesting cases. However, many had ended fotally before my departure from Brussels. GUNSHOT WOUNDS OF THp THORAX. Wounds of the lungs, abstracted from other mischief, are now well known not to be always fatal. Balls have been found in the substance of the lungs after having lodged there twenty years, during all which time the patients were healthy, and free from symptoms indicative of tbe ch;<; G18 GUNSHOT WOVNOS. (Percy, Manuel, fa. p. 25.) Mr. Hunter had some reason to believe, that wounds ofthe lungs, made with balls, were generally less dangerous than such as were made with sharp-pointed instruments ; for he had seen several patients recover after they had been shot through the lungs, while other persons died of very small wounds of those organs, done w:tii swords and bayonets. Perhaps, one cause of this fact may be owing to the circumstance of gunshot wounds generally bleeding less than other wounds, so that there is not so much danger of blood being nffused in the cavity of the chest, or the eells ofthe lungs. The indisposition ofthe orifice of a gunshot wound to heal up too soon, is also another circumstance that must lessen the hazard, as whatever matter bap- pens to be extravasated has thereby an op- portunity of escaping. Bui from what has been stated, it must not be iufeired, tbat gunshot wounds of (he lungs are not accompanied with a serious degree of danger. Frequently the patient expires instantly, being suffocated in conse- quence of profuse hemorrhage from those organs ; for though it be true, that gunshot wounds generally do not bleed much, when the injured vessels are under a certain size, yet the contrary is the case, when tbe wounded vessels are like those situated to- wards the root of the lungs. Gunshot wounds ofthe chest also often prove fatal by the inflammation that is excited within this cavity. Appearances sometimes create a belief, lhat a ball 1ms passed completely through the chest and lungs, when the fact is other- wise. "Thus (as Dr Hennen observes,) I have traced a ball by dissection, passing into the cavity of the thorax, making the circuit ofthe iungs, penetrating nearly op- posite to the point of entrance, and giving the appearance ofthe man having been shot fairly across, while bloody sputa seemed to prove tbe fact, and in reality, rendered the some measures, to a certain extent, as neces- sary as if the case had been what was sus- pected. The bloody sputa however, were only secondary,andneither so active and alar- ming as those which pour out at once from thelungswhen wounded." (Military Surgery, p. 368, Ed. 2.) A second cause of decep- tion is the frequent long course of a ball, round tbe chest under the skin and muscles, previously to its exit, whereby an appear- ance is presenter, as if the patient had been shot through the thorax. And another source of deception, as to the actual pene- tration of balls, U '• where they strike against a handkerchief, linen, cloth, he. and are drawn out unperceived in their folds, a pe- culiarity which bas not escaped M. Larrey, who gives an interesting notice on it iu the Bulletins de la Faculte de Med. Paris, lbl5, No. 2. I have also given an instance in the preceding pages." (Hennen loco cit.) In these cases, the absence of bloody expecto- ration directly after the injury, the undis- turbed state of respiration, and the greater freedom from oppression, anxiety, syncope. and other bad symptoms, than in cases where the lungs are hurt, form grounds for a correct opinion on the true nature of the accident. It cannot be supposed, tbat adhesions al- ways take place rouud the opening of a gun- shot wound in tbe chest because the lungs mu^t sometimes collapse, and become con- siderably distant from the pleura, especially when the communication established be- tween the atmospheric air and the cavity of Ihe thorax is very free and direct. However. as adhesions are extremely common between the outer surface of the lungs, und the inner surface of the pleura costalis, they must, in many instances, exist before the receipt of a wound, and of course, prevent the usual col- lapse ofthe lungs. As the general symptoms and treatment of wounds of (he ches(, are detailed in the arti- cle Wounds, I tiiall not here detain the read- er long upon this snbject. When a palient has been shot in the chest, the most impor- tant indication is to prevent and subdue in- flammation of the lungs and pleura. In few other cases can repeated and large bleedings be so advantageously practised. Here there w ill not be so much danger of an extravasa- tion ot blood as in stabs, and even if an effu- sion of that fluid were to happen within the cavity of the pleura, Ibe opening would ge- nerally be sufficient for its escape, and it would not be so frequently found necessary to dilate the wound, or make a new opening, as when (he injury has been inflicted with a sharp-pointed weapon. In this last kind of case, when attended in the beginning with bleeding, Bnon Larrey par- ticularly insists upon the advantage of imme- diately bringing the edges of the wound to- gether with adhesive plaster, instead of leav- ing it open, as advised by the generality of writers; and he endeavours to prove, tbat this immediate closure of the wound has great effect in stopping the hemorrhage from the pulmonary vessels. Supposing an ex- travasation of blood in the chest were to fol- low, he argues that it would be better to let it out afterward by a suitable incision, than to suffer (be patien( (o perish of hemorrhage at once, by not closing tbe wound. (Mem. de Chir. Mil. T. 4, p. 151, he.) Dr. Hennen is in favour of the same practice. (On Mili- tary Surgery,p. 373, Ed. 2.) In a penetra- ting gunshot wound of the chest, after taking away from thirty to forty ounces of blood, (he surgeon should exlract all extraneous substances, and splinters of bone within reach, and even dilate the external wound for this purpose, if necessary. Light unirri- tating dressings are then to be applied. The patient may now be (comparatively speaking) easy, until the spitting of blood, and danger of suffocation, from inward hemorrhage. come on again, when the lancet must be again employed; " and if by this manage- ment, repeated as often as circumstances demand, the patient survives the first twelve hours, hopes may begin-to be entertained of his recovering from the immediate effects of heinorrhage," and, until this danger is over, GUNSHOT WOUNDS. 619 as Dr. Hennen truly observes, the lancet is the only thing which can save life. After- ward, when the paroxysms of pain, the sense of suffocation, and the return of he- morrhage have become more moderate, di- gitalis may be prescribed with the most be- neficial effect; and if ihe cough be very troublesome, no medicine is more useful than the spermaceti mixture with opium. With this treatment must be combined the exhibition of saline purgatives, mild laxative clysters, and a strictly low diet, the patient being allowed only slops. (See Hennen's Military Surgery, p. 373. Ed. 2.) When matter forms in the thorax, in con- sequence of gunshot wounds, the opening will generally suffice for its escape; but should the collection of pus be confined, and occasion dangerous symptoms, the ex- ternal wound must either be enlarged, or a new incision practised, according as cir- cumstances may indicate. The mode of making an opening into the chest is consi- dered in the article Paracentesis. When a ball lodges, without falling into the chest, it may lie either in the substance of the parietes of this cavity between the muscles, or in one of the intercostal spaces, and continue there a very long time without causing much inconvenience, or making its way outward. But when it is lodged in the thoracic cavity itself, it descends by its weight, and sometimes excites considerable irritation, suppuration, sinuses, and hectic symptoms: in this case, if its situation can be ascertained, Baron Larrey recommends an attempt to extract it. In an early stage of the case, he says, that the intercostal space will often be wide enough to let the ball pass through it; but that, at a later period, this space becomes too narrow, and it will be necessary to cut away a portion of the upper edge of the lib with a lenticular knife, which is to be preferred to a trephine, or saw. This advice is supported by some very interesting cases. (See Mem. de. Chir. Mil. T. 4, p. 253.) Frequently the ball frac- tures the rib, and with the aid of dilatation, sufficient room for its extraction may be made ; but the possibility and propriety of removing it through the original opening will, of course, depend upon the situation of the foreign body, and the urgency of the symptoms. A case is recorded, in which a ball, weighing three ounces and a half, was thus removed. (Med. and Surg. Journ. Vol. 3, p. 353.) Alphons. Ferrius de Sclopetorum, sire Ar- chibusorum Vulneribus, fa. Svo. Roma,\5o2. J. F. Rota de Bellicorum Tormentariorum Vulneribus et Curalione, 4lo. Bonon. 1555. Botallus de Curat. Vulner. 1565. Wm. Clowe's Approved Treatise for all young Chirurgians concerning Burnings with Gunpowder, and Wounds made wiih Gunshot, fa. 4to. 1591. J. Quercctanus, Sclopelarius, sive de curandis vulneribus qua sclopetorum elsimilium tormen- torum iclibus acciderunt,Svo. 1591,12mo.Leips. 1614. Fr. Plazzonus,de Vulneribus Sclopeto- rum, fa. 4to. Venet. 1618. J. Woodall, Viati- cum, fol. Lond. 1639. H. F. Le Dran. Trnilr ou Rifleciions liries de la Pratique sur les Plaies d'armes a. feu, 2de Ed. 12»no. Paris, 1740. Desport, Traiti des Plaies d'armes a feu, 12mo. Paris, 1749. Ranby's Method of treating Gunshot Wounds, \2mo. London, 1781. Observations sur des Plaies d'armes u feu, compliquies de fracture, aux articulations des extremitis, ou au voisinage de ces articu- lations, par M. Boucher;in Mem. de I'Acad. de Chirurgie, T. 5, p. 279, Edit, in \2mo. Observations sur des Plaies d'armes h feu com- pliquies sur tout de fracas des os, par M. Boucher, in opere cit. T. 6, p. 109, fa. Edit. in 12mo. Observations sur les Plaies d'armes a feu: 1. Sur un coup de fusil, avec fracas des deux machoires; par M. Cannae. 2. Sur une Plaie d'arme a feu travcrsant la Poitrine d'un coti a. I'autre; par M. Gerard. 3. Sur une Plaie d'arme a feu, pinilrante depuis la parlie anterieure du pubis, jusqu' a I'os sacrum ; par M. Andouilli. 4. Sur une Jambe icrasie par un Obus, ou petite bombe,par M. Cannae. 5. Sur une Plaie d la parlie infirieure et interne de la Jambcfailc par un iiial de Grenade, sans fracas d'os; pur M. Cannae. 6 Pricis dc plusieurs Observations sur les Plaies d'armes a feu en diffirentes parlies, par M. Bordenave. All thesepapers are insertedinMim.de t'Acad. de Chirurgie, T. 6, in \2mo. and in T. 11 of ihe same edition, are inserted Mimoire sur le trailement des plaies d'armes a feu, par M. de la Marliniire, fy Mimoires sur quelques parli- cularitis concernant les Plaies faites par acmes a feu, par M. Vacher. M. Faure's memoirs relative lo amputation in cases of gunshot wounds may be seen in T. 8 of Ihe Recueil des Pieces qui onl concouru pour le Prix de I'Acad. de Chirurgie, Edit, in 12wio. John Hunter's Treatise on the Blood, Inflammation, and Gun- shot Wounds. Richter, Anfangsgrunde der Wundarzneykunst, B. 1. Schmucker, Ver- misehte Chir. Schriften, 3 vols. Svo. Berlin, 1776, 17S2. Chirurgische Wahrnehmungen, 2 vols. Berlin, 8ro. 1744, 89 ; works of high value. Discourses on the Nature and Cure of Wounds, by John Bell, p. 169, fa. Edit. 3. Richerand, Nosographie Chir. T. 1. Edit. 4. Chevalier's Treatise on Gunshot Wounds, Edit. 3. Leviille's Nouvelle Doctrine Chi- rurgicale, Tom. 1, Chap. 8, p. 436, fa. En- cyclopidie Mithodique, Parti Chir. art. Plaies d'armes a feu. Larrey, Mimoires de Chirur- gie Militaire, 4 Tom. Svo. Paris, 1812, 1817 ; o?i the whole the most instructive book for army surgeons ever published, Memoire pur M. Dc Conle, Prix de I'Acad. T. 8. Examen des plusieurs Parlies de la Chirurgie, par M. Bagieu, a Paris, 1756. Belguer's Disserl.dc Membrorum Amputatione rarissime adminis- tranda, aut quasi abroganda ; Hala, 1761. This work is celebrated as having attracled most deservedly the just und severe criticisms uf Pott, La Marliniire, Morand, fa. Morand's Opus- cules de Chirurgie, 1768. Van Gesscher,Ab- handlung Von der Nothwendigkeit der Ampu- tation; Freyburgh, 1775. M. G. Daignan, Reflexions Importanlcs sur le Service des Hos- pitaux Militaires, Svo. Par. 1785. Mursiniut, A'eue Medicinisch-Chiriu^isrlii Beobachtun- gen, Zweiter, Theil. S. loS. Berlin, 1796. Wcdckind's Nachrirhftn fiber das Fravsische. \>2u GUTTA SERENA. Kricgspitalwesen, Ersttr B. Leipsig. 1797. Baron Percj/, Manuel du Chirurgien d'Armic, Svo. Paris, 1792. Paroisse, Opuscules de Chir. Svo. Paris 1806. Graefe, Normen far die Ablosung Grdsserer Gliedmassen, 4to. Berlin, 1812. Asaatini, Manuale di Chin rgia,9vo. Milano, 1812. Guthrie on Gunshot Wounds of the Extremities, London, 1815; or the 2d Ed. entitled a Treatise on Gunshot Wounds, fa. Svo. London, 1820; a work detailing the practice of our military surgeons during the late war in Spain, andnplde with valuable in- formation. Tliomson's Report of Observations made in the military hospitals in Belgium, Edinburgh, 1816. .'/. C. Hunchinson's Prac- tical Observations in Surgery 1816; and Fur- ther Obs. on the Period for amputating in Gunshot Wounds, Svo. Lond. 1817. MUlen- gen's Manual, Svo. Lond. 1819. ./. Hennen's Principles of Military Sirgery, 2d F.d. Svo. Edmb. 1820 , a publication which I cannot too strongly recommend, not only to army and nary surgeo is, but to practitioners in general. James Mann, Medical Sketches of the Cam- paigns of 1812, 13, 14 lo which are added, Surgical Cases, Obs. on Military Hospitals and Flying Hospitals attached to a moving Army. fa. Sro. Dedham, 1816. GUTTA SERENA A term said to have been first applied by Actuarius to amaurosis, or the species of blindness arising from a morbid state of the retina, or optic nerve. (See Amaurosis.) In the present place, I mean first briefly to advert to a case, which tbe late Mr. W are has described as combined with a particular kind of ophthalmy, that occasions excrucia- ting pain, and requires peculiar treatment. One example of this kind was greatly re- lieved by a puncture, made through the tu- nica sclerotica into the ball of the eye with a grooved needle, somewhat larger than a common sized couching needle, nearly in the part where this instrument is introduced in the operation of depressing the cataract. Through the groove of the instrument, a watery fluid immediately issued, which was not unlike that which Mr. Ware several times found, after death, effused between the choroid coat and retina, in cases of gutta se- rena. After the pain of the operation had ceased, the patient became quite easy, and the inflammation soon subsided. Mr. Ware afterward performed a similar operation in a considerable number of resembling instan- ces, and in several of them the proceeding was attended with almost immediate good effect. (See Ware on the operniion of large- ly puncturing the capsule of the crystalline humour, fa. and on Ihe Guila Serena, accom- panied with pain and inflammation, 1812.) Underthe head of gutta serena, I promi- sed to notice Beer's opinions concerning amaurotic remedies, which, whether em- ployed upon rational or upon empirical principles, he divides into two classes, viz. general, or internal means ; and local, or ex- ternal. Sometimes only the first are requi- site ; more rarely only the second ; but fre- quently both together. Amongst the internal remedies are eme- tics, which may be useful in two ways, either as real evacuants, or as nauseating means. It is the opinion of Professor Beer, that for the purpose of exciting actual vo- miting, they should be exhibited only when the stomach is foul, and no considerable plethora exists ; and he deems them impro- per whenever a great determination of blood to the head and eyes prevails, or any in- creased velocity of the circulation. Should the surgeon find it necessary to employ eme- tic medicines, simply as alteratives, he must consider well whether the digestive organs w ill bear their great aud long-continued operation. (Lehre von den Augenkr. B. 2, p. 463.) Notwithstanding the favourable ac- counts given by Schmucker, Richter, and Scarpa, of the good effects of emetics in many cases of amaurosis abroad, this treat- ment lias had but little success in England. Mr. Travers even declares that he does not recollect an instance of decided benefit from the emetic practice, although he has often fairly tried it. " The cases of gastric disor- der, to which it is especially applicable, are most benefited by u long-continued course of the blue pill, with gentle saline purgatives and tonic bitters." (Synopsis of the Diseases ofthe Eye, p. 304.) When the bowels nre loaded, and there is frequent determination of blood to the head and eyes, and an accelerated circula- tion, and particularly if, after these effects, the sight is alwavs manifestly worse, brisk purgatives may be prescribed. When, bow- ever, constipation has prevailed for a long time, drastic purgatives should not be exhi- bited before one or two loose motions have been procured with laxative clysters. Gen- tle aperients are more particularly indicated when the patient does not have a stool daily, and the evacuation is never made with ease, nor without considerable strain- ing ; when he often passes two or three days without any evacuation at all, circumstan- ces sure to be followed by repeated deter- mination of blood to the head and eyes, and other ill consequences, which, accord- ing to Beer, have a very prejudicial effect on amaurosis. Beer is of opinion, that diaphoretics should be employed with great caution, because they are apt to bring on violent determina- tions of blood, and an accelerated state of tbe circulation ; and they can only be em- ployed with judgment, and a hope of bene- fit, when there are good grounds for belie- ving that a previous stoppage of the cuta- neous functions has bad a real share in pro- ducing, or keeping up, the blindness. They are still more strongly indicated, when the cessation of those functions is, in some mea- sure, evinced by the dry state of the inte- guments, wandering pains between the skin and muscles, and considerable melioration of the eyesight after the breaking out of any accidental perspiration. (B. 2, p. 465.) Professor Beer thinks, that in amaurosis medicines for promoting the menstrual dis- charge are too often employed on empirical principles, to the serious detriment of tho GUTTA SERENA. 621 patient, the cessation of tbis discharge being mostly regarded as the cause of the amauro- sis, while, in realily, it-is very seldom really so, both affections being dependent upon one and the same cause. Hence much cir- cumspection, and the closest investigation, are necessary to trace the connexion be- tween these morbid effects, and to ascertain when such medicines can be given without risk. Still greater mischief results from the treatment of amaurotic children with anthel- mintics ; nay, Beer assures us, that he has seen numerous amaurotic boys and girls thus wrongly treated, who had not the slightest symptom of worms However, when amaurosis is unattended with any leading indications, anthelmintics may be tried, for they are less injurious to the eyes than many other medicines, though, as they consist of drastic purgative means, they must soon occasion great debility. According to Beer, whenthere is good ground for suspecting any thing syphilitic about the patient, mercurials may be given with great prospect of benefit. Also, when no suspicion of this kind can be entertained, but amaurosis is accompanied with infarc- tion of the abdominal viscera, especially a manifest chronic disease of the liver, or serious chronic swellings and indurations of the glands, a periodical headach, of no de- terminate character in other respects, and aggravation of the blindness after every such attack, mercurial preparations, as Beer can assert from manifold observation, are pro- ductive of the best effects upon the disease of the eyes. Yet, says he, under these cir- cumstances, mercury should never be ex- hibited where the individuals are of a debi- litated scorbutic diathesis, or subject to bleedings, and more particularly where there is the least mark of a dissolution of the vitreous humour. (Lehre von den Au- genkr. B. 2, p. 466.) Upon the w hole, from what I am able to learn of the practice in London, mercury is more extensively and successfully used, as a remedy for amauro- sis, than any other medicine in the whole pharmacopoeia. " When the amaurosis is recent and sudden, (says Mr. Travers) and either the signs of an obscure inflammation are present, or only the amplitude and in- activity of the pupil correspond to the pa- tient's history—mercury should be introdu- ced with all convenient rapidity into the system, I mean so as to ruffle it iu the least possible degree. No advantage is obtained by salivation; on the contrary, I think it hurtful : when mercury is beneficial, its efficacy is perceived as soon as the mouth is sore." (Synopsis of the Diseases of the Eye, p. 305.) Anti-nervous medicines have, at all times, ranked very high, on empirical principles, as means for the cure of amaurosis; but, how often is this disease not simply a ner- vous affection ? Beer divides the medicines of this sort, employed in cases of amaurosis, into three classes, namely, antiparalytir, an- tispasmodic, and tonic. To the first class be- long arnica, naptha, camphor, millepedes, sulphur auratum antimonii, liquor ammo- nia? lavendulatus, pulsatilla, black hellebore, and phosphorus. These medicines can be safely given to amaurotic patients, when an evident general nervous debility, and mor- bid irritability prevail, without any other particular appearances of disease, and espe- cially when, at the same time, there are genuine paralytic appearances in the eye itself, or in the parts immediately surround- ing it, or not very far from it. Among the antispasmodic remedies, particularly when used on empirical principles. Beer has found the most efficacious to be valerian, liquor ammohiae carbonatis, assafcetida, opium, hy- osciamus, castoreum, musk, flores zinci, and extract of chamomile. Tonic nervous remedies, says Beer, are to be used with more caution ; for bitter medicines, when injudiciously prescribed for nervous debili- tated individuals, rather promote the forma- tion of amaurosis. When calamus aroma- tieus is in question, care must be taken that there be no tendency to pectoral complaints, which this medicine is too apt to bring on in weak subjects, in which event the sight is always very much impaired by it. In cos- tive habits, bark is likewise apt to render the blindness worse. And according to the same experienced oculist, it is necessary to be very circumspect with steel medicines, empirically prescribed, as they frequently occasion determinations of blood to the head and eyes, and quicken the circulation, whereby every remnant of vision may be abolished. Steel medicines do the greatest and quickest injury to amaurotic eyes, when combined with narcotics. Above all things, it is generally prudent, in cases of amauro- sis, carefully to abstain from all the stronger and long-operating nervous medicines, whenever plethora,determinations of blood, and tendency to inflammation exist. (Lehre von den Augenkr. B.2, p. 467.) In this country, I do not believe that antinervous and antispasmodic medicines have obtained credit for their efficacy in' this disease. Thus, Mr. Travers states, that be has never known any real benefit derived from cam- phor, assafcetida, valerian, &.c. though he bas seen much g od derived from tonics, the mineral acids, bark, steel, and arsenic, after a due regulation of the digestive func- tions. (Synopsis, fa. p. 304.) In arnica montana, aconite, euphrasia, and stimulants in general, he has no confidence. Local, or external medicines, for amauro- sis, are divided by Beer into two classes, namely, into those which are applied to parts more or less distant from the eyes, and having some sympathetic connexion with these organs ; and into others, whicb are usually put upon the eye itself. In the first class bleeding has obtained high repute, either by venesection in the common way, the application of leeches to the pudenda, the arms, behind the ears, or upon the temple ; cupping the back, or by opening the temporal artery or jugular vein. Bleeding is indicated when manifest pie- 6;v> GUTTA SERENA tbora, a determination of blood to the head and eyes, or an accelerated circulation, is combined with a considerable decrease of vision ; when the menses are nearly or quite suppressed in plethoric subjects ; a manifest determination of blood to the parts of gene- ration prevails ; or the same thing occurs in hemorrhoidal patients. (Beer, Lehre, fa. p. 469.) According to Mr. Travers, all the cases of direct debility, and proper paralysis of the optic nerve, are aggravated by loss of blood. (Synopsis, fa. p 303.) Professor Beer gives his testimony also, in favour ofthe efficacy of such applications as produce a counter-irritation, not merely as rubefacients, but as means occasioning au evacuation of lymph ; such are blisters, si- napisms, laid on the back or calves of the legs, vesication by means of the bark of me- zereon, issues, and setons. These means are proper when the blindness is attended with continual, but wandering pains in the aponeurotic covering of the head, or in the vicinity of the eye, with a whizzing noise and irritating pain in the ear, or with the suppression of a purulent discharge from the meatus auditorius In such c:ises, however, there must be no particular plethora, still less any determination of blood to the head and eyes. Here should also be mentioned friction with antimonial ointment, which is especially indicated where there is reason to believe, that the amaurosis has been pre- ceded, and partly produced, by a long inter- ruption of the cutaneous secretion. Formerly, according to Beer, clysters were too commonly employed in cases of amaurosis; for whenever the cause of the disease was not understood, it was usual to refer it to a morbid state of the abdominal viscera. At present, clysters in amaurotic cases are employed quite empirically, as sti- mulants to the intestinal canal, and eva- cuants, when the loaded state of the bowels and obstinate constipation require them, and when the scantiness and difficulty of the evacuations keep up a constant deter- mination of blood to the head and eyes and when perhaps for other reasons, common purgative medicines cannot be employed. Beer says that aperient clysters are attended with the most decided good effects in that amaurotic-weakness of sight, vvhich some- times occurs towards the end of pregnancy, and is combined with obstinate constipation, continual headach, evident determination of blood to the head and eyes, and such nn inflammatory diathesis as cannot be mis- taken. On the other band, the employment of c'ysters as anodyne remedies, notaseva- ruants, is principally useful in hypochon- driacal and hysterical amaurotic patients, when they are troubled with much general cramp, and spasms in the abdomen. (Vol. cit.p. 470.) According to tbe statements of the same writer, baths, whether warm or cold, adapt- ed for the whole body, or in tbe form of a slipper-batb, a pediluvium, or effusion, have hitherto not proved very efficacious empiri- cal remcdiesforamaurusis, aud this, whether they consist of simple water, or aromatic de- coctions, or of waters impregnated with| sul- phur or iron. The reason why baths in ge- neral are less frequently employed as .empi- rical remedies in cases of amaurosis, and why thev are still more rarely successful, may be, because in the very cases of amau- rosis, in vvhich baths of various kinds are clearly indicated, the greatest attention must be paid to the patient's constitution, to the state of the skin especially, and to the tem- perature of the fluid employed ; for, in a healthy subject, too w arm a bath may, un- der certain circumstances, (as for instance when there is plethora,) of itself occasion a serious auromatic amblyopia ; and there- fore, under similar circumstances, mu3t be likely to increase any present amaurotic weakness of sight into complete blindness. In general warm whole, or slipper, baths must be employed as empirical remedies in amaurosis only when the regular action of the skin is disturbed, without febrile symp- toms, when the affection of the eyes has been preceded by the sudden stoppage of a profuse perspiration ; or some cutaneous ef- florescence is coexistent with the amaurosis. On tbe contrary, pediluvia with salt, mus- tard, he. are chiefly proper when amaurosis is accompanied with a determination of blood to the head and eyes, or any local in- flammations, after which the eyesight is al- ways found to be worse. In casesof amau- rosis affusion can be seldom used empirical- ly, and only under those circumstances where modern experience has proved the shower bath to be allowable. Cold bathing generally agrees badly with an amaurotic pa- tient, and when his skin is extremely sensi- ble, ,\ hen wandering pains are felt between the integuments and muscles, or there is a tendency to erysipelatous inflammation, the power of vision evidently declines after every trial of the plan. But, according to Beer, mineral waters, impregnated with iron, in the form either of a bath for one half, or for the whole of the body, generally pro- duce, under these circumstances, the most favourable effects upon the skin, and through the medium of it, upon the diseased eye. The case, however, is to be excepted where flying rheumatic, and perhaps gouty pains constantly tease the patient, unaccompanied with fever, and where bathing of tbe whole body in sulphurous mineral water should be preferred. (Lehre von den Augenkr. B. 2, ;>.. 471,472.) If we are to believe Beer, the empirical employment of applications, which have the effect of increasing the secretion of mucus, is very seldom proper, such as irritating gar- gles, the smoking of tobacco, and sternuta- tory powders ; for these means can only be adopted with any prospect of benefit when amaurosis is accompanied with plelhora, a sense of spasm and weight about the frontal sinuses, an incessant obtuse heaviness at the bridge of the nose, and unusual dryness of the nostril, in an individual, who has fre- quently suffered catarrhal complaints, but GUTTA SERENA. C£3 .^uit time previously to the origin of the amaurotic symptoms has continued nearly, or quite free from colds ; and when the pa- tient has no tendency to plethora, determi- nation of blood to the head and eyes, and acceleration of the circulation. (Vol. cit. p. 473.) The application of sternutative powders to the nostrils is, perhaps, to be regarded as a mode of treatment, establishedon empirical principles, unless we can place confidence in the statement of Schmucker, Richter, and Beer, that an unusual dryness of the mucous membrane of the nose, following tedious and severe catarrhs, may have the effect of inducing amaurosis. The snuff employed by Schmucker, is thus composed: rj. Mer- cur. viv. 3j- Sacchar. alb. 3hj, Lill. Alb. Rad. Valerian, a a 3j- Misce. The late Mr. Ware imputed considerable efficacy to electricity and a mercurial snuff in cases of gutta serena. The snuff was compounded of ten grains of turbith mineral (hydrargyrus sulphurat us) well mixed, with about a dram of the pulvis sternutatorius, glycirrhiza, or common sugar. A small pinch of this snuff, taken up the nose, is found to stimulate it very considerably— sometimes exciting sneezing, but, in gene- ral, producing a very large discharge of mucus. (See Chir. Obs. relative to the Eye, Vol. 1.) Among the remedies, which, in cases of amaurosis, are intended to be applied direct- ly to the eye, and its surrounding parts, lo- cal bleeding merits the first rank. The ex- traction of blood, by means of leeches, is the only mode in which tbe practice can here be executed. The method, however, is only proper when manifest turgescence of the vessels of the conjunctiva and sclerotica is combined with a feeling of constant pres- sure about the eye, a sense of fulness and tension in the ball, and evident plethora, without any local inflammations or increase in the velocity ofthe circulation. Experience proves also, says Beer, that the empirical application of rubefacients, or drawing plasters, to the temples, or eye- brows, is fraught with not less efficacy, when all sensibility in the retina appears to be ex- tinguished, without any defect in the tex- ture of the eye, any varicose dilatation of its blood-vessels, or any particular determi- nation of blood to it. Applications, produ- cing an evacuation of lymph, including both blisters and antimonial ointment, may be al- ternately employed upon the eyelids and temples, when there are grounds for be- lieving, that the functions of (he skin have already been long suspended by porrigo, or the stoppage of perspiration on the fore- head. (.Beer, Lehre von der Augenkr. B. 2, p. 474.) As in the rational plan of treatment, tbe rubbing of fluid, pungent, or irritating me- dicines upon the eyebrows, in certain kinds of amaurotic blindness, is often attended with considerable efficacy : so, in Beer's opinion, it should not be neglected in cases ^vhere (he -nrgeon is compelled to have re- course to empirical methods of cure; for in- stance, where it is observable, that general- ly in the evening, or the shade, the eyesight immediately grows weaker; that, on the patient's first awaking in the morning, it is weaker than in the middle of the day; and what particularly merits notice, while the case is unattended with any sensations of imaginary flashes of light; a very feeble, or entirely abolished motion of the iris; not the least vestige of any defect in the struc- ture ofthe eye ; and no symptoms of deter- mination of blood to the head and eyes, or of a general tendency to inflammation. Beer recommends pungent applications to be first tried ; such as the spiritus aromati- cus, balsamus vitae Hoffmanni, or Cologne water. These may be followed by aqueous substances, naptha, he. then by narcotics, like the tincture of opium, and lastly, by ir- ritating remedies, like the tinctura lyttae. Fluid applications, which are applied in the form of vapour to the eye, demand greater circumspection, like naptha, the liquor am- monia?, he. These may be best applied by putting a small quantity of them into the hand, over which the eye must be held in such a manner that none of the fluid will come into contact with it. But as soon as the eye begins to be irritated by tbe va- pour, the tears to run, or actual pain is felt, the hand is to be removed, lest too much ir- ritation be produced. (Beer, Vol. cit. p. 475.) Not only in the empirical, but also in eve- ry scientific mode of treating amaurosis, says this author, such remedies, as are in- tended to produce a shock upon the nerves and vessels, require the utmost caution, be- cause, of all the various classes of remedies, they are the most powerful; and conse- quently, if misapplied, are likely to convert an amaurotic weakness of sight into com- plete blindness. This mournful event is most rapidly produced, when applications of this description are employed in plethoric subjects, affected with partial determinations of blood and local inflammations, a varicose state of the blood-vessels of the eye, defects in the transparent media of that organ, ov frequent headach. To this class of reme- dies belong especially the shower bath, electricity, galvanism, &.c. On the empiri- cal plan tbey can only be used with safety or advantage, when decided marks of para- lysis, either in the amaurotic eye or its ap- pendages, are present. (Lehre von den Au- genkr.'B. 2, p. 477.) Mr. Ware has observ ed, that the pupil has been generally dilated in (he cases benefited by electricity. He notices, however, that there are many instances, in which a contrac- tion of the pupil is the only change which takes place in the appearance of the eye. In tbis sort of case, tbe impairment of sight is usually- preceded by severe pain, and the original cause may be an internal ophthal- my of long continuance. The crystalline is sometimes visibly opaque. Here electrici- ty has been found useful; but Mr. Ware states, that in these instances, the snblimafp 624 HEMATOCELE. has proved superiorly and more certainly efficacious, and, consequently, he prefers it to all external applications whatever. He recommends one-fourth of a grain, as a quantity proper for a common dose, and says, that it agrees best with the stomach when first dissolved, as Van Swieten di- rects, in half an ounce of brandy, and taken in a basin of sago or gruel. For young pa- tients the dose must be diminished in pro- portion to their youth. The medicine is to be continued as uninterruptedly as the con- stitution will allow, for a month, six weeks, or even longer. Electricity is said to have proved more stikingly useful, in cases of amaurosis, ori- ginating from lightning, than when the dis- ease hi.s arisen from any otber cause. Mr. Ware relates a most interesting instance of the success of electricity, in a case which came on very suddenly, after great pain in the teeth, and a swelling of the face, had gone off The disorder came on more sud- denly ; the temporary blindness was more entire ; the eyelids were more affected, and the cure more speedy, than in the instances related by Mr. Hey, in tbe 5th Vol. of the Med. Obs. and Inq. (Chir. Obserr. relative to the Eye, by J. Ware, Vol 1.) However, the amaurosis produced by lightning may also be sometimes cured in other ways. Mr. Wardrop mentions that he has only seen one case of this kind, and the sight was re- stored by the repeated application of small blisters over the frontal nerve. (Essays on the Morbid Anatomy of the Human Eye, Vol. 2, p. 173.) With the exception of one case related by Valsalva, Scarpa was unacquainted with any instance of amaurosis, arising from a wound ofthe eyebrow, tbat was relieved, and he has, therefore, set down this species as in- curable. The opinion, however, is not per- haps correct, for the first case related by Mr. Hey arose from this cause, and was cured by giving every night the following dose : l£ Calomel, pp Camphor, a a iij. Conserv Cy- nosb. q.s. probe misceanl elf. Bolus, in con- junction with electricity. The lady, how- ever, had been previously bled twice, had taken some nervous medicines, and had had a blister between the shoulders. The pa- tient was first set upon a stool with glass feet, and had sparks drawn from the eyes, and parts surrounding the orbits, especially, where the superciliary, and infra-orbitary branches of tbe fifth pair of nerves spread themselves. After this operation had been continued half an hour, she was made to re- ceive,for an equal time, slight shocks through the affected parts. In a few days sight began to return, and iu less than three months it was quite restored :—In another case, one grain of calomel, and two of camphor, given every night, and the employment of electricity, ef- fecteda cure. The disease had comeon gradu- ally, without any previous accident, or pains in tbe head. The patient a boy nine years old. There are several other very interesting cases of amaurosis related by Mr. Hey, all of which make electricity appear an effica- cious remedy, though it is true, as Scarpa observes, that in most of these instances, in- ternal medicines were also given, and bleed- ing occasionally practised. Mr. Hey attri- butes,the benefit chiefly to the electrici- ty, because, in two of his cases, no medicines were used, yet the progress of the amend- ment seemed to be as speedy in them, as in the rest, and in two instances, a degree of sight was obtained by the first application of electricity. At present, I think electricity and galvanism, as means of benefiting amau- rosis, are now less valued in England than on the continent: Mr. Travers states, that he bas bad recourse to them in many cases, some of which were of a very favourable de- scription, but he never saw any good pro- duced by them. (Synopsis of the Diseates of the Eye, p. 303.) How far, however, tbe statementsof Beer) Ware, &o. about the efficacy of local appli- cations can be trusted, is yet a question; for they disagree with reports made by other writers. Thus, with the exception of cupping, issues, setons, and particularly blisters, Mr. Travers declares, that his experience leads him to attach no value to the various forms of external remedies. (Synopsis, fa. p. 30, 8vo. Lond. 1820.) In Dr. Vetch's Practical Treatise on Dis- eases ofthe Eye, 8vo. Lond. 1820, a work pub- lished since the article Amaurosis in this Dictionary was printed, the reader will find a chapter on this disease worthy of his at- tention. (See p. 133, fa.) H. a ___LiEMATOCELE, (from m/un, blood, and iOfXn, a tumour. This is a swelling of the scrotum, or spermatic cord,proceeding from, or caused by, blood. According lo Mr. Pott, when the tunica vaginalis has been long, or much distended, "it becomes thick and tough ; and the ves- sels (especially those of its inner surface) are sometimes so large as to be very visible, and even varicous. If one of these lies in the way of the instrument, vv herewith the pallia- tive cure is performed, it is sometimes wounded : in which case the first part of tbe serum which is discharged, is pretty deeply tinged with blood. " Upon the collapsion of the membranes, and of the empty bag, this kind of hemor- rhage generally ceases, and nothing more comes of it. But it sometimes happens, either from the toughness of the tunic, or from the varicose state of the vessel, that the wound (especially if made by a lancet) does not immediately unite; but continues to discharge blood into the cavity of the said tunic, thereby producing a new tumour. and a fresh necessity of operation." HEMATOCELE. 62b This is what Mr. Pott calls the first spe- cies of haematocele, which evidently pro- ceeds from a wound of a vessel ofthe va- ginal tunic. " Upon the sudden discharge of the fluid, from the bag of an over-stretched hydrocele, and thereby removing all counter pressure against the sides of the vessels, some of which are become varicous, one of them will, sometimes without having been wound- ed, burst; (hence, the last running of the water from a hydrocele is often bloody.) If the quantity of blood, shed from the vessel so burst be small, it is soon absorbed again ; and creating no trouble, the thing is not known. But if the quantity be considerable, it, like tbe preceding, occasions a new tu- mour, and calls for a repetition of the ope- ration." This, Mr. Pott calls the second species : '• which, like the first, belongs en- tirely to the vaginal coat, and has no con- cern either with the testicle, or with the spermatic vessels. In both, tbe bag which was full of water, becomes in a short space of time distended with blood ; which blood, if not carried off by absorption, must be dis- charged by opening the containing cyst: but in neither of these can castration (though said to be the only remedy) be ever neces- sary : the mere division of the sacculus, and the application of dry lint to its inside, will, in general, if not always, restrain the he- morrhage, and answer every purpose, for which so severe a remedy has been pre- scribed." With respect to filling the cavity of the tunica vaginalis with lint, I believe few good surgeons of the present day would consider the measure at all necessary or proper. I have seen three or four cases of haematocele of the above kind laid open, but never knew the surgeon compelled by the bleeding to cram the tunica vaginalis with lint to the great irritation and injury of the testicle itself. On the contrary, after taking out the blood, letting the parts col- lapse, and applying the cold lotio plumbi acetatis, for a few hours to the scrotum, by means of linen wet with the application, they substituted for the lotion an emollient poultice, and had recourse to fomentations, saline purgatives, leeches, and even vene- section, according to circumstances. The next example, pretended by Pott and Richter, to be a form of haematocele, is not admitted by Richerand, Jourdan, (See Did, des Sciences Mid. T. 20, p. 126.) and other modern surgeons. " If," says Mr. Pott, " blood be extravasa- ted within the tunica albuginea, or proper coat of the testicle, in consequence of a great relaxation, and (as it were) dissolution of part of the vascular compages of that gland, and the quantity be considerable, it will afford or produce a fluctuation, to the band ofoan examiner, very like to that of an hydrocele of the tunica vaginalis; al- lowing something for the different density ofthe different fluids, and the greater depth ofthe former from the surface. " If this be mistaken for a simple hydro- cele, and an opening be made, the discharge v0r I T9 will be blood, not fluid, or very thin ; not like to blood circulating through its proper vessels ; but dark and dusky in colour, and nearly of the consistence of thin chocolate (like to what is most frequently found in the imperforate vagina.) The quantity dis- charged will be much smaller than was ex- pected from the size of the tumour ; which size will not be considerably diminished. When this small quantity of blood has been so drawn off, the testicle will, upon exami- nation, be found to be much larger than it ought to be; as well as much more loose and flabby; instead of that roundness and resistance arising from an healthy state of the gland, within its firm strong coat, if is soft, and capable of being compressed al- most flat, and that generally without any of that pain and uneasiness, vvhich always at- tend the compression of a sound testicle. If the bleeding ceases upon the withdraw- ing the cannula (supposing a trocar to have been used) and the puncture closes, a fresh accumulation of the same kind of fluid is soon made, and the same degree of tume- faction is produced, as before the operation : if the orifice does not close, the hemorrhage continues, and very soon becomes alarming. In the two first species, " the blood comes from the tunica vaginalis, the testis itself being safe and unconcerned ; and tbe reme- dy is found, by opening the cavity of the said tunic; but in this the hemorrhage comes from the substance of the testicle from the convolutions of the spermatic ar- tery, within the tunica albuginea : the divi- sion of the vaginal coat can here do no good ; and an incision made into the albu- ginea can only increase the mischief: the testicle is spoiled or rendered useless, by that kind of alteration made in it, previous to the extravasation; and castration is the only cure which a patient in such circum- stances can depend upon." I confess, that no good reason appears for arranging cases of ihe preceding kind with haematocele ; for, what are they but diseased testicles ? which have been punctured, ei- ther on account of their seeming to contain a fluid, or really having within them cysts filled with a chocolate coloured or other fluid, as 1 have seen in hundreds of instan- ces of sarcocele, and, whatever blood is dis- charged, was not extravasated in the sub- stance ofthe testes previously to the punc- ture, but issues as a necessary consequence of that proceeding. However, of the pro- priety of the practice advised by Mr. Pott, no doubt can be entertained. "The last species of this disease, noticed by Mr. Pott, arises from a bursting of a branch ofthe spermatic vein, between the groin and scrotum, in what is generally- known by the name of the spermatic pro cess. This, which is generally produced by great or sudden exertions of strength, feats of agility, he. may happen to persons in the best health, whose blood and juices are in the best order, and whose genital parts are free from blemish or disease. '■' The effusion, or extravasation, is made 626 HARELir into the cellular membrane, which invests and envelopes the spermatic vessels, and has something the appearance of a true her- nia. When the case is clear, and the extra- vasated blood does not give way to discu- tient applications, the only remedy is to lay the tumour fairly open, through its whole length. If the vessel or breach be small, the hemorrhage may be restrained by mere compression with dry lint, or by the use of styptics; but if it be lar«e, and these means do not succeed, the ligature must be made use of." I cannot conceive, that, in any case of a mere rupture of one of the spermatic veins, it can ever be justifiable to tie the whole spermatic chord, and then perform castra- tion, though Mr. Pott advises this plan in case the bleeding branch cannot be tied singly. Discutient applications, and an oc- casional purge, will almost always disperse tbe swelling; and if not, opening it, taking out the blood, applying cold, or, if neces- sary, filling the cavity with lint, and using compression, would be, according to my humble judgment the most judicious treat- ment. A case, precisely of the latter kind, is not very common, yet Mr. Pott has not omitted it, as one of the forms of haematocele ; but, why he has not taken notice of the most frequent of all the varieties of this disease, I am at a loss to conjecture ; I mean the extravasation of blood in the loose cellular membrane of the scrotum from blows on the part, and sometimes from lithotomy, castration, he. quite unconnected with any rupture of the spermatic veins. These are the cases which are mostly met with in practice. I have seen them followed by suppuration; but, in general, the effused blood is gradually absorbed, with the aid of discutient applications, leeches, fomenta- tions, poultices, and saline purges. A sur- geon should generally be reluctant to lay open the tumour, as, in many instances, sloughing and very severe symptoms have been the result. Celsus and Paulus filgineta are the beat of ihe old writers on hamatocele. For modern information, consult Pott's Chir Works, Vol. 3. B. Bell on Hydrocele. Flajani, Collezione d' Osservazioni, fa. T. 2 ; Richter, Anfangsgr. der Wundarzn. B. 6; Richerand, Nosogra- phie Chir. T. 4; Osiander, in Arnemann's Magazin far die Wundarzn. 1 B.p.35o,—the patient died after an opening had been made in the swelling. Follet, in Journ. de Mid. continui, Vol. 13, p. 422,—a ease from con- tusion, cured by an incision. Harris in.Mem. of Lond. Med. Society, Vol.5. HARELIP. (Labia Leporina.) A fissure, or perpendicular division of one or both lips. The term has arisen from the fancied resemblance of the part to the upper lip of a hare. Occasionally the fissure is more or less oblique. In general, it is directly be- low the septum of the nose ; but sometimes it corresponds to one of the nostrils. The two portions of the lip are generally move- able, and not adheren' tu the alveolary process; in less common cases they are closely attached to the forepart of the jaw. Children are frequently born with this kind of malformation, which is called a na- tural harelip, while that which is produced by a wound is named accidental. Some- times tbe portions of the lip, which ought to be united, have a considerable interspace between them ; while in other instances, they are not much apart. The cleft is oc- casionally double a little lobe, or small portion of the lip, being situated between the two fissures. The fissure commonly affects only the lip itself, and usually the upper one. In many cases, however, it extends along the bones and soft parts forming the palate, even as far as the uvula; and sometimes those bones are entirely wanting. A harelip, in its least degree, occasions considerable deformity; and when more marked, it frequently hinders infants from sucking, and makes it indispensable to nou- rish them by other means. When the lower lip alone is affected, vvhich is rare as a mal- formation, the child can neither retain its saliva, nor learn to speak, except with the greatest impediment. The constant escape ofthe saliva, besides being an annoyance, is found to be detrimental to tbe health ; for its loss impairs the digestive functions, tbe patient becomes emaciated, and even death would sometimes ensue, if the incessant discharge of so necessary a fluid in the ani- mal economy were not prevented. Thus,a lady, who was in this state, consulted Tron- chin, who immediately saw the cause of her indisposition, and recommended the fis- sure in Ihe lip to be united ; the operation was done, and the dyspeptic symptoms then ceased. And, when tbe fissure pervades the palate, the patient not only articulates very imperfectly, but cannot masticate, nor swallow, except with great difficulty, on account ofthe food readily getting up into the nose. An early removal of the deformity must obviously be very desirable ; but, as it can- not be accomplished without an operation, attended with some degree of pain, Dionis, Garengeot, and others, advise waiting till the child is four or five years old, on the supposition, that, at an earlier age, the child's agitations and cries would render the operation impracticable, or derange all the proceedings taken to ensure its success. It is plain, however, that such reasons are not of great weight A child four or five years old, and, very often, even one eight or ten years of age, is more difficult to manage, than an infant only a few months old. Every child of the above age has a thousand times more dread of the pain, than ofthe deformity, or of the inconveniences of the complaint, to which he is habituated ; while an infant of tender years fears nothing, and only feels the pain ofthe moment A more rational objection is the liability of infants to convulsions after operations, and this has induced many excellent sur- geons of the present day to advise postpo- HARELIP. 627 tiing the cure of the harelip, till the child is about two years old. Perhaps, however, this apprehension does not vindicate quite so much delay. Mr. Sharp observes, " there are many lips, where the loss of substance is so great, that the edges of the fissure cannot be brought together, or, at best, where they can but just touch ; in which case, it need not be advised to forbear the attempt; it is like- wise forbid iu young children, and with reason, if they suck ; but otherwise it may be undertaken with great safety, and even with more probability of success, than in others that are older." (Operations in Sur- gery, chap. 34.) Le Dran performed the operation on chil- dren of all ages, even on those at the breast. B. Bell did it with success on an infant only three months old. Muys advises it to be un- dertaken as soon as the child is six months old. Roonhuysen operated on children ten weeks after their birth, and all his contem- poraries have praised his singular dexterity and success. As an essential step to tbe success of the operation, the latter surgeon recommended hindering the children from sleeping a certain length of time before it was undertaken, in order that they might fall asleep immediately afterward; and with the same view, opiates have been pre- scribed. Putting out of consideration the partial success, which has attended the use of blis- tering plaster for making the edges of the fissure raw and capable of union, all practi- tioners entertain the same sentiment, with regard to the object of this operation, which consists iu reducing the preternatural solu- tion of continuity to the state ol a smple wound, by cutting off the edges ofthe sepa- rated parts throughout their length, and then keeping these parts in contact until they have completely grown together. But al- though such principles have been generally admitted, there was formerly some differ- ence of opinion, with respect to the best method to be followed in practice ; some operators having preferred sutures for keep- ing the edges of the wound in contact; while others disapproved of them, believing that a perfect cure might always be accomplished by means of adhesive plaster and an uniting bandage, so as to save the patient from all the pain and annoyance of sutures. M. Louis thought, that the use of sutures, in the operation for the harelip, proceeded from a false idea respecting tbe nature of the disease ; for the fissure in tbe lip being wrongly imputed to loss of substance, it was deemed impossible to keep the parts in con- tact, except by a suture. " The separation of the edges of the fis- sure in tbe lip," says M. Louis, " is only the effect of the retraction of the muscles, and is always proportioned to the extent of the cleft. Persons with harelips, are capable of bringing the edges of the fissure together by muscular action, by puckering up their mouths. On the other hand, the separation 1 is considerably increased when they laugh. and the breach appears excessively large, after superficially paring off its edges on both sides. The interspace in the harelip must not, therefore, be mistaken for a loss of substance. Tbis truth is confirmed by the effects of sticking plaster, which has some- times been applied to the harelip, as a pre- paratory measure before the operation, and which materially lessens the separation of the parts. " According to the confession of all who have written fn favour of the twisted suture, it seems advisable only on the false idea, that the harelip is the effect of a greater or lesser loss of substance : and they say, posi- tively, that we must not have recourse to it when there is only a simple division to be united. The twisted suture must then be proscribed from the operation for the natu- ral harelip, since it is proved, that this mal- formation is unattended with loss of sub- stance. At the same time, a loss of substance is but too real, after the extirpation of scir- rhous and cancerous tumours, to which the lips are very subject. Yet, even in these cases, the extensibility of the lips allows an "attempt to be made to reunite the double incision, by which the tumour has been re- moved, and it succeeds without the smallest deformity, when care is taken to direct each incision obliquely, so that both of them form, where they meet, an acute angle, in the base of which the tumour is comprised. Here the means of union ought to be the more efficacious- because the difficulty of keeping the edges ofthe wound approxima- ted is greater. M. Pibrac in his memoir on the abuse of sutures, when speaking of the harelip, has already explained that they are badly conceived means, and more hurtful in proportion as there is a greater loss of sub- stance, because the greater the interspace is between the two parts, tiie more fear is there of their efforts on the needles or pins left in the wound. Hence, care has always been taken to make the dressings aid the opera- tion ofthe suture. After this consideration, judiciously made by the partisans of this plan, there was only one more step to be taken, according lo M. Pibrac, in order to evince the necessity of proscribing it. The cap, or copper head-piece, described by Ver- duc and Nuck, for compressing the cheeks ; the clasps of Heister ; and strips of adhesive plasters ; are all only inventions for the sup port ofthe parts, and keeping them from be- ing disunited. When the suture failed,it vvas by these mean?, that the original deformity was corrected, together with that produced by the laceration, which would not have occurred without the suture. As then the dressings, when methodically applied, are capable of effectually rectifying the mischief of the suture, M. Lous inquires, why should they be considered only as a resource in a mere accidental case/ Why should they not be made the chief and primary means of reuniting the lip, even when there is a loss of substance ? " Nothing can be opposed to the proofs adduced upon this point. Thev are even II ARK LI I' from the practice t.i those, who have em- ployed sutures without success. Such per- sons have themselves furnished the proofs of the bandage being capable of repairing the mischief resulting from the twisted su- ture." M. Louis, with a view of perfecting our notious on this matter, lays it down as a fact, tbat the retraction of the muscles be.ng the cause of the separation of the edges of the fissure, it is not to these edges we are to apply the force which is to unite them ; but that it should be applied further to the very parts, whose action (the cause of the sepa- ration) is to be impeded, and whose con- traction is thus to be prevented. A great many means for supporting the wound, only irritate the muscles and excite them to ac- tion, and it is this action which we should endeavour to overcome. The means for promoting union can only be methodical, when directly employed to prevent such ac- tion, by an immediate application on the point where it is to be resisted. The facility with which the parts may be brought for- ward, so as to bring the two commissures of the lips into contact, by the mere pressure of the hands, shows what may be expected from a very simple apparatus, vvhich will execute the same office without any effort, in a firm and permanent manner, and which will render sutures unnecessary, the incon- veniences of which are too well known. M. Lonis, after having explained the rea- sons ofthe theory, on which he founded his method, relates several cases, taken either from his own practice, or that of others, to il- lustrate itsadvantages. He details the history of twenty cases, in which his plan perfectly succeeded, both in accidental harelips, with considerable loss of substance, and in natu- ral ones. In most of these instances, how- ever, it was thought proper to assist the ban- dage with one stitch at the extremity of the fissure, close to the vermilion border of the lip, for the purpose of keeping the parts se- curely on a level. Notwithstanding the operation, as per- formed with the twisted suture, is opposed by an authority of such weight as that of M. Louis, still it is the method most com- monly practised. No modern surgeons doubt, tbat a harelip may be cured by means of adhesive plaster, and uniting bandages, quite as perfectly as with a suture ; and all readily allow, that the first of these methods, as be- ing more simple and less painful, would be preferable to the latter one, if it were equal- ly sure of succeeding. But it is considered far more uncertain in its effect. To accom- plish a complete cure, the parts to be united must be maintained in perfect contact, until they have contracted the necessary adhe- sion ; and how can we always depend upon a bandage for keeping them from being dis- phiced ? What other means, besides a suture, affords in this respect such perfect secu- rity ? ' I shall first describe the operation, as usu- ally done by surgeons of the present day with the twisted suture. The first thing i> to examine, whether there is any adhesion of the lip to the gum ; and if there be, to divide it with a knife. Some authors (Sharp) recommend the frenulum, vvhich attaches tbe lip to the gum, always to be divided: but when the harelip is at some distance from this part, it will not be in the way of the operation, and need not be cu». On the other hand, when the fraenuiuro is situated in the centre ofthe division, it is clear, that in operating we must necessarily include it in the incision, and it should therefore be divided beforehand, taking care not to en- croach too much upon the gum, lest the al- veolary process be laid bare ; nor too much upon the lip, because making it thinner would be unfavourable to its union. When one of the incisor teeth, opposite the fissure, projects forward, it must be drawn, lest it distend and irritate the parts, after they have been brought into contact. Sometimes, but particularly in cases in which there is a cleft in the bony part ofthe palate, a portion of the os maxillare superius forms such a projection, just in the situation of the fissure in the lip, that it would render the union very difficult, if not impracticable. In this circumstance, the common plan has been to cut off the projecting angles of bone with a strong pair of bone-nippers. The part was then healed, and the operation for the harelip performed. Instead of cutting oft'the projection of bone, which is always a painful measure, Desault used to employ simple compression, by which means the prominence was usually reduced in a few weeks, and the opportunity afforded of ope- rating for the cure of the harelip. (CEuvre* Chir. par Bichat, T. 2, p. 2o7.) Of course, the actual necessity for using bone-nippers, or even of having recourse to compression of the bony projection, will depend upon circumstances; for if the prominence of bone be sharp and irregular, no surgeon, 1 conceive, would hesitate about the removal of such inequalities, in preference to the trial of pressure. Mr. Dunn, of Scarborough, bas expressed to me his doubts whether cutting off the projections of the alveolary process be ever necessary, as the pressure of the entire lip gradually diminishes the de- formity. " I had (says he) two very un- seemly cases, with an immense division of the palate, together with a projection of the alveolar process, which, with the incisor teeth, resembled the talons of a bird. A tu- bercular appendage of skin hung upon the base of the nose. By drawing the teeth, in the first place, very delicately, I avoided fracturing the bony projection. I then cut off one edge of the nasal appendage, and of the lip of the same side, and attached them together with two needles. The wound was sufficiently united in a week or ten days to allow the same operation on the other side. In less than three weeks, the boy was sent home quite well to the astonishment of the neighbourhood, where bis frightful appear- ance made him an object of disgust and ridi- HARELIP. 629 cuie. 1 succeeded in the other case, even without the extraction of the teeth. Both the patients can now articulate labial sounds, retain their saliva, and are gradually losing the inconvenience of the passage of the mu- cus from the nose into the mouth, as the fissure is more contracted, and the projec- tion by no means so disagreeable." These facts should lessen the haste, with which certain operator^ proceed to cut off every projection of the alveolary process ; for a moderate prominence of bone witiout any sharp, irritating edges, or angles, will not hinder the success of tbe operation ; and even the propriety of reviving teeth must entirely depend upon their being likely, by their direction, to irritate the lip, and dis- turb the union of the fissure. In the operation, the grand object is to make as smooth and even a cut as possible, in order that it may more-certainly unite by the first intention, and of such a shape, that the.cicatrix may form only one narrow line. The edges of the fisiure should, there- fore, never pe cut off with scissors, vvhich constantly bruise the fibres which they di- vide, and a sharp knife is always to be pre- ferred. The best plan is, either to place any flat instrument, such as a piece of horn, wood, or pasteboard, underneath one por- tion of the lip. and then holding the part stretched and supported on it. to cut away the whole of the callous edge or else to hold the part with a pair of forceps, the un- der blade of which is much broader than the upper one : the first serves to support the lip ; the other contributes also to this effect, and at the same time, serves as a sort of ruler in guiding the knife in an accurately straight Tine. When the forceps are pre- ferred, the surgeon must of course leave on the side of the upper blade, just as much of the edge of the fissure as is to be removed, so that it can be cut off with one sweep of the knife. This is to be done on each side of the cleft, observing the rule, to make the new wound in straight lines, because the sides of it can never be made to correspond with- out this caution. For instance, if the harelip had this shape, the /~\ incision of the edges must be / \ continued in straight lines, till / \ Ihey meet in the manner here ' ] represented. In short, the two incisions are to be perfectly straight, and are ,. % to meet at an angle above, in or- /,\ der tbat the whole track of the s %. wound may be brought together f\ X\ and united by the first intention. Ij %^ Two silver pins, made with steel points, are next to be introduced through the edge of the wound, so as to keep them accurately in contact, tbe lowest pin being introduced first, near the inferior termination of the wound, and the upper pin afterward about a quarter of an inch higher up. A piece of thread is then to be repeatedly wound round the ends of the pins, from one side of the division to the other, first transversely, then obliquely, from the right or left end of one pin above, to the opposite end of the lower one, he. Thus the (bread is made to cross as many points of the wound as possible, whicb greatly contributes to maintaining its edges in even apposition. Any portibu of the wound above the pins, not closed by the preceding means, may now have its edges brought together with a strip of adhesive plaster. Lastly, the endsof the pins are to be supported by small dossils of lint, placed 1 t een them and the flesh ; a minute, but essential circumstance, which, as my friend, Mr. Dunn, ot Scarborough, reminds me, I forgot to mention in the last edition of this work. It is obvious, that a great deal of ex- actness is requisite in introducing the pins, in order that the edges of the incision may af- tervvard be precisely applied to each other. For (his purpose, some surgeons previously place the sides of the wound in (he best po- sition, and mark with a pen the points at vvhich the pins should enter, and come out again ; a method whirl], as far as my obser- vations extend, merit* imitation. The pins ought never to extend more deeply than about two-thirds t' . ough the substance of the lip, and it would be a great improvement always to have them of a flat, instead of a round shnpe, and a liltle^urved, as this is the course which they naturally ought to take when introduced. The steel points should also admit of being easily taken off when tbe pins have been applied, and, perhaps, having tinm to screw off and on is (he bes( mode, as removing them in this way is not so lik-ly to be attended with any sud- den jerk, which might be injurious to the wound, as if they were made to pull off. In general, the pins may be safely removed in about four days, when the support of stick- ing plaster will be quite sufficient. After the operation, the surgeon should never omit the use of compresses and a band- age for keeping forward the cheeks. The process just described, is what is well known by the name of the twisted suture, which is applicable to other surgical cases, in which the grand object is to heal some fistula or opening, by the first intention. Mr. Sharp says, it is of great service in fis- tula? of the urethra, remaining after the ope- ratiou for the stone, in whicb case tbe cal- lous edges may be cut off, and the lips ofthe wound held together by the above method. What has hitherto been stated, refers to the most simple form of the harelip, viz. to that which presents only one fissure. When there are two clefts, the cure is accomplish- ed on the same principle ; but it is rather more difficult of execution; so that the old sur- geons, until the time of Heisfer, almost all regarded the operation for the double hare- lip as impracticable, though tbey described it, with the direction to operate on each fis- sure, just as if it were single : M. de la Faye even operated in this way with success, (Mimoires de I'Acad. de Chirurgie, Tom. 4. 4/o.) M. Louis was of opinion, that all dif- ficulties would be obviated by doing Ihe ope- ration at two different times, and awaiting the perfect cure of one of the fissures, be- fore tbat of the other was undertaken. Heis- 630 HARELIP. ter had similar ideas ; but he never put the scheme in practice, nor did he even positive- ly ad rise it. After all, however, experience proves that it is not essential to perform two operations for the cure of the double harelip: Desault found, that when the edges of two fissures were pared off, and care taken to let one of the pins pass across the central piece of the lip, the practice answered extremely well. (See CEuvres Chir. par Bichat, T.2,p. 201.) In cutting off th»- edges of t> e fissure, the incision musi be carried lo the upper part of the lip ; and even when (he fissure does not reach wholly up (he lip, Ihe same thing should be done , for in this manner (he sides of the k ound will admit of being applied to gether mon un formly, and the cicatrix will have a better appearance. We should also not be ton sparing of tbe edges which are to be cut off. Practitioners, says M. Louis, persuaded that the harelip was a division with loss of substance, have invariably ad- vised the removal of the callous *dges. But in the natural harelip there is no callosity; the margins of the fissure are composed, like those of the lip itself, of a pulpy, fresh co- loured, vermiliontfesh, covered with an ex- ceedingly delicate cuticle. Tiie whole of the part having this appearance, must be ta- ken away, together with a little of the true skin. At the lower part of the fissure, to- wards the nearest commissure, a rounded red substance is commonly situated, which it is absolutely necessary to include in the incision. Were this neglected, the union below would be unequal, and, through an injudicious economy, a degree of deformity would remain. The grand object, however, is to make the two incisions diverge at an acute angle, so that the edges may" be put into reciprocal contact their whole length, without tbe least inequality. M. Louis used to operate as follows : the patient being seated in a good light, his head is to be supported on an assistant's breast, who, with the fingers of both hands, pushes the cheeks forward, in order to bring the edges of the fissure near to each other. These are to be laid on a piece of pasteboard, which is to be put between the jaw and lip, and be an inch and a half long, from twelve to fifteen lines broad, and at most one line thick. The upper end should be round- ed, by flattening ihe coiners. In order to fa- cilitate the incision, the lip is to be stretched over the pasteboard, the operator holding one portion over the right with the thumb and index finger of the left hand, while the assistant does the same thing on the left side. These being thus disposed, the edges of the harelip are to be cut off with two sweeps ofthe bistoury, in two oblique lines, forming an acute tingle above (hi- fi- ure. For the removal of (he edges of the hare- lip, scissors have sometimes been preferred lo a knife, but, notwithstanding Desault's partiality to them, as most convening, (See CEuvres Chir. par Bichat T. 2, p. 179,) tbey are now very generally disused. The pinch- ing and bruising which result from the action of the blades, are circumstances which can- not be favourable to the union of the wound ; and (hough they may not commonly be se- rious enough to prevent union by the first intention, they might occasionally tend, wiih any other untoward occurrence, to hinder (bis desirable eve^ t. Let not practitioners here be led by Mr. B. Bell's statement, that in one instance he eul off one side of tbe fissure with a knife, and the other w ith scis- sors ; thai the letter cut produced least pain, and that on this *ide there was no more swelling nor inflammation than ou the oppo- site one. The pins should be introduced at least two- thirds of (he way (hrough the substance of the lip. lest a furn>» should remain on the inside of the part, which might prove trou- blesome, by allowing pieces of food to lodge in it. There is, however, a stronger reason lor attending to this circumstance, viz. the hemorrhage which may take place when it is neglected. As soon as (he edges of the wound have been brought together by means of the suture, and the pins are properly placed, former of which are sometimes so distended as to be closed ; a feverish heat and thirst generally accompanyr it; the patient is rest- less, has a quick pulse, and most commonly a nausea, and inclination to vomit. " This accident generally happens to per- sons of bilious habit, and is indeed an in- flammation of the erysipelatous kind ; it is somewhat alarming to look at, but is not of- ten attended with danger. The wound does indeed neither look well, nor yield a kindly discharge, while the fever continues, but still it has nothing threatening in its appear- ance, nene of that look which bespeaks in- ternal mischief; the scalp continues to ad- here firmly to the skull, and the patient does not complain of lhat tensive pain, nor is he afflicted with that fatiguing restlessness which generally attends mischief under- neath the cranium. " Phlebotomy, lenient purges, and the use of the common febrifuge medicines, parti- cularly those of the neutral kind, generally remove it in a short time. When the inflam- mation is gone off, it leaves on the skin a yellowish tint, and a dry scurf, which con- tinue until perspiration carries them away, and upon the disappearance of the disease, the wound immediately recovers a healthy aspect, and soon heals without any farther trouble. " Wounds and contusions of the head, which affect the brain and its membranes, are also subject to an erysipelatous kind of swelling and inflammation : but it is very different, both in its character and conse- quences from the preceding. " In this, (which is one of the effects of inflammation of the meninges,) the febrile symptoms are much higher, the pulse har- der and more frequent, the anxiety and rest- lessness extremely fatiguing, the pain in the head intense ; and as Ibis kind of appearance is, in these circumstances, most frequently the immediate precursor of matter forming between the skull and dura mater, it is gene- rally attended with irregular shiverings, which are not followed by a critical sweat, nor afford any relief to the patient. To vvhich it may be added, that in the former ca«e, the erysipelas generally appears within the first three or four days; whereas in the latter, it seldom comes on till several days after tbe accident, when the symptomatic fe- ver is got to some height. In the simple erysi- pela-, although the wound be crude and undi- gested, yet it has no other mark of mischief j the pericranium adheres firmly to the skull, and upon the cessation of the fever, all ap- pearances become immediately favourable In that which accompanies injury done to the parts underneath, the wound not only has a spongy, glassy, unhealthy aspect, but the pericranium in its neighbourhood separates spontaneously from the bone, and quits all cohesion with it. In short, one is an acci- dent, proceeding from a bilious habit, and not indicating any mischief beyond itself; the other is a symptom, or a part of a disease, which is occasioned by injury done to the membranes of '.h". brain; "'ie nnrtei:it«IiMl«» 634 HEAD or no ill to the patient, and almost always ends well ; the other implies great hazard, and most commonly ends fatally. It is there- fore hardly necessary to say, that it behooves every practitioner to be careful in distinguish- ing them from each other. " If the wound be a small one, and has passed through the cellular membrane to the aponeurosis, and pericranium, it is sometimes attended with very disagreeable, and even very alarming symptoms, but which arise from a different cause, and are very distin- guishable from what has been yet mentioned. " In this, the inflamed scalp does not rise into that degree of tumefaction, as in the erysipelas, neither does it pit, or retain tbe impression of the fingers of an examiner, it is of a deep red colour, unmixt with the yel- low tint of the eryspelas; it appears tense, and is extremely painful to the touch ; as it is not an affection of the cellular membrane, and as the ears and the eyelids are not cover- ed by the parts in which the wound is inflict- ed, they are seldom, if ever, comprehended in the tumour, though they may partake of the general inflammation of the skin; it is generally attended with acute pain in the head, and such a degree of fever as prevents sleep, and sometimes brings on a delirium. " A patient, in these circumstances, will admit more free evacuations by phlebotomy, than one labouring under an erysipelas ; the use of warm fomentation is required in both, iu order to keep the skin clean and perspira- ble, but an emollient cataplasm, which is generally forbid in the former, may in this latter case be used to great advantage. *o HI'. AD tind abstinence, viz. by such means, •' those troublesome puffy enlargements and erysi- pelatous affections of the scalp, which so often succeed to bruises," are prevented, and, where the evacuant plan is duly ob- served, the " extensive and formidable ery- sipelatous affections, so common formerly, are rare and mild at present in military hos- pitals." 2. Effeds of Contusion on the Dura Mater and Parts within the Skull. It is observed by Mr. Pott, that by blows, falls, and other shocks, some of the larger of those vessels which carry ou the commu nication between the dura mater and the skull are broken, and a quantity of blood is shed upon the surface of that membrane. This is one species of bloody extravasation, and indeed the only one which can be formed between the skull and dura mater. If the broken vessels be few, and the quan- tity of blood which is shed be small, the symptoms are generally slight, and by pio- per treatment disappear. If they are large, or numerous, or the quantity of extravasa- ted fluid considerable, the symptoms are ge- nerally urgent in proportion ; but whether they be slight, or considerable, whether im- mediately alarming or not, they are always and uniformly such as indicate pressure made on the brain and nerves, viz. stu- pidity, drowsiness, diminution or loss of sense, speech, and voluntary motion. According to Mr. Pott, it also often bap- pens, from the same kjnd of violence, that some of the small vessels, which carry on the circulation between the pericranium, skull, and dura mater, are so damaged, as not to be able properly to execute that office, although there are none so broken as to cause an actual effusion of blood. " Smart and severe strokes on the middle part of the bones, at a distance from the su- tures, are most frequently followed by this kind of mischief; the coats of the small vessels, which sustain the injury, inflame and become sloughy, and in consequence of such alteration in them, the pericranium separates from the outside of that part of the bone, which received the blow, and the dura mater from the inside, the latter of which membranes, soon after such inflam- mation, becomes sloughy also, and furnishes matter, which matter being collected be- tween the said membrane and the cranium, and having no natural outlet, whereby to escape, or be discharged, brings on a train of very terrible symptoms, and is a very fre- quent cause of destruction. The effect of this kind of violence is frequently confined to the vessels connecting the dura mater to the cranium, in which case, the matter is ex- ternal to the said membrane ; but it some- times happens, that by the force either of the stroke or of the concussion, the vessels which pass between, and connect the two meninges, are injured in the same manner; in which case, the matter formed in conse- quence of such violence is found on foe surface of the brain, or between tbe pia and dura mater, as well as on the surface of the latter; or, perhaps, in all these three situa- tions at the same time. " The difference of this kind of disease, from either an extravasation of blood, or a commotion of the medullary parts of the brain, is great and obvious. All the com- plaints produced by extravasation, are such as proceed from pressure made on the brain and nerves, and obstruction to the cir- culation of the blood through the former; stupidity, loss of sense and voluntary-motion, laborious and obstructed pulse aud respira- tion, he. and (which is of importance to re- mark,) if the effusion be at all considerable, these symptoms appear immediately, or very soon after the accident. " The symptoms attending an inflamed or sloughy state of the membranes, in conse- quence of external violence, are very dif- ferent ; they are all of the febrile kind, and never, at first, imply any unnatural pressure; such are, pain in the head, restlessness, want of sleep, frequent and hard pulse, hot and dry skin, flushed countenance, inflamed eyes ; nausea, vomiting, rigour ; and toward the end, convulsion and delirium. And none of these appear at first, that is, immedi- ately after the accident; seldom until some days are passed. •' One set or class of symptoms is pro- duced by an extravasated fluid, making such pressure • on the brain and origin of the nerves, so as to impair or abolish voluntary motion and the senses ; the other is caused by the inflamed or putrid state of the mem- branes covering the brain, and seldom affects the organs of sense, until the latter end of the disease, that is, until a consider- able quantity of matter is formed, which matter must press like any other fluid. " If there be neither fissure nor fracture of the skull nor extravasation, nor commotion underneath it, and the scalp be neither con- siderably bruised, nor wounded, the mischief is seldom discovered or attended to for some few days. The first attack is generally by pain in the part which received the blow. This pain, though beginning in that point, is soon extended all over tbe head, and is attended with a languor, or dejection of strength and spirits, which are soon fol- lowed by a nausea, and inclination to vomit, a vertigo or giddiness, a quick and hard pulse, and au incapacity of sleeping, at least quietly. A day or two after this attack, if no means preventive of inflammation are used, the part stricken generally swells, and becomes puffy and tender, but not painful; neither does the tumour rise to any considerable height, or spread to any great extent: if this tumid part of the scalp be now divided, the pericranium will be found of a darkish hue, and either quite detached, or very easily separable from the skull, between which will be found a small quantity of a dark- coloured ichor. " If the disorder has made such progress, that the pericranium is quite separated and detached from the skull, the latter will even now be found to be somewhat altered in co- HEAD. 637 lour from a sound healthy bone. Of this al- teration it is not very easy to convey an idea by words, but it is a very visible one,and what some very able writers have noticed. " From this time the symptoms generally advance more hastily and more apparently ; the fever increases, the skin becomes hotter, the pulse quicker and harder, the sieep more disturbed, the anxiety and restlessness more fatiguing; a:;d to these are generally added irregular rigours, which arc not follow- ed by any critical sweat, and which, instead of relieving the patient, add considerably to his sufferings. If the scalp bas not been di- vided or removed, until the symptoms are thus far advanced, the alteration of the co- lour of the bone will be found to be more remarkable; it will be found to be whiter and more dry than a healthy one; or, as Fallopius has very justly observed, it will be found to be more like a dead bone : the sanies, or fluid, between it and the peri- cranium, will also, in this state, be found to be more in quantity, and the said membrane will have a more livid diseased aspect. " In this state of matters, if the dura mater be denuded, it will be found to be detached from the inside of the cranium, to have lost" its bright silver hue, and to be, as it were, smeared over with a kind of mucus, or with matter, but not with blood. Every hour after this period, all the symptoms are exas- Serated, and advance with hasty strides : the eadacb and thirst become more intense, the strength decreases, the rigours are more frequent, and at last convulsive motions, at- tended in some with delirium, in others with paralysis, or comatose stupidity, finish the tragedy. " If the scalp has not been divided till tbis point of time, and it be done now, a very of- fensive discoloured kind of fluid will be found lying on the bare cranium, whose appear- ance will be still more unlike to the healthy natural one ; if the bone be now perforated, matter will be found between it and the dura mater, generally in considerable quantity, but different in different cases and circum- stances. Sometimes it will be in great abundance, and diffused over a large part of the membrane ; and sometimes the quantity will be less, and consequently the space which it occupies smaller. Sometimes it lies only on the exterior surface of the dura mater; and sometimes it is between it and the pia mater, or also even on the surface of the brain, or within the substance of it, he. " As the inflammation and separation of the dura mater is not an immediate conse- quence of the violence, so neither are the symptoms immediate, seldom until some days have passed ; the fever at first is slight, but increases gradually; as the membrane becomes more and more diseased, all the febrile symptoms are heightened ; the forma- tion of matter occasions rigours, frequent aud irregular, until such a quantity is collected, as brings on delirium, spasm, and death." Hitherto Mr. Pott has been describing this disease as unaccompanied with any other, not even with any external mark of injury, except perhaps a trifling bruise of the scalp ; " Let us now, (says this eminent surgeon) suppose the scalp to be wounded at the time of the accident, by whatever gave the contusion ; or let us suppose, that the imme- diate symptoms having been alarming, a wound had been made, in order to examine the skull. " In this case, the wound will for some little time have the same appearance as a mere simple wound of this part, unattended with otbc- mischief, would have ; it will, like that at first discirarge a thin sanies, or gleet, and then begin to suppurate ; it will digest, begin to incarn, and look perfectly well; but, after a few days, all these fa- vourable appearances will vanish; the sore will lose its florid complexion, and granula- ted surface ; will become pale, glassy, and flabby ; instead of good matter, it will dis- chargeonly a thin discoloured sanies; the lint with which it is dressed, instead of coining off easily (as in a kindly suppurating sore) will stick to all parts of it; and the pericranium instead of adhering firmly to the bone, will separate from it, all round, to some distance from the edges. " This alteration in the face and circum- stances of the sore, is produced merely by the diseased state of the parts underneath the skull; which is a circumstance of great importance, in support of the doctrine ad- vanced ; and is demonstrably proved, by observing that this diseased aspect of the sore, and this spontaneous separation of the pericranium, are always confined to that part which covers the altered or injured portion of the dura mater, and do not at all affect the rest of the scalp; nay, if it has by accident been wounded in any other part, or a portion has been removed from any part where no injury has been done to the dura mater, no such separation will happen, the detachment above will always corres- pond to that below, and be found nowhere else. " The first appearance of alteration in the wound immediately succeeds the febrile attack; and as the febrile symptoms increase, the sore becomes worse and worse, that is degenerates more and more from a healthy kindly aspect. " Through the whole time, from the first attack of the fever, to the last and fatal period,an attentive observer will remark the gradual alteration of the colour of tbe bone if it be bare. At first it will be found to be' whiter, and more dry, than the natural one ; and as the symptoms increase, and either matteriscollected,orthedura mater becomes sloughy, tbe bone inclines more and more to a kind of purulent hue, or whitish yellow • and it may also be worth vvhiie in this place to remark, that if the bhnv was on or very near to a suture, and the subject young, the said suture will often separate in such a man- ner as to let through it a loose painful ill- natured fractures at- tended with depression, there are other inleti- tions. In these tbe depressed parts are to be elevated, and such as are so separated hs *<<■ HEAD. 643 be incapable of reunion, or of being brought to lie properly, and without pressing on the brain, are to be totally removed. These circumstances are peculiar lo a depressed fracture; but although they are peculiar, they must not be considered as sole, but as additional to those whicb have been men- tioned at large under the head of simple fracture : commotion, extravasation, inflam- mation, suppuration, and every ill which can attend on, or be found in the latter, are to be met with in tbe former, and will require the same method of treatment." That loo?e splintered pieces of the cranium, when quite detached, and already in view, in conse- quence of the scalp being wounded, ought to be taken away, no onr will be inclined to question. That they ought also to be ex- posed by an incision, even when the scalp is unvvounded, and then taken away, when- ever they cause symptoms of irritation, or pressure, I believe, will be universally al- lowed. But the reader will already under- stand, from what has been said in tbe prece- ding section, that several excellent surgeons do not coincide with Pott, in believing that every depressed fracture of the skull neces- sarily demands ibe application of tbe tre- phine. " There certainly are (says Mr. Aberne- thy) degrees of this injury, whicb it would be highly imprudent to treat in this manner. Whenever the patient retains his senses per- fectly, I should think it improper to trephine him, unless symptoms irose that indicated the necessity of it." (P. 21.) It is extraordinary and un ccountable, but it is not less true, tbat no calculation of tbe bad effects can be made by (he degree in which a part of tbe skull is depressed. This is a fact which has been long known. It has also been particularly adverted lo by an emi- nent modern writer. " Various instances also presented themselves, in vvhich, though a considerable degree of compression must have been occasioned, sometimes by the de- pression of both tables, and at other times by the depression ofthe inner table only of (he skull, yet neither stupor, paralysis, nor loss of memory were produced. In one of these cases, the middle of the right parietal bone was fractured, and considerably depressed by a ball, which was extracted on the twen- tieth day. In this case, neither stupor nor Earalysb appeared. In another, a musket- all had struck the right parietal bone, frac- tured it, and was flattened and lodged be- tween the tables of the skull. The inner ta- ble was much depressed, yet no bad symp- toms supervened." (See Thomson's Obser- vations made in the Military Hospitals in Bel- gium, p. 59, 60.) The same author also saw a singular case, in which a ball, entering be- hind the right lemple, and passing backwards and downwards, had fractured the bones in its passage, and lodged in tbe surface of the brain, over the tentorium, from which place it was extracted on tbe seventeenth day after Ihe injury. No bad symptom bad manifest- ed itself previously to the operation, and the man recovered under the strictest antiphlo- gistic regimen, with little or no constitutional derangement. Dr. Hennen has recorded two cases, fully proving the correctness of Mr. Ahernethy's opinion about the impropri- ety of using the trephine in cases of de- pression, unattended with urgent symptoms : in one of these instances, the upper and pos- terior angle of (he parietal, which bad been struck by a musket-ball, was depressed ex- actly an inch and a quarter from the surface rf the scalp, yet no bad symptoms followed, and wiih (he aid of bleeding and other anti- phlogistic remedies, the soldier recovered perfectly in a few weeks. " In a similar case, where tbe man survived thirteen years, with no other inconvenience than occasional determination of blood to the head on hard drinking, a funnel-like depression to the depth of an inch and a half was formed in the ver- tex." (See Hennen's Military Surgery, p. 287. Ed. 2.) If then the violence of the symptoms is not always in proportion to the compression, but is sometimes considerable when the pressure is slight, every surgeon cannot be too fully impressed with tbe following truth, tbat existing symptoms of dangerous pressure on the brain, which symptoms will be pre- sently related, can alone form a true reason for perforating the cranium. The mode of operating, in order to elevate depressed por- tions of tbe skull, is explained in the article, Trephine. In military surgery, particular cases pre*- sent themselves, vvhich scarcely admit of be- ing comprehended within (he tenor of any general rules and principles. Thus, it some- times happens, that a ball breaks the os fron- tis, and the whole or a part of it lodges in the frontal sinus, with or without fracture of (he inner boundary of (his cavity. In cases of this description, Baron Larrey recom- mends exposing tbe course of (he fracture by a free incision, and the use of the trephine for the removal of the extraneous body. When ihe inner side of the sinus was found broken and depressed, he next perforated that part of the cavity wiih a small conical trephine, took away such pieces of bone as required removal, and let out any extravasa- ted blood. Sometimes, however, tbe front of the sinus is so splintered, that the frag- ments, when taken away with (he forceps, leave tbe cavity sufficiently opened, not only for the extraction of the ball, but for the ap- plication of ihe trephine to the inside of the sinus, as we find exemplified in one of the two c«sesof this nature,which Larrey met within the Egyptian campaign. (Mem. de Chir. Militaire, T. 2, p 138.) After tbe battle of Witepsk, in 1812, he was called to two Rus- sian soldiers, whose cases were remarkable ; one of them had been struck above the ri^ht eyebrow with a grape-shot, which, after breaking and penetrating the frontal bone, entered the cavity of the cranium, so as to lodge upon the anterior right lobe of the brain, and the orbitar process and internal crista of the os frontis. Notwithstanding the large size of the bull, little of it could be seen externally, and the aperture through •i-H HEAD which it had passed, was not more than three or four lines broad ; every attempt to extract it, therefore, was vain. The patient experi- enced a painful sense of oppression and weight in the head, and whenever he inclined it backward, w-as seized with syncope. He kept himself constantly in a silting posture, with his head on his knees. Larrey adds, that every symptom of compression of the brain also prevailed, though this account is rather difficult to comprehend, considering that thepatient could sit up, and choose his pos- ture. As for any description given by him- self, of his sufferings, that is another circum- stance on vvhich I should not be inclined to dwell, supposing, that probably the Baron was notable to converse in the Russian lan- guage, and that the inferences, respecting tbe man's feelings, were made in some other way. But whatever might be the real slate of the symptoms, (and in a case of tbis kind a cor- rect account of them would have been in- teresting,) the ball was plainly ascertained, by means of a probe, to be of iron, and of much larger diameter than the opening, through which it had entered; and, that for the purpose of extracting it, the application of the trepan was urgently necessary. The fracture was fairly brought into view by suit- able incisions, three perforations were made with a small trephine at its upper part, and after (he removal of ihe angles of the bone between these perforations, the ball, which weighed seven French ounces, .was readily extracted w ith the aid of a strong pair of forceps, and an elevator. A considerable quantity of coagulated blood was also re- moved, under vvhich the brain was found with a depression of three or four lines deep. As soon as some splinters of the bone had been taken away, the part was dressed with a bit ot fine linen dipped in warm wine, sweetened with sugar, over which were placed charpie, several compresses, and a bandage. Wiih respect to the application of warm wine, and other stimulants, to the sur- face of the brain, in wounds exposing or in- teresting that organ, it seems to be an invaria- ble practice with Larrey, as well as Schmuc- ker, and the older surgeons. On what prin- ciple the custom is still kept up ? and whe- ther it is truly right and useful ? are questions which ma,, be rationally put. In whatever way experience may hereafter decide these matters, suffice it to add, that the patient was relieved by the treatment, and fell into a quiel sleep for two hours; but in tbe even- ing he became feverish, and the wound acutely painful. A considerable quantity of blood was taken from the vena saphena, (and w by bleeding was not practised at first, seems extraordinary.) The dressings, which according to my ideas, were highly objection- able, were removed, and a large emollient poultice applied. Cooling beverages, con- taining a small quantity of tartarized anti- mony, and antispasmodic anodyne medi- cines, were prescribed. The following day, the patient's state appeared satisfactory, without tbe slightest disturbance of the sen- ses, and in due time, he perfectly recovered. The other soldier had been wounded in the left temple, with a lead ball, five days he- fore Larrey saw him. One half of tbe ball had gone into the cranium, through a very narrow breach ; the other had burrowed under the temporal muscle, and lodged near the mastoid process. The rigbt side of the body was paralytic, the senses were annihi- lated, and the man was in a state of inces- sant agitation. After dilating the wound in the temple, and exposing (he fracture, Lar- rey discovered the track ofthe piece of lead, which had gone towards the mastoid process, and which he immediately extracted by a counter-opening. At the lower part of tbe temporal wound, he applied a trepan very near the spot where the other portion of the ball was lodged. This, w ith some fragments of (he bone, and extravasated blood, was easily extracted. The patient, however, was not saved; a circumstance ascribed by Larrey, to the operation having been done too late. In another case, one of the Imperial Guards, wounded at the battle of Moskowa, died with symptoms of compression, and, after death, a quarter of a bullet, and a frag- ment of bone, were found under the skull, attended with an ulcerated (or wounded) state of the adjacent portion of the brain. Larrey very properly expresses his opinion, tbat this soldier would have had a chance of being saved, had the trepan been used. (See Mim. de Chir. Mil. T. 4, p. 183, fa.) The practice of trephining for the removal of balls, situated near a fracture of the skull, within this bony cavity, or lodged among the fragments, or between the two tables, forced asunder, (see Engel's Case in Ver- misehte Chir. Schriften von J. L. Schmucker. B. \,p. 242,) is not peculiar to Larrey, for it has been done by many other surgeons, (see Schmucker's Wahrnehmungen, B. 1, p. 298; but, I do not know, that he has been antici- pated in his bold practice of making a coun- ter-opening in the skull, when the ball is lodged at such distance from the fracture, that it cannot be extracted through any per- foration made in the vicinity of the original injury ; for, it is a principle, which he ven- tures to lay down, that when a ball has enter- ed the cranium, without quilting the root of this cavity, the case is one requiring the appli- cation of the trepan. Mim. de Chir. Mil. T. 4, p. 180.) In the 2d vol of this work, (p. 139,) the reader will find the account of a soldier, who was struck on the middle of the forehead with a ball, which penetrated the os frontis, and then passed obliquely back- wards, between the skull and the dura mater, in the course of the longitudinal sinus, as far as the lambdoidal suture, where it stopped. Larrey traced the situation of the ball, by the introduction of an elastic gum catheter into the opening and measuring the distance between the fracture and the place, where he felt the ball, he cut down uponthat part of the skull, beneath which he con- cluded that the ball was lodged. The bone was then perforated with a large trepan ; a good deal of pus was discharged; the ball was extracted, and the patient recovered HEAD. 645 One thing here merits the attention of sur- geons : Larrey tells us, that a good deal of pus issued as soon as a" opening was made in the skull; there t ; /i then have been suppuration under tn- •>•■«, and inflamma- tion and detachment i-t the dura mater; cir- cumstances always indicated, according to Pott, by a corresponding separation of the pericranium, and a puffy tumour of the scalp. Did these symptoms take place in the foregoing case, so as to be of any assist- ance to Larrey, in judging of the place where the ball was lodged ? And, has the mentioi of them been omitted only by ac- cident ? or, are we to infer, that suppuration may happen between the cranium and dura mater, without any detachment of the pericranium and puffy tumour of the scalp; a thing, which Bichat asserts, is proved by daily experience in the Hotel- Dieu, at Paris ? (See CEuvres Chir. de De- sault, T. 2, p. 29.) Larrey, in his 3d vol. p. 82, gives us another case, in which a ball pierced the left parietal bone, and lodged near the lambdoidal suture. Its situation was detected with the aid of an elastic gum catheter, and partly in consequence of there being a slight ecchymosis over the part. Here a crucial incision was made through the scalp, and a small fissure discovered. As the symptoms of compression increased, the trepan was applied, so as to include the fis- sure. A half of the ball flattened was found directly under the perforation, and a good deal of blood was voided from the two openings in the cranium. For a fortnight, the case went on favourably, but the pa- tient was then attacked with what Larrey terms hospital fever, but which, in all probability, was inflammation and suppura- tion of the membranes of the brain, and died. The records of surgery furnish numerous instances, in which tbe patients lived a con- siderable time with balls lodged in the cavity of the cranium. Thus, one is related by Paroisse, where the patient soon recovered his senses after the injury, and at the end of six months, felt no inconvenience, except a difficulty of opening the mouth (Opuscu- les de Chir. Obs. 1, 8vo. Paris, 1806.) Ramdohr has published another case, where a soldier was shot through the frontal sinus, and the ball was found after death in the me- dullary substance of the left hemisphere of the brain, half an inch above the ventricle: yet, this patient lived four months after the injury, and soon recovered his senses after its occurrence. For a considerable part of this time, he was also free from any bad symptoms. At last, he was affected with a kind of stupor, and an inability to open his left eye, and fell into a lethargic, and con- vulsed state. (Schmucker Vermisehte Chir. Schriften, B. I, p. 277 ) A French soldier, at the battle of Waterloo, was wounded with a musket-ball, vvhich entered at tbe anterior portion of the squamous suture, lodged in the substance of the brain, and on the fifth day, after an enlargement of Ihe wound, and the removal of several fragments of bone, was extracted from the posterior lobe of the right hemisphere of the brain, where it was found resting on the tentorium. Yet, du- ring the several previous days, the man, with the exception of a slight headach, and par- tial deafness of the right ear, seemed to en- joy perfect health. The case ended well. (See Hennen's Mil. Surg. p. 289. Ed. 2.) Still more remarkable instances of the dura- tion of life, and even ofthe absence of very serious symptoms, after great and serious wounds of the brain, and the lodgment of balls, might here be cited ; but, it will suffice to refer to the instructive Essay of M. Q_uesnay, on the subject, in vol. 1, of the Mem. de I'Acad. de Chir. 4to. and to the ac- count of twenty-two French soldiers, whose vertices, with more or less of the brain, were cut off by sabre strokes All these men ultimately died ; but, at first, had not a single bad symptom, and performed a journey of thirty leagues after being wounded, and one half of this distance on foot. (See Paroisse Opuscules de Chir. p. 41, fa.) 5: Extravasation under the Cranium, Symp- toms of Pressure on the Brain, fa. Mr. Pott remarks, " the shock, which the head sometimes receives by falls from on high, or by strokes from ponderous bodies, does not unfrequently cause a breach in some of the vessels, either of the brain, or its meninges ; and thereby, occasions extra- vasation of the fluid, which should circulate through them. This extravasation may be the only complaint produced by the acci- dent ; or it may be joined with, or added to, a fraclure of the skull. But this is not all for it may be produced not only when the' cranium is unhurt by the blow, but even when no violence of any kind has been of- fered to, or received by the head." The effused blood may lie between the cranium and dura mater, between the latter membrane and the pia mater; or in the sub- stance, or cavities of the brain. The first species of extravasation, which is observed to be always more or less circumscribed may occur at any part of the skull, but when situated at its base, is generally fatal In the second, the blood is widely scattered about between the dura mater and arachnoides and on this account, unless its quantity be very considerable, it does not cause any great degree of pressure. In the third ex- ample, if the blood be situated in the convo- lutions, it is also widely diffused, but if it be within the substance, or ventricles, of the brain, it is circumscribed ((Euvres Chir. de Desault par Bichat, T. 2, p. 23.) Some- times, in cases of great violence, as Mr. Pott has justly observed, the blood is found at the same time in all these different parts When the blood is extravasated beneath the skull, the violence, which produces the rupture of the vessel, usually stuns the pa- tient, from which state, provided the quan! tity and pressure ofthe blood, and the force of the concussion be not too great, he gradually recovers, and regains his senses. If the first extravasation be trivial, the patient, after re- G4G HEAD. Saining his senses, may only feel a little rowsiness, and go to bed. The bleeding from the ruptured vessel continuing, and the pressure on the brain increasing, he becomes more and more insensible, and begins to breathe in a slow, interrupted, stertorous manner. In cases of compression whether from blood or a depressed portion of the skull, there is a general insensibility ; the eyes are half open, the pupils dilated, and motionless, even before the vivid liaht of a candle ; the retina is insensible ; the limbs relaxed ; the breathing stertorous ; the pulse slow, and, according to Mr. Abernethy, less subject to intermission, than in cases of con- cussion. The absence of stertor, however, as this gentleman admits, must not be relied upon, as a proof of there being no compres- sion ; for, Morgagni relates dissections of apoplectic persons, in whom the effusion was considerable, yet no stertor occurred. In a case of wound of the posterior part of the skull, with depression, seen by Dr. J. Thomson, the pulse at one time sunk as low as 36 strokes in a minute. This emi- nent professor, however, is at variance with Mr. Abernethy upon one point, by stating, that irregularity of the pulse is a very fre- quent attendant upon compres.sed brain. (Report of Observations, fa. p. 54, 55.) Some- times convulsions arose from the pressure of portions of the skull, driven in upon the brain. This is a very dangerous symptom ; but Dr. Thomson saw it cease iu a few ex- amples, after the depressed piece of bone had been elevated, and the antiphlogistic re- gimen adopted. (P. 60.) Convulsions, I am disposed to regard with Bichat, rather as a symptom of injury of the brain, than of compression. (CEuvres Chir. Desault, T. 2, p. 27.) Indeed, the difficulty of the diagnosis of many cases may be well conceived by what Dr. Hennen remarked, in his practice, viz. that, in some instances, the pupils were con- tracted, in others dilated, where the injury was nearly of a similar nature and degree ; while, sometimes,, in the same patient, one pupil was dilated, and the other much con- tracted. He saw, also, paralysis occur on one side, and convulsions on the other, when the blow had been on the forehead and the same when it had been on the occiput. (Op. cit. p. 300,301.) The patient is hardly ever sick, when the pressure on the brain and the general insen- sibility, are considerable ; for the very action of vomiting betrays sensibility in the stomach and oesophagus. These symptoms are not peculiar to pressure from blood, but arise also from that of many depressed fractures of the skull, and of suppuration under this part. They are all attributable to the unna- tural pressure made on the brain and nerves, and have too often been mistaken, as i, di' cations of an injury, which, considered ab- stractedly, can never cause them ; we allude to a simple undepressed fracture of the cra- nium, vvhich may be accompanied with them, but cannot cause them. They differ in degree, according to the quantitv, kind, and situation of the pressing fluid. The he morrhage from the nose and ears, vvhich often follows violence applied to the head, leads to no particular or useful inference : we cannot even calculate, by this sign, that the force has exceeded a certain degree; for, such bleedings take place, in some per- sons, from much slighter causes than in others. Paralysis is a symptom, which generally attends hurtful pressure on the brain. The particular circumstance-, however, which determine its degree, extent, and situation, are not well understood. " In some in- stances of paralysis from sabre-wounds, as well as in those made by gunshot, (says Dr. J. Thomson) paralysis was confined to the upper, and in others to the lower extre- mity. In every instance, in which it dis- tinctly appeared that the injury existed on one side of the head, the paralysis uniformly ma- nifested itself upon Ihe other ; but, we were unable to perceive any other fixed relation, between the part of the brain, which had been injured, and the part of tbe body affected with palsy. A wound of the right parietal bone by a musket-ball was followed by palsy of the left arm and .leg. In an- other case, a wound, penetrating the upper part of the right parietal bone, was accom- panied with a slight paralytic affection ofthe left side of the mouth, and complete palsy of the left leg. In a third case, a sabre- wound of the same bone, followed by exten- sive exfoliations, gave rise to a complete palsy ofthe leftside." (Observations made in the Military Hospitals in Belgium, p. o2, 53.) With respect to paralysis, it is unquestion- ably one ofthe common symptoms of pres- sure on the brain ; but, according to Bichat, it may also be caused by concussion; and we know,-that it may arise, in cases of in- flammation and suppuration, within the skull. Tbe above statement respecting the paralysis being always on the side of 'the body opposite that on which the brain is compressed, agrees with what is generally remarked by other surgical writers. (See Larrey's Mim. de Chir. Mil. T. 4, p. 180; Hennen's Principles, p. 301, Ed 2, fa.) Yet, at the H6tel Dieu, at Paris, says Bichat, extravasation has very often been found both on the side affected with paralysis, and the opposite one ; or else the blood was generally diffused, while the paralysis was local. (CEuvres Chir. de Desault, T. 2, p 27.) ' l The preceding class of symptoms only informs us, that the brain is suffering com- pression, and leaves us quite in the dark respecting several other very important cir- cumstances. " We not only have no cer- tain infallible rule, whereby to distinguish what the pressing fluid is, or where it is situated, but w are, in many instances, ab- solutely incapable of knowing, whether the symptoms be occasioned by any fluid af all; for, a fragment of bone broken off from the internal table of the cranium, and making an equal degree of pressure, will produce exactly HEAD. -647 the same complaints." (Pott.) In detailing the symptoms of pressure from blood, 1 took particular notice of the patient being at first enerally stunned by the blow ; of his gra- ually regaining his senses, and of his after- ward relapsing into a state of insensibility again. The interval of sense, which thus oc- curs, was pointed out by Petit as a circum- stance ofthe greatest consequence in eluci- dation ofthe nature ofthe case " A concussion, and an extravasation fas Mr. Pott observes,) are very distinct causes ol mischief, though not always very distin- guishable. " M. Le Dran, and others ofthe modern French writers, have made a very sensible and just distinction between that kind and degree of loss of sense which arises from a mere commotion of the brain, and that which is caused by a mere extravasation, in those instances, in which the time of the attack, or appearance of such symptoms, are different, or distinct. The loss of sense, which immediately follows the violence, say they, is most probably owing to a com- motion ; but that which comes on after an interval of time has past, is most probably caused by extravasation. "This distinction is certainly just and good, as far as it will go. That degree of abolition or diminution of sense, which im- mediately attends or follows the blow or fall, and goes off again without the assist- ance of art, is in all probability occasioned by the sudden shake, or temporary derange- ment of the contents ofthe head; and the same kind of symptoms recurring again some time after they had ceased, or not coming on until some time has passed from the receipt of the violence, do most proba- bly proceed from the breach of a vessel within or upon the brain. But unluckily, we have it not very often in our power to make this exact distinction An extravasa- tion is often made so immediately, and so largely, at the instant of the accident, that all sense and motion are instantaneous- ly lost, and never again return. And it also sometimes happens, that although an extra- vasation may possibly not have been made at the moment of the accident, and the first complaints may have been owing to com motion merely, yet a quantity of fluid hav- ing been shed from its proper vessels very soon after the accident, and producing its proper symptoms, before those caused by the commotion have had time to go off, the similarity of the effects of each of these different causes is such, as to deprive us of all power of distinguishing between the one and the other, or of determining with any tolerable precision, to which of them such symptoms as remain are really owing." As Bichat remarks, a man meets with a fall ; a slight concussion of the brain is the consequence, and the patient is instantly stunned. The effects of concussion gradu- ally subside, but an extravasation takes place, and the loss of the senses continues, (hough from a different cause. Here, accord- ing to HEAD discharge it. Mr. Pott then lays it down as a rule, that a large extrav asation must neces- sarily require a more free removal of bone than a small one ; and a grumous or coagu- lated extravasation, a still more free use of the instrument. All cases of pressure on the brain are at- tended with hazard of inflammation of this organ, and its membranes. The danger must be averted, as much as possible, by apply- ing cold washes to the bead, -ind employing free and repeated bleeding, leeches, anti- inonials, saline purgatives, aud other anti- phlogistic means. coijcussion, or commotion of the bkais. It is observed by Mr. Pott, that " very alarming symptoms, followed sometimes by the most fatal consequences, are found to attend great violence offered to the head; and upon the strictest examination, both of the living and the dead, neither fissure, frac- ture, nor extravasation of any kind can be discovered. The same symptoms, and the same event are met with, when the head has received no injury at all ab externo, but has only been violently shaken ; nay, when only the body, or general frame, has seemed to have sustained the whole violence." And he afterward remarks, that " the symptoms attending a concussion are generally in pro- portion to the degree of violence which the brain itself has sustained, and which indeed, is cognizable only by the symptoms. If the concussion be very great, all sense and power of motion are immediately abolished, and death follows soon; but between this degree, and that slight confusion (or stun- ning as it is called,) which attends most vio- lences done to the head, there are many stoges." I am of opinion, that Mr. Aberne- thy has particularly excelled other writers, in his description of the symptoms of con- cussion, which he thinks may be divided into three stages. " The first is, tbat state of insensibility and derangement of the bodily powers, which immediately succeeds the accident. While it lasts, the patient scarcely feels any injury that may be inflicted on him. His breath- ing is difficult, but in general without stertor; his pulse intermitting, and his extremities cold. But such a state cannot last long ; it goes off gradually, and is succeeded by ano- ther, which I consider as the second stage of concussion. In this, the pulse and respira- tion become better, and though not regu- larly performed, are sufficient to maintain life, and to diffuse warmth over the extreme parts of the body. The feeling ofthe patient is now so far restored, that he is sensible if his skin be pinched ; but he lies stupid and inattentive to slight external impressions. As the effects of concussion diminish, he be- comes capable of replying to questions put to him in a loud tone of voice, especially when they refer to his chief suffering at the time, as pain in the head, he.; otherwise, he answers incoherently, and as if his at- tention was occupied by something else. As long as the stupor remains, the inflam- mation of the brain seems to be moderate , but as the former abates, the latter seldom fails to increase; und this constitutes the third stage, vvhich is the most important of the series of effects proceeding from con- cussion. "These several stages vary considerably in their degree and duration; but more or less of each will be found to take place in every instance where the brain has been vio- lently sln.ken Whether they bear any cer- tain proportion to each other or not, I do not know. Indeed, this will depend upon such a variety of circumstances in the con- stitution, the injury, and the after-treatment, that it must be difficult to determine. " W ith regard to the treatment of concus- sion, it would appear, that in the first stage very little can be done; and perhaps, what little is done, had better be omitted, as the brain and nerves are probably insensible to any stimulants that can be employed. From a loose, and I think, fallacious analogy be- tween the insensibility in fainting, and that which occurs in concussion, the more pow- erful stimulants, such as wine, brandy, and volatile alkali, are commonly had recourse to, as soon as the patient can be got to swallow. The '-arae reasoning which led to the em- ployment of these remedies in the first stage, in order to recall sensibility, has given a kind of sanction to their repetition in the second, with a view to continue and in- crease it. " But here the practice becomes more pernicious and less defensible. The cir- cumstance of the brain having so far reco- vered its powers, as to carry on the animal functions in a degree sufficient to maintain life, is surely a strong argument that it will continue to do so, without the aid of means vvhich probably tend to exhaust parts alrea- dy weakened, by the violent action they in- duce. " And it seems probable, that these stimu- lating liquors will aggravate that inflamma- tion which must sooner or later ensue." (Essay on Injuries ofthe Head, p. 59.) The following passage, extracted from a writer, who has already been of material as- sistance to us on this subject, cannot be too deeply impressed on the memory of every surgical practitioner. '•' To distinguish between an extravasation and a commotion, by the symptoms only, is frequently a very difficult matter, sometimes an impossible one. The similarity of the effects in some cases, and the very small space of time which may intervene between tbe going off of the one, and accession of the other, render this a very nice exercise of the judgment. The first stunning or depri- vation of sense, whether total or partial, may he from either, and no man can tell from which ; but when these first symptoms have been removed, or have spontaneously disappeared; if such patient is again op- pressed with drowsiness, or stupidity, or to- tal or partial loss of sense, it then becomes most probable, that the first complaints were HEA HEM 651 from commotion, and that the latter are from extravasation ; and the greater the dis- tance of time between the two, the greater is the probability not only that an extravasa- tion is the cause, but that the extravasation is of the limpid kind, made gradatim, and within the brain. " Whoever seriously reflects on the nature of these two causes of evil within the cra- nium, and considers them as liable to fre- quent combination in the same subject, and at the same time considers, that in many in- stances no degree of information can be ob- tained from tbe only person capable of giving it (the patient,) will immediately be sensible, how very difficult a part a practi- tioner has to act in many of these cases, and how very unjust it must be to call that ig- norance, which is only a just diffidence ari- sing from the obscurity of the subject, and the impossibility of attaining materials to form a clear judgment. " When there is no reason to apprehend any other injury, and commotion seems to be the sole disease, plentiful evacuation by phlebotomy and lenient cathartics, a dark room, the most perfect quietude and a very low regimen, are the only means in our power; and are sometimes successful." (Pott.) With these means should also be associated the constant application to the head of cloths dipped in very cold water, or Schmucker's frigorific lotion ; and where the symptoms increase, or prove obstinate, blisters. Leech- es are also frequently of great service. I cannot conclude this article without ad- verting to the s;reat propensity to relapse, after patients have long appeared out of every danger from wounds of the head, the bad symptoms sometimes coming on again, and proving fatal, many years after the origi- nal injury, as is exemplified in a case related in a work of high character, (^ee Schmuc- ker's Vermisehte Schriften, B. I,p. 247.) Hippocrates, de Capitis Vulneribus, l2mo. Lutelia, 1578. Jac.Berengarius, de Fractu- ra Cranii Bologna, 1513. James Yonge, Wounds ofthe Brain proved curable, not only by the opinion and experience of many of the best authors, but ihe remarkable history of a child cured of two very large depressions, wiih the loss of a great part ofthe skull ; a portion of the brain also issuing through a penetrating wound of the dura and pia mater. \2mo. Lond. 1682. J.J- Wepjer, Observationes Me- dico-praclicai de Affedibus Capitis inlernis el cxternis. Scaphusii, 1727. Murray, An post gravem ab iclu vel casu capitis percussionem, non juvante etiam iterata terebratione, dura nieninx incisione aperienda f Luld. Paris, 1736. (Haller, Disp. Chir. 1, 97.) R. C. Wagner, De Contrafissura, Jena, 1708. (Haller, Disp Chir. I, 15.) J. C. Teubeler, De Vulneribus Cerebrinon semper lethalibus, Hala, 1760. ./. Chr. Camerarius Diss. Inaug. exhibens rarissimam sanationem Cerebri quas- saticum nolabili substantia deperditione, Tu- bing. 1719. Alex. Camerarius et Th. Fr. Faber De Aposlemale Pia Matris, Tubing. J722. J. A. Conradi, Dc Vulnere fronti in- flido,Lugd. 1722. M. E. Boretius et J. G. Arnoldt, De Epilepsia ex Depresso Cranio, Regiomont, 1724. G. A. Langguth, Pro- gramma de Sinus Frontalis Vulnere sine tere- bratione curamlo, Witlemb. 1748. Chopart, Mimoire sur les lesions de la 'Fete par contre- 'coup, Svo. Paris, 1771. J. La Fosse, De Cerebri Aff'eclibus a causis cxternis evidenii- bus, Monsp. 1763. .-/. J. Van Hulst, De Cere- bri ejusque membranarum inflnmmatione et suppuratio ne occulta, Ghidlenop. 178 4. P.J. Primelius, De Ulilitate Incisionis inlegumen- torum Capitis in Lasionibus Capitis, fa. Ael- thre, 1780. Bordenave, in Mem. de I'Acad. de Chirurgie, /'. 2 ; Le Dran, Traiti des Operations de Chirurgie. J. L. Petit, Traiti des Mai. Chir. T. 1. Dease, Obs. on Wounds ofthe Head.Svo. Lond. 1776. Pott on Inju- ries of the Head from External Violence : Hill's Cases in Surgery ; O'Halloran on the. different Disorders arising from External In- juries of tiie Head, Svo. Dublin, 1793. 5o?«e Cases in Desault's Parisian Chirurgical Jour- nal; Mimoire sur les Plaies de Tele, in CEuvres Chirurgicales de Desault, par Bichat, T. 2 ; Lassus, Pathologie Chirurgicale, T. 2. p 252, fa. Edit. 1809. Schmucker's Wahr- nehmungen, B. 1 ; and Vermisehte Chir. Schriften, B. 1 and 3, 8ro. Berlin, 1785. Richerand, Nosographie. Chir. T. 2, p. 230 et seq. Edit. 4. J. Abernethy on Injuries of the Head, in his Surgical Works, Vol. 2. Ed. 1811; Larrey, in Mem. de Chir. Militaire, T.2,3, et4, Svo. Paris, 1812—1817; Dr. Hennen, Principles of Military Surgery, Ed. 2, 8vo. Edinb. 1820. The three last works, and those of Le Dran, Petit, Desault, and Bi- chat, Dease, O'Halloran,Pott, and Schmucker, deserve particular attention. Also Dr. J. Thomson's Report of Observations made in the military hospitals in Belgium; Edinb. 1816. HEMERALOPIA. According to M. Din jardin, this term is derived from tipi^*., the day, «a.«sc, blind, and i-f, the eye, and its right signification is therefore inferred to be diurna ccccitudo, or day-blindness. (See Jour- nal de Med. T. 19. p. 348.) In the same sense, Dr. Hillary (06s. on the Diseases of Barbadoes, p. 298, Edit. 2.) and Dr. Heber- den (Med. Trans. Vol. 1, Art. 5.) have em- ployed the term. Hemeralopia then, which is of very rare occurrence, stands in opposition to the nyc- talopia of the ancients, or night-blindness. Numerous modern writers, however, have used these terms in the contrary sense ; considering the hemeralopia, as denoting sight during the day, and blindness in the night ; and nyctalopia, as expressing night- seeing, owl-sight, as the French call it, and blindness during the day-time. Hemeralopia, in the meaning of day-blind- ness, is a very uncommon affection. Dr. Hillary never met with but two examples. He mentions a report, however, that there are a people in Siam,in the East Indies,and also in Africa, who are subject to the dis- ease of being blind in the day, and seeing well by night. (Mod. Univ. Hist. Vol. 7.) \ccordingto Sanvages. hemeralopia, Cm HEMERALOPIA tins nomenclature called amblyopia crepuscu- luris,) was iu some degree epidemic in the neighbourhood ol Montpellier, in the villa- ges, in damp situations adjoining rivers, and it particularly affected the soldiers, who slept in the open damp air. They were cu- red, he says, by blistering, together with emetics and cathartics, and other evacuants. (Nosol. Method. Class 6, Gen. 3, Spec. 1.) See some ingenious observations on the subject in Dr. Rees's Cyclopadia, Art. He- meralopia, and by Mr. Bampfield in Med. Chir. Trans. Vol. 5, p. 34, fa. Scarpa, with the generality of modern writers, has considered hemeralopia as an affection, in which the patient sees very well in the day, but not in the nighttime. The abolition of eyesight by night (ob- serves Mr. Bampfield,) has occurred in all ages, and is a common disease of seamen in the East and West Indies, Mediterranean, and in all hot and tropical countries and lati- tudes, and affects more or less the natives likewise of those regions of the globe. It also occurs frequently among soldiers in the East and West Indies ; but he has been in- formed, that it is by no means so prevalent among them as sailors. It is not an un- common complaint of the Lascars, employ- ed in theEast-IndiaCompany's ships, trading between India and Europe. It bas very rarely indeed affected tbe officers of his Ma- jesty's, or of the East-India Company's ships. Celsus has remarked, that women and virgins, whose menstrual returns are re- gular, are exempt from (his disease (lib. 6, cap. 6,) and it may be observed,thatthe in- habitants of cold latitudes are less subject to hemeralopia in their own climate, than the natives of tropical countries are in their's ; but more so, when they visit the tropics. (Med. Chir. Trans. Vol. 5, p. 38.) " Hemeralopia, or nocturnal blindness (says Scarpa,) is properly nothing but a kind of imperfect periodical amaurosis, most com- monly sympathetic with the stomach. Its paroxysms come on towards the evening, and disappear in the morning. The disease is endemic in some countries, and epidemic, at certain seasons of the year, in others. " At sunset, objects appear to persons af- fected with the complaint, as if covered with an ash-coloured veil, which gradually changes into a dense cloud, which intervenes between the eyes, and surrounding objects. Patients with hemeralopia have the pupil, both in the day and night-time, more dila- ted, and less moveable, than it usually is in healthy eyes. The majority of them, how- ever, have the pupil more or less moveable in the daytime, and always expanded and motionless at night. When brought into a room faintly lighted by a candle, where all the by-standers can see tolerably well, they cannot discern at all, or in a very feeble manner, scarcely any one object; or they only find themselves able to distinguish light from darkness ; and at moonlight their sight is still worse. At daybreak they re- cover their sight, which continues perfect all the rest of the day, till sunset." (Cap. 19, p. 322, Edit. 8vo.) According to Mr. Bampfield, the disease always affects both eyes at the same time. " In general, (says this gentleman) the noc- turnal blindness is at first partial, the patient is enabled to see objects a short time after sunset, and perhaps will be able to see a lit- tle by clear moonlight. At this period of the complaint, he is capable of seeing dis- tinctly by bright candlelight. The noctur- nal sight, however, becomes daily more im- paired and imperfect, and, after a few days, the patient is unable to discriminate the largest objects after sunset, or by moon- light, &c. and finally, after a longer lapse of time, he cannot perceive any object distinctly by the brightest candlelight. If the patient is permitted to remain in this state of disease, the sight will become weak by daylight, the rays of the sun will be too powerful to be endured, whether they are di- rect, or reflected ; lippitude is sometimes induced ; myopism, or shortness of sight, succeeds ; and, in progress of time, vision becomes so impaired and imperfect, that ap- prehensions of a total loss of sight are enter- tained ; and this dreadful consequence has been known to ensue, where the complaint has been totally neglected, or left to nature, or where ineffectual remedies have been employed. (Bontius, p. 73.) " It has been remarked by some, that the patients are capable of seeing distinctly, at all periods of the complaint, with the aid of a strong artificial light; but, in bad cases of hemeralopia, in my practice, the patients positively denied the existence of the sense of distinct sight by very clear candlelight. (Bampfield in Medico-Chir. Trans. Vol. 5, p. 39, 40.) The duration of the disease, when left to itself, is generally from two weeks to three, or six months. Experience has not proved, that the disposition to the complaint de- pends upon any particular colour of the iris, as several writers have conjectured ; nor upon the largeness of the eyes, as alleged by Hippocrates. (Lib. 6, sec. 7.) In idiopathic cases, the health does not in general suffer, and except in the worst stage, the eye is not altered in appearance. But in cases of long duration, the pupil, according to Mr. Bampfield, " is often contracted, and the eyes and actions of tbe patient evince marks of painful irritation, if the eyes are ex- posed to a vivid light; or if he looks up- ward. But, if they meet the direct rays of the sun, which in the tropics are always powerful, or a strong glaring reflection of them, pain and temporary blindness are in- duced, from which the patient recovers, by closing his eyelids for a time to exclude the rays of light, and retiring to the shade. The pupil of the eye is considerably dilated, both by day and night, in the proportion of about one case in twelve, and at night the pupil is often dilated, and does not perform its ex- pansions and contractions, when exposed to the moon, or artificial light. The cases at- HEMERALOPIA. 653 tended with dilated pupil, were generally those of long duration, he. " Europeans, who have been once affected with hemeralopia, in tropical climates, are particularly liable to a» recurrence of this disease, as long as they remain in them." (Bamfield. »p. cit. p. 42, 43 ) The remote causes of idiopathic hemera- lopia are not well ascertained. Bontius im- putes the complaint to eatmg hot rice. (P. 72, 73.) Sleeping with the face exposed to the brilliancy of daylight, the vivid reflec- tion ofthe sun's rays from the sandy shores of hot countries, and bright moonlight, have been enumerated as causes. Dr. Pye thinks the disorder intermittent. (Med. Obs. and Inquiries, Vol. 1, art. 13.) But, as Mr. Bamp- field properly observes, though the complaint is certainly periodical, there is nothing in its character tending to prove, that it is influenced by the same causes as intermit- tent fever. The latter gentleman conjectures, "that too much light suddenly transmitted to the retina, or for a long period acting on it, may afterward render it unsusceptible of being stimulated to action, by the weaker or smaller quantities of light, transmitted to it by night." (P 44) Among other objec- tions to this explanation, however, it might be remarked, th it the patients do not always see, though the light be good ; and Mr. Bampfield's own " patients positively denied the existence of distinct sight by very clear candlelight." Besides, if the disease were entirely caused by the sudden, or long opera- tion of vivid light, one would conclude, that all persons subjected to tbat cause, ought to have the effect produced, which is far from being the case. When the tongue is white, and the patient has headach and bilious complaints, M. Las- sus thinks the cause of the disease is in the stomach and primae viae. The same author likewise states, that hemeralopia attacks de- bilitated persons, subject to catarrhal affec- tions, residing in damp situations, and living on indigestible food From the combina- tion of such causes, (says he) the disorder was epidemic in the vicinity of Montpellier, (Sauvage, Nosolog Method T. 2, p. 732 ) at Belle-Isle sur Mer, (Recuet d'Observ. de Mi- decine des Hopitaux militaires. pur Richard, T. 2, p. 573;) and hence it is endemic in watery situations, where the nights are cold and damp. They who expose themselves to this humidity, (says M. Lassus,) or who navi- gate along the eastern coasts of Africa, who traverse the Mozambic canal, or sail along the coasts of Malabar and Coromandel, are sometimes attacked by it. (See Pathologic Chirurgicale, Tom. 2, p. 542, 543.) Heme- ralopia sometimes occurs as a symptom of the scurvy. This fact was noticed by Mr. Telford, in Sir G. Blane's Treatise on Dis- eases of Seamen, and it is likewise confirm- ed by Mr. Bampfield, who remarks, that he- meralopia should be referred to the same causes as scurvy, " when the subject of it has for a long period subsisted on a salted diet at sea, &-c. and if any other scorbutic symptom be present, such as spongy gums. ecchymoses, saline smell of the secretions, ulcers with liver-like fungus, &.c. (Medico- Chir. Trans. Vol. 5, p. 45.) This disease (according to Scarpa) may commonly be completely cured, and often- times in a very short time, by treating it on the same plan by which the imperfect amau- rosis is remedied ; (see Amaurosis;) viz. by employing emetics, the resolvent powders, and pills, and a blister on the nape of the neck ; and topically, the vapours of the caustic volatile alkali: lastly, by prescribing, towards the end of the treatment, bark con- joined with valerian. In cases in which the disease has been preceded by plethora, and suppressed perspiration, bleeding and sudo- rifics are also indicated. (Cap. 19, p. 322— 333.) Scarpa supports this statement by the re- lation of three cases, in which he cured the disease by such treatment. These patients were all unhealthy, and evidently labouring under disorder ofthe gastric organs. One hundred cases, however, of idiopa- thic and two hundred of symptomatic he- meralopia, occurred in the practice of Mr. Bampfield, in different parts of the globe, but chiefly in the East Indies. All these cases perfectly recovered -. and hence, we may i. for, that under proper treatment, a favourable prognosis may always be given. Scarpa notices, that the ancients have strongly recommended, for the cure of this disease, the fumigations of a sheep's liver fried. These were directed against the eyes through a funnel; and the liver thus pre- pared, was also directedto be eaten. Even in Italy, according to Scarpa, this remedy in general obtains confidei.ee, not only with the vulgar, but also with surgeons. Some writers add, that it is productive of wonder- ful success among the Chinese, who are said to be very liable to this complaint. Scarpa says he has no observation of his own to offer in support of this account; but the plan was tried without success in a boy, whom Scarpa cured by emetic and aperi- ent medicines, ami the ammoniacal vapours. Celsus has stated that persons who have been for some time affected with amaurosis, have regained their sight on being attacked by a diarrhoea. I his seems to Scarpa to be corroborated by the case related by Doctor Pye. (Med. Obs. and Inq. Vol. 1.) A man, forty years of age, says he, had been affect- ed for two months with periodical amaurosis, which, for a certain time, had occurred re- gularly every evening, but afterward came on irregularly, at different intervals, with considerable dilatation of the pupil, and such obscuration of sight on the approach of night, tha' even the light of a candle could not be discerned The man was seized with a diarrhoea. Doctor Pye ordered him to take, for eight successive days, a potion with the kali prseparatum ; then he prescri- bed an electuary, composed of bark, nut- meg, and syrup of orange peel. The two latter ingredients were added to the bark, on account of the continuance of the diarrhoea. 54 HEMERALOPIA The second day after the electuary had been taken, the diarrhoea increased, and the patient vomited copiously ; after which he suddenly recovered his sight, so as to see equally well by day and by night. As the diarrhoea continued, the electuary was omit- ted, after having been taken two days. A violent fever succeeded the diarrhoea, and it was remarked, that during the highest stage of the former, the patient became rather deaf, but without losing his sight in the night or daytime. Dr. Pye does not mention what steps were taken to moderate the fever, which proved fatal to the patient. At all events, adds Scarpa, it is a fact, that this spontaneous laxness of the bowels en- tirely freed the man from an imperfect peri- odical amaurosis. Scarpa entertains no doubt, that by looking attentively into the numerous collections of medical observa- tions, one might find in them a great many facts similar to the preceding one, showing the influence of what he terms morbific gas- tric stimuli over the organ of sight, and con- sequently, the great utility of a spontaneous looseness of the bowels in the cure of the imperfect amaurosis. But, says Scarpa, even if such examples of the incomplete amaurosis being dissipated in consequence of spontaneous vomiting, or copious evacuation* from the bowels, pro- duced entirely by nature, were rare and noticed by few, we now have so many ob- servations, evincing the successful cure of tbis disease by means of such evacuations, artificially produced by emetics, and purga- tive medicines, that no doubt whatever can be entertained concerning the accuracy of the second part of Celsus's admonition rela- tive to the present view of the imperfect amaurosis: et recenli re, et interposito tempo- re, medicamentis quoque moliri dejediones, qua omnem noxiam maleriam per inferiora depellant. Of this Scarpa remarks, we un- doubtedly have numerous satisfactory proofs, in the accurate observations related by Schmucker and Richter; but our confi- dence, says Scarpa, in the above method of curing the imperfect and periodical amauro- sis must increase, when we take notice that the most respectable practitioners of past times have, in the majority of cases, cured this disease only by means of emetics, and opening medicines, though, in their wri- tings, they may have imputed the success of the treatment to other causes, or the effi- cacy of other remedies, which were also prescribed. Scarpa, after several valuable remarks on amaurosis in general, refers to the Mercure de France, for February, 1756, where there is an account of the cures performed by Fournier on several subjects affected with hemeralopia. The first were three soldiers, to whom an emetic was administered after bleeding them. The next day, as they also complained of a heaviness in their heads, and nausea, the bleeding and emetic were repeated. This expedient removed all the above symptoms, and these three soldiers were no longer unable to see in the night- time. Fournier met with equal success in treating eight other soldiers upon the same plan, who were affected with the same dis- ease, und belonged to the same garrison. Night-blindness is sometimes congenital, and therefore constitutional, and altogether beyond the reach of any curative measure. It is said sometimes to be hereditary, and the writer of the article Nyctalopia, in Dr. Rees's Cyclopaedia, was acquainted with an in- stance in which it occurred to two children of the -ame family. A case of congenital nyctalopia, which had continued many years without change, and independently of any disease, is related by Dr. Parhara. (See Med. Obs. und Inquiries, Vol. I. p. 122, note.) Scarpa notices that Peltier (Recueil de Mem. et Obs. sur I'CEil. Obs. 132.) cured cap- tain Micetti of an hemeralopia by repeated doses of tartar-emetic, a seton in the nape of the neck, and cooling aperient beverages. Peltier also assures us, that he has several times cured the recent imperfect amaurosis, by means ot small doses of tartar-emetic, and topical aromatic fumigations. (Observ. 136—138.) The method of treatment which Mr- Bampfield adopted, is certainly quite sim- ple. " A succession of blisters to the tem- ples, (says be) of the size of a crown or half- crown piece, applied tolerably close to the external canthus of the eye, has succeeded in every case of idiopathic hemeralopia, which I have seen, &.c. The first applica- tion of blisters commonly enables the pa- tient to see dimly by candlelight, or per- ceive objects without the power of discrimi- nating what they are. In some slight cases, that admitted of easy cure, the first applica- tion has succeeded perfectly. The second application of blisters commonly enables the patient to see by candlelight distinctly, per- haps by bright moonlight, and even half an hour after sunset, or the sight is restored for short periods during the night, and is again abolished. Tbe second application very often effects a perfect recovery. The third fourth, or fifth applications, in succession' generally produce a complete recovery, where the first or second have failed; but some rare instances of very obstinate heme- ralopia have required even ten successive blisters to each temple ; or instead of using them in succession, a perpetual vesicatory has been formed on each temple, and main- tained, until a cure has been accomplished, an event which has generally followed in a fortnight." (Bampfield in Medico-Chir. Trans. Vol. 5, p. 47, 48.) In some cases, shades over the eyes were worn durin* the treatment, and a certain time after the°cure. The patients were also often directed to bathe their eyes with cold water two or three times a day. Mr. Bampfield also knew of instances in which electricity was successfully employed as a topical stimulus to tbe eye. He also informs us, that a spontaneous cure some- times followed the eruption of boils on the HEM HEM 655 head or face, or the formation of abscesses on these parts, or in the ears. Although the blisters will generally effecta cure,there were particular cases in which Mr. Bampfield administered cathartics, such as calomel and the neutral salts. In these exam- ples the patient had bilious complaints, indi- cated by a yellow state of tbe tongue and skin,headach, and pain about the praecordia; or symptoms of indigestion, white tongue, loss of appetite, pain and flatulence of the stomach, &.c. In the scorbutic hemeralopia, tbe applica- tion of blisters is to be deferred until the state ofthe constitution is amended, by giving lemon and lime-juice, and fresh animal and vegetable food; because the hemeralopia often gradually ceases as the scurvy is cured ; and before this last event, the blister might produce a scorbutic ulcer. Mr. Bampfield estimates, that about one-third of the cases of scorbutic hemeralopia resist the efficacy of the antiscorbutic regimen and medicines ; and consequently, must ultimately be treated as idiopathic cases. The frequent recurrence of this disease, during the patient's continuance in a tropi- cal or hot climate, naturally suggests the propriety of recommending him to return to his native climate, by vvhich change the ten- dency to a relapse is in general completely removed. (Bampfield, in Medico-Chir. Trans. Vol. 5, p. 53.) Consult Celsus de re Medico, Cap. 6, lib. 6. Galeni Op. Lib. de Oculis purs 4, cap. 11.22. JEtii Sermo Septimus, cap. 48, 52,46. Paul. JEgina Lib. 3, cap. 48 Acluarius, De Me- thod, med. lib. 4, cap. 11. Rliasis, DeMgri- tud Ocul. cap. 4. Avicenna, Lib. 3, fen. 3, tradut.4. Fabricii Hildani Centur. 1, Obs. 24; centur. 5, obs. 13. Plainer, Praxis, Med. C. A. Bergen et J. C. Weise, De Nyctalopia seuCacitate Nocturna; Haller, Disp. ad Morb. fa. 359. Journal de Medicine et de Chirurgie ann. 1756, T. 4. Medical Observations and In- quiries, Vol. 1. Recueil d' Observations de Me- dicine des hopitaux militaires, par Richard, T. 2. Duporl, Mimoire sur la Goulle Sereine Nocturne ipidemique, ou Nydalopie. Obser- vations on Tropical Nyctalopia, by Mr. J. Forbes, in Edinb. Medical and Surgiced Jour- nal, No. 28, p. 417 et seq. Richter's Anfangs- grunde der Wundarzneykunst, B. 3, p. 483 et seq. Schmucker's Chirurgische Schriften, Band. 2. Saggio di Osservazioni e d'Esperienze Sulle Principali Malattie degli Occhi di Anto- nio Scarpa, p. 322 et seq. Edit. Svo. Venezia, 1802. Lassus, Pathologie Chirurgicale, T 2, p. 539, Edit. 2. Rees's Cyclopadia, art. Nyc- talopia. A Practical Essay on Hemeralopia, or Night-blindness, commonly called Nyctalo- pia, by R. W. Bampfield, in Medic -Chuurg. Trans. Vol. 5, p. 32. et seq. A. Simpson on He- meralopia, 8ro. Glasgow, 1819 ; C.H. Welltr, A Manual of the Diseases of the Eye, transl. by Dr. Monteath ; Vol. 2,p. 142, Svo. Glasgow. 1821. HEMIOPIA. (from »/ut<*, blood, and fwyvufjit, to break out.) Bleeding. This is doubtless one of the most impor- tant subjects in Surgery. The fear of hemor- rhage retarded the improvement of our pro- fession for ages : the ancients, ignorant how to stop bleeding, were afraid to cut out the most trivial tumour, or they did so with ter- ror. They generally performed slowly and imperfectly, by means of burning irons, or ligatures, the same operations which the moderns execute quickly and safely with a knife. If the old surgeons ventured to ampu- tate a limb, they only did so after it had mortified, by dividing the dead parts, and so great was their ^prehension of hemorrhage, that they only dared to cut parts which could no longer bleed. (John Bell's Principles of Surgery, Vol. 1, p. 142.) But nol only as a consequence of surgery, is hemorrhage to be feared ; it is also one of the most alarming accidents, which surgery 1s called upon to 056! HEMORRHAGE. relieve. " Un sentiment naiurel attache a I'idie de perdre son sang ; un terreur machi- nate, dont Penfant, qui commence h parler, et I'homme le plus dicidt, si.nt e'galemeni sus- ceplibles. On ne peut poml dire, que cette peursoit chimirique. Sil'on comptoil ceux,qui perdent la vie dans une bataille, on verroit, que les trols quarts ont piri pa- quelque he- morrhagic ; et dans les grandes operations de chirurgie cet accident est presque to jour* le plus formidable." (Morand. Mem. de I'Acad. Royale de Chirurgie, Vol. 5. 8vo. As the blood circulates in the arteries with much greater impetus and rapidity, than in the veins, it necessarily follows, that their wounds are generally attend, d with much more heinorrhage, than those of tbe latter vessels, and tbat such hemorrhage is more difficult to suppress. However, as 'he blood also flows through veins of great magnitude with great velocity, bleedings from them Jsre frequently highly dangerous, and sometimes unavoidably fatal. When nn artery is wound- ed, the blood is of a bright scarlet colour, and gashes from tne vessel per saltum, in a very rapid manner. The blood issues from a vein in an even unbroken stream, and i- of a dark purple red colour. Ii is of great practi- cal use to remember these distinguishing dif- ferences betweeu ,-irterial and venous hemor- rhage, because, though in both cases the oozing of blood may be equal in quantity, yet in the latter instance, the surgeon is ofien justified in bringing ihe sides of a wound .to- gether, without taking farther means to sup- press the bleeding, while it would not be pro- per to adopt the same conduct, were there an equal discharge of arterial blood. Dr. Jones has favoured the world with a matchless work, onthe present subject ; and as one grand obji ct of (nis Dictionary is to present a careful account of the principal modem improvements in surgical science, I shall first endeavour to make the reader ac- quainted with the more accurate doctrines first promulgated by this gentleman relative to the subject of hemorrhage. Afterward, tbe surgical means to be practised iu differ- ent cases, will be considered. The sides of the arteries are divisible into three coats. The internal one is extremely thin and smooth. It is elastic and firm, (considering its delicate structure) in the longitudinal direction, but so weak in the circular as lo be very easily torn by the slightest force applied in that direction. Its disensc.- shovv, that it is vascular, and it is also proba- bly sensible. The middle coal is the thickest, and is com- posed of muscular fibres, all arranged in a circular manner ; tbey differ, however, from common muscular fibres in being more elas- tic, by vvhich they alone keep a dead .ir'ery open, and of a cylindrical form. As this middle coat has no longitudinal fibres, the circular fibres are held together by a slender connexion, which yields readily to any force applied in the circumference of the artery. Tbt external coat is remarkable for its whiteness, density, and great elasticity. When an artery is surrounded with a tight ligature, its middle and internal coats are u completely divided by it as they could be by a knife, while the external coat remains entire. Besides these proper coat-, all (he arteries, in their natural situations, are connected by means of fine celltilai substance, with sur- rounding membranous sheaths. If an artery be divided, the divided parts, owing to their elasticity, recede from each other and the irngtn ofthecellular substances,connecting the artery with the sheath* admits of its re- trading a certain way within the sheath. Another important tad i : that when an artery is divided, its truncated extremities con- tract in a greater or less degree, and the con- traction is generally, if not always, perma- nent. Arteries are furnished with arteries, veins, absorbents, and nerves ; a structure, which makes them susceptible of every change to which living parts are subjected in common ; enables them to inflame when injured, and to pour out coagulating lymph, by which the in- jury is repaired, or the tube permanently clo- sed. (See Jones on Hemorrhage.) Petit the surgeon, in 1731, first endeavour- ed to explain the means which nature era- ploys for Ihe suppression of hemorrhage. He thought, that bleeding from a divided artery is stopped by the formation of a coagulum of blood, which is situated partly within, and partly without the vessel. The clot, he says, afterward adheres lo the inside of the artery, to its orifice, and to the surrounding parts; and he adds, that when hemorrhage is stop- ped by a ligature, a coagulum is formed above the ligature, which only differs in shape from the one vvhich takes place wheu no ligature is employed. His opinion leads him to recommend compression for Ihe sup- port of the coagulum. In 1736, Morand published additional inte- resting remarks. He allowed, that a coagu- lum had some effect in stopping hemorrhage ; but contended, that a corrugation, or plaiting of the circular fibres of tbe artery which di- minish its canal, and a shortening and conse- quent thickening of ils longitudinal ones, which nearly rendered it impervious, had some share in the process. He thought that the cavity of an artery might be obliterated by the puckering, or corrugation, when cir- cular pressure, like that of a ligature, is made. .Morand erred chiefly in his mode of ex- planation, and in his belief in the existence of longitudinal fibres, which no modern ana- tomists admit; for Ihe contraction and re- traction of divided arteries, are indisputable facts, and, as Dr. Jones remarks, (his does no( affect the (ruth of his general conclu- sion, that the change produced on a divided artery, contributes with the coagulum to stop the flow of blood. Mr. S. Sharp (2d Edit, of Operations of Surgery. 1739,) supported the same doctrine. " The blood-vessels, immediately upon their division, bleed freely and continue bleeding, till they are either stopped by art, or at length contracting and withdrawing them- selves into the wound, their extremities are shut up by coagulated blood." 658 HEMORRHAGE. agula, and is somewhat intermingled with ■ them or adheres to them, and is firmly uni- ted all round to the internal coat of the vessel. Dr. Jones further states, that the permanent suppression of hemorrhage chief- ly depends on this coagulum of lymph ; but that tbe end of tbe artery is also secured by a gradual contraction which it undergoes, and by an effusion of lymph between its tunics, and into the surrounding cellular substance ; whereby these parts become thickened, and so incorporated with each other, that one cannot be discerned from the other. Should the wound in the integu- ments not heal by the first intention, the coagulating lymph, soon effused, attaches the artery firmly t > the subjacent and lateral parts, gives it a new covering, and entirely excludes it from tiie outward wound. The same circumstances are also remark- able in the portion of the vessel, most re- mote from the heart. Its orifice, however, is usually more contracted, and its external coagulum smaller than the one vvhich at- taches itself to the other cut end of the artery. (Junes on Hemorrhage, p. 56.) The impervious extremity of the. artery, no longer allowing blood to circulate through it, the portion whicju lies between it and the first lateral branch gradually contracts, till its cavity is completely obliterated, and its tunics assume a ligamentous appearance. In a few days the external coagulum, which in the first instance stopped the hemorrhage, is absorbed, and the coagulating lymph, effu- sed around it, and by which the parts were thickened, is gradually removed, so that they resume again their ccljular texture. At a still later period, the ligamentous portion is reduced to a filamentous state, so that the artery is, as it were, completely an- nihilated from its cut end to the first lateral branch ; but long before this final change is accomplished, the inosculating branches have become considerably enlarged, so as to establish a free communication between the disunited parts of the main artery. When an artery bas been divided at some distance from a lateral branch, three coagula are formed : one of blood externally, which shuts up :ts mouth ; one of lymph, just with- in the extremity of its canal; and one of blood within its cavity, and contiguous to that of lymph. But, when the artery has been divided near a lateral branch, no internal co- agulum of blood is formed. (Jones, p. 63.) The external coagulum is always formed when the divided artery is left to nature; not so, however, if art interferes, for under (be application of the ligature it can never form. If agaric, lycoperdon, or sponge, be used, its formation is doubtful, depending entirely upon tbe degree of pressure that is used; but the internal coagulum of blood Will be equally formed, whether the treat- ment be left to art, or nature, if no collateral branch is near the truncated extremity of {ba artery; and lastly, effused lymph, which, when }n efficient quantity, forms a distinct roaguldm, just at the mouth of the artery, will be always found, if (he hemorrhage is permanently suppressed. (Jones, p. 74.) MKANS WHICH NATURE KMPLOYS FOR SUP- PRESSING IHE HEMORRHAGE I ROM PUNC- TUKtD, OR PARTIALLY DIVIDED ARTI RIES. The suppression of hemorrhage by the na- tural means is sometimes more easily ac- complished, when an artery is completely divided, than when merely punctured, or partially divided Completely dividing a wounded artery was one means practised by the ancients for the stoppage oi hemor- rhage : the modems frequently do the same thing, when bleeding from the temporal ar- tery proves troublesome. Dr. Jones has related many experiments, highly worthy of perusal, and which were undertaken to investigate the present part of the subject of hemorrhage. This gentle- man, however, owns, that in regard to the temporary means, by which the bleeding from a punctured artery is stopped, he has but little to add to what Petit has explained, in his third publication on hemorrhage. (Mem. de I'Acad. des sciences; 1735.) The blood is effused into the cellular substance, between the artery and its sheath, lor some distance, both above and below the wound- ed part; and when the parts are examined, a short time after the hemorrhage has com- pletely stopped, we find a stratum of coagu- lated blood between the artery and its sheath, extending from a few inches below the wounded part to two, or three inches above it, and somewhat thicker, or more prominent over the w ounded part, than else- where. Hence, rather than say the heinorrhage is stopped by acoa ulum, it is more correct to say that it is stopped by a thick lamina of coagulated blood- which, though somewhat thicker at the wounded part, is perfectly continuous with the coagulated blood lying between the artery and its sheath. (Jones. p. 113.) W hen an artery is punctured, the hemor- rhage immediately following, by filling up the space between the artery and its sheath, with blood, and consequently distending the sheath, alters the relative situation of tbe puncture in the sheath to that in the ar- tery, so lhat they are not exactly opposite to each other; and by this means a layer of blood is confined by the sheath over the puncture in the artery, and by coagulating there, prevents any further effusion of blood. But this coagulated blood, like the extern nal coagulum of a divided artery, affords only a temporary barrier to the hemorrhage: its permanent suppression is effected by a process of reparation, or of obliteration. Dr. Jones's experiments prove, that an ar- tery, if wounded only to a moderate extent, is capable of reuniting and healing so com- pletely, that after a certain time the cicatri- zation cannot be discovered, either on its internal, or external surface ; and that even oblique and transverse wounds (which gaps most) when they do not open the artery to HEMORRHAGE Pouteau (Melanges de Chirurgie, 1760,) denied that a cnagultim is always found afler an artery is divided: and u hen it is, he thought it only a feeble and subsidiary means towards the suppression of hemorrhage. He contended, that the retraction of ihe artery had not been demonstrated, and could not be more effectual than a coagulum. His theory was, that the swelling of the cellular membrane, at the circumference of the cut extremity of the artery, forms the principal impediment to the How of blood ; and that a ligature is useful in promoting a more im- mediate and extensive induration of the cel- lular substance. - Gooch, White, \ikin,and Kirkland, allop- Eose Pelit's doctrine of coagulum. Thf» first, lends some of Pouteau's theory with his own, by oliserving that " when a small artery is totally divided, its retraction may bring it under the surrounding parts, and with the natural contraction of the diameter of ils mouth, assisted by the compressive power of those parts, increased by their growing tu- ,mid, the efflux of blood may be stopped." White was convinced, from what Gooch had suggested, and Kirkland confirmed, that the arteries, by (heir natural contraction, coalesce, as far as their first ramification. Dr. Jones admits, that an artery contracts after it has been divided, and his experiments authorize him to say, that tbe contraction of an artery is an important means, but cer- tainly not the only, nor even (he chief means by whicb hemorrhage is slopped. When (he artery is above a certain size, the impetuous flow of blood through the wound of the artery would resist the contraction of the vessel in such a degree, that (lie consequen- ces would be fatal in almost every instance, were it not for the formation of a coagulum. (Jones.) Mr. J. Bell thinks, that when hemorrhage stops of its own accord, it is neither from (lie retraction of an artery, nor the constriction of its fibres, nor the formation of clots, but by the cellular substance,'which surrounds the artery, being injected with blood. We must refer the reader lo Dr Jones's work for a complete exposure of the incon- sistencies and absurdities in Mr. Ball's ac- count of his own theory. (See P.25. fa) Dr. Jones concludes his criticisms on Air. Bell with observing, lhat if this gentleman really means lo confine his doctrine of the natural means of suppressing hemorrhage to the injection of the cellular substance round ibe artery, with blood, he dwells improperly on one of the attendant circumstances to the exclusion of the retraction, and contraction of an artery, and Ihe formation of a distinct clot, all primary ports of the process. Tbe blood, besides filling the cellular sub- stance round the artery, also fills the cellular substance at tbe mouth of (he arlery iu a particular manner; for (be divided vesse', by its retraction within ils cellularslieaih, leaves a space of a determinate form, which, when all the circumstances necessary for the sup- pression of hemorrhage operate, is graduully fille I up by a distinct clot. (Jones.) You. I. S3 MEANS OF N VII RE IN STOPPING BLEKDINfi IR01I DIVIDED ARTERIES. • Dr. Jones has given a faithful and accurate detail of a series of experiment? on animals, which demonstrate " that the blood, the ac- tion, and even the structure of the arteries, their sheath, and the cellular substance, con- necting them with it," are concerned in stop- ping bleeding from a divided artery of mo- derate size, in the following manner : "An impetuous flow of blood a sudden and for- cible retraction of the artery within its sheath, and a slight contraction of its extre- mity, are the immediate, and almost simulta- neous effects of ils division. The natural impulse, however, with which the blood is driven on, in some measure counteracts the retraction, and resists the contraction of th# artery. The blood is effused into the cellular substance, betvvpen tbe artery and ils sheath, and passing through that canal of the sheath, which had been formed by tbe retraction of the artery, flows freely externally, or is ex- travasated into the surrounding cellular membrane, in proportion in (he open, or con- fined state of (he wound. The retracting artery leav> s the internal surface of the » sheath uneven, by lacei-alin?, or stretching the cellular fibres, that connected tiiem. These fibres entangle the blood as it flows, and thus the foundation is laid forthe forma- tion of a coagulum at Ihe mouth of (he ar- tecy, and which appears to be completed by the blood, as it passes through this canal of the sheath, gradually adhering and coagula- ting around its internal surface, till it com- pletely fills it up from the circumference to the centre." (Jones p. 53.) The effusion of blood into the surround- ing cellular membrane, and between the ar- tery and its sheath ; but in particular, the diminished force ofthe circulation from loss of blood, and the speedy coagulation of this fluid under these circumstances, most essen- tially contribute, says Dr. Jones, to the de- sirable effect. It appears then, that a coagulum, vvhich Dr. Jones calls the external one, situated at the mouth of the artery, and within its sheath, forms the first complete obstacle to the continuance of bleeding, and though it seems externally like a continuation of the artery, yet, on slitting open this vessel, its termination can be plainly observed, with the coagulum shutting up its mouth, and contained in its sheath. No collateral branch being very near the impervious mouth of the artery, the blood just within it is at rest, and usually forms a slender conical coagulum, which neither fills up the canal of the artery, nor adheres to its sides, except by a small portion of the circumference of its base, near the extremity of the vessel. This coagulum is distinct from the former, and what Dr. Jones calls the internal one. The cut end of the artery next inflames, and the vasa vasorum pour out lymph, vvhich fills up the extremity of (he artery, is situa- ted between the internal and external co- HEMORRHAGE. C59 a greater extent than one-fourth of its cir- cumference, are also filled up and healed by an effusion of coagulating lymph from their inflamed lips, so as to occasion but littl'-, or no obstruction to the canal of the artery The utmost magnitude of a wound, which will still allow the continuity of the canal to be preserved is difficult to be learnt; for when the wound Is large, but yet capable of being united, such a quantity of coagulating lymph is -poured out, that the canal of the vessel, at the wounded part, is more or less filled up by it. And when the wound is still larger, the vessel soon becomes either torn, or ulcerated completely across, by which its complete division is accomplished. Beclard made a series of experiments upon dogs, whose arteries are said not to differ much from those of man, though the impulse of the h< irl is not so itrong, and the blood is more coagulable ; two circumstances which should be duly considered, in applying any of the inferences drawn from such experi- ments to the human subject. " In his first experiment, he pricked the femoral artery with a needle ; the blood flowed ; but soon stopped. On removing the coagulum it again flowed, but in a small stream ; it gra- dually ceased to bleed, and finally stopped, though the coagulum was again scraped off'. On examination ofthe artery no trace of the cicatrix was found. Several similar experi- ments had the same result. In experiment 4, be denuded the femr-ral artery, and made a longitudinal cut in it, from two to three lines. The lips of the wound were seen in contact during the diastole of the ventricle, and to be separated by a jet of blood during the systole. The blood was stopped by a coagulum; this was removed twice, and each time tbe blood flowed in a diminished stream,but the animal died In experiment 6, he made thesameincision,but did not detach the sheath from the artery, and the wound was left to nature. The hemorrhage was not great; there wis an infiltration of blood into the sheath the size of an almdnd, vvhich at the end of some days began to diminish, and disappeared in two or three weeks. On the limb being examined fifteen days after- ward, a little white ridge was found adhe- ring firmly to the artery, and to tbe sheath, and completely closing the wound. In the interior, there was a depressed longitudinal cicatrix of the breadth ofthe fifth of a line. The canal was regular and pervious through its whole extent. " In experiments 7, 8, 9, he made trans- verse incisions of 1-4, 1-2, and 3-4 of the circumference of the femoral artery, separa- ted from ils sheath .- all the animals died. In experiment 10, he made a transverse ineision through 1-4 of the circumference, without disturbing the sheath. The bleeding was stopped by a coagulum, but on the animal moving, it again flowed, and the dog died. But in the next experiment of the same kind. the blood was stopped by a coagulum, ana the artery wa« closed by nen-ly thesame pro- cess as in the 6th experiment. So complete was tbe mre, at tbe end of six weeks, that the external part of the artery did not show any mark of a wound, and the cicatrix was scarcely observable on the interior surface. In his 12th experiment he cut one-half of the circumference ; the animal died ; and so did it in several similar experiments. In ex- periment 13, he cut 3-4 of tbe circumference ; after the animal was much reduced, the bleeding; ceased, and the artery was closed in the same manner that it is when the sec- tion is complete. " From tbesp experiments, he concludes wounds of the arteries of dogs arc cured by nature, when they are only occasioned by a fiuncture, or a longitudinal incision, whether he artery be denuded or not; but when arising from transverse incisions, they are always mortal if the artery be laid bare. If the artery retain its sheath, and the wound be 1-4, or 3-4 of the circumference, it may- be cured '.*/ the efforts of nature ; but it is always fatal, if 1 2 of it be cut through."' (See Quarterly Journ. of Foreign Medicine and Surgery, Vol. l,p. 26.) The inferences respecting the curability of a wound, ex- tending through 3-4 of the circumference, and the incurability of one that affects only 1-2 of Ihe circumference of the vessel, I should presume, must require further exa- mination, notwithstanding an accidental faintness produced by the sudden loss of blood in the first instance may have been the means of saving one or two of the animals on which Beclard made his experi- ments. Ibis author thinks it probable, that a puncture, or longitudinal incision, in the artery of a man, may be cured by nature : but that a transverse wound never cicatri- zes properly, but tbe clot becomes displaced, or, if a cicatrix be formed, it will be dis- tended and torn. One fact, made out by the same gentle- man, is, that when an artery is deprived of its sheath for an extent greater, than its dis- tance of retraction, the hemorrhage is mor- tal. 1 have not yet had time to look over the original paper; but it appears to me, that it would be desirable to know precisely to what sized arteries the author is referring, when he is making some ofthe above infe- rences. The size and condition of each animal, Ihe subject of experiment, should also be particularly specified; as experi- ments made on the femoral artery of a lady's lap-dog would surely not have the same results, as those performed on the same artery of a large terrier, setter, or New- foundland dog. . According to Dr. Jones, the lymph, which fills up the wound of an artery, is poured out very freely, both froin the vessel and ihe surrounding parts, and it accumulates around the artery, particularly over the wound, where it forms a more distinct tu- mour. The exposed surrounding parts at the same time inflame, and pour out coagu- lating lymph, with which the whole surface ofthe wound becomes covered, and vvhich completely, excludes the artery from the exterrral won nil. This lymph * rami lair's. 'fat efficacy. The ancients, centuries ago, le;; no application of this nature untried, anu the pretended discoveries of new and more effectual styptics in btter time = . fciav HEMORRHAGES. 661 almost all be met with in their writings. This fact merits particular notice, because the little success attending their practice, espe- cially when bleeding from a considerable artery was to be suppressed, clearly pr ives what little reliance ought to be piaccd on means of this description. (Encyclopidie Mithodique ; Parlie Chir.) The most vvnich styptics can do, is to stop hemorrhages from small arteries; but they ought never to be trusted when large vessels are con- cerned. There is no doubt, that cold air has a styptic property ; by which expression, I mean, that it promotes the contraction of the vessels ; for no styptics can contribute to make the blood coagulate, though such an erroneous idea is not uncommon. We frequently tie, on the surface of a wound, every artery that betrays the least disposi- tion to bleed, as long as the woind conti- nues exposed to the air. We bring the op- posite sides of this wound into contact, and put the patient lo bed. Not an hour elapses, before the renewal of hemorrhage necessi- tates us to' remove the dressings. The wound is again exposed to the air, and a^ain the bleeding ceases. This often happens in the scrotum, after t'.ie removal of a testi- cle, and on the chest, alter the removal of a breast. The proper conduct, in such ca- ses, is not to open the wound unnecessarily, but to apply wet linen to the part so as to produce such an evaporation from its sur- face, as shall create a sufficient degree of cold to stop the bleeding. As all styptics are more or less irritating, no judicious practitioners '«pply them to recent wounds. However, forthe suppression of hemorrhage from diseased surfaces, where the vessels seem to have lost t'teir natural disposition lo contract, these applications are sometimes indicated. COMPRESSION. We have already remarked, that all the best means of checking hemorrhage, operate on the principle of pressure; the actual and potential cautery, and some styptics except- ed ; the two first of which act by forming a slough, which stops up the mouths ofthe ves- sels; while the latter operate by promoting their contraction. Let us next consider the various modifications of pressure. In a dissertation on the manner of slop- ping hemorrhage, printed in (he Mem. de I'Acad. de Sciences, annie 1731, Petit endea- voured to prove, that different articles praised as infallible specifics, would seldom or never have succeeded without compres- sion. Even when caustics were employed, it was usual to bind compresses tightly on the part, so as to resist the impulse ofthe blood in the artery, and the premature sepa- ration of the eschar. Had this precaution not been taken, Petit believes, hemorrhage would almost invariably have followed, and indeed, notwithstanding the pains talven to avert it by suitable compression, it did but •oo frequentIv take place on the detach- ment ofthe eschar. Petit has noticed, that the end of a finder gently compressing the motitn of a vessel, is a sufficient means of stopping heinorrhage from K, and that no- thin- c!-.e would be necessary, if'he finger and stump could always be kept iu Ibis pos- tnre. Hence, he endeavoured to obviate these difficulties by inventing a machine which securely and incessantly executed the office of the finger. The instrument was a double toamiquct, which, when applied, compressed at once, both the extremity of the divided artery and its tt-jnk above ihr wound. The compression on the end of the vessel was permanent; that on the trunk was made only at the time of dressing tne wound, or when it was necessary to relax the other. An engraving and particular description of the instrume.it are to be found in Petit's memoir. Surgeons formerly filled the cavities of wounds with lint, or charpie, and then made pressure on tbe bleeding vessels, by apply- ing compresses and a ti;'ht roller, over the part. The practitioners of the present day are too well acquainted with the advantages of not allowing any extraneous substance to intervene between the opposite surfaces of a recent wound, to persist in the above plan. Tbey know, that the sides of the wound may be brought into contact, and that compression may yet be adopted, so as bob to restrain particular hemorrhages, and rather promote than retard, the union of the wound. When the blood does not issue from any particular vessel, but from numerous small ones, compression is preferable to the liga- ture. In the employment of the latter, it would be necessary to tie tbe whole surface ofthe wound. The sides of the wound are to be brought accurately together, and com- presses are then to be placed over the part, and a roller to be applied with sufficient tightness to make effectual pressure, but not so forcibly as to produce any chance of the circulation in the limb being complete- ly stopped. If, iu bleedings from large arteries, com- pression can ever be prudently tried, it is when these vessels lie immediately over a bone. Bleedings from the radial and tem- poral arteries are generally cited as cases of (his kind, though from the many instances of failure, which I have seen happen where the first of these vessels is concerned, I should be reluctant either to advise, or make such an attempt. Compression is sometimes tried, when the brachial artery is wounded in phlebotomy. Here it is occa- sionally tried, in preference to the ligature, because the latter cannot be employed without an operation to expose the artery. When there is a small wound iu a large artery, the following plan may be tried : a tourniquet is to be applied, so as to com- mand the flow of blood into the vessel. The edges of the external wound are next to be brought into contact. Then a compress, shaped like a blunt cone, and which is best formed of a series of compresses, gradually 662 HEMORRHAGE increasing in size, is to placed with its apex exactly on tbe situation of the wound in the irtery. This graduated compress, as it is tcr.ned, is then to be bound on the part with a roller. In this manner I once healed a wound of the superficial palmer anh, in a yoin g Iudy in Great Puitney-street. The outward wound was very small, and though the he- morrhage was profisi, I conceived, that it might be |ier nanently stopped, if compres- sion could be so made as to keep the exter- nal wound incessantly and firmly covered for the space of a day or two. At first I tried a compress of lint, bound on the part with a roller ; but this proving ineffectual, I took some piei-i-> of money, from the size of a farthing to that of a half crown, and, Wrapping tiiem up in linen, put the smallest one accurately ovpr the wound, so as • oin- pletely to cover it. then the others were arranged, and all of them were firmly con- fined with a roller, aud tbe arm kept as quiet as possible in a sling. They Were taken off after three days, and no hemor- rhage ensued. It is to be observed that tbe palmar facia, in this instance, would prevent the com- pression from operating on the vessel; but the case showsthut (his artery, w hen wound- ed, is capable of healing, if the blood be completely prevented from getting out of the external wound by the proper applica- tion of compression. W ere the outer \> ouud too large to admit of this plan, it would probably be the safest practice to cut down, at once, to the ulnar artery, and put a liga- ture round it, though as this would only cer- tainly stop the bleeding from one end of the vessel in the hand, pressure on the wound would yet be necessary. I have never seen a surgeon succeed in taking up the artery in the hand. Besides compressing the wounded part of the artery, some surgeons also apply a lon- gitudinal compress over the track of the vessel above the wound, with a view of weakening the flow of blood into it. What- ever good effect it may have in this way is more than counterbalanced by the difficulty which it must creut' to the circulation in the arm. If the graduated compress be pro- perly- arranged, an effusion of blood cannot possibly happen, and [•re-sure along the course of the artery must at all events be un- necessary, xfter relaxing the tourniquet, if no blood escape from the artery, the sur- geon (supposing it to be the brachial artery wounded) should feel the pulse at the wrist, in order to ascertain that (he compression employed is not so pov< erful as entirely to impede the circulation in the fore-arm and hand. The arm is to be kept quietly in a sling, and in forty-eight hours, if no bleed- ing take place, there will be great reason to expect that the case will do well. In ano- ther work I have given an engraving and description of an instrument, invented by Plenk, for making pressure on the wounded brachial artery, at the bend of (he arm, without pressing upon the wtiole circumfe- . rencp of the limb, and consequently with- out stopping the circulation. No one, how- ever, would prefer compression when large arteries are injured, except in the kind of cases to which we have just now adverted, or in those in which the wounded vessel can be firmly coinpiessed ag- inst a subjacent bone Sometimes the compresses slip off, or the bandages become slack, and a fatal hemorrhage may arise ; and a still greater risk is that of mortification from the con- stricted state of the limb. When the me- thod is tried, the tourniquet should always be left loosely round the limb, ready to be tightened in an instant. Sometimes the ex- ternal won; d heals, while the opening in the artery remains unclosed, and a false aneurism is tba consequence. TOURNIQUET. When hemorrhage takes place from a large artery in one of the limbs, where the vessel can be conveniently compressed above the wound in it, a tourniquet, judi- ciously applied, never fails in putting an im- mediate stop to the Needing. Before the invention of this instrument, which did not take place till (he latter part of the 17th century, surgery was really a very defective art. No important operation could be undertaken on the extremities, without placing the patient in the most im- minent peril; and many wounds were mor- tal, whicb with the aid of this simple con- trivance, would not have been attended with the least danger. The first invention of this instrument has been claimed by different surgeons, and even different nations. But whoever was the inventor, it was first presented to the public in a form exceedingly simple; so much so, indeed, that it seems extraordi- nary that its invention did not happen sooner A small pad being placed on the principal artery of a limb a band was ap- plied over it, so as to encircle the limb twice. Then a stick was introduced be- tween the two circles of the band, which was twisted: thus the pad was made to compress powerfully enough completely to stop (he flow of blood into the lower part of the vessel. Although, in the Armamentarium Chirur- gicum of Scultetus, ihere is a plate of a machine, invented by this author for com- pressing the radial artery by means of a screw J. L. Petit is universally allowed to be the first who brought the tourniquet to perfection, by combining the circular band with a screw, so that the greatest pressure may operate on the principal artery. The advantages of the modern tourniquet are, that its pressure can be regulated with the utmost exactness; tbat it operates chiefly on the point where the pad is pla- ced, and where the main artery lies ; that it does not require the aid ofan assistant to keep it tense ; that it completely commands the flow- of blood into a limb; that it can be relaxed or tightened in a moment; and that HEMORRHAGE. 603 when there is reason to fear a sudden re- newal of heinorrhage, it can be hft slackly round Ihe limb, and, in case of need, tight- ened in an instant. Its utility, however, is confined to the limbs, and as the pressure necessary to stop the flow of blood turqu^h the principal artery, completely prevents the return of blood through the veins, its application cannot be made very long w th out inducing mortification It is only of use also in putting a sudden stop to profuse hemorrhages for a time, that is, until the surgeon has put in practice some means, the effect of which is more permanent. LIGATURE. The ancients were quite unacquainted with the use of the tourniquet, ind though some of their writers ha-e made mention of the ligature, they do not seem to have known how to make proper use of it, nor to have possessed any other certain means of sup- pressing hemorrhage from wounds. In mo- dern times it is easily comprehensible, that when any great operation was undertaken, while surgery was so imperfect, there was more likelihood of the patient's life being shortened than lengthened by what was attempted. Under these circumstances, it is not surprising, that the old practitioners should have taken immense pains to invent a great many topical astringents But, now that the ligature is known to be a means which is sater and less painful than former methods, no longer search need be made for specifics against hemorrhage. It may, indeed, be set down as a rule in surgery, that whenever large arteries are wounded, no styptic application should ever be employed, but immediate recourse had to the ligature, as being, when properly ap- plied, the most simple and safe of all methods. In order to qualify the reader to judge of the best mode of applying Ilgai ires to arte- ries, I shall first explain to him their effect on these vessels, as related by Dr. Jones. This gentleman learned from Dr. J. Thom- son, of Edinburgh, that, in every instance in which a ligature is applied around an artery, without including the surrounding parts", the internal coat of the vessel is torn through by it, and that this fact had been o'< inally noticed by I esault. Dr I bom son showed to Dr. Jones, on a i ortion of artery taken from the human subject, that the infernal and middle coats are divided by the. ligature. (Jones, p. 126.) This led Dr. Jones to make some experi- ments on the arteries of dogs and ho ses, tending to the conclusion, that when several ligatures are applied round an artery with sufficient tightness to cut through its internal and middle coats, although the cords be immediately afterward removed, tbe vessel will always become impervious at the part which was tied, as far as the first collateral branches above and below the obstructed part. Dr. Jones thinks it reasonable to ex- pect, that the obstruction produced in the arteries of dogs and horses, in the manner he has related, '• might be effected by the same treatment in the arteries of the human subject ; and, if it should prove suc- ces-ful, it mi.lit be employed iu some of the most important cases in sureery. The Success ofthe late important improvements which ha^e been ii.troduced in the opera- tion for aneurism, may perhaps appear to most surgeons to have rendered t at opera- tion sufficiently simple and safe : but if it be possible to produce obstruction in the canal of an artery of the human subject, in the above-mentioned manner, may it not be ad- vantageously employed iu the cure of aneu- rism ; inas inch as nothing need be done to prevent the immediate union of the external wound ?'' Dr. Jones next questions, whe- ther this mode of obstructing the passage of blood through the arteries m; y not also be advantageously practised in cases of bron- chocele ? (P." 136.) Subsequent experimenters, as a late wri- ter observes, have not, however, been equally successful with Dr. Jones in obtain- ing the obliteration ofthe cavity of the ves- sel after this operation. Mr. Hodgson tried (be experiment iu two instances upon the carotid arteries of dogs ; and in neither of them was the cavity of the vessel oblitera- ted. The same experiment has been re- peated by several surgeons upon the ar- teries of dogs and horses; but, in no ex- ample, as far as Mr. Hodgson knows, nas the complete obliteration of the ca- vity of (be vessel been accomplished. >l It appears, however, that an effusion of lymph is an invariable consequence of the opera- tion : the want of union is therefore owing to the opposite sides ofthe vessel not being retained in a state of contact, so as to allow of their adhesion. (See Observations on the .tfplication of the Ligatun lo Arteries, fa. by B. Travers, Vol l, Med. Chir. Trans.) The presence ol the ligature, in the common mode of its application, effects this object; and for the success of Dr. Jones's experi- ment, it appeared only necessary, tbat the opposite sides of the wounded vessel should be retained in contact, until tin ir adhesion is sufficiently accomplished to resist the pas- sage of the blood through the tube. This object mi ht probably be effected by com- pression ; but the inconveniences attending such a degree of pressure as shall retain the opposite sides of an artery iu contact at the bottom of a recent wound, are too great to permit its employment. It occurred to Mr. Travers, that if h ligature were applied to an artery, and suffered lo remain only afew hours, the adhesion ofthe wounded surfaces ivould be sufficiently accomplished to en- sure the obliteration of the canal; and by the removal of the ligature at this period, the inconveniences attendin.-• its stay would be obviated. The dmger produced by the residence of a ligature upon an artery, arises from the irritation which, as a foreign body it produces in its coats Ulceration has never been obseived to commence in less than twenty-four hours after the application r»u4 HEMOKilHAGK. of a ligalure ; whilst it is an ascertained fact, lhat lymph is in a favourable state for or- ganization in less than siv hours,iu a wound, the sides of w hicb ure preserved in contact. (Joi.es, chap. 4, crp. 1 ) If it be sufficient, therefore, to enure their adhesion, that the wounded coats ofan artery be kept in con- tact by a ligature only three or four hours, ulceration and sloughing may in a great de- gree be obviated by promoting the immedi- ate adhesion of the wound. Justified by this reasoning, Mr. Travers performed seve- ral experiments, by vvhich he ascertained that if a ligature be kept six, two, or even one hour upon the carotid artery of a horse, and then removed, the adhesion was suffi ciently advanced to effect the permanent obliteration of the canal. It appeared pro- bable, that the same result would be obtain- ed upon the healthy artery of a human sub- ject .'" Hodgson on the Diseases of Arteries, fa. p. 228, et seq.) Mr. A. C. Hutchison, in the year 1S00, tied the brachial arteries of two dogs, and removed the ligatures imme- diately after their application. In both in- stances, the complete obliteration ot the ca- nal of the artery was the consequence of the operation. (See Practical Observations in Surgery, p. 103.) He has also tried this method, as modified by Mr. Travers, in an operation vvhich he performed for a popli- teal aneurism in a sailor, in Nov. 1813. A double ligature was passed under the femo- ral artery. The ligatures were tied with loops, or slip-knots, about a quarter of an inch ofthe vessel being left undivided be- tween them. All that now remained of (he pulsation in the tumour was a slight undula- tory motion. Nearly six hours having elapsed from the application ofthe ligatures, the wound was carefully opened, and the ligatures untied and removed without the slightest disturbance of the vessel. In less than half a minute afterward, the artery be- came distended with blood, and the pulsa- tions in the tumour were as strong as they were before the operation. Mr. Hutchison then applied two fresh ligatures ; hemor- rhage afterward came on ; amputation was performed, and tbe patient died. (See Prac- tical Observations in Surgery, p. 102, fa.) Now as, Mr. Hutchison chose to apply other ligatures, on finding that the pulsa- tion returned, the above case only proves, that the artery is not obliterated in about six hours, and we are left in the dark respect- ing the grand question, namely, whether the vessel would have become obliterated by the effusion of cftagulating lymph, and the adhe- sive inflammation, notwithstanding the re- turn of circulation through ft. As for the hemorrhage whicboccurred, I think it might have been expected, considering the dis- turbance and irritation which the artery must have sustained in the proceedings ab- solutely necessary for the application of not less than four ligatures, and the removal of two of them. According to my ideas, only one ligature ought to have been used, and none ofthe artery de'at htd. We also have no description of the sort of ligatures which were employed ; au essential piece of in- formation in forming a judgment of the me- rits ot the preceding method. The applica- tion removal, and reapplication of ligatures are not consistent with the wise principles inculcated by the late Dr. Jones, and have' in more instances than that recorded by Mr. Hutchison, brought on ulceration of the artery and hemorrhage. From Dr. Jones's experiments, it appears, (hat Ihe first effects of a ligature upon an ar- tery are, a complete division of its internal and middle coats, an apposition of its wound- ed surfaces, and an obstruction to (he circu- lation of Ihe blood through ils canal. There must be a small quantity of stagnant blood, just within tbe extremity of the artery ; but this does not, in every instance, immediate- ly form a coagulum, capable of filling up the canal of the artery. In mosl cases, only a slender coagulum is formed at first, which gradually becomes larger by successive coa- gulations of the blood ; nnd hence, the coa- gulum is always at first of n tapering form, with its ba*e at the extremity of the artery. But, es Dr Jones remarks, ihe'formation of this coagulum i> not material ; for soon after the ligature ha* been applied, the end of the artery inflames, and the wounded internal surface of its canal being kept in close con- tact by the ligature, adheres, and converts this portion ofthe artery into an impervious, and, at first,slightly conical sac. It is to ihe effused lymph that the base of the coagulum adheres, when found tobe adherent. Lymph is also effused between the coats of the ar- tery, and among the parts surrounding its ex- tremity. In a little time, the ligature makes the part on which it is directly applied ul- cerate ; and, acting as a tent, a small aper- ture is formed in the layer of lymph effused over the artery. Through this aperture, a small quantity of pus is discharged, as long as the ligature remains ; and, finally, tbe li- gature itself also escapes, and the little cavi- ty which it has occasioned, granulates aud fills up, and tbe external wound heals, leaving the cellular substance a little beyond tbe end of Ihe artery, much thickened and indura- ted. (Jones, p. 159, 161.) In short, when an artery is properly tied, Ihe following are the effects, as enumerated by Dr. Jones: 1 To cut through the internal and middle coat3 of the artery, and to bring Ihe wound- ed surfaces :nlo perfect apposition. 2. To occasion a determination of blood to tbe collateral branches. 3. To allow of the formation of a coagu- lum of blood just within the artery, provided a collateral branch is not very near the liga- ture It merits particular notice, however, that though the nearness ol a collateral branch prevents ihe formation of a coagulum, it cannot always prevent (he completion of tbe adhesive process. In the experiments made on the arteries of horses and dogs by Mr. Travers, the ligature was purposely applied close to large collateral branches, yet (be vessels were safely obliterated. (See Med. Chir. Trans. Vol. 6, p. 60S, 660.) HEMORRHAGE 660 i. to excite inflammation on the internal tnd middle coats of the artery, by having iut them through, and, consequently, to give rise to an effusion of lymph, by whicb ihe wounded surfaces are united, and the canal is rendered impervious ; to produce a simul- taneous inflammation on the corresponding external surface of ihe artery, by which it becomes very much thickened with effused lymph ; and, at the same time, from the ex- posure nnd inevitable wounding of the sur- rounding parts, to occasion inflammation in them, and an effusion of lymph, which co- vers (be arlery, and forms the surface of the wound. 5. To produce ulceration in ihe part ofthe nrtery, around which the ligature is imme- diately applied, viz. its external coat. 6. To produce indirectly a complete obli- teration, not only of tbe canol of the artery, but even of the artery itself, to the collate- ral branches on both sides of tbe part which has been tied. 7. To give rise to an enlargement of the collateral branches. (Jones, p. 163, 164.) Every part of an artery is organized in a similar manner to (be other soft parts, and its coats are susceptible of the same process of adhesion, ulceration, he. as the other parts nre. Hence, the precautions taken to secure the adhesion of other parts, should be ob- served for tbe same purpose with regard to an artery. The vessel is put in a state to ad- mit of adhesion by the ligature, which, when properly applied, cuts through its internal and middle coats, keeps their cut surfaces in contact, and affords (hem an opportunity of uniting by (he adhesive inflammation, as o(ber cul surfaces do. The immediate stop- page of the bleeding is merely the incipient and temporary part of what the ligature has to accomplish ; it has also to effect the adhe- sion of Ihe internal and middle coals of (he nrtery, which being (he tiling on which the permanent suppression of hemorrhage de- pends, is the most important. The size nnd form of the ligature, whether completely flat or irregular, have not been, as Dr. Jones re- marks, sufficiently attended to; nor is (he degree of force employed in tying the arte- ry, often considered. Some surgeons, wish- ing (o guard against the ligature's slipping off', tie it with very considerable force; while others, apprehensive lest they should cul through the artery, or occasion loo early a separation of the ligature, draw it only suffi- ciently tight to prevent the escape of any blood. A broad flat ligature is not likely to make such a wound in the internal and mid- dle coats of the artery, ns is most favourable lo adhesion, because it is scarcely possible to tie it smoothly round the vessel, which is very likely to be thrown into folds, or puck- ered by it, and, consequently, to have an ir- regular bruised wound made in ils middle and internal coats. By covering also a con- siderable space of the external coat, it may destroy the very vessels which pass on it in their way to the cut surfaces of the inner coats, and thus render them incapable of in- flaming. Even supposing th* wound to unite, Vo... I. ?J still such a ligature may rover that part of the external coal which is directly over the newly-united part, and, consequently, as soon as it has produced ulceration through the external coat, it will cause ihe same ef- fect on the newly-united parts, and, of course, secondary hemorrhage. (Jones, p. 168.) When a ligature is of an irregular form, it is apt to cut through (he iuternal and.middle coats of au artery more completely at some parts than others; but these coats must be perfectly cut through, in order to produce un effusion of lymph from the inside ofthe ves- sel, which seems to adhere most securely at ils cut surfaces. Also, when the ligature is not applied with sufficient tightness, the inner coats of the ar- tery will not be properly cut through. Dr. Jones thinks, that the ligature being some- times put on so as lo deviate from a circle, has a tendency to produce secondary he- morrhage. Dr. Jones conceives that ligatures are best when they are round, and very firm, and he adds, that though a very slight force is neces- sury to cut' through tbe internal and middle coats of an artery, it is better (o tie the ves- sel more tightly than is necessary, merely to cut through its inner coats, because the cut surfaces will thus be more certainly kept in contact ; the separation of the ligature ex- pedited ; and the danger of ulceration spread- ing to (he newly-cicatrized part diminished. The external coat will never ulcerate through. before the inner ones have adhered. The limb, however, should be kept in a perfectly quiet state. I am sincerely glad to find, flint so nccUrafe nn observer as Dr. Jones, litis refuted the idea, that ligntures occasionally slip off the vessels, in consequence of the violent im- pulse of the blood. In fact, (he blood does not continue (o be impelled againsl the extre- mity of the artery with the same impetuosi- ty with which it circulated through the ves- sel before it was tied. The blood is im- mediately determined (into the collateral branches, nor is there any pulsation for some way aborethe ligature. Dr. Jones much more rationally imputes (his occasional accident, either to the clum- siness of the ligature, which prevents its ly" ing compactly and securely round the artery; or to its not having been applied with suffi- cient tightness ; or to its having that very in- secure hold of the vessel, which the deviation from the circular application must occasion. (P- 173.) Dr. Jones is of opinion, that in cases of aneurism, in which the artery has only been tied with one ligature, and left undivided, and in vvhich secondary hemorrhage has arisen, lhat this has most probably been owing, either to a diseased state of the arte- ry ; to various contrivances for compressing a large portion of the vessel; to having a loose ligature above the one which is lied ; or, lastly, to not tying the artery sufficiently tight to cut through the iuternal and middle 6G6 HEMORRHAGE. coats, so as to fit ihe in for hu'hesion, but so as to cause a gradual ulceration through ll.ern, and, of couisp, bring on hemorrliHge, vvhirti returns with greater violence as Ihe ulceration advances. (P. 176.) These reflections must also obviously ex- plain why Scarpa's practice of using a largish ligature, with the intervention of a piece of cloth between the cord and the vessel, for (he express purpose of hindering the inner coals of the vessel from being divided, must be objectionable, because i( may be set down ns an axiom in all operations, where large arteries are to be tied, that the quantity of extraneous substances in the wound, and particularly ol" such ns are in contact with Ihe artery, should Le diminished ns much as possible. And though I may be dispi sed to go so far with Scarpa as lo believe, that the interposition of a piece of cork or wood is worse than that of a cylinder of linen, I cannot accede to the proposition, that (he lalter is free from objection, because it ra- ther acts as a cushion, than hs a body likely lo bruise. (See Mim. On the Ligature of Ar- teries, p. 44.) With the differences in the constitutions of man and animals, I know that the results of experiments on (be latter can never be look- ed upon as a positive proof of what would happen from (he same experiments perform- ed on the human subject. The stronger or weaker impulse of the heart, (he more or less coagulable nature of the blood, the greater or lesser degree of general and local irritability; the more or leas quick tendency to adbetire inflammation and ulceration; are circumstances which must make in differ- ent animals (he same experiments lead to opposite result;. The question, whether a small round ligature, or a larger flat one, with a piece of linen between it tnd the ves- sel, be best, must therefore after all be deci- ded, not by Dr. Jones's expeiintents, nor those of Scarpa, or Mis!ei, but by ihe prac- tice of surgery on the human body ; and that the principles defended in this Dictiona- ry are on the whole to be preferred, can hardly be questioned by any man, who knows bow much less frequent secondary hemorrhage now is in this metropolis, than it was formerly when those principles were neither observed, nor comprehended. (See Amputation, Aneurism, Arteries, and Liga- ture.) Dr. Jones seems to consider, that the ad- vantage of the retraction of the divided ar- tery within the cellular membrane, is com- pensated, in the case of the undivided artery, by the speedy and profuse effusion of lymph, which takes place over and round the vessel at the tied part,and even coversthe ligature itself. Another cause of secondary hemor- rhage, is the including of other parts in the ligature, together with the artery, by doing which, the division of the inner coats of the vessel may be prevented. In the valuable publication of Dr. Jones to which I have so freely adverted, some se- condary hemorrhages are also imputed to "up hidden separation, or haceration of the recently united parts ot an aitcrv, by pre- mature and extraordinary exertions of fhe patient. Hence, he strongly insists on keep- ing a limb, in whicb a large artery has been tied, perfectly at rest. I shall conclude these remarks on the liga- ture with a few practical rules. 1. Always tie a large artery ns separately as possible, but still let the ligature be ap- plied to a part of the vessel, which is close lo ils natural connexions. Besides the reasons for this practice, already specified, we may observe, that in- cluding other substances in the ligature causes immense pain, and a larger part of a wound to remain disunited. The ligature is aEo apt lo become loose, as soon as tbe sub- stance between it and the artery sloughs, or ulcerates. Sometimes the ligature thus ap- plied, forms a circular furrow in the flesh, and remains a tedious time, incapable of se- paration. The blood-vessels being organized like other living parts, the healing of a wounded artery can only take place favourably, when that part of the vessel, which is immediately contiguous to the ligature, continues to re- ceive a due supply of blood through its vasa vasorum, which are ramifications of the collateral arteries. Hence, the disadvantage of putting a ligature round the middle of a portion ofan artery, whicb has been separa- ted from its surrounding connexions; and hence, the utility, of making the knot as closely as possible to that part of the vessel which lies undisturbed among the surround- ing flesh. Small arteries neither allow, nor require, these minute attentions to the mode of tying them. 2. When a divided artery is large, open- mouthed, and quite visible, it is best to take hold of it, and raise its extremity a little way above the surface of the wound with a pair of forceps. When the vessel is smaller, the tenaculum is the most convenient instru- ment. 3. While the surgeon holds the vessel in IcVu*?'the assista»t is to place the noose Ot the ligature round it, and tie it according to the above directions. In order that the noose may not rise too high, and even above he mouth of the artery, when it is tightened, the ends of the ligature must be drawn as horizontally as possible, which is best done made thumbs- A k™t «s next to be 4. As ligatures always operate in wounds U efma-ne?UrS bod_ies' and one half °f each ^sufficient for the removal of the noose when detached, the other should always away. l° the kn0t' and tak*» As we have explained in the article Ampu- tation, and as we shall notice again in peaking of the Ligature, trials have of fnt^JFl ?un mJade ?( tbe Practice of cut" &, . -hu ends of the ngature close to the knot, with a view of diminishing, as far «* poss.ble tbe quantity of extraneous sub- HEMORRHOIDS. C67 nances in the wound. This plan requires the use of very small silk ligatures, in order to be duly judged of. (See Mr. Lawrence's Obs. in Medico-Chir. Trans. Vol.6, p. 156, et seq.) 6. When a large artery is completely di- vided, two ligatures, one to the upper, the other to the lower part of the vessel, are commonly necessary, in consequence of the anastomosing branches conveying the blood very readily into the part of the artery most remote trom (he heart, ns soon as the first li- gature has been applied. 6. When u large artery is only punctured, and compression cannot be judiciously tried, the vessel must be first exposed by an inci- sion, and then a double ligature introduced under it, with the aid ofan eye-probe. One ligature is to be tied above ; the other below the bleeding orifice ; with due attention to the principles explained in this article, and that on Aneurism. 7. Ligatures usually come away from the largest artery ever tied, in about a fortnight,. and from moderate-sized ones, in six or seven days. When tbey continue attached much beyond the usual period, it is proper to draw them very gently every lime tbe wound is dressed, for the purpose of accelerating their detachment. Great care, however, is re- quisite in doing Ihis ; for, ns Dr. Jones re- marks, as long as the ligature seems firmly attached, pulling it rather strongly must act, more or less, on the recently cicatrized e\- tremity of the artery, which is not only contiguous to it, but is still united to that portion of the artery, (the external coat) vvhich detains the ligature. ^Jones, p. 162.) In particular individuals, there appears to be an extraordinary tendency to profuse he- morrhage from very slight injuries. An in- stance of this kind was lately recorded by .Mr. Blagden, where a fatal hemorrhage arose from the extraction of a tooth. The patient, \ ho was twenty-seven years of age, had had a tooth extracted when a boy, in conse- quence of which operation, the bleeding continued for twenty-one days, from the socket, before it ceased. A very slight cut on the head was aHo followed by an alarm- ing bleeding, which could not be stopped by pressure, styptics, or the ILi-.ture, so ihat il became necessary to apply the Kali purum, which succeeded. On his having another carious tooth taken out, a profise bleeding followed, which resisted the etfoct of styp- tics, caustic, and every means adopted to stop up the socket. The actual cautery w; s tried in vain. The dangerous condition ot the patient seemed to -leave no other re- source but that of lying the carotid artery, vvhich was done by'.Nir. Brodie. But even this proceeding failed lo suppress ihe he- morrhage,which proved fatal. (Vid. Med. Chir. Trans. Vol. H, p. 224, London, lsl7.) On the mode of stopping hemorrhage from the sockets of the teeth,-the reader may find «ome remarks in the Einb. Med. and Surg. Journ. No. 58, p. 157. The heinorrhage from the btt?s of leeche* -onieliinesproYCScMeeJini-ly obstinate.and instances of death from ibis pause have oc- casionally happened, particularly in children. When common methods fail, the plan has been recently tried of passing a fine sewing- needle through the skin on one side of the wound, and then another through the skin on the opposite side, and then twisting some thread round tbe needles, so as to draw them together, and close the bile. The experi- ment folly answered (See Lond. Med. Re- pository, January, 1819. p. 23—26.) Eor more information, respecting hemor- rhage, see Amputation, Aneurism, Arteries, Ligature, and Wounds. Consult also Pelit's Memoirs, among those of I'Acad. des Sciences for the years 1731,1732, —1735 : Morn,id sur le Changement. qui ar- rive aur Arteries coupies. 1736: Pouteau, Melanges de Chirurgie .- Gooch's Chirurgical liorks. Vol. 1 : Kirkland's Essay on the Me- thod of suppressing Hemorrhages from divided Arteries, Svo. Lond. 1763: White's Cases in S.irgery: J. Hell's Principles of Surgery, Vol. 1.: Parlie Chirurgicale de I'Encycl. Mrlh. .- Larrey, Mimoires de Chirurgie Mi- litaire, Tom 2, p. 379. Pelleton, Clinique Chir. T 2. p. 240, fa. Mr moire Element aire sur les lit morrbagies. Richerand, Nosogrc phie Chir. '/'. 4. Seel, sur les Maladies des Arlcres. p. 23, fa. Fdi!. 4. Liveilli, Nou- velle Doctrine Chir. T. 1, Chap. 3, and, par- ticularly, Jones on the Process employed by Nature, in suppressing the llcmmorr huge from divided and punctured Arteries, 1805. Many useful remarks on the subject of hemorrhage will be found in Hodgson's Treatise on the Diseases of Arteries and Veins. See also 01- s?rrations upon the Ligature of Arteries, and ihe cause of secondary Hemorrhage, fa. by P. Travers, in Med. Chir. Trans. Vol. 4, p. 435, et seq Likewise further observations on the ligature o> Arteries, by the mnie, in Med. Chir. Trans. Vol. 6, p. 632, et seq. Lawrence on a New Mtl(iod of Tying the Arteries in Aneu- rism, Amputation, fa .in Vol. 6, of the Med. Chir. Trans, p. 1 ">(>, fa. r.nd Crampton in Vol. 7. tf the same u-ori;. Langenbeck, Bibl. B. 1. Dr. J. Thomson's Lectures on inflammation, p. 2"i0, fa. end Obiervntions made in the Military Hospital* i.i Br'gium, p. 42—4-'. Scarpa on Aneurism, and particularly his .Memoir on Ihe ligature of Arteries: this is con laitted i.-i the Secoiid Edit, of the Transl. by Mr. Wishart. Beclard, Experiences sur les Bicssiir.s des Arleres. John Cross. A Case uf Amputation, with some Experiments and O'sser-alions on the stcuring <>f Arteries with mir.iilc.iitlfligiilures.in Lond. Med. Repository, Vol. 7, /'. 3-33. The author relates several ex perimenU for the p>ir;wsr of ascertaining the utility of tying nrleri.i with such ligatures, a'id citllirg the ino ends off close to the k.i '.'. The;, ."trc perfumed on the caro'ids of dogs and i.ssis. The eonclusions are unfavourable t> Ihe j'r.tclice.. After one (•«.<- of amputation, where the method was f.-iii/, the stump healed slowly, mill for several months small abscesses repeatedly formed. HF.MORRHOIOS. (from<*iM«,blood,and jisa, to flow.) piles, divided into such as do nut bleed, and termed blind, and into othe:- G6M HEMORRHOID- subject to occasional hemorrhage, and dis- tinguished by the epithet open. 1 lie etymo- logical meaning of fhe word is evidently only a discharge of blood. Surgeons, how- ever, sanctioned by long custom, have generally implied, by the term hemorrhoids, either a simple bleeding from the veins of the lower part of the rectum recurring more or less frequently, yet not accompanied with any distinguishable permanent tumours, withi:,, or on the outside ofthe anus; or ehe swellings formed by a varicose disten- tion and morbid thickening of those vessels, either with, or without occasional hemor- rhage ; or lastly, tumours, originally pro- duced by effused blood, which is sometimes converted into an organized substance. (Abernethy, Surgical Works, Vol.2, p. 234.) According to Richter, blind hemorrhoids consist of preternatural cysts, or sues, at the low er extremity of the rectum, from the size of a pea to that of an apple. Sometimes they are distended with blood, and very much swelled; and, at other periods, entirely subside ; though, when they have been often considerably swelled, they never quite dis- appear, but are alternately in a full en- larged state, and empty and flaccid. Indeed, the more frequent and considerable the en- largement has been, the greater is their size. It is generally supposed, that these tumours, or cysts, are varicose expansions of the veins of tiie rectum ; and probably, says Richter, this may sometimes really be the case ; but the disease in not always of this nature. In particular instances, and perhaps, in most cases, they arise from an extravasation of blood under the inner coat of the rectum ; and then the cyst is altogether formed by this membrane, and not by the vein. The follow ing circumstances furnish proof of what has been here observed. Hemorrhoids are sometimes as large as a walnut, or apple ; yet it is scarcely credible, that a mere varix could attain such a size. When cut away, the bleeding is often very slight, even when they are large. Surely, if the tumours were varices, there would always be profuse hemorrhage. Sometimes the cyst is found quite empty ; but how can a varix be sup- posed to be in this state ? The shape of he- morrhoids is also remarked to be subject to greater variety, than can hardly attend dila- tions of veins : thus, they are sometimes ob- long, sometimes cylindrical, like a finger, fcc. Lastly, when cut away, the sac h plainly seen to consist only of a single mem- brane. (Anfangsgr.der Wundarzn. B.6,p.395, Ed. 2, Gott. 1802.) At the same time it should be recoilseted, that " the blood sometimes coagulates in the dilated vein, and the swelliug becomes hard, inflamed, and very painful. The coagulum is subsequentiy absorbed, but the thickened coats of the vein, and the surrounding parts, form a tumour, which >3 little liable to inllame, and afford great distress." (Hodgson on Diseases of Arteries, fa. p. 566.) In short, all surgeons, who ronsider the disease as varices, admit wiih Sp. E. Home, lhat in cases of Inn:; standing, the contents of hemorrhoidal tumours "coa- gulate, and become solid ; their coats in- crease in thickness, and they resemble pen dulous excrescent tumours in other situations in the body." (OnUlcers.fa.) Availingbimself of the extensive opportunity afforded by his dissecting room, Mr.Kirby has taken some- pains to ascertain the nature of these tu- mours ; and he observes, " I cannot say, that they seemed to be formed of a varicose distention of the great hemorrhoidal vein, even in a single instance. In every case of external hemorrhoids, the tumour appeared to be composed of a prolongation of the cellular substance in a state of unusual firm- ness, surrounded by some veins, and cover- ed by the integuments. The veins were branches of the internal iliac. In even case of internal hemorrhoid, the structure was pretty similar: the veins, however, seemed enlarged, and were branches of the hemorrhoidal." (On certain severe Forms of Hemorrhoidal Excrescence, p. 40.) The opinion, that piles are formed of cells filled with blood, is also adopted by Dr. Ribes. The distention of the hemorrhoidal veins with blood, he observes, gives rise lo varices; but, if any of their blood is extra- vasated in tbe cellular membrane, at the in- ferior and internal part of the anus, hemor- rhoids are the result. If the inferior me- senteric vein be dissected in hemorrhodial patients, the ramifications of the vessel are seen terminating in the cysts of blood, and, on completely removing the whole, the hemor- rhoids appear suspended from the branches ofthe vein, as grapes from the vine. (See Rivut 3Vd, T. 1, Svo. 1820) Montegre, well known as the author of a copious trea- tise on the present subject, is the only writer who defines a hemorrhoid to be a preterna- tural determination of blood (fluxion san- guine) to the extremity of Ihe rectum, be- cause he conceives, that hemorrhage, swell- ing, he. are accidental circumstances, not constantly attending the disease. (See Diet. des Sciences Mid. T. 20, p. 445.) Whether the account of some piles being formed of distinct cysts, or sacs of blood be correct, or not, there is no doubt, that the tu- mours sometimes consist of a varicose en- largement of the branches of Ihe hemorrhoi- dal veins. Were this not the fact, how could cases like the following ever take place ? " One of my patients (says M. Dela- tour) had several of these tumours of very large size, and at every contraction ofthe sphincter ani, the blood issued from them per solium." (Hist. Phil. Obs. 212.) Mon- tegre has likewise seen two instances, in which tbe blood spouted out of the tumours in a continued stream. (Did. des Sciences Mid. T.20, p. 453.) And Richerand men- tions a merchant who lived to the age of eighty-nine, quite free from infirmity, and whose good health was ascribed to periodi- cal bleedings from piles, during fifty years of his life ; the evacuation being very regr • lar. and so profuse, thatthe blood was thrown some distance, as from a vein opened in HEMORRHOIDS. 669 phlebotomy. (See Nosogr. Chir.) If many piles were not either varices, or cysts in di- rect communication with the large veins of the rectum, Petit would not have succeeded in taking blood from them bv puncture, as he often did in lieu of the ordinary mode of venesection. (Mai. Chir. T.2,p. 134.) Hemorrhoids vary in number, size, form, and situation ; some being external; others, internal; and some hardly larger than a pen, while others exceed a hen's-egg in size. Sometimes they bti-ig on very serious com- plaints, either by bursting and discharging blood so profusely as dangerously to reduce the patient ; or by exciting inflammation of the adjacent parts, and fusing abacesres and fistulas; or, lastly, by becoming strangu- lated by tbe contraction of the sphincter ani, so as to occasion severe pain. Piles, which bleed but little, are not of much con sequence ; but those which bleed profusely, cause violent pain, or which induce inflam- mation, and all its effects, demand the great- est attention. Lieutaud mentions a person, who lo.-t three quarts of blood from some piles in the course of a couple of days ; and the heretic Arius, and the celebrated philo- sopher Copernicus, are said to have bled to death in this manner. I do not know what credit ought to be given to the extraordinary case cited by Panaroli, in which a Spanish noblemen voided every day for four years a pint of blood from some hemorrhoids, and yet en- joyed perfect health ! (See Obs. Chir. Pentec. 2, Obs. 46.) For other curious facts of this nature, see Did. des Sciences Med. T. 20, p. 458. In general, when piles are situated far up the rectum, they are less painful than when low down. In the former case, the veins or tumours are surrounded by soft and yielding substances, which do not make any painful pressure on them ; but when they are situa- ted towards the anus, they often suffer pain- ful constriction from the action of the sphincter muscle. In fact, when they are quite within the rectum, the patient has sometimes no warning of his disorder, till he discharges blood from the anus. With regard to the cause of hemorrhoids, anyr (hing capable of retarding the return of blood through the hemorrhoidal veins, may occasion the disease. The pressn -e of the gravid litems costiveness, and the frequent retention of hardened feces in the rectum, are very frequent causes. Persons, who lead sedentary lives, are often troubled with the complaint. Hence, women are more subject lo piles, than men. The pressure of an enlarged liver, or of water accumulated in the cavity of the peri- tonaeum, it is said, may occasion piles. I have adverted to the opinion of Monte- gre, that hemorrhoids depend upon a deter- mination of blood to the lower pari of the rectum, which sentiment is perhaps correct in cases, where the disease arises from irri- tation in that bowel, or the neighbouring parts. When these tumours are produced by the pressure ofthe gravid uterus, no cure can be expected till after delivery, when one gene- rally follows spontaneously. Also, when piles are an effect of dropsy, they cannot get well before the pressure of the fluid in the abdomen has been removed by tapping. Gently laxative medicines, and an horizon- tal position ofthe body, commonly alleviate the uneasiness resut.ng from hemorrhoids. The application of an ointment, composed of equal parts of the powder of oak-galls, and of elder-ointment, or hog's-lard, contri- bute to the «nir,e beneficial effect. The application of warm water by means of a bidet, or semicupinci, is also frequently pro- ductive of great ease. V\ hen piles are con- stricted by the sphincter ani muscle, the pain may often be at once removed, by pushing the swellings up tbe rectum. When the disease is in a state of inflammation, leeches applied to the vicinity of the anus, and puncturing the dilated hemorrhoidal vessels with a lancet, for the purpose of taking away blood, and the application of cold lotions, are measures occasionally employed to procure ease. The usefulness of leeches was particularly noticed by Schmucker (Vermisehte Chir. Schriften, B. 1, p. 107.) Petit preferred tbe lancet. When the number and size of hemorrhoids are so considerable, as materially to obstruct the discharge of the feces ; when they are severely painful, aud subject to profuse bleedings ; when the patient is disabled from following his usual occupations ; and when the above means afford insufficient relief, the surgeon should recommend their removal. The extirpation of piles with the actual cautery and caustics, as practised by the old surgeons, is now altogether relinquished. The only plan, ever followed in Ihe present state of surgery, is either to cut the tumours off with a pair of scissors or knife, or to ap- ply a tight ligature round their base, so as to cause them to slough r.way. If possible, tho opportunity of doir- either of these opera- tions should always be taken when the dis- ease is in a tolerably qr.iet stale. When piles are to be cut oil", and they t;re not sufficiently visible, the patient must first strain, as at stool, in order to in?ke the swellings more apparent. With the aid of a pair of dissecting force;.-, the skin, cover- ing the hemorrhoids, is -hen to be separated from them with the knife, but not cutaway, and the tumours, being taken hold of with n tenaculum, are to be removed. Sabatier states, that saving the skin is very essential ; for any hemorrhage which may arise, can then be more easily suppressed ; Mid, when there are several hemorrhoids to be extirpa- ted, the loss of substance about the eniis will be less, and of course, the patient will not be so liable to a contraction of tbis part, which is sometimes a very great afflic- tion. Previously to the performance of any operation, Mr. Abernethy endeavours to bring the bowels into a more regular state, and takes care to clear them with any medi- 670 HEMORRHOIDS. cine, found by experience to answer the pur- pose without inducing a continuance of irri- tation and purging -The bowel being evert ed to the utmost by the efforts used in evacu- ating the feces, and the parts cleansed by bathing with tepid water, the piles should be taken hold of with a double book,and remo- ved by a pair of scissors. A protruded and thickened plait of the bowel may be remo- ved in the same way ; but I think it is best to use the bistoury in removing it, because the depth, to which the scissors may cut, is uncertain. The incision, made by the knife, resembles two curved lines, joined at each extremity." The direction of the incision, both tor the removal of piles, and that of plaits, lie says, should be longitudinal, in the direction of the. bowel. \\ hen there is a transverse fold of the bowel of considerable extw.t, he prefers taking away two elliptical portions iu the long axis of the rectum. (See Abemethy's Surgical Works, Vol.2, p. 239.) As I have explained in the former part of this work, (see Anus, Prolapsus of) the late .Mr. Hey used to remove these extensive diseased folds, about the verge of the anus, with great success. J. L. Petit used to fol- low the same practice, (Mai. Chir. T. 2, p. 134 ;) nnd more recently, Air. Kirby. (Obs. on the Hemorrhoidal Excrescence, Lond. 1817.) The late Mr. Ware, published some re- marks on the present subject, and the tenor of what he says is to prove, that when there are several hemorrhoids, the removal of one, or two of (he most painful of (hem, with a pair of scissors, will afford effectual relief. The same author asserts, that when the pain of hemorrhoids is not violent, but there is a constant distressinguneasiness, with frequent returns of a profuse debilitating hemorrhage, this method will frequently produce a radi- cal cure. The excision of piles is occasionally fol- lowed by dangerous bleeding, as a case, re- lated by Petit, confirms. A patient bad some hemorrhoids, which were supposed to be ex- ternal, while they were only temporarily protruded. Almost iinine.iiately after (hey bad been cut off, the skin which had support- ed them, was drawn inward. An internal hemorrhage ensued, which could not be sup- pressed, ond proved fatal in less than five hours. The rectum and colon were found lull of black, coagulated blood. Sir 1). Home speaks also of some instances within bis know ledge, where after ihe removal of i ilernal piles wiih the knife, the bleeding en- dangered life. (On Ulcers, p. 363.) If ihe bleeding should prove troublesome, and proceed from vessels within the rectum, the best plan would be to distend the gnt with a suitable piece of sponge, so us to make pressure on the wound. Cold should also be applied to the sacr.:m and nates. The removal of hemorrhoids, with h liga- ture, may generally be done with sufficient safety; but still it h s its inconveniences, thouth lii v are not constant Petit fre- quently practised this method, witiiout anv- il! effects. In other instances, he had reason fo repent of having adopted it. A woman, for whom he had tied three hemorrhoids with narrow pedicles, whicb were favoura- bly situated for this operation, did not at first experience a ar-al deal of pain. How- ever, five hours afterward he was informed, that she suffered violent colic pains, vvhich extended along the colon. She was bled four times, without material relief. At last, Petit cut the ligatures, which could not be loosened, in consequence of their being con- cealed so deeply in th"! substance of the swollen parts. The pr-in very soon subsi- ded. The ligi tures. had only been applied four and twenty hours, but the piles had he- come black, and the skin covering their bases was cul through. Petit then removed tin m, without the least effusion of blood. Petit also relates a case, in which a pa- tient, after having had some piles tied, died of symptoms resembling those vvhich take place in eases of strangulated hernia", not- withstanding the ligatures were cut as in the foregoing instance After these two cases, Petit abandoned the practice of tying hemor- rhoids. Air. Kirby bus mentioned two cases, proving the ill effects sometimes arising from the ligature of piles : in one of these exam- ples, the patient's life was saved with great difficulty ; and in tbe other, the operation was followed by tetanus and death. (Obs. on the Treatment of certain severe Forms of Hemorrhoidal Excrescence, p. 1—3, Svo. Lond. 1817.) I believe, on the whole, that it is best to remove hemorrhoids with a knife, unless tbey are situated high up the rectum, where the veins are of large size, and likely to bleed profusely. If a tumour so situated should absolutely require removal, which can rarely happen, a ligature might be put round ils base with the aid of a double ca- nula, as is sometimes tone in cases of ute- rine l\,liipi. When the base ofthe tumour, however, is large, admits of being brought into viev, and the surgeon prefers tying it, he shotdd puss a needle, armed with a strong double litature, through the root of the hemorrhoid, and tie one part of this ligature firmly over one side of tbe swelling, and the other over the opposite side. When the base ofthe tumour is narrow, and (he liga- ture is preferred, the part may be tied at once, without passing a double ligature through its middle. Old hemorrhoids, which have been re- peatedly in a state of inflammation, at length acquire a considerable degree of hardness. 'the .internal membrane of the rectum be- comes thickened, loses its natural sof'tue**, nnd forms a kind of cyst, which prevent* th- lumourfrom bursting and bleeding. (See The ten, lJrogres de la Chirurgie, Sect. 4. p. 73.) In tiie 'iid, it ulcerates, and pours out a fetid discharge. Its size cannot now be lis eneJ by the use of emollient applica- tions; and its excision is indispensably ne- cessary. (See Lassus, Pathotorie Chir. T l; p. 336.) An opinion has comm >rily p-<--v-i:lc.!. (hit HL.\H>RRHOlb>S. 671 the oleeding from piles is of a salutary, or critical nature ; an evacuation, by which some peccant, or morbid matter, is thrown off from the body. Hence, many patients have been advised to submit to all tiie pain and uneasiness vvhich the disease occasions, rather than seek a cure. If the fret (hat some patients lose th*;ir health aft-r their piles have been cured, be received as suffi- cient proof of the disease having had a salu- tary effect, the doctrine muU remain fully established. But before this inference should be drawn, it ought to be known, whether the frequency of Ihe fact is such as to war- rant the conclusion ; for it is not to be sup- posed, that the removal of piles places the patient altogether beyond the reach of dis- ease and illness ; and no one will deny, that such operation frequently leads to improve- ment of the health. Were a patient to ap- pear to suffer from the cessation of an ha- bitual bleeding from piles, fomentations and leeches should be applied. Consult L'Encyclopidie Mithodique ; Par- tie Chir. Petit, (Euvres Posthumes, T. 2. Cal- lisen, Syslema Chirurgia Hodierna, T. 2, p. 105, Edit. 1800. Sabatier, De la Midecine Opiratoire, T. 2. Latta's System of Surgery, Vol. 2. Ware on the Treatment of Hemor- rhoids, Trnka de Krzowitz. Ffistoria Hemor- rhoidum. 3 Vol Svo. Vindob. 1794, 1795. Sir J. Earle, Obs. on Hamorrhoidal Excrescences, 2d Ed. Svo. Lond. 1807. T. Copeland, Obs. on the Principal Diseases of the Redum and Anus, Svo Lond. 1814. Schrcger, Chirur- gischt Verstlche, B. l,p. 253, fa. Ueber tu- buculose Excrescens des Aslerdarms, Svo. Narnberg, 1811. John Kirby, Obs. on the Treatment of certain severe forms of Hamor- rhoidal Excrescence, 8vo. Lond. 1817. Aber- nethy on Hemorrhoidal Diseases, in Ai> Sur- gical Works, Vol. 2, p. 231, fa. Lassus Pa- thologic Chir. T. 1, p. 331, Ed. 1809. Li- veilli, Nouvelle Doctrine Chir. T. 3, p. 164. Richter Von der Blinden Guldnen Ader in Anfangsgr. der Wundarzneykunst, B. 6, p. 395, FAAS02. W. Hey, Pract. Obs. in Surg -y, p. 439, fa. Ed. 2, Svo. Lond. 1810. Did. des Sciences Med. T. 20, p. 441, fa. 8vo. Paris, 1817. Montegre, Des Hemorrhoides, on Traili Analytique de toutes les Affections Hemorrhoi- dales, Nouvelle Ed. Paris, 1819. ViVPEJNDIX ABDOMEN. Our author in his de- srription of the abdominal cavity, seems to give an incorrect idea ofthe distribution and connexions of the peritoneum. He would convey, that this substance had within it all the viscera, except the kid- neys and contents of tbe pelvis. Strictly speaking, however, there is nothing with- in tbe bag of the peritoneum save a va- pour, the secretion of exlialent arteries, which opening upon its inner surface, pour out this fluid to prevent the effects of friction during the motions of the seve- ral viscera. The peritoneum is a membrane, form- ing a circumscribed cavity, on the outside of which are situated afl the viEcera ; and divided into its visceral and reflected portions. The visceral portion is made up of the back part of this, bag, which, after closely enveloping the several visce- ra, except the kidneys, rectum, and uri- nary bladder, that are but partially co- vered, passes toward the posterior ab- dominal parietes, and there forms the mesentery, mesocolon, and mesorec- tum, with the broad suspensory and lateral ligaments of the liver, &-c. Afterward it becomes attached to the walls ofthe abdomen, constituting its re- flected portion, which becomes a general lining to the whole parietes. Thus, the viscera are all without the peritoneal ca- vity. We do not consider the abdominal cavity opened, until this bag shall have been cut into; hence, by the cavity of the abdomen, is really meant, the space within the peritoneum ; for if a wound had been inflicted upon the abdomen, and the peritoneal lining remained sound, we would not call it a wound of the ab- dominal cavity. The water of ascites is contained within the bag of the peritone- um, and the operation of paracentesis or tapping, consists in penetrating the cavi- ty of the peritoneum, to allow its escape. When, however, we speak of t!ie caviiy of the abdomen, without immediate re- ference to the bag of the peritoneum, we conceive of it as being a large cavity having certain boundaries containing large and important viscera; and withal lined by the perifoneura. So that there is still an ambiguity in the customary ex- pression, Abdominal Cavity, which should be removed, as the student is often led astray, by what appears a contradiction in terms. ACUPUNCTURE Notice having Vo*. I- "■• been taken by some ol the journalists of this country, of a work lately issued by- Mr. Churchill, of the London College of Surgeons, upon the subject of Acupunc- turation, it may be expected that I should enlarge a little upon the article in this appendix. This I shall do by a few ex- tracts from that publication. The subject is introduced, by presenting the manner of performance among the Darien Indians, as related by the Surgeon of Dampier, Mr. Wafer. The patient is taken to a river, and seated upon a stone in the middle of it. A native, dexterous in the use of the bow, now shoofs a number of small arrows into various parts of the body. These arrows are prepared purposely for this operation, and are so constructed that they cannot penetrate beyond the skin, the veins of which, opened by the punc- turniion, furnish numerous streams of blood, which flow down the body of tbe patient. The operation, as practised in Japan, is stated to be as follows. The place made choice of for the punc- ture, is commonly at a middle distance between the navel and the pit of the sto- mach, but often as much nearer to, or farther from, either, as the operator, after a due scrutiny, thinks most proper; and in this, and the judging rightly how deep the needle must he thrust below the skin, so as to reach the seat of the morbific matter, and giving it a proper vent, con- sists the main skill of the artist, and the success of the operation is said to de- pend. Each row hath its particular name, which carries with it a kind of direction with regard to the depth of each punc- ture and the distance of the holes from each other, which last seldom exceeds half pn inch in grown persons, in the perpendicular rows, though something more in those which are made across tho body, thus, The needles whicb perform the opera ■ tion, are made, either of the finest gold ox- silver, and without the least dross or alloy. They must be exquisitely slender, finely polished, and carry a curious point, and with some degree of hardness, which is given by the maker by tempering, and not by any mixture, in order to facilitate their entrance, and penetrating th« skjr< >.,* M'L'LMji.i But though uie country abounds with expert artists, able to make them in the lushest perfection, yet none are allowed but such as are licensed by the emperor. After a further introduction, by record- ing the opinions and practice of Mr. Ber- lioz of Paris, and of Dr. Haime of Tours, upon this important operation, Mr. Churchill ventures to exhibit his own ex- perience in regard to acupuncturation. The first case is that of a bricklayer, of thirty years of age, who he describes as truly halt; having come to the house of the Doctor supporting himself with a stick in one hand, and resting the other against the wall. " The body was bent at nearly right angles with the thighs, and his counte- nance indicated acute suffering. He had been attacked, he said, three days before with darting, excruciating pains in the loins and hips; every motion of the body produced an acute spasmodic pain, re- sembling an electric shock; and the at- tempt to raise the body to an upright po- sition, was attended by such insupporta- ble agony, as obliged him to continue in this state of flexion, rather than encoun- tering it by altering his position. There was no more constitutional disturbance than was to be expected from three day3 and nights of constant pain ; the pulse was a little quickened, and the tongue white, but I attributed this derangement to the irritation set up by the pain and loss of rest. I directed him to place him- self across a chair, for support during the operation, and I immediately introduced a needle of an inch and a half in length into the lumbar mass, on the right side of the spine ; in two minutes time J obser- ved that he seemed to rest the weight of his body more on his limbs, and in the next instant, without any inquiries being made, he observed that he felt his limbs stronger, from the 'puin having left his hips.' He next plainly indicated that the disease was lessened, by raising his body, from which he only"desisted by being desired to remain ut rest, through fear of the needle, being broken. The instrument having remained in its place for about six minutes, the patient decla- red that he felt no pain, and could, if he were permitted, raise himself upright; it was then withdrawn ; the man arose, adjusted his dress, expressed bis asto- nishment and delight at the sudden re- moval uf the disease, and having made the most grateful acknowledgments, left the house with a facility as though he had never been afflicted." Another case is one wherein Mr. Churchill succeeded in curing in the same astonishing manner. A young man who had been rendered unable to raise himself, being seized by violent pain in the loin* whjht i'.i the uctoflOinga very heavy piece of mahogany. Aniiougu t.voUays were devoted to try the effects of cupping and blistering, which had been immediately . administered, and which time passed vv itliout much relief, yet by the aid of the operation ofthe acupuncture, the patient was soon rendered fit for his usual em- ployment.—The case isas follows. " On the third day, the operation of acupuncturation was performed upon the part of the loins pointed out as the seat of the injury, which, as in the former case, dissipated the pains in five or six minutee, and restored the motions of the back. He returned, however, the next day with the same symptoms as at first, but in a mitigated degree. A needle was now passed to the depth of an inch on each side of the spine, which, as 1 expected, terminated the disease in a few minutes; and it was with pleasure that 1 under- stood the next morning that the man had gone to his usual employment." But the Climax.'—Mr. Jakes, of West- minster, (the gentleman who is said to have first introduced the operation into Kngland)received an urgent message from Mr. Scott, to visit him immediately. Mr. J. found him in bed, with a countenance expressive of n.uch anguish, having suf- fered, for three days, from severe pain iti the loins, which he attributed to a sudden transition from a warm room to a foggy nocturnal atmosphere. " VNitliin the last twelve hours it had acquired such a degree of violence, that even respiration was insupportable, ex- cept the body were fixed in such positiona as permitted the least possible motion. An attempt to resume the erect posture, produced violent spasmodic action of Ihe muscles of the back, which appeared to be communicated by sympathy to those of the abdomen and chest, impeding re- spiration with a convulsive effort; nor could any motion of the body be made without producing this effect. Neither fever nor general derangement was pre- sent, the secreting organs of the body properly performing their functions, pro- ved the external locality of the disease. In this state of things, acupuncturation presented itself to us, as likely to afford relief, and it waa therefore immediately resorted to. " I applied an exhausted cupping-glass upon the integuments, opposite tbe se- cond lumbar vertebra?, and midway be- tween this bone and the edge of the la- tissimus dorsi muscle, which was the part referred to as the most concentrated spot of the disease. As soon as a needle had penetrated to the. depth ofan inch, a sen- sation arose, apparently from the point of the instrument, which the pativnt descri- bed as resembling that which is produced by the passage of the electric aura, when directed to a metallic point, diffusing i» VPPENDIX'. self at iir3t to some distance around the part, and then extending itself to some distance up the side to the axilla. This sensation continued to be felt for the space of a minute, when a violent pain struck into the right iliac region, imme- diate! v above, andcorresponding with the line of the crista of the ilium. No pain was now felt in the back, except a dull aching of ahqut two inches in breadth on the right side of the spine, extending from the lower part of the neck to the sacrum, corresponding with the situation and course of the longissimus dorsi mus- cle. The pain above the hip now began to subside, and in the space of three mi- nutes from its commencement, had cea- sed altogether. " The uneasiness along the course of the spine still remaining, a needle was in- troduced about an inch from one of the dorsal vertebra;, and another in a corres- ponding situation, to one of the lower lumbar vertebra?. The pain in the right side was in a few minutes entirely dissi- pated, and the patient arose, declaring that, excepting a slight degree of uneasi- ness on tbe posterior part of the chest, near the angles of the inferior ribs, he .was completely relieved from the disease. He, however, requested I would pass a needle in this last situation ; on effecting vvhich, the pain soon left its last refuge, and the patient dressed himself, and left his house in the most perfect health. I have this day seen him, and he assures me that he has not experienced any re- turn of the affection." Mr. Churchill's manner of operating is in this wise. The handle of the needle being held between the thumb and fore-finger, and its point brought into contact with the skin, it is pressed gently, whilst a rotatory motion is given it by the finger and thumb, which gradually insinuates it into the part, and by continuing this rolling, the needle penetrates to any depth, with facility and ease. The operator should now and then stop, to ask if the patient be relieved; and the needle should always be atlowed to remain five or six minutes before it is withdrawn. This mode of introducing the needle, neither produces pain (or at least very little,) to the patient, nor is productive of hemorrhage, which Dr. Haime says arises from the fibres being se- parated, rather than divided by the pass- ing of the needle ; the former of which, (the absence of pain) is a point in its favour which few surgical operations possess. 1 must say, that 1 conceive this opera- tion to be an improvement on that of Perkins's celebrated Metallic Tractors, having its beneficial effects upon the same principle. AMAUROSIS. In the last American edition of this Dictionary, Dr. Dorsey states, that Dr. Physick lias punctured the cornea, and evacuated the aqueous hu- mour in some cases of gutta serena, with temporary advantage; having been induced to the step from an idea lhat prt-:- sure from an inordinate secretion of the humours might have occasioned the pa- ralysis of the retina. Mr. Ware, in like diseases, also has punctured the scleroti- ca, as mentioned under the article gutta serena, where also it is affirmed, that in several of the cases the proceeding was attended with almost immediate good effect. Now, by a reference lo the struc- ture of the globe of the eye, we are ena- bled to judge of the comparative benefit to he expected from the puncture in each situation. It is clear, advantage cannot follow such an operation, unless in cases wherein tho disease is kept up by pressure upon the filaments of the retina, and vvhich was occasioned by a watery fluid thrown out by the vessels of the choroid coat, among the reticular membrane connecting the retina to its inner surface, in the manner found by Mr. Ware, upon examination of the dead subject. Under such a view of the case, it is obvious, that a puncture into the globe, through the sclerotic coat, would afford opportunity for the escape of this fluid. And as far as it was the cause of the disease, the immediate good effects happening in Mr. Ware's cases would follow, and unless thpre was a dis- position in the. parts for its reproduction, which the operation might not overcome, a permanent cure would be accomplish- ed. When, however, in such cases, the puncture is made through the lucid cor- nea, this watery fluid is not evacuated ; the aqueous humour from the eye only escapes. For, in consequence of the con- nexions of the ciliary processes with the tunic ofthe lens, a complete partition ex- ists between the chambers of the eye, and the site of the morbid watery accu- mulation. Nevertheless, by the escape of the aqueous humour, the lens is allow- ed to he projected somewhat forward against the pupil by the compressed vi- treous mass, and until the chambers of the eye become filled again, the retina may be susceptible of impressions from the rays of lighf, but will 3000, on the reproduction of the aqueous humour. be returned to its former state of paraly- sis:—hence the temporary advantnge spoken of in reference to Dr. Physick's CAS6S AMPUTATION. OF LIGATURKS FOR THE ARTERIES. The size and material for ligatures, for the arteries on the face of a stump, will be, in a great measure, regulated by what is the intention of the surgeon. Whether he designs to cut them close to the stump previous to dressing, and at the time 67f, VrTEMJIA of the operation, or aiiow their ends to hang from the lips of the wound, to be removed when the arteries which thev embrace shall have been divi- ded* by ulceration. If the latter is the in- tention, then it matters little of what sub- stance they are composed ; perhaps the common white sevvinp; silk, waxed and flattened, will answer every purpose. But when the surgeon wishes to have a union effected speedily and throughout, by what has be**n called the first intention, and cuts tho. threads close to the knot, for ihe purpose of bringing together the parts over them, then it is expedient that the material of which the ligature is compo- sed, be one which will not act as an of- fending substance, at the bottom of the wound, and by eliciting the suppurative process, defeat the intention. To forward this end, such ligatures have been recom- mended, of substances of the nearest ally to animal matter, for the purpose of their more ready absorption ; and accordingly, they have been proposed of raw silk, carefully put together and waxed ; or of doc skin, of glove leather, or of catgut, fcc. If we examine into what must take place from such knots, so shut up in a wound, of whatever material they are composed, we shall be made acquainted how far the practice is to be approved. All consent, tnat the ligature around the vessel, effects adhesion of its sides, by the pressure it makes upon the tube at that part; and, as applied in amputa- tion, this is so great, that the ulcerative process supervenes, and is carried on un- til the artery is rid of this now offending substance. This process of ulceration is accompanied with a free supply of pus, in which the ligature lies until it is remo- ved. If the ends of the ligature have been cut off close to the knot, at the time of the operation, the process just spoken of will nevertheless have gone on thus far. Matter will now continue to be thrown out, in quantity proportionate to the pow- er of the substance composing the liga- ture to cause irritation, and to the time required for its complete solution; for the ligature must be dissolved before it can be absorbed, and the excess of pus required for its solution, must be absorbed also before the stump can be pronounced healed; and it is still a query, whether, notwithstanding how rapidly all this may have been accomplished,it can be called a healing by the first intention. More frequently, however, the pus in such a ease is found to disturb the newly cica- trized integuments,* and be the cause of one or more troublesome little abscesses * It is found, that tbe process for dissolving tbe li- g/Unre, does not retard the entire union of the inte- guments of the stump, by the first internum ; if it did, ibere might be, perhaps, less danger in Irving these ftperitnpats. on the face of' the stump, eitiier in un course of the cicatrix or through the ?kjn at other parts, (fori have seen them in both situations,) that may be referred te> unauthorized attempts, on the part of the surgeon, to produce a too speedy union after amputation. Mr. Lawrence, in favour of this prac- tice, has recommended very small and thin ligatures, of what is called dentist silk; but the inconveniency and trouble which must attend the tying of a large vessel with such small thread, must, in my opinion, overbalance any advantage that may have been attributed to the measure; besides, the same process of solution, previous to absorption, must take place in these cases ; so tbat even here we cannot have an absolute union by the first intention. In the last instance I witnessed this practice, the ligatures were made of doc skin, and cut off close to the knot, in am- putation below the knee. At the end of a week, a most alarming secondary he- morrhage took place, which nearly carri- ed off the patient, having been with much difficulty arrested. This I immediately attributed to the circumstance of thus dis- posing ofthe ligatures, and the surgeon who operated was so convinced of the force of the remark, that he resolved ne- ver to deal in the practice again. I can imagine that when the knots arc made by small thread or silk, they may become encysted, after the manner of some foreign bodies in wounds, and soon cease to be offending causes, but this must be a rare occurrence in comparison to the other issue. Upon the whole, I think, that the method of cutting off one end of the thread close to the knot, and letting tbe other pass beyond the lips of inte- gument, opposite the vessels to which they are applied, and so distributing the adhesive straps at the dressing as to al- low such accommodation, is a practice that cannot be improved upon. OF DRESSING THE STUMP. 1 have the pleasure to record an impor- tant feature in the practice of American surgery, which is a very effectual preven- tive of secondary hemorrhage, after the operation of amputation. 1 allude to a delay in dressing the stump, from half an hour to an hour after the ligatures arc applied. During tbis time the patient is put to bed, the paraphernalia ofthe ope- ration removed, and every ordinary means afforded for the reaction of the system, after the effects of fear, loss of blood, kc. By this plan, those small vessels which might have bled, without discovery, had the wound been immedi- ately dressed, will show themselves, and the surgeon will have an opportunity of securing them by ligature, before the plas- ters and bandages are applied. He will be APPENDBC WJ aole, also, to remove all the clotted blood, derived from an oozing from the capilla- ries ; and in this way, give facility for ad- hesion by the first intention. I am con- fident, that most of the cases of seconda- ry hemorrhage, after amputation, which I have seen, and they were many during the late war, might have been prevented by this precaution. And I feel assured, that most of those instances that were attended with extensive suppuration and delay, nay, sometimes followed by con- vulsions and death, are to be attributed to irritation, kept up by the presence of blood, which had oozed from the small vessels, succeeding a too early dressing after the operation. 1 have to state, that I first witnessed this excellent cau- tion in the practice of Dr. Parish, of Philadelphia. In regard to the direction of the line, made by bringing together the common integuments over the face of the stump, I believe it altogether unimportant what is the course giveu to the cicatrix, as to the ultimate shape of the stump. What is called a good and handsome stump, is not derived, in my opinion, from atten- tion to this particular; but from the cir- cumstance of preserving sufficient inte- gument to cover the muscles and bone. I also think, that if the flap operations had nothing else to recommend them than making a well-shaped stump, it would be better the practice was laid aside. I believe there is little danger to be dreaded from leaving too much integu- ment for this purpose, but that there is every thing to be feared from leaving too little. In amputations below the knee, however, it may be of consequence to bring the integuments together in a parti- cular manner; but then there is a differ- ent motive that directs the indication, than that of giving shape to the stump. It is expedient that this stump should be covered in a way that the bones may be least likely to make an injurious pressure against the skin ; and for this end, the union of integument should be directed downward and outward, which is in con- formity to the line made by the ends of the divided bones, in relation to each other; for we have many times seen the end of the tibia find its way through the ulcerated integuments, in a different si- tuation than wnere they were divided at the time of the operation. It maj he recollected likewise, that this line will be in a perpendicular direction, when the limb is placed on its side in bed, as effect- ed by separating it from the other, and putting pillows under the outside of the thigh; by this also a ready outlet is afford- ed for pus, as it may be formed during the cure. FLAP OPERATIONS. The manv objections that are now eon- firmed against the great variety of flap ope - rations, and that have been opposed to am - utation by the circular incision, have, 1 elieve, pretty well succeeded in making the latter the general practice at the pre- sent day. The greater extent Of wound- ed surface, the oblique division of blood- vessels, the difficulties experienced while searching for arteries in secondary he- morrhage, not being the least among the objections that have prevailed against flap operations in amputation. I have, however, witnessed,in Philadelphia, what might perhaps bear the name of a flap operation, by Drs. Parish and J. R. Bar- ton, vvhich for aught 1 know, is original with them ; and from not being subject to the weighty objections to flap operations generally, I think is, upon the whole, to bo advised in all cases where it is practica- ble, in amputations below the knee. The manner of the performance is as fol- lows. The surgeon, in making the first inci- sion, does not carry it circularly round the limb, but gives it an oblique direction, so that tbe incision round the limb is of an oval shape ; the lesser diameter of which is from side to side, and the place where the integuments are cut on the fore- part of the leg, is much higher than where they are divided behind. The whole of this incision is done by one sweep of the knife, and perhaps is not giving more pain in its performance to the patient, than that through the skin in the circular direction. The integument is then dis- sected back at the front of. the limb, from the forepart of'the tibia for about half an inch, and for a considerable extent behind, to prepare for the second incision, or that through the muscles, which is made in a circular direction, after the manner of the second cut ^n tfie opera- tion by the triple incision. The rest of the performances is gone through as in the old way. The benefit of this method is ascribed to the neat manner in which the face ofthe stump can bt- covered, by bringing forward the flap of skin which had been left at the back part of the leg. In this case, also, the line by which the integuments- are brought together, will be somewhat perpendicular when the limb is placed in bed, with the outside of the thigh against a pillow. SHOULDER JOINT OPERATION. In reference to amputation at the shoul- der joint, 1 shall not presume to add much, but when parts will permit, it is undoubt- edly the best method to amputate by making a flap ofthe deltoid muscle. The excellent covering afforded to the glenoid cavity, the permanent fleshy padding over the bone, are advantages which I would value above any derived from the other methods. Another benefit which I believe will accrue from this me. tliti vHPENDlX thod, i=, that the stump will he by it more likely to heal by the adnesive process. There is in these cases a strong exciting cause to suppurative inflammation, which I will undertake to say is owing to the presence of the cartilaginous covering, or lining of the glenoid 'cavity. Hence, it has been recommended to scrape the glenoid cavity, as a necessary step to this operation, although Mr. Cooper thinks the advice of little value, except when it is under disease. From the particular structure of intercarticular cartilages, they will not granulate, and are insuscep- tible of the adhesive inflammation, but are to he removed through a process of absorption, effected by the inflammation of the surrounding parts. It is their pre- sence which makes wounds of joints so dangerous, from the irritation they afford to the constitution, through the medium of a highly susceptible synovial mem- brane. There was lately a case in this city, which wis not well in twelve months after the operation ; and from the infor- mation I collected respecting it, 1 believe that the omission of scraping the cartilage from the glenoid cavity, was not the least among the causes that did,protract the cure. I cannot imagine any case wherein an amputation of the shoulder joint might be deemed adviseable, that it would be necessary or proper to secure the subcla- vian artery, by ligature, previously to the performance of the operation. The si- tuation of the subclavian artery, where it lies upon the firs.t rib, just .above the middle of the clavicle, is peculiarly con- venient for pressing the vessel, either by the thumb, or a pad, easily contri- ved on the handle of a key, &,c. if the surgeon should not choose to secure it first in the jftilla, or if the state ofthe disease prevented him. AMPUTATION OF THE THUMB. When it is necessary to remove with the thumb the metacarpal bone, a very pretty operation can be performed in this manner. An incision is to he begun up the inner part of the hand, opposite the os trapezium, and carried on each side of the metacarpal bone of the th'imb, in shape of letter V. These two lines are to meet under the root of the thumb, at the junction of the first phalanx with the metacarpal bone. The bone is then to be separated from thetrapezium,and with the whole thumb to be taken away. The adducter muscles and fleshy belly of flex- or pollicis brevis, form a fiiie cushion, so that when the parts are brought toge- ther, any great loss -of substance will not be perceived. ANASTOMOSIS. Under this head, might with propriety be introduced the resultof the several post mortem- examina- tions, instituted for the puipose of disco- vering the route of the circulation of the blood, in cases wherein some ofthe prin- cipal arteries had been tied, for the cure of aneurism, as well as from diseased ob- structions. A knowledge ofthe dilatable power ofthe arteries, however, is now so well confirmed, that the record at this time might be considered more a matter of curiosity than for direction to the sur- geon, as to what arteries he might attempt to tie. For since the human subject has undergone the sudden interruption in the course ofthe blood, through the aorta, by an> operation by Sir Astley Cooper, and through Ihe arteria innominata, by one performed by Professor Mott, with- out exhibiting any unpleasant symptom from the circumstance of the sudden sus- pension of the natural course of the blood. No surgeon need now hesitate, on this ac- count, in tying these or lesser arteries. As the postmortem appearances, however, in the case in which the carotid artery was tied by Profos-or Mott, previously to ex- tirpating a large tumour from the side of the neck, has not been recorded bjr the author of this Dictionary, I shall extend this article, by giving it a place. John M'.Garrigle, horn in Ireland, aged forty-nine years, was admitted into the New Yt-rk Hospital, on the 10th of No- vember, 1818, with a carcinomatous fun- gus, situated onthe right side of the face and neck, occupying a considerable por- tion of each. Fn>m its highly vascular appearance, as well as other reasons, it was, in a consultation of the surgeons of the Hospital, agreed, that an operation, which would lessen the flow of blood to the fungus, and permit as much of the tumour to be removed as possible, would afford the only possible means of prolong- ing the patient's life, and of mitigating his sufferings. With these views,* on the 14th ofthe same month, the right carotid was taken up. about an inch below the cricoid cartilage, and secured by two ligatures, but not divided in the inter- space, in consequence of the depth ofthe artery, occasioned by the swelling of all the parts surrounding the disease. And such was the enbrged size of the vessels, that it became necessary to take up se- veral artcrit s and veins before the carotid could be exposed. The tumour was now removed in a manner detailed in the se- cond number of the Register of Medical and Surgical Cases in the New-York Hospital, which can be referred to; suf- fice it to say, that the operation was com- pletely successful, but he died from a pulmonary disease on the following March 3d, having been greatly emaciated and worn out by a succession of hectic symp- toms. r By this, an opportunity was afforded for an examination into the new route AJrJPfiiNliiX Iriil Uie blood iiaU taken, succedent to the ob- literation of the carotid artery, and ha- ving seen the preparation, and compared it with the description by Dr. Mott, in the Hospital Register, I shall give the detail of the dissection, as it is there delineated. " As this afforded me an excellent op- portunity of examining the arteries on the right side of the head and neck, after the carotid had been tied, and not know- ing tbat any such case, had been recorded, I gladly availed myself of it, and separa- ted the head, neck, and shoulders in the following manner. Having sawed through the sternum at the upper part, so as to leave the cla- vicles attached, the superior extremities were removed from tne trunk, and the dorsal vertebra? and ribs divided between the second and third, so as to leave it of a bust-like shape. This preserved the shoulders in such a way, that the subcla- vian and their branches might be inject- ed. The ascending arch, and a portion of the descending aorta, were also inclu- ded in the preparation. To secure the filling of the arteries of the head and neck, a long pipe was passed up the aorta, into the left carotid, and a fine wax injection was thrown in with great care, and as the subsequent account will show, with great success. The aorta was next injected, to fill the subclavians and their branches. In the dissection, which was conducted with the greatest care and attention, I was assisted by David L». Rodgers and Alexander Vasche, two of my pupils, ardent in the pursuit of anatomical and surgical know- ledge. N 1 St. The arteries that supplied the right side of the head and neck, after the ca- rotid had been tied. To give a regular description of these arteries, would be incompatible with the principle of collateral circulation, inas- much as they are found to vary in differ- ent subjects, for, " the circulation is never carried on by any particular set of vessels, but by all the arteries of the neighbouring parts." Upon removing the integuments on the forepart of the neck, and laying bare the carotid artery, fftim the innominata- to the angle of the jaw, its calibre was found completely obliterated from its origin to its bifurcation; leaving a firm, ligamentous chord, which was divided into two parts, showing the place where the ligatures had been applied. The vein and nerve were perfectly na- tural. The right subclavian was much. enlarged, being equal in size to the inno- minata, from its origin to the scaleni muscles. The left carotid was enlarged to twice ••NiKitiU'-tidiaineti-r.ifibranclu'hincrcased in the same ratio, and assumed a tortuous and irregular course. When we take ir.to consideration the connexion vvhich the arteries of the left have with those of the right side of the head, and their free inosculation with the subclavian, we can have in our imagina- tion the. branches that must necessarily supply the place of the right carotid. First, we have tbe branches arising from the subclavian, vvhich are very numerous- secondly, those arising from the left ca- rotid, which are still more numerous. A minute derail of the numerous ves- sels which communicate with the carotid would be tedious and uninteresting, and would, perhaps, be impracticable, were it deemed expedient Suffice it to no- tice the principal branches, and to give a general description of the smaller, but not less beautiful inosculations. We find them arising from the right subclavian • first, the arteria thyroidea inferior, se- condly, the cervicalis profunda, thirdly, the cervicalis siiperficialis, and fourthly, the vertebral arteries. The inferior thyroid, as it arises from the subclavian, divides into four branch- es ; two passing downwards and out- wards, and the other two passing up- wards ; the latter are called the ramus thyroideus and the thyroidea ascendens. These require particular attention from" their large size, and tbe important sup- ply of blood which they furnish for the support of the arteries ofthe neck. While the superior arteries are enlarged to twice their natural diameter, the two in- ferior ones, viz. the transversalis colli, and the transversalis humeri, although arising from the same trunk, and receiving then- currents of blood in the most favourable direction, still retained their natura! di- mensions. But tbis phenomenon usually occurs in the circulating system. Johh Bell observes, " that in whatever way the demand of blood, upon an artery, or set of arteries, is increased, the effect is an accelerated motion of blood towards that artery." And again, " any demand of blood causes an enlargement of the arteries, leading to the part which de- mands the blood." Guided, then, by this principle, we need not be surprised, that the subclavian is so much enlarged from its origin to the sca- leni muscles, for here it affords a supply of blood to new and important parts. The ramus thyroideus passing upwards to the thyroid gland, and anastomosing with the superior thyroideal artery, was one great source of blood, its branches were large and tortuou«, forming commu- nications in every direction, with those from ab"ve. The thyroidea ascendens, naturally a small and unimportant branch; it was here three times its usual t-v/.e. mounting Al'iMi.N LlL* up the nock n; a /.igza^ direction, lying close to the vertebra*, forming frequent communications with the vertebral arte- ry, dividing into many small branches at the upper part of the mastoid muscles, forming a beautiful plexus of vessels, with the mastoid branch of the occipital arte- ry, and sending branches to all the mus- cles on the upper part of the neck. The cervicalis profunda and superficia- Hs, were much enlarged, sending frequent branches upwards to anastomose, with the descending branches of the oc- cipital artery. By far the most important and interesting part ofthe circulation yet remains to be described. 2dly. The arteries of the left side ofthe head and neck. The left carotid, passing up the neck, equal in size to the arteria innominata, fur- nished the greatest part of the blood for the right side. In order to determine what particular arteries werp enlarged, it is necessary on- ly to enumerate the branches given oft' from the carotid, and more particularly those whicb arise from its forepart. Be- low the jaw there are four, to wit, the su- perior thyroid, the lingual, pharyngeal, and the maxillaris interna, which inos- culate with open mouths, having the ap- pearance of continuous trunks, and send- ing a plentiful supply of blood to the neck, and internal parts of the face. The labial and temporal arteries lea- ving the axilla under the angle of the jaw, passing upwards upon the face, send off mail branches in a beautiful and fantastic manner. Branches, which before were considered unworthy the attention of the anatomist, now rise into importance. The plexuses and inosculations formed by these branches excite alike our sur- prise and admiration, and elucidate, in the most beautiful manner, the principles of collateral circulation. These arteries "n general are large and tortuous, and have frequent communications among themselves. The arteries most enlarged, were the mental, the inferior labial, the coronary, and the anguiaries. The optic artery was likewise much enlarged, beau- tifully anastomosing with the angularis. So freely did these arteries inosculate with those ofthe right side, that before the operation was finished, it was found necessary to secure the labial artery in a ligature. This was clearly illustrated by the retrograde course of the injection, af- ter death, which passed freely from the arteries of the opposite side, filling the su* perior portion of the labial, to the point at which the ligature had been applied. The temporal artery was of ils natural size, receiving its blood from " all the ar- teries of the neighbouring parts, from the amending branches of the oceiuital, the left temporal, tiie optitiialnue, unU tut transverse facial. This free communica- tion was distinctly shown by injection, which passing down the temporal, com- pletely filled the external and internal ca- rotids, and several of their branches; par- ticularly the inferior portion ofthe labial vvhich is seen emerging from underthe jaw to pass upon the face. The labial ter- minated at that point, where the mental is given off. The mental itself passed on to its usual destination, and received blood from its fellowfromtheoppositeside." ANEURISM. I was not a little sur- prised, when, upon a close inspection of this edition of the Dictionary, I found that the author had altogether omitted the case in which the arteria innominata was tied, in this country, for the purpose of diverting the blood from an aneurismal cyst/ which occupied the subclavian artery. This case having been on record sufficiently early, must have met the in- dustrious eye of Mr. Samuel Cooper, but I cannot account why its detail, or a bare mention of it had been neglected. I am aware, however, that the critics of this country did, in a great measure, succeed in establishing, for a time, an unbelief in what had been alleged by the operator : having presumed to assert, lhat the ope- ration was unauthorized; that the disease which was said to call it forth, was not an aneurism of the subclavian artery; and that the method adopted to get at the artery, was attended with an unnecessary violence to the surrounding parts, from which it was probable lhat the patient lost his life. Having seen the preparation, and care- fully examined into the history of the case, it does appear to me, that malevo- lence had dictated for the critics, and jea- lousy prescribed for the reviewers. But truth will be established and must out, although for a time its influence may be suspended by the ephemeral effects of ignorance, impudence, and folly. If the limits of this Appendix had per- mitted, it was my intention to present a general examination into the merits of this very important and singular opera- tion ; but I must content myself by mere- ly offering the case, and subjoining a re- ference to the several reviews; by which may be seen the motives of those who have declaimed against it, all which, with an appeal to the reader's own knowledge of the anatomy of the part, I feel assured will be sufficient to substantiate, that the disease was an aneurism of the right sub- clavian artery, that the arteria innomina- ta had a ligature placed around it in the .most apt manner, by Professor Mott, and that although the patient died on the 26th day after the operation, yet that his death was not the necessary consequence of its performance. I shall trinscribp T>\ MpM's comruuri- A1TENDIX. 681 tuition, from the New-York Hospital Re- ports. " Since the publication of Allan Burns's invaluable work on the Surgical Anatomy of the Head and Neck, 1 have been in the habit of showing in my surgical lec- tures the practicability of securing in a ligature the arteria innominata; and I have had no hesitation in remarking lhat it was my opinion, that this artery might be taken up for some condition of aneu- risms; and that a surgeon, with a steady hand and a correct knowledge of the fiarts, would be justified in doing it. 1 elt myself warranted in this, from the singular success which this celebrated anatomist informs us attended his injec- tions, and from my own investigations of this subject. If the right arm, right side of the head and neck, can be filled with injection, after interrupting its passage through the innominata, as we believe they can, who can doubt the possibility of the blood to find its way there also, as it will pass through thousands of channels, which art could not penetrate even by the finest injections ? The well-known anas- tomoses of arteries, and the great resour- ces of the system in cases of aneurism, encouraged me to believe, that this ope- ration might be performed with reasona- ble prospects of success. With all this sanction, and the analogy of the other great operations for aneurism, I could not for a moment hesitate in recommending and performing the operation. "The following operation,as the steps of it will show, was performed with the two-fold intention : 1st, of tying the sub- clavian artery before it passes through the scaleni muscles, if it should be found in h fit state; and 2dly, to tie the arteria innominata in case the former should be diseased or too much encroached upon by the aneurismal tumour. " Michael Bateman, aged 57 years, was horn in Salem, Massachusetts, and by oc- cupation a seaman. He was admitted into the New-York Hospital on the 1st of March, 1818, for a catarrhal affection, having at the same time his right arm and shoulder much swollen. At the time of his admission the catarrh being thought the most considerable disease ofthe two, he was received as a medical patient, and placed under the care of the physician then in attendance. During the three first weeks of his residence in the house, the catarrh had greatly yielded to the remedies prescribed. The inflammation, which had produced an enlargement of the whole superior extremity, extending itself to the muscles of the neck on the right side, was also gradually subsiding. " A tumefaction, however, situated above and posterior to the clavicle, at first involved in the genera! swelling, and not to be distinguished from it, began to show At l.l. 86 itself. This resisted the remedies which were effectual in relieving the other, and became more distinct and circumscribed as the latter subsided ; at length assuming the form of an irregular tumour. " The history which he gave ofthe caso is as follows : He said, about a week be- fore he entered the hospital, while at work on ship-board, his fret accidentally slipped from under him, and he fell upon his right arm, shoulder, and the back part of his head ; that he felt but little incon- venience from the fall, and after a short time returned to his duty. Two days subsequent to this, however, he felt pain in the shoulder, and the succeeding night was unable to lie upon it in bed. The whole arm and shoulder then began to swell, and became, so painful that he was unable an.y longer to perform his duty as a seaman. The ship having arrived in New-York, he was admitted into the hospital. " For some lime after the general swell- ing had subsided, leaving the tumour dis- tinct and circOmscribed, no circumstance occurred which gave rise to a suspicion of its being aneurismal. The enlargement was thought to be a common indolent tu- mour, and was repeatedly blistered, with a view to discuss it. The tumour gradu- ally diminished under this treatment; though a considerable time elapsed before any very striking change took place. " At length a faint and obscure pulsa- tion was perceived ; still it was a matter of doubt whether the tumour was aneu- rismal, or whether the pulsatory motion was communicated to it by the subclavian artery, immediately over which it was situated. From its firm unyielding na- ture upon pressure, the latter was consi- dered as the most probable, and the blis- ters were continued as before. During the whole of this time the patient had worn his arm in a sling, the motions of it being very limited, and always attended with pain. " The patient remained in this state for several days, without any marked change either in his feelings or in the appearance ofthe tumour. " On the 3d of May, at 6 o'clock in the afternoon, the patient complained that he " felt something give way in the tumour,"* that his shoulder was very painful, and that he was able to raise it only a few inches from his side. The tumour at this time, suddenly increased about one-third, and a pulsation was distinctly perceptible. Its most prominent part was below the clavicle; at which place the pulsation war most distinct. The portion above the. clavicle was also much enlarged ; it still, * In the preparation, the clavicle is lo be seen divi- ded about its middle, which from its appearance is shown to hHvr been effected by ahsorpU B. This Dr. M- seems to bare ouiittsd to ceniioc us2 k VITENDl.X however, had its usual firmness, except in one point near its centre. l; Mav 1th.—-The tumour is evidently increased, that portion of it more particu- larly vvhich is below the clavicle; it is not as firm and resisting ns it has been. Pulsation is not so di-tinct aw yesterday, but appears to be mor< dilfused. *' He was this day transferred to the surgical side ofthejiouse, and heciim* my patient. The cough having become com- paratively Might, the tiiiiiour .ippe.ued to be the most urgent dis« ase, and, in my opinion, to call for prompt attention. The arm i? now perfectly useless, and any motion at the shoulder joint gives him severe pain. The patient is naturally of a spare habit, and from the nature of nis disease, and the confinement to which he has been subjected, has become«much re- duced in strength. " May 5th and 6th.—The tumour is still progressing, and the pain in the shoul- der is also more severe. During the three last days his medicines havebeen discon- tinued, except that he is allowed to rub the parts about the clavicle with volatile liniment. " On the 7th I directed a consultation of my colleagues to be called, consisting of Drs Post, Kissain, and Stevens. 1 now stated to ihein that I wished to per- form an operation which would enable me to pass a ligature around ihe subcla- vian artery, before it passes through the scaleni muscles, or the arteria innominata, if the size of the tumour should prevent the accomplishment of the former. This 1 was permitted to do, provided the pa- tient should assent, after a candid and fair representation was made to him of the probable termination of his disease; and that the operation, though uncertain, gave him some chance, and, as we thought, the only one of his life. " Dr. Post, at my request, communica- ted with him privately on this subject, and after a full explanation of the nature ofthe case, my patient requested fo have any operation performed which promised him a chance for his life, saying that in his present state he was truly wretched. " May 8th, 9th, and 10th.—The tumour is acknowledged by all to be increasing, and it is thought proper not to defer the operation any longer. I therefore re- quested that preparation he made for performing it to-morrow. " It is difficult fo give an idea of the size of a tumour so irregular in its form, and so peculiarly situated. A thread passed over it, from the lower part of that portion of it which is below the clavicle, extending upward obliquely across the clavicle toward the hick of the neck, will measure five and a quarter inches. Ano- ther crossing this at right angles one inch above the clavicle, will measure four inch- es : two and a half inches of the thread are on the sternal side of the former, aud one and a half on the acromial. It rises fully an inch above the clavicle, which, added to the depression below the clavi- cle on the opposite shoulder, will make the size ofthe swelling above the natural surface about two inches. "May 11th.—One hour before the time assigned for the operation, the pa- tient appeared perfectly composed, and apparently phased with She idea that the opeiatiou afforded hnii'a prospect of some relief, lit was directed to take of Tuict. Upii. 70 drops. " No difference can be perceived in the puliation of the arteries in the two ex- tremities ; his pulses are uniform and re- gular, each beating 69 iu a minute. " Hf was placed upon a table ofthe ordinary height, in a recumbent posture, a little inclining to the left side, so that the light fell obliquely upon the upper part ofthe tnorax and neck. Seating my- self on a bench of a convenient height, 1 commenced my incision upon the. tumour, just above the clavicle, and carried it close to this bone and the upper end of the sternum, and terminated it immediately over the trachea ; making it in extent about three inches. Another incision about the same length, extended from the termination of the first along the in- ner edge of the sterno cleido mastoid muscle. The integuments were then dissected from the platisma myoides, he- ginning at the lower angle of the incisions, and turned over upon the tumour and side ofthe neck. " Cutting through the platisma myoides, I cautiously divided the sternal part ofthe mastoid muscle, in the direction of the first incision, and as much ofthe clavicu- lar portion as the size of the swelling would permit, and reflected it over upon the tumour. The internal jugular vein was encroached upon by the swelling, vvhich made this part ofthe operation of the utmost delicacy, from the morbid ad- hesion of that part of the clavicular por- tion of the muscle to it, which was de- tached. I separated this portion of the muscle to as great an extent, however, as the case would possibly allow, to make room for the subsequent s!«-ps of the ope- ration ; only a part of the vein was ex- posed. Tne sterno hyoid muscle was next divided, and then the sterno thyroid, and turned upon the opposite side ofthe wound, over the trachea. This exposed the sheath containing the caotid artery, par vagum, and internal jugular vein. A little above the sternum, 1 exposed the carotid artery, and separated the par va- gum from it; then drawing the nerve and vein to the outside, and the artery towards the trachea, I readily laid hare the subclavian about half an inch from its origin. In doing this, the handle of a scelnv' was principally used, nothing APPENDIX 633 more being required hut to separate the cellular membrane, as it covers the artery. * judged it would be very imprudent to introduce a common sralpel into so nar- row and deep a wound, especially as it Would be placed between two such im- portant vessels or parts, as the carotid and par vagum, and where the least mo- tion ofthe patient might cause a wound of one or the other of them. The proper instrument, in my opinion, for this part of the operation, is a knife, the size of a small scalpel, with a rounded point, and cutting only at the extremity ; this was used, and found to be very convenient for this stage of the operation. It can be introduced into a deep and nanow wound. among important part? without the ha- zard of dividing any hut such as are in- tended to be cut. This knife is contained in a set of instruments admirably calcu- lated for this and other operations on arteries deeply seated, and which 1 shall mention more particularly hereafter. " On arriving at the subclavian artery, it appeared to be considerably larger than com-non, and of an unhealthy colour; and when I exposed it to the extent of about half an inch from its origin, which was all that the tumour would permit, to ascertain this circumstance more satisfac- torily, my friends concurred w ith me in opinion that it would be highly injudicious to pass a ligature around it. The close contiguity ofthe tumour would of itself have been a sufficient objection to the application ofthe ligature in this situation, independent of the apparently altered slate of the artery. Art in this case could not"anticipate any thing like the institu- tion of the healthy process of adhesive inflammation in an artery in the imme- diate vicinity of so much disease. The Pathology of arteries has long since taught us, that ulcerative inflammation, and all its train of consequences, would have been the inevitable result. This was the fate ofthe only case, in which a liga- ture has been applied to the artery in this situation. The operation was performed by that eminent Surgeon of Dublin, Dr. Colles. " While separating the cellular sub- stance from the lower surface of the ar- tery, wiih the smooth handle of an ivory scalpel, a branch of artery was lacerated, which yielded for a few minutes a very smart hemorrhage, so as to fill the wound fierhaps six or eight times. It was a ho'it lalfan inch distant from the innominata, and from the stream emitted, was about the size of a crow-quill- It stopped with a little pressure. 1 cm scarcely believe this to have been the internal m.immary, from the hemorrhage ceasing so quickly ; though, from its situation, it would ap- pear so ; and if from some irregularity it were not the superior inlet■eostal, it ti.ttit have proceeded from an anomalous branch. " With this appearance of disease in the subclavian artery, it only remaiiietl for me either to pass the ligature around the arteria iiiuoniinata, or abandon my patient. Although I very well knew, lhat this artery had never been taken up for any condition of aneurisms, or ever per- formed as a surgical operation, y «'t with the approbation of my friends, and repo- sing great confidence in the resources of (he system, when aided by the noblest ef- orts of scientific surgery, 1 resolved upon the operation. " The bifurcation oi" the innominata being now in view, it only remained to prosecute the dissection a little lower be- hind the sternum. This was done most- ly with the round-edged knife, taking caie to keep directly over and along the up- per surface of the artery. Alter fairly denuding the artery upon its upper sur- face, 1 very cautiously, with the handle of a scalpel, separated the cellular sub- stance from the sides of it, so as to avoid wounding the pleura. A round silken li- gature was now readily passed around it, and the artery was tied about half an inch below the bifurcation. The recurrent and phrenic nerves were not disturbed in this part of the operation. " As most surgeons who have perform- ed operations upon large arteries, in deep and narrow wounds, complain of the em- barrassment whieh has attended the ap- plication of the ligature, I am happy in the present opportunity to have it in my power to recommend an instrument, or contrivance, which, in my opinion, is cal- culated to surmount all difficulties. This set of instruments consists of several needles of different sizes and curvatures, with sharp and blunt points, and having in each two eyes. The needles screw into a strong handle or shank of steei: two strong instruments in handles, with a ring or eye in the extremity similar to a tonsil iron, and perhaps they may be called ligature irons : a small knife round- ed at the extremity like a lancet for sca- rifying the eyes, and a small hook at the extremity of a steel shank, also fixed in a strong handle. These instruments are the invention of Drs. Parish, Hartshorne, and Hewson, of Philadelphia. They are the result of investigations made upon the dead body, as to Ihe best mode and place for tying the subclavian artery on the acromial side of the scaleni muscles.* " With the ligature introduced into the eye of one of the smallest blunt needles, which was nearest the shank of the in- strument, 1 pressed down the cellular substance ami pleura with the convex part, and very carefully insinuated it from * Fee Tli- I'nrish's Fapc". FM.-riic Rer. vol. iii. y ♦tot appi;ndi>. below upwards, under the artery. The point of the needle appearing on the op- posite side ofthe aMery, I introduced the hook into the other eye of it; then un- screwing the shank, the needle was drawn turough with the utmost facility, leaving the ligature underneath the artery. " In the application of the ligature to this artery, I would invite the attention of those who perforin it, to a circum- stance which, in my opinion, is somewhat important: it is to pass Ihe ligature from below upwards, in order to prevent the, pleura from being wounded. From the use of these instruments repeatedly, I would also recommend that the hook be fixed in the eye of the needle before the shank is unscrewed, otherwise very con- siderable difficulty will be experienced in finding it, and even when felt, not easily introduced, from the want of firmness which the handle part of the instrument would afford. '• I now made a knot in the ligature, and with my forefingers carried it dowa to the artery, and drew it a little so as partly to close its diameter and arrest the column of blood gradually. This was continued for a few seconds to observe the effect produced upon the heart and lungs; when no change taking place, it was drawn so as to slop the circulation entirely, as was shown by the radial ar- tery of tin- right arm, and the right tem- poral immediately ceasing to pulsate. The knot was drawn more firmly by the ligature irons, and a second knot applied in the same manner. "In no instance did I ever view the countenance of man with more fluctua- tions of hope and fear, than in drawing the ligature upon this artery. To inter- cept suddenly one-fourth of the quantify of blood, so near to the. heart, without producing some unpleasant effect, no sur- geon, u priori, would have believed pos- sible. I therefore drew the ligature gra- dually, and with my eyes fixed upon his face, I was determined to remove it in- stantly if any alarming symptoms had ap- peared. But, instead of this, when he showed no change of feature or agitation of body, my gratification was of the high- est kind. "Dr. Post now asked him if he felt any unpleasant sensation about his head, breast, or arm, or felt any way different from common, to which he replied, that he did not. " Immediately after the ligature was drawn tight, the tumour was reduced in size about one-third, and the course of the clavicle couid be distinctly felt. •'The parts were now brought into coaptation, and the integuments drawn together by three interrupted sutures and straps of adhesive piaster; a little lint and additional straps completed the dree- ing. Three small arteries were tied ui the course of the operation : the first was underthe sternum, and divided with tin: sternal part of the mastoid muscle, and from its course may have been a branch of the internal mammary reflected up- wards; the second, in raising the inner edge of the mastoid muscle, about the upper angle of the longitudinal ini-ision, and must have been the most descending branch of the superior thyroid; and the third was a branch ofthe inferior thyroid, and cut while raising the sterno thyroid muscle. The patient lost pel haps from two to four ounces of blood, most of which came from the ruptured branch of the subclavian. The operation occupied about one hour. " The curved spatulas recommended by Dr. Colles, 1 found of great use in the operation. I provided three for this pur- pose, two broad, and one narrow, bent at right angles, and sufficiently firm. After raising the muscles, they were of the greatest advantage in keeping separated the carotid artery and par vagum, as like- wise the divided muscles; they served also another very useful purpose, that of preventing by their equable pressure the constant oozing from the smaller vessels ; and the little room taken up in a small and deep wound, will give them a great superiority over the fingers introduced. " Ten minutes after the operation the pulse is regular, and not the least varia- tion can be perceived ; it beats 69 strokes in a minute; the patient says he is per- fectly comfortable, and has no new or unnatural sensation, except a little stiff- ness of the muscles of the neck, which he thinks is owing to the position in which his head was placed during the opera- tion ; the temperature of the right arm is a little cooler than the left; his breathing has not been the least affected by the ope- ration, but is perfectly free and natural. " £ o'clock, P. M.—Patient expresses a desire to eat, and is directed a little thin soup and bread ; the temperature of both arms is very nearly the same; breathing perfectly natural; pulse as before. " 3 o'clock, P. M.—There is still a tri- fling difference in the temperature of the two arras; ordered the right to he wrap- ped in cotton wadding; not the least un- pleasant symptom has as yet made Us appearance. " 6 o'clock, P. M.—Complains of a lit- tle pain in his head, not more on one side however than the other; describes it as a common headach: the pain of the shoulder and arm mueh less than before the operation: no difference can now hi: perceived in the temperature of the two arms ; pulse a litlie accelerated, and per- haps a little full. " 9 P. M.—Patient, complains of head- ach ; skin is rather hotter than natural: APPENDIX. 6'85 pulse strong and full, and beats 75 in a minute; the carotid on the left side of the neck is observed to be much dilated and in strong action; tongue moist and clean. "9 1-2 P. M.—Symptoms continuing the same, directed him to be bled from the left arm to gx*j. After bleeding the pulse fell 7 beats, and was less full. Com- plains of some thirst; let him drink com- mon tea. 12 P. M.—Patient has slept a little ; is free from pain; pulse full and less fre- quent, beats 60 ; skin moist and of a na- tural temperature. " Second day, 2 o'clock A. M.—Patient enjoys a natural and undistuihed sleep; respiration free, and performed without the least difficulty. " 5 A. M.—-He has rested well the last three hours. Says he has a slight head- ach, and a little pain in the right elbow: the latter he attributes to the position in which his arm has lain during sleep ; pulse full, but not so tense as before the vene- section ; skin natural and raoht; tempe- rature of both arms the same. He states that he can now incline more upon the right shoulder than he has been able to do since the second day after he received the injury. "9 A. M.—Pain in the head no way troublesome; skin moist and of natural temperature; tongue clean ; says his neck feels stiff, but is not painful; has no dif- ficulty in swallowing. His cough has thus far been much less frequent than be- fore the operation: expectoration is also attended with less difficulty; pulse 75, full, but not tense; has taken a dish of coffee, and some bread; complains of some thirst; directed a solution of super- tartrite of potass to be drank occasionally. " 10 A. M.—Symptoms as before; the veins of the fore-arm and hand since the operation have been as much distended as previous to it, and upon compressing tnem so as to stop the circulation, and idlow the vein to become empty for some distance above, the column of blood is seen to distend the vein immediately up- on the removal of the pressure, plainly showing that the circulation is going on with considerable, rapidity, although no pulsation has been felt in the brachial oi radial arteries. The radial artery can be easily distinguished by the fingers, and seems to be filled with blood. There is evidently a pulsation in the anterior branch of the temporal artery, just as it is passing a litlle above the exterior can- thus of t'he orbit; the. left external carotid is beating with increased action, ai,d ap- pears larger than natural. " :i P. M.—Mas taken a light dinner, and complains of a little headach; pulse lias become tense, and is also increased i:i iVeiiuency : skin is considerably hotter than natural; tongue too indicates a fe- brile action: was bled to ^viij. and di- rected to drink freely of a solution of the supertartrite of potass. "10 P. M.—Since the last report he has become more comfortable ; complains of no pain, and says he lies perfectly easy ; pulse increased in frequency to 78, but of the natural soft feel; the right side of the face has been at times a little cooler than the left, and is so at the present time: it is, however, not so much so as to be perceptible to the patient; tempera- ture ofthe right arm natural: that of the left, and the whole body, is above the na- tural standard, but it is moist; tongue is clean: having had no evacuation from his bowels since the operation, is directed to take a saline cathartic, in divided doses. "1 A. M.—Complains of nothing; has not slept any; cathartic has operated twice. " Third day, 5 A. M.—Has had no sleep in consequence of the operation of the medicine, it having produced free evacuations in the course of the night; skin not so moist, but of natural tempe- rature ; the two arms have equal warmth ; pulse full, and rather more frequent than last evening: says his right elbow is a little painful, and the arm feels tired. The complete flexion of the arm at the elbow is prevented by a little rigidity of the extensor muscles. " 9 A. M.—Be is now comfortable, has slept a little, and feels refreshed ; pulse is full, and rather more frequent than natu- ral ; skin natural and moist: the size of the tumour is considerably diminished ; has taken a dish of chocolate and some rusk. " 11 1-2 A. M.—Patient still free from pain, or any uneasiness; medicine has operated seven times; skin not hotter than natural, and moist; tongue clean ; the right facial and anterior temporal ar- teries communicate a distinct pulsation to the fingers : having slept but little du- ring the last night, directed him to take an anodyne of Tiuct. Opii. gtt. xxx. and to have the room made dark, and kept quiet, in order to procure him some sleep: let him have sago or panada as often as he inclines to take nourishment. "4 P. M.—Has slept the last two hours, and is still sleeping ; respiration free and easy ; nothing the least unnatural in his appearance. "10 P.M.—He has slept four hours, and is much refreshed ; is free from pain, except a little in the elbow ; pulse small and soft, beating 105 strokes in a minute ; tongue clean ; feels a little soreness in the wound when swallowing; has taken a considerable quantity of sago and panada; his appetite is good ; temperature natural and uniform in both arms. " VI P. M.-Patient has slept the greater Tr* »8ti APPENDIX. part of the time ; is free from pain, and perfectly comfortable: skin moist and natural; pulse soft, small, and frequent. " Fourth day, 6 o'clock A. M.—Patient has passed a good night; says his right elbow gives nim some uneasiness, but complains of nothing else; tongue is clean ; skin moist and natural; can move the right arm with considerable ease; says he takes as much light nourishment as he has been accustomed to for some time past: no unfavourable symptom has as yet made its appearance. " 11 A. M.—Symptoms continue much the same ; tongue slightly furred ; pulse comparatively small and soft, beats 105, and regular; respiration has been uni- formly natural since the operation ; sup- puratidh has begun to appar through the dressings, and is attended with a little fcetor; let them be covered with a yest poultice: it is thought that a faint pulsa- tion, or undulation, is at intervals felt in the radial irU-ry of the right arm : the left external carotid continues its in- creased action. " 6 P. M.—No change is observable in the patient's symptoms; he. still conti- nues comfortable, and complains of no- thing. ''Fifth day, 11 1-2 o'clock A.M.—The wound was dressed to-day : on removing the poultice the dressings were soft, and easily came away ; the suppuration was considerable, and of a healthy appear- ance ; it was found that the extremities ofthe two incisions were united as far as the sutures, each about one inch in ex- tent ; one suture at the angle of the wound was removed; the wound was dressed with dry lint, gently pressed into it; adhesive straps and a compress; his pulse beats 110, is fuller and stronger than yesterday. "5 P. M.—Patient is very comfortable, subject to no pain or unnatural sensation ; pulse still 110, but softer. " Sixth day, 6 A. M.—Patient sleeps ; respiration not attended with the least difficulty ; skin moist and natural. " 9 A. 31.—He has rested well during the night, and is perfectly free from pain; pulse 110, and soft; skin moist; tongue clean: having had no alvine evacuation since the 13th, directed to take of sul- phate of soda ^j, in divided doses. " 11 A. M.—The dressings were again removed, and the discharge seemed mure considerable than at the former dressing ; the sides of the wound are granulating, and appear perfectly healthy; on ihe ends of the muscles that were divided in the operation, there are small slo ;ghs vvhich are beginning to separate, leaving a heal- thy surface underneath; wound was dressed with lint spread with Ung. Res. Flav. and adhesive straps: pulsation is to'v perfectly distinct in the branches of the right external carotid artery: com- plains a little of the back part of his head, which he says is sore from lying; in other respects is comfortable. " 6 P- M.—Has no pain, and is in every respect much as usual: tongue clean; skin natural; s.iys he feels '"no weaker than before the operation." " Seventh day, 6 A. M.—He has passed a comfortable night, and is free from pain or any unea-iness ; pulse regular and soft, and beats 105 in a minute; skin moist, and of natural temperature. " 11 A. M.-The wound was again dress- ed; suppuration considerable and heal- thy ; some of the small sloughs came away, leaving a healthy and florid surface beneath : sprinkled the wound with pow- dered carbon, then filled it lightly with lint, and over this applied the yest poul- tice, which was secured with : ihesive straps: temperature of the two arms is the same, cathartic having produced no effect, Habeat enema purgans statim. "9 P. M.—Symptoms have not varied ni.i. rially: the enema has produced a copious evacuation : say* he feels more comfortable, and desires to sit up in bed, vvhich was allowed, taking care to have him raised Up.very cautiously, in order to prevent any exertion being made with the right arm and shoulder. " Eighth day, 6 A. M.—Patient has rest- ed well during the night; says he feels some pain on swallowing, and that when the attempt is made, it gives rise to a fit of coughing, which fatigues him ; it also occasions some soreness in the wound ; pulse still soft, and less frequent than yesterday : he takes a reasonable quan- tity of light food every day:—Directed a cetaceous mixture for his cough, and is permitted to sit up for a short time, if he feels disposed. " 11 A. M.-Pulsation ofthe radial artery of the right arm to be felt occasionally pretty distinct; cough has become more troublesome; pulse 100; skin natural and moist. The dressings were again remo- ved, and the suppuration is more profuse, apparently healthy, though attended with considerable fcetor; appearance of the wound every way favourable; small por- tions ofthe sloughs are removed at each dressing, and the sides of the wound look perfectly healthy; the same dressings to be continued. • '' tf P. M.—Complains only of his cough, which troubles him frequently ; can move his arm vvitii inucu more facility, and has no pain in it; circulation as before, and the temperature iniifor.ii and natural. The wound was dressed tbis evening in consequence ofthe fcetor being unpleasant to the patient : continue the dressings. " Ninth day, 7 A. .Vl.-Pdtient was found sitting up in bed, supported by a bed- rliair. having passed a good night; is in APPENDIX ivs: good spirits, and expresses his gratitude tor the relief afforded by the operation ; says he can move the arm with greater ease, and it gives him no pain ; pulse 105, regular and soft; skin natural; every symptom as favourable as could be wished. " 10 A. M.—Pulse less frequent, regular and soft ; temperature perfectly natural; wound has a more favourable appear- ance, discharges less in quantity, and it possesses less fcetor: dressed the wound as yesterday ; tumour has dimunsiied two-ihirds, is soft, and less florid. The apex of the tumour is now below the clavicle. " 6 P. M.—Patient still in every respect as comfortable as at the last report. " 9 P. M.—Pulse 110, regular and soft: the dressings were removed this evening ; the wound is much contracted in size, and is perfectly healthy, except a small slough which still remains in the deepest part of the wound: granulations are shooting up rapidly from the sides.— When preparing lo renew the dressings, an unexpected and unaccountable hemor- rhage took place, which suddenly filled the cavity of the wound. 1 he rapidity with which the blood (lowed, and the size ofthe stream, gave rise to fearful appre- hensions for the man's safety : dry lint was immediately placed in the wound, and as much pressure made as the pa- tient could conveniently bear, vvhich quickly stopped it. After continuing the pressure for a short time, the lint was re- moved, when no hemorrhage recurring, the usual dressings were repeated: the patient experienced no ill effects from the bleeding, nor did he seem to he much agitated. At 10 o'clock P. M. has no pain, nor has he as yet had any sleep. " Tenth day, 7 A- M.—Has passed a comfortable night, except that he has been fiequently disturbed by his cough : longue clean ; skin moist; pulse soft, and has much less strength lhan before. "II A. M.—The dressings were again removed, and the wound made clean ; its appearance is in every respect favourable ; does not appear lo have been the ieast injured by the hemorrhage : the dress- ings were renewed as before : he is di- rected to take half an ounce of the cold infusion of cinchona every hour, and to drink occasionally of ale whin thirsty: has had an evacuation from his bowels tu-dav. "0 P. M.—Symptoms much as before ; complains a little of his elbow, and a numbness in his hand, to reheve vvhich, he is directed to have the arm and hand rubbed well, and wrapped in wadding. " FAcventh day, 0 A. M.—Patient has rented well during the nigut; cough has not been so tiuublesome; says he has no pain, nn-1 fr-'ls perfectly comfortable: pulse better than yesterday; other symp- toms as before. " 11 A. M.—The wound is dressed daily at this hour ; its appearance is still very favourable, although there is still some Icelor in the suppuration : the wound hae contracted perhaps one-third : the tu- mour is also cousidi rably diminished, and softer than before ; pulsation in the right temporal and radial arteries as belore: the same dressings to be continued. " 6 P. M.—No change in tue patient's general sy niptoms ; pulse soft, and rather more frequent; appetite is as good as Usual. '• 9 P. M.-Appearances have not varied. " Twelfth day, 6 A. M.—Our patient was visited as usual this morning, but there is no evident change in any of his symptoms ; says he now rests well at night. " 11 A. M.—To-day, when ihe dressings were removed, thai portion of the slough which occupied tin boitoui of the wouud (apparently a portion ut the sheath of the vessels) came away: every part ol the wound now, where its surface can be seen, has a Healthy look: the most de- pending part is ib.-cureu oy a quantity of pus, whicucannolbe wholly removed by hnl, and it is uot thought safe to peimit the patient to he iu such a position as will allow it to be discharged: with the slough. came awny the ligature which had been applied to an artery underthe lower por- tion of ihe sterno-thyroid muscle; it was followed by no hemorrhage : the wound was now dressed with pledgets of lint, spread with Ung. Resinae Flavas and ad- hesive straps. He remains much as yes- terday, has drank freely of ale ; pulse ra • ' ther stronger than yesterday. " Thirteenth day, 7 A. M.—No percepti- ble change in his symptoms; complains of no pain, and says he feels very com- fortable ; cough has given him very little trouble for the last two days ; he is evi- dently considerably weaker than before the operation, but is not sensible of it himself. " 11 A. M.—The wound was again ex posed ; it is not as florid as yesterday, and there is a greater secretion of pusj the cavity of the wound was filled with dry lint only ; the pus appears well form- ed, and has very little fcetor. "The same dressings were repeated in the evening; there is still a quantity of pus at the bottom of the wound, which rises and falls at each inspiration and ex- piration ; it continues to contract above leav ing us uncertain of its extent beneath: during the last three days, the patient has sat up for several hours each day. " 9 P. M.—Pulse and skin perfectly na- tural ; has had a natural evacuation from his bowels to-day ; continues the infusion of bark as prescribed before. o»& APPENDIX "Wound was again dressed, and is as healthy as usual; suppuration just suffi- cient to moisten the lint: the same dress- ings to be continued. " Fourteenth day, 7 A M.—Patient has slept well during the night, and »> as well as usual ; complains of soreness of the ulcer which he has had for some time between his shoulders; it is improving in its ap- pearance, and is directed to be dressed as usual with Ung. Resinae Flavse. The erysipelatous blush which surrounded it, is not as florid as heretofore ; it is begin- ning to granulate, and assume a healthy- appearance : in other respects he is per- fectly comfortable : he is now able to raise the right arm to his lips, which he has not done since the fourth day after the accident by which his shoulder was injured; says, too, that he is getting stronger, and that he walked across the floor this morning without any assistance. ''11 A. M.—On removing the dressing, the granulations appear perfectly florid and healthy: the bottom of the wound is not visible, owing to the small quantity of matter which collects there, and from its depth cannot be easily removed, and perhaps not altogether safely: the posi- tion of the patient in bed must necessa- rily make the bottom of the wound the lowest: when he coughs or swallows, a small quantity of fluid pus at the bottom of the wound is seen to rise and fall ; from the general appearance however of the wound, the man's feelings, and many other circumstances, it is not probable that there is any considerable quantity: the large ligature lying very loose in the wound was taken hold of, merely how- ever to see if it wa8 separated ; no force was used: pulsation of the right radial artery more distinct than heretofore: countenance of our patient is improving; says he feels more comfortable than be- fore the operation: he can now straighten his arm, and raise it to his mouth with facility, as yet he has not recovered h'rl strength, but is improving daily; has been sitting up all day: directed him when lying down to assume a more re- cumbent posture ; continue the sulphuric acid and infusion of cinchona, as before: complains of the ale being too strong ; let it be diluted and made pleasant with sugar and nutmeg. " 9 P. M—-The large ligature, since the operation, has been confined upon the upper part of the sternum by a piece of adhesive plaster, to prevent any accident during the dressings. Upon dressing the wound this evening, the large ligature, as it lay in the wound, appearing to he loose, was again taken hold of with the forceps, and found floating upon the pus, being completely separated from the artery below. The ligature was drawn s^> firmly upon the artery, that the noose was only large enough to admit tiie rounded end of a common probe. The wound looks healthy, and is contracting rapidly; it is now perhaps not more than one-third of its original size. Suppura- tion is now only sufficient to moisten the lint through. " Fifteenth day, 12 o'clock.—The pa- tient is comfortable in every respect ; pulse and skin periectly natural; is sit- ting up in bed, and occasionally amusing himself with a book; not the least symp- tom about him indicating indisposition : wound is healthy, and continues to im- prove in appearance. The right arm at intervals gives him a sensation of numb- ness: not more, however, than can be accounted for from the uniform position in which the arm rests, and no doubt a more languid circulation, as it is readily removed by a little friction and motion of the arm. His appetite improves, and he expresses a desire to walk about the room. The bark and sulphuric acid to be continued. " 9 P. M.—In the afternoon he was re- moved down stairs, from the private room in which he was placed immedi- ately after the operation, to the ward in which he formerly lay, and appeared highly gratified with the idea of again seeing his friends, whom he had left with very little hope of ever returning to. The wound, upon being dressed, did not appear to have undergone any percepti- ble change. "Sixteenth day, 11 A. M.—Our patient's strength is improving. To-day he made an effort, and with success, to visit his friends in Ward No. 7, where he lay pre- vious to his being transferred to the sur- ical department, and returned, without aving any support; pulse as strong as before the operation, and in every respect natural; appetite better than before the operation; cough a little troublesome, but less so than for several days previ- ous; wound dressed with dry lint. "9 P. M.—Dressings removed ; patient as before ; suppuration small in quantity, and appears to be well-formed pus, and is not attended with the least fcetor. " Seventeenth day, 11 o'clock.—The ends ofthe divided muscles are nearly in contact, and the surfaces of the wound are rapidly granulating, and in every re- spect look well: patient's health conti- nues to improve; he walks about the room with perfect ease, and into several wards in the same story; the ability to move the arm increases; pulse and skin "?l u \, e.dressmS9 were removed at 4 P. >!., and also at 10. P. M. "Eighteenthday.-The patients strength continues to improve; every symptom remains highly flattering; cough less troublesome. The dressings were aeait- removed to-day three times. * APPENDIX. o*e Nineteenth day.—Continues the same as yesterday; wound dressed three times. " Twentieth day.—To-day he passed down two pair of stairs, and walked seve- ral times across the yard, and was highly delighted with his performance, and felt not the least inconvenience from it; sleeps uniformly well during the night, and takes more food during the day than he did previous to the operation; conti- nues the infusion of cinchona and sulph. acid as before, and directed to use dry lint as the dressing. " Twenty-firstdfy.—Dressed the wound three time.'; againto-day; it is nearly clo- sed at the bottom ; the power of motion in the right arm continues to increase: he can now i^iove it with as much faci- lity as the left, though not to the same extent: his strength is daily improving, and the operation is considered by all to have been completely successful; size of the. tumour continues the same, no dimi- nution of it having been perceived for the last week ; the most prominent part of the tumour is yet below the clavicle, that above rises to about the height of the clavicle, vvhich gives a little convexity to the place between the clavicle and trapezius muscle. " Twenty-second day.—Continues to im- prove in every respect; dressings renew- ed as often as yesterday; owing to the weather, he has not left his ward to-day;' pulse full and strong; temperature of both arms the same. " Twenty-third day.—A few minutes before the hour of visiting, to-day, a mes- sage was brought, that the patient was bleeding from the wound. The dressings were immediately torn off, and dry lint crowded into the wound, and slight press- ure applied for a few minutes, when the hemorrhage ceased. The patient lost at this time, perhaps, about 24 ounces of blood, and was very much prostrated. Pulsation ceased in the radial artery of the left arm, and the countenance, gasp- ing, and convulsive throes of the patient, threatened immediate dissolution: all present apprehended the instant death of the patient. The first impression was, that the trunk of the arteria innominata had given way. The conjecture after- ward was, that the subclavian artery, from the diseased state of it, had not uni- ted by adhesion, and that the fluid bldbd from the tumour had regurgitated through its ulcerated coats. This appeared to be the most probable, both from the sudden- ness with which the blood ceased flow- ing, and the cause the patient assigned for the hemorrhage. He says that he felt weary of lying on his left side and back ; that he had just turned on the right, which he had not done before since the operation, agreeable to my re- Vor, f. '!" quest. At the instant of turning over, something arrested his attention, which caused him to turn his head to the oppo- site side suddenly, and he felt the gush of blood from the wound. " He was directed some wine and water frequently, which soon revived the circu- lation. The wound was dressed with dry lint and a compress. Pube as fre- quent as natural, but very small and soft: he appears very languid, and complains of a numbness and painful sensation in his hands; says also that his hack aches. During the last twenty-four hours he has taken a pint and a half of Madeira wine : he also took occasionally some egg and wine, which was immediately rejected from the stomach. "9 P. M.-Patient has lost his appetite, and appears considerably depressed ; cir- culation very languid in the right arm ; temperature of it is a little less than the left: directed a hot brick to be wrapped in flannel, and placed close to the arm. For a profuse perspiration which he bas been in for the last three hours, he was ordered to be bathed with cold rum. " Twenty-fourth day, 6 A. M.—Slept the greater part of tiie night, and feels comfortable ; is still languid, and has no disposition to eat any thing; says he feels sick, and once last evening vomited after drinking some wine and water. " Wound looks exceedingly pale, and the discharge is thin and foetid, for which the carbon and yest dressings were ap- plied. He has vomited several times to- day, and has some considerable difficulty in swallowing, and complains of a sore- ness in the wound upon pressure. " 9 P. M.—Dressings removed ; wound very pale; right arm ofthe natural tem- perature ; feels occasionally a little numb- ness in the hand ; has taken very little nourishment during the day; pulse natu- ral, as to frequency, but small and feeble ; a few minutes after dressing the wound, information was brought tbat hemor- rhage had ensued, and before it could be commanded, he probably lost four ounces uf blood. For his restlessness and pain in the bones he was ordered two grains of opium. " Ticenty-fiflh day.—Has rested well during the night, and is perhaps a little better this morning. The repeated he- morrhages have debilitated him exceed- ingly, and from the irritable state of the stomach he can take only a very-little nourishment. In the morning he was directed the effervescing draught to be repeated every two hours; this allayed the irritability of his stomach, and ena bled him to take a little breakfast. " His countenance has altered since the first bleeding surprisingly, his eyes are now heavy, and for the most part fixed : his checks are sunken, and an unive'^>! «..- Al'PLNDlX. palor bas spread itself over his counte- nance ; and, from every appearance, a short time will terminate his existence. He has not vomited since early in the morning; is advised to take a little soup, and to drink freely of wine and water; dressing-! were renewed at 3 o'clock P. M., shortly after which the patient again bled, but not to exceed, however, an ounce. He was dressed with dry lint, as usual. "11 P. M.—Patient has not as yet had any sound sleep, is restless, and appa- rently distressed, although he says he feels no pain : breathing is attended with some difficulty ; his hands and legs are conti- nually in motion ; pulse small and feeble. " Twenty-sixth day, 6 A. M.—Patient has not rested well; is occasionally fall- ing into little slumbers, but is awaked by the least motion : pulse small and feeble ; respiration somewhat laboured ; appears to be sinking; seems disinclined to take any thing; legs and arms constantly in motion. "11 A. M.—More feeble than before: has been forced to take a liltle choco- late ; is evidently sinking; wound was dressed, but there was no secretion of pus in it; countenance of the patient foretells his approaching dissolution. " 6 P. M.—Is extremely low ; respira- tion very much laboured: is not able to articulate : for the last three hours there has not been such continued throwing of ' the legs and arms about the bed: he lays in a state of insensibility ; temperature of the two arms the same lo the last.—My upil, Abraham I. Duryee, the House urgeon (to whom I am indebted for the correct reports, and the most unwearied attention to this case, and whose inge- nious application of means, for the reco- very of many of my patients, will long be h d by them m grateful remem- brance,)' having for a few minutes left the patient, he was sent for immediately, as there was another bleeding from the wound, by which he lost probably eight ounces of blood: duiing the whole time he did not manifest the least appearance of consciousness, nor wis the least mo- tion perceptible, except that necessary for respiration and circulation: the he"- morrhage was stopped with lint, after removing the former dressings ; respira- tion is now performed with the utmost difficulty, and the patient appears as if every respiration would he the last: he expired at half past six in the aftprnonn : the temperature of the right arm, after death, appeared by the touch to be the same as the left;" it was as natural and uniform as other parts of the body. examination of the body. About eighteen hours after death, I "fctied tttshMy; there w^s considera- ble emaciation, and the surfaec of the wound was of a dark-brown colour, and fectid; the wound was perhaps about one-third of its original size ; it nad been enlarged by the pressure of lint into if, and other means to arrest, from time to time, the hemorrhage: the ulcer be- tween his shoulders was ill-conditioned. "For the purpose of examining the condition of the aorta, where the arteria innominata is given off, as also the origin of tbe latter vessel, as well as the state of the pleura at the part about which the ligature had been applied arpund the artery, the chest was opened in the fol- lowing manner: after removing the in- teguments and muscles from the fore- part of the chest, the sternum was care- fully sawed through, about an inch from its upper extremity, and raised by saw- ing through the ribs below the junction ofthe cartilages: this removed so much of the front part of the chest as to facili- tate and expose fully to view the subse- quent steps of the dissection; by thus leaving the clavicles attached, every part connected with the ulcer and great ves- sels could be seen and examined in situ. " The arch of the aorta and origin of the innominata being fairly exposed, not a vestige of inflammation or its conse quences could be discovered, either upon them, the lungs, or the pleura, at any part. An incision was next made longi- tudinally into the aorta, opposite the ori- gin of the innominata, and upon intro- ducing a probe cautiously up the latter vessel, it was seen to pass into the cavity of the ulcer; the innominata was then laid open with a pair of scissors into the ulcer; the internal coat of this vessel was smooth and natural about its origin, but for half an inch below where the ligature had cut through the artery, it showed appearances of inflammation, and there wasa coagulum adhering with considerable firmness lo one of its sides ; showing that nature had made an effort to plug up the extremity of so huge a vessel, after the adhesion, which no doubt had been effected by the ligature, was swept away by the destructive process of ulceration. The upper extremity of this vessel was considerably diminished in its diameter by the thickened state of its coats, occasioned by the surrounding inflammation. The innominata, about haTf an inrh from the aorta, and a little to the left side, gave off an anomalous artery, large enough to admit a small size crow-quill. " The ulcer at the bottom was more than twice the size of the wou d in the neck; it extended laterally towards the trachea and under the clavicle towards the tumour. The tripod of great vessels consisting of the innominata, subclavian' sr.r\ carotid r!f respiration the opening into the trachea was drawn alternately under the integuments above and below, beyond the extremities of the first incision. But the part being at length caught by the probes, it was held in a fit situation, so that the piece of nut-shell was seen within the la- rynx, opposite the cricoid cartilage. The probes being held by an assistant, the doc- tor, with the forceps, easily extracted it. The part being still retained by the probes, he had an opportunity of seeing wiihiu the tube above and below, and found an effusion of coagulable lymph, as observed in croup, lining the larynx and trachea above the wound. A probe passed up- ward produced excessive irritation and coughing, with suspended respiration du- ring the intervals, but When passed down- ward, even as far as the division at the broncliiae, the child showed no signs of irritation. The doctor now attempted to peal off the exuded coagulable lymph, which he did by aid of a probe, then with- drew it with the forceps. The layer of lymph was firm, and of much tenacity in itself, hut was easily separated from the side of the larynx. The membrane of the larynx, where the lymph was situated, was observed highly florid, marking high inflammation, the i-flVct of the presence ofthe extraneous body. At the end-of the operation the breathing was found additionally relieved by the removal of the layer of coagulable lymph from the larynx. The doctor, now much sattsfkti oyo -ii'PEISblX. with the result of the operation thus far, prepared to dress the parts, which he be- gan by applying strips of adhesive plas- ter ; but he had no sooner closed the wound than the child's immediate death was threatened, which obliged him quickly to tear away the dressing, and allow the infant to breathe again by the opening he had made in the trachea In this state the patient was permitted to re- main for eight days, in which time the side of the neck, and the breast were blis- tered, and an active antiphlogistic treat- ment made use of for subduing the in- flammatory symptoms. After this he was able to bring the parts together; upon which the child did well. This, 1 am informed, is the first instance of the successful performance of this operation in New-York. it does appear to me, that the circum- stances attending this operation are very- decisive in favour of the operation of bronchotomy as a remedy for croup. CARBUNCLE. I have to add to the value of this article, by inserting from the experience of Dr. Physick in Anthrax. It will have been observed, that Mr. Cooper speaks in the most decided man- ner aga'u.st the use of caustics in this disease ; and seems to depend solely upon constitutional treatment for the removal of this complaint. But Dr. Physick is of opinion, that the common caustic ve- getable alkali, as a local application, is highly beneficial, provided it is made use of at a proper period of the malady. In elucidation of this sentiment, he has given an instance, in which is detailed the pro- gressive treatment towards a cure of an inveterate case of carbuncle ; and after- war! explains the rationale of the prac- tice. He considers, that the disease is right- ly divided into three stages, which require to be traced, in order that the application of the caustic may be regulated and used to advantage. " The first stage to be that in which the disease is forming, and in which the pe- culiar inflammation exists in the cellular texture, under the skin, that ends in its death or mortification. This is attended by a burning pain, and sometimes by fever." " The second stage, that in which pim- ples appear with orifices through the skin, which, gradually increasing, join, and eventually form one or more large open- ings, through which the mortified parts and aerial fluids pass out. These effects are produced by the ulcerative process, which, during the- whole time of its con- tinuance, is attended with the most severe and distressing pain that is experienced in the course of the disease. The pa- tient's constitution also suffers so mate- nai!y. owing to loss of appetite, want of sleep, and fever, that death is the conse- quence in severe cases." And " The third stage, is that in which an ulcer remains, attended, however, with no peculiarity from its cause." Dr. Physick, therefore, has found all stimulating applications in the first stage of the disease highly improper; and considers the use of caustics at that peri- od as particularly injurious. He had, however, once thought, from what he observed as the effect of blisters in check- ing mortification proceeding from some kinds of inflammation, that they would he useful in arresting the progress of car- buncle. Yet in his experience they have not shown any. power in counteracting its progress to mortification. But it is in the second stage that he recommends the caustic, for the purpose of facilitating the discharge through the skin of the morti- fied cellular membrane, in which the in- flammation had originally been situated. And adds, in all cases in which he had used it, at this period of the disease, the sufferings of the patient ceased as soon as the pain from the caustic had subsi- ded. Its operation being, by accomplish - ing in a few minutes, what, if left to the process of ulceration, would require se- veral days, to the great suffering and con- sequent loss of the powers of the consti- tution of the patient. (See Philadelphia Journal of Medicine, Vol. 1, No. 3, p. 172.) FISTULA IN PERINEO. I enlarge upon this article, not for the purpose of introducing any new practice, but for re- cording a curious case, which turned out to be a very complicated instance of fis- tula in perineo. Mr. W. a gentleman of Elizabethtown, N. J. of forty years of age, and who had lived freely, began about eighteen months before his death to complain ofan almost constant pain in his back, which appeared like a rheumatic affection; after some weeks' treatment by the usual means for that disease, the symptoms were in a measure subdued, but there still remained a febrile disposition which could not be got under. About a year after this pe- riod Dr. Mott was sent for from New- York, in consequence of a peculiar dis- charge accompanying the flow of urine, this he soon found to be of the nature of fceces, which, however, the patient was most unwilling to believe. Examination was made by the rectum, to ascertain if there was any communication between that gut and the urinary bladder; but none could be found ; neither was there any tumefaction or tenderness at the pe- rineum, that would indicate the forming of a fistula in that situation. He was Ai- rected to pay attention to the state of his bowels, in order that the feculent dis- charge might be as much as possible in a fluid state. He passed a number of wecl<; APPENDIX. 697 after this under a constant hectic irrita- tion, until at length an uneasiness was felt in perineo, then a tumour, and quick- ly a spontaneous opening was formed, which discharged matter, urine, and fae- ces By an examination through this new-formed opening no communication could be traced with the rectum, but the cavity of the fistula was found supplied with urine and fseces from an opening through the membranous part ofthe ure- thra. From this time until the patient was carried off", he spent his life in great distress, becoming much emaciated, with continued hectic; the fistulous orifi- ces in perineo amounting to four or five in number, from each of which extensive excavations were made between bladder and rectum, and these parts and the sides ofthe pelvis. At about two months before his death, a fish-bone was discharged by perineum, incrusted with calculous matter. At hisdeceasp,the Doctor having much anxiety to inspect the body, obtained permission for an examination, and found upon searching the abdominal cavity, that the rectum descended the hollow of the sacrum far to Hip right side, and op- posite the right ileo-sacral articulation ; while the sigmoid flexure of the colon was in its usual place. But there was a straight portion of the colon connecting the sigmoid flexure with the beginning of the rectum, and placed before the base of the sacrum. This was an anomaly, called by Dr. Mott, in his communication to me, a pelvic arch to the colon. I be- lieve such a variety has been before noti- ced by an European author, whose name I have not at present in mind. Between this portion of the colon and the urinary bladder, there was an opening by which the two cavities were connected, but not in a simple manner. There was a sac placed between them, as if the fish-bone, in its effort to escape, had projected the side of the gut towards the fundus of the bladder, previously to any adhesion being formed; after which the commu- nication was effected with the vesica uri- naria. I have been made acquainted with ano- ther case something like the one sketch- ed ; but as the patient is at this time in life, I do not know that it would answer any useful end to give a detail of his ambiguous symptoms. FRACTURE. FALSE JOINTS, OR UNUNITED FRAC- TURKS. There is something yet to be learnt upon this subject, as to the rationale of the operation of setons, sawing off" the ends of bones, &c. a3 means produ- V©». 1. 88 cing cure in this form of disease. 1 will contend, that, when a want of union ex- ists between the broken extremities of a bone in any part ofthe body, owing to a deficiency in the constitution to form osseous matter ; that, taking out the ends of the hone, and sawing them off; saying nothing of the formidable nature of such an operation ; or serving the ends of the bones with caustic potash ; is mure calcu- lated lo confirm such deficiency tbau to renovate the constitution. I need not explain why; for a knowledge ofthe laws ofthe animal economy will answer for me. Also, how keeping up a puriform discharge for ten or twelve months, through means of a seton, from a limb under such circumstances of constitution ; will lead the vessels of the broken ends of the bone to an osseous deposit, is to me inexplicable; and I will affirm, that no conclusive evidence, that it is so, can be drawn from any of the cases on re- cord where a cure ha« taken place. When means then/applied lo the part, have beneficial tendency, (I intend the means hitherto made use of;) they must have influence upon some local cause preventing union. To be brief, for my limits oblige me, I will assume, that au insulated or loose splinter of hone, void of periosteum, acting as an extraneous body in the wound, is the only local cause which is preventing union and pro- ducing a hinge joint. Now, if we present this idea to the several recorded cures, we will find a ready explanation for the success of the different plans of treat- ment. "Stephen Hammond," some three years ago, " was admitted into the New- York Hospital, with lampness, in conse- quence of a fracture of the leg about seven months previous. Upon examination, the tibia was found ununited, and to ad- mit of very free motion between its ends; the fibula was entire,and the pa- tient believed it never had been broken. From the account which he gave, it ap- peared he had been subjected to the pro- per treatment for the restoration of a broken bone, but he stated that it never showed any disposition to unite under the course which was pursued. " As his general health was not good, he was put upon tonic medicines, and invigorating diet, and was directed a sti- mulating plaster of gum ammoniac and mercury should be applied over the part with the many-tailed bandage; and splints to reach above the knee and below the ankle, and to be very firmly secured; he was also advised to walk upon it w ith the assistance of his crutches, as much as the pain would any way per- mit, informing him that the object in wishing this exercise, was to inflame and irritate the ends of the bone; and that l".!-^ APPENDIX he must not desisf, even though cousider- afrp pain should accompany it. This was persevered in forsevnral weeks, hut find- ing little or no pain to attend it, and no appearance of inflammation in or about the fracture, and no hope of amendment, it was discontinued. Blisters were next repeatedly tried, hut to no purpose. Very powerful shocks of electricity also were passed in different directions through the part, but they produced no beneficial pffects. " A seton was next introduced : this was done by making a small incision upon the outside ofthe tibia, down to the frac- tured ends, then passing between the hones the stilette of a small trocar, and pushing it out on the opposite side, the seton was readily introduced with an eyed probe. "ina few days considerable inflamma- tion and pain supervened, which required emollient poulticus and the antiphlogistic treatment to subdue it. This was soon fol- lowed by a copious discharge of matter from the seton, and a collection of pus on the anterior part of the tibia, which was evacuated by a small incision. After five or six weeks, he became sensible of an increase of firmness in the leg, and from this time he was directed to dimi- nish the size of the seton one thread every other day, until it was all re- moved. It continued to grow stronger every day, and in a short time after the wounds healed, he. was permitted to walk a little upon it, when splinted and tightly bandaged, and in about three months the bone was firmly united." "John Smith, aged forty-one years, became a patient in the hospital in 1819, in consequence of an ununited fracture of thp thigh bone, of twelve months standing. It occurred at spa, and at the same time several of his ribs were frac- tured. Thirty-six days after the acci- dent, he arrived at Halifax, without hav- ing had any attention paid to the adjust- ment ofthe bones. After his arrival, he Ptates, that little notice was taken of his thigh, and no pttttmpt was made to re- duce it. He recovered without difficulty from the fracture of his ribs. The seve- ral means mentioned in the preceding ease were tried, but without benefit. The limb was considerably shortened from the obliquity of the fracture and ends of the bone overlapping. No advantage attending the use of the means referred to, a seton was recommended. In the introduction of this, much more difficulty was experienced than in the case of Ham- mond. "An incision was made on the inside of the thigh, a little to tbe outerside of the artery, so as to come down upon the centre of the ends of tbe bones, where they overlapped. The stilette was then attempted to be passed between the hones, but this was found altogether im- practicable, from their very close con- tact, even though the limb was changed from one position to another. Instru- ments of different sizes were resorted to, but they could only be made to pass a very small distance. A gimblet was tried, hut very little progress could he made. Having provided for the occasion a car- penter's bit, about the size of a large tro- car, 1 found with this a passage could be made with the greatest facility. Then, by making an incision down to the end ofthe instrument, on the outside of the thigh, a large seton was readily convey- ed through between the bones, by means of a long-eyed probe. "After the expirationof three months, thp thigh becoming firmer, and much Ipss motion being felt between the ends ofthe fracture, he was permitted gradu- ally to lessen the size of the seton. The firmness continued regularly to increase, hut it was not until after eight months had elapsed, that the thigh bad acquired sufficient firmness to enable him to sup- port the weight of his body by the aid of a crutch- "It is now more than twelvemonths since the seton was introduced, and the bone appears to be firmly united. The shortening of the limb does not exceed three inches and a half." These were cases in which I should say, the spicula of bone had either esca- ped the limb by the course of the seton, was pushed out by the carpenter's lit, or had found its way along the muscles, at some distance from its former situa- tion ; so that it ceased to prevent union between the broken bones; or perhaps it might have been dissolved and absorb- ed pursuant to the inflammation, the consequence of the seton; but this last result I should be less inclined to believe. I have observed, and I believe it is the fact, that the seton is of more doubtful success in cases of hinge joint ofthe hu- merus, than even of the femur, or either of the hones of the lower extremity; and I am satisfied with this explanation, why it is so, viz. that the. patient will keep his bed, no doubt, when the seton is in the thigh or leg, by which the spi- cula? will find a more ready escape ; but, when in the upper arm, the course of the seton may not be such as to invite the spi- cula outwardly : especially when the pa- tient walks about with his arm in a sling. While I was at Philadelphia, 1 Raw a man in the Alms-house who bad, 1 think, for three years been under a hinge joint of the humerus, and from the nature of the cause producing the fracture, 1 was convinced the bone had been comminuted. He had had the APPENDIX. oi»y Seton, as I was informed, applied twice, being kept in several months each time, under the special direction of Dr. Physick himself; yet the bone was still ununited. The patient was a good-looking fellow, a young man, and acknowledged by all to have got remarkably fat while in hos- pital. I expressed a great desire to the attending surgeons to have the bones cut down upon, and the spicula, which I felt assured was present, removed. 1 do not know whether it has yet been done. I have just met with a case of hinge joint of the humerus, by Mr. Earle, in the 12th vol. (just published) of the Me- dico-Chirurgical Transactions of Lon- don, which is not in contradiction to the opinion 1 hold of this disease. " Mr. C. of Teignmouth, fell from his horse in August, 1820, and fractured his left humerus, near the insertion of the deltoid muscle. He felt very little pain at the moment ofthe accident, and none at all after the limb had been placed in splints. Nothing worthy of remark oc- curred during the early treatment of the case ; but, at the usual period, on remo- ving the splints, it was found that no union had taken place After a lapse of some, mouths he consulted an eminent surgeon at Exeter, who wished him to submit to an operation, with a view to excite ossific inflammation. This, how- ever, he declined ; and the following May he came up to London, and placed him- self under my care. His age was about thirty, and he stated that be had gene- rally enjoyed good health. In his infancy he had suffered from fits, which haa caused a paralytic state ofthe right arm, which was wasted, and nearly useless. This circumstance rendered it mure im- portant to endeavour to restore the left, which had been fractured. On exami- ning it, I found the broken ends perfectly moveable, one upon the other, and the superior portion was drawn in towards the axilla, and did not appear in close coaptation with the inferior. While I was examining him, I was surprised to find that the integuments of the arm and fore- arm, in the space of a few minutes, be- came covered with urticaria. On remark- ing this to him, he stated, that he had been subject to this affection for many years; that he never suffered in his health from it; and that the slightest irritation, and even the friction of his clothes, would at any time produce it. This led me to be very particular in my inquiry into the state of his general health, and his vari- ous secretions. He had an unhealthy, sallow aspect; he perspired profusely, and his perspiration had a peculiar foetid smell, and stained his linen of a brownish tint. His appetite was good, and he slept well; but his: bowels were very irritable. Fermented liquors, Such as beer and ci- der, or any irregularity of diet, produced a copious deposit of lithate of ammonia in his urine ; although he was not sensi- ble of any dyspeptic feelings, and con- ceived himself in health. His common beverage was cider. I recommended him to have a seton passed through the arm, between the ends of the bone ; which, on a revision of all the circum- stances of the case, 1 was led to hope might he attended with success. 1 fur- ther recommended him to take the opi- nion of Mr. Brodie, who concurred with me in the propriety ofthe measure. " On the 16th of June the operation was performed. An incision was made down to the bone, along the outer edge of the biceps, when 1 found that the fracture had been oblique, and that there was a projecting point occupying the outer part of the inferior portion; behind this I passed the needle, directing it through the interval between the ends of the bone. There was but little resistance to its pro- gress. Considerable inflammation and a copious discharge ofuffensive matter fol- lowed ; and, for some days, there was a good deal of fever and constitutional dis- turbance. The soft parts around tho fracture became much thickened, and some hopes of union were entertained from this circumstance. After a time, however, this thickening subsided, leav- ing the limb quite as moveable as before the operation. The discharge became thin and ichorous, and excoriated the sur- rounding skin. The greatest attention was paid to maintain the ends steadily in contact, and his diet and general health were strictly regulated during the whole treatment of the case. At the end of seven weeks the seton was withdrawn, having totally failed in producing any bony deposit, though it had certainly caused considerable inflammation in the soft parts immediately around the bone. On mentioning the case to some medical friends, and considering with them the propriety of any further attempts to pro- duce the union, Mr. Green suggested an operation which he had seen successfully practised by the late Mr. Henry Cline, which consisted of applying caustic pot- ash to the ends of the bone. On consi- dering the subject, the practice appeared to afford some probability of success in the present case; and the age of the pa- tient, and the useless state of his other arm, fully warranted any attempt. The nature ofthe operation, and the possibi- lity of its failure, were fairly represented to him, and on the 2d of August he sub- mitted to the trial, on which occasion I was favoured with the assistance of Mr. Green. "An incision, about four inches in length, was made through the integu- '00 APPENDIX ments, over the broken part, the broken ends of the hone were laid bare, and were found to be separated by a small detached portion of bone and a uhro-cartilaginous deposit. A small quantity of pus was still in the tract ofthe seton. The inter- vening substance was freely removed with a scalpel, but owing to the irregular sur- face of the bone it could not be entirely separated. A stick of caustic potash was then rubbed upon the ends of the hone, until the whole appeared black. I was in hopes, by tlui* producing artificial ne- crosis, to call forth into action the ossify- ing powers of the surrounding bone and periosteum. In performing the opera- tion much caution was required, as the upper part of the bone lay close to the humeral artery. This rendered the ope- ration rather more t>-dious, but the patient endured it with much fortitude, and after- ward declared that he would rather sub- mit to a repetition of it, than have another seton passed. Very little constitutional irritation followed, and no more inflam- mation in the part than was desirable. Considerable thickening took place round the bone, and the patient expressed a consciousness of returning strength and power in the limb. The sloughs of the softer parts came away in about a week, and two trifling exfoliations at the end of about six weeks. The. wound granulated kindly, and was only kept from closing by the exfoliations. While there was a free discharge from the wound the dis- position to urticaria cea-ed, but it return- ed as soon as the wound was healed. The thickening round the fracture had a very firm feel, and bore all the character of a callus. The consciousness of return- ing strength, and the increased firmness of the lim\ were very encouraging, and induced Mr. Brodie, Mr. Green, and my- self, to entertain very sanguine hopes of success. In the beginning of October I constructed an apparatus, calculated to give very fir.n and steady support to the li nb, which was applied before he left town, at which time there was only a very slight degree of yielding, in one di- rection, towards the wound. I recom- mended him to he very careful, and to continue to wur the apparatus for some time. 1 have since had the mortification to hear from him, stating that he conti- nued to wear the apparatus until Christ- mas, and on leaving it off, he found that the whole of the callus had been absorb- ed, and the limb was as weak aud useless as before. " On reflecting on this case, the follow- ing question suggests itself:—Did the want of union depend on any peculiarity of constitution in the individual, arising from causes over which we have no con- trol ? All the circumstances of the case seem to favour such on opinion. In the first place, although the ends of the bone were not in very close adaptation, and a small piece of detached bone was inter- posed, the space between the n was not sufficient to prevent union in a healthy person, and the separate portion of bune was not deprived of vitality. Next, al- though he was certainly not in a good state of health ; yet, any flesh wounds which he had met with accidentally, and those which were inflicted in the opera- tions, healed without difficulty; which proves that his vital powers were suffi- ciently active; of vvhich, indeed, the state of his pulse, his time of life, and his power of enduring fatigue, afforded satis- factory evidence. It was clearly then not from debility that the bones would not unite. How far it may have been con- nected with the state of his skin, and di- gustive organs, must he determined by further experience Another question suggests itself, which may he worth men- tioning. Would it have been better to have left off the support earlier? To em- ploy the language of Hunter, would the stimulus of necessity have called forth greater activity, which was not roused so long is the artificial support was em- ployed ?" F hope the stimulus of necessity, or some ol tier cogency, will soon direof to a decision in favour of a true pathology for this disease. GONOURHCEA. In the New-York Hospital Reports, there are eight cases recorded of the use of cubehs in gonor- rhcea, by Dr. Stevens. In all except one the cubehs cured the disease ; in some cases in four days, in others within the month. In the case wherein it failed, it had been used for four weeks, beginning with a dessert spoonful, and ending with an ounce a day, without the least abate- ment of the discharge ; but by having re- course to an ordinary injection, he was discharged from the hospital in four days, " nearly or entirely cured." The doctor states, that although unwilling to believe it a specific, he is unable to point out any stage of the disease in which it does not appear to be gpnerally beneficial. In dis- charges from the urethra, attended with stricture, he had not occasion to try it ; neither had he ventured to prescribe it during the presence of high inflamma- tion. I think I shall render a service to th* American student, by giving a transcript of a paper of surgeon T. D. Broughton, of the St. George's and St. James' Dis- pensary, London, upon the efficacy of Cubehs, or Java Pepper, just published in the 12th volume of the Medico-Chirur- gical Transactions. He proceeds, "The history of this plant, its nature and tendency, and the best modes of pre- paring and exhibiting it, being already be- fore the public, I shall confine myself al- together to a summary account of the APPENDIX, tt'i results of my exhibition of Cuhebs in fifty casesof gonorrhoea ; the largest pro- portion of which were those of soldiers, and the remainder dispensary and private patients. "Thepreparations employed were the powder, and the wine or tincture; the former in doses of from half a drachm to two, the latter from one drachm to half an ounce, twice or thrice a day. "The following statement will exhibit a concise and general view of the results: Patients cured in from two to seven days, 10 eight to fourteen, 17 fifteen to twenty-one, 18 twenty-two to thirty, 1 in fifty-five days, 1 Patients in whom no sensible effects were produced, 8 Total, 50 " \nfive of the above cases, though the relief obtained was immediate and deci- dedly marked, the final cure was com- pleted underthe use of copivy in four of them, and an astringent injection in the other. " In one case, the complaint having been arrested, returned again, and was eventually removed by copivy. "Two cases, solely removed by the cubehs, were attended with swelling of the testicles, and one was accompanied by severe chordees, for which the usual remedies were used, in conjunction with cubebs. A small proportion of these cases only were of the severer kind, and two such were among the failures. " The greater part were recent cases ; but one of six months' existence yielded to cubehs in as many days, while the case of fifty-five days' cure had existed no more than a fortnight. " Among fifty casps treated with cu- bebs, there were, therefore, three total failures, five relieved, and one suffered a relapse ; leaving forty-one cases cured under the use of the pepper, in less time than a month, with one exception; the largest proportion in less than three weeks, and several in a few days, among which latter some were well in eight-and- forty or thirty-six hours; and, the fail- ures excepted, the relief in all cases, where the symptoms were urgent, was very sudden ; and only two instances of swelling of the testicles occurred, and one of chordees continuing after the ex- hibition of the pepper, although in other respects the clap was relieved directly; "The account may therefore stand thus: Cured, 41 Relieved, 0 Cured and relapsed, 1 Failed, V> Total, fin "It may be said that other plans of treatment are capable of affording simi- lar results, especially that of injecting. But there are some points of view in which 1 cannot avoid looking at the cu- behs pepper more favourably than any other remedy. It seems to possess the power of allaying irritation beyond that of alkalies, or the nitre and gum pow- ders, and also of diminishing the dis- charge. Over balsam of copivy it seems to hold an advantage, in being admissi- ble in the earliest and worst stages of the severest gonorrhoea, without being pro- ductive of inconvenience to the patient; while I have not found its continuance attended with that injury to the functions of the stomach which so frequently-ari- ses from full and continued doses of co- pivy. " It appears to be superior to injections in not possessing any one of their inju- rious effects; and a temedy which is equally effective, and introduced into the general system, is, 1 think, more valuable than one applied topically to such a mem- brane as that of the urethra. " As to the time which is usually con- sumed in removing a clap with cubebs, I think it might challenge most remedies in this respect, and is not more fickle in its operation. And, at the same time, we must take into consideration its negative qualities, which, rendering it a perfectly safe remedy, would naturally induce an inclination to sacrifice a little time, were it necessary, for the sake of avoiding the chances of a ruder, though a quicker plan of cure. "Upon the whole, considering the ef- fects in general of medicines on the hu- man constitution, the resistance which the latter often opposes to the former, and the variable state of medicines, there are grounds for presuming that the cu- bebs pepper, though certainly not a spe- cific, is as worthy of being relied upon, in removing gonorrhoea, as any other reme- dy, while its exhibition is unattended with any dangerous or disagreeable conse- quences ; and it is frequently a quicker remedy in its action than those usually employed. " As to the general use of this pepper, I agree with others in thinking, thst when it does not seem to act in three or four days, it should he superseded by some other remedy ; and as soon as (having relieved the urgent symptoms) it appears to cease exerting its influence on the constitution, the balsam of copaiva may be employed advantagpously. "Although no general rule can be laid down, yet it appears to me that those cases in which most benefit may be ex- pected to arise from the use of cubebs are the most recent, and perhaps not th ' severest cases: in short, those case0 :o-j APPENDIX. which are most usually met with in practice. " As a farther advantage of this medi- cine, it may be added, that the habits of life and mode of diet need not to be in- fringed upon any further than such as common sense would dictate to every individual labouring under a local inflam- matory affection, which, in every in- stance must be aggravated by exercise and intemperance; and recovery assisted by means of rest and abstinence, propor- tionate to the degree of the existing in- flammation ; the neglect of^it would he opposed to the beneficial influence of any remedy whatsoever." HEAD, injuries of. There is a circumstance connected with the after treatment in these cases, which, if made general practice, would, 1 think, soon be conspiruous among remedial means in injuries of the head. I allude to a long interval between the first and second dressings, after operations, or wounds of the cranium or scalp. I have frequently witnessed persons in low life, even bruisers and drunken peo- ple, having an extensive injury of the s'>tip, or even fracture of the cranium ; from circumstances neglected for a week or ten days, and recover without any had symptom. I have, even at this period, bei*n sent for ; and carefully cut- ting off ih< matted hair which cover- ed the wound, and which was not eisil> removed, have dressed witti ad- hesive plaster and a neat bandage. But by next morning, symptoms nave su- pervened wlneii required bleeding, and a mosi active antiphlogistic treatment ; whic'i i now feel assured would not have occurred, had I left the parts to themselves. I have been led to remark, moreover, that when wounds of the scalp and cranium have taken place in persons of a better standing, and who Lave been dressed daily from the com- mencement, especially if 1 had been join- ed :>y some formal consultants ; that they h::v«- generally been troublesome to ma- nage. Every practising surgeon, must be sensible of this fact. But how is it to be accounted for ? It does app.-ar to me, that these parts, and especially those within the cranium, are induced to accommodate themselves to the pressure ofthe first dressing ; and that, by it the inflammation, supervening to the injury, is moderated and regula- ted. But when the dressings an* removed daily, there is as often a reaction in the vessels set up, under which they receive more blood for a time, which becomes a new excitant to inflammatory action. The delay between fiotand second dress- ings, after the operaton of the trepan, is no doubt of decided advantage, and from this cause: by preventing an excess of inflammation in the vessels of the pia mater. . In the 1st vol. of the Physico-Medical Transactions of New-York, published in 1817, we have three cases recorded by Dr. Mott, to illustrate this practice. The first was a boy of fifteen years of age, who underwent the operation of the trephine, for an extensive fracture and depression of the cranium, accompanied with a laceration of the dura mater, and a wound of the arteria raennigea media; he was dressed the fifteenth day after the operation, and did well without a bad symptom. The second case I shall transcribe : " I was requested early this morning to visit Thomas Williams, aged ten years, who had fallen from a stoop leading into tbe second story of a house, about fifteen feet high. He struck upon some round paving stones which covered the yard, with his side, and the side and back part of his head. When taken up he was en- tirely insensible, and appeared to his friends to be dead. It was about three- fourths ofan hour after the accident, be- fore I saw him. I found him lying on his side, and when an attempt was made to move him he appeared very much offended, though he did not speak. The pulse, breathing, and eyes, were all natu- ral ; and there was no vomiting. " On the lower and middle part of the left parietal bone was a considerable tu- mour of the scalp, and a very small wound. The sensation to the feel around the tumour and wound, left no doubt (as far as the feel can be depended upon in these cases,) that there was a fracture, with considerable depression of the cra- nium. At this kind of treatment he com- plained a good deal, and requested to be left alone ; the stupor which was first pro- duced having now entirely gone off. "To ascertain the state of the skull, I made an incision to the extent of about two inches, which enabled me to intro- duce my finger, and even see the fracture and depression. " It became necessary in order to make the requisite divisions of the scalp, and to ascertain the extent of the depression, to request the assistance of five of the by- standers, in order to confine him. " The depression was such, that with the elevator several pieces of bone were removed. The trephine was applied three times before all the depressed part could be elevated or removed, so as to take off all the pressure from the brain. The trephine was applied twice to the parietal bone, and once upon the os occi- pitis, opposite the posterior and inferior angle of the parietal bone. Eighteen pie- ces of hone were saved during the ope- ration, and no doubt some of the smaller were lost. Two large pieces were e!e- APPENDIX. "03 vated, and appeared so firm that it was not deemed necessary to remove them. A large crack, (for it would admit the handle of a scalpel,) extended from the anterior part of the depressed portion, and, from the size of it, and the distance it was traced, it in all probability was continued into the left orbit. " Another fracture, not so wide as the first, went through the squamous part of the temporal bone, and may have termi- nated in the petrous part of the same. It was extremely difficult to remove and elevate the injured portions of the bone, owing to the' extent of the surrounding injury, and motion, as it were, of the whole side of the cranium. The fulcrum ofthe old cases, would have been an ex- cellent instrument in this operation, by resting at a distance upon the sound bone. " The dura mater under the os occipi- tis was lacerated about an inch in extent. " The head having been extensively shaved, the wound of the scalp was nice- ly drawn together, and retained by straps of adhesive plaster. The incision in the scalp resembled an inverted T; it was easily made to coaptate, except that part which extended transversely across the temporal muscle. At this place there was a trifling retraction of the edges, not- withstanding the plasters. The hemor- hage was considerable from the neces- sary division of the posterior branch of the temporal artery, and a large branch, if not the trunk, of the occipital artery. Over the straps of adhesive plaster, a large quantity of soft scraped lint was ap- plied,with a thin compress,and the whole secured by a night-cap, so as to avoid all pressure upon the brain. " He was now conveyed to bed, the room was darkened, and all noise direct- ed to be guarded against. When told that the operation was over, and he was to be dressed, he was pretty easily con- trolled. His hands werp secured toge- ther to prevent him from tearing off the dressings. "Before the operation was completed, the pupils of both eyes were considera- bly oilated, and almost motionless, and continued so for two days. '*The night after the operation, he was very restless, constantly tossing himself about the bed. The following morning, and occasionally during the next and succeeding days, he was affect- ed with retching, but it did not amount to complete vomiting. He appeared to understand when spoken to, but could not articulate a word for two or three days ; and when he began, it was in a low whisper, and with an awkward and clumsy motion of his tongue. Indeed it was evident that he understood before this, when spoken to, as he would an- swer by a significant motion of his head. "The arterial system was very little affected ; his pulse, for eight or fen days after the operation, was about a hundred strokes in a minute, but not the least tense. Hi- tongue was moist and clear, from the beginning to the end of his con- finement. He did not complain of any thing hut a soreness in his head, at any time, from the operation ; his bowels were kept open by the daily use of au enema. His diet was of the mildest kind, consisting of gruel, barley, and toast-water: this course was rigidly ob- served. " On the twelfth day from the opera- tion, he was walking about the room, and did not complain of any thing but weak- ness. " On the morning of the sixteenth day from the injury, I dressed the head. Every part of the wound was healed by the first intention, except about half an inch of that part which wpnt through the temporal muscle :—here were two gra- nulations, each about the size of half a pea, which was the only suppurating sur- face to be seen. It was dressed with a small pledget of simple cerate. " The head was again dressed on the nineteenth day from the operation, when it was completely healed at every point of the incision. The faculties of his mind and the functions of his body did not appear to be in the least impaired. For the general debility, he was recom- mended a more generous diet, and di- rected to take a little cinchona daily." The third case was wherein the os fron- tis was extensively depressed, accompa- nied with a laceration ofthe dura mater in several situations. The meninges in the whole were torn to the extent of nearly two inches, from which the cere- brum was constantly discharging ; and it is said, from the appearance there must have been nearly two tea-spoonsful of this substance lost. After the opera- tion of the trephine, the wound was dressed with adhesive straps, lint, and a nightcap, in the usual way, and the pa- tient put to bed. " On the sixteenth day from the opera- tion, the wound was dressed. It had all united by the first intention, except about half an inch in extent, which cicatrized in a few days by the use of a little argen- tum nitratum, to repress the exuberant granulations. He sat up in a chair, to have the first dressing removed, and bad been walking about the chamber for several days previously." The author says, "If renewing the dressings were entirely free from danger, there is another important reason why they should not be removed at this time ; and particularly if a large portion of the 504 APPENDIX. cranium has been taken away. The ant upon the removal of the first: the brain, by this time, has become accom- pressure of the second cannot be so modated to the pressure ofthe first dress- nicely graduated as the tender brain, at ing, and feels no way impatient under it; tbis time, so imperiously demands. therefore, besides the irritation attend- KND OP THE FIRST VOLUME. '-**» MAY ^0 1960 ^>3' NLM041391737