\4* DICTIONARY OB PRACTICAL SURGERY: i CONTAINING A COMPLETE EXHIBITION OF THE PRESENT STATE OF THE PRINCIPLES AND PRACTICE OF SURGERY, COLLECTED FROM THE BEST AND MOST ORIGINAL SOURCES OF INFORMATION, AND ILLUSTRATED BY CRITICAL REMARKS. BY SAMUEL COOPER* Member of the Royal College of Surgeons, London, and author of the " First Lines of the Practice of Surgery." WITH NOTES AND ADDITIONS, BY JOHN SYNG DORSEY, M. D. Adjunct Professor of Surgery in the University of Pennsylvania, &e IN TWO VOLUMES. VOL. I. PHILADELPHIA: Published by B. & T. Kite, No. 20, North Third street . 1810. Stnr£^ Ctirv DISTRICT OF PENNSYLVANIA, TO WIT: ##***#* ; * BE IT REMEMBERED, That on the sixth day of March, * L- s* * in the thirty-fourth year of the Independence of the United ******* States of America, A. D. 1810, Benjamin and Thomas Kite, 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: containing a complete Exhibition of the present State of the Principles and Practice of Surgery, collected from the best ami most original sources of information, and illustrated by critical remarks. By Samuel Cooper, Member of the Royal College of Surgeons, London, and author of the " First Lines of the Practice of Surgery." With notes and additions, by John Syng Dorsey, M D. Adjunct Professor of Surgery in the University of Pennsylvania, &c In two volumes." In conformity to the act of the Congress of the United States, intituled, "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 there- in mentioned." And also to the act, entitled, " An act supplementary to an act, entitled, ' An act for the encouragement of learning, by securing the copies of maps, charts, and books, to the authors and proprietors of such copies during the time therein mentioned,' and extending the benefits thereof to the arts of designing, engraving, and etching historical and other prints." D. CALDWELL, Clerk of the district of Pennsylvania TO DOCTOR EDWARD ROBERTS, F. R. S. Senior Physician TO ST. BARTHOLOMEW'S HOSPITAL; This Book is Dedicated, AS A TESTIMONY OF GRATITUDE FOR MANY FAVOURS AND CIVILITIES RECEIVED, AND OF RESPECT FOR HIS PRIVATE AND PROFESSIONAL CHARACTER; BV THE AUTHOR. March, 1809 ADVERTISEMENT. 1 HE principal reason which has induced the Editor to repub- lish Cooper's Surgical Dictionary, is a belief that it con- tains more useful practical knowledge than any other work of equal extent hitherto made public. In the United States such a book has long been wanted. The great improvements which Surgery has received since the publi- cation of itny regular system, render peculiarly desirable some accurate account of the present state of Surgical practice. The alphabetical arrangement adopted by Mr. Cooper gives to the present work the advantage of being readily consulted in cases of emergency; and as a book of reference for the younger members of the profession it is confidently recommended. The Editor has not taken the liberty to alter or omit a single word of Mr Cooper's book, but has enclosed in brackets [ ] such comments and additions as he has thought necessary or useful. Philadelphia, March 1, 1810. PREFACE. IT seems rather extraordinary that, notwithstanding the study of Surgery has been, for many years past, carried on with inde- fatigable zeal and industry, no tolerable Dictionary on the sub- ject should ever have made its appearance, at least, in the Eng- lish language. Numerous systems of Surgery have certainly been written, and some of them, no doubt, have had very great effect, both in facilitating the acquirement of Surgical know- ledge, and in giving publicity to the many new facts, which are continually becoming established by the genius and labours of different individuals. Still, however, I must confess, with re- gret, that I am not at this moment acquainted with any one work, which contains a full account of all the latest discoveries and improvements, or which is free from strong objections, in regard to, what is implied by, the doctrines of Surgery. I shall not flatter myself with a hope, that this work will alto- gether supply the deficiency; but, I am certain of one thing, viz. that it comprehends an account of many new opinions and practices, which, though exceedingly interesting, remain unex- plained in any systematical treatise hitherto published. I am aware, that an alphabetical arrangement of Surgery, in the form of a Dictionary, is attended with some disadvantages. The chief of these are, the manner, in which some of the sub- jects are unavoidably scattered about in various parts of the book, and the frequent trouble, which the reader is put to by the numerous references. However, it is hoped, that these in- conveniences, while they are diminished as much as possible, are more than counterbalanced by certain advantages, exclu- sively belonging to a Dictionary. One great recemmendation of a work of this kind, is the ease with which any part of the subject may be immediately found. Another material advan- tage is, the opportunity, which has been afforded me, of intro- ducing an explanation of the terms, and an account of the chief viii PREFACE. remedies and applications used in Surgery. These latter objects, which are of infinite importance, I have endeavoured to fulfil with care and diligence. A good deal of the matter, which forms the contents of this volume, has been taken from the writings of the most eminent Surgeons. The works of the late Mr. Pott, and the publications of Scarpa, have afforded me essential assistance. However, it is needless forme to enumerate here all the authors, whose labours have contributed to the present performance; because, I have interspersed in the body of the book the various authorities for what is described or recommended. I have also endeavoured to render this Dictionary still more useful by concluding all the principal articles with a reference to books, from which further information on each particular subject may be derived. My u First Lines of the Practice of Surgery," I wrote as an introduction to the subject, and the encouragement, which has been given to that work, has exceeded any expections, which I ever entertained. The Dictionary, which I now publish, is undertaken with a view of making the reader a little more deeply acquainted with several parts of Surgery, than could well be done in an elementary treatise. I have also chosen to print the work in its present style, in order that its portableness may be a recommendation with Mili- tary and Naval Surgeons. As these gentlemen are often not able to carry their libraries about with them, 1 think the plan of this volume will be certain of meeting their approbation In- deed, it contains the pith of many works, which even men, who have better opportunities of collecting books, may not wish to possess, after having the publication, now offered to them. SAMUEL COOPER. Golden Square, March lj 1809. A NEW DICTIONARY OF PRACTICAL SURGERY. ® ABA A B D A BAPTISTON,orABAPTisTA(from ken not to lean too hard on the instru- -t\- « priv. and /3«e;rr<£<«» to plung-e). ment, when the bone is almost sawn Galen Fabricius ab Aquapendente, and through. With respect to the imprac- especially Scultetus, in his Armamen- ticableness of inclining the cylindrical tarium Chirurgicum, so denominate the saw, on any particular part of the cir- crown of the trepan; or, in other words, cle, when sawn unevenly, (which was the circular saw which makes the per- formerly alleged) whoever will try the foration in the bone, when the above is experiment, will in a moment discover used. The term came into use, in con- the falseness of the assertion. The ve- sequence of this part of the ti'epan ha- ry instance stated overthrows this ving had, at its first invention, aconical reasoning; for, if the circle has alrea- form, which kept it from penetrating dy been made more deeply in one part the cranium too rapidly, so as to than another, it must imply, that we plunge the teeth of the saw in the dura have leaned with more force on one mater and brain.—Encyclopedic Metho- part than another, and, consequently, dique,- Partk Cldrurgicale. may at pleasure do the very same Whatever suppositious advantages thing again. Mr. Sharp next takes no- tlie ancient practitioners of surgery may tice of the supposed advantage which have imputed to the conical shape of the conical saw had, in receiving and the crowns of their trepans, certain it retaining the piece of bone j a circum- .s, that modern surgeons do not, in ge- stance which he, very properly, calls neral, adopt their notions on this sub- frivolous. Sharp on the Operation of Stir- ject •, but, almost universally, make use ge*9- of a circular saw, the figure of which ABDOMEN. The Belly. The term is simply cylindrical. is said to be derived from the Latin Mr. Samuel Sharp notices the idea of verb abdo, to hide, because many of the there being the above danger in em- chief viscera of the body are concealed ploying a cylindrical trepan, and re- in the cavity which it denotes. marks, that the great labour of work- When a surgeon speaks of the cavity ing so slowlyand difficultly (with aconi- of the abdomen, he confines his mean- cal one) is not only very inconvenient ing to the space which is included with- to an operator, but by no means ser- in the bag of the peritoneum. Hence, viceable to the operation; for, notwith- neither the kidneys, nor the pelvic vis- standing the saw be cylindrical, and cera, are, strictly speaking, parts of work without any other impediment the abdomen. than what lies before the teeth, yet, Anatomists have distinguished this even with this advantage, the operation large cavity into different regions, and goes on so gradually, that from the ex- the terms allotted to these are so very perience Mr. Sharp has had, he never frequent in the language of surgical found the least danger of suddenly pas- books, that some account of them in sing through to the brain, if care be ta- this Dictionary seems indispensable. vol. i. 1 2 ABDOMEN. The middle of the upper part of the abdomen, from the ensiform cartilage, as low down as a line dawn across from the greatest convexity of the car- tilages of the ribs, is called the epigas- tric regions. The spaces at the side^of the epigas- tric region, are termed* the right and kft hypochondria, or hypochondriac re- gions. The umbilical region extends upwards to the fine, forming the lower bounda- ry of the epigastric region, and down- ward, to a line drawn across from the anterior superior spinous processes of the ilium. All below the last line, down to the os pubis, is named the hypogastric re- gion. Tne abdomen is a part of the body, claiming the particular attention of ev- ery practical surgeon ; for, it is the fre- quent situation of several of the most important surgical diseases. It is also very mucli exposed to wounds, and va- rious operations are often requisite to be done in different parts of it. One of the most common afflictions to which mankind are subject, is that in which some of the bowels are protruded, poshing 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 know- ledge, without being well acquainted with the anatomy of the abdomen. In dropsical cases, it is frequently proper to tap the abdomen, and this operation, named paracentesis, simple as it may seem, requires more consideration, and attention to anatomy, than surgeons of- ten bestow on the subject. But the ab- domen is, above all, particularly liable to be wounded, to which ease we shall confine our present remarks, refer- ring the reader to hernia and paracen- tesis for information on these subjects. WOUNDS OF THE ABDOMEN. These are divided by almost all wri- ters, into such as penetrate the cavity of the abdomen, and into others, which only interest the skin and muscles. Tlie former differ very much in their nature and degree of danger, according as they do, or do not, injure parts of importance, contained in the peritone- um. The latter are not very different from the generality of other superficial wounds. The chief indications are to lower inflammation, «id to prevent col- lections of fnatter. A few particulari- ties, however, in the treatment of su- perficial wounds of the abdomen, seem to merit attention. superficial wounds. The most ancient surgeons, and their successors, regularly up to the present day, have recorded, that wounds of tendinous parts are more perilous, thaW those of fleshy ones. Almost the whole front of the abdomen is covered witli tendinous expansions, and on this ac- count it is not unusual to see wounds in this situation followed by great local inflammations, and the formation of ab- cesses. The patient is, at the 'same time, affected with a great deal of the sym- pathetic inflammatory fever. (See Fe- ver.) When the tension and swelling of the abdomen abate, shiverings some- times occur, and indicate the occur- rence of suppuration. The matter, which forms in these cases, sometimes makes its way into the tendinous sheath of the rectus mus- cle, and, when the collection of matter in this situation remains undiscoverevl until, a pointing appears, no sooner does the abscess burst or is it opened, than an extraordinary quantity of mat- ter is discharged. The surgeon should carefully remember the nature of this kind of case, as there is frequently no alteration in the appearance of the in- teguments to denote, either the exis- tence, or the extent of the suppuration. This kind of abscess forms one«re- markable exception to the excellent general rule of allowing acute phleg- monous abscesses to burst of their own accord. In the present instance, there is an aponeurotic expansion, interven- ing between the abscess and the skin, and nqthing retards the natural pro- gress of the matter to the surface of the body so powerfully, as the interpo- sition of a tendinous fascia. But, even in this circumstance, the propensity of pus to make its way outward is often seen to have immense influence. Though there is only a thin membrane, (viz. the peritoneum) between matter so situated and the cavity of" the abdomen, yet, in time, the abcess mostly points external- The proper treatment of this case is to prevent the surprising accumulation ot matter, and rapid increase of mis- chief, by making a depending opening ABDOMEN sometimes at the very lowest pari of the sheath of the rectus muscle, and this, as soon as the lodgment of matter is clearly ascertained. Superficial wounds of the abdomen are to be treated on the same principles, as similar wounds in other situations. The indications are to prevent inflam- mation as much as possible, and, if suppuration should be inevitable to let out the matter by a depending opening, as soon as the abscess is known to ex- ist. The inflammation is to be check- ed by general and topical bleeding, low diet, emollient clysters, diluent beverages, quietude, anft* the mildest, and most simple dressings. (See In- flaHimation.) Whenever the abdominal muscles are wounded, it is desirable to relax them; but, this object should not lead us to put the patient out of a horizontal po- sition. A very important point, in the treatment of wounds, which interest the parietes of the abdomen, is to afford a certain degree of support to the wounded part, when there seems the smallest chance of their being too weak to resist the pressure of the visce- ra. The parietes of the abdomen are almost wholly composed of soft parts, which easily yield. No part of the front, or sides, of the abdomen, is supported by the stability of a bony structure, and, as the viscera are, for the most part, more or less moveable, and close- ly compressed by the abdominal mus- cles, and diaphragm, they are very apt to be protruded, whenever the resist- ance of the parietes of the abdomen is not sufficiently potent. Thus very pe- rilous cases of herniae may originate. For the above reasons, all wounds of the abdomen, especially those in which both the integuments and muscles have been cut, demand strict attention to the precaution of supporting the wound- ed part, and this, though the peritone- um itself should not happen to be divi- ded. The patient ought to keep as much as possible in a horizontal posi- tion, while suitable compresses and bandages should be applied to the si- tuation of the wound. In order to guard against the occurrence of hernia, the part should be supported, in this way, a considerable time after the wound is healed. The peritoneum being connected by means of cellular substance, with the inner surface of the abdominal muscles, there is ulwavs some risk of the inflam- mation of these muscles extending to the membranous lining of the abdomen. The occurrence must be averted by the rigorous employment of the anti- phlogistic treatment. What renders the event still more dangerous is, that when one point of the peritoneum is affected, the inflammation usually spreads with immense rapidity over its whole extent, and too often proves fa- tal. As superficial wounds of the abdo- men are to be treated on the general principles, applicable to all other wounds of this sort in other situations, it is hardly necessary to state, that union by the first intention is always, v. hen pos- sible, to be attempted. op wounds penetrating the cavity of the abdomen. In these cases, the first things, which the surgeon is generally anxious to know, is, whether the wound penetrates the cavity of the abdomen, and whether any of the viscera are probably injured. When the wound is extensive, and any of the bowels protrude, the first part of the question is at once decided. But, when the wound is narrow, and allows none of the viscera to protrude, it is often exceedingly difficult to as- certain, whether the injury extends in- to the abdomen* or not. An opinion, however, may usually be formed, by carefully examining the wound with one of the fingers, or a probe, after ha- ving put the patient, as exactly as possi- ble, in the posture in winch lie was at the time of receiving the accident; by observing, if possible, the shape and dimensions of" the instrument, with which the injury was done; how much of the weapon has entered the flesh ; the direction in which it was pushed, by attending to the quantity of blood, which the patient has lost, the state of his pulse, Jkc. and, lastly, by observing whether there is any discharge of bile, faeces, or other fluids, known to be na- turally contained in some of the abdo- minal viscera. When the wound is sufficiently large to admit the finger, we may always as- certain whether the injury extends into the cavity of the abdomen, because the viscera may then be easily felt. There is only one chance of deception, and that arises from a possibility of the practitioner's mistaking the inside of the sheath of the rectus muscle for the 4 ABDOMEN*. Cavity of the "peritoneum. When the examination is made with a probe, we should be particularly cautious, in form- ing a judgment; for, the parts are so soft and yielding, that a very little force will make the instrument pass a consi- • derable way inward. Every examination of this kind should always be'tjaiderta- ken, if possible, when the patient is ex- actly in the same position, as he was at the time of receiving the wound. Injections have been employed for ascertaining, whether wounds pene- trate the cavity of the abdomen. This absurd experiment, however, has now been most justly exploded from prac- tice. It is well known to the moderns, that the space termed the cavity of the abdomen, is, in fact, completely filled with the various viscera, and that a fluid would, in general, not so easily find its way into the bag of the perito- neum,jas an unreflecting person might suppose. If the injection were propel- led with much force, it would be quite as likely to insinuate itself into the cellular substance of the parietes of the abdomen, or, perhaps, into the sheath of the rectus muscle. The least tortuo- sity of the wound, or a piece of bowel, or omentum, lying against the internal orifice of the injury, would completely prevent an injection from passing into the abdomen. When a considerable quantity of blood issues from a w ound of the abdo- men, we may pronounce, almost with certainty, that some large vessel, with- in its cavity, is injured. Excepting the epigastric artery, which runs in the forepart of the abdomen, along the in- ner surface of the rectus muscle, there is not one very considerable vessel, dis- tributed to the muscles and integuments. At the same time, it is deserving of particular notice, that a very large ar- tery may be opened in the abdomen, and, yet, not a drop of blood may be discharged from the external wound. A very large quantity may accumulate in this manner, even without there be- ing any palpable swelling of the belly. In such cases, the subsequent symp- toms very quickly lead us to suspect v, hat has happened. The patient com- plains of extreme debility and faintness ; his pulse faulters; he has cold sweats; and, if the bleeding should not speedily cease, these symptoms are, in general, soon followed by death. Sometimes, the first glimpse is enough to sh-.-w, that the wound ex- tends into the cavity of the abdomen. The event is indicated by the escape of chyle, bilious matter, faeces, or other fluids, known to be contained jn some of the viscera. The same information may also be obtained from seeing a considerable quantity of blood 'vomited up, or discharged by stool. The urine, however, may flow from a wound, which does not actually penetrate the abdomen, for the kidneys, ureter, and bladder may be said to be out of the abdomen, because they are really on the outside of the cavity of the perito- neum. When no symptoms of the above de- scription occur, when neither the fin- ger, nor probe, can be introduced; when none of the fluids, known to be contain- ed in the various receptacles in the ab- domen, are emitted from the wound: when the pulse remains natural, and the pain is not excessive, there is reason to hope, that the wound has not injured parts of greater consequence, than the integuments, and muscles. Encyclope- dic Methodique, Partie Chirurgicale. We have now taken a survey of such criteria, as are commonly noticed by surgical writers, for the purpose of" in- structing the reader how to discrimi- nate a wound, which has penetrated the abdomen from one which has not. It is our next place to warn the practition- er, that too much solicitude to deter- mine this point, is very frequently pro- ductive of serious harm. It may be set down, as an axiom 'in surgery, that whenever the probing of a wound is not rendered necessary by some particular ob- ject in view, it may, in general, be judi- ciously omitted. A narrow, oblique wound may enter the cavity of the ab- domen, without there being any parti- cular method of ascertaining, whether it has done so, or not. This, however, is of no practical importance; for, when there are no urgent symptoms, evincing the nature of the case, the treatment ought obviously to resemble that of a simple wound; and whether the wound is deep, or superficial, the antiphlogis- tic treatment is equally indicated The edges of a wound penetrating the abdomen, but, unattended with any obvious injury of the viscera, are to be brought together by sticking-plaster just in the same way as common wounds. In this situation, sutures are more frequently proper, than i„ most others. Particular care is also to be taken to keep the bowels from protru- ABDOMEN. 5 dinghy the application of a compress, and bandage. All the means of prevent- ing inflammation are to be adopted, (see Inflammation) and quietude is, above all things, to be enjoined. INFLAMMATORY CO NS EQUENCES OF WOUNDS OF THE ABDOMEN. Sometimes, notwithstanding the best treatment, alarming symptoms cannot be prevented. These are commonly, at first, of the inflammatory kind, con- sequently, repeated bleeding, and re- doubled attention to every part of the antiphlogistic treatment, are indicated. If the inflammation should not be sub- dued by such measures, internal mor- tification and death may follow, or ab- scesses form in the abdomen. SUPPURATION IN THE ABDOMEN IN CONSEQUENCE OF WOUNDS. If the abscess were in any other part of the body, and did not readily point, the wisest practice would undoubtedly be to make an opening sufficient for the evacuation of the matter. But suppu- ration in the abdomen can seldom be ascertained with certainty, before the collection of matter has existed a good while ; for, the situation of the abscess is so deep, that no fluctuation, nor swelling, becomes perceptible, until a considerable quantity of pus has accu- mulated. Besides, it would not be ju- dicious to expose the patient to the hazard, which might arise from making an opening, into the abdomen, merely for the sake of giving vent to a small collection of matter. Many, indeed almost all writers, im- pute a vast deal of the danger of wounds of the abdomen to the entrance of" air into the cavity of the peritoneum, and they also adduce this as an argument against opening abscesses of the abdo- men. In inculcating such opinions, however, they betray an inaccuracy of observation, which a very little reflec- tion would have set right. Too much stress has long been laid on the intro- duction of air into the abdomen, as be- ing a cause of inflammation. The fact is, that the cavity of the belly is always so completely occupied by the various viscera, that the whole inner surface of the peritoneum is constantly in close contact with them, and, consequently air cannot so easily diffuse itself from the vicinity of the wound, throughout the abdomen, as has been conceived. After tapping, in dropsical cases, we seldom see inflammation arise, though, air has, in this instance, quite as good an opportunity of entering the abdo- men, as in any case of a wound. The peritoneum in animals has been inflat- ed, without any inflammation being ex- cited. In the human subject, it seems probable, that, if a wound were made in a vacuum, the breach of continuity itself would lead to inflammatory con- sequences. We have also to remark, that collections of matter in the abdo- men are almost always completely cir- cumscribed, and separated from the general cavity of the peritoneum, by the adhesion of the viscera to each oth- er, and to the inside of the perito- neum. It is, in general, a very good rule, in all cases of wrounds of the abdomen, never to be officious about absces- ses, which may take place, nor con- cerning such viscera, as we may sus- pect to be injured. It is quite time enough to interfere, when the urgen- cy of the symptoms has confirmed our conjectures. A g-reat deal of harm is frequently done, by handling and disturbing the woundedparts more than is necesrary, and it is well known, that wounds, which arc at first attended with very alarming symptoms, fre- quently terminate in a favourable manner. Persons having been known to have swords passed completely through their bodies, without suf- fering afterwards any threatening symp- tom, or, indeed, any effects which would authorize one to conclude, that the viscera had been at all injured. We are aware, that severe inflammations may not end in suppuration, and we also know, that when pus has been formed, the fluid has been often ab- sorbed again. Nothing then indicates the necessity for giving vent to puru- lent matter lodged in the abdomen, ex- cept the fluctuation and situation of the abscess be very distinct, and the quanti- ty and pressure of the matter produc- tive of inconveniences. For making an opening, some writ- ers recommend a trocar; others, a lan- cet. The matter must be very copious and distinct, to justify the sudden in- troduction of such an instrument as a trocar. In other cases, the surgeon should make a cautious puncture with a lancet. 6 ABDOMEN PROTRUSION OF THE VISCERA.^ Wounds, penetrating the abdomen, sometimes allow considerable portions of the bowels, or omentum, to protrude, and, though these viscera may not have received any injury, yet, their being displaced in this way is sometimes pro- ductive of fatal consequences. The best mode of preventing such a catastrophe, is to return the viscera in- to the cavity of the abdomen, as speed- ily as possible. Almost all authors recommend fomenting the displaced parts, before attempting to reduce them ; but, in giving this advice, they seem to forget, that, while time is lost in this preparation, the protruded bow- els suffer much more harm from ex- posure, and other circumstances, than they can possibly receive good from any applications made to them. No kind of fomentation can be half so ben- eficial, as the natural warmth and mois- ture of the cavity of the abdomen. In order to facilitate the return of a pro- truded piece of intestine, or omentum. the abdominal muscles should be relax- ed by placing the patient in a suitable posture, and the large intestines empti- ed by a glyster. In mentioning the last measure, it is not meant, that the surgeon should delay the attempt to reduce the part, until the glyster has operated. No—this means is only enu- merated as one that may become ser- viceable, in case the surgeon cannot immediately accomplish the object in view.—The mesentery ought always to be reduced before the intestine; the intestine before the omentum ; but, the last protruded portion of each of these parts ought to be the first one reduced. It is only when the intestine and omentum are free from gangrene and mortification, that they are invariably to be returned into the cavity of the belly, without hesitation. Also, when the protruded parts are covered with sand, dust, or other extraneous matter, it is undoubtedly proper to make them as clean as possible, before putting them back into the abdomen. For this purpose, the parts should be tenderly washed with a little lukewarm milk and water. The two index fingers are the most convenient for reducing the parts, and, it is a rule to keep the portion, first re- turned, from protruding again by one finger, until it has been followed by another portion, introduced by the oth- er finger. The second piece is to be kept up, in the same way, by the finger used to return it; and so on, till the whole of the displaced parts have been, put into their natural situation. In attempting to reduce a piece of protruded intestine, the patient should be placed in the most favourable pos- ture ; the head and chest showld be elevated, and the pelvis raised by pil- lows. Nothing can be more absurd, than the advice to have the thorax rather lower than the pelvis^in order that the weight of the viscel-a may tend to draw inward the protruded parts. This is another erroneous idea, arising from the ridiculous supposition, that a great part of the abdomen is actually an empty cavity. The relaxation of the abdominal muscles is a much more ra- tional and useful object.—When this is properly attended to, and the wound is not exceedingly small, in relation to the bulk of the protruded viscera, the parts may generally be reduced by ob- serving the above directions. But, in addition to what has been already stat- ed, it is necessary to remark, that the pressure should be made in a straight direction into the abdomen ; for, when made obliquely, towai'ds the edges of the wound, the parts are liable to suf- fer contusion, without being reduced, and even to glide between the layers of the abdominal muscles, and become strangulated. When the wound is in the front of the abdomen, pressure made in this unskilful way, may easily make the viscera slip into the sheath of the rectus muscle, and cause the same perilous symptoms, as arise from an incarcerated hernia. (See Hernia.) When the reduction seems complete, the surgeon should assure himself of it, by introducing his finger into the cavi- ty of the abdomen, so as to feel, that the parties are all actually reduced, and suffer no constriction between the edges of the wound, and the viscera in the abdomen. A difficulty of reduction may arise from tlie protruded intestine being dis- tended with faces, or air. In this cir- cumstance, the contents of the gut may frequently be made to pass, by little and little, into that portion of the in- testinal canal, which is within the ab- domen. To accomplish this purpose, the surgeon must press the contents of the bowel towards the wound, and, if he succeeds in emptying the part, he will commonly experience equal sue- ABDOMEN. re&s in his next attempt to replace it in the abdomen. Sometimes, such very considerable pieces of intestine are found protruded, through narrow wounds of the abdo- men, that the reduction cannot be ef- fected, without doing more violence to the bowel, than its delicate structure would bear. In this case, dilating the wound becomes indispensable. How- ever, very frequently, when the reduc- tion seems almost a matter of impossi- bility, on account of the smallness of the wound, relaxing the abdominal muscles, drawing a little more intes- tine out of the wound, and gently pres- sing the contents of the bowel, through the constriction into the abdomen, will render the protruding part sufficiently reducible, without any operation to en- large the wound. When such operation is unavoidable, the dilation should be made in a direc- tion, which will not endanger the epi- gastric artery, and if possible, in the same fine as the muscular fibres. It would be unpardonable to make a more extensive incision, than absolutely re- quisite, as hernia: are very much dis- posed to occur, wherever the peritone- um has been divided. The operation may be done with a curved bistoury and a director, much in the same way as is done in cases of strangulated rup- tures. (See Hernia.) Instead of enlarging wounds of the abdomen, it has been proposed to let out the air from the intestine, by mak- ing small punctures with the point of a needle, and thus lessen the volume of the protruded part sufficiently to ren- der it easily reducible. As this expe- dient has been recommended by writ- ers of some weight, the subject should not be passed over in silence, and with- out a caution to the reader, never to put any confidence in the method. The plan certainly facilitates the business oCthe operator; but this seems to be the only solitary reason in favour of the practice. Though some patients, so treated, may have recovered; yet, ev- ery person, who has the least know- ledge of the animal economy, will easi- ly comprehend, how even the smallest opening, made in parts, so irritable and prone to inflammation, as the bowels, must be attended with greater danger than would result from enlarging a wound of the skin and muscles. Be- sides the air may frequently be pressed out of the intestine in a safer way, as was before described. (See Encyclope- dic Metliodique ; Partie Chirurgicak.) ' When the protruded intestine is wounded, the opening is to be closed with a particular suture, before the part is returned into the abdomen. Of this subject, when we speak of wounds of the intestines. Some of the exposed intestine may have mortified, before the arrival of surgical assistance. This event is ex- ceedingly rare in cases of wounds, but, is not uncommon in those of strangu- lated herniae. The treatment will be explained in the article Hernia. When the protruded intestine is in a state of inflammation, its immediate re- duction is, beyond all dispute, the means most likely to set every thing right. Even when the inflammation has risen to a vehement pitch, a timely reduction of the displaced part, and the employment of antiphlogistic means will often prevent gangrenous mischief. The dull, brown, dark red colour of the intestine, may induce the practi- tioner to suppose, either that the part is already mortified, or must inevitably become so, and, consequently, he may- delay returning it into its natural situa- tion. But, notwithstanding this suspi- cious colour of the intestine, its firm- ness will evince, that it is not in a state of gangrene. The ultimate recovery of a portion of intestine, so circum- stanced, is always a matter of uncer- tainty ; but the propriety of speedily replacing the part in its natural situa- tion is a thing most certain. In case the bowel should mortify after being reduced; all hopes of the preservation of life are not to be abandoned, as we shall notice again in the subject of hernia, where every thing necessary to be known, concerning the mode of re> ducing protruded omentum, will also be found. The protruded viscera having been reduced, the next object is to retain them in the abdomen, until the wound is completely healed. When the wound is small, this is a matter of no difficul- ty ; in this instance, it is enough to put the patient in such a position, as shall relax the fibres in the wounded mus- cles, while the edges of the wound are maintained in contact with sticking- plaster, and supported, in this way, by a compress and bandage. Costiveness is to be removed by the mildest purg- atives, such as the 6oda phosphoraU and oleum ricinr, or by laxative glys 8 ABDOMEN. ters, which are still preferable. But in cases of extensive wounds, even when the treatment is conducted with all pos- sible judgment, it is occasionally very difficult, and impossible, to lunder the protrusion of the bowels by common dressings, and a bandage. In this cir- cumstance the edges of the wound must be sewed together by a particu- lar suture, named Gastroraphe. (See this article). It is proper to remark, however, that, in modern times, this suture is very rarely employed, in com- parison with what it was formerly, and, in the description of gastroraphe, some remarks will be offered, for the pur- pose of proving, that even the general- ity of large wounds of the abdomen do pot require any suture whatsoever. EXTRAVASATION IN THE ABDOMEN. The usual consequence of a wound, which penetrates any of the parts, con- tained in the bag of" the peritoneum, is an extravasation of some fluid among the adjacent viscera. This fluid may be undigested aliment, chyle, the suc- cus pancreaticus, bile, urine, blood, &c. according to the nature of the in- jured part. Richter has very ably explained, (Anfangsgr der Wundarzn) that there are three distinct, and successive, clas- ses of bad symptoms, arising from the effusion of blood in the abdomen. I. The first class is altogether owing to the loss of blood itself, and consists of paleness, weakness, sinking pulse, and swooning. II. The second depends upon the presence of the blood in the cavity of the peritoneum, and consists of a swell- ing of the abdomen, and various incon- veniences produced by the pressure of the extravasated blood on the visce- ra. When the quantity is small, the inconvenience will be so trivial, as not to excite notice. III. The third is produced by the ir- ritation of the blood in the abdomen, and consists of convulsions, febrile symptoms, pain, inflammation, hic- coughs, vomiting, suppuration, and ab- scesses, pointing externally. Extravasated urine, bile, and the con- tents of the stomach, and intestines, produce a higher and more rapid de- gree of irritation, than is the conse- quence of effused blood. But, whatever the nature of the ex- travasated fluid may be, the principal effects belong to the third class, ayd are all of the inflammatory kind, indu- cing the danger of suppuration and mor- tification. The irritation arising from the quality of the effused fluid, and the pressure, resulting from its quantity, are sufficient to account for the origin of such pernicious effects. The symptoms caused by wounds of parts, contained in the abdomen, may either make their appearance immedi- ately, or some time after the accident, and they are of two kinds, viz. focal and constitutional. The ordinary constitu- tional ones are, convulsions, weakness, fever, vomiting,, anxiety, oppressed respiration, &c. The local symptoms are such as pain and tumefaction". When the symptoms appear soon .af- ter the occurrence of the wound, and, after a time, gradually diminish, or go off entirely, but, sooner or later, origi- nate again, there is reason to consider their first origin, as the immediate ef- fect of the injury ; their second occur- rence, as the effect of an extravasation. This method of forming a decision, however, may sometimes lead to error. When urine and bile are extravasated, the symptoms of the extravasation arise very quickly, and often continue from their commencement extremely ur- gent, without the leasj, abatement whatsoever. In these cases, the local pain, swelling, and fluctuation, fre- quently afford ample information con- cerning the nature of the accident. The fluctuation in particular is a very deci- sive criterion, when it precedes the pain. The escape of the extravasated fluid out of the external wound, some- times conveys information to the prac- titioner. Blood is more frequently extrava- sated in the abdomen, than any other fluid. Extra vacations of this kind, however, do not invariably happen, whenever vessels of not a very consid- erable size are wounded. The com- pact state of the abdominal viscera, in regard to each other, and their action on each other, oppose this effect. The action, alluded to, which depends on the abdominal muscles and diaphragm, is rendered very manifest by what hap- pens, in consequence of operations for hernia attended with alteration of the intestines, or omentum. If these vis- cera should burst, or suppurate, after being reduced, the matter, which es- capes from them, or the pus, which they secrete, is not lost in the abdo- ABDOMEN. 9 men; but is propelled towards the wound of the skin, and there makes its exit. The intestinal matter, effused from a mortified bowel, has been known to remain lodged the whole intenal, between one time of dressing the wound and another, in consequence of the surgeon stopping up the external wound with a large tent. When the above mentioned action or pressure of the muscles, is not sufficient to keep the blood from making its escape from the vessels, still it may hinder it from becoming diffused among the convolu- tions «f the viscera, and thus the ex- travasation is confined in one mass. The blood, effused and accumulated in this way, is commonly lodged at the inferior and anterior part of the abdo- men, above the lateral part of the pu- bis, and by the side of one of the recti muscles. The weight of the blood may propel it into this situation, or, perhaps, there may be less resistance in this di- rection, than in any otiier. In opening She bodies of persons, Who have died with such extravasations, things may put on a different aspect, and the blood seem to be promiscuously extravasated over every part of the abdomen. But when such bodies are examined with care it will be found, that the blood docs not insinuate itself among the vis- cera, till the moment when the abdo- men is opened, and the mass previous- ly lies in a kind of pouch. This pouch is frequently circumscribed, and bound- ed by thick membranes, especially when the extravasation has been of some standing. (Sabatier Medicine Operatoire.) It is of the highest consequence to a practical surgeon to remember, well, that all the parts contained in the ab- domen are closely in contact with each other, and with the inner surface of the peritoneum. This is one grand reason, why extravasations are seldom so extensively diffused, as one might imagine ; but commonly lie in one mass, as Sabatier and all the best moderns have noticed. The pressure of the elastic bowels, of the diaphragm, and abdominal muscles, not only frequently presents an obstacle to the diffusion of extravasated matter, but often serves to propel it towards the mouth of the wound. The records of surgery make mention of numerous instances, in which persons have been slabbed through the body, without any evil con- sequences. In such cases, the bowels have been supposed to have eluded the point of the weapon, and this may sometimes have been actually the fact; but, in many such examples, there can be no doubt, that the bowels have been punctured, and an extravasation of in- testinal matter has been prevented by the opposite pressure of the adjacent viscera. Such resistance and pressure may, also, have occasionally obliged in- testinal matter, or blood, actually ex- travasated, to pass through the wound of* the bowel into its cavity, and thus be speedily removed. Certain it is, such copious evacuations of blood per anum have followed stabs of the abdo- men, as could hardly proceed f'-om the arteries of the intestines. This way of getting rid of an extravasation must be rare, however, compared with that by absorption. The pouch, or cyst, including extra- vasated blood, or matter, as mentioned by Sabatier, is formed by the same process, which circumscribes the mat- ter of abscesses. (See Suppuration.) It is in short, the adhesive inflamma- tion. All the surfaces in contact with each other, and surrounding the extra- vasation, and track of the wound, gen- erally soon become so intimately con- nected together by the adhesive inflam- mation, that the place, in which the t-5*- travasation is lodged, is a cavity entire- ly destitute of all communication with the cavity of the peritoneum. The track of the wound leads to the seat of the effused fluid, but, has no distinct open- ing into the general cavity of the abdo- men. The rapidity with whicii the above adhesions form, is often very great, almost incredible. It should be known, however, that extravasations are occasionally difRis- cd in various degrees among the vis- cera, owing to the patient being sub- jected to a great deal of motion, or Ms having violent spasmodic contractions of the intestines, arising from the ir- ritation of the extravasated matter. Urine and bile are more frequently dis- persed to a great extent among-the ab- dominal viscera, than blood. Tne lat ter fluid, indeed, must often coagulate ; a circumstance, that must both tend to stop further hemorrhage ;u.d confine the extravasation in one mass. 10 ABDOMEN. TREATMENT OF EXTRAVASATION IN THE ABDOMEN. 1. Bkod. When the symptoms leave no doubt of there being a large quantity of blood extravasated in the abdomen ; when the patient's complaints are of a very seri- ous nature, and are evidently owing to the irritation and pressure of the blood on the surrounding viscera ; and when a local swelling denotes the seat of the extravasation, there cannot be two opin- ions about the propriety of making an incision for its evacuation. Surgeons, however, should recollect, that a small extravasation of blood may exist, without producing any very con- siderable irritation, provided no open- ing be made into the cyst, with which it becomes surrounded. On the con- trary, when such cyst is opened, the air then having free access to the blood contained there, that part of the fluid, which cannot be discharged, is very apt to putrify, and becomes so irritat- ing, as to excite inflammation of the surrounding parts.—Even though there may be an evident extravasation of blood, the bad symptoms are also some- times entirely owing to the injury done to the parts within the abdomen, and neither to the pressure, nor the irrita- tion of the effused blood. Sometimes the accumulated blood, at first, neither irritates the adjacent parts by its quantity nor quality. An inflammation, however, of' the parts surrounding the extravasation at length takes place. The tension, irritation, and pain, which, in the first instance arose from the wound itself, and sub- sided, seem now to be removed. When the extravasation is at the lower and anterior part of the abdomen, the pa- tient experiences pain about the hypo- gastric region. He is also constipated, and, as he suffers great irritation of the bladder, he feels frequent propensities to make water, but cannot relieve him- self. At last, a tumour makes its ap- pearance, attended with a fluctuation, more or less distinct. In this instance, it seems proper to give vent to the accumulated blood. If the fluid should be found coagulated, injections of warm water would facili- tate its discharge. (Sabatier Medicine Ope'ratoire.) 2. Chyle and Faces. These are not so easily extravasated in the abdomen as blood, because they do not require so much resistance, on the outside of the stomach and intes- tines, to make them continue their na- tural rout through the alimentary canal, as blood requires to keep it in the yes- sels. Extravasations of this kind, however, sometimes happen, when the wounds are large, and the viscera con- tract in a spasmodic manner. Nothing is a better proof of the difficulty, with which chyle and faeces are extravasated, than the operation of an emetic, when the stomach is wounded and full of aliment. In this instance, if the resistance to the extravasation of the contents of the stomach were not considerable, they would be effused iu the abdomen, in- stead of being vomited up. A peculi- arity in wounds of the stomach and in- testines is, that the opening, which al- lows their contents to escape, may also allow them to return into the wounded viscus. In these cases, general means are the only ones, which can be employed; venesection, fomentations, low diet, perfect rest, &c. All solid food must be most strictly prohibited. The close state of the viscera may also be increas- ed by applying a bandage round the body. 3. Bile. Bile, on account of its great fluidity, is more easily extravasated extensively in the abdomen, than either blood, or the contents of the stomach and intes- tines. Besides, the gall bladder has the power of contracting itself so com- pletely, as to expel the whole of its con- tents. Notwithstanding these circum- stances, however, extravasations of-this kind are exceedingly uncommon, doubt- less, on account of-the small size of the gall bladder, and its deep guarded sit- uation, between the concave surface of the liver, and upper part of the trans- verse arch of the colon. A case, in which the gall bladder was wounded, is related in the 3d vol. of the Edinb. Essays. The patient sur- vived the accident a week. Before death, there was a rumbling noise in the abdomen, which became very tense. There were no stools, and very little urine was discharged, though purga- tives, and glysters, and a good deal of liquid nourishment, were given. The patient never had one instant of sound sleep, but, was always restless, though anodynes were exliibited. There was ABDOMEN. 11 no appearance of fever, and the pulse was always natural, till the last day of the patient's life, when it became in- termittent. Theintestines were found, after death, very much distended, the gall bladder quite empty, and a large quantity of bile extravasated in the ab- domen. Sabatier met with an opportunity of observingthe symptoms of an extravasa- tion of bile, in consequence of a wound of the gallbladder. The patient's ab- domen swelled very quickly ; his respi- ration became difficult, and, he soon afterwards complained of tension and pain in the right hypochondrium. His pulse was small, frequent, and con- tracted ; his extremities were cold, and his countenance very pale. The bleed- ings, which were practised the first day, gave him a little relief; but, the tension of the abdomen, and the diffi- culty of breathing, still continued. A third bleeding threw the patient into the lowest state of weakness, and he vomited up a greenish matter. On the third day, the belly was observed to be more prominent, and there was no doubt of an extravasation. M. Sabatier intro- duced a trocar, and gave vent to a green- blackish fluid, which had no smell, and was pure bile, which had escaped from a wound of the gall bladder. After the operation, the patient grew weaker and weaker, and died in a few hours. On opening the body, a large quantity of yellow bile was found between the pe- ritoneum and intestines; but, it had not insinuated itself among the convol- utions of the viscera. A thick gluten connected* the bowels together, and they were prodigiously distended. The gall bladder was shrivelled and almost empty. Towards its fundus, ther* was a wound, about a line and a half long, corresponding to a similar wound in the peritoneum. The wound, which had occurred at the middle and lower part of the right hypochondrium, between the third and fourth false ribs, had glid- ed from behind forward, and from a- bove downward, between the cartilages of the ribs, until it reached the fundus of the gall bladder. M. Sabatier seems to think, that wounds of the gall bladder are abso- lutely mortal, and that no operation can be of any avail. (Medicine Ope-ra- toire.) 4. Urine. Urine being of a very fluid nature may, like the bile, be very easily extra- vasated in the abdomen, when the blad- der is wounded at % any part, which is connected with the peritoneum. If the urine, in this kind of case, be not drawn off with a catheter, so as to prevent this fluid issuing from the bladder, the patient soon perishes. There are many instances recorded of the bladder being injured even by gun shot wounds, which were not mortal. Such wounds, however, might only have injured the sides, or lower part of the bladder. But, in operating for the stone, above the pubis, the bladder has undoubtedly been occasionally cut at the part of the fundus, which is covered with the peri- toneum. However, as the accident was known in the first instance, the right treatment was adopted, and such pa- tients have recovered. (Sabatier Me- dicine Operatoire.) WOUNDS OF THE INTESTINES. The vomiting of blood, or discharge of it by stool, the escape of fetid air, or of intestinal matter, from the mouth of the wound ; an empty collapsed state of a portion of bowel, protruded at the opening in the skin, are the common symptoms attending a wound of this kind. When the wound is situated in the protruded portion, it is obvious to the surgeon's eye ; but, when situated deeply in the abdomen, the nature of the case cannot be known, till an extra- vasation takes place In the case of a wounded, or mortifi- ed, intestine, the surgeon may either endeavour to unite the breach of con- tinuity in the bowel by a suture, try to establish an artificial anus, or only em- ploy general means, and trust the rest to nature. Next of the circumstances which ought to determine our choice. When the wounded part of the bowel is pro- truded, the suture is to be made use of, before tiie piece of intestine is re- duced. When the wound of the bowel is within the cavity of the abdomen, a su- ture is impracticable, and except gen- eral means to avert inflammation, no- thing can be done. The true object of applying a suture to a wounded intestine, is not to pro- cure an union of the edges of the wound to each other, by making them touch at every point; nor is it designed to prevent the escape of air, and intestinal \ 12 ABDOMEN. matter, into the bag of the peritoneum. The thin moveable membranous edges of tile bowel would render such aims quite fruitless, unless such numerous stitches were employed, as would ra- ther create sloughing, than obtain an union of the wound. A breach of contin- uity in an intestine is never repaired by the growth of the opposite edges of the wound to each other. The inflam- mation, which regularly ensues, causes an adhesion of the adjacent viscera to the wounded portion of intestine, and thus the breach in it becomes closed. The only object of applying a suture to a wounded bowel is to confine the injured part closely behind the exter- nal wound, by means of the thread, in order that any extravasated matter may find its way outward, and not lodge in the abdomen. The suture, however, is only useful, for this purpose, during the first two or three days, after which the w oundc-d oowel is always securely fixed by the adhesive inflammation. ' When the wounded bowel is far in the abdomen, the surgeon seldom knows at first what has happened, and, when the nature of the case is afterwards manifested by an extravasation, it would be impossible to get at the injured part of the bowel, on account of the adhesions, which always very soon fol- low. But, even if the surgeon knew, to a certainty, in the first instance, that one of the bowels was wounded, no su- ture could be applied, without consid- erably enlarging the external wound, searching for the injured bowel, and drawing it out of the cavity of the ab- domen. In this way a wound, which might previously have been curable, would very probably be rendered fatal. When the extravasation, a few days after the accident, shows the nature of the case, a suture can be of no use whatever, as the adhesive inflamma- tion has already fixed the part in its situation, and the space, in wliich the extravasation lies, is completely sepa- rated from the general cavity of the abdomen, by the surrounding adhe- sions. When the bowel is not protruded, and the opening in it is situated closely behind the wound in the peritoneum, a suture is not requisite, for the contents of the gut not passing onward, will be discharged from the outer w ound, and not be diffused among the viscera, if care be taken to keep the external wound open. There is no danger of the wounded bowel changing it:-, situa- tion, and becoming distant from the wound in the peritoneum, for the situ- ation which it now occupies, is it* nati ural one. Nothing, but violent motions, or exertions, could cause so unfavour- able an occurrence, and, these should always be avoided. The adhesions, which take place in the course of" a day or two, at length render it impossible for the bowel to shift its situation. But, when the wounded part of the intestinal canal is protruded, no en- largement of the outer Wound is requi- site to be able to apply a suture, nor is there the least doubt concerning the nature of the case. The object of this suture, is, as has been already describ- ed, to prevent the. wound of the bowel from becoming very distant from the external wound, after the part has been put back into the abdomen-, and thus to diminish the chance of an extrava- sation among the viscera. The wound of the bowel, in this kind of case, is to be sewed up, the part reduced, and the ends of the ligatures left hanging out of the external wound, and, by their means, the injured intestine is to be confined near the aperture in the pe- ritoneum. When the whole intestine is not near- ly cut through, a single stitch is usual- ly sufficient, and this can create but little irritation. A fine round needle, threaded w ith silk, is the most proper for the purpose. Sometimes, only one end of the di- vided gut protrudes at the wound, and, the other lies concealed in the cavity of the abdomen. If the hidden con- tinuation of" the intestinal canal, cannot be found without enlarging the wound, it may be questioned, whether the ur- gency of the case does not justify this practice. If the upper end should happen to be the one concealed in the abdomen, almost certain death must re- sult from its continuance there; if it be the lower one, and no attempt be made to find it, the patient can only survive with the loathsome affliction of an artificial anus. When the protruded intestine is mor- tified, which must be a very rare oc- currence in cases of wounds, the sur- geon's conduct should be the same as in a mortified enterocele. (See Her- nia.) With regard to the constitutional treatment, in wounds of the intestines, the principal indication is to prevent a dangerous decree of inflammation. A B D A BS 13 Hence the antiphlogistic treatment is highly indispensable. Let not the sur- geon be deterred from putting it in ex- ecution by the apparent debility of the patient, his small concentrated pulse, and the coldness of his extremities, symptoms, cdmmon in acute inflamma- tion of the bowels, and, in fact, them- selves indicating the propriety of re- peated venesection. Wounds of the small intestines are attended with more vehement inflammation, than those of the large ones. All flatulent, stimula- ting, and solid food, is to be prohibited. The bowels are to be daily emptied with glysters, by which means, no mat- ter will be allowed to accumulate in the intestinal canal, so as to create ir- ritation and distention. , When excementitious matter is dis.* charged from the outer wound, it is highly necessary to clean and dress it very frequently, Gentle pressure should also be made, with the fingers, at the circumference of the wound, at each time of applying the dressings, for the purpose of* promoting the escape of any extravasated matter. For the same reason, the patient should always lie, if convenient, in a posture that will ren- der the external opening a depending one. The threads of the suture may be safely removed on the fifth, or sixth day, as the adhesions render them useless, and they must be regarded in the light of irritating, extraneous substances. After this period, the surgeon need not be afraid to let the outer wound heal up; for the adhesive inflammation, all around the course of the wound, will now prevent any extravasated matter r'rom being diffused among the viscera. If the case should end well, the intes- tine generally undergoes a diminution in its diameter at the place where the wound was situated. When this con- traction is inconsiderable, the patient occasionally experiences colic pains at the part, especially after eating such food, as tends to produce flatulence. \s these pains usually go entirely off after a certain time, and no inconveni- ence whatsoever remains, the intestine may possibly regain its wonted capa- city again. A more considerable con- striction of the above sort has been known to have occasioned a fatal mis- erere. Even the intestine itself has been known to burst in this situation, after its contents had accumulated be- hind the contracted part. Patients, who have recovered from the wounds of the intestines, should ever afterwards be particularly careful not to swallow any hard substances, or indigestible, flatulent food. In some instances, intestinal matter continues to be discharged from the outer wound, either in part, or entire- ly, so that either a fistula, or an artifi- cial anus is the consequence. A fistula is more apt to follow, when an intes- tine has been injured by a ball, has been quite cut through, or has mortified. But, numerous cases have evinced, that this is not invariably the conse- quence, and that a perfect cure has frequently followed each of these oc- currences. When an intestine is completely cut through, or when its whole calibre has mortified, and the lower portion of the canal lies inaccessibly concealed in (the abdomen, there is a necessity for pro- moting the formation of an artificial anus. For this purpose, the extremi- ty of the intestine is to be attached, with a fine suture, to the edges of the outer wound. To distinguish the up- per end of the intestine from the lower one, some recommend giving the pa- tient some milk to drink, and to wait a little, to see whether the fluid issues from the mouth of the gut. In the mean while, they content themselves with applying fomentation. If the up- per end of the intestines should be in the abdomen, it certainly seems justifi- able, when the accident is quite recent, to dilate the outer wound sufficiently to see, whether the part is near enough to be got at. If the surgeon should succeed in this object, the two ends of the bowel ought to be sewed together, as above directed. In gun-shot wounds of the abdomen, the treatment is limited to the employ- ment of general means. Consult Rich- ter's Anfangsgr. Encyclopedic M6tha- dique, and /. Bell on Wounds. [We cannot account for the omission of a reference to Mr. Hunter's invalua- ble work on this subject.] ABSCESS. This term signifies a tu- mour containing pus. Authors differ about the original derivation of the word. The most common opinion is, that it comes from the Latin abscedo, to depart, because parts, which were be- fore contiguous, become separated, or depart from each other. Abscesses are divided into two prin- cipal kinds, viz. acuian jij. Rad. Valer. s. p. j Summit. Arnicae. J Tart. Emet. gr. xviij. fiant pilulse gran, quinque. Six to be taken thrice a day for several weeks. The pills are here directed to be made larger, than Schmucker and Richter order, that die number in one dose may be diminished. Te prescribe 15 pills tliree times a day would seem absurd to the generality of patients in this coun- try. 20 AMAUROSIS. The following are the usual effects. The patient, after having vomited co- piously, experiences a general calm, and an easiness not felt before. Some- times, he begins to distinguish the out- lines of objects the very day, on wliich he takes the emetic ; at other times, he does not reap tliis benefit till the fifth, seventh, or tenth day; and, in some instances, not before some weeks have elapsed, after the exhibition of the emetic, and the uninterrupted use of the resolvent powders and pills. When the patient begins to recover his sight, the dilated state of the pupil di- minishes ; the iris contracts more on being exposed to the vivid light of a candle; and, in proportion as the pow- er of seeing- things increases, the con- tractions and moveableness of the pu- pil augments. On the whole, the cure is very seldom completed in less than a month, during which time the employ- ment of such remedies, as are calcula- ted to revive the languid action of the nerves of the eye, must? not be ne- glected. When the above plan has rectified the state of the stomach, and partly ef- fected the restoration of the sight, such remedies must be employed, as strengthen the digestive organs, and excite the vigour of the nervous sys- tem in general, and of the nerves 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 the morning, another in the evening, in any conven- ient vehicle, for, at least, five, or six weeks. During this time, the patient's nourishment must consist of tender succulent meat, and wholesome broths, with a moderate quantity of wine, and proper exercise in a salubrious air. To excite the action of the nerves of the eye, the vapour of the aqua ammonix purae, properly directed against the eye, is of the greatest service. This remedy is applied by holding a small vessel, containing it, sufficiently near the eye to make this organ feel a smart- ing, occasioned by the very penetrat- ing vapours, with which it is envelop- ed, and which cause a copious secre- tion of tears, and a redness, in less than half an hour after the beginning of the applications. It is now proper to stop, and repeat the application, three or fodr hours afterwards. The plan must be thus followed up till tbd incomplete amaurosis is quite cured. The ammoniacal vapours should be used as soon as the stomach has been freed from all irritating matter, and they should not be discontinued, till long after the eye has been cured. The operation of these vapours may be aided by other external stimulants, applied to such other parts of the body, as have a great deal of sympathy with the eyes. Of tliis kind, are blisters to the nape of the neck; friction on the eyebrow with the anodyne liquor ; the irritation of the nerves of the nostrils by sternutative powders, like that com- posed of two grains of turbith mineral, and a scruple of powdered betony leaves ; and lastly, a stream of" electri- city. The latter has been proposed, as one of the principal means of curing amaurosis ; but, experience has shown, that electricity only merits confidence, as a secondary remedy, and Mr. Hey, one of its most zealous advocates, con- fesses, that it only succeeds in cases of recent amaurosis, and, usually, not in these, unless it be combined with proper internal medicines, among which resolvents are the chief. (Med. Obs. and Inq. Vol. 5. p. 26.) Many might suppose bark to be a specific for the imperfect periodical amaurosis. This, however, is not the case. Bark, which is efficacious in in- termittent fevers, and otiier periodical diseases, far from curing the periodi- cal amaurosis, seems to exasperate it, rendering its return more frequent, and of longer duration, than before. On the other hand, this disease is most commonly cured, in a very short time, by exhibiting first emetics, then inter- nal resolvents, and, lastly, corrobor- ants, even bark, which was before useless and hurtful. The above plan of curing the recent imperfect amaurosis succeeds in the majority of cases, when the disease is only sympathetic, or dependent on the morbid state of the gastric system.- Hut, there are cases, in the formation ol which many other causes operate, .t68. I* U* most frequent one already^ m^S These1dem*»jus, dull, and *4, the ey#). Hippocrates means by tliis word, in his Aph. 31. Sect. 3. the dimness of sight, to wliich old people are subject. Paulas, Actuarius, and the 4>est modern writers, seem to think, that amblyopia means the same tiling as the incomplete amaurosis. (Encyclopedic Mcthodique ; Partie Chi- rim>gicak.). AMPUTATION, (from- amputo, to cut oft") This term signifies the oper- 24 AMPUTATION. ation of cutting off a limb, or other part of the body, as the breast, pen- is, &c. Such an operation frequently be- comes indispensably proper on the principle of sacrificing a branch, as it were, for the sake of taking the only rational chance of saving the trunk it- self. The amputation of the large limbs, was practised anciently under many disadvantages. The ignorance of the old surgeons, in regard to the method of stopping hemorrhage, made many patients die, who had had courage to submit to the operation. These prac- titioners were unacquainted with the mode of healing the wound by the first intention ; and their instruments were as awkward and clumsy, as their dres- sings were irritating and improper. The best modern practitioners have materially simplified all operations.— This object has been greatly promot- ed, by diminishing the number, and improving the construction, of instru- ments, and by abandoning the use of a multitude of external applications, most of which were useless, or hurtful. But, much improved as amputation has been, no one can dissemble, that it is an operation at once terrible to bear, dreadful to behold, dangerous in its consequences, and leaves the pa- tient for ever afterwards in a mutilated state. Hence, it is the surgeon's duty never to have recourse to so severe a proceeding, without a perfect and w ell- grounded conviction of the necessity for so doing. Though we seldom see the opera- tion adroitly executed, its performance is by no means difficult, and the rea- son of the knife being so badly handled in this part of surgery, may generally be imputed to carelessness, slovenly habits, and fear and confusion on the part of the operator. There are sev- eral egregious faults in the method of amputating, whicii even many hospital sunups in this metropolis are guilty of ;*mjT, these we shall find, when we criticise them, are, for the most part, very avoidable, widiout any particular share of unusual dexterity. The real difficulty is to ascertain with precision the cases whicii demand the operation; those in which it may be dispensed with, and to know the exact periods at which it should be practised. These are considerations requiring the most profound attention, and the brightest talents. For such reasons we y\r.M first take a view of the circumstances under which the best modern surgeons deem amputation necessary. Howev- er, it may be proper to observe, that in each of the articles, relative to the particular diseases and injuries which ever render amputation indispensable, additional information will be offered. 1. Compound Fractures. In a compound fracture the necessi- ty for amputation is not always pro- portioned to the seriousness of the ac- cident, but, also, frequently depends on other circumstances. For example, in the field, and on board of ship, it is not always in the surgeon's power to pay such assiduous attention as the cases demand, nor to procure for tho patient the proper degree of rest and stillness. In the field there is frequent- ly a necessity for transporting the wounded from one place to another.— In these circumstances it is proper to have immediate recourse to amputa- tion, in all recent cases of bad com- pound fractures, the appearances of which are such as necessarily excite apprehension of the consequences.— Doubtless, there are many cases, in wliich it would not be proper to adopt this practice, even under the most un- favourable 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, and in whicii there is only one bone broken, amputation would be unnecessary and cruel. But, when the limb has been considerably injur- ed, and the bones have been so brok- en that they cannot be kept in a prop- er position, after being reduced, we may make it a general rule to ampu- tate, under the circumstances above alluded to. The bad air in hospitals and large cities, whi#h is always so detrimental to wounds, is another consideration wliich may render amputation advisca- ble. But, if in camps, on board of ships, in large cities and hospitals, it is pru- dj. nt £«• the surgeon to conform to the above rule, it is not so in other situa- tions. When the patient can be put in a commodious place, whence it will not \MPUTATION. 25 be necessary to remove him ; when he can be left perfectly quiet, with good air and the aid of skilful surgeons; there are not many cases in which pa- tients, enjoying all these advantages, must of necessity submit to amputa- tion. However, if the bones, muscles, and other soft parts, should be so bruised and mangled, that there is no hope of" the limb ever being able to per- form its functions again, we should not hesitate about performing amputation. An injury, wliich would, by its inevit- able consequences, put the patient's life into the most imminent peril, may often be converted by amputation into one of the most simple nature, and easy of cure. (Encyclopedic Methotlique, Par- tic Cliivirsicale.) Jn compound fractures there are three points of time in which amputa- tion may become proper. The first of these is immediately, or as soon as may b;-, 'after the receipt of the injury. The second is, when the bones continue for a great length of time without any disposition 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 part of the limb, quite down to the bone, that upon the sep- aration 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 waggon, or loaded cart, or by the fall of a very ponderous bod) on it, or by a cannon 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 parts, that there shall be good reason to fear that there will not be vessels suflicient to carry on the circulation with the parts below the fracture, it becomes a matter of the most serious consideration, 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, therefore, must be# immediately after the accident. When inflammation, irritation, and ten- sion have taken pl.icc, nnd when the voi . -i. 1 air, admitted freely into the cellular membrane, has begun to exert its per- nicious influence, it is too late; an ope- ration, then, instead of being beneficial, would prove destructive. The necessity of immediate or very early decision, in this case, makes thi9 a very delicate part of practice ; for, however pressing the case may seem to the surgeon, it will not, in general appear in the same light to the patient, to the relations, or to bye-standers: They will be inclined to regard the proposition as arising from ignorance, or an inclination to save trouble, or a desire to operate ; and it will often re- quire more firmness on the part of the practitioner, and more resignation and conlidence on the part of the patient, than is generally met with, to submit to such a severe operation, in such a seeming hurry, and upon so little ap- parent deliberation; and yet it often happens, that the suffering this point of time to pass, decides the patient's fate. The necessity of early decision arises from the quick, tendency to mor- tification, which ensues in the injured limb, and too often ends in the patient's death. That this is no exaggeration, melancholy and frequent experience evinces, even in those whose constitu- tions previous to the accident, were in good order; but much more in those who have been heated by violent exer- cise, or labour, or liquor, or who have led very debauched and intemperate lives, or who have habits naturally in- flammable 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 determination for or against amputation, is really a determination for or against the pa- tient's existence. That it would have been possible to have saved some limbs wliich have been cut oft", no man will pretend to Say ; but, this does not render the practice injudicious. 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, w hich, from the same circumstances, would otherwise most probably have been lost" Pressing and urgent as the state of a compound fracture imv be, at thi^ fir,-- 26 AMPUTATION. 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 operation must be submit- ted to, or the patient must die. The most unpromising appearances at first, do not necessarily, or constant- ly end unfortunately. Sometimes, af- ter the most threatening first symp- toms, after considerable length of time, great discharges of matter, and large exfoliations of bone, success shall ulti- mately be obtained, and the patient shall recover bis health and the use of his limb. But sometimes, after the most judici- ous treatment through every stage of the disease; after the united efforts of physic and surgery, the sore, instead of granulating kindly, and contracting daily to a smaller size, shall remain as large as at first, with a 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 exfoli- ate, or to unite/ will remain as perfect- ly loose and disunited as at first, while the patient shall lose his sleep, his ap- petite, and his strength ; a hectic fe- ver, with a quick, small, hard pulse, profuse sweats, and colliquative purg- ing, contributing at the same time to bring him to the brink of the grave, notwithstanding ever) kind of assis- tance, in these circumstances, if ampu- tation be not performed, what else can rescue the patient from destruction .' The third and last period is a matter whicii docs not require much conside- ration. Too often the inflammation consequent upon the injury, instead of producing abscess and suppuration, tends to gangrene and mortification, the progress of which is often so rapid, as to destroy the patient in a very short space of time, constituting that very sort of case, in which amputation should 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 separation of the mor- tified parts, is left quite bare, and a circulation between the parts above and those below, is by this totally cut off. In this instance, whether the sur- geon saw through the bare bone, or leave the separation to be effected by nature, the patient must lose his limb. (See Pott on Amputation.) There is yet another circumstance which may render amputation necessa- ry, in cases of compound fractures, and this is, when such copious hemor- rhages occur, as cannot be stopped by any otiier means. These bleedings pro- ceed from arteries which have been lacerated by the ends of the broken bone, or some other cause, at the mo- ment of the accident. (Encyclopedic Methodique ; Purtic Chirurgicale.) 2. Extensive conHused and lacerated Wounds. These form the second class of general cases requiring amputation. Wounds without fracture, are not often so bad as to require this operat^n. When a limb, however, has been con- tused and lacerated, in such a degree, that all its principal blood vessels are injured, and there is no hope of a con- tinuance of the circulation, the imme- diate removal of the member should be recommended, whether the bones be injured or not. Also, since no ef- fort 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 undertaken the better. In these cases, as in those of com- pound fractures, though amputation may not be necessary at first, it may be- come so afterwards. The foregoing observations, relative to the second pe- riod of compound fractures, are equal- ly applicable to wounds, unattended with injury of the bones. Sometimes hemorrhages occur, which we cannot restrain ; or a rapid mortification comes on ; or such a copious suppuration, as the system cannot bear any longer. (Encyclopedic Methodique ; Par Ik Chi rurgicak.) 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 end of the stump from which the part has been separated, should be re- moved with a cutting instrument. This is an instance in which many surgeons dispute the necessity of am- putation. They urge as a reason, that tne limb being already removed, it is AMPUTATION. 27 better to endeavour to cure the wound as speedily as possible, than to increase the patient's sufferings and danger, by making him submit to amputation. It must be remembered, however, that the bones are generally shattered, and re- 'duced into numerous fragments; the muscles and tendons are unequally di- vided, and their ends torn and contus- ed. All allow it is absolutely necessa- ry to extract the splinters of bone, and cut away the irregular extremities of the tendons and muscles, whicii ope- rations would require a longer time than amputation itself. Besides, we should recollect, that by making the incision above the injured 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 accomplished in one third of the time which would otherwise be requisite. A much firmer cicatrix is also thus ob- tained. Such reflections must convince us, that amputation here holds forth very great advantages. It cannot in- crease the patient's danger, and, as for the momentary augmentation of pain which he suffers, he is amply compen- sated by all the benefits resulting from the operation. ( Encyclopedic Methodi- que ; Partie Chirurgicak.) See Gun- shot Wounds. 4. Mortification. Mortification is another cause, which, when advanced to a certain degree, renders amputation indispensably pro- per. We have noticed that bad com- pound fractures, and wounds, often ter- minate in the death of the injured limb. Such surgeons as, at all events, have been determined to oppose the per- formance of amputation, have pretend- ed that this operation is totally useless in the present instance. They assert, that when the mortification is only in a slight degree, it may be cured, and that when it has advanced to a consid- erable extent, the patient will persish, whether amputation be performed or not. But this way of viewing things is so contrary to facts, and the experi- ence of every impartial practitioner, that we shall make no attempt to refute the assertions. Though we allow that it would be very bad practice, every lime the slightest appearance of gan- grene occurred; yet, when the mischief has increased in such a degree, that all, or the greater portion of the soft parts are gangrenous, as is too frequently the case, there exists no remedy for this state ; or, at least, none with which we are acquainted, and amputation is ab- solutely necessary. Practitioners have entertained very opposite opinions, concerning the pe- riod 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 amputate immediately after the mortification has decidedly begun to form, and while the mischief is in a spreading state. Others believe, that the operation should ne- ver be undertaken, before the progress of the disorder has stopped, even not till the dead parts have begun to sepa- rate from the living ones. The advocates for speedy perform- ance of amputation, declare that the further progress of the mortification may be stopped, and the life of the pa- tient preserved, by cutting above the parts affected. Experience, however, has shown such practice to be highly dangerous, and not deserving of confi- dence. Whatever pains may be taken in the operation, only to divide sound parts, there is no certainty of succeed- ing in 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 which it covers, and the parts immediately surrounding the bone, may actually- be in a gangrenous state. But, even when the soft parts are found free from apparent distemper, on making the incision, still, if the operator should not have waited till the mortification had ceased to spread, the stump will almost always be attacked by gangrene. Sur- geons, who have had opportunities of frequently seeing wounds which have a tendency to mortify, entertain the lat- ter opinion. Such was the sentiment of Pott, who says, that he has often seen the experiment made, of amputa- ting a limb in which gangrene had begun to show itself, but never saw it succeed, and it invariably hastened the patient's death. The operation may be postponed, however too long. Mr. Samuel Sharp, in particular, recommended too much delay, advising the operation never to be done till the natural separation of the mortified parts had considerably ad- vanced. Mr. Sharp was a surgeon of 28 A.MPL'l immense experience, and his authority carries with it the greatest weight. But, perhaps, he was too zealous in his opposition to the practice, the peril of which he had so often beheld. When the mortification has ceased spreading, there is no occasion for further delay. We now obtain, just as certainly, all the benefits of the operation, and get rid of a mass of putridity, the pres- ence of which may become highly per- nicious, should the absorbents take up any of the matter into the circulation. However, this danger would not be so considerable as that which would arise from too precipitate an operation ; and, it is better to defer amputation a little more than is absolutely requisite, than to run any risk of doing it, before be- ing certain that the parts have lost their tendency to gangrene. AVhatever may be the particular cause of the mortification, it makes no alteration in the above doctrines ; the practice should always be the same. Though it has been thought that a dis- tinction should be made, between cases in which mortification is the effect of an internal cause, and those in which it is the consequence of an external one; yet, no practical advantage can be deduced from this discrimination. In no cases ought the operation to be performed before the period above specified, and in all it may be under- taken, as soon as there is a positive cessation in the progress of the disor- der. (Encyclopedic Methodique ; Par- tie Chirurgicak.) See Mortification. 5 White-Swellings. Scrophulous joints, with diseased bones, and distempered ligaments, is another case, in which amputation may become absolutely necessary. There is one circumstance attending this com- plaint which often renders it particu- larly unpleasant, which is, that the subjects are most frequently young children, so as to be incapable of de- termining for themselves, which inflicts a very distressing task on their nearest relations. All the efforts of physic and surgery often prove absolutely ineffec- tual, not only to cure, but even to re- tard this most terrible malady. Not- withstanding 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 ATIOV texture of the heads of the bones, form- ing the large articulations, such as the hip, knee, ankle, and elbow ; the bones become diseased in a manner, which we shall explain in the article (Articu- lation,) sometimes with great pain and symptomatic fever; sometimes with* very little of cither, at least in the be- ginning. The cartilages covering the ends of these bones, and designed for the mobility of the joints, are totally destroyed ;"the epiphyses in young sub- jects are either partially, or totally, separated from the said bones; the hg- nments of the 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 syn- ovia, become distempered in like man- ner ; all these together furnish a large quantity of stinking saiuous matter, which is discharged either through ar- tificial openings, made for the purpose, or through small ulcerated ones. These openings commonly lead to bones which arc diseased through their whole tex- ture. When the disease has got into tliis state, the constant pain, irritation, and discharge, bring on hectic symp- toms of the most destructive kind, such as total loss of appetite, rest, and strength, profuse night sweats, and as profuse purgings, which foil all the ef- forts of medicine, and bring the patient to the brink of destruction. It is an incontestible truth, that un- less amputation be performed, a patient thus situated must perish; and it is equally true, that numbers, in the same circumstances, have, by submitting to the operation, recovered vigorous health. (See Pott on Amputation.) It is a fact highly important to be known, that, in these cases, amputa- tion is attended with more success, when performed late, than when un- dertaken at an early period, before the disease has made great advances. This is particularly fortunate, as it affords time for employing such remedies as are at all likely to check the progress of the disorder. (Encyclopedic Metho- dique.) See Articulation—White-swell- 6. Exostoses. We shall here content ourselves with merely mentioning, '.ha': this disease AMPl" may render amputation necessary, when it is impracticable to remove flic bony swelling in the manner we shall explain in the article Exostosis, and the tumour becomes hurtful to the health, or insup- portable, on account of its weight, or other circumstances. 7. Caries and Necrosis. Another distemper, productive of the necessity of amputation, is a caries of a whole bone or bones, forming a limb. A caries is here meant, notmere- ly possessing the surface of such bones, but the whole internal substance, and that from end to end. Bones be- come carious from a variety of causes, such as struma, lues venerea, deep-seat- ed abscesses, pressure, &c. and such carious bones, properly treated, often exfoliate and cast oft' their dead parts. But, when the whole substance of the bone becomes diseased, from end to end, no means will avail. The use of the scalper, the raspatory, and the ru- gine, for the removal of the diseased surface of bones ; of the trephine, for perforating into the internal texture of carious bones, and of exfoliating ap- plications, will not succeed, and, unless the whole bone be removed by amputa- tion, the patient will die. Mr. Pott's refutation of M. Bilguer, who asserts that amputation is not requisite in these instances, is a masterly and most con- vincing production. Admitting, that internal and exter- nal remedies may so alter and correct even the carious part of" a bone, as to render it capable of parting with the rest, and becoming sound, yet, occa- sionally there is not time for such ex- periments, and even in very young sub- jects, the whole habit is, by the rotten bone so poisoned and spoiled, that the worst kind of hectic fever will ensue, in spite of bark and every other specific, in spite of drying, burning, rasping, and boring, and, in a very short space of time, destroy the patient, unless rc- stored-by amputation. (See Caries and A'ecrosis.) (Pott on Amputation.) 3- Cancerous and other inveterate Dis- eases, such as the Fungus Hamatodes. Cancerous, inveterate diseases, and ulcer>, on liniLs, s-ometimes render am- putation a matter of necessity. In t) ::>t.ng of c:.uccr, we shall remark, CATION. 29 that little or no confidence should be placed either in internal or any kind of topical remedies, and that there is no- thing, except the total separation of the part affected, upon which any ra- tional hopes of cure can be built. Can- cer is not frequently seen in the extrem- ities. Every man of experience, how- ever, must occasionally have seen, in this situation, if not actually cancer, diseases quite as intractable, and which cannot be cured except by removing the affected part. This may often be accomplished without cutting off the whole limb. But, when the disease has spread beyond certain bounds, am- putation, above the part affected, is the only thing to which recourse can be had with any hope of success. Some- times even amputation itself cannot ef- fect a cure, when the operation has been delayed too long. It has succeed- ed, however, when the disease has re- appeared, after a ciu-e had been seem- ingly achieved by the excision of tlie diseased parts. Besides cancerous, there are other ulcers, which may render amputation indispensable. Thus, when an exten- sive ulcer, of any sort whatsoever, is evidently impairing the health ; when, instead of yielding to remedies, it be- comes larger and more inveterate ; when, hi short, it puts life in imminent danger; amputation should be adrised. For further infoi mation refer to Cancer, Fungus Hamatodes, &c. 9. Various Tumours. That there are numerous swellings, which destroy the texture of the limbs render such members useless, afflict the patient with dreadful sufferings, and bring him into the most debilitated state, no man of observation can fail to have seen. When such tumours can neither be discussed, nor cut out with safety, amputation of the limb is the only resource. Mr. Pott has particularly described a tumour affecting the leg, for whicii the operation is sometimes requisite. It has its seat in the middle of the calf of the leg, or rather more towards its upper part, under the gastrocnemius and soleus muscles. Ic begins by a small, hard, deep seated swelling, sometimes very painful, sometimes but little so, andoniy hindering the patient's e\pici.ses. It docs not alter the natur- 30 AMPUTATION. al 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 incompressibly 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, and through a strangely distem- pered mass. This fluid is generally small in quantity, and consists of a sanies mixed with grumous blood ; the discharge of it produces very little diminution of the tumour, and very high symptoms of irritation and inflam- mation come on, and advancing with great rapidity, and most exquisite pain, very soon destroy the patient, either by the fever, wliich is high, and unre- mitting; or by a mortification of the whole leg. If amputation has not been performed, and the patient dies, after the tumour has been freely opened, the mortified and putrid state of the parts prevents all satisfactoiy examination ; but, if the limb was removed, without any previous operation, and (which Mr. Pott, in his experience, found to be the only way of preserving the pa- tient's life) the posterior tibial artery, will be found to be enlarged, distem- pered, and burst; the muscles of the calf to have been converted into a strangely morbid mass ; and the poste- rior part of both the tibia and fibula more or less carious. (Pott on Ampu- tation.) It seems only necessary to adduce another species of tumour to illustrate the necessity of amputation. The fol- lowing case is related by Mr. Aberne- thy. A woman was admitted into St. Bartholomew's Hospital with a hard tumour in the ham. It was about four inches in length, and tliree in breadth. She had also a tumour in front of the thigh, a little above the patella, of les- ser size and hardness. The tumour in the ham, by its pressure on the nerves and vessels, had greatly benumbed the sensibility, and obstructed the circu- lation of the leg, so that it was very odematous. As it appeared impossible to remove this tumour, and as its ori- gins and connexions were unknown, amputation was resolved on. On ex- amining the amputated limb, the tu- mour in the ham could only be divided with a saw. S-.veral 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 de- posited. The remainder of the tumour was macerated, and dried, and it ap- peared to be formed of* an irregular and compact deposition of the earth of bone. The tumour on the front of the thigh, was of the same nature as that of the ham, but containing 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 gener- ally arises from the disease of a bone. (Surgical Observations. 1804.) Before the late facts and improve- ments, relative to the treatment of an- eurisms, these cases, on the cxtremi- ties, were generally setdown as requir- ing amputation. Even Mr. Pott wrote in recommendation of such practice, and his observations on this subject are among the few parts of his writings, which the enlargement of" surgical knowledge, since his time, has ren- dered objectionable. We shall conclude these remarks on the causes requiring amputation, with advising surgeons never to undertake this serious operation, without consult- ing the opinions of" other professional men, when their advice can be ob- tained. General Remarks on Amputation. Before the invention of the tourniquet, the operation was attended with so much danger, that very few surgeons ventured to undertake it, and even since the above instrument became known, a long time elapsed before one half of the patients were saved on whom amputation had been executed. At present, perhaps, not more than one individual out of twenty loses his life after the operation, even taking into the account all those on whom it is prac- tised in hospitals. In private practice, where one can pay greater attention to various important circumstances, whicii relate to amputation, the proportion of deaths must be still less. The different parts of the operation, which deserve particular attention, are, the choice of the place where to am- putate; the measures for guarding against bleeding during the operation ; the division of the integuments, mus- cles, and bones, which is to be ac- AMPUTATION. 31 complished in such a manner, as to be able afterwards to cover the whole sur- face of the stump with skin ; tying the arteries, which should be done without including the nerves, or any other ad- jacent part ; placing the integuments in a proper position after the operation ; and, finally, the subsequent treatment of the wound. The ancients contented themselves, before making the incision, to have the skin forcibly drawn upward by an as- sistant; they next divided, by one sweep of the knife, the integuments and flesh down to the bone, and, after- wards sawed the bone on a level with the soft parts, which were drawn up- ward. It appears, however, that the views of Celsus extended further than those of most of his cotemporaries, and follow- ers, even almost down to modern times. After cutting the muscles down to the bone, he 6ays, that the flesh should be reflected, and detached underneath with a scalpel, in order to denude a portion of the bone, he says, which is then to be sawn as near as possible to the healthy flesh, which remains ad- herent. He states that, when this plan is pursued, the skin around the wound will be so loose, that it can almost be made to cover the extremity of the bone. It is to be lamented, that this advice, inculcated by Celsus, should not have been comprehended, or that it should have been so neglected, as to stand in need, as it were, of a new dis- coverer, and that a suggestion of such importance should have remained so long useless. But, the fact is, hemor- rhage formerly rendered amputation so dangerous, that the ancient surgeons could not devote much attention to any thing else in the operation, and the practitioners amputated so seldom, that we read in Albucasis, that he positive- ly refused to cut off a person's hand, lest a fatal hemorrhage should ensue, and the patient did it himself, and re- covered. Cheselden is regarded as the sur- geon, who revived Celsus's method, in proposing to divide the soft parts by a double incision, that is by cutting the skin and cellular substances first, and then, by dividing the muscles, down to the bone, on a level with the edge of the skin. In this manner the bone - sing how useless and inconvenient it was to apply a circular band round the limb, with a view of directing the track of the knife, and giving- steadiness to the parts, as was commonly done, be- fore his publication issued from the press. As soon as the tourniquet is applied, let an assistant grasp the limb circular- ly with both his hands, and firmly draw the skin and muscles upward. The operator must then fix his eye up- on the proper part, where he is to be- gin his operation, and he will now make ,the circular incision through the skin, and adipose membrane, with con- siderable facility and dispatch, as the knife will pass much quicker, in conse- quence of the tense s.-i:'.re, about three or four fingers'breadth higher,' than is usually done, by the com- mon perpendicular circular incision. Now draw the knife, towards you, then its point rests upon the bone, and keep- ing the edge in the same oblique line, already pointed out by the former inci- sion, the rest of the muscles are to be divided 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 divi- sion. The speedy execution of the above directed incision, will be much expe- dited, by one assistant continuing a firm and steady elevation of the 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. Many practitioners next proceed to deprive the bone of its pe- riosteum to a considerable extent, above and below the part, where the saw is to pass, and tliis they do so minutely, as to consume a considerable time in us execution. This step not only creates unnecessary delay, but, as the periosteum serves to support the ves- sels in their passage to the bone, is al- AMPUTATION 33 m apt to produce exfoliations, above the part where the bone is to be divided with the saw. Instead of this practice, first apply the retractor, as advised by "wooch and Bromfield, then denude the bone at the part, where you intend < he saw to pass, and you will noW saw it off higher than is usually practised, which, is a material object in prevent- ing a projection of the bone, and form- ing a small cicatrix. A stump, formed in the thigh, agree- ably to the foregoing plan, if you bring the parts gently forward after the ope- ration, and then view the surface of the wound, may be said to resemble, in some degree, a conical cavity, the apex of wliich is the extremity of the bone ; and the parts thus divided, are obviously the best calculated to pre- vent a sugar-loaf stump. The part, where the bone is to be laid bare, whether two, three, or four fingers' breadth higher than the edge of the retracted integuments; or, in other words, the quantity of muscular substance to be taken out, in making tiie double incision, must be regulated by considering the 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 substance taken out, must be in such an exact proportion to each other, as that by a removal of both, the whole surface of the wound will afterwards be easily co- vered, and the limb not more short- ened, than is necessary to obtain this end. After the removal of the limb, let each bleeding artery be gently drawn out with the tenaculum, and tied with a common slender ligature, as naked as possible. When the large vessels are tied, the tourniquet should imme- diately be slackened, and the wound well cleaned, to detect any vessel, that might otherwise lie concealed with its orifice blocked up by coagulated blood; and before the wound is dressed, its whole surface should be examined with the greatest accuracy, by whicii Mr. Alanson has frequently observed a pul- sation, where no hemorrhage previous- ly appeared and turned out a small clot of blood from within the orifice of a considerable artery. Particular atten- tion, is well bestowed in making every vessel secure, that is likely to bleed on the attack of the symptomatic fever; l'«»r besides the fatigue and pain, to vol. i. which such an accident immediate^ exposes the patient, the desired union of the wound is also considerably inter- rupted. The whole surface of the wound must always be well cleaned with a sponge and warm water, as any coagu- lated blood would be a considerable obstruction to a quick union of the parts. Let the skin and muscles be now gently brought forwards; fix the flan- nel circular roller round the body, and carry it, two or three times rather tight round the upper part of the thigh, as at this point, it is intended to form a sufficient basis, that materially adds to the support of the skin and muscles. Then carry it forwards in a circular di- rection, to the extremity of the stump, not so tight as to press rudely or forci- bly, but so as to give an easy support to the parts. You are now to place the skin and muscles over the bone, in such a direc- tion, that the wound shall appear only as a line across the face of the stump, with the angles at each side, from which points, the ligatures are to be left out, as their vicinity to either an- gle directs. The skin is easily secured in this posture by long slips of linen, or lint, about two fingers in breadth, spread with cerate, or any cooling ointment. If the skin do not easily meet, strips of sticking plaster are best. These are to be applied from below upwards, across the face of the stump, and over them a soft tow pledget and compress of linen; the whole to be retained with the many-tailed bandage, with two tails to come from below upwards to retain the dressings upon the face of the stump. Mr. Alanson thinks it very injudicious to raise the end of the stump far from the surface of the bed with pillows, as the posterior muscles become drawn upward by so doing. It is best to raise: the stump about half a hand's breadth from tiie surface of the bed, by which the muscles are put in an easy relaxed position. The many-tailed bandage is much more convenient than the woollen cap, frequently used to support the dressings, though this seems well cal- culated to answer that purpose; but, if not put on with particular care, the skin is liable to be drawn backwards from the face of the stump, nor can the wound be dressed, without first lifting up tiie. stump to remove the cap. Mi-. Hey thinks tiie place of hicision 5 34 AMPUTATION. through the muscles, the height to wTiich the skin must be retracted, and the place, where the bone must be sawn above the first incision, might all be reduced to determinate measures. A few experiments would enable you to determine precisely, in any limb of given circumference, how many inches the skin must be retracted, &c. and these might be measured by an assist- ant, if he had little bits of straw, or wood, marked for this purpose. The determination of the proper quantity of skin to be saved will be much assist- ed by reflecting that the diameter of a circle is a trifle more than one-third of its circumference; but, to call it one- third will be sufficiently exact for our purpose. Hence, if we perform the flap operation, upon a limb, the cir- cumference of which is nine inches, the flap required to cover this wound must be somewhat more than tliree in- ches long; and by the same rule, the quantity of integuments necessary to be preserved to cover a stump of given circumference in any limb operated upon without the flap, is easily deter- mined. If the limb be large, the division of the cellular and membranous attach- ment must be extended in proportion. In emaciated limbs, little more than the oblique turn of the knife to lay bare the bone sufficiently high, will be necessary for the preservation of as much skin, &c. as will cover tbe wounded surface, and, when practicable, the preference should always be given to the latter mode. Mr. Alanson used to operate with a double-edged knife, rather smaller, than a common amputation one, than which it is more handy; and being more rounded at the point, than the straight-edged knife, it completes the division of the attachments, and the oblique section of the muscles, more speedily; and, in the whole operation, it is an advantage, that either edge will cut by the slightest turn of the hand. (See Alanson's Practical Observations on Amputation). AMPUTATION OF THE THIGH, AS PRACTISED BY THE BEST MODERN SURGEONS. The thigh ought always to be ampu- tated as low as the disease will allow. The patient is to be placed on a firm Uble, with his back properly supported by pillows, and assistants, who are also to hold his hands, and keep him from moving too much during the operation. The ankle of the sound limb is to be fastened by means of a garter, to the nearest leg of the table. The next thing is the application of the tourniquet. (For a description of this instrument see Tourniquet). The pad should be placed exactly over the femoral artery, in as high a situation, as can conveniently be done. When the thigh is to be amputated very far up, it is perhaps better to let an as- sistant compress the femoral artery in the groin, by any commodious instru- ment, having a round blunt end, cal- culated for making direct pressure on the vessel, without injuring the in- teguments. Were tiie patient, how- ever, very weak, and unable to bear loss of blood, as there might, in this way, be some bleeding, by reason the anastomoses with the branches of the internal iliac artery, it would be better to employ the tourniquet, if possible. Whether the right, or left thigh is to be removed, it is customa- ry for the operator to stand on the pa- tient's right side. The great advan- tage of this situation seems to be, that the surgeon's left hand can be thus more conveniently, and quickly brought into use, than if he were always to stand on the same side, as the limb he is about to amputate. This seems to be the only assignable reason for this ha- bit ; for, when the left thigh is to be amputated, it is certainly some incon- venience to have the right limb, be- tween the operator, and the one that is to be removed. But, perhaps, this is less inconvenient than not having the left hand next the wound. An assistant, firmly grasping the thigh with both hands, is to draw up- wards the skin and muscles, while the surgeon makes a circular incision as quickly as possible through the integu- ments down to the muscles. When the thigh is bulky, the large amputat- ing knife will be found the best. Be- fore beginning this first cut, the arm is to be carried under the hmb, till the knife reaches almost round to the same side on which the operator stands.— With one sweep, penetrating to the fascia, the knife is then to be brought round to the point, where it first touch- ed the skin. Thus the wound is more regularly made, than by cutting first on one side, then the other, and the AMPUTATION. 35 patient is saved some degree of pain, m consequence of the uninterrupted quickness, with whicii the incision is made. The cellular substance, connecting I he skin, immediately above this wdund with the fascia, is next to be divided all round the limb, till as much skin can be drawn back, as will afterwards conjointly with the muscles, cut in a mode described in the foregoing ac- count of Mr. Alanson's plan, cover the end of the stump with the utmost fa- cility. The detached skin is to be turned up, in order to be out of the way, at the time of cutting the mus- cles, and sawing the bone. Here it seems useless to repeat the explana- tion of the division of the muscles as practised by Mr. Alanson, and still adhered to by the generality of sur- geons. M. Louis, a French surgeon of ex- traordinary talents, endeavoured to in- troduce into practice the plan of divid- ing the loose muscles first, and lastly those, which are 'closely connected with the bone. Tliis eminent man took notice, that the muscles of the thigh became retracted in an unequal degree, after being divided. Those which are superficial, and extended 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 through- out their whole length. The retrac- tion begins the very instant, wrhen the muscles are cut, and is not completed till a short time has elapsed. Hence, the effect should be promoted, and be as perfect as possible, before the bone is sawn. M. Louis was always desirous of letting the muscles contract as far as they could in the amputa- tion of the thigh, and, for this reason, he was rather averse to using the tourniquet, as the circular pressure of this instrument counteracted, in some measure, what he wished to take place, and hence he even advised mak- ing pressure on the artery by means of an assistant. Actuated by such principles, M. Louis practised a double incision, dif- ferent from either Cheselden's, or Al- anson's method. By the first wound, lie cut, at the same time, both the in- teguments and the loose superficial muscles ; by the Second, he divided those muscles, which are deep, and closely adlierent to the femur. On the first, deep, circular, cut being com- pleted, M. Louis used to remove a band which was placed round the limb, above the track of the knife. This was taken off, in order to allow the divided muscles to become retracted without any impediment, He next cut the deep adlierent muscles, on a level with the surfaces of those loose ones, which had been divided by 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 the painful dissection of the skin from the muscles was avoided. M. Louis was conscious, that there was more necessity for sav- ing muscles than skin ; he knew, that when an incision is made at once down to the bone, the retraction of the di- vided 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, by dissecting it from the muscles, and turning it up, quite unnecessary. The impartial reader, who takes the trouble to read the remarks on amputation, published by this greatest of the French surgeons in the Mem. de I'Acad, de Chirurg. will at once be impressed with the force and perspicuity of the matter and with the evident propriety of the practice inculcated. It gives me pleasure to remark, that many excel- lent surgeons, whom I have seen oper- ate, do not exactly follow Mr. Alan- son's plan of cutting in an qblique man- ner at once down to the bone, after the integuments have been cut, detached, and reflected; but, so far adopt the principles of M. Louis, as to divide the loose muscles first, immediately after saving the necessary quantity of skin, and, lastly, those which are intimately- attached to the bone throughout their whole extent. This is certainly a bet- ter mode of operating, than to follow precisely Mr. Alanson's directions— Candour, however, obliges me to con- fess, that the attempt to divide the loose muscles first, and then tiie more fixed ones, is very apt to make an un- skilful surgeon cut the whole, or a great part, of the same muscle through more than once ; a fault in modern practice, which, as far as my judg- ment extends, deserves reprobation, as much as any proceeding that can be in- 36 AMPUTATION stanced. To say how unnecessary it is to uiv • de a-iy muscle more than once is :.s needless as to remind tiie reader of its doubling the agony of a very se- vere operation. (First Lines of the Practice of Surgery.) Having cut all the fibres on every side, down to the bone, a piece of lin- en, somewhat broader than the diame- ter of the wound, shouK be torn at one end, along its middle part, to the ex- tent of about eight or ten inches. This is called a retractor, and is applied by placing the exposed part of" the bone in the slit, and drawing the ends of the linen upward on each side of the stump. In this manner, the retractor will obviously keep every part of the surface of the wound out of the way of the saw. I have seen tliis instrument do so much mischief", in consequence of the operator neglecting to use the retractor, that my conscience obliges me to censure such surgeons, as are in the habit of employing the saw, without defending the soft parts by tliis simple contrivance. Some have rejec- ted the use of* the retractor, because they have seen it get under the teeth of the saw, and obstruct the action of the instrument; but, tliis very circum- stance adduced against the retractor, is, when considered, the strongest one that could possibly be brought forward in its favour, as tiie surface of the wound, itself, and particularly the edg- es of the skin, would, in all probabi- lity, suffer the same fate as the linen, by getting under the teeth of the saw, if no retractor were employed, in at- tempting 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 the use of the retractor, and 1 know that many who have been with myself eyewitnes- ses of the mischief frequently done by the saw in amputations, are deeply im- pressed with an aversion to the neglect of this bandage. I have often Seen the soft parts adroitly divided, and I have in these same instances, seen the, oper- ators, directly afterwards, lose all the praise which every one was ready to bestow, by their actually sawing 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 sufferings, have now had their involuntary cries extorted from tllem by unneccssarv, unjustifiable tor- ture. But, besides defending the sur- face of the stump from the teeth of the saw, the retractor will undoubtedly enable the operator to saw the bone higher up than he otherwise could do. Another proceeding, which seems fit for reprobation, and which, indeed, Mr. Alanson very properly condemned, is the practice of scraping up the peri- osteum with the knife, as far as the muscles will allow. Nothing seems more probable thin that this may be tiie cause of the exfoliations which oc- casionally happen after amputations.— 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 circular di- vision of the periosteum will be made, and upon this precise situation tiie saw should be placed. (First Lines of the Practice of Surgery.) But, in no part of the operation of an amputation do operators in general display more awkwardness, than in sawing the bone, though perhaps not of" that pernicious sort as the errors al- ready noticed. At the time of sawing the bone, much depends upon the as- sistant who holds the hmb. If he should elevate the lower portion of the thigh bone too much, the saw becomes so pinched that it cannot be worked. On the other hand, should he allow the weight of the leg to operate too much, the thigh bone will break before it is nearly sawn through, and its ends will be splintered. It is one of the most common remarks of such persons, as are in the habit of frequently seeing amputations, that the part of these op- erations, which a plain carpenter would do well, foils the skill of* a consummate surgeon, and few operators acquit themselves well in using the saw. Many of them begin the action of tliis instrument, by moving it in a direc- tion contrary to the inclination of its teeth. Many, seemingly through con- fusion, endeavour to shorten this part of the operation, by making short, very rapid, and most' convulsive strokes, with the saw. Almost all operators fall into the error of bear'n" too heavily on the instrument. Thai operator will saw best who makes the first stroke of the saw by applying its neel to the bone, and drawing the in- AMPUTATION. 3r strum eat across the part, towards him- self ; tliis makes a slight groove in the boiu , which serves very materially to steady the future operations of the in- strument ; who makes long, regular sweeps with the saw, rather slowly than quickly, rather lightly than hea- vily. But, there is often a fault in the construction of the saw itself, wliich impedes its action, quite independent- ly of any fault on the part of the sur- geon himself. 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 rest of the instrument to move in. If the bone should happen to break before the sawing is finished, the sharp- pointed, projecting spiculse thus occa- sioned, must be removed by means of a strong, cutting sort of forceps, term- ed bone nippers. After the removal of the limb, the femoral artery is to be immediately taken hold of with a pair of forceps, and tied, taking care to leave the ac- companying branches of the anterior crural nerve out of the ligature. None of the surrounding flesh ought to be tied, though tiie ligature should un- doubtedly be placed round the artery, just where this vessel emerges from its lateral connections, Mr. Hey has been accustomed to tie the femoral artery twice, leaving a small space between the ligatures, and this method has been constantly used in the Leeds In- firmary. Some reasons against this plan will be found in the article (He- morrhage). The otiier 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 sup- puration, should never be allowed to remain. .Mr. Alanson directs the ends of the ligatures to be left hanging out at the two extremities 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 near- est part of the surface ; otherwise its running across one half the wound to get at cither angle, would civato a great deal of unnecessary irritation and suppuration. Sometimes, the sawn surface of the bone itself bleeds rather profusely.— When this happens, it is an excellent plan, which I have often seen Mr. Itamsden and others adopt with the greatest success, to hold a compress of lint over the end of tiie bone, during the time requisite for securing the rest of the vessels. At the end of tiie pe- riod, the compress may generally beta- ken away, as the bleeding from the bone will have 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 patient is faint with pain ; he should endeavour 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, otherwise he may expect to be obliged by a fresh hemorrhage to undo all the dressings, (On Amputation of the Larger Extre- mities, p. 475. Monro's Works). In the account of Mr. Alanson's plan, we have explained how the wound is to be brought together with strips of sticking plaster. Over these, and the ends of the ligatures, it is best to place some pieces of lint, spread with the unguentum spermatis ceti, to keep them from sticking, which becomes an exceedingly troublesome circumstance, 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, compres- ses, flannels, &c. 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 in a circular way, round the limb, from above downward. The first turn of the roller, indeed, should be fixed round the pelvis. The two cross bandages, often called the Malta- cross, are to be put over the end of the stump, one in each diameter. I ain completely of opinion with Mr. Alanson, that the elastic woollen cap, commonly placed over all the bandages and dressings, if not put on with a great deal of care, has a tendency to push the skin backward from the ex- tremities of the stump, and as it lniyst alsO heat the part very much, its em- 38 AMPUTATION. ployment ought apparently to be dis- continued. If possible, the dressings should ne- ver be removed before the fourth day, not reckoning the one on whicii the am- putation was performed. Monro set down the fifth, sixth, or seventh day, as generally soon enough for this pur- pose. He allows, however, that, if the smell of the wound should become offensive, the outer dressings may be removed sooner. Even when the dres- sings are to be taken away, it will fre- quently be found useful not to remove one strip of plaster; but, the stump must be made clean, and any discharge present washed away. (Monro). At the end of five or six days, the surgeon may begin to try, in a very gentle manner, whether any of the li- gatures are loose. However, he should not use the smallest force, nor persist if the trial should create pain. One would hardly try, whether the ligature on the main artery is loose, before the eighth or ninth day. Though, in tiie above account, we have directed the edges of the wound, after the amputation of the thigh, to be brought together 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. Alanson objected to the latter mode, asserting, that the cicatrix afterwards became situated immediately over the end of the bone, the pressure of wliich was very likely to make the part ulcerate. How ever, in St. Bartholomew's Hospi- tal, a thigh was lately amputated by Mr. Harvey, and the edges of the stump were brought together in the perpen- dicular direction, yet according to all accounts, a better stump could not have been made. In a case, in which I assisted Mr. Ramsden at Christ's Hos- pital, when an attempt was made to put up the wound in the common man- ner, the bone seemed to make consi- derable pressure against the skin wliich did not happen, when the line of the wound was made in the other direction, which of course was immediately adopted. Mr. Hey has noticed this sub- ject as follows: the integuments and muscles may be brought into contact by pressing either the anterior and posterior parts, or the sides of tiie thigh, together. The former method^ by the gradual retraction of the poster rior muscles, causes the integuments of the anterior part of the stump to cover more completely the extremity of the bone. The latter method causes the integuments and muscles to meet each other the more readily, and, there- fore it is to be preferred, w hen the quantity of soft parts preserved is some- what deficient. (Practical Observa- tions on Surgery, p. 516.) HEMORRHAGE AFTER AMP UTATION. 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 assistant should always be left with the patient, with directions carefully and repeatedly to look at the stump, and if any bleeding should arise, to apply the tourniquet, until further aid is obtained. In case no assistant can be spared for this purpose, as must fre- quently happen in country practice, the tourniquet should always be left slackly round the limb, and the nurse, or pa- tient himself, directed to turn the screw of the instrument, in order to tighten it in case of need. A slack tourniquet left round the hmb, after amputation, cannot do harm, and its not having been ready in this way, has cost many patients their fives, as I have known instances of. This kind of hemorrhage has often been known to arise from the pressure of a tight bandage round the stump. As Monro observes, the circular turns of the bandage, when tight, must stop the return of blood in the cutaneous veins, and by making thus a greater re- sistance to the blood in the arteries, which anastomose with them, occasion the contracting power of the heart and arteries to dilate, and force more blood into their other branches ; but, these being cut in the amputation will pour out their blood, and so an hemorrhage is brought on. Making much pressure round a stump is highly deserving of reprobation, and whenever there is an universal oozing of blood, be sure, that the circulation in the superficial veins is not impeded by the tightness of the bandage. If the bleeding should not be from an artery of consequence, the application of linen, clipped in the cold saturnine lotion, will sometimes check it, and the disagreeable necessity for removing the AMPUTATION. 39 dressings and opening the wound, may thus be avoided. But it often happens, that the w ound must he opened, and the bleeding ves- sel tied. This is a very painful proceed- ing to the patient, and when th£ dres- sings have been applied some hours, so that the stump has had time to inflame, nothing can exceed the suffering to which the patient is subjected. Here we see the prudence of being very care- ful to tie every suspicious vessel in tiie first instance. The second sort of hemorrhage, af- ter amputation, arises from ulceration of the large arteries, and may occur a month after the operation, when tiie ligatures are all away, and the patient seems nearly well. Two such cases are related by Mr. Bromfield (Vol. 1. p. 307.) This kind of bleeding is less common than former- ly, 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 patient out of danger, except by cutting down to the \ essel, and tying it. The trunk of the vessel can sometimes be more conve- niently tied, than the bleeding branch itself. Mr. Hey makes mention of a parti- cular sort of hemorrhage, after the operation ; " 1 have seen (says he) a few instances of the integuments be- coming so contracted after the opera- lion, as to compress the veins just a- bove tiie extremity of the stump, and bring on after some hours copious he- morrhage. When it has appeared clear to me, that the hemorrhage was venous, I have made a division of the integu- ments, on one side of the thigh, suffi- cient to remove the stricture, and this method has immediately suppressed the hemorrhage." (p. 518.) I shall make another extract from this interest- ing author on the present subject. " When we are under the necessity of amputating a limb, that has suffered great contusion, though the operation is performed upon a part apparently sound, the wound sometimes becomes sloughy and ill conditioned. No good gramdations arise to cover the extre- mities of the arteries; but the ligatures cut through these vessels, or becom- ing loose, cease to make a sufficient pressure upon them, and hence repeat- ed hemorrhages ensue. This is a dan- gerous state for a patient; for, if" the vessels are taken up afresh with the needle, the hemorrhage will now and then return in tiie course of two, or three days. In such cases, the applica- tion of dry sponge, cut transversely, as directed by Mr. White (Cases in Sur- gery) has been found singularly useful, and has saved the life of the patient. But, a constant pressure must be kept upon the pieces of sponge, by the fingers of a succession of assistants, till gra- nulations begin to rise upon the stump, and the prospect of future hemorrhage disappears. This method is of tiie greatest importance after amputation on the thigh, or leg, where the greafc vessels are deeply seated. In the arm, above the elbow, where the vessels are more superficial, the great artery may be taken up, with a portion of muscular flesh, above the surface of the stump, by making first an incision through the integuments. My colleague, Mr. Lo- gan, has done tliis twice within tiie last year, with complete success, when re- peated ligatures, applied in the usual way, had failed." " In the morbid sloughy state of the stump, above mentioned, the applica- tion of lint, soaked in a liquid, com- posed of equal quantities of lemon juice and rectified spirit of* wine, has been found very advantageous, and has caused it to put on soon a healthy as- pect." (p. 510, 520.) SPASMS OF THE STUMP. Spasmodic contractions of the mus* cles of the stump is another very afflict- ing occurrence. Such spasms put the patient to the greatest agony, and, in some cases, increase so much as to af- fect tiie whole body, and even occasion death. But, tliis unfortunate affection, which was rather frequent after ampu- tations performed in the ancient man- ner, is infinitely less so, after the mo- dern improved plans of" operating, ty- ing the vessels, and dressing the wound. When such spasms, however, do occur, the stump must be kept from starting, by fastening it to the pillow and bedding, on which it lies, and opium, and cam- phorated medicines, are to be liberally exhibited. (Encyclopedic ^Methodique, Par tie Chirurgicale. Lotto's Surgerv, Vol 3, &c.) AMPUTATION BELOW THE KNEE. In treating of amputation of the thigh, we have remarked, that as much of the, limb as possible should be preserved, The longer it is after operation, the 40 AMPUTATION. stronger and more useful will it be found. But when the leg is to be am- putated, authors have set it down, as almost an invariable rule, that the ope- ration is to be performed a little way below the knee, even though the dis- ease, for wliich the limb is removed, may be s;tuated in the foot, or ankle, and would allow the operation to be done much further down. The com- mon practice is to make the incision 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 lowness is necessary, in order not to deprive the stump of that power of mo- tion, which arises from the flexor ten- dons of the leg continuing undivided. It is alleged also, as a reason for this mode of proceeding, that it is quite suf- ficient to preserve a few inches of the leg, in order to afford the body a pro- per .surface of support, in walking with a wooden leg; whereas if a larger por- tion were saved, tiie superfluous part would be a great inconvenience both in walking, and sitting down, without being of the smallest utility, in any re- spect whatever. The tourniquet should be applied to the femoral artery, about two-thirds of the way down the thigh, just before the vessel perforates the tendon of the triceps muscle. This place is much more convenient than the ham. The patient is to be placed upon a firm ta- ble, as in the amputation of the thigh, and the leg being properly held by one assistant, while the integuments are drawn upward by another, the surgeon, with one quick stroke of the knife, in to make a circular incision tlirough the integuments all round the limb. Some recommend the operator to stand on the inside of the leg, in order that he may be able to saw both bones at once. No reflections couut ever make me per- ceive, that any re.a advantage ought strictly to be imputed to this plan. Ma- ny suppose this method diminishes the chance of the fibula being splintered, by tliis bone being completely divided rather before the tibia. But, splinter- ing the bones arises from the assistant depressing the limb too much, or else not supporting it enough. It would be difficult to explain, why the tibia, in this plan, should noi. be splintered, ins'-cau of the fibula, whe\ a certain th:cl::;i*s of it has been sawn through, if the as- sistant should be guilty of the misma- nagement. Having made a circular cut through the integuments, the next object is to preserve skin enough to cover 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 tiie latter bone. Throughout this extent, there are no bulky muscles, which can be made very serviceable in covering the end of the stump, and consequently, the operator must take care to preserve sufficient skin in this situation, by dis- secting it from the parts beneath, and turning it up. On the back part of the leg, on the contrary, the skin should never be de- tached from the large gastrocnemius muscle, which, with the soleus, will here form a sufficient mass for covering the stump. Hence, as soon as the skin has been separated in front, and on the outside of the leg, the surgeon is to place the edge of the knife in the divi- sion of" the integuments behind, and cut directly through the muscles of the calf, from the inner edge of* the tibia quite across the fibula, supposing the opera- tor to be on the patient's left side. Then the flap formed by the integu- ments, and muscles of the calf, is to be held back by one of the assistants, while the surgeon completes the divi- sion of the rest of the muscles, together with that of tiie interosseus ligament, by means of the catling, a kind of long, narrow, double-edged knife. It is of great consequence that the knee should be bent, when the gastroc- nemius and soleus are to be divided, as these muscles will then be cut through much lower down, than they would be, if the leg were extended, so as to put them in a state of" tension. li amputating below the knee, very particular care must be taken to cut every fasciculus of muscular fibres, be- fore using the saw. Every part, except 'he bones, being divided, the soft parts are next to be protected from the ceeth of the saw, by a linen retractor, made whh two slits to receive the two bones. On the leg, there are only three prin- cipal arteries, requiring ligatures, viz. the ai-terior, and posterior tibial, and the peroneal, arteries. Whether the above plan of amputa- ting the leg so high up, when the foot, AMPUTATION. 4l «r ankle, is the part diseased, or injured, be on tiie whole most advantageous, I cannot presume to determine. There are certainly many clever men who con- demn the practice, and though we see it pursued by tiie best surgeons in this metropolis, yet, we may.safely assert, that the matter requires further consi- deration. If it were a decided point, that the common custom of bending the knee, for the sake of bearing the wejght of the body on its anterior part, were the only one admissible, after am- putation of the leg, there could be no doubt of tiie propriety of performing the operation a little way below the knee, in preference to any otiier situa- tion. But since there have beennumc- rous.instances of persons walking very securely with machines, which allow them to make use of the knee, and are more pleasing to the eye, on account of their perfect resemblance to a natural limb; and since also, the operation at the lower part of the leg, is more easy of performance, and safer, than when done high up; some very eminent sur- geons have thought that it ought al- ways to be done near the ankle, when possible, instead of near the knee. Mr. White of Manchester, in a paper dated 1769, (Med. Obs. and Jnq. Vol. 4.) informs us, he took the hint to ampu- tate a little above the ankle, from seeing a caae, in which this had been done by a simple incision, with such success, that the patient could walk extremely well, though with a machine, that was very badly constructed- After tliis .Mr. White began to operate above the ankle with the double incision; and he invent- ed 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 ma- chine, both along a level surface, and in going up and down stairs, that it was difficult to perceive he had lost his foot. Mr. Bromfield was persuaded, however, to give up this practice, until he learnt, in 1754, that a Mr. Wright had thrice amputated in this way with success, when he again had recourse to it with- out the least unpleasant consequences. The operation just above tiie ankle is less painful, because there is not so much substance to be divided, as in the VOL. I. calf. There is also more facility in co- vering die bone entirely with skin. The wound would generally require less time to heal; its smaller size, and the greater exactness, with whicii its oppo- site edges can be brought into contact, are circumstances, which would fully warrant this conclusion, even were the sentiments of experienced men totally out of the question. The advantage of amputating a little below tiie knee, is that pressure on walking with a wooden leg, is entirely confined to the front of the limb, and the cicatrix itself is subjected to no sort of irritation whatever. After amputa- ting at the ankle, the pressure in walk- ing operates directly on the cicatrix; but, if the mechanical contrivances for walking are now brought to such per- fection, that such pressure does no harm, the operation should not be abandoned on this account. AMPUTATION WITH A FLAP. This was first proposed by Loudliam, an English surgeon; and published by Jacob Young, in 1679, in his Currus Triumphalis ex {terebinth. It was suc- cessfully practised by several others ; but soon fell into disrepute, probably in consequence of the rude measure adopted for stopping the hemorrhage, and the badness of the treatment of the stump, by wliich causes, pain, inflam- mation, andextensive suppuration must have been produced. We have already spoken of the flap operation having been done by White and Bromfield above the ankle. In the year 17o5, Sylvester O'Halloran, an eminent surgeon, of Limerick in Ire- land, published a revival of the flap- amputation, upon a plan entirely new. However, his fault consisted in not putting the flap in contact with tin- wound, till after inflammation had sub- sided, about the twelfth day. Messrs. Alanson and Lucas conjec- tured, that the cure might be render- ed more safe, easy, and expeditious, by applying the flap, with a view of uniting it by the first intention. The following case explains .Mr. Al- anson's flap-operation. The disease was in the left leg, the patient, there- fore, lay on his right side, upon a table of a convenient height, so as to turn di^ part to be first cut fully into view. The in- tended line, where the knife was to pass in forming the flap, had been previously 6 42 AMPUTATION. 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, andacrossthe tciuloAchillis; hence, the intended flap was formed, first by incisions through the skin and adipose membrane, and then complet- ed, by pushing a catling through the muscular parts in the upper incised point, and afterwards carrying it out below, in the direction of the line al- ready mentioned. Thus the whole flap was completed. The flap was thick, containing the whole substance of the tendo Achillis. The usual dou- ble incision was made ; the retractor applied to d fend the soft parts ; and the bone divided, as high as possible, with the saw. The Hap was placed in contact with the naked stump, and retained there, at first by three superficial stitches, between which adhesive plasters were used. Notwithstanding the patient caught an infectious fever, a few days afterwards, tiie 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 touched with caustic healed in a few days. The man was soon able to use an artificial leg, with whicii he walked remarkably well. He went several voyages to sea, and did his business with great activity. He bore the pres- sure of the machine totally upon the end of the stump, and was not troubled with the least excoriation or soreness. In the next instance, in which Mr. Alanson operated, he formed the flap by pushing a double edged knife through the leg, and, passing it downwards and then outwards, in a line, first marked out for the direction of the knife. In this way, the flap was made more quickly. (Alanson on Amputation.) The leg should be completely ex- tended during the operation ; and kept in that posture, till the wound is per- fectly healed. We shall next notice Mr. Hey's me- thod. This gentleman is satisfied, that very near the ankle, is not the most proper place for tliis kind of amputa- tion. Some cases occurring, in whicii from a scrophulous habit, tiie 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 com- plete 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. Hoy now prefers this method, and has reduced it to certain measures. It has been customary, at the Leeds Infirmary, to make the length of the flap equal to one-third of the. circum- ference of the leg. This was deter- mined by the eye of the" operator, who usually pushed the catling through the leg,near the posterior part of the fibula. Mr. Iky, finding the flap was not al- ways ot 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, together with the length and breadth of the flap, he draws upon the limb five lines, three circular, and two longitu- dinal ones. He first measures the length of the leg from the highest part of the tibia to the middle of the inferior protuberance of tiie fibula. At the mid-point, between the knee and ankle, he makes the first or highest circular mark upon the leg. There the bones are to be sawn. Here Mr. Hey also measures the circumference of the leg, and thence determines the length and breadth of the, flap, each of wliich is to be equal to one-third of the circum- ference. In measuring the circumfer- ence of the limb Mr. Hey employs a piece of marked tape, or ribbon, and places one end of it on the front edge of the tibia. Supposing the circum- ference to be twelve inches, he makes a dot in the circular mark on each side of the leg, four inches from the ante- rior 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 shew the direction, which the catling is to take in making the flap. At the termination of these lines, Mr. Hey makes a second mark round the limb, to shew the place where the flap is to end. Lastly, a third circular mark is to be made an inch below the upper one, for the purpose of directing the circular cut through the integuments, in front of the limb. The catling, for making the flap, shoidd be longer than those commonly employed in amputa- tions. Mr. Hey uses one which is se- AMPUTATION. 43 von inches long in the blade, and blunt at the back, to avoid making any lon- gitudinal wound of the arteries, which is very difficult to close with a ligature and', for the same reason, he pushes the catling through the leg a littiepfce- low the place where such muscles are (o be divided, as are not included in the flap. The limb being nearly hori- zontal, and the fibula upward, lie pushes the catling through the leg, where the dot was made, and carries it downward along the longitudinal mark, till it approaches the lowest cir- cular mark, a 'little below which the instrument is brought out. The flap being held back, Mr. Hey divides the integuments 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 be- low the place where the bones are to be sawn. No great quantity of these muscles can be saved, nor is it neces- sary, as the flap contains a sufficient portion of the gastrocnemius and soleus muscles to make a cushion for the end 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 are to be put between the ligatures. The sutures may be cut out on the eighth day, and the flap supported by plasters. Mr. Charles Bell describes another sort of flap-amputation. The operation is not to be done so low, as there will not be a sufficiency of muscle to cover the end of the bones. An oblique cut is to be made with the large amputat- ing knife, upward, through the skin of the back part of the leg. The as- sistant is to draw up the skin, and the knife is to be again applied to the up- per margin of the wound, and carried obliquely upward till it reaches the bones. The knife, without being with- drawn, is next to be carried, in a cir- cular direction, over the tibia and fas- cia, covering the tibialis anticus, until it meets the angle of the first incision on the outside of the hmb. The sur- geon is then to pierce the interoscous membrane, &c. The sawing being completed, and the arteries secured, the flap is to be laid down, and the in- teguments of the two sides of the wound will be found to meet. (See Bell's Opn-ntive Surgery, Vol. 1.) The flap-amputation is certainly more painful than the common method, and, though it has had very able men for its patrons, it is questionable, whether it is productive of the smallest advan- tage. Nor is there any necessity for adopting this kind pf operation, though you may choose to amputate near the ankle. Mr. Lucas (Med. Obs. andpiq. Vol.5.) does indeed endeavour to prove, that the stump will not bear the pres- sure of a machine for walking unless a flap be preserved. However, as the author of the article . Imputation, in the Encyclop. Method, remarks, if care be taken to save the muscle, a machine for walking may be worn as conve- niently as if a flap had been made. The flap-amputation of the thigh is now quite abandoned by all the best surgeons in this country, and no de- scription of it seems necessary. For- eign surgeons, however, seem not to have entirely rejected this way of opera- ting. We read in Uesault's works, by Bichat, that the former was in the ha- bit of adopting tliis kind of amputa- tion ; but, it is a jnstice due to the eminent M. Sabatier, to state his dis- approbation of the practice. (Medicine Operatoire, Tome 3. p. 2J7.) AMPUTATION OT THE ARM. The structure of the arm is very ana- logous to that of the thigh ; like the latter, it contains only one bone, round which the muscles are arranged. The interior ones 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 brachialis internus, and the two short heads of the triceps ; the second, 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, unless when we are necessitated to amputate very high up, above the in- sertion of the deltoid muscle. The patient being properly seated, the arm is to be raised from the side, and, if the disease will allow it, into a horizontal position. The surgeon is to stand on the outside of the limb, ap- ply the tourniquet as high as possible, and to have the skin and muscles made 44 AMPUTATION. tense, wliich he is about to divide, by the hands of an assistant. The soft parts are next to be divided, as much of the limb being preserved as possible. The bone is to be sawn with the usual precautions, and the bleeding stopped in the usual way. The stump is then to be dressed, and the patient put to bed, with the wound a little elevated from the surface of the bedding If the disease should require the arm to be taken off at its upper part, there wotdd be no room for the application of the tourniquet. A compress might then be put in the axilla, and com- pressed by arty strong bystander. With'a straight bistoury the surgeon is now to make a transverse incision dowm to the bone, a little above the lower extremity of the deltoid muscle. Two other longitudinal incisions, made along the front and back edge of this muscle, would form a flap, whicii must be detached and reflected. - Lastly, the rest of the soft parts of the limb are to be divided by a circular cut, made on a level with the base of the flap. CSabatier Medicine Operatoirc, Tome 3. p. 242—243J. With regard to placing a compress on the artery in the axilla, as advised by Sabatier, this is not so eligible, as making pressure on the artery, as it passes over the first rib, and of wliich method we shall speak when we treat of amputation at the shoulder. 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. The forearm is to be held by two as- sistants, one of whom is to take hold of the elbow, the other of the wrist. The tourniquet is to be applied to tiie 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 cut on a level with the reflected skin, at the same time directing the knife obliquely upward. As many of them are deeply situated between the two bones of the forearm, too much attention cannot be paid to dividing all of them, with a double edged knife in- troduced 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 together, for which purpose the forearm should be placed tn the utmost state of pronation. In any oth- er position, the ulna is situated almost directly under the radius. The ulnar, radial, and two interos- seous arteries, are those, which usu- ally require a ligature. AMPUTATION OF THE HIP-JOINT. The French Academy of Surgery proposed the following question in 1756, as the grand prize subject. In the case, in which amputation at the hip joint should appear to be the only resource for saving the patient's life, to determine whether this operation ought to be prac- tised, and what would be the best way of performing it ? No satisfactory me- moirs having been presented, the same subject was proposed in '1759. The approbation of the academy was now conferred on a paper, in wliich the pos- sibility of amputating at the hip joint was established. The cases demand- ing the operation are also determined by Barbet, the author. If, for instance, a cannon ball, or any other violently contusing cause, should have carried off' or crushed the thigh, so as only to leave a few parts to be cut to make the separation complete, we ought not to hesitate about doing it. A sphacelus, extending to the circumference of the joint, and destroying the greatest part of the surrounding flesh, might ren- der the operation equally necessary and easy. (See Sabatier, Tome 3. p. 271, &c.) Cases are adduced of the limb being taken off by the surgeon completing the separation of the dead parts with a knife. However, this can- not be considered as amputation at the hip joint. Dividing a few dead fibres was a thing of no importance, in re- gard to the likelihood of its creating any bad symptoms. The proceeding, in fact, seems to have no analogy at all to the bloody operation of taking tiie thigh bone out of the socket. I cannot conceive any case in which tiie circumstances, however perilous, would be at all improved by this operation. The following are Mr. Pott's senti- ments : " 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 AMPUTATION. 45 qf the hip, as an advisable thing, or as being preferable to the same operation in the thigh :" After a quotation or two, he continues ; " that amputation in the joint of the hip if,not an imprac- ticable operation (although it be a dreadful one) I very well know, I can- not 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 sometimes happens, that tiie caries is confined to the head of the os humeri, and that the scapula is per- fectly sound and unaffected. In the case of a carious hip joint, this never is the fact; the acetabulum ischii, arid parts about, are always, more or less in the same .state, or at least in a dis- tempered one, and so indeed most fre- quently are the parts within the pelvis, a circumstance this of the greatest consequence ; for the power of perfor- ming the operation beyond the seat of the disease, and, - consequently, to- tally removing all the distempered parts is the very decisive circumstance in fa- vour of amputation every, where, but, in the hip, where (to say nothing of the horridness of the operation itself) the hemorrhage, from a multiplicity of ves- sels, some of which are of considerable size, and the immense discharge which a sore of such dimensions must furnish, the distempered state of the parts which cannot by tiie operation be removed, will render it ineffectual, bold and bloody as it must be." (Pott on Am- putation.) AMPUTATION OF THE SHOULDER JOINT. The first description of this is to be found in Le Drun's Observations. His father, it seems, undertook the opera- tion, in a case of caries conjoined with exostosis, whicii affection reached from the middle to the neck of the humerus. He began with rendering himself mas- ter of the bleeding, by introducing a straight needle, armeltl with a strong ligature, doubled several times. This passed from the front to the back part of the arm, as closely to the axilla and bone as possible. The ligature, includ- ing the vessels, the flesh surrounding them, and the skin covering them, was tightened over a compress. Le Dran with a straight narrow knifc,made atrans verse incisiqn through the skin and del- toid muscle down to the joint, and through the ligament surrounding the head of the humerus. An assistant raised the arm, and dislocated the head of the bone from tiie cavity of the sca- pula. This allowed the knife to be passed with ease between the bone and the flesh. Le Dran then introduced the knife downward, keeping its edge con- tinually 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. LCDran (the son) does not state, that the operation was a new one, and it ap- pears, from the Recherches Critiques sxir I'origine, &c. de la Chirurgie en France, and from La Faye's notes on Dionis, that it had been previously practised by Morand the father. Garengeot thought a curved needle, with sharp edges, would be better for making the first ligature, and that the wound need not be so large, if the in- cision were to begin two or tliree fin- ger breadths from the acromion, and made so as to form two flaps, the lower one of wliich would correspond to the axilla, and might be brought into con- tact with the other, after the second ligature was applied. La Faye extended the improvements further. After placing the patient in a chair, and bringing the arm into a hori- zontal position, he made, with a com- mon bistoury a transverse incision into the deltoid muscle down to the bone, four finger breadths below the acromi- on. Two other incisions, one in front, the other behind, descended perpen- dicularly to this first, and made a large flap of the figure of a trapezium, which was detached and turned up to- wards the top of the shoulder. The two heads of the biceps, the tendons of the supraspinatus, infraspinatus, teres minor and subscapularis, and the cap- sular ligament, are next divided. The head oftlie humerus could now be easi- ly dislocated, when the assistant, who held the lower part of the hmb, made the bone describe the motion of a lever upward. La Faye next carried his in- cisions downward, along the inner part the arm, nntil he was able to feel tiie 46 AMPUTATION. vessels, which he tied as near the axil- la as possible. Then he complied tiie separation of the limb, one finger breadth lower down. All remaining to be done, was to bring down the flap over the glenoid cavity, and dress the wound. The advantages of this plan are ob- vious. As only one ligature is applied, the patient is saved a great deal of pain; the flap, whicii is connected with the acromion, is more easily applied and kept on the stump, than the one, which Garengeot recommended to be made, at the lower part of the axilla. Lastly, any discharge can readdy find vent downward. Mr. Samuel Sharp recommended the following plan. The patient's arm be- ing held horizontal, make an incision through the membrana adiposa, from the upper part of* the shoulder across the pectoral muscle, down to the armpit, 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 ex- posed by these openings. If they be not, cut still more of the deltoid mus- cle, and carry the arm backward.— Then with a strong ligature, having tied the artery and vein, pursue the circu- lar incision through the joint, and care- fully divide the vessels at a considera- ble distance below the ligature ; the other small vessels are to be stopped, as in other cases," " In doing this operation, regard should be had to the saving as much skin as possible, and to the situation of the processus acromion, which, pro- jecting considerably beyond the joint, an unwary operator would be apt to cut open." (Operations of Surgery.) Bromfield's plan consisted in first exposing the axillary vessels, by di- viding the integuments in the axilla.— These vessels he detached, and tied. Then having cut the capsular ligament with scissars, he finished the operation on Mr. Sharp's plan. At length, P. H. Dahl, in 1760, pub- lished at Goettingen, a Latin disserta- tion on amputation at the shoulder, in which publication he proposes making one's self master of the blood, before the operation, by a tourniquet, the pad of which pressed on the subclavian ar- tery under the clavicle. This enabled the operator to dispense with tying the vessels in tiie first instance. Camper had observed, that if we push the sca- pula backward, and press the axillary artery with the finger between the clavicle coracoid process, and great pectoral muscle* the pulse at the wrist instantly stops. Dahl's tourniquet was obviously con- structed, in consequence of what Cam- per had observed, and it consists of a curved, elastic plate of steel, the length of which may be readily imagined.— "A pad is attached to the shortest end of this plate, and is made capable of projecting further,by means of a scsew. The instrument is applied by making it embrace the shoulder from behind forward, while the pad presses on the hollow under the clavicle, between the margins of the deltoid and pectoral muscles. The long extremity of the steel plate, which descends behind the shoulder, is to be fixed to the body by a sort of belt. The pad is then to be depressed, until the pulsation of the ax- illafy "prtery is stopped. Further experiments have proved, however, that this tourniquet may be dispensed with* and the flow of blood in the axillary artery commanded, by properly comoressing this vessel with a pad, at the place where it emerges from between the scaleni muscles, above the middle part of the clavicle. Thus the artery becomes pressed between the pad and the first rib, across whicii it runs. This method, which is as sim- ple as possible, is preferable* to that, whicii requires a tourniquet that is so seldom at hand. Amputation at the shoulder has been in some degree superseded by a pre- ferable operation, even in cases in which it would formerly have been deemed quite indispensable, such as considerable gunshot fractures of tiie head of the humerus ; a caries of the substance of this part, &c. Boucher, in Tom. 2. Mem. de I'Acad. de Chir. shews, that considerable wounds, ex- tending into the shoulder joint, were capable of being successfully treated, by extracting the pieces of bone, which had been separated by violence. In- stances are also recorded, in which, when the head and neck of tiie hume- rus had been totally disunited from the body of that bone, a cure w as accom- plished by making such incisions as al- lowed the portions of bone, now be- come extraneous bodies, to be taken away. .Mr White of Manchester, pro- ceeded further, and ventured to make AMPUTATION. 4,7 a deep incision at the upper part of the arm, to dislocate the head of the hume- rus, which he knew was carious, and, pushing it through the wound, took it off with a saw. The patient recovered in four months. Bent, of Newcastle, has inserted a similar case in the 64th Vol. of" the Philosophical Transaction^. White made only one incision, from the vici- nity of the acromion down to the mid- dle of the arm. Bent, not being able to get at the head of the bone, through the wound, which he had made from the clavicle to the attachment of the pectoral muscle, detached a portion of the deltoid, where it is connected with the clavicle, and another part, where it is adherent to the humerus. Saba- tier has proposed making two cuts at the upper part of the arm, which meet below like the letter V. extirpating the flap, dividing the inner head of the biceps, and capsular ligament; dislo- cating the head of the bone, and saw- ing it off. (Medicine Operaloir. Tom. 3.) AMPUTATION OF THE HEADS OF BONES. In a letter, dated 1782, and addres- sed to Mr. Pott, Mr. Park, surgeon of the Liverpool Hospital, made tiie pro- posal of totally extirpating many diseas- ed joints, by wliich the limbs might be preserved, with such a share of the motions which nature originally allot- ted as to be considerably more useful than any invention which art has hith- erto been able to substitute. M r. Park's scheme, in short, was to entirely remove the extremities of all the bones, which form the joints, 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 and tibia, when the opera- tion was done on the knee ; and the humerus, radius, and ulna, when done on tiie elbow ; so as to have no movea- ble articulation in those situations. To determine whether the popliteal vessels could be avoided without much difficulty in the excision of the knee, Mr. Park made an experiment on tiie dead subject. An incision was made, beginning about two inches above the upper end of the patella, and extend- ing about as far below its lower part. Another one was made across tliis 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 angle* formed by these incisions were raised so as to lay bare the capsular ligament; the patella was then taken out; th» upper angles were raised, so as fairly to denude the head of the femur, and to al- low a small catling to be passed across the posterior flat part of the bone, im- mediately above the condyles, care be- ing taken to keep one of tiie flat sides of the point of the instrument quite close to the bone, all the way. The catling 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 carefidly dissected out; tiie 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 pos- terior part covering the vessel, which on examination had been in very little danger of being wounded. The next attempt was on the elbow, a simple longitudinal incision was made from about two inches, above, to the same distance below, the point of the olecranon. The integuments having been raised, an attempt was made to di- vide the lateral ligaments, and dislocate the joint; but, this being found difficult, the olecranon was sawn off, after which the joint could be easily dislocated, 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 different ina diseased state of the parts, and that a crucial incision would be requisite, as well as dividing the humerus, above the condyles, in tiie way done with respect to the thigh bone. Mr Park first operated, July 2,1781, on a strong, robust, sailor, aged 33, who had a diseased knee, often years' standing. The man's sufferings were daily increa->ing, and his health declin- ing. Mr. Park, in the operation, wish- ed to avoid making the transverse in- cision, 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, de- ceived him in this expectation. Hence the idea was relinquished, and the transverse incision made. The opera- 48 AxMPUTATION. tion was finished exactly as the one on the dead subject related above. The quantity of bone removed was a very little more than two inc hes of the fe- mur, and rather more than one inch of the tibia. The only artery divided was one on the front of tiie knee, and it ceased to bleed before tiie operation was concluded, but the ends of the bones bled very freely. To keep tiie redundant integuments from falling in- wards, and keep the edges of the wounds in tolerable contact, a few sutures*!/>.!?, crook- ed). This denotes intimate union of two bones, which were naturally con- nected by a moveable kind of joint. All joints originally 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 whatever can take place. Bernhard Connor (De stupendo ossium coalitu) describes an instance of a general anchylosis of all the bones of the human body. A still more curious fact is mentioned in the Hist, of the Acad. of Sciences, 1716, of a child 23 months old, affected with an universal anchy- losis. In the advanced periods of life, anchylosis more readily occurs, than in the earlier parts of it. The author of the article anchylosis in the Encyclo- pedic Methodique, mentions his having preserved a specimen, in which the fe- mur is so anchylosed with the tibia and patella, that both the compact and spongy substance of these bones ap- pears to be common to them all, with- out the least perceptible line of separa- tion between them. In old subjects, the same kind of union is commonly observable between the vertebrae, and between these and the heads of the ribs. The greater, or lesser degree of im- mobility, has caused anchylosis to be distinguished into the true and false. In the true anchylosis, the bones have grown together so completely, that not the smallest degree of motion can take place, and the case is positively incura- ble. The position, in which the joint has become thus inalterably anchylo- sed, makes a material difference in the inconvenience resulting from the oc- currence. The false anchylosis is that, in whicii the bones have not complete- ly grown together, so that their mo- tion is only diminished, not destroyed. The true anchylosis is sometimes term- ed complete; the false incomplete. In young subjects in particular, an- chylosis is seldom an original affection, but generally the consequence of some other one. It very often occurs after fractures, in the vicinity of joints; after sprains, and dislocations with a great deal of contusion; and after white swell- ings and abscesses in joints. Aneurisms, other swellings and abscesses on the out- side of a joint, may also induce anchy- losis. In short, every thing which keeps a joint long motionless, may give rise to the affection, which is generally the more complete the longer such causes have operated. When a bone is fractured near a joint, the limb is kept motionless by the ap- paratus, during the whole time requi- site for uniting the bones. The subse- quent inflammation also extends to the articulation, and attacks the ligaments and surrounding parts. Sometimes, these only become more thickened and rigid; on other occasions, the inflam- mation produces a mutual adhesion of the articular surfaces. Hence fractures so situated, are more serious than when they occur at the middle part of a bone. But, it is to be noticed, that all fractures leave, after their cure, a certain degree of stiffness in the adjacent joints; but, this arises from the inactivity, in which the muscles and articular surfaces have been, and may generally be cured by gradually exercising, and increasing the motion of tiie limb. The position of an anchylosed limb is a thing of great importance. When ab-> scesses form near the joints of the fin- gers, and the tendons mortify, the fin- gers should be bent, that they may'an- chyloseln that position, whicii renders the hand much more useful, than if the fingers were permanently extended. The knee, on the contrary, should al- ways be kept as straight as possible, when there is danger of anchylosis. The same plan is to be pursued, when the head of the thigh bone is dislocated in consequence of a diseased hip. When the elbow cannot be prevented from be- coming anchylosed, the joint should al- ways be kept bent. No attempt should ever be made to cure, though every pos- sible exertion should often be made to prevent, a true anchylosis. The at- tempt to prevent, however, is not al- ways proper, for many diseases of joints may be said to terminate, when anchy- losis occurs, When the false, or incomplete anchy- losis is apprehended, measures should be taken to avert it. The limb is to be moved as much as the state of the soft parts will allow. Boyer remarks, that this precaution is much more necessary in affections of the ginglymoid articula- tions, than of the orbicular ones, on ac- count of the tendency of the former to ANt; AXB 53 become anchylosed, by reason of the great extent of their surfaces, the num- ber of their ligaments, and the naturally limited degree of their motion. The exercise of the joint promotes the secretion of the synoria, and the grating, first perceived in consequence wf the deficiency of this fluid, soon ceases. A certain caution is necessary in moving the limb: too violent motion might create pain, swelling, and inflam- mation, and even caries of" the heads of the bones. It is by proportioning it to the state of the limb, and increasing its extent daily, as the soft parts yield and grow supple, that good effects can be derived from it. (S ee Boyer Mai. des Os. Tom. 2.) The use of embroca- tions, and pumping cold water on the joint, every morning, have great power in removing the stiffness of" a limb re- maining after the cure of fractures, dis- locations, &c. Unreduced dislocations are not al- ways followed by anchylosis. Nature often forms a new joint, especially in persons of the lower order, who are obliged to move their limbs a great deal, in order to obtain a livelihood. The surrounding cellular substance be- comes condensed, so as to form, around the head of the luxated bone, a mem- brane, serving the purpose of a capsu- lar ligament. The muscles, at first impeded in their action, become so ha- bituated to their new state, that they resume their functions. This is par- ticularly the case with bones which move in every direction, and have round heads ; but, in ginglymoid joints, the heads of the bones are only imperfectly dislocated, and the motion is greatly restrained by the extent of surface ; while some of the numerous ligaments are only sprained, not ruptured, i'hese causes promote the occurrence of an- chylosis. Anchylosis may follow contusions of the joints, and such shocks, as the ar- ticular surface experience in leaping, or falling on the feet, from great heights. This is more likely to happen, when the inflammatory symptoms, resulting from such violence, have not been properly counteracted by bleeding, and other general remedies. Sprains, which vio- lently twist tiie joints, very often, on this accoiv, cause an anchylosis, espe- cially, when the inflammation has long hindered such joints from being at all iwved. When diseases of joints end in a com- plete anchylosis, the occurrence is to be looked upon, as a very favourable one. In fact, it is as much a means of cure, as the formation of callus is for the union of broken bones. The dis- ease of the vertebrae, described by Pott, is cured, as soon as the bones anchy- lose, nor can the patient be considered well, before this event has taken place. See on this subject VEncyclopedic Me- thodique ; Partie Chirurgicak. Boyer sur ks Mai. des Os. Tom. 2.) ANEURISM, (from ayn^um, to dilate.) When any part of an artery has the ap- pearance of being dilated, the swelling is commonly named a true, or genuine aneurism. In such cases, the artery either seems only enlarged at a small part of its track, and the tumour has a determinate border, or, the vessel seems dilated, for a considerable length, in whicii circumstance, the swelling is oblong, and loses itself so gradually in the surrounding parts, that its margin cannot be exactly ascertained. The first case, which is the most common, is termed the circumscribed true aneu- rism ; the last, the diffused true aneu- rism. When blood escapes from a wound, or rupture, of an artery, into the ad- joining cellular substance, the swelling occasioned is denominated the spurious, or false aneurism. In this instance, the blood either collects in one mass, dis- tends the cellular substance, and con- denses it into a cyst, so as to form a distinctly circumscribed tumour; or it is injected 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 irregular, oblong swelling. The first case is na- med, the circumscribed fake aneurism ; the second, the diffused false aneurism. (Richter's Anfungsgr. Band. 1.) .Mixed aneurism was the name given by Dr. W. Hunter to one, which he sup- posed might proceed frc»n the outer coats of an artery being cut, and the inner ones becoming consequently di- lated. But, the experiments of Hunter and Home, as v. o shall have occasion to mention attain, fully prove, that an aneurism will not arise from the kind of weakness which cutting, or even stripping off", the external coat of an artery, must produce ; and Scarpa, as we shall presently notice, satisfactorily -,hev -; that'll 'nterpal coats arc alwavs 54 ANKURISM. l-uptured. By the mixed aneurism, Dr. Monro implied, the state of a true aneu- rism, when its cyst has burst, and the blood has become diffused in the adja- cent cellular substance. This event is certainly a real one, but, Dr. Hunter's case may be deemed altogether suppo- sititious. The symptoms of the circumscribed true aneurism take place as follows : the first thing the patient perceives is an extraordinary throbbing in some particular situation, and, on paying a little more attention, he discovers there a small pulsating tumour, which en- tirely disappears, when compressed, but, returns again as soon as the pres- sure is removed, It is commonly unat- tended with paiu, or change in the col- our of the skin. When once the tumour has originated, it continually grows larger, and, at length, attains a very considerable size. In proportion as it becomes larger, its pulsation becomes weaker, and, indeed, it is almost quite lost, when the disease has acquired much magnitude. The diminution of the pulsation has been ascribed to the coats of the artery losing their dilata- ble and elastic quality, in proportion as they are distended and indurated, and, consequently, the aneurismal sac being no longer capable of an alternate dias- tole and systole from the action of the heart. The fact is also imputed to the coagulated blood, deposited on the in- ner surface of the sac, particularly, in large aneurisms, in which some of the blood is always interrupted in its mo- tion. In true aneurisms, however, the blood does not coagulate so soon, nor so often, as in false ones. Immediate- ly, such coagulated blood lodgesinthe sac, pressure can only produce a par- tial disappearance of the swelling. In proportion as the aneurismal sac grows larger, the communication of blood in- to the artery beyond the tumour is les- sened. Hence, in this state, the pulse, below the swelling, becomes weak and small, and the limb frequently cold. and ccdematous. On dissection, the lower continuation of the artery is found preternaturally small and contract- ed. The pressure of the tumour on the adjacent parts also produces a vari- ety of symptoms, ulceration, caries, &c. Sometimes, an accidental contusion, or concussion, may detach a piece of coag- ulum from the inner surface of the cyst, and the circulation through the sac be obstructed by it. Tfie coagulum may possibly be impelled quite into the ar- tery below, so as to induce important changes. The danger of an aneurism arrives when it is on the point of burst- ing, by which occurrence tiie patient usually bleeds to death, and this some- times in a few seconds. The fatal event may generally be foreseen, as the part about to give way becomes particularly tense, elevated, thin, soft, and of a dark purple colour. Richter's Anfangsgr- Band. 1. A large axillary aneurism, which burst in St. Bartholomew's Hospital, a few years ago, did not burst by ulcera- tion, but by the detachment ot a small slough from a conical, discoloured part of the tumour. This case fell un- der my observation, and, I have since learnt, that this is the ordinary mode in which tiie fatal hemorrhage is in- duced. The false aneurism is always owing to an aperture in the artery, from wliich the blood gushes into the cellular sub- stance. The case may arise from an artery being lacerated in violent exer- tions ; but, the most common occa- sional cause is a wound. This is par- ticularly apt to occur at the bend of the arm, where the artery is exposed to be injured in attempting to bleed. (For this case see Hemorrhage.) In tliis cir- cumstance, as soon as the puncture has been made, the blood gushes out with unusual force, and in a bright scar- let,tirregular, interrupted current. It flow's out, however in an even, and less rapid stream, when pressure is applied higher up than the wound. These last are the most decisive marks of the artery being opened; for blood often flows from a vein with great rapidity, and, in a broken current, when the vessel is very turgid, and sit- uated immediately over tiie artery, which imparts its motion to it. The surgeon endeavours precipitately to stop the hemorrhage by pressure, and he commonly occasions a diffused false* aneurism. The external wound in tiie skin is closed, so that the blood cannot escape from it; but, hence, it insinu- ates itself into the cellular substance. The swelling, thus produced, is uneven, often knotty, and extends upward and downward along the track of the ves- sel. The skin is also usually of a dark purple colour. Its size in'teases, as long as the internal hemorrhage con- tinues, and, it this should proceed above a certain pitch, mortification of the hmb ensues. ANEURISM. 5> The circumscribed fake aneurism arises in the following manner. When proper pressure has been made hi the first instance, so as to suppress the he- morrhage ; but, the bandage has after- wards been removed too soon, or before the artery has healed, the blood passes through tiie unclosed wound, or that which it has burst open again, into the cellular substance. As this has now become agglutinated by tiie preceding pressure, the blood cannot diffuse itself into its cells, and, consequently, a mass of it collects in the vicinity of the aper- ture of the artery, and distends the cellular substance into a sac. Some- times, though not often, this circum- scribed false aneurism, originates im- mediately after the opening is made in the artery. This chiefly happens when the aperture in the vessel is exceeding- ly small, and consequently, the hemor- rhage takes place so slowly, that the blood, which is first effused, coagulates, and prevents the entrance of that wliich follows into tiie cavities of the cellular substance, and, of course, its diffusion. A membrane, aponeurosis, &c. may al- so be just over the orifice, so as to pre- vent the aneurism from being diffused. The circumscribed false aneurism consists of a sac, composed of cellular substance, filled with blood, and situa- ted close to the artery, with wliich it has a communication. At every pulsa- tion, fresh blood gushes from the open- ing of the artery into the sac, and dis- tends it; but, its elasticity then makes it contract a little, and urge a portion of the blood back into the vessel. Hence, in false aneurisms, a throbbing is always perceptible, and is more man- ifest, the smaller such tumours are. The larger the sac becomes, the less elastic it is, and the greater is the quantity of coagulated blood in it ; so that iu very large aneurisms of this kind, the pulsation is sometimes wholly lost. The tumour is at first small, and on compression entirely disappears ; but, returns as soon as this is removed. It also diminishes, when the artery above it is compressed; but, resumes its wonted magnitude, immediately when such pres- sure is discontinued. Wher. there is co- agulated blood in the sac, pressure is no longer capable of producing a total dis- appearance oi" the tumour, wliich is now hard. The swelling is not painful, anil the integuments are not changed in colour. It continually increases in size, and, at length, attains a prodi gious magnitude. The following arc generally enume- rated, as the discriminating differences between circumscribed true and false aneurisms : the true aneurism readily yields to pressure, and as readily re- curs on its removal; the false one yields very gradually, and returns in the same way, as the blood in the sac can only pass and repass slowly through the aperture in the artery. Frequently, a hissing sound is very audible, when the blood gushes into the sac. The pulsa- tion of the false aneurism is always more feeble, and, as the tumour enlarges, is sooner lost, than that of the true one, which even throbs after it has ac- quired a very considerable volume. The sac of the true aneurism is the artery itself; that of* the false one is cellular substance. (See Richter's Anfangsgr. Band. 1.) Besides these common di- visions of aneurism, there are two other- kinds, one named the aneurismal va- rix, or venous aneurism, the other called by Mr. J. Bell, the aneurism from anas- tomosis ; the particulars of both of which will be offered in due time. If the doctrines, however, of Profes- sor Scarpa, of Pavia, which were pub- lished in 1804, are correct, the grand distinction of aneurisms into true and false must be rejected, as erroneous : " for, (says he) alter a very consider- able number of investigations, institu- ted on the bodies of those, who have died of internal or external aneurisms, 1 have ascertained, in the most certain and unequivocal manner, that there is only one kind, or form of this disease ; viz. that caused by a solution of con- tinuity, or rupture of the proper coats of the artery, with effusion of blood into the surrounding cellular substance; which solution of continuity is occa- sioned sometimes by a wound, a stca- tomatous, earthy degeneration, a corro- ding ulcer, a rupture of the proper coats. of the artery, I mean the internal and muscular, without the concurrence of a preternatural dilatation of these coats being essential to the formation of this disease ; and, therefore, that every aneurism, whether it be internal or ex- ternal, circumscribed, or diffused, is always formed by effusion." Treatise on Aneurism by A. Scarpa. Transl. by Wishurt. Preface. If this opinion be true, the difference in the symptoms of aneurisms above related, is to be im- puted to the difference in tht degree of rupture, diffusion, , by .1- Scar- pa, translated by J. H. Wishurt. Edin- burgh, 1803.) CVRE OF ANEURISMS IN Gr.NFRAL. A complete cure of an aneurism can- not be effected, in whatever part of" the body the tumour is situated, unless the alter)-, from which the aneurism is de- rived, be, by nature or art, obliterated and converted into a perfectly solid, 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 strengthening the dilated proper coals of the artery, and restoring, especially lo the muscular coat, the power of pro- pelling the blood along the tube of the artery, as it did previously to its sup- posed dilatation. M. Petit, and Fou- bert thought, that the natural curative process sometimes consisted in a spe- cies of clot, which closed the lacera- tion, ulceration, or wound of the artery, and resisted the impuse' of the blood, so as still to preserve the continuity of the coats of the artery, and the previ- ous state of the vessel. I lallcr imbibed a similar sentiment, from experiments made on frogs.—Scarpa. That a punctured artery may occa- sionally be healed in this manner, Scar- pa proves by a case which he examined, in which an aneurism took place from the wound of a lancet in bleeding. In Hemorrhage we shall see, that Jones's experiments shew the same thing, and the particular circumstances in which it may happen. But, the occurrence is excessively rare, anil oan hardly be call- ed a radical cure, as the cicatrix is al- ways found in a state ready to burst and break, if the arm is, by any acci- dent, violently stretched or struck, where the wound was situated.—Scarpa. Whenever the ulcerated, lacerated, or vounded artery, is accurately compress- i-d against a hard body, like the bones, it ceases to pour blood into the surround- ing cellular sheath, because its sides, being kept in firm contact, for a certain extent, above and below the breach of continuity, become united by tiie adhe- sive inflammation, and converted into a solid, ligamentous, cylinder. Molinelli, Guattani, and White, have given ex- amples and plates, illustrative of tliis Sac. When aneurisms get well spon- taneously, the same fiet is observed af- ter death, as Valsalva, Ford, &c. have demonstrated. I have nryself seen in St. Bartholomew's Hospital, an instance, in which a man had had a spontaneous cure of an aneurism in the left axilla, but afterwards died of hemorrhage from another one under the right clavi- cle ; the artery on the left side was found completely impervious. My friend, Mr. Albert, has, at this moment, under his care in the York Hospital, Chelsea, a dragoon, who has just reco- vered spontaneously of a very large aneurism of the external iliac artery: the tumour sloughed, discharged about two quarts of coagulaied blood, and then granulated and healed up. Paoli relates a similar termination of a popli- teal aneurism. Moinichen and Guat- tani, relate other examples. Hunter found the femoral artery quite imper- vious, and obliterated, at the place where a ligature had been applied fif- teen months before. Boyer noticed the same fact in a subject, eight years after the operation. Petit relates a sponta- neous cure of an aneurism at the bifur- cation of the right carotid, and the sub- ject having afterwards died of apo- plexy, the vessel on dissection, was found closed up and obliterated from the bifurcation, as far as the right sub- clavian artery. Desault had an oppor- tunity of opening a patient, in whom a spontaneous cure of a popliteal aneu- rism was just beginning, he found a very hard, bloody thrombus, which ex- tended for three finger-breadths, with- in the tube of the artery, above the sac, and was so firm, as to resist injection, and make it pass into the collateral branches. Both the spontaneous and surgical cure of aneurisms, have two stages ; in the first, the entrance of the blood into the aneurismal sac is interrupted; in the second, the parietes of the arte- ry approach each other, and, becoming agglutinated, the vessel is converted into a solid cylinder. This doctrine is corroborated by the tumour first losing its pulsation, and then gradually di- minishing and disappearing. Dr. Thom- son as well as Scarpa, has long express- ed his opinion that the spontaneous radical cure of aneurisms, may some- times arise from the pressure of the aneurismal sac on the trunk of the in- jured artery, just above the communi- cation between the vessel and the cavi- ty of the aneurism. Morand proved ANEURISM. 61 that a violent blow may lead to the ob- literation of an artery, and Dr. Jones has demonstrated, that arteries always become impervious, after having atight ligature put round them, even though such ligature be removed tiie moment after its application. When an aneurism is affected deeply by gangrene, a dense, compact, bloody, coagulum is formed within the vessel, shutting up its canal, and interrupting completely the course of the blood. Hence the sphacelation which follows, and the bursting of the integuments, and of the aneurismal sac, are never accompanied by a fatal hemorrhage, and the patient is cured of the gan- grene and the aneurism, if he has .strength sufficient to resist the destruc- tive action of the sphacelus on the con- stitution. When a patient dies of" he- morrhage, after the mortification of an aneurism, it is because only a portion of the integuments and sac has slough- ed, without the root of the aneurism, and especially the arterial trunk, being in this way affected.—Scarpa. That compression may make the op- posite sides of an artery unite, and thus produce a radical cure of an aneurism, Scarpa says, the degree of pressure must be such as to place these opposite Miles in firm and complete contact, and such as to excite the adhesive inflam- mation in the coats of the artery, whicii must also possess a state of vitality, presently to be noticed. The point of compression must also fall above the laceration, or wound, of the artery ; for vthen it operates below, it hastens the enlargement of the tumour; and Scar- pa adds, that, in practice, bandages, which are expulsive and compressive, are more useful for making pressure, than any tourniquets or instruments, many of which are contrived to operate, without retarding the return of* blood through the veins. lor pressure to succeed, the coats of the vessel must possess, at the place where it is nude, such a degree of* vi- tality, as to be capable of feeling the stimulus, and of inflaming. When the arterial co:us, round tiie root of the ajicurism, are diseased, as above des- cribed, they arc insusceptible of the adhesive inflammation, although com- pressed toucher in the most scientific manner, and even when tied with a lig- ature, which oiily acts by making cir- cular pressure on the vessel. Some advise trying compression in every case of aneurism, whether small circumscribed, soft, flexible, indolent; or elevated, diffused, hard, and painful. In the latter case, however, compres- sion is hurtful. Every bandage which compresses the aueurism, and also con- stricts circularly the affected part, is always injurious. The bandage, like- wise, whicii compressing only the aneu- rism, directs the point of pressure be- low the rupture in the vessel; that which, on account of tiie great size, exquisite sensibility, depth of the root, of die aneurism, and fleshiness of the surrounding parts, cannot effectually compress the artery against the bones, so as to bring the opposite sides of the vessel into contact; and, lastly, the compression applied to a spontaneous aneurism, attended with a steatoma- tous, ulcerated, earthy, disease of the arterial coats; ought to be considered as an useless, or rather hurtful plan. Ii\ cases of a completely opposite descrip- tion, bandages have produced, and may produce, radical cures of aneurism, and should not be entirely disused. Scarpa. Guattani first employed compression systematically for the cure of aneu- risms, and he has related many cases in which he succeeded. Freer details other ones ; but, in general, pressure has hitherto been applied to the tumour itself, a method less likely to'answer, than that of making pressure on a sound part of the artery. Mr. Freer re- commends the employment of Sennfio's instrument, or the following method ; first place a bandage moderately tight, from one extremity of the limb to the other; then place a pad upon the ar- tery, a few inches above the tumour; next, surrounding the limb with a tour- niquet, let the screw be fixed upon thvi pad, having previously secured the whole limb from the action of the in- strument, by a piece of board wider than the limb itself, by which means the artery only will be compressed, when the screw is tightened. The tourniquet should now be twisted till the pulsation in the tumour ceases. In a few hours the limb will become cedematous and swelled, when the tourniquet may be removed, and the pressure of a pad and roller will afterwards be enough. By experiments which this gentleman made on the radial arteries of horses, these vessels were found to become in- 62 ANEURISM. fumed, and to be rendered impervious by such a process.—Freer, p. 112. Mr. A. Cooper, mentions an excellent machine for compressing the femoral artery, in case of popliteal aneurism. It was used by sir W. Blizard. " The points of support for this in- strument were the outer part of the knee, and the great trochanter, a piece of steel passing from one to tiie other ; and to the middle of this a semicircular piece of iron was fixed, which projected over the femoral artery, having a pad at its end, moved by a screw, by turn- ing wliich, the artery was readily com- pressed, and the pulsation in the aneu- rism stopped, without any interruption to the circulation in the smaller ves- sels." But, although the patient on whom it. was tried possessed unusual fortitude of mind, and indifference to pain, he was incapable of supporting the pressure of* tiie instrument longer than nine hours. Indeed, the agony arising from long continued pressure is insupportable to almost all men.— (Med. andPhys. Journal, Vol. 8.) The grand means most to be de- pended upon, however, for curing aneu- risms, is tying the artery above the tu- mour. This more certiunly prevents the usual ingress of blood into the sac, and, what is more important, more cer- tainly excites the adhesive inflamma- tion, by dividing the internal coats of the vessel. The blood in the sac is af- terwards gradually absorbed, and the tumour dwindles away in proportion. The natural course of the blood being now permanently interrupted in the ar- terial trunk, it passes more copiously into the collateral branches, and these enlarging and anastomosing with others, which originate from the large arte- ries beyond the obstruction, the neces- sary circulation is carried on. The ligature of the superficial femo- ral artery, may be performed with the same confidence of success, as the li- gature of the brachial artery, that is, without any fear of destroying the cir- culation, or depriving the subjacent limb of its vitality. Indeed, the nume- rous and conspicuous anastomoses, v. iiich arc met with all round the knee, correspond exactly with those which are observed round the elbow, and at the bend of the arm. This is not a pe- culiarity of the arteries of the extremi- ties, but it is a general rule whicii na- ture has followed in the distribution of all the arteries, that the superior trunks communicate with the inferior, by means of the lateral vessels. Aturthe principal trunk of an artery is tied, its lateral branches not only carry on the circulation in the parts below the liga- ture, biit do so with greater quickness and activity than they did before, when the course of tiie blood was unimpeded through the principal trunk. This evi- dently arises from the increase of pres- sure which the blood, that takes the rout of the lateral vessels, receives, as well as from the enlargement in the di- ameter of these vessels. After the am- putation of the thigh, while the blood flows in a full stream from the superfi- cial femoral artery, very little or no blood is poured out of the lateral ves- sels; but as soon as that artery is tied, the blood issues with impetuosity from the small arteries whicii run along, within the vasti and crurxus muscles ; and, on these smaller arteries being also tied, -the blood immediately oozes out, from tiie minute arterial vessel of the muscles and cellular membrane. When the principal trunk of an artery is tied, its lateral branches gradually acquire a much larger diameter. After amputation of the thigh, on account of a popliteal aneurism, the size and situa- tion of which could not fail materially to impede the course of the blood through the trunk of the femoral ar- tery, it has been often remarked, that, although both the trunk, and the greater and smaller branches, had been tied with the greatest accuracy, the patients have been in danger of losing their lives, on account of the repeated copi- ous hemorrhages from the innumerable small lateral vessels, that had become unusually enlarged. In several cases, during the treatment, and especially after the radical cure of the popliteal aneurism, by tying the superficial fe- moral artery, in the upper third of the thigh, all the ramifications of* the recurrent popliteal arteries have been felt beating strongly round the knee. Boyer found, in a man, who some years before had been operated on for a pop- luteal aneurism, but had afterwards died from a caries of the tibia, that the arte- rial branch, which runs through the substance of the sciatic nerve, was di- lated so much, as to be equal in diame- ter to the radial artery. White, in dis- secting the arm of •& lady, who, fifteen years before had been operated on for ANEffRISM 63 an aneurism in the bend of the arm, found tiie brachial artery obliterated, and converted into a solid cylinder, for three inches below the place of the li- gature, and as far as the division into the radial and ulna arteries; hut, the recurrent radial and ulna 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 extremity 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 tiie'collateral vessels ought to be much more easy and quick the low- er down the ligature is applied to the principal trunk; yet experience shew;, that this difference i.s not to be estima- ted very high ; for in cases of popliteal aneurism, caterkparibus, 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 tiie 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 ex- tremity. An age under forty-five, and the operation being done on the arm, which is nearer the source of the cir- culation, til an the lower extremity, in- creases the chance of success. The circumstances chiefly preven- tive of success, especially in the popli- teal and femoral aneurisms, are the following: Rigidity, atony, or disorga- nization of the principal anastomoses, between the superior and inferior arte- ries of the ham and leg, sometimes de- pending on advanced age, or on it, to- gether with the large size of the aneu- rism, which, by long continued pres- sure, has caused a great change in the neighbouring parts; or sometimes on steatomatous, ulcerated, earthy, carti- laginous, disorganization of the proper coats of tiie artery, not confined to the seat of the rupture, but extending a great way above and below the aneu- rism, and also to the principal poplite- al recurrent arteries, tibial arteries, and occasionally, to portions of the whole track of the superficial femoral arterv. Sometimes, the pressure of large aneurisms, renders the thigh bone carious. In such circumstances the li- gature is apt to fail in closing the trunk of the artery ; and, if it should succeed, the state of the anastomosing vessels will not admit of a sufficient quantity of blood being conveyed into the lower part of the limb. Hence, when the pa- tient is much advanced in life, languid and sickly, when the internal coat of the artery is rigid, and incapable of be- ing united by a ligature; when the aneurism is of long standing, and con- siderable size, with caries of the os fe- moris, or tibia; when the leg is weak and cold, much swelled, heavy, and (edematous ; Scarpa considers the ope- ration contra-indicated. I must, how- ever, declare in this place, that I have seen very large aneurisms, as well as aneurisms in persons of advanced age, cured by the llunterian plan, in St. Bar- tholomew's Hospital. It appears, then, that the obliteration of the artery, for a certain extent, abov - and below the place of rupture, forms the primary indication in the radical cure of aneurism, whether compret- sion, or the ligature, be employed. Ai- other means are only auxiliary. Intei nal remedies may be useful in so far a:. they tend to moderate the determina- tion of the blood towards the place, where the artery has been tied or com- pressed. Bleeding in young, very ro- bust, plethoric patients, low diet, dilu ent drinks, gentle laxatives and glys- ters, mental and bodily rest, and cool air, have such effect. When there is weakness, not from age, but from pain, long want of rest, or loss of blood, t< >- nics, cordials, and a moderate diet, may be given. Scarpa also advises the outward use of corroborants and sti- mulants ; but, I think, few English sur- geons will approve the practice. In internal aneurisms, debilitating remedies, abstinence, a milk diet, and quietude, are almost the only means ; for, such cases are completely out of the reach of surgery. As bleeding, however, cannot always be frequently repeated, instead of it, the hands and feet may be immersed in tepid water, the hmb rubbed, and water given in- ternally, with a small quantity of Hoff- man's liquor anodynus mineralis. (Spit: AStheris Vitriol. Comp.) The great dif- ficulty of breathing may receive a tem- porary relief, by applying sinapisms. (Scarpa.) All pressure on the tumour, when it protrudes externally, should be avoided, as it might increase the 64 ANEURISM. compression on the viscera, and would certainly accelerate the fatal bursting of the aneurism. Digitalis has been given with advan- tage ; but, occasional bleedings, and opium, have been found to produce most relief. In the latter stage, opium can alone be relied on.—(Freer.) OF THE POPLITEAL ANEURISM, AND OPERATION FOR ITS CURE. On whatever side of the artery the tumour is produced, it can be plainly felt in the hollow between the ham- strings, and its nature is as easily as- certained by the pulsation in every part of" the tumour. Though the disease may, perhaps, not occur in the poplite- al artery so often as in the aorta itself, yet, it certainly is seen more frequent- ly in the former vessel, than any other branch, which the aorta sends off". As Mr. Home has observed, this circum- stance has never been satisfactorily ex- plained, avid, what is rather curious, in many recent instances of this disease, the patients have been coachmen and postilions. Morgagni found aneurisms of the aorta most frequent in guides, post boys, and other persons, who sit almost continually on horseback. This he imputes to the concussion and agi- tation to w liich they are exposed. When we contemplate the effects of various postures of the leg and thigh on the popliteal artery, and the ob- struction, which the circulation in it must experience, when the knee is in a state of flexion, we perceive an assign- able cause, why this arterv should be so often diseased. This account is, in some degree, strengthened by aneu- risms of the aorta itself, occurring more frequently at its curvature, than any other part. Home. The popliteal aneurism is generally supposed to arise from a weakness in the coats of the arterv, independently of disease. If this were true, we might reasonably conclude, that, except at the dilated part, the vessel would be sound. Then the old practice of open- ing the sac, tying the artery above and below it, and leaving the bag to sup- purate and heal up, would naturally present itself. Mr. Hunter finding, that the arterial coats were altered in structure higher up, than the tumour, and that tiie artery, immediately above the sac, seldom united when tied; but, that, when the ligature came away, the bleeding destroyed the patient, con- cluded, that some disease affected the coats of the vessel, before the actual occurrence of the aneurism. Dissatis tied with Haller's experiments on frogs, showing that weakness alone could give rise to aneurism, he tried what would happen in a quadruped, whose vessels were very similar in structure to the human. Having denuded above an inch of the carotid artery of a dog, and removed its external coat, he dis- sected off the other coats, layer after layer, till what remained were so thin, that the blood could be seen through it. In about three weeks, the dog was killed, when the wound was found clo- sed over the artery, wliich was neither increased nor diminislied in size. Home. It being conjectured, that aneurism was, perhaps, prevented, by the parts being immediately laid down on the weakened portion of tiie artery, Mr. Home stripped 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 sides of the wound, and, in six weeks, killed the animal, ami injected the artery, which was neither enlarged nor diminished, and its coats had regained their natu- ral thickness and appearance. These experiments strengthened Mr. Hunter's belief, that aneurismal arte- ries are diseased; that the morbid af- fection frequently extends a good way from the sac along the vessels; and that the cause of failure in the old ope- ration, arose from tying a diseased ar- tery, whicii was incapable of uniting, before the separation of the ligature. Mr Hunter's reflections led him to propose taking up the artery in the an- terior part of the thigh, at some dis- tance 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 Meed. The flux of blood into the sac be- ing stopped, he concluded, the sac and its contents would be absorbed, and the tumour gradually disappear, So as to render any opening of the sac unne- cessary. Home. The first operation of this kind, ever done, was performed on a coachman, by Mr. Hunter, in St. George's Hospi- tal, December, 1785. An incision was made on the anterior and inner part of the tliigh, rather below its middle, which wound was continued obliquely across the inner edge of the sartorine ANEURISM. 65 muscle, and made large, in order to fa- cilitate doing whatever might be ne- cessary. Tiie fascia, covering the ar- tery, was then laid bare, for about three inches, after which the vessel itself could be plainly felt. A cut, about an inch long, was then made through this fascia, along the side of the artery, am the fascia dissected off. Thus the ves- sel was exposed. Having disengaged it from its connexions with the knife and a thin spatula, a double ligature was put under it, by means of an eye probe. The doubled ligature was then cut, so as to make two separate ones. The artery wras now tied by both these ligatures, but, so slightly as only to com- press tiie sides together. Two additional ligatures were similarly applied a little lower, with a view of compressing soma •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 hanging out of the wound, whicii was closed with sticking plaster. On the second day, the aneurism had lost one-third of its size, and; on the fourth, the wound was every where healed, except where the Ugatures were situated. On the ninth, there was a 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 liga- tures came away, followed by a small quantity of matter, and about the latter end of January, 1786, the man went out of the hospital, tjie tumour having be- come still less. In the course of the spring, some abscesses in the vicinity of the cicatrix followed, and some pie- ces of ligature were discharged, from time to time. In the beginning of July, a piece of* ligature, about one inch long i:une away, after which the swelling went off* entirely, and the man left the hospital 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 fe- moral artery was found impervious from the giving off" of the arteria pro- funda down to the place of tiie ligature, and an ossification had taken place for an inch and a half along the course of this part of the vessel. Below this por- tion, the vessel was pervious, till just before it came to the aneurismal sac, where it was again closed. What rc- yoL. 1 mained of the sac was somewhat lar- ger than a hen's egg, and it had no re- mains of the lower opening into the popliteal artery. The rest of the par- ticulars of this dissection are very in- teresting. (See Med. and Chir. Trans. Vol. 1. p. 153.) This celebrated case led to the know- ledge, that simply taking off the force of the circulation is sufficient to cure an aneurism, the tumour being then taken away by absorption. To confirm the fact, Mr. Home re- lates a case of femoral aneurism, wiiich got well without an operation, but, on the same principle. A trial of pressure had been made, without avail. The tumour became very large, and such inflammation took place in the sac and integuments, that mortification seemed impending. In this state, no pulsation could be felt in the tumour, or the ar- tery above it. A coagulum, which we know always occurs in an arterv previ- ously to mortification, seemingly to prevent bleeding, probably formed in this instance, and kept the blood from entering the sac. (Home.) 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, unluckily, made the experiment of dressingthe wound from the bottom, instead of uniting it at once: the event was, the man lost a good deal of blood, and died. After this Mr. Hunter's practice wa* to tie the artery alone with one strong ligature, and unite the wound as spee- dily as possible. Since the time of Hunter, several in- novations, and some considerable im- provements in the mode of operating have been proposed. The peculiarity in Mr. Abernethy's first operation consisted in applyingtwo ligatures round the artery, close to where it was surrounded with its na- tural connexions. For this purpose, he passed two common sized ligatures be- neath the femoral vessels, and having shifted one upwards, the other down- wards, as far as these vessels were de- tached, he tied both the ligatures firmly. The event of this case was success- ful. An uneasy sensation of tightness, however, extending from the wound down to the knee, and continuing for many days after the operation, made Mr. Abernethv determine, inanvfuture 9 66 ANEURISM Case, to divide the artery between the two ligatures, so as to leave it quite lax. Mr. Abernethy next relates a case of popliteal aneurism, for whicii Sir Charles Blicke operated, with the in- novation of dividing the artery between the ligatures The man did not expe- rience the above kind of uneasiness ; and no hemorrhage ensued when the ligatures came away, although there was reason to think, that the whole arterial system had a tendency to aneurism, as there was also another tumour of this kind in the opposite thiiih. Mr. Abernethy has referred bleed- ing, after operations for aneurisms, to two causes ; viz. 1st. the inflammation and ulceration of the artery; 2dly. the want of union between the sides of the vessel. When an artery is laid bare, and detached from its natural connex- ions, and the middle of such detached portion tied with a single ligature, as was Mr. Hunter's practice, it is ob- served by Mr. Abernethy, that the ves- sel, so circumstanced, must necessarily inflame, and be very likely to ulcerate. The occurrence of bleeding led to a practice, which this gentleman justly censures, viz. applying a second liga- ture above the first, and leaving it loose, but ready to be tightened, in case of hemorrhage. As the second ligature, however, must keep a certain portion of the artery separated from the sur- rounding parts, and must, as an extra- neous substance, irritate the inflamed vessel, it must make its ulceration more apt to follow. For the same reason, Mr. Abernethy thinks pieces of wood, cork, &c. hurtful, and when employed with a view of hindering the ligature from cutting completely through the artery, their interposition is not necessary, as such an accident scarcely ever occurs, and, as they would prevent the ligature from dividing tiie inner and muscular coat, (see Hemorrhage) they would tend to prevent the adhesion of the opposite sides of the vessel to each other. When the artery is tied in Mr. Aber- nethy's manner, and is divided in the space between the ligatures, it becomes quite lax, possesses its natural attach- ments, and is, as nearly as possible, in the same circumstances as the femoral artery is, when tied on the surface of a stump.—(See Surg, and Physiol. Essays by J. Abernethy.) Notwithstanding Scarpa has excelled other writers so much, in his descrip- tion of the anatomy and formation of aneurisms, his practice in regard to the operation, is certainly far inferior to Mr. Abernethy's, and that of prac- titioners in general in this country. His interposing a cylindrical roll of" linen, between the artery and knot of the liga- ture, and his not bringing the sides of the wound together immediately after the operation", arc particularly objec- tionable parts of his method. There is one excellence, however, in Scarpa's mode of operating, which 1 think will soon obtain the universal ap- probation of the surgical profession; he prefers malting the incision in the up- per third of the thigh, or a little higher than the place where Mr. Hunter used to make the wound. His reason for this, is to avoid the necessity of removing the 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 the best operators embarras- sed, by having the sartorius muscle im- mediately in their way after the first incision, and as the vessel is more su- perficial a little higher up, the place is further from the diseased part of the ar- tery, and there is no hazard of the anas- tomoses failing to keep up the circula- tion ; this part of Scarpa's practice is highly deserving of imitation. It will in no manner diminish the merit of those men, who have successfully la- boured to improve the present part of the practice of surgery, to state, that the most ancient surgeons seem to have known and practised lome of the chief things, upon which the superiority of the plan now adopted appears princi- pally to depend. Such methods having quite sunk into oblivion, and John Hun- ter not being one who pried into old works, his innovations claim all the honour due to the strictest originality. It is a fact, worthy of* notice, that the Greeks were acquainted with the prac- tice, lately commended, of tying and di- viding the trunk of the artery high above the tumour, as will appear from the following extract: (AStit. 4 Serm. Tetr. 4 cap. 10.) At vero quod in cubili cavitatefit aneurisma, hoc modo per chir- urgiam aggredimur : primum arteria su- perne ab ala ad cubitumper internum bra- chii parte simplicem sectionem, tribus, ant quatuor digitis infra ulam, per longitudi- nem facimus, itbi maxime ad tuctun arte- ANEURISM. 67 r/a occurrit; alque eapaulatim denvdata, deinceps incumbentia corpuscula sensim excoriamus ac separamus, et ipsam arte- riam cceco uncino attract am duobus fili vincidis probe adstringimus, mediamque inter duo vinculo dissecamus ; et sectio- nempoUine thuris expkmus, ac linamentis indilis congruas deligationes adhibemus. Afterwards we are directed to open the aneurismal tumour at the bend of the elbow, and when the blood has been evacuated, to tie the artery twice, and divide it again. If the ancients had only omitted the latter part of their opera- tion, they would absolutely have left nothing to be discovered by the mo- derns. What a striking example of the bold manner in which our forefathers have acted, without being guided by the light of anatomy and physiology ! but there are two or three passages in Ga- len, Celsus, and Hippocrates, from which we may suspect, that even iEtius him- self was not the inventor of tliis opera- tion, &c. See also Paul. ASgin. lib. 6. cap. 37. (Rees's Cyclopedia Art. Aneu- rism.) Mr. Astley Cooper has published a case of popliteal aneurism, in which a particular occurrence happened, that led this gentleman to make a little in- novation in tiie method of tying arte- ries for the cure of aneurisms. The femoral artery had been tied with two ligatures, as firmly as could be done without risk of cutting it through. " But, (says Mr. A. Cooper) as 1 was proceeding to dress the wound, I saw a stream of blood issuing from tiie ar- tery, and when the blood was sponged away, one of the ligatures was found detached from the vessel. Soon after the other was also forced off, and thus the divided femoral artery was left without a ligature, and unless immedi- ate assistance had been afforded him, the patient must have perished under hemorrhage." The same kind of accident has oc- curred in Mr. Chile's practice. These events naturally induced Mr. A. Cooper to reflect on the means, whicii were to be employed to obviate them, and the first which suggested it- self 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 ar- teries must be divided, and that it was a mode of security (if it was so) which rould only apply to particular cases of aueurism, since, in some situations of that disease, there is scarcely any length of vessel between the tumour and a principal anastomosing branch of the artery. Mr. A. Cooper thinks, that a plan of greater security, and more general ap- plication, consists in conveying the liga- ture, by means of two blunt needles un- der the artery, an inch asunder, and close to the coats of the vessel, exclud- ing the vein and nerve, but passing the threads through the cellular membrane surrounding the artery. When these are tied,, and the artery is divided be- tween them, the ligatures will be pre- vented from slipping from the artery by the cellular membrane through which they are passed. Mr. A. Cooper next relates a case of aneurism after bleeding, which he cured by this way of operating. " But although this plan, as to the event, answered my expectations, yet a different mode of securing the ligature, suggested to me by my young friend Mr. H. Cline, struck me so forcibly for its simplicity and security that I felt immediately disposed to adopt it." Mr. A. Cooper put the new plan to the test of experiment in operating for a politeal aneurism on Henry Figg, aged 29. " An incision being made on the middle of the inner part of the thigh, and the femoral artery expo- sed, the artery was separated from the vein and nerve, and all the sur- rounding parts, to the extent of an inch, and an eye-probe, armed with a double ligature, having a curved nee- dle at each end, was conveyed under the artery, and the probe cut away. The ligature nearest the groin was ti- ed ; tiie other was separated an inch from the first, and tied also. Then the needles were passed through the coats of tiie artery, close to each ligature and between them. The thread they car- ried, was tied into tiie knot of tiie liga- ture, which had been already secured around the vessel; and thus a barrier was formed in the artery, beyond 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 observations are necessary, and these I shall offer with due deference to the eminent character, whose fame alone has attached undue importance to th* innovation. 6& ANEURISM. In the first place I shall prove that Mr. Cline's proposal is not an original one; In the 13th chapter, on hemor- rhage, in Richter's Anfangsgrunde der Ji undarzneykunst, we read the follow- ing passage. Die hervorgczogagane Schlder umwickelt ?nan nut dem gewohn- lichcn Faden zweymal, befestigt densel- ben mit einem Knoten, ziehet derauf, wenn die Schhigudcr gross ist, vermittekl einer J\"adel em ende des Fudens vor der Un- terbindung durch dieseibe, kn&ft beyde Enden zusammen, und liisst sie wk gew- uhnlich herabhdngen. Dritte Aufiage. 1799." The artery, when drawn out, is to be twice surrounded with tiie com- mon ligature. 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 ordinary way. Kdition 3. 1799. I do not mean to as- sert, how ever, that the same plan may not be described in some more ancient work than Richter's : my object is to remove the supposition, that the world is indebted to Mr. II. Cline for the sug- gestion, if we may use the term indebt- ed, when the plan has certainly very little merit, and would undoubtedly ne- ver have acquired much celebrity, had not Mr. A. Cooper's name been coupled with it. What power can possibly force the ligature, when tied with the due tight- ness, oft' the extremity of" the vessel ? It' Mr. A. Copper had reflected a little, he would have seen, that no action of the heart, or artery itself, no turgid state of this vessel, could do so. It" a piece of string were tied round any tube for the purpose of preventing a fluid from escaping from its mouth, provided the string is applied with due tightness, no fluid can possibly es- cape, however great the propelling power may be, supposing that the string, and structure of the tube, do not break. If the ligature be applied so slackly as to slip, who can doubt, that a he- morrhage will still follow, even though tiie ligature is carried through the end of the vessel, and tied in the way men- tioned above. In the cases, in wliich the ligatures slipped off, as mentioned by Mr. A. Cooper, we must, therefore, conclude that the arteries were not tied with sufficient tightness, perhaps through an unfounded fear that a ligature, might? cut its way completely through all the coats of an artery. The inner coats of the artery we know, from the experU ments of Dr. Jones, are invariably cut through when the vessel is properly tied, and the circumstance is alwa)S useful in promoting its closure. OF ANEURISMS HIGH UP THE FE- MORAL ARTERV. Mr. Abernethy has been called upon in three cases to take up the external iliac artery. The events of all these have shewn, that the anastomosing ves- sels were fully capable of conveying blood enough into the limb below, and that a vessel even of this size could be- come permanently closed after being tied. Messrs. Freer and Tomlinson, of Birmingham, have both also done the same operation with success. Our limits, however, will only allow us to describe tiie operation, and the parti- culars must be consulted in Abernethy'8 Surg, and Physiol. Essays,- his Surgi- cal Observations, 1804. Edinb. Med. and Surg. Journal for January, 1807; and Freer's Observations on Aneurism, 1807. In Mr. Abernethy's first operation of this kind, an incision, about three inch- es in length, was made through the in- teguments of the abdomen, in the di- rection of the artery, and thus the apo- neurosis of the external oblique muscle was laid bare. This was next divided, from its connexion with Poupart's liga- ment, in tiie direction of the external wound, for the extent of about two inches. The margins of the internal oblique and transverse muscles being thus exposed, Mr. Abernethy intro- duced his fingers beneath them to pro- tect the peritoneum, and then divided them. Next he pushed this membrane with its contents upwards and inwards, and took hold of the external iliac ar- tery with his fingers and thumb. It now only remained to pass a ligature round the artery, and tie it; but, this required caution on account of* the contiguity of the vein to the artery. These Mr. A. separated with his fingers, and intro- ducing a ligature under the artery with a common surgical needle, tied it about an inch and a half above Poupart's li- gament. (Surg. Essays.) The following was the method Mr. Abernethy adopted the second time of tying the external Uiae artery. ANEURISM. 69 An incision of three inches in length was made through the integuments of the abdomen, beginning a little above Poupart's ligaments, and being conti- nued upwards; it was more than half an inch on the outside of the upper part of the abdominal ring, to avoid the epi- gastric artery. The aponeurosis of the external oblique muscle being thus ex- posed, was next divided, in tiie direc- tion of" the external wound. The lower part of the internal oblique muscle was thus uncovered, and the finger being introduced below the inferior margin of it and of the transversalis muscle, they were divided by tiie crooked bis- toury for about one inch and a half. Mr. Abernethy now introduced his fin- ger beneath the bag of the peritoneum, and carried it upwards by the side of the psoas muscle, so as to touch tiie artery about two inches above Pou- part's ligament. He took care to dis- turb the peritoneum as little as possi- ble, detaching it to no greater extent than would serve to admit his two fin- gers to touch the vessel. The pulsa- tions of the artery made it clearly dis- tinguishable, but Mr. Abernethy could not get his finger round it with facility. He was obliged to make a slight inci- sion on either side of it, in the same manner as is necessary when it is taken up in the thigh, where the facia whicii binds it down in its situation is strong. After tliis the forefinger could be put beneath the artery, whicii Mr. A. drew gently down, so as to see it behind the peritoneum. By means of an eyed- probe two ligatures were conveyed round the vessel; one of these w as carried upwards as far as the artery had been detached, and the other downwards: they were firmly tied, and the vessel was divided in the in- terspace between them. (Surg. Observ. 1804.) Mr. Abernethy, in his third instance of tying- this vessel, operated exactly as in the foregoing case, and with com- plete success. (See Edinb. Surg. Journ. Jan. 1807.) Mr. Freer, in his operation, made an incision about one inch and a half from the spine of the ilium, beginning about an inch above it, and extendingit down- wards about three inches and a half, so as to form altogether an incision four inches and a half long, extending to tiie base of the tumour. The tendon of the external oblique being exposed, was carefully opened, and also the in- ternal oblique, when the finger was introduced between the peritoneum and transversalis, and served as a di- rector for the crooked bistoury, which divided the muscle. Avoiding all un- necessary disturbance, Mr. Freer se- parated the peritoneum with his finger, till he could feel the artery beating, wliich was so firmly bound down, that he could not get his finger under it without dividing its fascia. The vessel being separated from the surrounding parts, a curved blunt needle, armed with a strong ligature was put under it, and tied very tight with the inten- tion of dividing the internal coats of the vessel. The operation led to a perfect cure. (Freer on Aneurism, p. 83.) Mr. Tomlinson applied only one liga- ture and, of course, left the artery un- divided : the event was attended with perfect success. The two last cases, on which Mr.- Abernethy operated, I was an eye-wit- ness of, and can, therefore, bear wit- ness to the simplicity and ease of the necessary operation. Perhaps, howe- ver, it would be better not to have re- course to it before the circumstances, were urgent. Tying the external iliac artery must at hast be deemed dange- rous, in regard to some chance of he- morrhage, though I think, from the cases already on record, there is not much risk of the anastomoses not be- ing sufficient. Besides there is always a certain chance of an aneurism getting spontaneously well, as did the aneu- rism" in the groin liuly under the care of my friend Mr. Albert, in the York Hospital. Ought a surgeon, however, to wait till the tumour extends too high to allow an operation to be done I I think not. ANEURISMS OF THE BRACHIAL ARTERV, AND THE OPE- RATION FOR THEM. Surgical writings contain many his- tories of aneurisms in the bend of the arm, produced by the puncture of the brachial artery in venesection, or caused by a deep wound inflicted at the bend of the arm, along the inner side of the humerus, or in the axilla. Such cases must indisputably be formed by effu- sion. Although Morand, &c. have found, that along with aneurisms, caused by a wound of the brachial 70 ANEURISM. artery, the diameter of the vessel is sometimes unusually enlarged through its whole length, above the seat of the tumour, this enlargement, which is very rare, might have existed natural- ly, before the puncture occurred. Even were it frequent, such an equa- ble longitudinal expansion of the tube of the artery could not explain the for- mation of the aneurismal sac in the bend of the arm, along the inner side of the humerus, or in the axilla, after wounds. (Scarpa, p. 160.) The proximate cause of these cases may invariably be traced to the solu- tion of continuity in the two proper coats of the artery, and the consequent effusion of blood into the cellular sub- stance. The effect is the same, whe- ther from an internal morbid affection, • apable of ulcerating the internal and fibrous coats of the artery, the blood be effused into the neighbouring cellu- lar sheath surrounding the artery, whicii it raises after the manner of an aneurismal sac; or, the wound of the integuments having closed, the blood issue from the artery, and be diffused in the surrounding parts. The cellular substance, on the outside of the wound- ed vessel is first injected, as in ecchy- mosis; the blood then distends it, and elevates it in the form of a tumour, and, the cellular divisions being destroyed converts it at last into a firm capsule, or aneurismal sac. (Scarpa, p. 167.) The circumscribed or the diffused nature of the aneurism, and the rapi- dity or slowness of its formation, de- pend on the greater or less resistance to the impetus of the blood, during the time of its effusion, by the interstices of the cellular substance surrounding the artery, and by the ligamentous fascia; and aponeuroses, lying over the sac. The aponeurosis of the bi- ceps muscle being only half an inch broad, and situated lower than the common place for bleeding, cannot, at least, in most cases, materially strength- en the cellular substance surrounding the artery, as is commonly supposed. Scarpa, p. 168—170. This author re- fers tiie greatest resistance to the in- termuscular ligament, which after hav- ing covered the body of the biceps muscle extends over the whole course of the humeral artery, and is implant- ed into the internal condyle. This li- gamentous expansion has a triangular shape, the base of whicii extends from the tendon of the biceps, to the inter- nal condyle, while the apex reaches upward along the inner side of the hu merus towards the os brachii. The humeral artery and median nerve, kept. in their situation by the cellular sheath, and this ligamentous expansion run in the furrow, formed between it and the internal margin of the biceps.—Scarpa, 171. This author anatomically explains many circumstances relative to the dif- fusion, circumscription, shape, &c. of brachial aneurisms, from this intermus- cular ligament. While aneurisms, from internal cause, are not unfrequent in the aorta, and ham, they are very rare in the brachial artery ; but, such in- stances, however, are recorded.— (Scarpa, 176 ) The mode of distinguishing a wound of the brachial artery, in attempting to bleed, and the method of trying to ef- fect a cure by pressure, are described in the article Hemorrhage. Anel is said to have been the first who tied the brachial artery, for the cure of aneurisms in the arm, in the same way tliat Hunter did the femoral, for the cure of those in the ham, viz. witii one ligature above the tumour, without making any incision upon, or into, the sac itself. 1'he operation is performed as fol- lows :—tiie surgeon having traced the course of the brachial artery, and felt its pulsations above the aneurism, he may either cut down to the vessel im- mediately above the tumour, or much higher, in the long space between the origins of the superior and inferior col- lateral arteries. The integuments are to be divided in the course of the arte- ry, and also the cellular sheath, for the space of about two inches and a half. The surgeon now introducing his left fore-finger to the bottom of the wound, will feel the denuded vessel, and, if it is not sufficiently bare, he must divide the parts which still cover it, observing to introduce the edge of the knife, on the side next to the internal margin of the biceps, to avoid dividing any of the numerous muscular branches, which go off" from the opposite side of the ar- tery. He is then to insulate, with the point of his finger, the trunk of tiie vessel, alone if he can, or together with the median nerve and vein, and raise it a little from tiie bottom of the wound. He is to separate the median nerve and vein, for a small space from the artery, and with an eyed needle is to pass a> ANEURISM 71 ligature under the latter, and then tie it with a simple knot. Whoever, after these directions, says Scarpa, shall have the treatment of a circumscribed aneurism in the bend of the arm, will no longer, it is to be hoped, follow the niSthod of those, who, supposing the tumour to be form- ed by the dilatation of the artery, used first to divide the integuments over the tumour, insulated the sac, and sought for the vessel above and below the aneurism, in order to tie it in two pla- ces; and then endeavoured to make the sac slough away. The operation is now reduced to the greatest simplicity, viz. tying the artery merely above the tu- mour. (See Scarpa, p. 358, 359.) When the aneurism is diffused, and accompanied with violent inflammation and swelling of the whole arm, from the excessive distention of" the clots of effused blood, Scarpa recommends the old operation of opening the tumour, and tying the artery at the bottom of" the sac, above and below the wound made by the lancet. In this method it will be proper to apply a tourniquet to the upper part of the arm, near the ax- illa ; or, if the limb should be very painful and swelled, it is better to let an assistant compress the artery from above the clavicle, against the first rib. The incision having been made into the tumour, and the blood discharged, a probe is to be introduced into the punc- ture in the vessel, from below upwards, so as to raise the artery. This, being separated from the parts beneath, and the median nerve, for a small extent, is to have two ligatures put under it, one of whicii is to be tied above, the other below, the wound in the vessel. Then the tourniquet, or pressure, is to be taken off, and if there be no bleed- ing, the wound is to be brought toge- ther.—(See Scurpa, p. 359.) mr. Lambert's proposal. Having observed, after an operation performed in the common way, by a li- gature above and below the aperture in the artery, such violent pain, swell- ing and inflammation, as threatened gangrene of the limb, and which symp- toms, when mitigated, left the arm weak, and with a much more feeble pulse, than in tiie other arm, this gen- tleman wished to sec the operation done, so as to make less disturbance of the circulation. I recollected, he re- marks, all that I had seen or read of the effects of styptics, of pressure, and of ligatures, in tiie cure of hemorrha- ges. I considered the coats and mo- tions of arteries, and compared . vrir wounds with the wounds of veins and other parts. I reflected upon the pro- cess of nature in the cure of wounds in general, and considered, in particular, how the union of" divided parts was brought about in the operation of the hare-lip, and in horses' necks, that are hied by farriers. Upon the whole, 1 was in hopes, that a suture of the wound in the artery might be successful; and, if so, it would certainly be preferable to tying up the trunk of the vessel. I communicated my thoughts to Mr. Hai- lowell, Mr. Keenlyside, and some other friends of the profession. A case of an aneurism from bleeding occurred, and fell to Mr. Hallowell's lot. I recom- mended the method I have hinted. He put it in execution June 15, 1759. Eve- ry thing was done in the usual method, till the artery was laid bare, and its wound discovered; and the tourniquet being now slackened, the gush of Wood per sultum shewed there was no decep- tion. Next, two ligatures, one above the orifice, and one below, were passed under the artery, that they might be ready to be tied at any time, in case the method proposed should fail. Then a small steel pin, rather more than a quarter of an inch long, was passed through the two lips of the wound in the artery, and secured by twisting a thread round it, as in the hare lip. This was found to stop the bleeding, upon which the arm was bound up, the pa- tient put to bed, and ordered to be kept quiet, &e." The pin came away with the dressings, June 29, and July 19th, the patient, was discharged from the hospital perfectly well, and with a pulse in that arm nearly as strong as in the other. Indeed the pulse was very little altered immediately after the opera- tion; it was weakened in a small de- gree, as might be expected from the diameter of the vessel being straiten- ed; but it was so strong and equal, that we had not the least doubt of the blood's continuing to circubite freely tiiroi;.rh it."— (Medical Uiservutums and Inquiries, Vol. 2.) > We need hardly inform the reader, that the idea of healing- the wound in the vessel, so as to preserve the pervi- ous state of it, is a mere hypothesis, certainly never realized by adopting 72 ANEURISM Mr. Lambert's method. If ever a small puncture of an artery heal, so as to leave the tube pervious, it is under the circumstances pointed out by Dr. Jones. (Sec Hemorrhage.) Had Lambert had an opportunity of examining the state of the vesscljsome time after the above operation, he would have found its ca- nal obliterated; and tiie preservation of the perviousness of the artery being the only foundation for Lambert's me- thod, the practice must of* course fall to the ground. AXILLARY ANEURISMS. Aneurisms occasionally take place in the axilla, and rather than that the patient should perish of hemorrhage, it is the duty of the surgeon to tie the ax- illary artery, if it be necessary, even as far inward, as where it proceeds over the first rib. This operation, however, should only be done in urgent circum- stances, as when the aneurism is far advanced, makes tiie arm very cede- matous, and insupportably painful, and when the tumour is in danger of burst- ing. For, in all cases of aneurism; there is a certain chance of the disease getting spontaneously well; and one axillary aneurism in a man in St. Bar- tholomew's Hospital a few years ago, had certainly disappeared of itself, as was proved by the account which the man gave of the case while living, and by the obliteration of* the artery, found on inspection after death. A wound of the axillary artery, might render it necessary to do this opera- tion. This vessel was tied by a Mr. Hall, in Cheshire, when it had been wounded with a scythe, so as to bring the ends of the artery into view; and the arm was preserved, though it re- mained afterwards a little weak, wliich indeed, might be owing to some large nerve being divided. (See Scarpa, p. 372.) Mr. White, of Manchester, re- lates another instance of this vessel be- ing tied, in the case of a wound; but, mortification of the limb, and death followed. Three of the nerves were found included in the ligature.—Lon- don Medical Journal, Vol. 4. In a case of axillary aneurism, which had actually burst, and the hemor- rhage from which could only be stopped by pressing the artery against the first rib, Mr. Keate, the surgeon-general, practised the following operation, whicii a-as attended with completely success- ful consequences. This gentleman de- termined on taking up the artery, above the diseased and ruptured part, in its passage over the &st rib. According- ly, he made aninufion obliquely down- wards, dividoipuc- fibres of the pecto- ral muscle, thff were in his way, and, when he came to the artery, passed a curved, blunt-pointed, silver needle, armed double, as he conceived, under the artery, and tied two of the ends. After a careful examination, finding that tiie artery pulsated below the liga- ture, he determined on passing another ligature higher up, and nearer to the clavicle: he, therefore, passed the nee- dle more deeply, so as evidently to in- clude the arterv. In a few days the swelling of the arm began to subside, the wound suppurated, and the liga- tures came away with the dressings The arm afterwards recovered its feel- ing, and the patient regained, in a great measure, the entire motion of the shoul- der, &c. Med. Review and Magazine for 1801. ' The axillary artery might certainly be got at by making an incision above the clavicle, and it is undoubtedly not a very difficult plan to accomplish in the dead subject, without any tumour under the clavicle. But 1 do not think it so eligible as Mr. Keate's, in a living subject, having a large axillary aneu- rism ; for, then die clavicle becomes so much elevated, and the artery lies so deeply below it, that it is exceedingly difficult to get at the vessel. This was the case in an attempt which I once saw made to tie the artery, and in whicii one of the cervical nerves, affected by the pulsations of the artery, was mis- taken for it, and tied, so that the aneu- rism soon afterwards burst, and a fatal hemorrhage arose. Were a surgeon^ however, to choose operating abovethe clavicle, he might adopt the following plan :—An incision should be made just over the sternal end of the clavicle, and the clavicular portion of the sterno-clei- do-mastoideus muscle detached with a blunt pointed curved bistoury. No fur- ther use should be made of a cutting instrument. The chief difficulty would now be, to get a ligature under the ar- tery; but, it might, perhaps be-done with the aid of" an aneurismal needle. As the artery communicates its pulsa- tions to the cervical nerves in the vici- nity, the operator should be particular- ly careful not to mistake one of them for the vessel itself. ANEURISM. ' v CAROTID ANEURISMS. The possibility of tying the carotid ar- "* ter), in cases of wounds and aneurisms, without any injurious effect on the functions of the brain, now seems com- pletely proved. I'etit mentions, that the advocate Vieillard, had an aneurism at the bifurcation of the right carotid, for the cure of whicii he was ordered a very spare diet, and directed to avoid all violent exercise. Three months af- ter this prescription, the tumour had evidently diminished; and, at last, it was converted into a small, hard, ob- long, knot, without any pulsation. The patient having died of apoplexy, the right carotid was found closed up and obliterated, from its bifurcation, as low down as the right subclavian artery.— Acad, des Sciences de Paris, an. 1765. Hebenstreit, vol. 5, of bis Translation of B. Bell's Surgery, mentions a case, in which the carotid artery was wound- ed, in extirpating a scirrhous tumour. The hemorrhage would have been fa- tal, had not the surgeon immediately- tied the trunk of the vessel. The pa- tient lived many years afterwards. Mr. Abernethy was under the neces- sity of tying the trunk of the carotid, in the case of a large, lacerated wound of the neck, in which accident the in- ternal carotid, and all the branches in front of the external one, were wound- ed. The patient seemed to be going on very well at first, but in the night he became delirious and convulsed, and died about thirty hours after the liga- ture was applied. Mr. A. considers the delirium and the inflammatory appear- ance found on the brain, on opening the body, as the effects of stopping the supply of blood to the brain. I was fortunate enough to be a spectator of this interesting case, and, with due de- ference to Mr. Abernethy, cannot help thinking, especially when the above facts press on my mind, that the deli- rium might more properly be regarded as the consequence of so terrible a lace- rated wound as tliis poor man received. Stopping the flow of blood to a part, has always been considered a chief means of averting inflammation of it, not bringing it on. Mr. A. Cooper tied the carotid for an aneurism ; the ligature came away on the twelfth day after the operation ; on the seventeenth, inflammation took place in the aneurismal sac, and pro- ceeded to suppuration. The conse- VOL. I. quence was, that such pressure was produced on the trachea and oesopha- gus, that the woman died suffocated on the twenty-first day. In order to get at the carotid artery in the safest manner, Mr. Abernethy has recommended making an incision on that side of it next the trachea, where no important parts are exposed to injury, and dien to pass a finger un- derneath the vessel. The par vagum must be carefully excluded from the ligature; for, to tie it would be fatal.— (Surgical Observations, 1804.) ANEURISMAL VARIX, OR VENOUS ANEURISM. The seat of this tumour is, in gene- ral, in the basilic vein, whicii is enlar- ged, so as to form an oblong swelling, in the middle of which is the scar, made by the lancet in bleeding. The tumour seldom extends more than two inches above and below the injury; beyond this distance the vein regains its natu- ral size. 4t Dr. W. Hunter is undoubtedly the first who gave an accurate description of this disease, although Professor Scarpa is disposed to claim a share of the merit for his own countryman Gu- attani, who, about the same time when Dr. Hunter wrote in the Medical Ob- servations and Inquiries, published the history of two cases of aneurismal va- rix. " Does it ever happen in surgery,'* says Dr. Hunter, " that when an artery is opened through a vein, a communi- cation, or anastomosis, is afterwards kept up between these two vessels ? It is easy to conceive this case, and it is not long, since I was consulted about one, that had all the symptoms that might be expected, supposing such a tiling to have actually happened, and such symptoms, as otherwise must be allowed to be very unaccountable. It arose from bleeding; and was of some years' standing, when I saw it about two years ago, and I understand very little alteration has happened to it since that time. The veins, at the bending of the arm, and especially the basilic, which was the vein that had been open- ed, were there prodigiously enlarged, and came gradually to their natural size, at about two inches above, and as much below the elbow. When empti- ed by pressure, they filled again almost instantaneously, and tilis happened. 74 ANEURISM. (ven when a ligature was applied tight round the fore-arm, immediately below the affected part. Both when the liga- ture was made tight, and when it was removed, they shrunk, and remained of a small size, while the finger was kept tight upon the artery, at tiie part where the vein had been opened in bleeding. There was a general swell- ing in the place, and in tiie direction of the artery, which seemed larger, and beat stronger, than what is natural, and there was a tremulous jarring motion in the vein, which was strongest at the part, wliich had been punctured, and became insensible at some distance both upwards and downwards." (Me- tlical Observations and Inquiries, Vol. 1.) In the second volume of this work, Dr. Hunter adds some further remarks on tiie aneurismal varix. " In the operation of bleeding, the lancet is plunged into the artery through both sides of the vein, and there will be three wounds made in these vessels, viz. two in the vein and one in the ar- tery, afid these w ill be nearly opposite to one another, and to the wound in the skin. This is what all surgeons know has often happened in bleeding, and the injury done the artery is commonly known by the jerking impetuosity of the stream, whilst it flows from the vein, and by the difficulty of stopping it, when a sufficient quantity is drawn." "In the next place, we must sup- pose, that the wound of tiie skin, and Of the adjacent, or upper side of the vein, heal up as usual; but, that the wound of the artery, and of* the adja- cent, or under side of tiie vein, remain open, (as the wound of the artery does in the spurious aneurism) and, by that means, the blood is thrown from the trunk of the artery, directly into the trunk of the vein. Extraordinary as this supposition may appear, in reality it differs from the common spurious aneurism in one circumstance only, viz. the wotmd remaining open in the side of the vein, as well as in the side of the artery. But, this one circumstance will occasion a great deal of difference in the symptoms, in the tendency of the complaint, and in the proper method of treating it: upon which account the knowledge of such a case will be of importance in surgery." '• It will differ in its symptoms from the common spurious aneurism princi- pally thus. The vein will be dilated, or become varicose, and it will have a pulsating jarring motion on account of the stream from the artery. It will make a hissing noise, which will be found to correspond with the pulse for the same reason. The blood of the tumour will be altogether, or almost entirely fluid, because kept in constant motion. The artery, I apprehend, will become larger in the arm, and smaller at the wrist, than it was in the natural state; which will be found out by com- paring the size, and the pulse, of* the artery in both arms, at these different places. The reason of whicii I shall speak of hereafter. And the effects of ligatures, and of pressure upon the vessels above the elbow and below it, will be what every person may readily conceive, who understands any thing of arteries and veins in the living body." " The natural tendency of such a complaint will be very different from that of the spurious aneurism. The one is growing worse every hour, be- cause of the resistance to the arterial blood, and if not remedied by surgeiy must at last burst. The other, in a short time, comes to a nearly perma- nent state; and, if not disturbed, pro- duces no mischief, because there is no considerable resistance to the blood. that is forced out of the artery." " The proper treatment must, there- fore be very different in these two ca- ses, the spurious aneurism requiring chirurgical assistance, as much, per- haps, as any disease whatever; where- as, in the other case, I presume it will be best to do nothing." " If such cases do happen, they will no doubt be found to differ among themselves, in many little circumstan- ces, and particularly in the shape, &c. of the tumefied parts. Thus the dila- tation of the veins may be in one only, or in several, and may extend lower, or higher, in one case, than in another, &c according to the manner of branch- ing, and to the state of the valves in different arms. And the dilatation of the veins may, also, vary, on account of the size of the artery, that is wound- ed, and of the size of the orifice in the artery and in the vein." "Another difference in such cases will arise from the different manner, in which the orifice of the artery may be united, or continued with the orifice of the vein. In one case, the trunk of the vein may keep close to the trunk of the artery, and the very thin stratum of cellular membrane between them, ANEURISM may, by means of a little inflammation and coagulation of the blood among its filaments, as it were, solder the two orifices of these vessels together, so that there shall be nothing like a canal going from one to the other; and then the whole tumefaction will be more re- gular, and more evidently a dilatation of the veins only. In other instances the blood, that rushes from the wound- ed artery, meeting with some difficulty of admission and passage through the vein, may dilate the cellular membrane, between the artery and vein, into a bag, as in a common spurious aneu- rism, and so make a sort of canal be- tween these two vessels. The trunk of the vein will then be removed to some distance from the trunk of the artery, and the bag will be situated chiefly upon the under side of die vein. The bag may take on an irregular form, from tiie cellular membrane be- ing more loose, and yielding, at one place, than at another, and from being unequally bound down by the fascia of the biceps muscle. And if the bag be very large, especially, if it be of an ir- regular figure, no doubt, coagulations of blood may he formed, as in the com- mon spurious aneurism." After relating two cases, very illus- trative of tiie nature of the aneurismal varix, Dr. W. Hunter proceeds to inquire: " Why is the pulse at the wrist, so much weaker in the diseased arm, than in the other; surely, the rea- son is obvious and clear. If the blood can easily escape from tiie trunk of the vein, it is natural to think, that it will be driven along tiie extreme branches with less force, and in less quantity." 2. " Whence is it, that the artery is enlarged all the way down the arm; I am of opinion, that it is the conse- quence of tiie blood passing so readily from the artery into the vein, and is such an extension, as happens to all arteries, in growing bodies, and to the arteries of particular parts, when the parts themselves increase in their bulk, and, at the same time, retain a vascular structure. It is well known, that the arteries of the uterus grow much larg- er in the time of utero-gestation. I once saw a fleshy tumour upon the top of a man's head, as large nearly as his head; and his temporal and occipital arteries, whicii fed the tumour, were enlarged in proportion. I have ob- served the same change in the arteries of enlarged spleen;,, testes, &c. so that 1 should suppose it will be found to be universally true in fact, and the reason of it in theory seems evident." (See Medical Observations and Inquiries Vol. 2-) Professor Scarpa, Dr. Hunter, Mr. B. Bell, Pott, and Garneri, mention cases of the aneurismal varix, which remain- ed stationary for fourteen, twenty, and thirty-five years. Several cases are re- lated byBrambilla, Guattani, and Mon- teggia, of a cure having been obtained by means of compression. But, as this method of cure, if it does not succeed, exposes the patient to the danger of a complication of the disease with an aneurism, it ought not to be employed, except in recent cases, where the tu- mour is small, and in slender patients, at an early period of life, and where both of the vessels can be compressed accurately against the bone. If the dis- ease is complicated with an aneurism, which threatens to become diffused, we are under the necessity of having recourse to an operation. Scarpa. ANEURISM FROM ANASTOMOSIS. This is the term, wliich Mr. John Bell, of Edinburgh, has given to a spe- cies of aneurism, whicii resembles such bloody tumours, (navi materni) as ap- pear in new-born children, grow to a large size, and, ultimately bursting, emit a considerable quantity of blood. The aneurism from anastomosis oft- en affects adults, increasing from an appearance like that of a mere speck, or pimple, to a formidable disease, anil being composed of a mutual enlarge- ment of the smaller arteries and veins. The disease originates from some acci- dental cause; is marked by a perpetual throbbing; grows slowly, but incon- trollably; and is rather irritated, than checked, by compression. The throb- bing is at first indistinct, but when the tumour is perfectly formed, the pulsa- tion is veiy manifest. Every exertion makes tiie throbbing more evident. The occasional turgid states of the tu- mour produce sacs of blood in die cel- lular substance, or dilated veins, and these sacs form little tender, livid, ve- ry thin, points, which burst, from time to time, and then, like other aneurisms, this one bleeds so profusely, as to in- duce extreme weakness.. The tumour is a congeries of active vessels, and the cellular substance, tlirough which these vessels, are ex 76 ANE ANT panded, resembles, as Mr. John Bell describes, the gills of a turkey cock, or the substance of the placenta, spleen, or womb. The irritated and incessant action of the arteries fills the cells with blood, and from these cells, it is reabsorbed by the veins. The size of the swelling is increased by exercise, drinking, emotions of the mind, and by all causes wliich accelerate the cir- culation. Mr. John Bell states, that the he- morrhage from the aneurism by anas- tomosis usurps, in the female subject, tiie place of menstruation. " This aneurism, observes the above writer, is a mere congeries of active vessels, which will not be cured by opening it; all attempts to obliterate the disease with caustics, after a sim- ple incision, have proved unsuccessful, nor does the interrupting of particular vessels, wliich lead to it, affect the tu- mour ; the whole group of vessels must be extirpated. In varicose veins, or in aneurisms of individual arteries, or in extravasations of blood, such as that produced under the scalp from blows upon the temporal artery, or in those aneurisms, produced in school- boys by pulling the hair, and, also, in those bloody effusions from blows on the head, which have a distinct pulsa- tion, the process of cutting up the va- rix, aneurism, or extravasation, enables you to obliterate the vessel and perform an easy cure. But, in this enlargement of innumerable small vessels, in this aneurism by anastomosis, the rule is ' not to cut into, but to cut it out.' These purple and ill looking tumours, because they are large, beating, pain- ful, covered with scabs, and bleeding, like a cancer in the last stage of ulce- ration, have been but too often pro- nounced cancers! incurable bleeding cancers! and the remarks, which I have made, while they tend, in some mea- sure, to explain the nature and conse- quences of the disease, will remind you of various unhappy cases, where either partial incisions only had been practised, or the patient left entirely to his fate." (See John Bell's Principles of Surgery, Vol. 1.) For information on aneurism, read Louth's Scriptores de Aneurismatibus, which contains Guattani, Asmt.n, &c. A paper by Mr. Home in the Medical and Cfururgicul Transactions. Some Cases and Remarks by Mr. Abernethy, inter- spersed in his Works. Monro's Observ. in the Edinb. Med. Essays. Various productions in the Med. Observ. and In- quiries. The Artick Aneurism in Rees's Cyclopadia. Freer's Observations on Aneurism, 1807. Above all, a Treatise on the Anatomy, Pathology, and Surgical Treatment of Aneurism by A. Scarpa, translated by J. H. Wishart, 1808. The original Italian was published 1804. ANODYNES, (from a. neg. and a£w» pain.) Medicines are so termed, which diminish, or remove, pain, and they are indicated in surgery in all cases, in which it is desirable to relieve any in- tense pain. Opium is the principal one deserving confidence. ANTHRACOSIS, (from av6g«£, a burning coal.) A red, livid, burning, sloughy, very painful, tumour, occur- ring on the eyelids. At first, antiphlo- gistic means are proper; but the grand thing is to make a free and early open- ing for the discharge of the matter con- tained in the swelling. The eyelids and eye should be bathed with a colly- rium, and kept cool with the saturnine lotion. ANTHRAX, (*v8g*f, a burning coal,) See Carbuncle. ANTIMONIUM CALC1NATUM.— (Supposed to be very similar to James's Powder.) Is commonly called the an- timonial powder. In all cases of sur- gery, in which it is desirable to pro- mote the secretions in general, and those of urine, perspiration, and of the alimentary canal, in particular, it is proper to have recourse to this im- portant preparation. In all inflamma- tions of the brain and its membranes, and, in every instance, in which there exists an inflammation of a viscus of high importance in the system, anti- mony should be exhibited, and, in ge- neral, the antimonial powder is as eli- gible a prescription as any. For an adult, four or five grains may be or- dered, and the dose, if requisite, may be repeated two or three times a day. ANTIMONIUM MURIATU.M. This has often been named, butter of anti- mony, and is employed in surgery as a caustic. ANTIMONIUM TARTAR1SATUM. Emetic Tartar. This medicine is well known as the most common emetic. For this purpose, it may be given in either of the following ways, as the in- dications^of the case may demand. Jg. AMT ANT 77 Antimonii Tart. gr. ij. \q. distil. Jiv. Miscectcola. Dosis *?ij.proemetico; vel Jss quadrante quoque horse, donee supervenerit vomitus. If tartarised antimony be exhibited merely to excite a diaphorocsis, half an ounce, or one table spoonful, of the above mixture is to be given once every six hours. This preparation is very much em- ployed by the best continental surgeons, for increasing the gastric secretions, and maintaining, for a length of time, a lax state of the bowels. We shall have occasion to notice its efficacy in the cure of numerous surgical dis- eases. ANTIPHLOGISTICS, (from avrt, against, and 9hty&, to burn.) All means are so termed, which have a tendency to subdue inflammation. (See Inflam- mation.) The first of these, to whicii the sur- geon should direct his attention, when he wishes to cure an inflammatory affec- tion, is to remove as far as it is in his power, the occasional cause. Extrane- ous bodies,lodged in parts, susceptible of this kind of irritation, and which substances produce inflammation by their mechanical operation, should be extracted as soon as possible, if their particular situation, shape, &c. will admit of it. The removal of substances, which irritate by their chemical pro- perties, is difficult, and sometimes im- practicable. On account of their great activity, however it is necessary to oppose their effects, without loss of time. This is accomplished, in a certain degree, by diluting such substances with aqueous fluids, defending the parts from their action by oily and sedative applications; and, by correcting the specific irritation of the substances applied, by means of other substances, wliich have a particu- lar affinity with them. Antiphlogistic remedies, properly so called, arc divided "-into general ones, by which are meant such as affect the whole system; and into topical ones, the operation of which is, at least, for a certain time, entirely local and cir- cumscribed. General antiphlogistics are.- 1. Bleed- ing. (See this word.) 2. Clysters, and gentle laxative me- dicines. The most active cathartics may sometimes be considered in tiie same light; but, there are many inflam- mations, in which the effect of strong purgatives is hurtful and dangerous. Such are, in particular, all instances, in wliich there is inflammation of the thoracic, and abdominal viscera. 3. Aqueous diluting beverages,taken in large quantities. 4. The warm bath. 5. Cooling medicines, such as acid drinks, saline draughts, and some of the neutral salts, such as nitre, the ammonia muriata, aq. amnion, acet.; &c. 6. Anodynes, especially opium, only to be given, however, under the cir- cumstances, and in the way, to be no- ticed in the article, Inflammation. With these, direct means of diminish- ing the action of tiie sanguiferous sys- tem, we must combine a more, or less complete abstinence from all solid ani- mal food. Too warm an atmosphere should also be avoided, as well as all stimulants whatever, every kind of noise, every thing likely to alarm, or disturb the mind, Sec. Topical antiphlogistics arc: 1. Local bleeding practised by means of leeches scarifications, or cupping. 2. Emollient poultices, which are proper, when the inflammation is ac- companied by an extraordinary degree of pain and hardness, ami, especially, when it is disposed to suppurate. The best emollient poultice is that of linseed oil described in the article Inflamma- tion. Some use the one made of bread and milk; some disliking milk, in conse- quence of its inutility, and its ten- dency to turn sour, only use water; while others make the bread into a poultice by softening it and beating it up, with Goulard's lotion. 3. Discutients are particularly used in all cases, in which the inflammation is less acute, and seems to have no tendency to suppurate. Cold water, va- rious preparations containing lead, a solution of sal ammoniac in vinegar and water, spirit of wine, vinegar, xther, the various infusions of bitter aromat- ic plants, and the decoction of bark, are very good discutient remedies. 4. The maintenance of a continual evaporation from the surface of the in- flamed part, by applying folded linen, wet with the lotio aq. litharg. acet. cold water, a solution of zincum vitriolatum, 8cc. Spirits, xther, snow, or powdered ice, produce more cold, and, are some- times, though not very commonly, made use of. This is the ordinary principle, 78 ANTRUM on which surgeons conduct the local treatment of phlegmonous inflamma- tion, when there is the prospect of avoiding- the formation of an abscess. 5. Fomentations. These are prepa- red by dipping flannels in some warm liquor, squeezing a certain quantity of fluid out of them, and then placing them quite warm on the inflamed part. They are mostly used in cases, in which emollient poultices are the permanent local applications, and when the patient suffers extraordinary pain. A decoction of white poppy heads, or camomile flowers, is the liquor commonly em- ployed. Fomentations are very tempo- rary means, being only applied in gene- ral, about half an hour, two, or three times a day. The best opportunity of doing this, is when the poultice is to be changed. 6. Among the means, essential to an antiphlogistic regimen, perfect quie- tude, both of body and mind, is not the least important. (See Inflammation.) En- cyclopedic Methodique ; Partie Chirur- gicale. ANTISEPTICS, from a.vn against, ond aKToe, to putrify.) This name is given to such remedies, as are supposed to have the virtue of resisting the tenden- cy to putrefaction in the human body, or to arrest its progress, after it has commenced. According to these ideas, they are indicated in cases of mortifica- tion, and sloughing ulcers. The greatest part of antiphlogistic remedies are also antiseptic, as we shall see the reason of in the article Mortification. The most renowned an- tiseptic remedies of the internal kind, are vegetable, and mineral acids, fluids impregnated with carbonic acid gas, wine, aromatics, camphor, bitters, in general, and, particularly, bark. The chief external antiseptic applications are preparations of lead, cold water, snow, ice, spirits, turpentine, or aro- matics, such as camomile flowers, rue ike. It has also been recommended to apply the carbonic acid gas itself. This may" be done, either by directing the air against the parts affected through a funnel, as soon as the gas is extricated from the substances, which contain it; or by applying to the parts affected poultices, composed of such ingredi- ents, as will ferment, and form a large quantity of the gas. (See l'Encyclopedic .Methodique ,- Pirtie Cldrurgicak.) ANTRUM MAX1LLARE. This is a considerable cavity, situated in the up- per jaw bone. It is also named the Si' nus Maxillarit, or Antrum Hirhmoria- num, from the name of an anatomist, who gave the first accurate description of it. The antra are liable to several mor- bid affections. Sometimes, their mem- branous lining inflames, and secretes- pus. At other times, in consequence of inflammation, or other causes, vari- ous excrescences and fungi are produ- ced in them. Their bony parietes are occasionally affected with exostosis, or caries. Extraneous bodies may be lodged in them, and, it is even asserted, that insects may be generated in them, and cause, for many years, very afflict- ing pains. ABSCESSES IN THE ANTRUM. Of all the above cases, this is far the most common. Violent blows on the cheeks, inflammatory affections of the adjacent parts, and, especially, of the pituitary membrane lining the nostrils, exposure to cold and damp, and, above all things, bad teeth, may induce in- flammation and suppuration in the an- trum. The first symptom is a pain, at first imagined to be a tooth-ach, parti- cularly if there should be a carious tooth, at this part of the jaw. This pain, however, extends more into the nose, than that usually does, which arises from a decayed tooth ; it also af- fects, more or less, the eye, the orbit, and the situation of the frontal sinuses. But, even such symptoms are insuffi- cient to characterize the disease, the nature of wliich is not unequivocally evinced, till a much later period. The complaint is, in general, of much long- er duration, than one entirely depen- dent on a caries of a tooth, and its vio- lence increases more and more, until, at last, a hard tumour becomes percep- tible below the cheek bone. The swell- ing, by degrees, extends over the whole cheek; but, it afterwards rises to a point, and forms a very circumscribed hardness, whicii may be felt above the back grinders. This symptom is ac- companied by redness, and sometimes by inflammation and suppuration of the external parts. It is not uncommon, al- so, for the outward abscess to commu- nicate with the antrum. The circumscribed elevation of the tumour, however, does not occur in all cases. There are instances, in which ANTRUM. 79 the matter makes its way towards the palate, causing the bones df 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 other examples, in which matter, formed in the antrum, makes its exit at the nostril of the same side, when the patient is lying with his head on the opposite one, in a low position. If this mode of evacuation should be frequent- ly repeated, it prevents the tumour, both from pointing externally, and bursting, as it would do if the puru- lent matter could find no otiier vent. But this evacuation of pus from the nos- trils is not very common ; for, accord- ing to Mr. Hunter, the opening between the antrum and cavity of the nose, is generally stopped up. This celebrated anatomist even seems inclined to think, that the disease may sometimes be oc- casioned by the impervious state of this opening, in consequence of whicii ob- struction, the natural mucus of the an- trum may collect there in such quanti- ty, as to irritate and inflame the mem- brane, with which it is in contact. This may happen in the same way as an ob- struction in the ductus nasalis hinders the passage of the tears into the nose, and causes an abscess in the lachrymal sac. However, in the majority of cases, we may conclude, that the impervious state of the opening is rather an effect, than the cause, of the disease, since in- flammation in the antrum is often mani- festly produced by causes of a different kind, and since the opening in question is not invariably closed. Abscesses in the antrum require a free exit for their contents, and, if the surgeon neglects to procure such open- ing, the bones become more distend- ed and pushed out, and, finally, ca- rious. When this happens, tiie 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 becomes fistulous. In all cases tiie principal indication is to discharge the matter, whether the pus is simply confined in the antrum, or whether the case be conjoined with a cnous affection of" the bones. Tiie ancients seem to have known very little of the treatment of diseases of the antrum. Drake, an English ana- tomist, is reputed to be the first propo- ser of a plan for curing abscesses of tliis cavity., Meibomius, however, had, a long while before him, proposed, with the same intention, to extract one or more of the teeth, in order that the matter might find an opening for its es- cape, through the sockets. This plan may be employed with success. The pus frequently has a tendency to make its way outward towards the teeth; it often effects their fanjs; and, after their extraction, the w.iole of the ab- cess is seen to escape through the sock- ets. But this very simple plan will not suffice for all cases, as there are nume- rous instances, in vliich there is no communication between the alveoli and the antrum. Drake, and, perhaps, before him, Cowper, took notice jf the insufficiency of Meibomius's mefhod, and, hence, they proposed makng a perforation through the socket into the antrum with an awl, for the purpose of letting out the matter, and njecting into the cavity such fluids as were judged pro- per. The extraction of one or more teetb, and the perforation of the alveoli, being essential steps in treating diseases of the antrum, we must consider what tooth ought to be tiken out in prefer- ence to others. A caries, or even a mere continual aching, of any particular tooth, in «-e- neral ought to decide the choice. But if all the teeth should be sound, wliich is not often the case, writers direct us to tap each of them gently, and to ex- tract the one, which gives most pain on this being done. When no information can be thus obtained, ather circumstan- ces ought to guide us. All the grinding teeth, except the first, correspond with me antrum. Thev even sometimes extend into this cavity, and the fangs are only covered by the pituitary membrane. The bony lamella, which separates the antrum from the alveoli, is extenuated, towards the back part of the upper jaw. Hence, it is best, when tiie choice is in our power, to ex- tract the third or fourth grinder, as, in this situation, the alveoli can be more easily perforated. Though, in general, the first grinder and canine tooth do not communicate with the antrum, yet, their fangs occasionally approach the side of tliis cavity When one or more teedi are carious, they should be removed, because they 80 ANTRUM are both useless and hurtful. The mat- ter frequently makes its escape, as soon as a tooth is extracted, in consequence of the fang having extended into tiie antrum, or rather in consequence of its bringing away with it a piece of the thin partition between it and the sinus. Per- haps a discharge may follow from the partition itself being carious. If the opening, thus produced, be sufficiently- large to allow the matter to escape, the operation is already completed. But as it can easily be enlarged, it ought al- ways to be so when there is the least suspicion of its being too small. How- ever, when no pus makes its appear- ance, after a tootii is extracted, the an- trum must be opened by introducing a pointed instrument in the direction of the alveoli. Some use a small trocar, or awl; others a jimblet for this pur- pose. The patient should sit on the ground, in a strong light, resting his head on the surgeon's knee, vho is to sit behind him. Immediately when the instrument has reached the cavity, it is to be with- drawn. Its entrance into the antrum is easily known by the cessation of re- sistance. After the matter is dischar- ged, surgeons advise the opening to be stopped up with a wooden stopper, to keep victuals fron. getting into the an- trum. The stopper is to be taken out, se- veral times a day, to allow the pus to escape. This plan soon disposes the parts affected to discontinue the suppu- ration, and resume their natural state. Sometimes, however, the pus continues to be discharged, for a long time after the operation, without any change oc- curring, in regard to its quality or quan- titv. In such instances tiie cure may often be accelerated by employing in- jections of brandy and water, hme-wa- ter, or a solution of zincuni vitriola- tum. Some surgeons prefer a silver can- nula instead of t'le stopper, as it can always be left pervious except at meals. If no opening- were made in the an- trum, the matter would make its way, sometimes, towards the front of this cavity, which is very thin ; sometimes, towards the mouth, and fistulous open- ings, and caries would inevitably fol- low. When the bones are carious, the above plan will not accomplish a cure, until the affected pieces of bone exfoli- ate. A probe will generally enable us to detect any caries in th- antrum The? fetid smell, and ichorous appearance of the discharge, also, leave little doubt that the bones are diseased; and, in proportion as the bones free themselves of any dead portions, the discharge has less smell, and its consistence becomes thicker. There are cases, in which there are loose pieces of dead bone to be extract- ed, and, in which it is requisite to make a larger opening into the antrum, than can be obtained, at its lower part. In- stances also occur, in which patients have lost all the grinding teeth, and the sockets are quite obliterated, so that a perforation from below could hardly be effected. Some practitioners have also objected to ever sacrificing a sound tooth. In these circumstances, it has been advised to make a perfora- tion in the antrum, above the alveolary processes. M. Lamorier is the first who proposed this method. It consists in making a transverse incision, below the malar process, and above the root of the third grinder. Thus the gum and periosteum are divided, and the bone exposed. A perforating instru- ment is to be conveyed into the middle of this incision and the opening in the antrum made as large as requisite. There are cases of very extensive ex- foliations of the antrum, in which it is absolutely necessary to expose a great part of the surface of tiie bone, and to cut away the dead pieces wliich are wedged, as it were, in the living ones. A small trephine may sometimes be advantageously applied to the malar process of the superior maxillary bone. Surgeons formerly treated carious affections of the antrum in the most absurd and unscientific way, introdu- cing setons 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 detachment of a dead portion of bone, in other terms, the process of exfoliation, is nearly, if not entirely, tile work of na- ture, in which the surgeon can at most only act a very inferior part. Indeed, he should limit his interference to pre- venting the lodgment of matter, main- taining strict cleanliness, and removing the dead pieces of bone, as soon as they become loose. But, it is to be understood, that there arc occasional ANTRUM. 81 examples, in which the dead portions of bone are so tedious of separation, and so wedged in the substance of the surl»unding living bone, that an at- tempt may be properly made to cut them away. TUMOURS OT THE ANTRUM. Ruysch, Bordenaave, Desault, Aber- netUy, and many others, have recorded cases of polypous, fungous, and can- cerous diseases of the antrum, and of the parietes of this cavity being affect- ed with exostosis. The indolence of any ordinary fleshy tumour in the antrum, while in an inci- pient state, certainly tends to conceal its existence; but, such a disease rare- ly occurs without being accompanied by some affection of the neighbouring parts, and, hence, its presence may ge- nerally be ascertained before it has at- tained such a size as to have altered tiie conformation of the antrum. This information may be acquired by exa- mining, whether any of the teeth have become loose, or have spontaneously fallen out; whether the alveolary pro- cesses are sound, and whether there are any fungous excrescences making their appearance at the sockets; whe- ther there is any habitual bleeding from one side of the nose; any sarcomatous tumour at the side of the nostril, or to- wards tiie great angle of the eye. When the swelling has attained a certain size, the bony parietes of the antrum are al- ways protruded outwards, unless the body of the tumour should be situated in the nostril, and only its root in tiie antrum. Tliis case, however, is very uncommon. As soon as a tumour is certainly known to exist in the antrum, the front part of this cavity should be opened, without waiting till the disease makes further progress. In a few instances, indeed, we may avail ourselves of the opening, wliich is sometimes found in the alveolary process, and enlarge it sufficiently to allow the tumour to be extirpated. If the front of the antrum were freely opened, it would in general be better to cut away the disease in Its interior. A swelling of the parietes of the an- trum, in consequence of an abscess, or a sarcomatous tumour in its cavity, may lead us to suppose the case an enlargement of the bones, or an exos- tosis. The symptoms of the two first VOL. i affections have been already detailed. A sign of an exostosis is, when besides the absence of the symptoms charac- terizing an abscess or a sarcoma, the thickened parietes of the antrum form a solid resistance; whereas, in cases of mere expansion, the dimensions of the surface of the bone being increased, While its substance is proportionally extenuated, the resistance is not so con- siderable. When such an exostosis depends up- on a particular constitutional cause, apd especially, upon one of a venereal nature, it must be attacked by reme- dies suited to this affection. But when the disease resists internal remedies, and its magnitude is likely to produce an aggravation of the case, a portion of the bone may be removed with a tre- phine, 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 dif- ferent from what we have mentioned, since instead of its being distinguisha- ble from other diseases of the antrum by the greater firmness of the tumour, Uie substance of the bone gradually ac- quires such suppleness and elasticity, tiiat it yields to the pressure of the fin- gers, and immediately resumes its for- mer plumpness, when the pressure is discontinued. If the bone be cut, it is found to be as soft as cartilage, and, in an advanced stage of the disease, its consistence is almost gelatinous. The swelling increases gradually, and ex- tends 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 recommended in other ca- ses of exostosis, only exasperate the patient's unhappy condition. Mr. Abernethy has related an ac- count of a very singular disease of the antrum. The patient, who was 34 years of age when the account was written, perceived, when about ten years old, a small tumour on his left cheek, which gradually attained the size of a walnut, and then remained, for some time, sta- tionary. About a year afterwards, the tumour having again enlarged, a caus- tic was applied to the integuments, so as to expose the bone. The actual cau- tery was next applied, and an opening U 82 ANTRUM. thus made into the antrum. After the exfoliation of the antrum became filled with a fungus, which rose out upon the cheek, and could not be restrained by any applications. Part of the fungus also made its way into the mouth, through the socket of the second tri- rc-aspid 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 29th year, the whole fungus sloughed away during a fever, and has not returned. • After this tiie sides of the aperture in the bone began to grow outwards, forming an exostosis, which has grown to a great magnitude. A smali exostosis took place in the mouth, but became no larger than a horse bean. The exostosis of the maxillary bone is of an irregular figure, and pro- jects from the whole circumference of the aperture a great way dircdtly for- ward. Mr. Abernethy compares its appearance, when he was writing, with that of a large tea-cup fastened upon the face, the bottom of whicii may be supposed to communicate with the an- trum. The diameter of the cup, form- id by tiie circular edge of the bone was 3 inches and a half; the depth 2 inches and seven-eighths. The general height of the sides of the exostosis, from the basis of the face was 2 inches; its walls were not thick, and terminated in a thin circular edge. The integuments, as they approach this edge, become exte- nuated, and the}' extend over the edge into the cavity. The exostosis now reaches to the nose in front, and to the masseter muscle behind; above it in- cludes the very ridge of the orbit, and below it grows from the edge of the alveolary process. A line that would have separated 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. (Med. Chi- rurg. Trans. Vol. 2.) In a case of fungus growing in the antrum, and whicht had distended the antrum, hindered the tears from pass- ing down into the nose, raised the low- er part of the orbit, caused a protrusi- on of the eye, made two of the grinding teeth fall out, and occasioned a carious opening in the front of the antrum, through which opening a piece of the fungus projected, Desault operated as follows: The cheek was first detached from tiie os maxillare, by dividing the internal membrane of the mouth, at the place where it is reflected over tliis bone. Thus, the outer surface of the bone was denuded of all the soft parts. A sharp, perforating instrument was applied to the middle of tliis 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, Jms obtained, being insufficient, Desault endeavoured to enlarge it below, by sa- crificing the alveolary process. This he endeavoured to accomplish with the same instrument, but, finding the re- sistance too great, he had recourse to a gouge and mallet. A considerable piece of the alveolary arch was thus detached, without any previous extrac- tion of the corresponding 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 ad- mit a walnut, Through this aperture a considerable part of the tumour was cut away with a knife, curved side- ways, and fixed in its handle. A most profuse hemorrhage took place, but Desault, unalarmed, held a compress in the antrum for a short time; this being removed, the actual cautery was applied repeatedly to the rest of the fungus. The cavity was dressed with lint, dipped in powdered colophony. On the eighteenth day the swelling was evidently diminished, the eye less prominent, and the epiphora less visi- ble. 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 25th day, and required a third and last re- course to the cautery. From tliis time the progress of the cure went on rapid- ly. Instead of fungous excrescences, healthy granulations were now formed in the bottom of the sinus. The pari- etes of the antrum, gradually approach- ing each other, the large opening made hi 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, at which time no vesti- ges of the disease remained, except the loss of teeth, and a very obvious de- pression just where they were situated. ANTRUM. 83 In all fungous diseases pf thai-an- trum, making a free exposure of them is an essential part of the treatment: if you neglect this method, how can you inform yourself of the size, form, and extent, of the tumour ? I low could yo'i remove the whole of the fungus, through a small opening, which would only allow you to see a very little por- tion of the excrescence? How could you be certain that the disease were extirpated, to its very root? Even when the antrum is freely opened, this cir- cumsttocc can only be learnt with dif- ficulty ; and how could it be ascertain- ed, when only a point of the cavity is opened ? A portion, left behind, veiy soon gives origin to a fresh fungus, the progress of wliich is more rapid, and the character more fatal, in conse- quence of being irritated by the surgi- cal measures adopted.—( (Euvres Chi- rurgicaks de Desault, Tom. 2. par Bi- chat. I imagine that English surgeons, un- accustomed to use the actual cautery, will peruse with a degree of aversion, tliis means so commonly applied in France by Desault, and other celebra- ted surgeons. Nor can 1 expect that they will altogether approve the use of the mallet and gouge, for making a free opening into the antrum. Per- haps, it might be better to trephine this cavity with a small instrument for the purpose, and then cut the fungus away. After removing as much of it as possi- ble in this manner, some instrument of suitable shape might be used to scrape the part, where the tumour has its root. However, if there be any case in whicii potent and violent measures, like Desault's, are allowable, it is the one of which we have just been treat- ing. Inveterate diseases demand pow- erful means, and tampering with them is generally more hurt'ul than useful. There is an interesting case of a fun- gus in the maxillary sinus, related hi the first volume of die Parisian Chirur- gical Journal. It was at last cured by opening the antrum, applying the cau- tery, and tying the portion of the tu- mour, wliich had made its way into the nose. In the second volume of tiie same work, is an excellent case, exhi- biting the dreadful ravages which the disease may produce when left to itself. INSECTS IX THE ANTRUM. It is said, that insects in this cavity sometimes make it necessary to open the part. This case, however* must be exceedingly rare, and even what we find in authors (Pallas de insectis viveu- tibus intra viventia,) appears so little authentic, that we should hard!) have thought it necessary to make mention of the circumstance, if there were not, in a modern work (Med. Comin. Vol. 1.) a fact which appears entitled to impli- cit belief. Mr. Heyshum, a medical practitioner at Carlisle, relates, that a strong woman, aged sixty, in the habft of taking a great deal of snuff", was subject, for several years, to acute pains in the antrum, extending over one side of the head. These pains never en- tirely ceased, but were more severe in winter than summer, and were always subject to frequent periodical exaspe- rations. The patient had taken seve- ral anodyne medicines, and others, without benefit, and had twite under- gone a course of mercury, by whicii her complaints had been increased. All her teeth on the affected side had been drawn. At length it was determined to open the antrum with a large trocar, though there were no symptoms of an abscess, nor of any other disease in tliis cavity. For four days no benefit re- sulted from this operation. During this space, bark injections, and the elix- ir of aloes, were introduced into the simus. On the fifth day a dead insect was extracted, by means of a pair of forceps, from the mouth of" the cavity. It was more than an inch long, and thicker than a common quill. The pa- tient now experienced relief for several hours; but, the pains afterwards re- curred with as much severity as before; od was next injected into the antrum, and two other insects, similar to the ^ former, were extracted. No odiers ap- peared, and the wound closed- The pains were not completely removed, but they were considerably diminished for several montiis, at the end of wliich time they became worse than ever, par- ticularly affecting the situation of tiie frontal sinus. Mr. Bordenaave has published, in the fourth and fifth volumes of the Mem. de I'Aeml. de Chir. two excellent papers on the diseases of the antrum. In the fifth volume he relates the history of" a case, in which a great many w orms, together widi a piece of fetid fungus, were discharged from the antrum, af- ter an opening had been made on ac count of an abscess of the antrum, at 84 ANUS. tended with caries. But, in tliis in- stance, the worms had probably been generated after the opening had been made in the cavity; for, when they made their appearance the opening had existed nine months.—(See on this sub- ject VEncyclopedic Methodique, Partie Chirurgicale. Mem. de I'Acad. de Chi- rurgie. Parisian Cldrurgical Journal. QSiivres de Desault par Bichat. Med>- eal Communications, Vol. 1.) ANUS. The lower termination of the great intestine, named the rectum, is so called, and its office is to form an outlet for the faces. The anus is furnished with muscles, which are peculiar to it; viz. the sphincter, which keeps it habitually closed, and the kvatores am, which serve to draw it up into its natural si- tuation, after the expulsion of the fae- ces. It is also surrounded, as well as the whole of the neighbouring intes- tine, with muscular fibres, and a very loose sort of cellular substance. The anus is subject to various disea- ses, in which the aid of surgery is re- quisite; of these we shall next treat. IMPERFORATED ANUS. This complaint is sometimes met with, though not very often. As it is of the ntmost consequence that such mal-for- mations should not remain long un- known, one of the earliest duties of an accfoucheur, after delivery, should be the examination of all the natural out- lets of the new-born infant. Such an inspection sometimes evin- ces, that the place in which the extre- mity of the rectum, or the anus, ought to be, is entirely, or partly, shut up by the membrane, or fleshy adhesion. In other instances, no vestige of" the in- testine can be found, as the skin retains its natural colour Over the whole space, between the parts of generation and the os coccygis, without being more elevated in one place than another. In such cases the intestine sometimes ter- minates in one of the two culs-de-sac, about an inch upward from the ordina- ry situation of the anus. Sometimes it does not descend lower than the upper part of the sacrum; sometimes it opens into the bladder, or vagina. When a surgeon is consulted for such tSases, he must not lose much time in deliberation; for, if a speedy opening be not made for the faeces, the infant will certainly very soon peri&b, with symptoms similar to those ofa strangu- lated hernia. After ascertaining the complaint, which is an easy matter, we should endeavour to Irani, whether the anus is merely shut by a membrane, or fleshy adhesion: or whether the anus is altogether wanting, in conse- quence of the lower portion of the ca- vity of the gut being obliterated, or the rectum not extending sufficiently far down. When a membrane, or production of the skin closes the opening of the rec- tum, the part producing the obstruc- tion, is somewhat different in colour from the neighbouring integuments. It is usually ofa purple or livid hue, in consequence of the accumulations 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 as before, when the pressure is removed. When a fleshy adhesion closes the intestine, the circumstance is obvious to the eye, if the part protrude, which is generally the case. The finger feels greater hardness and resistance, than when there is a mere membrane, and the li- vid colour of the meconium cannot be seen through the obstructing sub- stance. These last signs alone are enough to convince the surgeon of the necessity of the operation; but, they do not clear- ly shew, whether the intestine descends, as far as it ought, in order to form a pro- per kind of anus. Complete informa- tion 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 has proved ineffectual. Though there be no mark to denote, where the anus ought to be situated, and no degree of prominence, yielding, like soft dough, to the pres- sure of the fingers, and rising again, when such pressure is removed; yet, it may happen, especially on our being consulted immediately after the child is born, that, notwithstanding the ab- sence of such symptoms, denoting the presence of the meconium, and the na- tural 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 membrane, or adhesion, closing it. When the anus is only covered with skin, and its place pointed out by a prominence, arising from the contents ANUS. 85 of the rectum, we have only to make an opening with a knife, sufficient to let out the meconium. Levret recom- mends making a circular incision in the membrane; but, a transverse cut is sufficient. A small tent of lint is af- terwards to be introduced, in order to keep the opening from closing. If the anus should only be partly closed by a membrane, the opening may be 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 de- notes where the situation of the anus orngh* to be, tiie case is much more se- rious and embarrassing; and this, whe- ther the intestine is stopped lip by a fleshy adhesion, or the coalescence of its sides, or whether a part of the gut a 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 direction 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, a- long the concavity of the os coccygis, where there is no danger of wounding any part of importance. In all cases of this kind, the surgeon's finger is the best director. The operator, guided by the index finger of his left hand, in- troduced within the os coccygis, is to dissect in the direction above recom- mended, until he readies the faeces, 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 introducing, upon the finger, a long trocar, in such a direction as seems best calculated for finding the rectum. By the prudent adoption of such pro- ceedings, many infants have been pre- served, which otherwise would have been devoted to certain death. Hilda- nus, La Motte, Roonhuysen, and many others, have successfully adopted the above practice. Mr. B. Bell informs us, he has seen two of these cases, in which the intestine was very distant from the integuments, and in which he was so successful, as to form an anus, which fulfilled its office tolerably well for se- veral years ; but, he found it exceed- ingly difficult to keep the passage suf- ficiently large and pervious. As soon as he removed the dossils of hnt, and other kinds of tents, used for maintain- ing the necessary dilatation, such a do* gree of contraction speedily followed, that the evacuation of the intestinal matter became very difficult, for a long while afterwards. He employed, at dif- ferent times, tents made of .sponge, gentian root, and other substances, which swell on being moistened. But these always produced so much pain and irritation, that it was impossible to persevere in their use. After remark- ing such inconveniences, he recom- mends, in opposition to the advice of other authors, not to make use of such tents ie these cases. He is of opinioD, that whoever makes trial of them upon parts, as sensible as the rectum, will soon find, that the advice of the writers alluded to is ill founded. Tents, made of very soft lint, dipped hi oil, or rolls of bougie plaster, cause less irritation,' than those composed of any other materials. Though keeping the opening dilated may seem simple and easy, to such men as have had no opportunities of seeing cases of this description, it is far other-, wise in practice. Mr. Bell assures us, that he never met with any disease, which gave him so much trouble and embarrassment, as he experienced in the two cases of tliis sort, whicii occur- ed in his practice. Although in both instances he at first made the openings sufficiently large, it was only by very assiduous attention, for eight or ten months, that the necessity for another operation, and even repeated ones, was prevented. When only the skin hus been divided, the rest of the treatment is doubtless more simple; for, then, nothing more is requisite, than keeping a piece of lint, for a few days, in the opening made with the knife. But, when the extremity of the rectum is at a cer- tain distance, though we may general- ly hope to effect a cure, after having succeeded in giving vent to the intesti- nal matter; yet, the treatment, after the operation, will always demand a great deal of attention and care on the part of the surgeon, for a long while. The difficulty of success may be consi- dered as, in some measure, proportion- ed to the depth of the necessary inci- sion. 86 ANUS. Sometimes, while tiie anus appears pervious and well-formed, infants su£ fer the same symptoms, as if there were no anus at all. The reason of this de- pends upon the intestine being occasi- onally closed by a membranous parti- tion, situated more or less upward, above the aperture of the anus, and, sometimes the symptoms are owing to the termination of the gut in a cul-de- sac. This erroneous formation may al- ways be suspected, whenever an infant, whose anus is externally open, does not void any excrement, for two or three days after its birth, and, especially, when urgent symptoms arise, such as swelling of the belly, vomiting, &o. We are now to endeavour to ascertain, whether the rectum is impervious above the anus, by attempting to inject glys- ters, or to introduce a probe. If the gut be shut up, there is nothing to be done, but having recourse to the me- thod described above, and forming a communication by means of a bistoury guided on the finger, or else with a pharyngotomus. If the obstacle should only consist of a transverse membrane, the operation will be easy, and its suc- cess almost certain. But, if there should be a strangulation, or obstruction of the intestine, the case is infinitely more serious. 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 intestine sometimes opens into the va- gina, or bladder. The first of these cases is the least dangerous of all the malformations of this sort. The intes- tine may also open, and terminate at two places, at the same time, viz. at the usual place, so as to form a proper anus, more or less perfect; and also in the vagina. If these two openings should be am- ple enough for the easy evacuation of the excrement, nothing can be done at so tender an age ; for, Uiough voiding the feces through the vagina, is a most unpleasant inconvenience, yet, there is no effectual means of closing the open- ing of the intestine in this situation, nor could one be devised, which would not seriously incommode the infant. But, when the two openings are ex- ceedingly small, and the alvine evacua- tions cannot readily pass out, even with the aid of" glysters, the opening of the anus ought to be dilated by cannulae of different sizes. If this method should not avail, the knife must be employed, and the wound dressed, as already ex- plained. For the most part, the intestine has only one opening in the vagina. - In this circumstance, as in the instance in whicii the faeces have no vent at all, we must make an incision in that place, wliich the anus ought to occupy. The natural course of the faeces being open- ed by the operation, which in such a case is not at all perilous, much less excrement will pass out of the vagina, and, of course, the infirmity will be di- minished. By the introduction of a tube into the new anus, the communi- cation between the rectum and vagina might possibly be obliterated, and a perfect cure accomplished. The open- ing between the intestine and vagina, may, also, be too small for the easy eva- cuation of the' faces, and this might even expose the infant to the same sort of dangerous symptoms, as it would be subject to, if the rectum had positively no opening at all. rf" In male infants, the rectum some- times opens into the bladder, and, in this circumstance, there is generally no anus. The case is easily known by the meconium being blended with the urine, which acquires a thick greenish appearance, and is voided almost con- tinually, though in small quantities. The most fluid part of the meconium, is the only one voided in this manner. The thicker part not getting from the rectum into the bladder, nor from the bladder into the urethra,, greatly dis- tends the intestines and bladder, and produces the same symptoms, as take place, in case of total impcrforation* Hence, without the speedy interference of art to form an anus, capable of giv- ing vent to the faeces, with which the urinary orgaus cannot remain obstruct- ed, the infant will inevitably die. This case must, therefore, be treated like the foregoing ones. Though we can hardly hope to completely prevent the incon- veniences, resulting from the rectum opening into the bladder, since even a new passage will not completely hinder the faeces from following the other course; yet, we shall thus afford the child a very good chance of preserva- tion, and the only one which its situa- tion will allow In cases, in which we cannot procure an outlet for the faeces, by any of the methods pointed oui above, it iia^ been proposed to make an opening into the ANUS. 87 abdomen above the pubis, or on the right Side, in order to get at the colon, and form an artificial anus, in one of these situations. But the prospect of success would be so small, that the plan is "not likely to be much adopted. (See Medicine Operatoirc, par Sabatier.) Anus, abscesses of. Fistula in Ano. The custom of giving the appellation offistida to every collection of matter formed near to the anus, has, by con- veying a false notion of them, been pro- ductive of such methods of treating them, as are diametrically opposite to those which ought to be pursued. A email orifice or outlet from a large or deep" cavity, discharging a thin gleet, or sanies, made a considerable part of the idea, which our ancestors had of a fistulous sore, wherever seated. With the term fistulous, they always connec- ted a notion of callosity: and, there- fore, whenever they found such a kind of opening yielding such sort of dis- charge, and attended with any degree of induration, they called the complaint a fistula. Imagining this callosity to be a diseased alteration made in the very structure of the parts, they had no con- ception that it could be cured by any means, but by removal with a cutting instrument, or by destruction with es- charotics : and, therefore, they imme- diately attacked it with "knife or caus- tic, m order to accomplish one of these ends : and very terrible work they of- ten made. That abscesses, formed near the fun- dament, do sometimes, from bad ha- bits, from extreme neglect, or from gross mistreatment, become fistulous, is certain; but the majority of them have not, at first, any one character or mark of a true fistula; nor can, with- out the most supine neglect on the side of the patient, or the most ignorant mismanagement on the part of the sur- geon, degenerate, or be converted into one. Collections of matter from inflamma- tion (wherever formed) if they be not opened in time, and in a proper manner, do often burst. The hole, through which the matter finds vent, is gene- rally small, and not often situated in the most convenient, or most depend- ent part of the tumour: it therefore is unfit for the discharge of all the con- tents of the abscess; and, instead of closing, contracts itself to a smaller size, and becoming hard at its edges, continues to drain off what is furnished by the undigested sides of the cavi- ty. When an abscess about the anus bursts, the smallness of the accidental orifice; the hardness of its edges; its being found to be the outlet from a deep cavity; the daily discharge of a thin, gieety, discoloured kind of matter; and the induration of the parts round about, have all contributed to raise, and con- firm the idea of a true fistula. Upon this idea was built the old per- nicious doctrine of free excision, or as free destruction. Abscesses about the anus present themselves in different forms. Sometimes the attack is made with symptoms of high inflammation; with pain, fever, rigor, &c. and the fever ends as soon as the abscess is form- ed. In this case, a part of the buttock near to the anus is considerably swoll- en, and has a large circumscribed hard- ness. In a short time, the middle of this hardness becomes red, and inflam- ed; and in the centre of it matter is formed. This (in the language of our ances- tors) is called in general a phkgmon ; but wlien it appears in this particular part, a phyma. The pain is sometimes great, the fe- ver high, tiie tumour large, and exqui- sitely tender; but however disagreeable the appearances may have been, or how- ever high the symptoms may have risen, before suppuration, yet, when that end is fairly and fully accomplished, the pa- tient generally becomes easy and cool; and the matter formed under such cir- cumstances, though it may be plenti- ful, yet is good. On die other hand, the external parts, after much pain, attended with fever, sickness, &c, are sometimes attacked with considerable inflammation, but without any of that circumscribed hardness, which characterized the pre- ceding 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 mat- ter small, and the cellular membrane sloughy to a considerable extent. Sometimes, instead of either of the preceding appearances, there is formed in this part, what the French call une suppuration gangreneuse,- in which the cellular and adipose membrane is affect- 88 ATTCS. ed in the same manner, as it is In the disease called a carbuncle. In this case the skin is of a dusky red or purple kind of colour; and al- though harder than when in a natural state, yet it has, by no means, that de- gree of tension or resistance, which it has either in the pldegmon, or in the erysipelas. The patient has generally, at first, a hard, full, jan-ing pulse, with great thirst, and very fatiguing restlessness. If the progress of the disease be net stopped, or the patient relieved by me- dicine, the pulse soon changes into an unequal, low, faultering one ; and the strength and the spirits sink in such manner, as to imply great and imme- diately-impending mischief. The mat- ter formed under the skin, so altered, is small in quantity, and bad in quality; and the adipose membrane is gangre- nous and sloughy throughout the ex- tent of the discoloration. This gene- rally happens to persons, whose habit is either naturally bad, or rendered so "by intemperance. In each of these different affections, the whole malady is often confined to the skin and cellular membrane under- neath it; and no other symptoms at- tend, than the usual general ones,' or Much as arise from the formation of matter or sloughs in the part imme- diately affected. But it also often hap- pens, that, added to these, the patient is made unhappy by complaints arising from an influence, wliich such mischief has on parts in the neighbourhood of the disease; such as the urinary blad- der, the vagina, the urethra, the hje- mon-hoidal vessels, and the rectum; producing retention of urine, strangu- ry, dysury, bearing down, tenesmus, piles, diarrhoea, or obstinate costive- ness: which complaints are sometimes so pressing, as to claim all our atten- tion. On the other hand, large quanti- ties of matter, and deep sloughs are sometimes formed, and great devasta- tion committed on the parts about the rectum, with little or no previous pain, tumour, or inflammation. Sometimes the disease makes its first appearance in an induration of the skin, near to the verge of the anus, but with- out pain or alteration of colour; which hardness gradually softens and suppu- rates. The matter, when let out, in this case, is small in quantity, good in quality; and the sore h superficial, clean, and "well-conditioned. On the contrary, it now and then happens, that although the pain is but little, and the inflammation apparently slight, yet the matter is large in quantity, bad in qua- lity, 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 vari- ous and uncertain. Sometimes it is in the buttock, at a distance from the anus 5 at other times near its verge, or in the perineum -. and tliis discharge is made sometimes from one orifice only, sometimes from several. In some cases, there is not only an opening through the skin externally, but another through the intestine into its cavity: in other^, there is only one orifice and that either, external, or internal. Sometimes the matter is formed at a considerable distance from the rectum, whicii is not even laid bare by it; at others, it is laid bare also, and not per- forated: it is also sometimes not only denuded, but pierced; and that in more places than one. All consideration of preventing sup- puration, is generally out of the ques- tion : and our business, if called at the beginning, must be to moderate the symptoms; to forward the suppuration; when the matter is formed, to let it out; and to treat the sore in such man- ner, as shall be most likely to •produce a speedy and lasting cure. When there are no symptoms which require particular attention, and all that we have to do is to assist the matura- tion of the tumour, a soft poultice is the best application. When the disease is fairly of the phlegmonoid kind, the thinner the skin is suffered to become, before the abscess be opened, the bet- ter ; as the induration of the parts about will thereby be the more dissolved, and consequently, there will be tiie less to do after such opening has been made. This kind of tumour is generally found in people of full, sanguine habits; and who, therefore, if the pain be great, and the fever high, will bear evacuation, both by phlebotomy, and gentle cathar- tics: which is not often the case of those, wiio are said to be of bilious con- stitutions ; in whom the inflammation is of larger extent, and in which the skin wears the yellowish tint of the erysipelas; persons of such kind of ha- ANUS. 89 bit, and in such circumstances, being in general seldom capable of bearing large ev acuation. When the inflammation is erysipela- tons, the quantity of matter formed is small, compared with the size and ex- tent of the tumour; the disease is ra- ther a sloughy, putrid state of the cel- lular membrane, than an imposthuma- tion; 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 hi the membrane will extend itself, and, consequently, the cavity of the sinus, or abscess, be thereby greatly increas- ed. When, instead of either of the pre- ceding appearances, the skin wears a dusky, purplish-red colour; has a doughy, unresisting kind of feel, and is very little sensible : when these cir- cumstances are joined with an unequal, faultering kind of pulse, irregular shi- verings, 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 always bad; sometimes from nature, but much more frequently from glutto- ny and intemperance. What assistance art can lend, must be administered speedily; every minute is of conse- quence; and if the disease be not stop- ped, the patient will sink. Here is no need for evacuation qf any kind: re- course must be immediately had to me- dical assistance; the part affected should be frequently fomented with hot spirituous fomentations; a large and deep incision 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 obser- vation, 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 tiie cellular and adipose membrane; it always implies great de- generacy of habit, and, most commonly, ends ill. Strangury, dysury, and even total re- tention of urine, are no very uncom- mon attendants upon abscesses form- ing in the neighbourhood of the rec- VOL. 1 turn and bladder; more especially, if tiie seat of them be near the neck of the latter. They sometimes continue from the first 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 easily relieved by the loss of blood, and the use of gum-arabic, with nitre, &c. But the last (the total retention,) they who have not often seen this case, ge- nerally have immediate recourse to tiie catheter; but the practice is essentially wrong. The neck of the bladder does cer- tainly participate, in some degree, in the said inflammation. But, the princi- pal part of the complaint arises from irritation, and tiie disease is, strictly speaking, spasmodic. The manner in which an attack of this kind is generally made; the very little distention wliich the bladder often suffers; the small quantity of urine sometimes contained in it, even when the symptoms are most pressing; and the most certain, as well as safe, method of relieving it; all tend to strengthen such opi- nion. But whether we attribute the evil to inflammation, or to spasmodic irrita- tion, whatever can, in any degree, con- tribute to the exasperation of either, must be manifestly wrong. The vio- lent passage of the catheter through the neck of the bladder (for violent in such circumstances it must be*) can ne- ver be right. If tiie instrument be successfully in- troduced, it must either be withdrawn ^ as soon as the bladder is emptied, or it must be left in it: if the former be dope, the same cause of retention remaining, the same effect returns; the same pain and violence must again be submitted to, under (most likely) increased diffi- culties. On the other hand, if the ca- theter be left in the bladder, it will of- ten, while its neck is in this state, occa- sion such disturbance, that the remedy (as it is called) will prove an exaspera- tion of the disease, and add to the evil it is designed to alleviate ; nor is this all; for the resistance which the parts, while in this state, make, is sometimes so great, that if any violence be used, the instrument will make for itself a new rout in the neighbouring parts, and lay the foundation of such mischief as frequently baffles all our aiti 11 90 ANUS. The true, safe, and rational method of relieving this complaint is by evacua- tion 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 abscess. Loss of blood is necessary; the quantity to be deter- mined by the strength and state of the patient: the intestines should also be emptied, if there be time for so doing, by a gentle catharthic; but the most ef- fectual relief will be from the warm bath, or semicupium, the application of bladders with hot water to tiie pubes and perineum, and, above all other re- medies, the injection of glysters, con- sisting of warm water, oil, and opium. There may have been cases which have resisted and baffled tliis method of treatment; but Pott has never met with them. A painful tenesmus is no uncommon attendant upon an inflammation of* tiie parts about the rectum. if a dose ;«f rhubarb, joined with a warm anodyne, such as the conf. mith- rid. or such-like, dbes not remove it, the injection of thin starch and opi- um, or tinct. thebaic, is almost infal- lible. Tin- bearing down, in females, as it proceeds in tliis case, from the same kind of" cause (viz. irritation) admits relief from the same means as the* te- nesmus. In some habits an obstinate costive- ncss attends this kind of inflammation, accompanied, not unfrequcntly, with a painful distention and enlargement of the hemorrhoidal vessels, both inter- nally and externally. While a quantity' of hard faeces are detained within the large intestines, the whole habit must be disordered; and the symptomatic fever, whicii necessarily accompanies the formation of the matter, must be considerably heightened. And while the vessels surrounding the rectum (which are large and numerous) are distended, all the ills preceding from pressure, inflammation, and irritation, must be increased. Phlebotomy, laxa- tive glysters, and a low, cool regimen, must be the remedies; while a soft cataplasm applied externally serves to relax and mollify the swollen, indurated piles, at the same .time that it hastens the suppuration. When the abscesses have formed, and arc Jit to be opened, or when they have alrftdy 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 lancet should be passed in deep enough to reach the fluid; and, when it is in, the incision should be continued up- ward and downward, in such manner as to divide all the skin covering the mat- ter. By these means, the contents of the abscess will be discharged at once ; future lodgmenl of matter will be pre- vented; convenient room will be made for the application of proper dressings,; and there will be no necessity for mak- ing the incision in different directions, or for removing any part of the skin composing the verge of the anus. Notwithstanding all these collections of matter are generally etS\ec\ fistula, and are all supposed to affect the intes- tinum rectum, yet it is very certain that the seat of tiie abscess, 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 ori- gin ally fistula. In this state of the disease, we have no more necessarily to do with the in- testine, than if it was not there; the case is to be considered'merely as an abscess in the cellular membrane. Suppose a large and convenient open- ing to have been made by a simple in- cision ; the contents of the abscess to haye been thereby discharged; and a sore or cavity produced, wliich is to be filled up. The term filKng up, and the former opinion, that the 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 hol- low and hardness, was that the former is caused entirely by loss of substance: and the latter, 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 gra- dual regeneration of flesh, and the dressings, with which it was so filled, were most commonly of the escharotic kind, intended for the dissolution of hardness. The practice is a necessary conse- ANUS. 91 quence of the theory. Whoever sup- poses diseased callosity, and great loss «if substance, will necessarily -think himself obliged to destroy the former, and to prevent the. cavitj^ fcrmcd by the latter, from 'filling up too hastily. On the other hand, he who regards the cavity of the abscess as being princi-* pally the effect of thqtgradual distrac- tion and separation of its. sides, with very httle loss of substance, compared with the size of the said cavity; and who looks upon thaUnduration round about, as nothing more than a circum- stance which neeeasarily-%»cqinpanies every inflammation in membranous parts, more especially in those which tend to suppuration; will, upon the smallest reflection, perceive, that the dressings applied to such cavity ought to be so small in quantity, as to permit nature to bring the sides of the cavity toward each other, and that such small quantity of dressings ought to consist of materials proper only to encourage easy and gradual suppuration. Suppuration is to be produced and maintained, not by thrusting in such applications, as by their quantity dis- tend, and by their quality irritate and destroy; but hf > dressing slightly and easily with such as appease, relax and soften. If the hollow, immediately it is open- ed, be filled with dressings (of any kind,). the sides of it will be kept from ap- proaching each other, or may even be farther separated. But if this cavity be not filled, or have little or no dress- ings of any kjpd introduced into it, the sides immediately collapse; and, com- ing nearer and nearer, do, in a very short space of time, convert a large hollow into a small sinus. And this is also constantly the case, when the matter instead of being let out by an artificial opening, escapes through one made by the bursting of the containing parts. True, this sinus will not always be- come perfectly closed; but the aim of nature is not, tlierefore, the less evi- dent; nor tiie hint, which art, ought to borrow from her, the less palpa- ble. In this, as in most otiier cases, where there arc large sores, or considerable cavities, a great deal will depend on the patient'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; only to take care that they do not offend either in quantity or quality ^-iiut if the habit be bad, or in- judicious^ treated, he may use the whole farrago of externals, and only waste his own and his patient's time By light, easy treatment, large ab- scesses formed in the neighbourhood of the rectum will sometimes be cured, without any necessity occurring of meddling wjtii the said gut. But it much more frequently happens, that the intestine, although it may not have been pierced or eroded by the matter, has yet been so stripped or denuded,. that no consolidation of the sinus can be obtained, but by a division; that is, by laying the two cavities, viz. that of the abscess, and that of the intestine, into one. When the intestine is found to be se- parated from the surrounding parts by tiie matter, the operation of dividing it had better (on many accounts) be per- formed at the time the abscess is first opened, than be deferred to a future one. For, if it be done properly, it will add so little to the pain, which the pa- tient must feel by opening the abscess, that he ^rill seldom be able to distin- guish the one from tiie otiier, either with regard to time or sensation: where- as, if it be deferred, he must either be in continual expectation of a second cutting, or feel one at a time when he does not expect it. The intention in this operation is to divide the intestine rectum from the verge of tiie anus up as high as the top of the hollow in which the matter was formed; thereby to lay the two ca- vities of" the gut and abscess into one; and by means of an open, instead of a lipllow or sinuous sore, to obtain a firm and lasting cure. For this purpose, the curved, probe- pointed knife, with a narrow blade, i* the most useful and handy instrument of any. This, introduced into the si- nus, while tiie surgeon's fore-finger is in the intestine, will enable him to di- vide all that can ever require division ; and that with less pain to the patient, with more facility to the operator, as well as with more certainty and expe- dition than any other instrument what- ever. If there be no opening in the in- testine, the smallest degree of force will thrust the point of the knife through and thereby make one : if there be on^ already, the same point will find and pass through it In cither case, it will 92 ANUS. be received by the finger in ano; will thereby be prevented from deviating, and being brought out by the same fin- ger, must necessarily divide all that is between tiie 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 the two cavities of the sinus and of the intestine into one. Authors make very formal distinc- tion between those cases in which the intestine is pierced by the matter, and and those in which it is not; but al- though this distinction may be useful when tiie different states of" the disease are to be described, yet in practice, when tiie operation of dividing the gut becomes necessary, such distinction is of no consequence at all; it makes no alteration in the degree, kind, or quan- tity of pain whicii the patient is to feel; the force required to push the knife through the tender gut is next to none, and when its point is in the cavity, the, cases are exactly similar. Immediately after the operation, a soft dossil of fine lint should be intro- duced (from the rectum) between tiie divided lips of the incision; as well to repress any slight hemorrhage, as to prevent the immediate reunion of the said lips; and the rest of the sore should be lightly dressed with the same. This first dressing should be permitted to continue, until a beginning suppuration 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 kind- ly and gradual suppuration. The sides of the abscess are large; the incision must necessarily, for a few days, be in- flamed; and the discharge will, for some time, be discoloured and gleety: this induration, and this sort of dis- charge, are often mistaken for signs of diseased callosity, and undiscovered si- nuses ; upon wliich presumptions, es- charotics are freely applied, and dili- gent search is made for new hollows; the former of these most commonly in- crease both the hardness and the gleet; and by the latter new sinuses are some- times really produced. These occasi- on a repetition of escharotics, and, per- haps, of incisions; by which means, cases 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 ca- ses, which must have been in St. Bar- tholomew's Hospital, within these ten or twelve yeSrs, I do aver, (savs Pott) that I liave not met tttth one, in the cir- cumstances before described, that has not been cured by mere simpk division, toge- ther with light, easy dressings : and that I have not, in all that time, used, for this purpose, a single grain of pracipitate, or of any other eschar otic. The best and most proper method of dividing the intestine, in the case ofa collection of matter formed juxta anum, we have already described. The intention to be aimed at by inci- sion in the present case, is exactly the same, and ought to be executed in the same manner. Let us first suppose the matter to be fairly formed; to have made its point, as it is called; and to be fit to be let out. Where such a point is, that is, where tiie skin is most thin, and the fluctua- tion 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 col- lected ; but still to have been contain- ed within the cavity, until let out by an 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 sub- ject to some variety of appearance; and these different appearances have pro- duced, not only a multiplicity of appel- lations, but a groundless supposition also, of* a variety of essentially different circumstances. When a discharge of the matter by incision is too long delayed or neglect- ed, it makes its own way out, by burst- ing the external parts somewhere near to the fundament, or by eroding and making a hole through the intestine in- to 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 on- ly, are called blind external fistula; those, in which tiie discharge has been made into the cavity of the intestine, without any orifice in the skin, are na- ANUS. 93 med blind, internal; and those, which have an opening both through the skin, and into the gut, are called compute fistula. Thus, all these cases are deemed fis- tulous, 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 treatment as a true fis- tula may possibly stand in need of. The most frequent of all are what are called the blind, external,- and the compkte. The method whereby each of these states may be known is, by in- troducing 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, whe- ther there be an opening in the skin on- ly, or one there, and another in the in- testine, the appearance to the eye is much the same. Upon discharge of the matter, the external swelling sub- sides, and the inflamed colour of the skin disappears, the orifice, which at 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 some- times does) tiie induration, in some de- gree, remains; and if the orifice hap- pens not to be a depending one, some part of the matter lodges, and is dis- charged by intervals, or may be press- ed out by the fingers of an examiner. 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 about; it daubs the linen of tiie patient; and is, at times, very fetid; the orifice also sometimes contracts so, as not to be sufficient for the discharge; and the lodgment of the matter then occasions fresh disturbance. The means of cure proposed and practised by our ancestors, were three, viz. caustic, ligature, and incision. The intention in each of these is the same, viz. to form one cavity of the si- nus and intestine, by laying tiie former into the latter. The two first are now completely, and most properly explo- ded. Hitherto we have considered the dis- ease either as an abscess, from which the matter has been let out by an inci- sion, made by a surgeon; or from wliich the contents have* been discharged by one single orifice, formed by the burst- ing of the skin somewhere 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 hap- pens when the quantity of matter col- lected has been large, the inflammation of considerable extent, the adipose membrane very sloughy, and the skin worn very thin before it burst.—It is, indeed, a circumstance of" no real con- sequence at all; but from being mis- understood, or not properly attended to, is made one of additional terror 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 com- monly, quite otherwise; all these open- ings are only so many distinct burst- ings of the skin covering the matter; and do all, be they few or many, lead and open immediately into the one sin- gle cavity of the abscess: they neither indicate, nor lead to, nor are caused by distinct sinuses; nor would the ap- pearance of twenty of them (if possi- ble) necessarily imply more than one general hollow. If this account be a true one, it will follow, that the chirurgic treatment of tliis kind of case ought to be very little, if at all, different from that of the pre- ceding; and that all that can be neces- sary 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 expedi- tiously do; and when that is done, if the sore, or more properly its edges, should make a very ragged, uneven ap- pearance, the removal of a small por- tion of such irregular angular parts will answer all the purposes of making room for the application of dressings, and for producing a smooth, even cica- trix 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 9-t A sua. v 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 unexperi- enced practitioner be alarmed at tliis, and immediately fancy that there are so many distinct sinuses; neither let him, if he be of a more hardy disposi- tion, go to work immediately with his director, knife, or scissars: let him en- large the external wound by making his incision freely; let him lay all the se- parate orifices open into that cavity; let him divide the intestines lengthwise by means of his finger in ano; let him dress lightly and easily; let him pay proper attention to the habit of the pa- tient; and wait, and see what a few daysrunder such conduct, will produce. 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 cellular membrane ; and con- sequently, that his fears of a multiplici- ty of sinuses were groundless. On the contrary, if the sore be crammed or dressed with irritating, or escharotio medicines, all the appearances will be different: the hardness will increase, the lips of the wound will be inverted, the cavity of the sore will remain large, Crude, and foul; the discharge will be thin, gleety, and discoloured; the pa- tient will be uneasy- and feverish; and, if no new cavities are formed by the ir- ritation of parts, and confinement of matter, yet the original one w ill have no opportunity of contracting itself; and may very possibly become truly fistulous. Sometimes the matter of an abscess, formed juxta anum, instead of making its way out through the skin, externally near the verge of the anus, or in the buttock, pierces through the intestine only. This is what is called a blind in- ternal fistula. In this case, after the discharge has been made, the greater part of tiie tu- mefaction subsides, and the patient be- comes easier. If this does not produce a cure, which sometimes, though very seldom, happens, some small degree of induration generally remains in the place where tiie original tumour was ; upon pressure on this hardness, a small discharge of matter is frequently made per anum; and sometimes the expul- sion of air, from the cavity of the ab- scess into that of the intestine may ve- ry palpably be felt, and clearly heard i the stools, particularly, if hard, and re- quiring force to be expelled, are some- times smeared with matter; and al- though the patient, by the bursting of the abscess, is relieved from the acute pain whicii tiie collection occasioned, yet he is seldom perfectly free from a dull kind of uneasiness, especially if he sits for any considerable length of time in one posture. The real difference Between this kind of case, and that in wliich 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 this, as in the former, no cure can reasonably be expected, until the cavity of the abscess, and that of the rectum are made one; and the on- ly difference is, that in the one case we have an orifice at, or near the verge of the anus, by which we are immediately enabled to perform that necessary ope- ration; in tiie other, we must make one. , We come now to that state of the dis- ease, which may truly and properly be called fistulous. Ibis is generally de- fined, sinus angustus, callosus,profundus; acri sank dijfluens .- or, as Dionis tran- slates it, " tfn ulcere profond, & Ca- vrrneux, dont Ventree, est etroite, & le fond plus large ; avec issue d'unpus acre & virulent,- et uccnmpagne de callosites." V arious causes may produce or con- cur in producing such a state of the parts concerned as will constitute a fis- tula, in the proper sense of the word ; that is, a deep, hollow sore, or sinus, all parts of whicii are so hardened, or so diseased, as to be absolutely incapa- ble of being healed, wliile in that state ; and from wliich a frequent, or daily dis- charge is made, of a thin, discoloured sanies, or fluid. These are divided into two classes, viz. those which are the effect of neg- lect, distempered habit, or of bad man* agement, and whicii may be called, without any great impropriety, local diseases ; and those wliich are the con- sequence of disorders, whose origin and seat is not in the immediate sinus or fistula, but in parts more or less distant, and, wliich, therefore, are not local complaints. 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 gene- ANUS. 95 rally curable by proper treatment; the Utter frequently not so by any means whatever. Under the former are reckoned all such cases as were originally mere col- lections of matter within the coats of the intestine rectum, or in the cellular membrane surrounding the said gut; but which, by being long neglected, grossly managed, or, by happening in habits which were disonlered, and for which disorders no proper remedies were administered, suffer such altera- tion, and get into such state, as to de- serve 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 the loins, and parts adjacent thereto; and are either strumous, or the consequence of long and much distempered habits ; or the effect of, or combined with otiier distempers, local, or general; such as a diseased neck of the bladder, or pros- tate gland, or urethra, &c. &c. &c. Among the very low people, who are brought into hospitals, we frequently meet with cases of the former kind : cases, which, at first, were mere sim- {>le abscesses ; but which from unclean- ieess, from intemperance, negligence, and distempered constitutions, become such kind of sores, as may be called fistulous. In these the art of surgery is undoubt- edly, in some measure, and at some l iine, necessary; but it very seldom is the first or principal fountain from whence relief is to be sought: the general effects of intemperance, or debauchery, and diseases of tiie habit are first to be corrected and removed, before surgery can with propriety, or with reasonable prospect of advantage be made use of. The surgery required in these cases, consists in laying open and dividing the sinus, or sinuses, in such manner that there may be no possible lodgment for matter, and that such cavities may be fairly opened lengthwise into that of the intestine rectum • if the internal parts of these hollows are hard, and do not yield good matter, whicii is some- times the case, more especially where attempts have been made to cure by injecting 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 multiplicity of external orifices, or from the loose, flabby, hard- ened, or inverted state of the lips and edges of the wound near to the funda- ment, it seems very improbable that they can be got into such a state as to heal smootii and even, such portion of them should be cut off as may just serve that purpose. The dressings should be soft, easy, and light; and the whole intent of them to produce such suppuration as may soften the parts, and may bring them into a state fit for healing. If a loose, fungous kind of flesh has taken possession of the inside of the si- nus, (a thing much talked of, and very seldom met with) a slight touch of the lunar caustic will reduce it sooner, and with better effect on the sore, than any other escharotic whatever. The method and medicines by which the habit of the patient was corrected, must be continued (at least in some de- gree) through the whole cure ; and all those excesses and irregularities which may have contributed to injure it, must be avoided. By these means, cases which at first have a most disagreeable and formida- ble aspect, are frequently brought into such state, as to give very little trouble hi 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 whicii is too hard, and too quick; is thirsty, and does not get his due quantity of natural rest. A sore which has been so dressed, has generally a considerable degree of inflammatory hardness round about; the lips anil edges of it are tumid, full, inflamed, and sometimes inverted; the whole verge of the anus is swollen ; the he- morrhoidal vessels are loaded j the dis- charge from the sore is large, thin, and discoloured; and all the lower part of tiie rectum participates of the inflam- matory irritation, producing pain, bear- ing-down, tenesmus, &c. Contraria con- trariis 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 particular; and the first in- tention must be to alter that. All es- charotics must be thrown out, and dis- used ; and in lieu of them, a soft diges- 96 ANUS. tive should be substituted, in such man- ner as not to cai.-se any distention, or to give any uneasiness from quantity ; over which a poultice should be appli- ed : these dressings should be renewed twice, a day; and the patient should be enjoined absolute rest. At tiie same time, attention should be paid to tiie general disturbance, which the former treatment may have created. Blood should be drawn off from the sanguine; the feverish heat should be calmed by proper medicines ; the languid and low- should be assisted with the bark and cordials; and ease in the part must, at all events, be obtained by the injection of anodyne clysters of starch and opium. If the sinus has not yet been laid open, and the bad state of parts is oc- casioned by the introduction of tents imbued with escharotics, or by the in- jection of astringent liquors, (the one fot the destruction of callosity, the other for the drying up gleet and hu- midity) 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 medicines mu.st procure this : 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 executed, and will, in all' probability, be attended with suc- cess. On the contrary, if such opera- tion be performed while the parts are in a state of inflammation, the pain will be great, the sore for several days ve- ry troublesome, and the cure prolong- ed or retarded, instead of being expe- dited. Abscesses and collections of diseased fluids are frequently formed about the lumbar vertebrae, under the psoas mus- cle, and near to the os sacrum; in whicii cases, the said bones are some- times carious, or otherwise diseased. These sometimes form sinuses, which run down by the side of the rectum, and burst near to the fundament. The chirurgic treatment of such sores and sinuses can have little influence on the remote situation, where the collec- tion of matter is originally formed. (See Lumbar Abscess.) Fistulous sores, sinuses, and indura- tions about the anus, which are conse- quences of diseases of the neck of the bladder, and urethra, called fistulae in perinxo, require separate and particu- lar consideration. ,-?ce Fistula in peri- nea.) Pott may be considered as the source and authority of the foregoing remarks. For information, relative to former opinions concerning ./fafulu in uno, refer to Celsus ; Heist*-'.i Surgery,- Le Drun's Operations; Sharp's Operations ; La Faye'sJVotes on Dionis. In Kirkland's Medical Surgery, Vol. 2. may be found an account of the opinions and practice of ma- ny former celebrated practitioners. The best modern practical remarks are con- tained in Pott's Treatise on the Fistula in Ano, in which he has offered also an ex* celknt critique on some ofiinions of Le Dran, De.la Faye, and Cheselthm. The reader may also consult with advantage Sabutier's Medicine Opiratoire, Tom. 2; B- Bell's Surgery, Vol. 2 ; Latta's Sur- gery, Vol. 2. [See also the writings of Desault, in which are many valuable remarks on tliis subject.3 Anus, Prolapsus of. When a por- tion of the rectum is protruded out of the anus, in a preternatural degree, the disorder is termed prolapsus aid. Some- times, only a very small part'of the gut is thus displaced; on other occasions, there is a very considerable portion of it. The sphincter ani, and the surround- ing parts, serve, in the healthy state, as a base, and support, for the lower part of the rectum, and every tiling, which tends to weaken them, tends, also, to produce a prolapsus ani. The most common cause of this dis- ease, however, is referrible to too vio- lent and repeated exertions of the rec- tum itself, excited by some source of irritation about the extremity of this intestine. Thus, the too frequent em- ployment of aloetic medicines, tiie ac- tion of which particularly affects the large intestines, often occasions the above consequence. The same thing results from small worms, known by the name of ascarides, and which, lodg- ing about the lower part of the rectum, occasionally cause excessive irritation. Habitual costiveness; hemorrhoids; in a word, every thing, which by stimula- ting tiie rectum, excites too violent an action of this intestine, may induce the complaint under consideration. There are numerous instances, in which a prolapsed portion of the rec- tum has remained, for a long while, unreduced, and in which, notwithstand- ing such neglect, no serious bad conse- quences have ensued. It follows from ANUS. 97 tiiis, that this bdwel can hear exposure to the external au- much better, than any other part of the intestinal canal. But, we ought never, on this account, to omit doing every thing in our power for the immediate reduction of the in- testine. Authors of surgical works have, not uncommonly, recommended fomcntingthe prolapsed part with emol- lient and antiseptic decoctions, be- fore making an attempt to reduce it. They even advise the operator, for the purpose of succeeding with mOre ease, to cover his fingers with linen, smear- ed with wax and oil. But, all such preparations are useless, and, when a surgeon is called to a patient afflicted with a prolapsus ani, the greatest ser- vice he can render, is to put back the displaced part, as quickly as possible, into its natural situation, without leav- ing the intestine exposed to the dan- gerous effects, whicii may arise during the time wasted in employing fomenta- tions, &c. Also, as much greater ma- nual dexterity can be made use of, when the fingers are perfectly uncover- ed, than when they have greasy gloves on, it is best not to follow the latter method. However, if it should be judg- ed proper to cover the hands with any thing, a piece of fine cotton will best answer the purpose. The patient being in bed, lying upon his side, or, what is better, on the ab- domen, while his buttocks are raised rather higher than the rest of the body, the surgeon is to make strong, but equal pressure, with the palm of his hand on the 'ower portion of the pro- lapsed intestine. By continuing such pressure, tiie intestine may, in general, be easily reduced. But, if this plan should not suffice, the upper part of tiie protruded intestine must be com- pressed with the fingers of one hand, while the lower part is pressed upward by the palm of the other one. In this way, we are almost sure to succeed. It is true, that if, in consequence of having too long delayed the reduction, from some other cause, the gUt has be- come much swollen and inflamed, it will be impossible to reduce the part, before such symptoms have been sub- dued. For this purpose, it may be pro- per to take some blood from the pati- ent, in such quantity, as his strength will allow. The intestine may also be fomented with % warm solution of tiie , acetite of lead, (saccharum saturni.) When the swelling has been diminish- voi,. 1. ed by these means, there will be no difficulty in replacing the parts, by pursuing the plan already explained. The greatest difficulty is not th^ re- turning of the intestine, but keeping it in its place. The latter object often gives a great deal of trouble. For, af- ter the bowel has frequently descend- ed, the sphincter sometimes becomes so weakened, that it can no longer keep the part supported. Hence, the com- plaint not only recurs whenever the patient goes to stool; but, even when- ever he walks, or places himself in an erect posture; as there are examples of. Different bandages have been devi- sed, for supporting the anus after its reduction. But, it is not an easy mat- ter to invent one, which is in every respect adapted to what such an incon- venience requires. A compress, dou- bled several times, is usually applied to the anus, and supported in this po- sition by means of a T bandage. In many cases, this method of keeping up the intestine answers very well. A ma- chine was invented by Mr. Gooch, wliich has the double advantage of sup- porting tile intestine more securely, than any other, with wliich we are ac- quainted, and of allowing the patient to take a great deal more exercise, than he could do without its assistance. (See Gooclis Surgery.) But, what, in our opinion, is still bet- ter, than all such contrivances, are elas- tic gum pessaries, which were invent- ed a few years ago by M. Bernard, an ingenious artist, who has employed this substance for making various things, which are used by surgeons. The in- strument, which wa have just mention- ed consists of an oblong oval body, rounded at one end, and terminating at the other in a narrow, rather long neck, with a flat border at its extremity. The body of this instrument, when intro- duced into the intestine beyond the sphincter, dilates and supports the gut, while the sphincter embraces its neck, and the border of this part of the in- strument hinders it from ascending too far up the rectum. A string is also at- tached to the edge, which tends to pre- vent the occurrence. This pessary is very smooth, and, consequently, cannot do any injury to the parts. It is also very light, being only composed ofa very thin, though tolerably solid, sub- stance. As it is pierced at its termina- tion, it does not impede the discharge 98 ANUS. of air, whicii might otherwise incom- mode the patient. When the intestine is protruded at the time the patient is at stool, the part is to be immediately replaced. This the patient should accustom himself to do without assistance, and then the bandage, or pessary, is to be applied. Iu order to strengthen the sphincter ani and adjacent parts, the weakness of which must, in the majority of cases, be regarded as the entire cause of the disease, the patient should take prepa- rations of bark and steel, make use of the cold bath, and frequently have cold water dashed against his buttocks and loins. Astringent injections, particu- larly, such as are composed of an infu- sion of gall-nuts, or oak-bark, are also very serviceable. A small quantity of alum, or sugar of lead, has sometimes been added to these injections; but, in general, all additions of saline sub- stances are to be deemed improper, because salts usually produce an irrita- tion of the intestine. Diseases of tliis kind may always be cured, or at least palliated, so as to be very bearable, by the employment of some of tiie above means. Before concluding this article, we shall observe, however, that a much more serious disorder has been con- founded with the prolapsus ani; viz. one, in which a considerable portion of the colon, caecum, and, even sometimes, of tiie ilium, becomes everted and push- ed out at the anus. The generality of practitioners consider this occurrence in the same point of view, as the dis- ease of which we have just been treat- ing. In this case, they believe that tiie whole of the rectum becomes everted, in consequence of the relaxation of the sphincter and levatores ani, and, that it then draws after it other portions of the intestinal canal. But, they ought to have been undeceived by the stran- gulation, which sometimes occurs un- der such circumstances, and which not only throws a great obstacle in the way of the reduction of the displaced part, but even sometimes brings on mortifi- cation. Besides the connexions of the rectum with tiie neighbouring parts, by means of the cellular substance, which surrounds' it; and the attach- ment of this intestine to the posterior surface of the urinary bladder; render the above origin of the complaint im- possible. Such an explanation could only be admitted with regard to those protrusions of the rectum, which comr on in a very slow manner. This ac- count could not afford a satisfactory explanation of certain cases, in whicii the everted intestine presents a very enormous tumour. Fabricius ab Aqua- pendente mentions his having seen tu- mours, occasioned by a prolapsus of the rectum, which were as long as the forearm, and as large as the fist. In the Melanges des Curkux de la Jxalure, we find an account ofa tumour of tliis sort, whicii was two feet long, and oc- curred in a woman from parturition. Nor is a more satisfactory reason as- signed for these cases, by supposing, that they originate from a relaxation of the villous coat of the rectum, and separation from the muscular one. We are not authorized to imagine, that such a separation can take place to a considerable extent, nor so suddenly, as to give rise to the phenomena, some- times remarked in this disease. But more accurate observations have removed all doubt upon this subject. Lithe fourth volume of the Jlemoires de I'Academie de Chirurgk, we read an account of* a pretended prolapsus of the rectum, wliich, after death, was disco- vered to be an eversion of the caecum, the greater part of the colon being found at the lower end of this intestine, and most of the rectum at its upper part. This eversion began at the dis- tance of more than eleven inches from the anus, and terminated about five or six from this opening, tiie tumour, formed by the dise'ase, having been re- duced some time before the child's death. It was impossible to draw back the everted part, in consequence of the adhesions, which it had contracted. Another dissection has evinced the same fact. A child, after suffering ve- ry acute pain in the abdomen, after re- ceiving a blow, had a prolapsus of in- testine through the anus, about six or seven inches long. This was taken for a prolapsus of the rectum. After death, the termination of the bowel out of the anus was found to be nothing less, than the caecum, which had passed through the colon, and rectum, to make a pro- trusion at the anus. See Intussusceptio. (Encyclopedk Methodique ; Par tie Chi- rurgicak.) ANUS ARTIFICIAL. This signi- fies an accidental opening in the parie- tes of the abdomen, to whicii opening some part of the intestinal canal tends, ANUS. 99 *nd through which the faeces are, ei- ther wholly, or in part, discharged. When a strangulated hernia occurs, in which the intestine is simply pinch- ed, and this event is unknown; when the occurrence has not been relieved by the usual means; or when the ne- cessary operation has not been practi- sed in time; the protruded part be- comes gangrenous, and the faeces es- cape. Putrefaction takes place in the cellular substance, and under the ad- joining integuments, wliile the gangre- nous affection of the tumour spreads from within outward. One or more openings soon form in the mortified parts, and through these apertures the faeces are discharged, until the separa- tion of the sloughs gives a freer vent to the excrement. But if the patient should be at last operated upon, his faeces arc discharged through the wound, and the intestines are more ea- sily emptied. In both cases, the ex- crement continues to be discharged from the opening, when the loss of sub- stance in the intestine is great, and a considerable contraction of the bowels has taken place below the part affect- ed. When the mortification has been too extensive, and the cicatrix, follow- ing the detachment of the dead parts, has greatly diminished the diameter of the bowels, the faeces more readily pass out of the wound, than along the intes- tinal canal, and, consequently, they are entirely discharged through the artifi- cial opening. In this way, an artificial anus is formed, through which the ex- crement is evacuated during life. The same occurrence may follow wounds, penetrating the abdomen, and doing considerable injury to tiie intes- tines. The inflammation, which always accompanies such wounds, occasions sa- lutary adhesions, between the edges of the divided intestine and those of the opening in the peritoneum and muscles. This prevents any extravasation of mat- ter 'm l'ie abdomen. The fixed and per- manent situation of the large intestines renders all wounds, occurring to them, much more prone, than those befalling the small intestines, to this consequence, so favourable in many respects. How- ever, artificial anuses have been known to form after wounds of the small in- testines. A case of this sort may be perused in Fernel, and a second in Bauhin. (Sabatier sur les Anus centre .Vature, in Mem. de I'Acad, de Chir. Pom. 5.) In cases of hernia with gangrene, an artificial anus is formed, under- the a- bove circumstances, according to the design of nature, and it would frequently be wrong to hinder the occurrence, even though it were practicable to heal, the wound, which is the situation of it. For, the intestine being too much con- tracted at the place of the cicatrix, the patient would continue subject to cho- lic complaints. In this manner, he might be put in more or less immediate danger of perishing from a bursting of the intestinal canal within the abdomen, or else from a simple obstruction in the cavity of the bowels. This is not the case, when an artificial anus is formed, in consequence of a wound of the intestines, and if the patient could receive timely succour, before such a consequence had completely taken place, possibly, the event might often be prevented. However advantageous the formation of an artificial anus may be, in many cases, in whicii the patient's life de* pends upon the event, it must be con- fessed, that the consequence is a most afflicting and disgusting infirmity. It is true, however, that the matter, which is discharged, not having been long re- tained in the bowels, is not so fetid as that which is evacuated in the ordinary- way ; but, as tiie opening which gives vent to the matter 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 faeces are con- tinually escaping without any knowl- edge of the circumstance on the part of the patient. 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 excre- ment has been received. Schenckius relates the case of an officer, who was wounded in the belly, and who allowed Ills faeces to escape into a vessel made for the purpose. Dionis makes men- tion of a similar case. What occurred to an invalid soldier, says tliis eminent writer, is too singular to serve as an example in practice, since nature alone preserved him, by making the wound of the abdomen as an opening for the discharge of his faeces. The intestine has become adherent to it, and he daily evacuates his excrement through this opening. The matter coming away in- loo ANUS. voluntarily, necessitates him to have a tin-box for its reception M. Moscati, principal surgeon of the hospital at Milan, has also communica- ted to the academy of surgery, an ac- count of a wounded man, in whom an artificial anus took place, in conse- quence of a wound in the abdomen be- low the right hypochondrium. His ex- crement used also to be received in a tin-box, fastened to him by a belt. The above surgeon very properly remarks as a very singular circumstance in this wound, that it admitted ofa leaden can- nula being introduced, to which cannu- la tiie tin-box w-as accommodated. But, would the situation of wounds, liable to be followed by an artificial anus, be always sufficiently favourable, to allow of the intestinal matter being received in an appropriate vessel ? May not the pressure, which the edges of such ves- sels are apt to make on the circumfer- ence of the opening, be detrimental.' Lastly, would not such a vessel, though apparently fixed in a suitable manner, change its position, and sometimes al- low the faeces to escape on the patient's clothes ? Uncleanliness is not the only incon- venience of an artificial anus. Persons have been known to be quite debilitated by the affliction, and even ultimately to die in consequence of it. This is liable to happen, whenever the intestinal ca- nal is opened very high up, so that ali- ment escapes before chyiification is completed, and the nutritious part of the food, has been taken up by the lac- teals. But, when tiie opening only in- terests the lower circumvolutions of" tiie ilium, or, what is more frequent, when it has occurred in the large in- testines, the danger, to which the pa- tient is exposed by this event, is ren- dered very trivial. There is no fact of this kind recorded, which had a fatal termination; on the contrary, many writers confirm, that such patients as they have seen with an artificial anus, have been healthy and well-looking. 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 tiie rectum. The descent of the bowel is sometimes simple, only affecting a por- tion of the intestinal canal just above and below the opening. On other oc- casions the complaint is double, the bowel both above and below the opening being prolapsed. This de- scent of the intestine forms a tu- mour, the dimensions of which vary considerably in the different subjects in whom it is observed. When the pro- trusion is caused by the upper part of the intestinal canal, the faeces are voided at tiie extremity of the tumour, and, when the swelling consists of the lower portion of the bowel, the excrement is evacuated at the base of the prolapsed part. When the tumour is double, it is ea- sy to perceive, by observing this evacu- ation, to which end of the intestinal ca- nal each protruded portion belongs. This consequence of an artificial anus is very serious, because it greatly in- creases the inconvenience, which the patient suffers. Sometimes, the tumour is exquisitely sensible ; and, occasion- ally, when the eversion of the intestine is considerable, a strangulation is pro- duced, which puts the patient's life in danger, unless such prompt assistance be afforded, as the nature of the case demands. The business of the surgeon is to prevent, if possible, the formation of an artificial anus, as we shall see else- where ; but, when the event has occur- red, and, particularly, when the whole or the greater part of the stools are discharged in this way, no attempt can be made to stop up the opening with- out exposing the patient's life to the most alarming danger. Even when a considerable quantity of the faeces is discharged in the natural manner, it is always to be presumed, that the bowel is considerably contracted at the place, where it communicates with the wound, and that the intestine will be very apt to inflame, when an unusual accumula- tion of its contents has taken place, un- less they have an opportunity of escap- ing through the external opening. Such an occurrence would make the patient likely to die in a very short time. But, if it is dangerous to close an ar- tificial anus, when the case is of the most simple description, the thing is absolutely impracticable, when the af- fliction is compUcated with an everted prolapsus of a part of the bowel; al- though we read in the Philosophical Transactions, that M. Le Cat undertook such an operation, in a, case, in which there was an eversion of each portion of the intestinal canal. But the pain which he gave the pa- tient in endeavouring to reduce the protruded intestine, induced him to ANUS. 101 abandon all further attempts. When, also, in such a case, it were easy to re- duce the displaced portions of intes- tine, and /-hen that, which is connected with the rectum, is nearly of its natural diameter, (a circumstance not to be expected,) prudence does not allow us to place these portions opposite each otiier, for the sake of reestablishing the continuity of the canal. The num- ber and depth of the adhesions, which the intestines may have contracted with each other, and the neighbouring parts, are likely to render such an operation impracticable. It would also be terri- ble to make an unsuccessful attempt of this kind, and to plunge into imminent peril, a person in other respects quite well, and who, with the exception of some inconvenience, may enjoy life as well as subjects of the best constitu- tions. Though we cannot remedy such ever- sions of the intestine, as are brought on by an artificial anus, when the tumour is rather large, and of long standing ; yet, there is a possibility of affording relief, when the swelling is small and recent. In this circumstance, skilful treatment would probably prevent the progress of the disorder, and even ef- fect an entire cure. The treatment must obviously be very similar to that of the prolapsus ani, for both complaints are of the same nature. The practitioner should endeavour gently to return the tumour into the abdomen, and to retain it there by means of a soft pad of suit- able size. This pad should be changed very frequently, on account of the mat- ter discharged from the opening. As posture must greatly tend to bring about a cure, the patient should be re- commended to lie down, as much as possible, on the side opposite tiie dis- ease. He should be enjoined to make no violent exertion, which would put the abdominal muscles and diaphragm into action, and force the intestines through the external opening. If there be any difficulty in evacuating the fae- ces from the artificial anus, the belly should be kept gently open. The parts in the vicinity of the artificial anus should be strengthened by slightly as- tringent fomentations, &c. It might al- so be very useful to support the mar- gin of the opening by an ivory or elas- tic-gum compress, if the patient should void faeces of a thick consistence, and should feel, before the evacuation, the kind of inclination wliich precedes the discharge of the faeces in the natural way. Thus by advice, which is both simple and easy to follow, a grievous affliction maybe prevented; andone whicii would expose the patient to the most pressing danger, were tiie swelling, to which the intestines protruded from an artifi- cial anus are subject, to acquire such a size, that the bowels themselves become strangulated in tiie opening, through which they pass. (Encyclopedic Metho- dique ; Partie Chirurgicale. Art. Anus contre J\'ature.) Mr. Lawrence has made a few very ac- curate remarks on the present subject, and he has also related some particu- lars of a case of artificial anus, which convey considerable instruction. "If the complaint (a mortified lier- nia) terminates in the formation of an artificial anus, we must endeavour to alleviate those distressing inconve- niences, which arise from the involun- tary discharge of wind and faeces through the new opening, by supplying the patient with an apparatus, in which these may be received, as they pass off. An instrument of this kind, the con- struction of which appears very perfect, is described by Richter (Anfrangsgr der Wundarzn, Vol. 5.) from the Traite des Bandages of Juville. The patient will be best enabled to adapt any contri- vance of this sort to tiie particular cir- cumstances of his own case% It has been found, in some instances, that a common elastic truss, with a compress of lint under the pad, has been more serviceable than any complicated in- strument. (Parisian Journal, Vol. l.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 the gut often protrudes to the length of eight or ten inches, at the same time bleeding from its surface. This is at- tended with pain, and compels him to he down; in which position the intes- tine recedes. The patient has now dis- charged all his faeces at the groin for fifteen years; and has enjoyed tolerable health and strength during that time. His evacuations are generally fluid; but, sometimes, of the natural consis- tence. Whenever he retains 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 102 ANU APP the anus; and this may occur two or three times in the day. (P. 208.) When the protruded intestine is strangulated, an operation mav become necessary for the removal of the stric- ture.* We should always endeavour to prevent such protrusions, when a disposition to their formation seems to exist, by the use of a steel 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 the part, tiie patient being at the same time confined to bed. By these means, Desault (Parisian Jour- nal, Vol. 1. p. 178.) returned a very large prolapsus, and, by pressure on tiie opening, the faeces were made to pass entirely by the anus, although, for four years, they had been voided only through the wound. (Lawrence p. 209. 210.) In cases of mortified hernia, tiie wound sometimes closes, except a small fistulous opening, which dis- charges a thin fluid, and cannot be healed. Mr. Lawrence has related, in his excellent treatise on hernia, a case, in which the faeces came from the wound some time after an operation, although the bowel did not appear gangrenous when this proceeding was adopted. ( P. 21V) In the appendix to this work, the au- thor adds some further account of the case of artificial anus, which he has re- lated (P. 208.) The man is sixty years of age, and appears to be healthy, ac- tive, and even younger, than he really is'. He had had a scrotal hernia, whicii ended in mortification, and involved the testicle of the same side, anil a large portion of the integuments, in the destruction. It is now nearly seven- teen years since this event, and the fae- ces have during all this time been dis- charged from the groin. He has never made use of a truss, nor taken any step, except that of always keeping a quan- tity of tow in his 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, * Schmucker Vermischte Chirurgische Schriften, cause, are mentioned by Sabatier, in a memoir in refers to Le Blanc Precis d'Operauous de Chin Toi which is the largest part, measured nearly six inches in circumference. The prolapsus never recedes entirely, and it has occasionally protruded to the length of eight or ten inches, being as large as the forearm, and emitting blood. This occurrence is painful, and only comes on when the bow- els are out of order. Warm , fomen- tations, and a recumbent position, af- ford 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, al- though wrinkled 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 stools. When these are fluid, they come away repeatedly in the course of the day, and with considerable force. When of a firmer consistence, there is only one stool, every oiie or two days, and the evacuation requires much straining. Such faeces are not broader than the little finger. When the patient is purged, the food is often voided very lit- tie changed. This is particularly the case with cucumber. In tliis state he is always very weak. Ale is sometimes discharged five minutes after taken, being scarcely at all altered. The bow- els are strongly affected by slight doses of purgatives. (Lawrence, in Treatise on Hernia.) Consult Sabatier in Mem. de I'Acad. de Cldrurgie, Tom. 5, 4to. and in Mede- cine Operatoire, Tom. 2. L'Encyclope- dk Methodique, Partie Chirurg. Rich- ter's Anfangsgr. tkr Wundarzn, Band 5. Parisian Chirurgical Journal. CEuvres Chirurg. de Desault par Bichat. Schmuc- ker's Chirurgische Schriften, Vol. 2- Lawrence's Treatise on Hernia. APHJLRESIS, (from «, to re- move). This term was formerly much used in the schools of surgery, to signi- fy that part of the art, which consists in taking off any diseased, or preterna- tural, portion of the body. APOSTEMA (from awn/At to recede.) An abscess. APPARATUS. This implies thepre- om. 2. Two eases, which terminated fatally from this le 5 Tom. de l'Acad. de Chir. Mr. Lawrence also 2. p. 145. AQU AQU 103 paration, and arrangement of every tiling- necessary in the performance of an operation, or in the application of dressings. The apparatus varies ac- cording to circumstances. Instruments, machines, bandages, tapes, compress- es, pledgets, dossils of lint, tents, &c. are parts of the apparatus, as well as any medicinal substances used. It is a rule in surgery, to have the apparatus ready before beginning an operation. All preparations of this kind should not be made in the patient's room when the thing can be avoided, nor any where in his presence, as it would agitate him, and render him timid, and more restless in the opera- tion. APPARATUS MINOR; APPARA- TUS MAJOR; APPARATUS ALT US. Three ways of cutting for tiie stone. (See Lithotomy.) AQUA AMMONIAS ACETATJE. This is given in the dose of half an ounce in many surgical cases, in which the object is to keep up a gentle per- spiration. AQUA ARSENICATA. R Arsenici in pulverem triti unc. ss. Aquae distillatae lib. j. These are to be boiled together in a flask till one fourth of the liquor is eva- porated, and, when cold, filter the re- mainder through paper by means of a glass funnel. Has been apphed to foul ulcers and cancers. AQUA CLPRI VITRIOL ATI CAM- PHORATA. B Cupri vitriolati Boli Gallici sing. unc. ss. (.'amphora; drach. j. Aquae ferventis lib. iv. Boiling water is to be added to the other ingredients, and the liquor filter- ed when cold. Is chiefly employed in a diluted state, as acollyrium; but it may also prove of service as an application to foul ulcers. AQUA KALI. (L.) No adequate trial of tliis as an external application to ul- cers or herpetic eruptions has jet been made; but, in the dose of 40 drops, night and morning, Mr. Hunter thinks it cures some sores, resembling mild chancres, which were unaltered by the internal use of mercury and irritated by its use as a topic. AQUA KALI ARSENICATI. K Kali Arsenicati grana duo. Aquae Mentha: Sativae uncias qua- tuor Spiritus Vinosi tenuioris unciam. Misce et cola. Two drams of tliis may be given thrice a day in cases of cancer. Mr. Barnes lately shewed me a case of her- pes of the nose, or noli me tangere, which was greatly benefited by this re- medy externally apphed. The patient was under Mr. Harvey, hi St. Bartholo- mew's Hospital, and, at the time when I saw her, Mr. Barnes was; using the lotion with double the proportion of ar- senic. There are many ulcerations round the roots of the nails of the fin- gers and toes, to which many apply Plunket's caustic; but, the aqua kali arsenicati would, in all probability, be quite as efficacious an application, and, certainly, it is a neater one. AQUA KALI PURI, (L.) This has been given with a view of dissolving urinary calculi, in considerable doses, for a length of time. The trials, how- ever, have not proved so successful as could have been wished, nor is the ex- hibition of so active a remedy unattend- ed with disadvantageous consequences to the system; for wliich reason, un- der the name of mephitic alkaline water, vegetable alkali supersaturatedjwith fix- ed air, has of late been much substi- tuted. AQUA LITHARGYRI ACET ATI (L.) Is extensively used largely diluted. with water, as an application to inflam- ed parts. One dram to a quart of wa- ter is quite strong enough for common purposes. Mr. Justamond and Dr. Ches- ton used to apply it mixed with an equal proportion of a spirit resembling the tinctura ferri muriati, to the edges of cancerous sores. The fear of the absorption of lead, has induced many practitioners to give up the use of this remedy, and have re- course to solutions of vitriolated zinc, which, it is said, answer equally well; but it is now rendered probable, from the experiments of Mr. Baynton, of Bristol, that cold water alone is of as much service as either in removing inflammation. (See Pharmacopmia C/n- rurgica.J AQUA PICIS. May be applied to tinea capitis. There are ulcers on the legs, surrounded with a scorbutic red- ness, and pimples, covering a large ex- tent of the skin. In such instances, the aqua picis, used as an application round the limb, over the dressings, is of great service. 104 ARS ARS ARDOR URIN.E. Difficulty and pain in making water, attended with a sense of heat in the urethra, and is a symptom of gonorrhoea, and some other affections. ARC. EM A, or ARGEMON, (from *5>cc, white.) A small white, ulcer of the globe of the eye. (See Cornea, ul- cers of.) ARGENTUM NITRATUM, (JVi- trate of silver, lunar caustic.) Is the best of the mildest caustics. Its utility for stimulating indolent ulcers, and keeping granulations from rising too high, is known to eVery one. Mr. Hunter recommends the use of the argentum nitratum, on the first ap- pearance of a chancre, before absorp- tion can be supposed to have taken place. He directs the caustic to be scraped to a point, like a black-lead pencil; so that, when it is applied, every part of the surface of tiie chan- cre may come into contact with it; and he advises the repetition of this process, till the last slough, whicii is thrown off*, leaves the sore florid and healthy. (Hunter on the Venereal.) From this treatment, there is a chance, that the constitution will not be infected; but it is generally pru- dent, notwithstanding, to give the pil. hydrargyri. The important use of the argentum nitratum, in the cure of numerous dis- eases, we shall have occasion to re- mark in various places of this work; particularly when we come to the arti- cle Urethra, strictures of, in the remo- val of whicii disease it is peculiarly useful. ARNICA. (*f>viK>t, from age a lamb.) Leopardsbane. Amaurosis is the principal case in which surgeons now ever employ this medicine. From a dram to half an ounce of the flowers may be infused in a pint of water, and tliis may be ta- ken in the course of four and twenty hours. Arnica, thus exhibited, some- times produces vomiting, profuse per- spiration, and an increased secretion from the kidneys. At other times, no evident effects of tins sort arise. The virtues of this medicine have undoubt- edly been exaggerated, though no one can question that, as it is a powerful one, the trial of* it should still be con- tinued. ARSENIC, (from the Arabic Arsa- nek,orae the most subtile layers of the cellular substance, and to the surface of the tendons, ligaments, and capsule of? the articulation. This distemper has been named by Brambilla, Fungus Arti- ctrlatimis Acta Acad. Medico-Chirurg. Vindob.p'.l. Sometimes, the bones are not in the least diseaeed, though the ligaments and cartilages are much altered, the joint is immensely enlarged, and the severity of the disease has even render- ed amputation indispensable. Sometimes, the ligaments, cartilages, and bones are not the parts, which are chiefly distempered. In the instances, alluded to, tiie articulation is greatly increased in size, but, most of the swel- ling originates from a diseased state of the parts-on the outside of the capsular ligament. The disease does not con- sist of a thick kind of lymph, diffused throughout tiie structure of the parts on the outside of the joint; but, of a morbid change, in which such parts be- come at once enlarged, thickened, and bereft of all their original firmness. Ve- ry frequently, the texture of the heads of* the bones is softened, the ligaments are distempered, the cartilages absorb- ed, and the fanes carious. Sometimes, the surfaces of. the dis- eased bones are rendered rough and ir- regular by tiie secretion of" a kind of s-'ihsiance like spermaceti in appear- vol. i ance, hut, cf no importance in young subjects, and as a mere rheumatic, or gouty affec- tion,. in adults. Patients frequently ARTICULATION. 121 "oinplain of most of their painful sen- sations being in the groin, and all ac- curate observers have remarked, that in the hip-disease, the pain is not con- fined to the real seat of disease, but shoots down the limb, in the course of the vastus externus muscle to the knee. The early symptoms of disease in the hip-joint are only strongly delinea- ted to such practitioners, as have ac- quired the necessary information rela- tive to this part of surgery, from careful study, and extensive experi- ence. We shall next trace those characters of the present disease, which serve to denote its existence. It is a curious circumstance, that when the functions of a limb are ob- structed by disease, the bulk of the member generally diminishes, and tiie muscles become emaciated. Nearly as soon as the least degree of lameness can be perceived, the leg and thigh have actually wasted, and their circum- ference has become less. If tiie surgeon make pressure on the front of the joint, a little on the outside of the femoral artery, after it has de- scended below the os pubis, great pains will be experienced. The limping of the patient is a clear proof that something about the limb is wrong, and, if such limping cannot be imputed to diseased vertebrae, or some recent accident, and if, at the same time, the above mentioned emaciation of the limb exists, tliere is great cause to suspect, that tiie hip is diseased, particularly, when the pain is augmen- ted by pressing the front of the aceta- bulum. Diseased vertebrae, perhaps, always \ produce a paralytic affection of both Ivgs at once, and they do not cause painful sensations about the knee, as the hip-disease does. The increased length of the limb is a very remarkable and curious symptom, in tiie early stage of the present dis- ease. ' This occurrence is easily de- tected by a comparison of the condyles of the os felfloris, the trochanter major, and malleoli, of the diseased limb, with those parts of the opposite mem- ber, taking care that the patient's pel- vis is evenly situated. The thing is the more striking, as the increased length of the member is frequently as much as four inches. The rationale of thi6 fact, John Hunter used to ex- plain by the diseased side of the pelvis becoming lower, than the otiier. ( Crow- ther,p. 266.) The same thing was noticed by Fal- coner, before Mr. Crowther. (On Is- chias, p. 9.) Mr. Ford has very accurately called the attention of surgeons to the altera- tion, with respect to the natural ful- ness and convexity of the nates, that part appearing flattened, which is usu- ally most prominent. The gluteus mag- nus becomes emaciated, and its edge no longer forms so bold a line, as it naturally does at the upper and back part of the thigh, in the sound state of the limb. Though there may be more pain about the knee, than the hip, at some periods of the malady in its incipient state, yet, the former articulation may be bent and extended, without any increase of uneasiness ; but, the os femoris cannot be moved about, without putting the patient to immense torture. The patient soon gets into the habit of bearing the weight of his body chiefly upon the opposite limb, while the thigh of the affected side is bent a little for- ward, that the ground may only be par- tially touched with tiie foot. This po- sition is found to be the most comfort- able, and every attempt to extend the limb occasions an increase of pain. This is the first stage of the disease, or the one, which is unaccompanied with suppuration. The symptoms which precede the formation of pus, vary in different ca- ses, according as tliere is acute, or chronic inflammation present. When the diseased joint is affected with acute inflammation, the surrounding parts become tense and extremely painful; the skin is even reddish; and symp- toms of inflammatory fever prevail. When the severity of the pain abates, a swelling occurs in the vicinity of the joint, and a pointing quickly follows. When the abscess is a chronic one, there is no particular increase, of pain preceding the collection of matter. Startings and catching during sleep are said to be among the most certain signs of the formation of matter, in this stage of the disease. We have noticed the lengthened state of the limb, in the first periods of the hip-disease. This condition is not of very long duration, and is sooner, or later succeeded by a shortening of vol. 1. 1*3 122 ARTICULATION the affected member. When the re- traction is very considerable, it arises from nothing less, than an actual dis- location of the head of the thigh-bone, in consequence of the destruction of the cartilages, ligaments, and articular cavity. This retraction sometimes comes on long before any suppuration takes place. The head of the bone is sometimes dislocated, and the disease terminates in anchylosis, without any abscess whatever. The hip-disease generally induces hectic symptoms, after it has existed a certain time. In some subjects, such symptoms soon come on ; in others, the health remains unaffected a very considerable time. When abscesses of the above descrip- tion burst, they continue, in general, to emit an unhealthy thin kind of mat- ter for a long time afterwards. With respect to the morbid anatomy of the disease in its incipient state, lit- tle is known. Two dissections related by Mr. Ford are, perhaps, the only ones throwing light upon this point. In one, there was a tea-spoonful of matter in the cavity of the hip-joint. The head of the thigh-bone was a little inflamed, the capsular ligaments a httle thick- ened, and tiie ligamentum teres united in its natural way to the acetabulum. The cartilage lining the cotyloid cavity was eroded in one place, with a small aperture, through which a probe might be passed, underneath the cartilage, into tiie internal surface of the os pu- bis, on one side, and, on the other, into the os ischii; the opposite, or external part of the os innominatum shewing more appearance of disease, than the cotyloid cavity. In the other instance, the disease was more advanced. These examples are important, inasmuch as they prove that the hip-complaint pri- marily affects the cartilages, ligaments, and bones, and not the surrounding soft parts, as De Haen, and some others, would lead one to believe. As tiie disorder advances, the por- tions of the os ischium, os ilium, and os pubis, composing the acetabulum, together with the investing cartilage, and synovial gland, are destroyed. The cartilage covering the head of the os femons, the ligamentum teres, and capsule of the joint, suffer the same fate, and caries frequently affects not only the adjacent parts of the ossa in- nominata, but also the head and neck of the thigh-bone. The bones of the pelvis, however, are alway» more dis- eased than the thigh bone, afact, which displays the absurdity of ever thinking of amputation in these cases. Mr. Ford observes, " In every case of disease ot the hip-joint, whicii has terminated fa- tally, I have remarked, that the os in- nominatum has been affected by the ca- ries in a more extensive degree, than the thigh-bone itself." (Observationson the Disease of the Hip-Joint, p. 107.) Sometimes, however, the head and neck of the thigh-bone are annihilated, as well as the acetabulum. External violence; lying down on the damp ground in summer time ; and all kinds of exposure to damp and cold; are the causes to which the disease may sometimes be referred. Scrophula, no doubt, has frequently, some concern in the origin of the malady; but, often- times, no rational cause of the com- plaint can be assigned. TREATMENT OF THE DISEASE OF THE HIP-JOINT. Hippocrates, Celsus, Caclius Aurelia- nus, &c. convince us in their writings, that the ancients treated the present disease much in the same way, as the moderns. Forming an eschar, and keeping tiie sore open ; topical bleed- ing; cupping; fomenting the part, fkc. were all proceedings adopted in the earliest periods of surgery. Drs. Charl- ton, Oliver, and Falconer, have extol- led Bath water, as a most efficacious application to diseased hip-joints, pre- vious to the suppurative stage. How- ever, had not their accounts been ex- aggerated, all patients of this kind would long ago have flocked to Bath, and the surgeons in other places would never have had further occasion to a- dopt a more painful mode of treatment. The plan pursued at Bath, is to put the patient in a warm bath, two or three times a week, for fifteen or twen- ty-five minutes. In the early period of the disease, entire rest, the application of fomenta- tions, and the employment of topical bleeding, particularly cupping, are highly proper. Such practice, also, is invariably judicious, whenever the case is attended with symptoms of* acute inflammation. When the fomen- tations are not applied, the, lotio aquae lithargyri acetati may be used. This method of treatment ought ne- ver to be employed, unless there are BANDAGE. 123 manifest marks of active inflammation present. When no such state exists, this plan can only be regarded as pre- venting the adoption of a more efficaci- ous one, and, therefore, censurable. As far as morbid anatomy can inform us, tiie hip-disease consists of the same alteration of the bones, ligaments, and cartilages, as takes place in the majo- rity of* white-swellings. Hence, both diseases should be treated on the same principles. Quibus diuturno dolore, says Hippocrates, ischiadico vexatis coxa ex- cidit, iis femur contabescit et claudicant, nisi urantur. Forming an eschar, or issue, is the most efficacious plan of treating the disease even now known. A caustic issue seems to me more be- neficial than a blister, in cases of dis- eased hips. The depression, just be- hind and below the trochanter major, is the situation, in wliich surgeons usu- ally make the issue, and the size of the eschar should be nearly as large as a crown piece. It is, in general, neces- sary to keep the issue open a very long time. When the thigh-bone is dis- located, the case mostly ends in anchy- losis. BALSAMUM COPAIV.E. Exhibit- ed by surgeons principally in ca- ses of gonorrhoea, gleet, and piles. A dram may be given thrice a day. BANDAGE. (Deligatio. Fascia.) An apparatus, consisting of one or several pieces of linen, or flannel, and intended for covering, or surrounding parts of the body for surgical purposes. The use of bandages is to keep such compresses, remedies, &c. in their pro- per situation, as are applied to any par- ticular part; to compress blood-vessels, 3o as to restrain hemorrhage; to recti- i\ certain deformities by holding the deranged parts in a natural position; and to unite parts, in which there is a solution of continuity. As the application of bandages is a very important branch of surgery, au- thors have not neglected it. Much has been written on the subject, and almost every writer has devised new banda- ges, perhaps without much benefit to surgery. Unfortunately, it is next to impossible to gi\ e very clear ideas of the numerous sorts of bandages by de- For further information, the author begs leave to refer to his " Treatise on the Diseases of the Joints," being the ob- servations for which the prize for 1806 was adjudged by the Royal College of Surgeons, London. Mr. Ford's Obser- vations on the Disease of the Hip-Joint are particularly excellent. See also Crowther on White-Swelling, &c. Edit. 2, 1808. Lotto's System of Surgery. B. Bell's Surgery. Falconer on Ischias. The authors quoted throughout this arti- cle, both ancient and modern, may all be consulted with advantage. ASTRINGENTS (from astringo, to bind.) In medicine, are those substan- ces which possess a power of making the living fibres become contracted, condensed, and corrugated. They are employed in the practice of surgery chiefly as external applications, either for restoring diminished tonic power, or checking various discharges. They are also deemed very eligible local re- medies for phlegmonous inflammation. ATHEROMA (from *fl»/w, pap ) An encysted tumour, so named from its paplike contents. (See Tumours En- cysted.) scription. The surgeon can only ac- quire all the necessary instruction and information from the experience and habit resulting from practice. Hence, we shall confine ourselves to a general account of the subject. Bandages should be made of such materials as possess sufficient strength to fulfil the end proposed in applying them, and they should, at the same time, be supple enough to become ac- commodated to the parts to which they are applied. Bandages are made of linen, cotton, or flannel. If possible, they should be without a seam, and linen is woven for this purpose; but the selvage is always harsh, and, as the edges are necessari- ly covered by the next round, they are sometimes inconvenient. We prefer, therefore, old linen, and more readily submit to the inconvenience of the ed- ges unravelling, than to the irregulari- ty which any stitching would produce There are cases, in which the ban- dage should have a degree of firmness, that .doesrnot belong to the materials B \24 BANDAGE usually made use of. I his circum- stance is obvious in cases of hernia, and in all those in which there is occa- sion for elastic bandages. As we have already observed, linen, flannel, and cotton (calico,) are the common mate- rials. The first employment of flannel bandages is imputed to the Stotch sur- geons, who preferred them to linen ones, in consequence of their being bet- ter calculated for absorbing moisture, wliile, being more elastic, they yield in a greater tiegree in cases requiring this property; as in the swelling subse- quent to dislocations, fractures, &c. It has been asserted, that linen is bet- ter than flannel, because more cleanly; but neither one nor the other will con- tinue clean, unless care be taken to change it very often. The employment of cotton or calico bandages is a more recent method, and many advantages are attributed to the softness and elasticity of this material. In applying a bandage, care must be taken, that It be put on tight enough to fulfil the object in view, without running any risk of stopping tiie circu- lation, or doing harm in any other way. If it be not sufficiently tight to support the parts in a proper manner, it is use- less ; if it be too tense, it will produce swelling, inflammation, and even mor- tification. To apply a roller skilfully, the part whicii it is to cover, must be put in its proper situation ; the head of the roll- er held in the surgeon's hand, and only so much unrolled as is requisite for co- vering the part. In general the bandage should, if possible, be applied in such a manner as will admit of its being removed with the most ease, and allow the state of the parts beneath to be examined, as often as occasion requires. For this reason, in* fractures of the leg and thigh, the eighteen-tailed ban- dage is generally preferred to a simple roller. The former may be loosened and tightened, at pleasure, without oc- casioning the smallest disturbance of the 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 apphed, and it has become useless, its employment should be discontinued; for, by remaining too long on parts, it may obstruct the cir- culation, diminish the tone of the com- pressed fibres, and thus do harm. Bandages are either simple or com- pound. They are also sometimes divi- ded into general and particular. 'The latter often derive their names from tiie parts to which they are usually apph- ed. A simple bandage is a long piece of linen or cotton, of an indefinite length, and from three to six inches in breadth. When about to be applied, it is com- monly rolled up, and the rolled part is termed its head. When rolled up from each end, it is called a doubk-headed roller or bandage. The chief of the simple bandages arc the circular, the spiral, the uniting, the retaining, the expellent, and the creep- ing. The circular bandage is the simplest; the rolls cover each other, and it is sel- dom long, as two or three turns are ge- nerally enough. The spiral bandage is the most fre- quently used of all; for, it is this which we see in such common employment on the limbs, in cases of ulcers, &c In appl\ing a common roller to tiie whole of a limb, the bandage must be carried round the part spirally, or else it is obvious that tiie whole member could never be covered. When the leg is the part, the surgeon is to begin by surrounding the foot with a few turns. Then carrying the head of the bandage over the instep, he is to convey it back- ward, so as to make the bandage un- roll, and apply itself just above the heel. The roller may next be brought over the inner ancle; thence again over the instep, and under the sole; and the surgeon then brings tiie bandage spi- rally upward once more to the outer part of the leg. After this, every cir- cle of the roller is to be applied, so as to ascend up the limb in a gradual, spi- ral form, and so as to cover about one third of the turn of the roller immedi- ately below. 'The increasing and di- minishing diameter of the hmb, is one great cause, which brings into view the unskilfulness ofa surgeon in this com- mon operation; for, it prevents the roller from lying smoothly, although spirally applied, unless a particular ar- tifice 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 conti- nued in the common spiral way, with- BANDAGE. 125 out this manoeuvre. When the bulk of the limb increases very suddenly, it is sometimes necessary to fold, or, as it is termed, reverse, every circle of the bandage in the above manner, in order to make it lie evenly on the limb. It is manifest, that the pressure of the roller will be greatest where the du- plicatures are situated, and hence, when it is an object to compress any particular part, the surgeon should contrive to reverse the turns of the bandage just over the situation where most pressure is desirable. When a roller is to be apphed to tiie forearm, it is best to make the few first turns of the bandage round the hand. Care must betaken not to make the bandage very tight, if it be intended to wet it afterwards with any lotion; for, it is always rendered still more tense by moisture. Mr. John Bell describes the princi- pal purposes for which a roller is em- ployed, as follows: "Although in re- cent wounds, it is with plasters and sutures that wrc unite the parts point to point, yet it is with the bandage that we support the hmb, 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 js called the Uniting Bandage, and will be presently described.) But it is particularly to be oberved, that in gun- shot wounds, and other bruised wounds, though it would be imprudent to sew the parts, since it is impossible that ■they should altogether unite, yet tiie 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 lessens the extent of that surface, whicii must naturally fall into suppu- ration. " In the hemorrhagy of wounds, we cannot always find the artery; we dare not always cut parts for fear of greater dangers; we are often alarmed with bleedings from uncertain vessels, &c. or from veins as well as arteries : these 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. Frequently, in bleed- ings near the groin, or the arm-pit, or the angle of the jaw, wherever tiie bleed- ing i rapid, the vessels uncertain, the cavity deep, and the blood not to be commanded by a tourniquet, and where the circumstances forbid a deliberate and sure operation, we trust to com- press and bandage alone. " Bandage is very powerful in sup- pressing 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 extremity of the fingers or toes; the member must be thoroughly supported in all its lower parts, that it may bear the pressure above. It is partial stric- ture alone that does harm, creates into- lerable pain and anxiety, or brings on gangrene. Hemorrhagy requires a very powerful compression, which must therefore be very general, &c. It must not be made only over the bleeding ar- teries, which is all that the surgeon thinks of in general, &.c. " In abscesses, where matter is work- ing downwards along the limb, seeking out, as it were, the weak parts under- mining tiie skin, and wasting it, insu- lating and surrounding the muscles, and penetrating to the bones, tiie band- age does every thing. The expelling bandage, the propelling bandage, the defensive bandage, were among the names, which the older surgeons gave to tiie roller, when it was applied for these particular purposes; and thes-a are properties of the roller, whicii should not be forgotten." ("Principles of Surgery, Vol. 1.) Soon after this description of some of the chief surgical-uses of the roller, Mr. John Bell proceeds to explain, in what manner this most simple of all bandages may be put on a limb. " Practice will convince you, that the firmness and neatness of a bandage de- pend altogether upon these two points; first, upon the turns succeeding each other in a regular proportion; and, se- condly, upon making reverses, wher- ever you find any slackness likely to arise from the varying form of the limb. Thus, in rolling from tiie foot to the ankle, leg, and knee, you must take care, first, that tiie turns, or, as the French call them, doloires, of the roller lie over one another by just one third of the breadth of the bandage; and, se- condly, that at every difficult part, as 126 BANDAGE. over a joint, you turn the roller in your hand, make an angle, and lay tiie rol- ler upon the limb, with the opposite flat side towards it; you must turn the bandage so as to reverse it, making, what the French call, a renvcrse'e 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 be- low upwards, and support the whole limb by a general pressure. That you may be able to support tiie diseased part with a particular pressure, you must lay compresses upon the hollows and upon the bed of each particular ab- scess, and change the place of these compresses from time to time, so as now to prevent matter sinking into a particular hollow, now to press it out from a place where it is already lodg- ed, and again to reunite tiie surface of an abscess already completely formed, from whicii the matter has been dis- charged." (Principles of Surgery, Vol. 1.) In the article Articulation, we have taken notice of tiie good effects of the pressure of a roller in the cure of white- swellings. Here we shall just intro- duce 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 indul- gence, a very httle encouragement of fomentation, 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 ban- dage." ( Vol. 1. p. 127.) The uniting bandage, or spica descen- dens, used in rectilinear wounds, con- sists of a double-headed roller, with a longitudinal slit in tiie middle, of three or tour inches long. The roller, hav- ing one head passed through the slit, enables the surgeon to draw the lips of the wound together. The whole must be managed, so that the 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 order to press the deeper part of its sides together. When the wound is very long, two or three bandages should be employed, and great care must be taken, mat the pressure is perfectly equable. * Henkel and Richter recommend a uniting bandage, which allows the sur- geon to see the wound, over which on!y narrow tapes cross. The reader, if lie should ever wish to employ this con- trivance, may read a description of it in Rees's Cyclopaedia, or Motiierby's Medical Dictionary, though 1 confess I could not understand it from the de- scription in those works, until I looked at the plate m Richter's Anfangsgr. der Wundarzn. Band. 1. When we make use of a single-heaJ- ed roller, as a retentive bandage only, we should always remember to begin the application of it. on the side oppo- site the wound. The obvious reason for so doing is to prevent a farther se- paration of the lips of the wound, as the contrary manner of applying the roller would tend directly to divide them. (Gooch. Vol. 1. p. 143.) The intention of the expeUent bandage is to keep the discharge sufficiently near the orifice of the wound to prevent the formation of sinuses. In general, a compress of unequal thickness is ne- cessary ; the thinner part of" the com- press being placed next, and immedi- ately 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, circu- lar turns on the lower part of the com- press. The bandage must then be car- ried spirally upwards, but not quite so tightly, as below. It is afterwards to be rolled downwards 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 employed in cases, in which the object is merely to secure the dres- sings, and not to make any considera- ble, or equable pressure. A bandage is termed compound, when several pieces of linen, cotton, or flan- nel, are sewed together in different di- rections, or when the bandage is torn or cut, so as to have several tails. Such are the T bandage, the suspensory one, the capistrum, &c. The eighteen-taikd bandage is one of the most compound. It is now in gene- ral use for all fractures of the leg and thigh, sometimes for those of the fore- arm, and, frequently, for particular wounds. Its great recommendations are the facility, with wliich it can be un- done, so as to allow the parts to be ex- amined, and its not creating, on such an occasion, the smallest disturbance of the disease, or accident BANDAGE. 127 The eighteen-tailed bandage is made by a longitudinal 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 pro- portioned in length to the circumfer- ence of the part of the limb, to which it is to be applied ; so that in making this sort of bandage for the leg, or thigh, tiie upper tails will be twice as long as the lower ones. After laying the long part of the bandage on a table, fix the upper end of it in some way or other. 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 across the longitudinal band, they are to be stiched 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 the tails. This is usually brought under the sole of the foot, and then applied over the inner ankle in the first instance, after the bandage has 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 cross 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, used for covering parts of the abdomen and back, and, especially, the scro- tum, perinaeum, and parts about the ..nus. Its name is derived from its re- semblance 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- v erse piece, whicii encircles the body, very broad, and having split the tail- part into two portions, one of these is to be conveyed over each side of the neck, and pinned to the opposite part of tiie 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 groin, or private parts, the tail-part then becomes tiie most important part of the bandage ; ii'm the transverse piece, which is to encircle the pelvis, is smaller, while the tail-partis made very broad. When the disease is in the private parts, perinaeum, or anus, we often split the tail according to circumstances; but, when tiie disease is in one groin, we generally leave the tail-part of the ban- dage entire and broad. The linteum scissum, or split-cloth, is a bandage applied occasionally to the head, and consists of a central part, and six, or eight tails, or heads, whicii are applied, as follows: When the cloth has six 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 tiie forehead, the two middle tails are usually directed 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 tiie head, or obliquely, so as to make pressure upon any particular point. (Principles of Sur- gery, Vol. 1. p. 131.) The old surgeons usually split this middle tail into two parts, a broad and narrow one. In the broad one, they made a hole to let the ear pass through. This broad portion was tied under the chin, while the narrow ends were tied obliquely over the head. As Mr. John Bell has observed, though this gave the split-cloth the effect of eight-tails, yet, the ancient surgeons did not name it the split-cloth with eight tails. When tliey split the cloth into eight-tails, and especially, when they tied the eight- tails in the following particular manner, they called the bandage cancer, as re- sembling 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 forehe:-! and eyes, while the other four hung over the back of the head. They were tied, as follows : first, tiie two outermost tails, on each side in front, were tied over the fore- head, 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 tiie middle tails were tied, the two anterior ones being made to cross over each other, and pass round the temples to be pinned at the occiput; while tiie two middle tails behind, were nutde to cross each other', and pass 128 BANDAGE. round the temples, so as to be pinned over the ears, or near tiie forehead. (See John Bell's PrincipUs, 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 testi- cles, when swelled. The French term it couvre-chef en triangle. ' The nodose bandage, called also sca- pha, is a double-headed roller, made of a fillet four yards long, and about an inch and a half broad. It must be re- versed two, or three times, so as to form a knot upon the part, which is to he compressed. It is employed, when a hemorrhage from a wound is to be stopped, or for securing the compress, after bleeding in the temporal artery. The most convenient bandage in ge- neral for the fprehead, face, and jaws, is the four-taikd one, or singk split- cloth. It is composed of a strip of cloth, about four inches wide, which is to be torn at each end, so as to leave only a convenient portion of tiie middle part entire. This unsplit middle portion is to be applied to the forehead, if the wound be there, and the two upper tails are carried backward, and tied over the back part of the head, while the two lower ones are to be tied ei- ther over the top of the head, or under the chin, as may seem most conveni- ent. When the wound is on the top of the head, the middle of the undivided part is to be applied to the dressings. The two posterior tails are to be tied for- ward, and the two anterior ones are to be carried backward, so as to be tied behind the head. This is sometimes called Galen's bandage. It is curious, that writers on bandages should use the terms Jiead, and tail, synonymously, and hence this four-tailed bandage is often called the sling with four- heads. Such confusion of language is highly reprehensible, as it contributes, in a very great degree, to obstruct the com- prehension of any, the most simple subject. If the upper lip be cut, and a ban- dage needed, which is seldom the case, it is almost superfluous to say, that tliis bandage will serve the purpose. It serves also in cuts of the lower lip, though tliere, also, we trust rather to the twisted suture, than a bandage. The single split-cloth is particularly useful 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, supporting the lower jaw, is named capistrum, or bridle, be- cause it goes round the part somewhat like a horse's halter. " In some cases, (says Mr. John Bell) the circumstances require us to support the chin particularly, and then the unslit part of the bandage is appli- ed upon the chin, with a small hole to receive the point; but, where the jaw is broken, we pad up the jaw-bone into its right shape, with compresses press- ed in under the jaw, and secured by this bandage. When we are in fear of hemorrhagy after any wound, or opera- tion, near the angle of the jaw, we can give the sling a very remarkable de- gree of firmness. For this purpose, we tear the band into three tails on each side, and we stitch the bandage at the bottom of .each split, lest it should give way, when drawn firm," &c. (Princi- ples of Surgery, Vol. 1.) We have already described one way of applying a handkerchief, as a ban- dage to the head, when we noticed the triangular one, or couvre-chef en trian- gle. The other manner of applying the handkerchief, called tiie 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 lay tiie handker- chief upon the head, so as to make the lower fold, to which the projecting bor- der belongs, lie next the head; while the projecting border itself is left hang- ing over the eyes, till the bandage is adjusted. The two corners of the out- ermost fold are first to be tied under the chin; the projecting border is then to be turned back, and pinned in a cir- cular form round the face, while the corners of the fold next the head are to be carried backward, and tied. After the outer corners of this ban- dage have been tied under the chin; after the inner corners have been drawn out and carried round the occiput; and after the border has been turned back and pinned; the doubling of the hand- kerchief over each side of the neck hangs in a loose awkward manner. It remains, therefore, to pin this part of the handkerchief up above the ear, as BLADDER 129 neath/ as can be contrived. (See J. Bell's Principles.) The grand couvre-chef has certainly nothing to recommend it, either in point of utility, or elegance. A com- mon night-cap must always be infinite- ly preferable to it. In the event, how- ever, ofa cap not being at hand, it is proper that the surgeon should know, what contrivances may be substituted to fulfil the objects in view. Having, in the numerous articles of this Dictionary, noticed the mode of ap- plying bandages in particular cases, and allotted a few separate descrip- tions for such bandages, as are not here mentioned, but whicii are often men- tioned in books, we shall conclude for the present, with referring the reader to Motlierby's Medical Dictionary; Rees's Cyclopadia; and John Bell's Principks for further information. Ga- len and Vidus Vidius are reckoned tiie best of tlw old writers on the subject. M. Sue, Thillaye, Heister Lombard, and Bernstein; of the modern ones. The latter are said, however to be all too pro- lix. See Rees's Cyclopadia, art. Ban- dage. BELLADONNA. Deadly JK'ight- shade. Is violently narcotic. The leaves were first used externally for discus- sing scirrhous swellings, and they have been subsequently given internally, in scirrhous and cancerous diseases, amaurosis, &c. Five grains are reckon- ed a powerful dose. BINOCULUS, (from Mnns double, and oculus the eye.) A bandage for keeping dressings on both eyes. Its application will easily be understood by referring to Monoculus. BISTOURY, (Bistoire, French.) Any small knife for surgical purposes. BLADDER, PUNCTURE OF. This is an operation, to which we are obli- ged to have recourse, after having in vain employed all the other means in- dicated for preventing the bad, and even fatal consequences of a stoppage of the evacuation of the urine, and dis- tention of the bladder. Various acci- dents, and diseases, both acute and chronic, may occasion this dangerous state, as we shall more particularly no- tice 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 pints, than uneasy sensations ate ■experienced. The desire of dischar- ging the water now becomes very ur- vol. 1. gent, and if the inclination be not gra- tified, and the bladder be suffered to be dilated beyond its natural state, it loses all power of contraction, and be- comes paralytic. The desire, indeed, continues, and the efforts are renewed in painful paroxysms; but, the power is lost, and the bladder becomes more and more distended. When this vis- cus is dilated in the utmost degree, and neither its own structure, nor the space in the abdomen can allow a fur- ther distention; either the bladder must be lacerated, wliich it never is, so equally is it supported by the pressure of the surrounding parts; or its orifice must expand, and tiie urine begin to flow. After the third day of the re- tention, the urine often really begins to flow, and, whatever descends from the kidneys is evacuated in small quantities from time to time, and at this period, the bladder is distended in as great a degree, as it ever can be, however long the patient survive. This dribbling of the urine, which begins, when the blad- der is dilated to the utmost, and conti- nues till the eighth, or tenth day, or till the bladder sloughs, has long been un- derstood, and is named by the French, "urine par regorgement." To practi- tioners, who do not understand it, the occurrence is a most deceitful one. The friends felicitate themselves, that the urine begins to flow; the surgeon believes it, basins and cloths, wet with urine, are easily produced; but, the pa- tient lies unrelieved. The continued distention of the bladder is followed by universal inflammation of the abdomen. The insensibility, and low delirium of incipient gangrene, are mistaken for that relief, which was expected from the flow of urine, till either hiccough comes on, and the patient dies of fever, and inflammation, or the urine gets through an aperture, formed by morti- fication into the abdomen. Let no sur- geon, therefore, trust to the reports of nurses and friends, but, lay his hand upon the hypogastric region, and tap with his finger, that he may distinguish the distended bladder, and the fluctua- tion of urine. As the bladder suffers no further distention, after the third day, why should it burst ? Not from la- ceration; for, it is supported by the uniform pressure of the surrounding viscera; not by yielding suddenly, for it is distended to its utmost on the third day of the retention, and yet sel- dom gives way before the tenth; not 17 130 BLADDER. by attenuation, for it becomes thicken- ed. The term laceration was never more wrongly applied, than in this in- stance; for when there is a breach in the bladder, it is found, on dissection, to be a small round hole, such as might be covered with the point of the finger. The rest of the viscus, and the adja- cent bowels, are red and inflamed, white this single point is black, and mortified ! Delay is more dangerous, than even the worst modes of making an opening into the bladder, and, while life exists, the patient should have his chance.—(See John Bell's Principles of Surgery, VoL 2. Part 1. p. 262. &c. It is now acknowledged, that the fre- quently fatal result of" puncturing tiie bladder, is entirely owing to the opera- tion being too long delayed. Hence, when relief cannot be obtained by the treatment described in the article, Urine, Retention of; when no urine has come away, before the end of the third day: when it only does so in a drib- bling manner after this period, while the bladder continues distended, and no catheter can be introduced; the operation should not be delayed. In urgent cases, one should rather ope- rate, as soon as forty eight hours have elapsed. We shall next describe the three modes of puncturing the blad- der. 1. Puncture through the Perinaum. The manner of doing this, as de- scribed by most writers, is by pushing a common trocar into tire cavity of the bladder, from the place, where the ex- ternal wound is made, in the old way of cutting for the stone, and thus letting out the urine, through the cannula. Others, refining upon this practice, have ordered an incision to be earned on from the same part into the bladder, and the cannula to be then introduced. "Sharp on the Operations, chap. 15. The cannula is to be fixed, and left in, as long as necessary, and through it the Urine is to be let out, as Often as requi- site, by removing tile substance em- ployed as a stopper. The chief advan- tages, imputed to this mode of opera- ting, are, that it produces a more com- plete evacuation of the urine, and is attended with less danger 6f an effusion of mine m the cellular-substance, than the puncture above the probes. The operation, however, we have just de- scribed, is justly cortsidered by the most eminerirpractitioners in this coun- try, as by no means so eligible, as the two following methods: it is unneces- sary, therefore, to say more concerning it. 2. Punctttre above the Pubes. To this way of operating, Mr. Sharp was partial, and Mr. Abernethy has more recently recommended it, under certain circumstances. The former ce- lebrated surgeon remarks, that it is an operation ofno difficulty to the surgeon, and of little pain to the patient, tiie violence done to the bladder being at a distance from the parts affected. It is equally applicable, whether the disor- der be in the urethra, or prostate gland, and when there are strictures, the use of bougies may be continued, while the cannula remains in the bladder. Criti- cal Inquiry, p. 125. edit. 4. Some writers recommend making an incision, about two inches long, through the linea alba, a little way above the pubes, and then introducing a trocar into the bladder. Others deem this preliminary incision quite useless, as- serting, that the operation may be per- formed with equal safety, and less pain to the patient, by puncturing at once the skin, the linea alba, and the bladder. When the trocar has been introduced, the stilette must be withdrawn,-and the cannula kept in its position by a ribbon, passed through two little rings, with which it should be constructed, and fastened round the body. The orifice of the cannula should be stopped up with a little plug, so as to keep the urine from dribbling away involuntarily, and taken out as often as occasion re- quires. CEncyclopedic Methodique; Part. Chirurg. Art. Paracentese de la Vessie.J The trocar should be introduced in a direction obliquely downward and back- ward ; -for as this corresponds with the axis of the bladder, the instrument is less likely to injure the opposite side of that organ. (Sabatier de la Medicine operatoire.J Nearly all writers advise the punc- ture to be made an inch, or an inch and a half, above the pubes. 'The reasons for so etoing are the'following: " If the puncture be made "close to the os pu- bis, the bladder in that part, often ri- singwfthan almostperpendicular slope, leaves a chasm between it-and the ab- dominal st turgid, trying particu- larly to cu the largest completely across. DRY-CUPPING. We nay here mention this simple operatifi, performed by rarefying tiie air in ^cupping-glass, as above, and then atplying tiie vessel to the part af- fected A cupping-glass, furnished with a syrhge, might answer for th;s pur- pose.! think this operation is now not muchused in this country: a proof that it is fit a very efficacious one. ILL pONSEQUE NOES SOMETIMES FOL- LOWING BLEEPING IN THE AHM. 1. Ecchymosis. The most common is a thrombus, or ecchymosis, a small tumour around the orifice, and occasioned by the blood insinuating itself in/o the adjoining cel- lular substance, a"/ the time when this fluid is flowing out of the vessel. Chang- ing the posture j>f the arm will fre- quently hinder the thrombus from in- creasing in size/ so as to. obstruct the evacuation of Hood. But, in some in- stances, the tytaour suddenly becomes 13« BLEEDING. so large, that it entirely interrupts tiie operation, and 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 allow- ing the aandage to remain, a very considerable swelling may be indu- ced, and such as might be attended with great tiouble. If more blood be required to le taken away, it ought to be drawn fron another vein, and, what is still better, Trom a vein in the other arm. The best applications for promoting the absorption of these tumours, are those containing spirit, vinegar, or sal- ammoniac. Compresses, wetted with any lotion of* this sort, may be advan- tageously put on the swelling, and con- fined there by a slack bandage. 2. Inflammation of the Integuments and subjacent cellular substance. Mr. Abernethy says; that the inflam- mation and suppuratioi of the cellular substance, in which thevein lies, is the most frequent occurrence. On the sub- sidence of this inflammation, the tube of the vein is free fron induration. Sometimes it is more difiised, and par- takes of the erysipelatout nature. On other occasions, the affecton is of the phlegmonous kind. When the lancet has beenbad, so as rather to have lacerated, thai cut the parts; when the constitutions irrita- ble, and, especially, when ca-e is not taken to unite the edges of tie punc- ture, and the arm is allowed o move about, so as to make the two ides of the wound rub against each otter; in- flammation will most probably ensue. The treatment of this case onsists in keeping the arm perfectly at -est in a sling, applying the saturnine otion, and giving one or two mild saline purges. When suppuration takes place, a small poultice is the best local ap- plication. 3. Absorbents inflamed. Sometimes, particularly when the arm is not kept properly quiet after bleeding, swellings make their appear- ance about the miodle of the arm, over the large vessels, aid on the fore-arm, about the mid-spact, between the el- bow and wrist, in the integuments co- vering the flexor muscles. The swell- ing at the inner edge of the biceps is sometimes as large as va. egg. Before such swellings take plate, the wound in the vein often inflames, become* painful and suppurates, but without any perceptible induration of the venal tube, either at this time, or after the subsidence of the inflammation. Pains are felt shooting from the orifice in lines, up and down the arm, and upon pressing in the course of tliis pain, its degree is increased. On examining the arm attentively, indurated absorbents may be plainly felt leading to the tu- mour at the side of the biceps muscle. The pain and swelling often extend to the axilla, where the glands also some- times enlarge. Chord-like substances, evidently absorbents, may sometimes be felt, not only leading from the punc- ture to the swelling in the middle of the arm, but also from this latter situa- tion up to the axillary glands, and from the wound in the vein down to the en- larged glands of the mid space between the elbow and wrist, over the flexor muscles of the hand. The enlarged glands very often pro- ceed to suppuration, and the patient suffers febrile symptoms. Some may suspect that the "foregoing consequen- ces may arise from the lancet being en- venomed, and from the absorption of the virulent matter; but the frequent descent of the disease to the inferior absorbents militates against tliis sup- position. When the absorbents become in- flamed, they quickly communicate the affection to the surrounding cellular substance. These vessels, when indu- rated, appear like small chords, per- haps of one eighth of an inch in diame- ter ; this substance cannot be the slen- der 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 dedu- cible from two causes: one, the ab- sorption of irritating matter ; and the other, the effect of the mere irritation of the divided tube. When virulent mat- ter is taken up by tiie absorbents, it is generally conveyed to the next absor- bent 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 absorb- ents happens in consequence of irrita- tion, the part of the vessel nearest the irritating cause, generally suffers most, BLEEDING 137 wliile the glands, being remotely situ- ated, are not so much inflamed. The treatment of the preceding case consists in keeping the arm perfectly quiet in a sling, dressing the puncture of the vein with any mild simple salve, covering the situation of the uiflamed lymphatics with linen wet with the sa- turnine lotion, and giving some, gently purging medicine."" When the glandular swellings sup- purate, poultices should be applied, and if the matter does not soon spon- taneously make its way outward, the surgeon may open the abscess. (See Mr. Abernethy's Essay on this subject ) 4. Inflammation of the Vein. The vein itself is very likely to in- flame, when the wound does not unite. This affection will vary in its degrees, extent, and progress. One degree of in- flammation may only cause a slight thickening of the1" venal tube, and an adhesion of its sides. Abscesses, more or less extensive, may result from an inflammation of greater violence,' and the matter may sometimes become blended with the circulating fluids, and produce dangerous consequences, or the matter may be quite circumscribed, and, make its way to the surface. When the vein is extensively inflamed, a good deal of sympathetic fever is likely to ensue, not merely from the excitement, whicii inflammation usually produces, but also' in consequence of the irritation continued along the mem- branous'linihg of the vein to the heart. If, however, the excited inflammation should fortunately produce an adhesion "of the sides of the vein to each other, at'some little distance from the wound- ed part, this adhesion will form a boundary to the inflammation, and prevent its spreading further. The ef- fect of the adhesive ihflammation in 'preventing the extension of inflamma- tion along membranous surfaces has been ably 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 adhe- sion, as the inflammation was prevented from spreading further. When the in- flammation does not continue equally in both directions, but descends along •* the course of the vein, its extension in the other direction is probably prevent- ed b) the adhesion of the sides of the vein to each other. (S.^c Mr. Ifit.Htr,s vol.. 1. Paper in the Med. and Chirurg. Trans- actions, Vol. 1.) Mr. Abernethy mentions his oily having seen three cases, in which an in- flammation of the vein succeeded vene- section. In neither of these did the vein suppurate. In one, about three inches of the venal tube inflamed both above and below the puncture. The integuments over the vessel were V"ery 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 tiie diseased part. In another instance, the inflammation of the vein did not extend towards the heart, but only downward, in which direction it extended as far as the wrist. The treatment is to lessen the in- flammation of the vein, by the same means, which other inflammations re- quire, and to keep the affection from spreading along the membranous lini ng- of the vessel, towards the heart, by placing a compress over the vein, a lit- tle way above the puncture, so as to make the opposite sides of the vessel adhere together. Mr. Abernethy can conceive a case, in which the vein may suppurate, and a total division of the vessel might be proper, not merely to obviate the exten- sion of the local disease, but to pre- vent the pus from becoming mixed with the circulation. " Might it not be better to put a liga- ture under the suppurating vein, above the affected part of the vessel? Tliis plan would be quite effectual, without the objection of hemorrhage.. [We beg leave to recommend in this place, the. application of a blister over the puncture as the most valuable re- medy for this complaint; it should be applied as early as possible after the discovery of the disease ; a blister as large as the palm of the hand will be sufficient, and in a number of instances it has succeeded in removing imme- diately all the unpleasant symptom.! If the orifice in the vein be not closed, a dossil of lint may be applied over it to defend it from the flies, but commonly this caution is unnecessary.] 5. Inflammation of the Fa,cm of the Fore- arri. Sometimes, in consequence of the in- flammation 'arising from tiie wound of the lancet in bleeding, the arm becomes very painful, and cm hardlv be moved, IS 138 BLEEDING. The puncture often remains unhealed, but, without 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 erysipelas; being not very painful, when slightly touched, but when forci- bly compressed, so as to affect the infe- rior parts, the patient suffers a good deal. The pain frequently extends to- wards tiie axilla and acromion; no swell- ing, however, being perceptible in ei- ther direction. These symptoms are attended with considerable fever. After about a week, a small superficial collec- tion 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 fluc- tuation of matter is distinguished be- low the external condyle, and this ab- scess being opened, a great deal of matter gushes from the wound, the swelling greatly subsides, and the pa- tient's future sufferings are compara- tively triv ial. The last opening, however, is often inadequate to the complete discharge of the matter, which is sometimes ori- ginally 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 si- tuation. The collection of the pus de- scends to the lower part of the detach- ed 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 integuments are not much affected, and the patient complains of a tightness of the fore-arm. Matter does not always form, and the pliability of the arm, af- ter a good while, gradually returns again. Mr. Watson relates a case, which was followed by a permanent contraction of the fore-arm. Air. Abernethy is of opi- nion, that a similar contraction of the fbre-ann, from a tense state of" the fas- cia, may be relieved by detachiug tiie .fascia from tiie tendon of the biceps, to "which it is naturally connected. Mr. Watson seems to bave obtained success in liis first case, by having cut this con- nexion. The treatment of an inflamed fascia, in consequence of venesection, has in it no peculiarity, I'cncral means lor the cure of inflammation should be employed. The limb should be kept quiet, and the inflamed part relaxed. As soon as the inflammation abates, the extension of the fore arm and finger ought to be attempted, and daily per- formed, to obviate the contraction, which might otherwise ensue. (Aber- netliy.) Mr. Charles Bell objects to calling the affection an inflammation of the fas- cia, because he sees no proof of this part being inflamed; and he conceives that the symptoms proceed from the in- flammation spreading in the cellular membrane, and passing down among tiie muscles, and under the fascia. The fascia acts as a bandage, and, 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 perform the nice, if not dangerous operation, of cutting the fascia, at the point, where the ex- pansion goes oft' from the round ten- don of the biceps. When the elbow-joint and fore-arm continue stiff* after all inflammation is over, Mr C. Bell recommends frictions with camphorated mercurial ointment, &c. and the arm to be gradually brought into an extended state by placing a splint on the fore part of the limb. (Operative Surgery, Vol. I. p. 65.) 6. Ill Consequences ofa Wounded Jv'erve. Mr. Abernethy informs us, that Mr. Pott used to mention two cases, in which the patients had suffered dis- tracting pains, followed by convulsions and other symptoms, which could only be ascribed to nervous irritation, ari- sing from a partial division of the nerve, and he recommended its total division, as a probable remedy. Dr. Monro is said to relate similar cases, in wliich such treatment has proved suc- cessful. Hence, it is highly necessary to know the characteristic symptoms of the case particularly, as all the foregoing ones would be exasperated by the treatment just now alluded to. It is to Mr. Aber- nethy that we are indebted for several valuable remarks elucidating this sub- ject. He informs us, that the two cu- taneous nerves are those, which are exposed to injury. Most frequently BLE all their branches pass beneath the veins, at the bend of the arm; but, sometimes, although the chief rami go beneath these vessels, many small fila- ments are detached before 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 dis- pel 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 sup- plies. If,therefore,tiie cutaneous nerves were injured, tiie integuments of the fore-arm would seem to suffer pain ; if the median nerve, the thumb, and two next fingers, would be painfully affect- ed. (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 substance, unite? It seems pro- bable that it would do so, as nerves, as large as the cutaneous ones of the arm, are very numerous in various si- tuations of the body, and are partially wounded in operations, without any pe- culiar consequences usually ensuing. The extraordinary pain sometimes ex- perienced in bleeding, may denote that a cutaneous nerve is injured. The si- tuation of the nervous branches is such, that they must often be partially wound- ed in the operation, though they prp- bably unite again, in almost all cases, without any ill consequences. Yet, savs Mr. Abernethy, it is possible that an inflammation of the nerve may acci- dentally ensue, whicii would be aggra- vated, if the nerve were kept tense, in consequence of its' partial division. Mr. Abernethy thinks the disorder ari- ses from inflammation of tiie nerve, in common with the other wounded parts. Every one will admit that an inflamed nerve would be very likely to commu- nicate dreadful irritation to the senso- rium, and that a cure would be likely to arise from intercepting its communi- cation with that organ. The general opinion is, that tiie nerve is only partially divided, and that :i complete division would bring relief. Mr. Pott proposed enlarging the origi- nal 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 affect BLI 139 ed part, would, perhaps, fail in reliev- ing the general nervous irritation, wliich the disease has occasioned. To intercept the communication of the in- flamed nerve with the sensorium, does, however, promise perfect relief. This object can only be accomplished 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 as the fascia of the fore-arm, above wliich all the filaments of the cutane- ous nerves are situated. As the ex- tent of the inflammation of the nerve is uncertain, Mr. Abernethy suggests even making a division of the cutaneous nerve sti II further from the wound made in bleeding. In the foregoing account, the various ill consequences occasionally arising, after venesection, are represented s * parately; no doubt, in some cases, they may occur together. (See Essay on the III Consequences sometimes following Venesection, by J. Abernethy, F. R. S. Medical and Chirur- gical Transactions, Vol. 1. Medical Com- munications, Vol. 2. BLEEDING. Effusion of blood from accidental wounds. (See Hemorrhage.) BLEPH A ROPTOSIS, (from 0kwa, the eyelid, and irruo-it, a falling down.) Called also ptosis. An inability to raise the upper evelid. (See Ptosis.) BLISTERS. Topical applications, which, when put on the skin, raise the cuticle in the form of a vesicle,, filled with a serous fluid. Various substan- ces produce tliis effect on tiie skin; but, the powder of cantharides is what ope- rates with most certainty and expedi- tion, and, is now invariably made use of for the purpose. The blister piaster is thus composed: R Cantharidum tbj, Emplastri cera tbij, Adipis suilla prop. Hiss. 'The wax plaster and lard being melted, and allowed to become nearly cold, tiie powdered cantharides are af- terwards to be added. When it is not wished to maintain a discharge from the blistered part, it is sufficient to make a puncture in the cu- ticle to let out the fluid; but, when the case requires keeping up a secretion of pus, the surgeon must remove the whole of the detached cuticle with a pair of scissars, and dress tiie excoria- ted surface in a particular manner. Practitioners used formerly to mix powder of cantharides with anointment, 140 BLISTERS and dress the part with this composi- tion. But, such a dressing not unfre- quently occasioned very painful affec- tions of the bladder, a scalding sensa- tion in making water, and very afflict- ing stranguries. Am inflammation of the bladder, ending fatally, has been thus excited. The treatment of such complaints consists in removing every particle of cantharides from the blis- tered part, making the patient drink abundantly of mucilaginous drinks, giving emulsions, and some doses of camphor. These objections to the employment af salves, containing cantharides, for dressing blistered surfaces, led to the useof mezereon, euphorbium, and other irritating substances, which, when in- corporated with ointment, form very proper compositions for keeping blis- ters open, without the inconvenience of irritating the bladder, like cantharides. The favourite application, however, for keeping open blisters, is the pow- der of savine, which was brought into notice by Mr. Crowther, in the first edition of his book on the White Swell- ing. In the late edition, this gentle- man remarks, that he Was led to tiie trial of different escharotic applicati- ons, in the form of ointment, in conse- quence of the minute attention, which caustic issues demand; and among other things, he was induced to try powdered savine, from observing 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 ef- fect was produced. Mr. Crowther next inspissated a decoction of Savine, and mixed the extract with the ointment, which succeeded better, for it produ- ced a great and permanent discharge. At last, after various trials, he was led to prefer a preparation analogous to the unguentum sambuci P. L. and he now offers tiie following formula, as an- swering every desirable purpose.- R Sabina recentis contusa ibij, Ceraflava tbj, Adipis suilla ibiv. Adipe et cera liquefactis, incoque sabinam et cola. The difference of tliis formula from the one, which Mr. Crowther publish- ed 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, whicii 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 be- gins to crisp; the ointment is then strained off, and the proportion of wax, ordered, being previously melted, is added. On tiie use of the savine cerate, immediately after the cuticle, raised by the blister, is removed, it should be ob- served, says Mr Crowther, that expe- rience has proved the advantage of using the application lowered by a half, or two-thirds of the unguentum cerac. An attention to this direction will pro- duce less irritation, and more discharge, than if the savine cerate were used in its full strength. Mr. Crowther says also, that he has found fomenting tiie part with flannel wrung out of warm wrater, a more easy, and preferable way of keeping the blistered surface clean, and fit for the impression of the oint- ment, than scraping the part, as has been directed by others. An occasion- al dressing of the unguentum resinx flavae, he has found, a very useful ap- plication 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 se- parated by the probe, with as much readiness, as the cuticle is detached af- ter blistering. As the discharge dimi- nishes, the strength of the savine dress- ing should be proportionally increased. The ceratum sabinac must be used, in a stronger, or weaker degree, in pro- portion to the excitement produced on the patient's skin. Some require a greater stimulus, than others, for the promotion of the discharge, and this can only be managed by the sensations, which the irritation of the cerate occa- sions, i Mr. Crowther has used ointments, containing the flowers of the clematis recta, the capsicum, and the leaves of the digitalis purpurea. The two first produced no effect: the last was very stimulating; and Mr. Crowther men- tions his intention to take the first con- venient opportunity to determine its qualities more accurately.' He has also used kali purum, rubbed down with spermaceti cerate, in the proportion of one dram to an ounce: it proved very stimulating, but produced no discharge. He has tried one dram of the hydrar- gyrus muriatus mixed with two ounces of the above cerate ; but, the applica- tion was so intolerably painfu% that BOUGIE. 141 Mr. Crowther was sent for at the end of two hours, and found it necessary immediately to remove the dressing. The patient was attacked with the most severe ptyalism Mr. Crowther ever witnessed. (Practical Observations on t/ie White Swelling, &c. a New Edition, by B. Crowther, 1808.) BOIL. See Furunculus. BOUGIE (French for Wax Candle.) This signifies an instrument somewhat resembling a straight piece of wax-ta- per, and the chief use of which is to remove, obstructions in the urethra, by being introduced into this canal. The composition, of which they are made, ought, in particular, to possess a cer- tain degree of suppleness, combined with a good deal ot firmness. The making of bougies has now be-1 come so distinct a trade, that there is no occasion to enter into any particular account of it in this work. The com- position for bougies is now very simple, as modern surgeons place no confi- dence in the medicated substances, formerly extolled so much by the fa- mous Daran. The linen, whicii may he considered as the basis of the bou- gie, is impregnated with tiie composi- tion alluded to, and wliich is generally made of wax and oil, rendered some- what firmer by a proportion of resin. Some saturnine preparation is general- ly added, as the urethra is in an irrita- ble state, and the mechanical irritation might otherwise increase it. Of what- ever composition bougies are made, they must be of different sizes, from that of a knitting-needle to that ofa large quill, and even larger. The com- mon ones are made in the following manner. Having spread any composi- tion, 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 in- troduced into the urethra, should be somewhat smaller than the rest, the slips must be cut rather narrower in this situation, and, when the bougies are rolled up, that side must be out- ward, on which tiie plaster is spread. Mons. Daran, and some others, attri- buted the action of their bougies to the composition used in'forming them. Mr. Sharp apprehended that their efficacy was chiefly owing to the pressure, which they made on the affected part; and Mr. Aikin adds, that as bougies of very different compositions succeed equally well in curing the same disea- ses in the urethra, it is plain, that they do not act from any peculiar qualities in their composition, but, by means of some common property,probably, their mechanical form. There certainly is a great objection to making bougies of very active mate- rials : because the healthy, as well as the diseased, parts are exposed to their action. Hence, surgeons now prefer the common bougies, made of a simple unirritating composition. Plenck recommended bougies of cat- gut, which may be easily introduced even into a urethra greatly contracted, as their size is small, their substance firm, and they dilate with moisture. It is objected to catgut, however, that it dilates very much beyond the stric- ture, and gives great pain on being withdrawn. The elastic resin has been employed for this purpose with great success, as it unites firmness and flexibility. The resin is moulded on catgut by some se- cret method. Elastic gum bougies are in many cases highly serviceable, though their surface soon becomes rough, and they are expensive. Mr. Smyth, apothecary, of Tavistock* street, has discovered a metallic com- position, of whicii he forms bougies, to whicii some practitioners impute very superior qualities. These bougies are flexible, have a highly polished surface, ofa silver hue, and possess a sufficient degree of firmness for any force, neces- sary in introducing them for the cure of strictures in the urethra. The ad- vocates for the metallic bougies assert, that the short time they have been em- ployed has convinced them, that such instruments exceed any bougies, which have yet been invented, and are capa- ble of succeeding in all cases, in which the use of a bougie is proper. The) are made either solid, or hollow, and answer extremely well as catheters; for, they-not only pass into the bladder with ease, but, may also be continued there for any convenient space of time, and hence produce the most essential benefit, The bougies certainly do not swell with moisture, but they do not break, nor bend. See Sharp^s Critical Inquiry, ch. 4. Aikin on the external useof Lead. Bell's Surgery, Vol; 2. 20, &c. White's Sur- gery, S71. 142 BRONCHOCELE. The bougie, with its application, says Mr. Hunter, is perhaps one of the greatest improvements in surgery, which these last thirty, or forty years have produced. When 1 compare the practice of the present day, with what it was in the year 1750, 1 can scarcely be persuaded, that I am treating tiie same disease. I remember, when, about that time, I was attending the first hos- pitals in the city, the common bougies were, either a piece of lead, or a small wax candle, and, although tiie present bougie was known then, the due pre- ference was not given to it, nor its par- ticular merit understood, as we may see from the publications of that time. Daran was the first, who improved the bougie, and brought it into general use. He wrote professedly on tiie dis- eases, for which it is a cure, and also of the manner of preparing it; but, he has introduced so much absurdity in Ids descriptions of tiie diseases, the modes of treatment, and of the powers and composition of his bougies, as to create disgust. When Daran published his observa- tions on the bougie, every surgeon set to work to discover the composition, and each conceived that he had found it out, from the bougies he had made producing the effects described by Da- ran. It never occurred to them, that any extraneous body, of the same shape and consistence, would do the same thing. (Treatise on tiie Venereal Disease, p. 116, by John Hunter, 1788.) Of armed bougies, and of the man- ner of using bougies in general, we shall speak in tiie article, Urethra, Stric- tures )0j«'i quinsy, threatening suffocation, not- withstanding the inculcation of Cxlius Aurelianus, who treated it as fabulous. The mode of doing it, however, has not been well detailed by any who put it in practice, except by Paulus -.-Egincta, who is very precise and clear. " We must (says he) make the incision in the trachea, under the larynx, about the third or fourth ring. This situation is the most eligible, because it is not covered with any muscle, and no ves- sels are near it The patient's head must be kept backward, in order that the trachea may project more forward. A transverse cut is to be made between two of the rings, so as not to wound the cartilage, only tiie membrane." The knowledge of this method, and its ad- vantages in cases of the angina strun- gulans, when practised in time, ought to "have rendered its performance a general practice. The convulsive angina of Boerhaave, whicii particularly affects those, who can only breathe well in an upright posture, also demands the prompt per- formance of bronchotomy. Mead,in his Pracepta et Monita Medica, relates a case. The patient had been bled very copiously twice in the space of six hours, but he died notwithstanding this large evacuation. The same aQthor took notice in Wales, especially, on the seacoast, of an epidemic catarrhal quinsy, wliich carried the patients off in two or three days. In these instances, bleeding was not of much use, and bronchotomy, which was not perform- ed, was the only means of saving the patients. The compression of the trachea by foreign bodies, lodged in the pharynx. or by tumours, formed outward!}', and of sufficient size to compress the wind- pipe, is an equal reason for operating, more or less expeditiously, according to the symptoms. Mr. B. Bell men tions two instances of suffocation from bodies falling in the phaiynx. Respi- ration was.only stopped for a few min- utes; but, the cases were equally fatal, notwithstanding the employment of all the usual means. This author thinks, there was every reason to believe, thai bronchotomy would have been attend- ed with the greatest success, if it had been performed in time, before the ef- fects of the suffocation had becomo mortal. The operation should also be done, when the trachea is compressed by tumours. The author of the article Bronchotomie, in l'Encyclopedic .Metho- dique, says, that about twenty years ago, he opened a, man, who died of an emphysema, which came on instanta- neous!) . He had had, for a long while, a bronchocele which was of an enor- mous magnitude towards the end. of his life. The cavity of the trachea was so obliterated, that there was scarcely room enough to admit the thickness of a small piece of money. Doubtless, bronchotomy, performed before the emphysemamadeits appearance, would have prolonged this man's days. M. Habicot, in a treatise, intitled. Question Chirurgicale sur la Possibility et la JYecessite de la Bronchotomie, men- tions his having successfully performed this operation on a lad fourteen years old, who, having heard say, that gold, when swallowed,did no harm, attempt- ed to swallow nine pistoles, wrapped up in a piece of cloth, 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 stomach. Tht boy was on*the point of being suffoca- > ted 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. M. Habicot, to whose house tiie patient was brought, attempted in vain, by different means, to dislodge the foreign body. At length, perceiv- ing the patient in evident danger of being suffocated, he resolved to per- BRONCHOTOMY 147 form bronchotomy. This operation was no sooner done, than the swelling and lividity of the face and neck disap- peared. M. Habicot pushed the pieces of gold down into the stomach with a leaden probe, and the pistoles were, at different times, discharged from the anus, eight or ten days afterwards. The wound of the trachea very soon became quite well. 2. We have said, that foreign bodies in the trachea, may render it necessary to practise bronchotomy. M. Louis, in an excellent memoir, on extraneous substances in tiie trachea, has proved, more convincingly than all other wri- ters, the necessity of the operation, in circumstances of this kind. The proofs are adduced in a case, whicii fell un- der his own observation, and which we shall quote. On Monday, the 19th of March, 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 immediate- ly attacked with a difficulty of breath- ing, and with a convulsive cough, which was very afflicting. 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 succes- sively sent for, who vainly employed the different means, prescribed by art, for extracting foreign bodies from the ccsophagus, or forcing them into the stomach. A fine sponge, cautiously fastened to the end of a whale-bone probang, was repeatedly introduced through the whole extent of the oeso- phagus. The little girl, who made a sign with 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 whicii pro- duced convulsions in all her limbs. De- glutition was unobstructed; and warm water and oil of sweet almonds had been swallowed without difficulty. Two whole days had passed in sufferings, when tiie relations called M. Louis to render liis assistance. The little girl, with all possible fortitude and sense, was several times held in her friend's .-inns, ready to die of suffocation. M. Louis, well aware of what had happen- ed, came into the room where the pa- ♦ j-.-iit was. She was silting up in her bed, suffering no other symptom, than a very great difficulty of breathing. M Louis inquired where she felt pain, and she made such a sign in reply, as left no doubt concerning 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, with a view of dislodging the foreign body; the nature and the smallness of tliis body, which was not such as would be stopped in the passage for the food; and the facility of swal- lowing, were negative proofs that the bean was not in the oesophagus. Re- spiration was the only function dis- turbed; it was attended with difficulty, and a rattling in the throat. The lit- tle girl expectorated a frothy fluid, and she pointed out so accurately the pain- ful point where the object producing all her sufferings was situated, that M. Louis did not hesitate to declare to the relations, from this single inspection, that the bean was in the wind-pipe, and that there was only one way of saving the child's life, which was to make an incision, for the purpose of extracting the foreign body. He apprised them that the operation was neither difficult nor dangerous, that it had succeeded as often as it had been practised, and that the very pressing danger of the case only just allowed time to take the opinion of" some other well-informed surgeons, respecting the indispensable- necessity for such an operation. \i Louis thought this precaution necessa- ry, in order to acquire the confidence of the parents, and to shelter himself from all reproach, in case the event of the case should not correspond with his hopes. M. Louis went home to pre- pare all the requisites for bronchotomy, and, in two hours, he was informed the surgeons, who were consulted, waited for him. Since M. Louis went away, the child had become quiet, and was lying on its side asleep. The opinion he had delivered, had been ill explain- ed by the friends and attendants, and had been discussed, before his return They, who had been rendering their assistance, on the supposition, that the foreign body was in the ccsophag'us, evinced surprise at the proposal of* ex- tracting, by an operation, a substance, the presence of which, in any part of' this tube was not obvious. M. Louis explained his advice, in regard to bron- chotomy, and he did not expect, a doubt 148 BRONCHOTOMY. to be set up against so positive a fact. The investigation of truth may autho- rize objections, to which those who make them, only give the value wliich is due; but M. Louis was asked con- cerning the possibility of the case. It was objected, that a substance as large as a bean could not insinuate itself into the trachea. He brought every one in- to his sentiment, by a short explanation of cases of this sort with which he was himself acquainted. The little girl was examined, she was better than when M. Louis saw her before, and a very pal- pable emphysema was seen above the clavicle, on each side of the neck, a symptom which did not exist two hours previously. This swelling made M. Louis conclude, that the urgency for the operation was still greater. The friends, whose confidence had been shaken by the opposition he had expe- rienced in bringing about unanimity, were in the greatest embarrassment, when they were told, that the child might die of an operation, whicii he had represented as only a simple inci- sion, free from all danger. M. 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 tiling to fear du- ring the operation, it would be from the accident itself, and not from the as- sistance rendered. This distinction was not perceived, and M. Louis with- drew, at the same time refusing his consent to the exhibition of two grains of emetic tartar, the effect of which would be useless, and might be dange- rous. The medicine was given in the night: the child was fatigued with its operation, and quite unbenefited. On Tuesday morning, M. Louis found the little girl very quiet, and they who had paid their visits before him, found her wonderfully well. The respiration, however, continued to be still attended with a rattling noise, which M. Louis had observed in the evening, when the breathing was much more laborious. The child was nearly suffocated seve- ral times in the course of tiie day, and died in the evening, three days after the accident M. Bordenave, who had seen the pa- tient, informed M. Louis of the child's death on Friday. The body was open- ed, before a numerous assembly of per- sons. After making a longitudinal in- cision through the skin and fat, along the trachea, between the sterno-hyoi- dei muscles, M. Bordenave slit open the trachea, cutting three of its carti- lages. This very instant, every one could see the bean, and M. Louis took it out with a small pair of forceps. It was manifest, from the ease, with which this foreign body was extracted, that. the operation would have had, on the living subject, the most salutary effect 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 remove. (Mem. de I'Acad. Royale de Chirurgie.) This case evinces, in the most deci- ded manner, the symptoms, which re- sult from the presence of foreign bo- dies in the trachea, and shews the only one surgical proceeding, which can be of use. But, among the phenomena, apparently difficult of explanation, is' the calm, which, at different intervals, followed the afflicting cough. Anato- my, however, has dispelled much of the doubt on this matter. It is known, that the whole canal of the trachea is much less sensible, than the rima glot- tidis. A foreign body, like a bean, may remain a certain time in that canal without much inconvenience, the pas- sage being only somewhat obstructed, according to the position of the sub- stance. It may even remain several days, months, or years, without produ- cing any symptom of its presence, ex- cept a trivial sensation of obstruction, and this is what happens, when the bo- dy lodges in one of the ventricles of the larynx. Facts of this kind are to be found in Tulpius, Bartholine, and ma- ny other observers. But, when the ex- traneous substance quits its situation, and is carried into the trachea, the irri- tation, which it produces there, and, particularly, about the larynx, occasi- ons coughing, and if, in the fits, the fo- reign body should become fixed be- tween the lips of the glottis, it may cause instantaneous death, as probably has happened in many of the cases of suffocation from extraneous substan- ces. Another remarkable circumstance which deserves more attention, as it confirms the presence of a foreign bo- dy in the trachea, is the emphysema, which appeared about tiie clavicle, to- wards the termination of the case. M. Louis did not believe, that anv of the persons, who saw the patient, could entertain a just idea of the origin of BRONCHOTOMY 149 tliis symptom. It might be imagined, »hat the obstruction, which the foreign body caused, for two days, to the free pass • ge of the air, might have occasi- oned a forcible distention of the tra- chea, and a rupture of the membranes, which connect together the cartilagi- nous rings of this tube; but this error w as dispelled by the examination after death. The windy tumour had not ori- ginated in the circumference of the tra- chea; here its limits were only seen. The very substance of the lungs, and the mediastinum, were emphysema- tous. The air, which was confined by the foreign body, must have ruptured the air-cells, during the violent fits of coughing, and thus insinuated itself in- to the interlobular cellular substance of the lungs. 'Thence the air must have passed into the cellular substance of the lungs. Thence it must have pass- ed into the cellular substance connect- ing the pleura pulmonalis with the out- er surface of these organs, and by the communication of the cells with each other, it produced a prodigious swell- ing of the cellular substance, separa- ting the two layers of the mediastinum. The emphysema, in its progress, at length made its appearance above the clavicles. The swelling of the lungs, and the circumjacent parts, in conse- quence of the insinuation of air into the cellular substance, is a manifest cause of suffocation. The tumefaction ap- pears to be so natural an effect of the presence of a foreign body in tiie tra- chea, that one can hardly believe it is not an essential symptom, though be- fore M. Louis, no author made mention of it. Foreign bodies in the trachea, how- ever, do not always cause death so suddenly, which may be owing to their smallness, their smoothness, or the si- tuation in which they are fixed. An ex- ample is related in ks Ephemerides des Curieux de la Nature, Decad. 2. Ann. 10. A monk, in swallowing a cherry pre- cipitately, made the stone of the fruit pass into the trachea. A violent cough, and excessive efforts, as it were, to vomit, were the first symptoms of the accident, and of" these the patient thought he should have died. A sleep of some hours followed this terrible agitation, and the patient afterwards did not feel the least inconvenience du- ring a whole year. At the end of this time, he was attacked by a cough, at- tended with a fever. These symptoms became worse and worse, every day. At length the patient evacuated a stone as large as a nutmeg. It was externally composed oftartareous matter, to whicii the cherry stone had served as a nu- cleus. A copious pUrulent expectoration followed the discharge of the foreign body, and the patient died consump- tive some time afterwards. No men- tion is made of the body being opened ; but, from the symptoms, tliere is every reason to believe, that an abscess must have arisen in the substance of the lungs, from the prcscuce of the foreign body. Bronchotomy has been proposed in cases, in whicii the tongue is so en- larged, as totally to shut up the pas- sage through the fauces. Richter men- tions an inflammation of the tongue, which bec:ime four times larger than natural. Valescus had made the samo observations: Ego aliquando vidiitamag- nificatam, linguam propter humores, at, ejus substantiam venientes, et ipsam imbi- bentes, quod quasi totum os repkbat, et aliquando ex ore exibut. Lib. 2. cap. 66. Such prodigious swellings of the tongue are said sometimes to occur in malig- nant fevers, and the small-pox. They are also sometimes quite accidental, as the cases which happen from some stings of insects, or the unskilful em- ployment of mercury. Mr. B. Bell gives an instance of the latter sort. He says, that the patient had taken, in a very short time, so large a quantity of mer- cury, that the glands became alarm- ingly swollen in a few hours, and, though all the usual remedies were tried, none had the least effect. Bronchotomy was delayed till the patient was nearly suf- focated ; but he was restored as soon as an opening was made in the trachea. Some have objected to this practice, alleging-, that scarifying the tongue will bring relief in time. (Encyclopedic, Methodique.) M. Malle's observations on the swelling of the tongue, and tiie most effectual means of* relieving it, seem to confirm the latter sentiment. (Mem. de I'Acad, de Chirurgk, Tom. 5.) Bronchotomy has been proposed, when both the tonsils are so enlarged that they quite impede respiration. Here, the inflammatory swelling is not meant; this commonly soon suppurates, and the spontaneous bursting of the tumour, or the opening of it with a pharyngotomus, always does away the necessity for so extreme a measure. It is the chronic enlargement now alluded 150 BRONCHOTOMY. to, that case mentioned in the article Tonsils, and whiph sometimes acquires an immense size. From our remarks on the disease, it will be seen, that more is to be expected from the ex- cision of the tonsils, than from the ope- ration now in question. Besides, be- fore the glands are so large as to threat- en suffocation, they should be cut away, in preference to performing bronchoto- my, which would relieve the urgency, but not the cause. In general, there is here only a fear of suffocation, when the swelling is such as not only to shut up the posterior aperture of the mouth, but also the posterior openings of the nostrils, which is exceedingly rare. Nor is it common for a polypus to make this operation necessary. Boerhaave, how- ever mentions a case, in which the pa- tient was suffocated, as the surgeon was going to extirpate a tumour of this kind: no doubt, this patient might have been saved, if bronchotomy had been previously performed. Lastly, bronchotomy has been re- commended to be done on persons re- cently suffocated or drowned. Dcthard- ing is the first author who has treated of the necessity of this operation, in the latter case, in a letter addressed to Schroeck, intitled, De Methodo subven- kndi submersis per laryngotomiam. Hac- tenus recte, says Mailer, si spuma quo pulmo in submersis offercitur ed adminis- tratione repelli quiret, This writer main- tains, that drowned persons have no water in their chests, or air-vessels of the lungs, and that they perish suffo- cated, for want of air and respiration, and that, wliile the person is under wa- ter, the epiglottis applies itself* so close- ly over the glottis, that not one drop of water can pass. But, these assertions are quite contrary to the numerous ex- periments made by M. Louis, who drowned animals in coloured fluids, and proved that they who are drowned, in- spire water, with wliich the air vessels and cells are quite filled. M. Louis has also opened men, who have per- ished under water, but, in them, he never found tiie epiglottis applied to the glottis, as Detharding says it is, and anatomy proves the impossibility of its being so. Detharding's theories were wrong, and, as he did not use any power to distend the lungs with air, his mere practice of" bronchotomy must have been useless. When there is a free communication between the cells of the lungs and the atmosphere, the air will not expand these organs, if the inspiratory muscles can no longer act. Hence, after opening the trachea, and letting as much water run out of this tube as possible, the pipe of a pair of bellows should be introduced, and the air forcibly introduced into the lungs. Detharding's opinion, that drowning is a species of suffocation, was right, and that the privation of oxygen gas is the cause of death. Hence, we see the propriety of introducing this air into the lungs, as speedily as possible, when- ever we think, that animation has not been so long suspended, that every hope of restoration is over. Indeed, it is proper to distend the lungs with air, in all cases in which animation has been recently suspended by suffocation, immersion under water, or by noxious vapours and gases. This measure is highly proper, in conjunction with elec- tricity, the communication of warmth to the body, the application of strong volatiles to the nostrils, and the injec- tion of any fluid, like warm wine and water, into the stomach, through a hol- low bougie. Tobacco clysters, which even have had the sanction of the Royal Humane Society, should, however, be reprobated, as the qualities of this plant are peculiarly destructive of the vital principle, and not simply stimulating. DESCRIPTION OF THE OPERATION. No preparation is necessary, as de- lay only increases the danger. The pa- tient being seated in an arm-chair, or, what is better, laid on a bed with his head hanging backwards, an incision is to be made, which is to begin belovv the cricoid cartilage, and to be con- tinued downward, about two inches, along the space between the stemo- thyroidei muscles. Care should be ta- ken not to cut the lobes of the thyroid gland, lest a troublesome and danger- ous bleeding should be occasioned, and, as the left subclavian vein lies a little below the upper part of the first bone of the sternum, the incision should on no account ever extend in the least below the top of this bone. The knife must not be carried either to the right or left, in order to avoid all risk of in- juring the large blood-vessels situated at the 'Sides of the trachea. The inci- sion in the integuments being made, the sternothyroidei muscles are to be pushed a little toward the side of the neck, so as to bring the trachea fairly BRONCHOTOMY 151 nto view. Most authors recommend the point of the knife to be then intro- duced between the third and fourth cartilage of the trachea, and the open- ing to be enlarged transversely. It is true, that, in this way, an opening may be safely made, large enough to allow of the introduction of a small can- nula. It is safer, however, in all cases, to enlarge the opening in the perpendi- cular direction, by cutting from within outward. There is no advantage in avoiding a wound of the cartilages of the trachea, and this was the only rea- son for cutting the membrane between two of them, in a transverse direction ; while a sufficiently^large opening could not thus be safely obtained in cases in which it is necessary to introduce tiie muzzle of a pair of bellows, in order to inflate the lungs. In short, it is safer and better, in every instance, to make the wound in the trachea in a perpen- dicular manner. When bronchotomy is performed for the purpose of inflating the lungs, the cut in the windpipe must be made some- what larger than when only an opening is required to enable the patient to breathe through a small cannula. The larger size of the pipe of the bellows, is the reason of this circumstance. When a cannula is to be introduced, care must be taken not to pass it too far into the wound, lest it should injure the opposite side of the trachea. This is a caution, on which Fabricius ab Aquapendcnte dwells very strongly, and with good reason. Small as the vessels may be, which are divided in bronchotomy, they oc- casionally bleed so much, as to create apprehension, and even prevent the pro- cess of the operation. There is a case in Van Swietcn's Commentaries, confirm- ing this remark. A Spanish soldier, aged twenty-three, was in the most ur- gent danger from an inflammation of his throat. It was thought nothing could save him, except bronchotomy. After the longitudinal cut in the skin, and the separation of the muscles, the trachea was opened between two of the cartilages ; but the blood insinuated it- self into this canal, and excited so vio- lent a cough, that the cannula could ftot be kept in by any means, though it was replaced several times. M.Louis remarks, that, in this instance, the pa- tient's head should have been turned downward, in order to keep the blood from flowing backward into the trachea. It is asserted, that the opening of tliis tube was not always opposite the ex- ternal wound, in consequence of the convulsive action of the muscles, and that the patient on this account could hardly breathe. Hence M. Vigili was induced to slit open the trachea, down to the sixth cartilaginous ring ; and it was only then that he inclined the pa- tient's head forward. The bleeding now- ceased, the patient breathed with ease, and, on the second day, the inflamma- tion was so much better, that respira- tion could go on without the aid of the opening in the trachea. To obviate the preceding accident, a proposal has been made to adapt a cut- ting blade to a cannula, of a suitable size, and proper for remaining in the wound, and sufficiently compressing the orifice of such vessels as might be opened. In Richter's Observations Chir- urgie.c, a description of some instru- ments of this kind may be seen. Mr. Bell has described one, somewhat like a flattened trocar, only not quite so long. The patient's head being inclin- ed backward, as far as possible, the point of the instrument is to be intro- duced between two of the cartilages ; between the lower margin of the thy- roid, and the upper edge of the cri- coid, is said to be the best situation, being more extensive, less vascular, and, after the division of the sltin, there being only the crico-thyroid ligament to be divided. When the instrument has entered, the lancet is to be with- drawn, and the cannula fixed, by means ofa ribbon, which is tied to each wing- of the instrument, and must be fasten- ed at the back of the patient's neck. Should the instrument be too long, it should be passed through two or three little compresses, before being put into the windpipe, wliich artifice will make it answer as well as a shorter one. The piece of gauze is then to be tied once on the outward orifice of the cannula. Sometimes, though very seldom, the cannula becomes obstructed with mu- cus, or clots of blood. Such an acci- dent nearly suffocated a patient at Edinburgh. A man of genius, who was at hand, suggested the introduction of a second cannula into the first; the' second one being taken out, and clean- ed, as often as necessary, and then re- placed. Monro, the father, used to re- commend this plan. It is better, how- ever, to have at once a double cannula, to fit the stilette. l.i-2 BUBO. The use of the cannula must be con- tinued as long as the causes, obstruct- ing respiration, remain. When respiration is suspended by the presence of a foreign body in the trachea, and the extraneous substance does not make its appearance at the opening made, a trial may be made to discover its situation by means of a bent probe. When it lies downward, tiie wound in the trachea may be enlarged in tliis direction, and the body may be extracted with a small pair of forceps. When it cannot be immediately found, iomc practitioners (Heister and Raw) have succeeded by keeping the lips of the wound asunder with pieces of sheet- lead, by which means, the force of tiie air in expiration has, in a few hours, expelled the foreign body. If there were reason to think the substance to be situated in the ventri- cles of the larynx, it would be proper to make the openuig, between the thy- roid and cricoid cartilages. Richter thinks he has perfected bron- chotomy, by using a curved cannula ; but, the inconveniences, whicii he at- taches to the straight one, hardly ever occur. A curved cannula cannot be so conveniently introduced into another one similarly shaped. From the manner, in whicii the epi- glottis covers the top of the larynx, it is obviously very difficult to introduce t he muzzle of a pair of bellows into the 1 ima glottidis, even though the pipe be curved. Were the surgeon at last to succeed, the time lost in effecting the object, would create much more peril by far, than would arise from broncho- tomy. It is much wiser, to have re- course at once to a very safe and sim- ple operation. In l;.ct, the parts to be divided arc not at all important ones, s.nd the operation is as easy, as it is lit- tle likely to occasion of itself any ill consequences. In summd, (says Fabri- i_ius ab Aquapendcnte) Ires tantum par- ies concurrunt ad hujusmodi chirurgiam, cutis, musculi, et aspera arteria. Mus- culation incidttntur, sed manubrio scal- pelli invicem diducuntur', et seperantur, -■it arteria appareat,- qua apparente nul- lo negotio incidttur, in qua neque sanguis obstaculo esse potest, quod cutis cum ex- iguo sanguine inciditur, arteria vero nulk. BUBO, (/ZivCw The groin.) Modern _ surgeons mean, by this term, a swell- * ing of the lymphatic glands, particu- larly of those in the groin, and axilla. The disease may arise from the mere irritation of some local disorder; from the absorption of some irritating mat- ter, such as the venereal poison; or from constitutional causes. Of the first kind of bubo, that, which is named the sympathetic, is an instance. For an account of the venereal bubo, see Venereal Disease. The pestilential bubo, which is a symptom of the plague, and tiie scro- phulous swellings of" the inguinal and axillary glands; may be regarded, as examples of buboes from constitutional causes. See Scrophula. SYMPATHETIC BUBOES. The inguinal glands often become affected with simple phlegmonous in- flammation, in consequence of irrita- tion in parts, from which the absorbent vessels, passing to such glands, pro- ceed. These swellings ought to be carefully discriminated from others, wliich arise from the absorption of ve- nereal matter. The first cases are simple inflammations, and only demand the application of leeches, the cold sa- turnine lotion, and the exhibition of a few saline purges; but, the latter dis- eases render the administration of mer^ cury indispensable. Sympathetic is the epithet usually gi- ven 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 oc- casioned by the irritation of a virulent gonorrhoea. The pain, which such a swelling gives, is very trifling, compa- red with that of a true venereal bubo, arising from the absorption of matter, and it seldom suppurates. However, it has been contended, that the glands in the groin do sometimes swell and in- flame from the actual absorption of ve- nereal matter from the urethra, in cases of gonorrhoea, and which swellings must consequently be venereal. (Hun- ter on the Venereal,p. 57) The manner in which buboes form from mere irritation, will be better un- derstood by referring to the occasional ill consequences of venesection, in the article Bleeding. The distinguishing etiaracters of the venereal bubo are no- ticed in the article Venereal Disease. BUBO. 15.: TESTILENTIAL BUBO. A pestilential bubo, at it's commence- ment, is a small, hard, round tumour, readily perceptible to the touch, about the size and shape of a pea ; it is move- able under the skin, the appearance of which is not altered at an early peri).!, the bubo lying more or less deeply, and the swelling not appearing externally. As the tumefied gland enlarges, it changes from a round to an oval shape, becoming, at the same time, less move- able. The integuments now begin to thicken, and the swelling to appear ex- ternally. The appearance of the bubo is often preceded by a sense of tight- ness and pain, sometimes ofa lancina- ting kind, or by an itching in the p.-u-t, where it is about to appear, and, now and then, tiie disease is preceded by shivering. In many cases, however, the small swelling, just described, comes on, without being preceded by any peculiar symptoms. Some buboes are indolent and insen- sible, others very sensible and rapid in their progress. When the tumour ad- vances quickly to suppuration, the cir- cumstance is generally regarded as fa- vourable. Cases, however, in which the matter soon forms, are frequently fatal, and tliere are many histories of other cases, whicii terminated favoura- bly, though the buboes were extreme- ly indolent, and ended in resolution. It is difficult to foresee in what way a bubo will terminate. The fluctua- tion is often scarcely perceptible, where suppuration has taken place, and bu- boes are sometimes resolved, after there has been a very evident fluctua- tion. Their progress, indeed, is almost always, more or less, irregular, especi- ally, after the first week. At one time, they seem advancing to suppuration; at another time, they shew a tendency to resolution. But, these variations, Dr. Russell remarks, chiefly respected the integuments; for, the gland itself, when carefully explored, was seldom found to alter; and, when the tumour actually dispersed, it was not suddenly, but, by slow degrees. Thus, from the alteration in the integuments alone, the whole tumour, on a superficial view, seemed to lessen, or increase, though the gland remained the same; and Dr. ltussel was inclined to think, that tliis deception was often the cause of the bubo being said to fluctuate, or to va- nish in appearance, and again return. vol. 1. However, he is far from thinking, that this fluctuation was never real. Chenot observes: Vidimus quoque abrupt atn snp- puratiojf£m in his resuscitari, ac demum per effusionempnrk ubsolvi. The bubo, as it increases in size, be- comes somewhat flat; and, generally about the second week, the skin over it grows tense, and painful, and begins to be inflamed. In some cases, the in- flammation isjmoderate; in others, con- siderable ; but, it seldom terminates in gangrene, although the skin, now and then, assumes a blueish colour. Sometimes, however, the bubo sup- purates, without the skin seeming to be at all inflamed; and in this circum- stance, as the turn-Hir is generally hard- er, than a suppurated venereal bubo, it is often difficult to determine, whe tiier suppuration has taken place, or not. When buboes break spontaneous- ly, it generally happens in the third weeft; sometimes at a later period. The buboes most frequently appear in the groin, or a little lower, among the lowest cluster of inguinal glandsi They also frequently appear among the axillary glands; sometimes, though more rarely, they have their seat in the parotid, and the disease is then by ma- ny reckoned more dangerous, than when the buboes appear in the groini, or armpits. Still more rarely, they ap- pear in the maxillary, or cervical glands. These latter, Dr. Russell re- marks, were seldom observed to swell, without either the parotid swelling at the same time, or soon afterwards, or a carbuncle protruding near them. They never were the sole pestilential eruptions; and he recollects few in- stances of their coming to maturation It has been remarked by others, that the parotid bubo seldom appears un- accompanied by one, or more, in the axilla, or groin. Axillary buboes, generally speaking, suppurate more frequently than those about the fauces, and the inguinal more frequently than the axillary. Buboes often make their appearance on the first day of tiie complaint; some- times, indeed, they are among the first symptoms. It has been observed, that when they appear later, than the third, or fourth day, they are generally pre- ceded by an exacerbation of the febrile symptom. Those, which come out at so late a period, however, are not, for the most part, the first, which appear in the course of the complaint; for, a 10 154 jsuB BUR succession of buboes sometimes takes place, till three or four have made their appearance. Sometimes, no buboes appear, and these cases are, upon the whole, tiie most fatal. This is a circumstance, which particularly demands attention, as the cases, unattended with buboes, and other pestilential eruptions, gene- rally make their appearance at the commencement of the epidemic, and have often, in consequence of the ab- sence of the eruptions, been mistaken for other complaints. In other cases, particularly, towards the decline of the epidemic, the buboes, and other erup- tions, often form the principal part of the complaint, which is then unattend- ed with danger; from whicii it would appear, that the eruptions in the plague are to be regarded as favourable, s) mp- toms. When the inflamed gland advances to suppuration more rapidly, than the integuments; troublesome fistulous ul- cers are sometimes formed, if an artifi- cial opening has not been made in the skin. This accident, however, is rare : in general, the buboes, when left to themselves, do not prove troublesome. When they do not suppurate, and the patient recovers, they gradually dis- perse, generally in the space of* a few weeks. In some cases, they are suc- ceeded by an induration of the gland, which remains for many- months. Even when suppuration has taken place, if tiie cure proves tedious, either in con- sequence of the matter having been discharged by too small an opening, or the opening having repeatedly closed in the progress of the cure, a similar induration sometimes succeeds; which, in like manner, sooner or later disap- pears. In tiie plague, buboes, termed spu- rious, sometimes form. Spurious bu- boes differ from the true ones, in ap- pearing indiscriminately on every part of the body; while the latter are con- fined to the groin, axilla, and parts about the fauces. ' Spurious ones were observed, says Dr. Russell, on the head, the forehead, the throat, the shoulder, above the clavicle, the neck, on, or above, the scapulae, the back, the side, under the breast, on tiie belly, the hip, hind-part of the thigh, near the ham, the leg, tiie scrotum, the arm near the usual place of issues, inside of the arm near the elbow, outside of the fore-arm, and near tiie wrist. Some of these buboes, if not lanced at a proper time, grow to a great size, particularly,"those on the scapula:, or back. In other parts, however, they seldom much exceed the size ofa hen's egg. They generally appear about the second, or third day, after true buboes, or carbuncles; and usually suppurate, though not so quickly, as true pesti- lential buboes do. (See Wilson on Fe- brile Diseases.) BUBONOCELE, (from (kuQw, tiie groin, and kh\h, a tumour.) A species of hernia, in wliich the bowels protrude at the abdominal ring. The case is often called an inguinal hernia, because the tumour takes place in the groin. Every thing, necessary to be known on this subject, will be found in the article, Hernia. BURNS. A burn is an injury, more or less superficial, occasioned by the contact of some substance^ heated be- yond what the body can bear, without its fibres and organization being hurt. Burns present different appearances, according 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 ef- fect. Burns, which only irritate the surface of the skin, are essentially dif- ferent from those, which destroy it; and these latter have a very different aspect from what others present, which have attacked parts more deeply situ- ated, such as tiie muscles, tendons, li- gaments, &c. Scalds, whicii are the effect of heated fluids, do not exactly resemble burns, occasioned by the di- rect contact of veiy hot metallic bodies, or some combustible substance on fire. As fluids are not capable of acquiring so high a temperature, as many solid things, scalds are generally less violent than burns, in the injury which they produce; but, in consequence of liquids often flowing about with great rapidi- ty, and being suddenly thrown in large quantities over the patient, scalds are frequently dangerous on account of their extent. It is well worthy of" re- mark, that the danger of the effects of fire is more proportioned to the size, than the degree, of the injury. A burn, that is so violent, as to kill parts at once, may not be in the least danger- ous, if not extensive; while, a scald, which perhaps only raises the cuticle, may prove fatal, if very large. The degreee of danger, however, is to be rated from a consideration both of the BURNS. 155 size and violence of the injury. The worst burns, which occur in practice, arise from explosions of gun-powder, or inflammable gases, from ladies' dresses catching fire, and from tiie boil- ing over of hot fluids, in laboratories, manufactories, &c. Burns, which' only destroy the cuti- cle, and irritate tiie skin, are very si- milar to the effects, produced by can- tharides and rubefacients. The irrita- tion, which such injuries excite, increa- ses the action of the arteries of the part affected, aVid they effuser a fluid under the cuticle, which become ele- vated, and detached. Hence, the skin becomes covered with vesicles, or blad- ders, which are more or less numerous, and large, according to the manner, in which the cause has operated. But, when the skin, or subjacent parts, are destroyed,'no vesicles make their ap- pearance. In this circumstance, 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 whicii the destructive effects of the fire have extended. Tiie parts may either be killed, at the moment of the injury, by the imme- diate effect of the file, or they may first inflame, and then mortify. In all cases of burns, the quantify of injury depends on the degree of heat in the burning substances ; on the du- ration, and extent of their application; and on the sensibility of tho burnt part. XV hen a large surface is burnt, mor- tification sometimes makes its appear- ance with great violence, and very quickly after the accident: but, in ge- neral, the symptom, the most to be dreaded, in such cases, is inflamma- tion. The pain and irritation often run to such a pitch, that, notwithstanding every means, there is frequently im- mense trouble in keeping down the in- flammation. When the burnt surface is very large, the effects of the inflam- mation are not confined to tiie part, wliich was first injured; but, even cause a great deal of fever; and, in certain cases, a comatose state, which may end in death. It has been obser\-ed, that persons, who die of severe burns, seem to ex- perience a remarkable difficulty of breathing, and oppression of the lungs. These organs, and tiie skin, are cer- tainly both concerned in separating a lirge quantity of water from the cir- culation, and their participating in this function, may perhaps, afford a reason, for the lungs seeming to be affected, when a large surface of skin is injured in cases of burns. However, the kid- neys perform the same office, and they are not particularly affected in burnt patients; so that the asthmatic symp- toms, in these cases, are probably ow- ing to a sympathy between the lungs and skin, or rather to causes not at present understood. TREATMENT OF BURNS. The former plan of treating burns was founded on principles, which seem applicable to cases of" inflammation in general. The treatment was most commonly antiphlogistic, and even co- pious bleeding from the arm was not unfrequcntly practised. We shall first offer a concise account of tiie old practice, as explained by Mr. B. Bell. When the skin is not desU*oy- ed, but seems to suffer merely from ir- ritation, relief may be obtained by dip- ping the part affected in very cold wa- ter, and keeping it for some time im- mersed. This author states, that plun- ging the injured part suddenly into boiling water would also procure 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 gene- ral, astringent applications are best. Strong brandy, or alcohol, is particu- larly praised. At first, the pain is in- creased by this remedy; but, an agree- able soothing sensation soon follows. The parts should be immersed in the spirit, and, when this cannot be done, soft old linen, soaked in the applica- tion, should be kept constantly on tiie burn. Goulard's lotion, or a strong solution of the cerusa acetata, is re- commended, and, said to prove useful, however, only by being astringent, as equal benefit may be derived from a strong solution of alum, &c. Such ap- plications were frequently made with a view of preventing the formation of ve- sicles ; but, Mr. B. Bell always remark- ed, there was less pain, when the blis- ters had already appeared, than when prevented from rising, by remedies ap- phed immediately after tile occurrence of the injur)'. The applications should be continu- ed, as long as the pain continues; and in extensive burns, creating great irri- 156 BURV"-, lation, opium ^houhl be prescrilu ' The stupor, with which patients, so si- tuated, are often attacked, receives more relief from opium, than any thing else. Some recommend opening the vesi- cations immediately; others assert, that they should not be"meddled with. Mr. B. Bell thinks, they should not be open- ed till the pain arising from the burn, is entirely gone. At this period, he says, they should always be punctured; lor, when the serum is allowed to rest long upon the skin beneath, it has a bad effect, and even induces some de- gree 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 saccharum saturni, is to be applied. When there is much irritation and fever, blood-letting, and such remedies, as the particular symptoms demand, must be advised. When the skin ulce- rates, the treatment does not differ from what will be described, when we speak of Ulcere. When the burnt part, is, from the first, more 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 great- est celebrity. Even, iit this day, the ' application is very often employed. Mr. B. Bell advises it to be put on the parts, by means of a soft pencil, as the application and removal of the softest covering, are often productive of much pain. In some cases, Mr. B. Bell says, Gou- lard's cerate, and a weak solution of the saccharum saturni, procure ease more quickly than tiie above liniment The sloughs having come away, the sores are to be dressed according to common principles. (See Ulcers.) When burns are produced by gun- powder, some of the grains are apt to be forced into the skin. These should be picked out with the point of a nee- dle, and an emollient poultice ap- plied, whicii will dissolve and bring away any particles of gunpowder, which may yet remain. Burnt parts, wliich are contiguous, are apt to grow together in the pro- gress of the cure"! The fingers, toes, sides of the nostrils, and the eye-lids, are very liable to this occurrence. It is to be prevented by keeping dress- ings always between the parts, likely to become adherent, until they are per- fectly healed. The sores, resulting from burns, are, perhaps, more disposed, than any other ulcers, to form large granulations, wliich rise considerably above the le- vel of the surrounding skin. No poul- tices should now be used. The sores should be dressed with any moderately stimulating, astringent ointment: the basilicum wjth the pulv. hydrarg. ni- trat. rub, is now generally preferred - and, if the part wilL allow of tiie appli- cation ofa roller, the pressure of this will be of immense service in keeping down the granulations* and rendering them more healthy. When these me- thods fail, the sores should be gently rubbed with the argentum nitratum. MR. CLEGHORN'S FtAN. Mr. Cleghorn recommends the im- mediate application of vinegar, which is to be continued, for some hours, by any the .-most convenient means, until the pain abates. Should it return, the vinegar is to be repeated. Ifthe pain is so severe as to have destroyed any part, when the pain has.ceased, it is to be covered with a poultice, which must remain on six, or, at most, eight hours. When this is removed, the psft-t is to be entirely covered with very finely pow- dered chalk, so as to make every ap* pcarance of moisture on the surface of the sore, no longer visible This be- ing done, the whole is to be covered with the poultice again. The same mode is then \o be pursuedevery night and morning, until the cure is- com- plete. If the use of poultices should seem to, relax tiie ulcers too much, a plaster, or ointment, containing white lead, is to be applied; but, the chalk is still to be used next the sore- In respect to general remedies, Mr. Cleghorn allowed his patients to eat boiled, or roasted fowl, or, in short, any plain dressed meat, they liked. He did not object to their taking moderate quantities of wine, spirits and water, ale, or porter. His applications he-ob- served, allayed pain and inflammation, and either prevented, or removed fever, and, judging from their effects, lie thought they had powerful antiseptic virtues. He never had occasion to or- le?v bark, or any internal medicines whatever, and .he only once thought it necessary to let blood. When a pa- BURNS. 157 tient was costive, Mr. Cleghorn used to order boiled pot-barley and prunes, or some other laxative nourishing food, and sometimes an injection, but never any purgatives. It is distressing to a pa- tient with bad, sores, to be often going to stool. Besides, Mr. Cleghorn remark- ed, that weakness and languor, (which never, in his opinion, hasten the cure of any sore) are always brought on, more or less, by purgatives. From the ef- fects; too, which hefeltthem have upon himself, and observed thein to have upon others, they did not seem to him to have so much tendency to re- move heat and feverish symptoms as is generally supposed, and more fre- quently carry off" -useful humours, than hurtful ones. Diluted sulphuric acid would not an- swer well, instead of vinegar. The lat- ter produced most benefit, when it was fresh and lively to the taste. In cold weather, in particular, Mr. Cleghorn ns£d to warm the vinegar a little, place the patients near the fire, give them something warm internally, and; keep them, in every respect, in a comfortable situation. His object, in so doing, was to prevent the occur- rence of tremblings, and chilness, which in two instances, alarmed him a good deal, after employing vinegar, whicii was too cold. The account of Mr. Cleghorn's plan was published by Mr. Hunter, in the Mtdical Facts and Obsei*vations, Vol. 2. SIR JAMES EARLE'S PLAN. This gentleman exclusively advises the use of culd water, or rather ice ; and he has brought forward several cases of extensive burns, in wliich this method was employed with the best effect. We have mentioned cold water, among the applications to burns, enu- merated by Mr. B. Bell, and it was cer- tainly not uncommonly used long be- fore Sir James Earle published on the subject. This author, however, has made tiie plan more extensively known, and, as it is an eligible one, he has a certain claim to praise. The burnt parts may either be plunged in cold water, or they may be covered with linen dip- ped in the same, and renewed as often as it acquires warmth from the part. 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 Effects of Fire on tiie Human Body. 1799.) mr. Kentish's plan. From what has been stated, it ap- pears, that cold and hot, irritating and soothing, astringent and emollimt ap- plications, have all been outwardly em- ployed, in cases of burns, without much discrimination. But, the internal treatment has al- ways been of one kind, and both the ancients and moderns agree in ad- vising blood-letting, cooling purges, and, in short, the whole of the anti- phlogistic ^lan. Mr. Kentish is the only one, who^is ventured to put in prac- tice stimulating means, internally, as well as externally. It is to be remark- ed, at the same time, that Mr. Clegr horn's practice was somewhat analo- gous to that recommended by the lat- ter gentleman. He condemned purges, and. he allowed his patients to take stimulants internally. The theories advanced by Mr. Ken- tish, which, however, are very objec- tionable, lead him to lay down two practical indications, in injuries caused by a pernicious quantity of heat, sud- denly applied to a part of the body, and which injuries are attended with in- creased action. The two indications, for restoring the unity of action, are; first, gradually diminishing the excite- ment, or action, of tiie part ; secondly, increasing the action of the system to meet the increased action of the part, holding this law as the system in view : That any part of the system, having its action increased to a very high degree, must continue to be excited, thoughinakss degree, eiher by the stimulus, which caused the increased action, or some other having the nearest similarity to it, until by degrees the extraordinary action sub- sides into (he healthy action of the part. With this view, holding the part to the fire seems the best mode of relief; but, as parts of the body are injured, to which tliis cannot be done, the most stimulant applications must be had re- course to; for, in this class, there is little fear of any of them being greater, than that which originally caused the accident. The strongest rectified spir- its, made still stronger by essential oils, are proper, and may also be heated as much as the sound parts can bear. These, and many more applications of the same class, savs Mr. Kentish, will 158 BURNS. give tiie sp^<- diest and most effectual re- lief. These are only to lie continued for a certain time, otherwise they may afterwards cause the very ill they were given to cure. They are then to be suc- ceeded by less stimulant applications, until the parts act by common natural stimii^. The internal mode of relief is to give those substances, which soonest excite tiie system to great action, such as aether, ardent spirits, opium, wines, &c. by whicii means the solution of conti- nuity of action is allowed to continue the shortest time possible, and the uni- ty of action restored, which constitutes the cure. Suppose, for instance, a^L local ap- plication, we at first apply the strong- est alcohol, heated to the degree, whicii the sound part would bear without in- jury : it should afterwards be gradually diluted until it becomes a proof-spirit, and tiie }ieat should be diminished, al- though gradually, as cold is always pernicious, bringing on that tendency to shiver, whicii should ever be con- tinually guarded against, as being a most hurtful symptom, and the fore- runner of a violent sympathetic fever. To prevent this, the external heat should be kept at a high temperature, and the action of the whole system in as great a degree, as may be safe. By this means, you make the action of the whole meet the increased action of the part, by which the lessening of the in- creased action of the part to join the action of the whole, is rendered more easy. Thus, there is, says Mr. Kentish, a unity of intention by both the exter- nal and internal means, which leads to the restoration of the unity of action, and thus is the cure performed. It may be said, these circumstances can only take place, when there is ah increased action, and, that when the parts are destroyed, other means should be used, such as emollients, &c. In re- plying to this remark, Mr. Kentish dis- tinguishes burns into two kinds ; one, in which the action of the part is only increased; and, another, in which some parts have increased action, and other parts are destroyed. It is of httle con- sequence, says Mr. Kentish, what is ap- plied to the dead part, as tiie detach- ment of an eschar depends upon the ac- tion of parts, which remain alive, and not upon what is applied to those, which are dead. Mr. Kentish remarks, however, that he never saw an instance ofa burn, in which, though some part* w ere totally destroyed, there were not always other parts, in which there was only increased action. Now as our duty is always to save living parts, our mode of Cure, in the first instance, will al- ways be tiie same, viz. to cure the parts, which have only an increased action, in the doing of which the dead parts will not be the worse, as their separation is a process of the system, wliich requires time, and, if the injury is to any extent, draws forth the joint efforts of the sys- tem, and even, says Mr. Kentish, calls up all the energy of its powers, to vio- lent fever. This state should be sup- ported by every artificial aid, in order to bring tiie parts to suppuration, other- wise the subject falls in the contest; for, if the living parts have not the power to throw off the dead, the dead will assimilate the living to themselves, and a mortification ensue. When the living parts have been pre- served, (continues Mr. Kentish,) which according to this treatment, will*be in the course of two or three days, the dead parts will he more plainly ob- served, and the beginning of the pro- cess to throw them off will be com- mencing. This process must be assist- ed by keeping up the powers of the system against debility, by stimulant medicines and a generous diet The separation of the eschars willbe greatly promoted by the application of the stimulus of heat, by means'of catap- lasms frequently renewed. These may be made of milk and bread, and some camphorated spirit, or any essential oils, sprinkled upon the surface. Subh means need only be continued, until the suppuration is established, as then a different mode must be pursued. After Mr. Kentish had supported the system to a suppuration, he then found, that gradually desisting from his stim- ulant plan, diminished tiie secretion of pus, and wonderfully quickened the healing process. Thus we see, observes Mr. Kentish, the whole of the former treatment in- verted. The most gentle soothing means were used externally and inter- nally ; these were continued until sup- puration took place ; and then the sys- tem was excited, under an idea of" sup- porting it, which not unfrequently so fatigued the constitution, as to induce a hectic fever. The present mode is tiie reverse of this. When a part of the frame has been much excited, this part BURNS 159 is not allowed to cease to act for want of stimulus, but, is kept in action by an adequate stimulus, whicii is to*be gra- dually diminished, until the ordinary action returns. With the same view, the internal means are highly stimulant to the whole system, which must be supposed to be in a natural state at the time of the. accident. Thus increasing the action of the \vhole by strong stimuli, and decreasing the action of the part, by lessening the stimuli, the desired end will be" more readily obtained; that is, equilibrium of the action will be restored. When parts are, destroyed, there must be other parts with increased action; and the foregoing mode will be the best for restoring the living parts, and promoting the separation of the dead ones. Suppuration having taken place, the exciting of the system by any thing stimulant, either by food, or medicine, should be cautiously avoided. Should the secretion of pus continue too great, gentle laxatives, and a spare diet, are indicated. If* any part, as the eyes, for instance, remain weak, with a tendency to inflammation, topical bleedings, or small quantities of blood taken from the arm, are useful. To defend the new skin, Camphorated oil, or camphorated oil and lime-water, in equal parts, are good applications. Wounds of this kind heal very fast, when the diminution of pus is prevent- ed, by attention to diet: if necessary to keep up the patient's strength, small doses of bark, taken two or three times a da)-, in some milk, will answer that purpose, and will not excite a quickened circulation, as wine, ale, or spirits, are apt to do. By attention to these principles, (continues Mr. Ken- tish,) I can truly assert, that 1 have cured very many extensive and danger- ous burns and scalds, in one, two, three, and four weeks, which in the former method would have taken as many months; and some, which I believe to have been incurable by the former me- thod. After explaining his principles, Mr. Kentish takes notice of the several sub- stances, wliich have commonly been employed. Of these he would chiefly rely on alcohol, the fluid volatile alkali, aether (so applied as to avoid the cool- ing process of evaporation), and spirit of turpentine. In applying these, we are directed to proceed, as follows: the injured parts are to be bathed, two, or three times over, with spirits of wine, spirits of wine with camphor, or spirit of turpen- tine, heated by standing in hot water. After this, a liniment, composed of the common yellow basilicon, softened with spirit of turpentine, is to be spread on soft cloth, and applied. This liniment is to be renewed only once in twenty- four-hours, and, at the second dressing, the parts are to be washed with proof spirit, or laudanum, made warm. When a secretion of pus takes place, milder applications must be'made, till the cure is effected. The yellow ointment stops the pores of the cloth, impedes evaporation, and thus confines the effect of* the alcohol to the burnt surface. The first dress- ings are to remain on four and twenty hours. Mr. Kentish thinks it of im- portance, that the injured surface should be left uncovered, as little as possible. It is, therefore, recommend- ed, to have plasters, ready spread, be- fore removing the old ones, and then only to take off* one piece at a time. It will seldom be necessary to repeat the application of alcohol a second time, or that of oleum terebinthin. The inflammatory action will be found diminished, and, according to. Mr. Kentish's principles, the exciting means should therefore be diminished. Warm proof-spirits, or laudanum, may be sub- stituted for the alcohol, and the unguen- tum resinae flavae is to be mixed with oleum camph. instead of turpentine. If this should be found too irritating, Mr. Kentisli recommends ting, saturn. or cer. lap. calaminaris. Powdered chalk is to be used to repress the growth of exuberant granulations, and to absorb the pus. In the cavities of separated eschars, and in the'furrows, between sloughs, and the living parts, he introduces powdered chalk. Then a plaster is applied, and, in tedious cases, a poultice over the plaster. With respect to the internal treat- ment, the author observes, that great derangement of the system arises in certain persons, from causes, whicii, in others, produce no effect; and that this depends on a difference in the degree of strength. Hence, he concludes, that as strength resists the sympathetic irritative actions of* parts, and weak- ness induces them, we should, in all cases, make the system as strong as we can, immediately upon the receipt of the "injury. In considerable burns, 160 BUR BUR he supposes a disproportion of action to take place, between the injured parts, and the system at large, or what, he styles, a solution of the continuity of action,- and, that, by a law of the system, a considerable commotion arises, for the purpose of restoring- the equilibrium, or enabling the constitu- tion to take on the action of the part. Hence, Mr. Kentish is of opinion, that the indication is to restore the unity of actkn of the whole system, as soon as possibk,hy throwing it into such a state as to absorb the diseased action, and then gradually bring down the whole to the natural standard of action, by nicely diminishingthe exciting powers. iEther and alcohol, or other stimulants, are to be immediately given, in proportion to the degree of injury, and repftated, once or twice, within the first twelve hours, and, afterwards, wine or ale is to be ordered, till suppuration takes place, when it will be no longer neces- sary to excite the system. In a second essay, on the subject of burns, Mr. Kentish remarks, that, in the first species of burns, in whidi the action of the part is only increased, he has not found any thing better, for the first application, than the heated oleum terebiuthinae, and the digestive, thinned with the same. In superficial burns, when the pain has ceased, it will be ad- viseable to desist from this application in about four and twenty hours, as that time in many cases will be sufficient, and, at the second dressing, a digestive sufficiently thinned with common oil, will be adequate to the case, and, on the third day, we are to begin with the ceratum lap. calaminaris. Air. K. has frequently seen secondary inflammation excited by the remedy. The most cer- tain remedy, for this unpleasant symp- torn, is to apply a digestive thinned with oil, or a plaster of cerate, and over that a large warm poultice. The cerate will finish the cure. Should there be much uneasiness of the sys- tem, an anodyne, proportioned to the age of the patient, should be given. The growth of fungus, and the pro. fuse discharge of matter, are to be re- pressed, as already mentioned, by sprinkling powdered chalk on the sur- face, and the use of purgatives, in the latter stages. The chalk must be very -finely levigated. Mr. Kentish's theories are, certainly, visionary; they may amuse the fancy, but, can never improve the judgment. He is a man, however, who has had superior opportunities of observing this part of practice, and the great success of his plan of treatment has acquireil very extensive approbation, although there are still many practitioners, who prefer the common methods, and the antiphlogistic principles. BURSiE MUCOSA. These are small membranous sacs, situated about the joints, particularly, the large ones of the upper and lower extremities. For the most part, they lie under ten- dons. The celebrated Dr. A. Monro, of Edinburgh, published a very full ac- count of the bursae mucosae, and also of their diseases. These parts are na- turally filled with an oily kind of fluid, upon whicii the tendons play, in then- passage over joints. In the healthy state, this fluid is so small in quantity, that it cannot be seen without opening the membrane containing it; but, oc- casionally, such an accumulation takes place, that very considerable swellings are the consequence. Tumours of this sort are often produced by bruises and sprains, and, now and then, by rheumatic affections. These swellings are not often attended with much pain, though, in some cases, it is very acute, when pressure is made with the fingers. The tumours yield, in a certain degree, to pressure; but, they rise again, with an appearance of elasticity, not re- marked in other sorts of swellings. At first, they appear to be circumscrib.ul, and confined to a small extent of the joint; but, sometimes, the fluid, form- ing them, is so abundant, that they ex- tend over a great part of the.circum- ference of the limb. The skin, unless inflamed, retains its natural colour. In this morbid state of the burs* mucosae, they contain different kindaof fluids, according to the cause of the disease. When the tumour depends on a rheumatic affection, the contents are ordinarily very fluid. They are thicker, when the cause is ofa scrophu- lous nature. When the disease is the the consequence of a bruise, or sprain, the effused fluid often contains hard concretions, and, as it were, cartilagi- nous ones, which are sometimes quite loose, and, more or less, numerous. Such substances may frequently be felt, when the tumour is examined with the fingers. In practice, such distinctions are not of much consequence. While the swel- lings are not very painful, an attempt CESAREAN OPERATION. 161 may be made to disperse them, by warm applications, friction (particularly, with camphorated mercuiial ointment,) or blisters, kept open with the savin cerate. But, if these tumours should become very painful, and not yield to the above methods, Dr. Monro recom- mends opening them; a practice, how- ever, whicii can seldom be really neces- sary, or proper. This author was con- tinually alarmed at the idea of the bad effects of air, admitted into cavities of the body, and, hence, in the operation even of opening the bursa: mucosae, he is very particular in directing the inci- sion in the skin, not to be made imme- diately opposite that made in the sac. Care must also be taken to avoid cut- ting the tendons, near the swelling. Dr. Monro has seen cases, in wliich amputation became indispensable, in consequence of the terrible symptoms following tiie opening of bursae mu- cosae. CESAREAN OPERATION. (Pliny, book 7. of his Natural History, gives us the etymology of this operation. Auspicatius (says he) enectd parente gignuntur, sicut Scipio Africanus prior natus, primusque Casarum a caso matris utero dictus ; qua de causa casones ap- pelluti. Simili inodo natus est Manlius qui Curthaginem cum exercitu intravit.) The bringing of tiie foetus into the world from the uterus, through an in- cision, made in the parietes of the ab- domen, There are three cases in which this operation may he necessary. 1. When the foetus is alive, and the mother dead, either in labour, or the last two months of pregnancy. 2. When tiie foetus is dead, but cannot be delivered in the usual way, from tiie deformity of the mother, or the disproportionate size of the child. 3. When both the mother, and child are living, but delivery can- not take place from the same causes, as in the second instance. Delivery cannot possibly happen in the ordinary way, when the foetus is si- tuated in the ovaries, or Fallopian tube, or in the cavity of the peritoneum. There are many instances recorded of ventral pregnancies, which the mothers have survived, the dead putrified foetus vol. 1. On account of such evil consequen- ces, which are imputed to the air, though they would as often arise, were the same practice pursued in a situa- tion, in which no air could have access at all, it has been recommended to pass a seton through the swelling, and to re- move the silk, after it has remained just long enough to excite inflammation of the cyst, when an attempt is to be made to unite the opposite sides of the cavity by pressure. I have never seen any swelling of this kind, which could not be discussed, by the means usually employed for pro- moting the absorption of other tu- mours. Indeed, the treatment should be very like that of Hydrops articuli. (See Articulation.) Consult Monro's Works by his son; and Latta's System of Surgery. being discharged, cither out of an ab- scess, or through the rectum. Both the mother and child, if ac- counts can be credited, have often hved after the Caesarcan operation, and the mother even borne children afterwards. Heister gives a relation of such suc- cess, in his Institutes of Surgery, cap. 113. See also .Mem. de I'Acad. de Chi- rurgie, torn. 1. p. 623. torn. 2. p. 308. Edinb. Med. Essays, vol. V. art. 37, 38. In England, the Cesarean operation has almost always failed. Mr. James Barlow, of Ghorley, Lancashire, suc- ceeded, however, in taking a foetus out of the uterus by this bold proceeding, and the mother was perfectly restored to health. (See Haighton's Inquiry con- cerning the true and spurious Casarean operation, and Barlow's account in the Med. Reports and Researches, 1798.) Govei, p 401, relates a case of ven- tral conception, in which instance the Caesarean operation was done, and the child preserved. A lady, aged. 21, had a tumour in the groin, which, was at first supposed to be an epiplocele, but an arterial pulsation was perceptible in it. In about ten weeks, the swelling had become as large as a pound of bread. Govei, solicited by the lady, opened tbe tumour. He first d^ce^r- 21 C 162 CESAREAN OPERATION. c d a sort of membranous sac, whence issued a gallon ofa limpid fluid. 'The 6ac was dilated, and a male foetus found, about half a foot long, and large in proportion. It was perfectly alive, and was baptized. After tying the umbili- cal cord, the placenta was found to be attached to the parts just behind, and near, the abdominal ring; but it was easily separated. Govei does not men- tion whether the mother survived; but the tiling would not be very astonish- ing, considering the situation of the foetus. Bertrandi says, he was unac- quainted with any otiier example of the Caesarean operation being done, in ca- ses of extra-uterine foetuses, so as to save both the mother and infant This eminent man condemned operating, in ventral cases, on the ground that the placenta could not be separated from the viscera, to whicii it might adhere, or, if left behind, it could not be de- tached, without such inflammation and suppuration, as would be mortal. But if, in addition to such objections, says Bertrandi, the operation has been pro- posed by many, and practised by none, we may conclude that this depends on the difficulty of judging of such preg- nancies, and of the time when the ope- ration should be attempted. lie puts out of the question the dilatations, which have been indicated for extract- ing dead portions of the foetus, and al- so Govei's case, who operated without expecting to meet with a foetus at all. CBertrandi sur les Operations de Chi- i urgie.J \ When the foetus is contained in the womb, and cannot be expelled by rea- son of the invincible obstacles ahead\ mentioned, the Caesarean operation should be practised, before the mother, and foetus, both perish from the vio- lence of the pains, hemorrhage, con- vulsions, &c. For this purpose, an extensive inci- sion must be made in the integuments of the abdomen, and in the uterus. Some have thought, that cutting the parietes of the belly was mortal, while others have believed a wound of the uterus to be so. Hence, such persons "have condemned the operation on the principle, that religious reasons do not authorize taking one life to save an- other. All the opponents of the Caesa- rean operation fear the hemorrhage, which, they say, must follow. Indeed, if the uterus were not to contract suffi- ciently, when the foetus and after-birth have come away, the bleeding would really be perilous. But when, by means of the Cesarean operation, the foetus is extracted, together with the placenta and membranes, the uterus will then contract, just as it does after a natural labour. Besides, even when the mother is alive, the operation is not commonly done, till the uterus evinces a propen- sity to deliver itself, and begins to con- tract. 'The womb being delivered of its contents, the incision becomes clo- sed, the vessels obliterated, and there is no fear of hemorrhage. The wound must also make so irritable an organ more disposed to contract; but, what- ever arguments may be adduced, it is enough to say in this case: . Irtem ex- pericntia fecit, exemplo manxf route vium. Itousset, about the close of the 16th century, published a work, in French, intitled, llysterotomie, ou I', iccuuchemenl Cesarkn. 'This book was translated into Latin, and enlarged with an ap- pendix by the celebrated Bauhin. Even then, the practice of" the Cesarean ope- ration on the living mother had its de- fenders. Bauhin relates that, in the year 1500, a sow-geidur, performed th<: Caesarean operation on his wife, tamfe- liciter, iit eu posted gemellos ct quatuor adhuc infantes eiuxa fuerit. This is said to be the first instance, in which the operation was ever done on the li- ving mother with success. Many other cases were afterwards collected, and published. The possibility of operating success- ful1) on the living mother has been de- monstrated, with so much perspicuity and accuracy, by M. Simon, in Tom. 1. de I'.lcud. de Chirurgie, that there can- iioUbe a doubt of the thing having been frequently practised with success. Here vye are presented with a collection of sixty-four Cesarean operations, more than a half of wliich had been done on thirteen women. Some of these had undergone the operation once, or twice; others five or six times. There was one woman in particular, who iiad un- dergone it seven times, and always with success. This seems to prove, not- withstanding all assertions to the con- trary, that the operation, for the most part, succeeds. But if the life of the mother should not invariably be pre- served, the Caesarean operation 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 lithotomy are CX.H practised, though they are not con- stantly followed by success. Would any thing be more cruel, than to aban- don a mother and her child, and leave them to perish, while there is any hope of saving them both r It is true, that when a pregnant woman dies of any inward disorder, and not from the pains, and efforts of labour, the foetus is commonly still alive in the uterus; but, after difficult labours, and the great efforts, made by the uterus to overcome the obstacles to parturition, the foetus is almost always dead; and of what avail would the operation then be, which is usually done after the death of the mother? (See Bertrandi Traite des Operations de Chirurgie.) Notwithstanding all the descriptions of the Caesarean operation, to be found in books, there can be no doubt, that, when the foetus is not a ventral one, the proper place for making the inci- Bion, in order to get at the uterus, is in the linea alba. Here, no muscular fibres will be.wounded. The operator should first divide the integuments per- p'-.iidicularly, so as to expose the linea alba, making the wound about six inch- es long. An opening should then be carefully made through the aponeuro- sis, into the abdomen, either at the up- per, or lower part, of the linea alba in view. A curved bistoury is then intro- duced into the opening, and the ten- don and peritoneum cut from within outward, as far as the extent of tiie wound in the integuments. The latter cut should be cautiously made, with the crooked bistoury, guided by the forefinger of the left hand, lest any of the intestines should be accidentally injured. The uterus must next be carefully opened, making an incision in it, of the same length, as the preceding ones. The foetus is to be taken out through the wound, and then the pla- centa und membranes. In this way, M. Artiste operated, so as to save both mother and child. (See Edinburgh Surgical Journal, JYo. 14.) Mr. Wood, of Manchester, perform- ed the Caesarean operation, in a case, in whicii parturition was prevented by deformity of the pelvis. The incision was made nearly in a transverse direc- tion, on the left side of the abdomen, about five inches in length, beginning at the umbilicus. This part was fixed upon, because the nates of the child could be felt there, and it was evident, that no intestine \va* interposed he- CAL 163 twixt the abdominal parietes and the uterus. There was scarcely any effu- sion of blood, either from the external wound, or from that of the uterus, though the latter was made directly upon the placenta. Instead of dividing the placenta, Mr. Wood introduced his hand betwixt it and the uterus, and" laying hold of one of the child's knees, extracted the foetus with ease. His hand passed with ease, betwixt the pla- centa and uterus; this produced a he- morrhage, but, not in any considerable degree; for, the whole quantity of blood lost did not exceed seven, or eight ounces. After the uterus was emptied, the intestines and omentum protruded at the wound. These ha- ving been reduced, the integuments were brought into contact by sutures and adhesive plaster. This operation, however, did not save the woman's fife; she died on the fourth day from the time of its being done. (See Medical and Physical Journal, Vol. 6.) This subject is ably treated of by Denman, in his Introduction to Mid- wifery ,- and by Hull, in his Defence of the Casarean Operation, 8vo. 1798. > CALCULI'S, (from calx, a lime- stone, The gravel and stone. The Greeks call this disorder litldasis and adamitnm ,- the Latins name it calculus. In English, we understand, by gravel, small stones, which pass from the kid- neys, through the ureters in a few days ; and by the stone, a calculous concretion in the kidneys, or bladder, of too large a size to pass, or at least, without great difficulty. With gravelly complaints the sur- geon has nothing to do, and we shall therefore limit our remarks to the stone in the bladder. When once a stone, in this situation, has acquired'a moderate size, it usually occasions the following- symptoms : frequent inclina- tion to make water, excessive pain in voiding it drop by drop, and, some- times., a sudden stoppage of it if dis- , charged in a stream ; after making wa- ter, great torture in the glans penis, which lasts one, two, or three minutes; and, in most constitutions, the violent straining makes the rectum contract, and expel its excrements; or, if it be empty, occasions a tenesmus, which is sometimes accompanied with a prolap - sus ani. The urine is often tinctured with blood, from a rupture of the ves- sels, and sometimes pure blood itself is di charged. Sometimes, the urine is 164 CALCULUS very clear, but, frequently, there are great quantities of slimy sediment de- posited at the bottom of it, which is on- ly a preternatural separation of" the mu- cilage of the bladder, but, has often been mistaken for pus. For the symp- toms more particularly, see Lithotomy. Sharp on Operations. Late experiments have shewn, that oidy a very small portion, not exceed- ing one two-hundredth part of a urina- ry calculus, is earthy, and that it con- sists, in a great measure, of matters, which are volatile in a moderate heat. (Austin.) Calculi are occasionally found in the lachrymal sac, the ducts of the sublin-. gual glands, the gall-bladder, the kid- neys, ureters, urinary bladder, and ure- thra. Concretions of various kinds are formed in many otiier parts. Stony in- crustations have been found under the prepuces of infants, and in the joints of gouty people, matter, resembling chalk, is often abundant. The pineal gland naturally contains a sabulous matter. When stones are formed in parts without motion, they sometimes cause no pain, nor inconvenience. In the ducts of the sublingual glands, there have been instances of their increase to a large size, without producing suffi- cient sensation to be noticed, till they have burst their way through the inte- guments, and they are sometimes met with in tumours and abscesses, when there is no suspicion of them. In the hernia of the bladder, mentioned by Pott, whicii included a stone, as the part, in which the body lodged was motionless, there was no pain, and tiie patient felt no symptom of the stone, and was only conscious ofa lump in the groin. Stones, however, often give great pain by the distention of the sen- sible parts which contain them. (Earle.) As the bladder is the largest recep- tacle for fluid, and contains it a long while, it is more liable to calculi than any other cavity. Indeed, the urine, in this situation, seems so much concern- ed in the formation of these concretes, that any foreign body, of whatever kind, wliich accidently may be deposited in it, will there infallibly attract and col- lect solid particles, even in persons who are not constitutionally subject to the stone, nor have ever been affected with any disease of the bladder. When stones are formed in the cavity of this organ, the motions and contractions, to which it is subject, cause them to pro- duce the most exquisitely painful sen sations. CEarle.J The stone is a disease, to which both sexes and all ages are liable, and calculi have even been found in the bladders ol very young children, nay, of infants on- ly six months old. When, from what- ever cause, a nucleus is once formed, the solid matter, whicii is attracted, round it, collects and is deposited in laminae of different thicknesses. Some stones are of a reddish brown colour, others white, and some of a dark colour resembling iron ore : these last are ve- ry uncommon. Some stones are close, compact, and hard ; others of a texture as soft as chalk. Sometimes, the dif- ferent laminae in the same stone, differ from each other in texture, colour, and consistence. Soft stones grow faster, than hard ones, and are often angular ; hard ones, with a smooth surface, some- times do not excite great pain; when angular, or rough, the contractions of the bladder on them, cause exquisite pain and irritation, particularly, on the expulsion of the last drops of urine. Small stone of tliis description, falling into, and lodging in tiie neck of the bladder, are more painful, than when they are grown so large, as to continue in the cavity of* the bladder, where the pressure on them is not so violent. (Earle.) Women seem less subject to this complaint than men, either owing to constitutional causes, or to the capaci- ousness, shortness, and straightness of their urethrae, allowing the calculi to be discharged, while small, together with the urine. (Earle.) In children, the stone seems gene- rally to be formed in the bladder, as they seldom complain of pain in the kidneys; but, in adults, it frequently originates in the kidneys, and thence is washed by the urine into the bladder. This can scarc< ly be effected, without the person feeling pain, and a conscious- ness of having passed a stone; in which case, he should drink plenteously of diluting liquors, and retain his urine till the bladder is so distended, as to create a great desire to make an eva- cuation. He should then place himself on his knees, bend his body forward, and make water in that situation. The little stone by its weight will fall into the neck of the bladder, and, very pro- bably, be carried away with the urine, CALCULUS. 1&5 which is rushing out. Sir James Earle is persuaded, that, if persons subject to calculous concretions were attentive to such directions, we should see fewer cases of stone in the bladder. (Earle on the Stone, Edit. 2. 1796.) Internal medicines have been given, with a view of dissolving the stone in the bladder, and doing away all occa- sion for lithotomy, which is undenia- bly a very painful, and frequently fatal operation. The remedies, possessing, or said to possess such power, are termed lithontriptics, and, though we have no decisive evidence of their being able to dissolve the stone in the bladder of a living subject, they un- doubtedly mitigate the pain, and render the fits milder, and less frequent. From the experiments of Fourcroy, it appears, that almost every ingredient in calculi is dissolved by the caustic al- kali ; and various experiments have shewn, that the whole calculus yields to its powers. Lime water has also been found a solvent of urinary calculi out of the body. It is obvious, however, that what is taken by the mouth is sub- ject to many changes in the alimentary canal, and also the lymphatic, and vas- cular systems, and that, in this way, it must be exceedingly difficult to get- such substances, (even were they not liable to alterations) in sufficient quan- tity into the bladder. Indeed, there are very few well authenticated facts of the urine being so changed, as to become a menstruum for the stone. Excepting the case of Ur. Newcombe, recorded by Dr. Whytt, the instance of Mr. Home is almost the only one. Though lithon- triptic remedies, however, may not in general actually dissolve tiie stone in the living bladder, yet it is an incon- trovertible fact, that they frequently mitigate the paroxysms of" pain ; ahd, to lessen such torture, as that of the stone in the bladder, is surely an object of no little importance. Lime was long ago known as a sol- vent of" urinary calculi, and different methods were employed to administer it with safety. One of these plans fell into the hands ofa Mrs. Steevens, and her success caused great anxiety for the discovery of the secret. At last, Parliament bought the mystery for 50001. In many instances, stones wliich had been unquestionably felt, were no longer to be discovered; and, as the same persons were examined by sur- geons of the greatest skill and emi- nence, both before, and after, the ex- hibition of the medicines, it is no won- der, that the conclusion was drawn, that the stones had been really dis- solved. From the cessation of such success, and from its now being known, that the stones are occasionally pro- truded, between the fasciculi of the muscular fibres of the bladder, so as to become lodged in a kind of cyst, on the outside of the muscular coat, and cause no longer any grievances, surgeons of the present day, however, are inclined to suspect, that this must have happen- ed in Mrs. Steevens's cases. This was certainly what happened to one of the persons, on whom the above medicine was tried, as Dr. W. Hunter informs us. It is evident, that a stone, so situa- ted, would not only produce no parti- cular irritation, but would also be quite indiscoverable by the sound; for, in fact, it is no longer in the cavity of the bladder. Mrs. Steevens first gave calcined eggshells alone ; but, finding costive- ness produced, she added soap. In time, she rendered her process more complicated, adding snails burnt to blackness, a decoction of camomile flowers, parsley, sweet fennel, and the greater burdock. As soap was with reason supposed to increase the virtues of the lime, it led to the use of the caustic alkali, taken in a mucilage of veal broth. Take of kali prepared, 3 viij ; of quick -lime £iv; of distilled water lbij. Mix them well to- gether in a large bottle, and let them stand for 24 hours. Then pour off the lye, filter it through paper, and keep it in well stopped phials for use. Of this the dose is from 30 drops to ^ij, which is to be repeated, two, or three times a day. Mix the quantity to be used in the day, with three pints of plain broth, made of" the lean part of veal, all the fat, or oily parts being separated from the liquor, by skimming them off" when cold. Let the patient drink, within an hour, a pint of this broth three times a day; early in tiie morning, at noon, and in the evening. Continue this plan, for tliree or four months, living, during this course, on such things as least counteract the effect of the medicine. The common fixed alkali, or carbona- ted-alkali, and the acidulous soda wa- ter, have of* late been used as lithon- triptics. Honey has also been given, 166 CALCULUS. and Mr. Home, surgeon at the Savoy, has recorded its utility in his own, and his father's cases. Bitters have like- wise been tried. Dismissing all theories, limewater, soap, acidulous soda water, caustic al- kali, and bitters, are useful in cases of stone. Of soap, as much may be taken as the stomach will bear, or as much as will prove gently laxative; but, of the limewater few can take more, than a pint daily. The acidulous soda water may be taken in larger quantities, as it is more agreeable. The acidulous salt is now prepared, so as to produce this water extemporaneously. It must be swal- lowed, however, while the salt is dis- solving, as the carbonic acid gas es- capes very rapidly. For curing stone-patients, little reli- ance can be placed in any lithontriptics hitherto discovered, though they may rationally be given, with a confident hope of procuring a palliation of the fits of pain, attending the presence of a stone in the bladder. The only certain method of getting rid of the calculus, is making an opening in this viscus, large enough to allow the stone to be taken out with a pair of forceps. (See Lithotomy.) Consult Austin's Treatise oji the Stone, 1791. Eurk on the Stone, 1796. London -Medical Dictionary, ar- tick Calculus. Calculus in the interior of the Eye. Scarpa has dissected an eye, which was almost entirely transformed into a sto- ny substance. It was taken from the body of an old woman, and was not above half as large as the other sound one. The cornea appeared dusky, and, behind it, the iris, of a very singular shape, was distinguishable, being con- cave, and without any pupil in its cen- tre. The rest of the eyeball, from the limits of the cornea backward, was un- usually hard to the touch. On making an incision, Scarpa found the sclerotica and choroides, almost in their natural state, and a small quanti- ty of a limpid fluid issued from the an- terior chamber of the aqueous humour. Beneath the choroides, two hard calcu- lous concave plates presented them- selves, united together by means of a complete membranous substance. One was situated forward; the other back- ward; the latter occupied the bottom of the eye; the former the situation of the corpus ciliare and crystalline lens. Sr.vpa ma! ■ an incision, through the compact membrane, which joined together the margins of the two cal- culous bodies. He found in the cavity, instead of the vitreous humour, some drops of a glutinous bloody fluid, and, in the longitudinal direction of this ca- v ity, a little soft cylinder, which, ex- tending forward from the bottom of the eye, along the great axis of this or- gan, was inserted into a cartilaginous, elastic substance, situated in the centre of the front calculous body, precisely where, in the natural state, it is cus- tomary to find the lens, and its capsule, which were entirely wanting. The posteriour surface of the iris had formed a firm adhesion to the middle of the cartilaginous substance, situated in the centre of the front calculus. Hence, the iris, when beheld on the side next the cornea and anteriour chamber appeared, as it actually wan, concave in the middle. The optic nerve, which had degene- rated into a mere thread, entered the sclerotica and choroides, as well as the centre, or bottom, of the posteriour calculous body, and lost itself in the little soft cylinder, which, as was ex- plained, proceeded to be inserted into the cartilaginous substance, situated in the middle of the anteriour calculus, or the place naturally occupied by the lens, and its capsule. The greater part of this little cylinder, was, ac- cording to appearance, nothing else, than the membrane of the vitreous hu- mour, destitute of fluid, shrivelled, and changed into a compact substance. Holler met with a case similar to the foregoing one: « In furis cadavere, ' quod anno 1752 dissecuimus, diritas ' quidem non tanta, raritas autem major * fuit. Cum enim in eo homine nervos ' oculi sollicite pararenals, caecum fu- ' isse eo latere, atque cicatricem in ' cornea esse.et duritatem in oculo ipso ' apdaruit. Cum dissectione defuncti ' essemus, adparuit mira mali causa. ' Choroi'deae membranae suberat, retinae ' loco, lamina ossea, aut lapidea, (nam 'fibras osseas nullas vidimus) cui ipsa ' choroi'dea adhacrebat, ut alias retin;-- • solet concentrica, hemispherio cavo ' similis, nisi quod duplici lamina fieret, ' et in altero latere duobus quasi localis ' excavaretur. Is quasi scyphus accu- ' rate rotuwdo foramine perforabatur, ' qua nervus opticus subit, ut eo magis ' induratam retinam adpareret. ' Intra banc osseam caveam nullum ' vitreum h-g'vmum corpus, sed ner- CALLUS. 167 1 vum, quasi albam, nernpe cylindrum ' rcperiinus, quae per foramen ossei ' cyathitransmissa metiensejus diame- • trum, dcuique adhaerebat osseo con- ' fuso corpori, quod potuisses pro cor- ' rupta lente crystalline habere. Ei ' corpori undique et iris, et processus ' < ilioruin cognomines, connasebantur, ' it cornea denique ad quam iris pari- - ter confcrbuerat Nunc sive retinam, ' ut ego persuadeor, sive quidquam ' aliud f'uisse velis, quod in os oavum ' et hemisphiericum mutatum sit, in ' oculo tamcii tencrrima parte corporis ' indurationem pcrfectam natain esse ' adparet; nihil ergo in corpore nostra ' dari, quod indurari nequeat. Lapillos ' aliquos in lente crystallina repertos ' fnisse legi. Ujusmodi autem morbus, ' nescio an visus sit, qualem haec oppor- ' tunitas nob:s obtuut' (Obs. Pathol. Oper. Min. Obs. IJ.) Fabricius Hildanus, Lancisi, as quot- ed by Heister, Morgagni, Morand, Zinn, and I'ellier, make distinct men- tion of calculi in the interiour of the eye. " (Scarpa sulk Mulaltie degli Occhi. Venezia, 1302.) CALLOSITY, (from callus, q. v.) Cultositas. Preternatural hardness. CALLUS, (from ddx, the heel, or calco, to tread.) This term used to be applied to the thick skin, at the. bot- tom of the heel, hardened by pressure. In surgery, the meaning of the word callus is new bone, or the solid substance, which serves to join togeilier the ends of a fractured bone. The old surgeons believed callus to be a mere inorganic concrete, a fluid poured out from the extremities of" the ruptured vessels, which was soon har- dened into bone. 'They always des- cribed it, as an " exudation of the bo- ny juice," and imagined that it oozed from tiie ends of broken bones, as gum from trees, sometimes too profusely, sometimes too sparingly. The reunion of broken bones, and the hardening of callus, they compared with the glueing together of two pieces of wood, or the soldering of a broken pot. (A. Pare.) The old surgeons also conceived, that callus sometimes flowed into the joints, so as to form a clumsy, prominent pro- tuberance. They imagined, that callus was a juice, whicii congealed at a par- ticular period of time, and they there- fore had fixed days for undoing the bandages of each particular fracture. They supposed, that its exuberance might be suppressed by a firm and well rolled bandage, and its knobby deformities corrected by pillows and compresses; that it might be sottcned by frictions and oils, so as to allow the bone to be set anew. All their notions were mechanical; and their absurd doc- trines have been the apology for all the contrivers of machines, from Hildanus down to Dr. Aitken and Mr. Gooch. (John Bell's Principles of Surgery, Vol. 1). A bone is a well organised part of the living body; that matter, which keeps its earthy parts together, is of a gelatinous nature. The earthy mat- ter, to wliich a bone owes its firmness, is deposited in the interstices of the gluten, undergoing a continual change and renovation. It is incessantly taken up by the absorbents, and secreted again by the arteries. It is tliis 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 unceas- ing activity of tiie vessels of a bone, wliich enables it to renew itself, when it is broken or diseased. In short, it is by various forms of one secreting pro- cess, that bone is formed at first, is supported during health, and is renew- ed on all necessary occasions. Bone is a secretion, originally deposited by the arteries of" the bone, whicii arteries are continually employed in renewing it. Callus is not a concrete juice, deposited merely for tiding up the interstices be- twixt fractured bones, but it is a rege- neration of new and perfect bone, fur- nished with arteries, veins, and absor- bents, by wliich its earthy matter i.> continually changed, like that of the contiguous bone. Indeed, tliere 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 opinions now entertained, concerning callus, the supposition is still very common, that the slightest motion will destroy a callus, which is about to form. But, continues Mr. John Bell, it is an ignorant fear, proceeding mere- ly from not having observed the state of the parts; for, when callus forms, the perfect constitution of the bone is restored; the arteries pour out front each end of a broken bone a gelatin- ous matter ; the vessels, by which that gluten is secreted, expand and multi- ply in it, till they form, betwixt the 168 CAL CAL broken ends, a well organized, and an- imated mass, ready to begin anew the secretion of bone. Thus, the ends of. the bone, when the bony secretion commences, are nearly in the same condition, as soft parts whicii have re- cently adhered; and it is only when there is a want of continuity in the ves- sels, or when a want of energetic ac- tion incapacitates them from renewing their secretion, that callus is imper- fectly formed. This is the reason, why in scorbutic constitutions, in patients infected with syphilis, in pregnancy, in fever, or in any great disorder of the system, or while the wound of a com- pound fracture is open, no callus is ge- nerated. (John Bell's Principles of Surgery, Vol. 1. 600, 501. 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, as yet, delicate and unconfirmed; not a mere concrete, like a crystallization of a salt, wliich, if interrupted in the moment of forming, will never form; not liable to be discomposed by a slight accident, nor to be entirely des- troyed 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, and tiie process is imme- diately renewed. In consequence of tiie above circum- stances, when a hmb is broken a se- cond time, when the first fracture is nearly cured, the bone unites more easily, than after the first accident; and when broken a third, and fourth time, the union is still quicker. In these cases, the limb yields, it bends under the weight of the body, which it can- not support; but, without any snap- ping or splintering of the bone, and, generally, without any overshooting of the ends of the bone, and without any crepitation. Callus is found to be more vascular, than the old bone. Mr. John Bell mentions an instance of a bone, which had been broken twelve years, before he injected it, yet the callus was ren- dered very singularly red. When a recently formed callus is broken, many of its vessels are ruptured, but some are only elongated, and it rarely hap- pens, that its whole substance is torn. It is easy to conceive, how readily the continuity of the vessels will be re- newed in a broken callus, when we re- flect on its great vascularity; and the vigorous circulation, excited by the ac- cident, in vessels already accustomed to the secretion of bone. These rea- sons shew, why a broken, or bent cal- lus, is more speedily united, than a fractured bone. (Observations, con- nected with the subject of Callus, will be found in the article Fracture ) CALOMEL. Its extensive utility, in numerous surgical diseases, will be conspicuous in an immense proportion of the articles in this work. CALX CUM KALI PURO. This is the common strong kind of caustic, employed in surgery. It is chiefly used for making the eschars, when issues are to be formed. This is often neces- sary in cases of diseased vertebrae, white swellings, morbid hip-joints, &c. (See Vertebra.) This caustic is also sometimes used, though not so often as it was formerly, for opening buboes and other abscesses. Some are in the habit of making it into a paste with soft soap; they cover the part affected with adhesive plaster, in wliich there is a hole of" the size of the eschar in- tended to be made ; and into this aper- ture they press the paste till it touches the skin. A bandage is then applied to secure the caustic substance in its situation, till the intended effect is pro- duced. The action of the calx cum kali pU- ro, in this way, however, is more inert and tedious, and, perhaps, on this ac- count, more painful upon the whole. Hence, many of the best modern sur- geons never adopt this method; but, after covering the surrounding parts with sticking plaster, rub the caustic on the situation, where it is desirable to produce an eschar, till the skin turns brown. The end of the caustic must be first a little moistened. The calx cum kali puro is commonly employed also for destroying large fun- guses. Before the port-wine injection was found to be the best radical cure for the hydrocele, this caustic was mostly used in this instance. (See Hydrocele.) Mr. Else, in the case alluded to, used to mix the caustic with powdered opi- um, by which, it is said, though not with much appearance of truth, that CANCER. 1G9 tiie sloughs were made with little or no pain to itiie patient. Some assert that the kali purum alone, acts more quickly, than when mixed with quicklime. I have not found this to be the fact, and, after try- ing both, give the preference to the calx cum kali puro. CAMOMILE. Chnmamelum. The flowers are bitter and aromatic, and are employed in surgery in fomenta- tions. CAMPHOR, is used externally, chief- ly as a means of exciting tiie action of the absorbents, and thus dispersing many kinds of swellings, extravasations, indurations, &c. Hence, it is a very common ingredient in liniments. It has also the property of rousing the action of the nerves, and quickening the cir- culation in parts, on whicii it is rubbed. For tliis reason, in paralytic affections, it is sometimes employed. Perhaps, there is no composition, that has greater power in exciting the absorption of any tumour, or hardness, than camphorated mercurial ointment. Camphor is often given internally, in delirium, depending on the irritation of local surgical diseases, as we shall have occasion to explain in several parts of this work. It is also a remedy fre- quently administered in cases of morti- fication. Some have recommended it, as singularly useful for the relief of stranguries, even those depending on the operation of cantharides. But, al- though it may occasionally have suc- ceeded, when given with this view, it not only does not always do so, but, it lias been known' to cause an opposite ef- fect, sometimes producing great scald- ing in voiding the urine, and sometimes pains like those of labour. (Medical Transactions, Vol. 1. p. 470.) CANCER, (derived from the Latin cancer, a crab, to which fish a part af- fected with cancer, and surrounded with varicose veins, was thought to have some resemblance.) Practitioners distinguish cancer into two kinds, viz. occult and ulcerated. No definition can be offered, which is applicable to both, though each of these terms implies the same disease, only in a different stage. By occult cancer is meant a hard, scirrhous tumour, accompanied with pains, which are lancinating, excessive- ly acute, and recur more or less fre- quently. At length, the tumour break- ing, is converted into cancer, strictly vol. 1. so called, or the disease in a state of ulceration. The occult cancer is also sometimes termed scirrhus, on account of its pecu- liar hardness. OF SCIRRHUS, OR CANCER, NOT IS THE ULCERATED STATE. Mr. Abernethy has given a match- less history of this affection, as it ap- pears in the female breast, where it most frequently occurs, and can be best investigated. It sometimes, says this valuable writer, condenses the sur- rounding substance so as to acquire a capsule; and then it appears, like ma- ny sarcomatous tumours, to be a part of new formation. In other cases, the mammary gland seems to be the nidus for the diseased action. The bounda- ries of the disease cannot be accurately ascertained in tiie latter case, as the carcinomatous structure,having no dis- tinguishable investment, is confined with the rest of the gland. In either instance, carcinoma begins at a small spot, and extends from thence in all di- rections, like rays from a centre. This is one feature distinguishing this dis- ease from many others, whicii at their first attack, involve a considerable por- tion, if not the whole, of the part, in which they occur. The progress of carcinoma is more or less quick in dif- ferent 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 swellings. He is not, however, posi- tive on this point; for, surgeons have informed him, thatdiseases which even- tually 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 tu- mour, wliich ends in cancer, is not from the first of this nature, though it has in tiie end become so; consequent- ly, it may at first yield to local applica- tions, but will not do so, after the can- cerous action has commenced. Hence, Mr. Abernethy's opinion, that a true carcinomatous tumour cannot be par- tially dispersed, at least, remains un- weakened by the fact, that some tu- mours have at first been lessened by remedies, though they have at last end- ed in cancer. Mr. Home's observa- tions fully prove, what indeed every 22 170 CANCER surgeon has long known, that any sort of tumour may ultimately become can- cerous. Without risk of inaccuracy, we may set down the backwardness of a scir- rhous swelling to be dispersed, or di- minished, as one of its most confirmed features. This obdurate and destruc- tive disease excites the contiguous parts, whatever their nature may be, to enter into the same diseased action. The skin, the cellular substance, the muscles, and the periosteum, all be- come affected, if they are in the vici- nity of the cancer. This very striking circumstance distinguishes carcinoma, says Mr. Abernethy, from several other diseases. In what this author calls medullary sarcoma, the disease is pro- pagated along the absorbing system ; but the parts immediately in contact with the enlarged glands do not as- sume the same diseased actions. Nei- ther in the tuberculated species does the ulceration spread along the skin, but destroys that part only covering the diseased glands. Mr. Abernethy acquaints us, that Mr. Hunter took no- tice, that a disposition to cancer exists in the surrounding parts, before the actual occurrence of the diseased ac- tion. Hence arose the following rule in practice: The* a surgeon ought not to be contented with removing merely the indurated, or actually diseased part, but that he should also take away some por- tion of the surrounding substance, in which a diseased disposition may proba- bly have been excited. In consequence ot this communication of disease to the contiguous parts, the skin becomes in- durated, and attached to a carcinoma- tous tumour, wliich, in like maimer, is fixed to the muscles, or other part over which it was formed. As a carcinomatous tumour increa- ses, it generally, though not constantly, becomes unequal upon its surface, so that this inequality has been consider- ed as characteristic of the disease. A lancinating pain is common; but it is riot experienced in every case, without exception. It is also a symptom, at- tending other tumours, which are un- like carcinoma in structure, and it can- not, therefore, be deemed an infallible criterion of the nature of the disease. fAbernethy. J A hard arid painful glandular swell- ing, having a disposition to become cancer, says Richter, is the common, but, inadequate and erroneous defini- tion of scirrhus. The disease is not regularly attended with swelling; some- times scirrhous parts diminish in size, and shrink. Hardness is not a charac- teristic property; for, many tumours, which are not scirrhous, arc exceed- ingly indurated. The disease is not al- way's situated in a gland: it oftentimes attacks structures, which cannot be called glandular; and hard glandular swellings are often seen, whicii do not partake of scirrhus. The disposition to cancer cannot be enumerated among the marks of scirrhus, since it is not discoverable, till carcinoma has actu- ally commenced. Its termination in open cancer, is not an- invariable oc- currence ; and other tumours become cancerous, to which no one would ap- ply the term scirrhus. (Anfangsgr. der Wvndurzn. Band 1.) Scientific surgeons ought undoubt- edly to have a definite meaning, when they employ the word scirrhus; super- ficial practitioners do unquestionably use tiie word most vaguely; and, per- haps, influenced by its etymology, they call an immense number of various morbid indurations scirrhous. 1 have always considered scirrhus, as a diseased hardness, in whicii tliere is a propensity to cancerous ulceration, and a greater backwardness to recede, than exists in any otiier kind of disea- sed hardness, although the skin may occasionally not break during life, and a few scirrhous indurations may have been lessened. Though Richter states, that this dis- position cannot be discovered, till car- cinorna has actually taken place; though Messrs. Burns and Home confirm, that other indurations and tumours may- terminate in cancer; though Mr Aber- nethy shews, that sarcomatous, and encysted tumours may end in most ma- lignant diseases, and such as merit the name of cancer; yet, it is now well as- certained, that in all these instances, the changes, which precede cancerous ulceration, bear no similitude to the genuine 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 iixed attachment to the skin above, and muscles beneath, 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 Ohat the disease is about CANCER. in to acquire, if it have not already ac- quired, the power of contaminating the surrounding parts, and the lymphatic glands, to which the absorbents of the diseased part tend. (First Lines of the Practice of Surgery, p. 143.) The truly scirrhous tumour, which is known to be capable of forming the cancerous poison, when allowed to in- crease in size is known to be hard, lieavy, connected with the gland of the breast; and, when moved, the whole gland mov«.:s along with. The struc- ture of a scirrhous tumour in the breast, is different in the various stages of the disease; and a description of the appearances, exhibited in the three •principal ones, may give a tolerable idea of what the changes are, which it jroes through, previous to its breaking, or becoming, what is termed, an open cancer. When a section is made of such a tumour, in an early stage, provided the structure can be seen to advantage, it puts on the following appearance : the centre is more compact, harder to the feel, and has a more uniform texture, '.ban the rest of the tumour; and is nearly of the consistence of cartilage. This middle part does not exceed the size of a silver penny; and, fromtliis, in every direction, like rays, are seen ligamentous bands, of a white colour, and very narrow ; looking, in the sec- tion, like so many extremely irregular lines, passing to the circumference of the tumour, which is blended with the substance of the surrounding gland. In the interstices, between these bands, the substance is different, and becomes less compact towards the outer edge. On a more minute examination, trans- verse ligamentous bands, of* a fainter appearance, form a kind of net-work, in tlw? mashes of whicii tiie new-formed substance is inclosed. 'This structure accords with what Dr. Baillie describes to be the case, in cancerous diseases of the stomach and uterus. (Il,„ie.J In a further advanced stage of the tumour, the whole of the diseased part h.s a more uniform structure ; no cen- tral point can be distinguished ; the ex- ternal edge is more defined, and dis- tinct from the surrounding gland; and the ligamentous bands, in different di- rections, are very apparent, but do not follow any course, that can be traced. (Home.J When the tumour lias advanced to what in • bec:d'cd cancerous suppura- tion, which, however, does not always happen in the centre, before it has ap- proached tiie skin, and formed an ex- ternal sore; it then exhibits an appear- ance totally different from what has been described. In the centre is a small irregular cavity, filled with a bloody fluid, the edges of which are ulcerated, jagged, and spongy. Beyond these, there is a radiated appearance of ligamentous bands, diverging to- wards the circumference ; but, the tu- mour, near the circumference, is more compact, and is made up of distinct portions, each of wliich has a centre, surrounded by ligamentous bands, in concentric circles. In some instances, the scirrhus has no appearance of suppuration, or ulce- ration, in the centre, but consists of a cyst, filled with a transparent fluid, and a fungous excrescence, projecting into this cavity, the lining of which is smootii and polished. When a large hydatid of tliis 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 phis' heads, withp- out a large one. These hydatids are certainly, by no means, sufficiently fre- quent in their occurrence to admit of their forming any part of the character ofa cancerous tumour. (Home's Obser- vations on Cancer.J In the fourth chapter of this work, the author relates two cases of hyda- tids found in the breast. In the first, the contents of the cyst were bloody serum ; in the second, a clear fluid. These two cases of simple hydatids in the breast, unconnected with any other diseased alteration of structure, led Mr. Home to consider the hydatids some- times found in cancerous breasts ; and, he believes, that such hydatids are no part of* the poisonous disease, but ac- cidental complaints superadded to it; and, since such hydatids do occur in the natural state of the glands, they are much more likely to do so in disease. (HomeJ Mr. Home en ' avours to define his conception ofa cancer, as follows : as cancer is a term, too indiscriminately applied to many local diseases for which we have no remedy, though they dif- fer very much among themselves, ifc- become's necessary to state what the complaints are, which I include under this denomination. The present obser- vations, respecting cancer, app:y only 172 CANCER. to those diseased appearances, which are capable of contaminating other parts, either by direct communication, or through the medium of the absor- bents^ and when they approach the skin, produce in it small tumours of their own nature, by a mode of con- tamination, with which we are at pre- sent unacquainted. There is a disease, by which parts of a glandular structure are very fre- quently attacked, 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 con- taminating the neighbouring parts, with which it is in contact; and neither af- fecting the absorbent glands, nor the skin at a distance from it. It is, pro- perly 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 different modes of treatment. From the facts that have been stated, (in Mr. Home's case) it appears, that cancer is a disease, wliich is local in its origin. In this respect, the cases (al- luded to) only confirm an opinion very generally received. Mr. Home endeavours to establish a second point, that cancer is not a dis- ease, which immediately takes place in a healthy part of tiie body; but one, for the production of which it is neces- sary, that the part should have under- gone some previous change, connected with the disease. In proof of this, Mr. 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, after remaining for ten, fifteen, or thir- ty years, without producing the small- est inconvenience; but, at the age of sixty or seventy, upon being cut in shaving, bruised by any accidental vio- lence, or otherwise injured, assumes a cancerous disposition. All the cases of induration of the gland of the breast, or of indolent tu- mours in it, which have continued for years, without producing any symptom, and, after being irritated by accidental violence, have assumed a new disposi- tion, and become cancerous, admit of the same explanation; and may be con- sidered as so many proofs of the truth of this latter position. (Home. J DISTINGUISHING CHARACTERS OF SCIRRHUS. A scirrhous induration seldom ac- quires the magnitude, to whicii almost all other tumours are liable to grow, when no steps are taken to retard their growth. Many scirrhi are certainly at- tended even with a diminution, or shrunk state, of the part affected. Scirrhi are generally more fixed, and less moveable, than other sorts of tu- mours ; especially, when the latter have never been in a state of inflamma- tion. With the exception of the fungus haematoides, other diseases do not in- volve in their ravages indiscriminately every kind of structure, skin, muscle, cellular substance, &c. and the integu- ments seldom become affected, before the distention, produced by the size of such swellings, becomes very consi- derable. In scirrhous cases, the skin soon becomes contaminated, discolour- ed, and puckered. Some few tumours may be harder, and heavier, than a few scirrhous ones; but, the reverse, is commonly the case. As other indurations, and tumours, may assume the cancerous action, and even end in cancerous ulcerations; 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 of the latter disease is deduced from the assemblage of cha- racters already specified ; for, except the peculiar puckering, and speedy leaden discolouration of the skin, no other appearances, considered sepa- rately, form any line of" discrimination. The white ligamentous bands, around a scirrhus, is a very characteristic symptom ; but, these cannot be detec- ted, till the disease has been removed. Hence, how manifestly prudent it must be to take away a considerable portion of the substance surrounding a scir- rhous tumour ! Were any of these white bands left, the disease would inevitably recur. OF CANCER IN THE STATE OF UL- CERATION'. The diseased skin, covering a carci- nomatous tumour, generally ulcerates, CANCER. 173 before the tumour has attained any great magnitude; a large chasm is then produced in its substance, partly by a sloughing, and partly by an ulce- rating process. Sometimes, when cells, contained in the tumour, are by this means laid open, their contents, which are a pulpy matter of different degrees of consistence, and various colours, fall out, and an excoriating ichor distils from their sides. Tliis discharge takes place with a celerity, which would al- most induce belief, that it can hardly result from the process of secretion. When the diseased actions have, as it were, exhausted themselves, an at- tempt at reparation appears to take place, similar to that whicii occurs in healthy parts. New flesh is formed, constituting a fungus of peculiar hard- ness, as it partakes of the diseased ac- tions, by which it was produced. This diseased fungus occasionally even cica- trizes. But, though the actions of the disease are thus mitigated; though they may be for some time indolent and stationary ; they never cease, nor does the part even become healthy. In the mean while, the disease ex- tends through the mediun of the ab- sorbing vessels. Their glands become affected, at a considerable distance from tiie original tumour. The progress of carcinoma, in an absorbent gland, is the same as that, which has been al- ready described. 'The disease is com- municated from one gland to another, so that after all the axillary glands are affected, those, which lie under tiie col- lar-bone, at the lower part of the neck, and upper part of tiie chest, become disordered. Occasionally, a gland, or two, become diseased 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 internal mammary vessels, become affected. In the advanced stage of carcinoma, a number of small tumours, of similar structure 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, whicii the disease creates, aggravated by tiie ob- struction, whicii it occasions to the functions of absorption, in those parts, to which the vessels leading to the dis- eased glands belong. Towards the conclusion of the disease, the patient is generally affected with difficulty of breathing, and a cough. (Abernethy.) The edges of a cancerous ulcer are hard, ragged, and unequal, very pain- ful, and reversed in different ways, be- ing sometimes turned upwards and backwards, and, on other occasions, in- wards. The whole surface of tiie sore is commonly unequal: in some parts, there are considerable risings, whdst, 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 de- stroy, the neighbouring parts. In tiie 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 ulcerated surface; and, this is the most torment- ing symptom, that attends the disor- der. Those shooting, lancinating pains, which are generally very distressing in the occult state of the complaint, be- come now a great deal more so. Not- withstanding that cancerous diseases are not always situated in glandular parts, yet the situation of such sores affords some assistance in the diagno- sis; for, six times as many cancerous affections occur in the lips, and breasts of women, as in all the rest of the body together, f B. BeU.J Concerning the peculiar state of the parts in cancer, or the proximate cause, many opinions have prevailed. Until lately, the melancholic humour was supposed to be the fluid, wliich was obstructed, and accumulated, in conse- quence of which it fermented, and pro- duced a burning ulcer; and whatever promoted the generation of this hu- mour, was currently admitted, as a re- mote cause of cancer. " Women," says Pare, "are more subject to scir- rhus, than men: because their liver is warmer, and their spleen, being weak- er, is less able to purge the blood of choler." Grief and chagrin, by pro- moting the formation of this fiery fluid, were accordingly considered by Heis- ter as vcrv- apt to induce the "cancer- ous diathesis;" and he adds, by way of corollary, "oldmaids, and women, who do not breed, are very subject to can- cer in the breast." Some thought that the obstructed humour became char- ged with an acid, (Dionis) and that this produced an ulceration. Others conjectured, that by an adustion, or 174- CANCER. ovcr-concoction, it grew sharp and burning. Wiseman thought it more probable, that it might become arseni- cal. These changes were almost uni- versally believed to depend upon the previous stagnation, in consequence of obstruction; and this leading point has uniformly been insisted upon by every preceding author, whatever may be hii particular notion, with regard to the nature of the obstructed fluid, whether bile, blood, or lymph. Even Air. B. Bell insists fully on the cause of can- cer being a mechanical obstruction. Some have asserted, that they have de- tected httle worms in the parts, which, eating them up, produced all the mis- chief attendant on cancer ; and that to their introduction the disease was ow- ing. Others have ridiculously assigned a httle wolf in the part, as the cause of the disease ! Strange as this doctrine, of living creatures producing cancer, may appear, it is nevertheless adopted by Dr. Adams. (Observations on Mor- bid Poisons.) When hydatids find their way into a solid substance, the conse- quence, in his opinion, will be cancer; and the success of an operation will, he conjectures, depend, in a great mea- sure, upon these animals being confi- ned in a common cyst, for then they may be all removed; whereas, if they be unconnected, some of the smaller ones may be allowed to remain, From the surface of the cyst, whicii contains the animal, a fungus shoots out, and thus acts, as a barrier, between it and the skin; or, if the animal have been in the stomach, it separates it from the coats of that viscus, " preventing sup- puration in the one instance, and ab- sorption in the otiier." This suppura- tion, and " disposition to fungate, be- fore the skin is broken," is, (continues Mr. Burns) if I understand him, pro- duced by the death of the animal; for, says Dr. Adams, " if hydatids possess the principle of vitality, during their transparent state, and their opacity is the effect of the loss of that principle, would they not, in the latter stage, sti- mulate the part, in which they are si- tuated, to suppuration, as we find the case with the guinea-worm, when dead.'" Concerning the manner, in which these animals produce the symptoms of cancer, we are told, that " this en- largement of a foreign body in a solid substance, and so extremely sensible, as the breast, cannot but be attended with intense pain, and frequent inflam- mation." A doctrine not far removed, says Mr. Burns, from that taught in the humoral schools, which maintained, thut the coagulation, and inspissation of the fluids, distended the follicles of the glands, producing many cavities, and much pain. (See Burns on Inflam- mation, Vol. II.) We have already stated, that, though hydatids are occasionally found in can- cerous tumours, they are not found often enough to make any part of the character of the disease; and they are met with, iu 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 absorbed into the blood, and that all the humours were speedily assimi- lated. Hence, was explained the fatal and rapid progress of relapses, after an apparent cure, The only effect of absorption, however, is on the lympha- tic glands, whicii intervene betwixt the sore and the heart; for, beyond these, the absorbed matter is changed in its nature and properties. (Bums.J In many instances, cancer is evident- ly produced by the same causes, whicii are capable of producing simple in- flammation. It is, however, a general opinion, that cancer arises frequently from some unknown and mysterious cause, which we cannot detect, and which, therefore, has been resolved in- to some constitutional taint, or cancer- ous ferment. But, so far as we know, the constitution is perfectly healthy. in the commencement of this disease; nor is there the smallest proof, that it resembles scrophula, in depending on any peculiarity of constitution, before the causes operate. Blows, bruises, Sic. may give rise to cancer; but in ma- ny instances, there is no evident local cause acting directly on the part. In the breast, cancer frequently commen- ces, without the interference of any to- pical agent. There is always, how- ever, in these cases, an irregularity, or disappearance of the menses; and the affection of the mamma seems to de- pend 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. Cancerous diseases are undoubtedly most common in elderly persons ; but, no age is exempted from this disease. Mr. Bums mentions his having seen it distinctly marked, and attended with a fatal event, in children of five vei.rs CANCER. 175 old: he mentions two Instances of the eye being affected in such subjects. TREATMENT OF CANCER. Some have supposed cancers to be a general disorder of the system; while others have regarded them merely as a local affection. This is a point of much importance in practice; for, if cancers arc originally only local affec- tions, no objection can be made to ex- tirpating them. They who think, that cancer is a constitutional disease, re- gard 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. The best practitioners of the present day, however, have rejected the doc- trine of cancer depending on constitu- tional causes; and we have stated Mr. Home's sentiments, in opposition to the opinion. When cancer breaks out again, in the same part, after the per- formance of an operation, it is often owing to some part of the disease hav- ing been blameably left behind, or to the operation having been put off" too long. How likely it is, that some of the cancerous mischief may be left un- removed by the operator, is obvious, on considering the manner, in which the white bands, resembling ligament, shoot into the surrounding fat; and that, even the fibres of the muscle;, beneath a cancerous disease, are fre- quently affected. At the same time, it must be allowed, that the disease is sometimes, to all appearances, so freely - and completely removed, that its re- currence must perhaps be imputed to the continued operation of the same unknown cause, whicii originally pro- duced the first cancerous mischief. Until very lately, the accounts given of the results of operations for cancers, were so unpromising, that they must have deterred many patients from un- dergoing a timely operation; 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 inconsiderable influence even with practitioner., in making them much more backward in undertaking the ex- tirpation of cancers, than they other- wise, would probably have been. "Of near sixty cancers," says he, " whicii I have been present at the extirpation of, only four patients remained free of the disease, 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. V.) Dr. Monro also observes, that, in those, in whom he saw the disease relapse, it was always more violent, and made a quicker progress, than it commonly did in others, on whom no operation had been performed. Hence, he ques- tions, " whether ought cancerous tu- mours to be' extirpated, or ought the palliative method only to be followed?" and, upon the whole, he concludes against their extirpation, exceptin such as are of the occult kind, in young healthy people, and that have been oc- casioned by bruises, or some other ex- ternal causes. More modern experience has, how- ever, afforded a very different result, * and given ample encouragement to the early performance of an operation, and even to 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 executed, as not to leave a particle of the cancerous mischief behind. Mr. Hill, in 1772, published some va- luable remarks on the present subject. At this period, lie had extirpated from different parts of the body eighty-eight genuine cancers, wliich were all ulce- rated, except four; and all the patients, except two, recovered of the operation. Of the first forty-five cases, only one proved unsuccessful; in three more, the cancer broke out again in different parts; and, in a fifth, there were threatenings of some tumours, at a distance from the original disease. These tumours, however, did not ap- pear, till three years after the opera- tion ; and the woman was carried off' by a fever, before they had made any pro- gress. All the rest of the forty-five continued well, as long as they lived; or are so, says Mr. Hill, at this day. One of them survived the operation above thirty years; and, fifteen were then alive, although the last of them was cured in March 1762. Of the next thirty-three, one lived only four months; and, in five more, the cancer broke out afresh, after ha- ying been once healed. The reason, why, out of forty-five cases, only four or five proved unsuccessful, and six, out of thirty-three, was as follows, 176 CANCER. " The extraordinary success, met with, (says Mr. Hill,) made cancerous pa- tients resort to me from all corners of tiie country, several of whom, after delaying till there was httle probability of a cure by extirpation, or other means, forced me to perform the ope- ration, contrary both to my judgment and inclination." Upon a survey in April 1764, made with a view to publication, the num- bers stood thus: Total cured, of dif- ferent 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 occasion to ob- serve, that the different patients lived as long after the extirpation of the cancers, as, according to the bills of mortality, they would have done, had they never had any cancers, or under- gone any operation. The remaining twenty-five, which complete the eighty-eight, were cured since the year 1764. Twenty-tVo of these had been cured, at least, two years; and some of them, it may be remarked, were seventy, and one nine- ty years old. In the year 1770, the sum of the whole stood thus: Of eighty-eight can- cers, extirpated at least two years be- fore ; not cured, two ; broke out afresh, nine; threatened with a relapse, one; in all, twelve, which is less than a se- venth part of the whole number. At that time, there were about forty pa- tients alive and sound, whose cancers had been extirpated above two years before. M. B. Bell who was present at many of these cases, bears witness to Mr- Hill's accuracy ; and, the former very judiciously states, that, " from these and many other authenticated facts, which, if necessary, might be adduced, of the success, attending the extirpa- tion of cancers, there is, it is presum- ed, very great reason, for considering the disease, in general, as a local com- plaint, not originally connected with any disorder of the system ; and that a general cancerous taint seldom, or perhaps never, occurs, but, in conse- quence of the cancerous virus being absorbed into the constitution from some local affection. 'This, in every case of real cancer, or rather in such scirrhosities, as, from their nature, are knowm generally to terminate in can- cer, should certainly determine us to have recourse to extirpation as early as possible; and, if this were dpne soon after the appearance of such af- fections, or before the formation of matter takes place, their return would probably be a very rare occurrence." (System of Surgery, Vol. VII.) MEDICINES AND PLANS, WHICII HAVE BEEN TRIED, FOR THE CURE OF SCIRRHUS AND CAN- CER. Of the general remedies, narcotics, such as cicuta, opium, nightshade, tkc. have been employed with most confi- dence. Cicuta owed its reputation to the ex- perimenting 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 cases ; but, in less prejudiced hands, it has been found much less successful; and even in ma- ny of the instances, adduced by Baron Storck, of its utility, it is by no means proved, that the disease was really can- cer. The public have now with great reason, very little reliance in this me- dicine. In cancerous ulceration, Mr. Burns declares, that he never knew cicuta, even produce the temporary melioration, whicii many talk of. The common way of exhibiting the hemlock is to begin with small doses, and increase them gradually, until they produce vertigo. We may begin with two grains of the extract, or four of the powder, recently-prepared, twice, or thrice a day, and the quantity is to be gradually increased. In this way, some patients have at last been able to take an ounce of the extract daily; but, says Mr. Burns, if a much less quantity, than this, produce no good effect, we may consider it as useless to continue a remedy, which, in this dose, must injure the constitution every day that it is continued. On the continent, hemlock has been used in the form of a bath; but, it is so disagreeable, that few will submit to this method. The belladonna has been much re- commended by Lambergen. During its use, he kept the bowels open with CANCER. t7f 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 re- putation of belladonna has not been supported by much success. The hyocyamus has often been tried in cancerous cases, and was held in great estimation by the ancients. Mr. Burns says, he has employed it occa- sionally, but, with little effect. The dose, with whicii you may begin, is two grains of the extract. The aconitum lias also been given; and, as it is a very powerful and dan- gerous narcotic, a quarter of a grain of the extract is generally the dose, at first. The solanum dulcamara, Paris quadrifolia, phytolacco, &c. have been recommended; but, they are now hardly ever employed; which is a suf- ficient proof of their inefficacy. Air. Burns mentions his having tried the hepatized ammonia, without any bene- fit. Richter has given the laurus cerasus, but with little success. The dose of the distilled water being un- certain, four, or five grains of the fresh leaves may be infused in a httle water, as a dose. The digitalis diminishes vascular ac- tion, and may act on scirrhi, like absti- nence, bleeding, &c. It has, however, no specific virtue in curing cancerous diseases. Opium is seldom employed, with an intention of curing cancer, although it probably has just as much power of this kind, as other narcotics, which have been more frequently used. For the purpose of lessening the pain of cancerous diseases, however, opium is very freely employed. Tonics may sometimes improve the general health; but, as they never pro- duce any effect on the local disease, the)- are now seldom exhibited. Mr. Justumond thought arsenic a specific for cancers. Future experi- ence has not, however, confirmed tiie truth of tliis opinion. Mercury, in conjunction with decoc- 10ns of guaiacum, sarsaparillu, &c. has been recommended; but, as Mr. Burns very justly remarks, no fact is more certainly ascertained, than that mercury always exasperates the dis- ease, especially, when in the ulcerated state. » The cuprum vitriolatum has been vol 1 tried; but, it has at this day no fame whatever. The same may be said of muriated barytes. The carbonate (rust) of iron has been extolled, by Mr. Carmichael, for its ef- ficacy in curing cancer. This gentle- man used to begin with twelve grains of the preparation every six hours; while he also used, as a lotion, a satu- rated solution of the acetife of the same metal, or, else the powdered rust was sprinkled on the sore. Many remedies have acquired celebrity in cases of can- cer, because very bad and malignant diseases, only supposed to be cancers, have got well, under their use. Such is probably the case with the carbonate of iron. In some instances, Mr. Justamond used to join the corrosive sublimate with arsenic. Opium, added to both applications, mitigates the pain, with- out injuring the efficacy of the remedy. The only mode of treatment, which Mr. Pearson has ever seen do any par- ticular benefit to cancer, is that of keep- ing the patient on diet, barely suffici- ent for the support of life, such as bar^ ley water, alone, tea, &c. Patients, with cancers, receive considerable be- nefit from being kept strictly on a milk diet. The old surgeons commonly dressed cancerous sores, with narcotic applica- tions. Vesalius used cloths, dipped in the juice of the solanum; whilst others employed it mixed with the oil of roses, and preparations of lead and antimony. Others had recourse to the hyocya- mus ; but, of late, tiie cicuta poultices seem to have superseded most other narcotic applications. These have un- doubtedly, in many cases, as Mr. Burns observes, abated the pain, and dimi- nished the fetor; but, this is all which can reasonably be expected; and even this expectation will not always be re- alized. Carrot poultices are better, than those of hemlock, as they produce as much eas-j, and diminish the fetor more powerfully. 'The fetor of cancers having been thought to resemble that of the kali sulphuratum (liver of sulphur) and tiie oxygenated muriatic acid being the best agent for decomposing, and de- stroying such smell, it has been recom^ mended, as an application to cancerous sores. It may correct the fetor; but, it will never accomplish u cure. 23 J?8 CANCER. Carbonic acid has been said not only to correct tiie fetor, but in some in- stances, completely to cure the disease. It was long ago proposed, says Mr. Burns, by M. Peyrilhe, and, of late, it has again been brought forward by Dr. Ewart. Experience has, however, not shewn, that the efficacy of carbonic acid, in cases of cancer, is very great. Fourcroy remarks: " After tiie first applications, the cancerous sore ap- pears to assume a more favourable as- pect ; the sanies, wliich flowed from it, becomes whiter, thicker, and purer, and the flesh has a redder and fresher colour; but, these flattering appear- ances are deceitful, nor do they con- tinue long, for the sore speedily re- turns to its former state, and its pro- gress goes on, as before the applica- tion." 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 tiie other end. Sometimes, the fermenting poultice is employed. Digitalis, as a local application, is entitled to about as much confidence as cicuta. Tar ointment, gastric juice, absor- bent powders, &c. have been tried; but, without any evident good. (See Burns on Inflammation, Vol. II.) Mr. Fearon rejects, probably with much reason, all internal remedies, as inefficient in the treatment of cancer; and, he recommends, in the early sta- ges of the complaint, a method of prac- tice founded on his idea of the inflam- matory nature of the disease. " In the beginning of scirrhous affections of the breast and testis, the mode I have a- dopted of taking away blood, is by leeches repeatedly applied.to the parts. In this course, however, I have often been interrupted by the topical inflam- mation, produced 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 reapplication of them. When the symptoms lead me to suspect the sto- mach, uterus, or any of the viscera, to be so affected, that the complaint either is, or, most probably, soon will be- come cancerous, I then have recourse to general bleedings. But, whether to- pical, or general perseverance for a suf- ficient length of time, is necessary. Though the pulse never indicated such practice, yet the patients have not suf- fered 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 vegetable diet, avoid- ing wine, spirits, and fermented .li- quors." Mr. Fearon used also to keep the belly open, and employ saturnine applications. From the preceding accounts, we may infer, that scarcely any reliance is to be placed in any known remedy, or plan, in cases of real scirrhi, and ulce- rated cancers. The operation is the on- ly rational means of getting rid of the disease ; and, to waste time, so as to allow the disorder to increase in a se- rious degree, merely for the sake of trying a train of unpromising medicines, is a conduct, which is unworthy of a wise surgeon's imitation. Perhaps, in early cases, Mr. Fearon'a method is warrantable, together with diet merely enough to support life; but, the punishment, attending a resigna- tion to this regimen, would be greater, than that of having the disease cut away, while the chance of efficacy would be much less. Upon the whole, there- fore, the operation is what we should generally resort to, as the surest, and the safest means of getting rid of can- cerous diseases. As I have before re- marked, the operation is always admis- sible, when every particle of the dis- ease can be removed by it. Even large open cancers, if they can be entirely cut away, are often capable of being ef- fectually cured. The removal of cancerous disorders, even in the slightest and most trivial cases, should be always effected with the scalpel, in preference to caustic; the use of which, though formerly re- commended by some authors, and still adhered to by some ( Young) ought, for* very obvious reasons, to be entirely laid aside. The irritation generally occa- sioned by every application of the caus- tic kind, together with the pain and in- flammation, which commonly ensue, are strong objections in cancerous ca- ses. Plunket's remedy, wliich is chiefly arsenic, is equally objectionable. Nor can you, at once, so 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 sur- CAP car iro rounding the disease, so as to see and feci whether tiie disordered parts are completely removed, or whether any portion of the disorder requires a fur- ther employment of tiie instrument. With respect to the pain, that of caus- tics is infinitely greater, more intolera- ble, and more tedious, than that occa- sioned by the knife. When caustic al- so fails in destroying every particle of the disease at once, it almost always tends to enlarge in a very rapid way, the original boundaries of the mischief. For an account of the method of re- moving scirrhi and ulcerated cancers, see Mamma, Removal of. For information on cancer, the read- er is particularly referred to B. Bell's Surgery, Vol. 2. Justamond on Cancers. Hill's Cases in Surgery. Pearson on Can- cerous Complaints. Abernethy's Surgical Observations, 1804. Pearon on Cancers. B. Bell on Ulcers. Home on Cancer. Adams on Cancerous Breasts, and on Morbid Poisons. Medical Museum, Vol. 1. London Medical Transactions, Vol.1. Gooch's Med. Observations, Vol. 3. And article Cancer, in London Medical Dic- tionary and Rees's Cyclopadia. CANCER SCROTI. CHIMNEY- SWEEPER'S CANCER. (See Scrotum.) CAPEL1NA, (from capeline, a wo- man's hat, or bandage, French.) A re- flex bandage. It is a double-headed roller, about twenty -four feet long, and four inches broad; sometimes nar- rower. The middle is apphed to the occiput, and, after two or three circu- lar 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. Tliey next cross each other upon the fore- head, after which the first head is car- ried back obliquely toward the occiput, and reflected by the side of the otiier. The last is continued in a circular di- rection, but the first is brought again over the sagittal suture, backward and forward, and so continued, till the whole head is covered. This bandage used to be applied in cases of hydrocephalus ; it has no ad- vantage, however, and is now hardly ever used. CAPISTRUM, (xMri^Tfoi, from caput, the head ; as being made to guide and govern the head.) A surgical bandage, somewhat resembling a bridle or head- stall. (See Itandage.) CARBUNCLE, (from carbo, a burn- ing 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 heat and violent pain in ■•Some part of the body, on which arises a kind of pimple, attended with great itching; below whicii a circumscribed, but very deep-seated, and extremely hard tu- ^ mour soon as.sumes a dark red, or pur- ple colour about the edges A httle blister frequently appears on tiie apex, which, as it occasions an intolerable itching, isoften scratched by the patient. The blister being thus broken, a brown sanies is discharged, and an es- char makes it appearance. Many Such pimples are sometimes produced upon one tumour, in consequence of the pa- tient's scratching the part. The carbuncle sometimes appears in persons affected with putrid fevers, in which case it is attended with great weight and stiffness of the adja- cent 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 ex- aggerated degree, which attend ty- phoid fevers. Sometimes a little slough, of a black colour, appears in the mid- dle of the tumour. This was supposed by the ancients to be a part of the body burnt to a cinder, or hard crust, by the violence of the disease. The carbuncle is considered a sort of gangrenous af- fection of the cellular substance. (Lat- ta. J The progress of carbuncles to the gangrenous state is generally quick. Their size is very various ; they have been known to be as large as a plate. Considerable local pain and induration always attend the disease. The skin, indeed, has'a peculiar feel, like that of brawn. As the complaint advances, se- veral apertures generally form in the tumour. Through these openings, there is discharged a greenish, bloody, fetid, irritating matter. The internal slough* ing is often very extensive, even when no sign of mortification can be out- wardly discovered. The constitution is often So low and exhausted, that death follows. The car- buncle, 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, influenced by the ge- 180 CARIES. neral disorder of the system, should assume a dangerous aspect. The duty of the surgeon, in cases of anthrax, may be described in a very few words. With regard to tiie local treatment of a carbuncle, the grand thing is to make an early and free inci- sion into the tumour, so as to allow the sloughs and matter to escape rea- dily. As much of the contents as pos- sible is to be at once pressed out, and then the part is to be covered with an emollient poultice. With respect to the constitutional treatment, we should remember, that the disease is only met with in bad constitutions, and in per- sons who are weak and irritable. Hence, it is only when there is a full strong pulse, and the complaint is just begin- ning, that bleeding is allowable. Bark and camphor are the internal medicines most commonly needed. The vitriolic acid is also very proper, as well as wine and aromatics. As the pain is very severe, opium is, for tiie most part, productive of infinite relief. (See Bromjield's Chir- ■urgical Cases and Observations. L'En- cyclopedie Methodique, art. Anthrax. Pearson's Principles. Richhter's An- fansgr. der liundarzn, Band 1. CARCINOMA, (from wpwcf,, a crab.) See Cancer. CARIES, (from xti^a, to abrade.) The clearest way, in which we can con- vey an idea of caries, is by comparing it with ulceration of the soft parts, in which we know a In-each is produced by the action of the absorbents. All the bones are liable to caries; but the spongy ones are more frequently attacked, than such as are compact. Hence, the ver- tebrae, astragalus, and other bones of the tarsus, those of the carpus, the sternum, and the extremities of long bones, are the most common situation of this affection. The bones of young persons are stud to be more frequently parious, than those of old subjects. Many authors have confounded ca- ries with necrosis, wliich they have call- ed dry caries. Others have considered it to be tiie same as exostosis. The ca- rious part of a bone becomes so soft, that the end of a blunt probe may be easily forced into its substance. The openings, with which the bone is per- forated, are filled with fungous flesh, which bleeds from the slightest cause. A dark-coloured serum is discharged, which always has a disagreeable smell, but becomes particularly fetid, when '_ipos<-iI to the air. ?u n xerosis* the bone is entirely de- prived of the vital principle ; in caries, this principle exists, and there is a morbid actum g-oing on, which destroys the texture of the bone. Some of the causes of caries are in- ternal, others external. The former are the most frequent; a contusion, or external violence, being more apt to produce necrosis than caries. Abscesses are said to produce, occa- sionally, a caries of the bones, over which they take place. For this rea- son, it has been laid down, as a rule, to open such abscesses at an early pe- riod, in order to prevent the disorder of the bone. If some abscesses, how- ever, as for instance, those which form over the anterior surface of tiie tibia, and mastoid process of the temporal bone, be frequently attended with ca- ries, the latter is the cause and not the consequence of the suppuration. Pus, which is a bland, unctuous, inodorous fluid, never attacks the soft parts, with wliich 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 the abdomen, the peritoneum of that part, naturally a thin membrane, instead of being corroded, becomes thick, and strong enough to resist the effusion of pus into the cavity of the abdomen. The periosteum be- comes thickened in similar circumstan- ces, when the abscess is a consequence of an external injury. Scrophula invades the spongy struc- ture of the bones and the lymphatic system. A caries from this cause is very common in the tarsus, carpus, el- bow, and knee; but it is always prece- ded by a white-swelling. The venereal disease is sometimes a cause of caries, though its action on the bones generally occasions necrosis, or exostosis. However, when it at- tacks the bones of the nose, it renders them carious, by which they are con- sumed, and the face sadly disfigured. The bones of the palate are sometimes destroyed in the same manner, and by the same cause. In cancers of the mammi, the sides of the sternum are sometimes found ca- rious. A superficial caries is easily detect- ed. When the affected bone is deeply situated, the disease may be ascertain- ed by introducing a probe, which will readily pass into the substance of the bone. But, bones not easy of access, may become carious, in which cases, CARIES. 181 the diagnosis is not so obvious. How- ever, it a fistula, from which a fetid blackish matter flows, run forwards to a bone, and the adjacent soft parts be swollen and indurated, there is reason to suspect the existence of caries. Caries, occasioned by syphilis, affects most commonly the tibia, os frontis, ossa nasi, ossa palati, and sternum. A caries of the vertebra; is known by peculiar symptoms, among which a paralysis of the inferior extremities, and lumbar abscesses, are the most re- markable. A caries of the spongy parts of bones is much more difficult to cure, than a similar affection of their compact parts. Caries of the carpal and tarsal bones is particularly obstinate. These bones being in close contact, the affection cannot easily be prevented from spread- ing from one to the other. Amputa- tion is often the only means of cure. The same is frequently the case, when the spongy heads of the long bones be- come carious. Even this mode of re- lief is not practicable when the head of the bone lies very deeply, like that of the os femoris. Caries, resulting from scrophulous, or cancerous mischief, is more difficult of cure, than when it arises from vene- real or scorbutic causes; for, some ef- ficacious remedies against the latter are known; but cancer and scrophula resist all the remedies hitherto disco- vered. The prognosis is less favour- able in old, than young subjects, and much depends on the extent of the dis- ease, the patient's strength, and the state of the soft parts. To form a just idea of the treatment of caries, we should consider, that a bone, thus affected, is a prey to a mor- bid action of its own parts, and that this action creeps from one part to an- other, and pervades the whole with greater or less rapidity, if art should not interfere, and assist nature in ar- resting its progress. When the caries arises from consti- tutional disease, this should be resist- ed with suitable remedies. Thus mercurial and sudorific medi- cines put a stop to caries arising from the venereal disease. Spirituous drinks, vegetable diet, and acids, cure both the scurvy, and the caries dependent on it. But, when caries is altogether a lo- cal affection, tiie separation of the dis- cased parts may be promoted by ab- sorbent powders, and stimulant appli- cations. Lint, dipped in the tincture of aloes or myrrh, has often been put on such diseased bones. If these re- medies be found ineff'ectual, a pledget of lint, dipped in a solution of the ar- gentum nitratum, may be employed. 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 a previous use of the knife. It is thought, that the burn- ing iron acts by changing the caries in- to a necrosis, irritating the subjacent sound parts, and exciting that action of the vessels, by which the dead or dis- eased part of the bones must be thrown off. (See Boyer on Diseases of the Bones, Vol. 1.) Issues seem to be most effectual in checking the caries attendant on white- swellings and diseased vertebrae. (See Articulation and Vertebra.) Mr. Hey has succeeded in cutting away a carious part of the tibia. He began the operation by dissecting off the granulations of flesh, whicii had 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 removal of this portion brought into view a caries of the can- celli, almost as extensive as the piece already removed. With different tre- phines, suited to the breadth of the ca- ries, Mr. Hey removed the diseased cancelli of the bone, quite through to the opposite lamella. As the caries, extended in various directions, it was not possible to remove the whole of it with a trephine, without removing also a large portion of the sound part of the bone, wliich Mr Hey wished to avoid. By the assistance, therefore, ofa strong sharp-pointed knife, he pursued the ca- ries in every direction, until every part was taken away, whicii had an unsound appearance. The wound was simply dressed with dry lint; the whole sur- face was speedily covered with good granulations, and a complete cure was obtained, without any exfoliation. Mr. Hey concludes this subject, as follows: "I have treated some other cases of caries of tiie tibia in the same manner, and with equal success. Where the extent of the caries is not so great as to prevent a complete removal of the morbid part, this method is ex- tremely useful, and far superior to tiie use of the potential or actual cautery. 182 CASTRATION. " The trephine is not wanted, where the cancelli of the bone are not affect- ed with the caries. The diseased parts of the lamella may be removed with gouges or small chissels. Granulations of flesh will then arise from the sound parts of the bone, and become united with the integuments, which ought to be preserved as far as is possible." The two cases, which Mr. Hey has related, are exactly of that kind, to whicii several writers apply the term spina ventosa. (See Practical Observa- tions in Surgery.) CARTILAGES IN JOINTS. (See Articulation. CARUNCLE, (dim. of caro, flesh.) Carunctda. A small excrescence, which has the appearance of flesh. CASTRATION. Costratio. (from castro, to castrate.) The operation of removing a testicle. For an account of the cases rendering this necessary, see Testicle, Diseases of. The manner of operating is as fellows: The patient being laid on a table of convenient height, the integuments covering the spermatic vessels in the groin, are to be divided. This incision should begin as nearly as can be, opposite to tiie opening in the abdominal muscle, and should be continued a good way down the scrotum. The manner of beginning tliis incision is differently described by writers; some of them advising that the skin be held up by an assistant; others that the knife be used perpendicularly in this as in other parts. The latter mode is preferred by English surgeons in ge- neral. The length of the division is a more important consideration. A small wound will indeed serve to lay bare the spermatic chord; but it will not permit the operator to do what is necessary afterwards with dexterity, or facility; aiid as the scrotum must, first or last, be divided nearly to the bottom, it had better be done at first. The spermatic chord, thus hud bare, is to be freed from its surrounding membranous con- nexions ; and then the operator, with his finger and thumb, separating the blood vessels from the vas deferens, must pass a ligature between them, and having tied the former only, must cut through the whole chord, at a quarter or half an inch distance from the said ligature, according as the state of the process and testicle will admit. This done; he is then, with the same knife, w ith which he has performed the for- mer part of the operation, to dissect the testicle out from its connexion with the scrotum: the loose texture of the connecting cellular substance, the pre- vious separation of the testicle from the spermatic chord, and tiie help of an as- sistant to hold up the lips of tiie wound, will enable him to do this with very little pain to the patient, and great fa- cility to himself. If any considerable artery bleeds in the scrotum, it is to be tied. (Pott.) Mr. S. Sharp once castrated a man, whose testicle weighed above three pounds, and some of the vessels were so exceedingly varicous and dilated, as nearly to equal the size of the hu- meral artery. ( Operations of Surgery, chap. 10.) Desault first divides the chord, and, holding its upper end between the in- dex finger and thumb of his left hand, he then takes up the arteries with a pair of forceps, wliich are immediately tied by an assistant. (Desault par Bi- chat, torn. 2.) 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 woupd together, and endeavour to heal as much of it as possible by the first intention. Some, with tliis view, use sutures and stick- ing-plaster ; others, only the latter, aid- ed with compresses and a T bandage ; whicii means, in my humble opinion, are quite enough. Sometimes, one or more vessels be- gin to bleed soon after the patient is in bed, although they effused no blood just after the removal of the testicle. Keeping the dressings and scrotum continually wet with the cold saturnine lotion very often, suffices for the sup- pression of such hemorrhage: if not, the wound must be opened again, and the vessels tied. In every operation, in which a consi- derable portion of skin is to be divided, and particularly in this, and in the am- putation of women's breasts, it should always be remembered, that, as the di- vision of the skin (the general organ of sensation) is the most acute and pain- ful part of what is done by the knife, it cannot be done too quickly, and should always be done at once: the scrotum should always be divided to the bottom, and the circular incision in the skin ofa breast always made quite round, before any thing else be thought of. If this be not executed properly, CAT CAT 183 and perfectly, the operation will be at- tended with a great deal of pain which might be avoided, and the operator will be justly blameable. (Pott.) If the tumour beof apyriform figure, perfectly smooth, and equal in its sur- face, and free from pain, notwithstand- ing 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 is a true scir- rhus, let him immediately previous to the operation, pierce the anterior part with a trochar, in order to be certain. " My reason for giving this advice is, that I was once so deceived by every apparent circumstance of a true, equal, indolent scirrhus, that I removed a tes- ticle, which proved upon examination to be so little diseased, that, had I pierced it with a trochar previous to the operation, I could and certainly should have preserved it." (Pott.) It is well known, that the agony of tying the chord is immensely increased by including the vas deferens, and, as no good results from so doing, the prac- tice deserves the severest reprobation, notwithstanding tho opposite opinion of Pearson, and the writer of the arti- cle Castration in Rees's Cyclopaedia. Consult Le Dran. Sharp oh the Ope- rations of Surgery. Pott on the Hydro- cele, &c. Sabatier, de la Medicine Ope- ratoire, Tom. 1. Bertrandi sur ks Opt- rations de Chirurgie. QZuvres Cfururgi- cales de Desault par Bichat, torn'. 2. p. 409. A long account of the particular senti- ments of several eminent surgeons is to be found in Rees's Cyclopedia, art. Castration. CATAPLAS M, (from x*ra#A<*r«-», to spread.) Cataplasma. A poultice. The following ones are eminently useful. CATAPLASMA ACETOS.U. Son-el Poultice. ]& Acetosa Ifej. To be beaten in a mortar into a pulp. CATAPLASMA jERATUM. Fer. minting Poultice. R Farina Tritici. Cerevkix Spumaca, Yest dkta ; Singu- lorum; ibss. These are to be mixed to- gether and exposed to a moderate heat, till the effervescence begins. This is a celebrated application in cases of sloughing and mortification. CATAPLASMA C1CUT-E. Hemlock Poultice. 1& Herba cicuta exfoliata 3pj. Aqua fontana Ib'ij. To be boiled, till only a pint remains, w hen as much lin- seed meal as necessary h to be added. This is an excellent appncalion to many cancerous and scrophulous ul- cers, and other malignant ones ; fre- quently producing a great diminution of the pain of such diseases, and im- proving their appearance. Justamond preferred the fresh herb, bruised. CATAPLASMA DAUCI. Carrot Poultices. BcRadicis Daucirecentis, tbj. Bruise it in a mortar into a pulp*. Some, perhaps, with reason recommend the carrots to be first boded. The carrot poultice is employed, as an application to ulcerated cancers, scrophulous sores of an irritable kind, and various invete- rate malignant ulcers. CATAPLASMA LINI. Linseed Poul- tice. R Farina Lini Ibss. Aq. ferventis Ibiss. 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 the most con- venient of all the emollient poultices for common cases, and has, in a great measure, superseded the bread and milk one, so much in use formerly, Mr. Hunter speaks, in the following terms, of the linseed poultice, and its uses; " Poultices are commonly made too thin .- by which means, the least pres- sure, or their own gravity, removes them from the part: they should be thick enough to support a certain form when applied. " They are generally made of stale bread, and milk. This composition, in general, makes too brittk an applica- tion; it breaks easily into different por- tions, from the least motion, and often leaves seme part of tiie wound unco- vered, which is frustrating the first in- tention. " The poultice which makes the best application, 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." " "jhe 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 application is equally proper when parts are deprived of life, and consequently.will slough. It is therer fore the very best dressing for a gun- shot wound, and probably for most la- cerated wounds : for lint, applied to a part that is to throw off' a slough, will 184 CATARACT. often be retained till that slough is se- parated, which will be for eight, ten, or more days." CATAPLASMA LYTHARGYRI ACETATI. R Aqus lythargyri acetati drach. j Aquse distillate lib. j Micx panis q. s.—Misce. Practitioners, who place much confi- dence in the virtues of lead, externally applied, often use this poultice in case of inflammation. CATAPLASMA QUERCUS MA- RINE This is prepared by bruising a quan- tity of the marine plant commonly call- ed sea tang, wliich is afterwards to be applied by way of a poultice. Its chief use is in cases of scrophula; white swellings and glandular tumours more especially. When this vegetable cannot be ob- tained in its Jrecent state, a common poultice of soa-water and oatmeal has been substituted by the late Mr Hun- ter and other surgeons of eminence. CATARACT, (from wra^ta-a-v, to confound, or disturb; because the dis- ease confounds, or destroys vision.) This is a species of blindness,.arising al- most always from anppacity of the crys- talline lens, or its capsule; the cataract depending on an opaque state of the li- quor of Morgagni being very rare. Hippocrates called it, ■yxzu^ufAii. Ga- len wtbyufAit.. The Arabians, gutta opa- ca. Celsus, suffusio. Hippocrates and the ancient Greeks described the cataract, as a disease of the crystalline lens under the name a- bove mentioned; but, no sooner had Galen promulgated the doctrine of the lens being the immediate organ of sight, than the correct opinion of the ancient founder of medicine began to decline, and, for many ages afterwards, had no influence hi practice. In fact, the seat of the cataract seems to have been entirely forgotten, till about 1656. when first Lasnier, and afterwards, Bo- rel, Bonnetus, Blegny, Geoffroi, &c. re- vived the truth, which appears to have been so long extinct, and they, and a few others, believed that the disease was situated in the crystalline lens. The bulk of practitioners, however, re- mained ignorant of this fact even as late as 1713, or, in other words, until the several publications of Mery, Mai- tre-Jan, Brisseau, and Heister, com- bined to render the truth universally known. (Critical Reflections on the Ca- tnract.J ' SYMPTOMS O'F A CATARACT. The cataract shews itself, as a speck, or spot in the pupil of the eye, occu- pying sometimes the whole, and some- times only a part of this aperture. It is most commonly of a grey, or whit- ish colour ; but, sometimes, of a deep white, and, it may in all cases, be easi- ly distinguished from the naturally dark appearance of the pupil. In the commencement of the disorder, it oc- casions a weakness, or imperfection of the sight; and it terminates, sooner, or later, in the almost total extinction of this sense, During its progress, the persons, who are affected by it, per- ceive objects more distinctly in a mo- derate, than a strong light; the reason of which is, that the pupil being more dilated in a weak light still admits some rays, through the yet transparent cir- cumference of the crystalline. (Wen- zel on the Cataract.) A settled mist seems to cover objects and confuse those, which are minute. In this disorder, especially, when it arises without any assignable external cause, this mist is almost always per- ceptible by the patient, before any opa- city has become visible in the pupil. (Ware.) DIFFERENT KINDS OF CATARACT, AND PARTICULAR SYMPTOMS OF EACH. When the opaque lens is either more indurated, than in the natural state, or retains a tolerable degree of firmness, the case is termed, a firm, or hard ca- taract. \|/hen 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 consist- ence, neither hard, nor fluid, but, about as consistent, as a thick jelly, orcurds, the case is named a soft, or cuseous ca- taract. When the anterior, or posteri- or, layer of the crystalline capsule be- comes opaque, after the lens itself has been removed from this little membran- ous sac, by a previous operation, the affection is named a secondary membran- ous cataract. There are no certain criteria, by wliich it can be ascertained previously to an operation, whether a cataract is soft or hard; of a caseous or fluid can- PAT49AQT W •iltence ; or Fh^Uie^ toratiier w\t\\ an opacity of tin} crystalline Jens, ti^e mem- branous capsule, in which it is contain- ed, may not have fost its natural tran- sparency: those formerly mentioned by Richter, and other similar ones pro- posed for consideration by Mr. Pptt, cannot he sufficiently confided in tp, form a guide in practice. I tjhink it right, however, to state, in US concise a manner as possible, the symptoms and appearances, which Rich- ter has mfire recently explained, and, for a long series pf years, found gene- rally to portend the truth ; and If hall cqnfone myself to the hard, the nuicjj and the caseous or soft pa$aracts. The }ia?4pr the cataract is, the thin- ner and smaller it becomes. In this case, the disease presents either an asli- cQ(oure4, a yellow, or a brpwnish ap- pearance. The interspace, betwixt tlje cataract and pupil, is very considera- ble. The patjent very distinctly dis- cerns light from darkness, and can even plainly perceive large bright ob- jects. In the dilated state of the pupil, a black circle surrounding the te'is ip very perceptible. The motions of the pupil are free and prompt. 'The ante- rior surface of the cataract appears flat without any degree of convexity. (Rich- ter?p Anff^ngsgrynde der fi'undarzney- kuast,p. 177. 3 Band) The fluid, or m'dky cataract, has usually a white appearance,- and irre- gular spots and streaks, different in co- Jour from the rest of the cataract, are often observable on jit. These are apt lo change their figure and situation, when frequent and sudden motions of the eyes occur, or when the eyes are rubbed and pressed; sometimes, $§.9, these spots and Streaks vanish, and then reappear. The lower portion of the pupil seems more opaque than the upper, probably, because the untran- sparcnt and heavy parts of the milky fluid, gink downward to the bottom of the capsule. The crystalline lens, as it loses its firmness, commonly acquires an augmented sjze. Hence, the fluid .cataract is thick, and the opacity close fettL-kid the pupil. Sometimes one can perceive no space between tiie cataract and margin of .the pupil. In advanced c;ises, this aperture is .usually ycr.y much dilated, and the iris moves very ahwdy and inertly. This happens be- cause the cataract touches the irj$, and impedes its action. The ffuid ca.tjt'ract .yoi. 1. is sometim^C|f s^Sph a, tiucjpjess, that it protrudes in.to the pupil, and presses the iris so much forward, as to piake it assume a convex appearance. £atients, who have milky cataracts, generally distinguish light from darkness very indistinctly, and sometimes not at all; partly, because the cataract, when it is thick, lies so close: t° the iris, that few or no rays qf tigjjt can enter be- tween them into the eye; partly, be- cause the fluid cataract always assutnes, more or less, a globular form, and therefore has no thin edge, through which the rays of light can penetrate. (Richter's.infangsgrunde der JffundQTz- neykunst. 3 Band. 174, 276.) Sometimes the opaque tens is of a middling consistence, neither hard, nor fluid, hut aboift as cpnsistent as thick jelly, curds, or new chepse. Cases of this description are termed soft or ca- seou s cataracts. As the lens soft^ps in this maimer, it commonly gross's thicker and larger, even acq.uirjng a much greater size than the fluid. It js not unfrequent to meet with pasepus cataracts of twice the ordinary size of a hpakhy crystalline lens. It impedes the motion of the pupil more conside- rably than the fluid cataract, becj^jj's^ it lies closer to the iris. It is accom- panied by all the symptoms of fluid ca> taracts, except that the spots and streaks, sometimes also observable on tliis kind of cataract, do not vary their situation and figure. (Richter's An- fangsgri'iude der Wundarzneykunst. p. 178. 3 Band.) CAUSES OF THE CATARACT. Persons, who are much exposed to strongfir.es, as blacksmiths, locksmiths, glassmcn, and those, who are engaged in similar employments, seem to be more subject to the cataract, than others. Persons, above the age of for- ty, are reckoned more liable to cata- racts, than younger ones. (Wenz^l.) The disease, however, is, by no means, unfrequent in the latter; even children are often seen affected with tliis kind of blindness, and some are born with it. In tiie majority of instances, a cataract s&ems to arise spontaneously, without any assignable cause. Sometimes the opacity of 'he lens is the' consequence yof external violence: a case, which, more frequently, tb.an any p^ev', get? well \vithout an operation, 24 186 CATARACT. PROGNOSIS, AND MODE OF JUDGING OF CASES FIT FOR AN OPERA- TION. Some little attention is necessary to distinguish those cases of cataract, which afford a reasonable prospect^of benefit from an operation, and to dis- criminate them from others, either less promising, or absolutely prohibitory of relief. When, in the incipient state of the disease, the patient discerned objects, as it w ere, through a mist, which in- creasing in density, at length became a complete impediment to vision; when tiie opacity of the crystalline lens has supervened gradually, and has not been preceded, and is not accompanied by a chronic ophthalmy peculiarly affecting the interior of the eye; when no parti- cular head-ach, nor pains in the eye and eye-brow have been experienced; when the pupil, notwithstanding the cataract, preserves its circular figure, and the faculty of varying its dimen- sions in the different degrees of light; when the patient can distinguish a brilliant light from total darkness; and, especially, if in a moderate light, where, usually, the pupil is not too much con- tracted, he should be able to distin- guish bright colours, and the shadows of objects before him: there is every reason for performing, and expecting success from, an operation. (Scarpa sulk Malatlk degli Occhi.) The power of distinguishing light from darkness, is much more satisfac- tory, than motion of the iris. I have seen in St. Bartholomew's Hospital, and in the York Hospital under Mr. Albert, several cases of complete gutta serena in both eyes, in which tliere was the weest contraction and dilatation of the pupils. It is obvious, that, had such patients been, at the same time, afflicted with cataract (a complication by no means unfrequent,) and a sur- geon, induced by the moveable state of the iris, had undertaken an operation, how unavailing it must have proved, since the rays of fight could only have been transmitted to an insensible reti- na. Richter, and Wenzel, make men- tion of these peculiarities, and the lat- ter refers the phenomenon to the iris deriving its nerves wholly from the len- ticular ganglion, while the immediate organ of sight, is constituted entirely by another distinct nerve. Hence we call no longer consider motion of the iris as an infallible criterion, according to several authors, ( H athen) that the retina is endued with sensibility. Re- lating to this subject, is a curious re- mark by Mr. Lucas in the Medical Ob- servations and Inquiries: he attended, in conjunction with Messrs. Hey and Jones, his colleagues of the Leeds' In- firmary, five children of a clergyman at Leaven, near Beverly, who were all born blind. He writes, " None of them can distinguish light from darkness, and, although the pupil is, in common, neither too much dilated nor contract- ed, and has motions, yet these do not seem to depend upon the usual causes, but are irregular." (Vol. 6.) The reciprocal sympathy between the two organs of sight, is so active, that no one, solicitous te acquire either physiological, or pathological know- ledge 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 very impression of the rays of light upon one eye, sensible to this stimulus, is known to be often sufficient to produce cor- responding 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 mo- tionless, and yet sight shall be restored after the performance of an operation (IVenzel.) There are, however, two circumstances, which may prevent us from ascertaining, whether the retina is sensible to light or not: the first is, a circular adhesion of the crystalline capsule to the iris. It must be a diffi- cult thing to discriminate the nature of this case, by merely observing, as Rich- ter directs, the distance between the cataract and pupil; inferring, that when the space, between the pupil and opaque lens, is inconsiderable, such an adhesion has happened; and, that when the cataract does not seem parti- cularly close to the pupil, and yet the patient cannot discern light from dark- ness, it is complicated with amaurosis. 'The second circumstance, sometimes utterly preventing the ingress of any light to the healthy retina, is the round bulky form of the cataract. But although I have remarked, that the power of distinguishing light from darkness is more satisfactory, than mo- tion of the iris; it is not an unequiyo- CATARACT. 187 cal test of the retina being perfectly free from disease. Wliile the gutta serena is incomplete, the patient can yet distinguish light, and the shadows of objects. Dilatation of the pupil is, also, a deceitful criterion to ascertain the complication of gutta serena with the cataract. When the cataract is large, or adherent to the iris, the'pupil is frequently much dilated, however natural and sound the state of the op- tic nerve may be : the pupil often con- tinues quite undilated in the most per- fect gutta serena. (Richter.) From all this it must be manifest, 1st, that the irregularity, and inconstancy of the symptoms of gutta serena, toge- ther with the possibility of particular states of the cataract rendering the pa- tient utterly unconscious of the stimu- lus of fight, make it necessary for the surgeon to be particularly attentive to the appearance, and to the history of the origin and progress of the disease, in order to understand the real condi- tion of certain cases. 2d, That, when the patient can distinguish light from darkness, though tiie iris may be mo- tionless, there is good ground for trying antoperation. Possibly, in this circum- stance, an incipient amaurosis may ex- ist, but, the chance of the defect of the iris arising from other causes; the cer- tainty, that the opaque body must be re- moved from the axis of sight, (even were tiie disease of the retina cured,) ere sight could be restored; and the improbability, that an operation to ciu-e the cataract, would render the other complaint at all less remediable; fully justify^he attempt. 3dly, That, should the patient have been free from parti- cular pain in the head and eye; should lie, in a previous stage of the cataract, have been able to distinguish light from darkness, and then suddenly have lost that power, in consequence of in- flammation affecting the eye, and de- priving the iris of motion; in which case there is ample reason to conclude, that adhesions between the iris and ca- taract have taken place; and should there be ground to suspect, from the appearances which I have already no- ticed, that tiie cararact is of exceed- ingly large dimensions; notwithstand- ing the incapacity to feel the stimulus of light, there is yet sufficient founda- tion to entertaiu a little hope, and to vindicate the practice of the only effort that can be availing, and, excepting a trivial and a temporary pain, one that cannot be materially injurious to the patient. The concurrent testimony of almost all writers upon the subject confirms, that the restoration of sight has sometimes been effected in the most hopeless cases, and I am, therefore, of opinion with Mr. Lucas, that it is pro- per, in all doubtful cases, to try couch- ing, as a remedy by no means violent, or hazardous. (Med. Obsei-vations and Inquiries, Vol. 6. p. 257.) As it not unfrequently happens, that cataracts, produced by exter- nal violence, spontaneously disap- pear,' (Pott, Hey, &c.) the operation should never be too hastily recom- mended for such instances. One rea- son, assigned for not operating, when only one eye is affected, viz. that one eye is sufficient for the necessities of life, is but of a frivolous description; and, another, that the patient would never be able to see distinctly after the operation, by reason of the difference of the focus in the eyes, is (I have grounds for believing) only a gratui- tous supposition, blindly transmitted from one writer to another. For the reasons of what I have here advanced, and for the proofs, that success does sometimes, "probably in general (if no other causes of failure exist,) attend tiie practice of couching and extrac- tion, when only one eye is affected with a cataract, I must refer to my Critical Reflections on the Cataract, and to a pa- per in the Med. and Physical Journal for May, 1808. TREATMENT OF THE CATARACT. The principal external remedies, that have been employed in the cure of the cataract, are, bleeding, cupping, scari- fying, setons, issues, misters, and fufni- gations ; and the principal internal re- medies are, aperients, incisives, eme- tics, cathartics, sudorifics, cephalics, and sternutatories. Preparations of eye- bright, millepedes, wild poppy, lien- bane, and hemlock, have also been much commended, as specifics for tiie disorder. Scultetus asserts, that he checked the progress of a cataract, by applying to the eye tiie gall of a pike, mixed with sugar; and Spigelius, as we are informed by the same author, boasted of having successfully iised, for this purpose, the oil of the eel-pout (mustela fluvMtalis.) 188 CATAA V( 1 Cataracts ire laid lo haVc been curb- ed in venereal patients, while under a course of mercury. It is probable, how- ever, that mam SUcli castes have been mere, opacities" of the cornea, which have been mistaken for cataracts. Ba- roh" \Venzel placed ho reliance whatev- er in the power of an'v remedies to dis- sipate a cataract, and/ as he had "re- marked their inemcacy in numerous instances, he felt authorized in declar- ing, tiiat internal remedies, efther of the mercurial, or any other kind, are in- adequate to the cure of this disorder ; and equally so. whethfer the opacity be in the 'crystalfihe, or in the capsule, whether incipient, or advanced. Although Mr. Ware coincides with \Venzel, in regard to the uncertainty of all knoWn medicines to dissipate an Opacity, either in "the Crystalline, or its capsule, or even to prevent tlie progress -of such opacity, when once "begun, 'yet many cases have proved, that the pow- ers of nature are often sufficient to ac- complish these purposes. The opaci- ties, in "particular, which are produced by external violence, Mr. Ware has re- jfeafedly seen dissipated in a short space of time, whert no 6ther parts of tne e^e have been hurt. In such Ca&eS, the crystalline lens has generally been absorbed, as is proved by tlie benefit, which has afterly aids been derived from deeply convex glasses. In some of these casts, though the crystalline has "BfceU dissolved, tlie 'greater part of the cap- sule has remained opaque, artd the light has been transmitted to the retina only through a small aperture, which has become transparent in its centre. Instances are also not "wanting, in which cataracts, formed without any violence, have been suddenly dissipated in con- sequence of an accidental blow on the eye. Tlie remedies, which Nlr. Ware has found more effectual, titan others, have been the applicatioh to tlie eye itself of one, or two drops ot a.-ther, once, or twice, in the course of the day, and the occasional rubbing of (he eve, over tiie lid, with the point of the viin- jrer, first moistened with a weak vola- tile, or mercurial liniment. ChtVracts are usually cured, either by removing the opaque lens, from the ax- is of vision by means of a needle; or by extracting the lens from the eye, through a semi-circular incision, made at'the lower part of'the cornea. The first operation is termed couching, oint, it is blunt ahd rounded ; although to the naked eye this part appears shirp, on account of its being very thft. CATARACT. 189 And the fettrtmity of this edgft, to the extent of one eighth of an inch ftom the point, is keen, like the lower edgfe, ih order to facilitate the conveyance ©f the instrument through the Cornea. The Bwelhhg ih the middle of the blade is #ie*rely kitehdfed to prevent the instrument from breaking. The handle, in which the blade is fixed, has eight shies, whlth are alternately large and small. This form enables the operator to hold the instrument more "irmly, which is not so apt to turn round in tfte hand. It is generally three inches and two thirds in hmgth, ahd, from two lines, to two and a half, in thickness. The Made is so fixed in the handle, that the two sides >of the forme* lie pa- rallel With the broadest Side of the lat- ter. On the upper side of the handle, which answers to the upper, or blunt etige, of the knife, a small mark is pla- ited, Which directs the proper manner, in which the instrument should beheld ih performing tlie operation. The Shape of this knife is well calcu- lated to effect the division of the cor- nea, With the utmost ease ahd safely, h% it cuts this membrane, in propor- tioli as it enters the eyfe. (Wenzel.) The knife, employed by Mr. Ware, is, in regard to its dimensions, not im- Hke the Instrument employed by the BarOn. The principal difference be- tween them is, that Mr. Ware's knife is less spear-pointed; ih consequence of which, when this latter instrument has pierced through the cornea, its lower, or cutting edge will sooner pass below tlie Inferior margin of the pupil, than the knife used by Wehzel. Oh this ac- coUUt, Mr \\ are is of opinion, that tlie iris will be less likely to be entangled under the knife, Which he recommends, than under Wenzel's, when the instru- ment begm& to cut its way downwards, and the aqueous humour is discharged. Mr. Ware particularly advises great care to bfe taken to have the knifo in- crease gradually in thickness from the Jwint to'the handle; by which means, if it be Conducted steadily through "the COrnefc, it will be next to ah impossi- bility) that anypart of the aqueous hu- mour should escape, before the section is begun downwards; and, conse- qifently, during this time, tlie cornea will'preserve its due convexity. Btit, if the blade should hot increase in thick- nessti-om the pbint; or if it be incurva* WA much in its back, or edge, the aqxmu* humour will unavoidably **- cape, before the puncture it comple- ted ; and the iris, being brought under the edge of the knife, will be in great danger of being wouhded by it. ( Ware) Baroh Weiifcel considers all instru- ments, invented for fixing theeye, quite unnecessary: they render the operation more complicated, more dreadful to the patient, more embarrassing to the operator, and they are very liable to it- mate and wound the eye. If the above oculist could approve of any kind of speculum, he should give the prefer- ence to Ruihpelt's instrument, which is nothing more than a thimble, at the end of Which is a sharp pointed instru- ment, like the pique of Pamard. The thimble is to be placed bn the middle finger of the operator, and it has the advantage of not obstmctiftg the ttse of tite forefinger, but leaves it at liberty to keep down tlie lower eyelid. The pressure, occasiohed by all con- trivances for fixing the eye, is a serious objection to their employment, *hs such pressure is apt to cause a sudden pro- trusion and loss of great part of the vi- treous humour. (Wenzel.) Mr. Ware coincides very much with Wenzel' on the subject of specula. At the same time, he remarks, that, in some instances of children hot* with cataracts, he has been obliged to fix the eye with a speculum ; Without the aid Of which, he has fbuhd it totally im- practicable to make tiie incision through the cornea, with any degree of preci- sion, or safety. His specuTffm is a noval ring, the longest diameter of Which is about twice as long as 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 a rest, or shoulder, to support the up- per eyelid ; and, by its lower rim, it is fi-Xed to a handle of such a length, and bent in such a Way, as may render it Cohvehient to be held. (Ware.) When the patient is to undergo the operation, he should be seated in a low Chair, before a light, which is not tOo bright, and, which, consequently, does hot occasion too great a contraction Of tin; pupil. The sound eye being cover- ed with a compress, an assistant, pla- ced behind, must hold the patient's head, and support it on his breast. "With the forefirtker of tiie hand that is at liberty, he is then to raise the upper lid of the eye to be operated upon, and gently press the tarsus, with tiie ex- tremity of the finger,""against the upper 190 CATARACT edge of the orbit, avoiding all undue pressure on tiie eye. The operator is to be seated in a chair, a little higher, than that of the patient. The eyes naturally turning towards the light, he is to place the pa- tient's head obliquely at a window, so that the eye to be operated upon may be inclined towards the outer angle of the orbit. This position will enable the operator to bring out tlie knife, on the inner side of the cornea, opposite to the part, where it pierces this tunic, more exactly, than he would otherwise be able to do. The operator is to rest his right foot on a stool, placed near the patient, that his knee may be raised high enough to support the right el- bow, and to bring the hand, with which he holds the knife to a level with the eye, on which he is to operate. He is then to take the cornea knife in his right hand, if* it be the left eye, on which he is to operate, and, vice versa, in the left hand, if it be the right eye. The knife is to be held like a pen in writing, and the hand is to rest steadily on the outer side of the eye, with the little finger, separateil a little from the rest, on tiie edge of the orbit. In this posi- tion, the operator should deliberately wait, till the eye becomes quite still. (Wenzel.) When the eye is perfectly quiet, and so turned towards the outer angle, that the inner and inferior part of the cor- nea can be distinctly seen, through which Wenzel recommends the point of the knife to be conveyed, the opera- tor is to plunge the knife into the upper and outer part of this tunic, a quarter of a line distant from the sclerotica, in such a direction, that it may pass ob- liquely from above, downwards, paral- lel to the plane of the iris. At the same time, the operator must depress the lower lid with his fore and middle fin- gers, taking care to avoid all pressure on the eyeball. (Wenzel.) Mr. Ware does not approve of this plan of leaving the eye unfixed, while the incision is made through the cornea. The danger likely to arise from undue pressure, can only take place, after the instrument has made an opening into the eye: but, the pressure which Mr. Ware advises, in order to -fix the eye, is to be removed the instant the knife is carried through the cornea, and be- fore any attempt is made to divide this tunic downwards. To understand this subject better, however, the reader should know, that Mr. Ware divides the incision of the cornea into two dis- tinct processes; the first of which may be called 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 pass- ed through both sides of the cornea, and its extremity has advanced some way beyond this tunic, the aqueous hu- mour cannot be discharged, and pres- sure may be continued with safety. The punctuation 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 being useful, it will be hurtful. To avoid all bad ef- fects, Mr. Ware recommends the cor- nea to be cut in tiie following way. The operator is to place the fore and middle finger of the left hand, upon the tunica conjunctiva, just below, and a little on the inside of the cornea. At the same time, the assistant, who sup- ports the head, is to apply one, or, if the eye projects sufficiently, two of his fingers, upon tiie conjunctiva, a httle on the inside and above the cornea. The fingers of the operator and assist- ant, 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 diameter, and just before its connexion with the scleroti- ca. Thus introduced, it is to be push- ed on slowly, but steadily, without the least intermission, and in a straight di- rection, with its blade parallel to the iris, so as to pierce the cornea towards the inner angle of the 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 of the cornea. When the knife has reach- ed so far, continues Mr. Ware, 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 wounded. As every degree of pressure must now be taken off the eyeball, the fingers, both of the operator and his assistant, are instantly to be removed from tliis part, and shifted to the eyelids. These are to be kept asunder by gently pressing them against the edges of the orbit; and the eye is to be left entirely to the guidance of the knife, "by wliich, says Mr. Ware, it may be raised, depress- CATARACT. 191 ed, or drawn to either side, as may be found necessary. The aqueous hu- mour being now partly, if not entirely evacuated, and the cornea of course rendered flaccid, the edge of the blade is to be pressed slowly downward, till it has cut its way out, and separated a little more, than half the cornea from the sclerotica, following the semicir- cular direction, marked out by the attachment of the one to the other. (Ware.) As soon as the point of the knife had arrived opposite the pupil, Wenzel used to incline it gently backward, and thus puncture the capsule of the crys- talline. But, Mr. Ware very properly objects to this method of opening the capsule with the instrument used for cutting the cornea, and at the same time. The plan may exhibit dexterity; but, is of no use, and is often attended with considerable danger of wounding the iris. In the eyes of some persons, the iris is convex, and it is almost impossible to complete the section of the cornea, without entangling the iris under tiie edge of the knife, unless a particular artifice be adopted. Wenzel, in this circumstance, recommends gently rub- bing the cornea downward with the finger; one of the most important di- rections, 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 mo- dern oculists, however, do not attri- bute any superior uses to this method, and consequently do not imitate it. If the edge of the knife should in- cline too much forward, and its direc- tion be not altered, the incision in the cornea will be too small, and terminate almost opposite the pupil. In tliis case, tliere will be great difficulty in extract- ing the cataract, and the cicatrix after- wards 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, the incision will approach too near the part, srhere the iris and sclerotica unite, and there will be great danger of wound- ing one, or the other of these coats of the eye. Both those accidents may be prevented by gently rolling the instru- ment between the fingers, until the blade takes the proper direction. (Wen- zel.) Mr. Ware has seen operators, through a fear of wounding the iris, introduce and bring out the instrument at a con- siderable distance before the union of the cornea and sclerotica; in conse- quence of which, the incision from one side of the cornea to the other has been made too small to allow the easy ex- traction of the cataract, although from above downward, it was 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 section, afterwards, to all appearance, effectually comple- ted, yet, on account of the frictions, employed to disengage the iris from the edge of the instrument, the knife, in cutting downward, has been carried between the layers of the cornea, and, consequently, though the incision has appeared externally, to be of its proper size; internally, it has been much too small for allowing the cataract to be easily extracted. In this case, the in- cision must be enlarged, yby means of a pair of curved blunt-pointed scissars, which should be introduced to the part, where the knife first entered the cor- nea. (Ware.) After the knife has pierced through the cornea, and while it is cutting its way downward, the assistant, to whose care the upper eyelid is entrusted, is gradually to let it drop, in order to prevent the cataract from escaping too hastily. Then the whole charge of the eye devolves solely on the operator, Who is to solicit the extraction of the cataract by gentle pressure on the up- per part of the globe, the capsule of the crystalline having been previously- opened. Wenzel himself does not recommend opening the capsule of the crystalline, in every instance, at the same time, that the cornea is cut. In cases, where the pupil is much contracted, as well as in those, where the muscles of tiie eye and eyelids are easily thrown into convulsions, it is improper, says he; to puncture the capsule wtien the section is made through the cornea. Tliis is also improper when the space, between the crystalline, and tiie iris, termed the 'posterior chamber, is large. In all sucli cases, Wenzel acknowledges, that it is better simply to divide tlie cornea in the first instance, and then to puncture the capsule with a different instru- ment. 192 CATARACT- Wenzel and his father used to em- ploy, for this purpose, a flat needle, one line, that is, one twelfth part of an inch, in diameter, having its cutting extremity a little incurvated. This needle, which should be made of neal- ed gold, that Its pliability may allow llie operator to bend it in different di- rections, as occasion requires, is fixed in a handle, two inches and a half in length, and similar to that of the cor- nea 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 to extract the ca- taract. When the crystalline, dislodged from its capsule, protrudes through the wound in the cornea, its removal from the eye may sometimes be assisted by the use of the above needle; and after- wards the opaque and glutinous mat- ter, remaining, must be removed by means of the curette. It is always advisable, after the ope- ration, gently to rub the anterior part of the cornea over the lids, either with the thumb or the curette. This pro- cess usually collects in tiie centre of the pupil some small fragments of opaque matter, which the crystalline leaves behind it, and which, if not ta- ken away with the curette, might give rise to a particular kind of secondary cataract. Tlie curette is also of use for replacing the iris, a portion of which membrane occasionally comes through the incision in the cornea. (Wenzel.) Sometimes the cataract is hindered from coming out, on gentle pressure feeing made, in consequence of adhe- sions. Wenzel recommends these to be broken by means of the golden nee- dle, introduced under the cornea, and applied in different directions, accord- ing as the case requires, and more especially round the circumference of the crystalline. Sometimes, when the capsule of the crystalline is destroyed, and the crys- talline itself is perfectly free, tliis hu- mour plunges to the inferior part of the vitreous humour, leaving only its upper edge visible through the pupil. The hyaloid membrane is also most commonly destroyed, and the vitreous humour in a state of fluidity. All pres- sure, therefore, on the eyeball, must be avoided, since this would produce a large evacuation of the vitreous hu- mour. The only method is to intro- duce through the pupil, a small steel book to take hold of the crystalline, wliich, in this ease, is often very small, ind with this instrument to extract it from the eye. f Wenzel) When the capsule used to become opaque after the operation, so as to form, what is termed, the secondary membranous cataract, Wenzel, after dividing the cornea, used to remove the opaque substance, by means ofa small pair of forceps. After tiie operation, no fluid applica- tion, according to Wenzel, should be made to the eye. It should be simply covered, with a dossil of lint; over which a dry compress should be appli- ed. Tlie dressings should in general be removed every day. Mr. Ware, however, approves of flu- id applications. He has found, that a dossil of lint, steeped 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 impregnated with the discharge, from becoming stiff, and uritating the lids, Mr. Ware thinks the mode of applying the compress and bandage over the eye, a circumstance of no small importance, beeause, if too loose, the dressings are very apt to slip off, and, consequently, to press unequally and injuriously on the eye; and, if too tight, the undue pressure will excite pain and inflammation, and even force out some of tire vitreous humour. Mr. Ware's compress is made of soft linen, folded, two or tliree times, wide enough to cover both eyes, and sufficiently long to extend from tiie upper part of the forehead to the lower part of the nose This he pins at the top of tiie patient's nightcap; and its lower part, which is divided hi the middle, to allow tiie nose to come through it, he lays loosely oyer the eyes. The bandage, also made of old linen, and as broad as six fingers, he carries round the head over the compress, and pins to tiie side of the nightcap moderately tight, A slip of linen is afterwards carried under the chin, and pinned, at each end to the side of the bandage, to prevent it from slipping upwards. (Ware.) The patient should he continually on his back, after tlie operation, as tliis posture lias a tendency to prevent tiie escape of the humours. CATARACT. 193 Mr. Ware has published a very able inquiry into the causes preventing the success of extraction of the cataract. The first, whicii he considers, is ma- king the incision through the cornea too small. In this circumstance, a de- gree of violence will be required to bring the cataract through the wound; and, if tlie cataract be not altered in its figure, the wound will be forcibly dila- ted, and the edge of the iris compress- ed between tiie cornea and the cataract. In this way, either some of its fibres may lie ruptured, or it may be other- wise so much injured, as to excite a considerable degree of inflammation, and even induce, ih the end, a closure of the pupil. This accident may arise from the operator's cutting the cornea, without being able to see exactly the position of this membrane, in consequence of the eye having turned inward, owing to its not being properly fixed. The fault may also proceed from the inci- sion having been begun below the trans- verse diameter of the cornea. In tliis manner, nine sixteenths, or rather more than half of the circumference of this membrane, will not be divided; whicii extent the incision ought always to oc- cupy, in order to allow the cataract to be extracted with facility. When the cornea is remarkably flat, and the iris projects unusually forward in the anterior chamber, however, Mr. Ware recommends including only one- third of the cornea in the first incision, and afterwards enlarging the aperture, on the outer side, by means of curved scissars. Whenever the wound in the cornea is made too small, it should always be enlarged before proceeding further in tiie operation ; and this can be best ac- complished with a pair of curved blunt- pointed scissars, on the outer side of the cornea, where the knife first made its entrance. Taking care to fix the eye in Mr. \\ are's way, is certainly of great con- sequence in hindering tiie wound in the cornea from being made too small. Wounding the iris with tiie cornea- knife, is tiie second accident, which Mr. Ware considers. The principal cause seems to hi in to be a discharge of the aqueous humour, before the knife has passed through the cornea low enough to hinder the lower part of the iris, which forms the inferior rim of the pupil, from getting beneath tiie edge of vol. 1. the instrument. 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 the lower part of the iris un- der the edge of the knife, Mr. Ware believes, cannot always be prevented by the utmost skill, or precaution of the operator. Happily, 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 applying gentle frictions on the cornea, over the entangled part, with the point of the finger. By unsteadiness in passing the knife, Mr. Ware means, that the knife may not only be suffered to make a punctu- ation through this tunic, but, that its edge may, at the same time, be unin- tentionally pressed downward, so as to make an incision likewise; in conse- quence of which downward motion of tiie knife, an aperture must unavoida- bly be left in the cornea, through which tlie aqueous humour will escape. If the cornea-knife increase through its whole length, both in width and thick- ness, and if it be merely pushed through the cornea, no space will be left, through whicii any fluid can escape. The third accident, noticed by Mr. Ware, is the escape of the vitreous hu- mour. The common occasion of this occurrence is the undue application of pressure. It may take place, either when the incision is made through the cornea, or at the time of extracting the cataract out of the eye. Some eyes are subject to spasm; which renders them much more liable to this accident. To prevent it, Mr. Ware recommends eve- ry kind and degree of pressure to be taken from the eye, before tiie knife has completely cut its way through the cornea. And, as soon as the knife has proceeded sufficiently low to secure the iris from being wounded, the ope- rator should not only take heed, that his own fingers do not touch tiie eye, but should also direct the assistant, who supports tiie upper lid, to remove his fingers entirely from this part. Ths assistant seldom need make any pres- sure on the globe of the eye: however, when tliere is room for one of his fin- gers to be placed on tiie inner and up- per part of the globe, without inter- fering with those of the operator, the method may be followed, in order to make the eye still more fixed. But immediately the punctuation of the cor- 25 191 CATARACT. nea is completed, the assistant's finger should always be entirely removed, both from the eyelids and eye itself. Notwithstanding the upper fid is left thus free, there will be sufficient space between it and the lower lid, to allow the progress of tiie knife to be 6een; and, in finishing the wound, the opera- tor should depress tiie lower lid with great gentleness. The vitreous humour may also be lost, in consequence of opening the capsule of the lens nearer the circum- ference, than the centre of the pupil. As the crystalline is both thinner and ■ofter at that part, the instrument will be liable to pass through both sides of the capsule, and enter the vitreous hu- mour. Tliis humour having no longer any barrier to its escape, is liable to be forced out by the action of the eyelids alone; and, when pressure is after- wards made, to bring the cataract llirough, a much greater quantity will be lost, and the cataract, instead of coming forward, will recede from the pupil. The only way to extract it now, is, by having tiie upper lid gently rais- ed by an assistant, (a rare instance, in in which this 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, ap- plied beneath the incision of the cor- nea, prevents the cataract from sinking further. Then, with the right hand, let him introduce a hook under the flap of the cornea; and witb its point care- fully entangle tlie cataract, and bring it away. To prevent, however, such difficul- ties, Mr. Ware very judiciously advises never attempting to puncture the cap- sule, until the whole pupil is in view. This gentleman is in the habit of open- ing the capsule with a gold-pointed needle, arched towards its extremity. Wenzel's needle, for this purpose, is flat at its extremity: Mr. Ware's is pointed: and this is their only differ- ence. The latter introduces his in- strument under the flap of the cornea, with its arched part uppermost, until its point is on a level with tlie centre of the pupil. The end of the instru- ment should then be turned inward, and gently rubbed on the capsule of the crystalline, until it pierces it. In a few instances, Mr. Ware has found the capsule so tough, that the point of the gold needle would not enter it, and he has been obliged to use a sharp steel instrument, of the same shape as the gold-pointed one. The vitreous humour may also be lost, at the time of extracting the cata- ract, and tiie usual cause is an undue application of pressure. All violent pressure is quite unnecessary for for- cing out the cataract, when tiie wound in the cornea is sufficiently large. When the wound is too small, it should be enlarged, as above directed. If pres- sure be continued at all after the cata- ract is extracted, the capsule of the vi- treous humour will certainly be ruptu- red, and some of this part of the eye protruded. Pressure may even rup- ture the capsule of the vitreous hu- mour, before the cataract is brought through tiie incision in the cornea; and the same consequences will ensue, and the same practice be necessary, as in the case, in which the operator has un- skilfully opened the capsule of the vi- treous humour with the needle, in at- tempting to open that of the lens. In taking away fragments of opaque matter, remaining behind, by means of the curette, great care is requisite to avoid .wounding the posterior part of tlie capsule of the crystalline with the end of the instrument, so as to open a way for the escape of the vitreous hu- mour. The vitreous humour may, indeed, be forced out, after the extraction of the cataract, merely by a spasmodic ac- tion 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 this event, repeats his advice, " that the upper eyelid should be raised solely by the fingers of the left hand of" the operator," after cutting the cornea. Mr. Ware seems to think, that more evil has resulted from the operator's being deterred, by the readiness, with which the vitreous humour continues to start out, from ascertaining, that all the fragments of the cataract are re- moved, and that the whole of the iris has resumed its position, than from the mere loss of the vitreous humour, whicii is quickly regenerated. Mr. Ware afterwards takes notice of the accident of extracting only a part of the cataract, and leaving the remain- der behind. He is an advocate for re- moving all opaque substances from the pupil, except an extreme degree of ir- ritability, to which some eyes are sub- CATARACT. 195 ject, should render the introduction of every sort of instrument, after the ca- taract is extracted, difficult and dan- gerous. Mr. Ware usually removes opaque portions of the cataract by means of a curette ; and, occasionally, when the opaque substance has been large, and lias adhered to the capsule, he has been obliged to extract it with small forceps. Before finishing the operation, Mr. Ware approves of al- ways rubbing the end of the finger gently on the fore part of the eye, over the eyelids; wliich proceeding tends to bring in view any opaque matter, which may previously lie behind the iris. Mr. Ware relates a case, proving, that such opacities as cannot be removed in the operation, are capable of" being absorb- ed. This gentleman says, that an opaci- ty of the capsule can be the only rea- son for removing it. The anterior part, also, can alone become the object of the operator's attention ; its posterior part is necessarily hidden, while the ca- taract remains in the eye, and after- wards, if discovered to be opaque, it is bo closely connected with the capsule of the vitreous humour, that Mr. "Ware believes it cannot be removed by any instrument, without hazarding a de- structive effusion of this humour. When, however, the opaque lens, is accompanied with an opacity in the front part of the capsule. Mr. "Ware recom- mends the following plan. After cut- ting the cornea, 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 cor- nea, with its bent part upward, until its point is parallel with the aperture of the pupil. 'The point should then be turned toward the opaque capsule, which is to be punctured by it, in a cir- c ular direction, as near to the rim of the pupil as tiie instrument can be ap- plied, without hurting the iris. Some- times, the part included within the punctures, may. be extracted on the point of the instrument; and, if this cannot be done, it should be removed with a small pair of forceps. The lens, whether opaque, or transparent, should next be extracted, by making a slight pressure with the curette, either above, or below, the circumference of the cor- nea. Mr. Ware afterwards considers the bad consequences of allowing foreign bodies of any kind, after the operation, to press unequally on tiie globe of the eye ; comprehending, under this head, the intervention of the edge of the low- er eyelid between the sides of the di- vided cornea; the inversion of the edge of the lower eyelid ; and the lodg- ment of one, or more, loose eyelashes on the globe of the eye. To prevent the first accident, every operator, before applying the dressings, should carefully depress the lower eye- lid ; and, before lie suffers the lid to rise, should take care, that tiie flap of the cornea be accurately adjusted in its proper position ; and, that the up- per 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 good reason to suppose tiie wound in tlie cornea closed. (Ware.) The inversion of the lower eyelid is hurtful, in consequence of its making the eyelashes rub against the eye. These should be extracted the day be- fore the operation. For t hemode of ef- fecting a permanent cure, see Trichia- sis. Besides the danger, to wliich the eye is exposed, from tiie inversion of the edge of the lid, the eye may receive injury from tiie improper position of tiie eye lashes alone ; one, or more of which, during tiie operation, may hap- pen to bend inwards; or, becoming loose, may afterwards insinuate themselves between tiie inside of the lid and the eye. An eyelash, bent mward, should be rec- tified ; if broken off and loose, it should be removed, before dressing the part. Mr. Ware lastly considers prema- turely exposing the eye to a strong light. He censures the plan of opening the eyelids, within the first two or three days after the operation, because the stimulus of the light increases the ophthalmy, and the method is apt to disturb the wound in the cornea, before it is closed. Mr. Ware, however, wish- es it not to be inferred, that he is an advocate for long confinement after the operation. His mode is to keep the pa- tient wholly in bed, and to direct him to move his head, as little as possible, for tiie first three days after the opera- tion. During tilis time, a dossil of wet lint is kept on his eye6, covered with a saturnine plaster, compress, and ban- dage, as already described. The dres- sing is renewed once every day, and the outside of the eyelids washed with 196 CATARACT. warm water in winter, and cold in sum- mer. At each time of dressing, the skin of the lower lid is drawn g-ently down to prevent any tendency to an inversion. Animal food is prohibited, and the pa- tient enjoined not to talk much. On the fourth day, he is permitted to sit up, for two, or three hours, and, if he has had no stool since the operation, a mild opening medicine is now administered. On the fifth, the time of his sitting up is lengthened, and, presuming that the wound in the cornea is now closed, Mr. Ware usually examines the state of the eye. After this, no dressings need be applied in the day-time, care being taken to defend it from a strong light, by a pasteboard hood, or shade, and by darkening the room, so that no incon- venience is felt. The patient may now also look, for a short time, at large ob- jects. The following part of the treat- ment need interfere very little with the wishes of the patient, unless unexpect- ed accidents should occur. (Ware.) OF COUCHING, OR DErRESSION OF THE CATARACT. This operation consists in removing the opaque lens out of the axis of vi- sion, by means of a needle, constructed for tlu purpose. There are two couching needles, which now seem to be preferred to all others : and these are the only ones requiring a description here. 1 allude to the one used by Mr. Hey ; and to that employed by Professor Scarpa. The length of Mr. Hey's needle is somewhat less than an inch. It would be sufficiently long, if it did not ex- ceed 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 gradual- ly thinner to the extremity of the needle, wluch is semicircular, and ought to be made as sharp as a lancet. The Hat part extends in length, about an eighth of an inch, and its sides are parallel. From the part where the needle ceases to be flat, its diameter gradually increases towards the handle. The flat part is one fortieth of an inch. The handle, 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 cor- respond with the edge of the needle. Mr. Hey describes the recommenda- tions of this instrument in the follow- ing terms. 1 "It is only half the length of the common needle ; and this gives the operator a greater command over the motions of its point, in removing the 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 he has an opportunity of seeing It through the pupil; as it ought to be brought for- wards 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 exceed tiie diameter of the eye, than when the capsule is so opake that the point can- not be seen through tiie pupil. 2. " As this needle becomes gradual- ly thicker towards the handfo, it will remain fixed in that part of the scelo- rotis, to which the operator has push- ed it, while he employs its point in de- pressing and removing the cataract. But the spear-shaped needle, by ma- king a wound larger in diameter, than that part of the instrument, whicii re- mains in the sclerotis, becomes unstea- dy, and is with difficulty prevented from sliding forwards against the cilia- ry processes, while the operator is giv- ing it those motions whicii are neces- sary for depressing the cataract. " On the same account the common spear-shaped needle may suffer some of the vitreous humour to escape dur- ing the operation, whereby the iris and ciliary processes would be somewhat displaced, and rendered flaccid; where- as the needle which I use, making but a small aperture in the sclerotis, and filling up that aperture completely du- ring the operation, no portion of the vitreous humour can flow out so as to render the iris and ciliary processes flaccid. 3. " This needle has no projecting edges : but the spear-shaped needle, having two sharp edges, whicii 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 perform- ed by one of the most eminent surgeon; in the metropolis, now deceased, the iris was divided as far as the pupil. If tiie operator, in order to avoid this dan- ger, introduces his needle with its edges in a vertical position, he will di- CATARACT. 197 vide the fibres of the sclerotis trans- versely, and, by thus enlarging the wound, will increase the unsteadiness of the instrument., Besides, however the needle be introduced, one of its sharp edges, must be turned toward the iris in the act of depressing the ca- taract ; and, in the various motions which are often necessary in this ope- ration, the ciliary processes are certain- ly exposed to more danger, than when a needle is used whicii has no project- ing edge. 4. " It has no projecting point. In the use of the spear-shaped needle, the operator's intention is to bring its broadest part over the centre of the crystalline. In attempting to do this, there is great danger of* carrying the point beyond the circumference of the crystalline, and catching hold of the ciliary processes, or their investing membrane, the mcmbrana nigi-a. This accident is more probable, as the point of" the needle must unavoidably be di- rected obliquely forwards, and this mo- tion, if carried too far, brings the point into contact with the ciliary processes, as they -surround the capsule of the crystalline. " A needle, made according to the figure given in the annexed plate, will pass through the sclerotis with ease. It 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 chamber of the eye (which is often the case), he may do this with the greatest safety, 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 motions of iis point, he will do no unavoidable injury to the eye; and this caution be- comes the less embarrassing, as the point does not project beyond that part of the needle by whicii the depression is made, the extreme part of the needle being used for this purpose. (Hey.) Scarpa employs a very slender nee- dle, possessing sufficient firmness to enter the eye without hazard of break- ing, and having a point, wliich is slight- ly curved. The curved extremity of tiie 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 gentle eminence, that is continued a- long to tiie very point of the instru- ment : there is a mark on the side of the handle, which corresponds to the convexity of the 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 opera- tion demand. A couching needle is suf- ficiently long when it does not exceed, at most, an inch in length : this affords the 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, therefore, so much recommended by Scarpa, and so successfully used by him, and Doctor Morigi, principal sur- geon of the hospital at Piacenza, and one of the most expert operators of the present day in Italy, it seems proper to unite the improvement of having it made no longer than is necessary. The needle here described, will penetrate the sclerotic coat as readily as any straight one, of the same diameter, and, by reason of its slenderness, will im- pair the internal structure of the eve less in its movements than common couching needles. When cautiously pushed in a transverse direction, till its point has reached the upper part of the opaque lens, it becomes situated with its convexity tnwards the iris, and its point in an opposite direction ; and, upon the least pressure being made by its convex surface, it removes the ca- taract a little downward, by which a space is afforded at the upper part of the pupil, between the cataract and ci- liary processes, through which the in- strument may be safely conveyed in front of the opaque body and its capsule, which it is prudent to lacerate in the operation. In cases of caseous, milky, and membranous cataracts, the soft pulp of the crystalline may be most readily divided, and broken piecemeal by the edges of its curved extremity; and the front layer of* the capsule la- cerated into numerous membranous flakes, which, by turning the point of the instrument towards tiie pupil, may be as easily pushed through this aper- ture into the anterior chamber, where Scarpa finds absorption takes place more quickly, than behind the pupil. Inordinary cases, there is not the least occasion for any preparatory treat- ment previous to the operation ; all that prudence requires is, that the patient 198 CATARACT. should abstain from animal food, and fermented liquors, for a few days be- fore submitting to it, and should take one dose of a gentle purgative. But this, like every other general observa- tion, is liable to particular exceptions. Hypochondriacal men, hysterical wo- man, and patients subject to affections of the stomach and nervous system, should take, for two or three weeks be- fore the operation, tonic bitter medi- cines, particularly the infusion of quas- sia, either with, or without a few drops of aether vitrioltcum to each dose ; or, in other cases, Jj of Peruvian bark, w'rth 3j of valerian, may be administer- ed two or three times a day with par- ticular benefit. It is observed by the most accurate writers upon this sub- ject, that hi such persons the symptoms consequent to operations upon the eyes, are often much more violent than in common cases ; and it therefore seems {n-operto endeavour, previously,to me- iorate their constitutions. When the patient is timid, it is very advisable to give him, half an hour before the time of operating, about fifteen drops of the tinctura opii, with a little wine. Some patients, besides being afflicted with cataract, have the edges of the eyelids swollen and gummy, with re- laxation, and chronic redness of the conjunctiva. Before undertaking to couch, it is, in this case, advisable to apply a blister to the nape of the neck, and to keep it open for two or three weeks, by means of the Savin cerate, and to insinuate every morning and evening, between -the palpebrse and globe of the eye, a small quantity of the unguentum hydrarg. nitrat. nntiusj prepared according to the pharmaco- poeia of St. Bartholomew's Hospital,* increasing its strength gradually. In obstinate cases, when this ointment does not produce the desired effect, an ointment recommended by Janin, -j- should be substituted: it consists of •fss of hog's lard, ^ij of prepared tut- ty, ^ij of armenian bole, and ^j of the 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 rose water, £ss of the mucilage of quince seeds, and gr. v. of the sul- phate of zinc, may also be frequently used with considerable advantage By such means the morbid secretion from the Meibomian glands, and membra- nous lining of the eyelids, will be checked, and the due action of the ves- sels, and natural flexibility of the eye- lids, will be restored. (Saggio di Us- servarioni, &c. sidle principali muluttie degli occhi. Venez. 1802.J FIRM CATARACT. In the operation, the patient should be seated rather low, opposite a win- dow, where the light is not too 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 covered with a hand- kerchief, or any thing convenient for tlie purpose ; for, so strong is the sym- pathy between the two organs, that the motions of the one constantly produce a disturbance of'the other. The sur- geon should sit upon a seat rather high- er than that upon which the patient is placed; and, to give his hand a greater degree of steadiness in the various ma- noeuvres of couching, he will find it useful to place his elbow upon his knee, which must be sufficiently raised for this purpose, by a stool placed un- der the foot. The chair, on which the patient sits, ought to have a high back, against which his head may be so firm- ly- supported, that he cannot draw it backward during the operation. The back of the chair must not slope back- ward, as that of a common one, but be quite perpendicular, in order that the patient's head may not be too dis- tant from the surgeon's breast. (Rich- ter's Anfangsgrunde der Wundarzney- kunst. P. 207. 3. Band.) The propriety of supporting the pa- tient's head rather upon the back of the chair, on which he sits, than upon an assistant's breast, must immediately strike every impartial mind; for, as Bischoff has observed, the least motion of the assistant, even that necessarily occasioned by respiration, causes, also, a synchronous motion of the part, sup- * &• Unguenti hydrargyri nitrati, ^iv. Adipis Suillae, *viij. Olei Olivae, ^ij. f Memoires sur I'Oeil. CATARACT. 199 ported on his breast, which cannot fail to be disadvantageous, both in the ope- ration of extraction, and of couching. Hence Callisen and Richter have re- commended the same method of sup- porting the patient's head, as I have here submitted to public consideration. In certain cases, where tiie muscles of the eye, and eyelids, are incessantly affected with spasm ; or, where the eye is peculiarly diminutive, and sunk, as it were, in the orbit, the elevator for the upper eyelid, invented by Pellier, and approved by Scarpa, may possibly prove serviceable: hi operating upon young subjects, I think it might contribute much to facilitate the operation. The couching needle (if the curved one) is to be held with the convexity of* its curvature forward ; its point back- ward; and its handle parallel to the patient's temple. The surgeon, having directed the patient to turn the eye to- wards the nose, is to introduce the in- strument boldly through the sclerotic coat, at the distance of not less than two lines from the margin of the cornea, for fear of injuring the ciliary proces- ses. Most authors advise the puncture to be made at about one line, and some even at the minute distance of l-16th of an 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 aponeurosis of the abductor muscle, as some have con- ceived, the propriety of puncturing the globe of tiie eye, at the distance of two lines, or two and a half, from the mar- gin of the cornea, as advised by Petit, Platner, Bertrandi, &.c. must, in all ca- sts, be sufficiently manifest. Nor is it a matter of indifference, at what height the needle is introduced, if it be desirable to avoid, as much as possible, effusion of blood in the ope- ration. Anatomy reveals to us, that the long ciliary artery pursues its course to the iris, along tiie middle of the ex- ternal convexity of the eyeball, between the sclerotic and choroid coats; and hence, in oi-der to avoid tliis vessel, it is prudent to introduce the instrument about one line below the transverse di- ameter of the pupil, as Duddell, Guntz, Bertrandi, Scarpa, Sec. have directed. If tiie couching needle were introduced higher than the track of the long cilia- ry artery, it would be inconvenient for the depression of the cataract. The esact place, where the point of the needle should next be guided, is, no doubt, between the cataract and ci- liary processes, in front of the opaque lens, and its capsule : but, as 1 con- ceive, the attempt to hit this dehcate invisible mark, borders upon impossi- bility, and, with a straight pointed nee- dle, might even endanger the iris, I cannot refrain from expressing my dis- sent to the common metliod of passing a couching needle at once in front of the cataract. On the ' contrary, it seems safer to direct the e xt remity of the in stru- ment immediately over the opaque lens, and, in the first instance, to depress it a little downward, by means of the con- vex flat surface of the end of the nee- dle, in order to make room for the safe conveyance of the instrument, between the cataract and corpus ciliare, in front of the diseased crystalline and its cap- sule ; taking care, in this latter step of the operation, to keep the marked side of the handle forward, by which tlie point of the needle will be in an oppo- site 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. Having done this (supposing it to be a firm cataract), the instrument will be visible through tiie pupil; and now we are to push its point transversely, as near as possible the margin of the lens, on the side next the internal angle of the eye, taking strict care to keep it continually turned backward. The ope- rator is then to incline the handle of the instrument towards himself, by whicii its point will be directed through the capsule, into the substance of the opaque lens ; and, on making a move- ment of the needle, describing the seg- ment of a circle, at the same instant in- clining it downward and backward, he will lacerate the former, and convey it, in the generality of cases, with tlie lat- ter, deeply into the vitreous humour. It happened, unfortunately for the credit of the operation of depression, that M. Petit admonished surgeons to beware of wounding the anterior layer of the crystalline capsule: he had an idea, that, in observing tills caution, the vitreous humour would afterwards fiH up the space, previously occupied by the lens, and that thus the refracting powers of the eye nii^ht become as strong as in the natural state, and tlie necessity for using spectacles might 200 CATARACT. thereby be considerably obviated. But, we are now apprized, that leaving this very membrane, from whicii M. Petit anticipated such great utility, even were it practicable to leave it constant- ly uninjured in its natural situation, would be one of the worst inculcations that could possibly be promulgated; for, in many cases, where Extraction proves fruitless, in some, where De- pression fails, the want of success is owing to a subsequent opacity of the crystalline capsule; in short, blindness is reproduced by the secondary mem- branous cataract. It seems more than probable, that, in some of the instan- ces, where the opaque lens has been said to have risen again, nothing more had happened, than the disease in ques- tion. Therefore, notwithstanding the whole capsule may be, in the majority of cases, depressed with the lens out of the axis of vision, as it is not a con- stant occurrence, I cannot too strongly enforce the propriety of extirpating, as it were, every source and seat of the cataract in the same operation, and in imitation of the celebrated Scarpa, the only one who, as far as my information reaches, has put sufficient stress upon this practice, I shall presume to re- commend, as a general rule in couch- ing, always to lacerate the front layer of tlie capsule, whether in an opaque or transparent 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, he might unintentionally leave this membrane entire in its natu- ral situation. Therefore, if there should be any reason for suspecting, that the anterior layer of the capsule has esca- ped laceration; if, in other words, the resistance made to moving the convex- ity 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 gentie rotatory motion, by which its point will be turned forward, and disengaged, through tiie transpa- rent 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 future trouble. FLUIO, OR MILKY CATARACT- When the case is of this description, the operator frequently finds, that, on passing the point of the couching nee- dle through the anterior layer of the capsule, its white milky contents in- stantly flow out, and spreading like a cloud over the two chambers of the aqueous humour, completely conceal the pupil, the iris, and the instrument, from his view; who, however, ought never to be discouraged at this event. In my Critical Reflections on the Cata- ract, I have dissented from continuing the operation, when, in its commence- ment, blood is effused into the aqueous humour; I have there adverted to the effusion of the milky matter of cata- racts, into the same situation; and, I have said, that the two cases are not to be considered in a different light; but, I only alluded to the consequences of these occurrences. I shall now lake the opportunity to observe, that, al- though it seems to me most prudent, to postpone the completion of the ope- ration, in the example of blood con- cealing the pupil, in the first step of couching, and not to renew it, before the aqueous humour has recovered its transparency; yet, I am inclined to adopt this sentiment, chiefly because the species of cataract is, in this cir- cumstance, quite unknown to the ope- rator, consequently, he must be abso- lutely incapable of employing that me- thod of couching, which the peculiari- ties of the case may demand. It is ve- ry different when a milky fluid blends itself* with the aqueous humour, and prevents the surgeon from seeing the iris and pupil: this event is itself a source of information to him, inasmuch as it gives him a perfect insight into the nature of the cataract, which he is treating; and instructs him what me- thod of operating it is his duty to adopt The surgeon, guided by his anatomical knowledge of the eye, should make the curved point of the needle describe the segment of a circle, from the inner, to- ward tiie outer canthus, and in a direc- tion backward, as if he had to depress a firm cataract. (Scarpa.) I'hus he will succeed in lacerating, as much as is necessary, the anterior layer of the capsule, upon which, in a great mea- sure, the perfect success of the opera- tion depends; and, not only in the milky, but almost every other species of cata- ract.* CATARACT 201 In regard to the extravasation of the milky fluid, into the two chambers of the aqueous humour, numerous obser- vations, from the most creditable au- thorities, prove, that it spontaneously disappears, very soon after the opera- lion, and leaves the pupil of its accus- tomed transparency. " In twelve ca- ses of a dissolved lens, on whicii I have operated," says Latta, " the dissolution was so complete, that, on entering the needle into the capsule of the lens, the whole was mixed with the aqueous hu- mour, 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 completely res- tored in four weeks from tiie opera- tion." Mr. Pott, in treating of this cir- cumstance, viz. the effusion of the fluid contents of the capsule into the aque- ous humour, observes, that so far from being an unlucky one, and preventive of success, it proves, on the contrary, productive of all the benefit which can be derived from the most successful depression or extraction, as he has often and often seen. But as this point is, I believe, no longer made an objection to couching, it would be superfluous to enlarge, in confirmation of what has been stated concerning it. SOFT, OR CASEOUS CATARACT When the cataract is of a soft, or ca- seous description, tiie particles of which it is composed, will frequently elude all efforts made with the needle to de- press them, and will continue behind the pupil in the axis of vision. This has been adduced as one instance that baffles the efficacy of couching, and may really seem, to tiie inexperienced, an unfortunate circumstance. It often happens that, in the operation of ex- traction, fragments of an opaque matter are unavoidably overlooked and left behind; yet Richter, who once so stre- nuously signalized himself in favour of the new operation, confesses, that such matter is removed by the absorbents. Supposing a caseous cataract should not have been sufficiently broken, and disturbed in the first operation, and that, consequently, the absorbents do not completely remove it, such a state may possibly require a reapplication of the instrument; but this does not ge- nerally occur, and is the worst that can happen. It is quite impossible to de- vol. 1. termine a priori, what effect will result from the most trivial, disturbance of a cataract; its entire absorption may, in some instances, follow, while in others, a repetition of an operation be- comes necessary for the restoration of sight. Even where the whole firm lens has reascended behind tiie pupil, as Latta and Hey confirm, the absorbents have superseded the necessity for couching again. The disappearance of the opaque particles of cataracts was, in all times, and in all ages, a fact of such conspicuity, that, as appears from the authorities already quoted, it was recorded, even previous to the disco- very of the system of lymphatic vessels in the body. Indeed, the modern ob- servations of Scarpa, and others, so strongly corroborate the account which I have given, of the vigorous action of tlie absorbents, in the two chambers of the aqueous humour; and, particular- ly, in the anterior one, that, from the moment the case is discovered to be a soft, or caseous cataract, it seems quite unnecessary to make any further at- tempt to depress it into the vitreous hu- mour. Mr. Pott sometimes, in this circumstance, made no attempt of this kind, but contented himself with a free laceration of the capsule, and, after turning the needle round and round, between his finger and thumb, withiw the body of the crystalline, left all the parts in their natural situation, where he hardly ever knew them fail of dis- solving so entirely, as not to leave the the smallest vestige of a cataract. This eminent surgeon even practised occa- sionally what Scarpa so strongly incul- cates at this day; he even pushed the firm part of such cataracts through the pupil into the anterior chamber, where it always disappeared, without produ- cing tiie least inconvenience -. we must, at the same time add, that he thought this method wrong, not on account of its inefficacy, but in apprehension that it would be apt to produce, an irregula- rity of the pupil, one of the worst in- conveniences attending the operation of extraction. But the deformity of the pupil, after extraction, seems to proceed either from an actual lacera- tion of the iris, or a forcible distention of the pupil, by the passage of large ca- taracts through it, a kind of cause that would not be present in pushing the broken portions of a caseous lens into the anterior chamber; therefore, it does not seem warrantable to reject this ve- 26 202 CATARACT. ry efficacious plan of treatment, for which the curved pointed needle is, undoubtedly, the best calculated. It is very deserving of" notice, that Mr. Hey, who has several times seen the whole opaque nucleus, and very frequently small opaque portions fall into the an- terior chamber, makes this remark: " Indeed, if the cataract could, in all cases, be brought into the anterior chamber of the eye, without injuiy to the iris, it would be the best method of performing tlie operation." What the same author also observes in the sub- sequent part of this work, is strikingly corroborative of the efficacy of Scarpa's practice. The practice of the Italian professor consists in lacerating the an- terior portion of the crystalline capsule, to the extent of* the diameter of the pu- pil, in a moderately dilated state; in breaking the pappy substance of the diseased lens piecemeal; and in push- ing the fragments through the pupil, into the anterior chamber, where they are gradually absorbed. MEMBRANOUS CATARACT. One great advantage in favour of couching, depends upon its generally removing the capsule, at the same time with the lens, from the passage of the rays of light to the retina. Sometimes, however, this desirable event, by which the patient is extricated from the dan- ger ofa secondary membranous cata- ract, does not take place even in the operation of depression; and, when the lens included in its capsule is extract- ed from the eye, by tiie other method, it may always be considered as rather an uncommon circumstance. What most frequently constitutes the secon- dary membranous cataract, is the an- terior half of the capsule, which not having been removed, or sufficiently broken, in a previous operation, conti- nues more or less entire in its natural situation, afterwards becomes opaque, and thus impedes the free transmis- sion of" the rays of light to the seat of vision. Sometimes the secondary mem- branous cataract presents itself* beyond the pupil, in the form of membranous flakes, apparently floating in the aque- ous humour, and shutting up the pupil: at other times it appears in the form of triangular membranes, with their ba- ses affixed to the Membrana Hyaloidea, and their points directed towards the centre of tile pupil. When there is on- ly a minute membranous flake sus- pended in the posterior chamber, it is on no account necessary for the pa- tient to submit to another operation; vi- sion 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 frag- ments of the capsule, accumulated so as either in a great degree or entirely to close the pupil; or when the disease consists of the whole anterior half of the opaque capsule, neglected in a pri- or operation, and continuing adherent in its natural situation, it is indispensa- ble to repeat an operation; for, al- though in the first case, there may be good reason to hope that the collection of membranous fragments might, in time, disappear, yet it would be unjus- tifiable to detain the patient for weeks and months in a state of anxiety and blindness, when a safe and simple ope- ration would restore him, in a very short space of time, to the enjoyment of this most useful of the senses. In the second case, it is absolutely indis- pensable ; for while the capsule re- mains adherent to its natural connec- tions, the opacity seldom disappears, and may even expand itself over a lar- ger portion of the pupil. The opera- tion should be performed as follows: when the aperture in the iris is obstruct- ed by a collection of membranous flakes, detached from the membrana hyaloi- dea, the curved needle should be in- troduced, with the usual precaution of keeping its convexity forward, its point backward, until arrived behind the mass of opaque matter; the surgeon is then to turn the point of the needle to- wards the pupil, and is to push through this opening, regularly one after ano- ther, all the opaque particles into the anterior chamber, where, as we have before noticed, absorption seems to be carried on more vigorously than behind the pupil. All endeavours to depress them into the vitreous humour, Scarpa has found to be 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, besides being inca- pable of blocking up the pupil, they he, without inconvenience, at the bot- tom of that cavity, and in a few weeks are entirely absorbed. CATARACT 2(33 When the secondary membranous cataract consists of the whole anterior layer of the crystalline capsule, or of several portions of it connected with the membrana hyaloidea, the surgeon, after cautiously turning the point of the needle towards the pupil, is to pierce the opaque capsule; or, should there be any interspace, he is to pass the point of the instrument through it; then, having turned it again backward, he is to convey it, as near as possible, to the attachment of the membranous cataract, and after piercing the capsule, or each portion of it successively, and sometimes carefully rolling the handle of the instrument between his finger and thumb, so as to twist the capsule round its extremity, he will thus break the cataract, as far as is practicable, at every point of its circumference. The portions of membrane, by this means separated from their adhesions, are next to be cautiously pushed, with the point of the couching needle turned forward, through the pupil, into the anterior chamber. In these manoeu- vres the operator must use the utmost caution not to injure the iris, and cilia- ry processes, for, upon this circum- stance depends having no bad symp- toms after the operation, notwithstand- ing its duration may have been long, and the necessary movements of the needle numerously reiterated. If a part of the membranous cataract should be found adherent to tiie iris, (a com- plication, that will be indicated when, upon moving it backward or downward, with the needle, the pupil alters its shape, and, from being circular be- comes of an oval, or irregular figure,) even more caution is required than in the foregoing case, so as to make re- peated, but delicate movements of the needle, to separate the membranous opacity, without injuring the iris. Nov will it be necessary to vary the plan of operating already explained, if occasionally the cataract should be formed of the posterior layer of the capsule. The same plan also succeeds in those rare instances where the substance it- self of the crystalline wastes, and is almost completely absorbed, leaving the capsule opaque, and including, at most, only a small nucleus, not larger than a pin's head. Scarpa terms it the Primary Membranous Cataract; he de- scribes it as being met with in chil- dren, or young people under the age of twenty; as being characterized by a certain transparency, and simditude to a cobweb: by a whitish opaque point, either at its centre or circumference; and, by a streaked and reticulated ap- pearance : he adds, that whosoever at- tempts to depress such a cataract is baffled, as it reappears behind tiie pu- pil soon after the operation; he recom- mends breaking it freely with the cur- ved extremity of the couching needle, and pushing its fragments into the an- terior chamber, where they are gradu- ally absorbed in the course of about three weeks. No other topical application is gene- rally requisite, after the operation, than a small compress of fine linen; tiie pa- tient ought to be kept in a quiet, dark room, and in bed. A dose of some mild purgative salt, such as the natron vitriolatum; magnesia vitriolata; soda phosphorata, &c. may usually be admi- nistered, with advantage, on the follow- ing morning, I shall not enlarge upon the method of treatment, when the in- flammation, subsequent to couching, exceeds the ordinary bounds; in hypo- chondriacal, hysterical, and irritable constitutions, this is more frequently met with, and I have already touched upon the propriety of some preparatory measures, before couching such unfa- vourable subjects. I cannot help remarking how judici- ous it is never to attempt too much at one time of couching. It happens in this, as in most other branches of ope- rative surgery, that celerity is too often mistaken for skill: the operator should not only be slow and deliberate in achieving his purpose; he should be taught to consider, that a repetition of couching may, like the puncture of a vein, be safely and advantageously put into practice again and again; and with far greater security than if, for the sake of appearing expeditious, or avoiding the temporary semblance of failure, a bolder use of the couching needle should be made, than the delicate struc- ture of the eye warrants. We read, in Mr. Hey's Practical Observations on Surgery, that he couched one eye seven times, before perfect success was ob- tained; had he been less heedful, and struggled to effect by one or two rough applications of the instrument, what he achieved by seven efforts of a gentler description, it is highly probable that the structure of the eye would have been so impaired, as well as the con- 2C4 CATHETER sequent ophthalmy so violent, as to have utterly prevented the restoration of sight. Critical Reflections on several impor- tant pi-aclical points relative to the Cata- ract, 1805. On the subject of Cataract consult particularly the writings of Cel- sus, Pott, Hey, Daviel, Wenzel, Richter, Ware, and Scarpa. CATHETER (from hoBim/jo, to thrust into.) A tube which is introduced through the urethra into tiie bladder, for the purpose of drawing off the urine. (See Urine, Retention of) Of course there are two kinds of catheters, one intended for the male, the otiier for tiie female urethra. The common catheter is a silver tube, of such a diameter as will allow it to be introduced with ease into the urethra, and of various figure and lengths, according as it is intend- ed for the young or adult, the male or female, subject. A common male ca- theter, is ten or eleven inches long. In general, a large instrument of this kind, like a large bougie, will enter the bladder with more ease than a small one, because less likely to be entangled in the lacunae of the urethra. One third Qf the male catheter, towards its point, should be moderately curved; the other two thirds, towards its handle, should be straight. The instrument, when gently curved, is found to be more ea- sy of introduction than when it is very much bent. The female catheter is straight, excepting a slight curvature towards its point, and it is about six inches long. The catheter, as it need not enter far into the neck of the bladder, though it should always be as big as the ure- thra will easily admit, should not, says John Bell, be long, and should have a very gentle and simple curve. ( Princi- pks of Surgery. Vol. 2, p. 193.) The common flexible catheter is on- ly a hollow bougie, and the elastic one contains in its composition elastic gum. The two last descriptions of catheters have the advantage of being less irri- tating to the urethra, and less apt to become covered with calculous incrus- tations, than silver tubes. They can also be frequently introduced when an inflexible metallic one will not pass. Flexible catheters are now generally made of wove silk cyUnders, covered with a coat of elastic gum. The best have hitherto been "fabricated by M. Bernard, of Paris; but they are at pre- sent well Baanufactured by Mr. Walsh, of London. Their size and form vary, according to tiie age or sex of the pa- tient- Bernstein, in his Dictionary of Surgery, gives the following account of this instrument, as it is fabricated in Germany: " One of the most useful in- ventions which have been made, with respect to these instruments, is to con-, struct them of elastic gum, and the me- rit of this invention is to be ascribed, without doubt, to Theden. Neue Be- merkungen u. Erfahrungen, &c. Th. 2. Berlin, 1782. p. 143. They were after- wards improved by a silversmith at Pa- ris, of the name of Bernard, who di- rected not to apply the dissolved elas- tic gum to a wire cylinder, as Theden had done, but to one made of knitted silk; and these catheters certainly de- serve to be recommended in preference to all others. But with respect to their price, the elastic catheters, that are prepared by Pickel, of Wirzburg, (Richter's Chir. Bibliothek. B. 6,p. 512,) deserve particular recommendation. These consist of silk cylinders, plaited, or worked upon a probe, and after- wards covered with the following var- nish : three parts of white-lead, mini- um, or sugar of lead, with boiled lin- seed oil, which is the common varnish used by cabinet-makers, mixed with one part of melted amber, and the same quantity of oil of turpentine. With this varnish he spreads the silk cylin- ders, and repeats this three times, as soon as the former coating has dried in the open air; after which he puts the catheters into a baker's oven 24 hours, when bread has been baked in it the last time, and when it retains the temp. of 60.70. Reaum. Here he lets them remain 10 or 12 hours. When he has taken the catheter out of the oven, he rubs the inequalities off* with a little pumice-stone, sews up the end, cuts in- to it the oblong lateral aperture, and then spreads it 12 or 15 times more with the varnish. Every time, however, the catheter must be 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 into the oven again, so that it must in all have received from'l5 to 18 coatings with varnish, and have been laid five or six times in the oven. The end is smoothed off will oil. Each of these catheters costs a dollar." Cyclo- padia by Rees. Art. Catheter. Sometimes it is difficult to introduce the inflexible catheter, in consequence CATHETER. 205 of the urethra and neck of the bladder being affected with spasm. In this case a dose of opium should be admin- istered, before a second attempt is made. When inflammation prevails in the passage, the introduction may often be facilitated by a previous bleeding. The operation of introducing the ca- theter may be performed, either when the patient is standing up, sitting, or lying down. In doing it, one of the most impor- tant maxims is, never to force forward the 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 circum- stances. Its beak may be pushed a- gainst the os pubis. This chiefly oc- curs when the handle of the instrument is prematurely depressed. Here the employment of force can obviously do no good, and may be productive of se- rious miscliief. The back of the cathe- ter may take a wrong direction, and push against the side of the urethra, especially at its membranous part, which it may dilate into a kind of pouch. In this circumstance, if force were ex- erted, it would certainly lacerate the urethra, and occasion a false passage. The end of the catheter may get en- tangled in a fold of the lining of the urethra, and here force would be equal- ly wrong. Lastly, the point of the in- strument may be stopped by the pros- tate gland, in which case force can be of no service, and may do great harm. Hence it is always proper to withdraw the instrument a httle, and then push it gently onward in a different posi- tion. The operation may he divided into three stages. In the first, the catheter passes, in the male subject, that por- tion of the urethra wliich is surrounded by the corpus spongiosum ; in the se- cond, it passes the membranous 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 supported by the surrounding corpus spongiosum, thatit cannot easily be pushed into tiie form ofa pouch, in which the end of the instrument can be entangled. The operator need only observe the following circumstance: the penis should be held, by placing the corona glandis between the thumb and the index finger of the left hand : in this way the entrance of the urethra will not be at all compressed. The pe- nis is then to be drawn upward: the catheter being well oiled, is now to be introduced, with the concavity towards the abdomen, into the urethra, directly downward, until its point reaches the bulb. As soon as this is accomplished, and the beak of the instrument has pas- sed under the arch of the pubis, the surgeon must very slowly bring the handle of the catheter forwards, be- tween the patient's thighs, and, as he is doing tliis, the beak of the instru- ment becomes elevated, and glides into tiie bladder. In this stage of the ope- ration the penis must be allowed to sink down, and not be kept tense, as this would only drag the membranous part of the urethra against the os pubis, and render the passage of the instru- ment more difficult. The operation, however, is not always successfully accomplished in this man- ner. The beak of the catheter 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 stop- ped 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 the point has passed beyond the arch of the pubis. 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 different direction. When this expedient is unavailing, the index finger of the left hand may be introduced into the rectum, for the purpose of supporting the membranous part of tlie urethra, and finding the ex- tremity of the catheter. When the prostate gland is enlarged, tiie diameter of tlie urethra does not undergo any diminution as it passes through the diseased body; but it turns up very suddenly, just as it ap- proaches the bladder. In such cases, the end of the catheter should be more bent upward, than the rest of its cur- vature. 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, 206 CATHETER. and from the instrument being pushed against the prostate gland. The first impediment may generally be obviated by waiting a few moments, and gently rubbing the perineum, before pushing onward the catheter. The hindrance, caused by the prostate, is best eluded by using an instrument 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 the passage of the catheter, by increasing tlie sud- den curvature at this part of tiie 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 pubis, and is just about to enter the neck of the bladder, is the critical moment, in which may be seen, whe- ther a surgeon can or cannot pass a cathe- ter ', for, if he knows how to pass it, he suddenly, but not violently, chan- ges its direction. He depresses the handle with a particular kind cf ad- dress, and raises the point, which, as if it had suddenly surmounted some obstacle, starts into the neck of the bladder, and the urine bursts out in a jet from the mouth of the catheter. Those, who are unskilful, press the tube forward, and persist, as they had begun, in drawing up the penis, on the supposition that by stretching this 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. p. 213 J Mr. Ware passes the catheter in the following manner : the instrument be- ing first thoroughly oiled, he introdu- ces it into the urethra, with its convex part uppermost, and carries it as far as it will pass without using force. He then turns it slowly round, so as to bring its concave side uppermost; and in doing this he makes a large sweep with the handle of the instrument, and at the same time keeps his attention steadily fixed on its apex, which he takes particular care not to retract, nor to move from its first line of direction. When the catheter is turned, it must still be pressed onward, and its handle at the same time gently depressed. By this method, says Mr. Ware, it will be made to enter the bladder. The catheter, made use of by Mr. Ware, is twelve inches long, which is more than an inch above the ordinary length; and the curvature is larger than-common. With this instrument he has often succeeded, when with others of a different sise and curvature it was not possible to succeed. A great number of excellent modern surgeons prefer introducing the cathe- ter as far as the perineum, as Mr. Ware does, with its convexity towards the abdomen. They then keep the point stationary while they make the handle describe a semicircular movement up- ward, so as to bring the concavity of the instrument towards the pubis. The catheter becomes situated just as it is in the other method. Mr. Hey has offered some good prac- tical remarks on the introduction of the catheter. If, says he, tlie point of the catheter be less turned than the ure- thra, the point will be pushed against the posterior part of the passage, in- stead of following the course of the canal. The posterior part of the ure- thra has nothing contiguous to it which can support it; and no considerable degree of force will push the point of the catheter through that part between the bladder and the rectum. 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 illus- trated, by the assistance which is deri- ved, whenever the catheter stops at the prostate, from elevating the point of the instrument with a finger introdu- ced in the rectum. Mr. Hey takes notice of the impro- priety of pushing forwards the point of the catheter, before its handle is suf- ficiently depressed, as the point would move in a horizontal direction, and be likely to rupture the posterior side of the urethra. The difficulty, arising from the in- flamed and dry state of the passage, Mr. Hey says, is greatly obviated by the previous introduction of a bougie well covered with lard. In order to pass the catheter, Mr Hey places his patient on a bed, in a recumbent posture, his breech advan- cing to, or projecting a little beyond, the edge of the bed. If the patient's feet cannot rest upon the floor, Mr. Hey supports the right leg by a stool, or by the hand of an assistant. The pa- tient's head and shoulders are elevated CATHETER. 2or by pillows ; but the lower part of the abdomen is left in a horizontal position. Mr. Hey commonly introtiuces the ca- theter 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 some- times keeps the handle at the same dis- tance from the patient's abdomen, and sometimes makes it gradually recede ;' but, in either method, he avoids push- ing forwards the point of the catheter any farther than is necessary to carry- it just beyond the angle of the symphy- sis pubis. When he feels that the point is beyond that part, he pulls the cathe- ter gently towards him, hooking, as it were, the point of the instrument upon the pubis. He then depresses the han- dle, making it describe a portion ofa circle, the centre of whicii is tiie angle of the pubis. When the handle of the catheter is brought into a horizontal position, with the concave side of the instrument upwards, he pushes for- wards the point, keeping it close to the interior surface of the symphysis pu- bis ; for when passing in this direction, it will not hitch upon the prostate gland, nor injure the membranous part of the urethra. If the surgeon uses a flexible cathe- ter, covered with elastic gum, it is of great consequence 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. It the stilet is too tliick, it is withdrawn with diffi- culty. When the stilet is of a proper thick- ness, this instrument has one advan- tage over the silver catheter, whicii is, that its curvature may be increased while it is in the urethra, whicii is of- ten of great use, when the point ap- proaches the prostate gland. When the proper manoeuvres with an inflexible catheter do not succeed, the surgeon must change it, taking a big- ger or more slender one, with a greater or less curve, according to what obser- vations 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 flexi- ble catheter is generally slender, and of sufficient length, and its shape may be accommodated to all occasions, and to all forms of the urethra; for, having a stiff wrire, we can give that wire, ei- ther before or after it has passed into the catheter, whatever shape we please; and what is of still greater importance, we can introduce the instrument with- out, or with the wire, as circumstances may require ; or what is more advan- tageous, we can introduce tlie wire par- ticularly so as not quite to reach the point of the catheter, but to within two inches or a little more of this part, by which contrivance the point, if previ- ously 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 sur- mount any slight resistance. If this too fail, and especially, if there be the slightest reason to suspect, that the re- sistance is not merely spasmodic, but arises from stricture near the neck of the bladder in a young man, or swell- ing of the prostate in an old one, we mav take a small bougie, turn up the exTremity of it with the finger and thumb, so as to make it incline to- wards the pubis, 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 withdrawing it in about ten minutes or a quarter of an hour, the urine gene- rally escapes, or the catheter may now be introduced. (John Bell's Principles of Surgery, Vol. 2. p. 215.) Air. Hey has found, that in withdraw- ing the stilet of an elastic gum cathe- ter, the instrument becomes more curv- ed ; and he has availed himself of this information, by withdrawing the stilet, as he is introducing the catheter be- yond the arch of the pubis, by which artifice the point is raised into the due direction. Mr. Hey says, you may sometimes, though not always, succeed in introdu- cing an elastic gum catheter, by using one which has acquired a considerable degree of curvature and firmness, by having had a curved stilet kept in it a long while. Introduce this without the 208 CAT CAU 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 depressed into a horizontal position. When it is necessary to draw off* the urine frequently, and the surgeon can- not attend often enough for this pur- pose, a catheter must be left in the urethra, till an attendant, or tiie patient himself, has le»rnt the mode of intro- ducing the instrument. (Hey.) Mr. Hey imputes the formation of a false passage, or the rupture of the membranous part of the urethra, gene- rally to the methodof 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 the curvature in the catheter, and of sufficient bluntness in its point, greatly contribute to faci- litate this injury. In this case the point of the instrument passes more readily into the wound, than onward along the urethra against the symphysis pubis. Without this pressure, the point is apt to recede, and not readily enter the membranous part" of the urethra, ft 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 tiie an- terior part of the urethra, and thereby pass over the wound made in the pos- terior 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 whicii he made a stilet, and having given it tiie same curvature as that of the silver catheter, he introduced it about four hours after the preceding operation, 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 ca- theter of unusual thickness, after he had failed with instruments ofa smaller bore. He suspected that the urethra v/as ruptured, and was obliged to raise the point of the catheter by a finger in- troduced into the rectum, and hi use bleeding, purgatives, the warm bath and opium, before it could be made to pass. The elastic gum catheter was af- lerwards 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 regained, orto draw off the urine twice a day, and withdraw the catheter after each ope- ration. Mr. Hey thinks that no general rule can be laid down ; some patients cannot bear the catheter to remain in- • troduced ; others seem to suffer no in- convenience from it. On the whole, however, Mr. Hey commonly prefers removing the catheter. In this manner, he is of opinion, that the power of ex- pelling the urine again is soonest ac- quired. To one acquainted with anatomy, the introduction of the female catheter is exceedingly simple. From motives of regard to the sex, the instrument should always be passed without any exposure. The surgeon should hold the catheter in his right hand, wliile he in- troduces the forefinger of his left hand between the nymphae so as to feel upon the upper surface of the passage the little papilla, which surrounds, and de- notes to the touch, the precise situa- tion of the orifice of the meatus urina- rius. Holding the concavity of the ca- theter forward, the surgeon, guided by the forefinger of his left hand, is then to introduce the instrument upward in- to the bladder. (See Urine, Retention of) (See Hey's Practical Observations on Surgery. John Bell's Principles, Vol. 2. Ware on the Catheter. Richter's . In- fongsgr. de Wundarzneykunst. Rees's Cyclopadia, art. Cutheter.) CATHETERISMUS, (from K*6.rT§ the instrument.) A technical word, employed by P. JEgineta, to denote the operation of introducing the catheter. CATULOTICA, (from **t*xm», to cicatrize.) Medicines, for healing wounds. CAUSTICS, (from **/&>, to burn.) Cuustico. Medicines, which destroy parts by burning, or chemically decom- posing them. CAUTERIZATION, (from wti^«, to cauterize.) Cauterisatio. The burn- ing any part with a cautery. CAUTERY, (from *.%u*, to burn.) Cauterium. Cauteries are of two kinds ; viz. actual and potential. By the first term is implied a heated iron j by the CER CHE 209 second, surgeons understand any caus- tic application. CELE, (from wixun, to swell out) A tumour. CELOTOMIA, (from juiak, a tumour or hernia, and tium, to cut.) This has two meanings; viz. the operation for a hernia, and castration. CERAT.MALGAMA, (from *.$<*, wax, and a.fjL£hy*fjut, a mixture.) A cerate. CER ATOTOME, (from Mg*r, a horn, and Tt/moa), to cut.) This is the name which Wenzel has given to the knife, which he was in the habit of using to divide the cornea, or horny coat of the eye. CERATE, (from x»goc, wax, the usual basis of its composition.) Ceratum. A composition rather harder than oint- ment, and softer than plaster. In this work we need only mention a few particular ones. CERATUM CALOMELANOS. R Calom. Ji. Cerati Lapid. Calimin. §ss- M . . . , ,. Some practitioners are partial to tins as a dressiug for chancres. CERATUM CICUTjE. R. Unguen- ti Cicuta lbj. (See Unguentum^) Sper- matis Cell Jij. Cera Alba, ^hj. M. One of the formulaat St. Bartholomew's Hospital, occasionally applied to can- cerous, scrophulous, phagedenic, her- petic, and other inveterate sores. CERATUM SABINE. R. Sabina Recentis Contusa, Cera Flava, sing. lbj. Adipis Suilla, lbiv. Mix the sa- vin with the melted wax and hog's lard, and strain the composition. This is the famous application for keeping open blisters, on the plan re- commended by Mr. Crowther. We have noticed in the article Blisters, what he says on the subject in the last edition of his work. CERATUM SAPOXIS. (L.) R. Lithargyri lavigati lib. j. Aceti cong. j. Saponis unc. viij. O/ei oliva. Cera. flava sing. lib. j. This is the soup cerate of St. Barthol- omew's Hospital, and adopted by the College* In preparing it, the utmost caution must be used. The three first ingredients are to be mixed together and boded gently till all the moisture is evaporated; after wliich the wax and oil, previously melted together, must be added. The whole composi- tion, from first to last, must be inces- santly and effectually stirred, without vol 1- Z which the whole will be spoiled. This formula was introduced into practice by Mr. Pott, and is found to be a very convenient application in fractures, and also as an external dressing for ulcers ; being of a very convenient degree of adhesiveness, and at the same time possessing the usual properties of a saturnine remedy. In applying this cerate, spread on linen, in fractures of the leg or arm, one caution is necessary to be obser- ved, namely, that it be in two distinct pieces; for if, in one piece, the hmb be encircled by it, and the ends over- lap each other, it will form a very in- convenient and partial constriction of tiie fractured part, in consequence of the subsequent tumefaction. Pharm.' Chirurg. CERCOSIS, (fromxfjKcc, a tail.) An enlargement of the clitoris, which hangs from the vagina like a tail. CEREBRUM. The brain ; for con- cussion of; compression of, &c. see Head, Injuries of. For inflammation of, see Phrenitis. For hernia of, see Hernia Cerebri. CERION, (from x»gof, wax.) A hon- ey-comb. A small sore, with an ori- fice like the cell of a honey-comb. CHALAZIUM, (from £*a.«£*, a hail- stone.) This signifies a little tubercle on the eye lid, whicii has been whimsi- • cally supposed to resemble a hail-stone. It is the same as tlie hordeolum or stye. (See Hordeolum.) CHANCRE, (from x*gwvor, cancer ve- nereus.) A sore which arises from the direct application of the venereal poi- son to any part of the body. Of course it almost always occurs on the genitals. Such venereal sores, as break out from a general contamination of the system, in consequence of absorption, never have the term chancre applied to them. (For an account of the nature and treat- ment of chancres, see Venereal Dis- ease.) ' CHARPIE, (French ) Scraped linen, or lint. CHEMOSIS, (from £*««, to gape.) When ophthalmy or inflammation of the eye, is very violent, it frequently happens, that one or more vessels be- come ruptured on tiie side next the eye ball, and a quantity of blood is ef- fused into the cellular membrane, which connects the conjunctiva with the anterior hemisphere of the eye. Hence, the conjunctiva becomes gra- 210 cHI dually elevated upon the eye ball, and projects towards the eye lids, so as to conceal within it the cornea, whicii ap- pears, as if it were depressed. (Scar- pa.) In this way tiie middle of the eye assumes the appearance of a gap, or aperture. When blood is extravasated under the tunica conjunctiva, 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 imme- diately done by pressing the other hand against it. The hand is then to be ap- plied to the eye, and kept so close to it, that the spirit, as it evaporates, may insinuate itself into the part affec- ted, and act on the blood, so as to disperse it. (Ware on Ophthalmy.) In a few instances of chemosis, in which the swelling and inflammation of the conjunctiva have been great, the following application has been found particularly beneficial, after free eva- cuations : R. Interiorumfoliorumreccn- tium Lactuca Sissilis, §iij. Coque cum Aq. Pur. §ss. In balnea maria pro semi- hora ; tunc exprimatur succus, et ap- pHcetur pauhilum ad oculos et ad palpe- bras, sape in die. (Ware.) Ophthalmy, attended with chemosis, demands the most rigorous employ- ment of the antiphlogistic treatment. Both general and topical bleedings should be speedily and copiously put in practice, with due regard however, to the age and strength of the patient. Leeches should be applied to the vi- cinity of the eye lids, or, what is pref- erable, the temporal artery should be opened. When the chemosis is very considerable, the distentien of the conjunctiva may be relieved by making an incision into this membrance, near its junction with the cornea. (See Oph- thalmy.) CHILBLAINS are the effect of in- flammation, arising from cold. A chil- blain, in the mildest form, is attended w ith a moderate redness of the skin, and a sensation of heat and itching, all which symptoms, after a time, sponta- neously disappear. 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 and leave excoriations. These are soon converted into ill-conditioned CHI sores, which sometimes penetrate even as deeply as the bone, discharge a thin ichorous matter, and generally prove very obstinate. The worst stage of chilblains is attended with sloughing. Chilblains arc particularly apt to oc- cur in persons, who are in the habit of going immediately to the fire, when they come home in winter with their fingers and toes very cold; they are also particularly frequent in persons, who often go suddenly into the cold, while very warm. Hence, the disease most commonly affects parts of the body, which are peculiarly exposed to these sudden transitions ; for instance, the nose, ears, lips, hands, and feet. Richter remarks that the) are still more frequently occasioned, when the part, suddenly exposed to cold, is in a moist perspiring state, as well as a warm one. Young subjects are much more liable to this troublesome complaint than adults ; and females brought up in a very delicate manner, are general- ly more afflicted, than the other sex The most likely plan of preventing chilblains is to accustom the skin to moderate friction : to avoid hot rooms and making the parts too warm; adapt the quantity and kind of clothing to the state of the constitution, so as to avoid extremes, both in summer and winter; to wash the parts frequently 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 tiie 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, wliich are most effectual in the relief of in- flammation in general. One of the best modes of curing chil- blains 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 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 al- ways congenial to the feelings and ca- price of patients; with the constitutions of some it may even disagree. In such cases, the parts affected may be rubbed CIIO with spirit of wine, linimentum saponis, tinctura myrrhae, or a strong solution of alum, or vinegar. A mixture of oleum terebinthinae and balsamum co- paivz, in equal parts, is a celebrated application. A mixture of two parts of camphorated spirit of wine, and one of the aqua lithargyri acetati, has also been praised. When chilblains have suppurated and ulcerated, the sores require stim- ulating dressings, such as lint dipped in a mixture of the aqua lithargyri ace- tati, and aqua calcis; in tinctura myrrhae, or warm vinegar. If a salve be employed, one which contains the hydrargyrus nitratus ruber, is best. Ulcers of this kind frequently require being touched with the argentum nitra- tum, 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 stim- ulating ointment, such as the unguen- tum resinsc flavae. With this, in a day or two, a little of tiie hydrargyrus ni- tratus ruber may be mixed; but the surgeon should not venture on the em- ployment of very irritating applications, till he sees what the parts will bear, and whether such, will be requisite at all. Were he too bold, immediately he leaves off" the poultices, he might even bring on sloughing again. The reader may find a long list ofap- plicatwnsfor chilblains in Rees's Cyclo- padia, article chilblains. See also Rich- ter's Anfangsgr. der Wundorzn. Band. I. CHIMNEY SWEEPER'S CAXCER. See Scrotum. CHORDEE, (French, from ^ojJa, a chord.) When inflammation is not confined merely to the surface of the urethra, but affects the corpus spongi- osum, it produces in it an extravasa- tion of coagulable lymph, as in the ad- hesive inflammation, whicii uniting the cells together, destroys the power of distention of the corpus spongiosum urethrs, and makes it unequal in this respect to the corpora cavenrosa penis, and therefore a curvature takes place at the time of an erection, wliich is cal- led a chordee. The curvature is gene- rally 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 cause a profuse bleeding from the urethra, that often relieves the patient, CIC 2H and even sometimes proves a cure. (Hunter on Venereal.) This is the inflammatory chordee ; there is another kind, which has been named spasmodic. In the beginning of the inflammatory chordee, bleedingfrom the arm is often of service : but it is more immediately useful to take away 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 re- lieved. Relief may often be obtained by exposing the penis to the steam of hot water. Poultices have also benefi- cial effects ; and both fomentations and poultices will often do more good when they contain camphor. Opium, given internally, is of singular service ; and if it be joined with camphor, the effe ct will be still greater. When the chordee continues, after all inflammation is at an end, no evacua- tions are required. The consequence of the inflammation will cease gradual- ly by the absorption of the extravasa- ted coagulating lymph. Mercurial oint- ment rubbed on the part will conside- rably promote this event. Cicuta has seemed to do considerable good, after the common methods of cure have not availed. Electricity may be of service. A chordee is often longer in going off, than any other consequence ot a gonor- rhoea, but it disappears at last. Camphorated mercurial ointment is better than the simple unguentum hy- drargyri, to bring about the removal of the extravasated lymph The spasmodic chordee is very much benefited by bark. (Hunter on the Venereal. ) CHRONIC, (from*govsc, time.) Chro- nicus. Of long continuance ; opposed to acute. CHYMOSIS. See Chemosis. CICATRISANTIA, (from cicatrico, to skin over.) Epulotic medicines, or such as dispose wounds and ulcers to heal, and become covered with skin. CICATRIX. The scar remaining on the skin, after the healing of a wound or ulcer. CICATRIZATION*. The process by which wounds and sores heal. Granu- lations having been formed, the next object of nature is to cover them with skin. The parts which had receded by their natural elasticity, in conse- quence of the breach made in them now begin to be brought together, by 212 CICATRIZATION. the contraction of the granulations. The contraction takes place in every point, but principally from edge to edge, which brings the circumference of the 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 degree proportioned to the general healing disposition of the sore, and looseness of the parts. When granu- lations are formed upon a fixed surface, their contraction is mechanically im- peded ; as, for instance, on the skull, the shin, &c. Hence, in all operations on such parts, as much skin should be saved as possible. When there has been a loss of sub- stance, making a hollow sore, and the contraction of the granulations has be- gun, and made a good deal of progress, before they have had time to rise as high as the skin, then the edges of the skin are generally drawn down, and tucked in by it, in the hollow direction of the surface of the sore. The contraction of the granulations continues, till the healing is complete; but it is greatest at first. That there is a mechanical resistance to such con- traction, is proved by the assistance, whicii may be given to the process by the application ofa bandage. Besides the contractile power of the granulations, there is also a similar power in tlie surrounding edge of the cicatrizing skin, which assists the con- traction of the granulations, and is ge- nerally more considerable than that of the granulations themselves, drawing the mouth of the wound together, like a purse. The contractile power of the skin is confined principally to the very edge, where it is cicatrizing, and, as Mr. Hunter believed, to those very gra- nulations, which have already cicatri- zed ; for, the natural or original skin surrounding this edge does not con- tract, 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 gra- nulations are various. It facilitates the healing of a sore, as there are two ope- rations going on at the same time, viz. contraction and skinning. It avoids the formation of much new skin, the advantage of which 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 tlie purposes of life, than those that arc newly formed, and not nearly so liable to 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 hardly any thing more is left than what the new skin stands upon. This is a very small part, in comparison with the first formed gra- nulations, and it in time loses most of its apparent vessels, becoming white and ligamentous. All new healed -ores are at first redder than the common skin, but in time they become much winter. As the granulations contract, the surrounding old skin is stretched to cover the part, which had been depri- ved of skin. When a sore begins to heal, the sur- rounding old skin, close to the granu- lations, becomes 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 symptom of healing as any. While the sore retains its red edge all round, for perhaps a a quarter, or half an inch in breadth, we may be certain it is not a healing one. Skin is a very different substance, with respect to texture, from the gra- nulations upon which it is formed; but it is not known, whether it is a new substance formed by .tiie granulations, or a change in the surface of the gra- nulations themselves. The new skin most commonly takes 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 sur- rounding skin have but little tendency to contract, and the cellular membrane underneath to yield, or the old skin to become drawn over the ulcerated sur- face, the nearest granulations do not acquire a cicatrizing disposition. In such cases, new skin forms in different parts of the ulcer, standing on the sur- face of the granulations, like littie islands. Whatever change the granulations undergo to form new skin, they are ge- nerally guided to it by the surrounding skin, which gives this disposition to the surface of tiie adjoining granulations. CIC CIR 213 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 the surrounding old skin. If the sore is si- tuated where the adjoining skin is loose, as in the scrotum, then the contractile power of the granulations being quite free from obstruction, a very little new skin is formed; but if the sore is situ- ated 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. Tliis how ever is not the case with scalds and burns, which frequently heal with a ci- catrix, higher than the skin, although the granulations have been kept from rising higher than this part. The new-formed cutis is neither so yielding nor so elastic as the original is; it is also less moveable. It gradu- ally becomes, however, more flexible and loose. At first it is very thin and tender, but it afterwards become firm- er and thicker. It is a smooth conti- nued skin, not formed with those in- sensible indentations, which are obser- ved in the natural or original skin, and by wliich the latter admits of any dis- tention, which the cellular membrane itself will allow of. This new cutis, and indeed all the substance whicii had formerly been granulations, is not nearly so strong, nor endowed with such lasting and proper actions, as the originally form- ed parts. The living principle 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 vessels; but these afterwards disap- pear, and the part becomes white. The surrounding old skin, being drawn towards the centre by the con- traction of the granulations, is thrown into loose folds, while the new skin itself seems to be upon the stretch, having a smooth shining appearance. The new cuticle is more easily form- ed from tiie cutis, than the cutis itself from granulations. Every point of the surface of the cutis is concerned in forming cuticle, so that tliis is forming equally every where at once: but the formation of the cutis is principally pro- gressive from the adjoining skin. The new cuticle is at first very thin, and rather pulpy than homy. As it be comes stronger, it looks smooth and shining, and is more transparent than the old cuticle. The rete mucosum is later in form- ing than the cuticle, and in some cases never forms at all. In blacks who have been wounded, or blistered, the cica- trix is a considerable time before it be- comes dark; and 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, how- ever, are even darker than any other parts of the skin. (Hunter on the Blood, Inflammation, &c.) CILLOSIS, (from cilium,, the eyelid.) A spasmodic trembling of the eyelids. CIONIS, (from mo,v, the uvula) A diseased and painful enlargement of the uvula. CIRCUMCISION, (from circumcido, to cut round.) The operation of cut- ting off a circular piece of the prepuce, sometimes practised in cases of phymo- sis. (See Phymosis.) CIRSOCELE, (from x/go-oc, a varix, and kmxji, a tumour.) The cirsocele is a varicose distention and enlargement of the spermatic vein; and whether con- sidered on account of" the pain, which it sometimes occasions, or on account of a wasting of the testicle, which, now and then follows it, may truly be called a disease. It is frequently mistaken for a descent of a small portion of omentum. The uneasiness which it oc- casions, is a dull kind of pain in the back, generally relieved by suspension of the scrotum. It has been resembled to a collection of earthworms; but who- ever has an idea of a varicose vessel, will not stand in need of an illustration by comparison. It is most frequently confined to that part of tlie spermatic process, which is below the opening in the abdominal tendon; and the ves- sels generally become rather larger, as they approach the testis. Mr. Pott ne- ver knew any good effect from exter- nal applications of any kind. In general the testicle is perfectly unconcerned 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 sometimes after such symp- toms have been removed, Mr. Pott has seen the testicle so wasted as hardly to be discernible. He has also obser- ved the same effect from the injudici- ous application of a truss to a tine cir- > CLU COL socele; the vessels, by means of the pressure, became enlarged to a prodi- gious size, but the testicle shrunk to al- most nothing. (Pott's Works, Vol 2.) The cirsocele is more frequently than any other disorder, mistaken for an omental hernia. As M r. Astley Cooper remarks, when large it dilates upon coughing; and it appears in an erect, and retires in a recumbent, posture of the body. Tliere is only one sure me- thod of distinguishing the two com- plaints : place the patient in a horizon- tal posture, and empty the swelling by pressure upon the scrotum; then put the fingers firmly upon the upper part of tiie abdominal ring, and desire the patient to rise; if it is a hernia, the tu- mour cannot reappear, as long as the pressure is continued at the ring; but if a cirsocele, the swelling returns with increased size, on account of the re- turn of blood into the abdomen being prevented by the pressure. (A. Cooper on Inguinal Hernia.) The cirsocele can generally only be palliated, and seldom radically cured. When the 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 taken away by means of leeches: the bowels 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 necessary to keep up the testicle by this kind of suspensory bandage. Gooch, and other writers, have rela- ted cases of cirsocele, in which the pain was so intolerable and incurable, that nothing but castration could afford the patient any relief. C1RSOS, (from juga-sa, to dilate.) A varix, or preternatural distention of any part of a vein. CLAUDICATIO, (from claudico, to halt) Halting or limping. CLAVICLE, (dim. of clavis, a key.) Clavicula or Claviculus. The collar- bone, so named from its likeness to an ancient key. (See Dislocations and J^7*CLCtl£T*£8 1 CLITORIS M US, (from sArfegir, the clitoris.) A morbid enlargement of the clitoris. CLUNESIA, (from chines, the but- tocks.) An inflammation of the but- tocks. CLYSTER, (from k\v?*, to cleanse,) Clysma, Clysterium. An enema, or li- quid injected into tiie anus. (See Ene- ma.) COALESCENCE, (from coaksco, to grow together.) Coakscentia. The uni- on or growing together of parts, wliich before were separated. CODOCELE, (from jcaxT,*, a bulb, and lax*, a tumour.) A bubo. CCELOMA, (from xmaoc, hollow.) A round hollow ulcer on the cornea. COLLISION, from collido, to beat together.) When any part of the body, and some hard substance are driven at the same time against each other, a collision is said to take place. COLLOBOMA, (from s.ok\uu, to glue together.) An adhesion between tlie eyelids. COLLUTORIUM, (from colluo, to cleanse.) A gargle, or wash for the mouth. COLLUVIES, (from colluo, to cleanse.) The discharge from an old sore. COLLYRIS, (xoxn/gtt, a little round cake.) A lump, caused by a blow. COLLYRIUM, (from Hrnhv®, to re- strain, because it stops the inflamma- tion.) An application to the eyes, and generally an eye water- The following are some of the most useful collyria. COLLYRIUM ALUMINIS. R. Alu- minis purif. """Jj. Aq. rosse Jvj. This is a good astringent collyrium, employed at Guv's Hospital. COLLYRIUM AMMMONIiE ACE- TATJE. R. Aq. amnion, acet. Acj. ros* COLLYRIUM AMMONLE ACETA- TiE CAMPHORATUM. R. Collyrii ammon. acet. Misturae camphoratae sing gij. M. COLLYRIUM AMMONIA ACET \- TJE OPIATUM. R. Collyrii ammon. acet. Jiv. Tinct. opii. gutt. xl. M. COLLYRIUM CUPRI YITRIOLA- TI CAMPHORATUM. R. Aq. Cupri vitriolati camphoratae Jij. Aq. distilla- te ^iv. M. Recommended by Mr. Ware, for the purulent ophthalmy of children. COLLYRIUM HYDRARGYRI MU- RIATI. R. Hydrarg. muriati grss. Aq. distillat. §iv. M. This collyrium is fit to be employed, after the acute stage of the ophthalmy has for some time subsided, and it will disperse many su- perficial opacities of the cornea. ** CON- CON 215 COLLYRIUM LITHARGYRI ACE- TATI. R. Aq. distillats £iv. Aq. li- tharg. acet. gutt. x. M. COLLYRIUM ZINCI VITRIOLATI. Zinci vitriol, gr. v. Aq. distillats ^iv. M. This is the most common collyrium of all: it may be gradually made stronger. COLLYRIUM ZINCI VITRIOLATI CUM MUCILAGINE SEMINIS CY- UONH MALI. R. Aq. plantaginis giv. zinci vitriol, gr. v. et mucil. sem. cydon. inal. ^ss. M. In order to check the morbid secre- tion from the eyelids, in cases of fistu- la lachrymalis, or what Scarpa calls ilflusso palpe brale puriforme, this cele- brated Professor recommends a few drops of the above collyrium to be in- sinuated between the eyelids and eye. COLPOCELE, (from *oxa-or, the va- gina, and iuimi, a tumour.) A tumour, or hernia situated in the vagina. COLPOPTOSIS, (from xswroc, the va- gina, and «rw7», to fall down.) A bear- ing or falling down of tiie vagina (See Vagina, Prolapsus of.) COMA, (from xw or am, to lie down.) Anciently any total suppression of the powers of sense ; but now it means a lethargic drowsiness. It is a symptom of several surgical disorders. COMATOSE. Comatosus. Lethargic. COMMINUTED, (from comminuo, to break in pieces.) A fracture is termed comminuted, when the bone is broken into several pieces. COMPRESS, (from comprimo, to press upon.) Compressa. A compress. Folded linen, lint, or other materials, making a sort of pad, which surgeons place over those parts of the body on which they wish to make particular pressure, and for this purpose, a ban- dage is usually applied over the com- press 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 RRA1N. (See Head, Injuries of.) CONCUSSION, (from concutio, to shake together.) Concussio. A concus- sion, or shock. CONCUSSION OF THE BRAIN. (See Head, Injuries, of.) CONDUCTOR, (from conduco, to guide.) A surgical instrument for di- recting the knife in certain operations. It is more commonly called a director. CONDYLOMA, (from wwW, a tu- bercle, or knot.) A small very hard tu- mour. The term is generally applied to excrescences of this description about the anus. The practitioner may either destroy them with the lapis in- fernalis, tie their base with a ligature, so as to kill them, or remove them at once, with a knife : the first is general- ly the worst; the last tiie best and most speedy method. CONGESTION, (from congero, to amass.) Congestio. A collection of pus, particularly one of the chronic kind. CONGLUTINANTIA, (from conglu- tino, to glue together.) Such medicines as heal and unite parts. CONSTIPATION, (from constipo, to crowd together.) Constipatio. Costive- ness. CONTRA-APERTURA, (from con- tra, against, and aperio, to open.) A counter-opening. An opening made op- posite to one that already exists. CONTRA-FISSUKA, (from contra, against, and findo, to cleave.) A crack in the skull opposite to the part on which the blow was given. CONTUSED WOUNDS. See Wounds. CONTUSION, (from contundo, to bruise.) Contusio. A bruise. Slight bruises seldom meet with much attention ; but wheh'Biey are se- vere, very bad consequences may en- sue, and these are the more likely to occur, when such cases are not taken proper care of. In all severe bruises, besides the in- flammation which the violence neces- sarily occasions, there is an instantane- ous extravasation, in consequence of the rupture of many of the small ves- sels of the part. In no other way can we account for those very considera- ble tumours, whicii often rise immedi- ately after injuries of this nature. Tin- black and blue appearance, instantly following many bruises, can only be explained by their being an actual effu- sion of blood from the small vessels. which had been ruptured. Even large vessels are frequently burst in this manner, and very considerable collec- tions of blood are the consequence. Blows on the head very often cause a large effusion of blood under the scalp I have seen four or five ounces thus extravasated. Besides the rupture of an infinite number of small vessels and extravasa- tion, whicii attend all bruises, in a greater or less degree, the tone of the fibres and vessels which have suffered contusion, is considerably disordered. Nav, the violence may have been so 216 CON COR great, that the parts are from tiie first deprived of vitality, and must slough. Parts at some distance from such as are actually struck, may suffer greatly from tiie violence of the contusion. This effect is what the French have named a contre-coup. The bad consequences of bruises are not invariably proportioned to the force which has operated; much depends on the nature and situation of the part. When a contusion takes place on a bone, which is thinly covered with soft parts, the latter always suffer ve- ry severely, in consequence of being pressed, at the time of the accident, between two hard bodies. Hence, bruises of the shin so frequently cause sloughing and troublesome sores. Con- tusions affecting the large joints are always serious cases; the inflammation occasioned is generally obstinate, and abscesses and other diseases, which may follow, are consequences truly enough to excite alarm. In the treatment of" bruises, the prac- titioner has three indications, whicii ought successively to claim his atten in the progress of such cases. The firsts to prevent and diminish the inflammation, which, from the vio- lence done, must be expected to arise. The bruised parts should be kept per- fectly at rest, and be covered with linen, constantly wet with thelotio aq. litharg. acet. When there are muscles bruised, they are to be kept in a relaxed posi- tion, and never used. If the bruise should have been very violent, it will be proper to apply leech- es, and this repeatedly, and even, in some cases, particularly, when joints are contused, to take blood from the arm. In every instance, the bowels should be kept well open with saline purgatives. A second object in the cure of con- tusions, is to promote the absorption of the extravasated fluid by discutient applications. These may at once be em- ployed in all ordinary contusions, not attended with too much violence ; for then nothing is so beneficial as maintain- ing a continual evaporation from the bruised part, by means of the cold sa- turnine lotion, and, at the same time, repeatedly applying leeches. In com- mon bruises, however, the lotio sails ammoniaci (See this article) is an excel- lent discutient application; but most surgeons are in tiie habit of ordering liniments for all ordinary contusions, and certainly they do so much good in accelerating the absorption of the ex- travasated blood, that the practice is highly praiseworthy. The linimentum saponis or the linimentum camphors, are as good as any that can be employ- ed. (See Linimentum.) In many cases, unattended with any threatening appearances of inflamma- tion, but in which there is a good deal of blood and fluid extravasated, banda- ges act very beneficially, by the remark- able power wliich they have of exciting the action of the lymphatics, by means of* the pressure whicii they produce. A third object in the treatment of contusions, is to restore the parts to their proper tone. Rubbing the parts with liniments has a good deal of ef- fect in this way. But, notwithstanding such applications, it is often observed, that bruised parts continue for a long while weak, and even swell, and be- come oedematous, when the patient takes exercise, or allows them to hang down, as their functions in life may re- quire. Pumping cold water two or three times a day, on a part thus cir- cumstanced, 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 to- gether with perseverance in tiie use of liniments, and in exercise gradually in- creased, will soon bring every tiling in- to its natural state again. CORNEA TUNICA, (from comu, a horn.) The anterior transparent con- vex part of the eye, which in texture is tough, like horn. Opacities of.—Opa- city of the cornea is one of the worst consequences of obstinate ophthalmy. Scarpa distinguishes the superficial and recent species of opacity from the albu- go and kucoma, (see these words,) which are not in general attended with in- flammation, assume a clear colour, af- fect the very substance of the cornea, and form a dense speck upon this coat of the eye. The nebula, or slight opa- city, here to be treated of, is preceded and accompanied by chronic ophthal- my; it allows the iris and pupil to be discerned through a kind of cloudiness, and consequently does not entirely be- reave the patient of vision, but permits him to distinguish objects, as it were, through a mist. The nebula is an ef- fect of protracted or illtreated chronic ophthalmy. The veins of the conjunc- tiva, much relaxed by the long continu- ance of the inflammation, become pre- CORNEA. 217 ternaturally turgid and prominent; af- terwards they begin to appear irregu- lar and knotty, first in their trunks, then in their ramifications, near the union of the cornea with the sclerotica, and lastly in their most minute ramifi- cations, returning from the delicate layer pf tiie conjunctiva, spread over the cornea. It is only, however, in ex- treme relaxation of the veins of the conjunctiva, that these very small branches over the cornea become en- larged. When this happens, some reddish streaks begin to be perceptible, in the interspaces of which, very soon after- wards, a thin milky albuminous fluid is effused, which dims the diaphanous state of the cornea. The whitish, de- licate, superficial speck, thence result. ing, forms precisely what is termed, ne- bula, or that kind of opacity here to be considered. And since tliis extravasa- tion may happen only at one point of tiie cornea, or in more places, the opacity may be in one speck, or in several dis- _ tinct ones, hut which all together dimi- nish, more or less, the transparency of this membrane. The cloudiness of the cornea, which sometimes takes place in the inflamma- tory stage of the violent acute ophthal- my, essentially differs from the species of opacity expressed by the term nebula. The first is a deep extravasation of coa- gulating lymph into tiie internal cellu- lar texture of the cornea, or else the opacity proceeds from an abscess be- ' tween the layers of this membrane about to end in ulceration. On the other hand, the nebula forms slowly upon the superficies of the cornea, in the long protracted chronic ophthal- my ; is preceded first by a varicose en- largement of the veins in the conjunc- tiva, next of those in the delicate lami- mina of this tunic, continued over the front of the cornea; and finally, it is followed by an effusion of albuminous lymph into the texture of this thin lay- er, expanded over the transparent part of the eye. This effusion never ele- vates itself in tiie shape of a pustule. Wherever tlie cornea is affected with the species of opacity, termed nebula, the part of the conjunctiva, correspond- ing to it, is constantly occupied by a network of varicose veins, more knotty and prominent than other vessels of the same description, and though the cor- nea be clouded at more points than one, there are distinct corresponding fasci- VOL. X culi of varicose veins in the white of the eye. Scarpa injected an eye affected with chronic ophthalmy, and nebula, and he found that the wax easily pass- ed, both into the enlarged veins of the conjunctiva, and of that part of the sur- face of tlie cornea where the opacity existed; the inosculations all round the margin of the cornea were beautifully variegated, without trespassing that line, which bounds the sclerotica, ex- cept on that side, where the cornea was affected with this species of opacity. This kind of opacity of the cornea, from its very origin, requires an effica- cious plan of treatment; for though at first it may only occupy a small portion of the cornea, when left to itself it ad- vances towards the centre of this mem- brane, and the ramifications of the dila- ted veins upon this coat growing still larger, at length convert the delicate continuation of the conjunctiva upon the surface of the cornea, into a dense opaque membrane, obstructing vision, either partially or totally. The curative indication in this dis- ease is to make the varicose Vessels re- sume their natural diameters, or if that be impracticable, to cut off all commu- nication between tiie trunk of the most prominent varicose veins of thejeonjunc- tiva, and the ramifications coming from the surface of the cornea, the seat of" the opacity. The first mode of treat- ment is executed by means of topical astringents and corroborants, especially Janin's ophthalmic ointment, and suc- cess attends it, when the opacity is in an early state, and not extensive. But when advanced to the centre of the cornea, tiie most infallible treatment is the excision of the fasciculus of vari- cose veins near their ramifications, that is, near "the seat of the opacity. By means of this excision, the blood re- tarded in the dilated veins of the cor- nea is voided; the varicose veins of the conjunctiva have an opportunity to contract and regain their tone, no long- er having blood impelled into them; and the turbid secretion effused in the texture of the layer of the conjunctiva continued over the cornea, or in the cellular substance, connecting these two membranes, becomes absorbed. The celerity, with which., the nebula disappears, after this operation, is sur- prising, commonly in twenty-four hours. The extent, to whicii the excision of the varicose veins of the conjunctiva must be performed, depends uf>on the 218 CORNEA. extent of tlie opacity of the cornea.^ Thus, should there be only one set of varicose vessels, corresponding to an opacity of moderate extent, it is suffici- ent tp cut a portion of them away. Should tliere appear several dim specks upon the cornea, with as many distinct sets of varicose vessels, arranged round upon the white of the eye, the surgeon must make a circular incision into the conjunctiva, near the margin of the cornea, by which he will certainly di- vide every plexus of varicose vessels. But let it be observed, that a simple in- cision through the varicose vessels is not permanently effectual in destroy- ing all direct communication between the trunks and ramifications of these vessels upon the cornea, after such an incision made, for instance, with a lan- cet; though it be true that a separa* tionofthe month of the divided ves- sels follows in opposite directions, it is no less true, that in the course of a few days after the incision, the mouths of the same vessels approximate each other, and inosculate, so as to resume their former continuity. Hence, to de- rive from tliis operation all possible advantage, it is essential to extirpate with tiie knife a smaU portion of the varicose plexus, together with the ad- herent particle of the tunica conjunc- tiva. To do this operation properly, the plan of passing a needle threaded with silk through the varicose plexus is to be dispensed with. The eyelids are to be separated from the affected eye by a skilful assistant, who is, at tiie 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,J""near the edge of the cornea, and to lift them a little up, wliich the lax state of the con- junctiva renders easy; then, with a pair of small curved scissars, he is to Cut away the plexus of varicose ves- sels, together with a small piece of the conjunctiva, making the wound of a semilunar form, and as near as possi- ble to tiie cornea. If it should be ne- cessary to operate upon more than one plexus of varicose vessels, situated at some distance apart, the surgeon must elevate them one after the other with the forceps, and remove them. But when they are very close together, and occupy every side of the eye, he must make an uninterrupted circular inci- sion into the conjunctiva, guiding it closely to t e margin of the cornea all round, thuir dividing, with the conjunc- tiva, all the varicose vessels. This being done, he may allow the cut vessels to bleed freely; even pro- moting the hemon-hage by fomenting the eyelids, until tiie blood disconti- nues to flow. Then the eye is to be covered with an oval piece of the em- plastrum saponis, and a retentive ban- dage. The eye ought not to be open- ed till twenty-four hours after the ope- ration, when, usually, the opacity of the cornea will be found completely dis- persed; for during the ensuing days, the patient is to be enjoined 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. It is worthy of ob- servation, when the inflammation of the conjunctiva happens, about the second or third day after the operation, parti- cularly in cases in which the incision is made all round, that while the great- er part of the sphere of the eye reddens, a whitish circle, in the place of the in-, cision, forms a line of boundary to tlie redness which does not extend further upon the cornea. This inflammation of the conjunctiva, with the a& of in- ternal antiphlogistic remedies, and to- pical emollients, abates in a few days, and then pus is secreted along the track of the incision in the conjunctiva. The wound contracts, and growing smaller and smaller, soon cicatrizes. Bathing tiie eye with warm milk and rose-wa- ter is the only local treatment necessa- ry in this state of the complaint. Thus not only the transparency of the cornea is revived, but also the pre- ternatural laxity of the conjunctiva is diminished, or even removed. When afterwards the conjunctiva appears yel- lowish and wrinkled, the use of topical astringents and corroborants, and of Janin's ophthalmic ointment, will yet prove highly beneficial, in preventing the recurrence of the varicose state of the vessels. (Scarpa sulk muluttie degli occhi.) For other opacities of the cornea re- fer particularly to Albugo, Leucoma, and Staphyloma. CORNEA, Ulcer of. This is a very common consequence of the bursting ofa small abscess, which not unfre- quently forms beneath the delicate lay- er of the conjunctiva continued over the cornea, or in the very substance of the cornea itself, after violent ophthal- CQRNEA. 219 my. At other times, tlie ulcer of the cornea is produced by the contact of corroding matter, or sharp-pointed bo- dies insinuated into the eyes, such as quick lime, pieces of glass, or iron, thorns, &c. The little abscess of the cornea is attended with the same symp- toms, as the severe acute ophthalmy; especially with a troublesome sensa- tion of tension in the eye, eyebrow, and nape of the neck; with ardent heat; copious secretion of tears; aversion to light; intense redness of the conjunc- tiva, particularly near the point of sup- puration. The inflammatory pustule, compared with similar ones, in any other part of the body, is slow in burst- ing after the matter is formed. Expe- rience has nevertheless evinced, that it is improper to puncture the small ab- scess; for, though it assumes the ap- pearance of being perfectly maturated, the matter contained in it, is so tenaci- ous, and adherent to the substance of the cornea, that not a particle issues out of the artificial aperture, and the wound exasperates the disease, increa- ses the opacity of the cornea, and often occasions-another small abscess to form in the vicinity of the first. The safest plan, in this case, is to temporize, until th6 pustule spontaneously bursts, pro- moting it by means of frequent fomen- tations, 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 into- lerable 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 inspection, and at the spot where the white pustule existed, a cavity ap- pears, as may best be seen, when the eye is viewed in the profile. Extrane- ous bodies in the eye, whicii have sim- ply divided a part of tiie cornea, or lod- gaBL in it, when soon extracted, do not in general cause ulceration, as the in- jured part heals by the first intention. Those which destroy, or burn the sur- face of this membrane, or which, when lodged, are not soon extracted, excite acute ophthalmy, suppuration at the injured part, and at length ulceration.. The ulcer of the cornea has this, in common with all solutions of continuity in the skin, where it is dehcate, 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 ,- dis- charges, instead of pus, an acrid serum, and tends to spread widely and deeply. Such is the precise character of ulcers upon the cornea, and such is that of those upon the nipples of the mamms; the glans penis; lips; apex of the tongue ; the tarsi; the entrance of the meatus auditorius externus ; nostrils ; &c. Ulcers of this description, neg- lected, or ill-treated, speedily enlarge, make their way deeply, and destroy the parts in whicii they are situated. If they spread superficially upon the cornea, the transparency of this mem- brane is destroyed; if they proceed deeply, and penetrate the anterior chamber of the aqueous humour, this fluid escapes, and a fistula of the cor- nea may ensue ; and if it should form a larger opening in it, besides the exit of the 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 crystalline lens and vitreous humour, in short, a total destruction of the whole organ of sight. This afflicting accident is not unfrequent, in conse- quence of acute ophthalmy from gon- orrhea, when neither internal nor ex- ternal means avail, to arrest the pro- gress of ulceration. It is therefore of the highest importance, as soon as an ulcer appears upon the cornea, to im- pede its growing larger, as much as the nature of it will permit; the mor- bid process should be converted into a healing one, and the surgeon must ex- ert his skiff with more attention, the more extensive and deep the ulceration has proceeded. The cicatrix of a large ulcer impairs the texture of the cor- nea so much, that the injury is irre- parable. They, who inculcate, that no exter- nal application can be adopted with benefit, for the cure of this disease, before the acute ophthalmy has been subdued, or, at least, diminished, are, in Scarpa's opinion deceived. Expe- rience teaches, that local remedies ought, in the very first instance, to be applied to the ulc-'r, such as are appro- priate 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 subside gradually, as the ulcer heals. It is a fact, confirmed by repeated observa- 220 CORIfEA. tion, that it is the ulcer which keeps up tlie ophthalmy, not the ophthalmy the ulcer.* On opening the little abscess of the cornea, it is true the symptoms of acute ophthalmy become aggravated; the ^redness of the conjunctiva is increased, as well as the turgid state of its ves- sels ; but it is equally certain, that it happens from no other cause, than an increased inflammation in the part, in consequence of the augmented sensi- bility m the ulcerated spot of the cor- nea. As soon as this increase of sensi- bility in the ulcer of the cornea ceases, or abates, in violence, the ophthalmy retreats with equal speed, and, final- ly, when the ulcer heals, the inflamma- tion vanishes gradually, or, at most, requires only the use of an astringent, and corroborant collyrium, for a few days. Analogous 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 tiie nipples, on the glans penis, which, as was described above, at their first ap- pearance, assume an ash-coloured sur- face, excite inflammation 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 repel the excessive irritability in these ul- cers, and convert the ulcerative process into cicatrization. This done, the sur- rounding inflammation immediately disappears of itself. The resource of art, productive of such speedy and such good effects, in these cases, is the caustic. It imme- diately destroys the naked extremities of the nerves in the ulcerated part, and soon removes that diseased irritability prevalent in the part affected; it con- verts tiie ash-coloured surface of the ulcer, and the serous discharge upon it, into an eschar and scab, which, as a kind of epidermis, moderates the con- tact of the neighbouring parts upon the ulcer, and at length, converts the pro- cess of ulceration into that of granula- tion and cicatrization. To cauterize the ulcer of the cor- nea, the caustic to whicii Scarpa gives the preference, is the argentum nitra- tum. It must be scraped to a point, like a crayon pencil, and the eye lids. being opened perfectly, and the upper eye lid suspended, by means of Pel- lier's elevator, the ulcer of the cornea is to be touched with the apex suffi- ciently to form an eschar. Should any of the caustic dissolve in the tears, tlie eye must be copiously bathed with warm milk. At the instant the caustic is apphed, the patient complains of a most acute pain ; but this aggravation is amply compensated, by the ease ex- perienced a few minutes after the ope- ration : the burning heat of the eye ceases, as it were, by a charm; the eye and eye lids become capable of mo- tion without pain; the flux of tears and tlie turgidity of the vessels of the con- junctiva decrease : the patient can bear a moderate light, and enjoys repose. These advantages last wliile the eschar 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 caus- tic, the primary symptoms of the dis- ease recur, especially the smarting and burning pain at the ulcerated part of the cornea; the effusion of tears; the restraint in moving the eye and eye fids; 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 application of the argentum nitratum, making a good eschar, as at first, upon the whole surface of the ulcer, which 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 separa- tion of the eschar, tiie extreme irrita- bility in the ulcer is notexhausted, and its progressive mischief checked. When the case goes on favourably, it is a constant phenomenon in the cure of this disease, that, at every sepa'ra- tion of the eschar, the diseased sensi- bility of the eye is decreased, the ulcer also, abandoning its pale ash-colour, assumes a delicate fleshy tint, a certain sign that the destructive process which prevailed, is turned into a healing one. * Except the case, in which the ulcer makes its appearance in the heie-ht nf -, severe ophthalmy ; here the first indication is to abate inflammation beforJ attempting to heal the ulcer. «"*uon, oetore COR COR " 221 The turgid state of the vessels of the conjunctiva, and the degree of ophthal- my, disappears, in proportion as the ulcer draws near to a cure. At this epoch, when the formation of granula- tions has begun, tire surgeon would act very wrongly, did he continue lon- ger tiie use of the argentum nitratum; it would now reproduce pain, effusion of tears, and inflammation in the eye ; and the ulcer would take on that foul ash-coloured aspect, with swelled and irregular edges, which it had at the be- ginning. Platner has noticed this fact. JVecesse est, ut hoc temperotd manu, nee crebrius fiat, ne nova infiammatio, no- vaque lachrymq hie acrioribus concitetur. Inst. Chirurg. § 314. As soon as ease is felt in the eye, and granulations be- gin to rise, whether after the first, second, or third application of the caus- tic, the surgeon must refrain from the use of every strong caustic, and use no other application than the vitriolic col- lyrium. R Zinci Vitriol, gr. iv. in Aq. Rosa l'iv cum gss mucil. Sem. Cydon. malt. M. To be used every two hours, defending the eye, in the intervals, from the contact of the air and light, by means of a slight compress, and reten- tive bandage. In cases in which, besides the ulcer of the cornea, a slight relaxation of the conjunctiva remains, Janin's ointment, towards the end of the treatment, introduced between the eye and eye lids, morning and evening, proves extremely serviceable. It must be qualified in strength and quantity to the particular sensibility of the patient. TO cure those superficial excoriations of the cornea, which make no incava- tionin the substance of this membrane, and which, in reality, are only a detach- ment of the cuticle, covering the layer of the conjunctiva continued over the cornea, the use of caustic is not re- quisite. The above vitriolic collyrium, combined with the mucilage, is suffi- cient. Tiie symptoms which accompa- ny such slight excoriations, or detach- ments of the cuticle, arc unimportant, and when the patient takes care to bathe his eye, every two or tliree hours, with the solution of vitriol, and to avoid too much light, and the impres- sion of the atmosphere, they soon get well. Thus far of the ulcer of the cornea, and the best mode of curing it in ordi- nary cases. However, sometimes, in consequence of ill treatment, the ulcer, already very extensive, assumes the form of a fungous excrescence upon the cornea, appearing to derive its nourishment from a band of blood-ves- sels of the conjunctiva; and, on this ac- count, 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 re- quires the speedy adoption of some ac- tive and efficacious plan, to destroy all the fungus upon the cornea, to annihi- late the vessels of the conjunctiva tend- ing to it, and to impede the progress of ulceration. This consists first in cut- ting away the fungus, with a pair of small scissars, to a level with the cor- nea, continuing the incision far enough upon the conjunctiva, to remove, with the excrescence, that string of blood- vessels, from which it seems to derive its supply. Having effected this, and al- lowed tlie blood to flow freely, it is proper to apply the argentum nitratum to all the space of the cornea, wliich appears to have been the seat of the fungus, so as to make a complete es- char ; and if, upon its separation, the whole morbid surface should not be destroyed, the caustic must be re- peated, until the ulcerative process changes into a healing one. To exe- cute commodiously such a full applica- tion of the caustic, it is not in general enough to have tiie upper eyelid raised by an assistant, and the lower one de- pressed ; it is also further requisite, that the operator, by means of a spatu- la, introduced between the upper eye- lid and the eyeball, should hold the same elevated with his own left hand, wliile, with the right, he applies the caustic, so as to form a strong deep es- char. It must be acknowledged, the action of the caustic cannot always be calcu- lated with precision, and therefore a portion of" the whole thickness of the cornea may be destroyed with the fun- gus, which never fails to be followed by a prolapsus of part of the iris, through the aperture made in the cor- nea. The accident may seem to some very grievous ; it is, however, not ir- reparable, as shall be shewn in the ar- ticle Iris, prolapsus of; and when the surgeon can produce a firm cicatrix at the point, where the excrescence was situated, which resists a reproduction of the fungus, and a total destruction of the eye, he has fulfilled the indica- tions required. (Scarpa sulk Malattk degli Occhi.) CORNS. A corn, technically called 222 CORNS. claws, from its fancied resemblance to the head of a nail, is a brawn-like hard- ness of the skin, with a kind of root sometimes extending deeply into the subjacent cellular substance. When this is the case, the indurated part is fixed ; but while the hardness is more superficial, it is quite moveable. Some corns rise up above tiie level of the skin, in the manner of a flat wart. They are hard, dry, and insensible, just like the thickened cuticle, which forms on tiie soles of the feet, or on the hands of labouring people. Corns are entirely owing to repeated and long-continued pressure. Hence, they are most frequently in such situa- tions as are most exposed to pressure, and where* the skin is near bones, as on the toes, soles of the feet, &c. How- ever, corns have occasionally been seen over the crista of the ilium, from the pressure of stays, and even on the ears, from the pressure of heavy ear rings. Corns of the feet are usually owing to wearing tight shoes, and, conse- quently, 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 mer- its the appellation. In shoes thus made, the whole weight of tiie body falls principally upon the toes, which be- come quite wedged, and dreadfully compressed in tiie end of tiie shoes. Though some persons, who have corns, suffer very little, others occa- sionally endure such torture from them, that they are quite incapable of standing or walking. Doubtless the great pain proceeds from the irritation of the hard corn on the tender cutis beneath, which is frequently very much inflamed, in consequence of tlie pres- sure. It is observed, that every thing whicii accelerates the motion of the blood, which heats the feet, which in- creases the pressure of the com on the adjacent parts, or the determination of blood to tiie feet, or which promotes its accumulation in them, exasperates 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, pla- cing His feet in a horizontal posture, and becoming a little cool? the promi- nent portion of the corn should be cut off, as far as it can be done without exciting pain, or bleeding, and the feet should be bathed in warm water. The radical cure essentially requires the avoidance of all the above causes, and, particularly, of much walking, or standing. Wide, soft shoes, should be worn. Such means are not only requi- site for a radical cure; but they alone very often effect it. How many women become spontaneously free from corns in child-bed, and otiier confinements ? Though the radical cure is so easy, few obtain it, because their perseverance ceases as soon as they experience the wished-for relief. i When business, or other circum- stances, prevent the patient from adop- ting this plan, and oblige him to walk, or stand a good deal, still, it is possi- ble to remove all pressure from the corn. For this purpose from 8 to 12 pieces of linen, smeared with an emol- lient 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 has been applied some weeks, the corn commonly disappears, without any other means. Should the corn be in the sole of the foot, it is only necessary to put in the shoe a felt-sole, wherein a hole has been cut, corre- sponding to the situation, size, and figure, of the induration. A corn may also be certainly, perma- nently, and speedily eradicated, by the following method, especially, when the plaster, and felt-sole with 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 the volatde liniment, wliich is still better; and in the interim, is to be covered with a softening plaster. Every morning and evening, the foot is to be put for half an hour in warm water, and whdst there, the corn is to be well rubbed with soap. Afterwards, all the softy white, pulpy outside of the corn, is to be scraped off* with a blunt knife; but, the scraping is to be left off, the mo- ment the patient begins to complain of pain from it. The same treatment is to be persisted in, without interruption, until the com is totally extirpated, CQX CUP 223 which is generally effected in eight o r 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 princi- pal are green wax, soap, mercuiial, and hemlock plasters, a piece of green oil-skin, &c. They are to be applied to the corn, and renewed as often as necessary. An infallible composition consists of two ounces of gum ammo- iiiacum, the same quantity of yellow wax, and six drams of verdigrease. In a fortnight, if the corn yet remain, a fresh plaster is to be applied. It is frequently difficult, and hazar- dous to cut out a corn. The whole must be completely taken away, or else it grows again ; and the more frequent- ly it is partially cut away, the quicker is its growth rendered. When the skin is moveable, and, consequently, the corn not adherent to the subjacent parts, its excision may be performed with facility and safety, but, not with- out pain. But, in the opposite case, either leaving a piece of the corn be- hind, or vounding the parts beneath^ can seldom be avoided. The latter circnmstaice may excite serious mis- chief. A person, entirely cured of corns, is sure to be affected with them again, unless the above mentioned causes be carefully aroided. Some subjects are, indeed, mere or less, disposed to have the comphint. There are persons, who for life wear tight shoes, and take no care of tltir feet, and, yet, are never incommoded with corns. On the con- trary, others are constantly troubled with them, hough they pay attention to themselv^. Many are for a time vexed with corns, and then become quite free frtm them, though they con- tinue to weaithe same kind of shoes, and stockings The above account is chiefly taken from Richtein of tiie 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 con- siderably depressed, the condyles slide from behind forward, under the trans- verse root of the zygomatic process. Tiie cartilaginous cap, which envelopes the condyles, and follows them in all their motions, still affords them an ar- ticular cavity ; but, the depression of the bone continuing, the ligaments give way, the condyles glide before the eminentia articulares, and slip under the zygomatic arches. Hence, a dis- location mostly happens, while the pa- tient is laughing, gaping, &c. A blow on the jaw, when the mouth is wide- open, may easily cause the accident. The case has occasionally arisen from the exercise of great force in drawing out the teeth. Whenever the j aw has once been dislocated, the same causes more easily reproduce the occurrence. There have been persons, who could scarcely ever laugh heartily, without having their lower jaws luxated, in consequence of so doing. But, of all the causes of this occurrence, yawning alone, even without the combination of any external force, is by far the most common. When the jaw is depressed, and its angles, to the external sides of which the masseters are attached, are car- ried upwards and backwards, if these muscles contract, the greater part of their force is employed to bring the condyles into the zygomatic depres- sion. (Boyer.) Dislocations of the lower jaw are at- tended with a great deal of pain, which Boyer imputes to the pressure produ- ced by the condyles on the deep-seated temporal nerves, and those going to the masseters, which nerves pass be- fore the roots of the zygomatic proces- ses. The mouth is wide-open^ and can- not be shut. It is more open in recent dislocations, than in those, which have continued for some time. An empty spuce is felt before the ear, the natu- ru. si; a., tion of the condyles. The cor- onoid process forms under the cheek- bone a prominence, wlucn may be felt through the cheek, or from within the mouth. The cheeks and temples are flattened by the lengthening of the tem- poral, masseter, and buccinator mus- cles. The sahvu Hows in large quan- tities from tiie mouui, the secretion of which fluid is greatly increased by the- DISLOCATIONS. 233 irritation of the air. The arch, formed by the teeth of the lower jaw, is situa- ted more forward, th:.n that formed by the teeth of the upper jaw. The pa- tient can neither speak, nor swallow, during the first days after the accident. (Boyer.) When only one condyle is dislocated, the mouth is distorted, and turned towards the opposite side, wliile tiie fellow teeth of the jaws do not cor- respond. Hey says, however, the chin is frequently not altered. (Practical Observations, p. 322._^ The symptoms are not so well mark- ed, when the accident has remained unreduced for several days or weeks. In such instances, the chin becomes gradually approximated to the upper jaw : the patient recovers by degrees the faculty ofspeaking and swallowing; but, he stammers, and the saliva drib- bles from his mouth. The sufferings 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 he positively declares the acci- dent mortal, if not reduced before the tenth day. Dislocations of the lower jaw are to be reduced in the following manner: The surgeon is first to wrap some linen round his thumbs to keep them from being hurt by the patient's teeth, and then introduce them into the mouth, as far as possible on the grinding teeth. At the same time, he is to place his fingers under the chin and base of the jaw, and while he depresses tiie molares with his thumbs, he raises the chin with his fingers, by whicii means the condyles become disengaged from their situation under the zygomas : at which instant the muscles draw these parts so rapidly back into the articular cavities again, that the surgeon's thumbs would very probably be hurt, did he not im- mediately move them outward between the cheek and the jaws. The reduction being accomplished, a recurrence of the accident is to be prevented by applying a four-tailed ban- dage, as recommended for the frac- tured jaw. The patient should for some time avoid eating food, which re- quires much mastication. The ancients used to place two pieces of stick between the grinding teeth, and while they used these as levers to depress the back part of the bone, they raised the chin by mean* vol. 1 of a bandage. Devigo has described this method. It is not preferable to the modern plan, in regard to efficacy; and it has the disadvantage of exposing the teeth to be broken by the sticks. DISLOCATIONS OF THE VERTEBRA. The large surfaces, with whicii these bones support each other; the num- ber and thickness of their ligaments ; the strength of their muscles ; the ht- tle, which each vertebra naturally moves; and the vertical direction of their articular processes; make dislo- cations of the dorsal and lumbar ver- tebrae quite impossible, unless there be also a fracture of the processes just mentioned. Of those cases I shall on- ly remark, that they can only result from immense violence; that the symp- toms would be an irregularity in the disposition of the spinous processes, retention or incontinence of the urine and faeces, paralysis and a motionless state of the lower extremities, the ef- fects of the pressure, or other injury, to whicii the spinal marrow is subject- ed. Similar symptoms may also arise, when the spinal marrow has merely un- dergone a very violent concussion, without any fracture or dislocation whatever ; and, it is certain, that most of the cases mentioned by authors as dislocations of the lumbar and dorsal vertebrae, have only been concussions of the spinal marrow, or fractures of such bones. The cervical vertebrae, however, not having such extensive articular surfa- ces, and having more motion, are oc- casionally luxated. 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 tiie cervical vertebrae lower down, though very rare, are possible. (Boyer.) DISLOCATION OF THj4 HEAD FROM THE FIRST VERTEBRA, OR ATLAS. The os occipitis, and first cervical vertebra are so firmly connected by ligaments, that there is no instance of their being luxated from an external cause, and, were the accident to hap- pen, it would immediately prove fatal by the compression and injury it would occasion of the spinal marrow. 30 234 DISLOCATIONS. "DISLOCATIONS OT THE TIRST CER- VICAL VERTEBRA FROM THE SE- COND. Every surgeon is aware, that the ro- tatory motion of the head is chiefly performed by the first vertebra moving on the second. When this motion is forced beyond its proper limits, the ligaments which tie the processus den- tatus to the edges of the foramen mag- num 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 articulating surface, while the right side falls behind its corresponding sur- face. Sometimes the processus denta- tus, whose ligaments are ruptured, quits the foramen formed for it by the transverse ligament and the anterior arch of the first vertebra, and presses on the spinal marrow. In other in- stances, the processus dentatus does not leave its natural situation ; but the diameter of the vertebral canal is al- ways diminished at this place, and the spinal marrow consequently compress- ed, and otherwise injured. Patients cannot survive mischief of this kind in so high a situation. M. Louis found, that in persons hanged, the first ver- tebra was dislocated from the second, when the executioner twisted their bodies at the moment of their being suspended. Many dislocations of the cervical vertebrae do not prove fatal; but these occur at the third, fourth, fifth, or .sixth of these bones, and only one articular process is luxated. In these instances the vertebral canal is not so much les- sened as to compress the spinal mar- row, and occasion death. If the luxation produce no symptom, which indicates a compression of the spinal marrow, it is prudent to abstain from all attempts to reduce it. When the symptoms are urgent and alarming, and some attempt to relieve the patient is the only chance he has of hving, we are to begin by inclining the head to the side towards which it is directed, in order to disengage the articulating process of the upper vertebra : this part of the operation is extremely dan- gerous, as it may instantly produce death by increasing the pressure on the spinal marrow. When the process is disengaged, the head and neck are brought to their right direction, b) making them perform a rotatory mo- tion, the contrary of that, which had taken place in the luxation. A relapse is to be prevented by keeping the head and neck perfectly motionless. (Boyer.) There can be no doubt of the ration- ality of attempting an immediate re- duction of the processus dentatus, if signs of life should exist. This pro- cess is thrown back, so as to compress or injure the spinal marrow-, while the atlas and the head itself" are thrown forward. The recollection of these cir- cumstances will enable a surgeon to do what is proper, better than any detailed directions. DISLOCATIONS OF THE CLAVICLE These are much less common, than fractures, which are said to occur six times more frequently. The clavicle may be luxated at its sternal extremity, forwards, backwards, and upwards, but never downwards, on account of the situation of the cartilage of the first rib. The luxation forward is the most frequent, and almost the only one ever met with. It may arise from the other end of the clavicle being forced very much backward. Disloca- tions backwards and upwards are very unusual. To cause the first sort of ac- cident, tlie shoulder must have been violently driven forwards, and at the same time depressed with great force. The dislocation backward, is more rare than the one upward. If the dislocation be forwards, a hard circumscribed tumour is felt, or even seen, on the front and upper part of the sternum. When the shoulder is car- ried forward and outward, this tumour disappears, and, previously, there is a vacancy where the head of the clavicle ought to be. When the luxation is upwards, the distance between the sternal ends of the clavicles is diminished. When the dislocation is backwards, there is a depression where the end of the clavicle ought to be, and the head of the bone forms a projection at the front and lower part of the neck, which, as J. L. Petit remarks, may compress the trachea, oesophagus, jugular vein, carotid artery, and nerves. The head is inclined towards the side, on which the accident is. In reducing these dislocations of the sternal end of the clavicle, we are to make a lever of the arm, by means of which the shoulder is brought out- DISLOCATIONS. 235 wards; and when thus brought out- wards, it is to be pushed forwards, if the dislocation is in that direction; backwards, if the dislocation be be- hind ; and upwards, if the dislocation be above. It is as difficult to keep the bone re- duced, as it is easy to reduce it, so smooth and oblique are the articular surfaces. The same position of the arm, and the same apparatus, as in fractures of the clavicle, 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 tour- niquet used, whicii was proposed by Brasdor, to make a pressure on the end of the bone. The dislocation of the scapular end of the clavicle from the acromion is much less common. The luxation upwards is almost the only one that ever oc- curs. It is possible, however, for the accident to take place downwards, and for the end of the clavicle to glide un- der the acromion. The rarity of the dislocations of the scapulary end of the clavicle, is owing to the strength of the ligaments tying the clavicle and acro- mion together. A fall on tiie top of the shoulder may cause the dislocation upwards. The scapulary end of the clavicle then slides upwards on the acromion, and the shoulder is drawn inwards by the muscles whicii approximate the arm to the body. The violent action of the trapezius muscle, in pulling upward the clavicle, may tend to produce the accident. Pain at the top of the shoulder, and a projection of the end of the clavicle, under the skin covering the acromion, are symptoms indicating what has hap- pened. The patient also inclines his head to the affected side, and avoids moving his arm or shoulder. This dislocation is reduced by carry- ing the arm outwards, putting a cushion in the axilla, and applying Desault's bandage for fractures of the clavicle, making such turns as ascend from the elbow to the shoulder, and press the luxated end of the bone downward, so as to keep it in its due situation. (See Boyer's Lectures on the Diseases of the Bones.) Most surgeons, in this country, would be content with applying a compress, ■and suppor'.ng the arm in a sling. DISLOCATIONS OF THE OS BRACHII Nature, which varies, according to the necessities of different animals, the number of their joints, has also been provident enough to vary the structure of these parts, according to the use of the different portions of their economy. To great moveableness some unite con- siderable solidity; for instance, the vertebral column. Others are very strong, but only admit of a slight yield- ing motion, as we observe in the car- pus, tarsus, &c. Lastly, other joints admit of a great latitude of motion; but their strength is easily overpower- ed by the action of external bodies. Such are, in man, the shoulder-joint, and that between the sternum and clavicle. The last kinds of articulation are particularly subject to dislocations, and, of all, not one is so often luxated as the shoulder-joint. Bichat mentions, that it appears, from a comparative table, that, in some years, this accident, at the Hotel-Dieu, has been as frequent, and even more so, than dislocations of all the other bones taken collectively. Here every thing seems to facilitate the escape of the bone from its natural cavity. An oval shallow cavity, sur- rounded by a margin of little thickness, receives a half-spherical head, which is twice as broad as the cavity in the per- pendicular 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, co- racoid process, and triangular hga- ment, form an almost insurmountable obstacle to such an accident. With regard to the muscles, and motions of this joint, strong and numerous fasci- culi surround the articular surfaces, make them easily move in all direc- tions, and pushing the head of tiie os brachii against the different points of the capsule, distend this ligamentous bag, and, when their power exceeds the resistance, actually lacerate it.. As for external bodies, what bone is more exposed than the os brachii, to the ef- fect of their force ? Thus subjected to the influence of these predisposing causes, the os brachii would be in continual danger of being dislocated, if the scapula, wliich 236 DISLOCATIONS. it as moveable as itself, did not furnish a point of support for it, by accom- panying its motions. This point of support accommodates itself to the va- riations in the position of the head of the os brachii, so that to the movea- bleness of the articular surfaces, their strength is in a great measure owing. DIFFERENT KINDSOF DISLOCATION. The shoulder-joint, 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 pos- sible, such an accident has never been observed. Hence, before examining the mechanism of dislocations of this joint, it is essential to determine with precision the directions in which they may take place. Here, indeed, au- thors differ in a very singular manner. Sometimes, they have employed dif- ferent terms to express the same thing: and, sometimes, they have employed the same words to signify different thing9. Invariably agreed about cer- tain kinds of dislocations, they enter- tain opposite sentiments concerning others; and, in the midst of these dif- ferences, the perplexed surgeon often cannot decide on what basis to found his practice. DIVISION ADOPTED BY AUTHORS. The ancients, who knew very littie of the natural relation of the parts sur- rounding the joint, were totally igno- rant of the accidental relations, which such parts present in the case under consideration. Hence, no doubt, arose the confusion in their doctrines. Many admitted four kinds of dislo- cations ; many only three; some ac- knowledged only two ; while others only allowed the possibility of one kind. The first distinguished the different directions, in which the bone can be luxated. The dislocations, were ter- med upward, downward, forward, and backward. Such was the opinion of the predecessors of Hippocrates, who, in informing us of it, demonstrates its in- accuracy. Others divided the disloca- tions of the shoulder into such as take place downward, upward, outward, and forward. This division is adopted by Galen, who, however, only cites an example of the luxation forward, and does not illustrate what he means^ by dislocations upward, and inward. The second class of writers distin- guished the species of dislocation, sometimes into those which occur downward, forward, and backward. Oribasius was one of these. Sometimes, tiiey named the luxations downward, outward, and inward. Paul of JEgina followed this plan, and, no doubt, his meaning is the same as that of Oriba- sius, only expressed by different terms. Sometimes, they called the dislocations downward, forward, and upward. Al- bucasis did so, and thought the latter case exceedingly uncommon. The third set believed, that when the head of the os brachii was displa- ced, it could only be carried downward into the armpit, a very common case ; and forward, whicii is less frequently seen. Celsus is almost the only one, who has established this difference ; he remarks, Humerus modo in ulam excidit, modo in partem priorem. Lastly, the fourth body of men only believed in the dislocation downward ; whicii was the sentiment of Hippocra- tes, who had only seen tliis one sort of case in his practice. At vero hu- merus inferior em in partem excidit; aliam in partem excidere non audivi. The moderns borrowed from the an- cients their divisions of dislocations of the shoulder-joint, and, at first, like their predecessors, they only deter- mined in a vague manner the precise situations of these accidents. How- ever, they afterwards 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 consecutive luxations. Petit admits four kinds of disloca- tions. 1, Downward on the inferior costa of the scapula, vwy 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, For- ward, between the coracoid process and the clavicle. Heister, like this eminent practitioner acknowledged four dislocations ; but with a difference both of expression and meaning. One is downward, in the axilla ; one forward, under the great pectoral muscle ; ano- ther backward, under the scapula ; and a fourth outward, under the spine of this bone. According to Duverney, DISLOCATIONS. 237 primitive luxations never occur in any other direction than downward; the others being the constant effect of mus- cular action. DIVISION ADOPTED BY DESAULT. In the midst of these very confused ways of viewing a very simple subject, it is, in the first place, necessary, in order to have determinate ideas, to di- vide dislocations of the humerus into primitive ones, which are the sudden effect of external violence, and into consecutive ones, which follow the first, by the influence of causes, which will be investigated. Let the oval surface of the glenoid cavity be included within four lines ; one representing its upper edge; ano- ther its lower ; a third its inner edge; and a fourth its external one. It is manifest, that the head of the humerus cannot be displaced towards the upper edge. There wre situated tiie acromion and coracoid process, the triangular ligament stretched between them, the tendons of the triceps, supra- spinatus, and tiie fleshy portion of the deltoid, insurmountable obstacles to the luxation of the head of the bone, propelled by any force upward. Be- sides, what power could, this be ? Sup- posing there were such a force, the head of" the bone must necessarily be driven outward as well as upward, ere its head could be displaced. This is impossible, because the trunk prevents the lower part of tiie arm from being directed sufficiently inward to produce this effect. On the contrary, at tiie other mar- gins, tliere is little resistance. At the inferior one, the long portion of the triceps ; at the internal one, the tendon of the subscapularis ; and at the exter- nal edge, those of the infraspinatus, and teres-minor; are capable of easily yielding to any power directed against thein, and of allowing primitive luxa- tions to take place, downward, inward, ur outward. Downward, between the tendon of the long portion of the triceps, and the tendon of the subscapularis; inw.'.rd, between the fossa subscapu- laris, and muscle of this name; out- ward, between the fossa infraspinata, and infraspinatus muscle. After being pushed out of its cavity, and firstjilaced in one of these three directions, the head of the humerus often changes its position ; and then, to primitive luxations, downward, or in- ward, a consecutive one succeeds. But, the latter could never follow the primitive dislocation outward, were this to exist; as the spine of the scapula would form an obstacle. A consecutive luxation inward may succeed a primitive one downward: indeed, nothing resists the head of" the humerus, in the course which it then follows to get between the fossa sub- scapularis and the muscle similarly named. On the contrary, should it tend outward, it is opposed by the ten- don of the triceps, and notwithstanding what Petit has written, there is never a consecutive dislocation in this direc- tion. It sometimes happens, that, after the head of the bone has escaped from the internal, or inferior part of the cap- sule, it is carried behind the clavicle, and then forms a consecutive disloca- tion upward; an event already noticed by Ambroise Pare, perhaps by Galen, and a specimen of" whicii was preserved in Desault's cabinet. But, here, the secondary derangement only takes place slowly, and, when it occurs, it is almost always out of the power of art to rectify it, on account of the strong adhesions, contracted by the surfaces of the bone. Thus, in the instance to which allusion has been made, a new cavity was seen formed behind the clavicle, and the humerus adhered by new kinds of ligaments to the surroun- ding parts. It follows from what we have just been saying, that the humerus is sub- ject to four kinds of dislocation. 1. Downward. 2. Outward. In these two directions the accident is always prim- itive. 3. Inward, which is sometimes primitive, sometimes consecutive. 4. Upward ; a case which can never oc- cur, except as a consecutive one. The second and fourth cases are so very rare in comparison with the others, that these alone claim the practitioner's attention. causes, &c. These vary according as the dislo- cation's primitive, or consecutive. PRIMITIVE DISLOCATION. The action of external bodies, direc- ted against the arm ; but, particularly, falls, in which tliis part is forced 238 DISLOCATION'S. against a resisting body, give rise to primitive dislocations, and then the different species of the accident are determined, by the particular position of the humerus at the instant, when the injury takes place. Should tliis bone be raised from the side, without being carried either for- ward, or backward; should the elbow be elevated, and tiie fall take place on the side; then the weight of the trunk, almost entirely supported by this bone, forces downward its upper part, and this stretches and lacerates the lower part of the capsular ligament. Thus a luxation downward is produced, and its occurrence may also be facilitated by the combined action of the latissimus dorsi, pectoralis major, and teres major, muscles, as Fabre has judiciously re- marked. Then, indeed, involuntarily contracted to support the trunk, these muscles act with the power of a kind of lever ; in which operation the resist- ance is the head of the bone, which they draw downward, while the fixed point is the lower end ofthe bone, rest- ing against the ground. Some authors also consider, as the immediate cause of a dislocation downward, the strong action ofthe deltoid, which then de- presses the head of the bone, and pushes it downward out ofthe capsule. Certain observations seem incontesta- bly to establish this mode of disloca- tion. Bichat mentions the well-known case ofa notary, who luxated his arm downward, in lifting up a register. The rationale of the primitive luxa- tion inward differs very little from that of the preceding case. The elbow is both separated from the side, and car- ried backward : in falling, the weight of the body acts on the humerus, the front part of the capsule is lacerated, and a luxation takes place in this di- rection. The dislocation outward is produced in the same sort of way. The elbow is carried forward, towards the opposite shoulder; the capsule is stretched out- ward, and if a sufficient force should act on the limb, is lacerated. But, how could such a force arise ? In a fall, the arm pushed against the trunk, and kept there, could not move exten- sively enough to cause such a lacera- tion. Hence, the luxation outward must necessarily be exceedingly rare. Indeed, there is no instance recorded of it in surgical books, and Desault, in particular, never had occasion to ob- serve such an accident. Besides, when, in a fall, the arm, raised from the side, is inclined forward or backward, tiie weight of the body only operates upon it obliquely, and the limb is very little exposed to the action of the latissimus dorsi, pectoralis major, and teres major muscles. No dislocation must occur more frequently, than that downward, in which the influence of* both these causes is direct. The luxation inward, however, is very common, and a multi- tude of cases, which occurred to De- sault, confirm this kind of primitive dislocation, doubted by several modern authors, who are of opinion, with Hip- pocrates, that all dislocations at first take place downward. The capsule may only be stretched in a primitive luxation, and then the articular surfaces only lose their rela- tions imperfectly ; but, most frequent- ly, it is lacerated, and the head ofthe bone passes through the rupture. Au- thors have, in general, paid too littie attention to this circumstance, which dissections have repeatedly demonstrat- ed to practitioners, and to Desault in particular. This eminent surgeon had two specimens made of wax ; one, ofa dislocation inward; the other of one downward; both of which were met with in subjects, who died at the Hotel Dieu. Bell also makes mention of* si- milar facts, and another English sur- geon has observed the same occur- rence.** Here the same thing often happens, which is seen to occur in compound fractures, in which the ends of the broken part protrude through the skin. The capsule is sufficiently torn to let the head of tiie bone escape; but, the opening, afterwards, being too narrow, forms a kind of constriction round the neck of the humerus, so as to prevent the return of the tiead of the bone into the place, whicii it originally occupied- Thus, in the fractures, of which we have just been speaking, the opening * I suppose Bichat alludes to Mr. Thompson, who noticed the laceration of the capsule long ago, and particularly called the attention of surgeons to the subject, m the Medical Observations and Inquiries. DISLOCATIONS. 239 of the skin will not allow the end of the fracture to be reduced, without a pre- vious dilatation of the wound. In this state, should we endeavour to reduce the dislocation, the capsule be- ing pushed against the glenoid cavity, becomes compressed between it and the head of the bone, which the sur- geon now in vain attempts to reduce. Desault, was the first who noticed tliis practical fact, two examples of which are recorded in his journal, and cases of which have since very often present- ed themselves at the Hotel Dieu. In these cases, the head is commonly very moveable, because, being entirely on the outside of the capsule, nothing re- strains its motions. CONSECUTIVE DISLOCATION. When a consecutive luxation follows a primitive one, several causes may concur in producing it. If a fresh fall should happen, when the arm is sepa- rated 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, which it accidentally occupies. A man, in going down stairs, meets with a fall, and dislocates the humerus downward: 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 accident oc- curred, and Desault, on his return, in- stead of finding the head of the hu- merus as it was in the morning, in the hollow of the axilla, finds it behind the pectoralis major muscle. The action of muscles is a permanent cause ofa new dislocation. When the humerus, indeed, is luxated downward, the pectoralis major, and the deltoid draw upward and inward, the upper part of" this bone, whicii only making a weak resistance to their action,changes its position, and takes one in the above double direction. The various motions imparted to the arm, may also produce the same effect, according to their direction. Thus a luxation inward has often been observ- ed to follow one downward, in conse- quence of unskilful efforts to reduce Hie latter. SYMPTOMS. The diagnosis of dislocations of the humerus is, in general, attended with no difficulty. Whatever may be the mode and si- tuation ofthe dislocation, there always exists, as Hippocrates has remarked, a manifest depression under the acro- mion, wliich forms a more evident pro- jection, than in tiie natural state. Al- most all the motions of the arm are painful; some cannot be performed at all; and they are all very limited. The arm cannot move without the shoulder moving also, because the articulation being no longer able to execute its functions, both it and the shoulder form, as it were, one body. To these symptoms, generally cha- racteristic of every sort of dislocation of the humerus, are to be added such as are peculiar to each particular case. When the luxation is downward, the arm is a httle longer, than in the na- tural state; it is capable of being moved a little outward; but, an acute pain is the inevitable consequence of moving it forward, or backward. The elbow is more or less removed from the axis of the body, by tiie action of the deltoid, the long head of" the biceps, and supraspinatus, muscles, which, be- ing stretched, contract and tend to dra"w the bone outward. The pains, which result from this position, com- pel the patient, in order to avoid them, to lean towards tiie side, on which the dislocation is, to keep the fore-arm half bent, and the elbow supported on his hip, in such a way, that the arm, hav- ing a resting place, may be sheltered from all painful motion, and stretching ofthe muscles. By this posture alone, Desault was in the habit of detecting a luxation downward, and his diagnosis was seldom found to be erroneous. Thus, in a fracture of the clavicle, the leaning posture of the patient is often, at the first glimpse, characteristic of the accident. In the axilla, there is constantly a more or less evident pro- minence, formed by the head of the humerus. With the general symptoms of dislo- cations of the humerus, that inward has the follow ing : the elbow, separat- ed from the axis of the body, is inclined a little backward ; the humerus seems to be directed towards the middle of 240 DISLOCATIONS. the clavicle ; motion backward is not very painful, but that forward is infi- nitely so ; there is a manifest promin- ence under tiie 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. If there should be a dislocation out- ward, it would be particularly charac- terized by a hard tumour under the ipine of the scapula; by the direction of the elbow forward ; by its separation from the trunk; and by tiie somewhat increased length of the arm. A projection behind the clavicle ; a manifest shortening of tiie arm ; and its direction ; would clearly denote a dis- location upward. The symptoms, distinguishing the nature of dislocations of" the humerus, do not always present the same degree of certainty, as those announcing tlie existence of such an accident. Often nothing is more difficult, than to deter- mine, whether the case is a primitive dislocation inward, or a consecutive one ; the same phenomena being ob- servable in both cases. An accurate history ofthe case, by representing the order in which such phenomena oc- curred, can alone throw light on this point, which is the more interesting, as in the two cases, the means of reduc- tion should vary. In the first, the head of the bone returns, through a short track, into its natural cavity; in the second, it has to traverse a much great- er distance to arrive there. If, as Petit pretended, there were dislocations backward, sometimes pri- mitive, sometimes consecutive, this remark would be equally applicable to them. Some analogous symptoms, between dislocations of the humerus, the frac- ture of its neck, and luxations of the scapular end of the clavicle, might here create some uncertainty, if, in the latter case, the absence of a tumour in the armpit, and of a depression un- der the acromion, did not prevent an error, which, Hippocrates says, may be easily made ; into which, Galen states, the masters of the art fell; and which Pare cautions us to avoid. Uncertainty might arise, if in the fracture of the neck ofthe humerus, the proper symp- toms of a fracture did not prevent a most detrimental mistake, which the occasional direction of the humerus, and a kind of prominence, formed by the lower end of the fracture in the axilla, might cause. (S» e Fracture of the J\'eck of the Humerus.) Inflammatory symptoms seldom fol- low dislocations of the humerus. Many authors, particularly B. Bell, speak of an osdematous swelling of the whole upper extremity, as a very common consequence of a dislocation inward, and it is referred to the compression of" the axillary glands. Experience has not often demonstrated this occurrence at the Hotel Dieu, except in very old luxations ; and when the thing has oc- curred, very beneficial effects have been obtained, in certain instances, by ap- plying, for a few days, a moderately tight bandage from the fingers to the axilla, after the reduction has been ac- complished. Bichat relates a case, in which the oedema did not disappear with the cause, but even rather in- creased ; but the day after a bandage had been applied, the swelling was found diminished by one half. There is another consequence, to whicii autho'rs have paid but little at- tention; but, it was known toAvicenna, and was several times observed by De- sault. This is a palsy of the upper ex- tremity, arising from the pressure, made by the head of the.bone, disloca- ted inward, upon the axillary plexus of nerves. This consequence sometimes resists all the means of art, as Bichat proves by a case, which he relates. The affection is very difficult of cure, when the nerves have been a long time compressed. Desault several times ap- plied the moxa above the clavicle. The success, which he first experienced on some patients, did not follow invaria- bly in others. But, when the head of the humerus has only made, as it were, a momenta- ry pressure on the nerves, and the re- duction has been effected, soon after the appearance of the symptoms, the paralytic affection often goes off" of it- self, and its dispersion may always be powerfully promoted by the use of vo- latile liniments. OF THE REDUCTION. We may refer to two general classes, the infinitely various number of means, proposed for the reduction ofthe dislo- cated humerus. The first are design- ed to push back, by some kind of me- chanical force, the head of the bone, in- DISLOCATIONS. 241 to the cavity from which it is displaced, either with, or without making previ- ous extension. The others are merely intended to disengage the head ofthe bone from the place which it accident- ally occupies, leaving it to be put in its natural situation by the action of the muscles. By the first means, art effects every thing; by the second, it limits its inter- ference to the suitable direction ofthe powers of nature. In the first method, the force externally applied always ope- rates on the bone in the diagonal of two powers, which resist each other at a more or less acute angle; in the last, the power is only in one direction. 1 lere it is only necessary to state, that all the means, intended to operate in the first way, act nearly in the fol- lowing manner. Something, placed under the axilla, serves as a fulcrum, on which 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 condyles ofthe humerus being pushed downward and inward, the head of the bone is necessaiily moved in the oppo- site direction, towards the glenoid ca- vity, into wliich it slips with more or less facility. Thus operated the machine, so cele- brated among the ancients and mo- derns, under the name of the ambi of I lippocrates; whether used in the form described by this father of medicine, or with tiie numerous corrections devi- sed by Paul of iEgina, Ambroise Paru, Duverney, Freke, &c. By this ma- chine, a double motion is communica- ted to the head of the humerus, as above explained. Tiie extension usually moves the bone from its unnatural situation, and is executed in different ways. Some- times the weight of the body on one side, and the dragging of the end of the dislocated bone on the other, tend to produce this effect. Such was tiie action of the ladder, door, &c. descri- bed in Hippocrates's Treatise on Frac- tures, and repeated in modern works. Sometimes, the trunk is fixed in an un- changeable manner, while the arm is powerfully extended, as is practised in employing the machine of Oribasins, anil v. as one of the methods formerly revered in the public places, where tlie wrestlers combated. Sometimes, no extension is sensibly executed, and while the end ofthe hu- merus is pushed outward by the body placed under the axilla, the surgeon pushes it upwards into the glenoid ca- vity. We shall not here inquire into the in- conveniences peculiar to each of these methods. Petit and B. Bell have al- ready done so. We shall only point out the objection, common to all of them. The exit of the head of the bone, through the lacerated capsule is here necessarily attendant on the dislocation. Nor is it even possible to know with precision the situation of this opening. Why then should we make use of an artificial force to direct the head 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 dread- ful stretching and laceration of parts, in consequence of its application, when the trunk is suspended upon it, as in the instance of the door, &c. In this way, Petit has seen a fracture of the neck of the humerus produced, and even a laceration and aneurism of the axillary artery. 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 mo- ment in the reduction ; for it is always the more easy, the sooner it is accom- plished. When the luxation is consecutive, how can mechanical means bring back the head ofthe bone through the track it has taken? For instance, if to a dis- location downward one inward has suc- ceeded, the head of the bone must ne- cessarily be brought down, before it can be replaced in its cavity. The above artificial means often act repug- nantly to the action of the muscles, which is a chief and essential agent in the reduction. It" the dislocation should be upward, they would obviously be ineffectual. Perhaps, however, they might be ad- vantageously employed, when a primi- tive luxation downward is quite recent, and when the head ofthe bone is very near its cavity. Then the interior cos- ta ot" the scapula presents an inclined plane, along which tlie end ofthe bone can easily glide, when propelled by any- kind of external force. No doybt, it is vol. 1. 31 242 DISLOCATIONS. to this tendency of the head of the bone to be replaced, that we must attribute the success, certainly exaggerated, but in part real, on which the inventor of such machines endeavours to establish the superiority of his plan. But, in this case, it is useless to mul- tiply artificial powers, when natural means suffice, and when we can ac- complish the reduction with the hands more effectually, because we can vary the motions with more precision. Thus Desault very often employed the following method with great suc- cess. The patient being seated upon a chair of moderate height, he took hold of the hand on the affected side, placed it between his knees, which he moved downward and backward, in or- der to make the extension, and disen- gage the head of" the bone, while an as- sistant held back the trunk to effect the counter-extension. This was some- times executed by the weight of the body, and effort ofthe patient. At the same time, the surgeon's hands applied to the arm, in such a way, that the four fingers of each were put on the hollow of the axilla, and the thumbs on the outer part of the arm, pushed upward, and a little outward, tlie head of tiie humerus, which usually returned with ease into its natural cavity. Petit explains this plan, though not as here described, but complicated with the use of a napkin, passed under the patient's axilla, and over the sur- geon's neck, who contributes to raise the dislocated end of the bone, by lift- ing up his head. This accessory me- thod is always useless, and little me- thodical, preventing, also, such varia- tion of the motions, as one may wish. The hands alone are always suffieieiu, and a multitude of instances attest tlie efficacy of this method, employed in Desault's way. When the luxation downward has been very recent, Desault has, two or three times, succeeded in reducing it, by a still more simple process. Marie- Louise Favert fell in going down stairs, dislocated her arm downward, and was conveyed, immediately after the acci- dent, to the Hotel-Lieu. Desault ha- ving recongised tiie disorder, placed his left hand under the axilla, to serve as a fulcrum, while with the right, ap- plied to the lov/er and outer part of the arm, he depressed the humerus to- wards the trunk, and at the same time •ai*ed tiie upper part ofthe bone. The head of the humerus directed upward and outward -by this double motion, returned into the glenoid cavil \, with- out the least resistance. The arm was placed in a sling for two days, and on the fourth, the patient resumed her wonted labour. Dislocations downward arc not the only ones, to which the first of the above simple plans is applicable. Pri- mitive luxations inward sometimes yield to its adoption. Two examples of such success are to be found in tiie Journal de Chirurgie. . REDUCTION BY EXTENSION ALONE For the most part, however, such means are inadequate, and extension must be made. This employed alone, forms a second sort of means for redu- cing dislocations of the shoulder, and a few practitioners have deviated from tiie beaten path, and tried this latter plan. Celsus had recourse to nothing- hut extension in the ordinary cases of dislocation downward and forward. Albucasis was acquainted with no other mode. Douey, Douglas, and Heister, among the moderns, absolutely reject- ed the use of machines, always useless, frequently dangerous, Lastly, Dapoui and Fabre examined with more exact- ness the process of extension, pointed out the manner of* rendering it most advantageous in all cases, by the pro- per application ofthe extending force; and, in the dislocation of the humerus in particular, tiiey obviated the incon- venience of pulleys, placed under the arm-pit on the affected side, shewing that tiie motion, vulgarly termed, co- aptation, was of no utility. In these respects, the Art is indebted to them for real improvement, and their doc- trine, now universally diffused, was principally put into practice by Desault, who made it the base of his method of reducing all fractures, and dislocations in general. To reduce a dislocation of the hu- merus, it is necessary to have a suffici- ent number of* assistants, in order to increase the power according to tiie resistance which is to be overcome. But, two are usually sufficient for ma- king the extension: in doing which, one should employ a linen pad, of sufficient tiiickness to project above the level of" the pectoralis major, and latissimus dorsi. There must also be two banda- ges; one made of linen, several times DISLOCATIONS. 243 doubled, four inches wide, and eight or nine feet long; the other being a towel, folded in the same way, and which is often unnecessary. The patient is to sit on a chair of moderate heiglit, or else he may lie down upon a table, whicii is firmly fix- ed, and covered with a mattress. Desault, for a long while, used to put the patient in the first of these posi- tions, which, though generally employ- ed in practice, is not the best. 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 obstructed, and cannot vary, at the pleasure ofthe sur- geon, the direction in whicii 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 a horizontal plane. Hence, Desault, in the latter years of his practice, abandoned the first posi- tion, and invariably adopted the last. The patient being put in the proper position, the linen compress is to be put under the axilla, on the side affec- ted, and upon this compress the mid- dle of the first extending bandage is to be put, while its two heads ascending obliquely before and behind the chest, meet each other at the top ofthe sound shoulder, and are held there by an as- sistant, so as to fix the trunk, and make the counter-extension. The ac- tion of this bandage does not affect tiie margin ofthe pectoralis major and lat- issimus dorsi, in consequence of the pad projecting higher than them. If this were not attended to, these mus- cles being drawn upward, would pull in this direction the humerus, to which they are attached, and would thus des- troy the effect of the extension, whicii is to be made in the following man- ner :— Two assistants take hold ofthe fore- arm, above the wrist* or else the tow- el, doubled several times, is to be ap- plied to this part. The two ends are to be twisted together, and held by one or two assistants, who are to begin pulling in the same direction in wliich the humerus is thrown. After this first proceeding-, which is designed to dis- engage the head ofthe bone from its accidental situation, another motion is to be employed, which differs accor- ding to the kind of luxation. If this should be downward, the arm is to be gradually brought near the trunks at the same time that it is gently pushed upward. Thus, the head of the bone being separated from the trunk, and brought near tlie glenoid cavity, it usually glides into this situation with very little resistance. ("" I cannot omit to mention here, that the counter-extension or at least a part of it should in every instance be made against the acromion scapulae. This process in-all luxations ofthe shoulder is found very prominent; and it is very easy, by the pressure of an assistant's hand, or by means of a strap,passed over it, to make the counter-extension against it. The advantage of the prac- tice is obvious ; all the force is direc- ted on the joint, tiie scapula being completely fixed; whereas, when the counter-extension is made against tlie thorax or in the manner above recom- mended, the scapula and clavicle move with the os humeri, and much of the extending force is thereby lost. M r. Freke and Benj. Bell both advise to secure the scapula, but not precisely in the manner I have taken the liberty torecomend, which I have been induced to do from having repeatedly witnessed its good effects in the Pennsylvania hospital and in my own practice.] When the luxation is inward, after the extension has been made in the di- rection of thediumerus, the end of* this bone should be inclined upward awd forward, in order that its head may be guided backward; vice versa, when the luxation is outward. When the head ofthe bone has been disengaged by the first extension, the motion imparted to it by the rest of the extension, should in general be exact- ly contrary to the course whicii the liead of the bone has taken, after quit- ting the glenoid cavity. When there is diffiqjDlty experienced in replacing the head of the bone, we should, after making the extension, move the bone ab»ut in various manners, according to the different direction of tiie dislo- cation, and the principle just noticed. This plan often accomplishes what ex- tension alone cannot; and the head of the bone, brought by such movements towards its cavity, returns into it, while they are being executed. When the dislocation is a consecutive one, it is the first extension, made in the direction of tlie displaced bone, 244 DISLOCATIONS Which brings back Its head to where it was primitively lodged, in order to act upon the bone afterwards, just as if the luxation were one of the primitive sort. Often it is only at the moment of the reduction, that it is possible to distinguish, whether a luxation is of one or the other kind. Indeed, as the reduction mostly takes place of itself, when the extension is properly made, if the head be situated consecutively inward, it is soen to descend along the internal part of the scapula, then to proceed to the lower part, and, lastly, to ascend towards tiie opening of the capsule, into which opening it returns. When the extension is properly made; the reduction is almost spon- taneously effected. Indeed, Whatever may be the kind of primitive disloca- tion, it is clear, that the muscles on one side of the articulation must be put upon the stretch, while those on the other must be relaxed. Hence, a change must necessarily follow both in their directions and contractions, and also in the direction of these con- tractions. From tliis change the mus- cles, when they act, instead ot draw- ing hack the head of the bone towards the ruptured capsule, pull it in another direction, and thus produce a consecu- tive dislocation. But, if by rectifying things, the ex- tension should chance to restore to the muscles their former direction, then obeying their natural irritability, in- creased by the stretching of the ex- tending power, they will bring back the head ofthe bone to the opening in the capsule, and oblige it to enter w ith much more certainty, than the efforts ofthe surgeon could do, who is always ignorant of the precise situation of this opening. On the contrary, if the ex- tension, in consequence of not having been properly made, should not have restored to the muscles their natural direction, then the head of the bone will be drawn to some other point of the capsule, away from that which has been lacerated: and hence arise the very frequent difficulties attendant on the reduction of dislocated shoulders. It follows froniwhat has been said:— 1. That all the art of treating disloca- tions, consists in giving a proper direc- tion to the extending force. 2. That in general the coaptation is useless. 3. That reducing a dislocation does not consist in putting back the head of the bone into its cavity; but, in putting the muscles in a proper state for v> complishing this reduction, and that here, as every where elsr, art is only the handmaid of nature. There are cases, however, in which the action of the muscles, being per- verted by the oldness ofthe dislocation, and by the adhesions contracted with the surrounding parts, it becomes necessary to employ such means, as will serve to force, as it were, the head ofthe bone into its cavity whither tiie muscles cannot bring it. With reasoning is combined expe- rience, which is always the most ef- fectual proof of this doctrine, both res- pecting reductions of the dislocated humerus, and of such accidents in general. Desault only employed ex- tension, variously diversified, till he had put the muscles in a state, favoura- ble for accomplishing reduction. The most prompt success constantly crown- ed this part of his practice, and, daubtless, much of this success must be imputed to his wisely refusing to interfere in too great a degree. When the reduction has been ac- complished, if* the arm should be very moveable, and seem to have a tendency to be dislocated again, it must be fixed, for a few days, in such a way as will prevent all motion. A sling-, well applied, suffices for this purpose; and indeed, the arm should alw u\ s be kept quietly suppor- ted in one, after a dislocation. The French apply tiie bandage whicii De- sault has recommended for the frac- tured clavicle. OF SOME CIRCUMSTANCES, RENDER- IMG THE REDUCTION MORE DIF- FICULT. i. uVarrowness of the Opening of the Capsule. The opening of the capsule, being too narrow to allow the head of the bone to return into the glenoid cavity, is one of the chief impediments to re- duction. The obvious indication is to enlarge such an opening, by lacerating its edges. This is fulfilled by moving the bone about freely, in every direc- tion, particularly in that in which the dislocation has taken place. Xow, by pushing the head of the bone againtt the capsule already torn, the latter becomes lacerated still more, in con- sequence of being pressed between two hard bodies. The reduction, which is DISLOCATIONS. 245 frequently impracticable before this proceeding often spontaneously follows, immediately after it has been adopted. In the Journal de Chirurgie are two cases, by Anthaume, and Faucheron, establishing this doctrine. 2. Oldness of the Dislocation. This is a second impediment to re- duction, still more difficult to surmount than the foregoing one. The head of the bone, wliich has lodged a long while in its accidental situation, con- tracts adhesions to it. The surroun- ding cellular substance becomes con- densed, and forms, as it were, a new capsule, whicii resists reduction, and which, when such reduction cannot be accomplished, supplies, in a certain dfgree, the office of the original joint, by the motion whicii it allows. The majority of writersj and Bell in particular, advise, in this case, no at- tempt at reduction should be made, as it would be useless in regard to the dislocation, and might be injurious to the patient, from tlie excessive stretch- ing of parts. This was for some time tlie doctrine of Desault; but, in his lat- ter years, experience led him to adopt a bolder practice. Complete success, obtained in dislo- cations, which had existed from fifteen to twenty days, encouraged him to at- tempt reduction at the end of thirty, and thirty-five days, and, in the two years, preceding his death, he suc- ceeded, three or four times, in redu- cing dislocations whicii had existed two months and a half, and even three months, both when the head of the bone wiis situated at the lower, and at the internal part of the scapula. However violent or protracted the extension may have been, none of the terrible, consequences with which au- thors threaten us, ever occurred. One phenomenon, which it was difficult to foresee, and of which we shall speak presently, only took place m two in- stances. In these cases it is necessary, before making the extension, to move the bone about extensively in all directions, for the purpose of first breaking its ad- hesions, lacerating tlie condensed cel- lular substance, serving as an acci- dental capsule, and T>f producing, as it were, a second dislocation, in order to remove the first. Extension is then to be made in the ordinary way, but with an additional number of assist- ants. The first attempts frequently fail, and the dislocated head of the bone continues unmoved, notwithstanding the most violent efforts. In this case, after leaving off the extension, the arm is to be again moved about most ex- tensively. The humerus is to be car- ried upward, downward, forward, and backward. Force the resistances. Let the arm describe a large segment of a circle, in the place where it is situated. Let it be once more rotated on its axis ; then let the extension be repeated, and directed in every way. Thus, the head ofthe bone will be first disengaged by the free motion, and will afterwards be reduced. In these cases, when the dislocation,. in consequence of being very old, pre- sents great obstacles in the way of re- duction, even though the attempts made for tliis purpose should fail, they are not entirely useless. By forcing the head of the bone to approach the glenoid cavity, and even placing it before the cavity, and making it form new adhesions, after the destruction of the old ones, the motions of the arm are rendered freer. Indeed, they are always the less obstructed, the nearer the head of the bone is to its natural situation. 3. Contraction of tlie Muscles. A third impediment to the reduction of every kind of dislocation, is the pow- er of tlie muscles, which is augmented beyond the natural degree, in conse- quence of their being on the stretch. Sometimes, this power is so considera- ble, that it renders the head of the bone immoveable, though the most violent efforts are made. Here the means to be adopted are such as weak- en tiie patient, bleeding, the warm bath, &.c. Extension unremittingly, but not violently, continiiedfora length of time, will ultimately fatigue the re- sistmg muscles, and overcome them with more safety and efficacy, than could be accomplished by any sudden exertion of'force. The swelling about the joint, brought on by the accident, usually disappears without trouble. Another consequence, whicii seldom occurs in practice, concerning which, authors have scarcely said any thing, and which Desault several times had occasion to observe, is a considerable emphysema, suddenly originating at the tune of reduction. In the middle of such violent extension, as the long 246 DISLOCATIONS. standing of the dislocation requires, a tumour suddenly makes its appearance under the great pectoral muscle. K*. pidly increasing, it spreads towards the armpit, the whole extent of which it soon occupies. It spreads backward, and, in a few minutes, it sometimes be- comes as large as a child's head. A practitioner, unacquainted with this ac- cident, might take it for an aneurism, occasioned by the sudden rupture of the axillary artery, from the violent extension. But, it attention be paid to the elasticity of the tumour, to its fluc- tuation, to the situation where it first appears, commonly under the great pectoral muscle, and not in the axilla; to the continuance of the pulse; and to the unchanged colour of the skin; the event may easily be discriminated from any rupture of the artery.—(OZuvres Chirurgicaks de Desault, par Bichat. Tome 1.) The saturnine lotion, and gentle com- pression with a bandage, are the most advantageous means for dispersing tiie above kind of swelling. DISLOCATIONS OF THE FORE-ARM FROM THE HUMERUS. Notwithstanding the extent of the articular surfaces of the radius and ul- na with the os humeri, the strength of the muscles and ligaments surround- ing the joint, and the mutual reception of the eminences, which makes it a per- fect angular ginglymus, a dislocation of these two bones off the humerus, may take place at the same time. They are most frequently luxated backward; sometimes laterally, but very rarely forward: the latter luxation cannot oc- cur without a fracture of the olecra- non*. Luxation backwards is facilita- ted by the small size of the coronoid process, whicii may slide behind the humerus, when this is forcibly pushed downwards and forwards, and ascend as high as the cavity, which receives the olecranon during the extension ofthe fore-arm. Luxations laterally are much less frequent, and are always incomplete. The great extent of the articular sur- faces in tiie transverse direction, the reciprocal union of their inequalities, and especially the strength of the liga- * This kind of dislocation is so unci met with it. mentsand muscles, which, arising from the internal and external condyles of the inferior extremity of the humerus, go to the fore-arm and hand, give great strength to the articulation, and render it impossible to effect by any violence, a complete luxation laterally. . In the luxation backwards, the radi- us and ulna may ascend more or less behind the humerus; but the coronoid process of the ulna is always carried above the articular pulley, and is found lodged in the cavity destined to receive the olecranon. The head of the radius is placed behind and above the exter- nal condyle of the humerus. The an- nular ligament, which confines the su- perior extremity of the radius to the ulna, may be lacerated: in which case, even when the bones are reduced, it is difficult to keep them in their proper places, as the radius tends constantly to separate from the ulna. This luxation always takes place from a fall on the hand; for, when we are falling, we are led by a mechanical instinct to bring our hands forwards to protect the body. If in this case the superior extremity, instead of resting vertically on the ground, be placed ob- liquely with the hand nearly in a state of supination, the repulsion which it re- ceives from the ground will cause the two bones of the fore-arm to ascend behind the humerus, whilst the weight ofthe body pressing on the humerus, directed obliquely downwards, forces its extremity to pass down before the coronoid process of the ulna. The fore-arm, iw this luxation, is in a state of half-flexion, and every attempt to extend it occasions acute pain. The situation of tlie olecranon, with respect to the condyles ofthe humerus, is chan- ged. The olecranon, which in the na- tural state is placed on a level with the external condyle, which is itself situa- ted lower than the internal, is even higher than the latter. This luxation may be mistaken for a fracture ofthe olecranon, of the head ofthe radius, or even of the inferior extremity of the humerus. Such a mistake is attended with very bad con- sequences ; for, if the reduction be not effected before the end of" fifteen or twenty days, it is often impossible to accomplish it afterwards. The swell- i, that neither Petit nor Desault ever DISLOCATIONS. 247 ing which supervenes in twenty-four hours after the accident, renders a di- agnosis more difficult; but the olecra- non and internal condyle, are never so obscured, that the distance between them cannot be found to be increased, though Boyer makes a contrary asser- tion. It is true, that the rubbing of the coronoid process and olecranon against the humerus, may cause a gra- ting noise, similar to that ofa fracture; and some attention is certainly requi- site to establish a diagnosis between a fracture of the head of the radius, and a dislocation of the fore-arm back- wards. The following method of reducing the case is advised by Boyer :—The pa- tient being firmly seated,.an assistant is to take hold of the middle part of the humerus, and make the counter-exten- sion, wliile another assistant makes ex- tension at the inferior part of the fore- arm. The surgeon, seated on the out- side, grasps the elbow with his two hands, by applying the four fingers of each to the anterior part of tiie hume- rus, and tiie thumbs to tlie posterior, with which he presses on the olecra- non, in a direction downwards and for- wards. This method will be in gene- ral successful. If the strength of the patient, or the long continuance of tiie luxation, render it necessary to employ a greater force, a fillet is to be applied on the wrist, to make extension, and a cushion is to be placed in the axilla, and the arm and trunk fixed, as is done in cases of luxation ofthe humerus. A bandage may afterwards be appli- ed, in the form of a figure of 8, and the arm is to be kept in a sling.,v The laceration which always takes place, is always followed by more or less swelling, which is to be combated by antiphlogistic means. At the end of" 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 to pre- vent an anchylosis, to which there is a great tendency. In this luxation, the annular ligament which confines, the head of the radius to tin'extremity of the ulna, is some- times torn, and the radius passes be- fore the ulna. In such cases, pronation and supination are difficult and painful, though the principal luxation has been reduced. The head ofthe 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 the superior and external, part of the fore-arm. The bandage and compres- ses are to be taken off' every two or three days, and reapplied. This is ne- cessary, on account of the necessity of moving the articulation to prevent an anchylosis. If the luxation be not soon reduced, it becomes irreducible; the heads of the radius and ulna grow to the back part of the humerus, and the patient can neither bend nor extend his arm. However, in some cases, especially in young persons, some motion is acqui- red in time; the heads of the radius and ulna making in the humerus cavi- ties, in which they perform some mo- tions, but always imperfectly. The luxation forwards should be treated as a fracture ofthe olecranon, with which it would be inevitably ac- companied. It may be necessary, on account of the great injury done to the soft parts, to bleed tlie patient copious- ly, and put him on an antiphlogistic re- gimen. As to the lateral luxations, either in- wards or outVards, they are always in- complete, and easily discovered. They are reduced by drawing the humerus and fore-arm in contrary directions, and at the same time pushing the ex- tremity of the humerus, and the two bones of the fore-arm in opposite direc- tions. These luxations cannot be produced without considerable violence; but when the bones are reduced, they are easily kept hv their place. It will be sufficient to pass a roller round the part, to put the fore-arm in a middle state, neither much bent nor extended, and to support it in a sling. But much inflammation is to be expected from the injur) done to the soft parts. In order to prevent it, 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 aq. litharg. acet.* It is scarcely necessary to repeat, that the arm is to * Boyer say-j emollient cataplasms. 248 DISLOCATIONS. be moved as soon as the state of the soft parts will admit of it.* The dislocation ofthe fore-arm back- ward, is said to occur ten times as fre- quently as lateral luxations; and those forward are so rare, that no compari- son whatever can be dravvn.f Lateral luxations have been divided into complete, that is, when the articular surfaces have entirely lost their state of reciprocal contact; and into incom- pkte, that is, when only one bone, or a part of it, is thrown off" the humerus. But, what cause can operate with suffi- cient force to produce the first occur- rence ' The mischief would also be so great, were such a case to happen, that amputation would most likely be re- quisite. The incomplete lateral luxation may be produced by a blow, whicii drives the upper part ofthe fore-arm violent- ly outward, or inward. A footman, says Petit, in falling from a coach, had his arm entangled in the spokes of a wheel, and a dislocation outward was the consequence. Another man luxa- ted his fore-arm inward, by falling from his horse and driving his arm against an uneven place. When the ulna is pushed into the situation of the radius, the space, be- tween the olecranon and internal con- dyle, is much greater, than is natural. These points of bone are always very distinguishable, let the joint be ever so much swollen; and hence, the infor- mation to be derived from an examina- tion of them, may be obtained in every case, without exception. Also, when the ulna is pushed into the place ofthe radius, the latter bone cannot be easily rotated, nor can the fore-arm be bent, and extended, in a perfect manner. The dislocation inward must be very uncommon, as the form of the bones is almost an insurmountable obstacle to such an accident. It may happen, however, as the authority of Petit con- firms. All recent dislocations of the elbow are very easily reduced, and as easUy maintained so; for the reciprocal man- ner in which tiie articular surfaces re- ceive each other, and their mutual em- inences and cavities, will not readily allow the bones to become displaced again. The application of a bandage in the form of a figure of 8, and supporting the arm in a sling, are proper in all these cases. DISLOCATION' 0 1 THE RADIUS FROM THE ULNA. The majority of authors, who have written on dislocations of the fore-arm, have not separately considered thosi ofthe radius. Some detached obser- vations, on luxations of* its superior ex tremity, are to be found here and there; a subject, which Duverney alone has fully treated of. The dislocations of its lower end, which are more frequent, and easy of-occurrence, have almost escaped the notice of French, and, also, of English writers. At present, cases of this sort have been so nume- rously collected, that a particular ac- count of them may be ottered. DIFFERENCE OF STRUCTURE, BE- TWEEN THE TWO JOINTS OF Tilt RADIUS, WITH THE ULNA. The radius, the moveable agent of pronation and supination, rolls round the ulna, whicii forms its immoveable support by means of two articular sur- faces; one above, slightly convex, broad internally, narrow outwardly, and corresponding to the little sigmoid cavity of the ulna, in whicii it is lodged; the other below, concave, semicircu- lar, and adapted to receive the convex edge of the ulna. Hence, there are two joints, differing in their motions, articular surfaces, and ligaments. Bv ascertaining such differences, we shall be enabled to find out those, which exist between the luxations of the up- per and lower head ofthe radius. Above, the radius, in pronation and supination, only moves on its own axis ; below, it rolls round the axis of the ulna. Here, being more distant from the centre, its motions must be- both more extensive and powerful, than they are above. The head ofthe rad- ius, turning on its own axis in the an- nular ligament, cannot distend it in any direction. On the contrary, below, the radius, in performing pronation, stretches the posterior part of the cap- sule, and presses it against the immove- * Boyer on Diseases ofthe Bones, vol. ii. f OZuvres Chirurgicahs de Desault. Par Bichat. Tome 1 DISLOCATIONS. 249 able head ofthe ulna, which is apt to be pushed through, if the motion be forced. A similartevent, in a contrary sense, takes place in supination. The front part of the capsule, being ren- dered tense, may now be lacerated. Add to this disposition, the differ- ence of strehgth between tile ligaments of the two joints. Delicate, and yield- ing, below; thick, and firm, above; their difference is very great. The upper head ofthe radius, supported on the smaller immoveable articular sur- face of* the ulna, it is protected from dislocation in most of its motions. On the contrary, its lower end, carrying along with it, in its motions, the bones of the carpus, which it* supports, can- not itself derive any solid stability from them. DIFFERENCES OF DISLOCATION OF THE RADIUS. From what has been said, the fol- lowing conclusions may be drawn: 1. That with more causes of luxation, the loyer articulation ofthe radius has less means of resistance; and, that un- der the triple consideration of motions, ligaments tying the articular surfaces together, and the relations of these surfaces to each other, this joint must be very subject to dislocation. 2. That, for opposite reasons, the upper joint cannot be very subject to such an accident. Indeed, what could be the cause pro- ducing it in this situation' Can it arise from a violent pronation, orsupination? The lower joint being the weakest, would give way the first, and however forcible any motion of this kind might be, the upper head ofthe radius would only-lie rotated on its own axis. How then can tliis part be dislocated, with- out being pushed forward, or back- ward ? All the muscular and ligament- ous support ofthe joint must be brok- en ; and the muscles and ligaments are too strong to admit of this, and the motion itself too feeble. Can tiie acci- dent originate from any impulse on the radius, from below upward ? The im- moveable resisting end ofthe hume- rus would then prevent the radius from quitting the capsular ligament. Can the accident arise from a violent ex- tension, or flexion of the fore-arm > Here the whole force operating on the ulna, the radius scarcely feels the im. pulse. vol. 1. Hence, accidental dislocations of tlie radius, suddenly produced by an ex- ternal cause, must, if they ever hap- pen, be exceedingly uncommon at its upper end. This is not the case, with respect to such dislocatious, which oc- cur slowly at this joint, especially in whom the ligaments become lax in consequence of repeated efforts. With this kind of case, wre Jjave here no- thing to do. ^ Experience sometimes seems to mili- tate against the above reflections. Duverney quotes some instances of dis- locations of the radius, suddenly pro- duced by external causes. Some other practitioners mention similar examples. But, in their examination, have these men paid all due attention ? An anal- ogous case has been transmitted to the French Academy of Surgery, by one of its fellows; but, doubts have arisen concerning its reality, and there are too few facts for, and too much pre- sumptive evidence against, the truth of such cases, to believe their existence. Desault himself rejected their reality. DISLOCATION OF THE LOWER END OF THE RADIUS. The causes are the same, as those of all analogous cases. 1. Violent action ofthe pronator and supinator muscles This is, dotibtlesss, a very unusual cause, for Desault never knew an in- stance of it. 2. External force, moving the radius violently into a state of" pro- nation, and rupturing the back part of the capsule; or into a state of supina- tion, and breaking the front part of the capsular ligament. Hence, tliere are two kinds of dislo- cation; one forward, the other back- ward. The first is very frequent; the second is much less so. The latter case never presented itself to Desault, but once, in the dead body of a man, who had both his arms dislocated, and no particulars could be learnt. The other case occurred very often in the practice of this eminent surgeon. Five examples have been published. Doubt- less, this difference is owing to all the principal motions ofthe radius being in the prone direction. This observation is confirmed by the fact, that the lower joint of the radius in the dead subject, may be dislocated as easily by a supine, as a prone mo- tion of this bone. The symptoms of the luxation for- 32 250 DISLOCATIONS. ward are: 1. Constant pronation ofthe forearm: 2. An inability to perform supination, and great pain on this being attempted: 3. An unusual projection at the back of the joint, in consequence ofthe protrusion of the little head of the ulna through the capsule : 4. The position ofthe radius is more forward than natural : 5. Constant abduction of the thumb, which is also almost always extended: 6."*"" A half-bent state of the forearm, and very oftenTof the fingers. This, indeed, is the position, whicii the forearm usually assumes in all af- fections of its bones, and, in the pre- sent instance, the posture cannot be changed, without considerable pain: 7. More or less swelling around the joint. This sometimes comes on im- mediately after the accident, but always afterwards, if the reduction should remain unaccomplished. The condition of the joint may thus be ob- scured, and the accident mistaken for a sprain; as Desault often observed to have occured with surgeons, who had been called to these accidents before him. The serious consequence of tliis mistake is, that no attempt at reduc- tion is made, and the articular surfaces having time to contract adhesions, the disorder is frequently rendered irreme- diable. A luxation ofthe radius backward is characterized by symptoms, the reverse of those above mentioned. They are, a violent supination ofthe limb; inability to put it prone ; pain on making the attempt; a tumour in front ofthe fore- arm formed by the head ofthe ulna; a projection backw ard of the large head of the radius; and abduction of the thumb. REDUCTION. When the dislocation is forward, an assistant is to take hold of the elbow, raising the arm a little from the body ; another is to take hold of the hand and fingers. The surgeon is to take hold of the end of the forearm with his hands ; one applied to the inside, the other to the outside, in such a manner, that the two thumbs meet each other before, between the ulna and radius, while the fingers are applied behind. He is then to endeavour to separate the two bones from each other, pushing the radius backward and outward, while the ulna is held in its proper place. At the same time, the assistant, holding tiie hand, should try to bring it into a state of su- pination, and consequently the radius, which is its support. Thus pushed, in the direction opposite that of the dis- location, by two powers, the radius is moved outward, and the ulna returns into the opening of the capsule, and into the sigmoid cavity. If chance should present a disloca- tion of the radius backw aid, the same kind of proceeding, executed in the opposite direction, would serve to ac- complish reduction.* DISLOCATIONS OF THE WRIST. The carpal bones may be luxated from the lower ends of the radius and ulna forwards, backwards, inwards, or outwards. The two first cases, espe- cially the one backwards, are the most frequent. The dislocation backwards is rendered easy by the direction of" the convex articular surfaces of the sca- phoid, semilunar, and pyramidal bones, whicii sloping more backwards, than forwards, must make them more dis- posed to slip in this direction, than any other. The accident may be caused by a fall on the back of" the hand while much bent; in which event the first row of the carpal bones slide back- wards into the oblong cavity of the radius, lacerate the posterior ligament, and form an eminence behind the lower ends of the bon"fcs of the forearm. This prominence, the depression in front of the wrist, and the extraordi- nary flexion of the hand, whicii cannot be extended, are the characteristic signs of this kind of dislocation. The dislocation forwards generally arises from a fall on the palm, the fin- gers being extended, and more force operating on the lower, than upper part ofthe palm. The luxation is seldom complete ; and the hand remains pain- fully extended. The great many ten-. dons, which run before the wrist, and the annular ligament, being pushed for- ward, the prominence formed by the * See Q2avres Cfdrurgicaks de Desault; par Bichat. Tome I. DISLOCATIONS. 251 carpal bones, in front ofthe ends of the radius and ulna, is not easily detected, and the case may be mistaken for a sprain. Dislocations inwards, or outwards, are never complete. The projection of the carpal bones at the inner, or outer side of the joint, and the distor- tion of tiie hand, make such cases suffi- ciently evident. All dislocations ofthe wrist are very easy of reduction. For this purpose, gentle extension must be made, wliile the two surfaces of tiie joint are made to slide on each other in a direction contrary to what they took when the accident occurred. Dislocations of the wrist are always attended with a great deal of spraining of numerous tendons, and laceration of ligaments, and consequently considera- ble swelling generally follows, and the patient is a long time in regaining the perfect use of the joint. To relieve the symptoms as much as possible, the best plan is to keep the hand and wrist continually covered with linen wet with the saturnine lotion, and to put the fore- arm and hand in splints, as in the case of a fracture. See Fractures ,of the forearm.* The arm must also be kept perfectly at rest in a sling. .^ When the ruptured ligaments have united, the use of liniments will tend to remove the remaining stiffness and weakness of the joint. DISLOCATIONS OF THE BONES OF THE CARPUS AND METACARPUS. A dislocation of the carpal bones from each other seems almost impossi- ble. The os magnum, however, has been known to be luxated from the deep caftty formed for it by the sca- phoides and semilunare, in consequence of too great a flexion of the bones ofthe first phalanx on those of the second, and it forms a tumour on the back of the hand. (Chopart,- Boyer; Riche- rand.) The metacarpal bones are never lux- ated from each other. The first one is sometimes, though very rarely, push- ed oft' the trapezium. DISLOCATION OF THE FINCERS. The first phalanges may be dislocat- ed backwards off the heads of the me- tacarpal bones. A luxation forwards would be very difficult, if not impossi- ble, because the articular surfaces of the metacarpal bones extend a good way forwards, and the palm of the hand makes resistance to such an acci- dent. The first phalanges of the thumb and little finger can alone be dislocated inwards; and the first phalanx of the thumb is alone subject to be luxated outwards. This phalanx is also most liable to dislocations backwards, be- hind the head of the first metacarpal bone, in which case it remains extend- ed, while the second is bent. These dislocations should be speedi- ly reduced; for, after eight or ten days, they become irreducible. In a luxation of the first bone of the thumb, wliich was too old to be reduced, De- sault proposed cutting down to the head of the bone, and pushing it into its place with a spatula. Dislocations of the thumb and little finger inwards, that of the thumb outwards, and luxa- tions ofthe first phalanges of tiie other fingers backwards, are all reduced by making extension on the lower end of the affected thumb, or finger. The first and second phalanges may also be dis- located backwards. After the reduction, the thumb, or finger, affected, should be rolled with tape, and incased, and supported in pasteboard, till wie lacerated ligaments have united; taking care to keep the hand and forearm quietly in a sling. DISLOCATIONS OF THE BONES OF THE PELVIS. M. Louis, in Tom. 4, ofthe Mem. de VAcad. de Chir. relates a case, in wliich the os ilium of tiie right side was found separated from the sacrum, so as to pass nearly three inches behind it. This accident was caused by a very heavy sack of wheat falling on a labourer, and the truth of it wa§ ascertained by dissection. Such a case must be ex- ceedingly uncommon. The os coccygis is not so easily dis- located as fractured. Boyer, however, has seen it displaced in a man, who was greatly emaciated by disease. This subject had considerable ulcerations about the coccyx, and the bone itself was bare. There was an interspace of nearly two inches, between the sacrum and base of the os coccygis. In propor- tion as the man regained his strength, the bone recovered its right position ; and at length united to the os sacrum, notwithstanding the action of the leva- j 252 DISLOCATIONS. tores ani, which, are inserted into it. (Boyer.) This case, however, was not an accidental luxation; and it clearly arose from the destruction of the liga- ments by disease. Authors mention two kinds of dislo- cation, to which the os coccygis is lia- ble, one inward, the other outward. The first is always occasioned by ex? ternal violence ; the second, by the pressure ofthe child's head in difficult labours. The nature of these accidents is easily discovered by the preceding causfe, and by an examination with tiie fingers, externally, and within the rec- tum. Pain, difficulty of voiding the farces and urine, tenesmus, and inflam- mation, sometimes ending in abscesses, which interest the rectum, are symp- toms, said to attend and follow dislo- cations ofthe os coccygis. These luxations are easily reduced, by means of a finger in the rectum, as- sisted by tlie other fingers externally. No more can be done, than in the case of a fracture. See Fracture. DISLOCATION OF THE RI|H. J. L. Petit was silent on this subject, a« he thought such cases never occur- ed. Since his death, a French surgeon, Buttet, has related an instance, whiclj he supposed to be a dislocation of the posterior extremity ofthe rib from the vertebra:; but, Boyer clearly shews he had no true reasons for this opinion, and that the case was only a fracture of the neck, or end of the bone, near the spine. Ambroise Pare, Barbette, Junker, Platner, and Heister, not only admit tiie occurrence of luxations of the ribs, but, describe different species of them. Lieutaud also termed cases, in whicii the head of the rib was separated by disease, luxations. On the whole, we may conclude, that the ribs are so rare- ly dislocated, that tiie subject is not deserving of much attention in this work. DISLOCATIONS OF THE THIGH-BOMB The head of the thigh-bone may ba dislocated upwards and outwards on the dorsum of the ilium ; upwards and forwards on the body of the os pubis ; downwards and inwards on the fora- men ovale; and downwards and out- wards on the os ischium. The dislocation upwards and out- wards, and the one downwards and in- wards, are the most frequent. First, of luxations on the ilium. The common kind of dislocation of the thigh-bone, upward and outward, is attended with the following symp- toms. The affected thigh is shorter, than its fellow, is a little bent, and car- ried inwards. The knee inclines more forwards and inwards, than the oppo- site one ; the leg and thigh arc turned inwards, and tiie foot points in this di- rection. The trochanter major is brought nearer the anterior superior spinous process of the os ilium, and is at the same titae elevated and carried a littie forwards. The natural length of the limb cannot be restored, without reducing the luxation; the foot cannot be turned outwards, and any attempt to do so causes pain; but, the inclina- tion of the foot inwards may be in- creased. (Boyer.) This luxation has nothing in common with a fracture ofthe neck ofthe thigh- bone, except the shortness of tiie limb. The cases are at once discriminated by this difference, that, in. this kind of i luxation, the limb and toes are turned inwards, while id all fracturif* of the ■ m thigh-bone, t/iey are intiariably turned outwards. Many> writers have been puzzled how to account for the toes being in-, clined inwards. We have only to re- flect, however, that the trochanter ma- jor is situated forwards, and that the head of the bone lies backwards, when we shall immediately perceive, that the limb is mechanically prevented from being rotated outwards. To reduce this dislocation, the pa- tient should be placed on his opposite side upon a table firmly fixed, or a large four-posted bedstead. A sheet, folded longitudinally, is first to be placed under the perineum, and one end being carried behind tho patient, the other, before him; they are to be fastened to one of the legs, or posts of the bed. Thus 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 exten- sion to keep the scrotum and testicles from being hurt, or tiie pudenda in women, by the sheet passed under the perineum. The patient must be further fixed by being held by assistants. DISLOCATIONS. 253 The best practitioners of the present day in France, advise the extending force to be applied to the inferior part of tlie leg, in order to have it as far as possible from the parts, which resist the return of the bone into its natural situation. In this country, surgeons generally prefer making the extension by means of a sheet, fastened round the limb just above the condyles of the os femoris. ■ As soon as the head ofthe bone lias 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 press- ing on the great trochanter. The extension should always be made in a gradual and unremitting manner : at first, gently ; but after- wards, more strongly; yet never vio- lently. The difficulty of reduction arises from the great power and resist- ance ofthe muscles, and these must at length be fatigued, so as to yield to the extending force, if care be taken, that it be maintained the necessary time, without the least intermission. In very strong, athletic subjects, it may be proper to bleed them, in order to produce a temporary weakness, for the purpose of facilitating the reduc- tion. The disappearance of all the symp- toms, and the noise made by the head ofthe bone, when it slips into the ace- tabulum, denote, that the reduction is effected. The bone is afterwards to be kept from slipping out again, by ty- ing the patient's thighs together with a bandage placed a little above the knees. The patient should be kept in bed for at least three weeks; live low, and rub the joint with the linimentum camph. et suponis. Due time must be given for the lacerated ligaments to unite, and the sprained parts to reco- ver; and premature exercise may bring on irremediable disease in the joint. Mr. Hey gives the following direc- tions, and description of the way, in whicii he reduced a case of this kind. " The extension ofthe limb must be made in a right line with the trunk of the body: and, during the extension, the head ofthe bone must be directed outwards as well as downwards. A rotatory motion ofthe os femoris on its own axis, towards the spine, (the patient lying prone) seems likely to ele- vate the great trochanter, bring it near- er to its natural position, and direct the head of the bone towards the ace- tabulum. These circumstances led to the following method. A folded blan- ket was wrapped round one of the bed posts, so that the patient, lying in a prone position, and astride of the bed post, might have the affected hmb on the outside of tiie bed. The bed was rendered immoveable, by placing it against a small iron pillar, whicii had been fixed for the purpose of support- ing the curtain rods. The leg was bent to a right angle with tlie 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 mo- tion, 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 of the patient, to press the head of the bone downwards and out- wards during the extension. Two long towels were wrapped round the thigh just above the condyles, one towel pass- ing on the inside of" the knee, the other on the outside. Tliree 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 the 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 ef- fect, and the head of the bone moved downwards and outwards into the ace- tabulum." (Hey's Practical Observa- tions, p. 313.) There is another kind of dislocation upward and outward, so rare, that ma- ny experienced men have never seen it, and few have mentioned it. I allude to the case, in which the head of tiie thigh- bone is so situated on the dorsum of the ilium, that it lies forward, the tro- chanter major backward, and an in- stance of which I have myself seen in St. Bartholomew's hospital. This case deserves very particular attention, be- cause being attended with a considera- ble turning of the toes outwards, as well as a shortening of the limb, it is the only example, which is at all likely to be mistaken for a fracture of the neck of the thigh-bone. The case, however, is not difficult of detection; for, you can even feel the head of the 254 DISLOCATIONS. bone projecting forward on the ilium, and you cannot rotate the limb inwards, which can be done in cases of fracture, though doing so is productive of im- mense suffering. This rare kind of luxation is to be reduced by the same means, and in the same manner, as the common disloca- tion upwards and outwards, already treated of. Another of the most frequent luxa- tions of the thigh-bone, is downwards and inwards, upon the obturator fora- men. The occurrence of this accident is facilitated by tiie great extent of the motion of abduction of the thigh; by the notch at the inferior and internal part of the acetabulum; by the weak- ness of the orbicular ligament on this side; and by the ligamentum teres not opposing, nor being necessarily rup- tured by it. The head of the bone is thrown between the obturator ligament, and obturator externus muscle. The symptoms are as follows: the affected thigh is longer, than the sound one; the head of the femur being situ- ated lower than the acetabulum, the trochanter major is removed to a great- er distance from the anterior superior spinous process of the ilium, and the thigh is flattened, in consequence of the elongation of the muscles. A hard, round tumour is felt at the inner and superior part of the thigh, formed by the head of the femur. The leg is slightly bent; and the knee and foot, are turned outwards, and cannot be brought back into their proper direc- tion. This case, like a fracture, is attend- ed with a turning ofthe toes outwards; but, besides being easy of discrimina- tion on every account, the elongation of the limb at once denotes, that tliere is no fracture, which always causes a shortening of the member. Dislocations on the obturator fora- men, are very easy of reduction. The extension is to be made downwards and outwards, so as just to dislodge the head ofthe bone, and then the mus- cles generally draw it in into the ace- tabulum, on the extending force being gradually relaxed, and the surgeon pushing the upper part of the bone outward. The thigh-bone is sometimes,~though very seldom, luxated upwards and for- wards, into the groin. The whole limb is turned outwards and shortened; the the trochanter major is approximated . to the anterior superior spinous pro- cess ofthe ilium; the head ofthe bone forms a tumour in the groin, and press- ing on the anterior crural nerves, cau- ses great pain, numbness, and even pa- ralysis ; and the knee is carried back- wards. The head of the bone felt in the groin; the inclination ofthe knee back- wards; and the impossibility Of rota- ting the limb inward; distinguish it from a fracture ofthe neck of the bone. It is reduced, in the same way, as the luxation downwards and forwards. Mr. Hey says, that " In this species of dislocation, (downwards and for- wards,) as the head of the bone is si- tuated 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 far- ther 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 exten- sion has removed the head of the bone from the external obturator muscle, which covers the great foramen of the os imiominatum, the upper part ofthe os femoris must then be pushed or drawn outwards; which motion will be greatly assisted by moving the lower part ofthe os femoris, at tlie same mo- ment, in a contrary direction; and, by a rotatory motion of the bone upon its own axis, turning tiie 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 cur- tain rods of the 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 abdomen 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 rece- DISLOCATIONS. 255 ding backwards. He was also support- ed on eacli side. " Two long towels were put round the lower part of the thigh, after the part was well defended from excoria- tion by the application of a flannel roll- er. The knot, whicii the towels form, was made upon the anterior part of the thigh, that the motion intended to be given to tlie leg might not be impe- ded by the towels.' " The thigh being placed in a hori- zontal position, or rather a little eleva- ted, with the leg hanging down at right angles to the thigh, I sat down upon a chair, directly fronting the patient, and directed a gentle extension to be made by the assistants standing at my left side. This was done with the view of drawing tiie head of the bone a little nearer to the middle ofthe thigh, and the extension had this effect. I then placed the two assistants, who held the towels, at my right side, by which means the extension would be made in a direction a little inclined to tiie sound limb. Mr. Logan stood on the right side of the patient, with his hands pla- ced on the upper and inner side of the thigh, for the purpose of drawing the head ofthe bone towards the acetabu- lum, when the extension should have removed it sufficiently from the place in whicii it now lay. " I desired the assistants to make the extension slowly and gradually; and to give a signal when it arrived at its greatest degree. At that moment, Mr. Logan drew the upper part ofthe bone outwards, while I pushed the knee inwards, and also gave the os fe- moris a considerable rotatory motion, by pushing the right leg towards the left. By these combined motions, the head of the os femoris was directed upwards and outwards, or, in other words, directly towards the acetabu- lum, into which it entered at our first attempt made in this manner. " The scrotum, as the patient assu- red me, was not hurt in the least by the extension " (Hey, p. 318.) The last dislocation ofthe thigh re- maining to be spoken of, is that down- wards and backwards. The head of tiie bone rests against that part of the ossa innonimata where the ilium and ischium join. The limb is turned out- wards. When the luxation is primary, the extremity is lengthened. A hard tumour is felt at the posterior and in- ferior part ofthe buttock, and the great trochanter is removed further from the spine of the ilium. When secondary (which is far more frequent,) the pri- mary luxation having been upwards and outwards, the foot is turned in- wards. The primary luxation down- wards and backwards, with the toes turned outwards, is as unusual, as the case upwards and backwards, with the foot in the same position. The length- ening of the limb, however, at once shews the case not to be a fracture. The pelvis being fixed, as already described, the extension is to be made downwards and forwards, to dislodge the head of the bone, while the sur- geon, with a napkin, placed just below the trochanter minor, pulls the upper part of the femur towards the aceta- bulum. DISLOCATIONS OF THE PATELLA. This bone may be luxated, either in- wards, or outwards, when violently pushed in this direction. The luxation outward is the most frequent, because the bone more easily slips in this di- rection off" the outer condyle of the fe- mur, than inwardly. All these cases are easily reduced, on relaxing the ex- tensors of the leg, and bending the thigh ; but, owing to a relaxed state of the ligament of the patella, or other predisposing causes, the bone is some- times difficultly kept in its proper situ- ation, without applying a roller to the part. The inflammatory affection of the joint is to be opposed by bleeding, purging, and using the saturnine lotion. The joint must be kept quiet a few days, and then gently moved to prevent stiffness. DISLOCATIONS OF THE KNEE. The tibia may be luxated forward, backward, or to either side. The dislocation backward is always incomplete, and sometimes is seconda- ry, being a consequence of white-swell- ings. The luxation forward is even more rare, than the one backward. Disloca- tions inward, or outward, are the most frequent, and are always incomplete. The nature of all these cases is so con- spicuous at first view, that there is no need of any detail of particular symp- toms. The bones of the leg are sometimes twisted outward, and the internal la- 256 DISLOCATIONS. teral ligament ruptured; but, this may happen without the crucial ligament being broken. On the otiier hand, when tiie bones ofthe leg are violently twisted inward, both the crucial liga- ments, and external lateral ligament, must inevitably be ruptured. These accidents are all most easily reduced, on making gentle extension, and pushing the head of the tibia in the proper direction. The grand object, after the reduction, is to avert inflam- mation of the knee, and promote the union of the ligaments. The first de- mands the rigorous observance of the antiphlogistic plan ; both require the limb to remain perfectly motionless, supported by one, or two splints. As soon as the ligaments have grown to- gether, and the danger of inflammation is over, which will be in about tliree weeks, the joint should be gently bent and extended a certain time every day to prevent stiffness. Liniments will now also be of service. DISLOCATIONS OF THE FOOT. The foot may be dislocated inwards, or outwards ; forwards, or backwards ; and either of these luxations may be complete, or incomplete. Dislocations inwards, or outwards, are the most common ; the former occurring, how- ever, more frequently, than the latter, wliich are greatly resisted by the low- nessof the malleolus externus. Many of theise accidents are com- pound ; that is, attended with a wound communicating with the joint; a cir- cumstance that greatly increases the danger, and is frequently the occasion ofthe patient losing his limb, and even his life. It is only, however, when the soft parts are very much contused, and extensively lacerated, that amputation should be had recourse to in the first instance. When the bones are reduced, and the edges of the wound brought into contact, the unpromising aspect of the case is very much diminished, and many, who might think amputation advisable at first view of the accident, would change their mind, as soon as the bones have been replaced. Dislocations inwards, or outwards, are very easily reduced, and require very little extension. In accomplish- ing the reduction, it is best to relax the strong muscles of the calf by bending the leg on the tiiigh. The case is af- terwards to be treated in the same way as a fracture of the leg. Mr Pott has called the attention of 9urgeons to a particular kind of dislo- cation, in which the utility of relaxing the muscles, is strikingly illustrated. I mean the instance, in which, " by leap- ing, or jumping, the fibula breaks in the weak part already mentioned, that is, within two or three inches of its lower extremity. When this happens, the inferior fractured end of the fibula falls inward toward the tibia, that ex- tremity of the bone which forms the outer ankle, is turned somewhat out- ward and upward, and the tibia having lost its proper support, and not being of itself capable of steadily preserving its true perpendicular bearing, is forced off from the astragalus inwards; by which means the weak bursal, or com- mon ligament of the joint, is violently stretched, if not torn, and the strong ones, which fasten the tibia to the as- tragalus and os calcis, are always la- cerated ; thus producing at the same time a perfect fracture and a partial 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 whicii pass behind or under, or are attached to the extremities of the tibia and fibu- la, or os calcis, have their natural di- rection and disposition so altered, that, instead of performing their appointed actions, they ail contribute to the dis- tortion ofthe foot, and that by turning it outward and upward. " When this accident is accompa- nied, as it sometimes is, with a wound ofthe integuments of the upper ankle, and that made by the protrusion ofthe bone, it not infrequently ends in a fatal gangrene, unless prevented by timely amputation; though I have several times seen it do very well without. But in its most simple state, unaccompanied with any wound, it is extremely trou- blesome to put to rights, still more so to keep it in order, and, unless mana- ged with address and skill, is very fre- quently productive both of lameness and deformity ever after. " After what has been said, a farther explanation why this is so, is unneces- sary. Whoever will take even a curso- ry view of the disposition of tlie parts, wdl see that it must be so. By the fracture of the fibula, the dilatation of DLS DIS 257 the bursal ligament of the joint, and the rupture of those which should tie the end of tiie tibia firmly to the astra- falus and os calcis, the perpendicular earing of the tibia on the astragalus is lost, and the foot becomes distorted ; by this distortion the direction and ac- tion of all the muscles already recited are so altered, that it becomes (in tlie usual way of treating this case) a diffi- cult matter to reduce the joint,- and, the support of the fibula being gone, a more difficult one to keep it in its place after reduction. If it be attempted with compress and strict bandage, the consequence often is a very trouble- some, as well as painful ulceration of the inner ankle, which very ulceration becomes itself a reason why such kind of pressure and bandage can be no longer continued ; and if" tho bone be not kept in its place; tiie lameness and deformity are such, as to be very fa- tiguing to the patient, ahd to oblige him to wear a shoe with an iron, or a laced buskin, or something of that sort, for a great while, or perhaps for life. " All this trouble, pain, difficulty, and inconvenience, are occasioned by putting and keeping the limb in such position as necessarily puts the mus- cles into action, or into a state of re- sistance, winch in this case is the same. This occasions the difficulty in reduc- tion, and the difficulty in keeping it re- duced ; this distorts the foot, anil by pulling it outward and upward makes that deformity which always accompa- nies such accident; but if the position ofthe limb be changed, if by laying it on its outside, with the knee moderate- ly bent, the muscles forming tlie calf of the leg, and those whicii pass behind the fibula, and under the os calcis, are all put into a state of relaxation and non-resistance, all this difficulty and trouble do in general vanish immedi- ately ; the foot may easily be placed right, the joint reduced, and by main- taining the same disposition of the limb, every thing will in general suc- ceed very happily, as I have many times experienced." (Pott.y It occasionally happens in compound luxations of the ankle, that the astra- falus only remains attached by a few bres, in wliich circumstance, if it be judged prudent to attempt the preser- vation of the limb, it is best to imitate Ferrand and Desault, by extirpating this bone entirely^ so as to allow the vol. 1. tibia to become anchylosed to the up- per surface of the os calcis. Dislocations forwards and backwards are not very common. The first case is the most difficult to produce. The facility, with which all disloca- tions of the ankle are recognised by surgeons, acquainted with anatomy, renders a particular account of the symptoms quite superfluous. Both the latter cases are easy of re- duction, when care is taken to relax the muscles of the calf, which attention is most particularly essential to pre- vent the bones from becoming dis-' placed again. The hmb must be put in splints, just as if tiie case were a fracture. The os calcis and astragalus are so intimately connected, that they are never completely luxated from each ether. But, one, or both of these bones may be dislocated from the scaphoides and cuboides by violent force, when the forepart ofthe foot is fixed. (J. L. Petit.) The astragalus and os calcis, particularly the former, may then be luxated upwards into the cavity on the back of the scaphoides, so as to form a tumour on the back of the foot. The reduction is difficult: Boyer in one case could not succeed ; but no lame- ness remained with tiie deformity, The first phalanx of the great toe is sometimes dislocated from the first metatarsal bone. The reduction is too simple to need explanation. On the subject of Dislocations, con- sult Petit, Traite des .Maladies des Os. Boyer's Lectures on the Diseases of the Bones, Vol. II. QZuvres Chirurgicaks de Desault,- par Bichat, Turn. I. Pott's* Remarks on Fractures and Dislocations, and Hey's Practical Observations in Sur- gery. Kirkland's Observations upon Mr. Pott's General Remarks on Frac- tures, &c. fVhite's Cases in Surgery. Medical Observations and Inquiries, Vol. II. Bromfleld's C/ururgical Cases and Observations. DISTICHIA, or DISTICHIASIS, (from tv», to cut. The opera- tion of cutting into the womb, in order to extract the foetus. (See Cesarean Operation.) EMOLLIENTIS, (from emollie, to soften.) Emollientia. Such applica- tions, as have the property of softening and relaxing parts. EMPHYSEMA, (from tjU^urao,, to inflate.) A swelling produced by air being diffused in the cellular substance. The common cause of this affection is a fractured rib, by which the vesicles ofthe lungs being wounded, the air escapes through them into the cavity ofthe thorax. But, as the rib on being fractured, and pushed inwards, wounds the pleura, which fines the ribs and in- tercostal muscles, part of the air most commonly gets through the pleura, and those lacerated muscles into the cellular membrane, which is on the out- side of the chest, and thence it is dif- fused through the same membrane over the whole body, so as to inflate it sometimes to an extraordinary degree. This inflation ofthe cellular membrane has been commonly looked upon, as the most dangerous part ofthe dis- ease; how justly, will appear in the se- quel. (Hewson, Med. Obs. and Inqui- ries. VoL 3.) Emphysema is most frequent after a fractured rib, because there is, in tliis instance, a wide laceration of the lungs, and no exit for the air; it is less fre- quent in large wounds with a knife, or broad sword, because the air has an open and unimpeded issue; it is again more frequent in deep stabs with bay- onets, or small swords; and it is pecu- liarly frequent in gun-shot wounds, be- cause the orifice in the skin inflames, and swells, wliile the wound is wider within. (Joltn Bell on Hounds of tlie Breast.) The symptoms, attending emphyse- ma, are generally ofthe following kind. The patient at first complains of a con- siderable tightness of the chest, with pain, chiefly in the situation of the in- jury, and great difficulty of breathing. This obstruction of respiration gradu- ally increases, and becomes more and more insupportable. The patient soon finds himself unable to lie down in bed, and cannot breathe, unless when his body is in an upright posture, or he is sitting a little inclined forward. The countenance becomes red and swollen. The pulse, at first, weak and contract- ed, becomes afterwards irregular. The extremities grow cold, and, if tlie pa- tient continue unrelieved, he soon dies, to every appearance suffocated. The emphysematous swelling, where- 272 EMPHYSEMA. soever situated, is easily distinguished -from crdema, or anasarca, by the cre- pitation wliich occurs on handling it, or a noise, like that whicii takes place on compressing a dry bladder half fill- ed with air. (Encyclo/kdie Methodi- que ; Partie Chirurgicale.) The wound of the pleura and inter- costals may sometimes be too small to suffer tlie air to get readily into the cellular membrane, and to inflate it, but may confine a part of it in the cavi- ty of the thorax, so as to compress the lungs, prevent their expansion, and cause tiie same symptoms of tightness of the chest, quick breathing, and sense of suffocation, wliich water does in the hydrops pectoris, or matter in the empysema. (Hevison.) To understand, why the air passes at all out of the wound of the lungs, we must advert 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 tiie 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, to expand and contract, so as to maintain their external surface constantly in contact with the inside of the thorax, which is continually under- going an alternate change of dimen- sions. Every muscle, that has any con- cern in enlarging and diminishing the capacity of the chest, must contribute to the effect of adapting the volume of" tiie lungs to the cavity, in which they are contained, 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 expand- ed in the same way, and the air enter- ing through the windpipe into the air- cells of these organs, prevents the oc- currence ofa vacuum. But, in cases of wounds, when there is a free communication between the atmosphere and inside of the chest, on this cavity being expanded, the air na- turally enters it, at the same tune, and for the same reasons, that tiie air en- ters tiie lungs through the trachea, and the lung itself remains proportionally collapsed. When the thorax is next contracted, in expiration, the air is compressed out of the lung, and also, out of the bag of* tiie pleura, through the external wound, if there be a di- rect one. In the latter circumstance, the emphysematous swelling is never very extensive But, in the case of a fractured rib, attended with a breach in the pleura costalis, pleura pulmonalis, and some ofthe air-cells ofthe lungs, there is no direct communication between the ca- vity of the chest and the external air; in other words, tliere is no outward wound in the parietes of the thorax. There is, however, a preternatural opening formed between the air-cells of the lungs and the cavity ofthe chest, and also another one between the latter spnee, and the general cellular sub- stance of tlie body, through the breach in the pleura costalis. Tue conse- quence is, that, when the chest is ex- panded 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, which they naturally occupied, when distend- ed, 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 of the pleu- ra, cannot get back into the aperture in the collapsed lung, because this is already full of" air, and is equally com- pressed on every side, by that wliich 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 en- large the chest, remove the pressure from the surface ofthe wounded lung, more air would be sucked out of it, aa it were, into the space between the pleura costalis and pleura pulmonalis, and this process would go on, till the lungs of tlie wounded side were com- pletely collapsed. But, in the case of a fractured rib, or of a narrow stab, in which there is also a breach in the pleu- ra costalis, without any free vent out- ward, for the air, whicii gets out of the lung into the cavity of tiie pleura, as "isoon as the expiratory powers lessen the capacity of the chest, this air, not being able to get back through the breach in the collapsed lung, passes 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 be- comes diffused most extensively over the whole body, in proportion as the expiratory muscles continue in their EMPHYSEMA 273 turn to lessen tlie capacity ofthe chest, and pump the air, as it were, through the breach in the pleura costalis, im- mediately after it had been sucked, as it were, out ofthe wound in the lung, in inspiration. (See John Bell on Hounds of the Breast. Halliduy on Emphysema. 1807.) 1 * To prove, that the confinement of air in the chest, is the cause of the dangerous symptoms attending emphy- sema, Mr. Hewson adverts to the his- tories of some most remarkable cases, published by M. Littre, M. Mery, Dr. Hunter, and Mr. Cheston. (See Mem. de I'Acad. Royale des Sciences, for 1713. Med. Observations and Inquiries, Vol. 2. and Pathological Inquiries.) In M. Littre's case, the patient, who had been wounded in the side with a sword, could not breathe, without ma- king the most violent efforts, especial- ly, during the latter part of his disease: he died on the fifth day. In M. Mery's case, a man had the fourth and fifth true ribs broken by a coach passing over his chest, his respi- ration was much impeded from the first, and became more and more diffi- cult, till he died, which was on the fourth day after the accident. In Dr. Hunter's case, the patient had received a considerable hurt on his side by a fall from his horse. He had a dif- ficulty of breathing, whicii increased in proportion as the skin became elevated and tense; it was laborious as well as frequent. His inspiration was short, and almost instantaneous, and ended with a catch in the tiiroat, whicii was produced by the shutting of the glot- tis ; after this he strained to expire for a moment without any noise, then sud- denly 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 endeavours seemed to be to keep his lungs always full; in- spiration succeeding 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. lie had a little cough, which exasperated his pain, and he brought up blood and phlegm from his lungs. He was relieved by scarifi- cations, and recovered. In Mr. Cheston's case, the man had received a blow on the chest. He had a constant cough, bringing up, after many ineffectual efforts, a frothy dis- charge, lightly tinctured with blood; vol. 1. he seemed to be in the greatest ago- nies, and under a constant appearance of suffocation. His pulse was irregu- lar, and sometimes scarcely to be felt, his face livid, and, when he was sensi- ble, 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 compres- sion by the hand alone affected him in the same way. Notwithstanding bleed- ing, repeated scarifications, and other means, his sense of suffocation, and dif- ficulty of breathing increased. On the fourth day, the air no longer got into the cellular membrane, when on a sud- den inclining his head backward as it were, for the admission of more air, than usual, his breathing became more difficult and interrupted, he turned wholly insensible, and soon afterwards died. M. Littre, M. Mery, and Mr. Ches- ton, opened their patients after death. M. Littre, besides a wound of the lungs and fractured rib, found a consi- derable quantity of blood in the cavity of the thorax, and was sensible of some putrid air escaping, on Iris first punc- turing the intercostals and pleura. The wounded lobe was hard and black, and the other two ofthe same side were in- flamed. In M. Mery's patient, no blood was extravasated, nor was there any thing preternatural, except the fractured ribs, the wound of the pleura, and that ofthe lungs. Mr. Cheston found a fracture of the tenth and eleventh ribs, and a wound ofthe lungs. The lungs, below the wound, were livid, and more compact, than usual; but every tiling else was natural, no extravasation, no inflamma- tion, no internal emphysema. Mr. Hewson made experiments on animals to shew, that air in their chests produced great difficulty of breathing, such as occurs in cases of emphysema, and in one case, wliich he examined af- ter death, air was actually discharged on puncturing the thorax. The object of Mr. Hewson's paper is to recommend making an opening into the chest, for the purpose of giv- ing vent to the air confined in that ca- vity, just as is done for the discharge 35 274 EMPHYSEMA. of pus, in cases of empyema, and water, in those of hydrops pectoris. In wounds of the lungs, says this author, whether occasioned by fractu- red ribs, or other causes, when symp- toms of tightness and suffocation come on, so far should we be from dreading the emphysematous swelling of the cellular membrane, that we should ra- ther consider it, as a favourable symp- tom, shewing that the air is not likely to he confined in the thorax; and so far should we be from compressing the wound to prevent the inflation, or em- physema, that we should rather dilate it (if not large enough already,) or per- form the paracentesis thoracis. We may judge ofthe necessity of this ope- ration from the violence of the symp- toms, such as the oppressed breathing, &c. For when these are not conside- rable, and the air gets out of the chest with sufficient freedom, the operation then becomes unnecessary. The best place for performing the operation, says Mr. Hewson, if the dis- ease is on the right side, will be on tiie fore-part of the chest, between the fifth and sixth ribs ; for, there the integu- ments 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 the open- ing between the seventh and eighth, or eighth and ninth ribs, that we may be sure of avoiding the pericardium. As large penetrating wounds are inconve- nient on account of the air entering by the aperture in such a quantity, as to prevent the expansion of tlte lungs, a small wound will be eligible, and espe- cially as air does not require a large one for its escape. Mr. Hewson re- commends dissecting cautiously with a knife, in preference to the coarse and hazardous metliod of thrusting in a trocar. There is one error, prevailing in Mr. Hewson's paper, for which he has been justly criticized by Mr. John Bell; viz. the idea, that it is possible and proper to make the collapsed lung expand by making an opening into the chest, in cases of emphysema. Bromfield and B. Bell have both imbibed the same er- roneous 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 pro- moted by the quiet state, in which the collapsed lung remains; a state, also, the most favourable for the stoppage of any bleeding from the pulmonary vessels. The true object then of making an opening into the thorax, when the symptoms of suffocation are very vio- lent in cases of emphysema, is not to obtain an expansion of the lung on the affected side, not to take the pressure of the air from it; but, to remove the pressure caused on the opposite lung by the distention of the mediastinum, and, at the 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 ad- vantageous, that it should do so. The opposite lung is that, which for a time must of itself carry on respiration, and it is known to be fully adequate to this function, provided the quantity of air, on the other side of the chest, do not produce too much pressure on the me- diastinum, and diaphragm. Mr. John Bell concludes his remarks on this subject, with advising the fol- lowing practice. 1st. Upon observing the crackling tumour beginningto form itself over a fractured rib, you should make small punctures 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 this air was in the thorax, before it came into the cellular substance, it is plain, that the thorax is still lull, 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 mak- ing them so near the fractured part, is not to relieve the lungs, but, merely, to prevent the air spreading more widely beneath the skin. 2nd. If, before you arrive, the air shall have spread to very remote parts of the body, as to tiie 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 you bring it up to the punctures made on the chest, over the wounded part. 3rd. If, notwithstanding free punc- tures, and pressing out the air in tliis way, you should find by the oppression, that either air, or blood, is accumulat- ing within the cavity of the thorax, so as to oppress not the wounded lung only, which was of course collapsed and useless from the first, but so as to EMP oppress aho the diaphragm, 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 one delicately in- to the thorax to let out the confined air, or blood. (John Bell.) After a few days, tlie wound, in the collapsed lung, becomes closed by the adhesive inflammation around it, so that the air no longer gets out of it in- to the cavity ofthe chest, and any ex- tensive opening may be healed. What air is already there is ultimately ab- sorbed, and the lung, expanding in proportion, resumes its original func- tions. Emphysema has been known to arise from the bursting of a vomica, and ulceration of the surface of the lungs ; but, the air, which escapes, in this instance, cannot find its way into the cavity of the thorax, because the inflammation, which precedes the ab- scess and ulceration of the air-cells, closes those whicii are adjacent, and produces an adhesion of the edges of the vomica, or ulcer, to the inner sur- face of the chest, so as entirely to se- parate the two cavities. We are not acquainted with any instance of the symptoms, imputed to the confinement of air in the chest, originating from suppuration and ulceration of tiie sur- face of the lungs; but, Palfyn, Dr. Hunter, and the author of the article emphysema, in the French Encyclopae- dia, have seen cases, in wliich emphy- sema has arisen from abscesses of the lungs, attended with adhesion to the pleura, and ulcerations in the situation of such adhesion. In such instances, the pus having made its way through the pleura and intercostal muscles, the air escapes also through the same track, so as to get into the cellular membrane on the ontside of the chest. A violent effort of respiration has, sometimes, produced a certain degree of emphysema, which first makes its appearance about the clavicles, and afterwards spreads over the neck and adjacent parts. The efforts of labour have been known to occasion a similar symptom ; but, no bad consequences have followed. (Medical Commumca- tions, p. 176.) M. Louis has described an emphyse- ma of this sort, which, on account of its cause, and the indication, which it furnishes to the practitioner, is highly important. This famous surgeon had occasion to remark it in a young girl, who died suffocated, from a bean 1'aU- EMP 275 ing into her wind-pipe, and he consi- ders it, as a pathognomonic symptom of such an accident, concerning the existence of which it is so essential not to commit any mistake. (See Broncho- tomy.) This emphysema made its ap- pearance on both sides of the neck, above the clavicles, and came on sud- denly, on the third day after the acci- dent. The inspection of the body proved, that the lungs and mediasti- num were also in an emphysematous state. The retention of the air, con- fined by the foreign body, produced, says M. Louis, at each attempt to ex- pire, and, especially, when the violent fits of coughing occurred, a strong pro- pulsion of this fluid towards the sur- face of the lung, into the spongy sub- stance of this viscus. Thence, the air passed into the cellular texture, which unites the surface of the lung to the pleura pulmonalis ; and, by communi- cations from cells to cells, it caused a prodigious swelling of the cellular substance, between the two layers of the mediastinum. The emphysema, increasing, at length made its appear- ance above the clavicles. This tume- faction of the lung, and surrounding parts, in consequence of air getting in- to their spongy, and cellular texture, is an evident 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. (Memoires de I'Acad. de Chirurgie, Tom. 4.) An emphysematous swelling of the head, neck, and chest, has also been noticed in typhoid fevers. Dr. Huxham relates an instance, of* this sort, in a sailor of a scorbutic habit. (Medi- cal Observations, and Inquiries, Vol. 3, Art. 4.) Surgeons often observe a partial em- physema, in cases of gangrene. The reader may consult, with ad- vantage, I'Encyclopedk Methodique ; Partie Chirurgicale. Hewson's Paper in Med. Obs. and Inq. Vol. 3. Mem. de I'Acad. Royale des Sciences for 1713. Dr. Huuter in Med. Obs. and Inq. Vol.2. Cheston in Pathological Inquiries. A Case in Abernethy's Works. John Bell on Wounds of the Breast. HalUday on Emphysema, 1807. EMPLASTRUM, (from ty&k&tro-x, to spread upon.) A plaster. The following are some of the most useful plasters, employed in surgery. 2 ?6 EMP ENC EMPLASTRUM AMMONIACI CUM ACKTO. R. Ammoniaci gij. Aceti Distillati §iij. Ammoniacum in aceto liquefactum evapora in vase fer- reo ad emplastri crassitudinem. EMPLASTRUM AMMONIACI SC1LLITICUM. R. Gumm. ammo- niaci |j. Aceti Scillitici, q. s. ut fiant emplastrum, quo pars affecta tegatur. Mr. Ford has found this plaster use- ful in some scrophulous affections. It may be rendered more stimulating by sprinkling it with squills. I'ord on tlie Hip-joint, p. 59.) It has been recom- mended by Swediaur ; London Medical Journal, Vol. 1, p. 198.) The first plaster partakes ofthe same stimulating property, though in a mild- er degree. EMPLASTRUM AMMONIACI CUM HYDRARGYRO. Discutient. EMPLASTRUM AMMONIACI CUM CICUTA. R. Gum. ammon. giij. Succi cicutae spissatx 3'j. Aq. litharg. acet. 3J. Dissolve the ammoniacum in a little vinegar of squills, then add the other ingredients, and boil them all slowly to the consistence of a plaster. This is discutient. EMPLASTRUM AMMONIiE. R. Sapon. 3'j. Einplastr. litharg. ^ss. Ammon. mur. ^j. The two first articles are to be melt- ed together, and when nearly cold, the muriated ammonia, finely powdered, is to be added. Its use is to stimulate the skin, and excite the action of the ab- sorbents. Hence, it disperses many chronic swellings and indurations. EMPLASTRUM CANTIIAR1DIS. (See Blister.) EMPLASTRUM LITHARGYRI. Diacholon. EMPLASTRUM LITHARGYRI COMPOSITUM. Properties Discutient. EMPLASTRUM LITHARGYRI CUM HYDRARGYRO. Properties discutient. EMPLASTRUM LITHARGYRI CUM RESINA. The Adhesive or Sticking-plaster. EMPLASTRUM SAPONIS. The plaster commonly used for fractures. It is also frequently apphed to bruised parts, and to many indurations of a chronic nature. EMPROSTHOTONQS, (from tfx- rreotrBiv, before or forwards, and tuw, to extend.) A spasmodic, or tetanic, af- fection, in which the body is bent for- wards. EMPYEMA, (from ev, within, and vuoy, pus.) A collection of matter in the cavity ofthe thorax. There is reason for believing, that matter is contained in the cavity of" the chest, when, after a pleurisy, or inflam- mation in the thorax, the patient has a difficulty of breathing, particularly, upon lying on the side, opposite the af- fected one; and when an oedematous swelling is externally perceptible. I have seen a patient in St. Bartholo- mew's Hospital, who had so large a quantity of matter in the left, bag of the pleura, that it completely displaced the heart, which pulsated against the in- side of tiie chest, at a considerable dis- tance to the right of the sternum. This man's life might probably have been saved, had paracentesis thoracis been performed in time. Some suspected an aneurism from the throbbing on the right of the sternum ; and the case was fully understood after death, when the body was opened. A little attention to tiie s)mptoms, however, might have convinced any man of moderate under- standing, that it was an empyema, and that making an opening, for the dis- charge ofthe matter, afforded tlie only rational chance of preserving life. There had been pain and inflammation in the chest, followed by shiverings; there was very great difficulty of breathing; tiie heart, which previously used to beat in the usual place, no longer did so; but, now, pulsated on the right side of the thorax. With regard to the mode of making an opening into the chest; see Para- centesis Thoracis. EXCANTHIS, from iv and **vfl«, the angle of the eye.) The encanthis, at its commence- ment, is nothing more, says Scarpa, than a small, soft, red, and sometimes rather livid, excrescence, which grows from the caruncula lachrymalis, and, at the same time, from the neighbour- ing semilunar fold of tiie conjunctiva. The inveterate encanthis is ordinarily of a very considerable magnitude; its roots extend beyond the caruncula lachrymalis, and semilunar fold, to the membranous lining of one, or both eye- lids. The patient experiences very serious inconvenience from its origin, and interposition between the conmis- sure ofthe eyelids, which it necessari- ly keeps|| asunder, on the side towards the nose. ENCANTHIS. 27r The encanthis keeps up a chronic ophthalmy, impedes the action of the eyehds, and prevents in particular the complete closure ofthe eye. Besides, partly by compressing, and partly by displacing the orifices of the puncta lachrymalia, it obstructs the free pas- sage ofthe tears into the nose. The excrescence, on its first appear- ance, (continues this eminent writer,) is commonly granulated, like a mul- berry, or is of a ragged, and fringed structure. Afterwards, when it has acquired a certain size, one part of it represents a granulated tumour, while the rest appears like a smooth, whitish, or ash-coloured substance, streaked with varicose vessels, sometimes ad- vancing as far over the conjunctiva, covering the side ofthe eye next to the nose, as where the cornea and sclero- tica unite. In this advanced state, the encanthis constantly interests the ca- runcula lachrymalis, the semilunar fold, and the membranous lining of one, or both eyelids. In addition to the roots, which in such circumstances con- nect the excrescence with the carun- cula lachrymalis, the semilunar fold, and the conjunctiva ofthe globe of the eye, the encanthis emits an appendage, or prominent, firm elongation, along the inside of the upper, or lower eye- lid, in the direction of its edge. The middle, or body, of the encanthis di- vides near the cornea, as it were, like a swallow's tail, to form two appendages, or elongations, one of which extends along the inner surface of the upper eyelid by the margin of" which it is covered, while the otiier shoots, in a di- rection from the internal towards the external angle, along the inside of" the lower eyelid, whicii also conceals it beneath its edge. The body of the encanthis, or that middle portion of the whole excres- cence, which reaches, from the carun- cula lachrymalis and semilunar fold, in- clusively, over the conjunctiva almost to the junction ofthe sclerotica with the cornea, sometimes forms a promi- nence, as large as as mall nut, or chest- nut. At other times, it is of consider- able size, but depressed, and broken down, as it were, at its centre. Still, however, the body of the encanthis preserves that granulated appearance, which prevailed at first; while one, or both tiie'appendages, on the inside of the eyelid, appear rather like a lippo- matous, than a granulated substance. On turning out the inside of the eye- lids, these appendages, or elongations of the encanthis, form a prominence projecting forward. When both eye- lids are equally affected, and turned inside out, the lippematous appendages conjointly represent, as it were, a ring, the back of which rests on the globe of the eye. Fabr. Hildanus was acquainted with this disease, which he treated with success, and named, ficus scirrhosus ad mujorem oculi cant/turn. (Cent. 1. Obs. 2) However, in the case related by Hil- danus, the encanthis seems only to have had one appendage, situated on the inner surface of the upper eyelid, below its edge. Sometimes, as is noticed on the sub- ject of the pterygium, the encanthis assumes a cancerous malignancy. This character is evinced by the-dull red, and, as it were, leaden colour of the excrescence; by its exceeding hard- ness, and the lancinating pains, which occur in it, and extend to the forehead, the whole eyeball, and the temple, especially, when the tumour has been slightly touched. It is, also, evinced by the propensity of the excrescence to bleed, by tlie partial ulcerations on its surface, whicii emit a fungous sub- stance, and a thin, and exceedingly acrid discharge. This malignant spe- cies, or rather tliis degenerate state ofthe encanthis, only admits of pallia- tive treatment; unless, indeed, an ef- fort be made to extirpate it entirely, together with the whole of what is con- tained in the orbit, and, even then, the event is very dubious. The benign encanthis, how large soever it may be, is always curable by extirpation. Those instances, which are small, incipient, and granulated, Uke a mulberry, or of a fringed struc- ture, 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 internal commissure of the eyelids, may be raised by means of a pair of forceps, and cut off from the whole of their origin, closely to their base, with the curved scissars with convex edges. In the performance of this operation, it is unnecessary to in- troduce a needle and thread through tliis httle excrescehce, as some are wont to do, for tiie purpose of raising it, and «tostroying more accurately all 278 ENCANTHIS. its origins, and adhesions. The same object is fulfilled by means of forceps, without inconveniencing the patient with a puncture of this kind, and draw- ing a thread through the part, in order to make a noose. However, in cutting out an encanthis of this small size, care should be taken not to remove, togeth- er with that portion of the excrescence which originates from the caruncula lachrymalis, any more of this latter bodyj than what is absolutely necessary for the precise eradication of the dis- ease, in order that no irremediable weeping may be occasioned. When the little excrescence has been detached from all its roots, says Scar- pa, the eye must be washed several times with cold water to cleanse it from the blood, and then it is to be covered with a piece of fine linen, and a reten- tive bandage. On the 5th, 6th, or 7th day, the inflammation arising from the operation entirely ceases, and the sup- puration from the wound is accompa- nied 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 collyrium, containing the mucilage of quince-seeds, is to be injected into the eye in question several times a day. If these means should not bring about the wished-for cicatri- zation; but, on the contrary, the small wounds situated on the caruncula, and internal commissure of the eyelids, should become stationary, and covered with proud-flesh, the argentum nitra- tum ought to be applied to them. The conjunctiva, however, should be avoi- ded as much as possible, especially, if at all wounded. When the fungous granulations have been destroyed, the cure may be perfected by the collyrium already mentioned, or rather by intro- ducing, thrice a day, between the eye- ball and internal angle of the eyelids, the powder of tutty, and the armenian bole. Bidloo extols veiy much pow- dered chalk, either alone, or in con- junction with burnt alum. (Exercit. Anat. Chir. Decad. 2.) Excision is equally applicable to the inveterate encanthis, whicii is of considerable size, and broken down at its body, or which forms a prominence, as large as a nut, or chestnut, with two lippomatous appendages extending along the inner surface of one, or both eyelids. The application of a ligature to such an execrescence ought never to be regarded as a method of cure; for, the large, inveterate encanthis never has a sufficiently narrow neck to admit of being tied. On the contrary, when the tumour is voluminous, its roots, in- variably, extend to the caruncula lach- rymalis, the semilunar fold, and the conjunctiva covering the eyeball, oftentimes, nearly as far as the cornea. In this state, also, the encanthis has one, or two lippomatous appendages, whicii reach along the membranous lining of one, or both eyelids. Hence, though the ligature were to produce a separation of the body ofthe encanthis, one, or both the lippomatous appen- pages would still remain to be extir- pated. This second operation could only be accomplished by recision. In this disease, there is no foundation for the fear of" hemorrhage, to which the advocates for the ligature attach so much importance; for, cases are re- corded of considerable, inveterate en- canthes being removed, without the least untoward occurrence from loss of blood. To these, Scarpa observes, he could add a great number of* his own, so that no doubt can now be entertained on this point. Pellier relates a case, in which an encanthis was follwed by a dangerous hemorrhage, though it had been cut out by an expert oculist. He enters, however, into no detail concerning the nature of the complaint, nor the way, in which the operation was performed; circumstances from which one might deduce the reason of an unusual acci- dent. Indeed, the same author adds. " I have often performed this operatiu:'. for such excrescences, and have never met with a similar occurrence." Jie- cueil a"Observ. sur les Maladies del'QZil. Part 2. Obs. 118. In the above mentioned case of a large, inveterate encanthis, with only one elongation on the inside of the up- per eyelid, as soon as Fabricius Hilda- nus had taken hold of the body of the tumour with a hook, and drawn it towards him, he turned out the inside ofthe eyelid, so that the lippomatous appendage was made to project through its whole extent. Then he dissected this production away by means of a small bistoury, and, continuing the incision, he entirely detached the body of the encanthis from the conjunctiva covering the eyeball, from the semilu- nar fold, and from the caruncula lach- rymalis. The operation was followed ENC ENC 279 by the most complete success, and ought to serve as a model, and guide, to all surgeons, who have occasion to treat this disease. When the encanthis is large, and in- veterate, with two lippomatous elon- gations, one on the inside of the upper eyelid, and the other on that ofthe lower end, we are to proceed in the following manner. The patient being seated, an assistant is to turn out the inside of the upper eyelid, so as to make one ofthe appendages of the en- canthis project outward. By means of a small bistoury, a deep incision is next to be made into tiie elongation, in the direction ofthe margin of the eye- lid ; and then having taken hold of, and drawn it forwards with a pair of forceps, we are to separate it, through- out its whole length, from the inside of the upper eyelid, proceeding from the external, towards the internal an- gle of the eye, as far as the body, or middle, ofthe encanthis. We are then to do the same to the lippomatous ap- pendage on the inside of the lower e) e- lid. Afterwards the body of the en- canthis is to be elevated, if possible, with a pair of forceps; but when this instrument will not answer the purpose, a double hook must be employed. This middle portion is now to be detached, partly by the bistoury, and partly by the curved scissars from the subjacent conjunctiva, on the globe of the eye, from the semilunar fold, and from the caruncula lachrymalis; dividing the substance of this last part more, or less deeply, according to the depth and hardness of the large, inveterate encanthis. Here it is proper to state distinctly, that when we have to deal with an old, large tumour of this na- ture, that is deeply rooted in the car- uncula lachrymalis, it is not regularly in our power to preserve a sufficient quantity of the substance of this part, to prevent the tears from dropping over the cheek, after the wound is healed. The eye is to be repeatedly washed with cold water. The restof the treatment, consequent to the extirpation of a large encanthis, is almost the same, as what was ex- plained in speaking of the small incip- ient one. Bathing the eye very fre- quently in the lotion of mallows, and employing anodyne, detergent colly- ria, are the best local means, until the mucous appearance, preceding sup- puration, has taken place on the sur- face of the wound. Then we may have recourse to mild astringent ointments and collyria. The mildest topical ap- plications are generally the best, both in the first stage of suppuration, as well as afterwards, particularly, when, together with the encanthis, we have removed a considerable piece of the conjunctiva, whicii covered the eyeball towards the nose, and was intimately connected with the body ofthe excres- cence. The following case, related by Mar- chetti, will throw additional light on the contents of this chapter. Curavi quemdam canomcum Polonum laboran- tem meliceride magnitudinis jujuba, qua a camnculd anguli majoris oculi ad to- tam pupillam porrigebatur. A multis tentata curatio medicamentis, decoctis scilicet, collyriis, et aliis hujusmodi,- om- nia tamen octo mensium spatio incassiim adhibita. Cum vera me consuhusset, ip- sum tumorem evelkndum censui; quod cum reformidaret, spe tamen salutis ope- rationem admisit, quant statim molitus sum, corpore priiis expurgato occuralissi- me, ab aliis medicis. Paravi itaque ha- mulum, quo ipsam mehceridem perforavi, et manu apprehendi, altera verd forcipe eamdem cum folliculo sectione separavi turn a caruncula, turn d tunica adnata, et ipsa pnpilld ; atque ita totum tumorem eduxi sine ulld offensd ipsius oculi; d quibus statim applicui gossypium imbn- tum aqua rosacea cum ovi albumine agi- tata, et portiunculd croci, palknte tres dies lioc modo fascia vincto; adhibito postmodum collyrio cum aqua rosarum, et pulvere tutia praparata; quibus spatio octo dierum omnino convaluit aifer,- in- crepante licet meant praceptore meo ab Aquapendente audaciam,- cutn tamen brevi spatio temporis idprastiterim, quod alii medici non potuerunt perficere,- idque prasentibus prac/arissimo Joanne Domi- nico Said cum multis studiosis. (Obs. Med. Chir. Sylloge, obs. 21.) The preceding account is taken from Scarpa sulk Malattie degli Occhi. I know of no better work, to which I can refer the reader. They who under- stand German, however, may peruse Richter's remarks on the subject, in his Anfangsgr. der Wundarzn. He is doubt- less one of the best writers on the dis- eases of the eye in general. ENCEPHALOCELE, (from tyxepvw, the brain, ond khxh, a tumour.) A her- nia of the brain. (See Hernia Cerebri.) 280 ent EPU ENCYSTED TUMOURS. (See Tu- mours Encysted.) ENEMA, (from noifxi, to inject.) A glyster. The following are some of the most useful glysters, employed in the prac- tice of surgery. Cathartic. R. Decocti Hordei lbj. Salis Muriatici Jj.—Misce. R. Decocti A vena: fbj. Olei 01iv3e|ij. Magnesia vitriolatae 3J.—Mis- ce.* Anodyne. R. Mucilaginis Amyli, Aquae dis- tillate sing. ^ij. Tinctura Opii guttas xl.—Misce. R. Olei Olivae, giv. Tinctura: Opii guttas xl.—Misce. The two latter glysters are particu- larly useful in cases in which there is great irritation about the rectum, blad- der, or urethra. They have great ef- fect in diminishing spasmodic affec- tions of this canal and the neck ofthe bladder. Tobacco, Employed in cases of strangulated Her- nia. R. Nicotianae 5"j. Aq. ferventis ftj. The plant is to be macerated ten mi- nutes, and the liquor then strained for use. One half should be first injected, and soon afterwards the other, unless the glyster should operate with dan- gerous violence, as it sometimes does in particular constitutions. ENTEROCELE, (from &\t, the bowels, and xhkh, a tumour.) A spe- cies of hernia, in whicii the contents of the tumour are intestine. ENTERO-EPIPLOCELE, (from iv7s- £*, the bowels, rrrrhw, the omentum, and x»x», a tumour.) A species of her- nia, in which the contents ofthe swell- ing are composed both of intestine and omentum. EMEKO-HYDROCELE, (from »7«- 5*, the bowels, and txTgojoOix, a dropsy ofthe scrotum) This must mean a common scrotal rupture, with a good deal of water in tiie hernial sac: or else a congenital hernia, (in which the bow- els descend into the tunica vaginalis testis,) attended with a collection of fluid in the cavity of this membrane. EXTEROMPHALOS, (from w7«5», the intestines, and o/uexxoc, the navel.) A hernia at tlie navei, formed by. a pro- trusion of intestine. ENTERORAPHE, (from tv7t$*. the intestines, and §*?», a suture.) A su- ture of the intestines. ENTEROSCHEOCELE, (from iv7«g*, the intestines, and ov^KtuKKs, a hernia in the scrotum.) Such a case, in whicii the protruded parts are intestine. ENTROPIUM, (from tv and iTa>, to turn.) An inversion of the eyehds. (See Trichiasis.) EPIPHORA, (from tn-ia>, to carry with force.) By this term is meant an accumulation of tears on the anterior part of the eye; in consequence of which, the person afflicted is not only under the necessity of frequently wi- ping them away, but vision is injured by the morbid refraction, which they produce in the rays of light that enter the pupil. The disease may arise from a more copious secretion of tears than the puncta lachrymalia can absorb, or, as is most common, from an obstruc- tion in the lachrymal canal, in conse- quence of which the tears are prevent- ed from passing freely from the eye in- to the nose. Ware on the Epiphora, or Watery Eye. (See F'istula Lachryma- lis.) EITPLOCELE, (from trt-rrhoov, the omentum, and jma», a tumour.) A her- nia, formed by a protrusion ofa piece ofthe omentum. (See Hernia.) EPIPLOOMPHALON, (from vrnrKt- ov, the omentum, and o/z-paxec, the na- vel.) An omental hernia, protruding at the navel. EP1PL0SCHE0CELE, (from «™rx«- ov, the omentum, ec-^tsv, the scrotum, and mxh, a tumour.) An epiplocele, or omental hernia in the scrotum. EPISTHOTONOS, (from ewfl»„ for- wards, and ruvu, to extend.) A spasm, by whicii the body is drawn forwards. EPULIS, (from mi, upon, and ka*, 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. [* A glyster equally efficacious and always at hand may be prepared by mix- ing together, a table spoonful of olive oil, two, of molasses, and one of common marine salt, with a pint of warm water.} ERYSIPELAS. 281 EPULOTICS, (from *ir*\u», to cica- trize.) Epuloticu. Applications con- ducive to the healing of wounds. ERETHISMUS, (from ^9/fc, to irri- tate.) Any thing which causes irrita- tion. Mr. Pearson has described a state of the constitution, produced by mercury acting on it as a poison. He Calls it the mercurial erethismus, and mentions, that it is characterized by great depression of strength, anxiety about, the praecordia, irregular action of the heart, frequent sighing, trem- bling, a small, quick, sometimes inter- mitting pulse, occasional vomiting, a pale contracted countenance, a sense of coldness ; but the tongue is seldom 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 tlie dangerous tendency of this affection, the immedi- ate discontinuance of the use of mer- cury ; and exposing the patient to a dry cool air. The incipient erethismus may often be averted by the camphor mixture with large doses ofthe volatile alkali, if mercury be also left off. Sar- saparilla is also beneficial, when the stomach will bear it. (Pearson on Lues Venerea, page 156, &c. Edit. 2) EROSION, (from erodo, to gnaw off) Erosio. This word is very often used by surgical authors in the same sense as ulceration; viz. the formation of a breach, or chasm, in the substance of parts, by the action of the absorb- ents. ERYSIPELAS, (from «jw*, to draw, and -at**?, adjoining.) St. Anthony's fire; so called, from its tendency to draw the neighbouring parts into the same state, or, in otiier words, from its propensity to spread. Erysipelas may be defined to be an inflammatory, cutaneous, and trivially elevated swelling, the other characters of which will be presently explained. In this definition, we have adopted the opinion of medical and surgical writers, who have generally agreed to arrange erysipelas in the class of in- flammatory complaints. However, though the affection may have such re- lations with the latter disorders, as will not allow it to be considered as a posi- tively separate species' of disease, yet, if its symptoms be investigated with care, it will be found, that these rela- tions are sufficiently remote to make erysipelas and phlegmon be regarded vol. I. as two very distinct kinds of inflamma- tion. It has been thought, that the principal difference, existing between tlie two affections, consisted in the si- tuation whicii was peculiar to each; erysipelas commonly affecting the sur- face of the skin, which is very irritable, while phlegmon is situated more deep- ly in the very substance of parts. It will presently be seen, that this expla- nation is not sufficient to account for the very different symptoms, which belong to the two affections. As the symptoms of erysipelas are Very much the same, in whatever parts of the body the disorder makes its ap- pearance, we shall begin with describ- ing its various phenomena and its pro- gress, when the face is affected; and we shall afterwards explain the parti- cular circumstances, which belong to the complaint in other cases. The attack often takes place in a sud- den manner, either with or without fe- ver ; but it is also frequently preceded by shiverings, complaints about tiie re- gion of the heart, and other symptoms very similar to those which indicate the approach of an intermittent fever. The heat is often accompanied with a little delirium, and almost always with drowsiness of a more or less evident kind. A swelling afterwards makes its appearance, attacking the forehead, the cheek9, the nose, or eyelids. This swelling is elastic and smooth; but it is not distinctly circumscribed, and it gradually spreads over such parts of the face as were not at first affected. The skin ofthe part affected becomes of a bright red colour, occasionally ha- ying a tendency to a livid hue, in other instances having a mixture of yellow, These colours disappear when pres- sure is made on the part affected, but very soon reappear when such pressure is discontinued. The patient experi- ences a burning heat, and a disagreea- ble pricking in the part, rather than any acute pain: sometimes he com- plains of a very troublesome itching. The surface of the tumour is shining, and, as it were, semi-transparent: but without hardness, tension, or any sen- sation of throbbing. The eyehds are often so swollen that the patient cannot see, and the whole countenance is ex- ceedingly disfigured. Small vesicles arise over a more or less extensive part ofthe erysipelatous tumour, and they are filled with a transparent serous fluid, and bear a great resemblance to those 3i3 -82 ERYSIPELAS which are occasioned by boiling water. "When such vesicles burst, the fluid w hich is discharged, sometimes excori- ates the neighbouring parts. Very fre- quently, tliere is even a slight ulcera- tion at the case of these vesicles, which ulceration, in the worst sort of cases, assumes a gang-i'enous appearance, and falls rapidly into a state of complete mortification. When the disease takes a favourable course, the fever, which till now has continued, begins to abate; the vesicles dry up; and, at the end of an interval of eight or twelve days, the cuticle peels off. The degree of dan- ger, attendant on erysipelas, depends on the delirium and other symptoms indicating an affection of the brain. The seat of erysipelas seems to be under the cuticle, in the rete mucos- um : but it is not confined to this part, ,as the cellular membrane is always af- fected even in a considerable degree. The affection of this membrane, how- ever, is very different from what hap- pens in phlegmonous inflammation. In a genuine case of erysipelas, healthy pus is very rarely found enclosed in a circumscribed cavity; and when there is any secretion of purulent matter, a feel is communicated, on compressing the part, almost like that which a sponge would give. In such cases the cellular substance has suffered conside- rably, and the part is frequently at- tacked by gangrene. It is not easy to determine the causes which give rise to this complaint. There are a great many which, in con- junction with concomitant circumstan- ces, manifestly contribute, in many cases, to the production of the disorder. Such are in particular: 1. Violent passions, such as anger, acute grief, &c. t 2. Exposure to the heat of the sun, or that of the fire, too long contin- ued. 3. The impression of cold damp air. 4. The action of various vegetable, mineral, and animal poisons. 6. Wounds, contusions, fractures, he. There is no doubt, that erysipelas is, for the most part, intimately de- pendent on the state of the constitution. Persons in the habit of drunkenness, and other kinds of intemperance, and who, in a state of intoxication, meet with local injuries, often have erysipe- latous inflammation in consequence of them. Other subjects, who lead more regular lives, experience, when they meet with similar injuries, healthy phlegmonous inflammation. The opinion of Hippocrates and Ga- len, with respect to the origin of this disorder from a congestion of the bile, is universally 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 en sipelas to an acrid humour, commonly a bilious one, diffused through the mass of the blood. But, much as I despise the ab- surdity of this theory, observation obliges me to confess, that the com- plaint seems frequently to be connec- ted with a wrong state ofthe chylopoie- tic viscera, and, probably, with a mor- bid state of the bilious secretion in particular. A sudden suppression of perspiration, by exposure to cold and damp, or other more obscure causes, is set down by every writer on this sub- ject, as frequently having a great share in exciting, and keeping up erysipela- tous affections. A further proof, that erysipelas is mostly dependent on constitutional causes, is that the affection most fre- quently happens in autumn or in any season, when hot weather is succeeded by cold and wet. After what has been said, the charac- ters, which distinguish erysipelas from phlegmon, may be taken notice of. 1. The inflammatory swelling, which takes place in the former, is not so elevated as in the latter, and is never plainly circumscribed. 2. In most cases, the surface of the skin seems as if" it were burnt. 3. The redness, though of a bright description, disappears on pressure. 4. The sense of throbbing, and dart- ing pain, attendant on phlegmon, is not observable. 5. The inflamed part is free from tension, and appears as it were affec- ted with oedema, or rather with emphy- sema; only one can perceive no crepi- tation. As we have already remarked, however, it must not be inferred from these differences, that erysipelas is to be considered as a disease essentially distinct from those, which are called inflammatory, as it has some charac- ters in whicii it manifestly approaches thenx Like phlegmonous inflamma- ERYSIPELAS. 283 tions, it may end in suppuration, though of a less perfect sort, than that in which phlegmon ends, and rarely con- tained in a circumscribed cavity. The pulse, in this disease, as well as in others ofthe same class, is generally- full, and frequently hard, 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 otiier kinds of inflammation. It is proper, however, to notice, that practitioners are not universally agreed with respect to the nature of the pulse in erysipelas: itis, according to some, particularly Mr. Pearson, soft, fre- quent, and often irregular. But, if due attention be paid, this difference will be found to depend on particular circumstances. 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 in- flammatory, especially those which are attendant on wounds, affect the body, and the sanguiferous system in parti- cular, in a very different manner from what is observed when the patients are living in a more salubrious air. All inflammations assume a character more or less unfavourable, in conse- quence ofthe influence Of bad air. This is particularly striking in cases of ery- sipelas. In such instances, living in an impure atmosphere has a singular effect in augmenting the sense of weak- ness and dejection, wliich patients 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 puis-. But, if atten- tion be paid to the disease in a situation where the atmosphere is not impregna- ted with putrid effluvia, it will be found to put on a very different shape. The 1 symptoms of dejection, of nervous irri- tation, and of the brain being affected, are much lebs conspicuous; and the state ofthe pulse, especially inpatients who have not been previously debilita- ted by > other diseases, bears a great resemblance to that which takes place in an inflammation of the chest. We have also to remark, that, besides bad air, many other circumstances, which do not even belong to the nature of erysipelas, may have a share in pro- ducing an alteration of its symptoms. Thus, while inflammations of another kind, such as pleurisy and acute rheu- matism, particularly affect robust per- sons, 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 constitu- tions. The latter is also seen making its appearance as a symptom, in weak- ened parts, which have in a certain degree been deprived of their tone, as is the case with cedematous parts. It is not surprising, that, in these differ- ent cases, in which the tone of the sys- tem has already suffered, tlie state of the pulse, in persons affected with erysipelas, should seem different from what it is in individuals, who are more healthy and robust. These observations on the nature ot' erysipelas lead us to remark, that tins disease is not simple and uniform in its progress and symptoms, and that the mode of treatment ought to \ ary ac- cording to the particular form which the disorder may put on. The com- plaint has been distinguished into three species, viz. the acute erysipelas, the cedematous emdpelasi and the mtiligjuinl or gangrenous erysipelas. These tliree species, which are strictly only differ- ent degrees of one same disease, or varieties produced by the particular circumstances, in which the patient \:< placed, maybe c idler symptomatic, t ■ idiopathic. The acute erysipelas is mostly met with in persons of a sanguineous and choleric temperament; it mairc.j its attack suddenly, and is very apt to affect the face. The pulse is alwav * frequent, and most commonly full and hard. All the otiier general symptoms of inflammation are observable. These subside a little when the erysipelas has completely formed, though they oftens increase, during the first periods of tiie swelling. The heat in the part affec- ted is very great: the skin is ofa bright- er red colour than it is in the .other kinds of er)sipclas; vesicles form on tlie surface of the swelling, but they are less numerous, and more distinct, than those originating in the other spe- cies of this complaint. In the acute erysipelas, the inflammation is seldom followed by suppuration, except just at the edges of the eyelids, and tiie dis- ease speedily terminates, sometimes in three or four days. The part affected changes its colour, and becomes yel- lowish; and the cuticle seperates in small scales. The whole scalp is often affected withapainful sensibility, which 284 ERYSIPELAS. even continues a long while after the disease is entirely at an end. The acute erysipelas is often idiopa- thic. It is sometimes observed to at- tack the same person periodically, at certain times of the year. It is also very frequently a consequence of wounds, &c. The attack ofthe edematous erysipelas is neither so sudden, nor so violent, as that ofthe preceding kind. The swel- ling increases more gradually; it spreads to a greater extent; the heat is less ardent ; the inflammatory symp- toms are less evident; the pulse is not so hard, and the strength is more de- pressed. The symptoms of the brain being affected are more alarming. The colour ofthe skin is, in this case, much deeper, and intermingled with yellow and brown; the vesicles are small and numerous ; and when the part affected has been exposed a few days to the air, it becomes covered with a brown dark- coloured scab, which somewhat resem- bles the one which occurs in the con- fluent small-pox. This sort of erysipelas is far more uncommon than the foregoing one, and is much more dangerous. The patients often are in a state of delirium, or rather of lethargy, on the seventh, ninth, or eleventh day, or sometimes a little later. It is chiefly in hospitals that the disorder occurs, often appear- ing tliere to be epidemic, though it cannot be said to be ever contagious. It is particularly prone to attack per- sons weakened by age or intemperance, children, anddropsical subjects. When the oedematous erysipelas makes its appearance, as a symptom of some other affection, it is not nearly so dan- gerous as when idiopathic. It is always, however, to be considered as a serious malady, whatever may be its occasion- al cause. It is more apt, than the acute erysipelas, to shift its situation from the surface ofthe body to the internal parts. It is also seen affecting one leg, and then the other, several times in the course of one indisposition. When the brain becomes affected in this manner, delirium, and other most alarming symp- toms, are immediately excited. The gangrenous erysipelas bears a considerable resemblance to the pre- ceding kind, in regard to tiie symp- toms, with which it makes its attack; but it is much more rapid in its pro- gress. The swelling soon becomes covered with phlyctena, the basis of which is livid ; and symptoms of gan- grene, attended with a state of the pulse, similar to that which takes place in malignant fevers, are not long before they make their appearance. Th'rS species of erysipelas is very liable to occur on the face, shoulders, and chest. The danger, which attends it, is pro- portioned to the more or less vigorous state ofthe system ; the case is often fatal, particularly when the disease at- tacks persons who have been already debilitated by other causes. When it terminates favourably, small cavities and sinuses are often found in the cel- lular substance, which contain pus of a bad quality. In this sort of case, one or more ulcers form externally, through which considerable sloughs of tiie eel- lular membrane are discharged. "Miifren erysipelas in the legs termi- nates favourably, it generally leaves those parts more or less affected with an oedematous swelling, which it is often very difficult to cure. The observations, which we have just been making, on the different kinds of erysipelas, shew, that the treatment ofthe disease cannot be the same in all cases. Hence, we shall describe, se- parately, the mode of treatment pro- per for each particular case. The first indication in the treatment ofthe acute erysipelas, is to lessen tiie inflammation by bleeding, which is tq be repeated, more or less, according to symptoms. Such other means are also to be adopted, as tend to diminish the force of the circulation. In short, the antiphlogistic plan, in the full sense of the expression, is proper. In general, it is unnecessary to re- peat bleeding, in any case of erysipe- las, so frequently as is done in other inflammatory cases. We ought to be guided, however, in this respect, by the state of the pulse, and other symp- toms, never forgetting the patient's age, the degree of strength before the disease, and the situation of tiie disor- der itself. Cateris paribus, the patient will bear bleeding better in the coun- try, and in an open, pure air, than in a large city, and especially in an hospital. The circulation, in the vessels on the surface ofthe body, should also be pro- moted by diluting beverages, proper doses of nitre, the saline mixture, and, above all, by administering small dose3 of the antimonial powder, or tartar emetic. The bylly should be ke:-.t ERY EXC 285 open by glysters, and mild laxatives, and, when the patient is verv much in- convenienced by the irritation and ex- cessive heat of the part affected, small doses of opium may occasionally be given. A gentle emetic very often has an exceedingly good effect in calming the fI'ver, and expediting the cure of the erysipelas, especially after bleeding has been practised. But emetics are not to be continued, when they have a pur- gative effect. In this complaint, as in every other one, in which the head is affected, the patient should be made to keep his head, as much as possible, in an ele- vated position. In the a?dematous erysipelas, per- haps, bleeding is never admissible. The loss of even a very small quantity of blood may have tiie most fatal con- sequences. One should also be ex- ceedingly sparing of other evacuations. A determination to the skin should in particular be kept up by antimonials, and irritation and pain soothed by ad- ministering the spiritus atheris vitriolici compositus, sther, camphor, opium, &c. When the disorder seems to shift its situation to any internal part, and, par- ticularly, to the brain, blisters should, without tiie least delay, be applied between the shoulders, to the head or legs. In order to prevent the complaint from terminating in mortification, tiie patient's strength should be supported by tonic remedies, such as wine and bark. With regard to the treatment of the gangrenous erysipelas, nothing more need to be said than what is contained in the article on mortification. Various topical applications have been recommended in cases of erysipe- las, and the unfounded fear of repelling the local affection, lest grievous con- stitutional derangement shoidd arise, has created the most absurd prejudi- ces against the most efficacious reme- dies. All medicines, derived from the classes of medicines called narcotics, repellents, and astringents, are con- demncd as topical applications, on the assertion, that they have a tendency to produce gangrene. Spirituous ones are reprobated as having the effect of- in- creasing the inflammation, and all emol- lient, aqueous, and oily ones are con- demned, as tending to protract the dis- ease and make tlie swelling spread. Those practitioners, who entertain these opinions, extol farinaceous pow- ders, such as starch, flour, &c. as the most proper and least objectionable of all topical applications. These are re- commended to be repeatedly sprinkled on the inflamed parts. For my own part, I have always been in the habit of applying Goulard's lo- tion to erysipelatous cases arising from wounds, and other kinds ot local irrita- tion, and I have always had every rea- son to think such applications as bene- ficial in these affections as in phleg- mon. Mr. Pearson prefers mild warm cata- plasms, composed of the powders of aniseed, fennel, camomile flowers, &c. mixed with a fourth part, or an equal quantity of milk. Linseed powder may sometimes prove a coirvenient addi- tion. Consult I'Encyclopedic Methodique, partk Chirurgicale ; Peursorfs Princi- ples of Surgery,- and Les GZuvres Chi rurgicaks de Desault, par Bichat. ERYTHEMA, (from tguflgoc, red-) .A redness of any part. For the erythema mercuriale, see Mercury. ESCHAR, (from wjctt^m, to form a scab, or crust.) Eschara. 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, cautery, all that has been submitted to the action of this application, loses its sensibility and vital principle, becomes hard, rough on the surface, and of a black, or gray, colour, forming what is properly named an eschar. This, in short, is only a slough, produced by caustics, or actual fire. ESCHAROTICS, (from •*■£*§««, to form a crust over.) Eschurotica. Ap- plications which form an eschar, or deaden the surface on which they are put By escharotics, however, sur- geons commonly understand the milder kind of caustics, such as the hydrargy. rus nitratus ruber, arugo aris, &c. EX JERESIS, (from tgeupui, to remove.) One of the divisions of surgery adopted by the old surgeons ; the term implies the removal of parts. EXCISION, (from excindo, to cut off.) Excisio. The cutting off any part. EXCORIATION, (from excorio, to take off the skin.) Excorialio. A se- paration of the cuticle; a soreness, merely affecting the surface of the skin. 286 EXFOLIATION. EXCRESCENCE, (from excresco, to grow from.) Excrescentia. A tumour, growing out of, or from any part, and not included in its substance. EXFOLIATION, (from exfolio, to cast the leaf.) Exfoliatio. The sepa- ration of a dead piece of bone from the hving is termed, exfoliation. One part of a bone is never separated from another by the rotting ofthe dead part, for that which comes away is as sound as it ever was. Exfoliation takes place soonest in bones, wherein are the fewest cells, and whose texture is the closest. Before any part of a bone can be thrown ofT, 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. Bones are com- posed of two substances, viz. a true ani- mal matter, and an earthy one, which are only intermixed with each other. A dead bone acts on tlie system, in the same manner, as any other extraneous body. It stimulates the adjacent living parts ; in consequence of which, such a process is begun, as must terminate in its being thrown off. The effects of this stimulus are, first, that the 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 of the living part, where it is in contact with the dead bone, is absorbed; hence, the bone becomes softer, and adheres by its animal matter only. Thirdly, that the living animal part is at last absorb- ed along the surface of contact: this part of the process commences long before the last is finished. Both of them begin, first 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, a fungus arises from the living surface, and fills up the intermediate space, so that there is no vacuum. These different stages together consti- tute ulceration. When any part of a bone is once loose, it will be pushed to the surface in the same manner, as most other inanimate bodies would be, and tliis stage is partly mechanical, and partly a continuation of ulceration. A proof ofthe third stage, above men tioned, may be derived 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 follows the irregularities of the living and dead surfaces. After the applica- tion of the trepan, a circular piece of bone is frequently thrown off, whicii is always less than the space from which it came. This, however, would never be the case, were there not a loss of substance. (John Hunter.) It was anciently believed, that when- ever a bone was denuded, the exposed surface must necessarily exfoliate, and, this being taken for granted, the old surgeons used to set about bringing on an exfoliation as quickly as possible. For this purpose, the actual cautery was usually applied to the part of the bone, which was uncovered, and, as under such treatment, a portion of the bone was of course killed, and then ex- foliated, the prejudiced practitioner be- lieved, that he had only accelerated a process, which must of necessity have followed in a slow and tedious manner. Mr. Hunter very truly remarks, that neither caustics, nor the actual cautery, hasten exfoliation ; they only produce death in a part of the bone, which is the first step towards exfoliation. If caustics ever hasten exfoliation, when the bone is already dead, it must be by producing inflammation in the adjacent living bone; this brings about a change in it, and makes it exert a power, which it was incapable of before. Exfoliation is not a necessary conse- quence of a bone being laid bare, and deprived of its periosteum. If the bone be in other respects uninjured, healthy, and enjoying a vigorous circu- lation of blood through its texture, granulations will be generated on the surface of such bone, which will cover and firmly adhere to it, without the smallest exfoliation being thrown off"; especially, in young subjects. But, if caustic, stimulating, or drying applica- tions be made use of, the circulation in the surface of the bone will necessarily be disturbed and destroyed, and that part of the surface, through which the circulation ceases to be carried on, will be separated, and cast oft", by the pro- cess of exfoliation. If any application to an exfoliating portion of bone be at all efficacious, it must be one, whicii will stop the mor- tification in tiie affected bone, and pro- mote the absorption of those particles of bone, which form the connexion be- EXO EXO 2S? tween 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 the same principles in practice, whicii we do in the latter instance, and, though from the inferior vascularity and vital powers ofthe bones, we can- not expect surgery to have so much control over their affections, as over those of the soft parts, yet, every good will be obtained, wliich it is possible to acquire. Attention to such principles will at least teach us to avoid making the death of part of a bone more ex- tensive, than it would be, if the caute- ry, caustics, and strong astringents, were not employed. The best mode of attempting to pre- vent an exfoliation from occurring at all on 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. This, as we shall notice in the article, Head, Injuries of, may generally be practised with advan- tage, when the scalp has been detached from tiie cranium, provided tiie flap is still connected with tiie rest of the integument. When the exposed bone cannot be covered, it should be dressed with the mildest and simplest applications, with plain lint, or lint spread with the un- guentum spermatis ceti. The dead pieces of bone, when very tedious in exfoliating, when wedged in the substance of the surrounding living bone, and when so situated as to admit of being safely sawn, or cut away, may be removed in this manner, as is de- scribed in the articles Caries and Ne- crosis. In such operation, Mr. Hey's saws are eminently advantageous. In speaking of necrosis, we shall have occasion to notice the efficacy, which Mr. Crowther has found blisters possess in quickening tiie cure of ne- crosis, when kept open by the savin cerate, as recommended in his work on the white-swelling. EXFOL1ATIVUM, (from exfolio, to shed the leaf.) A raspatory, or instru- ment for scraping exfoliating portions of bone. EXOMPHALOS, (from ^, out of, and op«i>*.w, the navel.) A hernia, pro- truding at the navel. EXOPHTHALMIA, (from (-', out, and edivided into two species, with re- gard to diseased parts ; viz. parts call- ed vital, and others not of this nature. 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 tumours, either in, or so as to press upon, a vital part, or one, whose functions are immediately con- nected with life. Scirrhi in the sto- mach, and mesenteric glands ; diseased lungs, liver, &c. produce hectic fever very soon. When hectic fever arises from a dis- ease of" a part, that is not vital, it com- mences sooner, or later, according as it is in the power of the part to heal, or continue tlie disease. If the part be far from tiie source of the circulation, the fever 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 situations, 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 most joints. We must also include parts, whicii have a tendency to such specific diseases, as are not readily cured in any situation. Although hectic fever commonly arises from some incurable local dis- ease of a vital part, or of an extensive disease ofa common part, yet it is pos- sible 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 weak- ness. But, there is rather weak action, than real weakness ; for, upon the re- moval ofthe hectic cause, the action of strength is immediately produced, and every natural function is reestablish- ed, however much it was impaired be- fore. The particular symptoms are debili- ty ; a small, quick, and sharp pulse ; the blood forsakes the skin; Joss of appetite; frequently, a rejection of all aliment from the stomach; wasting ; a great readiness to be thrown into sweats; spontaneous perspirations, when the patient is in bed; the urine is pale-coloured, and very copious; and there is often a constitutional purging. Hectic fever has been imputed to the absorption of pus into the circulation ; FEVERS. 295 but, this cause has been much exag- gerated, as concerned in occasioning many of the bad symptoms, which fre- quently attack persons, who have sores. The hectic fever almost con- stantly attends suppuration, when in particular parts, such as vital ones. It also attends many inflammations, be- fore actual suppuration takes place, as in cases of white swelling of the large joints. The same quantity and species of inflammation and suppuration in any of the fleshy parts, especially such as are near the source of the circula- tion, have in general no such effect. Hence, in the first instances, the fever is only an effect on the system, pro- duced by a local complaint, that has a peculiar property. The constitution sympathizes more readily with diseases of vital parts, than with those of any other parts ; their diseases are also in general more difficult to cure, than the same affec- tions of parts, whicii are not vital. All diseases of bones, ligaments, and ten- dons, affect tiie constitution more readi- ly, than those of muscles, skin, cellular membrane, &c. When the disease is in vital parts, and is such as not to kill, by its first constitutional effects, tlie system then becomes teazed with a complaint, which ij disturbing the necessary ^actions of health. In the large joints, a disease continues to harass the constitution, by attacking parts, wliich have no power, or rather, no disposition to produce a salutary inflammation and suppuration. Thus, the system is also irritated by the existence of an incurable disease. Such is tiie theory of tlie cause of hec- tic fever. If the absorption of matter always produced the symptoms, above describ- ed, how could any patient, who has a large sore, possibly escape becoming hectic ; for, there is no reason to sup- pose, that one sore can absorb more readily than another. If absorbed mat* ter occasioned such violent effects, as have been commonly ascribed to it, why does not venereal matter do the same ? We often know, that absorption is go- ing on, by the progress of buboes. A large one, just on the point of* burst- ing, has been known to be absorbed, in consequence of a few days' sea-sick- ness. The person continued at sea for four and twenty days afterwards ; yet, no hectic symptoms followed, pnly tiie specific constitutional effects, which are of a very different description. Matter is sometimes formed on the inside of the veins, when their cavities are inflamed, and this matter cannot fail to get into the circulation; yet, hectic symptoms do not arise. Also, very large collections of matter, which have been produced without visible in- flammation, as many abscesses of the scrophulous kind, are wholly absorb- ed, in a very short time, but no bad symptoms are tiie consequence. (Hun- ter ) Hence, we may conclude, that the absorption of pus has no share in oc- casioning hectic fever. Many otiier arguments might be adduced to shew the absurdity of the doctrine; but, we can here only refer the reader to what Mr. Hunter has said farther on tiie sub- ject, in his work on inflammation. It is much more probable, that tlie hectic fever arises from the effect, which the irritation of a vital organ, or other parts, such as joints, have on the constitution, when either incurable in themselves, or are so for a time to the constitution. (Hunter.) TREATMENT OF HECTIC FEVER. We have no method of curing tlie consequences above related. All re- lief must depend on the cure of tiie cause, (viz. the local complaint,) or on its removal. Tonic medicines have been recom- mended on account of the evident ex- istence of great debility. Antiseptics have also been given, in consequence ofthe idea that, when pus is absorbed, it makes the blood disposed to putrify. For these reasons, bark and wine have been exhibited. Bark will, in most cases, only assist in supporting the constitution. Until tiie cause is removed, however, there seems no prospect of curing a disorder of the constitution. It is true, tonic medicines may make the system less susceptible of the disease, and also con- tribute to diminish the cause itself, by disposing the local complaints to heal. When, however, the hectic fever arises from a specific disease, such as the ve- nereal, though bark may enable the constitution to bear the local affection better, than it otherwise could do, yet, this medicine can never remove the syphylitic mischief. (Hunter.) 296 J'KV F1S No medicine, not even bark itself, has any direct power of communicat- ing strength to the human constitution. All that can be done, in the treatment of hectic fever, when it is thought in- expedient, or impracticable, to remove the morbid part, is to combat particu- lar symptoms, and to promote diges- tion. It is by bringing about the latter object, that bark is useful in these ca- ses. The infusum cinchonae being more apt to agree with the stomach, than the decoction, or powder, should generally be preferred. Nourishing food, easy of digestion, should be fre- quently 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 some- times does in hectic patients. Ma- deira is less apt to have this disagree- able effect, than port. In these cases, it is often found useful to administer gentle cordial aromatic draughts. Rut, of all medicines, opium is perhaps the most valuable to those, who are afflict- ed with hectic fever ; it alleviates pain, procures sleep, and checks the diar- rhoea, whicii so frequently attends such cases. When the local complaint, connect- ed with the-fever, is totally incurable, it must, if possible, be removed by a manual operation. Thus, when a dis- eased joint keeps up hectic fever, and seems to present no hopes of cure, am- putation must be performed. But, when the local disease holds out the chance of being cured, provided the state of the constitution were improv- ed, the surgeon is, in this circumstance, to endeavour 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. Al- though patients, in an abject state of weakness, have oftentimes been restor- ed to health by a removal of the mor- bid part, yet many have been suffered to sink so low, that no future treatment could save them from the grave. Cle- mency in the practice of surgery, does not consist so much in delaying strong and vigorous measures, as in boldly de- ciding to put them in execution, as boon as they are indicated. When the hectic fever arises from local diseases in parts, which the con- Btitution can bear the removal of, the morbid part should be taken away, if it cannot be cured, consistently with the advice already given. When the disease arises from some incurable dis- ease, in an extremity, all the above mentioned symptoms cease, almost im- mediately after the limb has been taken off. A hectic pulse, at one hundred and twenty, has been known to sink to ninety in a few hours after the removal of tiie hectic cause. Persons have been known to sleep soundly the first night afterwards, who had not slept tolerably for weeks before. Cold sweats have stopped immediately, as well as those, called colliquative. A purging has immediately ceased, and the urine be- gun to drop its sediment. (Hunter.) FIBULA, (quasi figilula, from figo to fasten.) So named from its resem- blance to a Roman clasp. The small bone of the leg. See Fractures and Dislocations. FICATIO, or F1CUS, (a fig.) A tu- bercle about the anus, or pudenda, re- sembling a fig. FISSURE, (from findo, to cleave asunder.) Fissura. A very fine crack in a bone, has this term often apphed to it. See Fracture. FISTULA, in surgery, strictly means a sore, whicii has a narrow orifice, runs very deeply, is callous, and has no dis- position to heal. The name is evidently taken from the similitude, whicii the long cavity of such an ulcer has to that of a pipe, or reed. A fistula common- ly leads to the situation of some dis- ease keeping up suppuration; and from whicii place the matter cannot readily escape. No technical term has been more misapplied, than this has; and no misinterpretation of a word has had worse influence in practice, than that of the present one. Many simple, heal- thy abscesses, with small openings, have too often been called fistulous; and, being considered as in a callous state, the treatment pursued has in re- ality at last rendered them so, and been the only reason of their not hav- ing healed. FISTULA IN ANO. See Anus. FISTULA LACHRYMALIS. A dis- ease, arising from an obstruction in the ductus nasalis, and preventing the tears and mucus of the lachrymal parts of the eye from descending into the nose. No one can have a proper conception of this disorder, without adverting to tlie anatomy, and functions, of the parts FISTULA, t$t concerned, fience, I shall first insert the interesting relation of these sub- jects, as delivered by Mr. Pott. " That the motions of the eyelids may be performed with the utmost ease, that the tunica cornea may be kept constantly clean, bright, and fit for the transmission ofthe rayS of light, and that dust, and other hurtful parti- cles, may be immediately washed away, the Surface of the eye is continually moistened by a fine limpid fluid. " This fluid is derived principally from a large gland, situated under the Upper edge ofthe orbit, near the outer corner ofthe eye, which gland is ofthe conglomerate kind, and lies in a small depression ofthe os frontiS; its excre- tory ducts, or thosfe by which it dis- charges tiie secreted fluid, piercing the tunica conjunctiva, just above the Car- tilaginous borders of the upper eye- lids. " While the caruncule was thought to be the secretory organ of the tears, this gland bore the title of glandula innominata ; but now, that its use and Office are known, it is called glandula lachrymalis. " By irritation from any sharp or poignant particles, a large quantity of this fluid is immediately secreted, and by the motion of the eyelids is as im- mediately derived over the surface of the eye, by which means such particles are washed and wiped off. Sometimes also the passions of the mind produce an immediate increase of lymph, which is then strictly and properly called rears; a constant secretion of too large a quantity causes a disease, called epi- phora; and a deficiency of" it makes the motions of the lid difficult and painful. " Although the fluid secreted by the lachrymal gland is considerable in quantity, yet, when it is not suddenly produced by irritation from without, or passion within, it is so constantly and gradually carried off, as to create neither trouble, uneasiness, nor ble- mish. " The edge, or border of each eye- lid, is formed by a thin cartilage, the figure and consistence of which keep the lids properly expanded; these car- tilages are covered by a fine membrane, and are called cilia; their internal ed- ges do, upon every motion, sweep over every point of the surface of the cor- nea; this motion, though almost im- perceptible, unless attended to, is very vol. 1. frequently performed; and as the se- cretibn ofthe fluid is also constant, the eye is by this means kfcpt always moist, 'clean, and bright. "At the extremity of each of thesft cartilaginous borders of the eyelids, oh the Bide next the nose, is a small pa- pilla, or eminence ; ahd in the middlfe of each of these is a small hole, or per- foration, which being made in the car- tilage, is not liable to collapse while the parts are in a sound state, but re- mains always open; they are called the puncta lachrymalia; and their office is to receive the lachrymal fluid, as it runs off the cornea along the edges of the eyelids, thereby preventing k from trickling down the cheek; and tha"t tliere may be no impediment to tlie constant execution of this office, during the time of sleep, as well as that of being awake, the internal edges of the cilia do not come into immediate con- tact with each other in that point where these orifices are. " From each of these puncta lachry-- malia proceeds a small membranous tube; which tubes soon enter into, or form a pouch or bag, situated near the inner angle of the eye, just below the union of the two lids, under the mus- culus orbicularis palpebrarum; the bag is called the Sacculus lachrymalis, and its office is to receive all the lymph brought by the puncta and dufctS; the upper part of this sacculus lies in an excavation, formed partly by the nasal process ofthe os maxillare superius, and partly by the os unguis; the lower part of it is confined in a long channel, and forms a tube, or duct, which de- scending obliquely backward, commu- nicates with the cavity of the nose, be- hind the os spongiosum superius, by an opening whose size is somewhat different in different subjects. " This passage is called the ductus ad nares or the ductus nasalis, and through it whatever is received By the sacculus from the puncta does, in a healthy and sound state of these p;arts, pass into the nose. " The membrane which liries tliis sacculus and duct, is in its structure much like to the membrana pituharia harium, from the surface of which a clear viscid mucus is secreted, and by which the sacculus and passages are constantly moistened and kept pervi- ous. " While the parts are in a healthy, sound state, the fluid secreted bv the- 38 298 FISTULA. lachrymal gland passes off through the puncta, sacculus, and duct, into the nose, without any trouble: but when they are in a diseased state, the case is otherwise. This membrane, like all other vascular parts, is liable to inflam- mation, by whicii means it often hap- pens, that it is so thickened as to ob- struct the nasal duct, and thereby much impede, or totally hinder the passage of any thing through it; in conse- quence of which obstruction, the sac- culus is filled by its natural mucus, and the derivation of the serum from the lachrymal gland through it being thus prevented, it runs off from the eyelid down the cheek; this obstruction con- tinuing, and the mucus still lodging, the sacculus is dilated, and produces that tumour in the inner corner of the eye, and that discharge, upon pres- sure, which characterize the first state ofthe disease in question, and, in con- junction with several other attending symptoms, prove its seat to be in the la- chrymal sac, and nasal duct. " Although the seat of this disease is the same in almost every subject, yet its appearance is very different in different persons, and under different circumstances. These variations de- pend principally on— 1. The degree of obstruction in the nasal duct. 2. The state of the cellular membrane covering the sac. 3. The state ofthe sacculus itself. 4. That of the bone underneath. 5. The general state and habit of the patient.* " Sometimes a serous kind of de- fluxion, by which the lining of the sac and duct are so thickened as to ob- struct, or prevent the passage of the fluid through them into tlie nose, makes the whole complaint; and the cellular membrane on the outside not being dis- eased, there is no appearance of in- flammation. In this case the duct is stopped, and the sacculus dilated, but without any alteration m the colour of the skin; a fulness appears in the cor- ner of the eye next to the nose; and upon the application of a finger to this tumour, a clear viscid mucus is dis- charged through the puncta lachryma- lia ; the patient feels no pain, nor finds any inconvenience, except what is pro- duced by the discharge of this mucus, and by the trickling ofthe lymph down tiie cheek. " In some cases the mucus is not perfectly and always clear, but is some- times cloudy, and looks as if it had a mixture of milk or cream in it; at first waking, some of it is generally found in the corner of the eye; and the eye- lashes, being smeared over with it du- ring sleep, most commonly adhere to- gether in the morning. " This is the most simple state of the disease, what the French have call- ed the hernia, or hydrops sacculi la- chrymalis : it is frequently met with in children who have been rickety, or are subject to glandular obstructions; and in this state it sometimes remains for some years, subject to little altera- tions, as the health or habit shall hap- pen to vary, the sacculus being some- times more, sometimes less full, and troublesome; the mucus which is press- ed out, is sometimes more, sometimes less cloudy, and now and then it is at- tended with a slight ophthalmy, or an inflammation of the eyelids, but which, by common care is easily removed. " If the sacculus is not much dilated, the discharge small, and produced on- ly by pressure, the chief inconveniences are the weeping eye, and the gumming together of tiie lids, after sleeping; but these, by being attended to, may be kept from being very troublesome; and, if" the disease makes no farther progress, may be so regulated as to render any more painful process totally unnecessary. " If the dilatation is considerable, the swelling is more visible, and the quan- tity of mucus is larger; it is also in this state more frequently mixt and cloudy, and more troublesome, from the more frequent necessity of empty- ing the bag; but if the patient be adult, it may, even in the more dilated state of it, be kept from being very inconve- nient. "If an inflammation comes on, the tumour is thereby considerably increa- sed, the discharge is larger, as well du- ring sleep as upon pressure; the skin covering it loses its natural whiteness and softness, becomes hard, and ac- * As the state and circumstances of this disease are really various, and differ very essentially from each other, the general custom of calling them all by the one name of fistula lachrymalis is absurd. FISTULA. 299 quires an inflamed redness; and with the mucus a mixture of something, which in colour resembles matter, is discharged, especially if the pressure be made with any force, or continued for any time: this circumstance, added to the painful sensation, and inflamed appearance of the parts, has been pro- ductive of a supposition, that in this state there is either an ulcer or an ab- scess within the sacculus or duct." Mr. Pott next attempts to prove, that the contents of the sac are only of a mucous, not a purulent, qua- lity. On quitting this discussion, Mr. Pott remarks, " The inflammation of the cellular membrane covering the sac, is a circumstance which makes a considerable difference, both in the ap- pearance of the disease, and in its requisite treatment; in some cases it is confined merely to the surface of the tumour in the corner of the eye; in others it spreads still farther, affec- ting the eyelids, cheek, and side ofthe nose. " When the parts are in this state, the mucus within the bag has generally the appearance of being matter, that is, it wears a deep yellow, and is of a more thin consistence; if the puncta lachrymalia are naturally large and open, and the inflammation confined to the surface of the sac, its contents will pass off pretty freely, and the skin will remain entire; this is what the ancients called the simple, or imper- fect, anchylops. "But when the skin covering the lachrymal bag has been for some time inflamed, or subject to frequently re- turning inflammations, it most com- monly happens, that the puncta lachry- malia are affected by it, and the fluid not having an opportunity of passing off through them, distends the inflamed skin, so that at last it becomes sloughy, and bursts externally. This is that state ofthe disease which is called per- fect aigylops, or aegylops ; the dis- charge which used to be made through the puncta lachrymalia, while the skin was entire, is now made through the new opening ; and, by excoriating the eyehds and cheek, increases the inflam- mation, and gives the disease a much more disagreeable appearance. In some, the matter bursts through a small hole, and after it has discharged itself, the tumour subsides, the neigh- bouring parts become cool, and though the skin covering the surface of the sacculus is sloughy and foul, yet there is no reason to believe that the sac itself is much diseased below; in others, the breach is large, the skin remains hard and inflamed, and from the ap- pearance of the sore, there is reason to suppose the whole inside ofthe bag to be in a diseased state; and in some cases, which have been much neglec- ted or irritated by ill treatment, the cavity of the sacculus seems to be filled with a loose ill-natured fungus, which gleets largely, and produces inflamma- tion and excoriation of all the parts about. " There is also another circumstance whicii sometimes is found to attend this disorder, viz. a carious state of the bones. This was by our forefathers supposed to be a frequent one, and was the principal reason for their so free use of the caustic, cautery, and scalpra, in the treatment of it; but since the disease has been more mi- nutely examined into, this circum- stance has been found to be a very rare one. When the fistula lachrymalis is a symptom of the lues venerea, as it sometimes is, the bones are indeed often carious; but then, the fistula is not the original complaint, but pro- duced secondarily, and is a consequence ofthe diseased state of the os ethmoi- des, and ossa spongiosa of the nose, and is not curable by any local means or applications, but depends entirely on the cure of the disease of which it is a symptom. " I have also seen an abscess after" the small-pox, which, by falling on the lachrymal bag, has made it all slough away, and leave the bones bare; which circumstance I have also seen attend the free use of strong escharo- tics apphed to destroy what is called the cyst; but without the accession of some other disorder producing it, or the most absurd method of treating the complaint, I believe that a caries of the bones will very seldom be met with. Indeed, tiie combination of other dis- eases, either of the general habit, or affecting the same, or the neighbour- ing parts, does often make a very ma- terial difference, both in the appear- ance of the disorder, in the prognostic, and the proper method of treating it, whicii therefore should always be in- quired into : for instance,' tiie patient is sometimes subject to an habitual ophthalmy, or lippitudo, which will 300 FISTULA. add to the deformity, and give a good deal of additional trouble during the cure ; an ozoena, or some other dis- ease of the membrane, and cells of the ethmoid bone, or a polypose ex- crescence within the nose, are now and then combined with it ; the habit is 40HH'times, as 1 have before obser- ved, infected with the lues venerea, of whic!i ihis disease may be a symptom ; strumous glandular obstructions are its too frequent companions ; and, what is worst of all, it is sometimes can: cerous." TREATMENT OF THE FIRST STAGE OF THE FISTULA LACHRYMALIS. Mr. Pott continues: " From what has been said, 1 think it will appear that this d'sease, in its primary and most simple state, consists in a deten- tion or lodgment of mucus in the sac- culus lachrymalis, in consequence of an obstruction of the natural passage from that bag into the nose ; that by means of this lodgment the sacculus is dis,ended, irritated, and sometimes inflamed ; that the fluid whicii passes from the lachrymal gland over the eye to the puncta lachrymalia, being pre- vented by the fulness of the sac from getting into it, runs down the cheek ; and therefore that the characteristic marks of tlie c^i6ord.er, when recent, are a small tumour in the corner of the eye, an involuntary flux of the serum down that side ofthe face, and a dis- charge of mucus through the puncta lachrymalia upon pressure. " This lodgment, being originally produced by the stoppage of the natu- ral duct, it follows, that the first cura- tive intention is, the removal of that obstruction ; which is sometimes prac- ticable, but more often not; the de- gree of obstruction, its date, tiie state ofthe adjacent parts, and some other circumstances, rendering it more or "fess so in different subjects. " That the inexperienced practitioner may be guarded against giving a hasty prognostic, or making attempts, which, however fatiguing to the patient, must ih the end prove fruitless ; and that he may be enabled to understand the dis- ease more perfectly, I shall take the liberty to divide it into four general heads, or states, under which all its lesser distinctions may be comprehen- ded- "The first consists in a simple dilata- tion of the sacculus, and obstruction of the nasal duct, discharging upon pres- sure a mucus either quite clear, or a little cloudy ; the skin covering the bag being entire and perfectly free from inflammation. " In the second, the tumour is some- what larger; the skin which covers it is in an inflamed state, but entire; and the discharge made through the punc- ta lachrymalia is of a pale yellow, or purulent colour. " In the third, the skin covering the sacculus is become sloughy and burst, by which means the swelling is in some measure lessened; but the mucus, which, while the skin was entire, used to be pressed out through the puncta lachrymalia, now discharges itself through the new aperture ; the ductus ad nares, both in this and the preced- ing state, are not otherwise diseased, than by the thickening of its lining. " In the fourth, the passage from the sacculus lachrymalis into the nose is totally obliterated, the inside of the former being either ulcerated, or filled up with a fungus, and attended some- times with a caries of tiie bone under- neath." Our limits oblige us to pass over what Mr. Pott next states, concerning the practice ofthe ancients. " In the first and most simple state of the disease, viz. that of mere ob- struction, without inflammation, much pains have been taken to restore the parts to their natural state and use, Without making any wound or division at all ; the introduction of a probe, the injection of a fluid, and a constant compression made on the outside of the sacculus in the corner of the eye, are the principal means by wliich this has been attempted. " Some few years ago, M. Anel made a probe of so small a size as to be ca- pable of passing from the eyelid into the nose, being introduced at one of the puncta lachrymalia, and passing through tlie sacculus and duct ; with whicii probe, he proposed to break through any small obstruction, which might be found in its passage. " He also invented a syringe whose pipe is small enough to enter one of the puncta, and by that means to furnish an opportunity of injecting a liquor into the sacculus and duct; ^n "ay be at a considerable distance from the bladder. The stricture is often inclu.- ded in the ulceration, by which means it is removed; but, unluckily, this does not always happen. The ulceration is always on the side of the urethra, next to the external surface. The internal membrane and substance of the urethra having ulcerated, the urine readily gets into the loose cellu- lar membrane of the scrotum and pe- nis, and diffuses itself all over those parts; and as this fluid is very irrita- ting to them, they inflame and swell. The presence ofthe urine prevents the adhesive inflammation from taking place; it becomes the cause of suppu- ration *vherever it is diffused, and the irritation is often so great that it produ- ces mortification, first in all the cellu- lar membrane, and afterwards in seve- ral parts of the skin; all of w hich, if the patient live, slough away, making a free communication between the ure- thra and external surface, and produ- cing fistula in perinao. However, when the ulceration takes place further back than the portion of the urethra, between the glans penis and membranous part of this canal, the abscess is generally more circum- scribed. ' The urine sometimes insinuates itself into the corpus spongiosum urethrae, and is immediately diffused through the whole, even to the glans penis, so as to produce a mortification of all those parts. Although the ulceration of the ure- thra may be in the perineum, yet the urine generally passes easily forwards into the scrotum, which contains the loosest ct llular substance in the body; and there is always a hardness, ex- tending along tiie perinaeum to the swelled scrotum, in the track of the pus. Ulceration can only be prevented by destroying the stricture; but, when the urine is diffused in the cellular mem- brane, the removal of the stricture will generally be too late to prevent all the mischief, although it will be necessary for the complete cure. Therefore, an attempt should be made to pass a bou- gie, for perhaps the stricture may have been destroyed by the ulceration, so as to allow this instrument to be intro- duced. Whcu this is the case, bou- gies must be almost constantly used, to FISTULA. 307 procure as free a passage forwards, in the right way, as possible. When the bougie cannot pass, the application of caustic would in many cases be too slow in its operation, and, in others, cannot be tried, by reason ofthe situa- tion ofthe stricture. While we are attempting to cure the stricture, antiphlogistic measures, par- ticularly 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 glysters; with a view of diminishing any spasmodic affection. But, all these proceedings are often insufficient, and, therefore, an immediate effort must be made, both to unload tlie bladder, and prevent the further effusion of urine, by making an opening into the urethra, somewhere beyond the stricture, but, the nearer to it, the better. Introduce a director, or some such instrument into the urethra, as far as the stricture, and make tiie end of it as prominent as possible, so as to 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 es- cape,and destroy the stricture. If the instrument cannot be felt, at first, by tiie finger, we must cut down towards it; and, on afterwards feeling it, pro- ceed as above. When the stricture is opposite the scrotum, as the opening cannot be made in this situation, it must be made in the perinseum, in which case, tliere can be no direction given by an instru- ment, as one cannot pass sufficiently far, and the only guide is our anatomi- cal knowledge. The opening bving made, proceed as directed in the cure of a false passage. (See Urethra, Fake Passage in. In whichsoever way the operation is done, a bougie, or a cathe- ter, whicii is better, must afterwards be introduced, and the wound healed over it. When the inflammation, from the extravasation of urine, is attended with suppuration and mortification, the parts must be freely scarified, in order to give vent both to the urine and pus. When there is sloughing, the inci- sions should be made in the mortified parts. Sometimes, when the urethra is ul- cerated, and the cellular membrane of the penis and prepuce is so much dis- tended, as to produce a phymosis, it is impossible to find the orifice ofthe ure- thra. Frequently the new passages for the urine do not heal, on account of the stricture not being removed; and even when this has been cured, they often will not heal, but become truly fistu« lous, and produce fresh inflammations and suppurations, wliich often burst by distinct openings. Such new absces- ses and openings often form, in conse- quence ofthe former ones having be- come too small, before the obstruction in the urethra is removed. Such diseases sometimes bring on intermittent disorders, whicii do not yield to bark; but do not recur, when the fistulae, and disease ofthe urethra, have been cured. In order to cure fistula in perimeo, unattended 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 passage 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 operation becomes indispensable. The sinuses are to be laid open in the same manner as otiier sinuses, which have no disposition to heal. In doing tliis, as littie as possible of the sound part of the urethra must be open- ed. Hence, the surgeon must direct himself to the inner orifice ofthe fistu- lae, by means ofa staff, introduced (if possible) into the bladder, and a probe passed into one of* the fistulous passa- ges. The probe should be first bent, that it may more readily follow the turns of the fistula. When it can be made to meet the staff, so much the better, for, then the operator can just cut only what is necessary. When the fistula is so straight, as to admit ofa director being introduced, this instrument is the best. When nei- ther 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. Having divided the fistulae, as far as their termination, in the urethra, a ca- r 308 FOM FRA theter should be introduced, and worn at first, almost constantly. This is bet- ter than a bougie, which must be fre- quently withdrawn to allow the patient to make water, and it often could not be introduced again without getting en- tangled in the wounds. Whatever instrument is used for keeping the passage clear and open, while the sores are healing, whether the sores are the consequence of the causes ofthe fistula, or the above ope- ration, there is, in many cases, a limit- ed time for its employment. 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 ex- traneous body. Hence when the sores become stationary, let the catheter be withdrawn, and introduced only occa- sionally. Even after the sores are well, the bougie may afterwards be used, in or- der to determine whether tiie passage is free from disease. When fistulae in perinaeo have been laid open, the wounds are to be at first dressed down to the bottom as much as possible, which will prevent the re- union of the parts first dressed, and make the granulations shoot from the bottom so as to consolidate the whole by one bond of union. (See Treatise on the Venereal Disease, by John Hun- ter.) FLUCTUATION, (from fluctuo, to float.) Fluctuatio. That motion and agitation, whicii is evident upon the pressure of a part containing any fluid. FOMENTATION. Fomentatio, Fo- mentum, F'otus. By a fomentation, sur- geons commonly mean the application of flannel, or some other substance, wet with warm water, or some medici- nal decoction, to any part of the body. Fomentations are chiefly of use in sur- gery in relieving pain, and inflamma- tion, and in promoting suppuration when this is desirable. Some particu- lar decoctions, however, are used for fomentations, with a view of affecting, by means of their medicinal qualities, scrophulous, cancerous, and other sores of a specific nature. We shall just mention a few of the most useful fomentations in common use. FOMENTUM AMMONLE MURI- ATvE. R. Fomenti Communis ifcij. Ammon. Mur.$j. Spirit. Camph. sjij. 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 promoting the absorption of some tumours, and suppuration in others. FOMENTUM CICUTJE. R. Fol. Cicut. recent, lbj. vel Fol. Cicut. exsic- cat. 31 ij. Aq. Comm. Ibiij. Coque usque reman. tbij, et cola. This fomentation is considered, as a very proper one for many scrophulous, cancerous, and phagedenic ulcers. FOMENTUM CHAM7EMELI. R. Lini contusi ^j. Chamameli Jij. Aq. Distillat. Ibvj. Paulisper coque, et cola. This is a common fomentation for or- dinary purposes. FOMENTUM GALLJE R. Galla Contusa £ss. Aq. Ferventis ibij- Muce- ra per horam, et cola. I'sed for the prolapsus ani. It is sometimes also employed, as a cold application, in ca- ses of hemorrhoids. FOMENTUM PAPAVERIS ALBI. R Papuv. Alb. Exsiccati $\v. Aq. Pur. "tbvj. Bruise the poppies, put them in the water, and boil the liquor, till only a quart remains, whicii is to be strain- ed. This fomentation is a very excel- lent one, for very painful inflammations of the eyes, and for numerous ulcers, and other diseases, attended with into- lerable pain. FONTANELLA, (dim. of fons, a fountain.) An issue, so named from its continually running. FONTICULUS. The same. FORCEPS. A surgical instrument, being a pair of pincers, of" various sizes and forms, according to the pui-poses for whicii it is designed. Thus the common forceps, for removing the dressings from sores and wounds, and for taking away any loose exfoliating pieces ot bone, differ from the forceps intended to be used in lithotomy ; and the -e latter are very different from the forceps used for taking up the mouths of the large arteries, in order that they may be tied. F R ACT C RE, (fromfrango,to break.) Fractura. Is a solution of continuity of one, or of several bones, produced in general by external force, but, occa- sionally, by the powerful action of mus- cles, as is often exemplified in the broken patella. The long bones are particularly subject to be broken, and, mostly, at their middle part. They may, however, be fractured near their extremities. Sometimes, the same bone is broken in different places, which case is termed a comminuted fracture. FRACTURES. 309 Though, when tiie middle part of a bone is fractured, the ends of the frac- ture are more apj to be displaced, on account of the contiguous surfaces be- ing less extensive, yet, this kind of fracture is the least dangerous, be- cause the violence, which iias caused the accident, has seldom been applied to the broken part, and consequently, the adjacent soft parts are uninjured. The middle of a bone also is broken by less force, than any other part of it, and the fracture being distant from any joint, no stiffness, nor anchylosis, is likely to result from the injury. Fractures are also distinguished into transverse and oblique. Duvemey has admitted another class, viz. longitudinal ones ; but, J. L. Petit has denied the possibility of, this case, and Boyer adopts the opinion of the latter, re- jecting, as impossible, the longitudinal fracture, unless that name be given to longitudinal splinters of comminuted fractures. The most important division of frac- tures, 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, communicating 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, which lacera- tion is produced by the protrusion of one, or both ends, of" the fracture. The dangerous nature of compound fractures will be fully understood, when we presently treat separately of this subject. The causes of fractures are divided into predisposing and remote. In the hist class are comprehended, the situation and functions of the bones, tiie age of the patients, and their dis- eases. Superficial bones are more ea- sily fractured, than those, which are covered by a considerable 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 tiie ulna. The clavicle, which serves to keep the shoulder in its proper position, and support on its arched extremity all the motions ef the upper extremity, is hence very subject to be broken. The gradual increase of the quantity of the phosphate of lime, in the structure of the bones, makes them brittle, in pro- portion as we advance in years, and, in old age, the proportion of the inor- ganized to the organized part is so great, that the bones are fractured by the slightest causes. In childhood, the fibrous and organized part bears a greater proportion to the earth, and the bones being, consequently, more clastic and flexible, are not so easily broken, as in old age. Louis and Sa- viard mention cases, in which, women affected with old ulcerated cancers, have fractured their bones in merely executing the natural, and ordinary motions of the body, as merely chang- ing their position in bed. The remote cause of fractures is ex- ternal force, variously applied, in falls, blows, &e. In particular instances, the bones are broken by the violent action of the muscles attached to them ; this is almost always the case with the frac- tured patella. I remember a very strong man, whom Mr. Ramsden at- tended at Pentonville, who broke his os brachii, in making a powerful blow, although he missed his aim, and struck nothing at all. Some of the symptoms of fractures are very equivocal. The pain, and in- ability to move the limb, commonly enumerated, may arise from a mere bruise, a dislocation, or other cause. The crepitus, the change in the form of the limb, and the shortening of it, are circumstances, communicating the most certain information ; and the crepitus, in particular, is the principal symptom to be depended upon. The signs of fractures, however, are so exceedingly various, according to the bones, which are the subject of" injury, that, it can- not be said, that tliere is any one, which is invariably attendant on such cases, and characteristically confined to them. The writers of systems of surgery have usually noticed loss of motion in the injured limb, deformity, swelling, tension, pain, &c. as forming the general diagnosis of fractures. However, it is easily comprehensible by any one, acquainted with anatomy, that numerous fractures cannot pre- vent the motion of the part, nor occa- sion outward deformity; and every surgeon must know, that, though, at first, tliere maybe pain in the situation of a fracture, no swelling and tension take place, till after a certain period. 310 FRACTURES. 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 with his fin- gers, whether there is any inequality along the anterior surface, and along the sharp front edge of that bone. If it be the clavicle, let him trace the su- perficial course of the bone, in the same attentive manner. Wherever any unusual pain occurs, or any unnatural irregularity appears, then let him try, if a grating, or crepitus, cannot be felt on endeavouring to make one end of the fracture rub against the otiier. When the os brachii, or the os femoris, is the subject of inquiry, a crepitus is felt almost as soon as the limb is touch- ed, and, in the case of the broken thigh, there is a considerable shorten- ing ofthe extremity, unless sometimes when the fracture is of the transv erse kind. 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 fin- gers. I am aware, that considerable harm, and great unnecessary pain, have been occasioned in the practice of surgery, by an over officious care to feel the grating of" fractured bones, and, when- ever the case is sufficiently evident to the eyes, I cannot refrain from censur- ing those • practitioners, who indulge their own ill-judged habits, at the ex- pense of torture U) the unfortunate pa- tient. A fracture is an injury, that is necessarily attended with a great deal of pain, and followed by more, or less swelling, and inflammation t and to in- crease these evils by roughly, or unne- cessarily handling the part, is both ig- norant i) cruel, and, if I may use the expression, unsurgical. In some kinds of fractures, the bro- ken bone is so surrounded with thick fleshy parts, that it is very difficult to feel a crepitus, or ascertain the exist- ence ofthe injury. Some fractures of the neck ot the thigh-bone, unattended with much retraction of the limb, are instances illustrative of this observa- tion. Tut prognosis of fractures varies, according to tiie bone injured, what part of it is broken, the direction of the breach of continuity, and what other- mischief complicates the case. Fractures of bones, which have many strong muscles inserted into them, are more difficult of cure, than those of other bones, which have not so many powers attached to them, and capa- ble of disturbing the ends of their frac- tures. The fracture of the middle part of a long bone, is less dangerous, than a similar injury near a joint, with which the bone is articulated, for reasons mentioned above. - Oblique fractures are more trouble- some, and difficult of cure, than trans- verse ones, because an oblique surface does not resist the retraction of the lower portion ofthe broken bone, and, consequently, it is very difficult to keep the ends of the fracture applied to each other, in jk proper manner. Fractures complicated with a violent contusion of the soft parts, or with a wound, rendering them compound ones, are much more dangerous, than other ones free from such accidents. Fractures of the leg are generally more serious, than similar injuries of the up- per extremity. A fracture may be rendered a very dangerous case, by being attended with a wound of a large artery. In a debilitated old man, a fracture is less likely to end well, than in a healthy child, or strong young subject. The scurvy is said to retard the formation of callus ; but, it is not true, that preg- nancy prevents the union of fractures. There are certain indescribable consti- tutions, in which bones, more particu- larly, however, the os brachii, will not unite again after being broken. These temperaments are also very various; at least, I infer so from two subjects, to whom 1 paid particular attention. One was a strong, robust man, whose chief peculiarity seemed to be his in- difference to pain : he had the o.ids of the broken os brachii cut down to, turned out, and sawn off, by Mr. Long, in St. Bartholomew's hospital, and the limb afterwards put in splints, and taken the greatest care of; but no union followed. The other case was a broken tibia and fibula, which remained disunited for about four months ; but, afterwards, grew together. The latter subject was a complete instance of hy- pochondriasis. I have since seen a woman, under Sir James Earle, in the above institution, whose os brachii did FRACTURES. 311 not unite in the least, though it had been broken several months. Every attempt to move the bone occasioned excruciating torture. The womandied of some illness in the hospital, and, on dissecting the arm, the cause of the fracture not having united was found to arise from the upper, sharp, pointed extremity of the lower portion of the broken bone having been forcibly drawn up by the muscles, and penetrated the substance of the biceps, in wliich it still remained. I am indebted to Mr. Henry Erftrle tor the account of the ap- pearance on dissection; and I do not know, that this kind of impediment to the union of a fracture has been noticed by any writer. I shall only remark on this part of the subject, that cutting down to the fracture and scraping, or sawing off, the ends of the bone, is an operation, to which we are not much encouraged by the results of cases, on which the experiment has been made. Besides the failure of the operation, which was most completely executed by Mr. Long, before numerous specta- tors, I understand, that Mr. Cline, and other surgeons, have tried the same proceeding, with no better success. The process, by which broken bones grow together again, is nearly of" the same nature, as that, by which the soft parts are united in wounds. The only difference is, that in uniting a fracture, tiie vessels after a time deposit the phosphate of lime. The vessels rami- fying on the ends of the fracture, -first effuse coagulating lymph. This gra- dually becomes vascular, and in pro- portion as the vessels acquire the pow- er of secreting earthy matter, it is by degrees converted into new bone, term- ed callus, which, from being at first soft and flexible, at length becomes firm and unyielding, like the original bone, and fit for constituting the future bond of union, between the two extre- mities of the fracture. In order that the first connecting substance may speedily become organized, and fitted for the formation of callus, nothing is so favourable as perfect quietude. Hence, the chief surgical indication, in the treatment of fractures, after the bones are replaced, is to keep them per- fectly motionless: nature completes tiie rest (See Callus.) TREATMENT OF FRACTURES IN GE- NERAL. The general doctrine, relative to fractures, is contained under the fol- lowing heads, as part of the treatment of them. Extension. Counter-Extension. Coaptation, or Setting. Application of Medicaments. De ligation, or Bandage. Position. Prevention, or Relief of Accidents. In the subsequent part of the present article, little more remains for us to do, than to follow Mr. Pott in his judi- cious observations on this part of prac- tice. It is very material to understand, how the ends of a fracture become dis- placed, because the greatest object in the treatment is to prevent such de- rangement. The separating of the ends ofthe fracture is not, however, an invariable occurrence; for fractures frequently take place, and yet no defor- mity is produced. When the tibia alone is fractured at its upper part, the shape of the limb is unaltered, because the diameter of the bone there is so great, and the surfaces of the fracture in contact so extensive, that they can- not be easily separated, and the unbro- ken fibula also aids in keeping the ends ofthe fracture from being displaced. A fracture of the upper thick part of the ulna alone is seldom deranged. In cases, however, in whicii both bones of tlie leg, or forearm, are broken, the ends of the fracture are commonly more or less displaced, and the limb consequently deformed. The causes, and the varieties, of the derangement, attendant on fractures, form a most interesting subject. In transverse fractures, the ends of the broken part cannot be deranged in the longitudinal direction, before they have been so much displaced, in the direction of the diameter of the bone, that no points of the fractured surfaces remain in contact. But, when the fracture is oblique, and the surfaces not extensive, the de- rangement may happen in the direction ofthe axis ofthe bone, and the limb be shortened. 312 FRACTURES. The third way, in which a fracture may be displaced, has not been much attended to; it is when the portions of the broken bone form an angle one with the other. In comminuted fractures this is most common; but, it also oc- curs both in simple fractures of the leg and thigh, when the foot is too much elevated, or depressed. The fourth species of derangement is produced by a rotation of the infe- rior fractured portion on the superior, as is very common in fractures of the thigh. The bones being only passive instru- ments of loco-motion, possess not, in their own organization, any cause of the change of situation, which takes place, but yield to exterior causes, to the weight of the member, and to mus- cular contraction. The force produ- cing the fracture may, in some instan- ces, not merely break the bone, but, also, displace the ends of the broken part. Of all the causes, however, which tend to separate the ends of a fracture from each other, the action of the mus- cles, is the most important, and diffi- cult to counteract. Mr. Pott, after censuring the violent extension, and counter-extension,indis- criminately practised and recommend- ed by the old surgeons, proceeds to inquire, whence arose the evils and difficulties formerly encountered. " Nei- ther extension, nor counter-extension, says he, can ever be necessary on ac- count of the mere fracture, considered abstractedly. The broken ends ofthe bone, or bones, are of themselves inac- tive, and, if not acted upon by other parts, they would always remain mo- tionless. When any attempt is made to put them into motion, they of them- selves can make no possible resistance; nor can any be made on their part, save an accidental one arising from the points of the fracture being entangled with each other; and when they have been once, by the hand of the surgeon, placed properly and evenly with regard to each other, they would of themselves for ever remain so. What then is the reason why fractured bones always suffer a greater or a less degree of dis- placement? why is a broken limb al- most always shorter than its fellow ? what creates the resistance which we always find in attempting to bring the fractured parts aptly together ? whence does it proceed, that when we have done all that is in our power (accord- ing to this mode of acting) the ends of the fracture will, in many cases, be- come again displaced, and lameness and deformity frequently ensue ? In short, what are the parts or powers which act on the bones, and which, by so acting on them, produce all these consequences ? " These parts are the muscles, the only moving- powers in an animal body. By the action of these on the bones, all locomotion is performed, and cannot be performed without them; and al- though all bones, when broken, are in some degree displaced and shortened, yet it will always be found, that in pro- portion as the muscles surrounding, or in connexion with a bone, are strong or numerous, or put into action by inad- vertence or spasm, so will tiie displace- ment of the ends of such bone, when fractured, be. The even and smooth position of the fractured ends of a tibia, when the fibula of the same leg is en- tire and unhurt; that is, when the mus- cles therefore cannot act upon the for- mer ; the visible and immediate defor- mity, when both the before mentioned bones are broken nearly in the same place; that is, when the muscles can act upon and displace such fracture; the great difficulty frequently met with, in endeavouring to get a broken os fe- moris to lie even tolerably smooth, and to prevent such broken limb from being much shorter than the other, are, among others which might be produced, such strong, and irrefragable proofs, as need no comment. " From the muscles then, and from them only, proceeds all the difficulty whicii we meet with in making our ex- tension ; and by the resistance of these, and of these only, are we prevented from being always able to put the ends of a fractured bone immediately into the most apt contact. " Let us in the next place consider, what it is which gives to a muscle, or to the principal muscles of a limb, the greatest power of resisting any force applied to them ab exlerno, in order to draw them out into greater length; for whatever that is, the same thing will be found to be the cause of the different degrees of resistance in set- ting a fracture. " Does not the putting the muscles in a state of tension, or into a state ap- proaching nearly to that of tension, al- most necessarily produce this effect i FRACTURES. 31C or, in other words, does not that posi- tion of a limb, which puts its muscles into, or nearly into such a state, give such muscles an opportunity of exert- ing their greatest power, either of ac- tion, or of resistance? This I believe cannot be denied. On the other hand, what is the state or position of a mus- cle which is most likely to prevent it from acting, and to deprive it of most of its power of resistance, or what is that position of a limb which, in the case of a broken bone, will most inca- pacitate the muscles from acting on, and displacing it; and in the greatest degree remove that resistance which they have it in their power to make to the attempts for the reduction of such fracture ? Is it not obvious, that put- ting a limb into such position as shall relax the whole set of muscles, belong- ing to, or in connexion with, the bro- ken bone, must best answer such pur- pose ? Nothing surely can be more evi- dent. If this be granted, will it not, must it not follow, that such posture of a broken limb must be the best for making the reduction; that is, it must be that in which the muscles will re- sist the least, and be least likely to be injured; that in which the broken bone will be most easily set, the patient suf- fer least pain in present, and that from which future lameness and deformity will be least likely to happen. A little attention to what frequently occurs, may perhaps serve to illustrate and confirm this doctrine better than mere assertion. " What is the reason why no man, however superficially acquainted with his art, ever finds much trouble in set- ting a fractured os humeri, and that with very little pain, and a very small degree of extension? 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? and is it not for tlie same rea- son that we so very seldom see (com- paratively speaking of this bone with others) a deformity in consequence of a fracture of it ? Let the reduction be attempted with the arm extended from the body, and the difficulty of setting will be much increased: let the arm be deposited in an extended straight posi- tion, and the fracture will be displaced and lie uneven. " Apply the same kind of reasoning to the os femoris; that bone whose VOL. 1. fracture so often lames the patient, and disgraces the surgeon. " Will it not be more cogent, and more conclusive, in proportion as the muscles in connexion with this bone are more numerous and stronger? I would ask any man, who has been much conversant with accidents of this kind, what is the posture which almost every person (whose os femoris has been newly broken) puts himself into in order to obtain ease, until he gets proper assistance ? Do such people I stretch out their limb, and place their leg and thigh straight, and resting on the calf and heel ? I believe seldom or never. On the contrary, do not such people almost always bend their knee, and lay the broken thigh on its out- side ? and is not the reason, why this must be the most easy posture, obvi- ous ? " From want of attention to, or from not understanding these few self-evi- dent principles, many people permit their patients to suffer considerable inr convenience, both present and future. " It is a maxim universally taught and received, that a fractured limb may be in such state as not to admit of the extension necessary for its being set; that is, if assistance be not at hand, when the accident happens ; if they who bring the patient home, do it so awkwardly or rudely, as to bruise and hurt the part; if from drunkenness, folly, or obstinacy in the patient, it happens that the limb is so disordered that it is found to be much swollen, inflamed, and painful, it is allowed not to be in a state to admit extension. " This, I.say, is a general maxim, and founded upon very just principles; but what is the general practice in con- sequence of it ? It is, to place tiie limb in an extended, straight position, to secure it in that, and then by proper means, such as fomentation, poultice, 8cc. to endeavour to remove the tension and tumour. Now, if it be considered, that the swollen, indurated, and in- flamed state of the muscles, is the cir- cumstance which renders extension improper, surely it must be obvious, that such position of the limb as neces- sarily puts-these very muscles in some degree on the stretch, must be a very improper one for the accomplishment of what ought to be aimed at. Under this method of treatment, the space of time whicii passes in the removal of the tension, ^s sometimes considerable ; so 40 314- FRACTURES. considerable, that a happy and even coaptation becomes afterwards imprac- ticable : and then this accident, which nine times in ten is capable of imme- diate relief, is urged as an excuse for unnecessary lameness and deformity. " How then are we to conduct our- selves in such circumstances ? The na- ture of the complaint points out the relief. Extension is wrong ; a straight position of the thigh or leg is a degree of extension, and a still greater degree • of it in proportion as the muscles are in such circumstances as to be less eapable of bearing it. Change of pos- ture then must be the remedy, or ra- ther the placing the limb in such man- ner as to relax all its muscles, must be the most obvious and certain me- thod of relieving all the ills arising from a tense state of them: whicii change of posture will be attended with another circumstance of very great consequence ; whicii is, that the bones may in such posture be immediately set, and not one moment's time be thereby lost; a circumstance of great advantage indeed ! For, whatever may be the popular or prevailing opinion, it is demonstrably true, that a broken bone cannot be too soon put to rights; :»s must appear to every one who will for a moment consider the necessary state of the muscles, tendons, and membranes surrounding, and the me- dullary organs contained within, a large bone broken and unset; that is, lying in an uneven irregular manner. Can any truth be more clear, than that if the fracture, tension, and tumefaction be such, that the muscles cannot bear to be stretched out in the manner ne- cessary for setting the broken bone without causing great pain, and per- haps bringing on still worse symptoms, the more the position of that limb makes its muscles approach toward a state of tension, the less likely it must be that such symptoms should remit, andt'.e longer it must be before the ..ished for alteration can happen ; and consequently, that while the accom- plishment of such purpose is by every other means aimed at, the position of the limb ought most certainly to con- tribute to, and not to counteract it? In short, if the experiment of change of posture be fairly and properly made, the objections to immediate reduction, rom tension, tumour, &c. will most requentiy be found to be groundless ; and the racture will be capable of being put to rights, as well at first, as at any distance of time afterward." For some criticisms on the foregoing remarks, relative to the relaxation of the muscles, in cases of fractures, the reader is referred to Fractures of the Thigh. Mr. Pott next continues: " Exten- sion having been made, and the bro- ken ends of the bone having been placed as smootii and as even as the nature ofthe case will admit, the next circumstance to be attended to is the application of some medicament to the limb ; particularly to the fractured part of it. " The intention in applying any kind of external medicine to a broken limb is, or ought to be, to repress inflam- mation, to disperse extravasated blood, to keep the skin lax, moist, and per- spirable, and at the same time to afford some, though very small degree of restraint or confinement to the frac- ture, but not to bind or press ; and it should also be calculated as much as possible to prevent itching, an herpetic eruption, or an erysipelatous efflores- cence. At St. Bartholomew's hospital, we use a cerate made by a solution of litharge in vinegar, which with soap, oil, and wax, is afterwards formed in- to such consistence as just to admit being spread without warming. " This lies very easy, repels inflam- mation, 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 ap- plication made to the 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 be necessary^without moving the limb in any manner : it being certain, that when once a broken thigh or leg has been properly put to rights, and has been deposited proper- ly on the pillow, it ought not ever to be lifted up or moved from it again without necessity, until the fracture is perfectly united; and it is as true, that such necessity will not very often oc- cur. This may perhaps seem strange to those who are accustomed to roll simple fractures, and consequently to lift them up every three or four days, in order to renew such kind of band- age ; but tiie necessity of this motion arises merely from the kind of bandage made use of, and not from any circum- stance of tlie fracture itself. That the FRACTURES 315 frequent motion of a fractured limb cannot possibly contribute to the ease ofthe patient, will, I suppose, be rea- dily admitted; as I suppose it will, that when a broken limb has been once deposited in the best position possible, it is impossible to mend that position merely by taking such limb up and lay- ing it down again; from whence it must follow, that such kind of appara- tus as necessitates the surgeon fre- quently to disturb the limb, cannot be so good as one that does not; provided the latter will accomplish the same kind of cure as tiie former: the truth of wliich position will appear in the most satisfactory manner to any, who will take a view ofthe method, in which simple fractures are treated at the be- fore mentioned hospital. Such applica- tion having been made as the surgeon thinks right, the next thing to be done is to put on a proper bandage.—That used by- the ancients, and by the ma- jority of the present practitioners, is what is commonly called a roller. This is of different lengths, according to the surgeon's choice, or as it may be used in tiie form of one, two, or more pieces. Hippocrates used three; (see Fab. ab Aquupendente, Wiseman, Scultetus, Hil- danus, Petit, Duvcrney;) Celsus six; but the present people seldom use more than one. By such kind of band- age three intentions are aimed at, and said to be accomplished, viz. to confine the fracture, to repress or prevent a flux of humours, and to regulate the callus, (see Duvcrney.-) but whoever will reflect seriously on this rr-fttter, will soon be, convinced, that altlxiugh some sort of bandage is necessary in every simple fracture, as well for pre- serving some degree of steadiness to the limb, as for .tiie retention of the applications, yet none, nor either of these three ends can be answered mere- ly, or even principally, by bandage of any kind whatever: 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 accessory kind of assistance, and that in a small degree and very littie to be depended upon, it will follow that such kind of bandage as is most difficult to be ap- plied with justness and exactitude, 6uch as is soonest relaxed and out of order, such as stands most frequently in need of renewal, and, in such renew- al, is most likely to give pain and trouble, must be more improper and less eligible, than one which is more easily applied, less liable to be out of order, and whicii can be adjusted with- out moving the limb. " The ancient method of applying the roller, in case of simple fracture of the leg or thigh, was to make (see Fab. ab Aquupendente, and Wiseman,) four or five turns round the fracture first, and then to continue the bandage up- ward and downward, until tlie whole limb was enveloped properly. This was done in this manner with a double view ; to keep the broken ends of the bone in their place, and to prevent the influx of humour. Modern practition- ers, although they have the same ends in view, generally begin their bandage from the inferior extremity of the limb, and continue it up to the top. Whether the old or the later method be follow- ed, whether one or more rollers be made use of, the whole is executed while the limb is kept, by means of tlie assistants, in the same extended pos- ture in whicii the coaptation was made, so that the whole bandage is finished before the leg is deposited on the pil- low ; in the doing of all which, if from tiie tired state ofthe surgeon, or either of his assistants, or if, from the awk- wardness, or unhandiness of any of the parties concerned, the true "and exact position of the limb be at all deviated from, the ends of the bone will again be in some degree displaced, and the bandage, instead of being of use, will become prejudicial, by pressing hard on the inequalities of the fracture : to which let me add, that the roller, espe- cially when applied to a leg, if it be not put on with due dexterity, that is, if it does not sit perfectly smooth and even, is the most unequal and worst kind of bandage in use. " These objections, however just, are not the least to which the roller in the case of simple fracture of the leg or tiiigh are liable ; for, as I have al- ready hinted, it must, in a very short space of time, even while the parts sur- rounding the fracture are in the most tender and most painful state, be re- newed, and that more than once; whicii renewal cannot be executed without again taking tiie hmb off from the pil- low, again committing it to the hands of assistants, and again running a risk of displacing the fracture ; all which, not to mention the repetition of pain to the patient every time such operation 316 FRACTURES. is performed, and which must be at least every four or five days, are, (as I have already said) very material ob- jections to the roller, even in the most judicious and dexterous hands, and still more so in those of the rude and ignorant. " The prevention of a flux of hu- mours to a broken limb by bandage, is a common phrase : but they who use it have either no idea at all annexed to it, or a very erroneous one. " If by the points and edges ofthe bro- ken bone, the muscles and membranes be unavoidably wounded and torn, or if the same kind of mischief be incur- red by the inadvertence or indiscretion ofthe patient, or of those who assisted in getting him home, or from the vio- lence used in extending the limb and Betting the fracture, inflammation must be excited, and pain and tumefaction will be the consequence ; and these will continue for some time in every fracture ; but that space will be longer or shorter in different cases, and under different circumstances : evacuation, rest, and a favourable position ofthe hmb, will, and do in general, remove all these complaints ; but bandage can contribute nothing more than by keep- ing the applications in their proper place ; so far from it, that if the ban- dage be a .roller, it must, by the fre- quent necessity of its being adjusted, and the frequent motion ofthe hmb, in some degree counteract the proper in- tention of cure. " The old writers are, in general, very precise as to the number of days during which the roller should be suf- fered to remain without being shifted ; and the number of times which such shifting should be repeated within the first fortnight. (See Fab. ab Aquupen- dente.) This exactitude i; by no means necessary ; but if the bandage be sup- posed to be of any use at all, it is obvi- ous, that it ought to be renewed or ad- justed as often as it may cease to per- form the office for wliich it is designed, or whenever it shall be found to coun- teract such office ; that is, as often as it shall become so slack as not to con- tain the fracture at all ; or whenever the limb shall be so swollen, that the roller makes an improper degree of stricture ; the former generally occurs every four or five days ; the latter is most frequent within the first week. " In most of the writers on the sub- ject of fractures, wc also find marks or signs laid down for our information concerning the due or undue effect of the bandage on tlie limb. They tell us, that when that part of it whicii is below the termination of the roller, does not swell at all, that the bandage is not sufficiently strict, and will not retain the fracture; that when the same part is considerably swollen, or tense, or inflamed, it implies, that the binding is too strait; and that a mode- rate degree of tumefaction is a sign that the deligation ib properly execut- ed. (See Fabricius ab Aquupendente.) " In consequence of these precepts, many practitioners look more anxiously after this degree of tumefaction, than after the true and exact position of the limb ; and cannot be induced to be- lieve, that any thing can be wrong un- der this appearance ; although, if they would for once assume the liberty of thinking for themselves, they might be convinced, that even this degree of swelling is wrong; that it implies some kind of Dbstrjuction to the ciiculation, and cannot serve any good purpose ; and consequently, that as far as it may be supposed to be the effect of ban- dag-e, so far that bandage must be faulty. " The third purpose for which the roller is said to be used, is the regula- tion and restraint of tiie callus. " If we were to form our notion of callus by what the generality of writers have said on this subject, we should suppose, that it was not only a particu- lar juice always ready for the purpose, but tifcit, if not restrained and regulat- ed by'art, it would always flow in such quantity, as to create trouble and de- formity ; that tliere were specific re- medies for increasing or decreasing it ; and that it always required the hand and art of surgery to manage it. That the callus is so far a particular juice, as that it consists of whatever is des- tined to circulate through the bones for their particular nourishment, is be- yond all doubt; and that this gelatinous kind of fluid is the medium by which fractures are united, is as true ; but that it requires art to manage it, or that art is in general capable of mana- ging and directing it, is by no means true. That this callus or uniting me- dium does oftentimes create tumefac- tion and deformity, or even lameness, is true also,- but the fault in these crises does not lie in the mere redundance of such juice ; it is derived from the na- FRACTURES. 317 ture of the fracture, from the inequa- lity of it when set, and from tiie unapt position of the broken ends with re- gard to each other -, nor is surgery or the surgeon any otherwise blameable in this case, than as it was or was not originally in their power to have pla- cid them better. It is the inequality of the fracture whicii makes both the real and apparent redundance of callus, and the tumefaction in the place of union. When a bone has been broken trans- versely, or nearly so, and its inequali- ties are therefore neither many nor great, when such broken parts have been happily and properly coaptated, and proper methods have been used to keep them constantly and steadily in such state of coaptation, the divided parts unite by the intervention of the circulating juice, just as the softer parts do, allowing a different space of time for different texture and consist- ence. When the union of a broken bone, under such circumstance:., has been procured, the place where such union has been made will be very httle perceptible,, it will be no deformity, nor will it occasion any inconvenience. It will, indeed, be discoverable like a ci- catrix of a wound in a softer part; but there will be no redundance of callus, because none will be wanted; neither will there be any necessity for any par- ticular management on the part of the surgeon, to repress or keep it in order : but when a bone has been broken very obliquely or very unequally, when the parts, of a fracture are so circumstan- ced as not to admit of exact coaptation, when such exact coaptation as the frac- ture perhaps would have admitted has not been judiciously made, when from ■ nmanageableness, inadvertence, or spasm, the proper position of the limb has not been attended to or preserved, in all such cases there must be consi- derable inequality of surface; there must be risings on one side, and de- pressions on another ; and in such ca- ses the juices circulating through the bone, cannot accomplish the union in the same quantity, the same time, or in the same manner. The broken parts not being applied exactly to each other, there cannot be the same aptitude to unite ; and according to the greater or lesser degree of exactitude in the co- aptation, that is, according as the ends of the bones are, or have been, placed more or less even with regard to each other, will the inconvenience and the deformity be ; and still most where the fracture is not set at all; but the bro- ken ends ofthe bone unite laterally or by touching each other's sides. The reason of all this is so obvious, without having recourse to a particular specific juice under the name of callus, that it would be an insult upon the reader's understanding to explain it farther. The periosteum covering every frac- ture will remain thickened for some time, and a degree of fidness or rising will be thereby caused about the place where such fracture has been united ; but time and the use of the muscles, soon in general remove this. " In short, this doctrine of callus, considered as a particular kind of juice, and. as being liable to great redundance, if not prevented by art, has not only misled many people, but has often been made use of as a cover to ignorance and neglect. When lameness and de- formity have been the consequences of one or both these causes, more than of the nature and circumstances of a frac- ture, the callus has been found ready at hand to take the blame ; and the ideal exuberance of this cement has of- ten been urged as an excuse for real want of knowledge, or for gross neg- lect. " The best and most useful bandage for a simple fracture of tlie leg or thigh, is what is commonly known by the name ofthe eighteen-tailed bandage, or rather one made on the same principle, but with a httle difference in the dispo- sition ofthe pieces. The common me- thod is to make it so, that the parts which are to surround the limb make a right angle with that whicii runs length- ways under it; instead of which, if they are tacked on so as to make an acute angle, they will fold over each other in an oblique direction, and there- by sit more neatly and more securely, as the parts will thereby have more connexion with and more dependence on each other. In compound fractures, as they are called, ever)- body sees and acknowledges the utility of this kind of bandage preferably to the roller, and for very obvious and convincing rea- sons, but particularly because it does not become necessary to lift up and disturb the limb every time it is dres- sed, or every time the bandage loosens. " The pain attending motion in a compound fracture, the circumstance of tiie wound, and the greater degree of instability of parts thereby produced, 318 FRACTURES. are certainly very good reasons for dressing such wound with a bandage, which does not render motion necessa- ry; but I should be glad to know what can make it necessary, or right, or eli- gible, to move a limb in the case of simple fracture? 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 inten- tion to procure unition? Can moving the limb every two or three days con- tribute to such intention ? must it not, on tiie contrary, obstruct and retard it ? Is not perfect quietude as necessary to- ward the union of the bone, in a simple as in a compound fracture ? It is true, that in the one there is a wound which requires to be dressed, and the motioa ofthe limb may in general be attended with rather more pain than in the other; but does motion in the simple fracture give ease, or procure more expeditious union ? " Every benefit then which can be supposed to be obtained from the use of the common bandage or roller, is equally attainable from the use of that which I have just mentioned, with one additional, and to the patient, most in- valuable advantage, viz. that of never finding it necessary to have Iris leg or thigh once, during the cure, removed from the pillow on which it has been properly deposited. In short, to quit reasoning and speak to fact, it is the constant practice at St. Bartholomew's and attended with all possible success. We always use the eighteen-tailed ban- dage; and never move the limb to re- new or adjust it. " The parts of the general apparatus for a simple fracture, which come next in order, are the splints. " These are generally made of paste- board, wood, or some resisting kind of stuff', and are ordered to be applied lengthways on the broken hmb; in some cases three, in others four; for the more steady and quiet detention of the fracture. " That splints, properly made and judiciously applied, are very servicea- ble, is beyond all doubt, but their uti- lity depends much on their size and the manner in which they are applied. " The true and proper use of splints, is, to preserve steadiness in the whole limb, without compressing the fracture at all. By the former they become ve- ry assistant to the curative intention; by the latter they are very capable of causing pain and other inconvenien- ces ; at the same time that they cannot, in the nature of things, contribute to tlie steadiness ofthe limb. *' In order to be of any real use at all, splints should, in the case of a broken leg, reach above tiie knee, and below the ankle; should be only two in num- ber, and should be so guarded with tow, rag, or cotton, that they should press only on the joints, and not at all on the fracture. " By this they become really service- able ; but a short splint, which extends only a little above and a littie below the fracture, and does not take in the two joints, is an absurdity, and, what is worse, it is a mischievous absurdity. "By pressing on both joints, they keep not only them, but the foot steady; by pressing on tiie fracture only, they cannot retain it in its place, if the foot be in the smallest degree displaced; but they may, and frequently do, occa- sion mischief, by rudely pressing the parts covering the fracture against tiie edges and inequalities of it. " I suppose it will be said, that al- though short splints do not of them- selves sustain and keep steady the two joints, and consequently tiie limb, yet that purpose in the broken leg may be and is fulfilled by junks, fanons, and other contrivances: to which I answer, that then the short splints are in that case of no use at all, and had better be laid aside; they should be used for no other purpose but that of keeping the limb steady; and if they do not answer that end, they are an incumbrance, and multiply the articles in the apparatus for a fractured leg, very unnecessa- rily. " In the case of a fractured os femo- ris, if the limb be laid in an extended posture, one splint should certainly reach from the hip to the outer ankle, and another (somewhat shorter) should extend from the groin to the inner an- kle. In the case of a broken tibia and fibula, there never can be occasion for more than two splints, one of which should extend from above the knee to below the ankle on one side, and the other splint should do the same on the other side. The manner of applying FRACTURES. 319 them, if the limb be deposited in a state of flexion, will come under the next article. " This, and indeed the mpst essen- tial article in the treatment of a frac- ture, is, tiie position of the limb. Upon the judicious or the injudicious, the proper or improper execution of this, depends the ease of the patient during his confinement, and the free use and natural appearance of his limb after- ward. " If I meant to describe, or if I ap- proved (pardon the phrase) the com- mon method of placing the broken leg and thigh in a straight manner, this would be the place to mention tiie ma- ny very ingenious contrivances and pieces of machinery, which practition- ers, both ancient and modern, have in- vented for the purpose of keeping the whole limb straight and steady, that is, of keeping all the muscles surround- ing the fractured bone constantly upon the stretch, and at the same time, of preventing any inequality in the union of it, and any shortening of the limb, in consequence of such inequality. " But as it is my intention by these sheets, to inculcate another, and, as it appears to me, a better disposition of the limb, in which such boxes, cradles, and pieces of machinery are not want- ed, nor can be used, it is needless for me to say any thing about them. " According to this plan, the fractu- red leg and thigh should be deposited on the pillow, in the very posture in whicii the extension was made, and the fracture set, that is, with the knee bent. '• 1 have already been so explicit, or perhaps prolix, on the tense and lax slate of the muscles, as depending on posture, under the head of extension, that I shall spare the reader, as well as m) self, a good deal of trouble by re- ferring back to that artiole. All that is there urged, or that can be urged for making the extension, that is, for setting a fracture in such disposition of »limb or its muscles, is equally pow- erful and conclusive with regard to the manner of depositing and leaving it af- ter it has been set. Whatever ren- ders reduction and coaptation easy, must as necessarily maintain ease du- ring the confinement, preserve recti- tude of figure, and prevent displace- ment. The same principle must act on both occasions; and whether the doctrine be right or wrong, consider- ed by itself, it must be equally so in both circumstances, that is, in the man- ner of setting a fracture, and in the manner of depositing the limb after- ward. In the case of the fractured ots humeri, the only position in wliich it can with any tolerable convenience to the patient be placed is, with the elbow bent, that very position which necessa- rily relaxes and removes all the resist- ance ofthe surrounding muscles. Daily experience evinces the utility of this, by our very seldom meeting with lame- ness or deformity after it, notwithstand- ing the prevailing apprehension of ex- uberant callus. " The deformity frequently conse- quent to the fracture of tiie bones of the cubit' particularly that of the radi- us only, will generally, if' not always, be found to be in proportion as the muscles concerned in the pronation and supination ofthe hand happen to be put more or less into a state of action or tension by the position of the limb. " In the thigh, the case is still more obvious, as the muscles are more nu- merous and stronger. " The straight posture puts the ma- jority of them into action, by which action that part of the broken bone, which is next to the knee, is pulled up- ward, and by passing more or less un- derneath that part which is next to the hip, makes an inequality or rising in the broken part, and produces a short- ness of tiie limb. " In the fracture of both bones of the leg, the case is still the same: a straight position puts the muscles upon endeavouring to act; a moderate flexi- on ofthe knee relaxes them, and takes off* such propensity. " The disposition, therefore, of the broken cubit ought to be that which, by putting the hand into a middle state between pronation and supination, and by bending the fingers moderately, keeps the radius superior to the ulna ; or, in other words, the palm of the hand should be applied to the breast, the thumb should be superior, the lit- tle finger inferior; and the hand should be kept in this posture constantly by means of two splints, wliich should reach from the joint of the elbow on each side, and should be extended be- low the fingers; or the same purpose may be still better answered by a sim- ple neat contrivance ofthe very ingeni- ous Mr. Gooch of Norfolk; of wliich he has given a draught, and which is 320 FRACTURES. preferable to a common splint, by its admitting the fingers to be more easily bent. " Extension will be made with more facility, and coaptation more happily executed; a patient will suffer a great deal less pain during these operations, as well as during the necessary con- finement for a broken leg or thigh, and both patient and surgeon will be less likely to bo disappointed in their inten- tion and wisn, that is, the former will be less liable to lameness or deformity, when a fractured thigh or leg has been treated in the way I have described, than in the common one. " The resistance necessarily made by the muscles, joined to the great in- stability of parts in every species of fractured leg or thigh, except in the few where the bones are broken trans- versely, has constantly exercised the invention and ingenuity of practition- ers, in devising means to prevent ine- quality in the callus as it is called, and shortness and deformity of the limb. Our books abound with draughts and descriptions of machines for this pur- pose ; ligatures, pulleys, leaden weights and fracture-boxes, so constructed as to overcome and constantly to resist that action of the muscles surrounding the broken bone, that natural tendency in them to contract, which the extend- ed position of the hmb necessarily in- duces. Every body who has been con- versant with matters of this sort knows, that even the best of these various con- trivances often prove successless; and every one who will reflect ever so little, may see why they must be so. That they do prove ineffectual, the number of deformed legs and shortened thighs, which are daily met with, evinces; and that they must frequently prove so, will be obvious to every one, who will consider that the effect can last no longer than the cause is continued, un- less there happens to be some very fa- vourable circumstance in the fracture itself. What I mean is this; when the reduction of the fracture is set about, the limb is put into such position, that tlie surrounding muscles resist the ex- tending force very considerably, and this in proportion to their strength and number.- that force is continued and increased till the muscles give way, and tlie resistance being overcome, an opportunity is thereby obtained of pla- cing the ends of the fracture in as apt position with regard to oach other as the nature of it will admit. If tlie frac- ture be of the transverse kind, that is, if the ends ofthe broken bone be large, and afford a good deal of space for contact with each other, such apposi- tion will contribute a good deal to the keeping the limb steady, and the frac- ture even; but if the fracture be ofthe oblique kind, if tliere be several loose pieces, and consequently neither large contact nor stability from the apposi- tion, or if due extension has not been made, or could not, or if the ends of the bones have not been properly and judiciously set, the muscles will act as soon as the extension is relaxed, tiie fracture will be more or less displaced, according to the nature of it, the limb will be shortened, the time of union will be prolonged, and the place of it (the callus as it is called,) will be in proportion more or less unequal. " I take it for granted that it will be asked, have, not our ancestors in all times happily redressed fractured leg-s and thighs, by the method which they have delivered down to us, and whicii in the preceding pages I have taken the liberty to object to? have not such limbs frequently been rendered as straight, as useful, and as little deform- ed as possible ? I answer, most certain- ly, yes; it is an undoubted truth, and cannot be denied. But in my turn, let me be permitted to ask, whether in the same method great and even unsur- mountable difficulty is not frequently met with ? whether in many cases tiie act of setting, as it is called, isnot ex- cessively painful at the time, and pro- ductive of* inflammation and other dis- agreeable symptoms afterward? and whether, in spite of all care, of every contrivance, of every species of machi- nery wliich has yet been used, broken thighs and legs are not often, very of- ten, left deformed, crooked, and short- ened, and that merely from the action of the muscles, and the obliquity or shattered state of the fracture ? The fact is notorious, and the sole question is, whether or no a different disposi- tion of the parts, preventing such ac- tion and such resistance, will in many instances prevent these evils? To wliich, from repeated experience, I answer, yes. If this should be found to be the case in general, of which I make no doubt that it is; if by this method, many of'such unfortunate cases, as in the common method of treatment dis- appoint both patient and surgeon, FRACTURES. 321 should be found in general to succeed so well as to satisfy both, it will prove all I wish it to prove. Superior utility and more frequent success arc all I con- tend for. " Many people did very well under amputation before the double incision was practised ; but is the double inci- sion therefore no improvement ? The operation for the bubonicele may be performed with that clumsy instru- ment the probe scissars, but is the bis- toury therefore not preferable ? A surgeon may cut off some ounces, or even pounds of flesh from a patient's backside, in order to cure a sinus, but is the cure by the simple division of that sinus therefore not easier or more ex- peditious ? Neither of these can, I think, be proved, unless it can at the same time be proved, that pain is no evil, confinement not at all irksome, and that deformity and elegance of fi- gure are synonymous terms. " Let not the reader fancy that I would dare to amuse him with specu- lation, or merely specious reasoning on a subject like this. What 1 have said is from experience, repeated ex- perience, both of myself and of others for a considerable length of time past, and on a great variety of subjects; from an experience wliich has perfect- ly satisfied me, and I think will every man who will make the trial fairly and candidly.—I do not pretend to say, that by these means every kind of broken hone will infallibly and certainly be brought to lie smooth, even, and of proper length ; if 1 did, they who are versed in these things, would know that I said too much : but I will say, (what is sufficient for my purpose) that it will not only succeed in all those, in which the old method can ever be suc- cessful ; but also in the majority of those in which it is not, nor in the na- ture of things can. In those fortunate cases, in which either method will do, the old one is fatiguing, inconvenient, and even sometimes offensive, from the supine and confined posture of the pa- tient; whereas that which is here pro- posed, gives the patient much greater liberty of motion for every purpose either of choice or necessity; and in man) of those cases, wherein tiie old method proves most frequently so for successless, as to leave the limb short, lame, or deformed ; I say, in most of these, the proposed metliod will not be attended with these inconveniences. vol. 1. " I have already said, that in most cases of broken thigh or leg, the me- thod just described will be attended with great success ; but there is one particular case in which its utility is still more conspicuous; a case which, according to the general manner of treating it, gives infinite pain and trou- ble both to the patient and surgeon, and very frequently ends in the lame- ness and disappointment ofthe former, and the disgrace and concern of the latter: I moan the fracture of the fibu- la attended, with a dislocation of the tibia. " Whoever will take a view of the leg ofa skeleton, will see that although the fibula be a very small and slen- der bone, and very inconsiderable in strength, when compared with the ti- bia, yet the support of the lower joint of that limb (the ankle) depends so much on this slender bone, that with- out it the body would not be upheld', nor locomotion performed, without ha- zard of dislocation every moment. The lower extremity of this bone, which de- scends considerably below that end of the tibia, is by strong and inelastic liga- ments firmly connected with the last named bone, and with the astragalus, or that bone of the tarsus which is principally concerned in forming the joint of the ankle. This lower extre- mity of the fibula has, hi its posterior part, a superficial sulcus for the lodg- ment and passage ofthe tendons ofthe peronei muscles, which are here tied down by strong ligamentous capsulas, and have their action so determined from this point or angle, that the small- est degree of variation from it, in con- sequence of external force, must ne- cessarily have considerable effect on the motions they are designed to exe- cute, and consequently distort the foot. Let it also be considered, that upon the due and natural state of" the joint of the ankle, that is, upon the exact and proper disposition of the tibia and fibu- la, both with regard to each other and to the astragalus, depend the just dis- position and proper action of several other muscles ofthe foot and toes; such as the gastrocnemii, the tibialis aivticus, ami posticus, the flexor pollicis longus, and the flexor digitorum pedis longus, as must appear demonstrably to any man who will first dissect, and then at- tentively consider these parts. If the tibia and fibula be both bro- ken, they are both generally displaced 41 322 FRACTURES. in such manner, that the inferior ex- tremity, or that connected with the foot, is drawn under that part of the fractured bone which is connected with the knee; making by this means a de- formed, unequal tumefaction in the fractured part, and rendering the bro- ken limb shorter than it ought to be, or than its fellow, And tliis is generally the case, let the fracture be in what part tof the leg it'may. If the tibia only be broken, and no act of violence, indiscretion, or inad- vertence be committed, either on tiie part of the patient or of those who conduct him, the limb most commonly preserves its figure and length; the same thing generally happens if the fibula only be broken, in any part of it between its upper extremity, and with- in two or three inches of its lower one. " Two kinds of fracture there are, and only two that I can recollect (rela- -tive to the limbs) which do not admit of the bent position of the joints, I mean that ofthe processus olecranon at the elbow, and that of the patella; in these a straight position of the arm and leg is necessary; in the former to keep the fractured parts in contact till they are united, in the latter, to bring them as near to each other as may best serve the purpose of walking after- ward.* " With regard to the fracture of the patella, an opinion has long and gene- rally prevailed, which seems to me to have no foundation in truth, or (when duly considered) even in probability; it is, that the great degree of stiffness in the joint of tiie knee, which is some- times found to be the consequence of this kind of fracture, is owing to, or produced by, a quantity of callus fall- ing into it from tiie edges of the broken bone: and that the nearer the broken pieces are brought to each other, the more likely such consequence is. " Every part of this doctrine seems equally absurd. In the first place, the fractured bone is by no means capable of supplying such a quantity of callus as to produce this end, unless it may be supposed to run from it as solder from a plumber's ladle; in the second place, if this was the case, the most likely, and indeed the only probable way of preventing the deposition of such juice, must be by bringing the broken pieces into close contact; and in the third place, there is no authority from the appearance of such joints af- ter death, (at least as far as my experi- ence goes) to suppose this to be the case, or to countenance such opinion. The cause therefore of tliis rigidity, which is now and then found to attend tlie broken patella, must be sought for elsewhere, viz. in the long rest and confinement of the joint as a means used by many to procure exact union ; in mischief done to the ligament, which is formed by the united tendons of tiie four extensor muscles of the leg, at the time of and by the fracture; and in the nature of the fracture itself, that is, the manner in which the bone shall happen to be broken. " But, be all this as it may, the fact undoubtedly is, that they walk best af- ter such accident, whose patella has been broken transversely, and that into two nearly equal fragments; whose confinement to the bed has been short, * "Although a straight position ofthe hmb is necessary for the broken patella, yet this very position becomes so upon the same principle, as renders the bent posture most advantageous in the broken tibia and femur, viz. the relaxation of the muscles and tendons attached to the fractured bone. " Whoever will for a moment attend to the disposition of the pieces in a patel- la, wliich has been broken transversely, will see how little necessary or useful the many contrivances of bandages, straps, compresses, buckles, buttons, &c. to be found in writers are, especially all that part of them which are applied to the in- ferior fragment. "By the action ofthe united tendons ofthe extensores muscles ofthe leg, the superior fragment is pulled upward and separated from the inferior, but the lat- ter remains nearly, if not absolutely, where it was before the accident; tliere is nothing to act upon it, and therefore it cannot, nor does it move. " The extension of the leg puts the muscles attached to the upper part of the broken bone into a state of relaxation, and prevents their acting; and though a small compress just above this piece, with a moderate bandage may be useful to- ward retaining it, yet it is the position of the leg, wliich must keep the broken piece down, and effect the cure." (Pott) FRACTURES. 323 that is, no longer than while the inflam- mation lasted; whose knee, after such period, has been daily and moderately moved; and in whom the broken pie- ces are not brought into exact contact, rbutlie at some small distance from each other. " I cannot take leave of this subject of simple fractures, without mention- ing a circumstance relative to them, wliich although, when rightly under- stood, is of little or no importance, yet by being misunderstood, becomes fre- quently of considerable consequence. " I mean, the use of the term, rising end of a broken bone. " By the expression, any one unac- quainted with these things would be inclined to think, that the prominent part of a broken bone rose, or was ele- vated from its natural place; and be- came, by such rising, superior to the other part or extremity ofthe fracture. This would certainly be the idea of an ignorant person, and as such would be of little consequence; but by the prac- tice of many, who call themselves sur- geons, it is as certainly their idea also, and this renders it a matter of great consequence. Many instances are pro- ducible, in whicii our conduct is in a great measure regulated by the lan- guage which we use. Having no ideas annexed to our words, leads us into absurdity and unintelligibility; but false ones influence us still more, and frequently produce very material er- rors. " The fistula lachrymalis, the fistula in perinaco, and that in ano, are glaring proofs of this; and my present subject is full as much so: for upon the erro- neous idea annexed to the term rising end, stands all the absurd practice of compress, bolster, and strict bandage, in the cases of simple fracture. " The truth is, that there is really no rising end to a broken bone; I mean, when applied, as the term usually is, to the leg, thigh, and clavicle. There is indeed a superior or prominent end or part, and an inferior or depressed one, but the former of these is in its proper place, from wliich it cannot by art be moved; and the latter, which is not in its proper place, is very capable by art of being put into it. " Perhaps this may to some appear a mere play of words, a nominal distinc- tion, without a real difference; but when the influence, which a right, or wrong idea of this produces on prac- tice, is attended to, the consequence will be obvious and serious. When a collar-bone, os femoris, or tibia and fibula are broken, by the ac- tion ofthe muscles, by the motions of the patient, and by the mere weight of the inferior part of the arm, thigh, or leg, the fractured ends of such bones are displaced, and always displaced in such manner, that the inequality occa- sioned necessarily by such displace- ment, proceeds from the inferior end ofthe fractured bone being retracted or drawn under the superior: this pro- duces a tumefaction or unequal rising, and the upper extremity of the frac- ture is therefore called the rising end of it. Now the man who regards this rising end as that part of the fracture which has by such rising got out of its place, and not as having accidentally- become the prominent part merely by the insinuation or retraction of tiie other part underneath it, will go to work with bolster, compress and ban- dage, in order to bring and keep such end down; by whicii means he will give his patient considerable pain, and while he depends on such means alone, will most certainly be frustrated in his intention and expectation, the means not being adequate to the proposed end. But the man who looks on this in the true light, that is, who looks on the superior part as being in its proper place, and the inferior as being dis- placed by the weight of the limb, and tiie action ofthe muscles, will know, that by the mere position of such limb, he shall be able to remedy all the in- convenience and deformity, as far as they are by art capable of remedy, without the parade or the fatigue of useless apparatus. " He will, for example, know that the prominent part of a broken clavi- cle, that part of it which is next to the sternum, is just where it should be; and that the inferior part, that which is connected with the scapula, is out of its place, by being drawn down by the weight of the arm; and therefore instead of loading, as is usual, the pro- minent part with quantities of com- press, which never can do any service, he, by a proper elevation of the arm, will bring the lower end upward into contact with the other; and thereby, with very little trouble, easily accom- plish what he never can do in any other manner, however operose. S2* FRACTURES ** The same thing wVd happen from the same principles in the leg and thigh: a prominence, or a rising end, there always w ill be, but that risiug end is never to be brought down by any pressure from compress or ban- dage; the fallen or inferior one must always be brought up to it by the pro- per position of the rest of the limb; this will always remove the inequality as far as it is removeable, and nothing else can.*" COMPOUND FRACTURES. " I use the term compound fracture, (says Mr. Pott) in the sense in whicii the English have always used it; that is to imply a broken bone complicated with a wound. " In this kind of case th>a first object of consideration is, whether the pre- servation of the fractured limb can, with safety to the patient's fife, be at- tempted; or, in otiier words, whether the probable chance of destruction, from the nature and circumstances of the accident, is not greater than it wou\d be from the operation of ampu- tation. Many things may occur to make this the case. The bone or bones be- ing broken into many different pieces, and that for a considerable extent, as happens from broad wheels, or other heavy bodies of large surface, passing over or falling on such limbs; the skin, muscles, tendons, &c. being so torn, lacerated and destroyed, as to render gangrene and mortification the most probable and most immediate conse- quence; the extremities ofthe bones forming a joint being crushed, or as it were comminuted, and the ligaments connecting such bones being torn and spoiled, are, among others, sufficient reasons for proposing and for per- forming immediate amputation. Rea- sons, whicii (notwithstanding anything that may have been said to the contra- ry) bang and reiterated experience has approved, and which are vindicable up- on every principle of humanity, or chirurgic knowledge. " When a surgeon says, that a hmb, which has just suffered a particular kind of compound fracture, ought ra- ther to be immediately cut off, than that any attempt should be made for its preservation, he does not mean by so saying, that it is absolutely impossi- ble for such limb to be preserved at all events; he is not to be supposed to mean so much in general, though some- times even that will be obvious; all that he can truly and justly mean is, that from the experience of time it has been found, that the attempts to pre- serve limbs so circumstanced, have most frequently been frustrated by the death of" the patients, in consequence of such injury; and that from the same experience it has been found, that the chance of death from amputation is by no means equal to that arising from such land of fracture. " Every man knows, that apparently desperate cases are sometimes cured ; and that limbs so shattered and wound- ed, as to render amputation the only probabk means for the preservation of life, are now and then saved. This is an uncontroverted fact, but a fact which proves very little against the common opinion; because every man of experience also knows, that such escapes are very rare, much too rare to admit of being made precedents, and that the majority of such attempts fail. " This consideration relative to am - putation is of the more importance, because it most frequently requires im- * " In a professed regular treatise on this subject, it would be right to take notice off what may be called the infortunia, or accidental evils, wliich sometimes ac- company even simple fractures: such are, disease arising from injury done to the medullary membrane, within the bones, in bad habits: hemorrhage, or a spe- cies of spurious aneurism, from a wound of the interosseal artery, between the ' tibia and fibula, or of either of the carpal arteries: mischief from the fracture becoming accidentally the seat of the crisis ofa fever: deficiency of callus, or the accident of the broken bone not uniting*: the fractured limb becoming the seat of an erysipelas, terminating in a slough ofthe common membrane and pe- riosteum : the gelatinous juice or callus, which should unite the fracture,, being in 60 morbid a state, as to produce a kind of caries with exostosis, instead of its doing its proper duty, &c. Of all these there are examples, but they do not come within the plan which I •prescribed to myself when I began these papers." (Pott.) FRACTURES 325 mediate determination; every minute of delay is, in many instances, to the patient's disadvantage; and a very short space of time indeed, frequently makes all the difference between pro- bable safety and fatality. If these ca- ses in general would admit of delibera- tion for two or three days, and during that time such circumstances might be expected to arise, as ought necessarily to determine the surgeon in his con- duct, without adding to tiie patient's hazard, the difference would be consi- derable; the former would not seem to be so precipitate in his determina- tion as he is frequently thought to be ; and the latter, being more convinced of the necessity, would submit to it with less reluctance. But unhappily for both parties, this is seldom the case; and tlie first opportunity having been neglected or not embraced, we are very frequently denied another. Here therefore tiie whole exertiou of* a man's judgment is required, that he may neither rashly and unnecessarily deprive his patient of a limb, nor through a false tenderness and timidity, suffer him to perish, by endeavouring to pre- serve such limb. Some degree of ad- dress is also necessaiy upon such occa- sion, in order to convince the patient, that what seems to be determined up- on hastily and with precipitation, will not safely admit of longer deliberation. " The limb being thought capable of preservation, tiie next consideration is the reduction of the fracture. The ease or difficulty attending this, de- pends uot only on the general nature of the case, but on the particular disposi- tion of tiie bone with regard to the wound. " If the bone be not protruded forth, the trouble of reducing, and of placing the fracture in a good position, will be much less than if the case be other- wise: and in the case of protrusion or thrusting forth of the bone or bones, the difficulty is always in proportion to the comparative size of tiie wound, through whicii such bone has passed. In a compound fracture ofthe leg or thigh, it is always tiie upper part of the broken bone which is thrust forth. If the fracture be ofthe transverse kind, and the wound large, a moderate de- gree of extension will in general easily reduce it; but if the fracture be ob- lique, and terminates, as it often does, in a long sharp point, this point very often makes its way through a wound no larger than just to permit such ex J tension. In this case, the very placing the leg in a straight position, in order to make extension, Obliges the wound or orifice to gird the bone tight, and makes all that part of it, wliich is out of such wound, press hard on the skin of the leg underneath it. In these cir- cumstances, all attempts for reduction in this manner will he found to be im- practicable ; the more the leg is stretch- ed out, the tighter the bone will be be- girt by the wound, and the more it will press on the skin underneath. " Upon this occasion, it is not very unusual to have recourse to the saw, and by that means to remove a portion of the protruded bone. " 1 will not say that this is always or absolutely unnecessary or wrong, but it most certainly is frequently so. In some few instances, and in the case of extreme sharppointedness of the ex- tremity ofthe bone, it may be, and un- doubtedly is right: but in many instan- ces, it is totally unnecessary. " The two most proper means of overcoming this difficulty are, change of posture of the limb, and enlarge- ment of the wound. In many cases the former of these, under proper conduct, will be found fully sufficient; and where it fails, the latter should always be made use of. Whoever will attend to the effect, which putting the leg or thigh (having a compound fracture and protruded bone) into a straight posi- tion always produces ; that is, to the manner in which the wound in such po- sition girds the bone, and to the in- creased difficulty of reduction thereby induced, and will then, by changing the posture of such limb from an ex- tended one, to one moderately bent, observe the alteration thereby made, in both the just-mentioned circumstances, will be satisfied of the truth of what I have said, and of the much greater de- gree of ease and practicability of re- duction in the bent, than in the ex- tended position ; that is, in the relax- ed, than in the stretched state ofthe muscles. Reduction being found im- practicable, either by extension or change of posture, the obvious and ne- cessary remedy for this difficulty is enlargement of the wound. This to some practitioners, who have nit seen much of this business, appears a dis- agreeable circumstance, and therefore they endeavour to avoid it ; but their apprehensions are in general ground- 326 FRACTURES. less and ill-founded : in enlarging the wound tliere is neither difficulty nor danger, it is the skin only wliich can require division, and in making such wound there can be no possible hazard. It is needless to say that the division should be such as to render reduction easy ; or to remind the practitioner, that such enlarged opening may serve very good future purposes, by making way forthe extraction offragments, and the discharge of matter, sloughs, &c. " If the bone be broken into several pieces, and any of them be either total- ly separated, so as to lie loose in the wound, or if they be so loosened and detached as to render their union high- ly improbable, all such pieces ought to be taken away ; but they should be removed with all possible gentleness, without pain, violence or laceration, without the risk of hemorrhage, and with as little poking into the wound as possible. If the extremities ofthe bone be broken into sharp points, which points wound and irritate the surround- ing parts, the y must be removed also. But the whole of this part of the treat- ment of a compound fracture should be executed with great caution ; and the practitioner should remember, that if the parts surrounding the fracture be violated, that is, be torn, irritated, and so disturbed as to excite great pain, high inflammation, &.c. it is exactly the same thing to the patient, and to tiie event of the case, whether such vio- lence be the necessary consequence of the fracture, or of his unnecessary, and awkward manner of poking into, and disturbing the wound. The great ob- jects of fear and apprehension in a compound fracture, (that is, in the first or early state of it) are, pain, irrita- tion, and inflammation ; these are to be avoided, prevented, and appeased by all possible means, let every thing thing else be as it may ; and although certain things are always recited, as necessary to be done, such as removal offragments of bone, of foreign bodies, &c. ike. &o. yet it is always to be under- stood, that such acts may be perform- ed without prejudicial or great vio- lence, and without adding at all to the risk or hazard necessarily incurred by the disease. " Reduction of, or setting a com- pound fracture is the same as in the simple ; that is, the intention in both is the same, viz. by means of a proper degree of extension to obtain as apt a position of the ends ofthe fracture with regard to each other, as the nature of the case will admit, and thereby to produce as perfect and as speedy union as possible. " To repeat in this place what has already been said under the head of extension, would be tedious and unne- cessary. If the arguments tliere used for making extension, with the limb so moderately bent as to relax the mus- cles, and take off their power of resist- ance, have any force at all, they must have much more when applied to the present case : if it be allowed to be found very painful to extend, or to put or keep on the stretch, muscles which are not at all or but slightly wounded, and only liable in such extension to be pricked and irritated, it is self-evident that it must be much more so when tlie same parts are torn and wounded con- siderably ; when the ends of" the frac- tured bone have made their way quite through them, divided the skin, and laid all open to the access of the air. " Every consequence, which does, or may be supposed to flow from wound, pain, or irritation, in conse- quence of violence, must necessarily be much greater, when a lacerated wound, and that made by the bone, is added to the fracture ; not to mention the ills arising from extending or stretching out muscles already torn or half divided. " One moment's reflection must be sufficient to convince any reasonable man : but experience is tiie only proper test of all these kind of things. Let this metliod of treatment, then, be fairly and properly subjected to it ; and if the great advantage of the one over the other does not appear, that is, if the less sensation of pain by the patient, and the more happy, more perfect, and more expeditious accomplishment of his purpose by the surgeon, do not determine greatly in favour of relaxed position, 1 am, and have for a consider- able length of time, been greatly mis- taken. " The wound dilated, (if necessary) loose pieces removed, (if there were any) and the fracture reduced, and placed in the best possible position, the next thing to be done is to apply a dressing. " On this subject a great deal has been said by writers, particularly by such of them as have implicit faith in external applications ; but, in order to FRACTURES. 327 be able to execute this part ofthe pro- cess properly, a man has only to ask himself, What are the intentions which, by any kind of dressing to a compound fracture, he means to aim at the ac- complishment of ? And a rational an- swer to this will give him all that he can want to 1 now. " The dre s:.ig necessary in a com- pound fracture is of two kinds, viz. that for the wound, and that for the limb. By the former, we mean to main- tain a proper opening for the easy and free discharge of gleets, sloughs, mat- ter, extraneous bodies, or fragments of bone, and this in such manner, and by such means, as shall give the least possible pain or fatigue, shall' neither irritate by its qualities, nor oppress by its quantity, nor by any means contri- bute to the detention or lodgment of what ought to be discharged. By the latter, our aim should be the preven- tion or removal of inflammation, in or- der, if the habit be good, and all other circumstances fortunate, that the wound may be healed, by what the sur- geons call the first intention, that is, without suppuration or abscess ; or, that not being practicable, that gan- grene and mortification, or even very large suppuration may be prevented, and such a moderate and kindly de- gree of it established as may best serve the purpose ofa cure. The first, there- fore, or the dressing for the wound, can consist of nothing better, or indeed so good, as soft dry lint, laid on so lightly as just to absorb the sanies, but neither to distend the wound, or be the smallest impediment or obstruction to the discharge of matter. This lint should be kept clear of the edges, and the whole of it should be covered with a pledget spread with a soft easy diges- tive. The times of dressing must be determined by the nature of the case ; if the discharge be small or moderate, once in twenty-four hours will be suffi- cient ; but if it be large, more frequent dressing will be necessary, as well to prevent offence, as to remedy the in- conveniences arising from a great dis- charge of an irritating sharp sanies. " The method of treating the limb, with a view to the prevention of such accidents and symptoms, as pain, in- flammation, and laceration of parts are likely to produce, is different with dif- ferent practitioners; some using from the very first, relaxing, greasy appli- cations ; others applying medicines of very different nature. Both these may be right conditionally, that is, accord- ing to different circumstances in the case, but they cannot be equally so in the same circumstances. " Many practitioners are accustom- ed to envelope compound fractures in a soft, warm, relaxing cataplasm from the very first; whether the limb be in a tense swollen state, or not. This, if I may take the liberty of saying so, ap- pears to me to be1 injudicious. When from neglect, from length of time pas- sed without assistance, from miscon- duct or drunkenness in the patient, from awkwardness and unhandiness in the assistants, or from any other cause, a tension has taken possession of the limb, and it is become tumid, swollen and painful, a warm cataplasm is cer- tainly the best and most proper appli- cation that can be made, and that for very obvious reasons ; the state ofthe parts under these circumstances is such, that immediate union is impossi- ble, and nothing but a free and plenti- ful suppuration can dissipate or remove impending mischief: every thing there- fore which can tend toward relaxing the tense, swollen, and irritable state of the parts concerned, must necessa- rily be right; the one thing aimed at, (plentiful suppuration) cannot be ac- complished without it. But when the parts are not in this state, the intention seems to be very different. To relax swollen parts, and to appease pain and irritation by such relaxation, is one thing; to prevent inflammatory de- fluxion and tumefaction, is certainly another ; and they ought to be aimed at by very different means. In the former, a large suppuration is a neces- sary circumstance of relief, and tlie great means of cure ; in tiie latter it is not, and a very moderate degree of it is all that is required. The warm ca- taplasm therefore, although it be the best application that can be made use of in the one case, is certainly not so proper in other, as applications ofa more discutient kind, such as mixtures of spirit- vini, vinegar and water, with crude sal ammoniac, spirit, mindereri, acet. litharg. and medicines of this class, in whatever form the surgeon may choose. By these, in good habits, in fortunately circumstanced cases, and 328 FRACTURES. with the assistance of what should ne- ver be neglected,* (I mean phleboto- my, and the general antiphlogistic re- gimen,) inflammation may sometimes be kept oft", and a cure accomplished, without large collections or discharges of matter, or that considerable degree Of suppuration, which, though necessa- ry in some cases, and almost unavoid- able in others, are and must be rather promoted, and encouraged, than retard- ed, or prevented, by warm relaxing applications of tiie poultice kind. " Compound fractures in general re- quire to be dressed every day ; and the wounded parts not admitting the small- est degree of motion without great pain, perfect quietude becomes as ne- cessary as frequent dressing. " The common bandage therefore (the roller) has always in this case been laid aside, and what is called the eighteen-taiied bandage substituted, very judiciously, in its place. Of tliis 1 have already spoken so largely, as to make repetition unnecessary. " Splints, that is, such short ones as are most commonly made use of in simple fractures, arc by all foi bid in the compound, and that for the same reason which ought to have prevented them from having ever been used in the former, viz. because the probable good to be derived from them can be but little; and the probable mischief is obvious and considerable. " But although short splints are for many reasons palpably improper, in both cases, yet those of proper length, those which reach from joint to joint, comprehend them both, and are ap- plied on each side of the leg only, are very useful both in the simple and in the compound fracture, as they may, thus apphed, be made to keep the limb-more constantly steady and quiet, than it can be kept without them. " With regard to position of the hmb, I have already been so explicit, when speaking of the simple fracture, that to say any thing more about it here would be an abuse of the reader's time and patience. The only, or the material difference between a simple and a compound fracture, as far as relates to this part of the treatment, is, that as the parts surrounding the broken bone in tiie latter are more injured, and consequently more liable to irritation, pain, inflammation, and all their consequences, therefore every method and means, by which the alle- viation of such symptoms, and the pre- vention of such consequences can be obtained, is still more necessary and requisite. Among these, the posture of the limb is so principal a circum- stance, that without its concurrence every other will be fruitless. The points to be aimed at are, the even po- sition of the broken parts of the bone, and such disposition of the muscles surrounding them, as is most suitable to their wounded, lacerated state, as shall be least likely to irritate them, by keeping them on the stretch, or to produce high inflammation, and at best large suppuration. These, 1 say, are the ends to be pursued ; and how much tiie position ofthe limb does, and must necessarily contribute to the advantage, or disadvantage just recited, must be so obvious to any body capable of re- flection, that nothing more need be said about it. " At the beginning of these sheets, I have said, that it was not my inten- tion to write a regular treatise, but only to throw out a few hints which I hoped might prove useful to such as have not yet received better informa- tion. The part of my subject at which I am now arrived, does not indeed ad- mit of much more : a few general pre- cepts are all which a writer can give; the particular method of conducting each particular case must be .deter- mined by the nature of that case, and by the judgment of the surgeon. " Every body knows, or ought to know, that these cases, of all others, require at first the most rigid obser- vance of the antiphlogistic regimen; that pain is to be appeased, and rest obtained, by anodynes ; that inflamma- tion is to be prevented or removed, by free and frequent bleeding, by keeping the body open, and by the administra- tion of such medicines as are best known to serve such purposes.—And that, during this first state or stage, tiie treatment of the limb must be cal- culated, eitiier for the prevention of inflammatory tumefaction, by such ap- plications as are in general known by the title of discutients; or, such tu- mour and tension having already takeu possession of the limb, that warm fo- mentation, and relaxing and emollient medicines are required. * Bleeding is now not frequently practised, except on very plethoric persons, and out of large cities. FRACTURES. 329 " If these, according to the particu- lar exigence of the case, prove suc- cessful, the consequence is, either a quiet easy wound, which suppurates very moderately, and gives little or no trouble ; or a wound, attended at first with considerable inflammation, and that producing large suppuration, with great discharge, and troublesome for- mation and lodgment of matter. If, on the other hand, our attempts do not succeed, the consequence is gangrene and mortification. " These are the three general events or terminations of a compound fracture, and according to these must the surgeon's conduct be re- gulated. " In the first instance, he has indeed nothing to do but to avoid doing mis- chief, either by his manner of dressing, or by disturbing the limb. Nature let alone, will accomplish her own pur- pose ; and art has little more to do than to preserve the due position ofthe % limb, and to take care, that the dress- ing applied to tiie wound proves no impediment. " In the second stage, that of for- mation and lodgment of matter, in con- sequence of large suppuration, all a surgeon's judgment will sometimes be required in the treatment both of the patient and his injured limb. Enlarge- ment of the present wound, for the more convenient discharge of matter* ; new or counter-openings for the same purpose, or for the extraction of frag- ments of broken or exfoliated bone, will very frequently be found necessa- ry, and must be executed. In the doing this, care must be taken, that what is requisite be done, and no more; and that such requisite operations be performed with as little disturbance and pain as possible; the manner of doing business of this kind, will make a very material difference in the suffer- ings ofthe patient. " Very contrary, or at least very different intentions, seem to me to re- quire the surgeon's very particular at- tention in the two parts of this stage of the disease. " Previous to large suppuration, or considerable collections and lodgments of matter, tumefaction, induration, and high inflammation, attended with pain, irritation, and fever, require evacua- tion by plilebotomy, an open belly, and antiphlogistic remedies, as well as the free use of anodynes, and such appli- cations to the limb as may most serve the purpose of relaxation. But the matter having been formed and let out, and the pain, fever, &c. which were symptomatic thereof, having disappear- ed, or ceased, the use and purpose of such medicines and such applications cease also, and they ought therefore to be discontinued. By evacuation, &c. the patient's strength has necessarily (and indeed properly) been reduced; by cataplasm, &c. the parts have been so relaxed as to procure an abatement or cessation of inflammation, a subsi- dence of tumefaction, and the estab- lishment of a free suppuration; but these ends once fairly and fully an- swered, another intention arises, wliich regards the safety and well-doing of the patient, nearly, if not full as much as the former; which intention will be necessarily frustrated by pursuing the method hitherto followed. The pa- tient now will require refection and support, as much as he before stood in need of reduction ; and the limb, whose indurated and inflamed state hitherto required the emollient and relaxing poultice, will now be hurt by such kind of application, and stand in need of such as are endued with contrary qualities, or, at least, such as shall not continue to relax. Good light, easily digested nutriment, and the Peruvian bark, will best answer the purpose of internals; the discontinuation of the cataplasms, and the application of me- dicines of the corroborating kind, are * " It is a practice with some, from a timidity in using a knife, to make use of bolsters and plaster-compresses for the discharge of lodging matter. Where another, or a counter opening can conveniently and safely be made, it is always preferable, the compress sometimes acting diametrically opposite to the inten- tion with which it is applied, and contributing to the lodgment by confining the matter; beside which, it requires a greater degree of pressure to make it effi- cacious, than a limb in such circumstances generally can bear." vol.. 1. -12 330 FRACTURES. as necessary with regard to exter- nals.* " In short, if there be any rationale in the use of the cataplasm in the first stage, its impropriety in the second, must be evident from the same princi- ples. So also with regard to evacua- tion and the antiphlogistic regimen, when all the good proposed to be ob- tained by them has been received, a pursuit of the same method must be- come injurious, and that for the same reason why it was before necessary and beneficial. " A non-attention to this has, I be- lieve, been not unfrequently the cause of the loss both of limbs and lives. " Every body who is acquainted with surgery knows, that in the case of bad compound fracture, attended with large suppuration, it sometimes happens, even under the best and most judicious treatment, that the discharge becomes too great for the patient to sustain; and that, after all the fatigue, pain, and discipline, which he has undergone, it becomes necessary to compound for fife by the loss of the limb.f This, I say, does sometimes happen under the best and most rational treatment; but I am convinced that it also is now and then the consequence of pursuing the reducing, the antiphlogistic, and the relaxing plan too far. I would there- fore take the liberty seriously to ad- vise the young practitioner, to attend dihgently to his patient's pulse and general state, as well as to that of his fractured limb and wound; and when he finds all febrile complaint at an end and all inflammatory tumour and hard- ness gone, and his patient is rather languid than feverish, that his pulse is rather weak and low than hard and full, that his appetite begins to fail, and that he is inclined to sweat, or purge, Without assignable cause, and this in consequence of a large discharge of matter from a limb whicii h:.3 suffered great inflammation, but which is now become rather soft and flabby, than hard and tumid ; that he will in such circumstances set about the support of his patient, and the strengthening of the diseased limb totis viribus ; in which I am from experience satisfied, he may often be successful, where it may not be generally expected that he would. At least, he will have the sa- tisfaction of having made a rational at- tempt ; and if he is obliged at last to have recourse to amputation, he will perform it, and his patient will submit to it, with less reluctance, than if no such trial had been made. " I have said that a compound frac- ture either unites and heals, as it were, by the first intention, which is the case of" some of the lucky few, (and was my own£ ;) or it is attended with high in- flammation, multiplied abscesses, and large suppuration, demanding all a surgeon's attention and skill, and even then sometimes ending in the loss of life, or limb, or both; or, that all our attempts prove fruitless from the first, and gangrene and mortification are the inevitable consequence of the accident. " The two first I have already spo- ken to, the last only remains. " Gangrene and mortification are sometimes the inevitable consequences »f the mischief done to the limb at the time that the limb is broken ; or they are the consequences of the laceration of parts made by the mere protrusion ofthe said bone. " They are also sometimes the effect of improper or negligent treatment; of great violence used in making exten- sion ; of irritation of the wounded parts, by poking after, or in removing fragments or splinters of bone; of painful dressings ; of improper dispo- * " It is surprising how large and how disagreeable a discharge will be made for a considerable length of time, hi some instances, from the detention and irri- tation of a splinter of bone. If therefore such discharge be made, and there be neither sinus nor lodgment to account for it, and all other circumstances are fa- vourable, examination should always be made, iii order to know whether such cause does not exist, and if it does, it must be gently and carefully removed." f " There is one circumstance relative to compound fractures, which perhaps may be deemed worth noting; which is, that I do not remember ever to have seen it necessary to amputate a limb for a compound fracture, on account of the too great discharge, in which the fracture had been united. In all those cases, where the operation has been found necessary on account of the drain, the frac- ture has always been perfectly loose and disunited." (Pott.) * Mr. Pott met with a compound fracture himself. FRACTURES. 331 sition of the limb, and of the neglect of phlebotomy, anodynes, evacuation, &.i. Any, or all these, are capable ei- '.1; r of inducing such a state of inflam- mation us shall end in a gangrene, or cf permitting the inflammation, neces- sa, iiy attendant upon such accident, to •-. liuiaute in the same event. " When- such accident or such dis- cus'. , is the mere consequence of the i.ijury done to the limb, either at the tii-ieof, or by the fracture, it general- ly makes its appearance very early ; in which case also, its progress is gene- rally too rapid for art to check. For these reasons, when the mischief seems to be of such nature as that gangrene and mortification are most likely to en- sue, no time can be spared, and the impending mischief must either be sub- mitted to or prevented by early ampu- tation. I have already said, that a very few hours make all the difference be- tween probable safety and destruction. If we wait till the disease has taken possession of the limb, even in the smallest degree, the operation will serve no purpose, but that of accele- rating the patient's death. If we wait for an apparent alteration in the part, we shall have waited until all opportu- nity of being really serviceable is past. The disease takes possession of the cellular membrane surrounding tlie large blood-vessels and nerves, some- time before it makes any appearance in the integuments ; and will always be found to extend much higher in the former part, than its appearance in the latter seems to indicate. I have more than once seen the experiment made of amputating, after a gangrene has been begun, but I never saw it succeed ; it has always hastened the patient's de- struction. " As far therefore as my experience will enable ine to judge, or as I may from thence be permitted to dictate, I would advise that sUch attempt should never be made ; but, the first opportu- nity having been neglected, or not em- braced, all the power of the chirurgic art is to be employed in assisting na- ture to separate the diseased part from the sound ; an attempt which now and then, under particular circumstances, has proved successful, but whicii 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 immediate effect of such mischief, the. consequence of omitting amputation, and of attempt- ing to save the limb is, as I have alrea- dy observed, most frequently very early destruction : but, if the gangre- nous mischief be not merely and.im- mediately tiie effect of the wounded state of the parts, but of high inflam- mation, badness of general habit, im- proper disposition of the limb, &c. it is sometimes in our power so to alle- viate, correct, 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 na- ture of things, be varied according to the producing causes or circumstan- ces : the sanguine and bilious must be lowered and emptied ; the weak and debilitated must be assisted by such medicines as will add force to the vis vita ,- and errors in tiie treatment of the wound or fracture must be correct- ed ; but it is evident to common sense, that for these there is no possibility of prescribing any other than very gene- ral rules indeed. The nature and cir- cumstances of each individual case must determine the practitioner's con- duct. " In general, inflammation will require phlebotomy and an open belly, toge- ther with the neutral antiphlogistic medicines; pain and irritation will stand in need of anodynes, and the Peruvian bark, joined in some easels, and at some times, with those of the cooling kind, at others with the cordial, will be found necessary and useful. So also tension and induration will point out the use of fomentation and warm relaxing cata- plasms, and the most soft and lenient treatment and dressing. But there are two parts of the treatment of this kind of case mentioned by the generality of writers, which I cannot think of as they sepm to have done. One is, the use of stimulating antiseptic applications to the wound ; tiie other is what is com- monly called scarification ofthe limb. [Let it be remarked, that I speak of both these, as prescribed and practised while the gangrene is forming, as it were, and the parts are by ao means mortified.] While the inflammatory tension subsists, alleviation of pain, and relaxation of tile wounded and swollen parts, in order to obtain a suppuration, and consequently a separation, seem to constitute the intention, which ought 332 FRACTURES. to be pursued upon the most rational principles : warm irritating tinctures of myrrh, aloes, and euphorbium ; mix- tures of tinct. myrrh, with mel. iEgyp- tiac. and such kind of medicines, which are found to be frequently ordered, and indeed are frequently used, parti- cularly in compound fractures produ- ced by gun-shot, seem to me to be very opposite to such intention, and very little likely to produce or to con- tribute to the one thing which ought to be aimed at, I mean the establish- ment of a kindly suppuration. I know what is said, in answer to this, viz. that such kind of stimulus assists nature in throwing off the diseased parts : but this is a kind of language, whicii I be- lieve will be found upon examination to have been first used without any suffi- cient or good ground, and to have been echoed ever since upon trust. It had its foundation in the opinion that gun- shot wounds were poisonous, and that the mortification in them was the effect of fire; and it has been continued ever since, to the great detriment of many a sufferer. A gun-shot wound, whe- ther with or without fracture, is a wound accompanied with the highest degree of contusion, and with some degree of laceration ; and every great- ly contused and lacerated wound re- quires the same kind of treatment wliich a gun-shot wound does, as far as regards the soft parts. The inten- tion in both ought to be to appease pain, irritation, and inflammation ; to relax the indurated, and to unload the swollen parts ; and by such means to procure a kindly suppuration ; the con- sequence of which must be, a separa- tion of the diseased parts from the sound. Now, whether this is likely to be best and soonest accomplished by such dressings and such applications as heat and stimulate, and render the parts to wliich they are applied crisp and rigid, may fairly be left to common sense to determine. " Scarification, in the manner, and at the time, in which it is generally or- dered and performed, has never appear- ed to me to have served any one good purpose. When the parts are really mortified, incisions made of sufficient depth will give discharge to a quantity of acrid and offensive ichor ; will let put the confined air, which is the effect of putrefaction ; and thereby will con- tribute to unloading tiie whole limb ; and they will also make way for the ap- plication of proper dressings. But while a gangrene is impending, that is, wliile 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 imagine ; nor, though I have often seen it practised, do I remember ever to have seen any real bBnefit from it. If the skin be still sound, and of quick sensation, the scratching it in this su- perficial manner is painful, and adds to the inflamed state of it ; if it be not sound, but quite altered, such superfi- cial incision can do no possible ser- vice ; both the sanies and the imprison- ed air, are beneath the membrana adi- posa ; and merely scratching 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 com- pound fracture, in which amputation ofthe limb may be necessary and right; and these three points of" time are so limited, that a good deal of the hazard or safety of the operation depends on the observance or non-observance of them. " The first is immediately after the accident, before inflammation has taken possession ofthe parts. If this oppor- tunity be neglected 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 operation ought never to be thought of, till there is a perfect and absolute separation of the mortified parts. If the latter, no man can possibly propose the removal of a limb, until it be found, by sufficient trial, that tliere is no prospect of ob- taining a cure without; and that, by not performing the operation, the pa- tient's strength and life will be exhaust- ed by the discharge. When this be- comes the hazard, the sooner amputa- tion is performed the better. In the first instance, the operation ought to take place before inflammatory mis- chief is incurred ; in the second, we are to wait for a kind of crisis of such inflammation ; in the third, the pro- portional strength and state of tiie pa- tient, compared with the discharge and state of the fracture, must form our determination." (Pott's Remarks on Fractums.) FRACTURES 3* r» PARTICULAR FRACTURES. Fractures ofthe Ossa Nasi. These bones, from their situation, are much exposed to fractures. The fragments are sometimes not deranged; but, most frequently, they are depres- sed. In order to replace them, the surgeon must pass a female catheter, a ring-handled forceps, or any such in- strument, into the nostrils, and, using it as a lever, push the fragments out- wards ; while, with the index finger of the left hand, he prevents them from being pushed out too far. When the fragments are inclined to fall in- wards again, authors advise supporting them with an elastic gum cannula, or lint, introduced into the nostril. Fractures of tiie ossa nasi are some- times attended with very dangerous symptoms ; which may depend, either on the concussion of the brain, produ- ced by the blow, which caused the fracture ; or, on the cribriform lamella and the crista galli ofthe os ethmoides being driven inwards, so as to injure and compress the brain. When tiie symptoms of pressure on this viscus exist, (see Head, Injuries of) and the ossa nasi are much depressed, the surgeon must immediately raise them, together with the perpendicular process of the os ethmoides, whicii is connected with the cribriform lamella and crista galli. Perhaps, a pair of closed common forceps introduced into the nostrils, might best enable the sur- geon to do what is necessary. In all cases, in which the ossa nasi are bro- ken, bleeding and the antiphlogistic treatment are proper ; for the vicinity of the eye renders it very liable after- wards to become inflamed ; and when there are symptoms of the brain being also injured, the necessity of'such prac- tice is still more strongly indicated. Fractures ofthe Lower Jaw. This bone is sometimes fractured near the chin ; but, seldom so as to produce a division ofthe symphysis of that part, though tliis is not impossible. In other instances, the fractures occur near the angles ofthe jaw. The bone may also be broken in two places at the same time; in which event, the middle portion is extremely difficult to keep right, because many of the muscles, which draw the lower jaw downwards, are attached to that part. The condyles and coronoid processes are also sometimes broken; the former the most frequently. Fractures ofthe lower jaw may be either perpendicular to its basis, ob- lique, or longitudinal: of this latter, examples have been known, in which a portion of the alveolar part, with the teeth in it, was detached from tiie rest ofthe bone. In the present cases, the soft parts are commonly contused and wounded. J. L. Petit mentions a case, in which the bone was broken, and the coronoid Srocess quite denuded, by the kick of a orse. Fractures of the lower jaw are de- ranged in the following way. When the fracture is near the symphysis, the side on wliich the processus innomina- tus is situated, is drawn downward and backward by the sub-maxillary muscles, while the other fragment is supported by the muscles which close the jaw. When the fracture is more backward, the derangement occurs in the same way, but not so easily. When the bone is fractured in two places, the middle portion is always pulled downward and backward by the mus- cles attached to the chin, wliile the two lateral pieces are kept up by the levator muscles When the ramus of the jaw is broken, the masscter, being attached to both pieces, prevents much derange- ment. When the neck of the concly lc is fractured, the pterygoideus externus may pull the condyle forward. When a blow is received on the lower jaw, or the bone is injured by a fall, or by the pressure of some heavy body; when an acute pain is experienced in the part, and an inequality may be felt at the basis of the bone ; when some ofthe teeth, corresponding to that ine- quality, are lower than tiie others ; and when a crepitus is perceptible on mov- ing the two pieces of the jaw on each other ; there can be no doubt ofa frac- ture. When the gums are lacerated, or the bone denuded by a wound, the case is, (if possible) still more mani- fest. Fractures of tiie rami and condyles, though not so easily distinguishable, may be known by the great pain felt near the ear; particularly when the jaw is moved, and the crepitus, which the surgeon may discover with his fin- gers. Fractures ofthe lower jaw, whether simple, or double, are easily set, by pushing the deranged part upward, and 3.3-1- FRACTURES. a little forward, and then pressing on the basis of the bone, so as to bring it exactly on a level with the portion, which has preserved its natural posi- tion. The maintenance of the reduc- tion, however, is difficult; and can only be well executed by supporting tlie lower jaw, and keeping it applied to the upper one. As soon as the fracture is set, the surgeon should adapt some thick paste- board, previously wet and softened with vinegar, to tiie outside of the jaw, both along its side and under its basis. Over this moistened pasteboard, a ban- dage with four tails is to be applied, the centre being placed on the patient's chin, while the two posterior tails are to be pinned to the front part ofa night- cap, and the two anterior ones fastened to a part of the same cap more back- ward. When the pasteboard becomes dry, it forms the most convenient appa- ratus imaginable for incasing and sup- porting the fracture. A piece of soap- plaster mny now be applied to the skin underneath, which will prevent any ill effects ofthe hardness and pressure of the pasteboard. Until the bone has become united with some firmness, the patient should be allowed only such food as does not require being masticated, which may be given by introducing a small spoon between the teeth a littie separated. Indeed, he should be recommended to live principally on broths, soups, jel- lies, &c. To keep the middle portion of the bone from being drawn downward, and backward, toward the larynx, it is fre- quently necessary to apply tolerably thick compresses just under and behind the chin ; which are to be well support- ed by the bandages already desbribed. I need hardly state the necessity of enjoining the patient to avoid talking, or moving the jaw in any manner what- ever. When the condyle is fractured, as it is incessantly drawn forward by the ac- tion ofthe pterygoideus externus ; and, on account of its deep situation, cannot be pressed back, the lower portion must, if possible, be pushed into con- tact with it. For this purpose, the ban- dage must be made to operate particu- larly on the angle of the jaw, where a thick compress should be placed. Compound fractures of the lower jaw, are to be treated on the same prin- ciples, as such injuries of the bone. The external wound should, if possi- ble, be healed by the first intention ; and, when this attempt fails, care must be taken to keep the wound clean by changing the dressings about once in three days : oftener would disturb the fracture too much. It is observed, that compound fractures of the jaw, and even simple ones, wliich are followed by abscesses, are particularly liable to be followed by troublesome and tedious exfoliations. In very bad fractures, in which all motion of the jaw must have the most pernicious effect, it might even be pru- dent to administer every kind of nou- rishment in a fluid form, through a hollow bougie, introduced from one of the nostrils down the oesophagus. Fractures ofthe Vertebra. The shortness and thickness of these bones do not render them very apt to be broken. The spinous processes, whicii project backwards, are the most exposed to such an injury ; for they are the weakest, and most superficially situated. The violence, which is great enough to break the vertebrae, must produce a greater, or less concussion, or other mischief, of the spinal mar- row ; from which accident much more perilous consequences are to be appre- hended, than from the injury of the bones, abstractedly considered. The displaced pieces of bone may press on the spinal marrow, or even wound it, so as to occasion a paralytic affection of all the parts, which derive their nerves from the continuation of this substance below the fracture. As the mere concussion of the spine may occasion symptoms, which very much resemble those, which usually occur when the vertebrae are fractured, the diagnosis is certainly very obscure. Perhaps, an inequality in tiie line ofthe spinous processes might be observed, The lower extremities, and the rectum, and bladder, are generally paralytic ; the patient is afflicted with retention of urine and fteces, or with an involuntary discharge of the latter.—(Boyer.) Fractures of the spinous processes, without any other serious mischief, are not dangerous ; and are the only in- stances of fractures of the vertebrse, which admit of being ascertained with certainty. Any attempt to set fractures of the bodies of the vertebrae, even were they known to exist, would be both useless FRACTURES. 333 and dangerous. General treatment can alone be employed. Cupping will tend to prevent inflammation in the situation of the injury. When the patient is af- fected with a flatulent distention of the abdomen, vomiting, hiccough, &c. the belly may be rubbed with a camphorat- ed liniment, and purgative clysters, and anti-spasmodics, given. If requi- site, the urine must, be drawn off with a catheter. The removal of the paralysis of the bladder rectum, and lower extremities, if it should be in- clined to take place, ought to be pro- moted by rubbing the back, loins, sacrum, and the limbs, with liniments containing the tinct. canthar. (Boy- er.) Some authors recommend trepanning, or cutting out a portion ofthe fractured bone, when the compression ofthe spi- nal marrow, or its injury by a splinter, is suspected ; but, exclusively of the difficulty of that operation, cm account of the great depth of tiie intervening soft parts, the indication is never suf- ficiently evident to authorize it. (Boy- er.) A fracture of the upper cervical ver- tebrae, or of the processus dentatus, is always suddenly fatal. In such cases, the paralysis of the diaphragm, imme- diately produced, affords ample cause for instantaneous death. Frjictures of the Sternum. When these accidents occur, the frac- tured portions may be driven inward so as to wound the pericardium, heart, or lungs ; and a considerable quantity of blood may be extravasated from ruptured vessels, and collect in the an- terior mediastinum. Such an effusion, however, does not cause symptoms so urgent as those, which blood extrava- ited beneath the cranium produces. Fractures of the sternum, when mere solutions of continuity, only re- quire common treatment, viz. apiece of soap-plaster to the situation of the in- jury, a roller round the chest, quietude, and, in particular, bleeding, with a view of preventing, what may be con- sidered as the most dangerous conse- quence, inflammation of the parts within the chest. In cases, attended with great de- pression of the fractured bone inward, the necessary incisions should be made for raising with an elevator the por- tions of bone driven inward, or ex- tracting with forceps any splinters, which seem to be similarly circum- stanced. It is very seldom necessary to trephine the sternum, either to raise a depressed portion, or to give vent to extravasated fluid. The only case, in which such an operation may be con- sidered proper, is when the bone be- comes carious, and the diseased part is exceedingly tedious in separating. The ensiform cartilage, being ossifi- ed in old subjects, may in them be fractured. Littie more, however, 'can be done in such a case, than relaxing the abdominal muscles by raising the thorax and pelvis, and then applying a piece of soap-plaster and a roller over the part, for the purpose of keeping it steady. When the blow has been vio- lent, the patient should always be bled. Fractures of the Ribs. These generally happen near the greatest convexity of the bones, seve- ral of which are often broken together. The first rib, being protected by the clavicle, and the lower ones being very flexible, are less liable to be fractured, than the middle ones. When a spicula of a fractured rib is beaten inward, it may lacerate the pleura, wound the lungs, and cause the dangerous train of symptoms at- tendant on emphysema. (See Emphy- sema.) A pointed extremity of the rib, pro- jecting inwards, may also cause an ex- travasation of blood ; or, by its irrita- tion, produce inflammation in the chest. A fracture, which is not at all displa- ced, is very difficult to detect, particu- larly in fat subjects ; and, no doubt, is very frequently never discovered. The surgeon should place his hand on the part, where the patient seems to ex- perience a pricking pain in the mo- tions of respiration, or where the vio- lence has been applied. The patient should then be requested to cough, in wliich action the ribs must necessarily undergo a sudden motion, by which a crepitus will often be rendered percep- tible. All the best practitioners, how- ever, are in the habit of adopting the same treatment, when there is reason to suspect a rib to be fractured, as if this were actually known to be the case, by the occurrence of a crepitus, or the projection of one end ofthe fracture; which, indeed, in instances, which are displaced, makes the nature of the accident sufficiently plain. 336 FRACTURES. A broken rib cannot be deranged, either in the direction of" the diameter. of the bone, nor in that of its length. The ribs, being fixed posteriorly to the spine, and anteriorly to the sternum, cannot become shortened. Nor can one of the broken pieces become high- er, or lower, than the other, because the same muscles are attached to both fragments, and keep them at the same distance from tiie neighbouring ribs. The only possible derangement is either outward, or inward. (Boyer.) Simple fractures of the ribs, free from urgent symptoms, require very simple treatment. The grand object is to keep the broken bones as motionless as possible. For this purpose, after applying a piece of soap-plaster to the side, and over it proper compresses; a broad linen roller is to be firmly put round the chest, so as to impede the motion of the ribs ; and compel the pa- tient to perform respiration chiefly by the descent and elevation of the dia- phragm. A scapulary will prevent the bandage slipping downwards. When the fractured part seems depressed in- ward, the compresses should be placed on the anterior or posterior part of the bone. As a roller is very apt to be- come slack, many surgeons, with good reason, never employ one in the present case ; but take a piece of strong linen, large enough to surround the chest, and lace it with pack-thread, so as to com- press the ribs in the necessary man- ner. When there is reason from the sym- toms to think the lungs injured, or dis- posed to inflame, copious and repeated bleedings should be practised. Indeed, as peripneumony is always apt to suc- ceed the accident, and is a most danger- ous occurrence, every person, free from debility, either having a broken rib, or supposed to have such, should always be bled in the very first instance. The spermaceti mixture, with opium, is an excellent medicine for appeasing any cough, which may disturb the fracture, and giye the patient infinite pain. Fractures of the Sacrum. . These accidents do not often occur ; and, when they do, must be occasion- ed by some powerful cause, such as the fall of a very heavy body, or the passage of a carriage wheel on tlie convex side of the bone, or a fall from a great height on that part. No mus- cle tends to derange the position of the broken portions. Indeed, the principal danger depends on the injury, which the pelvic viscera may have suffered from the violence which broke the bone. To prevent tiie inflammation of such parts, of course, antiphlogistic means, particularly bleeding, are highly prop- er. Another source of grievous com- plaints, occasionally arising from frac- tures of the sacrum, is the injury done to the sacral nerves. Hence often pro ceed, retention of" urine, inability to retain tliis fluid, involuntary discharge of the faeces, paralysis of the lower ex- tremities, &c. With respect to the relief of these symptoms, we need add nothing to what we have already said on the sub- ject, in speaking of fractured vertebrae. The reader must also refer to the arti- cles, Urine, Retention of; Incontinence of, &c. Should the lower portion of the sacrum be displaced inward by the force applied, it is to be reduced in the same way as the os coccygis. With regard to the particular means for pro- moting the union of the fractured sa- crum, all that can be done is to apply a piece of the emplastrum saponis to the part, and put a roller round the pelvis, or a T bandage. Fracture of the Os Coccygis. Though much slighter than the sa- crum, it is less frequently broken. Its not being much exposed to external force, and its moveableness, are the reasons of this. When the os coccygis is fractured by a fall on the buttock, the pain, arising from the accident, is increased by walking, in consequence of some fibres of the glutei being at- tached to this bone, and disturbing it when in action (Boyer.) When the detached piece of bone is driven inw ard, the surgeon is to intro- duce his fore-finger, previously oiled, into the rectum, and, with the assis- tance of the fingers of his other hand externally, he is to reduce the displa- ced part. This being accomplished, lit- tle more can be done, than applying a piece of soap-plaster to the injured part, together with a T bandage; adopting the antiphlogistic regimen, and enjoining the patient to avoid lying on his back, or sitting down. He should also avoid walking, so as to put the glutei muscles into action, which would disturb the broken bone. FRACTURES. 337 Fractures of the Ossa Innominata. Such cases are not common; and, when they happen, are generally pro- duced by the passage of heavy carriage wheels, over the pelvis ; and are always attended with considerable contusion of the external soft parts, and some- times with great injury of the pelvic viscera. The anterior superior spinous process has been broken off, by the kick of a horse. (Boyer.) In St. Bartholomew's hospital, seve- ral instances occurred, during my ap- prenticeship to Mr. Ramsden, in which tlie os ilium, os ischium, and os pubis, were found fractured on opening the bodies after death; and, wiien we con- sider the great violence necessary to produce such accidents, we cannot wonder that the injured state of the pelvic viscera should frequently prove fatal. The fractures themselves are seldom displaced, so that what relates to their treatment is exceedingly sim- ple, merely consisting in applying a roller round the pelvis, and putting a piece of soap-plaster on the broken part. The grand indication is to obvi- ate the consequences of inflammation of the parts within the pelvis, and even of the peritonaeum and abdominal vis- cera, by copious and repeated blood- letting. Any complaints respecting the evacuation of the urine and faeces, must also be attended to. W hen the contusion is excessive, and the bones very badly broken, the patient cannot move, nor go to stool, without suffer- ing the most excruciating pain. To af- ford some assistance in such circum- stances, Boyer, in a particular case, passed a piece of strong girth web un- der the pelvis, and, collecting the cor- ners into one, fastened them to a pulley suspended from the top of the bed. Thise nabledthe patient to raise himself with very little effort, so that a flat vessel might be placed under him. Certainly, a bed on the principles re- commended by Sir James Earle, might be of infinite service, both in these cases, as well as in many others, par- ticulaiiy compound fractures, and par- alytic affections from diseased verte- brae. (See Observations on Fractures •f the Lower Limbs ; to which is added, un account of a contrivance to adminis- ter cleanliness and comfort to the bed-rid- den ; by Sir J. Eark, 1807-) Sometimes, notwithstanding the rig- orous adoption of antiphlogistic mea- sures, abscesses cannot be prevented VOL. I. from forming in the pelvis; particular- ly, when there are detached splinters driven inwards. Such splinters may wound the bladder, and cause an ex- travasation of urine. Desault extract-, ed a splinter, which had done so, from the bottom of a wound, which he had made to give exit to the effused urine. In these cases, a catheter should be kept introduced, to prevent the urine from collecting in the bladder, and af- terwards insinuating itself into the cav- ity of the abdomen. (Chopart.) Fractures of the Thigh. To this subject I shall allot as much room as the work will possibly afford, because it is one, which strongly claims the consideration of modern surgeons, and may be deemed even yet unsettled; the illustrious Pott defending one method of treatment; tiie celebrated Desault another. The os femoris is liable to be broken at every point, from its condyles to its very head. It is, however, at the mid- dle third of this extent, that fractures mostly occur. The fracture is some- times transverse, but, more frequent- ly oblique. Tlie latter direction of the injury makes a serious difference in the difficulty of curing the case, without future deformity, or lameness. Some- times the fracture is comminuted, the bone being broken in more places than one ; and sometimes the case is attend- ed with a wound, communicating with the fracture, and .making it, what is termed, compound. As Petit remarks, however, the thigh-hone is less seldom broken into several pieces, than others more superficially situated. A fractured thigh is attended with the following 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 hmb. The latter change, viz. the deformity, ought to be accurately understood; for, having a continual tendency to re- cur, especially, in oblique fractures, our chief trouble in the treatment is to prevent it. (Desault, par Bichat.) Almost all fractures of the thigh are attended with deformity. When this is considered, in relation to length, it appears, that, in oblique fractures, the 43 338 FRACTURES. broken limb is always shorter than the opposite one; a circumstance denoting, that the ends ofthe fracture ride over each other. We may also easily con- vince ourselves, 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 communicate to the low- er portion of the fractured bone, a mo- tion from below upwards ? At one end, attached to the pelvis; and, at the other, to this part ofthe bone, the patella, the tibia, and fibula, they make the former insertion their fixed point, and drawing upward tlie leg, the knee, and the low- er portion of the thigh, they cause di- rectly, or indirectly, the derangement in question. In producing this effect, the triceps, semitendinosus, semimem- branosus, rectus, gracilis, sartorius, 8ic. are the chief agents. To shew the power of the muscles to displace the ends of such fractures, mention is made, in Desault's works by Bichat, of a carpenter, who fell from a scaffold, and broke his thigh. The limb, the next day, was as long as the other? but, the man had a complete palsy of his lower extremities, and could not discharge his urine. The moxa was applied, and the muscles soon regained their power, and then the shortening of the hmb began to make its appearance. Besides the action of muscles, there is another cause producing a derange- ment of the fracture, in the course of the treatment. How firm soever 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 an inclina- tion in the plane on which the trunk lies; wliich, gliding from above down- ward, pushes before it tiie upper end of the fracture, and makes it ride over the lower one. The muscles, irritated by the points of the bone, increase their contraction, and draw upward the lower part of the bone; and from this double motion of the two ends of* the fracture in opposite directions, their riding over each other results. (Desault, par Bichat.) Transverse fractures are less liable to be displaced in the longitudinal di- rection ofthe bone, because, when once in contact, the ends of the fracture form a mutual resistance to each other; the lower one, drawn upward by the muscles, meets with resistance from the upper one, whicii 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 ac- companies that which is longitudinal; but, sometimes, it exists alone. This is the case, when, in a transverse frac- ture, the two ends ofthe bone lose their contact; one being carried outward, the other inward; 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, mo- tionless in regard to the muscular ac- tion ; the contraction of the pectineus, psoas, iliacus internus, and upper part ofthe triceps, deranges it from its na- tural direction, and contributes to dis- place it. The deformity ofthe limb, in regard to its direction, is either the conse- quence of the blow, which produced the fracture, or, what is more common, ofthe ill directed exertions of those who carry the patient. I'hus we see that an injudicious posture bends the two portions, so as to make an angle. (Desault, par Bichat.) Whatever may be the kind of defor- mity, 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 outward, whicii is very common, or inward, which is more unusual. This rotation always aggra- vates the displaced state of the frac- ture, and should be attended to in the reduction. (Desault,par Bichat.) Having presented the reader with these accurate remarks on the kinds of derangement, to which fractured thighs are subject, I shall beg his at- tention to a few observations of*my own, on Mr. Pott's account of the effects of posture on fractured limbs; on what constitutes the chief displacement ofa broken thigh, and what muscles can principally produce this effect; and, lastly, on the actual condition of such muscles in the bent position of the limb. 1. Almost every one, initiated in the surgical profession, imbibes a vague kind of information, that relaxation of the muscles, both in the reduction, and during the whole cure of fractures, was what Mr. Pott most strenuously re FRACTURES. 339 commended, as the proper condition, in which those powers ought to be pla- ced, under such circumstances; and was what he had in view in adopting the bent position for a fractured thigh. The love of* truth, leads me, how- ever, to remark, that this eminent sur- geon has not availed himself of the light, resulting from anatomical inqui- ries, to elucidate tlie effects of posture upon fractured limbs. Though many practitioners may now feel persuaded, how much greater the advantages are in the bent, than in the straight pos- ture of the limb, in the case of a bro- ken thigh; yet, few are so well ac- quainted with the exact reasons why, and precise manner how those advan- tages arise. It is true, as already sta- ted, it is known in a vague manner, that the advantages alluded to, arise from the relaxation of muscles connect- ed with the fractured bone: Mr. Pott contents himself with making mere as- sertions to this effect, and supporting them upon an appeal to - experience, leaves the rationale of tiie subject in perfect obscurity. When we have practical evidence in favour of any adoption, and when, at the same time, no rational theory can be formed to coincide with it, certainly, it behoves us to follow the more useful dictates of the former, and to beware of any dan- gerous hypothesis into whicii too eager a pursuit ofthe latter might allure us. When numerous surgeons, however, are in a state of indetermination, nay, what is more urgent, when one half of the profession seems to be at variance with the other upon a point important to be decided, and without the pros- pect of approaching harmony of prac- tice, what resource remains, but that of reason, to instil into the mind those facts and principles, by whicii all must be governed; and, from a due obser- vation of which, only one opinion and practice would result? To rest con- tented with barely knowing, that the superior utility of tiie bent posture, in the case of a broken thigh, proceeds from the relaxation of muscles, is to remain in a certain state of ignorance, from which, by an unfettered exercise of our own intellects, we might possi- bly disengage ourselves. Nor will any man of reflection contend, that such naked information, so void of illus'tra- lion, ts enough to saturate with fuU conviction that philosophical spirit of inquiry, from which tlie present en- lightened state of medical science is so eminently derived. And might it not tend to advance, and very usefully to improve our, knowledge ofthe subject, if we could ascertain more accurately upon what principle the posture of the limb ought to be selected with the greatest possible advantage to the pa- tient? Until that is accomplished, we are acting as mere surgical automa- tons; without true science, and with- out a ray of judgment. Neither will it be satisfactory to answer, that posture is to be determined upon the principle of relaxing the majority ofthe muscles connected with the broken bone. More is essentially required to make the solu- tion in this way accurate; for, even ad- mitting, what some may be inclined to doubt, that the bent position does relax more muscles than the straight one, its precision will vanish, when we shall have explained, that certain muscles, moving the thigh bone, possess much greater power to impede the favoura- ble coaptation and union of the frac- ture, than others performing the same office, and of not inferior bulk. I am humbly of opinion, that those practi- tioners, who still adhere to the old plan of placing fractured thighs in the straight posture, have never been struck with this distinction; and, in contend- ing that their mode of treatment relax- es as many muscles connected with the broken bone as the opposite one, they have not reflected upon what consti- tutes the relative displacement of the two ends of the fracture. I have heard it more than once remarked, that what Mr. Pott terms the relaxed position of the limb, cannot really merit that ap- pellation, because there are, perhaps, as many muscles thrown into a state of tension in this very posture, as in the straight qne. According to my ideas, there is some reason in this criticism ; but no one must thence infer, that the straight position is equally proper; for provided we shall be able to make Out the truth of what has been delivered above, the question under considera- tion will be much altered, and, instead of inquiring, " Are more muscles re- laxed in the bent, than in the straight position?" we must inquire, "Are more of those muscles, possessing most influence over the fracture, relaxed in tliis or that position ofthe limb ?" Were we to resign the privilege of thinking for ourselves, and implicitly to mould our opinions, according to anv 340 FRACTURES. 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 then sup- pose it possible and practicable to re- lax at once, by a certain posture ofthe limb, every muscle connected with a fractured bone. In the first vol. of his works, page 389, edit. 1783, he ob- serves, in speaking of what must best answer the purpose of incapacitating the muscles from displacing the frac- ture. " Is it not obvious, that putting the hmb into such position as shall re- lax 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 superfici- ally acquainted with his art, ever finds much trouble in setting a fractured os humeri ? 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 sur- rounding the broken bone ?" Also in page 393, he continues, " Change of posture must be the remedy, or rather 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 practicable, every one will admit; but the possibility of accomplishing it, so long as different muscles have differ- ent uses, different situations, and dif- ferent attachments to the bones, every one must grant to be more than vision- ary. For instance, do not tiie patient and surgeon, in the case of fractured os humeri, adverted to above, rather concur in putting the fibres of the tri- ceps and anconeus into a state of ten- sion, at the same moment that they re- lax the biceps and brachialis internus ? In short, the indetermination of many practitioners, with regard to the greater propriety of placing a frac- tured thigh-bone in the bent, than in the straight position, must, in a great measure, be attributed to the imper- fect explanations, hitherto offered of the way, in which the former becomes more advantageous, than the latter; especially, if it be true, that a com- parative and fair trial in practicerwould shew, that the bent posture is in no respect inferior to the straight one, and will even succeed in many instan- ces, where deformity, shortening of the limb, and lameness, would be in- evitable consequences of the other. 2. By what 1 am now going to re- mark, I do not mean to question the accuracy of Desault's account of the various kinds of derangement to whicii a broken thigh is liable. The rising end of the bone has now been put into its proper point of view, and even Or- dinary practitioners are well aware of the erroneous ideas once entertained concerning it, and the more pernicious treatment often had recourse to in con- sequence. In the fractured thigh, the rising ;end of the bone is the upper extremity of the fracture, that which is connected with the hip, that which is truly in its right and natural situa- tion, and that which no surgical means can therefore possibly alter for the better. On the other hand, the lower end of the fracture, or that whicii is connected with the knee, is that which is displaced, that which is drawn more or less underneath the other extremity of the bone, and that which well di- rected surgery can generally set right again. No doubt can, I think, exist about the accuracy of these preceding propo- sitions, when we consider, that the superior portion of the broken bone is properly articulated with the acetabu- lum ; that its broken extremity is nei- ther removed further from, nor nearer to, that cavity than nature placed it; that the position, in which the upper portion of the broken os femoris is found, is not in the least deranged, and precisely ,such as it has oftentimes been put into previously to the occur- rence of the accident. But, tiie lower end of the fracture is not only wrong in relation to the upper end, it is out of its due situation in all other respects; it is drawn upward nearer to the pelvis than it ever could be naturally, and hence tiie limb is shortened ; the posi- tion, in which it is constantly found, is so deranged in relation to the pelvis, its axis is so altered, that even were we to overleap the bounds of possibili- ty, and to suppose the upper end of the fracture brought into apposition with it so situated, we should at the same time be obliged to construct in our wanton imagination a new acetabu- lum, differently situated from the natu- ral one for the reception of the head of the bone; or, perhaps, it might best suit such chimera to alter the or- FRACTURES. 341 , dained shape of the thigh-bone. The deviation from the natural and relative situation of the two ends of the frac- ture, it is then my wish to imply, pro- ceeds, not from any derangement of the upper portion, but, from a refrac- tion of the inferior part of the broken bone. If it be received as an irrefragable truth, that the upper extremity of the fracture is not out of its due situation, and that the lower end is so, it must necessarily follow from the admission of this principle, that the first grand indication in the management of the case, is to put the lower end of the fracture into its right and relative situ- ation, by drawing it downward, and placing it into as perfect apposition, as the nature of circumstances will allow, and not to make any vain attempts to press down tiie prominent end of the bone; a thing altogether impracticable and highly improper. Let us now suppose, that the surgeon proceeds to replace the lower end of the fracture, which we have described as being retracted, more or less, un- derneath the other. Mr. Pott has judiciously remarked, that to impede the accomplishment of this purpose, little or no difficulty can arise from the fracture itself, the bro- ken ends of the bone being of them- selves inactive. The muscles must be looked upon as those powers, which can, and do make opposition to the reduction of the fracture ; and, when set right, to its continuing so. The muscles alone are the powers causing the retraction of the bone and shor- tening of the limb. It is well, and universally known, that muscles can only contract to a certain length; and, it is upon a knowledge of this fact, that the prin- ciple and utility of relaxing their fibres are founded; for, in proportion as they become relaxed by the approximation of their attachment, they are partly deprived both of their disposition and power to act. What then is implied by relaxation of a muscle is most simple of comprehension ; it is that condition, in which its origin and insertion are more or less approximated to each other. We shall now inquire, what muscles are so circumstanced as to be capable of making most resistance to the re- duction and coaptation of the fracture ; for, should we succeed in ascertaining them with precision, it must be a pri- mary consideration to relax them, ra- ther than any others, less empowered to do harm ; and, after what has been delivered, it seems a most easy matter to determine them. That those muscles, destined to move the os femoris, and affixed only to part of this bone above the situation of a fracture, cannot make any opposi- tion to its reduction, nor principally disturb the coaptation; and that, there- fore, their relaxation is not what the skilful surgeon ought primarily to aim at, appeal- to my mind two very mani- fest propositions, arising from the facts already premised. But, that he ought to aim principally at the relaxation of those muscles whicii can concur to retract the lower end of the fracture; all which must necessa- rily have their insertions below the breach of continuity in the bone, ap- pears to me a fact equally obvious; and, is what I think not unworthy the attentive consideration of all practical surgeons. My sentiments, however, are not at all repugnant to Desault's description of the derangement; for, I would not take upon me to deny altogether a cir- cumscribed power in muscles attached only to the superior portion of tiie broken bone to affect the fracture un- favourably; especially, when such frac- ture is of the transverse kind. It is possible, that they may do so in a limited degree; though, I am inclined to believe, that, in, the bent posture, their power of acting injuriously must be so trivial, as to be unworthy of serious notice. The reasons, for my entertaining this opinion, I shall ex- plain. When a transverse fracture is re- duced, and its broken extremities are placed in even apposition with each other, it is possible to conceive, that the first deviation from the proper situ- ation of the two ends of the fracture, may arise from the contraction of some muscle, that has only a power of moving the upper portion of the bone, and that, in consequence of the superior end of the fracture being removed, and its re- sistance taken away, the inferior end may become more easily retracted. This idea, however, plausible it may at first appear, will, upon mature con- sideration, be found in no degree to militate against the opinion advanced, that the muscles attached to the lower 342 FRACTURES. portion of the broken bone have most in- fluence over the fracture ; and it is at once obvious, that, without the action of these latter muscles, no retraction of the lower end of the fracture could take place, into whatever position the other might be drawn by the contrac- tion of other muscles. I am also of opinion, that most of those fractures of the thigh, which I have seen, have been oblique, and the ample experi- ence of Pott and Desault seems to have made them of a similar sentiment. Whether this remark be true, to the extent which I have stated, or not, it must at least be granted, that, in ob- lique fractures of the thigh, the re- sistance made by the upper end of the fracture to the retraction of the lower, will not be effectual enough to defeat the continual tendency of the muscles to produce that effect. It seems ra- tional to suppose, that those few in- stances, where little difficulty is expe- rienced in maintaining the fracture in a proper state of coaptation, and where no retraction happens, are cases of the transverse kind, and, consequently, if in such rare instances alone, and in such instances, as constantly end well, the muscles attached above the frac- ture can do harm, it is not of so much importance. Besides, admitting (what v indeed I have already admitted) that, in transverse fractures of the thigh, the resistance made by the upper end of the fracture to the retraction of the lower, becomes of considerable utility, it is evident, that it becomes so only by counteracting the action of* those muscles, which tend to draw upward the inferior portion of the fractured bone. Were it only in our power ef- fectually to incapacitate them by pos- ture, or any other means, oblique fractures of the thigh would be no more difficult to unite favourably, than transverse ones. The majority of cases also being oblique, and these being such as so often baffle tiie surgical art, we can only rely upon our means of diminishing the power of muscles to retract the inferior portion of the frac- tured bone for the accomplishment of a good cure. In the bent position of the hmb, an advocate of which I am, let me also inquire, in what direction can the su- perior end of the fracture be first drawn by the action of muscles ? The flexors of the thigh being relaxed, we cannot suppose, that they make it pro- ject forward, as it actually does, or ai least has done in every instance of dis- placement that I have yet seen. It muj be suggested, that the adductor mus- cles may do so; but, as these ought also to be perfectly relaxed in the bent position, they cannot, when the bone is set right, and placed as circumstances demand, do what we are considering. The glutei are tense, and may there- fore be conceived capable of disturbing the coaptation ; but, to appeal to fact, and the incontestable evidence of ex- perience, do we ever find the upper end of the fracture situated eitiier be- hind, or on the outside of the lower end ? Do we not constantly find it pro- jecting in front, and the latter drawn up more or less behind it ? Even sup- posing the upper end of a transverse fracture were first drawn in a direction backward, would it not rather tend to prevent retraction of the lower end, ac- cording to the manner in which it is uniformly found to be displaced ? In short, we can account for every thing, relating to the displaced condition of the fracture, without having recourse to the doctrine admitting much influ- ence over the fracture to reside in muscles attached only to tlie superior portion of the fractured bone. If, at the same time, we concede, for tiie sake of a reconciliation of opinions, that muscles inserted into the os fe- moris, above the situation of a frac- ture, may act in some degree unfavour- ably, it yet remains a manifest and un- shaken truth, that since no posture of the limb will at once relax all its mus- cles, it is the duty of the surgeon to select that one, which brings with it the greatest share of advantages, and wliich disarms, as it were, those mus- cles, endued with most power t° dis- turb tiie union ofthe fracture. What renders the foregoing remarks more deserving attention is, that the majority of fractures of the thigh-bone happen at some joint below the at- tachment ofthe gluteus maximus, and that the majority of the muscles, in- serted directly into the os femoris, have their attachments so high, that they cannot be supposed to possess great influence over fractures situated at any point much below the trochan- ters. The psoas magnus and iliacus internus, the glutei, and all the rotators ofthe thigh-bone outward come within this description, together with, the pectinalis, the superior fibres of the FRACTURES. 343 adductor magnus, and all the adductor brevis. What muscles now remain to anta- gonize so powerfully the endeavours of the surgeon } In this general view of the subject, the greater part of the triceps will be the only power, inserted immediately into the os femoris, pos- sessing considerable Itifluence ; yet, there are several other very bulky muscles, concerned in the motions of the knee-joint, which may combine very forcibly to retract the lower end of the fracture, and thus resist the re- duction and disturb the coaptation, and union of the bone. Such are the extensor muscles of the leg, especially, the rectus, as we presently shall explain, and the flexor muscles, sartorius, gracilis, semimem- branosus, semitendinosus, and biceps. If these are really the muscles, capable of exerting themselves, with most ef- fect, in producing the difficulties ac- companying the treatment of all those fractures of the thigh, which happen below the tendon of the gluteus maxi- mus, it certainly becomes a matter of considerable importance to observe, if possible, their relaxation, rather than that of any other set of muscles, less empowered to do harm. When the fracture is above this point, other muscles come into power, and hence the difficulties augment. 3: In noticing the condition, into which the above muscles are put in the bent position of the limb, we shall, as occasion requires, mention those cir- cumstances, whicii diminish, or in- crease, their influence over tiie frac- ture. The triceps is the principal adduc- tor of the thigh ; it may also, from the nature of its attachments, combine to bring the thigh-bone forward, and hence, bending the thigh must in a certain degree contribute to its relaxa- tion. It is probable, that of all the muscles capable of impeding, with the greatest effect, the setting of a broken thigh, tiie triceps is that, which pos- sesses the highest share of power, con- sidering its vast bulk, and its exten- sive insertion into the bone. Its per- fectly relaxed state cannot, therefore, be too particularly insisted upon ; it is not enough, for this purpose, to bend the tiiigh upon the pelvis; this alone can only produce a very partial relaxa- tion of its fibres. The patient ought to be placed upon a firm mattress, and, as he lies upon his side with the thigh bent to an acute angle with the trunk, the pelvis is to be turned completely upon its lateral part, and the fractured bone somewhat raised by pillows. Thus the os pubis and os ischium (from which the three heads of the triceps arise) will become approximated to the linea aspera, and the ridge above the internal condyle of the os femoris (into which they are in- serted) as much as circumstances will permit, and thus the relaxation of the muscle will be effected. The pectinalis can only be a primary power in disturbing the fracture, when the accident has occurred very high up. As it is an assistant both in tiie flexion and adduction of the thigh, it must be relaxed in the above position. I need only observe further respecting it, that the majority of fractures hap- pen below its insertion, and, conse- quently, in such instances, it will, with tiie upper fibres of the triceps, possess no power of displacing the lower end of the fracture, The next muscles, claiming our at- tention, are the extensors of the leg. In considering the effect of the ac- tion of different muscles upon a frac- tured thigh-bone, it is useful to carry in our mind the precise direction in which the inferior end of the fracture is displaced. We should bear in our recollection, that it is drawn up more or less behind the upper portion of tlie bone ; and muscles, which can most concur to produce such retraction, are those, which can most impede the fa- vourable union of the fracture. The situation of the extensor muscles of the leg at once suggests to us, that they cannot produce this effect nearly in so great a degree as the flexors. It is true, that the sartorius is situated in front of the thigh, and has been enu- merated as possessing much influence over the fracture ; but, it is to be re- membered that the direction of its force is entirely changed in conse- quence of its spiral course, and its passing behind the internal condyle of the os femoris. The rectus may un- doubtedly aid in the retraction of the lower end of an oblique fracture: its power to disturb a transverse one s.uems doubtful. Being a loose mus- cle, not attached to the thigh-bpne, and acting only from two points very remote from each other, viz. the ante- rior inferior spine ofthe ilium, and the 344 FRACTURES. patella, it can on this account exert the strength of every fibre, both above and below the breach of continuity in the bone, in combining to retract the inferior end of an oblique fracture. The vasti and cruralis, on the contrary, being muscles intimately attached to the os femoris, and having no origin whatever from the pelvis, can only em- ploy the force of those fibres, which happen to be situated above the frac- ture in aiding to retract the lower por- tion of the broken bone. For instance, supposing the fracture to be situated about the middle of the thigh, all those fibres of the vasti and cruralis deriving their origin from the os femo- ris below the breach of continuity in the bone, and inserted into the patella, can obviously have no effect in pro- ducing the retraction and displacement of the inferior end of the fracture. This fact must considerably lessen the influence of these three extensors in acting injuriously toward fractures. There are yet other circumstances, which must tend to diminish their power. If we reflect upon the lower end of the fracture, when displaced ; if we remind ourselves, that it is con- stantly drawn up behind the other ; it must immediately strike us, that the vasti and cruralis, the fibres of which embrace and adhere so intimately to the surface of the bone, both above and below the fracture, must be more or less detached from their origin, in proportion to the degree of retraction and displacement; that the fibres of the vasti, taking their origin from the lower part of the linea aspera above the fracture, must in all probability be detached from such connexion by the retraction of the lower end of the frac- ture in that situation ; and that the fi- bres of the cruralis must at the same time be partially detached from their intimate connexion with the anterior surface of the bone below the fracture. Such separated fibres can exert no power over fractures. When we also reflect, that the fibres of the cruralis and the anterior ones of the vasti must inevitably be more or less stretched round the upper end of the fracture, by which the direction of their force upon the lower end must be so chang- ed, that, instead of tending to draw it upward, they can only pull it forward, 11 hink it must be granted that their faculty of materially disturbing a frac- tured thigh is involved in doubt. The rectus is certainly to be considered, in every respect, as one of the primary powers acting in the displacement of fractures, and, as such, it ought to be perfectly relaxed, if other considera- tions should not forbid it; that is, if we should not throw a larger bulk of muscular fibres, disposed to act unfa- vourably on the fracture, into a state of tension, by observing its perfect re- laxation, than we should, by such means, relax, and according to our principles, this would undoubtedly happen. Consequently, in the bent position of the hmb, though we do not completely relax the rectus, since, the knee is bent, at the same time that the thigh is in a state of flexion, yet we must, of necessity, be content with a partial relaxation of its fibres, for the sake of relaxing a more powerful set of muscles next to be considered. It may not however be inapplicable to state, that in the bent position, the an- terior inferior spine of the ilium is al- most, if not quite, as near to the patel- la as in the straight one, and of course even the rectus must be equally fa- voured in point of relaxation. The vasti and cruralis are tense in the bent position; but, I cannot consider their power over the generality of fractures to be of primary importance. The higher the fracture is situated, the less can they exert that little share of in- fluence which they may be supposed to possess ; and accidents of this descrip- tion,, when in a high situation, being always the most troublesome, is a cir- cumstance proving, that it is to other powers we ought to attribute the aug- mentation of difficulty. The flexor muscles ofthe leg, above enumerated, are capable of acting very powerfully in resisting the reduction, and disturbing the coaptation of the fracture. For the sake of surveying them more clearly in this surgical point of view, they may be divided into two classes. The first comprehends two muscles arising from the pelvis in front, viz. the gracilis and sartorius, which are favoured in all respects by the bent position of the limb, as well by flexion of the thigh, as by that of the leg ; and also in a very important degree by observing to place the pelvis strictly upon its side, and to raise the thigh by proper pillows. The second class consists of three muscles coming from the tuberosity of the ischium be- hind, viz. the semimembranosus, se- FRACTURES. 345 mitendinosus, and long head of the bi- ceps, being such as are only favoured, with a view to relaxation, by flexion of the knee. That the sartorius and gracilis are in every respect favoured by the bent posture, no one acquainted with the origins and insertions of" those mus- cles ; no one knowing the effect of their action, will feel inclined to deny; and presuming upon tiie admission of this truth, I shall pass on to reflect up- on the state of the three otiier flexors enumerated above. In deriving their origin from tiie tu- berosity ofthe ischium, they acquire a power of contributing to draw the limb backward, as well as of bending the knee. Hence, their perfect relaxation is obviously unaccomplished in the bent position. One might even conjec- ture d priori, that they are little, or not in the least, benefited in such condition, because bending the thigh may seem to counteract all the good effect, in re. gard to relaxation, resulting from flexi- on of the knee. Measurements on the skeleton, however, will shew, that the tuberosity of the ischium is approxima- ted considerably more to the heads of the tibia and fibula in the bent, than in the straight posture. I may also take the liberty of remarking, that horizon- tally situated, as the thigh bone is in a straight position, it cannot be regard- ed, as affording an equal degree of re- laxation to such muscles, as if it actu- ally were in a state of perfect exten- sion. The short head of the biceps will, in many instances, be enabled to assist in the retraction of the inferior end of the fracture, and it is manifestly relaxed in the bent position. I am not inclined to allow any share of power to reside in the popliteus. Daily experience justifies my laying it down, as a fact, that the higher tiie fracture is situated, cateris paribus, the greater is the difficulty experienced in keeping it in a state of apposition. In contemplating the subject, upon the principles advanced in tiie preceding remarks, we immediately discern tiie reason of it. When the fracture is ve- ry high, almost the whole of" the triceps and pectinalis concur to retract the bone. When immediately below the trochanters, the gluteus maximus is to be added to the numerous class of muscles, capable of disturbing tiie uni- on of tlie fracture. When in the neck ofthe bone, the multitude of muscles, vol. 1. inserted into the two trochanters, be- come enabled to assist in the retrac- tion and displacement ofthe main por- tion of tiie bone. Hence, the immense difficulty to be surmounted in accom- plishing the union of such cases, with- out shortening the Umb, and the foot being distorted outward. In cases of this kind, the short head ofthe biceps, the vasti, and the cruralis, will how- ever, have no force over the fracture. When the neck of the os fembris is fractured within the orbicular ligament (which remains entire,) it is clear, that the retraction must be much limited. I might strengthen the preceding ob- servation, that in proportion as the fracture is high, the greater is the dif- ficulty experienced in maintaining the ends ofthe fracture in contact, by no- ticing, that I have seen several cases, in which the os femoris was broken ve- ry low indeed, and in which no retrac- tion nor displacement whatever hap- pened. Perhaps, these fractures might have been of the transverse kind, and, perhaps the greater surface for apposi- tion, on account of the expanded form of the bone, at this part, might have had some share in preventing retrac- tion. But, it must appear certain, that, in such instances, several muscles would have lost almost, or entirely, their influence to produce that effect; such as the triceps, pectinalis Sec. and the muscles moving the leg, remained the only powers capable of such ac- tion. The position ofthe fractured os fe- moris, says Mr. Pott, should be on its outside, resting on the great trochan- ter; the patient's whole body should be inclined to the same side; tile knee should be in a middle state between perfect flexion, or extension, or half- bent ; tiie leg and foot lying on their outside also, should be well supported by smootii pillows, and should be ra- ther higher in their level, than the thigh; one very broad splint, of deal, hollowed out, and well covered with wool, rag, or tow, should be placed under the thigh, from above the tro- chanter quite below the knee; and an- other somewhat shorter should extend from the groin below the knee on the inside, or rather in this posture on the upper side. The bandage should be of* tiie eighteen-tail kind, and when the bone has been set, add the thigh well placed on the pillow, it should not without necessity, (which necessity in 44 346 FRACTURES. this method will seldom occur) be ever moved from it again, until the fracture is umted; and this union will always be accomplished, in more or less time, in proportion as the limb shall have bee . more or less disturbed. (Pott.) lit -c only twj splints are mentioned; the surgeons ofthe present day always employ four. Af-er placing the patient in a proper position, tiie necessary ex- tension is 10 be made. Then the un- der-splint, having upon-it a b'-oad soft pad, and an eighteen-tailed bmdage, is to be laid under the thigh, Lorn the great trochanter to the outer condyle. 'The surgeon, before applying the soap plaster, laying down the tails of the bandage, ..nd 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 tlie thigh; with what particular design I have not myself been able to make out. Whoever meditates uj-*>n the consequence of elevating the leg and foot above the level of the thigh, in the bent position, will know, that it is to twist the condyles of the os femo- ris 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 conside- rably higher than the thigh, and 1 am disposed to think, that this is one cause, why so many broken thighs are united in so deformed a manner, that the foot remains permanently distorted out- ward. The great propensity of the triceps, and other muscles to produce this effect, may also serve to explain the frequency of the deformity. It is not merely the depression of the mid- dle of the bed which is disadvantage- ous, as the weight of the patient's bo- dy falls more upon one side ofthe bed, than the other, in the bent position of the hmb, unless the sacking is tight and the mattress very firm, it happens, that such a declivity is formed, as to render it exceedingly difficult, if not impracticable, to make the patient con- tinue duly upon his side. It cannot be enjoined too forcibly, that fractured thighs should always be laid upon beds not hkely to sink much. When tliis 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. From what has been delivered it may easily be discerned, that inferen- ces from anatomical circumstances are in most fractures of the thigh chiefly in favour of the bent position; for it appears, that of all those muscles which have primary influence over the majority of such accidents, that is, over all those which occur below the inser- tion of the gluteus maximus, there is only one muscle, viz. the rectus femo- ris, that is not more, or quite as much relaxed in it, as in the straight posi- tion. Since, however, experience is the great arbitrator of all practical 3uestions, we must still look to it for ecisive information, and to form a true judgment in this way, the straight and bent positions ought to be contrasted in every hospital with due attention to all collateral circumstances; the pro- gress and termination of every case ought to be registered; and the com- parative view, thus kept up, would quickly diffuse one kind of conviction throughout the profession. There are some very excellent re- marks on the treatment of fractured thighs in Les (Euvres Chirurgicaks de Desault par Bichat. It is observed, that, if we compare the natural powers of displacement with the artificial re- sistance of most of our apparatuses, we shall find, that the disproportion between such forces is too great to make .the former yield to the latter. The action of the muscles, however, which is always at first very strong, may afterwards be gradually diminish- ed by the extension exercised on them. A power incessantly operating can ef- fect, what another greater power tem- porarily applied, cannot at once ac- complish, and the compression of cir, cular bandages tends also to lessen the force of the muscles. Desault cured in the Hotel-Dieu an immense number of fractured thighs, without any kind of deformity. It was particularly to the well-combined em- ployment of extension, and compres- sion of the muscles, that such success was owing. The advantage of keep- ing the muscles a long while extended', in order to diminish their power, is es- pecially evident in the reduction of certain dislocations, as those of the shoulder, in which we often cannot suc- ceed till the muscles have been kept FRACTURES. 347 on the stretch for a greater, or lesser time. The fracture of the patella and olecranon equally demonstrates the utility of compression for the same purpose ; as when the muscles are not compressed by tlie bandage they draw upward the fragment of bone with double, or triple force. (Desault par Bicliat.) Against reducing fractured thighs in the bent posture, Desault entertain- ed the following objections : the diffi- culty of making the extension and counter-extension, when the limb is so placed : the necessity of then applying 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 precision 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 pressure of a part of the trunk on the great trochanter of the affected side ; the derangement, to which the limb is exposed when the patient has a motion ; tiie difficulty of fixing the leg firmly enough to prevent the effect of its motion on the thigh-bone ; the man- ifest impossibihty of adopting this metliod, when both thighs are fractur- ed ; lastly, experience in France having been littie in favour of such posture. Also, what is gained by the relaxa- tion of some muscles, is lost by the tension of others. For such reasons*. (certainly strong ones,) Desault aban- doned 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 ofthe os femo- ris. Dupouy was one ofthe first to re- mark, that this practice rendered it ne- ( cessary to employ very great force, and that it would be better to make the ex- tension from the foot. Fabre takes in- to consideration also the inconvenience of the pressure, made on the muscles, which irritating and stimulating them to action, multiplies the obstacles to setting the fracture. Desault adopted their doctrine, for nearly the same mo- tives, introduced it at the Hotel-Dieu, and the success he experienced in con- sequence, did not contribute a little to its wider diffusion. (Desault par Bi- chat.) Desault, as we have stated, preferred the straight posture, and laid his pa- 'tients on surfaces, not likely to 4ink with the weight of the body. The feather beds, formerly in common use at the Hotel-Dieu had this inconven- ience ; for these, in cases of fractures, Desault substituted a firm, tolerably hard mattress, which did not allow the continual change of posture to occur, whicii a soft bed does. The object of every apparatus 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 derangement. These are, 1. the action ofthe muscles, drawing upward the lower end of the fracture ; 2. the weight of the trunk propelling downward the upper end. Hence, every apparatus, intended to prevent derangement of a thigh frac- tured obliquely, should, 1. draw and keep downward the lower end of the fracture ; 2. carry and maintain up- ward the upper end of the fracture, and the trunk, which is above it. The principle is of general application, and only subject to a few exceptions ih transverse fractures, attended only with derangement in the direction of the diameter ofthe limb, or else none at all. 3. There must also be in the apparatus a resistance to the rotation of the lower portion ofthe broken bone, which will keep the limb steady, even in case of any sudden motion. (De- sault par Bichat.) If we compare the operation of the different pieces of our apparatuses with the above indications, we shall find, that, without permanent exten- sion, they are not very effectual. With regard to bandages, whether a roller, or eighteen-tailed bandage, be used, they all have one common mode of op- erating ; they press the muscles to- wards the end ofthe 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 materially aid in preventing derangement side-ways, and are particularly useful in trans- verse fracture , But, what is there to hinder the two inclined surfaces of an oblique fracture from slipping one over the other ? What power is there to keep tiie limb from receiving the effects of b48 FRACTURES. accidental shocks ? Is the pelvis kept back ? Is the action of" the muscles re- sisted ? The latter is indeed somewhat diminished by the pressure, and this is the chief use of the bandage ; but, will such compression be enough to prevent the longitudinal derangement of the broken bone, especially, if the bandage be applied slackly, as some advise ! (Desault par Bichat.) These remarks apply also to com- presses ; 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 bandages, in prevent- ing lateral derangement, and, hence, they suffice for transverse fractures, without any permanent extension being employed. They can also resist tiie ro- tation of the thigh outward, or inward. But, when the breach of continuity is oblique, will they hinder the ends of the bone from gliding over each other, and tiie consequent shortening of the limb ? They obviously could only do so, by the friction of tiie different pieces of the apparatus, especially, the tapes, which fasten it, and then, to make the resistance effectual, they must be tied so tightly as to create a danger of mor- tification. Will the splints prevent the trunk from descending, and propelling before it the upper end of the fracture ? Will they paralize the action of the muscles on the lower end ? Will they, in short, fulfil all the above indications ? Their use is almost limited to prevent- ing lateral derangement, and steadying tiie limb. Hence, they should extend along the leg, as well as the thigh, which is disturbed by the motions of the lower part of the Umb. The pads are chiefly useful in keep- ing the limb from being galled by the splints, and tend only trivially to keep the fracture from being displaced. From the above account, it appears, that the ordinary pieces of apparatus, which do not execute any permanent extension, may perhaps suffice for transverse fractures, whicii are not common ; but, that they are always in- effectual, when the division is' oblique, because they do not fulfil the two fold indication of drawing downward the lower end of the fracture, and keeping the other one upward. (Desault pur Bichat.) Desault ascertained, that the object particularly to be aimed at, was such a disposition as that the foot, leg, thigh, and pelvis, should constitute but one whole ; so that, though the different parts thereof should be drawn in dif- ferent directions, yet they should still, with tiie respect to one another, pre- serve the same mutual relation. He invented the follow ing apparatus to an- swer these purposes. A strong splint, long enough to ex- tend from the ridge of the os ilium to a certain length beyond the sole of the foot, is a principal part of this appa- ratus : this splint should be two inches and a quarter broad, and have each of its extremities pierced in shape of a mortise, and terminated by a semicir- cular niche- It is applied on the exte- rior side of the thigh, by means of two strong linen bands, each being more than a yard long. [Dr. Physick has greatly improved this splint by increasing the length of it sufficiently to extend up to the axil- la ; an account of tliis improvement is contained in the following extract from Dr. Caldwell's translation of Desault. " Dr. Physick having observed that in the application of Desault's apparatus, the patient was sometimes injured by the pressure ofthe strap or roller which passes under the tuberosity of the is- chium for the purpose of making coun- ter-extension, devised the following method of remedying this inconvenience in whicii he succeeded to his wishes. " He directed the upper end of the long external splint to be formed like the head of a crutch, and the splint it- self to be lengthened so as to reach and bear against the axilla of the af- fected side, which must be well de- fended from pressure by a bolster of flannel or some other soft material. By this expedient the Dr. evidently formed two points, of counter-extension, in- stead of one, as in the case in the ap- paratus of Desault. Between these two points, namely, the axilla and the peri- neum, the same quantity and force of pressure is, by Dr. Physick's improve- ment, divided, which, in the original apparatus of Desault, is borne by the perineum alone. The risk of excori- ation and injury to the patient, then, in the former case, is to that which he runs in the latter, only as one to two, or nearly so. As it is no less the duty of the surgeon to prevent suffering than it FRACTURES. 349 i s to remove deformity, or to save life, Or. Physick has certainly in this re- spect made an important step in the advancement of his profession. "Butthere is still another advantage derived from the lengthening of the ex- ternal splint. In the original apparatus of Desault, the strap intended for counter-extension, by passing no high- er up than the spine of the ilium, runs too much across, and therefore acts too much on, the upper part of the thigh. By this it not only irritates the muscles of the part, and induces them to con- tract, but also tends to draw the up- per fragment of the os femoris a little, outward, and thus to render the thigh in some measure deformed. But, in the improvement of Dr. Physick, the strap is secured in a mortise cut in tiie external splint, about midway between the spine of the ilium and the axilla. This strap, by being thus carried high- er up on the body, does not run across the thigh at all. It consequently press- es on and irritates the muscles .much less, acts more in the direction of the os femoris, and has no tendency to draw the superior fragment outward."] 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 semicurcular 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 of the ischium, which Desault considered as the principal point of action of this band. The inferior part of the leg is, in tiie next place, covered with com- presses, on which the middle part of the second band is placed : the extrem- ities of this band are crossed on the instep and upper part of the foot, then on the sole, after wliich they are con- veyed outward, and one end passed through the mortise and knotted with the other on the niche, with such a de- gree of force as to pull the inferior por- tion of the femur downward, and to push the splint upward, and, by this means, the pelvis and superior fractur- ed portion. On the internal side of the limb is placed a second splint, whicii xtends from the superior part of the thigh, to a certain distance beyond the foot. A third is placed on tiie anterior part, and extends from the abdomen to the knee. The superior extremities of the anterior and exterior splints are fixed by means of a bandage passed round the pelvis. A band, the middle part of which is placed under the sole of the foot, and the extremities crossed on its superior surface, and fastened to the splints, prevents the motion of the foot, as do also the splints. Before applying the apparatus, the whole limb is to be covered with com- presses, wet with a solution of the ace- tite of lead. Over these, Scultetus's bandage is to be put, and a roller round the foot, all moistened hi the same manner. For more particulars, the reader is referred to the Journal Chir- urgicak, ou ks QZuvres Chirurgicaks de Desault par Bichat; and Bayer's Lec- tures on tlie Bones, Vol. I. [The reader must decide for himself between the two opposite methods of treatment here recommended in frac- tures of the lower extremity. The method taught in the University of Pennsylvania is that of Desault improv- ed by Dr. Physick; its success is such, as perfectly satisfies me, and I beheve most of those who have properly tried it.] Fractures of the Neck of the Thigh-bone. This part of the bone may be frac- tured either by falls on tiie great tro- chanter, on the sole of the foot, or the knee. But the first accident produces the injury much more frequently, than the latter ones. Of" thirty cases, which occurred to Desault, four-and-twenty arose from falls on the side. All those inserted by M. Sabatier in his interest- ing Memoir, were the result of a simi- lar accident. 1. The fracture may take place in the middle of the neck, where tliere is less thickness, and the texture is not com- pact, as in the middle of the cylindri- cal bones, wliich are so much exposed to fractures. 2. Where it is united to the head of the bone. 3. Where it joins the great trochan- ter ; in which event, the breach of con- tinuity may be on the outside of the joint, which happens more frequently, than has been supposed. The division is seldom oblique, al- most always transverse; the neck be- ing sometimes, in the latter case, wedg- ed in the body of the bone, as Desault found in several instances ; a model of one of which, in wax, is preserved in the collection of L'Ecok de Saute, and 350 FRACTURES. the natural specimen of which was in the possession of Bichat. The fracture of the neck of the thigh-bone is some- times complicated with that of the tro- chanter major. The diagnosis is occasionally so diffi- cult, that the best-informed practition- ers cannot always ascertain the acci- . dent with certainty. At tiie instant of the fall, an acute pain is felt, (some- times a crack is distinctly heard) and sudden inability to walk occurs ; the patient cannot raise himself from the ground, which, however, is not invari- My the case. In the fourth vol. of the Mem. de I' Acad, de Chirurgie, a case is related, in which the patient walked home after the accident, and even got up the next day. Desault published a similar example. The locking of one end of the fracture in the other, may offer an explanation of this circum- stance. A shortening *of the limb almost al- ways takes place ; but this symptom is more or less striking, according as the breach of continuity is out of" the cavity ofthe orbicular ligament, whicii then keeps the bone from being retracted ; or as the extremity of the fracture is confined by this ligament, The action of the muscles drawing upward the lower end of the fracture, the weight of the trunk propelling downward the pelvis and upper end of the fracture, are the two causes of the shortening of the hmb. A slight effort suffices, in general, for the removal of this short- ening of the limb; but, the symptom recurs almost as soon as such effort ceases; and Gou'-sault and Sabatier have remarked, that it sometimes does not take place at all, till a long while after the accident. A swelling is ob- servable at the upper and front part of the thigh, always proportioned to the retraction, of which it appears to be an effect. The projection of tiie great trochan- ter is almost entirely effaced. Direct- ed upw ards and backwards, tliis emi- nence becomes approximated to the crista of the os ilium ; but, if pushed in the opposite direction, i± readily yields; and, when arrived at its na- tural level, the patient becomes capa- ble of moving his thigh. The knee is a littie bent. Adduction of the limb always occasions acute pain. If, while the hand is placed on the great trochanter, tiie limb is ro- tated on its axis, this bony prrjection may be felt revolving on itself, as on a pivot, instead of describing, as in the natural state, the segment of a circle, of which the neck of the femur is the radius. This symptom, whicii was par- ticularly 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 per- ceptible when tiie breach is near the head ofthe bone. In the rotatory mo- tions, the lower fragment rubbing against tiie upper one, produces a dis- tinct crepitus, which, however, is not an invariable symptom. v The toes are usually turned out- ward ; a position wliich Sabatier, &c. consider as the inevitable effect of the fracture, though Par£ and Petit have noticed, that it did not constantly oc- cur. Two cases adduced by these il- lustrious surgeons, were not credited by M. Louis; but the experience of Desault has fully confirmed the possi- bility of the occurrence. The position outward is commonly imputed to the rotator muscles. But, then it is clear, that such position ought always to exist; that all the muscles, wliich proceed from the pel- vis to the trochanter, are, with tiie ex- ception of the quadratus, in a state of relaxation, by the approximation of the femur to their point of insertion ; and that the contracted muscles would not allow the foot to be so easily turned in- ward again. It is not more probable that the weight of this part itself may pull it into the position, in which it is commonly found. It follows from the preceding ac- count, that none of the symptoms of a fracture ofthe neck of the thigh-bone are exclusively characteristic; that each considered separately, would be insufficient, ,and that their assemblage can alone throw light on the diagnosis. In every instance of doubt, however, the sure course must be pursued, and the apparatus apphed, which, though useless, is not dangerous, should tlie injury not exist, and is indispensably necessary when it does. (Desault paj' Bichat.) It was at one time supposed, that fractures of the neck of the thigh-bone could not be cured, without some short- ening of the limb, and lameness, re- maining afterwards. Professor Lud- wig, Sabatier, and M. Louis, broached this doctrine, and imputed tlie circum- stance to the destruction of the neck of FRACTURES. 351 the bone. Desault, however, rarely met with instances of such lameness in his practice. The treatment of these cases is not at all different from that of other frac- tures of the body of the bone. Most surgeons in this country adhere to Mr. Pott's plan of laying the limb in a bent posture ; while, in France, they prefer the straight position, with Desault's ap. paratus, above described. Fracture of the Patella. This bone is almost always -broken transversely, and the accident may be occasioned either by the action of ex- ternal bodies, or by that of the exten- sor muscles. In the latter case, the fall is only consequent to tiie fracture, and, as Camper has remarked, is most frequently only an effect of it. For in- stance, the line of gravity of the body is, by some cause or another, inclined backward; the muscles in front con- tract to bring it forward again ; tlie ex- tensors act on the patella; this breaks, and the fall ensues. A soldier broke his patella in endeavouring to kick his Serjeant; tiie olecranon has been broken in throwing a stone. A m,an, at the Hotel-Dieu, fractured both bones of his knee, in the operating theatre there, by the violent spasms of the muscles, which followed an operation for the stone. The force of the muscles occa- sionally ruptures the common tendon of tiie extensor muscles, or, what is more frequent, the ligament of the pa- tella. Petit, Desault, and Sabatier, have remarked these occurrences. The patella can only be broken longitudi- nally by outward violence. Here it is only necessary to treat of transverse cases. The symptoms are, a considerable separation between the two fragments of the bone, very perceptible to the finge*r, when the hand is placed on the knee. This separation is not occasion- ed equally by both portions ; the upper one, embraced by the extensor mus- cles, is drawn upward very forcibly by these powers, which the patella no longer resists. The inferior portion, being merely connected with the liga- ment below, is, on the contrary, not moved by any muscle, and can only be displaced by the motions of the leg, to which it is^ttached. Hence the sepa- ration is least when the limb is extend- ed, as it is then only produced by the upper fragment; greatest, when the limb is bent, because both pieces con- tribute to it;. and it may be increased, or diminished, by bending the knee more or less. The diagnosis is also made clearer, by the possibility of moving the two portions of bohe transversely, so as to cause a crepitus and pain. The swell- ing of the knee, apt to follow fractures of the patella, may, when very great, obscure the other diagnostic symp- toms. The difficulty of standing up, and the almost utter inability of walk- ing, in consequence of tlie extensors not being able to move the leg, unless the fracture be very low down, are other symptoms. The two grand indications, in the treatment of tiie fractured patella, are to overcome tiie action of the extensor muscles of the leg, and to keep this part immoveably extended. The lat- ter object is easily accomplished ; the first requires, that the contractile force ofthe muscles should be first lessened, so as to diminish the effort, wliich they make to draw up tiie superior portion of the bone, and then to oppose to them a mechanical resistance, which, ope- rating in a diametrically opposite di- rection, will render their efforts inef- fectual. The power of the muscles is to be diminished by relaxing their fibres,, which may easily be done, by bending the thigh on the pelvis, and extending the leg, and by compressing the mus- cles with a roller. With regard to the mechanical resistance, which must ope- rate directly against the contraction of the muscles, and prevent them from pulling upward the superior portion of the patella, it should consist of some- thing placed and maintained above it, with sufficient force to keep it from ascending. Desault used to set a fractured pa- tella as follows : one assistant fixes the pelvis, while another keeps the leg, completely extended on the tiiigh, and this on tiie pelvis. The surgeon, stand- ing on the side of the fractured limb, is to apply a longitudinal linen compress to tiie whole front ofthe leg and thigh, taking care to make two openings in it, corresponding with the sides of the pa- tella. This strip of linen is to be then fixed, by two or three turns of a roller, at the ankle ; its lower end then turn- ed up, and the roller also apphed over it. The circular bandage is next to be continued to just below the knee, when 352 FRACTURES. the surgeon is to push upward the low- er portion of the patella, apply two or three turns of the roller j ust below it, in order to fix it; desire an assistant to hold the roller, enjoin him, who has the care of the longitudinal piece of linen, to draw it up firmly, wliile the integuments are pushed in the same di- rection, lest they should sink between the two pieces of the bone. The fin- gers of the left hand are then to be in- troduced into the openings of the linen compress, for the purpose of pushing downwards the upper part of the pa- tella. The two pieces being in accurate contact, the surgeon takes the roller again ; carries it obliquely behind the ham, brings it up behind the upper part of the bone, withdraws his fingers, which served to keep it down, substi- tutes for them two or three moderately tight turns of the bandage, then covers the whole of the knee and thigh with the same. When arrived as high as the upper part of the limb, the assist- ant, who draws the longitudinal piece of linen forcibly upwards, is to turn down its ends over the circles of the roller, with a few turns of which it is then to be fixed. The bandage is then to be applied round the limb down to the ankle, where its application is to end. The separation of the lower frag- ment is further to be prevented by ex- tending the leg on the thigh, and the muscles relaxed by extending the lat- ter on the pelvis. Nothing keeps the leg more surely extended, than a long, strong splint, which Desault next ap- plied to the posterior part of the thigh and leg, and fixed there with a roller, while the tiiigh itself is to be bent by raising the whole limb, from the heel to the top of the thigh, with pillows, which, of course, must form a gradual ascent from the tuberosity of the is- chium to the foot. Desault used also to keep all the ap- paratus wet with the saturnine lotion. (Desault par Bichat.) The above method certainly fulfils every indication; and the chief trouble of the surgeon is to keep the bandages from becoming too slack. In this coun- try, practitioners overlook many little niceties of apparatus, which the French are, perhaps, too fond of, and, in the case of a fractured patella, trust to the roller, apphed with tolerable tightness, just above the upper piece of the bone. and then over the knee, in the form of a figure of 8, while the limb is kept in the above position, with a splint and pillows. The broken patella is almost always united by a ligamentous substance, in- stead of a bony one. Pott, and some others, thought, that there being com- monly an interspace afterwards be- tween the two pieces of tiie patella, with a certain length of tiie connecting substance might be advantageous in the motion of the joint; but Desault always noticed, that the greater the distance between the two pieces of the bone, the greater was the difficulty af- terwards in walking up a rising, or over an unequal ground. Fractures of both Bones of the Leg. These may be transverse or oblique. The longitudinal derangement is much less common than the horizontal or angular. In the former case, the infe- rior pieces are almost always drawn outward and backward, whilst the su- perior project internally and forward The angular derangement may be pro- duced either by the action of the pos- terior muscles of the leg, or the weight ofthe body, and in either case the an- gle will be salient anteriorly. The sa- lient angle may take place posteriorly, if the heel be too mucli raised. The derangement in the circumference ari- ses from the inclination of tiie foot in- ward or outward, but it most common- ly falls in the latter direction. The longitudinal derangement is extremely rare, and cannot easily take place in transverse fractures, on account of the considerable extent of the fractured surfaces ; but, in oblique fractures, the inferior pieces are almost always drawn upward by the action of the posterior muscles ofthe leg, in which position of the parts the lower ends of the supe- rior portions project anteriorly, and may be felt by the hand. Sometimes, however, when the solution of continu- ity is obliquely downward and outward, the anterior projection will be pro- duced by the lower pieces. In some cases, the pointed ends of the bones tear and penetrate the integuments in both kinds of derangement, so as to cause a compound fracture. The usual symptoms denoting a frac- ture of the leg, are, change of direc- tion and shape of the Umb, pain, and FRACTURES. 3.>3 incapability of motion, mobility of the fractured pieces, and a crepitus always distinct, &.c. Fractures, which take place near the knee, are not much subject to derange- ment, on account of the thickness of the bone in that part; but are, how- ever, more dangerous than those ofthe middle part, as being subject to be followed by a stiffness of the knee- joint. Fractures of the inferior part are still more dangerous. Oblique frac- tures are very difficult to be managed; and when tiieir derangement is upward and outward, the integuments are very apt to be torn by the projecting points ofthe superior portion of bone. (Boyer.) Fractures ofthe Tibia. If the fracture take place near the ankle, tiie great extent of the fractured surfaces prevents any considerable de- rangement of the fractured portions ; and the fibula acting as a support on the external side, contributes also to this effect. This circumstance renders a diagno- sis of fractures of the tibia often very difficult, and the difficulty is further increased by the httle pain and incon- venience produced by such a fracture, with wliich 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 examined. The fingers are to be moved along the anterior side of the tibia, the slightest inequality in which may be easily perceived, on ac- count 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 them in contrary directions. This motion, how- ever, and the crepitus which accompa- nies it, are very indistinct, on account of the fibula not allowing the fractured portions to be sufficiently moved on one another. (Boyer.) Fractures oj the Fibula. Sometimes the foot is turned forcibly inwards or outwards, in which case, the ligaments of the articulation are al- ways strained, and very frequently la- cerated. It is in a case of this kind, when the foot is forcibly turned out- wards, that the fibula is fractured by the pressure of the astragalus. We have given Pott's account of such ac- cident in the article Dislocation. vol. i. To the fractures, produced by this cause, are to be added those resulting from a fall, or a blow on the external side of the leg, in wliich the bone al- ways yields in tiie part to which the force is immediately applied. Whatever be the manner in which a fracture ofthe fibula is produced, the pieces are not susceptible of the longi- tudinal derangement; but are in all cases drawn a httle towards the tibia, by the muscles placed in the interval between them. Hence a fracture of this bone wjll be best ascertained by pressing the fractured portions inward. This symptom, and the consequent crepitus, may be also observed in the abduction and adduction of the foot. These signs are more evident when the fracture takes place near the ankle, than when it happens high up, where the bone is covered with thick mus- cles, (Boyer.) Treatment of Fractures ofthe Leg. As in cases of fractured thighs, the practitioner may adopt either a bent or straight position of the limb. In this country, surgeons mostly follow Mr Pott's advice, and select the first one, of which alone I shall treat. " In the fracture of the fibula only, the position is not of much consequence; because by the tibia remaining entire, 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 of the knee, in a moderately bent position, does not ren- der it so incapable of flexion and use afterward, as the straight or extended position of it does, and consequently that the patient will be much sooner able to walk, whose leg has been kept in the former posture, than he whose leg has been confined in the latter. " In the fracture of both tibia and fibula, tiie knee should be moderately bent, the thigh, body, and leg, being in the same position as in the broken thigh. If common splints be used, one should be placed underneath the leg, extending from above the knee to be- low the ankle, the foot being properly supported by pillows, bolsters, &c. and another splint ofthe same length should be placed on the upper side, compre- hending both joints in the same maoT ner; which disposition of splints ought always to be observed, as to their 45 354 FRACTURES. length, if the leg be laid extended in the common way, only changing the nominal position of them, as the pos- ture of the leg is changed, and calling what is inferior 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 in one of them a provision for the more easy support of the foot and ankle, by an excavation in, and a prolongation of the lower, or fibular splint, for the purpose of keeping the foot steady." (Pott.) The strong muscles of the leg being relaxed by placing the hmb in the bent position, as advised by Pott, the sur- geon 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 littie way from the surface of the bed, by taking firmly hold of the limb, above and below the fracture, and elevating 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 tliis moment, an assistant should put, exactly beneath the leg, the under splint, which has been previously got 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, before proceeding further, must once more observe that the ends of" the bones are evenly in contact. Being assured of tliis important point, he is to apply a piece of soap-plaster, and lay down the tails ofthe bandage. Another soft pad, well filled with tow, is next to be put over the upper surface of the leg, and over that the other splint, when the straps are to be tightened. Fractures ofthe Scapula. The acromion, inferior angle, neck, and coracoid process, are the parts most commonly fractured. When the acromion is broken, the weight of the arm, and the contraction of the deltoid "muscle, draw it downward, while the trapezius and levator scapulae draw the rest of the bone upward and backward. The serratus major anticus draws for- ward the lower angle, when this part is fractured, while the rest of the sca- pula remains in its natural situation ; or, if the angular portion be considera- ble, the teres major, and some fibres i ofthe latissimus dorsi, contribute to its : derangement forward and upward. The pectoralis minor, coraco-brachi- ; alis, and short heads of the biceps, i concur in drawing forward and down- , ward the coracoid process, when it is broken. (Boyer.) i When the neck ofthe scapula is frac- 1 tured, the weight of the arm makes it t drop down so considerably, as to give i the appearance of a dislocation ; but, l- the facility of lifting the os brachii up- i ward, the crepitus, and the falling of the limb downward again, immediately j it is unsupported, are circumstances t clearly marking, that the case is not u dislocation. Sometimes great pains, ; and a crepitus, are experienced, on f moving the shoulder-joint, after an ac- i cident ; and yet the spine, flat part of j the scapula, and all the above parts, are r not broken. In this circumstance, we ; may suspect either that a small portion rt ofthe head of theos brachii, or a littie i piece of the glenoid cavity of the sca- L pula, is broken oft'; which latter oc- t currence I think is not a very uncom- i mon one. i Fractures ofthe acromion are attend- i ed with pain, which is increased by the ; motion of the arm ; the form of the ; shoulder is changed; the broken part » which has descended, may be raised, : by bringing up the elbow close to the , side. (Boyer.) \ When the inferior angle is broken, ! the part remains motionless, while the L rest ofthe scapula is moved ; and it is so separated, that no mistake can be i made. (Boyer.) : Fractures of the spine and body of the bone, are all attended with acrepi- , tus ; and, in the first cases, an irregu- 1 arity in the course of the spine of the bone may generally be easily felt. TREATMENT. When the scapula is fractured longi- tudinally, 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 shoulder to the elbow. Thus the motions of the shoulder, which are only concomitant with those of the aim, are prevented. (Boyer.) When the inferior angle is broken, and drawn downward and forward by the serratus major anticus, the scapula must be pushed toward the fragment, FRACTURES. 355 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 possible, with compresses and a roller. The arm is to be supported in a sling. (Boyer.) The fractured acromion requires the arm to be so raised, that the head of the os brachii will push up the acro- mion, while an assistant pushes the scapula forward and downward, in a contrary direction to that of the 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 bandage, to make the head of the os brachii project more upWard, on bringing the arm near the side. -Com- presses are to be placed on the scapula, which, with this means, and a roller, are to be kept downward and forward. When the coracoid process is frac- tured, the muscles attached to it are to be relaxed, by bringing the arm for- wards towards the breast, and confin- ing it there in a sling; while the shoul- der is kept downward and forward, and a compress confined just under the broken part, with a roller. The treatment of a fracture of the neck of tiie scapula consists in raising the shoulder to its proper height; in completely taking off the weight ofthe arm, by wearing a proper sling-, which always supports the limb from the el- bow to the fingers ; and in entirely preventing all motion of the arm by binding it to the trunk with a roller. Fractures ofthe Clavicle. This bone being long and slender, unsupported at its middle, and pro- tected externally only by the integu- ments, is very often broken. Its serv- ing to keep tiie scapula at a proper distance from the sternum, and as a point d'appui for the os brachii, every impulse of which it receives, makes its fractures still more common. It may be broken at any part; but, its middle, where the curvature is greatest, is most frequently the situa- tion of the injury. It is not very often fractured at its scapulary 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 lacera- ted. A comminuted fracture may be thus occasioned, and, if the violence be very great, the subclavian vessels and nerves may be torn. The fall ofa heavy body on the shoulder often gives rise to a pa- ralysis 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 shall protrude through the skin. Fractures of this bone are usually attended with derangement ofthe bro- ken ends, except when the injury takes place at the scapulary extremity, and within the ligament, tying together the clavicle and coracoid process. The external portion of the clavicle is always that which is deranged. The internal part cannot be moved out of its natural situation, by reason of the costo-clavicular ligaments, and of its being drawn in opposite directions, by the sterno-cleido-mastoideus, and pec- toralis major, muscles. The external portion, drawn both by the weight of the arm, and the action ofthe deltoid muscle, and forward and inward by the pectoralis major, is carried under the internal portion which projects over it. The broken clavicle no longer keeping the shoulder at a due distance from the sternum, the arm falls forward towards the breast. The patient finds it impos- sible to put his hand to his forehead, because this act makes a semicircular 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 op- posite side. The motion ofthe pieces of bone on one another may be felt, as well as the projection ofthe end of the uiternal portion. When the shoulder is moved, a crepitus may also be per- ceived, but doing tliis is productive of great pain, and the diagnosis is so ob- vious, 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 patient was placed on a low stool, so that an assistant might put his knee between his shoulders, 3.-> (i FRACTURES. which he drew back at tlie same time with both hands, while the surgeon ap- plied the bandage which was to keep the parts in this position. But, in thus drawing the shoulders towards one an- other, the scapula is-obviously pushed towards the sternum, and with it tiie external portion of the clavicle, which passes under the internal one. The figure of 8 bandage has com- monly been used for maintaining the parts in this portion. Wliile the as- sistant keeps back the shoulders, as above described, tiie surgeon is to ap- ply one end of a roller to the armpit on the side affected, and then make it cross obliquely to the opposite shoul- der, round whicii it is to pass, and from this to the other shoulder, about whicii it is to be rolled in the same manner, and crossed afterwards re- peatedly before and behind. The tight- ness, with wliich it is necessary to ap- ply this bandage, produces a great deal of excoriation about tiie armpits, and the effect is to make the ends of the fracture overlap each other, the very thing which it is wished to avoid. Boyer remarks, that the iron-cross pro- posed by Heister, the corselet descri- bed by Brasdor in the Mem. de I'Acad. de Chir. and the leather strap recom- mended by Brunninghaussen, are only modifications ofthe figure of 8 ban- dage, and not at all better. Extension is to be made, by means of t he limb, whicii is articulated with the fractured bone. This is done by con- verting the humerus into a lever, by carrying its lower end forward, inward, and upward, pushing the shoulder backward, upward, and outward, and putting a cushion in the armpit to serve as a fulcrum. Desault used to put in the armpit a hair or flock cushion, five or six inches long, and three inches and a quarter thick at its base. Two strings are at- tached to the corners of the base, pla- ced upward, whicii cross the back and breast, and are tied on the shoulder of the other arm. The cushion being thus placed in the armpit, and the fore- arm bent, Desault used to take hold of the patient's elbow, and carry it for- ward, upward, and inward, pressing it forcibly against the breast. By this manoeuvre, the humerus carries the shoulder outward, the ends of the frac- ture 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 yards long, is to place one end of it in the armpit ofthe opposite sidi«, and thence apply the bandage over the upper part ofthe arm, and across the back to the same situation. The arm and trunk are to be covered with such circles of tiie roller, as far down as the elbow, draw- ing the bandage more tightly, the low- er it descends. Compresses, dipped in camphorated spirit, are next to be placed along the fractured bone. Desault then used to take a second roller, ofthe same length as the first, and put one end of it under the opposite armpit, whence it was carried across the breast over the com- press and fracture, then down behind the shoulder and arm, and, after hav- ing passed under the elbow, upward on the breast. Desault 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, carri- ed it down in front of the shoulder and arm, under the elbow, and obliquely behind the back to the armpit, where the application began. The same plan is repeated, until all the roller is spent. The apparatus is to be secured by pins, wherever they promise to be useful, and the patient's hand is to be kept in a sling. Boyer has invented an apparatus for fractured clavicles, which is more sim- ple, than that employed by Desault. The cushion is to be applied under the arm. The apparatus consists of a girdle of linen cloth, which passes round the trunk on a level with the el- bow. 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 tiie arm. On tiie lower part ofthe arm, is to be laced a piece of quilted cloth, five or six fingers broad. Four straps, are attached to it, which correspond to the buckles on the outside of the gir- dle, and serve both to keep the arm close to the trunk, and from moving either backward or forward. (See Boyer's Lectures upon Diseases of the Bones.) Certainly, the methods recommend- by Desault and Boyer are very judici- FRACTURES. 357 ous and scientific. They are not, how- ever, much adopted in this country, perhaps in consequence of the univer- sal aversion among English surgeons to all apparatuses, which are not ex- ceedingly simple. It is to be hoped, at the same time, that, in the treatment of fractured clavicles, they will always attend to the principles, which Desault and Boyer have inculcated. If they understand, why the position of the arm should be such as these eminent surgeons point out, they will have no difficulty in doing what is proper, and with a cushion sling, and a couple of rollers, they will easily maintain the proper posture. I cannot quit this subject without cautioning the surgeon never to fall in- to the error of supposing the rising end ' of a broken clavicle to be the end whicii is displaced. This is the one whicii is truly in its right situation, and which has often been made, by injudicious pressure, to protrude through the in- teguments, as I myself have seen. FRACTURES OF THE OS BRACHII, OR HUMERUS. This bone may be fractured in any point of its length; in the middle, at either extremity, or above the insertion of the pectoralis major, latissimus dor- si, and teres major. This last case is termed fracture of the neck of the hu- merus ; but that denomination has not the merit of being strictly anatomical. It is possible, however, that what is strictly called the neck of the humerus may be fractured, particularly, by a gun-shot wound. By neck of the hume- rus, we understand that circular nar- rowing, which separates tiie tuberosi- ties from the head. The fractures of this bone may be transverse or oblique, simple or com- pound. In short, whatever has been said of the differences" of fractures in general, is applicable to these in parti- cular. The same may be said of the causes, whether acting on the extremi- ties of the bone, or immediately on the part fractured. The transverse fractures ofthe mid- dle part, under the insertion ofthe del- toid muscle, are attended with but a trifling derangement. The brachialis internus and the triceps, attached pos- teriorly and anteriorly to both fractu- red portions, counteract one another, and admit only a slight angular de- rangement. When the fracture takes place above the insertion ofthe deltoid muscle, the inferior portion is first drawn outward and then upward on the external side of the superior. Frac- tures of the humerus, near its lower end, such particularly as are transverse, are not subject to much derangement: an effect which is to be attributed to the breadth of the fractured surfaces ; to their being covered posteriorly by the triceps muscle, and, anteriorly, by the brachialis interior, whicii admit only a slight angular derangement by the inferior portion being drawn a Httle forward. Oblique fractures are always attend- ed with derangement, whatever be the part fractured. The inferior portion being drawn upward by the action of the 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 always attended with derangement, which is produced by the action of the pectora- lis major, latissimus dorsi, and teres ma- jor, which being attached to the lower portion near its superior extremity, draw it first inward and then upward, in which last direction it is powerfully aided by the biceps, coraco-brachialis, and long portion of the triceps. The superior portion itself is, in this case, directed a little outward by the action of the infraspinatus, supraspinatus, and teres minor, which make the head of the humerus perform a rotatory mo- tion in the glenoid cavity. We proceed to examine the different marks, by which these fractures may be ascertained. The shortening and change in the direction of the limb, the crepitusi which may be very distinctly perceived by moving the broken pieces in oppo- site directions, the pain, and impossi- bility of moving the arm, &.c. joined to the history of the preceding circum- stances, render it easy to establish a diagnosis. Fractures ofthe neck of the hume- rus are not so easily ascertained, and have been frequently, for want of at- tention, confounded with luxations, of that bone. The diagnostic symptoms of these two affections are however very different. When tiie neck of the humerus is fractured, a depression is observed at tiie superior extremity and external 358 FRACTURES. side ofthe arm, whicii is very different from that accompanying tiie luxation downward and inward of that bone. In the latter case, under tiie projection of the acromion, a deep depression is found in the part which the head ofthe humerus naturally occupies ; whereas, in the 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, in examining the armpit, instead of finding there a round tumour formed by the head of tiie humerus, the fractured and une- qual extremity of that bone will be easi- ly distinguished. The motion of the broken portions, and the crepitus, which may be produced by moving them, serve still further to establish the diagnosis. (Boyer on the Bones, Vol. 1.) A simple fracture ofthe body ofthe humerus is not very dangerous: in that near the ends of the bone, there is some reason to expect the neigh- bouring joint to inflame, and remain stiff* for some time after tlie cure. In ordinary fractures of the os bra- chii, it is usual to apply two pieces of soap-plaster, which together surround the limb, at the situation where the ac- cident has happened. Extension, if necessary, being now made by an as- sistant, who at once draws the lower portion of the bone downward and bends the elbow, the surgeon is to ap- ply a roller round the limb. The ex- ternal splint is to extend from the acro- mion to the outer condyle, and, being lined with a soft pad, the wood cannot hurt the limb by pressure. The inter- nal splint is to reach from the margin of* the axilla to a little below the inner condyle, and is to be well guarded with a pad, filled with tow, or any other soft materials. Some surgeons are content with the application of two splints ; but, though the two, above described, are those on which we are to place the greatest re- liance, yet, as the cylindrical form of the arm conveniently allows us com- pletely to incase this part of the limb in splints, I shall always be an advocate for the employment of four ; one on the outside, one on 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 tapes. (See First Lines of the Practice of Surgery, p. 527.) The elbow and whole of the forearm are to be quietly ahd effectually sup- ported in a sling, throughout the treat- ment of tlie case. FRACTURE OF THE HEAD, OR NECK OF THE OS BRACHII. 1. General Considerations. Chirurgical language here differs from that adopted by anatomists, and, under the name of fracture of the neck of the humerus, is not meant, that of the circular, hardly perceptible de- pression, which separates the head from the tuberosities of this bone. By this expression, surgeons imply the fracture of" that contracted part of the humerus, which is bounded above by these tuberosities, whicii below is con- tinuous with the body of the bone ; which has the tendons ofthe pectoralis major, latissimus dorsi, and teres ma- jor inserted below it; and which many practitioners extend even as low as the insertion of the deltoid muscle. Indisputable facts, however, prove the possibility of the anatomical neck of the bone being fractured, and C. Larbaud shewed Bichat the humerus of a young man, aged 17, the head of whicii bone was accurately detached from its body, by a division whicii had obliquely interested the upper part of the tuberosities. But there are too few instances of this kind, in the re- cords of* surgery, to admit of our tak- ing a general view of this sort of fracJ ture." 2. Varieties and Causes. The operation of external bodies, active, when driven against the shoul- der, passive, when the shoulder or arm is driven against them, is the constant cause of the fracture of the neck of the humerus. The solution of conti- nuity, thus occasioned, is sometimes direct, and at other times, the result of a contre-coup. The first almost always arises from a fall on the fleshy part of the shoul- der, and, as the motion must be ex- ceedingly violent to produce this ef- fect through the thick covering form- ed by the deltoid, tliis muscle is some- times contused and affected with ec- chymosis. Even blood may be effused from some of the ruptured articular veins, or arteries, and form a collec- FRACTURES. :.?9 tion, which Desault has remarked should be speedily opened.* The counter-fracture arises from a fall on the elbow, when this part is se- parated from the trunk, or else from a fall on the hand, whicii a natural in- stinct makes us extend, with the arm and forearm, to protect ourselves at the time of falling. 3. Symptoms, &c. The whole of the symptoms of a fracture of the neck of* the humerus sufficiently denote its existence; but, it is not always an easy matter to see this whole, and here more difficulties occur in the diagnosis, than in any other fracture of the humerus. There is an acute pain experienced at the moment of the fall; sometimes, tlie noise of something breaking is heard. There is always a sudden in- ability to move the limb, which, left to itself, remains motionless. But, on ex- ternal force being applied to the mem- ber, this readily yields, 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 dislocation. Below the acromion a depression is remarkable, always situated lower down, than that which attends the latter accident. If we place one hand on the head, while the lower part of the bone is moved in various directions with the other hand; or if, while ex- tension is made, an assistant commu- nicates to the bone a rotatory motion, the following circumstances are per- ceived; 1. We discover, that the head of the humerus remains motionless. 2. A more or less distinct crepitus, arising from tlie two ends of the frac- ture rubbing against each other. These two symptoms are invariably charac- teristic of the accident; but the swell- ing of the joint sometimes prevents us from detecting them. The ends of the fracture are some- times not at all deranged, and, as then most ofthe symptoms are absent, the diagnosis is rendered still more diffi- cult. In general, however, 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 ex- tent, and is not acted upon by many muscles. The displaced state of the fracture is, generally, not very perceptible, in regard to length, unless the fracture be very oblique, and its pointed spi- cule irritate the muscles, and make them contract with increased power; or unless the blow, wliich is very vio- lent, continue to operate after the bone has been broken, and force the ends of the fracture from their state of apposi- tion. In this way, the body ofthe bone has been known to have been drawn or driven upward, so as to protrude through the deltoid muscle, and inte- guments far above the height of the head of the bone. But commonly, as Petit observes, the weight of the limb powerfully resists the action of the muscles, and the de- rangement of the fracture is more lia- ble to be transverse. In this circum- stance the lower,end of the fracture is displaced outward or inward, and very rarely in any other direction. In the latter case, which is much the more frequent, the elbow is separated from the trunk, and cannot be brought near it without pain ; in the instance of the bone being displaced outward, the limb has a tendency to the opposite direc- tion. 4. Prognosis. A fracture of the neck of the hume- rus is not a serious event, and if, as Heister remarks, prope caput, fractura pejor, et dijicilius curatur, it is less on account of the nature and situation of the disease, than of the difficulty expe- rienced in maintaining the ends of the fracture in contact. 5. Reduction. This object usually presents but few difficulties, and the multiplicity of means formerly employed for its ac- complishment, serve only to exhibit the uselessness of such resources. Most of the machines, designed for reducing dislocations of the humerus, have been applied to this kind of frac- * I must enter my protest against such practice, however; both because I have observed that large extravasations of blood about the shoulder are usually very coon absorbed, and making an opening may do harm, and cannot do good. 360 FRACTURES. ture. To such machines succeeded the use of pulleys, weights suspended to the hmb, &c. useless plans, as their only tendency was to increase the na- tural power, wliich was always more than sufficient. Petit proposes to reduce the frac- ture, by first placing the arm at a right angle with the body'; and then making extension with the hands of an assist- ant, applied above the elbow; while the counter-extension is made by ano- ther assistant, who is to take hold of the fleshy part of the shoulder. This method is liable to three kinds of in- conveniences. It fatigues and even pains the patient; it lessens the extend- ing powers by bringing them near the moveable point; it irritates such mus- cles as proceed from above to the lower end of the fracture, and thus increases their disposition to contract Hence difficulties sometimes attended the re- duction, which is always simple, when, the trunk being fixed, gentie extension is made on the fore-arm half bent. De- sault used to accomplish the reduction in the following way : The patient may either sit upon a chair, or tiie 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 ofthe opposite side. This mode of making extension is preferable to that common- ly employed, and which is effected by applying the hands to the upper part of the affected shoulder. The other be- ing more distant from the resistance, there is no need for exerting so much power ; and the patient's body being quite uncovered, the surgeon can con- veniently apply the bandage, without deranging Jhe extension. A second assistant extends tlie 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, applied 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 resist- ance. The relaxation of muscles, produced by the half flexion of the fore-arm, and the position of the arm a little raised from the side, are peculiarly favourable to this mode of extension, recommend- ed by the ancients and English. This method has also the advantage of leav- ing uncovered every part of the limb, to which the apparatus is to be applied, and thus the assistant's hands can re- main in the same position during all the time of applying whatever may be needed. In this way the reduction takes place of itself, on employing a very little force, methodically directed, accord- ing as the fracture is displaced inward or outward. If the surgeon put his hands on the situation of the fracture, it is rather to examine the state of the ends of the broken bone than to accom- plish a thing seldom required, namely, what is implied by the term coaptation. MEANS OF MAINTAINING THE RK- DUCTION. All the apparatus for a fracture be- ing only resistances, opposed by art to the powers causing the derangement of the broken 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 mobi- lity ofthe arm and shoulder ; 2. Of the action of the latissimus dorsi, pectora- lis major, and teres major, which draw inward the lower end of the fracture, or, what is more common, of the del- toid, which pulls it outward ; 3. Of the contractions ofthe muscles ofthe arm, which tend to draw a little upward the said end ofthe fracture. Hence, 1. to render the arm and shoul- der immoveable; 2. to bring either out- ward, or inward, the lower end of the fracture ; 3. to draw downward the same ; are the three indications, wliich every bandage, destined for a fracture of the neck of tiie humerus ought to fulfil. The last object merits less at- tention, 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 fractures of the neck ofthe humerus. 1. Two bandages, one about five or six ells long, the other eight or ten; both being about three finger-breadths wide. 2. Three strong splints, of dif- ferent lengths, and two finger-breadths broad. 3. A linen pillow, three or four inches thick at one of its ends, termi- nating at the other in a narrow point, and long enough to reach from the ax- ula to the elbow. 4. A shng to support* FRACTURES. 361 tiie fore-arm. 5. A towel to cover the whole ofthe 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 aq. veg. min. and is to fix one of its heads by applying two circular turns to the upper part of the fore-arm. The bandage is now to be rolled moderately tight round the arm upward, making each turn overlap two-thirds of that which is immediately 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 the inequality of the part would create. The bandage is af- terwards to be carried twice under the opposite axilla, and the rest of it, rolled up, is to be brought up to the top ofthe shoulder, and committed 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 se- cond, on the outside from the external condyle to the same height. The third, behind, from the olecranon to the mar- gin of the axilla. The pillow, inter- posed between the arm and thorax, serves as a fourth splint, which becomes useless. 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 ofthe remainder of the ban- dage. The surgeon takes hold of tiie ban- dage again, and applies it over the splints with moderate tightness, and the bandage ends at the upper part of the fore-arm, where it began. The assistants continually keeping up the extension, the surgeon is to place the pillow between the arm and trunk, taking care to put the thick end up- ward, if the fracture be displaced in- ward; but downward, if this should be displaced outward, which is most com- mon. It is to be attached by two pins to the upper part ofthe roller. The arm is to be brought near the trunk, and fixed upon tiie pillow, by means of the second roller, applied round the arm and thorax. The turns of tliis bandage should be very tight below, and rather slack above, if the fracture should be displaced inward; but, if outward, they should be slack below, and tight above. VOL. II. The fore-arm is to be supported in a sling, and the whole of the apparatus is to be enveloped in a napkin, which will prevent any friction from derang- ing the bandages. If we compare the effect of the above apparatus in fulfilling the indications above specified, we shall easily see, that they are very well accomplished. The arm, firmly fixed against the trunk, can only move with it, and then nothing displaces the lower end of the fracture, which is equally motionless. The shoulder cannot communicate any mo- tion to the upper end of the fracture. The pillow, differently disposed, ac- cording to the direction, in which the lower extremity of the fracture is dis- placed, serves to keep this part in the opposite position. Should this part of the bone project inward, the thick end ofthe pillow will remove it further from the chest. The bone will be kept at this distance from the side by the turns of the bandage, whicii being very tight downward, will act upon the limb as a lever, the fulc- rum for whicii will be the pillow, and the resistance, the action of the pecto- ralis major, latissimus 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 fracture 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 outward, whicii is most com- monly the case, the contrary effect will be produced, both from the pressure exercised by the bandage on the upper end of the displaced portion of the bone, and from the situation of the el- bow, which is kept outward by the thick part of the pillow. The outer splint will also prevent the lower end of the fracture from being displaced outward, both by its mechanical resist- ance to the bone, and by compressing the deltoid muscle, which is the chief cause ofthe derangement in this direc- tion. All derangement of the lower end of the fracture, forward or backward, is prevented by the front and back splints. All derangement in regard to length, already prevented by the weight ofthe limb, is still more effectually hindered by the compression exercised on the muscles of the arm, causing such de- 46 362 FRACTURES. rangement both by the splints and roller.* FRACTURES OF THE LOWER END OF THE OS BRACHII, WITH SEPARA- TION Of THE CONDYLES. Tractures ofthe os brachii, with de- tachment of its condyles, seem to have escaped the notice of most authors, who have written on the diseases of the bones. The ancients have transmitted to us nothing upon the subject. Heis- ter only mentions the fracture of the lower end of this bone, with a view of making an unfavourable prognosis. This accident is not uncommon, and Desault, in particular, had frequent occasion to meet with it. Whatever the cause of this kind of fractures may be, they are commonly produced in such a way, that a longi- tudinal division separates the two con- dyles from each other, and, extending more or less upward, is bounded by another transverse, or oblique division, which occupies the whole thickness of" the bone. Hence, there are three dif- ferent pieces of bone, and two frac- tures. Sometimes the division is more sim- ple. Then, taking a direction outward, or inward, it crosses obliquely down- ward the lower end of the os brachii, terminates in the joint, and only de- taches one ofthe condyles from the bo- dy of the bone. The other remains continuous with it. In the first case, the deformity is greater, and the fractured part is more moveable. When pressure is made, either before, or behind, on the track of the longitudinal fracture, the two condyles becoming further separated from each other, leave a fissure be- tween them, and the fractured part is widened. The fore-arm is almost al- ways in a state of pronation. On taking hold of the condyles, and moving them in different directions, a very 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 bro- ken, Desault found the limb always supine : a position, in effecting which, the muscles inserted into this part are, doubtless concerned. An acute pain, the almost inevitable effect of bending, or extending, the fore-arm; the habitual half-bent state of this part ofthe limb, and sometimes a subsequent swelling of it, together with more or less tumefaction around the joint, are observable in both kinds of cases. These accidents may also be complicated with wounds, splinters of bone, &c. when the blow has been very violent, or a pointed piece of the bone protrudes through the flesh. PROGNOSIS. Almost all writers consider tlie com- munication of" a fracture with a joint, as a fatal kind of complication. Swell- ing and inflammation of the adjacent parts; continuance of pain after the reduction; large abscesses; even mor- tification of the soft parts, and caries of the bones, are, according to such au- thors, the almost inevitable consequen- ces of these fractures, and anchylosis the most favourable termination. Pare", Petit, Heister, Duverney, all give this exaggerated picture of these accidents. Analogous fractures ofthe olecranon and patella shew, that this representa- tion is magnified beyond truth. Mo- „ dern observation has dispelled the an- cient doctrine of the effusion of callus in the joint, and with it one ofthe prin- cipal causes, assigned by authors for the symptoms they so much dread. The communication ofthe cavity of the joint with the external air might here indeed, have more real influence ; this can only occur in compound frac- tures. Desault has often learned from experience, that the contact of air is not so dangerous, as has been suppo- sed. The defect in the mode of treatment was, formerly, the general cause of all the ill consequences. Desault has ne- ver seen them in his extensive prac- tice. r REDUCTION, AND MANNER OF MAIN- TAINING IT. The detached condyles, being drawn in opposite directions by the muscles ofthe arm and fore-arm, commonly re- main unmoved between these two pow- * See CEuvres Chirurgicales de Desault. Par Bichat. Tome 1. FRACTURES. 363 ers, and are but little displaced. Ex- ternal force may, however, put them Out of their proper situation, and they may then become displaced forward, or backward, or they may separate from each other sideways, leaving an interspace between them. The appa- ratus, should, therefore, resist them in these four directions, and this object is easily accomplished by means of four splints, kept on by a roller. The two lateral splints are, in particular, neces- sary, when the condyles are separated from the body of the bone, with an in- terspace between them. If one of them be still continuous with the humerus, tiie splint on this side will be of less use. There is no occasion for the appa- ratus to 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 the body of the bone, so much above the injury? Their only utility would consist in restraining the action of the brachialis and triceps, by compressing these muscles. On the other hand, the roller should be continued over tiie fore-arm, in or- der that the joint, according to the ju- dicious precept of Paulus JEgineta, may correspond to the middle of the ban- dage, wliich is here firmer, than any where else. This method is also of use by producing a gentie compression on the muscles implanted into the con- dyles. Desault recommends having the front and back splints flexible at their middle part, which should be applied to the bend of* the arm and elbow.* Tlie detail of the reduction of the fracture, and application of the roller and splints, becomes useless after what has been said. A further account may be found in the work mentioned at the bottom of the page. FRACTURE OF THE FORE-ARM. The fore-arm is much more frequent- ly broken, than the arm, because ex- ternal force operates more directly up- on it, than the latter part, especially, in falls, on the hands, which are fre- quent accidents. Bichat mentions, hi his account of Desault's practice, that fractures ofthe fore-arm often held the first place in the comparative table of such cases, kept at the Hotel-Dku. We know, that the fore-arm is com- posed of two bones, the ulna and radi- us. The last is much more liable to fractures, than the first one, because it is articulated with the hand by a large surface. All the shocks, received by the latter part, are communicated to the radius. The situation of this bone more immediately exposes it to such causes, as may break it; a circum- stance, whicii we may readily convince ourselves of on the first inspection. Both bones ofthe fore-arm may be bro- ken at the same time, or one alone may- be fractured One fracture has been absurdly termed complete ; the other, incomplete. FRACTURES OF BOTH BONES. These may occur at the extremities, or middle of the fore-arm. They are frequent at the middle; very common below ; but, seldom happen at tiie up- per part of the fore-arm, where the nu- merous muscles, and the considerable thickness of the ulna, resist causes, wliich would otherwise occasion the accident. The bones are usually bro- ken in the same line; but, sometimes, in two different directions. The frac- ture is almost always single; but, in some instances, it is double, and De- sault, in particular, was one day called to a patient, over whose fore-arm the wheels of a cart had passed, so as to break the bones, at their middle and lower part, into six distinct portions. The middle ones, notwithstanding they were quite detached, united very well, with hardly any deformity. These accidents are most commonly occasioned by direct external violence; but, occasionally, they are produced by a counter-stroke, which is generally the case, when the patient has fallen on his hand. But, in tliis instance, as tlie band is principally connected with the lower broad articular surface of the radius, this bone alone has to sustain almost the whole shock of the blow, and hence is usually the only one bro- ken. * OZuvres Chirurgicales de Desault. Par Bichat. Tome 1. 364 FRACTURES. SYMPTOMS. It is, in general, difficult to be de- ceived by the symptoms, indicating fractures ofthe fore-arm. Motion at a 5>art ofthe limb, where it was previous- y inflexible; a crepitus, almost always easily felt; sometimes a distinct de- pression in the situation of the fracture; a projection of the ends ofthe fracture beneath the skin, but, a less common symptom; pain produced by moving the part; a noise sometimes audible to the patient at the moment of the acci- dent; an inability to perform the mo- tion of pronation and supination ; and an almost constant half-bent state of the fore-arm; are the symptoms, which, with the phenomena, common to all other fractures, characterize this one. These are sufficient to dispel all doubts, which immense swelling of tiie limb may create. 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 de- formity, will discover whether the cause be a fracture, or dislocation. In a fracture the part is also more move- able, and there is a crepitus.* As Boy- er remarks, the two cases may be dis- tinguished by simply moving the hand, by which motion, if tliere be a luxation without fracture, the styloid processes ofthe radius and ulna will not change their situation; but, if a fracture do ex- ist, these processes will follow the mo- tion ofthe hand.-j- The connexion of the two bones of the fore-arm, by the interosseous liga- ment, which occupies the interval by whicii they are separated, and the man- ner, in which the muscles which are attached to both, are inserted into them, render the derangement of the broken pieces in the longitudinal direction ve- ry difficult; and, in reality, a derange- ment in this direction has been seldom observed, and never to any considera- ble degree: when it does take place, it is to be ascribed to the cause of the fracture, rather than to muscular con- traction. The derangement in the di- rection of the diameter, oft the contra- ry, always takes place in such a man- ner, as that the four pieces approach one another, and the interosseous inter- val diminishes, or is entirely oblitera- ted at that part near the seat of the fracture; which approximation at the ends of the bones causes an evident deformity of the part. To this must be added the angular deformity, which the fracturing cause always produces, cither forward or backward, according to its direction. Boyer gives the following account of the treatment of a fracture of" the fore- arm, both bones being broken. In order to adjust a fracture of these bones, the fore-arm is to be bent to a right angle with the arm, and the hand placed in a position between pronation and supination. The fore-arm and hand being thus placed, an assistant takes hold of the four fingers of the patient, and extends the fractured parts, while another assistant makes counter-exten- sion by fixing the humerus with both his hands. By these means, the opera tor is enabled to restore the bones to their natural situation, and to push the soft parts into the interosseous space, by a gentle and graduated pressure on the anterior and posterior sides ofthe arm Coaptation is very easy in frac- tures of these bones, as are indeed all the other parts of the operation, in which effort and violence are not at all required. The fracture being thus set, the bones are kept in tiieir place by apply- ing first on the anterior and posterior sides ofthe fore-arm two longitudinal and graduated compresses, the base of which is to be in contact with the arm. The depth of these compresses should be proportioned to the thickness of the arm, increasing as the diameter ofthe arm diminishes. In the next place, the surgeon takes a bandage about six yards long rolled up in one, and makes three turns of it on the fractured part, descends then to the hand by circles partially placed over one another, and envelopes the hand by passing the ban- dage between the thumb and index : the bandage is then carried upward in the same manner, and reflected wher- ever the inequality of the arm may ren- der it necessary. The compresses and bandage being thus far applied, the surgeon lays on two splints, one ante- * QZuvres Chirurgicales de Desault. Par Bichat. Tome 1. | Boyer on Diseases of the Bones. Vol. 1. FRACTURES. 365 riorly the other posteriorly, and passes the part of the bandage that yet re- mains over them, in such a manner as entirely to cover them. It may not be unnecessary to remark, that the com- presses and splints should be of the same length as the arm. It would be useless to employ lateral splints in this case, unless (what is scarcely ever to be expected or met with) a derange- ment should have taken place in that direction. It is evident, that lateral splints would counteract the compress- es and two other splints, by increasing the radio-cubital diameter of the arm, and by concurring with the action of the pronatores to move the pieces into the interosseous space. The surgeon's attention should be most particularly directed to preserve the interosseous space ; for, if this be obliterated, the 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 man- ner as that the fleshy parts may be for- ced into, and confined in, the interosse- ous space, and by renewing the ban- dage every seven or eight days. If tlie fracture be simple, and the contusion inconsiderable, the patient need not be confined to bed ; he may be allowed to walk about with his arm in a sling.* OF FRACTURES OF*THE RADIUS. Of all fractures of the fore-arm, this is the most frequent. The radius being almost the sole support of the hand, and placed in the same line with the humerus, is for both these reasons more exposed to fractures, than the ulna. Fractures of the radius, whether transverse or oblique, near its middle part or extremities, may be caused by a fall or blow on the fore-arm, or, as happens in most cases, by a fall on the palm of the hand. When likely to fall, we extend our arms, and let the hands come first to the ground; in which case, the radius, pressed between the hand on the ground, and the humerus, from which it receives the whole mo- mentum 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 a difficulty of performing the motions of pronation and supination supervene, the probability of a fracture of the ra- dius is very strong. The truth is fully ascertained by pressing with the fingers along the external side of the fore-arm. Also, in endeavouring to perform supi- nation or pronation of the hand,, a cre- pitus and a motion of the broken por- tions will be perceived, if the bone be in reality fractured. When the fracture takes place near the head of the radius, the diagnosis is more difficult on ac- count of the depth of soft parts over the bone in that part. In this case, the thumb is to be placed under the exter- nal 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 po- sitions. If in these trials, always pain- ful, the head of the bone rests motion- less, there can be no doubt of its being fractured. The causes of derangement are here the same as in fractures ofthe fore-arm, and it can never take place, except in the direction ofthe diameter of the bone, and is effected principally by the action of the pronating muscles. The ulna serves as a splint in fractures ofthe radius ; and the more effectually so, as these two bones are connected with one another throughout their whole length. Notwithstanding the evident mechanism, which prevents the longi- tudinal derangement, J. L. Petit has thought that derangement possible.f When only the radius is fractured, no extension is ordinarily requisite. During the treatment the elbow is to be bent, and the hand put in the mid state, between pronation and supination; that is to say, the palm of the hand is to face the patient's breast. Having re- duced 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 utility; but it makes the limb seem to the unknowing by-standers more comfortable, than if it were omit- ted, and, as it does no harm, the sur- geon may honestly apply it. However, no one can doubt, that tight bandages may act very perniciously in fractures ofthe fore-arm, by pressing the radius * Boyer on the Diseases of the Bones. "Vol. 1. ■f See Boyer on the Diseases of the Bones. Vol. 1. 366 FRACT and ulna together, causing them to grow to each other, or, at all events, making the fracture unite in an exceed- ingly uneven manner. Only two splints are necessary ; one is to be placed along the inside ; the other along the outside ofthe fore-arm. Soft pads must always be placed between the skin and the splints, in order to obviate the pres- sure of the hard materials, of which tiie 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, af- ter having had their fingers kept, for several weeks, in a state of perfect ex- tension, have been a very long time in becoming able to bend them again.* Sometimes, it may be proper to ap- ply a compress just under the ends of the fracture to prevent their being de- pressed towards the ulna too much, the consequence of which has occasion- ally been the loss of the prone and su- pine motions of the hand. In setting a fractured radius, the hand should be inclined to the ulnar side of the fore-arm. OF FRACTURES OF THE ULXA. Fractures of this bone, less frequent than those of the radius, take place generally at its lower extremity, be- cause it is smaller and less covered at that part, than at any other. A frac- ture of tliis bone is almost always the result of a force acting immediately on the part fractured; as, for instance, when one falls and strikes the internal side of the fore-arm against a hard re- sisting body. On applying the hand, iudiciously on the inside of the fore- arm, this fracture is easily ascertained by the depression in that part, in con- sequence of" the inferior portion being drawn toward the radius by the action of the pronator radii quadratus. This derangement is in general less, than that which takes place in fractures of the radius. The superior portion of the cubitus remains unmoved, as has been well observed by J. L. Petit. In this case, the assistant who makes whatever little extension may be neces- sary, should incline the hand to the ra- dial 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 frac- tures of the bones of the fore-arm, and, particularly, in those which are near the head of the radius, a false anchylo- sis is to be apprehended, and should be guarded against by moving the el- bow gently and frequently, when the consolidation is advanced to a certain degree.f Fractures of the fore-arm always re- quire this part to be kept quietly in a sling. FRACTURES OF THE OLECRANON; The ancients seem to have been lit- tle acquainted with fractures of the ole- cranon, on which subject they have been quite silent, unless Paulus iEgi- neta alludes to it in the following pas- sage : Cubitus frangitur—circa partem ad cubiti gibbum. Even most of the moderns, Petit, Duverney, Bell, he. have not given a satisfactory account of such cases. The olecranon may be fractured either at its base, or its ex- tremity ; but, tlie first occurrence is the most frequent. The division is al- most always transverse, though occa- sionally oblique. The causes, produ- cing the accident, are, either the action of the muscles, which is a very uncom- mon one, or external violence, which is much more usual. With regard to symptoms, the con- traction of the triceps, being no longer resisted by being connected 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. Tliis inter- space is found situated at the back part of the joint, and it may be increas- ed, or diminished at will, by augment- ing the flexion of the fore-arm, and put- ting the triceps into action, or else ex- tending the limb. Another symptom, is the impossibility of spontaneously extending the fore-arm, the necessary effect of the detachment of the triceps from the ulna. The fore-arm is con- stantly half-bent, the biceps, and brach- ialis having no antagonists. The ole- cranon is, more or less conspicuously, drawn up higher, than the condyles of the os brachii, wliich latter parts, on the contrary, are naturally situated * First Lines of the Practice of Surgery, p. 528, 529. j See Boyer on the Diseases ofthe Bones. Vol. 1. FRACTURES. 367 higher, than the olecranon, when the fore-arm is half-bent. The upper piece of bone may be moved in every direc- tion, without the ulna participating in the motion. Besides these symptoms, we must take into the account, the con- siderable pain experienced, the crack sometimes distinctly heard by the pa- tient, and the crepitus frequently per- ceptible. The indications are to push down- ward the retracted portion of the ole- cranon, and to 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. Desault says, however, it should not be completely extended, as when the pieces 01 bone touch at their back part, they leave a vacancy in front, whicii is apt to be followed by an irregular callus, prejudicial to the fu- ture free motion of the elbow. Hence, this celebrated practitioner used to put the arm between the half-bent state and extension. This posture, however, would soon be changed, if permanent means were not taken to maintain it. Desault, with this view, was hi tiie ha- bit of applying a splint along tiie fore- part of the arm. But, position evi- dently only operates on the lower part ofthe olecranon, by approximating it to the upper one. The latter requires also to be brought near the latter, and fixed tliere, which is, doubtless, the most difficult object to effect, because the triceps is continually resisting. Desault used to adopt the following method : the fore-arm being held in the above position, tiie 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 exten- sion ofthe limb, might insinuate itself between the ends of the fracture, and consequently it must now be pulled up- ward 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 ap- plying it in the form of a figure of 8. A strong splint, a little bent, just before the elbow, is next to be 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. It is calculated, that, on an average, the olecranon becomes firmly united about the twenty-sixth day. (Desault par Bichat.) FRACTURES OF THE FINGERS. On this subject, we need only re- mark, that the treatment consists in applying a piece of soap-plaster, roll- ing 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 elbow well supported in a sling. For Fractures of the Cranium, see Head, Injuries of. [Before concluding this article, it is highly proper to remark, that fractures in the limbs, treated by any of the pre- ceding methods, in some instances, do not form a bony union, but leave at the place of fracture a free motion in all directions, and, in fact, a joint. This is a most serious evil, and completely destroys the usefulness ofthe hmb. In order to obviate the evil and produce a bony union of the parts, various reme- dies have been suggested and env ployed. " Whether the fractured portions have passed one another, or whether an ar- ticulation has been formed between the fractured surfaces, if the fracture has been already of several months dura- tion, the action of the fractured surfa- ces ought to be revived, by rubbing them forcibly one against the other, ih order to excite the degree of inflamma- tion necessary for the generation of cal- us. The fractured ends of the bones, having by this means acquired a dis- position favourable to their agglutina- tion, the apparatus should be reap- plied, the extension continued if neces- sary, and the treatment prolonged un- til the cure be complete. " If, notwithstanding these means, the pieces do not unite, there remains another and last resource, the cutting off of their extremities. This opera- tion is painful, terrifying, and of dubi- ous event. Its success, however, has been frequent enough to warrant the trial. It would be impracticable in frac- tures of the leg or fore-arm, on account of the difficulty of separating from the integuments the two bones of which each of these parts is formed, and on account of the numerous nerves and arteries wliich would be in danger of 368 FRA being wounded by the large incisions necessary for this operation, it is there- fore practicabk only in the femur and hu- merus, especially the latter." (Boyer.) Mr. Boyer proceeds to describe the manner of performing this operation, and relates a case in which it was done The fracture was in the middle of the humerus—The patient aged thirty-six. Gangrene came on, and he died on the sixth day'. In other cases, amputation has been performed. Mr. Hunter proposed ex- posing the cavity between the ends of the bone, and hoped that this would occasion the necessary degree of in- flammation. But a plan has been in- vented by Dr. Physick, which promises to supersede the horribly cruel and fa- tal operations hitherto in use, and to procure more effectually, than any ever proposed, the cure of those unfortunate patients, in whom the artificial joints are formed. In the Medical Repository, Hexade H. vol. 1. p. 122. is recorded a case of fracture, in which an artificial joint formed which was cured by this re- medy. The patient, Isaac Patterson, was admitted into the Pennsylvania Hospi- tal in December, 1802. " I had seen," says Dr. Physick, " in our Hospital, when a student, in 1785, a case simi- lar to this in every essential circum- stance, in which an incision was made down to the extremities ofthe fractur- ed bones, which were then sawed off, putting the parts into the condition ofa recent compound fracture. No bene- fit, however, was derived from this painful operation ; and some months afterwards the arm was amputated. This case had made a strong impres- sion on my mind, and rendered me un- willing to perform a similar operation. I therefore proposed to the medical gentlemen of the hospital, who attended in consultation, that a seton needle, armed with a skein of silk, should be passed through the arm, and between the fractured extremities of the bone, and that the seton should be left in this situation, until by exciting inflamma- tion and suppuration, granulations should arise on the ends of the bone, whicii uniting an ossifying, would form the bony union that was wanting. This operation, being agreed to, was per- formed on the 18th December, 1802, twenty months after the accident. Be- fore passing the needle, I directed the FR-C assistants to make some extenslm" hl the arm, in order that the setoni mig* be introduced as much ^ P0Shlb^,,,_e tween the ends of the bone Some lint and a pledget were »PPhedJ° ""J orifices made by the seton needle, ana secured by a roller. " The patient suffered very httle pain from the operation. After a few days, the inflammation (which was not great- er than what is commonly excited by a similar operation through the flesh in any other part) was succeeded by a mo- derate suppuration. The arm was now a- ga'in extended, and splints applied. The dressings were renewed daily for twelve weeks, during which time no amend- ment was perceived; but soon after- wards, the bending of the arm at the fracture was observed to be not so easy as it had been, and tiie patient com- plained of much more pain than usual, whenever an attempt was made to bend it at that place. From this time the formation of the new bony union went on rapidly, and on the 4th May, 1803, was so perfectly completed, that the patient could move his arm in all di- rections, as well as before the accident happened. On the 28th May, he was discharged from tlie hospital, perfectly well, and he has since repeatedly told me, that his arm is as strong as it ever was." Dr Phy&ick has since effected ano- ther cure in the same manner. The operation, however, failed in a case which occurred at Baltimore. Here the cause of" failure was, however, evi- dent: The seton remained in the arm but six weeks, and was removed in consequence ofthe patient's ill health. She was very old and sickly. Twelve weeks had elapsed in Patterson's case, before any symptom of amendment was perceived. A\ e would urge, to any surgeon who may be disposed to avail himself of this remedy, tlie propriety of continuing the seton at least twelve weeks.] The best modern works on Fractures are, Pott's Remarks on Fractures and Dislocations. Boyer's Lectures on Dis- eases of the Bones, trans, by Farrell. OZuvres Chirurgicaks de Desault par Bichat, Tom. 1. Parts of the Parisian Ltururgical Journal. FRiL'NUYI LINGUiE, (from frano, to curb.) Occasionally it happens, in infants, that their tongues are too close- ly tied down, by reason ofthe franum being too short, or continued too far FRA FUN 36? forwards towards the point. In the latter case, the child will not be able to use its tongue, w ith sufficient ease in the action of sucking, swallowing, &c. in consequence of the point being too much confined at the bottom ofthe mouth. Though this affection, how- ever, is not unfrequent, yet, it is much lesB common, than it is supposed to be -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 fact, it is only the smallness of the child's tongue, that prevents it from surround- ing the nipple, so as to enable it to suck with facility. Mothers also commonly- suspect the existence of such an erro- neous formation, whenever the child is long in beginning to talk. The reality of the case may always, however, be easily ascertained by ex- amining the child's mouth. In the na- tural state, the point of the tongue is always capable of being turned up- ward towards the palate, as the fraenum does not reach along about a quarter of an inch ofthe lower part ofthe tongue from the apex. But, in tongue-tied children, by looking upon one side, we may see tlie fraenum extending from the back part to the very point, so that the whole length of the tongue, from the back part to the very point, is tied down, and unnaturally confined in its motion. 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 car- ried more extensively backward, than is necessary, lest the raninal arteries should be cut; an accident, that has been known to have proved fatal. For the same reason, -the scissars, used for this operation, should have no points. (See Lotto's System of Surgery, Vol. 2.) FRAGILITAS, (from frango, to break.) Frugilitas Ossium. A morbid brittleness of the bones. The gelati- nous part of the bones, to which they owe their flexibility, may be so defi- cient in them, that they are capable of being broken by the slightest causes. The state of a bone, thus distempered, may be well conceived, from that of a calcined one. Boyer imputes the mollifies ossium to a deficiency of lime in their structure ; the fragilitas ossium to a deficiency of the soft matter naturally entering into vol 1 tlie texture of these parts. He states that a certain degree of the fragilitas ossium necessarily occurs in old age, because the proportion of lime in the bone naturally increases as we grow old, while that of the organized part diminishes. Hence it is, that the bones of old persons more easily break, than those of young subjects, and that they are longer of uniting again. In persons, who have long been af- flicted with cancerous diseases, the bones are said occasionally to become as brittle, as if they had been calcined. Saviard and Louis relate such cases. The latter mentions a nun, who broke her arm by merely leaning on a ser- vant ; and in the London Medical Jour- nal an account is given of a person, who could not even turn in bed with- out breaking some of his bones. The bones are said sometimes to be remarkably brittle in the latter stages of syphilis. In bad cases of scurvy, the bones oc- casionally become so brittle, as to be broken by the slightest causes, and do not grow together again. The fragilitas ossium of old age is incurable : 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.) FUMIGATION, (from fundgo ) Fu- migatio. In surgery, means any ap- plication in tlie form of a steam, or va- pour. FUNGUS, (from ylo(, a sponge.) Any sponge-like excrescence. Granu- lations are often called fungous ones, when they are too high, large, flabby, and unhealthy. FUNGUS HiEMATODES, (from fungus, and cupa., blood.) The Bleed- ing Fungus. Spongoid Inflammatkn. This disease has only been accurate- ly described of late years, having be- fore been generally confounded with cancer. The public are indebted to Mr. Burns, of Glasgow, for the first good account of it; and the subse- quent publications of Mr. Hey, of Leeds, and Mr. Freer, of Birmingham, have made us still better acquainted with the subject. It is perhaps 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 47 370 FUNGUS. very difficult to persuade a patient to submit to it. Fungus Hamatodes, is the name ap- plied to it by Mr. Hey. Mr. Burns has called it spongoid inflammations, from the spongy elastic feel, whicii pecu- liarly characterizes it, and whicii con- tinues even after ulceration takes place. The disease begins with a small co- lourless tumour, which is soft and elastic, if there be no thick covering aver it, such as a fascia; but other- wise is tense. At first, it is free from uneasiness; but, by degrees, a sharp acute pain darts occasionally through it, more and more frequently, and, at length, becomes incessant. For a con- siderable time, the tumour is smooth and even ; but, afterwards, it projects irregularly in one, or more points ; and the skin at this place becomes of a livid red colour, and feels thinner. In this place, it easily yields to pressure, but instantly bounds up again. Small openings now form in these projec- tions, through wliich is discharged a thin bloody matter. Almost immedi- ately after these tumours burst, a small fungus protrudes, like a papilla, and this rapidly increases, both in breadth and height, and has exactly the ap- pearance of a carcinomatous fungus, and 'frequently bleeds profusely. The matter is thin, and exceedingly fetid, and the pain becomes of the smarting kind. The integuments, for a little around these ulcers, are red, and ten- der. After ulceration takes place, the neighbouring glands swell, and assume exactly the spongy qualities of the pri- mary tumour. If the patient still sur- vive the disease in its present advanc- ed progress, similar tumours form in other parts of the body, and the patient dies hectic. After death, or amputation, the tu- mour is found to consist of a soft sub- stance, somewhat like the brain, of a grayish colour, and greasy appearance, with thin membrane-like divisions run- ning through it, and cells, or absces- ses, in different places, containing a thin bloody matter, occasionally in very considerable quantity. There does not seem uniformly to be any entire cyst, surrounding the tumour; for, it very frequently dives down betwixt the mus- cles, or down to the bone, to which it often appears to adhere. The neigh- bouring muscles are of a pale colour, and lose their fibrous appearance, be- coming more like liver, than muscle. The bones are always carious in the vicinity of these tumours. The distemper is sometimes caused by external violence, though in gene- ral there is no evident cause whatever. (Dissertations on Inflammation by J- Burns, Vol. 2.) Mr. Hey has given several cases of the fungus haematodes. If we notice the most particular circumstances, re- lative to one of these, it will suffice to inform our reader of the form, in which this terrible affliction has pre- sented itself in this gentleman's prac- tice. A young man, aged twenty-one, two years before applying to Mr. Hey, per- ceived a small swelling on the inside of the right knee, not far from the patel- la. This tumour was moveable, and did not impede the motion ofthe joint: it was not discoloured, but was pain- ful, 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 the size of an egg. The skin was now discolour- ed with blue specks, which he took to be veins. He could still walk with ease, and follow his business. Two months before his admission in- to the Leeds Infirmary, he met with a fall, and violently bent his knee, but did not strike it against any thing. The tumour began immediately to enlarge ; and, within a few hours, it extended half way up the inside of his thigh. About a fortnight after this accident, the skin burst at the lowest part ofthe tumour, and discharged some blood. A dark-coloured fungus, about the size of a pigeon's egg, here made its ap- pearance, and, a few weeks afterwards, the skin burst at another part of tiie large tumour, and some blood was again discharged. From the fissure arose another fungus, whicii had in- creased, in the course of the last week, to the size of a small melon, and now measures eight inches from one side of its base to the other. The base of the fungus frequently bled, especially, when the man allowed bis hmb to hang down. The whole tumour was now of an enormous size, being nineteen inches across, when the measure was carried over the last mentioned fungus. From its highest part in tiie thigh to the low- est part, just below the knee, it mea- sured seventeen inches, without in- FUNGUS 3H eluding the fungus. The base of the tumour at the knee, exclusive of that part, which ran up the thigh, measured twenty-four inches in circumference. The tumour was situated on the inner side ofthe limb, and was distinctly de- fined. The skin, covering the disease, was in some places livid, and had se- veral fissures and small ulcerations up- on it; but, had not burst asunder, ex- cept in the two places above described. The tumour was soft, and gave a sen- sation of some contained fluid, when gently pressed with the hands alter- nately in opposite directions. The pa- tient said he had walked without pain in his knee, a week before his admis- sion into the Infirmary; he had lost very little blood in his journey to Leeds. He complained ofthe greatest uneasiness in the highest part of the tumour. It had become hot and pain- ful in the night-time, for some days past. His pulse was 114 in a minute ; his tongue was clean ; and his appetite had been good, till the last few days. He had never felt any pulsation in the tumour. In a consultation it was determined, that the tumour should be laid open, by cutting off a portion of the distend- ed integuments; and that after re- moving the contents, if the sac should be found in a sound state, the disease should be treated as a simple wound; but, if in a morbid state, amputation of the Umb should be immediately per- formed. A large oval piece of the integuments being removed, the tumour was found to contain a very large quantity of a substance, not much unlike coagulated blood ; but more nearly resembling the medullary part of the brain in its con- sistence and oily nature. It was of a variegated reddish colour, in some parts approaching to white, and, as blood issued from it, Mr. Hey conceiv- ed it was organized. This mass was partly diffused through the circumja- cent parts in innumerable pouches, to which it adhered, and was partly con- tained 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 tliis morbid mass. Amputation of the limb was imme- diately performed, on finding such to be tiie nature of the case. Mr. Hey, unfortunately, however, left a portion of the diseased surface behind on the inner part of the thigh, and hoping, that a small narrow portion of the up- per part of the sac would soon become a clean sore, and not impede the cure, he made the circular incision two inches below its higher part. On examining the amputated limb, the vastus internus was found to be brown, and much softer, than the other muscles, which were healthy. There were many small portions of blood ex- travasated in the substance of this mus- cle. The sac was formed of the apo- neurotic covering of the muscle, and ended below where this aponeurosis begins to cover the capsular ligament of the knee. The two fungous sub- stances, above described, appeared to have been only extensions of the mor- bid mass, where this had made its way through the sac and the integuments. The joint of the knee, and muscles of the leg were perfectly sound. I need not detail all the particulars after the operation. Suffice it to say, the man suffered a great deal of con- stitutional disorder. After a few weeks, tiie granulations upon the stump be- came good, and the cicatrization was nearly completed at the end of the sixth week, after the amputation. At this period, that small and superficial portion of the upper part of the great sac, which Mr. Hey 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 of the thigh, beneath the cicatrix. This contained a soft substance, ex- actly similar, as far as the touch could discover, to that which had filled the large sac. This tumour became pain- ful, and sometimes discharged a bloody serum, sometimes dark-coloured blood, through four, or five, small openings in the cicatrix. Mr. Hey laid open the tumour, and removed its contents ; but no advan- tage was gained by this proceeding. The interior surface was found to be too much diseased to produce good granulations. Blood continued to ooze out of the wound for a few days. Then the inner surface became covered with a blackish substance, whicii gradually extended itself, and formed a new fun- gus. A variety of escharotics were ap- phed to destroy the fungus, and mor- bid surface of the wound; but, to no 37fl FUNGUS. purpose, the growth of the fungus al- ways exceeded the quantity destroyed. Undiluted oil of vitriol, applied freely, had very httle effect. An attempt was once more made to cut away the disease ; but, on examin- ing the wound carefully, after the con- tained substance was removed, the muscular substance was found dege- nerated into a hard mass, which felt somewhat like cartilage. The adipose membrane was also diseased, and form- ed into large cells, which had con- tained the fungous substance. Hence, another amputation seemed the only resource. After this operation, tlie whole sur- face of the stump seemed sound, ex- cept the principal artery, which was fiUed with a somewhat stiff matter, re- sembling coagulated blood, whicii pre- vented its bleeding. The inside of the vessel, on being touched with the scal- pel, felt hard, and communicated a sensation, like that of scraping bone. The man was sent home, as soon as his state would ,admit of it -, but, he died consumptive about six months af- terwards. Besides this instance, in the thigh, Mr. Hey relates cases of fungus haematodes, situated in the female breast, in the leg, in the neck, (extend- ing from the jaw to the clavicle, and producing 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, (says Mv. Hey,) this disease not unfrequently af- fects the globe of the eye, causing an enlargement of it, with the destruction of its internal organization. If the eye is not extirpated, the sclerotis bursts at the last, a bloody sanious matter is discharged, and the patient sinks under the complaint." (P. 283.) Besides some cases, in similar situa- tions, to those mentioned by Mr. Hey, one is related by Mr. Burns, in which the hip-joint was the seat of* this terri- ble affection. After detailing the pro- gress of the case to the poor man's death, this author states, that he found, on dissection, the hip-joint completely surrounded with a soft matter, re- sembling the brain, inclosed in thin cells, and here and there cells full of thin bloody water; the head of the thigh-bone was quite carious, as was also the acetabulum. The muscles were quite pale, and almost like boiled "Ver, having completely lost their fi- brous appearance, and muscular pro- perties. The same sort of morbid mis- chief was also found within tiie pelvis, mos* of the inside of the bones, on the affected side, being quite carious. An attempt had been made, before the pa- tient died, to tap tiie bladder; but, the trocar had only entered a cell, filled with bloody water, and situated in a mass of the soft brain-like substance We have already said enough, to render the description of the dread- ful nature of the fungus luematodcs tolerably complete. Littie can be said of the treatment; for, we know of no one medicine, that seems to have the least power in putting a stop to the disease, and we have no reason to believe, that there is ever the smallest chance even of any spon- taneous amendment, much less of such a cure. We have seen, that when the chief part of a fungus haematodes is cut away, and only a small portion of its cyst is left behind, that the fungus is reproduced from this part, and soon becomes as formidable, nay more for- midable, than it was before, and this notwithstanding the application of the most powerful escharotics. Neither the hydrargyrus nitratus ruber, the hydrargyrus muriatus, the antimonium muriatum, nor the undiluted vitriolic acid, have always been able to repress the growth of such fungus. (Hey.) There is no remedy, that has the power of checking, or removing the complaint. Friction, with anodyne bal- sams, sometimes gives- relief in the early stages ; but, it does not seem to retard the progress of the disease. In short, the only chance of cure consists in extirpating the whole of the distempered parts, removing not only the soft, brain-like, fungous substance, but every particle of the cysts, sacs, or pouches, in which it may be contained. An operation of this kind, however, is only advisable in the early stages, while the disease is entirely local; for, after the neighbouring glands have become affected, the chance of recovery is al- most destroyed. It is sometimes difh\ cult, however, to persuade patients at this time to submit to amputation, or extirpation, because the pain and in- conveniences are inconsiderable; but, the operation ought to be urged with all the forc«, which a conviction of its absolute necessity, and the fatal peril of delay, ought to inspire. FimUNCULUS. 373 When a fungus haematodes is on a .limb, and every atom ofthe disease can be cut away, without amputating the limb, this plan should first be tried. Should the disease repeatedly recur, notwithstanding such a mode of pro- ceeding, or should it be imprudent, or impracticable, to try to cut away the disease and save the limb, the latter must be amputated. See Dissertations on Inflammation, by I. Burns, Vol. 2. Hey's Practical Ob- servations in Surgery. Freer on Aneu- rism. A case of this disease is related in Vol. 5. of the London Medical Journal. It was the consequence of an attempt to cure a ganglion by means ofa seton, and it proved fatal. A case is also re- lated by Mr. Abernethy in Surgical Ob- servations, 1804, p. 99. F U RUNCULUS, (from furo, to rage.) A boil, so named from tlie violence of the heat and inflammation attend- ing it. A boil is a circumscribed, very pro- minent, hard, deep-red, inflammatory swelling, which is exceedingly painful, and commonly terminates in suppura- tion. The figure of the tumour is ge- nerally that of a cone, the base of which is considerably below the sur- face. Upon the most elevated point of the boil, tliere is commonly a whitish, or livid pustule, which is exquisitely sensible, and immediately beneath this is the seat of the abscess. The matter is sometimes slow in forming, is sel- dom very abundant, never healthy, at first, being always blended with blood. The complaint is seldom attended with lever, except, when the tumour is very large, situated on a very sensible part, or when several of these swellings oc- cur at the same time in different places. In the last circumstance, they often oc- sasion in children, and even in irritable adults, restlessness, loss of appetite, spasms, &c. They seldom exceed a pigeon's egg in size, and they may ori- ginate on any part of the body. Boils commonly arise from constitu- tional causes. The suppuration, that attends a boil, is never perfect, and the matter, whicii ' forms, is not only tinged with blood, but surrounded with a sloughy sub- stance, whicii must generally be dis- charged, before the part affected will suppurate kindly, and the disease end. Richter compare* the slough with a kind of bag, or cyst, and the whole boil with an inflamed encysted tumour. The best plan is always to endeavour to make boils suppurate, as freely as possible, by applying external emolli- ent remedies. This seems to be the natural course of the disease in its pro- gress to a cure, and, indeed, all endea- vours to discuss furunculous tumours commonly fail, or succeed very imper- fectly; only removing the inflamma- tion, and leaving behind an indolent hardness, whicii occasions various in- conveniences, according to its situation, every now and then inflames anew, and never entirely disappears, until a free suppuration has been established. In a very few cases, perhaps, it may be proper to try to discuss boils. For this purpose, besides bleeding, gentle evacuations and a low diet, which are requisite in this, as well as other local inflammations, some prescribe as ex- ternal applications honey strongly aci- dulated with sulphuric acid; alkohol: or camphorated oil. But, in the generality of instances, suppuration must be promoted, by the use of emollient poultices. The tu- mour, when allowed to burst, general- ly does so at its apex. However, as the opening, which spontaneously occurs, is generally long in forming, and too small to allow the sloughy cellular sub- stance to be discharged, it is always best, as soon as matter is known to ex- ist in the tumour, to make a free open- ing with a lancet, and immediately af- terwards to press out as much of the matter and sloughs, as can be prudent- ly done. This having been accomplish- ed, and the rest of the sloughs pressed out, as soon as it is practicable, healthy pus will be secreted, and the part will granulate and heal. Until the suppu- ration becomes of the healthy kind, and the sloughy substances are entirely dis- charged, an emollient linseed poultice is the best application, and when gra- nulations begin to fill up the cavity, plain lint, and a simple pledget, are the only dressings necessary. When an indolent hardness conti- nues, after the inflammatory and sup- purative state of boils has been cured, the part should be rubbed with cam- phorated mercurial ointment. Besides the above acute boil, authors describe a chronic one, which is said frequently to occur, in subjects, who have suffered severely from the small- 374 GANGLION. pox, measles, lues venerea, scrophula, and in constitutions, which have been injured by the use of mercury. The chrome boil is commonly situa- ted upon the extremities, is of the same size as the acute one, has a hard base, is not attended with much pain, nor any considerable discoloration of the skin, until suppuration is far advanced, and tiie matter is seldom quite formed, before three, or four weeks. This, like the former, sometimes appears in a considerable number at a time. The discharge is always thinner, than good pus, and when the boil is large, and has GANGLION, (yzPyxtov.) In anato my, a knot in the course of a nerve; in surgery, a tumour on a ten- don, or aponeurosis. A ganglion is an encysted, circum- scribed, moveable swelling, commonly free from pain, causing no alteration in the colour ofthe skin, and formed up- on tendons in different parts of the bo- dy, but, most frequently upon the back of the hand, and over the wrist. A French gentleman consulted me about a year ago, who had one upon the up- per part of his foot, which created a great sensation of weakness in the mo- tion of the foot, and I have taken no- tice, that ganglions occur particularly often just below the kneepan, in house- maids, who are in the habit of kneel- ing a great deal in order to scour rooms. It is curious to remark, that pressure, which is the best common means of getting rid of ganglions, in this instance, seems to act as a cause. These tumours, when compressed, seem to possess considerable elasticity. They often occur unpreceded by any accident; frequently, they are the con- sequence 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 tiie contrary. When opened, they are found to be filled with a viscid transparent fluid, resembling white-of- egg. If they do not disappear of them- selves, or are not cured, while recent, by surgical means, they, in some cases, become so large, that they cause great inconvenience, by obstructing the mo- been long in suppurating, a great deal of sloughy cellular membrane must be cast off", before the sore will heal The principal thing, requisite in the local treatment of ali furunculous, and carbuncular tumours, is to make an early free opening into them, and to press out the matter and sloughs, em- ploying emollient poultices, till all the mortified parts are detached and re- moved, and afterwards simple dress- ings. (See Pearson's Principles of Sur- gery. Richter's Anfangsgrunde der Wundarzn. Band. 1. tion of the part, and rendering it pain- ful. 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 treat- ment, but seldom cured, and, no soon- er has the friction been discontinued, than the fluid in the cyst has in gene- ral accumulated again. Compression is usually more effectu- al, than discutient liniments. Persons with ganglions have been recommend- ed to rub them strongly with their thumb, several limes a day. After this has been repeated very often, the tumour is said sometimes to have ab- solutely disappeared while the friction was employed. But, the best metliod is to make continual pressure on gan- glions, by means ofa piece of sheet- lead, bound upon the part with a ban- dage. There is no objection, however, to using once, or twice a day, in con- junction with this treatment, frictions with the oleum origani, or camphora- ted mercurial ointment, provided these measures do not seem likely to make the tumour inflame, an event, which should always be carefully avoided. Ganglions, when irritated too much, have been known to become most ma- lignant diseases. Setons have been recommended to be introduced 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 G GAN the records of surgery fully shew. Cancerous diseases, and even the fun- gus haematodes (Med. Journal, Vol. 5.) have arisen from the irritation ofa se- ton passed through a ganglion. Frequently, when a ganglion in- flames, and ulcerates, the cyst throws out a fungus, which is of a very malig- nant nature. Hence, on every account, the practitioner should avoid making such a tumour inflame, and whatever measures he may take, they should ne- ver act so as to produce this effect. The caution just given, is the more necessary, as books mention instances, in whicii ganglions have been suddenly cured by pressure, of such force, as to rupture the cyst, and some authors have even recommended putting the hand affected upon a table, and then striking the ganglion several times with the fist, or a mallet. Let such impru- dent practices never be imitated: a ganglion is a simple disease, by no means a serious one, while free from irritation, but, no sooner is it in an ul- cerated state, and has its cyst formed a fungus, than it is a formidable case, and the sooner it is entirely cut away, the better. In almost every instance, a ganglion may be cured by pressure and friction, and, if not actually cured, the disease may be rendered so bearable by these means, that few patients would choose to have the tumour cut out. Under this plan, the swelling becomes very much diminished, and, should it en- large again, the mode of relief is so simple, and the case so little trouble- some, that patients generally content themselves with every now and then wearing a piece of lead on the part. But, when ganglions resist all at- tempts to disperse, or palliate them; when they become extremely inconve- nient, either by obstructing the func- tions of a joint, or causing pain; these tumours should be carefully dissected out, by first making a longitudinal inci- sion in tiie skin covering them, then se- parating the cyst on every side from the contiguous parts, and lastly cutting every particle of it off the subjacent tendon, or fascia. The greatest care must be taken, not to make any open- ing in the cyst, so as to let out its con- tents, and make it. collapse; a cir- cumstance, which would render the dissection of it entirely out much more difficult. GAN 375 The operation being accomplished, the skin is to be brought together with sticking-plaster, and a compress pla- ced over the situation of the tumour, with a view of healing tiie wound and the cavity by adhesion When the ganglion has burst, or is ulcerated, it is best to remove the dis- eased skin, together with the cyst, and of course the incision must be oval, or circular, as may seem most convenient- The grand object is not to allow 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, whicii this gentleman thought it right to extir- pate. These had become adherent to the tendons of the fingers. In the ope- ration, he was obliged to cut the trans- verse ligament ofthe wrist, and,the patients, who before could not shut their hands, nor close their fingers, perfectly regained the use of these parts. Mr. Gooch relates a case of the same kind, wliich had been occasioned by a violent bruise, three, or four, years before. The tumour reached from the wrist to the middle of the hand, and created a great deal of pain. Mr. Gooch extirpated it, and then restored the po- sition of the hand, and free motion of the joint, by tiie use of emollient ap- plications, and suitable pressure, made with a machine constructed for the purpose. The ganglions, which occur just be- low the knee, I have seen cured by a little blister, applied over them, and kept open with the savin cerate. For information relative to ganglions, consult I Vomer's Cases in Surgery. Chi- rurgical Works of B. Gooch, Vol.2,p. 376. Heister's Surgery. B Bell's Sur- gery. Latta's System of Surgery. L'En- cyclopedic Methodique ; Partie Chirur- gicak. Richter's Anfangsgrunde der Wundarzneykunst; Band. 1. GANGRENE, (from yntvce, to feed upon.) Gangrana. An incipient mor- tification, so named from its eating away the flesh. Authors have generally distinguish- ed mortification into two stages; the first, or incipient one, they name gan- grene, which is attended with a sudden diminution of pain in the place affected; a livid discoloration of the part, which, from- being yellowish, becomes of a greenish hue ; a detachment ofthe cu- 376 GASTRORAPH1A. tide, under which a turbid fluid is ef- fused ; lastly, the swelling, tension, and hardness, of the previous inflam- mation, subside, and, on touching the part, a crepitus is perceptible, owing to the generation of air in the gangre- nous parts. Such is the state to which the term gangrene is applied. When the part has become quite cold, black, fibrous, incapable of mov- ing, and destitute of all feeling, circu- lation, and life ; this is the second stage of mortification, termed sphacelus. Gangrene, however, is frequently used synonymously with the word mortifica- tion. (Mortification.) GASTRITIS, (from >**», a suture.) Gustroruphe. A suture of the belly, or some of its contents. Although the term gastroraphe, in strictness of etymology, signifies no more, than sew ing up any wound of the belly, yet Mr. Samuel Sharp in- forms us, that in his time, the word implied, that the wound of the abdo- men, was complicated with another of tlie bowels. The moderns, I think, seem to limit the meaning of the word to tiie opera- tion of sewing up a wound of the pa- rietes ofthe abdomen. What was formerly meant by gastro- raphe, could scarcely ever be practis- ed, 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 ope- ration of stitching the bowels can only take place, when they fall out of the abdomen, and when we can see where the wound is situated. The circumstances, making the prac- tice of sewing 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 fasliion of duel- ling, declared, he never had once had an opportunity of practising the gas- troraphe, according to the former ac- ceptation of that word. Upon the supposition ofthe intestine being wounded in such a manner as to require the operation, Mr. Sharp advi- ses taking a straight needle with a small thread, laying hold of the bowel with your left hand, and sewing up the wound with the glover's stitch, that is, by passing the needle through the lips of the wound from within outwards all the way, so as leave a length of thread at both ends, whicii are to hang out of the incision of the abdomen. He then directs you carefully to make the in- terrupted suture of the external wound, and to pull the bowel by the small threads into contact with the perito- neum, for the more readily uniting with it afterwards by adhesion ; though he seems to think it would be more secure to pass the threads with the straight needle through the lower edges of the wound of the abdomen, which would more certainly hold the intestine in that situation. In about six ' days, the ligature of the intestine will be loose enough to be drawn away ; in the interim, superficial dressings are to be applied, and the patient kept on low diet. (Sharp.) On this operation, we have only to remark, that as "the only use of a su- ture ofthe bowel is to keep the wound of it near the external wound, in case any extravasation should occur, this object can be as effectually accomplish- ed by one fine stitch, as by sewing up all the breach in the intestine, and without being so likely to excite in- flammation of the parts. We shall add no more concerning sutures ofthe bowels, to what is contained in the arti- cles Abdomen, and Hernia. Gastroraphe, or merely sewing up a wound of the parietes of the abdomen, may be done, as Mr. Sharp explains, with the common interrupted suture, (see Suture,) or with the quilled one, which is better, as follows : A ligature, capable of splitting into two, has a needle attached to each end of it, The operator is to put the in- dex finger of" his left hand into the Wound, under the lip furthest from him. This finger is in contact with the peri- toneum, in order that it may with the thumb pinch up, and raise the whole tiiickness of the parietes. With the other hand, one of the needles is to be introduced into the abdomen, guiding its point on the index finger, in order to avoid wounding the omentum, or in- testines. The lip of the wound is to be GASTRORAPHIA. 377 pierced, from within outward, 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 su- tures must be made, as the extent of the wound may require. The sides of the wound are next to be brought together, and we are to pre- pare to tie the ligature, not in a bow, in the way of the interrupted suture, because the continual action of the ab- dominal muscles might make the liga- tures cut their way through the parts. It is better, to divide each end of the ligature 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 tiie wound being closed, another piece of bougie is to be placed along the other lip of the wound, and the oppo- site ligatures tied over it, with suffi- cient tightness, to keep the sides ofthe wound in contact. This suture is cer- tainly 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 ofthe threads cutting their way through the part, in which they are introduced; consequently, it must be avoided. To prevent, as muck as possible, the exer- tion of" the muscles, the bowels should be kept open with clysters ; and opium * is the best thing for putting a stop to the vomiting, sometimes attendant on wounds of the abdomen, and producing very injurious effects, in regard to the Wound. In about a week, the sutures may generally be removed, and sticking pla:.li:r alone employed. As to what more relates to these particular cases, we must refer to Abdomen, Wounds of. It is generally allowed, that sutures arc violent means, to which we should only resort, when it is impossible to ki ip tiie lips of a wound in contact by tiie observance of a proper posture, and the aid of a methodical bandage. M. Pibrac believes such circumstances evceedingly uncommon, and in his ex- cellent production, in the third volume VOL. I. of Memoirs of the Royal Academy of Surgery, relative to the abuse of su- tures, cases are related, which fully prove, that wounds ofthe belly readily unite by means of a suitable posture and a proper bandage, without having recourse to gastroraphe. These, how- eve1-, are less decisive and convincing, (if possible to be so,) than the rela- tions of the Caesarean operation, the extensive wound of which has often- times 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 ma- nifested, that this operation has some- times occasioned very bad symptoms. Under certain circumstances, how- ever, it may be essentially necessary to practise gastroraphe. for instance, were a large wound to be made .-.cross the parietes of the abdomen, a suture might become indispensably requisite, to prevent a protrusion of the bowels. Yet, even in this case, the sutures should be as few in number as pos- sible. A bandage of the eigiiteen-tailed kind, might prove very useful in a longitudinal wound of the abdomen, and do away all occasion for gastro- raphe. (See Sutures.) We shall conclude this article with a fact, perhaps, more curious, than in- structive, related by Mr. Bordier, of Pondicherry, in the Journal de Medi- cine, vol. 26. 538. An Indian soldier, angry with his wife, killed her, and at- tempted to destroy himself by giving himself a wound with a broad kind of dagger in the abdomen, wliich caused a protrusion of the bowels. A doctor of the country, being sent for, dissect- ed between the muscles and skin, and introduced there 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 afterwards hung, and M. Bordier, when the body was opened, assured himself more particularly of the fitct. Indeed, numerous cases prove, that lead may lodge in tlie living body, without occasioning tiie inconvenience, which results from the presence of almost any other kind of extraneous body. See Le Dran's Operations da Chirur- tne. Sharp's Treatise, on the Operations of Surgery. L'Encyckpidk Met ho- 48 "j 78 GLA GLE digue t Partie Chirurgicak. La Medi- e.nw Operatoirepar Sabatier, Tom. 1. GASTROTOMIA, (.from >*v»g, the belly, and rtywe, to cut.) The opera- tion of opening the abdomen and ute- rus. The Caesarean operation. It also signifies opening the abdomen for oth- er purposes. GLAUCOMA, (from y^*UKK, blue.) A disease of the eye, in whicii the crystalline lens becomes of a blue, or sea-green colour. The exact meaning of this ancient term, however, is very undetermined ; some say it is a disease of the crystalline; others, that it is an affection of the vitreous humour. Ga- len in his book de usu purtium imputes glaucoma to a morbid dryness of the crystalline ; in which sentiment he has been followed by jEuus, and Maitre- Jan, at the commencement of the 18th century. Since, however, the cataract has been decidedly ascertained to de- pend upon a disease of the crystalline; the term glaucoma, has been reserved for an opacity of the vitreous humour, as we may learn from Heister, Platner, and all the oculists, who published about the middle of* the last century. Lancisi mentions, that he once found the vitreous humour cartilaginous ; and Morand has seen it converted into a stony substance. These instances, and some others, are in favour of the opin- ion, that glaucoma, may arise from an opacity of the vitreous humour. A glaucoma, even of a confirmed kind, cannot always be easily distinguished from a cataract, especially, while the latter is in an incipient state. It is said, however, that suspicions of the disease may be entertained, when the unnatural colour, which characterizes it, is reflected from a deep surface, be- hind the pupil; whereas the opacity of a cataract is more superficial, and near- er to the margin of the uvea. Glaucoma is certainly an exceeding- ly uncommon disease. Authors recom- mend applying blisters, and giving in- ternally tlie extract of cicuta, calomel, and soap, Encyclopedic Methodique ; Partie Chir.) The topical use of aether may also be tried, which we have men- tioned, as one of Mr. Ware's remedies for promoting the absorption of catar- acts. From our present knowledge of the power of the absorbents to remove opaque substances in the eye, when such are detached and loose, as they actually become after being disturbed with a couching needle, tliere can be no doubt that, if an opacity of a part ofthe vitreous humour were to present itself in practice, and not yield to the above means, it would be justifiable conduct, on the part of the surgeon, to endeavour to move such opacity out of tiie axis of sight, and, at all events, to disturb it so freely with a couching needle, as to afford a chance of its be- ing absorbed. GLAUCOSIS, same as Glaucoma. GLEET. By the term gleet, we com- monly understand a continued running, or discharge, after the inflammatory symptoms of a clap for some time have censed, be"lng unattended with pain, scalding in making water, Ike. Mr. Hunter remarks, that it differs from a gonorrhoea in being uninfectioug, and in the discharge consisting of" globular bodies, contained in a slimy mucus, in- stead of serum. He says, that a gleet seems to take its rise from a habit of' action, which the parts have contract- ed. The disease, however, sometimes stops of itself, even after every method has been ineffectually tried. This probably depends upon accidental changes in the constitution, and not at all upon the nature of the disease itself. Mr. Hunter suspected some gleets were connected with scrophula. The sea-bath cures more gleets, than the common cold bath, or any other mode of bathing. An injection of diluted sea-water cures some gleets, though it is not always effectual. Gleets are always attended with a relaxed constitution. •They also some- times arise from other affections of the urethra, besides gonorrhoeas. A stric- ture is almost always attended with a gleet; so sometimes is disease of the prostate glund. When a gleet, observes Mr. Hunter, does not arise from any evident cause, nor can be supposed to be a return of a former gleet, in consequence of a gonorrhoea, either a stricture ordiseased prostate gland is to be suspected ; and inquiry should be made whether the stream of urine is smaller than com- mon, whether there be any difficulty in voiding it, and whether the calls to make it are frequent. If there should be such symptom, a bougie, rather un- der the common size, should be intro- duced ; and, if it passes on to the blad- der with tolerable ease, the disease is probably in the prostate gland, which should next be examined. (See Ureth- GLE GON $7$ *c, Strictures of; and Prostate Gland, Diseased.) Balsams, turpentines, and canthari- des, given internally, are of use, es- pecially in slight cases; and when they are useful, prove so almost immediate- ly. Hence, if they neither lessen nor remove tiie gleet in five or six days, ■ Mr. Hunter never continued them long- «r. As the discharge, when removed, is also apt to recur, such medicines should be continued for some time af- ter the symptoms have disappeared. The cold bath, sea-bath, bark, and steel, may be given when the whole constitution is weak. The astringent gums, and salt of steel/given as inter- nal astringents, have little power. With regard to local applications, the astringents commonly used are, the decoction of bark, white vitriol, alum, and preparations of lead. The aqua vitriolica caerulea, of the Londoji Dis- pensatory, diluted with eight times its quantity of water, makes a very good injection. Irritating applications are, either in- jections, or bougies, simple or medi- cated with, irritating medicines. Vio- lent exercise may be considered as having the same effect. Such applica- tions should never be used till the oth- er methods have been fully tried, and found unsuccessful. They at first in- crease the discharge. Two grains of the hydrargyrus muriatus, in eight ounces of water, are a very good irri- tating injection. In irritable habits, such an application may do great harm, and the capability of the parts to bear its employment, should first be made out, if possible. Bougies sometimes act violently, and are more efficacious than injections. A simpl-_- unmedicated one is generally sufficient, and must be used a month or six weeks; before the cure can be de- pended upon. Those medicated with camphor, or turpentine, need not be used so long. The size of the bougie should be under the common. Mr. Hunter has known a gleet dis- appear on the breaking out of two chan- cres on the glans. Gleets have also been cured by a blister on the under- side of the urethra; and, by electricity. In every plan of cure, rest, or quiet- ness, is generally of great consequence ; but, after the failure of tiie usual modes, riding on horseback bus immediately effected 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 infection ; but the difference between this and a fresh infection is, that here the return is almost immediately after the connexion. Gleets in women, are cured like those of men. Turpentines, however, have no specific effect on the vagina. The astringent injections may also be stronger, than those for men. See A Treatise on the Venereal Disease, by John Hunter. Also, Swediaur's Prac- tical Observations on Venereal Com- plaints. GLOSSOCA'TOCHUS, (from yimr** the tongue; and k*t%», to depress.) An instrument for pressing down the tongue ; a spatula. The ancient glos- socatochus was a sort °f forceps, one of the blades of which served to depress the tongue, while the other was appli- ed under the chin. GLOSSOCOMION, (from yiaxrtr*, the tongue; and x.ojuta>, to guard.) By this was formerly meant a case for the tongue of a hautboy ; but the old sur- geons, by metaphor, used the term to signify a case for a broken limb. GOITRE. See Bronchocele. GONORRHOEA, from ya», the se- men ; and gs«, to flow.) Etymokfgical- ly, an involuntary discharge of the se- men ; but always, according to modern surgery, a discharge of a purulent in- fectious matter, from the urethra in tiie male, and from the vagina and surfaces of the labia, nymphs, clitoris, &c. in the female subject. The disease occurs, in Latin authors, under the different denominations of gonorrhoea, G. Viruknta, Fluor albus ma- lignus. Dr. Swediaur, after censuring the etymological import, as conveying an erroneous idea, says, if a Greek name is to be retained, he would call it blennorrhagia, from Sxw*, mucus, and em, to flow. However, as most moderns consider the discharge as pus, not mu- cus, the etymological import of blen- norrhoea is as objectionable as that of gonorrhoea. In English, the disease is commonly called a clap, from the old French word clapises, wliich were pub- lic shops, kept and inhabited by single prostitutes, and generally confined to a particular quarter of tlie town, as is ?ven now the case in several of the S80 GONORRHOEA. great towns of Italy. In German, the disorder is named a tripper, from drip- ping ; and in French, a chaudepkse, 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 notice of what some other writers have said. When an irritating matter of any kind is applied to a secreting surface, it increases that secretion, and changes it from its natural state to some other. In the present instance, it is changed from mucus to pus. Till about the year 1753, it was gen- erally supposed, that the matter from the urethra, in a gonorrhoea, arose from ulcers in the passage ; but it was then clearly ascertained, that pus could be secreted without a breach of substance. It was first accidentally proved, by dis- section, that pus could be formed in the bag of the pleura, without ulcera- tion ; and, Air. Hunter afterwards ex- amined the urethra of malefactors and others, who were executed, or died, while known to be affected with gonor- rhoea, and demonstrated that the canal was entirely free from every appear- ance of ulcer. The time, when a gonorrhoea first ap- peal's, after infection, is very various. It generally comes on sooner, than a chan- cre. Mr. Hunter has had reason to be- lieve, that, in some instances, the dis- ease has begun in a few hours, while, in others, six weeks have previously elapsed; but he has known it begin at all the intermediate periods. About six, eight,.ten,'or twelve days, howev- er, after infection, is the most common period. -v The surface ofthe urethra is subject to inflammation and suppuration, from various other causes besides the vene- real poison ; and sometimes discharges happen spontaneously, when no imme- diate cause can be assigned. Suchmay be called simple gonorrhoea, having no- thing of the venereal infection in the in. Mr. Hunter has known the urethra sympathize with the cutting of a tooth, and produce all the symptoms of a gonorrhoea. This happened several times to the same patient. The urethra is known to be sometimes the seat of the gout; Mr. Hunter has known it to be the seat of rheumatism. When a secreting surface has once received the inflammatory action, its secretions are increased and visibly al- tered. Also, when the irritation has produced inflammation, anil an ulcer in the solid parts, a secretion of mat- ter takes place, the intention of which, in both, seems to be to wash away the irritating matter. But, in inflamma- tions, arising from specific, or morl id poisons, the irritation cannot be thus got rid of; for, although the first irri- tating matter be washed away, yet, the new matter formed has the same qual- ity as the original had ; and, therefore, upon the same principle, it would pro- duce a perpetual source of irritations, even if tlie venereal inflammation, like many other specific diseases, were not what it really is, kept up by Jhe spe- cific quality of the inflammation itself. ( This inflammation seems, however, to be only capable of lasting a limited time, the svmptoms peculiar to It van- ishing of themselves, by the parts be- coming less and less susceptible of ir- ritation. The consequent venereal matter can have no power of continu- ing the original irritation, otherwise there would be no end to the disease. The time, whicii the susceptibility of the irritation lasts, must depend upon the difference in the constitution, and not upon any difference in the poison itself. The venereal disease only ceases spontaneously, when it attacks a secre- ting surface, and produces a mere se- cretion of pus, without, ulceration. SYMPTOMS OF GONORRHOEA. The first symptom is generally an itching at the orifice of the urethra, sometimes extending over the whole glans. A little fulness of the lips of the urethra, the <-liectof inflammation, is next observab:e, and soon afterwards a running appears. The itching chan- ges into pain, more particularly at tlie time of voiding the urine. There is nl'ien no pain till some time after the appearance of the discharge, and otiier symptoms; and in many gonorrhoeas, there is hardly any pain at all, even when the discharge is verv- considera- ble. At other times, a great degree of soreness occurs long before any dis- charge appears. There is generally, at this time, a particular fulness in the penis, and more especially in the glans. The glans has also a kind of transpa- GONORRHOEA. 381 rency, especially, near the beginning of the urethra, where the skin, being dis- tended, smooth, and red, resembles a ripe cherry. The mouth ofthe urethra is, in many instances, evidently excori- ated. The surface of the glans itself is often in a half" excoriated state, con- sequently very tender; and it secretes a sort of" discharge. The canti ofthe urethra becomes narrower, wliich is known by the stream of urine being smaller than common. This proceeds from the fulness of the penis in gene- ral, and from the lining of the urethra being swollen, and in a spasmodic state. The fear ofthe patient, while voiding his urine, also disposes the urethra to contract. The stream of urine is gene- rally much scattered and broken, as soon as it leaves the passage. There is frequently some degree of hemor- rhage 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 ofthe urethra. These, Mr. Hunter suspected to be en- larged glands of the passage. They occasionally suppurate, and burst out- wardly, but now and then in the ure- thra itself. Mr. Hunter has also sus- pected such tumours to be ducts, or lacunae .of tiie glands ofthe urethra distended with mucus, in consequence ofthe mouth of the 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-induce inflammation, suppuration, and ulcera- tion. Hardness and swelling have al- so occurred in the situation of Cowper's glands, and ended in considerable ab- scesses in the perineum. The latter tumours l>rc:.k either internally or ex- ternally, and sometimes in both ways, so as to produce fistulae in ,perinaeo. A soreness is often felt all along the under side ofthe penis, frequently ex- tending as far as the anus. The pain is particularly great in erections; but the case differs from chordee, the penis remaining straight.—Erections are fre- quent in most gonorrhoeas, and even sometimes threaten to bring on morti- fication. As opium is of great service, Mr. Hunter thinks,there is reason to suppose them ofa spasmodic nature. The natural slimy discharge from the glands ofthe urethra is first changed, from a fine transparent ropy secretion, to a watery whitish fluid; and the lu- bricating fluid, whicii the passage na- turally exhales, becomes less transpa- rent; both these secretions becoming gradually thicker, assume more and more the qualities of common pus. The matter of gonorrhoea often chan- ges its colour and consistence, some- times from a white to a yellow, and of- ten to a greenish colour. These chan- ges depend on the increase and de- crease of the inflammation, and not on the poisonous quality of the matter it- self; for, any irritation on these parts, equal to that produced in a gonorrhoea, will produce the same appearances. The discharge is produced from the membrane lining the urethra, andfroiu the lacunae, but, in general, only for about two or three inches* from tlie external orifice. Whenever Mr. Hun- ter had an opportunity of examining the urethra affected with gonorrhoea, he always found the lacunae loaded with matter, and more visible than in the natural state. Before the time of this celebrated man, it was commonly supposed, that the discharge arose from the whole surface of the urethra, and even from Cowper's glands, the pros- tate and vesiculx seminales. But,'if the matter were secreted from all these parts, the pus would collect in the bulb, as the semen does, and thence be emitted in jerks; for, nothing can be in the bulbous part ofthe ure- thra, without stimulating it to action, especially, when in a state of irritation and inflammation. When the inflammation is violent, some of the vessels of the urethra of- ten burst, and a discharge of blood en- sues. Sometimes such blood is only just enough to give the matter a tinge. The erections often stretch the part so much as to oause an extravasation. When the inflammation goes more deeply than the membranous fining, and affects the reticular membrane of the urethra, it produces in it an extra- vasation of coagulable lymph, the con- sequence of which is a chordee. (See Chordee.) Mr. Hunter suspected, that the dis- ease is communicated or creeps along * P. 50. Mr. Hunter says, seldom further than an inch and a half, or two inches at most. This he terms tiie specific extent of the inflammation. 382 GONORRHOEA. from the glans to the urethra, or, at least, from the lips ofihe urethra to its inner surface, as it is impossible, that the infectious matter can, during co- ition, get as far as the disease extends. He mentions an instance, in whicii a gentleman, who had not cohabited with any woman for many weeks, to all ap- pearances caught a gonorrhoea from a piece of plaster, which had adhered to his glans penis, in a necessary abroad, and which is accounted for by suppo- sing that some person, with a clap, had previously been to tliis place, and had left behind some of the discharge, and that the above gentleman had al- lowed his penis to remain in contact with tiie matter, till it had dried. Many symptoms, depending on tlie sympathy of other parts with the ure- thra, sometimes accompany a gonor- rhoea. An uneasiness, partaking of soreness and pain, and a kind of weari- ness, are every where felt about the pelvis. The scrotum, testicles, perinae- um, anus, and hips, become disagree- ably sensible to the patient, and the testicles often require being suspend- ed. So irritable, indeed, are they in such cases, that the least accident, or even exercise, which would have no such effect at another time, will make them swell. The glands of the groin are often affected sympathetically, and even swell a httle, but do not "suppu- rate, as they generally do when they inflame from the absorption of matter. Mr. Hunter has seen the irritation of a gonorrhoea so extensive as to affect with real pain the thighs, buttocks, and ab- dominal muscles. He knew one gen- tleman, who had never had a gonor- rhoea without being immediately seized with universal rheumatic pains. When the gonorrhoea, exclusive of the affections arising from sympathy, is not more violent than has been descri- bed, it may be called a common, or sim- ple venereal one; but, if the patient is very susceptible of such irritation, ur of any other mode of action which may accompany tiie venereal, then the symp- toms are in proportion more violent. In such circumstances, we sometimes find the irritation and inflammation ex- ceed the specific distance, and extend through the whole urethra. There is often a considerable degree of pain in the perinxum; and a frequ' t»t, though not a constant symptom, is a spasmodic coiv.raction ofthe acceleratores urinae, and erectores muscles. The infiuin- mation, in these cases, is sometimes considerable, and goes deeply into the cellular membrane, without producing any effect, however, except swelling. In other instances, "it goes on to suppu- ration, often becoming one of the cau- ses of fistulae in perinxo. Cowper's glands may hence suppurate, and the irritation is often extended even to the bladder itself. When the bladder is affected, it be- bomes more susceptible of every kind of irritation. It will not bear the usual distention, and, therefore, the patient cannot retain his water the ordinary > time, and the moment the desire of making water takes place, he 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 immediately, the* pain be- comes almost intolerable; and even when the water is evacuated, there rer mains, for some time, a considerable pain, both in the bladder and glans. The ureters, and even the kidneys, sometimes, though rarely, sympathize, when the bladder is much affected. Mr. Hunter had reason to suspect, that the irritation may be communicated to the peritonaeum, by means of the vas deferens. Mr. Hunter mentions a case in which, when the inflammatory symptoms of a gonorrhoea were abating, an inconti- nence of urine came on,; but, in time, got spontaneously well. A very common symptom, attending a gonorrhoea, is a swelling of the testi- cle. See Hernia Humoralis. Another occasional consequence of a gonorrhoea, is a sympathetic swelling ofthe inguinal glands. (See Bubo.) A hard chord is sometimes observed, leading from the prepuce along the back of the penis, and often directing its course to one of the groins, and af- fecting the glands. There is most commonly a swelling in the prepuce, at the part where the chord takes its rise. This sometimes happens when there are an excoriation and a discharge from the prepuce, or glans penis. From the above account, the symp- toms of gonorrhoea, in different cases, seem to be subject to infinite variety. Tiie discharge often appears without any pain; and the coming on ofthe pain is not at any stated time after the ap- pc; »nce of the discharge. There is * GONORRHOEA. 383 often no pain at all, although the dis- charge is in considerable quantity, and of a bad appearance. The pain often goes off, while tiie discharge continues, and will return again. An itching, in some cases, is felt for a considerable time, which is sometimes succeeded by pain; though, in many cases, it conti- nues to tiie end of the disease. On the other hand, the pain is often trouble- some, and considerable, even when there is little or no discharge. In ge- neral, the inflammation in the urethra doe's not extend beyond an inch or two from the orifice; sometimes it runs all along the urethra to the bladder, and even to the kidneys, and in some cases, Spreads into the substance of the ure- thra, producing a chordee. The glands of the urethra inflame, and often sup- purate ; and Mr. Hunter suspected that Cowper's glands sometimes do the same. The neighbouring parts sym- pathize, us the glands of the groin, the testicle, the loins, and pubes, with the upper parts of the thighs, and abdomi- nal muscles. Sometimes the disease appears a few hours after the applica- tion of the poison ; sometimes six weeks elapse first. It-is often not pos- sible to determine whether it is vene- real or only an accidental discharge, arising from some unknown Cause. GONORRHOEA IN WOMEN. The disease is not so easily ascer- tained in them as in men, because they are subject to a disorder called fluor albus, which resembles gonorrhoea. A discharge simply from women, is less a proof of the existence of a gonorrhoea, than even a discharge without pain in men. The kind of matter does not en- able us to distinguish a gonorrhoea from a fluor albus ; for the discharge in the latter affection often puts on all the ap- pearance of venereal matter. Pain is not necessarily present, and therefore forms no line of distinction. The ap- pearance ofthe parts often gives us but little information.; for, continues Hun- ter, I have frequently examined the parts of those who confessed all the symptoms, such as increase of dis- charge, 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 ca- ses where there are no symptoms sen- sible to the person herself, or where the patient ha9 a mind to deny any uncommon symptoms, but from the circumstances preceding the discharge; such as her having been connected with men supposed to be unsound, or her being able to give the disorder to others; which last circumstance being derived from the testimony of another person, is not always to be trusted to, for obvious reasons. From the manner, in which the dis- ease i3 contracted, it must principally attack the vagina, a part not endowed with much sensation. In many cases, however, it produces a considerable soreness on the inside ofthe labia, nym- phae, clitoris, carunculae myrtiformes, meatus urinarius. Those parts are so sore, in some cases, as not to bear be- ing touched; the person can hardly walk; the urine gives pain in its pas- sage through the urethra, and when it comes into contact with the above men- tioned parts. The bladder sometimes sympathi- zes, and, even the kidneys. The mu- cous glands, on the inside of the labia, often swell, and sometime suppurate, forming small abscesses, wliich open near the orifice ofthe vagina. Mr. Hunter states, that the venereal matter from the vagina sometimes runs down the perinaeum to the anus, and produces a gono:rhxa, or chancre, in that situation. The disease in women may probably wear itself out, as in men; but it may exist in the vagina for years, if the testimony of patients can be refi.- ed on. TREATMENT OF GONORRHOEA. As every form of the venereal dis- ease 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, there- fore, that it must be no difficult task to cure the disease, when in the form of inflammation and suppuration in the urethra. Experience, however, teach- es us, 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 ofthe venereal disease; many cases termina- ting in a week, while others continue for months, under the same treatment. The only curative object is, to de- stroy the disposition and specific mode of action in the solids of the parts, and as they become changed, tiie peissn* 384 GONORRHOEA. eus quality ofthe matter produced will also be destroyed. This effects the cure of the disease, but not always of the consequences. This form of the disease is not ca- pable of being continued beyond a cer- tain time in any constitution; and when it is violent, or of long duration, it is owing to the part being very suscepti- ble of such irritation, and readily re- taining it. As we have no specific re- medy for the gonorrhoea, it is fortunate that lime alone will effect a cure. It is worthy of consideration, however, whe- ther medicine can be of any service. Mr. Hunter is inclined not to think it ofthe least use, perhaps, once in ten cases. Hut even this would be of some consequence, if the cases capa- ble of being benefited could be distin- guished. The means of cure, i; cncrally adopt- ed, are of two kinds, internal remedies, and local applications; but, whatever plan is pursued, we are always to at- tend more to the nature of the constitu- tion, or to any attending disease in the parts themselves, or parts connected with them, than to tiie gonorrhoea it- Self. When the symptoms arc violent, but of the common inflammatory kind, known from the extent ofthe inflamma- tion not exceeding the specific distance, the local treatment may be either irri- tating or soothing. Irritating applications, in these ca- ses, are less dangerous, than when tliere exists irritable inflammation, and they may alter the specific action; but, to produce this effect, their irritation must be greater, than that of the original in- jury. The parts will afterwards reco- ver of themselves, as from any otiier common inflammation. Mr. Hunter believes, however, that the soothing plan is the best at the be- ginning. If the inflammation be great, and ofthe irritable kind, no violence is to be used, for it would only increase the symptoms; nothing should be done that may tend to stop the discharge, as doing so would not put a stop to the in- flammation. The constitution is to be altered, if possible, by remedies adapt- ed to each disposition, with a view of altering the actions of the parts arising from such 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 al- lowed to wear itself out. When the inflammation has abated, the cure may be attempted by internal remedies, or local applications, not ope- rating violently, which might repro- duce the irritat ion. 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 tiie symptoms for a time; but, when it is left off, they will often abate, or wholly disappear. In such a state of parts, astringents may be used, the discharge being now the only thing to be removed. When itching, pain, and other un- common sensations are felt for some time before the discharge appears, Mr. Hunter diffidently expresses his incli- nation to recommend the soothing plan, instead of the irritating one, in order to bring- on the discharge, whicii is a step towards the resolution of* the irri- tation ; and he adds, that to use astrin- gents would be bad practice, as by re- tarding the discharge, they would pro- tract the cure. When there are stric- tures, or swelled testicles, astringents should not be used; for, while there is a discharge, such complaints are re- lieved. Mr. Hunter thus expresses himself in regard to the effect of mercury in gonorrhoea: "1 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 mercu- ry as with it, &c. So little effect, in- deed, has this medicine upon a gonor- rhoea, that I have known a gonorrhoea take place while (the patient was) un- der a course of mercury, sufficient lor the cure of a chancre. Men have al- so been known to contract a gonorrhoea when loaded w ith mercury for the cure of a lues venerea; the gonorrhoea, ne- vertheless, has been as difficult of cure as in ordinary cases." Mr. Hunter does not say much in fa- vour of evacuants, diuretics, and astrin- gents, 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, m.iy help to lessen the discharge, in proportion as the inflammation abates. Local applications may be either in- ternal to the urethra, external to the penis, or both. Those which are ap- phed to the urethra seem to promise - GONORRHOEA. 385 mo9t 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 temporary application. The solid ones, or bougies, may remain a long while, but in general 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 bail effects from them, when applied with caution. The fluid applications, or injections, in use, are innumerable; and as gonor- rhoeas frequently get well with so many of various kinds, we may infer, that such complaints would, in time, get well of themselves. Injections, how- ever, certainly often have an immedi- ate effect on the symptoms, and hence must have power -, though the one whicii possesses the greatest specific power is unknown. As injections are only temporary applications, they must be used often, especially when found useful, and they are not of an irritating kind. Mr. Hunter divides injections into four kinds, the irritating, sedative, emol- lient, and astringent. Irritating injections, of whatever kind, act in this disease upon the same principle; that is, by producing an ir- ritation of another kind, wliich ought to be greater than the venereal; by which means the venereal is destroyed and lost, and the disease cured, although the pain and discharge may still be kept up by the injection. Those ef- fects, however, will soon go off, when the injection is laid aside. In this way bougies also perform a cure. Most of the irritating injections have an astrin- gent effect, and prove simply astringent when mild. Irritating injections should never be used when there is already much fo. flammation; especially, in constitu- tions, which are known to be incapable of bearing much irritation; nor should they be used when the inflammation has spread beyond the specific distance; nor when the testicles are tender; nor when, upon the discharge ceasing quick- ly, these parts have become sore; nor when the perinxum is very susceptible of inflammation, and especially if it for- merly should have suppurated; nor w hen there is a tendency in the blad- der to irritation, known by the frequen- cy of making water. VOL. I. In mild cases, and in constitutions which are not irritable, such injections often succeed, and remove the disease almost immediately. The practice, however, ought to be attempted with caution, and not, perhaps, till milder methods have failed. Two grains of the hydrargyrus muriatus, dissolved in eight ounces of distilled water, form a very good irritating injection ; but, an injection of only half this strength may be used, when it is not intended to at- tempt a cure so quickly. If, however, the injection, even in that proportion, gives considerable pain in its applica- tion, or occasions a great increase of pain in making water, it should be di- luted. Sedative injections will always be of service, when the inflammation is con- siderable, and they are very useful in relieving the pain. Perhaps, the hes\ sedative is opium, as well when given by the mouth, or anus, as when applied to the part affected, in the form of an injection. But, even opium will not act as a sedative in all constitutions, and parts; but, on the contrary, often has opposite effects, producing great irrita- bility. Lead may he reckoned a seda- tive, so far as it abates inflammation, while, at the same time, it may act as a gentle astringent. Fourteen grains of saccharum saturni, in Jviij of dis- tilled water, make a good sedative as- tringent injection. Drinking freely of diluting waters 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 is there, and to the urethra in its passage through it. Diluting drinks may possibly lessen the .-sus- ceptibility of irritation. The vegeta- ble mucilages of certain seeds and plants, and the emollient gums are re- commended.—Mr- Hunter does not en- tertain much opinion of their efficacy, though some of his patients told him they experienced less uneasiness in making water, when their drink was impregnated with mucilaginous sub- stances. Emollient injections are the most proper, when the inflammation is very great; and they probably act by first simply washing away the matter, and then ieaving a soft application to the part, so as to be singularly serviceable, by lessening the irritating effects of the urine. Indeed, practice proves 4,9 386 GONORRHOEA. this ; for a solution of gum-arabic, milk and water, or sweet oil, will often les- sen the pain, and other symptoms, when the more active injections have done nothing, or seemed to do harm. The irritation at tiie 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 inflammation has abated; but, in the mean wliile, fomentations may be employed. Astringent injections act by lessen- ing the discharge. They should only be used towards the latter end of the disease, when it has become mild. But, if the disease should begin mildly, they may be used at the very begin- ning ; for, by gradually lessening the discharge, without increasing the in- flammation, we complete the cure, and prevent a continuance of the discharge called gleet. They will have an irri- tating quality, if used strong, and hence increase the discharge, instead of les- sening it Mr. Hunter's experience did not teach him, that one astringent was much better than another. The astrin- gent gums, as dragon's blood, the bal- sams, aud the turpentines, dissolved in water ; the juices of many vegetables, as oak bark, Peruvian bark, tormentii root, and, 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 ex- ternal applications are poultices and fomentations, which can only be useful when the prepuce, glans, and orifice ofthe urethra are inflamed. Since Mr. Hunter's time, many sur- geons have been in the habit of* keep- ing the penis, in the incipient inflamma- tory stage of gonorrhoea, covered with linen, kept continually wet with the sa- turnine lotion ; a practice wliich is cer- tainly both rational and beneficial. Mr. Abernethy, in his Lectures on Surgery, speaks in favour of this method. When the glands of the urethra are enlarged, mercurial ointment may be rubbed on the part ; and this will pro- bably be of more service after the in- flammation has subsided. TREATMENT OF GONORRHOEA IN WOMEN. This is nearly the same as that of the disease in men, but is more simple. When the disorder is in the vagina, in- jections are best; and after them, the parts may be smeared with mercurial ointment, and the external parts wash- ed with the injection. It is almost im- possible for the patient to throw an in- jection into the urethra, when it is af- f'ected. The same injections are pro- per as for men ; but they may be made doubly strong. When the glands of the vagina are enlarged, mercurial ointment should be freely applied; and when they form abscesses, these should be opened and dressed. CONSTITUTIONAL TREATMENT OF GONORRHOEA. In many strong plethoric constitu- tions, the symptoms are v iolent, and there is a great tendency to inflamma- tory fever. In such instances, opiate clysters, though at first productive of relief, sometimes occasion in the end fever, and consequently aggravate all the symptoms. The balsam capivi, sometimes, in such cases, increases the inflammatory symptoms. The treat- ment of this kind of constitution, con- sists chiefly in evacuations, the best of which are bleeding and gentle pur. ging. To live sparingly, and, above all, to use little exercise, is necessary. In the weak and irritable constitu- tion, the symptoms are frequently very violent, the inflammation extending beyond the specific distance, running along the urethra, and even affecting the bladder. The indication, in tins instance, is to strengthen ; and bark alone has been known to effect a cure. All evacuations are hurtful. The fever has been known to stop the discharge, relieve the pain in mak- ing water, and finally cure the disease. On other occasions, Mr. Hunter has seen all the symptoms of gonorrhoea cease on the accession of a fever, and return when the fever was subdued. In other examples, a gonorrhoea mild at first, has been rendered severe by the coming on of a fever, and, on this ceas. ing, the gonorrhoea has ceased. Al- though a fever does not alwavs cure a gonorrhoea, yet, as it may do so, no- thing should be done while it lasts. If the local complaint should continue af. ter the fever is gone, it is to be treated according to symptoms. A gonorrhoea may be considerably affected by the patient's manner of hvmg, and by other diseases attacking GONORRHOEA. 387 the constitution. Most things which hurry or increase the circulation, ag- gravate the symptoms ; such as violent exercise, drinking strong liquors, eat- ing strong indigestible food, some kinds of which act specifically on these parts, so as to increase the symptoms more than simply heating the body would do; such as peppers, spices, and spirits. In cases which have begun mildly, in which the inflammation is only slight, or in others, in which the vio- lent symptoms have subsided, such medicines as have a tendency to lessen the discharge, may be given, together with the local remedies before men- tioned. Turpentines are the most effi- cacious. Cantharides, the salts of lead and copper, and alum, have also been recommended. Mr. Hunter advises small doses of mercury, in consequence of the possi- bility of absorption, and with a view of preventing lues venerea. TREATMENT OF OCCASIONAL SYMP- TOMS OF GONORRHOEA. Bleeding from the urethra is some- times relieved by the balsam, capivi. Mr. Hunter did not find astringent in- jections of use. Painful erections are greatly prevent- ed by taking twenty drops of tinctura opii at bed-time. Cicuta has also some power in this way. 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 perinae- um. When this affection lasts a consi- derable time, and is not mitigated by common methods, Mr. Hunter advises trying an opiate plaster on the pubes, or the loins, where the nerves of the bladder originate ; or a small blister on the perinaeum. In another place, he mentions bark, cicuta, sea air, and sea bathing, among the proper means. Swelled testicle. See Hernia Humor- alis. For a more full account of Gonor- rhoea, according to the above doctrines, see a Treatise on the Venereal Disease, by John Hunter, from page 29 to 90. ON THE QUESTION, WHETHER GO- NORRHOEA IS REALLY A FORM OF THE VENEREAL DISEASE ' The foregoing remarks, and other ones in Mr. Hunter's work, would lead one to believe, that the poison of go- norrhoea and the venereal virus are the same. Here it is our duty impartially to state the arguments which have been urged for, and against, this important doctrine. Mr. Hunter assures us, that he has seen all the symptoms of lues venerea originating from gonorrhoea alone; that he had even produced venereal chan- cres by inoculating with the matter of gonorrhoea; and that he afterwards re- peated these experiments in a manner in whicii he could not be deceived. P. 294, & seq. Mr. Hunter's experiments, it is true, have been repeated with a different re- sult ; but, as an eminent modern writer remarks, can we wonder at this, when we consider from how many causes go- norrhoea may arise, and how impossible it is to distinguish the venereal from any other ? (Observations on Morbid Poisons, by J. Adams, M. D. p. 91. edit. 2.) Another argument adduced by Hun- ter, in favour of the poisons of gonor- rhoea and chancres being the same, is the probability, that the Otaheiteans had the venereal disease propagated to them by European sailors, 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 applica- tion of venereal poison to the penis, and the commencement of ulceration. Therefore, Bougainville's sailors, allud- ed to by Mr. Hunter, might have con- tracted the infection at Rio-de-la-Plata; but actual ulcers on the penis might not have formed till about five months afterwards, when the ship arrived at Otaheite. (See First Lines ofthe Prac- tice of Surgery, p. 411.) In attempting to explain why a go- norrhoea and a chancre do not equally produce lues venerea, and why the medicine which almost universally 388 GONORRHOEA. cures chancre, has less effect on gonor- rhoea, a modern advocate for Mr. Hun- ter's doctrine, says, that we must take into consideration, that the seat of the two diseases is different; that the same cause may produce different effects up- on different parts ; that the same pois- on, when mixed with different fluids, may be more or less violent in its ope- ration ; and that there may be greater or less attraction of certain fluids to a part, according to its nature and com- position. (Inquiry into some Effects of the Venereal Poison, by S. Sawrey, 1802, p. 4.) Mr. Sawrey very truly remarks, p. 6, that if gonorrheal matter has clearly and decidedly produced chan- cre, or contaminated the system, in any one instance, the question is deter- mined. It could in no instance produce these effects, unless it had tiie power of doing so. This writer brings for- ward some cases to shew, that the pois- on of gonorrhoea may produce gonor- rhoea, or chancre; but, the limits of this work only afford room to observe, that these instances are by no means decisive of the point, as some objec- tions may be urged against them, as, indeed, Mr. Sawrey himself allows. That Mr. Hunter's cases are inconclu- sive, I have endeavoured to explain in the First Lines of the Practice of Sur- gery, to which 1 must refer my read- ers. Why does not gonorrhoea commonly produce ulceration in the urethra ? Mr. Sawrey tries to solve this question, by saying, that the product of the venere- al inflammation, the diseased contents of the small arteries of the urethra, are thrown out of these open-mouthed ves- sels into this canal, without any breach in the texture, which otherwise would be a necessary consequence. Why does not gonorrhoea equally contaminate the system as chancre ? In gonorrhoea, says Mr. Sawrey, the dis- charge is very plentiful; it is not, in general, attended with ulceration; the poison is much more diluted, and mix- ed with a mucous and puriform fluid. It is deposited in the urethra, and its lacunae, where little or no pressure is applied, and it finds easy egress out of the canal. In chancre there is a breach of substance, the poison is not much diluted, &c. Why does not chancre generally, in tiie same person, produce gonorrhoea, and gonorrhoea chancre ." Mr. Sawrey, in answer, expresses his belief, that these incidents are not very unfrequent^ He says, he has known persons having a chancre, which continued for months, become affected, after that time, with a clap, without any further exposure. His opinion is, that the matter of a chancre had insinuated itself into the urethra, and produced the disease; though, he confesses, many would ex- plain the circumstance, by supposing that the chancre and gonorrhoea were both communicated at the same time by two different poisons. Mr. Hunter remarks, that the presence of" one disease renders the adjacent parts less susceptible of its influence. Mr. Sawrey concludes his second chap, with inclining to the idea, that the matter of gonorrhoea is not strictly pus, but of a more mucous nature than that of a chancre. However, when he mentions chemical attractions, as draw- ing the poison from mucus to the ure- thra, and from pus to the dry parts, in order to explain the last of the above questions, every sober reader must feel sorry, that a work, which contains some really sensible observations, should comprehend this most unfortu- nate one. Mr. Whately has also written, in support of the opinion, that the matter of gonorrhoea and that of chancre, are the same. (See IVhately on Gonorrhoea Viruknta.) Another defender of this side of the question is Dr. Swediaur, who endeav- ours to prove the fallacy of the follow- ing positions : 1. That the poison which produces the clap, does never, like that of chancres, produce any venereal symptoms in the mass or lues itself. 2. That the poison of the clap never produces chancres, and that the poison of chancres never pro- duces a clap. 3. That mercury never contributes to, nor accelerates the cure of a clap ; but that, on the contrary, every bknnorrhagia may be certainly cured without mercury, and without any danger of leaving a lues behind. His arguments run thus :—the reason why claps do not, like chancres, con- stantly produce the lues, is, that the most of them excite only a superficial inflammation in the membrane of the urethra, without any ulceration. Hence absorption cannot easily take place, the poison being out of the course of the circulation. But he has seen claps, with an ulcer in the urethra, followed by tlie most unequivocal symptoms of lues itself. He mentions the urethra GONORRHOEA. 389 !*-ing defended with a large quantity of mucus, as the thing impeding the common formation of ulcers, which do occasionally occur when the mucus is not secreted as usual, or is washed away. He asserts, that in many cases, where he had occasion to examine both parties, he was convinced that chancres were communicated by a person affect- ed with a simple gonorrhoea ; and, vice versa, that a virulent clap had been the consequence of an infection from a per- son having merely chancres. He says, that if a patient, with a venereal run- ning, does not take care to keep the prepuce and glans perfectly clean, chancres will very often be produced. He owns a great many claps are cured without mercury; yet, repeated expe- rience has shewn him, a cure cannot always be thus accomplished. Mild cases, without ulcer or excoriation in tiie urethra, may certainly be radically cured without a grain of mercury; and though mercury should be given, it would not have the least effect: not be- cause the disease does not proceed from a venereal poison, but because out of the course of the circulation. He con- tends, that the topical use of mercury in injections, acts usefully even in these cases. But, when a clap is joined with ulceration in the urethra, it is always cured more safely and expeditiously with mercury, and is frequently incur- able without it. A lues also follows cases attended with ulcers in the ure- thra. He allows that all claps are not venereal. (See Practical Observations on Venereal Complaints, by J. Swedi- aur.) One argument urged against the identity of gonorrhoea!, and chancrous virus, is, that gonorrhoea was not des- cribed as a symptom, till nearly half a century after the other symptoms of the venereal disease were known. Fal- lopius is among the first who observed gonorrhoea as a symptom of the vene- real disease. " If, however," says Dr. Adams, " venereal gonorrhoea was un- noticed till ubout fifty years after the other forms of the disease were describ- ed, what does this prove, but that con- tagious genorrhaea was so common, as to be disregarded as a symptom of the new comphiiut ? Can there be a doubt, from the caution given by Moses, that gonorrhoea was considered as conta- gious in his days ? During the classical age, we find inconveniences of the uri- nary passages, were imputed to incon- tinence ; and the police of several states, before the siege of Naples, made laws for preserving the health of such as would content themselves with public stews, instead of disturbing the peace of families. This is enough to lessen our surprise, that gonorrhoea should be unnoticed for some time after the ap- pearance of the veneral disease. But, so far is it from proving the two conta- gions are different, that the fairest in- ference we can draw is in favour of their identity. For, if by this time the venereal disease began to be so far un- derstood, that secondary symptoms were found the consequence of prima- ry ones in tiie genitals, it is most prob- able that the first suspicion of venereal gonorrhoea arose from tiie occurrence of such secondary appearances, where no other primary symptoms could be traced." (Adams on Morbid Poisons, p. 95. edit. 2.) In relating the arguments maintained by the best modern writers, to repel the attacks made on the doctrine, that gon- orrhoea and chancre arise from the same poison, we have been compelled to dis- close the" chief grounds," on which the assailants venture to entertain a contra- ry theory. Mr. B. Bell is the principal author who has written against the opinions maintained by Hunter, Sawrey, Swedi- aur, Adams, &c. Our limits wiRonly allow us j ust to enumerate a few of his leading arguments. If the matter of gonorrhoea, and that of chancre, were of the same nature, we must admit that a person with a chancre only, can communicate to another, not only every symptom of pox, but of gonorrhoea ; and that another, with gonorrhoea only, can give to all, w ith whom he may have connex- ion, chancres, with their various conse- quences. This ought, indeed, to be a very frequent occurrence ; whereas, all allow that it is even in appearance very rare. On the supposition of the matter of gonorrhoea and lues venerea being the same, the latter ought to be a much more frequent occurrence than the for- mer, from the greater ease with which the matter of infection must, "in every instance, be applied to those parts on w hich it can produce chancres, than to the urethra, where, instead of chancre or ulceration, it almost always excites gonorrhoea. It is difficult to conceive how the matter, by which the disease 390 GON GRA is communicated, should find access into the urethra; wliile all the external parts of the penis, particularly the glans, must be easily and universally exposed to it; and yet gonorrhoea is a much more frequent disease than pox. Cases of gonorrhoea are in proportion to those of chancre, according to Mr. B. Bell's experience, as three to one. It is obvious that tiie very reverse should happen, if the two diseases were pro- duced by the same kind of matter. I need not adduce other arguments, as the reader must be already acquaint- ed with any worth knowing, from what is said in the previous part of the pre- sent article. The grand practical consideration, depending on the possibility of the ve- nereal disease arising from gonorrhoea, is, whether mercurials should not be exliibited, in all cases, with a view of preventing such a consequence. Waving, on my own part, all at- tempts to decide the point, whether the matter of a chancre, and that of gonorrhoea, are of the same nature, I shall merely content myself with stat- ing, that, as far as my observation and inquiries extend, the majority of the best practitioners of the present day consider the exhibition of mercury un- necessary, and, consequently, impro- per in cases of gonorrhoea. This fact almost amounts to a proof, that if ve- nereal symptoms do ever follow a clap, they are so excessively rare, and, I may add, always so imputable to other causes, that the employment of mercury, as a prevention, would, upon the whole, do more injury than benefit to mankind ; and this even admitting (what, in my mind, has never been un- equivocally proved) that the matter of gonorrhoea is really capable, in a very few instances, of giving rise to the ve- nereal disease. The reader must weigh the different arguments himself. Some of Mr. B. Bell's reasoning is certainly untenable, as Sawrey has clearly shewn ; but the latter, also, is not invulnerable in many points, which he strives to defend. The reader is referred, for further in- formation, to A Treatise on the Venereal Disease, by John Hunter ; 1788. Whate- ly on the Gonorrhoea Viniknta,- 1801. Practical Observations on Venereal Com- plaints, by F. Swediaur, M. D. edit. 3. An Inquiry into some of the Effects of tlie Venereal Poison, by S. Sawrey; 1802. Observations on Morbid Poisons, by J. Adams, M. D. edit. 2. 1807- GRANULATIONS, (from granum, a grain.) The little grain-like, fleshy bodies, which form on the surfaces of ulcers, and suppurating wounds, and serve both for filling up the cavities, and bringing nearer together and unit- ing their sides. Nature, in bringing parts as nearly as possible to their original state, whose disposition, action, and structure have been altered by accident, or disease ; and after having, in her operations for this purpose, formed pus, she immedi- ately sets about forming new matter, upon surfaces in which there has been a breach of continuity. This process is called granulating, or incarnation; and the substance formed is called granulations. Granulations are an accretion of ani- mal matter upon the wounded, or ex- posed surface; they are formed by an exudation of the coagulating lymph from the vessels ; into which new sub- stance, both the old vessels probably extend, and in which new ones are formed. Hence granulations are very vascular ; indeed, more so than almost any other animal substance. The ves- sels in granulations pass from the ori- ginal parts to their basis, and thence towards their external surface, in to- lerably regular parallel lines. The sur- face of this new substance has the same disposition to secrete pus, as the parts which produced it. The surfa- ces of granulations are very convex, the reverse of ulceration, having a great many small points, or eminences, so as to appear rough. The smaller such points are, the more healthy the granulations. The colour of healthy granulations, is a deep florid red. When livid, they are unhealthy, and haveonly a languid circulation. Healthy granulations, on an exposed or flat sur- face, rise nearly even with the surface of the surrounding skin, and often a little higher ; but, when they exceed this, and take on a growing disposition, they are unhealthy, become soft, spon- gy, and without any disposition to form skin. Healthy granulations are always prone to unite to each other, so as to be the means of uniting parts. Granulations are not easily formed on the side of an abscess, nearest the surface ofthe body. GUA GUN 391 They are not endowed with the ■ame powers as parts originally form- ed. Hence they more readily ulcerate, and mortify. The curious mode in which granulations contract, when sores are healing, and even for some time after they are healed, we have explain- ed in the article Cicatrization. (See A Treatise on the Blood, Inflammation, &c. by John Hunter, p. 473, et sea. 1794.) GUAIACUM, (from an Indian word.) Many writers of the sixteenth century, contended that guaiacum was a true specific for the venereal disease ; and the celebrated Boerhaave, in the eigh- teenth, maintained the same opinion. Mr. Pearson mentions, that when he was first intrusted with the care of the Lock Hospital, in 1781, Mr. Bromfield and Mr. Williams were in the habit of reposing great confidence in the effica- cy of a decoction of guaiacum wood. This was administered to such patients as had already employed the usual quantity of mercury; but who com- plained of nocturnal pains, or had gum- mata, nodes, ozxna, and such other ef- fects of the venereal virus, connected with secondary symptoms, as did not yield to a course of mercurial frictions. The diet consisted of raisins, and hard biscuit; from two to four pints of the decoction were taken every day; the hot bath was used twice a week ; and a dose of antimonial wine and lauda- num, or Dover's powder, was common- ly taken every evening. Constant con- finement to bed was not deemed ne- cessary ; neither was exposure to the vapour of burning spirit, with a view of exciting perspiration, often practis- ed; as only a moist state of the skin was desired. This treatment was, sometimes, of singular advantage to those whose health had sustained in- jury from the disease, long confine- ment, and mercury. The strength in- creased ; bad ulcers healed ; exfolia- tions were completed ; and these ano- malous symptoms, which would have been exasperated by mercury, soon yielded to guaiacum. Besides such cases, in which the good effects of guaiacum made it be erroneously regarded, as a specific for the lues venerea, the medicine was also formerly given, by some, on tiie first attack of the venereal disease. The disorder being thus benefited, a radical cure was considered to be accomplish- ed ; and, though frequent relapses fol- lowed, yet, as these partly yielded to the same remedy, its reputation was still kept up. Many diseases, also, wliich got well, were probably not re- ally venereal cases. Mr. Pearson seems to allow, that, in syphilitic affections, it may, indeed, operate like a true anti- dote, suspending, for a time, the pro- gress of certain venereal symptoms, and removing other appearances alto- gether ; but, he observes, that expe- rience has evinced, that the unsub- dued virus yet remains active in the constitution. Mr. Pearson has found guaiacum of little use in pains of the bones, except when it proved sudorific; but, that it was then inferior to antimony, or vola- tile alkali. When the constitution has been impaired by mercury, and long confinement, a thickened state of the ligaments, or periosteum, or foul ul- cers, still remaining, Mr. Pearson says, these effects will often subside, during the exhibition of the decoction. He says, it will often suspend, for a short time, the progress of certain secondary symptoms of the lues venerea ; for in- stance, ulcers of the tonsils, venereal eruptions, and even nodes. Mr. Pear- son, however, never knew one instance in whicii guaiacum eradicated the vi- rus ; and he contends, that, its being conjoined with mercury, neither in- creases the virtue of this mineral, les- sens its bad effects, nor diminishes the necessity of giving a certain quantity of it. Mr. Pearson remarks, that he has seen guaiacum produce good ef- fects in many patients having cutaneous diseases, the ozaena, and scrofulous af- fections of the membranes and liga- ments. (See Pearson on the Efl'ects of Various Articles in tlie Cure af Lues Ve- nerea, edit. 2. 1807.) GUMMA, a soft tumour, so named from the resemblance of its contents to gums. GUN-SHOT WOUNDS are made by the projection of hard obtuse bodies from cannons, muskets, &c.; but the latter fire-arm occasions by far the greatest number. These wounds are tiie most considerable of the contused kind; and what is to be said of" them, will apply, more or less, to all contused wounds, according to the degree of contusion. It is said, that a ball may injure parts of the body in two ways, namely, by actually striking them, and by passing near them, without touch- ing them at all. The latter case is 392 GUN-SHOT WOUNDS thought to be occasioned by the violent commotion produced in the air, by the rapid motion of* tlie ball; and consists of a contused, and even crushed state ofthe soft and hard parts, situated un- der the skin, whicii itself continues en- tire. Injuries, probably, never arise from such a cause. The air does not move with the same rapidity as the ball; but its motion is less in proportion as it is a more subtile matter, and must be too feeble to account for such a violent de- gree of injury. The air, to which the ball must really communicate the greatest motion, is what is directly be- fore it; and this never bruises the part untouched by the ball itself. It is only the air situated laterally to the shot, that is imagined to do injury, and it cannot be greatly agitated. The vio- lent consequences of" sudden explo- sions, and effects produced on the or- gans of hearing, by strong commo- tions of" the air, prove nothing relative to the point in question. 1 .astly, ex- perience does not confirm the reality of such wind contusions, for cannon- balls often tear off whole members, without the adjacent parts being in the least injured. (See V,e Vacher, in Mem. de I' Acad, de Clururgie, torn. 4. p. 22.) Neither can this kind of accident be attributed to an electrical shock on the parts, inconsequence of the ball being rendered electrical by friction in the calibre of the gun, and giving off the electricity as it passes by. (XideFknk's Sammlungen, 1 Theil. p. 99.) Metals never acquire this property from fric- tion. The mischief, imputed to the air, is occasioned by tlie ball itself. Its pro- ducing a violent contusion, without tearing the skin, and entering the limb, is to be ascribed to the oblique direc- tion in which it strikes the part. Daily observation evinces, that balls, which obliquely strike a surface, do not pene- trate, but are reflected ; though they may be impelled with tlie greatest force, and the body struck may be as soft and yielding as water. This al- teration in the course of the ball, not only happens on the surface of tiie hu- man bociv, but also in the substance of a limb wliich it has entered. A bone, a tendon, ike. may change the direction of a ball whicii touches them at all ob- liquely. Hence it is manifest how it happens, that the track of a gun-shot wound is not always straight, and how balls sometimes run under the inte- guments nearly all round the body, or a limb. A ball, when it strikes a part of the body, may cause four kinds of injury. 1. It may only occasion a contusion, without penetrating the part, on ac- count of its being too much spent, or of the oblique way in which it strikes the surface of the body. 2. It may en- ter and lodge in the surface of a part ; in which case, the track of the wound has only one aperture. 3. It may pierce through and through ; and then there are two openings, one at the entrance, the other at the exit of the ball. The circumference of the aperture, where the shot entered, is usually depressed ; that of the opening, from which it came out, elevated. At the entrance, there is commonly more contusion than at the exit of the ball. The former is generally narrower; the latter wider, and more irregular, especially when the round smootii figure of the ball has been changed by its having struck a bone. 4. A cannon-ball may tear off a whole limb. (Richter.) Gun-shot wounds differ very much, according to the kind of body project- ed, its velocity, and the nature and pe- culiarities of the parts injured. The projected bodies are mostly bullets, sometimes cannon-balls, sometimes pieces of broken shells, and very often, on board of ship, splinters of wood. From the contusion, which the parts suffer, on the violent passage of the ball through them, there is most com- monly a part of the solids surrounding the wound deadened, which is after- wards thrown off in the form of a slough, and which prevents such wounds from healing by the first intention, and makes most of them necessarily sup- purate. This does not take place equally in every gun-shot wound, nor in every part of the same wound ; and the difference commonly arises from the variety in the velocity of the body projected; for, where the ball has passed with little velocity, which is sometimes the case at their entrance, but, still more frequently at the part last wounded, the injury may often be healed by the first intention. (J. Hun- ter, p. 523.) Foreign bodies are more frequently met with in gun-shot wounds than any others, and are commonly of three kinds. 1- Pieces of clothing, or other things, which tlie ball forced before i* GUN-SHOT WOUNDS. 393 into the limb. 2. The ball itself. 3. Loose splinters of bone. It is only when the ball strikes a naked part, touches no bone, and goes through and through, that the wound can be free from extraneous matter. Foreign bo- dies are tiie cause of numerous unfa- vourable symptoms, by irritating sen- sible parts, and exciting pain, inflam- mation, convulsions, hemorrhage, long suppurations, ike. They are constantly more productive of such evils, the more uneven, pointed, and hard they are. Hence spiculx of bone are always the most to be dreaded. (Richter.) When a ball strikes a bone, the con- cussion produced is another occasion of bad symptoms, to be added to those already mentioned. When slight, its effects are confined to the injured limb. Sometimes they extend to the neigh- bouring joints, in which they produce inflammation and abscesses. It is commonly stated, in surgical books, that when a cannon-ball tears off a limb, it produces a most violent concussion of the whole body, and a general derangement of all its func- tions. This, however, is by no means true. I have lately seen, in London, a young sailor, whose arm was com- pletely torn off at the shoulder, by a cannon-ball from one of the forts at Guadaloupe, in March 1808; he suffer- ed no dreadful concussion of his body, nor were his senses at all impaired. This case was very remarkable, as the scapula was so shattered, that Mr. Cumniings, of Antigua, was under the necessity of removing the whole of it. The patient recovered in two months. From the account I heard, I do not be- lieve the axillary artery bled immedi- ately after the accident. This young man was lately shewn to the gentle- men of St. Bartholomew's Hospital, quite well. There is one curious effect which oc- casionally follows gun-shot wounds; but, I do not pretend to understand tiie rationale of it: viz. inflammation and suppuration of some internal viscus af- terwards, especially ofthe liver. Seve- ral such cases are related in tiie Mem. de I'Acad. de Chirurgie. From tiie circumstance of the inner surface of gun-shot wounds being more or less deadened, they are late in infla- ming. But when a ball has fractured a bone, whicii fracture has occasioned great injury of the soft parts, indepen- dently of that caused immediately by vol. 1. the ball itself, the inflammation will come on as quickly, as in cases of com- pound fracture; because the deadened part bears no proportion to the lacera- tion or wound- in general. (J. Hunter, p. 524.) From the same circumstance of a part being often deadened, gun-shot wounds frequently cannot be complete- ly understood in the first instance, for, in many cases, it is at first impossible to know what parts are killed, whether bone, tendon, or soft part. Nor can this be ascertained tiU the slough se- parates, which often makes the wound much more complicated than was pre- viously imagined. For, very often,. some viscus, or a part of some viscus, or a part of some large artery, or even a bone, has been killed by the violence. If a piece of intestine has been killed, the contents of the bowel will begin to come through the wound when the slough separates. If a portion of a large blood-vessel be killed, a profuse, and even fatal hemorrhage may come on when the slough is detached, al- though not a drop of blood may have been previously lost. (See Hunter, p. 525.) When the ball moves with little ve- locity, tiie mischief is generally less ; the bones are not so hkely to be frac- tured; the parts are less deadened, ike. However, when the velocity is just great enough to splinter a bone, wliich is touched, the splintering is ge- nerally more extensive, than if the im- petus of the ball had been much great- er, in which case, it would rather have taken a piece 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 hkely to take a winding course. When a ball enters a part with great velocity, but is almost spent, when 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 littie or none about the exit, owing to the different degrees of celerity with which the ball traversed the parts. (See Hunter.) As tiie ends of the torn vessels are contused and compressed, gun-shot wounds have httle propensity to bleed much, and, unless very considerable vessels are lacerated, they do not bleed at all; sometimes not in this case. The greatest danger of bleeding is always 50 394 GUN-SHOT WOUNDS. when the dead parts are detached, eight or ten days after the injury. An- gular uneven bodies, such as pieces of iron, cut lead, ixc. always occasion far more dangerous wounds, than round even bodies, like leaden bullets. Wounds occasioned by a small shot, are fre- quently more perilous, than others pro- duced by larger balls; because their track is so narrow', that it cannot be traced, nor consequently the extra- neous body itself extracted. Such a shot oftentimes injures a viscus, when there is not the smallest external symp- tom of such an occurrence. Sometimes a great part ofthe danger, also, arises from the number of shots whicii have entered. TREATMENT OF GUN-SHOT WOUNDS. The first thing in the treatment of a gun-shot wound is to determine, whe- ther it is most advisable to amputate the limb immediately, or to undertake the cure of the wound. When a bone, especially at a joint, is very much shat- tered; when the fleshy parts, particu- larly the great blood-vessels and nerves, are lacerated; when the whole Umb 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 mortification commen- ces. But, besides this violent degree of injury, in which the propriety of am- putation is obvious, there are several lower degrees, in wliich it is often a difficult thing to decide whether am- putation is necessary or not. Here the surgeon must look not only to the in- jury, but also to the patient's constitu- tion, and even to external circumstan- ces, such as the possibility or impossi- bility of procuring good accommoda- tion, rest, attendance and pure air. But it is impossible to determine the ne- cessity of amputation by general rules. In every individual case, the surgeon must consider maturely the particular circumstances, before he ventures to decide. The grounds against the ope- ration are; tiie pain which it causes at a period when the whole system is dis- ordered by a terrible inj ury; the pri- vation of a limb; and frequent exam- ples, in whicii nature, aided by judici- ous surgery, repairs the most horrible wounds. The following are the rea- sons in favour of the operation. By it the patient gets rid of a dreadful con- tused wound, which threatens tlie greatest peril, and whicii is exchanged, as it were, for a simple incised one. The pain of amputation is not of more moment than the pain which the requi- site incisions, and the extraction of fo- reign bodies, would cause in case the operation is abandoned. The wound of amputation is not so much to be ap- prehended, as experience shews, that incisions, in cases of gun-shot wounds, are not only exempt from particular danger, but are often useful. The loss of the limb cannot be taken into the account; for, the surgeon only under- takes the operation where he designs to save the patient's life by that priva- tion, and anticipates that the part itself" cannot be preserved. Even, if he should deprive the patient of a limb, that, per- haps, might have been preserved, there is this atonement, that he can furnish him with an artificial leg, whicii often proves far more serviceable, than the lost limb would have proved, had it been preserved. Should the operation be fixed on, it is to be immediately per- formed above the wound. (Richter.) When amputation is deemed unne cessary, the surgeon, according to cus- tomary precepts, is to enlarge the wound by incisions. Such a dilatation has been said to have numerous advan- tages; to facilitate the extraction of foreign bodies; to occasion a topical 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 li- gamentous aponeuroses, which other- wise might give rise to spasmodic and other untoward symptoms. More modern experience, however, shews (Hunter, p. 529.) that the utility of such incisions has been overrated; that they generally increase the inflam- mation, which, in these cases, is so much to be apprehended; that wounds which are not dilated, commonly heal more speedily, than others which are; and, that there are only a few cases in whicii incisions are beneficial. The cases of gun-shot wounds are various. Sometimes the track of the ball lies superficially under the skin, and only has one opening. When it lies in soft parts, and the ball has nei- ther touched a bone, nor a considerable blood-vessel, all incisions are useless let the wound have one or two aper- tures. Though dilating the wound has GUN-SHOT WOUNDS. 39o been practised with a view of giving vent to matter, eschars, and foreign bodies, and even its whole track has been laid open, when superficial; yet, experience proves the inutility of such steps. As in the skin there is a real loss of substance, arising from a por- tion being driven inward before the ball, it follows, that the opening ofa gun-shot wound must be more capaci- ous than that of a punctured one. By the separation of sloughs, tiie wound becomes still more dilated, so that not only matter, but foreign bodies which approach the skin, may easily find an exit. Besides, 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. When a cannon-ball has torn off a limb, some advise the amputation of the stump, to procure the patient an even smooth incision, instead of an ir- regular, jagged, and highly dangerous wound. As the limb has commonly suffered a violent concussion, is almost bereft of sense, and power of motion, and the bone frequently has a fissure extending some way upward, the am- putation is also recommended to be done, if possible, above the nearest joint. Others condemn the operation in this instance, asserting, that such wounds may sometimes be healed, and that tiie constitution, immediately after such violence, is not in a favourable state for submitting to such a painful measure. But, as when the operation is not done, this kind of injuiy requires large and free incisions, for the extrac- tion of foreign bodies, the shortening of projecting muscles and tendons, the discharge of extravasated fluids and abscesses ; and, as these incisions are hkely to occasion at least as much irritation as amputation itself, without being productive of equal good, the last objection is not very weighty. The operation may, also, in many cases, be delayed until the immediate irritation of the injury on the system is over. The occasional healing of euch wounds only proves, that it is not altogether impossible, in every instance, to effect a cure without amputation. The sur- geon can tiie more readily make up his mind to amputate in this case, as it does not occasion the loss of a limb. However, it is very credible, that the injury may sometimes be so condition- ed, and the circumstances in which the patient finds himself such, that there are good grounds for deeming the ope- ration unnecessary, and even pernicious. No one would be j ustified in amputat- ing above the knee, when the Umb is injured at the foot or ankle. In gun-shot wounds, ligamentous fibres and fasciae, are often found going quite across them. It is advised to di- vide such parts completely, lest, when the wound inflames, they should cause violent spasms and nervous symptoms, and afterwards impede the discharge of matter and foreign bodies. No doubt this counsel is judicious. However, it is frequently difficult, at first, to discov- er and divide such parts, and then it is better to defer tiie incision until one can easily get at them without irritating the wound, and it is manifested, that their remaining undivided is the cause of inconvenience. These remarks arc, also, applicable to membranous expan- sions perceptible at the sides of tiie wound, and to entire fasciae, stretched over the inflamed muscles. Tlie extraction of foreign bodies ranks as one ofthe most urgent mo- tives for the dilatation of the wound, and, no doubt, it is right to remove, at first, as many of them as possible. Their lodgment irritates tiie wound, causes violent nervous and inflamma- tory symptoms, and copious suppura- tion ; circumstances which the timely extraction of them may prevent. Yet, let it be remembered, that the extrac- tion of foreign bodies is frequently at- tended with immense irritation, and that, while they he too firmly fixed in parts, it is often a matter of impossibil- ity. After the sloughs have separated, and the wound has become widened, suppuration frequently does not prevail long before the extraneous substances become loose, spontaneously approach the skin, and easily admit of removal without any dilatation. In cases, where from necessity, foreign bodies have not been removed at first, no disadvantages have occasionaUy resulted from their continuance. Hence, it is prudent, at first, to ex- tract only such foreign bodies as are near the external opening, quite loose, and removeable without much irrita- tion ; or such as press on parts of im- portance, and, thereby excite danger- ous symptoms. The surgeon should avoid interfering with those which arc- deeply and firmly lodged in the wound He should await suppuration, and the 396 GUN-SHOT WOUNDS. detachment of sloughs, and when the foreign bodies become moveable and ap- parent, he should extract them, with or without an incision, as circumstances may demand. The examination of the wound ought to be made as much as possible with the finger, which irritates less, and feels more distinctly, than a probe. Hand-screws, gimblets, bullet- drawers. &c. ought not be used to ex- tract foreign bodies, but only the fin- gers, or, at most, a fine pair of forceps, which is to be guided on the finger. The event of such treatment is vari- ous. Extraneous substances remaining in the wound, either loosen gradually, and come into view so as to be easily removeable ; or they continue conceal- ed, prevent the cure, and give birth to a fistulous ulcer. In some instances, the w ound closes, and the foreign bo- dies remain in the limb during life, without inconvenience; and, in otiier cases, after a time, they bring on a re- newal of inflammation and suppuration. Sometimes a foreign body varies its situation, sinking down, and afterwards making its appeal ance at a different part, where it may excite inflammation and suppuration. When the ball lodges in the wound, it is usually difficult to trace it, as the parts collapse after its passage. The ball does not regularly take a straight direction through the injured part, but, oftentimes, a very tortuous one. The latter circumstance is more apt to oc- cur, as the ball is more spent. In eve- ry case, in which it is not easily discov- erable, all painful examinations should be abandoned, and the foreign body left in its situation, where it rarely cre- ates any trouble. 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 skin. 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 baU lies so remotely from the skin that it can only just be felt, and the skin it- self is quite uninjured, no counter- opening ought to be made. The wound heals better when the ball is left in, and far less inflammation takes place in the vicinity of this extraneous body, than about the orifice of the wound. A counter-opening always renders the in- flammation at the bottom of the wound, as great as its orifice. It is better t« let the wound heal up, and extract the baU afterwards. (See Hunter, p. 541.) 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 loos- ened and extracted, by means of an el- evator with a thin and somewhat curv- ed extremity. Should the attempt fail, hope may still be entertained, that, when suppuration takes place, it will become loose, and admit of extraction. In case nothing of this kind should oc- cur, some advise the employment of a trepan to remove the ball from its situ- ation. As this cannot be done without great irritation, and experience proves that a ball may lie in a bone during life, without occasioning unpleasant symp- toms, it is obviously preferable to allow it to remain. Richter's Anfangsgr. der Wundarzn. Band. 1. Besides these principal circumstances, there are various contingent ones, which often demand a particular mode in making the incisions, and in the sub- sequent management. To explain them all here is impossible. Hemorrhage from a torn blood-vessel of considera- ble magnitude, for which a ligature is necessary, may require incisions to get at it. As soon as the requisite incisions are made, and foreign bodies extracted, the prime objects in the treatment of gun-shot wounds are then accomplish- ed, and the rest is, in reality, not differ- ent from the surgery of other wounds. With regard to probing gun-shot wounds ; when it is evident that the shot has passed out, and no particular object can be fulfilled by introducing an instrument, it is often better to dis- pense with such examinations, at least tiU suppuration has come on. Intro- ducing any instrument is generally pro- ductive both of pain and irritation. But when the ball, or any other extraneous substance, has lodged in the wound, and its situation is not immediately evi- dent, it will often be adviseable to search for it at once, that it may, if its situation wUl allow, be extracted before inflammation begins. The surgeon, therefore, considering all the circum- stances which can assist him in form- ing a reasonable 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. GUN-SHOT WOUNDS. 397 is very painful, and the course of the wound obscure, it will often be better to desist, and renew the search when suppuration has taken place, when it can be undertaken with more ease, and a greater prospect of success. When gun-shot wounds are inflamed, the ten- derness and swelling of the parts are peculiarly strong reasons against prob- ings, or efforts to extract foreign bo- dies, as long as this state lasts. (See Chevalier's Treatise on Gun-shot Wounds, p. 67—68. Edit. 3.) There is no fact in tiie practice of surgery better established, than that the cramming of narrow stabs and gun- shot wounds with lint is particularly hurtful. The only possible reason for doing so in the latter cases must be to keep the orifice of the wound from healing up, and confining extraneous bodies, matter, &c. The apprehension of this happening at first is quite un- founded ; for the inside of the mouth of the injured part is lined with a slough or eschar, which must necessa- rily be detached before the parts can heal. The first dressings, therefore, should be quite superficial, and of a mild unirritating nature. Hunter used to employ fomentations, pledgets of simple ointments, and, frequently, over the latter an emolhent poultice. In the suppurative stage of gun-shot wounds, poultices are also the best applications, and a little piece of Unt may be gently introduced into the mouth ofthe wound in order to preserve an outlet for the matter, extraneous bodies, and sloughs, which are making tiieir way outward. Possessing these ideas, I cannot al- together approve the following direc- tions, though they are certainly better than are given in many surgical books. " A smaU bit of soft lint may be placed Ughtly between the lips of the wound, in order to keep it from closing. In some instances, it should be introduced a Uttie beyond the lips, in order to con- duct off the fluids effused, and to pre- vent irregular adhesions from forming near the surface during the inflammatory stage i as these would impede the di- rect 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 bv 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 whatl considerobjectionable.name- ly, introducing lint on first dressing the wound, are too frivolous to need comment. When the track of the ball has two apertures, some advise a seton to be drawn through it, with a view of pre- venting a premature closure of the wound, and introducing proper appli- cations. A seton is, also, imagined to give free vent to pus, and to promote tiie evacuation of foreign bodies. But a gun-shot wound is littie inclined to close prematurely, and a seton rather obstructs the exit of pus, and may as easily push foreign bodies deeper into the limb as out of it. There are pre- ferable modes of applying the necessa- ry remedies, and, as a seton is an ex- traneous substance itself, its employ- ment must be deemed pernicious. Gun-shot wounds require, in gene- ral, the employment of antiphlogistic means, just as other cases attended with equal inflammation do. When they are in the inflamed state, the ap- plication of leeches is highly proper. Bleeding is recommended in these cases, and in such a manner, as if it were of more service in them than wounds in general. But the necessity for the practice is really not greater than in other wounds whicii have done the same degree of mischief, and from which the same quantity of inflamma- tion and other consequences are ex- pected. Bleeding is certainly proper here, just as it is in all considerable wounds attended with a strong full habit, and great chance of extensive in- flammation, and much symptomatic fe- ver. In every instance, however, the practitioner must take particular care not to be too bold in the practice of bleeding; for when the patient is re- duced below a certain degree, his strength is inadequate to support the large and long-continued suppurations which often cannot be avoided. (See Hunter, p. 563, 564.) As the orifices of the vessels torn by the ball, are compressed, and, as it were obliterated, considerable hemor- rhage is seldom remarked at first. But after some days, and frequently at a very late period, when the sloughs se- parate, very copious hemorrhages are 398 GUN-SHOT WOUNDS. apt to occur, wliich are the more dan- gerous as they come on unexpectedly, and, oftentimes, when the suppuration has already induced great debility. A sense of heaviness, throbbing, and plethora, at the wounded part, often announces the approach of such an event. The surgeon himself may oc- casion the bleeding, by removing the dressings carelessly. Hence, in every case, where there is reason to appre- hend from the situation of the wound, that a considerable vessel is injured, the patient must be constantly and at- tentively watched, and every thing ne- cessary for the immediate stoppage of the hemorrhage must be provided. Another kind of hemorrhage, still more dangerous than the former, parti- cularly occurs in such gun-shot wounds as have long been in a state of copi- ous suppuration. The blood does not issue from one individual vessel, but from the whole surface of the wound, as from a sponge, and is so thin as to resemble blood and water. This he- morrhage is very dangerous, because it is very apt to completely exhaust the patient, who is already extremely debilitated, and its causes are difficult of* removal. The case demands the exhibition of bark, alum, and dilut- ed sulphuric acid. Decoctions of bark, and muriatic acid, may, at the same time, be applied to the wound. (Rich- ter.) Sometimes, in gun-shot wounds, the inflammation lasts very long, and there is no appearance of suppuration. In other instances, fresh inflammation comes on suddenly, during the suppu- rative stage, without any evident cause, and puts a stop to the secretion of mat- ter. Sometimes the wound suppurates to an extraordinary degree, without any perceptible reason. All these cir- cumstances often depend on splinters of bone remaining behind, wliich should be extracted as soon as it is practica- ble. (Richter.) For the first days, the matter sel- dom assumes a healthy appearance; but as soon as the sloughs separate, it then becomes of a proper quality, and the wound is to be treated as a simple abscess. Sometimes the healing process does not commence, after suppuration has prevailed for a considerable time. On the contrary, notwithstanding the ex- hibition of tonics, and a generous diet, the suppuration ceases to proceed vi- gorously, and the wound becomes un- healthy, and the matter thin. The bones shew no disposition to unite, and the patient, reduced by hectic symptoms, is rapidly advancing to dis- solution. In this state, life may some- times be preserved by amputation ; the anceps, but unicum remedium. We ought never to be deterred from un- dertaking the operation by the fever and weakness, which frequently soon disappear when the local cause is re- moved. GUTTA SERENA. A term, said to have been first applied by Actua- rius to amaurosis, or the species of blindness arising from an insensible state of the retina, or optic nerve. (See Amaurosis.) HEMATOCELE. 399 H HEMATOCELE, fromw^a, blood, and joixir, a tumour.) This is a swelling of the scrotum, or spermatic cord, proceeding from, or caused by, blood. A distinction of the different kinds of haematocele, though not usually made, is absolutely necessary toward rightly understanding the disease; the general idea, or conception of which, appears to Mr. Pott to be somewhat erroneous, and to have produced a prognostic whicii is iU founded, and hasty. Ac- cording to this eminent surgeon, " the disease, properly called haematocele, is of four kinds ; two of whicii have their seat within tiie tunica vaginalis testis; one within the albuginea; and the fourth in the tunica communis, or com- mon cellular membrane, investing the spermatic vessels. " In passing an instrument, in order to let out the water from an hydrocele ofthe vaginal coat, a vessel is some- times wounded, which is of such size, as to tinge the fluid pretty deeply at the time of its running out: the ori- fice becoming close, when the water is all discharged, and a plaster being ap- plied, the blood ceases to flow from thence, but insinuates itself partly into the cavity of the vaginal coat, and part- ly into the cells of the dartos ; making, sometimes, in the space ofa few hours, a tumour nearly equal in size to the original hydrocele. This is one spe- cies. " It sometimes happens, in tapping an hydrocele, that although the fluid discharged by that operation be per- fectly clear and limpid, yet, in a very short space of time, (sometimes in a few hours,) the scrotum becomes as large as it was before, and palpably as full of a fluid. If a new puncture be now made, the discharge, instead of being limpid (as before) is now either pure blood, or very bloody. This is another species : but, like the preced- ing, confined to the tunica vaginalis. "The whole vascular compages of the testicle is sometimes very much enlarged, and at the same time ren- dered so lax and loose, that the tu- mour produced thereby has, to the fin- gers of an examiner, very much the appearance of a sweUing composed of a mere fluid, supposed to be some- what thick or viscid. This is in some measure a deception; but not totally so: the greater part of the tumefac- tion is caused by the loosened tex- ture of the testis; but there is very frequently a quantity of extravasated blood also. " If this be supposed to be an hydro* cele, and pierced, the discharge will be mere blood. This is a third kind of hxmatocele ; and very different, in all its circumstances, from the two preceding .- the fluid is shed from the vessels of tiie glandular part of the testicle, and contained within the tu- nica albuginea. " The fourth consists in a rupture of, and an effusion of blood from, a branch of the spermatic vein, in its passage from the groin to the testicle. In wliich case, the extravasation is made into the tunica communis, or cel- lular membrane investing tiie sperma- tic vessels." Each of these four, Mr. Pott says, he has seen so distinctly, and perfect- ly, that he has not the smallest doubt concerning their existence, and of their difference from each other. " The tunica vaginalis testis, (he continues,) in a natural and healthy state, is a membrane, wliich, although firm, is of no great thickness ; it is white, or rather of a reddish white co- lour ; and its blood-vessels are (in a healthy state) no more apparent to the eye, than are those of the tnnica albu- ginea : but when it has been long or much distended, it thereby becomes thick, and tough; and the vessels (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 tiie instru- ment, wherewith the palliative cure is performed, it is sometimes wound- ed ; in which case, as I have already observed, the first part of the serum whicii is discharged, is pretty deeply tinged with blood. " Upon the collapsion of the mem- branes, and of the empty bag, this 400 HEMATOCELE. kind of hemorrhage generally ceases, and nothing more comes of it. But is sometimes happens, eitiier from the toughness of the tunic, or from the varicous state of the vessel, that the wound (especially if made by a lancet) does not immediately unite ; but con- tinues to discharge blood into the ca- vity of the said tunic, thereby pro- ducing a new tumour, and a fresh ne- cessity of operation." This is what Mr. Pott calls the first species of haematocele, which evident- ly consists in a wound of a vessel of the vaginal tunic. " Upon the sudden discharge of the fluid, from the bag of an over-stretch- ed hydrocele, and thereby removing all counter-pressure against the sides of the vessels, some of which are be- come varicous, one of them will, some- times, without having been wounded, burst. 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 the preceding, occasions a new tumour, and calls for a repetition of the operation." This, Mr. Pott caUs the second species : " wliich, like the first, belongs entirely to the vaginal coat, and has no concern either with the testicle, or with tiie spermatic vessels. In both, the 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 discharged by opening the containing cyst: but in neither of these can castration (though said to be the only remedy) be ever necessary: the mere division of the sacculus, and the application of dry lint to its in- side, will, in general, if not always, restrain the hemorrhage, anil answer every purpose, for wliich so severe a remedy has been prescribed. The other two are indeed of more conse- quence ; they interest either tiie testi- cle itself, or the vessels by which it is supplied with blood, and rendered ca- pable of executing its office ; and are sometimes not curable, but by removal, of the part. " One of these is seated within the tunica albuginea of the'testicle; the other in the tunica communis of its ves- sels : they are neither of them very fre- quent ; but when they do happen, they call for all our attention. " If blood be extravasated within the tunica albuginea, or proper coat of the testicle, in consequence of a great re- laxation, and (as it were) dissolution of part of tiie vascular compages of that gland, and the quantity be considera- ble, it will afford or produce a fluctua- tion, to the hand of an examiner, very like to that of an hydrocele of the tuni- ca vaginalis; allowing something for the different density of the different fluids, and the greater depth of the former from the surface. " If this be mistaken for a simple hy- drocele, and an opening be made, the discharge 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 ofthe consistence of thin chocolate (like to what is most frequently found in the imperforate vagina.) The quantity discharged will be much smaller than was expected from the size of the tu- mour; which size will not be conside- rably diminished. When this small quantity of blood has been so drawn off, the testicle will, upon examination, be found to be much larger than it ought to be; as well as much more loose and flabby; instead of that round- ness and resistance arising from an healthy state of the gland, within its Arm strong coat; it is soft, and capa- ble of being compressed almost flat, and that generally without any of that pain and uneasiness, which always at- tend the compression of a sound testi- cle. If the bleeding ceases upon the withdrawing the cannula (supposing a trochar to have been used) and the puncture closes, a fresh accumulation ofthe same kind of fluid is soon made, and the same degree of tumefaction is produced, as before the operation: if the orifice does not close, the hemor- rhage continues, and very soon becomes alarming. " In the two preceding species, the blood comes from the tunica vaginalis, the testis itself being safe, and uncon- cerned -, and the remedy is found, by opening tiie cavity of tiie said tunic; but in this, the hemorrhage comes from the substance ofthe testicle ; from the con volutions ol tiie spermatic artery, with- in the tunica albuginea: the division of * Hence, the last running of the water from an hydrocele, is bloody. HARE-LIP. 40! the vaginal coat can here do no good; and an incision made into the albugi- nea 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 cas- tration is the only cure, whicii a pa- tient in such circumstances can depend upon. " Tlie last species of tliis disease ari- ses from a bursting of a branch of the spermatic vein, between the groin and scrotum, in what is generally known by the name of the spermatic process. This, which is generally produced by gre at or sudden exertions of strength, feats of agility, &c. may happen to per- sons in the best health, whose blood and juices are in the best order, and whose genital parts are free from ble- mish, or disease. " The effusion, or extravasation, is made into the cellular membrane, whicii invests and envelopes the spermatic vessels, and has something the appear- ance of a true hernia. When the case is clear, and the extravasated blood does not give way to discutient appli- cations, 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 restrain- ed by mere compression with dry lint, or by the use of styptics; but if it be large, and these means do not succeed, the ligature must be made use of." (Pott's Chirurgical Works, Vol. II.) The bleeding point should be tied singly. It oan never be warrantable to tie the whole spermatic chord, and then perform castration, in a case like this, notwithstanding Mr. Pott advises this plan, in case the bleeding branch can- not be tied singly. Discutient applica- tions, and an occasional purge will al- most always disperse the swelling; and if not, opening it, taking out tlie blood, filling the cavity with lint, and using compression, one may say, will always answer. The best of the old writers on Hama- tocek, are Celsus and AUgineta; Pott has excelled every modern one. ILEMORRHAGIA. (See Hemor- rhage.) 1LEMORRHOIDES. (See Hemor- rhoids.) HARE-LIP. Labia Leporina. A fis- sure, or longitudinal division of one or both lips. Children are frequently bom with this kind of malformation, particularly of the upper lip. Sometimes the por- tions of the Up, which ought to be uni- ted, have a considerable interspace be- tween them; in other instances, they are not much apart. The cleft is occa- sionally double, there being a little lobe, or small portion of the lip, situa- ted between the two fissures. Every species of the deformity has the same appellation of hare-lip, in consequence of the imagined resemblance whicii the part has to the upper lip of a hare. The fissure commonly affects only the lip itself. In many cases, however, it extends along the bones of the pa- late, even as far as the uvula. Some- times these bones are totally wanting; sometimes, they are only divided by a fissure. Such a malformation is always pecu- liarly afflicting. In its least degree it constantly occasions considerable de- formity ; and when it is more marked, it frequently hinders infants from suck- ing, and makes it indispensable to nou- rish them by other means. When the lower lip alone is affected, which is not most frequently the case, the child can neither retain. its saliva, nor learn to speak, except with the greatest impe- diment. But when the fissure pervades the palate, the patient not only never articulates but very imperfectly, but cannot masticate nor swallow, except with great difficulty, on account of the food readily getting up into the nose. After these remarks, it is obviously very important to cure the malforma- tion as soon as possible. But as this object cannot be accomplished without an operation, attended with some de- gree of pain, several practitioners, as Dionis, Garengeot, and others, have advised waiting till the child is four or five years old, on tiie supposition, that, at an earlier age, the child's agitations and cries would render the operation impracticable, or derange all tiie pro- ceedings taken to ensure its success. It is plain, however, that such reasons are not exceedingly weighty. A child four or five years old, and, very often, even one eight or ten years of age, is more difficult to manage, in this cir- cumstance, than an infant only a few months old. There is no child, though advanced to that age, which has not a thousand times more dread ofthe pain than ofthe deformity, or ofthe incon- veniences of the complaint, te which he vol. 1. 51 402 HARELIP- is habituated; wliile an infant of tender years fears nothing, and only feels the pain ofthe moment. A more rational objection is tiie lia- bility of infants to convulsions after operations, and this has induced many excellent surgeons of the present day to advise postponing the cure of tiie hare-lip, till the child is about two years oldi Perhaps the apprehension, how- ever, does not vindicate the delay. Mr. Sharp observes, "there are ma- ny 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 likewise for- bid in young children, and with reason, if they suck; but otherwise it may be undertaken with great safety, and even with more probabiUty of success than in others that are older." (Operations in Surgery, chap. 34.) Le Dran has performed the operation on children of all ages, even on those at the breast. B. Bell did it with suc- cess on an infant only three months old. Muys advises it to be undertaken as soon as the child is six months old. Roonhuysen operated on children ten weeks after their birth, and all his con- temporaries have praised his singular dexterity and success. This latter sur- geon advises, as a step essential to the success ofthe operation, to hinder chil- dren from sleeping a certain time be- fore undertaking it, in order that they may fall asleep immediately afterwards. Opiates have also been recommended to ensure this occurrence. M. Louis is of opinion, that the operation done without any suture will succeed better on infants, than any other metliod. This subject, however, we shall treat of* in due time. All practitioners entertain the same sentiment with regard to the object of this operation, whicii consists in redu- cing the preternatural solution of con- tinuity to the state of a simple wound, by cutting off the edges ofthe separa- ted parts throughout their length, and then approximating these parts, so as to make them continue in contact until they have completely grown together. But although such principles are ad- mitted by all surgeons, all are not of the same opinion with respect to the method, wliich it is best to follow in practice; some having recourse to su- tures to keep the edges of tiie wound in contact; others disapproving of tlie plan, and believing that a perfect cure may always be accomplished by means of adhesive plaster and a uniting ban- dage, so as to save the patient a great deal of pain, wliich sutures always oc- casion. M. Louis has been the chief advo- cate for the method, whicii proscribes sutures, and he has published on this subject two very interesting memoirs, whicii we shall presently quote, for the purpose of informing the reader of the reasons, on which tliis celebrated man founded his opinion on this mat- ter, and of tiie means which he em- ployed. M. Louis thought that the use of su- tures, in the operation for the hare-lip, originated from a false idea which pre- vailed, respecting the nature of the disease. The fissure in the lip having been improperly imputed to a loss of substance, it was thought impossible to keep the parts in contact, except by a suture. " The separation of the edges ofthe fissure in the lip is only the effect of the retraction of the muscles, and is al- ways proportioned to the extent of the cleft. Those who have hare-lips are capable of bringing the edges of the fissure together by muscular action, when they pucker up their mouths. On the other hand, the separation is con- siderably increased when such persons laugh, and the breach appears exces- sively large, after superficially paring off its edges on both sides. Hence, the interspace in the hare-lip must not be mistaken for a loss of substance. The truth of this is confirmed by the effects of sticking plaster, wliich has some- times been applied to the hare-lip, as a preparatory measure before the opera- tion, and which exceedingly lessens the separation of the parts. " According to the confession of all who have written in favour of tiie twist- ed suture, it seems advisable only on the false idea, that the hare-lip is the effect of a greater or lesser loss of sub- stance ; and they say, positively, 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 natural hare-Up, since it is proved that this malformation is unattended with a loss of substance. But the loss of substance is but too real, after tlie extirpation of scirrhous and cancerous HARE-LIP. 403 tumours, to whicii the lips are very subject. Yet, even in these very cases, the extensibility of the lips allows an attempt to be made to reunite the dou- ble incision, by whicii the tumour has been removed, and it succeeds without the smaUest deformity, when care has been taken to direct each incision ob- liquely, so that both of them form, where they meet, an acute angle, in the base of whicii tiie tumour is comprised. It is on this occasion, that the means to procure an union ought to be the more efficacious, because the difficulty of keeping the edges of the wound ap- proximated is greater. M. Pibrac has already shewn, in his memoir on the abuse of sutures, when speaking ofthe hare-lip, that they are a badly conceiv- ed means, and more hurtful in propor- tion to the greater loss of substance, 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 dres- sings aid the operation of" the suture. After this consideration, judiciously made by the partisans of tliis plan, there was only one more step to be taken, ac- cording to M. Pibrac, in order to evince the necessity of proscribing it. The cap, or copper head-piece, des- cribed by Verduc and Nuck, for com- pressing the cheeks ; the clasps of Heister ; the strips of adhesive plaster, which no author has neglected express- ly to recommend; all this has been in- vented in order to support the parts, and keep them from being disunited. When the suture failed, it was by these means, 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 ap- plied, are capable of effectually rectify- ing the mischief of the suture, why should they be considered only as a re- source in a mere accidental case ? Why should they not be made the chief and primary means of reuniting the lips, even when tliere is a loss of substance " " Nothing can be opposed to. the proofs adduced upon this point. They are even drawn from the practice of those, who have employed sutures without success. Such persons them- selves have furnished the arguments in favour of the bandage being capable of repairing the mischief resulting from the twisted suture. Practitioners can only be vindicated in employing this suture by confessing, that the true principles of the art have not been es- tablished concerning this subject." M. Louis, with a view of perfecting our notions on this matter, lays it down as a fact, that, the retraction of the muscles being the cause of the sepa- ration 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 separation) is to be impeded, and whose contraction is thus to be prevented. A great many means for supporting the wound, only irritate the muscles and excite them to action, and it is this ac- tion which we should endeavour to overcome. The means for promoting a union can only be methodical, when directly employed to prevent such action, by an immediate application on the point where it is to be re- sisted. The facility, with which the parts may be brought forward, so as to bring the two commissures of the Ups into contact, by the mere pressure of the hands, shews what may be expect- ed from a very simple apparatus, which will execute the same office without any efforts, in a firm and permanent manner, and which will render sutures unnecessary, the inconveniences of which are too well known. M. Louis, after having explained the reasons of the theory, on which he founded his method, relates several cases, taken either from his own prac- tice, or that of others, to illustrate its advantages. He details the history of twenty cases, in which his plan per- fectly succeeded, both in accidental hare-lips, with considerable loss of sub- stance, and in natural ones. In most of these instances, however, it was thought proper to assist the bandage with one stitch at the extremity of the fissure, close to the vermilion border of the lip, for the purpose of keeping the parts securely on a level. Notwithstanding the operation, as performed with the twisted suture, is opposed by an authority of such weight as that of M. Louis, still it is the one most commonly practised. Few prac- titioners doubt that a hare-lip may be cured, by means of adhesive plaster, and uniting bandages, quite as perfect- ly as by a suture; and aU readily allow, that the first of these methods, as being more simple and less painful, would be 404 HARE-LIP. preferable to the latter one, if it were equally sure of succeeding. But it is considered far more uncertain in its effect. To accomplish a complete cure, the parts to be united must be main- tained in perfect contact, until they have contracted the necessary adhe- sion ; and how can we always depend upon a bandage keeping them from being displaced ? What other means, besides a suture, affords in tliis respect such perfect security ? We shall not take upon us to decide which of these two methods is the best, contenting ourselves with explain- ing the mode of proceeding in both, and leaving it for surgeons to deter- mine, by their own experience, and the evidence of facts, which one merits the preference. First, of the ancient plan. . Having placed the patient in a con- venient situation, the first thing is to examine whet her there is any adhesion of the lip to the gum ; and, if tliere be one, to divide it with a knife. Some authors (Sharp) recommend always dividing the fraenulum, which attaches the lip to the gum ; but, when the hare-lip is at some distance from this part, and will not be in the way in the operation, tliere is no need of dividing it; but, when the fraenulum is situated in the centre of the division, it is clear that, in operating, we must necessarily include it in the incision, and it must be divided beforehand, taking- care not to encroach too much upon the gum, lest the alveolary process should be laid bare; nor too much upon the lip, because making it thinner would be unfavourable to its union. Sometimes one of the incisor teeth being opposite the fissure, and project- ing forward, must be drawn, lest it should distend and irritate the parts, after they have been brought into con- tact. Sometimes also, but particularly in cases in which there is a cleft in the bony part of the 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 imprac- ticable. In this circumstance, the only plan is to cut off the projecting angles of bone, which may easily be done with a strong pair ot bone-nippers. In the operation, the grand object is to make the wound as smooth and even a cut as possible, in order that it may more certainly unite by the first inten- tion, and of such a shape, that the etc, atrix may form only one narrow line. The edges ofthe fissure should, there- fore, never be cut off* with scissars, which always bruise the fibres which they divide, and a sharp knife is al- ways to be preferred. The best plan is, either to place any flat instrument, such as a spatula, 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 under blade of which is much broader than the upper one : the first serves to support the lip ; the oth- er contributes also to this effect, and, at the same time, serves as a sort of rule in guiding the knife in an accu- rately straight line. When the forceps are preferred, 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 without f~\ this caution. For instance, / >v if the hare-lip had this shape, / J the incision of the edges must be con- tinued in straight lines, till they meet in the manner here repre- /\ sented. In short, the two JPx\ incisions are to be perfectly Ij yv straight, and are to meet at an angle above, in order that the whole track ofthe wound may be brought to- gether, and united by the first inten- tion. Two silver pins, made with steel points, are next to be introduced through the edges of the wound, so as to keep them accurately in contact. 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 low- er one, &c. Thus the thread is made to cross as many points of the wound as possible, which greatly contributes to maintaining its edges in an even appo- sition. It is obvious, that a great deal of exactness is requisite in introducing the pins, in order that the edges of the incision may afterwards be precisely applied to each other. For this pur- pose, some previously place the sides HARE-LIP. 405 of the wound in the best position, and mark with a pen the points at whicii the pins should enter, and come out again. The pins ought never to ex- tend more deeply than about two-thirds through the substance of the lip, and it would be a great improvement always to have them constructed a little curv- ed, as tliis is tiie course which they na- turally ought to take when introduced. The steel points should also admit of being easily taken off", when the pins have been applied; and, perhaps hav- ing them to screw off" and on is the best mode, as removing them in this way is not so likely to be attended with any sudden jerk, whicii might be injurious to the wound, as if" they were made to pull off. The pins may commonly be safely removed in about four days, after whicii the support of sticking-plaster will be quite sufficient. The process we have just been de- scribing, is what is well known by the name ofthe twisted suture. It is worthy of attention, that this su- ture is applicable to other surgical ca- ses, in which the grand object is to heal some fistula or opening, by the first in- tention. Mr. Sharp says, it is of great service in fistulae ofthe urethra, remain- ing after the operation for the stone, in which case the callous edges may be cut off, and the lips of the wound held together by the above method. What has hitherto been stated, re- fers to the most simple form of the hare-lip, viz. to that whicii presents on- ly one fissure. When there are two clefts, tiie cure is accomplished on the same principles; but, it is more diffi- cult of execution; indeed, so much so, that the old surgeons, until the time of Heister, have almost all regarded the operation for the double hare-lip, as impracticable, though they have descri- bed it, directing us to operate on each fissure, just as if there were only one. M. de la Faye, however, performed this operation with success, as may be learned in the Memoires de I'Acad. de Chirurgk, Tom. 1. But, we are indebt- ed to M. Louis for having obviated all the difficulties, by simply proposing to do the operation at two times, and to await the perfect cure of one of the fis- sures, before undertaking that of the other. Heister seems to have conceiv- ed a similar idea, about the same time, but he never put it in practice, nor did he even positively advise it. In cutting off the edges of the fis- sure, the incision must be carried to the upper part of the lip; and even when the fissure does not reach wholly up the lip, the same thing should be done; for, in this manner the sides of the wound will admit of* being applied together more uniformly, and the cica- trix will have a better appearance. We should also not be too sparing of the edges whicii are to be cut off. Prac- titioners, says M. Louis, persuaded that the hare-lip was a division with loss of substance, have invariably advised the removal of the callous edges. But, in the natural hare-lip there is no callosi- ty : the margins ofthe fissure are com- posed, like those of the lip itself, of a pulpy, fresh-coloured, vermilion flesh, covered with an exceedingly delicate cuticle. The whole ofthe part having this appearance, must be taken away, even encroaching a little way on the true skin. At the lower part of the fissure, towards the nearest commis- sure, a rounded red substance is com- monly situated, whicii it is absolutely necessary to include in the incision. Were this neglected, the union below would be unequal, and, through an in- judicious economy, a degree of defor- mity would remain, winch is always unpleasant, when it can be avoided. The grand object, however, is to make the two incisions diverge at an acute angle, so that the edges may be put in- to reciprocal contact their whole length, without the least inequality. M. Louis used to operate as follows: tiie patient being seated in a good light, his head is to be supported on an as- sistant's breast, who, with the fingers of both hands, pushes the cheeks for- ward, 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 rounded, by flattening the corners. To facilitate the incision, tiie lip is to be stretched over the paste- board, the operator holding- one por- tion over the right with the thumb and index finger of the left hand, while the assistant does the same thing on the left side. Things being thus disposed, the edges of the hare-lip are to be cut off with two sweeps ofthe bistoury, in 406 HARE-LIP. two oblique lines, forming an acute an- gle above the fissure. For a long while scissars were pre- ferred to a knife, for cutting off the edges of the hare-lip; but, they are now very generally disused for this purpose. The pinching and bruising, which result from the action of the two blades, in overlapping each other, are deemed obstacles to the union of the sides of tlie wound; for, the bruised fibres must necessarily suppurate; and, shght as this may be, the cure is at least retarded by it. Let not practi- tioners be led by Mr. B. Bell's stating, that in one instance he cut off one side of the fissure with a knife, and the other with scissars ? that the latter cut produced least pain, and that on this side there was no more swelling nor inflammation than on the opposite one. The pins should be introduced at least two thirds of the way through the substance of the lip, lest a furrow shouldremain on the inside ofthe part, which might prove troublesome, by al- lowing pieces of food to lodge in it. There is, however, a stronger reason for attending to this circumstance, viz. the hemorrhage which may take place when it is neglected. The bleeding almost always ceases, as soon as the edges ofthe wound have been brought together by means of the suture, when the pins are properly placed; but, when they have not been introduced deeply enough, the posterior surfaces ofthe incisions not been applied to each other, the blood may continue to run into the mouth, and give the surgeon an immense deal of trouble. In the memoir written by Louis, there is the history of a case, in whicii the patient died in consequence of such an acci- dent. Persons who had undergone the operation, were always advised to swal- low their spittle, even though mixed with blood, in order to avoid disturb- ing the wound, by getting rid of it otherwise. In the case alluded to, the patient, who had been operated upon for a cancer which he had in the lip, swallowed the blood as he had been directed to do, and he bled so profuse- ly as to die. On the examination of the body, the stomach, and small intestines were found full of blood. " This de- plorable case," says the illustrious au- thor who relates it, " deserves to be recorded for public instruction, for the purpose of keeping alive the attention of surgeons on all occasions, where, in consequence of any operation whatso- ever, there is reason to fear any bleed- ing in the cavity of the mouth. Platner is the only writer, who, as far as I know, foresaw this kind of danger. The bleeding from the edges of the wound stops of itself, (says he) as soon as they have been brought into con- tact, and stitched together; but, care must be taken that the patient does not swallow the blood, which might make him vomit, or else suffocate him. Hence his head should be elevated, that the blood may escape externally, a precaution more particularly necessa- ry in regard to young children." Having described the mode of ope- rating for the hare-lip, as approved of by the generality of practitioners, and detailed every thing which seemed material, we have now only to describe the method which M. Louis adopted. His sentiments respecting several par- ticular points ofthe operation, have been already stated; and an account ofthe means which he employed, in lieu of the twisted suture, for uniting the edges of the wound, is all we have to offer farther on the present subject. Different authors, as already men- tioned, have devised bandages for sup- porting the two portions of the divided lip, and lessening the pressure which they make against the pins designed for uniting them. Franco and Quesnay, in particular, have described two kinds, which have been considered very well calculated for this object; and these means were not only employed as auxiliary, but even sometimes as cu- rative ones, when it was impossible to use needles. To such bandages, too complicated and too uncertain, in their effect, M. Louis prefers a simple linen roller, one inch wide, three ells long, and rolled up into two unequal heads. He begins with applying the body of this bandage to the middle of the forehead: he unrolls the two heads, from before backward, above the ears, between the upper part of the carti- lage, and the cranium, in order to make them cross on the nape of the neck, and then be carried forward again. The assistant, who supports the head, and pushes forward the cheeks, must lift up the ends of his fingers, in the place of which, on each side, a thick compress is to be put. This being co- vered, and pushed from behind for- ward, by tlie roller, wiU constantly perform the office of the assistant's HARE-LIP. 407 fingers, who is to continue to support the apparatus, until it is all completely applied. The longest of the two heads ofthe roller, being slit in two places near the Up, presents two parallel open- ings; the remnant ofthe shortest one is divided into two parts, as far as its end. The two little narrow bands, in wliich it terminates, must be passed through the openings of the former, and made to cross upon the middle of the lip. The ends of the roller being carried from before backward, are then to be made to cross again on the nape of the neck, where the shortest is to end. The remainder of the long one is to be employed in making turns round the head. This bandage may be ren- dered much more stable, by a piece of tape, which is to pass the forehead, over the sagittal suture, and be pinned at each end to the circumvolutions of the roller; while a second piece of tape is to cross the first one at the top of the head, and also to be attached, at its extremities, to the uniting bandage, and the compresses, placed under the zygomatic arches, for the purpose of pushing forward the cheeks. This bandage is extremely simple, and would promise great advantages, even if its success had not been already proved by the cases wliich it has effect- ed under the hands of its inventor, and several other surgeons, who have em- ployed it, in consequence of his recom- mendation. Perhaps, if it has not been equally successful with others, this is rather owing to the defective manner of applying it, than to any fault in the plan itself. Howsoever it may be, it is much to be wished that tliis means were sufficiently certain in its effect, to become more generally adopted, so that the suture might be relinquished. All that we have said concerning the operation for the hare-lip, is equally applicable, not only to the treatment of cancer of the lip, but also to that of accidental cuts, or lacerations, of this part, from any cause whatsoever. We shall only remark that, in a recent wound, all the duty of the surgeon is to have recourse immediately, either to the twisted suture, or the uniting bandage. In cases, in which the fissures affects the bones forming the roof of the mouth, after the soft parts have been united in the manner above related, the bones, and other separated parts, are ordinarily observed to become approx- imated, and nature thus corrects, more or less, this kind of deformity. But this does not always happen, and when these parts remain so considerably se- parated, as to obstruct speech and de- glutition, or cause any other inconve- nience, a plate of gold or silver, ex- actly adapted to the arch ofthe palate, and steadied by means of a piece of sponge, fixed to its convex side, and introduced into the cleft, may some- times be usefully employed. When the sponge is of suitable size, and very dry, before being used, it will be swell- ed by the moisture of the adjacent parts, which alone will be sufficient, in many cases, to keep it in its situation, so as greatly to facilitate speaking and swallowing. Sometimes, however, the fissure is so shaped, that the sponge cannot be fixed in it: this principally happens when the opening widens very much, as it approaches externally. In such cases it has been proposed to fix a plate of gold, by means of springs, made of the same metal, so construct- ed as to fit the cavity; but, no con- trivance seems yet to have answered. On the subject of the hare-lip, con- sult B. Bell's Surgery, Vol. 4. Heis- tei's Surgery. Le Dran's Operations ; Sharp's Operations,- Lotto's Surgery, Vol. 2 ; L'Encyclopedic Methodique, Partie Chirurgicak, Art. Bee. de Lie- vre. The Observations of M. Louis, in Mem. de I'Acad. de Chirurgk. De la Medicine Operatoire, par Sabatier, Tom. 3. QZuvres Chirurgicaks de Desault, par Bichat, Tom. 2. Traite des Opera- tions de Cldrurgie, par A. Bertrandi. Chap. 19. HEAD, Injuries or. 1. Wounds of the Scalp. Mr. Pott remarks, that, though the scalp be called the common tegument ofthe head, yet, from the variety of parts of which it is composed, from their structure, connexions, and uses, injuries done to it by external violence, become of much more consequence, than the same kind of ills can prove, when inflicted on the common tegu- ments of the rest of the body. Passing over incised wounds, which have no particularity, Mr. Pott pro- ceeds immediately to those which, (though tiie mischief is originally con- lined to the mere scalp) yet are fre- quently >ery terrible to behold, are. 408 HEAD. often attended with alarming symp- toms, and sometimes with danger. La- cerated and punctured wounds, are those referred to. " The former may be reduced to two kinds, viz. those in which the scalp, though torn, or une- qually divided, still keeps its natural situation, and is not stript nor separat- ed from the cranium, to any considera- ble distance beyond the breadth of the wound ; and those, in which it is con- siderably detached from tiie parts it ought to cover. " The first of these, if simple, and not combined with the symptoms, or appearance of any otiier mischief, do not require any particular or different treatment, from what the same kind of wounds require on any other parts; but tlie latter, (those in whicii tiie scalp is separated and detached from the parts it ought to cover,) are not only, by the different methods in whicii they may be treated, frequently capable of be- ing cured with a considerable deal more or less ease and expedition, but are also sometimes a matter of great consequence to the health and well- being of the patient. Mr. Pott makes no scruple of de- claring it as his opinion, that the pre- servation of the scalp ought always to be attempted, unless it be so torn as to be absolutely spoiled, or there are manifest present symptoms of otiier mischief. This kind of wound is sometimes terrible to look at, and they who have not been accustomed to see it, may be inclined to think tliere is no remedy but inci- sion ; but, Mr. Pott says, he has so of- ten made the experiment of endeavour- ing to preserve the torn piece, and so often succeeded, that he would recom- mend it as a thing always to be at- tempted, even though a part of the cranium should be perfectly bare. The removal of it necessarily produces a larger sore, whicii must require a good deal of time to heal, and must leave a considerable deformity: the preserva- tion of it prevents both. Here we may remark, that all prac- titioners now invariably avoid cutting away the scalp, even in the circum- stances, in which such practice w-as al- lowed by Pott. By spoiled this emi- nent writer must mean so injured as necessarily to slough afterwards. How- ever, as no harm results from ta. ing the chance of its not slougi.ing, which never can be with certainty foretold; and as the excision of the part is pain- ful, and productive of no benefit, evert if sloughing must follow, such opera- tion is, in every point of view, quite wrong. With respect to otiier mis- chief, as a reason, the examination of the cranium, and even trephining, ne- ver require any of the scalp to be cut away. See Trephine Let the surgeon, therefore, always make the torn piece clean from all dirt, or foreign bodies, and restore it as quickly, and as perfectly as he can, to its natural situation. Notwithstanding Mr. Pott assents to the employment of sutures, for uniting certain lacerated wounds of the scalp, we may state, that the best practition- ers of the present day only employ sticking-plaster. Sometimes, the loos- ened scalp will unite with the parts from which it was torn and separated, and there will be no otiier sore than what arises from the impracticability of bringing the lips of the wound into smootii and immediate contact, the scar of wliich sore must be small in proportion. Sometimes such perfect reunion is not to be obtained; in which case, matter wiU be formed and col- lected in those places where the parts do not coalesce ; but this does not ne- cessarily make any difference, either in the general intention, or in the event; this matter may easily be discharged, by one or two small openings made with a lancet; the head will still pre serve its natural covering; and the cure will be very little retarded by a few small abscesses In some cases (as Pott proceeds to describe) the whole separated piece will unite perfectly, and give little or no trouble, especially in young and healthy persons. In some, the union will take place in some parts and not in others ; and, consequently, matter will be formed, and require to be dis- charged, perhaps at several different points ; and, in some particular cases, circumstances, and habits, there will be no union at all, the torn cellular membrane, or the naked aponeurosis, will inflame, and become sloughy, a considerable quantity of matter will be collected, and, perhaps, the cranium will be denuded. But, even in this state of things, wliich does not very often happen, where care has been taken, and is almost the worst which can happen, in the case of mere simple lacerat. .n and detachment, if the sur- geon will not be too syyu, nor too much HEAD 409 alarmed, nor in a hurry to cut, he will often find the cure much'more feasible than he may at first imagine : let him take care to keep the inflammation un- der by proper means, let him have pa- tience till the matter is fairly and fully formed, and the sloughs perfectly se- parated, and when this is accomplish- ed, let him make a proper number of dependent openings for the discharge of them, and let him by bandage, and otiier proper management, keep the parts in constant contact with each other, and he will often find, that al- though he was foiled in his first inten- tion of procuring immediate union, yet he will frequently succeed in this his second; he will still save the scalp, shorten the cure, and prevent the great deformity arising, (particularly to wo- men) not only from the scar, but from tlie total loss of hair. This union may often be procured, even though the cranium should have been perfectly denuded by the acci- dent : and, it is true, not only though it should have been stripped of its pe- ricranium at first, but even if that pc ricranium should have become sloughy and cast, as Mr. Pott has often seen. " Exfoliation from a cranium laid bare by external violence, and to which no otiier injury has been done, than merely stripping it of its covering, is a circumstance (says Pott) wliich would not so often happen, if it was not taken for granted that it must be, and the bone treated according to such expec- tation. The soft open texture of the bones of children and young people, will frequently furnish an incarnation, whicii will cover tiieir surface, and render exfoliation quite unnecessary ; and even in those of mature age, and, in whom the bones are still harder, ex- foliation is full as often tiie effect of art as the intention of nature, and pro- duced by a method of dressing, calcu- lated to accomplish such end, under a supposition of its being necessary. Sometimes, indeed, it happens that a small scale will necessarily separate, and the sore cannot be perfectly healed till such separation has been made ; but this kind of exfoliation will be very Small and thin, in proportion to that produced by art, that is, that produced by dressing the surface of the bare bone with spirituous tinctures, &c. and when a wound on the head, with a sound uninjured bone, denuded by ac- cident, shews a disposition to heal vol.. i without exfoliation, it never can be right to counteract nature, and oblige her to do what she is not inclined to, and which she would accomplish her purpose better without doing. " Small wounds, that is, such as are made by instruments, or bodies which pierce, or puncture, rather than cut, are in general more apt to become in- flamed, and to give trouble, than those wliich are larger, and in this part par- ticularly, are sometimes attended with so high inflammation, and with such symptoms as alarm both patient and surgeon." The parts capable of being hurt by such kind of wound, are the skin, the cellular membrane, tiie expanded ten- dons of the muscles of the scalp, and the pericranium. " If the wound affects the cellular membrane only, and has not reached the aponeurosis or pericranium, the in- flammation and tumour affect the whole head and face, the skin of which wears a yellowish cast, and is some- times thick set with small blisters, con- taining the same-coloured serum; it receives the impression of the fingers, and becomes pale for a moment, but returns immediately to its inflamed co- lour ; it is not very painful to tiie touch, and the eyelids and ears are al- ways comprehended in the tumefac- tion, the former of wliich are sometimes so distended, as to be closed; a fever- ish heat and thirst generally accompa- ny it; the patient is restless, has a quick pulse, and most commonly a nausea, and inclination to vomit. " This accident generally happens to persons of bilious habit, and is in- deed an inflammation of the erysipe- latous kind; it is somewhat alarming to look at, but is not often attended w#h 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 appearance, none of that look wliich bespeaks internal mischief; the scalp continues to adhere firmly to the skull, and the patient does not complain of" that tensive pain, nor is afflicted with that fatiguing restlessness which gener- ally attends mischief underneath the cranium. " Phlebotomy, lenient purges, and the use of the common febrifuge med- icines, particularly those of the neutral kind, generally remove it in a short time. When the inflammation is gone 410 HEAD. off, it leaves on the skin a yellowish lint, and a dry scurf, which continue until perspiration carries them away, and upon the disappearance of the dis- ease, the wound immediately recovers a healthy aspect, and soon heals with- out any further trouble. " Wounds and contusions of the head, which affect tiie brain and its membranes, are also subject to an erysipelatous kind of swelling and in- flammation ; but it is very different, both in its character and consequences, from the preceding. " In this (which is one of the effects of inflammation of" the meninges,) the febrile symptoms are much higher, the pulse harder and more frequent, the anxiety and restlessness extremely fa- tiguing, the pain in the head intense ; and as this kind of appearance is, in these circumstances, most frequently the immediate precursor of matter forming between the skull and dura mater, it is generally attended with ir- regular shiverings, which are not fol- lowed by a critical sweat, nor afford any relief to tiie patient. To which it may be added, that in the former case the erysipelas generally appears within the first tliree or four days ; whereas in the latter, it seldom comes on till sev- eral days after the accident, when the symptomatic fever is got to some height. In the simple erysipelas, al- though the wound be crude and undi- gested, yet it has no other mark of mischief; the pericranium adheres firmly to the skull, and upon the cessa- tion of the fever, all appearances be- come immediately favourable. In that whicii accompanies injury done to the parts underneath, the wound not only has a spongy, glassy, unhealthy as- pect, but tlie .pericranium in its neigh- bourhood separates spontaneously from the bone, and quits all cohesion with it. In short, one is an accident, pro- ceeding 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 tiie membranes of the brain ; one portends little or no ill to the pa- tient, and almost always ends well; the other impUes great hazard, and most commonly ends fatally. It is therefore hardly necessary to say, that it behoves every practitioner to be careful in dis- tinguishing them from each other. " If the wound be a small one, and has passed through the ceUular mem- brane to the aponeurosis, and pericran- ium, it is sometimes attended with very disagreeable, and sometimes very a- larming symptoms, but which arise from a different cause, and are very distinguishable 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-the impression of the fingers of an examiner; it is ofa deep red colour, unmixt with the yellow tint of the ery- sipelas ; it appears tense, and is ex- tremely painful to the touch; as it is not an affection of the cellular mem- brane, and as the ears and the eye lids are not covered by the parts in which the wound is inflicted, they are seldom, if ever, comprehended in the tumour, though they may partake of the general inflammation of the skin ; it is gener- ally 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 fomen- tation is required in both, in order to keep the skin clean and perspirable, but an emollient cataplasm, whicii is generally forbid in the former, may in this latter case be used to great advan- tage. " When the symptoms are not very pressing, nor the habit very inflamma- ble, this method will prove sufficient : but it sometimes happens, that the scalp is so tense, the pain so great, and the symptomatic fever so high, that by waiting for the slow effect of such means, the patient runs a risk from the continuance ofthe fever, or else the in- jured aponeurosis and pericranium be- coming sloughy, produce an abscess, and render the case both tedious and troublesome. A division of the wound- ed part by a simple incision down to the bone, about half an inch or an inch in length, will most commonly remove all the bad symptoms, and if it be done in time, will render every thing else unnecessary." (Pott.) The injuries, to which the scalp is li- able from contusion, or the appearances produced in it by such general cause, may be divided into those in which the mischief is confined merely to the scalp ; and those in which other parts are interested. HEAD. 411 The former, which only comes under our presentconsideration, is not indeed of importance, considered abstracted- ly. The tumour attending it is eitiier very easily dissipated, or the extrava- sated blood causing it, is easily got rid of by a small opening. Mr. Pott par- ticularly notices this case on account of an accidental circumstance, whicii, sometimes attends it, and renders it li- able to be very much mistaken. " When the scalp receives a very smart blow, it often happens that a quantity of extravasated blood imme- diately forms a tumour, easily distin- guishable from all others, and general- ly very easily cured. But it also some- times happens, that this kind of tu- mour produces to the fingers of an un- advised or inattentive examiner, a sen- sation, so like to that of a fracture, with depression ofthe cranium, as may be easily mistaken." Now, if, upon such supposition, a surgeon immediate- ly makes an incision into the tumid scalp, he may give his patient a great deal of unnecessary pain, and for that reason runs some risk of his own char- acter. " The touch is, in this case, so liable to deception, that recourse should al- ways be had to other circumstances and symptoms, before an opinion be given. " If a person, with such tumour oc- casioned by a blow, and attended with such appearances, and feel, has any complaint, which seems to be tiie effect of pressure made on the brain and nerves, or of any mischief done to the parts within the cranium, the division, or removal ofthe scalp in order to in- quire into the state of the skull, is right and necessary ; but if there are no such general symptoms, and the patient is in every respect perfectly well, the mere feel of something like a fracture will not authorize or vindicate such op- eration, since it will often be found, that such sensation is a deception, and that when the extravasated fluid is re. moved, or dissipated, the cranium is perfectly sound and uninjured. ' " The second kind of tumour attend- ing the contused scalp, viz. that which arises from injury done to the cranium, and parts within, does so absolutely proceed from, and depend upon such injury, as not to fall under our consid- eration in this place at all, but will be considered at large when we come to apeak of tlie mischiefs done to the skull and brain by collision, or contu- sion. " From what has been said it ap- pears, that the scalp, taken in a gener- al sense, is, when wounded or bruised, liable to be affected with four kinds of tumour, each of which has a distinct cause, and requires, or permits, a dif- ferent method of treatment. " The first does not imply any injury done to the parts within the skull, re- quires no operation, and almost always is cured by general remedies. " The second, or that wliich is caus- ed by the spontaneous separation of the pericranium from the skull, in conse- quence of internal mischief, is not at first attended with very pressing symp- toms ; but whoever has observed their progress, and attended to tiieir event, must know what fatal and frequently irresistible evil it is the forerunner of, nothing less than the inflammation and putrefaction of the membranes of the brain, and the formation of matter be- tween them and the skull; and that is a case which, of aU others, will least admit delay. " The third, though it sometimes gives way to free evacuation, and leni- ent external applications, yet is some- times also attended with symptoms wliich are too pressing to wait the ef- fect of such remedies, and is capable of being immediately relieved by a di- vision of the inflamed and irritated parts : whereas the same incision, made into the first kind of tumefaction, would most probably exasperate the disease, and heighten the symptoms. " The fourth, consisting of extrava- sated blood, seldom requires any chir- urgic operation ; time, and tiie use of tiie common discutient applications, (of which the ktio salis ammoniaci is best,) almost always dissipate it; and it only becomes of consequence, by tiie possibility of its being misunderstood and mistreated."—Pott on Injuries of the Head. 2. Effects of Contusion on the Dura Ma- ter, and Parts witlun the Skull. Mr. Pott remarks, " that in order to understand rightly, and to have a clear idea of this kind of* injury, it is neces- sary to recollect, that the vessels of the pericranium, those of the diploe, or medullary substance between the two tables of some parts of the crani- 412 HEAD. urn, and those of the dura mater within it, do all constantly and freely communicate with each other; and that this communication is carried on by means of innumerable foramina, found in all parts of both surfaces of the skull, as well as at the sutures ; that upon the freedom of this commu- nication depends the healthy and sound state of all the parts concerned in it; and that from the interruption or de- struction of this, proceed most of the symptoms attending violent contusions ofthe head, extravasations of fluid be- tween the cranium and dura mater, inflammation of the said membrane, and simple undepressed fracture of the skull. " The pericranium is so firmly at- tached to the outer surface ofthe skull, as not to be separable from it without considerable violence ; and when such violent separation is made in a hving subject, (especially if young,) the cra- nium is always seen to bleed freely, from an infinite number of small fora- mina. The dura mater, which is a firm strong membrane, is almost as in- timately attached to the inside of the skud, as the pericranium is to the out- side, and by the same means, viz. by vessels ; and by these means a constant circulation and communication are preserved and maintained between the two membranes and the bones dividing them. This, all the appearances which attend the scalping a living person, or the separation of the skull from the dura mater of a dead one, (especially if such person died apoplectic, or was hanged,) prove beyond all doubt: in the former, the blood will be seen is- suing from every point of" the surface ofthe cranium ; in the latter, not only a considerable degree of force will be found necessary to detach the sawed bone from the subjacent membrane, but when it is removed, a great num- ber of bloody points will be seen all over the surface of the latter ; whicii points, if wiped clean, do immediately become bloody again, being only the extremities of broken vessels. These vessels are largest at, and ;.b mi the sutures, at which places the adhesion is tiie strongest, and the hemorrhage upon separation the greatest. " It has been thought by many, that the dura mater was attached to the skull, only at the hutures; that in all other parts it was loose and uncon- nected with it; and that it constantly enjoyed or performed an oscillatory kind of motion, and was alternately elevated and depressed. This idea and opinion were borrowed from the appearance which the dura mater makes in a living subject after a por- tion of the skull has been removed: but although it has been inculcated by writers of great eminence, yet it has no foundation in truth or nature, and has misled many practitioners in their opinions, not only of the structure and disposition of this membrane, but in their ideas of its diseases. " The dura mater does on the inter- nal surface of the bones ofthe cranium, the office of periosteum, in the same manner as the pericranium does on the external; (at least they have no other:) to this it is so firmly, and so generally attached, as to be incapable of any, even the smallest degree of motion. The alternate elevation and subsidence of it, whicii are observable when any portion of it is laid bare, are owing to a very different cause from any power in itself; neither is, nor can ever be performed, until a piece of the cranium has been forcibly taken away ; and con- sequently cannot possibly be natural, or necessary. " By blows, falls, and other shocks, some of the larger of those vessels wliich carry on this communication be- tweenthe 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 extrava- sation, and indeed the only one which can be formed between the skull and dura mater. If" the broken vessels be few, and the quantity of blood which is shed be small, the symptoms are generally slight, and by proper treat- ment disappear. If they are large, or numerous, or the quantity of extrava- sated fluid considerable, the symptoms are generally urgent in proportion ; but whether they be slight, or consi- derable, whether immediately alarm- ing or not, they are always, and uni- formly, such as indicate pressure made on the brain and nerves, viz. stupidity, drowsiness, diminution or loss of sense, speech, and voluntary motion. '* This every practitioner knows to be one frequent consequence of blows on the head. But it also often hap- pens, from the same kind of v iolence, that some of the small vessels, which carry on the circulation between tho pericranium, skull, and dura mater HEAD 413 are so damaged, as not to be able pro- perly 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 sutures, are most frequently followed by this kind of mischief; the coats ofthe small vessels, wliich sus- tain the injury, inflame and become sloughy, and, in consequence of such alteration in them, the pericranium se- parates 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 inflammation, becomes sloughy also, and furnishes matter, which matter being collected between 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 frequent cause of destruction. The effect of* this kind of violence is frequently confined to the vessels con- necting the dura mater to the cranium, in whicii case the matter is external to the said membrane; but it sometimes 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 consequence of such violence is found on the surface of the brain, or between the pia and dura mater, as well as on the surface ofthe latter ; or perhaps in all these tliree situations at the same time. " The difference of this kind of dis- ease, from eitiier an extravasation of blood, or a commotion of tiie medul- lary parts of the brain, is great and obvious. All the complaints produced by extravasation, are, such as proceed from pressure, made on the brain and nerves, and obstruction to the circula- tion of the blood through the former; stupidity, loss of sense and voluntary motion, laborious and obstructed pulse and respiration, &c. and (which is of importance to remark) if the effusion be at all considerable, these symptoms appear immediately, or very soon after the accident. " The symptoms attending an in- flamed or sloughy state of the mem- branes, in consequence of external vi- olence, are very different; they are all of the febrile kind, and never, at first, imply any such 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, ri- gor ; and toward the end, convulsion, and delirium. And none of these ap- pear at first, that is, immediately after the accident; seldom until some days are past. " One set or class of symptoms is produced by an extravasated fluid, making such pressure on the brain and origin of the nerves, as to impair or abolish voluntary motion and the sen- ses ; the other is caused by the inflam- ed or putrid state of the membranes covering the brain, and seldom affects the organs of sense, until the latter end of the disease, that is, until a consi- derable quantity of matter is formed, whicii matter must press like any other fluid." Mr. Pott next refutes the generally- received opinion, that blood shed from its vessels, and remaining- confined in one place, will become pus ; and that the matter found on the surface of the dura mater, toward the end of these cases, was originally extravasated blood. Both these positions are false. That pure blood shed from its vessels, by- means of external violence, and kept from the air, will not turn to, or become matter, is proved incontestably by eve- ry day's experience, in many instances, in aneurisms by puncture, in retained menses by imperforate vaginae, and in all ecchymoses. True pus cannot be made from blood merely, as may be known from the maimer in wliich all abscesses are formed, and from every circumstance attending suppuration ; and that the matter found on the sur- face of* the dura mater, after great con- tusions of the head, never was mere blood, Mr. Pott is as certain, as obser- vation and experience can make him. " If there be neither fissure nor fracture of the skull, nor extravasa- tion, nor commotion underneath it, and the scalp be neither considerably 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 whicii re- ceived the blow. This pain, though beginning in that point, is soon extend- ed all over the head, and is attended with a languor, or dejection of strength and spirits, which are soon followed by a nausea, and inclination to vomit, a vertigo or giddiness, a quick and hard 414 pulse, and an incapacity of sleeping, at least quietly. A day or two after this attack, if no means preventive of inflammation are used, the part strick- en generally swells, and becomes puffy, and tender, but not painful; neither does the tumour rise to any considera- ble height, or spread to any great ex- tent -. 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 separa- ble from the skull, between whicii and it will be found a small quantity of a dark-coloured ichor. " If the disorder has made such pro- gress, that the pericranium is quite se- parated and detached from tiie skull, the latter will even now be found to be somewhat altered in colour from a sound healthy bone. Of this alteration 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 ge- nerally advance more hastily and more apparently; the fever increases, the skin becomes hotter, the pulse quicker and harder, the sleep more disturbed, the anxiety and restlessness more 'fa- tiguing; and to these are generally added irregular rigors, which are not followed by any critical sweat, and which, instead of relieving the patient, add considerably to his sufferings. If the scalp has not been divided or re- moved, until the symptoms are thus far advanced, the alteration of the colour 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 pericranium 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 cra- nium, 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- perated, and advance with hasty strides : the head-ach and thirst be- come more intense, the strength de- creases, the rigors are more frequent, and at last convulsive motions, attend- HEAD. ed in some with delirium; in others with paralysis, or comatose stupidity, finish the tragedy. " If tiie scalp has not been divided till this point of time, and it be done now, a very offensive discoloured kind of fluid will be found lying on the bare cranium, whose appearance 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 ca- ses and circumstances. Sometimes it will be in great abundance, and diffus- ed over a very large part of the mem- brane ; 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 tiie brain, or within the substance of it. " The primary and original cause of all tliis, is the Stroke upon the skull: by this tiie vessels which should carry on the circulation between the scalp, pericranium, skull, and meninges, are injured, and no means being used to prevent the impending mischief, or such as have been made use of proving ineffectual, the necessary and mutual communication between all these parts ceases, the pericranium is detached from the skull, by means of a sanies discharged from the ruptured vessels, the bone being deprived of its due nou- rishment and circulation loses its heal- thy appearance, the dura mater (its at- taching vessels being destroyed, or ren- dered unfit for their office) separates from the inside ofthe cranium, inflames and suppurates. " Whoever wiU attend to the appear- ances which the parts concerned make in every stage of tiie disease, to the na- ture of the symptoms, the time of their access, their progress, and most fre- quent event, will find them all easily and fairly deducible from the one cause, whicii has just been assigned, viz. the contusion. As the inflammation and separation ofthe dura mater, is not an immediate consequence ofthe violence so neither are the symptoms immediate seldom until some days have passed • the fever at first is slight, but increa- ses gradually; as the membrane be- comes more and more diseased aU the febrile symptoms are heightened- the formation ol matter occasions rigors HEAD. 415 frequent and irregular, until such a quantity is collected, as brings on de- lirium, spasm, and death. Hitherto Mr. Pott has been describ- ing this disease as unaccompanied by any other, not even by any external mark of injury, except perhaps a tri- fling bruise of the scalp; " Let us now, (says this jeminent surgeon,) suppose the scalp to be wounded at the time of the accident, by whatever gave the con- tusion ; or let us suppose, that the im- mediate symptoms having been alarm- ing, a wound had been made, in order to examine the skull. " In this case, tiie wound will for some littie time have the same appear- ance as a mere simple wound of this part, unattended with other mischief, would have; it will, like that, at first discharge 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 granulated surface; will become pale, glassy, and flabby; instead of good matter, it will discharge only a thin discoloured sanies; the lint with which it is dressed, instead of coming off ea- sily (as in a kindly suppurating sore) will stick to all parts of it; and the pe- ricranium, instead of adhering firmly to the bone, will separate from it, all round, to some distance from the edg- es. " This alteration in the face and cir- cumstances 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 advanced; and is demonstrably proved, by observing that this diseased aspect of the sore, and tliis spontaneous separation of the pericranium, are always confined to that part which covers the altered or injured portion ofthe dura mater, and do not at all affect the rest of tiie scalp; nay, if it has by accident been wound- ed in any other part, or a portion has been removed from any part where no injury has been done to the dura ma- ter, no such separation will happen, the detachment above will always corre- spond to that below, and be found no where else. " The first appearance of alteration in the wound immediately succeeds the febrile attack; and as the febrile symp- toms increase, the sore becomes worse and worse, that is, degenerates more and more from a healthy, kindly as- pect. " Through the whole time, from the first attack ofthe fever, to the last and fatal period, an attentive observer will remark the gradual alteration ofthe co- lour ofthe bone, if it be bare. At first it wiU be found to be whiter, and more dry, than the natural one; and as1 the symptoms increase, and either matter is collected, or the dura mater becomes sloughy, the bone inclines more and more to a kind of purulent hue, or whi- tish yellow ; and it may also be worth while in this place to remark, that if the blow was on or very near to a su- ture, and the subject young, the said suture will often separate in such man- ner as to let through it a loose, painful, ill-natured fungus; at which time also it is no uncommon thing for the pa- tient's head and face to be attacked with an erysipelas." " In those cases, in which the scalp is very little injured by the bruise, and in which there is no wound, nor any immediately alarming symptoms or ap- pearances, the patient feels little or no inconvenience, and seldom makes any complaint, until some few days are past. At the end of this uncertain time, he is generally attacked by the symptoms already recited; these are not pressing at first, but they soon in- crease to such a degree, as to baffle all our art: from whence it will appear, that when this is the case, the patient frequently suffers from what seems at first to indicate his safety, and prevents such attempts being made, and such care from being taken of them, as might prove preventive of mischief. " But if the integuments are so inju- red as to excite or claim our early re- gard, very useful information may from thence be collected; for whether the scalp be considerably bruised, or whe- ther it be found necessary to divide it for the discharge of extravasated blood, or on account of worse appearances, or more urgent symptoms, the state of the pericranium may be thereby sooner and more certainly known; if in the place of such bruise, the pericranium be found spontaneously detached from the skull, having a quantity of disco- loured sanies between them under tiie tumid part, in the manner already men- tioned, it may be regarded as a pretty certain indication, eitiier that the dura mater is beginning to separate, in the 416 HEAD. same manner, or that, if some preven- tive means be not immediate!) used, it will soon suffer; that is, it will inflame, separate from the skull, and give room for a collection of matter between them. And with regard to the wound itself, whether it was made at the time of the accident, or afterward artificially, it is the same thing ; if tlie alteration of its appearance be as related, if the edges of it spontaneously quit their adhesion to the Lone, and the febrile symptoms are ut the same time making their at* tack, these circumstances will serve to convey tlie same information, and to prove tiie same thing. " This particular effect of contusion is frequently found to attend on fis- sures, and undepressed fractures ofthe cranium, as well as on extravasations of fluid, in cases where the bone is en- tire , and, on the other hand, all these do often happen without the concur- rence of this individual mischief. All this is matter of accident; but let the other circumstances be what they may, the spontaneous separation of the alter- ed pericranium, in consequence ofa se- vere blow, is almost always followed by a suppuration between the cranium and dura mater; a circumstanced\- tremely well worth attending to in fis- sures and undepressed fractures ofthe skull, because it is from this circum- stance principally, that the bad symp- toms, and tiie hazard, in such cases arise. " It is no very uncommon thing for a smart blow on the head to produce some immediate and bad symptoms, whicii after a short space of time dis- appear, and leave the patient perfectly well. A slight pain in the head, a lit- tle acceleration of pulse, a vertigo and sickness, sometimes immediately fol- low such accident, but do not continue many hours, especially, if any evacua- tion has been used. Tuese are not im- probably owing to a slight commotion ofthe brain, which ha\ ing suffered no material injury thereby, soon cease. But if, after an interval of some time, the same symptoms are renewed; if the patient, having been well, becomes again feverish, and restless, and that without any new cause; if he com- plains of being languid and uneasy, sleeps disturbedly, loses his appetite, has a hot skin, a hard quick pulse, and a flushed, heated countenance; and neither irregularity of diet, nor acci- dental cold, have been productive of these; mischief is most certainly im- pending, and that most probably under the skull. "If the symptoms of pressure, such as stupidity, loss of sense, voluntary motion, &c. appear some few days af- ter the head has suffered injury from external mischief, they do most proba- bly imply an effusion of a fluid some- where : this effusion may be in the substance of the brain, in its ventri- cles, between its membranes, or on the surface of the dura mater; and which of these is the real situation of such extravasation, is a matter of great un- certainty, none of them being attended with any peculiar mark or sign, that can be depended upon, as pointing it out precisely; but the inflammation of the dura mater, and the formation of matter between it and the skull, in con- sequence of contusion, is generally in- dicated and preceded by one which Mr. Pott has hardly ever known to fail; a puffy, circumscribed, indolent tu- mour ofthe scalp, and a spontaneous separation of the pericranium from the skull under such tumour. " These appearances, therefore, fol- lowing a smart blow on the head, and attended with languor, pain, restless- ness, watching, quick pulse, head-ach, and slight irregular shiverings, do al- most infallibly indicate an inflamed du- ra mater, and pus, either forming or formed, between it and the cranium." By detachment ofthe pericranium, is not meant every separation of it from the bone which it should cover. It may be, and often is cut, torn, or scraped oil", without any such consequence; but these separations are violent, whereas that which Mr. Pott means is sponta- neous, and is produced by the destruc- tion of those vessels by whicii it was connected with the skull, and by which the communication between it and the internal parts was carried on; and tiierefore it is to be observed, that it is not the mere removal of that mem- brane whicii causes the bad symptoms, but it is the inflammation of the dura mater; of which inflammation, this spontaneous secession of the pericrani- um is an almost certain indication. Sometimes the scalp is so wounded at the time of the accident, or so torn away, as to leave the bone perfectly bare; and yet the violence has not been such as to produce the evil just now spoken of. In this case, if the pericra- nium be only turned back, along with HEAD. 41? the detached portion ofthe scalp, there may be probability of its reunion: and it should therefore be immediately made clean and replaced, for the pur- pose of such experiment; which, if it succeeds, will save time, and prevent considerable deformity. Should the attempt fail, it can only be in conse- quence ofthe detached part sloughing. Hence, removing it with a knife, though allowed by Pott, is now never practi- sed. Frequently, when the scalp does not adhere at once, it becomes attach- ed to the cranium afterwards by a gra- nulating process. When the detached piece sloughs, the worst that can hapS pen, is an exfoliation from the bare skull. Sometimes, the force which detach- es, or removes the scalp, also occasions tiie mischief in question ; but, the in- teguments being wounded or removed, We cannot have the criterion of the tu- mour of the scalp for the direction of our judgment. Our whole attention must be directed to the wound and gen- eral symptoms. The edges ofthe for- mer will digest as well, and look as kindly, for a few days, as if no mischief was done underneath. But, after some little space of time, when the patient begins to be restless, and hot, and to complain of pain in the head, these edges will lose their vermilion hue, and become pale and flabby. Instead of matter, they will discharge a thin gleet, and the pericranium vyill loosen from the skull, to some distance from the said edges. Immediately after this, ail the general symptoms are increased and exasperated; and as the inflam- mation ofthe membrane is heightened, or extended, they become daily worse and worse, until a quantity of matter is formed, and collected, and brings on that fatal period, which, though uncer- tain as to date, very seldom fails to ar- rive. " The method of attempting the re- lief of this kind of injury consists in two points, viz. to endeavour to prevent the inflammation ofthe dura mater; pr, that being neglected, or found im- practicable, to give discharge to the fluid collected within the cranium, in Consequence of such inflammation. " Of all the remedies in the power of art, for inflammations of membranous parts, there is none equal to phleboto- my. To this truth many diseases bear testimony ; pleurisies, ophthalmies, vol. I strangulated hernias, &c. and if any thing can particularly contribute to the prevention of the ills likely to follow severe contusions ofthe head, it is this kind of evacuation ; but then it must be made use of in such a manner as to become truly a preventive; that is, it must be made use of immediately, and freely." This eminent surgeon says, he is very sensible that it w'U in general be found very difficult to persuade a per- son, who has had what may be called only a knock on the pate, to submit to such discipline, especially if he finds himself tolerably well: yet, in many instances, the timely use, or the neg- lect of this single remedy, makes all the difference between safety and fatal- ity. " It may be said, that as the force of the blow, the height of the fall, the weight ofthe instrument, &c. can never precisely, or certainly determine the effect, nor inform us, whether mischief is done under the bone, or not, a large quantity of blood may be drawn off un- necessarily, inj order to prevent an im- aginary evil. This is in some degree true; and if the advice just given was universally followed, many people would be largely bled without necessi- ty ; but then, on the other hand, many a very valuable life would be preserv- ed, which,for want ofthiskind of assis- tance, is lost. Nihil interest, prasidium an satis tutum sit, quod unicum est, is an incontested maxim in medicine; and if it be allowed to use such means as may be in themselves hazardous, surely it cannot be wrong to employ one which is not so ; at least, if it be considered in a general sense, whatever it may ac- cidentally prove to some few particu- lar individuals." Acceleration, or hardness of pulse, restlessness, anxiety, and any degree of fever, after a smart blow on the head, are always to be suspected and attended to. Immediate, plentiful, and repeated evacuations by bleeding, have, in many instances, removed these, in persons to whom, Mr. Pott verily be- lieves, very terrible mischief would have happened, had not such precau- tion been used. In this, as well as some otiier parts of practice, we neither have, nor can have any other method of judging, than by comparing together cases apparently simdar. Mr. Pott has more than once or twiee seen that 53 418 HEAD increased velocity and hardness of pulse, and that oppressive languor, which most frequently precede mis- chief under tiie bone, removed by free and repeated blood-letting ; and has of- ten, much too often, seen cases end fa- tally, whose beginnings were full as slight, but in which such evacuation had been either neglected, or not com- plied With. This judicious writer, " would by no means be thought to in- fer from hence, that early bleeding will "always prove a certain preserva- tive ; and that they only die, to whom it has not been applied: this, like all other human means, is fallible; and, perhaps, there are more cases out of its reach, than within it; but, where preventive means can take place, this is certainly the best, and the most fre- quently successful. " The second intention, viz. the dis- charge of matter, collected under the cranium, can be answered only by the perforation of it. «' )V'hen, from the symptoms and ap- pearances already described, there is just reason for supposing matter to be formedjinder the skull, the operation of perforation cannot be performed too soon > it seldom happens, that it is done soon enough. " The propriety, or impropriety, of applying the trephine, in cases where there is neither fissure, fracture, nor S) mptoin of extravasation, is a point w hich has been much litigated, and re- mains still unsettled either by writers or practitioners. " When there is no reason for sus- pecting any of those injuries, either from the symptoms, or from the ap- pearances ; and the pericranium, whether the scalp be wounded or not, remains firmly attached in all parts to the skull; tliere certainly is not (let the general symptoms be what they may) any indication where to apply the instrument, and consequently no sufficient authority for using it all: but whenever that membrane, after the head has received an external v iolence, separates, or is detached spontaneous- ly from the bone underneath it, and such separation is attended with the collection of a small quantity of thin, brown ichor, an alteration of colour in the separated pericranium, and an unnat- ural dryness ofthe bone, Mr. Pott can- not help thinking, that there is as good reason for trepanning, as in the case of fracture ; he believes experience would vindicate him, if he said, better reason ; since it is by no means infrequent for the former kind of case to do well with- out such operation ; whereas suppura- tion under the skull never can. " The spontaneous separation ofthe pericranium, if attended with general disorder of the patient, with chilliness, horripilatio, languor, and some degree of fever, appears to Mr. Pott, from all the observation he has been capable of making, to be so sure and certain an indication of mischief underneath, either in present, orimpending, that he Should never hesitate about perforating de bone in such circumstances. " When the skull has been once per- forated, and the dura mater thereby laid bare, the state of the matter must principally determine the surgeon's fu- ture conduct. In some cases, one op- ening will prove sufficient for all neces- sary purposes; in others, several may be necessary. This variation will de- pend on the space of detached dura mater, and the quantity of collected matter. The repetition of the opera- tion is warranted, both by the nature of the case, and by the best authori- ties ; there being no comparison to be made between the possible inconveni- ence arising from largely denuding the dura mater, and the certain, as well as terrible evils wliich must follow the formation and confinement of matter between it and the skull. " It can hardly be necessary to ob- serve, that notwithstanding the opera- tion of perforation be absolutely and unavoidably necessary, yet the repeti- tion of blood-letting, of cooling laxa- tive medicines, the use of antiphlogis- tic remedies, and a most strict observ- ance of a low diet and regimen, ire as indispensably requisite after such ope- ration as before; the perforation sets the membrane free from pressure, and gives vent to collected matter, but nothing more ; the inflamed state of the parts under the skull, and the ne- cessary consequences of such inflam- mation, call for all our attention, full as much afterwards as before ; and al- though the patient must have perished without the use of the trephine, yet, the merely having used it, will not pre- serve him, without every other caution and care." Both tables of the skull sometimes exfoliate in consequence of external violence. The dead bone must be re- moved, as soon as loose ; and, if neces- HEAD. 419 sary, the scalp divided for the pur- pose. 3. Fissures and Fractures of the Crani- um, without Defiression. " Fractures of the cranium, (says Mr. Pott) were, by the ancient writers, divided into many different sorts, each of which was distinguished by an ap- pellation of Greek etymology, borrow- ed either from the figure of the frac- ture, or the disposition of the broken pieces. These are to be found in most of the old books ; but as they merely load the memory, without informing the understanding, or assisting the practitioner, modern authors have gen- erally laid them aside. " This kind of injury is divisible in- to two general heads, viz. those in whicii the broken parts keep their prop- er level, or equality of surface, with the rest of the skull, and those in wliich they do not; or, in other words, frac- tures without depression, and fractures 'with. " These two cUstinctions are all whicii are really necessary to be made, and will be found to comprehend every violent division ofthe parts of the skull (not made by a cutting-instrument) from the finest capillary fissure, up to the most complicated fracture: for, fissures and fractures differing from each other only in the width of" the breach, or in the distance of tiie sepa- rated parts, and the disposition of brok- en pieces, hi large fractures, being sub- ject to an almost infinite variety, dis- tinctions and appellations, drawn and made from these circumstances, might be multiplied to even three times the old number, without imparting the smallest degree of useful knowledge to the man, who should be at the pams to get them by heart. " What are the symptoms of a frac- tured cranium ? is often asked; and there is hardly any one who does not, from the authority of writers, both an- cient and modern, answer, Vomiting, giddiness, loss of sense, speech, and voluntary motion, bleeding at the ears, nose, mouth, 8tc. This is tlie doctrine of Celsus, which has been most invari- ably copied by almost all succeeding authors, and implicitly believed by al- most all readers. " The symptoms just mentioned do indeed very frequently accompany a broken skull, but they are not pro- duced b^the breach made in the bone, nor do they indicate such breach to have been made. They proceed from an affection of the brain, or from inju- ry done to some of the parts within the cranium, independent of any ill which the bones composing it may have sus- tained. They are occasioned by vio- lence offered to the contents of the head in general -r are quite independent ofthe mere breach made in the bone ; and eitiier do, or do not accompany fracture, as such fracture may happen to be; or not to be, complicated with such other ills. " They are frequently produced by extravasations of blood, or serum, up- on, or between the membranes of the brain ; or by shocks, or concussions of its substance, in cases where the skull is perfectly intire and unhurt. On the other hand, the bones of the skull are sometimes cracked, broken, nay even depressed, and the patient suffers none of these symptoms. In short, as the breach made in tlie bone is not, nor can be the cause of such complaints, tiny ought not to be attributed to it; and that for reasons, which are by no means merely speculative. For the practi- tioner, who supposes that such symp- toms do necessarily and certainly im- ply that the cranium is fractured, must regulate his conduct by such supposi- tion, and remove the scalp, very often without either necessity or benefit; that is, without discovering what he looks for: and, on the other hand, if he does not find the skull to be broken, believing all these complaints to be caused by, and deducible from the fracture, he will most probably pay his whole attention to that supposed cause, and may think, that when he has done what the rules of his art prescribe for such case, he has done all that is in his power :—an opinion not infrequently embraced ; and wliich has been the de- struction of many a patient. For, as on the one hand, the loss of sense, speech, and voluntary motion, as well as the hemorrhage from the nose, ears, &c. are sometimes totally removed by, or at least disappear, during the use of free and frequent evacuation, without .any operation on the scalp or skull; so, on the other, as these symptoms and appearances are not produced by the solution of continuity of the bone, they cannot be remedied by such chi- rurgic treatment as the mere f racture. may require. 420 ire AD. " If any one doubts the truth of this doctrine, (continues Mr. Pott,) 1 would desire him to consider the nature, as well as most generally successful me- thod of treating these symptoms; and, at the same time, to reflect seriously on the operation of the trepan, as prac- t'sed in simple, undepressed fractures ofthe skull. " The sickness, giddiness, vomiting, and loss of sense and motion, can only be the consequence of an affection of the brain, as the common sensorium. They may be produced by its having been violently shaken, by a derange- ment of its medullary structure, or by unnatural pressure made by a fluid ex- travasated on its surface, or within its ventricles ; but never can be caused by the mere division of the bone, (consi- dered abstractedly) ; whicii division, in a simple fracture, can neither press on, nor derange, tiie structure of the parts within the cranium. " If the solution of* continuity in the bone be either produced by such a de- gree of violence, as hath caused a con- siderable disturbance in the medullary parts of the brain, or has disturbed any of tiie functions of the nerves going off from it; or has occasioned a breach of any vessel, or vessels, whether san- guine or lymphatic, and that hath been followed by an extravasation, or lodg- ment of fluid ; the symptoms necessa- rily consequent upon such derange- ment, or such pressure, will follow : but they do not follow, because the bone is broken; their causes are super- added to the fracture, and although firoduced by the same external vio- ence, are yet perfectly and absolutely independent of it: so much so, that they are frequently found where no fracture is. " The operation ofthe trepan is fre- quently performed in tiie case of sim- ple fractures, and that very judiciously and properly ; but it is not performed, because the bone is broken, or crack- ed : a mere fracture, or fissure of" the skull, can never require perforation, or that the dura mater under it be laid bare ; the reason for doing this, springs from other causes than the fracture, and those really independent on it: they spring from the nature of* the mis- chief which the parts within the cra- nium have sustained, and not from the accidental division of the bone. From these arise the threatening symptoms; from these all the hazard ; and from these, the necessity, and vindication of performing tiie operation of the tre- pan. " If a simple fracture of the cranium was unattended in present with any of the before-mentioned symptoms, and there was no reason for apprehending any other evil in future, that is, if tiie solution of continuity in the bone was the whole disease, it could not possi- bly indicate any other curative inten- tion, but, the general one in all frac- tures, viz. union of the divided parts." In many cases of simple undepress- ed fractures of the cranium, it is true, that trephining is necessary; but, the reasons for the operation, in these in- stances, are, first, the immediate relief of present symptoms arising from the pressure of extravasated fluid; and, secondly, tlie discharge of matter, formed between the skull and dura ma- ter, in consequence Of inflammation. The operation of trephining was also recommended by Pott, as a preventive of ill consequences ; a practice, how- ever, which is now never adopted by the most eminent surgeons ; and many writers of the highest reputation, es- pecially, Desault, Dease, Mr. John Bell, and Mr. Abernethy, urgently, and pro- perly remonstrate against the method. The latter remarks : " In the ac- counts, which we have of the former practice in France, it is related, that surgeons made numerous perforations along the whole track of a fracture of the cranium; and, as far as I am able to judge, without any clear design. Mr. Pott also advises such an opera- tion, with a view to prevent the inflam- mation and suppuration of the dura mater, whicii he so much apprehend. ed. But, many cases have occurred of late, where, even in fractures with de- pression, the patients have done well without' an operation." Mr. Abernethy next relates several cases of fracture of the cranium with depression, which terminated favoura. bly, although no operation was per- formed. This judicious surgeon thinks, that these cases, as well as a great ma- ny others on record, prove, that a slight degree of pressure does not derange the functions of tlie brain, for a limited time after its application; and all those, whom he had an opportunity of knowing for any length of time after the accident, continued as well as if nothing of the kind had happened tb them. In Mr. Hill's cases iu surgery HEAD. 421 two instances of this sort are related, and Mr. Hill knev. both the patients for many years afterwards ; yet, no in- convenience arose. Indeed, it is not easy to conceive, that the pressure, which caused no ill effects at a time, when the contents of the cranium filled its cavity completely, should after- wards prove injurious, when they have adapted themselves to its altered size and shape. Severe illness, indeed, does often intervene between the receipt of tlie injury, and the time of its recove- ry ; and many surgeons might be in- clined to attribute this to pressure; but, it -equally occurs when the de- pressed portion is elevated. If a sur- geon, prepossessed with the opinion, that elevation of the bone is necessary in every instance of depressed cranium, should have acted upon this opinion, in several of the cases, whicii Mr. Aber- nethy has related, and afterwards have employed proper evacuations, his pa- tients would probably have had no bad symptoms, and he would naturally have attributed their well-doing to the mode of treatment, wliich he pursued : .yet, these cases did equally well with- out an operation. (Abernethy on the Injuries of the Head.) Depressed fractures of the skull not being our immediate consideration, we need not expatiate upon them ; but, it seemed right to make the preceding remarks to shew how unnecessary it must be to trephine a patient, merely because there is a fracture of the cra- nium, and with a view of preventing bad consequences. Even when the fracture is depressed, it is not necessa- ry, unless there are evident signs, that the degree of pressure, thus produced on the brain, is the cause of existing bad symptoms. The inflammation and suppuration of the parts, beneath the skull, which "Mr. Pott wished so much to prevent by trephining early, do not arise from the Occurrence of a breach in the cranium, but, are the consequence of the same violence, which was the occasion of the fracture. Hence, it is obvious, that re- moving a portion ofthe bone cannot in the least prevent the inflammation and suppuration, which must result from tiie external violence which was first applied to the head ; but, on the con- trary, such a removal being an addi- tional violence, must have a tendency to increase the inevitable inflammatory mischief From what has been said, it is not to be inferred, however, that trephining is never proper, when tliere is a sim- ple undepressed fracture of the skull. Such injury may be joined with an ex- travasation of blood on the dura ma- ter ; or it m-iy be followed by the formation of matter between this mem- brane and the cranium ; in both which circumstances, tiie operation is essen- tial to the preservation of the patient, immediately, but not before, the symp* toms indicative of the existence of dan- gerous pressure on the brain, begin to shew themselves. (See Trephine.) A fracture of the skull, unattended with urgent symptoms, and not brought into the surgeon's view by any acci- dental wound of the integuments, often remains for ever undiscovered; and as no benefit could arise from laying it bare by an incision, such practice should never be adopted. The sur- geon ought only to be officious in tins way, when he can accomplish by it some better object, than the merely satisfying his own curiosity. And as we shall find from the perusal of this article, and the one entitled Trephine, that the removal of pressure off the surface of the brain is the only possi- ble reason for ever perforating the cranium with this instrument; and as dividing the scalp is only a useful mea- sure, when it is preparatory to such operation; neither the one, nor the other, should ever be practised, unless there exist unequivocal symptoms, that there is a dungerous degree of pres- sure operating on the brain, and caused either by matter, extravasated blood, or a depressed portion of the skull. The true mode of preventing the bad effects, frequently following, but not arising from, simple fractures of the skull, is not to trephine, but, to put in practice all kinds of antiphlogistic means. For this purpose, let the pa- tient be repeatedly and copiously bled, both from the arm and temporal arte- ries; let him be properly purged; give him antimonials; keep him on the low- est diet; let him remain in the most quiet situation possible; and if, not- withstanding such steps, the symptoms of inflammation of the brain continue to increase, let his head be shaved, and a large blister be applied to it. When, in spite of all these measures, matter forms under the cranium, attended with symptoms of pressure, a puffy tumour of the inj ured part of the scalp, or those 423 HEAD changes ofthe wound, if there is one, whicii Mr. Pott has so excellently de- scribed, and we have already related; not a moment should be lost in delay- ing to perforate the bone with the tre- phine, and giving vent to the matter beneath. 4. Fractures of the Cranium with De- pression. "Simple fractures of the skull, or those in whicii the parts of the broken bone are not depressed from their situ- ation (observes Mr. Pott) differ from what are called fissures, only in tiie distance of the edges ofthe breach from each other. When the separation is considerable, it is called a fracture ; when it is very fine and small, it is call- ed a fissure. The chirurgical inten- tion, and requisite treatment, are the same in each, viz. to procure a dis- charge for any fluid which may be ex- travasated in present, (here we must understand supposing the pressure of such extravasation produces urgent symp- toms) and to guard against the forma- tion, or'confincinent of matter." The prevention of suppuration will, as we have already remarked, lie best accom- plished, not by perforating the crani- um, as Mr. Pott advised, but by copious bleeding, evacuations, blisters, and a rigorous antiphlogistic regimen. The confinement of matter, producing symp- toms of pressure on the brain, certain- ly indicates tiie immediate use of the trephine. " But, in fractures, attended with de- pression, (says Pott) the intentions are more. In these the depressed parts are to be elevated, and such as are so separated as to be incapable of reunion, or of being brought to lie properly, and without pressing on the brain, are to be totally removed. These circum- stances are peculiar to a depressed fracture; but, although they are pecu- liar, they must not; be considered as sole, but, as additional to those, whicii have been mentioned at large under the head of simple fracture: commo- tion, extravasation, inflammation, sup- puration, and every ill, which can at- tend on, or be found in the latter, are to be met with in the former, and will require the same method of treatment." That loose splintered pieces ofthe era- nium, when quite detached, and alrea, dy in view, in consequence of the scalp being wounded, ought to be taken away, no one will be inclined to ques- tion. That they ought also to be ex- posed by an incision, even when the scalp is unwounded, and then taken away, whenever they cause symptoms of irritation, or pressure, 1 believe, will be universally allowed. But, the read- er will already understand, from what has been said, in the preceding section, that several excellent surgeons do not coincide with Pott, in believing, that every depressed fracture of the skull necessarily demands the apphcation of the trephine. " There certainly are (says Mr. Aber- nethy) degrees of this injury, which it would be highly imprudent to treat in this manner. Whenever the patient retains his senses perfectly, I should think it improper to trephine him, un- less symptoms arose, that indicated the necessity of it." P. 21. Every surgeon, indeed, cannot be too fully impressed with the following truth, that existing symptoms of dan- gerous. pressure on the brain, which symptoms will be presently related, can alone form a true reason for perfo- rating the cranium. The mode of ope- rating, in order to elevate depressed portions ofthe skull, is explained in the article Trephine. 5. Extravasation under the Cranium j Symptoms of Pressure on the Bruin, &c. Mr. Pott remarks, "the shock, which the head sometimes receives by falls from on high, or by strokes from pon- derous bodies, does not infrequently cause a breach in some of the vessels, either of the brain, or its meninges ; and, thereby, occasions extravasation of the fluid, which should circulate through them. This extravasation may be the only complaint produced by the accident; or it may be joined with, or added to, a fracture of the skull. But tins is not all, for it may be produced not only when the cranium is unhurt by the blow, but even when no violence ot any kind has been offered to, or re- ceived by the head." When blood is extravasated beneath the skull, the violence which produces the rupture of the vessel, usually stuns the patient, from which state, provided the quantity and pressure of the blood, and the force of the concussion be not too great, he gradually recovers, and regains his senses. If the first extra vasation be trivial, the patient, after regaining his senses, may only feel a HEAD. 423 little drowsiness, and go to bed. The bleeding from the ruptured vessel con- tinuing, 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 pupil dila- ted, and motionless even when a can- dle is brought near the eye; the retina is insensible; tiie limbs relaxed; the breathing stertorous; the pulse slow, and, according to Mr. Abernethy, less subject to intermission, than in cases of concussion. Nor is the patient ever sick, when the pressure on the brain, and the general insensibility, are con- siderable ; for, the very action of vo- miting betrays an irritability in tlie sto- mach and oesophagus. These symp- toms 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 unnatural pressure made on the brain and nerves, and have too often been mistaken, as indications of a disease, which, consi- dered abstractedly, can never cause them; we allude to a simple undepres- sed fracture of the cranium, which may be accompanied by them, but can- not cause them. They differ in de- gree, according to the quantity, kind, and situation, of the pressing fluid. The hemorrhage from the nose and ears, which often follows violence ap- plied to the head, leads to no particu- lar or useful inference: we cannot even calculate, by this sign, that the force has exceeded a certain degree; for, such bleedings take place, in many per- sons, from much slighter causes, than in others. The preceding class of symptoms only informs us, that the brain is suf- fering compression; and, leaves us quite in the dark, respecting several other very important circumstances. " We not only have no certain infallible rule, whereby to distinguish, what the pressing fluid is, or where it is situa- ted, but we are, in many instances, ab- solutely incapable of knowing, whe- ther the symptoms be occasioned by any fluid at all; for, a fragment of bone, broken off from the internal table of the cranium, and making an equal de- gree of pressure, will produce exactly the same complaints."1 (P«tf). In de- tailing-the symptoms of pressure from blood, I took particular notice of the patient being at first generally stunned by the blow, of his gradually regaining his senses, and of" his afterwards re- lapsing into a state of insensibility again. The interval of sense, which thus occurs, is a circumstance, of the greatest consequence in making the surgeon understand the nature ofthe case. " A concussion, and an extravasation (as Mr. Pott observes) are very dis- tinct causes of mischief, though not al- ways very distinguishable. " M. Le Dran, and others of the mo- dern French writers, have made a very sensible and just distinction between that kind and degree of loss of sense whicii arises from a mere commotion of the brain, and that which is caused by a mere extravasation, in those instan- ces in which the time of the attack or appearance of such symptoms are dif- ferent or distinct. The loss of sense, which immediately follows the violence, say they, is most probably owing to a commotion; but that which comes on after an interval of time has passed, is most probably caused by extravasa- tion. " This distinction is certainly just and good, as far as it will go. That degree of* abolition or diminution of sense, which immediately attends or follows the blow or fall, and goes off again without the assistance of art, is in all probability occasioned by the sud- den shake or temporary derangement of the contents of the head; and the same kind of symptoms recurring again some time after they had ceased, or not coming on till some time has pass- ed from the receipt of the violence, do most probably 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 dis- tinction. An extravasation is often made so immediately, and so largely, at the instant of the accident, that all sense and motion are instantaneously lost, and never again return. And it also sometimes happens, that although an extravasation may possibly not have been made at the moment ofthe acci- dent, and the first complaints may have been owing to commotion merely, yet a quantity of fluid having been shed from its proper vessels very soon after the accident, and producing its proper symptoms, before those caused 424 HEAD. by the commotion have had time to go off, the similarity ofthe effects of each of these different causes is such, as to deprive us of all power of distinguish- ing between the one and the other, or of determining with any tolerable pre- cision to which of them such symptoms as remain are really owing. " When an extravasation of any kind is made, either upon or within the brain, if it be in such quantity, or so situated, as to disorder the economy ofthe animal, it always produces such disorder, by making an unnatural pres- sure on the parts where it lies. The nature and degree of the symptoms hereby produced are various and dif- ferent in different persons, according to the kind, quantity, and situation of the pressing fluid. Sometimes it is mere fluid blood, sometimes blood in a state of coagulation, sometimes it is clear lymph, and at others blood and water are found mixed together ; each of these is found either simple or mix- ed in different situations, that is, be- tween the skull and dura mater, or in the natural cavities of the brain called its ventricles, and sometimes, in cases of great violence, they are found at the same time in all these different parts. Sometimes a considerable quantity is shed instantly, at the time of the acci- dent: and sometimes the breach by which the effusion is made is so cir- cumstanced, both as to nature and si- tuation, that it is at first very small, and increases by faster or slower de- grees. In the former, the symptoms are generally immediate and urgent, and the extravasation is of the bloody kind; in the latter, they are frequently slight at first, appear after some little interval of time, increase gradually till they become urgent or fatal, and are in such case generally occasioned by extravasated lymph. So that although the immediate appearance of bad symp- toms does most certainly imply mis- chief of some kind or other, yet, on the other hand, no man ought to suppose his patient free from hazard, either be- cause such symptoms do not shew themselves at first, or because they ap- pear to be but slight: those wliich come on late, or appearing slight at first, in- crease gradually, being full as much to be dreaded as to consequence, as the more immediately alarming ones; with this material difference between them, that the one may be the conse- quence of a mere concussion of the brain, and may by means of quietude and evacuation go quite off; whereas, the other being most frequently owing to an extravasation of lymph, (though sometimes of blood also) within the substance of the brain, are very sel- dom removed by art." (Pott.) The case of extravasation, between the cranium and dura mater, is almost the only one, which admits of relief from trephining. Mr. Abernethy in- forms us, that, in the cases, which he has seen, of blood extravasated, be- tween the dura and pia mater, on a di- vision of the former membrane being made for its discharge only the serous part of it could be evacuated: for, the co- agulum was spread over the hemisphere of the brain, and had descended, as low as possible, towards its inferior part, so that very little relief was ob- tained by the operation. P. 32. Fractures ofthe cranium, which take place across the lower and front angle of the parietal bone, and the rest of the track of the trunk, and large branches of the spinous artery of the dura mater, are cases very apt to be at- tended with a copious extravasation. This vessel, and others more deeply seated, however, may be ruptured, pour out a considerable quantity of blood, and induce urgent symptoms of pressure on the brain, not only without the coexistence of a fracture, but even of any external mark of violence on the scalp. The effused blood is, more frequent- ly, situated below the part, on which the violence has operated, and, hence, when such part is pointed out by a wound, or discoloration of the scalp, and the symptoms of pressure are con- siderable, there cannot be two opinions, respecting the propriety of immedi- ately trephining, and the place, where to make the perforation. But, what is to be done, when dangerous symptoms of pressure prevail, without any exter- nal mark to denote, what part of the head received the blow, or whether any at all; for, a general concussion of the head may produce an effusion of blood within the cranium. Under these circumstances, Mr. Pott was against the operation, and says that " the only chance of relief is from phlebotomy, and an open belly ; by which we may hope so to lessen the quantity of the circulating fluids as to assist nature in the dissipation or absorption of what has been extravasated. This is an ef- fect which, although not highly im- HEAD. 425 probable in itself, yet is not to be ex- pected from a slight or trifling applica- tion of the means proposed. The use of them must be proportioned to the hazard of the case. Blood must be drawn off freely and repeatedly, and from different veins ; the belly must be kept constantly open, the body quiet, and the strictest regularity of general regimen must be rigidly observed. By these means, very alarming symptoms have now and then been removed, and people in seemingly very hazardous circumstances have been recovered." If the symptoms, however, were ur- gent, it certainly might be proper to perforate the cranium in the course of the spinous artery of the dura mater. If no blood should be found under one parietal bone : the operation might be done on the other. This situation, we know, is the chief one for copious ex- travasations between the cranium and dura mater, and, if the blood be more deeply effused, we have the consola- tion of knowing, that the patient had the chance of that benefit, which might have resulted from the operation, had the pressure originated from an extra- vasation in one of tiie most common places, between the dura mater and the skull. This part of practice, however, is ex- ceedingly doubtful and obscure. But, should the mode of judging, whether blood lies immediately under the skull, suggested by Mr. Abernethy, prove, invariably correct, our line of conduct may be hereafter more easily determin- ed, respecting whether tiie trephine should be applied in such dubious cases, or not. Even when the injured scalp shews where the violence has operated, the criterion, we are about to notice, may inform us, whether we should perforate the bone, or not -, for, though the extravasation is found immediately under the external mark, yet, it often is not so ; but, is in a part distant from that mark, to which we have nothing to lead us, and to which, indeed, if we knew it, we could not reach. Mr. Ab- ernethy has observed," that unless one of the large arteries of the dura mater be wounded, the quantity of blood, poured out, will probably be inconsid- erable ; and the slight compression of the brain, whicii this occasions, may not be attended with any peculiar symp- toms, or, perhaps, it may occasion, some stupor, or excite an irritation, disposing the subjacent parts to be- vol. 1. come inflamed. It is indeed highly probable, that, in many cases, which have done well without an operation, such an extravasation has existed. But, if there be so much blood on the dura mater, as materially to derange the functions of the brain, tiie bone, to a certain extent, will no longer receive blood from within, and by the operation, performed for its exposure, the peri- cranium must have been separated from its outside. I believe, that a bone, so circumscribed, will not be found to bleed." In some cases, related by this gentle- man, there was no hemorrhage; twice he was able, by attending to this cir- cumstance, to tell how far the detach- ment of the dura mater extended; and often, when symptoms seemed to de- mand a perforation ofthe skull, he has seen the operation contra-indicated by the hemorrhage from the bone, and as the event shewed, with accuracy. P. 33. Pott justly remarks, that " if the ex- travasation be of blood, and that blood be in a fluid state, small in quantity, and lying between the skull and dura mater, immediately under or near to the place perforated, it may happily be all discharged by such perforation, and the patient's life may thereby be saved; of which many instances are producible. B ut if the event does not prove so fortunate, if the extravasation be so large or so situated that the ope- ration proves insufficient, yet the symp- toms having been urgent, general evac- uation having been used ineffectuaUy, and a wound or bruise of the scalp having pointed out the part which most probably received the blow • although the removal of that part of the scalp should not detect any injury done to the bone, yet the symptoms still sub- sisting, I cannot help thinking, that perforation of tiie cranium is in these circumstances so fully warranted, that the omission of it may truly be called a neglect of having done that which might have proved serviceable, and, re- bus sic stantibus, can do noharm. It is ve- ry true that no man can beforehand tell whether such operation will prove ben- eficial or not, because he cannot know the precise nature, degree, or situa- tion of the mischief ; but, this uncer- tainty properly considered, is so far from being a dissuasive from the at- tempt, that it is really a strong incite- ment to make it; it being fully as im- possible to know, that the extravasated 54 416 HEAD. fluid does not lie between the skull and dura mater, and that under the part Btncken, as that it does; and lf'the latter should be the case, and the operation be not performed, one, and most prob- ably the only means of relief, will have been omitted." When there is no interval of sense, between the blow, and the coming on of perilous symptoms, it is frequently impossible to determine, whether tiie nmchief be owing to the largeness and suddenness of the extravasation, to the violence of the shock, which the brain has received, or to both these causes at once, which, unfortunately, is too often the case. In this latter complica- tion, indeed, trephining will frequently be of no avail, even though it serve for the entire removal of all pressure off the brain; for, the patient carnot re- cover from the violence of the concus- sion, andnever regains his senses. This is no reason, however, why the chance ofthe operation doing good should not be taken, when there are evident symp- toms of pressure. Let usin these dark- ened cases, call to mind the sentiments of Pott, who says ; " No man, who is at all acquainted with this subject, will ever v enture to pronounce or prom- ise success from the use of the tre- phine, even in the most apparently slight cases; he knows that honestly he cannot; it is enough that it has of- ten been successful where and when evtiy other means have failed. The true and just consideration is this; does the opt ration of perforating the cranium in such case add at all to that degree of hazard which the patient is in before it is performed ? Or can he in many instances do well without it ? If it does add to thy patient's hazard, that is certainly a very good reason for laying it aside, or for using it very cautiously ; but, if it does not, and the only objection made to it, is, that it frequently fails of being successful, surely it cannot be right to disuse that, which lias often been, not only saluta- ry, but the causa sine qua non of pres- ervation, merely, because it is also of- ten unsuccessful, that is, because it is not infellible." Mr. Pott thought, that, whenever the dura was detached from the inner surface of the skull by blood, as well as matter, the pericranium covering the outer part of the same bone would generally become detached also, and tliis spontaneous separation of the lat- ter membrane he very justly regards, as a positive indication for the opera- tion. However, it is very certain, that if, in cases of extravasation, the sur- geon were to wait for this criterion, the operation would be done too late, and, therefore, whenever unequivocal symp- toms of pressure on the brain exist, trephining should never be delayed. Giving vent to the confined blood " may produce a cure, or it may prove only a temporary relief, according to the dif- ferent circumstances of different cases. The disappearance, and even the alle- viation of the most pressing symptoms is undoubtedly a favourable circum- stance, but is not to be depended upon as absolutely portending a good event. Either a bloody, or limpid extravasa- tion may be formed, or forming be- tween the meninges, or upon, or with- in the brain, and may prove as certain- ly pernicious in future, as the more ex- ternal effusion would have done, had it not been discharged ; or the dura ma- ter may have been so damaged by the violence ofthe blow as to inflame and suppurate, and thereby destroy the pa- tient." (Pott.) " If tiie disease (says the same emi- nent surgeon) lies between the dura and pia mater, mere perforation of the skull can do nothing ; and, therefore, if the symptoms are pressing, there is no remedy but division of the outer of these membranes. The division of the dura mater is an operation, whicii I have several times seen done by others, and have often done myself; I have seen it, and found it now and then suc- cessful ; and, from those instances of success, am satisfied of the propriety, and necessity of" its being sometimes done." He next states, however, his sentiment, that wounding the dura ma- ter is itself" attended with dangerous consequences. Mr. Abernethy's opi- nion of' such operation has already been given. " Upon the removal of a piece of bone by means of the trephine ; if the operation has been performed over the part where the disease is situated, and the extravasation be of the fluid kind, and between the cranium and dura ma- ter; such fluid, whether it be blood, water, or both, is immediately seen, and is partly discharged by such open- ing ; if, on the other hand, the extra- vasation be of blood in a coagulated or gi unious state, it is either loose, or in some degree adherent to the dura ma- HEAD. 427 ter ; if the former of these be the case, it is either totally or partially discharg- ed at the time of, or soon after, the operation, according to the quantity or extent of the mischief; if the latter, the perforation discovers, but does not immediately discharge it. In both in- stances, the conduct of the surgeon, with regard to repetition of the opera- tion, must be determined by the parti- cular circumstances of each individual case ; a large extravasation must ne- cessarily require a more free removal of bone than a small one ; not only on account of freedom of discharge, but on account of larger detachment of dura mater; and a grumous or coagu- lated extravasation requires a still more free use ofthe instrument, not only be- cause the blood in such state is dis- charged with difficulty, but because the whole surface of the dura mater so covered is always put under the neces- sity of suppurating-, wliich suppuration has but one chance of a happy event, and that derivable from the free use of the perforator. " When the extravasation is not be- tween the cranium and dura mater, but eitiier between tlie meninges, or in the ventricles ofthe brain, the appearan- ces are not only different from the pre- ceding state of the case, but from each otiier. " When the extravasated fluid lies between the skull and dura mater ; as soon as that extravasation is discharg- ed, or the grumous blood has been wiped off, the dura mater appears flac- cid, easily yields to or does not resist the impression of a finger, and (the discharge being made) enjoys that kind of motion, that elevation and depres- sion, whicii our fathers supposed it to have naturally and always, but which is only the consequence of the circula- tion through the brain, and the artifi- cial removal of the piece of bone. But when the extravasation is situated be- tween the meninges, or on the surface of die brain, the appearance is not the same. In this case, there is no dis- diarge upon removing the bone ; and the dura mater, instead of being flac- cid and readily obeying the motion of the blood, appears full and turgid, has little or no motion, and pressing hard against the edges of the perfora- tion, rises into a kind of spheroidal form in the hole of tiie perforated bone. If tiie extravasation be of the limpid kind, tiie membrane retains its natural colour ; but if it be either purely fluid blood, or blood coagulated, and the subject young, the colour ofthe mem- brane is so altered by what lies under it, that the nature ofthe case is always determinable from this circumstance. " Be the extravasated fluid what it may, it has no natural outlet; absorp- tion was the only chance the patient had whereby to get rid of it without an operation, and that we must now suppose to have failed; an artificial opening therefore must be made, by the division of tiie dura mater, and per- haps of the pia also. This operation, under the circumstances and appear- ances already mentioned, is absolutely necessary and has been successful; it is performed to give discharge to what cannot be got rid of by any other means, and consists in a division of the membrane or membranes, made in a crucial form with a point of a lancet. The operation in itself is extremely easy and simple, but the patient is thereby put into the state of one whose meninges have been wounded, with on- ly this difference, that the wound made for this purpose is smootii and simple, and inflicted with the least possible vi- olence : whereas an accidental wound of the same parts may be lacerated, contused, and attended with circum- stances whicii must aggravate the evil, and may induce worse consequences." (Pott.) All cases of pressure on the brain are attended with hazard of inflamma- tion of this organ, and membranes. This danger must be averted as much as possible, by the antiphlogistic means recommended in speaking of fractures of the skull. CONCUSSION, OR COMMOTION OF THE BRAIN. " Very alarming symptoms, follow- ed sometimes by the most fatal conse- quences, (Pott remarks,) are found to attend great violence offered to the head; and, upon the strictest exami- nation both of the living and the dead,, neither fissure, fracture, nor extravasa- tion 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 externa, but has only been violently shaken; nay, when only the body, or general frame, has seemed to have sustained tiie whole violence." ^""uid the same writer after> 426 HEAD. wards accurately observes, that " the symptoms attending a concussion are generally in proportion to tiie degree of violence, which the brain itself has sustained, and which, indeed, is cog- nizable only by the symptoms. If the concussion be very great, all sense and power of motion are immediately abo- lished, and death follows soon: but, be- tween this degree, and that slight con- fusion (or stunning, as it is called) which attends most violence, done to the head, there are many stages." I think Mr. Abernethy has particularly excelled other writers, in his descrip- tion of the symptoms of concussion, wliich, he is of opinion, may be proper- ly divided into tliree stages. " The first is, that state of insensi- bility and dei-angement of the bodily powers, whicii immediately succeeds the accident. While it lasts, the pa- tient scarcely feels any injury that may be inflicted on him. His breathing is difficult, but in general without ster- tor ; his pulse intermitting, and his ex- tremities cold. But such a state can- not last long; it goes oft" gradually, and is succeeded by another, whicii I consider as the second stage of concus- sion. In this, the pulse and respira- tion become better, and, though not regularly 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 in- attentive to slight external impressions. As the effects of concussion diminish, he becomes 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, &.c. ; otherwise, he answers incoherently, and as if his attention was occupied by something else. As long as the stupor remains, the inflam- mation of the brain seems to be mode- rate ; but as the former abates, the latter seldom fails to increase : and this constitutes the third stage, which is the most important of the series of effects proceeding from concussion. " The several stages vary considera- bly 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 violently shaken. Whe- ther they bear any certain proportion to each other or not, I do not know. Indeed this will depeed upon such a variety of circumstances in the consti- tution, the injury, and the after-treat- ment, that it must be difficult to deter- mine. " With regard to the treatment ot concussion, it would appear, that in the first stage very littie 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 between the insensibility in fainting, and that which occurs in concussion, the more powerful stimulants, such as wine, brandy, and volatile alkali, are com- monly had recourse to, as soon as the patient can be got to swallow. The same reasoning which led to the em- ployment of these remedies in tiie first stage, in order to recall sensibility, has given a kind of sanction to their repe- tition in the second, with a view to con- tinue and increase it. " But here the practice becomes more pernicious, and less defensible. The circumstance of the brain having so far recovered 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 wliich probably tend to exhaust parts already weakened, by the violent ac- tion they induce. " And it seems probable, that these stimulating liquors will aggravate that inflammation wliich must sooner or later ensue." (Essay on Injuries of the Head, p. 59.) The following passage, extracted from a writer, who has already been of material assistance to us in this subject, cannot be too deeply impress- ed on the memory of every surgical practitioner: " Te distinguish betw-een an extrava- sation and a commotion, by the symp- toms only, i, 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 the going off of the one and accession of the other, render tliis a very nice exer- cise of the judgment. The first stun- ning or deprivation of sense, whether total or partial, may be from either, and no man can tell from wliich ; but when these first symptoms have been removed, or have spontaneously disap- peared ; if such patient is again op- HEMERALOPIA. 429 pressed with drowsiness, or stupidity, or total or partial loss of sense, it then becomes most probable, that the first complaints were from commotion, and that the latter are from extravasation ; and the greater the distance of time between the two, the greater is the probabiUty not only that an extravasa- tion is the cause, but that the extrava- sation is of the limpid kind, made gra- datim, and within the brain. " Whoever seriously reflects on the nature of these two causes of evil within tlie cranium, and considers them as Uable to frequent combination in the same subject, and at the same time considers, that in many instances no degree of information can be obtain- ed from the only person capable of giv- ing it (the patient,) will immediately be sensible, how very difficult a part a practitioner has to act in many of these cases, and how very unjust it must be to call that ignorance, which is only a just diffidence arising from the obscur- ity of the subject, and the impossibili- ty of attaining materials to form a clear judgment. " When there is no reason to appre- hend any other injury, and commotion seems to be the sole disease, plentiful evacuation by phlebotomy and lenient cathartics, a dark room, the most per- fect quietude, and a very low regimen, are the only means in our power ; and are sometimes successful." (Pott.) The reader, who wishes to acquire the most accurate information, concern- ing injuries of the head, may consult, with advantage, various dissertations in the Mem. de I' Acad, de Clururgie ; Traite des Operations de Chirurgie par Le Dran; Dease on Wounds of the Head; Pott on Injuries of the Head from External Violence ; Hill's Cases in Surgery,- O'Halkran on the different Disorders arising from External Inju- ries of the Head ; Some Cases in De- sault's Parisian Chirurgical Journal; Memoire sur ks Plaies de Tete, in CEu- vres Chirurgicaks de Desault, par Bi- chat, torn. 2 ; arid Latta's System of Sur- gery, vol. 2. HECTIC FEVER. See Fevers, Sur- gical. HEMERALOPIA, (from iS/uig*, a day, and ovla, to see.) A defect in the sight, whiqh consists in being able to see in the day-time, but not in the evening. The following is Scarpa's description of this curious disorder. " Hcmeralopia, or nocturnal blindness, (says Scarpa) is properly nothing but a kind of imperfect periodical amau- rosis, most commonly sympathetic with the stomach. Its paroxysms come on towards the evening, and disappear in the morning. The disease is en- demic in some countries, and epidemic at certain seasons of the year, in oth- ers. " At sunset, objects appear to per- sons affected with the complaint, as if covered with an ash-coloured veil, which graduaUy changes into a dense cloud, which intervenes between the eyes, and surrounding objects. Pa- tients with hemeralopia have the pupil, both in the day and night-time, more dilated, and less moveable, than it usu- ally is in healthy eyes. The majority of them, however, have the pupil more or less moveable in the day-time, 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 moon-light their sight is still worse. At day-break they recover their sight, which continues perfect, all the rest of the day, till sunset." This disease (according to Scarpa) may commonly be completely cured, and oftentimes in a very short time, by treating it on the same plan by whicii the imperfect amaurosis is rem- edied ; (see Amaurosis,) viz. by em- ploying emeties, 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 conjoined with valeri an. In cases, in wliich the disease has been preceded by plethora, and sup- pressed perspiration, bleeding and su- dorifics are also indicated. In this manner, Scarpa has succeeded in curing three subjects, affected with the complaint. The first was a boy, fourteen years old, who, for several weeks, had, in vain, made use of the fumigation of a sheep's liver, which had been fried. The second was a wa- terman ; the third a countryman, living in the rice-fields in the vicinity of Pa- via. The two last were between thirty and forty years of age, and emaciated, 430 HEMEKALOPIA. witii bloated, sallow countenances. Af- ter the boy had vomited a good deal, in consequence of taking, at repeated doses, in the space of two hours, a grain and a half of* tartar emetic, dissolved in four ounces of water, he took on the following days, the resolvent powders, mentioned in Amaurosis. They produ- ced nausea, and two or three copious stools, regularly every day. On the evening of the fifth day, the patient be- gan to discern surrounding objects by the faintest light of a lantern. Even since the emetic was administered, he continued the topical use of the vapours of the spirit of sal-ammoniac, and, on the sixteenth day, was perfectly cured. The waterman thrice vomited up a con- siderable quantity of a yellowish, vis- cid matter. Afterwards, he took tiie resolvent powders, which made him vomit again on the third day, and, in the day-time, he regularly exposed his eyes, every four hours, to the action of the ammoniacal vapours. It was not till the eleventh day, that he began to distinguish objects in the night-time by a weak candle-light. The country- man vomited only once copiously, but afterwards experienced considerable nausea during the nine following days, on which he took the resolvent powders, and he daily discharged by stool a con- siderable quantity of greenish matter. From the beginning, this patient also employed the ammoniacal vapours, as a topical application, and, on the even- ing of the fourteenth day, he began to see by candle-light. From this period, he continued to regain the faculty ot* seeing objects in the night-time regu- larly more and more, until he was com- pletely cured. Towards the conclusion ofthe treatment, Scarpa gave these pa- tients bark and valerian. But, the most expeditious cure was that which Scarpa effected on Mauru Bonini, a robust husbandman, of Donal- asco, aged two-and-twenty. This man began, in March to perceive, that, at sunset, he could only distinguish objects very imperfectly. The complaint in- creased to such a degree, that, in the beginning of Mav, he was almost total- ly blind in the evening. On the tenth of May, he came to the hospital at Pa- via. Having examined both his eyes in the day-light, Scarpa found both the pupils very much dilated, and almost motionless. In the evening, he repeat- ed the examination, and assured him- self, that the patient could not see ob- jects, which were visible to tiie by- standers, consequently, that he whs af- fected with hemeralopia. He also com- plained of bitterness in the mouth, heaviness in his head, and his tongue was foul. On the eleventh, Scarpa ordered him an emetic, which did not produce so much effect as was expected, and there- fore a stronger one was prescribed the next day. It was composed of a dram and a half of ipecacuanha, and two grains of tartar emetic. This dose made him vomit up a considerable quantity of yellow, greenish matter. The patient found his head relieved immediately afterwards, and the bitter- ness in his mouth was no longer per- ceptible ; the pupils of his eyes con- tracted a little, and became somewhat moveable in a vivid light. The ammo- niacal vapours were now externally ap- plied. The same evening, the patient's sight seemed amended, and, on the thirteenth, all internal medicines were discontinued, the vapours alone being used. On the fourteenth, the patient com- plained again of bitterness in his mouth, and his tongue appeared furred. Scar- pa ordered him to take the resolvent powders every three hours. These produced nausea, and some evacuations from the bowels. The use of the va- pours was continued. In the evening, Scarpa exposed the patient to the same degree of light, as when the preceding examinations were made, and the pa- tient was able to distinguish all objects which were presented to him, exceed- ingly well. On the 16th, the symptoms of foulness in the stomach entirely dis- appeared, and the pupil of each eye contracted in a moderate light, as in healthy persons. The man left the hos- pital, on the 17th, perfectly cured. Scarpa notices, that the ancients have strongly recommended, for tiie cure of this disease, the fumigations of a sheep's liver roasted. These were directed against the eyes through a funnel; and the liver, thus prepared, was also directed to be eaten. Even in Italy, according to Scarpa, this reme- dy in general obtains confidence, not only with the vulgar, but also with sur- geons. Some writers add, that it is productive of wonderful success among the Chinese, who are said td be very li- able to this complaint. Scarpa says, he has no observation of his own to of- fer in support of tliis account; but, tiie HEMERALOPIA. 431 case ofthe above mentioned boy seems to be repugnant to it. If, however, the efficacy of this remedy should be a mat- ter of fact, surgeons wiU possess another means of curing nocturnal blindness, besides that which we have been explaining. Celsus, in the chapter on Mydriasis, has the following words : Quidam sine uUd manifestd causd subito obcacati sunt. Ex quibus nonnulli, cam aliquandiu ni- ful vidissent, repentind profusione alvi lumen recuperant. Qua minus alienum videtur, et recenti re, et interposita tem- pore medicamentis quoque moliri dejec- liones, qua omnem noxiam nmteriam per inferiora depellant. This passage, Scar- pa thinks, refers not only to the treat- ment of the dilated pupil, but also to that of the imperfect amaurosis, whicii occurs suddenly; and it appears to him to merit the attention of practitioners. The first part of what Celsus has stated, viz. that persons who have been for some time affected with amaurosis, have regained their sight on being at- tacked by a diarrhoea, seems to Scar- pa to be corroborated by the case, re- lated by Doctor Pye. (Med. Obs. and Inq. Vol. I.) A man, forty years of age, says he, had been affected for two months, with periodical amaurosis, which, for a certain time, had occurred regularly every evening, but afterwards cams on irregularly, at different inter- vals, with considerable dilatation ofthe pupil, and such obscuration of sight on the approach of night, that even the light of a candle could not be discern- ed. The man was seized with a diar- rhoea. Doctor Pye ordered him to take, for eight successive days, a potion with the kali prseparatum ; then he pre- scribed an electuary, composed of bark, nutmeg, and sirup of orange-peel. The two latter ingredients were added to the bark, on account of the continu- ance of the diarrhoea. The second day after the electuary was taken, the diar- rhoea increased, and the patient vomit- ed copiously; after whicii he suddenly recovered his sight, so as to see equal- ly well by day and by night. ,. As the diarrhoea continued, the electuary was omitted, 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 day time. Doctor Pye does not men- tion what steps were taken to moderate the fever, whicii proved fatal to the pa- tient. At all events, adds Scarpa, it is fact, that this spontaneous laxness of the bowels entirely freed the man from the imperfect periodical amaurosis. Scarpa entertains no doubt, that, by looking attentively into the numerous collection of medical observations, one might find in them a great many facts similar to the preceding one, shewing the influence of what he terms morbific gastric stimuli over the organ of sight, and, consequently, the great utility of a spontaneous looseness of the bowels in the cure of the imperfect amauro- sis. But, says Scarpa, even if such ex- amples of the incomplete amaurosis be- ing dissipated in consequence of spon- taneous vomiting, or copious evacua- tions from the bowels, produced entire- ly by nature, were rare, and noticed by few, we now have so many observa- tions, evincing the successful cure of this disease by means of such evacua- tions, artificially produced by emetics, and internal resolvents, that no doubt whatever can be entertained, con- cerning the accuracy of the second part of Celsus's admonition, relative to the present view of the imperfect amau- rosis : et recenti re, et interposito tempo- re, medicamentis quoque moliri dejectia- nes, qua omnem noxiam materiam per in- feriora depellant. Of this Scarpa re- marks, we undoubtedly have nume- rous, satisfactory proofs, in the accu- rate observations, related by Schmuck-V er and Richter; but our confidence, says Scarpa, in the above method of curing tiie imperfect and periodical amaurosis, 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 internal resolvents, though, in their writings, they may have imputed the success of the treatment to other causes, or the efficacy of other remedies, which they prescribed conjointly with emetics, and resolvents. Scarpa, after several valuable re- marks on amaurosis in general, refers to the Mercure de France, for Februa- ry, 1756, where is an account of the cures performed by Fournier, on seve- ral subjects, affected with hemeralopia. The first were three soldiers, to whom an emetic was administered, after bleed- ing them. The next day, as they also complained ofa heaviness in tiieir head, 432 HEMORRHAGE. and nausea, the bleeding and emetic were repeated. This expedient remo- ved all the above symptoms, and these three soldiers were no longer unable to see in the night time. Founder met with equal success, in treating eight other soldiers upon the same plan, who were affected with the same disease, and belonged to the same garrison. Scarpa notices, that Pellier* cured Captain Micetti of an hemeralopia by repeated doses of tartar emetic, a seton in the nape of the neck, and cooling, aperient beverages. The same authorf assures us, that he has several times cured tiie recent imperfect amaurosis, by means of small doses of tartar eme- tic, and topical aromatic fumigations. (See Scarpa sulk Malattie degli Occhi. Venezia, 1802.) HEMORRHAGE, (from <*/>*, blood, and fityvu/uu, to break out.) Hamorrhagia. Bkeding. This is doubtless one ofthe most im- portant subjects in Surgery. The fear of hemorrhage in fact retarded the im- provement of our Profession for ages; for the ancients, ignorant how to stop bleeding, were afraid to cut out the most trivial tumour, or they did so with terror. They generally performed ope- rations slowly and imperfectly, by means of burning-irons, or ligatures, which the moderns execute quickly and safely with the knife. If the old surge- ons ventured to amputate a limb, they only did so, when it had mortified, by dividing the dead parts, and so great was their apprehension of bleeding, that they only dared to cut parts which could no longer bleed. (John Bell's Principles of Surgery, Vol. 1. p. 142.) But, not only as a consequence of sur- gery, is hemorrhage to be feared; it is also one ofthe most alarming accidents, which surgery is called upon to relieve. " Un sentiment naturel attache d Vkke de perdre son sang; une terreur machi- nate,dont I'enfant, qui commence a parkr, et I'homme k plus decide, sonl egakment susceptibks. On ne pent point dire, que cette peur soit cldmerique. Si I'on comp- toit ceux, qui perdent la vie dans une batuilk, on verroit, que ks trois quarts ont peri par quelque hemorrhogie; et dans ks grandes operations de clururgie cet accident est presque toujours le plus fornudobk. (Morand. Mem. de I'Acad. Royak de Chirurgie, Vol. 5. 8vo. See Jones on Hemorrhage.) As the blood circulates in the arte- ries with much greater impetus and ra- pidity, than in the veins, it necessarily foUows, that their wounds are general- ly attended with much more hemor- rhage, than those of the latter vessels, and that such hemorrhage is more dif- ficult to suppress. However, as the blood also flows through veins, of great magnitude, with great velocity, bleed- ings from them are frequently highly dangerous, and sometimes unavoidably fatal. When an artery is wounded, the blood is of a bright scarlet colour, and gushes from the vessel per solium, in a very rapid manner. The blood issues from avein in an even, unbroken stream, and is ofa dark purple red colour. It is of great practical use to remember, these distinguishing differences, be- tween arterial and venous hemorrhage, because, though the oozing of blood may be in both cases equal in quantity, yet, in the latter instance, one is often justified in bringing the sides of a wound together, without taking farther means to suppress the bleeding, while it would not be proper to adopt the same conduct, were there an equal oozing of arterial blood. Dr. Jones has favoured the world with a matchless work, on the present subject; and as one grand object of this Dictionary is to convey a concise account of all the latest improvements in surgical science, I shall first endea- vour to make the reader acquainted with the more accurate ideas, which this gentleman has lately published, relative to the doctrines of hemorrhage, Afterwards, we shall consider the sur- gical means to be practised in different cases. The sides of the arteries are divisi- ble into three coats. The internal one is extremely thin and smooth. It is elastic, and firm, (considering its deli- cate structure) in the longitudinal di- rection, but so weak in the circular as to be very easily torn by the slightest force applied in that direction. Its diseases shew, that it is vascular, and it is also probably sensible. The middle coat is the thickest, and is composed of muscular fibres, all ar- ranged in a circular manner; they dif- * Recueil de Mem. et Obs. sur l'OJil. Obs. 132. \ Ibid. Observ. 136, 138. HEMORRHAGE. 433 fer, however, from common muscular fibres in being more elastic, by which they alone keep a dead artery open, and ofa cyUndrical form. As this mid- dle coat has no longitudinal fibres, the circular fibres are held together by a slen- der connexion, which yields readily to any force, applkd in the circumference of the artery. The external coat is remarkable for its whiteness, density, and great elas- ticity. When an artery is surrounded isith a tight ligature, its middle and in- ternal coats are as completely divided by it, as they could be by a knife, w/uk the external coat remains entire. Besides these proper coats, all the arteries, in their natural situations, are connected, by means of tiie fine ceUu- lar substance, with surrounding mem- branous sheaths. If an artery be divi- ded, the divided parts, owing to tiieir elasticity, recede from each other, and tlie kngth of the cellular substance, connect- ing the arteiv/ with tlie sheath, admits of its retracting a certain way within tlie sheath. Another important fact is : that when an artery is divided, its truncated extre- mities contract in a greater, or less, de- gree, and the contraction is generally, if not always, permanent. Arteries are furnished with arteries, veins, absorbents, and nerves ; a struc- ture, which makes them susceptibk of every change to wldch living parts ave subjected in common,- enables them to in- flame, when injured, and to pour out coa- gulating lymph, by wldch the injury is re- paired, or the tube permanently closed. (See Jones on Hemorrhage.) M. Petit, the surgeon, was the first, who, in 1731, endeavoured to explain the means, which nature employs for the 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, afterwards adheres to the inside of tiie artery, to its orifice, and to the surrounding parts; and, he adds, that when hemorrhage is stopped by a ligature, a coagulum is formed above the ligature, which only differs in shape, from the one, whicii takes place when no ligature is em- ployed. His opinion leads him to re- commend compression to support the coagulum. / In 1736, M Morand published addi- tional interesting remarks. He allow- ed, that a coagulum had some effect in stopping hemorrhage; but, contended, that a corrugation, or plaiting, of the circular fibres of the artery which di- minished its canal, and a shortening and consequent thickening of its * lon- gitudinal 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 circular pressure, as that of a ligature, is made. Morand erred chiefly in explanation; for, the contraction and retraction of di- vided arteries are indisputable facts, and, as Dr Jones remarks, this does not affect the truth of his general con- clusion, that the change produced on a divided artery, contributes with the coa- gulum to stop the flow of blood. Mr. Samuel Sharp (2d Edit, of Ope- rations of Surgery, 1739,) supported the same doctrine. "The blood-ves- sels, immediately upon their division, bleed freely, and continue bleeding, till they are either stopped by art, or at length contracting, and withdrawing themselves into the wound, their ex- tremities are .shut up by coagulated blood." Pouteau (Melanges de Chirurgie, 1739,) denied that a coagulum is al- ways found after an artery is divided; and, when it is, he thought it only a feeble and subsidiary means towards the suppression of hemorrhage. He contended, that the retraction of the artery had not been demonstrated, and could not be more effectual, than a co- agulum. His theory was, that the swelling of the cellular membrane, at the circumference of the cut extremity of the artery, forms the principal impe- diment to the flow of blood; and that a ligature is useful in promoting a more immediate and extensive induration of the cellular substance. Gooch, White, Aikin, and Kirkland, all oppose Pe tit's doctrine of coagulum. The first blends some of Pouteau's the- ory with his own, by observing, that *' when a small artery is totally divided, its retraction may bring it under the voi>. 1 * Anatomists do not acknowkdge that such exist. 55 134 HEMORRHAGE. surrounding parts, and with the natu- ral contraction of the diameter of its mouth, assisted by the compressive power of those parts, increased by their growing tumid, the efflux of blood may be stopped." White was convinced, from what Gooch had suggested, and Kirkland confirmed, that the arteries, by their natural contraction, coalesce, as far as their first ramification. Dr. Jones admits, that an artery con- tracts after it has been dividecl, and his experiments authorize him to say, that the contraction of an artery is an important means, but certainly not the only, nor even the chief means, by which hemorrhage is stopped. The impetu- ous flowing ofthe blood through the wound of the artery would resist the contraction of the vessel in such a de- gree, that would, in almost every in- stance be attended with fatal conse- quences, when the artery is above a certain size, were it not for the forma- tion of a coagulum. (Jones.) Mr. J. Bell thinks, that when hemor- rhage stops of its own accord, it is nei- ther from the retraction of an artery, nor the constriction of its fibres, nor the formation of clots, but, by the cellular substance, which surrounds tiie artery, being injected with blood. We must refer the "reader to Dr. Jones's work for a complete exposure ofthe inconsistences and absurdities in Mr. Bell's account of his own theory. (See P. 25, &c.) Dr. Jones very accurately concludes his criticisms on Mr. Bell with observ- ing, that if this gentleman really means to confine his doctrine of the natural means of suppressing hemorrhage to the injection ofthe cellular substance, round the artery, with blood, he dwells improperly on one of the attendant cir- cumstances to the exclusion of the re- traction, and contraction of an artery, and the formation of* a distinct clot, all primary parts of the process. The blood, besides filling the cellu- lar substance round the artery, also fiUs the cellular substance at the mouth of tlie artery in a particular manner; for, the divided vessel, by its retraction within its cellular sheath, leaves a space of a determinate form, which, when all the circumstances necessary for the suppression of hemorrhage operate, is gradually filled up by a distinct clot. (Jones.) MEANS OF NATURE IN STOPPING BLEEDING FROM DIVIDED ARTE- RIES. Dr. Jones has given a faithful and accurate detail of a series of experi- ments on animals, wliich demonstrate " that the blood, the action, and even the structure of the arteries, their sheath, and the cellular substance con- necting them with it," are concerned in stopping bleeding from a divided ar- tery of moderate size, in the foUowiH^, manner : " An impetuous flow of blood, a sudden and forcible retraction of the artery within its sheath, and a slight contraction of its extremity, are tiie immediate, and almost simultaneous, effects of its division. The natural im- pulse, however, with which the blood is driven on, in some measure counter- acts the retraction, and resists tiie con- traction ofthe artery. The blood is effused into the cellular substance, be- tween the artery and its sheath, and passing through that canal of the sheath, wliich had been formed by the retrac- tion of the artery, flows freely exter- nally, or is extravasated into the sur- rounding cellular membrane, in propor- tion to the open, or confined state of the wound. The retracting artery leaves the internal surface ofthe sheath uneven, by lacerating, or stretching the cellular fibres that connected them. These fibres entangle tiie blood, as it flows, and thus the foundation is laid for the formation of a coagulum at tiie mouth of the artery, and wliich ap- pears to be completed by the blood, as it passes through this canal of the sheath, gradually adhering and coagu- lating, around its internal surface, till it completely fiUs it up from the cir- cumference to tlie centre." (Jones, p. 53.) The effusion of blood into the sur- rounding cellular membrane, and be- tween the artery and its sheath; but, in particular, the diminished force of the circulation from loss of blood, and a speedy coagulation of this fluid in this circumstance, most essentially contri- bute, says Dr. Jones, to the desirable effect. It appears then, that a coagulum, which Dr. Jones calls the external one, at the mouth of tiie artery, and within its sheath, forms tiie first complete ob- stacle to the continuance of bleeding, and though it seems externally Uke a HEMORRHAGE. 435 continuation ofthe artery, yet, on slit- ting open this vessel, its termination can be plainly observed, with the coa- guium shutting up its mouth, and con- tained in its sheath. (Jones, p. 55.) '^No collateral branch being very near thft impervious mouth of the artery, the blood just within it is at rest, and usually forms a slender conical coagu- lum, whicii neither fills up tiie canal of the artery, nor adheres to its sides, except by a small portion of the cir- cumference of its base, near the extre- mity 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 in- flames, and the vasa vasorum pour out lymph, which fills up the extremity of the artery, is situated between the in- ternal and external coagula, is some- what intermingled with them, or ad- heres to them, and is firmly united all round to the internal coat of the vessel. Dr. Jones further states, that the per- manent suppression of the hemorrhage chiefly depends on this coagulum of lymph; but, that the end of the artery is also secured by a gradual contrac- tion, which it undergoes? and by an ef- fusion 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 inte- guments not heal by the first intention, the coagulating lymph, soon effused, attaches the artery firmly to the subja- cent and lateral parts, gives it a new covering, and entirely excludes it from the outward wound. (Jones, p. 55.) The same circumstances are also re- markable in the portion ofthe vessel, most remote from the heart. Its ori- fice, however, is usually more contract- ed, and its external coagulum smaller, tiiin the one whicii attaches itself to ti"te other cut end of the artery. (Jones on Hemorrhage, p. 56.) The impervious extremity of the ar- tery, no longer allowing blood to cir- culate through it, the portion, which lies between it and the first lateral branch gradually contracts, till its ca- vity is completely obliterated, and its tunics assume a" ligamentous appear: ance. The external coagulum, which, In the first instance, had stopped the hemorrhage, is absorbed in a few days, -md the coagulating lymph, effused > around it, and by which tiie parts were > i thickened, is gradually removed, so that they resume again their cellular texture. (Jones, p. 57.) At a still later period, the ligamen- tous portion is reduced to a filamentous state, so that the artery is as it were, completely annihilated from its cut end to the first lateral branch. Long, how- ever, ere this final change is accom- plished, the inosculating branches have become considerably enlarged, so as to establish a free communication, be- tween the disunited parts of the main artery. (Jones, p. 58.) When an artery has been divided at some distance from a lateral branch, three coagula are formed: one of blood externally, which shuts up its mouth; one of lymph, just within the extremi- ty of its canal; and one of blood, with- in its cavity, and contiguous to that of lymph. But, when the artery has been divided near a lateral branch, no inter- nal coagulum 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 in- terferes, for under the application of the ligature it can never form. If aga- ric, lycoperdon, or sponge, be used, its formation is doubtful, depending en- tirely upon the degree of pressure, that is used; but, the. internal coagulum of blood will be equally formed, whether the treatment be left to art, or nature, if no collateral branch is near the trun- cated extremity of the artery; and last- ly, effused lymph, which, when in suffi- cient quantity, forms a distinct coagu- lum, just at the mouth of the artery, will be always found, if the hemorrhage is permanently suppressed. (Jones, p. 74.) MEANS, WHICH NATURE EMPLOYS FOR SUPPRESSING THE HEMOR- RHAGE FROM PUNCTURED, OR PARTIALLY DIVIDED ARTERIES. The suppression of hemorrhage by the natural means is much more easily accomplished, when an artery is com- pletely divided, than when merely punc- tured, or partially divided. Complete- ly dividing a wounded artery was one means practised by the ancients in or- der to stop hemorrhage: the moderns frequently do the same thing, when bleeding from the temporal artery proves troublesome. 436 HEMORRHAGE. Dr. Jones has related many experi- ments, highly worthy of perusal, and which were undertaken to investigate the present part of the subject of he- morrhage. This gentleman, however, owns, that, in regard to the temporary means by which bleeding from a punc- tured artery is stopped, he has but lit- tle 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, for some distance, both above and below the wounded part ; and when the parts are examined, a short time after the hemorrhage has com- pletely stopped, we find a stratum of coagulated blood between the artery and its sheath, extending from a few inches below the wounded part to two, or tliree inches above it, and somewhat thicker, or more prominent over the wounded part, than elsewhere. Hence, rather than say the hemor- rhage is stopped by a coagulum, 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 be- tween the artery and its sheath. (Jones, p. 113.) When an artery is punctured, the hemorrhage, 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 the punc- ture in the sheath to that in the artery, so that they are not exactly opposite to each other ; and by that means a layer of blood is confined by the sheath over the puncture in the artery, and, by coagulating there, prevents any fur- ther effusion of blood. But, this coagulated blood, like the external coagulum of a divided artery, affords only a temporary barrier to the hemorrhage ; its permanent suppres- sion is effected by a process of repara- tion, or of obliteration. Dr. Jones's experiments shew, that an artery, if wounded only to a mode- rate extent, is capable of reuniting and healing so completely, that, after a cer- tain time, the cicatrization cannot be discovered, either on its internal, or external surface; and that even ob- Uque and transverse wounds, (which gape most,) when they do not open the artery to a greater extent, than one fourth of its circumference, are also filled up and healed by an effusion of coagulating lymph from their inflamed lips, so as to occasion but little, 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 be- comes either torn, or ulcerated com- pletely across, soon afterwards, by whicii its complete division is accom- plished. The lymph, which fills up the wound of an artery, is poured out very freely both from the vessel and the surround- ing parts, and it accumulates around the artery, particularly, over the wound, where it forms a more distinct tumour. The exposed surrounding parts at the same time inflame, and pour out coagu- lating lymph,,with which the whole surface of the wound becomes covered, and whicii completely excludes the ar- tery from the external wound. This lymph granulates, and the wound is filled up and healed in the usual man- ner. (See Jones on Hemorrhage, p. 113, &c.) SURGICAL MEANS OF SUPPRESSING HEMORRHAGE. It must be plain to every one, who understands the course of the circula- tion, that pressure, made on that por- tion of* a wounded artery, wliich ad- joins the wound towards the heart, must check the effusion of blood. The current of blood in the veins, running in the opposite direction, requires the pressure to b» applied to that side df the wound, wliich is most remote from the heart. As pressure is the most rational means of impeding hemor- rhage, so it is the most effectual; and almost all the plans, employed for this purpose, are only modifications of it. The tourniquet, the ligature, the appli- cation of a roller and compresses, even agaric itself, only become useful in the suppression of hemorrhage, on the principle of pressure, the cautery, caustics, and styptics excepted. HEMORRHAGE. 437 MEANS EMPLOYED »Y THE AN- CIENTS. In order to prevent a wounded per- son from dying of hemorrhage, Celsus advises the wound to be filled with dry lint, over which is to be laid a sponge dipped in cold water, and pressed on the p«rt with the hand. If, notwith- standing this, the hemorrhage should continue, he recommends repeatedly applying fresh lint, wet with vinegar; bux, he is against the use of corroding escharotic applications, on account of the inflammation, which they produce ; or only sanctions the employment of Ihe mildest ones. When the hemor- jhage resists these methods, he advises two ligatures to be applied to the wound- ed part ofthe vessel, and then to divide the portion situated between t/iem :— •" Quad si ilia quoque profluvio vincun- tur, vena, qua sanguinem fundunt, ap- prehendenda, circaque id, quod ictum tst, duobus lock deliganda, interciden- daque sunt, ut et in se ipsa coeant, et huhilominus ora praclusa habeant." Lib. 5. cop. 26. When the ligature is im- practicable, he proposes the actual • cautery, if the wound should bleed suf- ficiently, and there should be no nerves, nor muscles at the bleeding part. Galen also mentions tying the vessels to stop the hemorrhage from wounds : and tliere are some traces of the same information in other authors, who lived before him, as Archigenes, and Rufus. However, it is more than probable, that, in their days, the ligature was very little used, as we must infer from the multitude of topical astringents, caustics, and other applications, which they have advised for stopping bleed- ing, and in whicii they would have put less confidence, had they been familiar- ly acquainted with the use of the liga- ture. No one can doubt, that they would very soon have tied the vessels Jfter amputations, had they had many pportunities of seeing the advantages of the ligature ; but, so far were they from adopting such practice, that, Al- bucasis, a long while afterwards, re- fused to amputate a wrist, lest he should see his patient bleed to death. Pare passes for the first, who em- «loyed the ligature after amputation. llis method having been attacked, he fiodestly defends it in the part of his works, intitled, Apologie. He takes great care to impute the origin of it to the ancients, and cites many of them, who have made mention of it. However, he thinks its utility in ampu- tations of such high consequence, that he considers himself as inspired hy the Deity in having first adopted this prac- tice. The method, in which the ancients placed most confidence, for stopping hemorrhage after the amputation of a limb, was the cauterization of the cut vessel, and part of the surrounding flesh. The parts, thus affected by the heat, formed an eschar, of greater, or less thickness, which blocked up the opening ofthe vessel, and hindered the blood from escaping. The separation ofthe eschar, however, which frequent- ly took place too soon, occasioned a re- turn of the hemorrhage, and rendered it the more dangerous, as its suppres- sion became more difficult, than before the cautery was apphed. The instru- ment being too much heated, even, sometimes, immediately brought away with it the eschar, which it had just formed. At the present time, the cau- tery is never employed, as a means of suppressing hemorrhage, or, at most, only in a few very unusual cases, in whicii neither compression, nor the li- gature can be made use of. In Great Britain, the cautery may be said to be entirely exploded ; but, in France, the best hospital surgeons now and then employ it to stop bleedings from the antrum, and the mouth. It was once a practice to apply pledgets, dipped in boiling turpentine, to the mouths ofthe bleeding vessels : of this it is only necessary to say, that the method now has long been most justly abandoned. ASTRINGENTS, STYPTICS, &C. Le Dran, in his treatise on the ope- rations of surgery, says, that a button of vitriol, or alum, applied, and proper- ly confined on the extremity ofthe ves- sel, is sufficient to stop the hemorrhage in amputations. Heister recommends the application of vitriol, in preference to the ligature, in the amputation of the fore-arm. Great praises have also been conferred on agaric, and sponge, for their styptic properties. Solutions of iron, and all the mineral acids in vari- ous forms, have been recommended to the public, as remedies of the same kind, and possessing great efficacy. 438 HEMORRHAGE. The ancients, indeed, had already ex- hausted this class of remedies in such a degree, that the pretended discove- ries of the moderns, in this way, may almost all be met with in their writ- ings ; and the little success, attending their practice, especially, when bleed- ing from a considerable artery was to be suppressed, clearly shews what lit- tle reliance we ought to place on means of this description. (Encyclopedic ^Me- thodique ; Partie Chirurgicale.) Styp- tics do, indeed, possess the power of stopping some hemorrhages from small arteries ; but, they ought never to be trusted, when large ones are con- cerned. There is no doubt, that cold air has a styptic property ; by which expres- sion I mean, it promotes the contrac- tion of the vessels, for, no styptics can contribute to make the blood coagu- late, though such an erroneous idea is not uncommon. We frequently tie, on the surface of a wound, every artery, that betrays the least disposition to bleed, as long as the wound continues exposed to the air. We bring the op- posite sides of this wound into contact, and put the patient to bed. Not an hour elapses, before the renewal of he- morrhage necessitates us to remove the dressings. The wound is again ex- posed to the air, and again the bleed- ing ceases. This often happens in the scrotum, after the removal of a testi- cle, and on the chest, after the removal of a breast. The proper conduct, in such cases, is not to open the wound unnecessarily, but, to apply w-et linen to the part so as to produce such an evaporation from its surface, as shall create a sufficient degree of cold to stop the bleeding. As all styptics irri- tate, judicious practitioners seldom ap- ply them to recent wounds. It is some- times, however, very proper to employ them to suppress hemorrhages from many diseased surfaces, where the ves- sels seem to have lost their natural dis- position to contract. COMPRESSION. We have already remarked, that all the best means of checking hemor- rhage, operate on the principle of pres- sure, the actual and potential cautery, and some styptics excepted; the two first of which act by forming a slough, which stops up the mouths of the ves- sels ; while the latter operate by pro- moting their contraction. Let us next consider the various modifications of pressure. M. Petit endeavours to shew, inf a dissertation on the manner of stopping hemorrhage, printed in the Menu de I'Acad. de Sciences, annee 1731, that the different things which have been prais- ed as infallible specifics, would seldom, or never, have succeeded without com- pression. It was always requisite, even when caustics were employed, to apply compresses, which were botmd on with sufficient tightness to resist the, impulse of the blood in the artery, and the premature separation ofthe eschar, occasioned by the actual or potential cautery. Had this precaution not beep taken, there would have been reason to have feared hemorrhage, almost in-, variably, and which, indeed, did recur but too frequently, when the eschar. was detached, notwithstanding the^ pains taken to avert it by suitable corn, pression. M. Petit has noticed, that the end of the finger, gently compress, ing the mouth of a vessel, is a suffix cient means of stopping hemorrhage from it, and that nothing else would be necessary, if the finger and stump could j always be kept in this posture. Hence, he endeavoured to obviate these diffi- culties by inventing a machine which securely and incessantly executes the t office of tiie finger. This instrument is a double tourniquet, which, when "" applied, compresses, at once, both the extremity of the divided artery and its trunk above the wound. The com- pression on the end of the vessel is to be permanent; that on the trunk is only to be made at the time of dress- ing the wound, or when it is neccssa- d ry to relax the other. An engraving' and particular description of the in,' strument are to be found in Petit's me- moir. Surgeons used formerly to fill'tiie cavities of. the wounds with lint, and then make pressure on the bleeding vessels, by applying compresses and a tight roller over the part. The practU turners ef the present day are too well acquainted with the advantages of not allowing any extraneous substance to intervene between the opposite sur-4 faces of a recent wound, to persist in the above plan. They know, that tho,' sides of the wound may be brought in> to contact, and that compression mafc yet be adopted, so as both to restrain particular hemorrhages, and rather '. HEMORRHAGE. 439 promote, than retard the union of the wound. When the blood does not issue from anv particular vessel, but from numer- ous" smaU ones, compression is prefera- ble to the ligature. The employment of the latter would render it necessary to tie the whole surface of the 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 roUer to be applied with suJScient tightness to make effectual pressure, but not so forcibly as to pro- duce a danger of the circulation in the Umb being completely stopped. If compression can ever be safely trusted in bleedings from large arte- ries, it is when these vessels lie imme- diately over a bone, against which they can be advantageously compres- 'sed. Bleedings from the radial and temporal arteries are of this kind. Compression is sometimes tried, when - ineffectual, 1 took some pieces of money, from the size of a farthing to tW "of a half-crown, and, wrapping tl*m up in linen, put the smallest one accurately over tiie wound, so as com- pletely to cover it. Then the others were arranged, and all of them were firmly confined with a roller, and the arm kept as quiet as possible in a shng. They were taken off* after three days, and no hemorrhage ensued. It is to be observed, that the palmar fascia, in tliis instance, would prevent the compression from operating on the vessel; but the case shews, that this artery, when wounded, is capable of healing, if the blood be completely pre- vented from getting out of the exter- nal wound by the proper application of compression. Were the outer wound too large to admit of this plan, it would probably be necessary to dissect for the ends of the artery, in order to tie them. This operation, however, is by no means easy; and, perhaps, upon the whole, it might be better to cut down, at once, to the ulnar artery, and put a ligature round it, though this would only certainly stop the bleeding from one end of the vessel in the hand. Besides compressing tiie wounded part of the artery, some surgeons also apply a longitudinal compress over the track of the vessel above the wound, with a view of weakening the flow of blood into it. Whatever good effect it may have in this way, is more than counterbalanced by the difficulty which it must create to the circulation in the arm. If the graduated compress be properly arranged, an effusion of blood cannot possibly happen, and pressure along the course of the artery must at all events be unnecessary. After 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 the compression emploved is not so powerful as entirely to impede the cir- culation in the fore-arm and hand. The arm is to be kept quietly in a shng, and, in forty-eight hours, if no bleeding- take place, tliere will be great reason to expect that the case will do well. In the First Lines of the Practice of Sur- gery, I have given an engraving and description of an instrument, invented by Pleuk, for making pressure on the wounded brachial arterv, at the bend of" the arm, without pressing upon the whole circumference of the limb, and consequently stopping the circulation. (See page 56, plate 1.) No one, howev- er, would prefer compression when large arteries are injured, except in the kind of cases, to which we have just 440 HEMORRHAGE. adverted, or in those in which the wounded vessel can be firmly compres- sed against a subjacent bone. The compresses sometimes slip off, or the bandages become slack, so that a fatal hemorrhage may arise. Hence, when this metliod is adopted, the tourniquet should always remain loosely round the limb, ready to be tightened in an in- stant. Sometimes the external wound heals, while the opening in the artery remains unclosed, and an aneurism is the consequence. This is particularly apt to occur, when the pressure has not been powerful enough , and, when too great, mortification is apt to come on : such are the objections to placing much confidence in compression, ex- cept when the vessels are not of con- siderable size. TOURNIQUET. When hemorrhage takes place from a large artery in one ofthe limbs, where tiie vessel can be conveniently com- pressed above the wound in it, a tour- niquet, judiciously applied, never fails in putting an immediate stop to the bleeding. Before tiie invention of this instru- ment, which did not take place till the latterpart ofthe 17th century, surgery was really a very defective art. No important operation could be underta- ken on the extremities, without placing the patient in the most imminent peril; and the want of the aid, afforded by the tourniquet, made many wounds mortal, whicii otherwise would not have been attended with the least dan- ger. As the first invention of this instru- ment has been claimed by different surgeons, and even different nations, we shall not take upon us to determine where it had its origin. But whoever was tlie inventor, it was first presented to the public in a form exceedingly simple; so much so, indeed, that it seems extraordinary, that its invention did not happen sooner. A small pad being placed on the principal artery of a limb, a band was applied over it, so as to encircle the limb twice Then a stick was introduced between the two circles of the band, and twisted : thus the pad was made to compress with quite power enough completely to stop the flow of blood into the lower part of the vessel. Although, in the Armamentarium Chirurgicum of Scultetus, there is a plate of a machine, invented by this author for comprising the radial, ar- tery, by means of" a screw, M. Petit is uhp ersally allowed to be tiie first who brought the tourniquet to perfec- tion, by combining the circular band with a screw, in such a manner that the greatest pressure operates on the principal artery. The advantages of the modern tour- niquet are, that its pressure can be re- g-u!ated with the utmost exactness; that it operates chiefly on the point where the pad is placed, and where tlie main artery lies ; that it does not re- quire the aid of an 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 mo- ment ; and that, when there is reason to fear a sudden renewal of hemor- rhage, it can be left slackly round the limh, and, in case of need, tightened in an instant. Its utility, however, ris confined to the limbs, and as the pres- sure necessary to stop the flow of bloqd through the principal artery, complete- ly prevents the return of blood through the veins, its apphcation cannot bje made very long without including mor- tification. It is only of use also in put- ting a sudden stop to profuse hemor- rhages for a time, that is, until the sur* geon has put in practice some "means,; the effect of which is more perma- nent. "LIGATURE. The ancients were quite unacquain£ ed with the use of the tourniquet, and though some of the writers have madje 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"suppressing hemorrhage from wounds. In modern times, it is easily comprehensible, that, when any great operation was under- taken, while surgery was so imperfect, there was more likelihood of harm, than good being done to the patieat! Nor can it be wondered at, that the o|d practitioners should have taken im- mense pains to invent a great many topical astringents. Hut now that the ligature is known to be a means which is safe, easy, and much less painful tl|a* HEMORRHAGE. 441 former methods, we need no longer search for such remedies. It may, indeed, be set down, as a rule in surgery, whenever large arteries are wounded, never to trust to any styptic application whatsoever ; but to have immediate recourse to the Ugature, as being, when properly applied, the most simpfe and safe of all methods. In fcrder to qualify the reader to judge of the best mode of applying li- gatures to arteries, I shaU first explain to him their effect on these vessels, as , related by Dr. Jones. This gentleman learned from Mr. J. Thomson, of Edinburgh, that, in every instance in which a ligature is applied around an artery, without including the surrounding parts, the internal coat ' ofthe vessel is torn through by it, and , that this fact has been originally noticed by Desault. Mr. Thomson shewed to t Dr. Jones, on a portion of artery taken rfrom the human subject, that the in- ternal and middle coats are divided by /the ligature. (Jones, p. 126.) j This led Dr. Jones to make some ex- / periments on the arteries of dogs and , horses, shewing, that when a ligature ( is applied with sufficient tightness round an artery to cut through its in- ternal and middle coats, although it be i immediately afterwards removed, the vessel always becomes permanently ' 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 expect, that the obstruction produced in the arteries of dogs and horses, in the man- ner he has related, " might be effect- ed by the same treatment in the arte- ' ries of the human subject; and, if it 1 should prove successful, it might he employed in some of the moat impor- tant cases in surgery. The success of the late important improvements which have been introduced in tiie operation for aneurism, may perhaps appear to most surgeons to have rendered that operation sufficiently simple and safe; ' but, if it be possible to produce ob- struction in the canal of an artery of i the human subject, in the above men- ' tioned manner, may it not be advanta- * geously employed in the cure of aneu- rism; inasmuch as nothing need be ' done to prevent tiie immediate union of the external wound?" Dr. Jones next Questions, whether this mode of ob- structing the passage of blood through ■ the arteries may not also be advanta- VOL. I geously practised in cases of broncho- cele ? (p. 136.) From Dr. Jones's experiments, it ap- pears, that the first effects of a ligature upon an artery are, a complete division of its internal and middle coats, an ap- position of its wounded surfaces, and an obstruction to the circulation ofthe blood through its canal. There must be a small quantity of stagnant blood, just within the extremity of the artery; but this does not, in every instance, immediately form a coagulum, capable of filling up the canal ofthe artery. In most cases, only a slender coagulum is formed at first, which gradually be- comes larger hy successive coagula- tions ofthe blood; and hence, the coa- gulum is always at first of a tapering form, with its base at the extremity of the artery. But, as Dr. Jones remarks, the formation of this coagulum is not material; for, soon after the ligature has been applied, tiie end of the artery inflames, and the wounded internal surface of its canal being kept in close contact by the ligature, adheres, and converts tliis portion ofthe artery into an impervious and, at first, slightly co- nical sac. It is to the effused lymph, that the base ofthe coagulum adheres, when found to be adherent. Lymph is also effused between the coats of the artery, and among the parts surround- ing its extremity. In a little time, the ligature makes the part, on which it is directly applied, ulcerate; and, acting as a tent, a small aperture is formed in the layer of lymph effused over the ar- tery. Through this aperture, a small quantity of pus is discharged, as long as the ligature remains; and, finally, the lig-ature itself also escapes, and the little cavity, which it has occasioned, granulates and fills up, and the exter- nal wound heals, leaving the cellular substance a little beyond the end of the artery, much thickened and indurated. (Jmies, p. 159, 161.) In short, when an artery is properly tied, the following are the effects, as enumerated by Dr. Jones : 1. To cut through the internal and middle coats of the artery, and to bring tiie wounded surfaces into perfect ap- position. 2. To occasion a determination of blood to the collateral branches. 3. To allow of tlie formation of a co- agulum of blood just within the artery, provided a collateral branch is not very near the ligature- 56 442 HEMORRHAGE. 4. To excite inflammation on the in- ternal and middle coats of the artery, b) having cut them through, and, con- sequently, to give rise to an effusion of lymph, by which the wounded surfaces are united, and the canal is rendered impervious; to produce a simultaneous inflammation on the corresponding ex- ternal surface of the artery, b) which it becomes very much thickened with effused lymph; and, at the same time, from the exposure and inevitable wound- ing of the surrounding parts, to occa- sion inflammation in them, and an ef- fusion of lymph, which covers the ar- tery, and forms the surface of the wound. 5. To produce ulceration in the part ofthe artery, around which the liga- ture is immediately applied, viz. its ex- ternal coat. 6. To produce indirectly a complete obliteration, not only ofthe canal of the artery, but even, of the artery itself to the collateral branches on both sides of the 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 the other soft parts, and its coats are susceptible of the same processes of adhesion, ulcera- tion, &c. as the other parts are. Hence, the precautions taken to secure the ad- hesion of other parts, should be obser- ved for the same purpose, with regard to an artery. The vessel is put in a state to admit of adhesion by the liga- ture, which, when properly applied, cuts through Its internal and middle coats, keeps their cut surfaces in con- tact, and affords them an opportunity of uniting by the adhesive inflamma- tion, as otiier cut surfaces- do. The immediate stoppage of the bleeding is merely the incipient and temporary part of what the ligature has to accom- plish ; it has also to effect the adhesion of the internal and middle coats of the artery, which being the thing on which the permanent suppression of the he- morrhage depends, is the most impor- tant. The size and form of the liga- ture, whether completely flat, or irre- gular, have not been, as Dr Jones re- marks, sufficiently attended to; nor is the degree of force employed in tying the artery, often considered. Some surgeons, wishing to guard against the Ugature's slipping off, tie it with a ve- ry considerable force i while others, apprehensive lest they should out through the artery, or occasion too ear- ly a separation ofthe ligature, draw it only sufficiently tight to prevent tlie escape of any blood. A broad flat U- gature is not likely to make such a wound in tiie internal and middle coats of tiie arterv, as is most favourable to adhesion, because it is scarcely possi- ble to tie it smoothly round the Vessel, whicii is very .likely to be tlirown», into folds, or puckered by it, and, coiise- quently, to have an irregular bruised* wound made in its middle and internal coats. By covering also a considerable space of the external coat, it may de- ■ stroy the very vessels which pass on it. in their way to the cut surfaces of the inner coats, and thus render them inca- pable of inflaming. Even supposing i the wound to unite, still such a ligature may cover that part of the external , coat, which is directly over the newly- united part, and, consequently, as soon as it has produced ulceration through j the external coat, it will cause the same effect 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 the inter- nal and middle coats of an artery more completely at some parts than others; but these coats must be perfectly cut ■ through, in order to produce an effu- sion of* lymph from the inside of the vessel, which seems to adhere only at its cut surfaces. Also, when the ligature is not appli- ed with sufficient tightness, the inner coats of the artery will not be properly cut through. Dr. Jones thinks, the li- gature being sometimes put on so as to deviate from a circle, has a tendency to produce secondary hemorrhage. Dr. Jones thinks ligatures are bestj' when they are round, and very firm, and, he adds, that though a very slight force is necessary to cut through thd internal and middle coats of an artery,' it is better to tie the vessel more tight- ly 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 expedited; and the danger of * ulceration spreading to the newly cica- ' trized 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. s HEMORRHAGE. 443 t am sincerely glad to find, that so accurate an observer as Dr. Jones, has refuted the idea, that ligatures occasi- onally slip oft* the vessels, in conse- qhence of the violent impulse of the blood. In fact, the blood does not con- tinue to be impelled against the extre- mity ofthe artery with the same impe- tuosity with which it circulated through the vessel before it was tied. The blood is immediately determined into the col- lateral branches, nor is there any pul- sation for some way above the liga- ture. Dr. Jones much more rationally im- '. putes this occasional occurrence, either to the clumsiness ofthe ligature, which prevents its lying compactly and se- curely round the artery; or to its not j having been applied with sufficient tightness; or to its having that very insecure hold of the vessel, which the i deviation from the circular application f must occasion. (P. 173.) ) Dr. Jones is of opinion, that, in cases 'of aneurism, in whicii the artery has I only been tied with one ligature, and left undivided, and in which secondary hemorrhage has arisen, that this has most probably been owing, either to a i diseased state ofthe artery; to various { contrivances for compressing a large portion ofthe vessel, or having a loose ligature above the one, whicii is tied; 1 or, lastly, to not tying the artery suffi- ciently tight to cut through the inter- r nal and middle coats, so as to fit them for adhesion, but, so as to cause a gra- ; dual ulceration through them, and, of course, bring on hemorrhage, whicii re- v turns with greater violence, as the ul- ceration advances. (P. 176.) ; Dr. Jones seems to consider, that the i advantage of the retraction of the divi- ded artery within the cellular mem- brane, is compensated, in tiie ca>e of the undivided artery, by the speedy and pjofuse effusion of* lymph, which takes place over and round the vessel, at the tied part, and even covers the ligature »itself. However, he admits the objec- tion, urged by Mr. Abernethy, to using only one ligature, viz. that the vessel cannot be tied, where it lies among its ' nai ural connexions, or if tied in this > manner either at tiie upper, or lower part of the wound, the hemorrhage will , proceed from that part of the vessel, /which has the detached portion of the 'arterv for its extremity. This gentle- man concludes this point, with allowing it to be safest and best to apply two liga- tures, and to divide the artery between them. P. 179. See Aneurism. Another cause of secondary hemorrhage is by including other parts in the ligature, together with the artery, by doing which, the division of the inner coats ofthe vessel may be preveiited. In the valuable publication of Dr. Jones's, to which we have so freely ad- verted, some secondary hemorrhages are also imputed to the hidden separa- tion, or laceration of the recently unit- ed parts of an artery, by premature and extraordinary exertions of the pa- tient. Hence, he strongly insists on keeping a limb, in which a large artery has been tied, perfectly at rest. We shall conclude our remarks on the ligature with a few practical rules. I. Always tie a large artery, as sep- arately as possible, but still let the lig- ature be applied to a part of the vessel, which is close to where it lies among its natural connexions. Besides the reasons for this practice, already specified, we may observe, that including other substances in the liga- ture causes immense pain, and a larger part of a wound to remain disunited. The ligature is also apt to become loose, as soon as the substance between it and the artery sloughs, or ulcerates. Sometimes the ligature thus applied, forms a circular furrow in the flesh, and remains a tedious time, incapable of separation. . The blood-vessels being thus organ- ized like otiier parts, the healing of the wounded artery can only take place fa- vourably, when the part of the vessel, which is immediately contiguous to the ligature, continues to receive a due supply of blood through its vasa vaso- rum, which are ramifications of the collateral arteries. Hence, the disad- vantage of putting a ligature round the middle of a portion of an artery, which has been separated from its sur- rounding connexions. Hence, the "util- ity, however, of making the knot, as closely as possible to that part of the vessel which lies undisturbed among the surrounding flesh. Small arteries neither allow nor re- quire these minute attentions to the mode of tying them. 2. When a divided artery is large, open-mouthed, and very visible, it is best to take hold of it, and raise its ex- tremity, a little way above the surface 444 HEM of the wound with a pair of forceps. When the vessel is smaller, the tenacu- lum is the most convenient instrument. 3. While one surgeon holds the ves- sel in this way, another is to place the noose of a ligature ioum it, and tie it according to the above directions. In order that the noose may not rise too high, and even above the mouth ofthe artery, when it is tightened, the ends of the ligature must be drawn as horizon- tally as possible, which is best done with the thumbs. A knot is next to be made. 4 Ligatures always operating in wounds as extraneous bodies, and one ei.it of each being sufficient for its re- moval, the otiier should always be cut off' close to the knot, and taken away. 5. Wber a large artery is either par- tially divided, or completely divided, two ligatures, one to the upper, the, other to the lower part of the vessel, are commonly necessary, in conse- quence of the anastomosing branches conveying the blood so readily into the part of the artery most remote from the heart, as soon as the first ligature has been applied. 6. When a large artery is only punc- tured ; when compression cannot be judiciously tried; and when the he- mori liage continues ; the vessel must be first exposed by an incision, and then a double ligature introduced un- der it, with the aid of an eye-probe. One ligature is to be tied above ; the other below the bleeding orifice ; with dur- attention to the principles already advanced. 7. Ligatures usually come away from the largest artery ever tied, in about a fortnight, und from moderate-sized ones in six or seven days. When they continue attached much beyond the usual period, it is proper to draw them very gently every time the wound is dressed, for the purpose of accelerat- ing their detachment. Great care, how- ever, is requisite in doing tliis ; for, as Dr. Jones remarks, as long as the liga- ture seems firmly attached, puliing it rather strongly must act, more or less, on the rt cently cicatrized extremity of the arteiy, which is not only contiguous to it, but is still united to that por- tion ofthe artery, (the external coat,) which detains the ligature. (Jones, p. 162.) For information concerning hemor- rha.t, consult Petu'\-Memoirs, among those of I'Acad. des /Sciences for the years HEM 1731, 1732, 1735: Morand sur le Chungement, qui arrive aux Arteret coupees, 1736; Pouteau's Melanges de ('hirurgie .- Gooch's Chirurgical Works, Vol. I: Kirkland's Essay on the Method of suppressing Hemorrhages from divided Arteries: II late's Cases in Surgerg .- John Bell's Principles of Surgery, Vol. I.- Partie Chirurgicale de I' Eficyc. Meth.: and, particularly, Jones bn the Process employed by Nature, in suppress- ing the Hemorrhage from divided and punctured Arteries, 1805. ^ HEMORRHOIDS, (from m/jm,blood, j and ffu, to flow.) Hemorrhoides. Piles. \ The etymological meaning of the word . is evidently only a discharge of blood. ' Surgeons, however, sanctioned by long custom, always imply by the term, he- morrhoids, either a bleeding from the I veins of the lower part of the rectum, * or else a considerable distention of these vessels, so as to form tumours, but quite unattended with hemorrhage. When the dilated veins do not bleed, the swellings are called blind piles; \ but, when they are attended with occa- \ sional discharges of blood, they are , named open piles. These tumours vary } in number, size, form, and situation : some are external, others internal. In general, the inconvenience which they •, occasion, is very supportable; but, * sometimes they bring on very serious , complaints, either by bursting and dis- i charging blood so profusely as danger- ( ously to reduce the patient; or by ex- citing inflammation of the adjacent ' parts, and causing abscesses and fis- ' tulae ; or, lastly, by becoming strangu- ' lated by the contraction of tiie sphinc- ^ ter ani, so as to occasion very acute pain. Piles, which bleed but little, are i not of much consequence ; but those ' which bleed profusely, cause violent ■ pain, or which induce inflammation, and all its effects, demand the greatest attention. Lieutaud makes mention of a person, who lost three quarts of blood from some open piles in the course of a couple of days; and the v heretic Arius, and the celebrated phi- losopher Copernicus, are said to have bled to death in this manner. When piles are situated far up in the rectum, they are commonly less pain- > ful, than when low down. In the for- mer case, the veins are surrounded by soft and yielding substances, which do i not make any painful pressure on the swellings ; but, piles, situated towards the anus, are apt to suffer a very pain- ' HEMORRHOIDS. 445 ful Constriction from the action of the sphincter muscle. Hence, when such tumours are very high up in the rec- tum, the patient has sometimes no warning of his disorder, till he dis- charges blood from the rectum, and, so violent a bleeding may at once en- sue, us to prove fatal. With regard to the causes of hemor- rhoids,* any thing capable of retarding the return of blood through the he- morrhoidal veins, may occasion the disease. The pressure of the gravid uterus, costiveness, and the frequent retention of hardened faeces in the rec- tum, are very frequent causes. Per- sons, who lead sedentary lives, are often troubled with the complaint. From what has been stated, we may 'easily discern the reason, why women are more subject to piles, than men are, though the disease is so common, that the latter are also very frequently 'troubled with it. The pressure of an enlarged liver, or of water accumulated in the cavity of jthe peritonaeum, is said sometimes to be the occasion of piles. When these tumours are produced by the pressure of the gravid uterus, no cure can be expected till after deU- very, when one generally follows spon- taneously. Also, when piles are an ef- fect of dropsy, they can only get well, after the pressure of the fluid in the abdomen has been removed by tapping. Gently laxative medicines, and an hori- \ zontal position of the body, commonly alleviate the uneasiness resulting from i hemorrhoids. The application of an i ointment, composed of equal parts of , tiie powder of oak-galls, and of elder- .ointment, or hog's lard, contribute to " ' the same beneficial effect. Applying warm water to the tumours, by means of a bidet, or semicupium, is also fre- quently productive of great ease. When pile-, are constricted by the sphincter ani muscle, the pain thus arising, may often be at once removed, by pushing the swellings with the finger a little 'higher up the rectum. Leeches ap- ' plied to the vicinity of the anus, and puncturing the dilated hemorrhoidal vessels with a lancet, for the purpose • of taking away blood, are measures oc- casionally employed to procure ease. Mr. Ware seems to give the preference to leeches : Petit preferred the lancet. When the number and size of he- ' morrhoids are so considerable, as ma- terially to obstruct the discharge of the feces ; when they are very painful, and subject to profuse bleedings ; when the patient is disabled from following his usual occupations; and when all the above means are not of sufficient avail; the surgeon should recommend the re- moval of the tumours. Extirpating piles with the actual cautery and caustics, as practised by the old surgeons, is now very properly altogether relinquished by modern practitioners. The only plan ever fol- lowed in the present state of surgery, is either to cut the tumours off with a pair of scissars or knife, or to apply a tight ligature round their bases, so as to make them slough away. When piles are to be cut off, and they are not sufficiently visible, the pa- tient must first strain, as at stool, in order to make the swellings more ap- parent. With the aid of a pair of dis- secting forceps, the skin, covering the hemorrhoids, is then to be separated from them with the knife, but not cut away, and the tumours are to be re- moved Sabatier states, that saving the skin is very essential; for, any he- morrhage which may arise, can then be more easily suppressed; and, when there are several hemorrhoids to be ex- tirpated, the loss^of substance about the anus will be less, and, of course, the patient will not be so liable to a con- traction of this part which is sometimes a very great affliction. Mr. Ware thinks it unnecessary to remove all the swellings, when there are several of them. He remarks, that though the number of hemorrhoidal tumours, protruded through the anus, is often considerable, yet the pain which the patient suffers, is not pro- duced equally by all of these ; but, that he will point to one, or at most to two, of the tumours, whence all his pain proceeds. These will be found to be much harder and more inflamed than the rest; but, generally, smaller and less prominent, protruding only just low enough to be compressed by the sphincter muscle. Hence, Mr. Ware contends, that cutting off the whole number of hemor- rhoids with a scalpel, or scissars, and tying a ligature round them, in order to make them die and fall off, are un- necessary. He says, we have only to direct our attention to the hard inflam- ed tumour, wliich is the cause of the pain, and wliich is not unfrequently si- tuated in the centre of the rest. This 446 HEMORRHOIDS. is often not larger than the end of the Uttle finger, and the removal of it al- most instantly abates the pain, and soon makes the rest of the tumours col- lapse and disappear. Mr. Ware ope- rates as follows : having secured with a common dissc-cting-hook, or forceps, the little hard tumour, which is often in tiie middle of the rest, and much darker coloured, he snips it off, as close to its basis as possible, with a sharp pair of curved scissars. The pain is trifling, and the hemorrhage so slight, that Mr. Ware says, he has rarely had occasion to use any application to check it. If the hemorrhoids are constantly protruded, the operation may be per- formed at any time ; but, if they only appear after the feces are voided, that opportunity must be taken. When the pain of hemorrhoids is not violent, but there is a constant dis- tressing uneasiness, with frequent re- turns of a profuse debilitating hemor- rhage, Mr. Ware states, that his me- thod of operating will frequently pro- duce a radical cure. The excision of piles is occasionally followed by a very dangerous bleed- ing, as a case, related by M. Petit, con- firms. A patient had some hemor- rhoids, which were supposed to be ex- ternal ones, though in fact they were not, and had only become protruded. Almost immediately after they had been cut off, the skin, which had sup- ported them, became drawn inward. An inward hemorrhage ensued, which could not be suppressed, and proved fatal in less than five hours. The rec- tum and colon were found full of black, coagulated blood. After the operation, Mr. Ware ad- vises a thick compress to be applied, wet either with cold brandy and water, or with a cold saturnine lotion, and re- tained on the part with the T bandage. The patient should be kept quietly in a cooler temperature than usual, and be enjoined to eat or drink nothing of a stimulating quality. Certainly, if the bleeding should prove troublesome, and proceed from vessels within the rectum, the best plan would be to distend the gut with a suitable piece of sponge, so as to make pressure on the wound, observ- ing to adopt at the same time the means above recommended. Tying hemorrhoids is free from the danger of hemorrhage ; but, still it has its inconveniences, though they are not constant ones. Petit frequently prac- tised this method, without any ill ef- fects. In other instances, he had rea- son to repent having adopted it. A woman, for whom he had tied three hemorrhoids with narrow pedicles, whicii were favourably situated fortius operation, did not at first experience a great deal of pain. However/ five hours afterwards he was informed, that she suffered violent colic pains, which extended along the colon. The woman was bled four times, without^ relief. At last, Petit cut the ligatures, j which could not be loosened, in conse- , quence of their being concealed so ' deeply in the substance of the swollen parts. The pain very soon subsided.< The ligatures had only been applied four and twenty hours, but the piles • had become black, and the skin cover- \ ing their bases was cut through. Petit removed them, without the least effu-4 sion of blood. 1 M. Petit also relates a case, in which a patient, after having some piles tied, died of symptoms resembling those, j which take place in cases of strangu- lated herniae, notwithstanding the liga, 1 tures were cut as in the foregoing in- ; stance. After these two cases, Petit \ abandoned the plan of curing hemor- 1 rhoids by tying them. I believe, on the whole, that it is best 1 to remove hemorrhoids with a knife, unless they are situated high up in the / rectum, where the veins are of large ' size, and likely to bleed profusely. If / a tumour so situated should absolutely f require removal, a ligature might be 1 put round its base with the aid of a / double cannula, in the way we shall re- j late in speaking of Polypi. When the t base of the tumour, however, is large, 1 admits of being brought into view, and the surgeon prefers tying it, he should/ pass a needle, armed with a strong double ligature, through the root of tile hemorrhoid, and tie one part of thi$ ligature firmly over one side of the swelling, and the other over the oppo- • site one. When the base of the tu- « mour is narrow, and the ligature is pre- ' ferred, the part may be tied at once, ( without passing a double Ugature T through its middle. I As piles very seldom prove fatal, an opinion has commonly prevailed, that they are of a salutary, or critical na- ture. They have not unfrequently ' been regarded, as an evacuation, by \ which some peccant, or morbific mat- \ \ HEMORRHOIDS. 447 ter, is thrown off from the body; and hence, patients have frequently been taught to submit to all the pain, and uneasiness, which the disease occa- sions, rather than seek a cure. This opinion, however, is neither founded upon impartial and mature observa- tion, nor upon solid reasoning; for, granting that there was any morbific matter in the body, it is impossible to explain why it should be collected in the blood, whicii fills the dilated veins about the rectum, more than any where else. For information on hemorrhoids, consult L'Encyclopedic Methodique ; Partie Chirurgicak. Sabatier, De la Medicine Operatoire, Tome 2. Lotto's System of Surgery, Vol. 2. Ware on the Treatment of Hemorrhoids. END OF VOLUME I. JOHN BOUVIER, PRINTER. ) A ^.77?^ ^ I«1 0 v.l %W •V -t •V 1