£ **\ UU /*% ^fc> /\ DICTIONARY OF PRACTICAL SURGERY: CONTAINING A COMPLETE EXHIBITION OF THE PRESENT STATE OF THE PRINCIPLES AND PRACTICE OE SURGERY, COLLECTED FROM THE BEST AND MOST ORIGINAL SOURCES OF INFORMATION, AMD 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, inc. IN TWO VOLUMES VOL.11. ( ^ 5%9 *■> PHILADELPHIA: Published by B. and T. Kite, No. 20, North Third Street 18J0, NEW DICTIONARY PRACTICAL SURGERY. HERNIA. JLIE'RNIA, (from s^vo?, a branch, from its protruding forward.) Sur- geons understand by the term hernia, a tumour, formed by the protrusion of some of the viscera of the abdomen, out of that cavity, into a kind of sac, com- posed of the portion of peritonaeum, hich is pushed before them. How- , there are certainly some cases •h will not be comprehended in this rition; either because the parts are protruded at all, or have no hernial as the reader will learn in the rse of this article. ENERAL REMARKS ON HERNI*. The places, in which these swellings most frequently make their appearance, are the groin, the navel, the labia pu- dendi, and the upper and forepart of the thigh; they do also occur at every point of the anterior part of the abdomen; and there are several less common in- stances, in which hernial tumours pre- sent themselves at the foramen ovale, in the primeum, in the vagina, at the ischi- atic notch, &c. These rarer species of hernia will be noticed in their proper place. The parts, which, by being thrust forth from the cavity, in which they ought naturally to remain, mostly pro- duce hemix, are either a portion of the omentum, or a part of the intestinal canal, or both together. But, the sto- mach, the liver, spleen, uterus, ovaries, bladder, &c. have been known to form the contents of some hernial tumours. From these two circumstances of situation and contents, are derived all the different appellations, by which hernise are distinguished. If a portion of intestine only forms the contents of the tumour, it is called enterocele; if a piece of omentum only, epiplocele; and if both intestine and omentum contri- bute mutually to the formation of a tu- mour, it is called entero-epiplocek. When the contents of a hernia are protruded at the abdominal ring, but only pass as low as the groin, or labium pudendi, the case receives the name of bubonocele, or inguinal hernia; when the parts descend into the scrotum, it is called an oscheo~ cele, or scrotal hernia. The crural, or femoral hernia, is the name given to that which takes place below Poupart's liga- ment. When the bowels protrude at the navel, the case is named an exomphalos, or umbilical hernia; and ventral is the epithet given to the swelling, when it occurs at any other promiscuous part of the front of the abdomen. The congeni- tal rupture is a very particular case, in which the protruded viscera are not covered with a common hernial sac, of peritoneum, but are lodged in the cavity of the tunica vaginalis, in contact with the testicle, and, as must be obvious, it is not named, like herniae in general, from its situation, or contents, but from the circumstance of its existing from the time of birth. When the hernial contents lie quietly in the sac, and admit of being readily put back into the abdomen, it is termed a reducible hernia; and, when they suffer no constriction, yet cannot be put back, owing to adhesions, or their large size in relation to the aperture, through which they have to pass, the hernia is termed irreducible. An incarcerated, or strangulated hernia, signifies one, which not only cannot be reduced, but suffers constriction; so that, if a piece of intes- tine be protruded, the pressure, to which it is subjected, stops the passage of its contents onwards, towards the anus, makts the bowel inflame, and Vol. II. A 2 HERNIA. brings on a train of most alarming, and often fatal consequences. The causes of hernia are either pre- disposingor exciting. Of the former kind, writers mention a naturally large size of the openings, at which the bowels protrude; a weakness and relaxation of the margins of these apertures; a pre- ternatural laxity of the peritonaeum; an unusually long mesentery, or omentum, &c. It is very certain, that, with regard to the abdominal ring, the transverse tendinous fibres, which naturally cross and strengthen its upper and outer part, are much weaker in some subjects than others. No idea seems more prevalent in books, than, that taking a good deal of oil with one's food, is conducive to the occurrence of ruptures. Some of the alleged predisposing causes, may justly excite scepticism; but there are several circumstances which tend to prove, that a natural deficiency of re- sistance, in any part of the parietes of the abdomen, is certainly a cause of this kind. We need only mention, how very liable persons are, who have had the peritonaeum wounded, to the present disease; and how much more liable men are than women, to the inguinal hernia, owing evidently to the larger size of the abdominal ring in the former, than the latter subjects. These, however, having a larger space for the protrusion of the viscera, below Poupart's ligament, are more exposed than men to femoral her- niae. With regard to the exciting causes, our knowledge is involved in less doubt. The grand cause of this kind, is the powerful action-of the abdominal mus- cles and diaphragm on the viscera. In feats of agility, such as jumping, &c the pressure which the contents of the abdomen must often encounter, suffi- ciently accounts for their protruding at ✓ any part, where the abdominal parietes do not make adequate resistance. The same consideration explains, why her- nia: very often take place in lifting and carrying heavy weights, running, vo- miting, straining at stool, parturition, &.c. and in people who inhabit moun- tainous countries. . This diminution of the capacity of the abdomen, by the action of the abdomi- nal muscles and diaphragm, on many occasional exertions, must take place in every one, by reason of the common habits and necessities of life. But, as only a certain number of persons meet with the disease, it is fair to infer, that, either the exciting causes must operate with gre.Tter force in them than in the generality of people, or else their abdo- minal parietes have not been capable of the ordinary degree of resistance. Many patients who meet with herniae, in mak- ing violent efforts and exertions, maj be in the former circumstance; while others, who have their viscera protrud- ed from such trivial things as coughing, sneezing, crying, &.c. must be consider- ed as being under the influence of some predisposing cause. A gentleman, who has gained great honour by a late pub- lication on hernia, remarks, that, " her- niae, which originate in predisposition, generally come on gradually, and almost imperceptibly; while those which arc produced by bodily exertion,are formed suddenly, and by the immediate action of the exciting cause. The occurrence of the complaint is often indicated, in the first instance, by a fulness, com- bined with a sense of weakness, about the abdominal ring. The swelling is increased by any action of the respira- tory muscles, and disappears on pres- sure, and in the recumbent position of the body. It gradually finds its way through the tendon of the external oblique muscle, into the groin, and afterwards into the scrotum. When a hernia takes place suddenly, it is gene- rally attended with a sensation of some- thing giving way at the part, and with pain." {Lawrenccon Hernia; 1807;p. 11.) The general symptoms of a hernia, which is reducible, and free from stran- gulation, are: an indolent tumour at. some point of the parietes of the abdo- men; most frequently descending out of the abdominal ring, or from just below Poupart's ligament, or else out of the navel; but, occasionally, from various other situations, as will be presently explained. The swelling mostly origi- nates suddenly, except in the circum- stances above related, and, it is subject to a change of size, being smaller when the patient lies down on his back, and larger when he stands up, or holds his breath. The tumour frequently dimi- nishes when pressed, and grows large again when the pressure is removed. Its size and tension often increase after a meal, or when the patient is flatulent. Patients with hernia, are apt to be trou- bled with colic, constipation, and vo- miting, in consequence of the unnatural situation of the bowels. Very often however, the functions of the viscera seem to suffer little or no interruption. HERNIA. 3 If the case be an enterocele, and the portion of intestine be small, the tumour is small in proportion; but, though small, yet, if the gut be distended with wind, inflamed, or have any degree of stricture made on it, it will be tense, resist the impression of the finger, and give pain upon being handled. On the contrary, if there be no stricture, and the intestine suffers no degree of in- flammation, let the prolapsed piece be of what length it may, and the tumour of whatever size, yet the tension will be little, and no pain will attend the handling it; upon the patient's cough- ing, it will feel as if it was blown into; and, in general, it will be found very easily returnable. {Pott.) A guggling noise is often made when the bowel is ascending. If the hernia be an epiplocele, or one of the omental kind, the tumour has a more flabby, and a more unequal feel; it is in general perfectly indolent, is more compressible, and (if in the scro- tum) is more oblong, and less round, than the swelling occasioned in the same situation by an intestinal hernia; and, if the quantity be large, and the patient adult, it is, in some measure, distinguishable by its greater weight. {Pott.) If the case be an entero-epiplocele, that is, one consisting of both intestine and omentum, the characteristic marks will be less clear than in either of the sim- ple cases; but the disease may easily be distinguished from every other one, by 'any body in the habit of making the examination. {Pott, p. 28.) On the subject of prognosis, Mr. Pott remarks, " that the same kind of rupture, in different people, and under different circumstances, wears a very various face; the age and constitution of the subject, the date of the disease, its being free, or not free from stricture, or inflammation, the symptoms which at- tend it, and the probability or improba- bility of its being returnable, necessa- rily-producing much variety; the degree of hazard attending this complaint will be also more or less, as it shall happen to be circumstanced. " If the subject be an infant, the case is not often attended with much diffi- culty, or hazard; the softness and duc- tility of their fibres generally rendering the reduction easy as well as the de- scent; and though from neglect, or in- attention, it may fall down again, yet it is as easily replaced, and" seldom pro- duces any mischief: I say seldom, be- cause I have seen an infant, one year old, die of a strangulated hernia, which had not been down two days, with all the symptoms of mortified intestines. " If the patient be adult, and in the vigour of life, the consequences of ne- glect, or of mal treatment, are more to be feared than at any other time, for reasons too obvious to need relating. The great and principal mischief to be apprehended, in an intestinal hernia, is an inflammation of the gut, and an ob- struction to the passage of the aliment and fxces through it; which inflamma- tion and obstruction are generally pro- duced by a stricture made on the intes- tine. In very old people, the symptoms do not usually make such rapid pro- gress, both on account of the laxity of their frame, and their more languid cir- culation; and also that their ruptures are most frequently of ancient date, and the passage a good deal dilated; but then, on the other hand, it should also be remembered, that they are by no means cxemptfrom inflammatory symp- toms; and that, if such should come on, the infirmity of old age is no favourable circumstance in the treatment, which may become necessary. " If the disease be recent, and the patient young, immediate reduction, and constant care to prevent its pushing out again, are the only means whereby it is possible to obtain a perfect cure. " If the disease be of long standing, has been neglected, or suffered to be frequently down, and has given little or no trouble,the aperture in the abdomi- nal muscle, and the neck of the hernial sac, may both be presumed to be large; which circumstances in general render immediate reduction less necessary and less difficult, and also frustrate all ra- tional expectation of a perfect cure. On the contrary, if the rupture be re- cent, or, though old, has generally been kept up, its immediate reduction is more absolutely necessary, as the risk of stricture is greater from the sup- posed smallness of the aperture, and narrowness of the neck of the sac. If the rupture be very large and ancient, the patient far advanced in life, the in- testine not bound by any degree of stric- ture, but does its office in the scrotum regularly, and no other inconvenience be found to attend it, but what pro- ceeds from its weight, it will in gene- ral be better not to attempt reduction, as it will, in these circumstances, most 4 HERNIA. probably prove fruitless, and the hand- ling the parts in the attempt, may so bruise and injure them as to do mis- chief; but this must be understood to be spoken of those only in which there is not the smallest degree of stricture, nor any symptom of obstruction in the' intestine; such circumstances making reduction necessary at all times, and in ever\ case. " With regard to the contents of a hernia, if it be a portion of omentum only, and has been gradually formed, it seldom occasions any bad symptoms, though its weight will sometimes ren- der it very troublesome. But if it be produced suddenly, by effort or vio- lence, that is, if a considerable piece of the caul by accident slip down at once, it will sometimes prove painful, and cause very disagreeable complaints; the connexion between the omentum, sto- mach, duodenum, &c. being such as to render the sudden descent of a large piece of the first sometimes productive of nausea, vomiting, colic, and all the disagreeable symptoms arising from the derangement of these viscera. When the piece of caul is engaged in such a degree of stricture as to prevent the circulation of blood through it, it will sometimes, by becominggangrenous,be the occasion of very bad symptoms, and even of death, as I have more than once seen: and thus, as a mere omental hernia, it may sometimes be subject to great hazard. But even though it should never be liable to the just-mentioned evil,' that is, though the portion of the caul should remain uninjured in the scrotum, yet it renders the patient con- stantly liable to hazard from another quarter; it makes it every moment pos- sible for a piece of intestine to slip into the same sac, and thereby add to the case all the trouble and all the danger arising from an intestinal rupture. It is by no means an uncommon thing for a piece of gut to be added to a rupture, which had for many years been merely omental, and for that piece to be stran- gulated, and require immediate help. "An old omental hernia is often ren- dered not reducible, more by an altera- tion made in the state of the prolapsed piece of caul, than by its quantity. It is very common for that part of the omen- tum which passes through the neck of the sac, to be compressed into a hard, smooth body, and lose all appearance of caul, while what is below in the scro- tum is loose and expanded, and enjoys its natural texture; in this case, reduc- tion is often impossible, from the mere figure of the part; and I have so often seen this, both in the living and the dead, that I am satisfied, that for one omental rupture, rendered irreducible by adhesions, many more become so from the cause above-mentioned. " In the sac of old omental ruptures that have been long down, and only suspended by a bag truss, it is no very uncommon thing to have a pretty con- siderable quantity of fluid collected: this, in different states and circum- stances of the disease, is of different colour and consistence, and seldom so much in quantity as to occasion any par- ticular attention to it; but on the other hand, it sometimes is so much in quan- tity as to become an additional disease to the original one. I have more than once been obliged to let it out, in order to remove the inconvenience arising from its weight, and the distention of the scrotum, which I have also seen become gangrenous by the neglect of this operation. " If the hernia be of the intestinal kind, merely, and the portion of gut be small, the risk is greater, strangulation being more likely to happen in this case, and more productive of mischief, when it has happened: for the smaller the portion of gut is which is engaged, the tighter the tendon binds, and the more hazardous is the consequence. I have seen a fatal gangrene, in a bubo- nocele, which had not been formed forty-eight hours, and in which the- piece of intestine was little more than half an inch. There are few practi- tioners, who have seen business, but know the truth of this; but perhaps the reason of it is not sufficiently explained to the unknowing: it is this; when a considerable portion of intestine passes out from the belly in a hernial sac, it necessarily and unavoidably carries with it a proportional quantity of the mesentery, which every body knows is a strong double membrane. When the prolapsed part is at all considerable, this double membrane is again in some mea- sure folded on itself, and takes off a good deal of the effect of the stricture on the intestine. Now although this cir- cumstance will not prevent the effect, if the means of relief be totally neglect- ed, yet it will most certainly retard the evil, and give^more time for assistance; whereas, when there is Uttle or none of the mesentery got through the tendon, HERNIA 5 and the thin, tender intestine bears all the force of the stricture, it is imme- diately brought into hazard. "The practical inference to be drawn from hence, is too obvious to need men- tioning. " In the intestinal, as in the omental hernia, they which have been often or long down, are in general more easily returned, and do not require such im- mediate assistance, as they which have seldom been down, or have recently descended; and in the one kind of her- nia, as well as in the other, the siate of the hernial sac, with regard to size, thickness, &c. depends very much on the date of the disease, and the regard that has been paid to it. " If the hernia be caused by a por- tion of the intestine ileum only, it is in general more easily reducible than if a part of the colon has descended with it, which will also require more address and more patience in the attempt. The reduction of a mere intestinal hernia too {ceteris paribus) will always re- main more practicable than that of a mere omental one, after it has attained to a certain size and state, as the part contained within the former is liable to less alteration of form than that within the latter; which alteration has already been mentioned as no infrequent hin- drance of the return of an old caul rup- ture. " Not that the parts within a mere intestinal hernia are absolutely exempt from such an alteration as may render their retiu-n into the belly impractica- ble, even where there is no stricture; for I have seen that part of the mesen- tery, which has lain long in the neck of the sac of an old rupture, so considera- bly hardened and thickened, as to prove an insuperable obstacle to its reduction. " Upon the whole, every thing con- sidered, I think it may be said, that an intestinal rupture is subject to worse symptoms, and a greater degree of ha- zard, than an omental one, though the latter is, by no means, so void of either as it is commonly supposed to be; that bad symptoms are more likely to attend a recent rupture than one of ancient date; that the descent of a very small piece of intestine is more hazardous than that of a larger; that tire hernia, which consists of gut only is in general atteniled with worse circumstancesthan th.U waich is made up both of git and caul; and that no true judgment can be formed of any rupture at all, unless every circumstance relating to it be tak- en into consideration." {Pott on Rup- tures.) Mr. Hey coincides with Pott, in thinking the prognosis more unfavour- able when the tumour is small. " I think it is not a bad general rule, that the smaller the hernia, the less hope there is of reducing it by the taxis. Long-continued efforts to reduce a pro- L.psed intestine, are most likely to suc- ceed in old and large hernias, when no adhesions have taken place." (Pract. Observ. in Surgery, p. 203.) " The opening (says Mr. Lawrence) through which the parts protrude, is narrower in some situations than in others; the progress of the case will, therefore be more rapid, and the danger of the patient more urgent. The aper- ture is generally very small in femoral hernia; this kind of rupture in men, and the bubonocele in women, have a parti- cularly narrow entrance." {Treatise on Hernia, p. 29.) GENERAL OBSERVATIONS ON THE TREATMENT OF HEUNIJE. 1. Treatment of those which are capable of easy and immediate reduction, and are not attended by any troublesome or bad symptoms. " This case," says Pott, " is very fre- quently met with in infants, and some- times in adults, and is too often neglect- ed in both. In the former, as the descent seldom happens but when the infant strains to cry, and the gut is either easi- ly put up, or returns sua sponte, as soon as the child becomes quiet, it often is either totally unattended to, or an at- tempt made to restrain it only by a ban- dage made of cloth, or dimity, and which being ineffectual for such pur- pose, lays the foundation for future trouble and mischief. " This is, in great measure, owing* to a common opinion, that a young in- fant cannot wear a steel truss: a ge- nerally prevailing error, and which ought to be corrected. There is no age at which such truss may not be worn, or ought not to be applied; it is, when well made, and properly put on, not only perfectly safe and easy, but the only kind of bandage that can be de- pended upon: and as a radical cure de- pends greatly on the thinness of the hernial sac, and its being capable of being so compressed as possibly ta unite, and thereby entirely close the passage from the belly, it must there 6 HERNIA. fore appear to every one who will give himself the trouble of thinking on the subject, that the fewer times the parts have made a descent, and the smaller and finer the elongation of the perito- neum is, the greater the probability of such cure must be. " The same method of acting must, for the same reasons, be good in every age in which a radical cure may reason- ably be expected; that is, the prolapsed parts cannot be too soon returned, nor too carefully prevented from falling down again, every new descent render- ing a cure both more distant and more uncertain. " As soon as the parts are returned, the truss should be immediately put on, and worn without remission, care being taken, especially if the patient be an infant, to keep the parts on which it presses constantly washed, to prevent galling. " It can hardly be necessary to say, that the surgeon should be careful to see that the truss fits, as his success and reputation depend on such care. A truss which does not press enough, is worse than none at all, as it occasions loss of time, and deceives the patient, or his friends; and one which presses too much, or on an improper part, gives pain and trouble, by producing an in- flammation and swelling of the sper- matic chord, and sometimes of the tes- ticle. " In adults, whose ruptures are of long standing, and accustomed to fre- quent descent, the hernial sac is ge- nerally firm and thick, and the aperture in the tendon of the abdominal muscle large; the freedom and ease with which the parts return into the belly, when the patient is in a supine posture, and the little pain which attends a rupture of this kind, often render the persons who labour under it careless: but all such should be informed, that they are in constant danger of such alteration in their complaint, as may put them into great hazard, andpcrhaps destroy them. The passage from the belly being open, the quantity of intestine in the hernial1 sac is always liable to be increased, and when down, to be bound by a stricture. An inflammation of that portion of the gut which is down, or such obstruction in it as may distend and enlarge it, may at all times produce such complaints as may put the life of the patient into im- minent danger; and there fore, notwith- standing this kind of hernia may have been borne for a great length of time, without having proved either trouble- some or hazardous, yet as it is always possible to become so, and that very suddenly, it can never be prudent or safe to neglect it. " Even though the rupture should be of the omental kind, (which considered abstractedly is not subject to that de- gree or kind of danger to which the in- testinal is liable) yet it maybe secon- darily, or by accident, the cause of all the same mischief; for while it keeps the mouth of the hernial sac open, it renders the descent of a piece of intes- tine always possible, and consequently always likely to produce the mischief which may proceed from thence. " They who labour under a hernia thus circumstanced, that is, whose rup- tures have been generally down while they have been in an erect posture, and which have either gone up of them- selves, or have been easily put up in a supine one, should be particularly care- ful to have their truss well made, and properly fitted; for the mouth of the sac, and the opening in the tendon being both large and lax, and the parts hav- ing been used to descend through them, if the pad of the truss be not placed right, and there be not a due degree of elasticity in the spring, apiece of intes- tine will, in some posture, slip down behind it, and render the truss produc- tive of that very kind of mischief which it ought to prevent. " It is scarcely credible how very small an opening will serve for a por- tion of gut or caul to insinuate it- self into at some times. Now, though in persons of mature age it most fre- quently proves impracticable so to com- press the mouth of the hernial sac, as absolutely to close it, yet by the con- stant use of a well-made truss, it may be so lessened, as to render the descent of a piece of intestine into it much more difficult: from whence we may learn the great consequence of having the part completely reduced before the truss is applied, and the danger that may be incurred by laying such bandage aside after it has been worn some time; since the same alteration which renders the descent of the gut less easy, will also make the reduction more difficult, if a piece should happen to get down: and hence also we may learn why the bandage should be long and unremit- tingly worn by all those whose time of life makes the expectations of a perfect HERNIA. * cure reasonable, many of the ruptures of adults being owing to the negligent manner in which children at school arc suffered to wear their trusses. " I know a gentleman who has for some years - had an omental rupture, which was neglected while he was young, and he having naturally a lax habit, and the abdominal opening being much dilated, he finds it extremely dif- ficult to keep it up, even with the best truss he can get, behind which it will sometimes slip down: when this hap- pens, it gives him such immediate and" acute pain at his stomach, and makes him so intolerably sick, that he is oblig- ed immediately to throw himself on his back, and procure the return of the piece of omentum." {Pott on Ruptures.) When we have considered the ana- tomy of particular herniae, we shall be better able to judge of the proper con- struction of trusses. (See Truss.) TREATMENT OF IRREDUCIBLE HER- RIA., FREE FROM INFLAMMATION, AND UNATTENDED WITH TROU- BLESOME, OR DANGEROUS SYMP- TOMS. * " This incapacity of reduction may be owing to several causes, but most frequently arises either from the large- ness of the quantity of the contents, from an alteration made in their form and texture, or from connexions and adhesions, which they have contracted with eacli other, or with their contain- ing hag. " I have already mentioned it as my opinion that ruptures are sometimes rendered difficultto be reduced, by that portion of the intestinal canal which is called the caecum, or, the beginning of the colon, being contained in the her- nial sac. Of which fact I am as much convinced as the nature of such kind of things will permit; that is, by observa- tions made both on the living and the dead. " When a hernia of this kind (viz. one containing such a part of the intes- tinal tube) has been long neglected, and suffered to remain in the scrotum without any bandage at all to support its weight, the hernial sac being con- stantly dragged down, and kept in a state of distention, necessarily becomes thick, hard, and tough; by this means the diameter of its neck is lessened, and the return of the intestine back from the scrotum into the belly ren- dered more and more difficult, as the parts through which it is to pass be- come harder, and less capable of yield- ing. This will, indeed, in time prove an obstruction sufficient to hinder any part of the intestine, or even of the omentum, from being returned, but the more the difficulty is, which proceeds from the mere figure and size of the portion of gut, the greater will be the obstruction when added to that arising from the just-mentioned cause. " An alteration produced by time, and constant, though gentle, pressure in the form and consistence, or texture of the omentum, is also no infrequent cause, why neglected omental ruptures become irreducible. " The cellular membrane in all parts of the body, however loose and light its natural texture may be, is capable of becoming hard, firm, and compact, by constant pressure. Of this there are so many, and so well known instances, that it is quite unnecessary to produce any. " The omentum, from its texture, is liable to the same consequence. When a portion of it has been suffered to re- main for a great length of time in the scrotum, without having ever been re- turned into the belly, it often happens that although that part of it which is in the lower part of the hernial preserves its natural soft, adipose, expansile state, yet all that part which passes through what is calh d the neck of the sac is, by constant pressure, formed into a hard, firm, incompressible, carnous kind of body, incapable of being expanded, and taking the form of the passage in which it is confined, exactly filling that pas- sage, and rendering it impossible to push up the loose part which fills the scrotum. " This is no theoretic opinion, but a fact, which I have seen and proved of- ten; and whoever willrefiect on it, will immediately find in it one insuperable. objection to the return of some old omental ruptures. " The same reason for incapacity of reduction is also sometimes met with in ruptures of the intestinal kind, from an alteration produced on that part of the mesentery which has been suffered to lie quiet for a great length of time in the neck of an old hernial sac. " The other impediment, which I mentioned, to the return of old rup- tures, is connexion and adhesion of the parts, either with each other, or with the bag containing them. This is com- 8 HERNIA. mon to both the intestinal and omental hernia, and is produced by slight in- flammations of the parts, which have been permitted to lie long in contact with each other, or perhaps in many cases from the mere contact only. These adhesions are more or less firm in dif- ferent cases, but even the slightest will almost always be found an invincible ob- jection to the reduction of the adherent parts, by the hand only. " Many, or perhaps most of these irreducible ruptures become so by mere time and neglect, and might at first have been returned; but when they are got into this state, they are capable of no relief from surgery but the applica- tion of a suspensory bag, to take off or lessen the * inconvenience arising from the weight of the scrotum. " People in this situation should be particularly careful not to make any at- tempts beyond their strength, nor aim at feats of agility; they should take care to suspend the loaded scrotum, and to keep it out of the way of all harm from pressure, bruise, &c. When the tumour is very large, a soft quilted bolster should be worn at the bottom of the suspensory to prevent excoriation, and the srrotum should be frequently washed for the same reason; a loss of skin in this part, and in such circum- stances, being sometimes of the utmost importance. They ought also to be par- ticularly attentive to the office of the intestinal canal, to see that they do not by any irregularity of diet disorder it, and keep themselves from being cos- tive, for reasons too obvious to need re- lating. By these means, and \\ ith these cautions, many people have passed their lives for many years free from disease, or complaint, with very large irreduci- ble ruptures. " On the other hand, it is fit that mankind should be apprised, that the quiet, inoffensive state of this kind of hernia is by no means to be depended upon; many things may happen to it, by which it may be so altered, as to be- come hazardous, and even fatal: an in- flammation of that part of the gut which is down, any obstruction to the passage of the aliment or faeces through it, a stricture made by the abdominal tendon, either on what has been long down, or on a new portion which may at any time be added to it, are always capable of so altering the state of the case, as to put the life of the patient into danger. " Indeed the hazard arising from a stricture made on a piece of intestine contained in the sac of an old irreduci- ble hernia, is in one respect greater, than that attending one that has been found at times reducible; since from the nature of the case it win hardly ad- mit of any attempt toward relief, but the operation, and that in these circum- stances must necessarily be accompa- nied with additional difficulty. " Among the ruptures which have been thought not reducible, and treat- ed as such, there have been some which, upon more judicious and more patient attempts, have been found capa- ble of reduction. " When this is suspected to be the case, the proper method is by absolute rest, in a supine posture, for a consider- able length of time; by great absti- nence, and the use of evacuants, so to lessen the size of the parts in the her- nial sac, as to render them capable of passing back again into the belly." {Pott on Ruptures.) Fabrieius Hildanus gives an account of a man, who was radically cured of a rupture, of twenty years'date, by six months' confinement to bed. {Cent. 5. Obs. 54.) Le Dran and Arnaud relate instan- ces of monstrous bubonoceles, which disappeared entirely, after the patients had been long confined to bed, and be- come much emaciated, by tedious ill- ness. Some of the moderns have imita- ted this operation of nature, and by fre- quent bleedings, and repeated purges, have sometimes so far reduced the size * I am not unaware (says Pott) that most of these are capable of being cured by the operation for the bubonocele, as it is called; but as I should never think of proposing it in any case, in which there are not symptoms, that threaten the life of the patient, so I have not mentioned it in this place as a means of cure. I also am not unapprised what influence a successful operation or two of this sort has had on the unknowing; but I also know, that such accidental successes have em- boldened the same operators to commit more than one or two murders, in similar cases; and that, from the prevalence of fashion, some of these rupture-doctors have been largely rewarded, when they ought to have been hanged. HERNIA 9 of the hernia, that it has been returned into the abdomen. Mr. Hey has several times succeeded in this way. (P. 219.) But, this practice cannot prove suc- cessful, when the viscera adhere to the sac, or to the peritonaeum, just within the abdomen. The greatest objection to this method of cure, is the want of an absolute criterion, by which to dis- tinguish, when the parts do, or do not adhere to the hernial sac, and, in ad- vanced years, though one were sure, that the viscera were free from the sac, the possibility of hurting the body by the necessary evacuations, is also ano- ther objection. {Sharp's Critical Inqui- ry, p. 15.) Were the plan to be thought worthy of trial, keeping up a constant pressure on the tumour, by means of a suspen- sory bandage, made to lace in front, would be proper for promoting the ab- sorption of the thickened parts in the hernial sac. Mr. A. Cooper has redu- ced such herniae, after applying ice ,to them, the good effects of which he im- putes to its producing a contraction of the scrotum, which performs the office •fa strong and permanent compression of the tumour. Whenever any attempts of this kind succeed, " a truss should be immedi- ately put on, and worn constantly with- out remission; for, in these people, the largeness of the abdominal aperture, the thickness of the hernial sac, and the relaxation of the mesentery, make a new descent always to be apprehend- ed, and guarded against." {Pott.) There are instances however, on re- cord, in which the capacity of the abdo- men had become so adapted to the di- minished quantity of the viscera, that when the contents of the hernia were reduced, serious complaints arose from their introduction into the belly. Schmucker has met with several such cases, in which he has been obliged to take off'the truss. Petit has known the reduction of a hernia of this kind prove fatal, the parts not descending again when the truss was removed, the nau- sea and vomiting, which arose, continu- ing, and peritonitis taking place. Chi- rurgische, Wahrnehmungen, vol. 2. p. 243. Traitt des Maladies Chirurgicaks, torn. 2. p. 392. Mr. Pott remarks, that " an omental rupture, which has been so long in the scrotum as to have become irreducible, is very seldom attended with any bad symptoms, considered abstractedly; but, it is constantly capable of being the occ.ision of an intestinal hernia, and all its consequences; neither is that all, fc* the omentum, either so altered in form and texture, or so connected as to be incapable of reduction, may by accident inflame, and either become gangre- nous, or suppurate, and the occasion of a great deal of trouble." In a few in- stances, epiploceles produce very bad symptoms indeed, cases of which are to be found in G; reng* ot, Dionis, &c. Sometimes, in old cases of entero- epiplocele, the intestine is reducible, but the omentum is not, in which case some have advised keeping up the piece of bowel with a truss, the pad of which must be so contrived as not to press on the omentum. Mr. Pott, how- ever, contends, that this is not often practicable, and, should such a truss be used, he advises its being particularly attended to, lest a small piece of guj slip down, and, being pressed on by the truss, produce fatal mischief. " Irreducible herniae must of course be exposed to all the consequences of external injury and violence; hence, various cases are recorded, in which the bowels have been burst by blows, falls, &c." {Laiurence on Hernia, p. 53.) SYMPTOMS AND TREATMENT OF A STRANGULATED, OR AN INCARCE- RATED, HERNIA.--MEANS TO BE TRIED, BEFORE AN OPERATION. " Difficulty of reduction (says Pott) may be owing to several causes. The size of the piece of omentum, or the inflamed state of it; the quantity of in- testine and mesentery, an inflammation of the gut, or its distention by faeces, or wind: or the sm.dlness of the aperture of the tendon, through which the her- nia passes. But, to whatever cause it be owing, if the prolapsed body cannot be immediately replaced, and the patient suffers pain, or is prevented thereby from going to stool, it is called an incarcerated hernia, a strangulated hernia, or a hernia with stricture. " The symptoms are a swelling in the groin, or scrotum, resisting the impres- sion of the fingers: if the hernia be of the intestinal kind, it is generally pain- ful to the touch, and the pain is increa- sed by coughing, sneezing, or standing upright. These are the very first symp- toms, and, if they are not relieved, are soon followed by others, viz. a sickness at the stomach, a freque nt retching, or inclination to vomit, a stoppage of all Vol. II. B 10 HERNIA discharge per anum, attended with a frequent, hard pulse, and some degree of fever." A patient, thus circumstanced, is in some danger, and demands immediate assistance. A stricture made on the prolapsed part of the gut, by the aper- ture, through which it passes, is the immediate cause of all the bad symp- toms, and of course, the removal of such stricture is the only thing, which can bring relief. This object can only be accomplished by returning the bow- el back into the abdomen, or dividing the parts, which form the stricture. The former plan is always the most de- sirable, when practicable. We next proceed to notice the vari- ous measures to be adopted for the re- lief of a strangulated hernia, so as to obtain the best chance of doing away the necessity of an operation. After treating of the merits of each plan, a few remarks will be offered on the or- der in which the means should be put in practice, a subject that has been most lamentably neglected, even by the latest writers on this interesting dis- ease. Taxis.—This is the term applied to the operation of reducing a hernia with the hand. It is much promoted by the position of the patient's body; Winslow thought it advantageous to have it pla- ced in an inclined plane, and the thighs bent towards the trunk. Mr. A. Cooper advises the same practice, observing, that this posture, by relaxing the fascia of the thigh, relaxes also the aperture, through which the hernia passes. Eve- ry degree of tension, and relaxation of the femoral fascia must undoubtedly be attended with a corresponding change in the abdominal ring. But flexion of the thigh, besides relaxing this fascia, also reLxcs the abdominal, internal ili- ac, and psoas muscles. The pressure, which is made on the tumour by the hands of the surgeon, should always be directed upwards : nd outwards, in ca- ses of inguinal herni.<, along the course of the spermatic cord, and Mr. A. Coo- per advises it to be continued from a quarter to half an hour. {On Inguinal and Congenital Hrnia.) As the femoral i.ernia passes down- wards, and then forwards, the pressure must be directed first backwards and then upwards. No violence should ever be used, fur, besides being unavailing, it must greatly aggravate the inflamed state of the contents of the hernial sac, and, it has even made the intestine burst. (See Cooper on Inguinal Hernia, Oc.p. 23.) Besides bending the thigh, care should also be taken to rotate it in- wards, which will have great effect in relaxing the femoral fascia, and tendon of the external oblique muscle. Sus- pension of the patient over the shoul- ders of an assistant has been thought to facilitate reduction: I have tried it of- ten, (says Mr. Hey;) but have not found it to be of such superior efficacy, as some authors have represented." P. 144. The return of a piece of intestine is generally preceded by a peculiar noise, caused by the passage of air through the stricture. It recedes at first gradu- ally, and then slips up suddenly. The omentum goes up slowly to the very last portion, which must be actually pushed through the opening. If the tax- is should not succeed at first, it will of- ten do so after the warm bath, bleed- ing, or cold applications. Small herniae, being attended with the closest stric- ture, are the most difficult to reduce, and, for the same reason, crural ones do not so often yield to the taxis, as in- guinal ones in the male subject. The taxis becomes less likely to succeed, the longer the inflamed viscera have been down, because adhesions are like- ly to have formed. Mr. Lawrence ob- serves, (p. 63.) " When the rupture becomes painful, we are no longer jus- tified in persevering in attempts at re- duction by the htind. A sufficient pres- sure cannot row be endured; and the force which is employed only tends to increase the inflammation, and accele- rate the approach of gangrene. At this period, the operation is required, and should be performed without delay." De- sault even proscribed the taxis alto- gether in the inflammatory strangula- tion, until the previous use of other means had produced a change in the state of the swelling. However, I sliould never advise the reader to fancy he can diminish the inflammation of a strangulated he:nia in any other wav, than by delivering the bowels from the pressure of the stricture. Bleeding may check, but cannot stop, much less di- minish, the inflammation, that prevails. Bleeding.—The inflammation, which attacks the protruded viscera, and spreads thence over the whole abdo- men, and the temporary weakness and often fainting, which the sudden loss HERNIA. 11 of blood induces, and which is a pecu- liarly favourable opportunity for redu- cing the hernia by the hand, are the reasons in favour of bleeding in the present disease. Sharp, Pott, B.Bell, Sabatier, Richter, and Callisen, names which can never be surpassed in res- pectability, are all subscribed in favour of bleeding. Wilmer, Alanson, and A. Cooper, have published against the practice. Mr. Hey has related two ca- ses, which strongly evince the manner, in which bleeding facilitates the return of a hernia: the protruded viscera, in one instance, went up spontaneously, on blood being taken away; in the other, the taxis succeeded immediately after- wards, though the attempt before had been made in vain. (P. 125, 126.) Mr. Hey's experience, however, leads him to concur so far with Wilmer and Alan- son, as to declare, that bleeding has generally failed to procure a reduction of the strangulated intestine, though he is persuaded that, in many cases, it may be used wtth advantage. But he cannot agree with Wilmer, that it ge- nerally renders the subsequent opera- tion more dangerous. (P. 126.) The majority of candid practitioners, I be- lieve, will allow, that bleeding is always proper, when the hernia is small and recent, the abdomen tense and painful, and the patient young, strong, and ple- thoric. Purgative Medicines.—My experience, (says Mr. Hey) leads me to condemn almost universally the use of purgatives taken by the mouth, while an intestine remains firmly strangidated. In the en- tero epiplocele, when the intestine has retired, and the omentum remains strangulated; or in a simple strangula- tion of the omentum, where the intes- tine has not been prolapsed, purgatives are of great utility. So likewise in very large and old hernias, where there is reason to doubt, whether the disease is not to be considered as a morbid af- fection of the intestinal canal, rather than the effect of strangulation, purga- tives may be as useful as in the simple ileus without hernia. While the intes- line remains firmly strangulated, they usually increase the vomiting, and add to the distress of the patient. If they are to be tried at any time with hope of success, the trial would appear to have the greatest advantage when the vo- miting has been removed by nv-ans of an opiate; yet I have repeatedly given them in vain during such an interval of relief." {Pract. Observ. in Surgery, p. 128.) Purgatives are supposed to operate by exciting the peristaltic action of the intestine and thereby extricating it from the stricture. Besides the above eminent surgeon, Pott and Richter have joined in their condemnation in general, and to all appearances, with very great reason. Purgative glysters certainly have not the objection of in- creasing the irritation; but, their effi- cacy is not deserving of much confi- dence. Mr. Hey says, he has never seen one case, in which either purga- tive, or emollient glysters produced a return of a strangulated hernia. Such injections will empty the large intes- tines; but, they have seemed to him to do no more. It is common also for a natural evacuation to be the immediate consequence of a strangulation. (P. 131.) Warm Bath.—" Many instances (says Hey) are upon record of the good ef- fect of warm bathing, in procuring the reduction of a strangulated hernia. I have often seen it useful; but I have al- so often seen it fail of success. When- ever it is used in this disease, the pa- tient should be placed, if possible, in a horizontal position. Gentle efforts with the hand to reduce the prolapsed part are perhaps attended with less danger, and with greater prospect of success, while the patient lies in the bath, than in any other position. The free use of opiates coincides with that of warm ba- thing, and under some circumstances, these means deserve to be tried in con-" junction." (P. 132.) Cold Bath, and Cold Applications.— The cold bath, and dashing of cold wa- ter on the patient are little to be de- pended upon, though success seems sometimes to have been obtained in this manner. {Petit Traitides Mai. Chir. torn. 2. p. 325. Hey, p. 136.) Wilmer has strongly recommended the application of cold to the tumour it- self, and this plan has acquired the ap- probation of the most celebrated mo- dern surgeons. It is generally tried in conjunction with the effect of tobacco glysters, which will be presently noti- ced. Cold applications, in the form of ice, were indeed, particularly recom- mended by B. Bell. The best way is tu fiound the ice, tie it up in a bladder, and place it on the rupture. When ice cannot be procured, Mr. A. Cooper em- ploys a mixture of equal parts of nitre 12 HERNIA and sal-ammoniac. To one pint of wa- ter, in a bladder, ten ounces of the mix- ed salts are to be added. " If, after four hours, (says this distinguished sur- geon) the symptoms become mitigated, and the tumour lessens, this remedy may be persevered in, for some time longer; but, if they continue with una- bated violence, and the tumour resist every attempt at reduction, no farther trial should be made of the application." {On Inguinal and Congenital Hernia.) When ice has not been at hand, aether has occasionally been found a good substitute, when allowed to evaporate from the surface of the swelling. Care must be taken, that the cold be not so applied as to freeze the scrotum, and bring on sloughing. {A. Cooper, p. 15.) Opiates.—Mr. Hey has seen several cases, in which opiates, given freely, (in athletic persons after bleeding) have procured a reduction of strangu- lated hernia. He cannot say, however, that this remedy is generally success- ful; but, it has the advantage of remo- ving, for a time, the pain and vomiting usually attendant on strangulation, even though it prove ultimately inefficacious. Opiates should be given in large doses, when it is wished to try their effect in procuring reduction; and whenever the symptoms of strangulation return, after having been removed by opiates, the operation should be performed without delay. (P. 134,135.) Tobacco Glysters.—For this purpose, some surgeons prefer a decoction of tobacco, made by infusing, or boiling, one drachm of the plant, for ten minutes, in a pint of water; others employ the smoke, which is prepared, and'introdu- ced into the rectum, by means of a well-known apparatus for the purpose. Perhaps, both methods are equally effi- cacious; but, as one requires an appa- ratus, while the other does not, and is equally proper, the decoction may be entitled to most recommendation. The machine for the smoke is also frequent- ly found out of order. Tobacco glysters are, next to the operation, the most certain means of bringing about the re- duction of the strangulated parts. They not only excite the action of the intes- tines, they also exert a peculiar de- pressing influence on the whole sys- tem, reducing the pulse, and causing* nausea and sickness, cold sweats and fainting, under which circumstances the parts recede spontaneously, or may be easily reduced. Mr. A. Cooper pru- dently advises injecting half the above quantity at first; for, he has seen two drachms, and even one, when used as an infusion, and introduced at once, prove fatal. (P. 24.) The rest should present- ly be injected, when it appears, that the tobacco does not operate with the ex- traordinary violence, with which it does in a few particular constitutions. Poultices and Fomentations.—We only make mention of these, to say, they have not the least confidence of any ex- perienced, or intelligent surgeon. Who- ever wastes time, in these urgent ca- ces, in trying the effects of such appli- cations, merits censure for his creduli- ty, ignorance, and unfitness to under- take the treatment of a rapid disease, in which, as Pott remarks, if we do not get forward, we generally go back- ward; and whatever does no good, if it be at all depended upon, certainly does harm, by occasioning an irretrievable loss of time. \_Placing the patient on an inclined plane, with his feet highest.—Winslow and Cooper recommend this position of the body during the efforts to reduce the hernia by taxis. I would recommend it however, to be continued longer; from having seen two cases in which this simple measure succeeded after seve- ral of those, already recited, had been tried in vain. The patient should lie upon his back, and the foot of the bed be elevated about twenty inches higher than the head. This posture need not interrupt the administration of other remedies, and in some cases will be found powerfully to aid them.] OF THE ORDER, IN WHICH THE PRE- CEDING METHODS AND REMEDIES SHOULD BE TRIED, AND OF THE TIME, WHEN THE OPERATION SHOULD NOT BE DELAYED. Ill the treatment of a strangulated hernia, a surgeon cannot be too deeply impressed with the danger of spending time in the trial of methods of inferior efficacy, or of such, as are evinced to be ineffectual in the cases before them. The taxis is of course the first thing to be tried, and Mr. A. Cooper thinks the attempts should be continued for a quarter, or half an hour. When these have been ineffectual, the patient, if the circumstances do not forbid, should be immediately bled, and have a large opening made in the vein, so that the suddenness of the evacuation may be HERNIA. 13 most likely to bring on fainting. The taxis should be tried once more as soon as this operation is finished. If the manual efforts at reduction should not now succeed, the warm bath may be employed, provided it can be got ready in a very short time, but none should ever be lost in waiting for it to be prepared. When the bath is used, the taxis may be attempted, as the pa- tient lies in the water; a situation, in which I have succeeded myself in re- ducing several herniae. Certainly not more, than one hour should ever be allotted for putting in practice the first attempts at reduction, bleeding, and the warm bath. The plan should be, while the trial of one thing is going on, another should be preparing. So when the preceding measures have been tried in vain, the application of a bladder filled with ice, or the solution of salts, and the injec- tion of tobacco, in the form of smoke, or decoction, should never be delayed for want of due previous preparation of all the requisites. Both these measures sliould be practised at the same time, immediately after the failure of the taxis, bleeding, and the warm bath. Mr. A. Cooper states, that four hours are enough for the trial of the tobacco glyster, together with cold applica- tions. In omental herniae, the necessity for operating may frequently be obviated, by the good effects of bleeding, purga- tive medicines, and glysters, and leech- es applied to the tumour. Mr. Law. mice has justly observed, that " when, as it very frequently happens, the aid of the surgeon is not required, until the complaint has lasted for some time, a trial of the tobacco, together with the topical use of cold, should be immedi- ately resorted to, as circumstances will not admit of delay in the previous use of less powerful remedies." (P. 87.) Every man who has seen much of herniae, will immediately recognise the propriety of the following sentiments of tlie experienced Mr. Hey: " 1 can scarcely press in too strong terms the necessity of an early recourse to the operation, as the most effectual method of preserving life in this dan- gerous disease. If Mr. Pott's opinion be true, that the operation, when per- formed in a proper manner, and in due time, docs not prove the cause of death oftener than perhaps once in fifty times; • t would undoubtedly preserve the lives of many, to perform it almost as soon as the disease commenced, without in- creasing the danger by spending much time in the use of means, which cannot be depended upon for a cure. " I have twice seen this disease prove fatal in about twenty-four hours. In such cases it is evident there is lit- tle time for delay. A surgeon, who is competent to perform the operation, is not perhaps consulted till the intestine is on the point of being mortified, or is actually in a state of mortification. The dilemma into which he is then cast, is painful indeed. But when the fullest opportunity is afforded him of using the best mode of treatment, I am satisfied that his success will be the greatest when the operation is not long delayed. This, at least, has been my own expe- rience. When 1 first entered upon the profession of surgery, in the year 1759, the operation for the strangulated her- nia had not been performed by any of the surgeons in Leeds. My seniors in the profession were very kind in afford- ing me their assistance, or calling me into consultation when such cases oc- curred; but we considered the opera- tion as the last resource, and as impro- per until the danger appeared immi- nent. By this dilatory mode of practice, I lost three patients in five upon whom the operation was performed. Having more experience of the urgency of the disease, I made it my custom, when called to a patient who had laboured two or three days under the disease, to wait only about two hours, that I might try the effect of bleeding (if this evacuation was not forbidden by some peculiar circumstances of the case) and the tobacco glyster. In this mode of practice I lost about two patients in nine upon whom 1 operated. This com- parison is drawn from cases nearly si- milar leaving out of the account those cases in which a gangrene of the intes- tine had taken place. " I have now, at the time of writing this, performed the operation thirty- five times; and have often had occasion to lament that I had performed it too late, but never that I had performed it too soon. There are some cases so ur- gent, that it is not advisable to lose any time in the trial of means to produce a reduction. The delay of a few hours may cut off all hope of success, when a speedy operation might have saved the life of the p:<.tient." (P. 141, &c.) To determine the exact moment. 14 HERNIA when to give up the trial of the prece- ding measures, and to have immediate recourse to the operation, is certainly difficult; but, no one can doubt, that this should rather be resorted to too early, than too late- All directions must be general ones, liable to many exceptions: in rapid ca- ses, little or no time should be allotted to the trial of any plan, and the opera- tion should be done without the least delay. In other instances, we have full time to try the effects of every thing at all likely to succeed. The symptoms, which ought to guide us, in having re- course to the operation, arise from an attack of inflammation in that part of the intestine contained in the hernial sac, and from its spreading into the ab- dominal cavity. It is in proportion to their violence, that we ought to urge the performance of the operation. Mr. A. Cooper considers pain on pressing the belly, and tension, as the symptoms, which point out its immediate necessi- ty. He adds, " Indeed, there is scarcely any period of the symptoms, which should forbid the operation; for, even if mortification has actually begun, the operation may be the means of saving life, by promoting the ready separation of gangrenous parts." {On Inguinal and Congenital Hernia, p. 27.) Whenever the surgeon has succeed- ed in reducing the parts, without ha- ving recourse to the knife, if the symp- toms of pain, inflammation, &c. ran high before such reduction, they will not always cease immediately after- wards. As they probably depend on the reduced bowel having been infla- med by the stricture, the body should be kept open, and the diet and regimen should be low and sparing, while the least degree of pain and tension re- main; in short, till all complaint is ab- solutely removed from the abdomen, and the intestihes do their office freely, and without trouble. {Pott.) PROGRESS OF THE SYMPTOMS OF A STRANGULATED HERNIA. The earliest symptoms have been al- ready related; viz. "tumour in the groin, or scrotum, attended with pain, not only in the part, but all over the belly, and creating a sickness and incli- nation to vomit, suppression of stools, and some degree of fever. These are the first symptoms, and if they are not appeased by the return of the intestine, - that is, if the attempts, made for this ; purpose, do not succeed; the sickness t becomes more troublesome, the vomit- t ing more frequent, the pain more in- > tense, the tension of the belly greater, the fever higher, and a general rest- , lessness comes on, which is very terri- - ble to bear. When this is the state of I the patient, no time is to be lost; a very- little delay is now of the utmost conse- t quence, and if the one single remedy I which the disease is now capable of be ; not administered immediately, it will , generally baffle every other attempt. This remedy is the operation, whereby i the parts engaged in the stricture may f be set free. If this be not now perform- [ ed, the vomiting is soon exchanged for . a convulsive hiccough, and a frequent > gulping up of bilious matter; the ten- sion of the belly, the restlessness and fever having been considerably increas- • ed for a few hours, the patient sudden- , ly becomes perfectly easy, the belly subsides, the pulse from having been hard, full, and frequent, becomes low, languid, and generally interrupted; and i the skin, especially that of the limbs, cold and moist; the eyes have now a • languor and a glassiness, a lack-lustre i not easy to be described; the tumour of I the part disappears, and the skin cover- ing it, sometimes changes its natural colour for a livid hue; but whether it keeps or loses its colour, it has an em- physematous feel, a crepitus to the touch, which will easily be conceived by all who have attended to it, but is not so easy to convey an idea of by words: this crepitus is the too sure in- dicator of gangrenous mischief within. In this state, the gut either goes up spontaneously, or is returned with the smallest degree of pressure; a dis- charge is made by stool, and the pa- tient is generally much pleased at the ease he finds; but this pleasure is of short duration, for the hiccough and the cold sweats continuing and increasing, with the addition of spasmodic rigors and subsultus tendinum, the tragedj soon finishes." {Pott.) ANATOMY OF THE BUBONOCELE, OR INGUINAL HERNIA. This subject must necessarily pre-- cede the account of the operation, which would otherwise be unintelligi- ble. It is chiefly in the anatomical in- formation, relative to herniae, and the mode of operating, that modern sur HERNIA. 15 geons have a decided superiority over their predecessors; for, before Gimber- nat, Camper, Hey, and A. Cooper, pub- lished their several works on herniae, the anatomy of the disease was only imperfectly understood. The tendinous fibres of the aponeu- rosis of the external oblique muscle, as they run downwards and forwards to- wards the pubes, separate from each other, so as to leave a triangular open- ing, called the abdominal ring. The upper and inner pillar (as it is termed) of this aperture is inserted into the symphysis of the pubes; the lower and outer one, which is only the continua- tion of Poupart's ligament, is fixed into the angle and crista of the same bone. Some tendinous fibres cross the upper and outer angle of the ring, so as to di- minish the triangular appearance of the whole aperture: these are said to be very strong in old herniae. The ante- rior and thicker layer of the aponeuro- sis of the internal oblique muscle joins the tendon of the external oblique; the posterior and thinner one joins that of the transversalis; but the lower portion of this tendon, together with the cor- responding part of the transversalis, goes wholly in front of the rectus mus- cle. Thus the inferior border of the obliquus internus and transversalis, which originates from the upper part of Poupart's ligament, lies behind the outer pillar of the abdominal ring. Mr. A. Cooper was the first, who noticed, that a thin fascia proceeded from the inner edge of Poupart's ligament, and spread itself over the posterior surface of the transversalis. This forms the only partition between the peritonaeum and the outer opening of the abdominal ring, and were it not for its existence, inguinal herniae would probably be much more frequent. The spermatic vessels, joined by the vas deferens, proceed before Ae epi- gastric artery, very near the place where it arises. They then run through the above fascia, go under the edge of the internal oblique and transverse muscles, and next obliquely down- wards and forwards, between the above fascia, and aponeurosis of the external oblique to the opening of the ring. Thus we see, that the spermatic cord runs through a kind of canal, before it actually emerges at what is named the abdominal ring. This oblique passage of the cord, through the abdominal pa- rietes, was well known to, and elegant- ly delineated by, Albinus; Cimbernat makes distinct mention of it in his Account of a New Method of Operating for Femoral Hernia, p. 19—32; but, no one, before Mr. A. Cooper, consider- ed the thing with due attention. The abdominal ring is then only the outer opening of the canal, or passage, through which the spermatic cord passes before it emerges. The inner one, at which the viscera in cases of inguinal hernia first pr trude, is situat- ed about an inch and a half from the abdominal ring, in the direction to- wards the anterior spinous process of the ilium. This inner opening is rather nearer the pubes, than the ilium, and its upper border is formed by the lower edge of the internal, oblique, and trans- verse muscles, which can be plainly felt with the finger, introduced upward and outward into the abdominal ring. The epigastric artery runs behind the spermatic cord, along the inner margin of the internal opening of the above canal, then upwards and inwards, so as to pass at the distance of half an inch, or an inch, from the upper extre- mity of the outer opening-, or abdominal ring. In common cases of inguinal hernia, the viscera, protruded at the inner opening, above described, lie over the spermatic cord, and form a tumour on the outside of the abdominal ring. They may, however, insinuate themselves into the inner opening, without descend- ing sufficiently to protrude through the external one, or abdominal ring. The stricture may take place at either of these openings. In recent and small hernias, according to Mr. A. Cooper, the strangulation is most frequently si- tuated at the inner opening; in large old ruptures, at the abdominal ring. Even when the parts are completely protrud- ed out of the latter opening, the stran- gulation may exist at the inner one: but, there may occasionally be two strictures, viz. one at each opening. {Lawrfnce on Hernia, p. 103.) The hernial sac descends through the abdominal ring over the spermatic cord, and is covered by a fascia, sent off from the tendon of the external oblique muscle. Beneath this fascia, the cre- master muscle is also situated over the sac. When this has descended a certain way, it lies on the tunica vaginalis, as well as the spermatic cord. As the epigastric artery naturally runs first behind the spermatic cord, 16 HERNIA and then along the inner margin of the internal opening of the ring, and as the viscera are protruded over the cord, they must be situated on the outer side of the artery, which runs first behind the neck of the sac, and then on its inner side. Hence, the inner margin of the s.ic, when inspected on the side to- wards the abdomen, seems to be form- ed, as it were, by the track of the ves- sel. (See Lawrence, p. 106.) That this is the ordinary situation of the epigas- tric artery, in relation to the inguinal hernia, is confirmed by the concurrent testimonies of Camper, Chopart, De- sault, Sabatier, A. Cooper, 8cc. and by preparations to be seen in almost every museum. In recent inguinal herniae, the inter- nal and external openings of the ring are at some distance from each other, the first being situated obliquely up- wards and outwards in relation to the former; but, the pressure of the pro- truded viscera, gradually brings them nearer together, so that in large herniae of long standing, the opening into the abdomen is almost direct, and the epi- gastric artery becomes situated nearer the pubes, than in the natural state. Though such is the ordinary direc- tion, in which a bubonocele protrudes, there are occasional varieties. In one of these, the viscera, instead of descend- ing through the canal of the ring, are at once thrust through the abdominal ring itself, and the opening into the belly is then direct: the hernial sac, in- stead of passing on the external side of the spermatic vessels, as is usual, now lies on their inner, or pubic side; and the epigastric artery, which is com- monly situated behind, now pursues its course, in front of the sac, at its usual distance from the upper and outer angle of the abdominal ring. In the other va- riety, the vas deferens is found on the outer side of the sac, while the rest of the spermatic cord lies, as it usually does, on the inner side, or rather under this part. {Cooper.) Le Dran, Schmuck- er, and Blizard, have found the whole cord situated in front of the sac. Some- times the vas deferens has run on the front and inner part, and the rest of the cord on the back and external part of the swelling. {Camper, Hey) The cord has been known to be before, and the vas deferens behind the sac. {Camper, f'oper.) The hernial sac is commonly describ- ed as an elongation of peritoneum. When more minutely examined, how- ever, it is found, in cases of inguinal hernia, to consist of the portion of peri- tonaeum, pushed out with the viscera; of a layer of cellular substance on the outside of this, which becomes more or less thickened by the pressure of the rupture in different cases; of a fascia, sent off from the tendon of the external oblique muscle; and of the ere master muscle, which latter parts form the ex- terior covering, which consisting of several layers, often leads the operator to fancy he has opened into the cavity of the sac, when, in reality, he has not. When surgeons speak of a hernial sac being usually thicker and stronger, in proportion to the magnitude and du- ration of the hernia, they do not imply, that this alteration only occurs in the mere peritonaeum. In very enormous herniae, the pressure of the contents is so great, that, instead of thickening the sac, it attenuates it, and even makes it ulcerate. The protruded viscera have been met with immediately beneath the integuments, when the sac has been burst by a blow. {Cooper; T. L. Petit.) The outer surface of the peritoneal part of the hernial sac, is always most closely adherent to the other more ex- ternal covering by means of cellular substance. This connexion is formed so soon, after the first occurrence of a hernia, that any hopes of returning a hernial sac into the abdomen are now considered as merely chimerical. There must, however, be a certain space of time, before adhesions form, though it is, no doubt, exceedingly short. The following is an admirable ac- count of the parts of an inguinal hernia, as they appear on dissection: " the re- moval of the integuments exposes the exterior investment of the hernial tu- mour, continuous with the margins of the ring, and formed of tendinous fibres from the aponeurosis, the cremaster muscle, &c. This is connected by cellu- lar substance with the proper hernial sac, formed of the peritonaeum. This production of the peritonaeum passes through the ring of the external ob- lique, and then goes upwards and out- wards. Behind and above the ring, the inferior margin of the obliquus internus and transversalis crosses the neck of the sac. When these muscles are re- flected towards the linea alba, the fas- cia, ascending from Poupart's ligament, and forming the upper opening of the ring, is exposed, and the epigastric ar,- HERNIA. 17 tery is discovered emerging from the inner side of the neck of the hernial sac, {Camper,-) which at this precise point, becomes continuous with the peritonaeum, lining the abdomen. The removal of the hernial sac will disclose the course of the spermatic cord in its descent towards the testicle; and when this is also elevated, the first part of the course of the epigastric artery, and its origin from the iliac trunk, are laid open." {Lawrence on Hernia, p. 115, 116.) In females, the I'ound ligament of the uterus bears the same relation to the tuiiHuir, as the spermatic cord in males. In the former subjects, bubonoceles are uncommon. Mr. Lawrence had a very rare instance pointed out to him, in which a bubonocele in a female was si- tuated on the inner side of the epigas- tric artery. MARKS OF DISCRIMINATION BE- TWEEN SOME OTHER DISEASES AND INGUINAL HERNIJE. The disorders in which a mistake may possibly be made, are the Cirsocele, Bubo, Hydrocele, and Hernia Humoralis, or Injiamed Testicle. For an account of the manner of dis- tinguishing the first complaint from a bubonocele, see Cirsocele. " The circumscribed incompressible hardness, the situation of the tumour, and its being free from all connexion with the spermatic process, will suffi- ciently point out the first, at least while it is in a recent state; and when it is in any degree suppurated, he must have a very small share of the tactus eruditus, who cannot feel the difference between matter, and either a piece of intestine, or omentum. " The perfect equality of the whole tumour, the freedom and smallness of the spermatic process above it, the power of feeling the spermatic vessels and the vas deferens in that process, its being void of pain upon being han- dled, the fluctuation of the water, the gradual formation of the swelling, its having begun below and proceeded up- wards, its not being affected by any posture or action of the patient, nor in- creased by his coughing or sneezing, together with the absolute impossibili- ty of feeling the testicle at the bottom of the scrotum, will always, to an intel- ligent person, prove the disease to be a hydrocele." Mr. Pott, however, allows, fUat there are some exceptions, in which the testicle cannot be felt at the bottom of the scrotum in cases of her- nia. In recent bubonoceles, while the hernial sac is thin, has not been long, or very much distended, and the scrotum still preserves a regularity of figure, the testicle may almost always be easi- ly felt at the inferior and posterior part of the tumour. But, in old ruptures, which have been long down, in which the quantity of contents is large, the sac considerably tliickened, and the scrotum of an irregular figure, the tes- ticle frequently cannot be felt, neither is it in general easily felt in the con- genital hernia for obvious reasons. {Pott.) " In the hernia humoralis, the pain in the testicle, its enlargement, the har- dened state of the epidydimis, and the exemption of the spermatic cord from all unnatural fulness, are such marks as cannot easily be mistaken; not to men- tion the generally precedinggonorrhoea. But, if any doubt still remains of the true nature of the disease, the progress of it from above downward, its differ- ent state and size in different postures, particularly lying and standing, toge- ther with its descent and ascent, will, if duly attended to, put it out of all doubt, that the tumour is a true hernia." {Pott.) When an inguinal hernia does not de- scend through the abdominal ring, but only into the canal for the spermatic cord, it is covered by the aponeurosis of the external oblique muscle, and the swelling is small and undefined. Now and then, the testicle does not descend into the scrotum till a late pe- riod. The first appearance of this body at the ring, in order to get into its na- tural situation, might be mistaken for that of a hernia, were the surgeon not to pay attention to the absence of the testicle from the scrotum, and the pe- culiar sensation occasioned by pressing the swelling. OPERATION FOR THE STRANGULAT- ED INGUINAL HERNIA, OR BUBO- NOCELE. This consists in dividing the integu- ments; dissecting down to the sac, and opening it; removing the stricture; and replacing the protruded viscera. The external incision should begin an inch above the external angle of the ring, and extend over the middle of the tumour to its lower part. The advantage of beginning the wound so high, is to Vol. II C 18 HERNI * obtain convenient room for the incision of the stricture. By this first cut, the external pudic branch of the femoral ar- tery may be divided; it crosses the her- nial sac near the abdominal ring, and sometimes bleeds so freely, that it should be immediately tied. In general, however, a ligature is unnecessary. When carrying this incision low down, we should always bear in mind the caution given by Camper, that there is a possibility of dividing the spermatic vessels, should they happen to be situated, as they sometimes are, in front of the hernia. The division of the integuments brings into view the fascia, which is sent off from the ten- don of the external oblique muscle, and covers the hernial sac. The layers of tendinous fibres, cellu- lar substance, &c. intervening between the skin and sac, should be carefully divided, one after another, with the knife and dissecting forceps, taking care to incline the edge of the instru- ment horizontally, for fear of cutting too deeply at once, and injuring the vis- cera contained in the sac. After making a small opening through some part of the fascia cover- ing the sac, some advise introducing a director, and laying it open upward and downward as far as the tumour ex- tends. The same manner of proceeding, they next recommend in regard to the cremaster muscle. Thus the sac be- comes completely exposed. When this method is followed, Mr. A. Cooper ad- vises the incisions not to be earned up- ward, nearer than one inch, to the ab- dominal ring, for reasons which will be presently explained. However it may be rationally doubt- ed, whether there is any good in these regular and successive divisions of the whole length of the coverings of the sac; and it is certain, that they protract the operation very much. As the grand object, after dividing the skin, is to make a small opening into the sac, suf- ficient for the introduction of a direc- tor, dissecting down at one particular place, answers every purpose, and ena- bles us, in the end, to lay open the whole of the sac and its coverings in the shortest time. Let the operator on- ly take care to raise the successive lay- ers of fibres with the forceps, and di- vide the apex of each elevated portion with the knife held horizontally. As there is commonly a quantity of fluid in *he sac, and it gravitates to the lower part, to which place the intestine sel- dom quite descends; this is certainly the safest situation for making the first opening into the sac. The operator^ however, relying on the presence of such fluid, should not cut too boldly: sometimes none at all is found, and the viscera are in immediate contact with, nay, adherent to, the inner surface of the sac. The circular arrangement of the ves- sels of a piece of intestine, and its smooth polished surface, sufficiently distinguish it from the hernial sac, which has a rough cellular surface, and is always connected with the sur- rounding parts. {Lawrence, p. 125.) We have mentioned, that Mr. A. Cooper only advises cutting the fascia, and other coverings of the sac, un- der the skin, to within an inch of the abdominal ring: he also recommends, of course, limiting the division of the sac itself to the same extent. His rea- sons, for this practice, are to avoid making the closure of the wound more difficult, and to lessen the danger of peritoneal inflammation. Having laid open the hernial sac, with a probe-pointed bistoury, guided on a director, or the fore-finger, intro- duced into the opening, which is made at the lower part of the sac, the next desideratum is to divide the stricture, unless the viscera admit of being easily reduced, without such an incision being made, as occasionally happens. From the anatomical account we have given of the bubonocele, it ap- pears, that the stricture ma)' either be situated at the abdominal ring, and be formed by the margins of this opening, or else at the inner aperture of the ca- nal, about one inch and a half, in a di- rection upward and outward, from the outer opening in the tendon of the ex- ternal oblique muscle. This latter stran- gulation is caused by the semicircular edge of the transversalis muscle and its tendon, which p. ss over the neck of the hernial sac, and by a fascia, arising from Poupart's ligament, the semicir- cular border of which passes under this part of the sac. The common, and probably the best practice is to divide the hernial sac, to- gether with the stricture. When this is situated at the abdominal ring, the sur- geon is to introduce the end of a direc- tor a little way into the neck of the sac within the aperture in the tendon, and with a probe-pointed bistoury, guided HERNIA. 19 •n the latter instrument, he is to cut the stricture upward and outward, or else directly upwards, a manner, which Mr. A. Cooper recommends because it is applicable to all cases, even those less frequent ones, in which the hernia protrudes on the inner side of the epi- gastric artery. This vessel, as we have -already explained, commonly runs up- ward round the inner side of the neck of the sac; so that cutting the stricture upward and inward would be very apt to divide it. Cutting upward and outward is, in ordinary cases, perfectly safe; and i« only objectionable in a few occasional instances, in which the hernia descends on the inner side of the artery. Mr. A. Cooper's rule, of always cutting in one direction, viz. upward, which is proper in every instance, is in my opinion well worthy of universal adoption. No more of the parts, forming the stricture, should be cut, than is just sufficient for allowing the protruded viscera to be re- duced, without brusing, or otherwise hurting them. The middle of the up- per margin of the ring is the safest place for making the necessary incision. Mr. A. Cooper, in his late work on the Inguinal Hernia, advises a mode of dividing the stricture, considerably dif- ferent from the usual method. He di- rects the finger of the operator to be introduced into the sac, (which in his plan, we know is left undivided for the space of one inch below the ring.) When the stricture is felt, a probe- pointed bistoury is to be conveyed over the front of the sac into the ring (be- tween the two parts), and the latter only is then to be divided, in the direc- tion upward, opposite the middle of the neck of the sac, and to an extent just sufficient to allow the protruded parts to be returned into the abdomen, with- out their being hurt. The two chief ad- vantages, which Mr. A. Cooper im- putes to this method, are, that the dan- ger of peritoneal inflammation will be less, and that the epigastric artery, if wounded, would not bleed into the ab- domen. I am of opinion, that what Mr. Lawrence has remarked, concerning this proposal, is exceedingly judicious: " An accurate comparative trial of both methods would be necessary, in order to determine the weight of the first reason. The second circumstance can- not be a matter of any importance, if we cut in such a direction as to avoid the risk of wounding the artery. Many circumstances present themselves as objections to this proposal. The ma- noeuvre itself, although perhaps easy to the experienced hand of such an able anatomist as Mr. C, would, I am con- vinced, be found highly difficult, if not impracticable, by the generality of sur- geons. This difficulty arises from the firm manner, in which the sac and sur- rounding parts are connected, we might almost say, consolidated together. The experience of Richter ( Traite" des Her- nies, p. 118.) shows, that this objection is founded in reality. He once tried to divide the ring, without cutting the sac, but he found it impracticable. If the stricture is so tight, as to prevent the introduction of the finger, there must be great danger of wounding the protruded parts. The practice would still be not advisable, even if it could be rendered as easy as the common method of operating. Mr. C. leaves an inch of the sac, below the ring, undivi- ded; thus a bag remains ready to re- ceive any future protrusion, and the chance of a radical cure is diminished. It would be better to follow the advice of Richter, and scarify the neck of the sac, in order to promote an adhesion of its sides. He has found this practice so successful in accomplishing a radical cure, that he advises (p. 191.) its em- ployment in every operation for stran- gulated hernia." {Treatise on Hernia, p. 144.) If the stricture should be felt to ex- ist at the inner opening of the canal for the spermatic cord, Mr. A. Cooper advises the operator to introduce his finger into the sac, as far as the stric- ture, and then to insinuate a probe- pointed bistoury, with the flat part of its blade turned towards the finger, between the front of the sac, and the abdominal ring, till it arrives under the stricture, formed by the lower edge of the transversalis and obliquus internus. Then the edge of the instrument is to be turned forward, and the stricture cut in the direction upward. This plan of not cutting the neck of the sac, is lia- ble to ail the objections stated by Mi- Lawrence, in regard to the case, in which the strangulation takes place at the abdominal ring. It should be men- tioned, that Mr. A. Cooper's bistoury is a very proper one for dividing the scricture, as it only has a cutting edge to a certain distance from the pointy Perhaps, on the whole, we may. infer, that it is both most easy and advahta- 20 HERNIA. gcous to divide the neck of the sac, to- gether with the stricture, whether this be situated at the ring, or more inward. In the latter case, cutting upward and outward would always be perfectly safe, because the hernia always pro- trudes on the outer side of the epigas- tric artery; but, as it is easiest for the memory to adhere to one rule, making the incision immediately upward is a very proper plan. Room being made for the reduction of the protruded parts into the abdo- men, by the division of the stricture, they are to be immediately returned, if sound, and free from adhesions. This object is considerably facilitated by bending the thigh. The intestines are to be reduced before the omentum, but, when a portion of mesentery is protru- ded, it is to be returned before either of the preceding parts. The intestine should always be reduced, unless it be found in a state of actual mortification. It often appears so altered in colour, that an uninformed person woidd deem it improper to return it into the abdo- men. However, if such alteration should not amount to a real mortification, ex- perience justifies the reduction of the part. Mr. A. Cooper has judiciously cautioned the operator not to mistake the dark chocolate-brown discoloura- tions, for a state of gangrene. With these the protruded part is frequently found affected; and, as they generally produce, no permanent mischief, they ought to be carefully discriminated from the black purple, or lead-coloured spots, which usually precede mortifica- tion. To determine, whether a disco- loured portion of intestine be positively mortified, some recommend pressing forward the blood contained in the veins, and, if they fill again, it is looked upon as a proof, that the bowel is still possessed of life. In returning a piece of intestine into the abdomen, the surgeon should first introduce the part, nearest the ring, into this aperture, and hold it there till another portion has succeeded it. This method is to be followed up, till the whole of the protruded bowel is redu- ced. Writers on surgery cannot too se- verely reprobate the employment of any force, or violence, when endeavouring to return the contents of a hernia in the operation: a method the more perni- cious, because such parts are common- ly more or less in a state of inflamma- tion. It is always more judicious to en- large the stricture, than to pinch and bruise the bowel in trying to get it through an opening which is too small. Distention of the intestine sometimes prevents the reduction: but, the bowel can then be generally returned as soon as its contents are first compressed in- to the part of the intestinal canal with- in the stricture. It is better, however, to dilate the strangulation a little more, than to use any force in trying to get the intestine back into the abdomen in the manner just suggested. Reduction is sometimes impeded by the protruded parts adhering to each other, or to the hernial sac. The intes- tines are not often found very firmly ad- herent together. The omentum and in- side of the sac are the parts, which are most subject to become intimately con- nected by adhesions. The fingers will commonly serve for breaking any re- cent slight adhesions which may have taken place between the intestines and inside of the hernial sac. When these adhesions are firm, and of long stand- ing, they must be cautiously divided with the knife; an object, which can be most easily and safely accomplished, in case they are long enough to permit the intestine to be elevated a little way from the surface of the sac. But, pro- vided their firmness and shortness keep the external coat of the bowel and inner surface of the sac in close contact, the greatest care is requisite in separa- ting the parts with a knife, so as to avoid wounding the intestine. In doing this, the most prudent and safe method, is not to cut too near the bowel, but rather to remove the adherent parts of the sac, and return them with the intestine into the abdomen. Every preternatural con- nexion should always be separated, be-^ fore the viscera are reduced: Mr. A. Cooper mentions, that a fatal obstruc- tion to the passage of the intestinal mat- ter has arisen from the mere adhesion of the two sides of a fold of intestine together. (P. 31.) When the adhesions, which prevent reduction, are situated about the neck of the sac, so as to be out of the operator's view, it is best to make the wound through the skin and abdominal ring somewhat larger, so as to be able to separate the adhesion* with more safety. Having reduced the parts, the opera- tor should introduce his finger, for the purpose of being sure that they are fairly and freely returned into the abdo- HERNIA. 21 men, and no longer suffer constriction, cither from the inner opening of the ring, or the parts just within the cavity of the peritonaeum. TREATMENT OF THE OMENTUM. In entero-epiplocele, this part, if healthy and free from gangrene, is to be reduced after the intestine. When, however, it is much diseased, thicken- ed, and indurated, as it frequently is found to be, after remaining any consi- derable time in a hernial sac, the mor- bid part should be cut off". Its reduc- tion, in this circumstance, would be highly improper, both because an im- moderate enlargement of the woimd would be necessary, in order to be able to put the diseased mass back into the abdomen, and because, when reduced, it would, in all probability, excite in- flammation of the surrounding parts, andbringon dangerous symptoms. (See Hey, p. 172.) The diseased omentum should al- ways be cut off with a knife; and, if any of its arteries should bleed, they ought to be taken up with a tenaculum, and ti- ed separately with a small ligature. An unreasonable apprehension of hemor- rhage from the cut end of the omentum has led many operators to put a liga- ture all round this part, just above the diseased portion, which they are about to remove. This practice cannot be re- probated in terms too severe; for, a frequent effect of it is to bring on a fa- tal inflammation, and even mortification of the omentum, extending within the abdomen, as high as the stomach and transverse arch of the colon. Mr. A. Cooper has remarked with great truth, that it is surprising, this custom should ever have prevailed. The very object of the operation is to extricate the omentum from its strangulated state, arising from the pressure of the sur- rounding tendon, and no sooner has this been done, than the surgeon in- cludes it in a ligature, which produces a more perfect constriction, than that which existed before the operation was undertaken. " When the omentum has suffered strangulation for a few days (says Mr. Lawrence), it often becomes of a dark red, or livid colour; and there is an ap- pearance, on cutting it, as if some blood were extravasatcd in its substance. This, I believe, is the state, which sur- geons have generally described under 1 he term of gangrene." (P. 167) When cut in this state, if it does not bleed, I need hardly observe, that the dead part must be amputated, and never reduced. Some have advised leaving the omentum in the wound, especially in cases of old herniae, in which ithas been a long while protrud- ed. Hey mentions cases, showing that granulations form very well, and the wound becomes firmly healed, when this plan is followed. (P. 180, &c.) Every one, however, will acknowledge the truth of what Mr. Lawrence says on this subject. The method " is at- tended with no particular advantage, but certainly exposes the patient to the possibiUty of ill consequences. The omentum, left in the wound, must be liable to injury, inflammation, or dis- ease; and hence arises a source of dan- ger to the patient. Unnatural adhesions, formed by this part, have greatly im- paired the functions of the stomach. Cases are recorded, where the unfortu- nate patient has never been able to take more than a certain quantity of food, without bringing on instant vomiting: and even where it has been necessary for all the meals to be taken in the re- cumbent position, with the trunk curv- ed, and the thighs bent. {Gum.) To avoid the possibility of such afflicting consequences, we should, after remov- ing any diseased portion, carefully re- place the sound part of the omentum in the abdominal cavity." {Treatise on Hernia, p. 181.) TREATMENT, WHEN THE INTESTINE IN THE SAC HAS MORTIFIED. Sometimes, on opening the hernial sac, the intestine is found to be in a gangrenous state, although the occur- rence could not be previously known, owing to the integuments and the her- nial sac itself not being affected with the same mischief. In ordinary cases, however, both the skin and sac become gangrenous at the same time with the contents of the hernia. The tumour, which was before tense and clastic, now becomes soft, doughy, emphyse- matous, and of- a purple colour. Some- times the parts now become spontane- ously reduced; but, the patient only survives a few hours. Mr. A. Cooper has accurately re- marked, that, in other instances, the skin, covering the swelling, sloughs to a considerable extent, the intestine gives way, and, as the faeces find vent at the wound, the symptoms of stran- 22 HERNIA. glation soon subside. When the patient continues to live in these circumstances, the living part of the intestine becomes adherent to the hernial sac, the sloughs separate and come away, and thus an artificial anus is established, through which the faeces are commonly dis- charged, during the remainder of life. (See Anus, Artificial.) However, though when the patient survives the mortification of an intesti- nal hernia, he commonly obtains the blessing of life only combined with the loathsome affliction of an artificial anus; yet, things sometimes take a still more prosperous course; the faeces gradually resume their former route to the rec- tum, and in proportion as the artificial anus becomes unnecessary, it is shut up. Many instances of this sort have fal- len under my own observation in St. Bartholomew's hospital. The chance of a favourable event is much greater in some kinds of hernia than in others. When the strangulation only includes a part of the diameter of the gut, the faeces are sometimes only partially dis- charged through the mortified open- ing. This quantity lessens, as the wound heals, and the patient gets perfectly well. {Louis; Mem- de C Acad, de Chir. torn. 3.) A small gangrenous spot, or two, may end in the same manner. Mortification of the caecum and its ap- pendix, in a hernial sac, has happened several times, without much disturbing the usual course of the faeces to the anus, and the patients have very soon recov- ered. {Med. Obs. and Inq. vol. III. p. 162, &c.) The grand thing, on which the esta- blishment of the continuous state of the intestinal canal depends, in all these cases, is the adhesion, which the living portion of the bowel, adjoining the mortified part, contracts with the peri- tonaeum all round. In this manner, the escape of the contents of the bowels into the cavity of the peritonaeum be- comes in general completely prevent- ed. When the intestine has not already burst, the stricture should be divided; an opening made in the mortified part to let out the faeces, and very mild pur- gatives and glysters administered. {Lcnvrence, p. 186.) It is an observation of Mr. A. Coop- er's, that the degree of danger, attend- ing an artificial anus, depends or. the vicinity of the sphacelated part of the intestinal canal to the stomach. Thus, if die opening be in the jejunum, there is such a small extent of surface for ab- sorption, between it and the stomach, that the patient dies of inanition. Let us now suppose, that the morti- fied state of the intestine has only been discovered, after laying open the her- nial sac in the operation. The mischief may only consist of one, or more spots; or of the whole diameter of the protrud- ed bowel. In the first case, the proper practice is to divide the stricture, and return the intestine into the abdomen, with the mortified spots towards the wound. Mild purgatives and glysters are then to be exhibited. The most fa- vourable mode, in which a case of this kind ends, is, when the intestinal mat- ter graduallyresumes its natural course, after being either partly, or entirely dis- charged from the wound. But, some- times, an artificial anus continues for life. The repeated observations of modern surgeons have now decided, that no li- gature, passed through the mesentery, to keep the gangrenous part of the bowel near the wound, is at all neces- sary.. The parts, in the neighbourhood of the ring, have all become adherent together, in consequence of inflamma- tion, at the same time, that the parts in the hernial sac mortify; and, of course, the partially gangrenous bowel, when reduced, is mechanically hindered, by these adhesions, from slipping far from the wound. Desault and De la Faye, both confirm the fact, that the intestine never recedes far from the ring; and, even were it to do so, the adhesions, which it soon contracts to the adjacent surfaces, would, as Petit has explained, completely circumscribe any matter, which might be effused, and hinder it from being extensively extravasated among the convolutions of the viscera. {Mem. de VAcad. de Chir. torn. I. and II) Mr. Lawrence, in his late very valu- able Treatise on Hernia, has clearly shown the impropriety of sewing the ends of the intestinal canal together, introducing one within the other, sup- ported by a cylinder of isinglass, &c. put in their cavity, in those cases, in which the whole circle of the intestine has mortified, and been cut away, as is advised by the majority of writers. " By drawing the intestine out of the cavity, in order to remove the dead part, the adhesion behind the ring, on which the prospectof a cure chiefly de- pends, must be entirely destroyed; and HERNIA. 25 new irritation and inflammation must be unavoidably produced, by handling and sewing an inflamed part." (P. 199.) Instead of such practice, this gentle- man very judiciously recommends di- lating the stricture, and leaving the subsequent progress of the cure entire- ly to nature. The sloughs will be cast off*, and the ends of the gut are retain- ed by the adhesive process in a state of apposition to each other, the most fa- vourable for their union. Thus, there is a chance of the continuity of the in- testinal canal becoming established again. However, in recent wounds of the abdomen, attended with a protrusion of a portion of intestine, cut completely across, the bowel is as yet neither in- flamed, nor adherent to the vicinity of the wound in the peritonaeum, so that it is proper practice to connect the ends together, (as advised in the article Abdo- men, Wounds of the Intestines,) by means of a few stitches with silk, or thread, and a small sewing needle; and to con- fine the wounded part of the intestine, near the breach in the peritonaeum, un- til adhesions have had time to form. Mr. A. Cooper has recommended this mode of proceeding in cases of her- nia, attended with mortification of the whole diameter of the bowel; but, for reasons already stated, and many facts, referred to in Mr. Lawrence's work, it is to be hoped, that the plan of sewing the intestines in these cases will be forever abandoned. OPERATION FOR VERY LARGE IN- GUINAL HERNIA. When the tumour is of very long standing, is exceedingly large, perhaps extending half way down to the knees, and its contents have never admitted of being completely reduced, the indica- tion is to divide the stricture, provided a strangulation takes place; but without laying open the hernial sac, or attempt- ing to reduce the parts. The reasons, against the common plan of operating, under such circum- stances, are, the difficulty of separating all the old adhesions; the hazardous in- flammation, which would be excited by- laying open so vast a tumour, and the probability that parts, so long protrud- ed, might even bring on serious com- plaints, if reduced. J. L. Petit, and af- terwards, Dr. Monro, advised the sac not to be opened in operating on certain cases. (See Mai. Chir. torn. II.p.372 Description of Burses of hernia congenita, which actu- ally take place when the testicle de- scends into the scrotum before birth, the event may commonly he referred to the testicle having contracted an adhe- sion to a piece of intestine, or of the omentum, in its passage to the ring. Wrisberg found one testicle, which had not passed the ring, adhering, by means of a few slender filaments, to the omen- tum, just above this aperture, in an in-< fant, that died a few hours after birth. Excepting the impossibility of feeling the testicle in hernia congenita, as we can in most cases of bubonocele, (which criterion Mr. Pott should have men- tioned,) the following account is very excellent." The appearance of a hernia in very early infancy, will always make it probable that it is of this kind; but, in an adult, there is no reason for suppos- ing his rupture to be of this sort,* but his having been afflicted with it from his infancy; there is no external mark, or characte r, whereby it can be certain- ly distinguished from one contained in a common hernial sac; neither would it be of any material use in practice, if there was. " When returnable, it ought, like all other kind of ruptures, to be reduced, and constantly kept up by a proper bandage; and when attended with symptoms of stricture, it requires the same chirurgic assistance as the com- mon hernia. " In very young children, there are some circumstances, relative to this kind of rupture, which are very well worth attending to, as they may. prove of very material consequence to the pa- tient. " A piece of intestine, or omentum, may get pretty low down in the sac, while the testicle is still in the groin, or even within the abdomen; both which I have seen. In this case, the ap- plication of a truss would be higldy im- proper; for in the latter, it might pre- vent the descent ofthe testicle from the belly into the scrotum; in the former, it must necessarily bruise and injure it, give a great deal of unnecessary pain, and can prove of no real use. Such bandage, therefore, ought never to be applied on a rupture in an infant, unless the testicle can be fairly felt in the scro- tum, after the gut or caul is replaced; and when it can be so felt, a truss can never be put on too soon. " As this kind of rupture is subject to stricture, with all its consequences. 30 HERNIA ks much as that which is contained in a common hernial sac, and therefore lia- ble to stand in need of the chirurgic operation; it may be very well worth an operator's while to know, that an old rupture, which was originally congeni- tal, is subject to a stricture made by the sac itself, independent of the abdomi- nal tendon, as well as to that made by the said tendon. " Whether this be owing to the weight of the testicle at the bottom of the sac, and the endeavours which na- ture makes to close the upper part of the tunica vaginalis, or to what other cause, I will not pretend to say, but the fact I have several times noticed, both in the dead and in the living. I have seen such stricture made by the sac of one of these herniae, as produced all those bad symptoms which render the operation necessary; and I have met .with two different strictures, at near an inch distance from each other, in the body of a dead boy, about fourteen, one of which begirt the intestine so tight, that I could not disengage it without dividing the sac. " In this kind of hernia I have also more frequently found connexions and adhesions of the parts to each other, than in the common one; but there is one kind of connexion sometimes met with in the congenital hernia, which can never be found in that which is a com- mon hernial sac, and which may require all the dexterity of an operator to set free; I mean that of the intestine with the testicle, from which 1 have more than once experienced a good deal of trouble. " When a common hernial sac has been laid open, and the intestine and omentum have been replaced, there ean be nothing left in it which can re- quire particular regard from the sur- geon; but by the division ofthe sac of a congenital hernia, the testicle is laid tare, and after the parts composing the hernia have been reduced, will require great regard and tenderness, in all the future dressings, as it is a part very ir- ritable, and very susceptible of pain, inflammation, &c. " If a large quantity of fluid should be collected in the sac of a congenital hernia, and, by adhesions and connex- ions of the parts within, the entrance into it from the abdomen should be to- tally closed, (a case which I have twice seen) the tightness of the tu- mour, the difficulty of distinguishing the testicle, and the fluctuation of the fluid, may occasion it to be mistaken for a common hydrocele; and if without attending to other circumstances, but trusting merely to the feel and look of the scrotum, a puncture be hastily made, it may create a great deal of trouble, and possibly do fatal mischief. " By what has fallen within my ob- servation, I am inclined to believe that the sac of a congenital hernials very sel- dom, if ever, distended to the degree which a common hernial sac often is: it also, from being less dilated, and rather more confined by the upper part of the spermatic process, generally preserves a pyriform kind of figure, and, for the same reason, is also generally thinner, and will therefore require more atten- tion and dexterity in an operator when he is to open it. To which I believe I may add, that common ruptures or those in a common sac, are generally gradually formed, that is, they are first inguinal, and by degrees become scro- tal; but the congenital are seldom, if ever, remembered by the patient to have been in the groin only." {Pott on Ruptures, vol- 2) The reader must not conclude, how- ever, from the above account, that eve- ry rupture in children is a congenital one. Mr. Lawrence has related a case of strangulated bubonocele, which took place in an infant only fourteen months old. (.P. 31.) If circumstances will admit of a truss being applied and worn, in cases of congenital hernia, in young subjects, there will be a considerable chance of a radical cure being effected, in conse- quence ofthe natural propensity ofthe opening between the abdomen and tu- nica vaginalis to become closed. The only material difference in the operation, from that for a bubonocele, is, that the surgeon has to lay open the tunica vaginalis, instead of a common hernial sac. The stricture is to be di- vided on the same principle as that of an inguinal hernia, and much in the same manner. The parts having been reduced, the edges of the wound are to be immediately brought together, and retained so by means of one or two su- tures, and sticking plaster, which is much preferable to the plan of applying the dressing to the testicle and inside of the tunica vaginalis, so as to heal the part by the granulating process. A new species of hernia congenita has lately been described, in which a HERNIA. 31 common peritoneal hernial sac, con- taining the viscera, is included in the tunica vaginalis. It arises from the parts being protruded, after the communica- tion, between the abdomen and tunica vaginalis, is closed, so that the perito- naeum is carried down along with the intestine, and forms a hernial sac, with- in the tunica vaginalis. It is evident also, that such a hernia can only be produced, while the original tunica vaginalis re- mains, in the form of a "bag, as high as the abdominal ring. Operators should be aware of the possibility of having a sac to divide, after laying open the tuT nica vaginalis. (See the accounts of this hernia in Hey's Practical Observations, p. 221, &c. and A. Cooper's Work on In- guinal Hernia, p. 59.) UMBILICAL HERNIA, OR EXOMTHA- LOS. " The exomphalos, or umbilical rup- ture (says Pott), is so called from its situation, and has (like other hernia) for its general contents, a portion of in- testine, or omentum, or both. In old umbilical ruptures, the quantity of omentum is sometimes very great " Mr. Ranby says, that he found two ells and a half of intestine in one of these, with about a third part of the stomach, all adhering together. " Mr. Gay and Mr. Nourse found the liver in the sac of an umbilical hernia; and Bohnius says that he did also. " But whatever are the contents, they are originally contained in the sac, formed by the protrusion ofthe perito- neum. " In recent and small ruptures, this sac is very visible; but in old, and large ones, it is broken through at the knot of the navel, by the pressure and weight of the contents, and is not always to be distinguished; which is the reason why it has by some been doubted whe- ther this kind of rupture has a hernial sac or not. " Infants are very subject to this dis- ease, in a small degree, from the sepa- ration of the funiculus; but in general they either get rid of it as they gather strength, or are easily cured by wearing a proper bandage. It is of still more consequence to get this disorder cured in females, even than in males, that its return, when they are become adult, and pregnant, may be prevented as much as possible; for at this time it wften happens, from the too great dis- tention ofthe belly, or from unguarded motion when the parts are upon the stretch. During gestation, it is often very troublesome, but after delivery, if the contents have contracted no adhe- sion, they will often return, and ma) be kept in their place by a proper ban- dage. " If such bandage was always put on in time, and worn constantly, the dis- ease might in general be kept within moderate bounds, and some ofthe very terrible consequences which often at- tend it might be prevented. The woman who has the smallest degree of it, and who from her age and situation has rea- son to expect children after its appear- ance, should be particularly careful to keep it restrained. " In some the entrance of the sac is large, and the parts easily reducible; in others they are difficult, and in some absolutely irreducible. Ofthe last kind many have been suspended for years in a proper bag, and have given little or no trouble. They who are afflicted with this disorder, who are advanced in life, and in whom it is large, are generally subject to colics, diarrhoeas, and, if the intestinal ci.nal be at all obstructed, to very troublesome vomitings. (Hence, patients arc often supposed to labour under a stricture, when they really do not) It therefore behooves such to take great care to keep that tube as clean and free as possible, and neither to eat, or drink any thing likely to make any disturbance in that part." {Pott on Rup- tures, vol. 2.) Authors, who have published since the time of this celebrated surgeon, have not added much to the stock of information, which he has left, relative to the exomphalos. The writings of Mr. A. Cooper, and of all the most accurate moderns, confirm the fact, described by Pott, that, in the umbilical rupture, there is a hernial sac, just as in other instances of hernise. Every one, ac- quainted with anatomy, knows, that behind the opening in the linea alba at the umbilicus, the peritonaeum is com- plete, and consequently must be pro- truded before the viscera, in cases of exomphalos. In the only two cases, which Mr. A. Cooper has seen of a de- ficiency of the sac, the membrane had been partially absorbed, or lacerated, so as to allow the protrusion of its con- tents, and threaten, from this cause, a double stricture. Similar appearances, less closely inspected, probably gave 02 HERNIA. rise to the opinion so firmly maintained by Dionis, De la Faye, G-ivngeot, and J. L Petit, that, in the umbilical hernia, the peritonaeum was always lacerated, and there was no hernial sac. It is ob- served by Bichat, that the umbilicus is a kind of cicatrix, formed, in conse- quence of the separation of the funis, by the contraction of the parts with which it was continuous; and that it only gradually acquires the degree of firmness which it has in the adult sub- ject. As it is for a long while weaker than the rest of the abdominal parietes, it only makes an inferior degree of re- sistance to the viscera; but tliis resist- ance increases with age; and, as the cicatrix now becomes stronger than the surrounding parts, it forms a more im- penetrable barrier against any escape of the bowels. From these anatomical facts, the following pathological infer- ences, confirmed by expt rience, are de- ducible:—1. That infancy is more sub- ject, than any other age, to the umbilical hernia, strictly so called, in which the parts protrude through the navel. 2. That other periods of life are more sub- ject than infancy to false umbilical her- niae, or to those which arise in the vici- nity of the umbilicus. {(Euvres Chir. de Desault par Bichat, torn. 2. p. 315.) Besides a true hernial sac, the exom- phalos is also covered with a more su- perficial expansion, consisting of con- densed cellular substance. In operating, we should always cut, however, with great caution, for, often the integu- ments and hernial sac, in front of the tumour, are inseparably adherent; and sometimes, in consequence ofthe pres- sure ofthe viscera, in large cases, hav- ing caused an absorption of part of the sac, they are even found adherent to the integuments. Pregnant women, and dropsical and corpulent subjects, are peculiarly liable to the exomphalos. In adults, there is almost always omentum in the sac when there is intestine. The transverse arch ofthe colon is observed to be par- ticularly often contained in umbilical herniae, though the small intestines are not unfrequently protruded. {Lawrence, 265.) In the true umbilical hernia, the stricture is made by the tendinous open- ing imthe linea alba. We shall next consider the umbilical hernia in the three particular forms in which it has been noticed by the latest writers. CONGENITAL UMBILICAL HERNIA. Dr. Hamilton has met with about two cases of this kind annually, for the space of seventeen years; and they strictlv deserve the epithet congenital, as they appear at birth. The funis ends in a sort of" bag, containing some ofthe viscera, which pass out ofthe abdomen through an aperture in the situation of the navel. The swelling is not covered with skin, so that the contents of the hernia can be seen through the thin distended covering of the cord. The disease is owing to a preternatural defi- ciency in the abdominal muscles, and the hope of cure must be regulated by the size ofthe malformation, and quan- tity of viscera protruded. The plans of cure proposed, consist of the employment of a ligature, or of a bandage. The latter seems preferable, and was practised by Mr. Hey, as fob Iowsj having reduced the intestine, he desired an assistant to hold the funis compressed sufficiently near the abdo- men, to keep the bowel from returning into the hernial sac. " I procured (says he) some plaster spread upon leather, cut into circular pieces, and laid upon one another in a conical form. This compress I placed upon the navel, after I had brought the skin on each side of the aperture into contact, and had laid one of the lips a little over the other. I then put round the child's abdomen, a linen belt; and placed upon the navel, a thick, circular, quilted part, termed about two inches from one extremity ofthe belt. " This bandage kept the intestine securely within the abdomen, and was renewed occasionally. The funis was separated about a week afterbirth; and at the expiration of a fortnight from that time, the aperture at the navel was so far contracted, that the crying ofthe child, when the bandage was removed, did not cause the least protrusion. I thought it proper, however, to continue the use of the bandage a while longer. A small substance, like fungous flesh, projected, after the funis had dropped off', about half an inch from the bottom of that depression which the navel forms. A dossil of lint spread with cerat. e lapide calaminari, and assist- ed by the pressure of the bandage, brought on a complete cicatrization "— (P. 227.) This gentleman has related another HERNIA. 33 e.t ample, in which the intestines were quite uncovered, and inflamed, the sac having burst in delivery. The parts were reduced; but the child died. UMBILICAL HERNIA IN CHILDREN. The umbilical hernia, which is some- limes formed in the foetus, from causes difficult of explanation, takes place, in other instances, at the moment of de- livery; and then, as Sabatier remarks, should it, by mistake, be tied with the funis, death would be the consequence. Most frequently, however, it is not till the second, third, or fourth month after birth, that the disease occurs; and the numerous cases collected by Desault, prove that, of ten infants attacked with this hernia, nine become afflicted at the periods just mentioned. The umbilicus, still open, now be- gins to contract, so as to close the cica- trix, which, as has been already stated, forms, in the adult state, an obstacle soon capable of preventing a protrusion ofthe viscera, when nothing resists its formation. But, the repeated crying of the child, propelling the viscera out- ward, pushes them through the open- ing. Thus the cicatrix is forced before them, and they distend it so powerfully forward, that its closure is prevented. As their continued action gradually dilates it more and more, the intestines insinuate themselves through it, in- crease its natural width, project beyond it, and thus a tumour arises, which, .from being of trivial size at first, be- comes afterwards more considerable; at length, attains the size of an egg, or large walnut, and presents itself with all the characteristic marks of a hernia. The presence of a piece of intestine and omentum in the tumour, keeps the umbilicus open, and opposes the conti- nual tendency which it has to close. Such tendency, however, being some- times superior to the resistance of the protruded parts, forces them to return back into the abdomen, obliterates the opening through which they passed, and thus the spontaneous cure of the umbilical hernia in children is accom- plished. Two cases illustrative of this fact, are related in (Euvres Chir. de De- sault, par Bichat, torn. 2. p. 318. Nature, however, does not effect ma- ny such cures, and when the case is left to her alone, she not only fails in bring- ing about a radical cure, but gradually renders it impossible. In short, the pro- pensity of the openingto close diminish- es, and is lost, as the subject grows old- er. In the adult, it is not the lodgment of the intestines in the opening, that prevents its obliteration; it is its having no disposition to undergo this beneficial change. Hence, the umbilical hernia of chil- dren seems to be essentially distin- guished from that of adults, by the ten- dency ofthe aperture to contract. Hence the ease of effecting a radical cure in children, and the almost utter impossi- bility of doing so in adults. In the for- mer, it is enough to keep the intestines from protruding into the opening, and it becomes of itself obliterated; in the latter, it always continues, whether the bowrels continue in it or not. Hence, the inaccuracy of the inferences dedu- ced by some writers, from the umbili- cal hernia of" infants, as being applica- ble to that of adults, and the necessity of not delaying the assistance of art in the former cases. The means of curing the umbilical hernia of children, are of three kinds: external applications; compression; and the ligature. The first are totally use- less; and, as they occasion a waste of time, are improper. Compression, and the ligature, are the only rational plans; and to these we shall limit our observa- tions. The former is the most modern, the latter the most ancient, as it was practised by the Greeks, and then by Celsus. Desaidt has drawn a most able parallel between the two modes; he tells us, that the design both ofthe lig- ature and compression is the same: viz. to prevent the lodgment of the protru- ded viscera in the opening- of the um- bilicus, and thus facilitate the approxi- mation of its sides. To accomplish this end, the ligature retrenches the hernial sac, and skin pushed before it; and, by the union ofthe cut parts, occasions a cicatrix, which hinders the protrusion of the viscera. At the same time, the sides of the opening, obeying their na- tural tendency, and affected by the irri- tation which they have sustained, con- tract, obliterate the opening, and put the cicatrix in its proper place, though now it is only an accessory means of hindering a protrusion. Compression stops up the aperture by something ap- plied externally; thus, the deficiency, or opening, in the parietes ofthe abdo- men, hinders the protrusion ofthe bow- els, and keeps these parts from resisting Vol. II. E 34 HERNIA. the contraction ofthe sac. Hence it is clear, that the two methods are found- ed on a different basis. Reason and ex- perience also show, that their results are equally different. Though compression occasions no pain, it causes the child an irksome in- convenience, during the great length of time its employment is necessary. The ligature produces momentary pain; but there is nothing irksome attending its use, and it effects in a few days, what compression, when successful, accom- plishes in several months. In one plan, continual attentions are requisite: should its employment be only for a short time neglected, the previous ef- fect becomes almost destroyed. The other method always accomplishes its object with certainty, independently of the crying of the child, and the care of its attendants. The first, by continually compressing the sides of the opening, counteracts, in this point of view, its natural disposition to contract. The se- cond, by artificially irritating this natu- ral process ofthe umbilicus, accelerates its contraction. When compression is adopted, it is executed either by means of a flat compress applied to the open- ing, and which does not enter it, or else by means of some round or oval body, such as a ball of wax, a nutmeg, &c adapted to the shape of the aper- ture, and, as Platner, and Richter (in his Treatise on Hernia) advise, made continually to enter the opening. But, in the first case, if the bandage be ex- actly applied, the skin and sac, forming a fold in the aperture ofthe naval, will hinder its closure, and operate in the same manner, from without, inward, as the protruded intestines did from within outward. In the second case, the foreign body, being depressed into and maintained in the opening, will oc- casion, notwithstanding what Richter says, the same inconveniences, and, in a more striking manner, similar conse- quences. But, on the contrary, when the ligature is employed, the sac and skin of the tumour are removed, while the opening remains free, and nothing prevents its obliteration. In this me- thod, the omentum can never protrude outward; but, in the other, if the com pression should ever be inexact, the parts slip out again, above or below, and the disorder prevails on one side of the useless application. Supposing com- pression successful, both plans effect a closure of the umbilicus; but, while compression only accomplishes the lat- ter object, the ligature has the addi- tional advantage of producing an adhe- sion ofthe sides of the opening, either to each other, or the adjacent parts. This adhesive process arises from the inflammation excited, and occasions a degree of firmness, not producible by any other mode of cure. To this parallel, dictated by reason, (continues Desault) let us add that, which is the fruit of experience. On one side, we shall discover, that the beneficial effects of compression are on- ly reckoned in the midst of its want of success, andthat the children, on whom it is employed, miserably endure for years its irksomeness and inconveni- ences. If we look the other way, we shall find, that the ligature, which is em- ployed at the Hotel-Dieu, presents an uninterrupted series of well authenti- cated cures, which in Desault's prac- tice amounted to the number of fifty. In the latter years of his practice, you might see many persons bringing to his public consultations their children, which were immediately operated on without any preparation, carried home immediately afterwards, and brought the next, and every following day, to be dressed, till the cure was complete. To these considerations, are to be added other motives, which are, per- haps, not immaterial. The children of the poor may be cured in an hospital, by the ligature, in the space of a few days. But, when compression is adopted, the parents are_ frequently put to repeated expense, as the bandage wears out; and to additional loss from the time consu- med in paying the necessary attentions. The ancients had different modes of applying the ligature; but, what they have transmitted to us, may be refer- red to two different processes. One consisted in reducing the parts, and afterwards tying the integuments and sac, without opening the latter at all. In the other, an incision was made in the sac, either before, or after tying it, for the, purpose of being sure, that no piece of intestine was, and could be- come, strangulated in the ligature. Cel- sus adopted the first plan. Paulus v£gi- neta preferred the second, and was imi- tated by all the Arabian physicians, and their successors. Avicenna, Albucasis, and Guy de Chauliac give us proofs of this in their several works. Experience soon decides, which of these modes of operating ought to be chosen. One is less painful, and equally safe; for, one soon becomes habituated' HERNIA $5 to ascertaining, whether there is still any intestine in the sac, by rubbing the opposite sides of this bag against each other. The other, which is unnecessa- rily cruel, increases the pain, without making the method at all more certain- ly successful. The latter has been usu- ally adopted, and Par£, who has de- scribed it, does not even mention the former. Latterly, some variations in the plan of operating were made. Some simply tied the base of the tumour; others passed through it one, or two needles, armed with ligatures, for the purpose of fixing such ligatures in a better manner, and even making, for this purpose, a circular incision for the lodgment of them. It is chiefly in the Arabian practice, that we meet with this cruel proceeding, which was also useless, as the ligature was never known to fail, when properly applied. Par£ also describes it; but, Saviard, the only modern, who has practised the ligature, rejected it, and followed the plan long ago advised by Celsus. Saba- tier seems to recommend, in his work on the operations, both plans indiffer- ently, with the exception of the circu- lar incision. Desault's method, which much resembles that of Saviard, is sim- ple, and attended with little pain: in short, it is the following: The cluld, on whom the operation is to be done, must be placed on its back, with its thighs a little bent, and its head inclined towards the chest. The surgeon is to reduce the protruded parts, forming the tumour, and to hold them so with his finger, at the same time, that he raises the hernial sac, and rubs its 6ides between his fingers, so as to be sure, that there is nothing con- tained in it. Being certain, that the parts, which he lifts up, are only the skin and sac, he is to direct an assistant to surround their base several times with a waxed ligature, of middling size, each turn being tied with a double knot, in such a manner as only to occa- sion little pain. The tumour, thus tied, is to be covered with lint, which is to be supported with one or two com- presses, and a circular bandage, secur- ed with a scapularv. A slight swelling commonly takes place in the constrict- ed parts, by the following day, just as a polypus swells, after its base has been tied. No pain accompanies this tumefac- tion, which is itself often scarcely per- ceptible, as may be seen by referring to the first case of this operation rela- ted in the Parisian Journal. On the se- cond, or third day, the parts shrink, and then the ligature becomes loose, so that a fresh one must now be applied in the same manner as the first, taking care to draw it a little more tightly. The sensibility of the parts, increased by the inflammation, which the con- striction ofthe ligature has already pro- duced, usually renders this second liga- ture more painful. After the operation, the same dressings, as before, are to be applied. The tumour soon becomes dis- coloured, Uvid, and smaller. A third ligature, put on in the same way as the preceding ones, entirely obstructs the circulation in it. The part turns black and flaccid, and commonly falls off on the eighth, or tenth day. A small ulcer is left, which, being properly dressed, very soon heals, and leaves a cicatrix sufficiently strong to resist the impulse occasioned by coughing, or other ef- forts of the abdominal muscles. For two, or three months, however, after the operation, the child should wear a circular bandage, in order to prevent, with still more certainty, the viscera from being propelled against the cica- tix, so as to interrupt the process of na- ture, which is now producing a gradu- al closure of the umbilical opening. Numerous cases might here be addu- ced, in confirmation of the above prac- tice; but several (nine) are already published in the Parisian Chirurgical Journal. The relation of others here would only prolong our observations in a fruidess manner. Suffice it to remark, that since those alluded to were pub. lished, Desault has practised an infinite number of operations of this sort with equal success; that, ever}'week, many children were brought b^r their mothers into the amphitheatre, where he pub- licly delivered his lectures: that here the ligature was applied in the pre- sence of all his pupils; and that chil- dren, thus operated upon, were carried home, and brought back every day to be dressed, till the cure was comple - ted. But, one may doubt, (says Sabatier) quotingthe article in the journal, where Desault treats of the present disease,- whether the infants got rid of the her- nia, as it might have returned some time afterwards. Numerous facts re- move this doubt; for, several ofthe sub- jects were brought to' Desault's pub- lic consultation, for other diseases, a 36 HERNIA. long while after they had been operat- ed upon, and the great number of stu- dents, who examined them, all acknow- ledged, that the ring was completely obliterated, and there was no impulse of the viscera in coughing, sneezing, &c. Other children, in the knowledge of the surgeons of the Hotel-Dieu, have remained perfectly cured of their umbilical herniae, by the operation, which Desault has revived. Bichat is acquainted with two young subjects, who were operated on four years ago, and have since had no relapse. The operation is almost certainly successful in young infants; but, it be- comes less so, in proportion as their age increases. Bichat relates three ca- ses, which tend to show, that success may be completely obtained at the age of a year and a half; that the cure is difficult, when the child is four years old; and impossible, when it is nine. Several other operations, done too late, have had the same result. (See (Euvres Chir. de Desault par Bichat, torn. 2. p. 315, &c.) Mr. Pott notices the plan of curing the exomphalos with the ligature, and expresses himself strongly against the practice in general. This treatment, however, on children, is now satisfacto- rily proved to be an eligible one. To adults the plan is not applicable, parti- cularly, when the tumour is large. Mr. Pott was decidedly in favour of com- pression, and he observes, that, in young subjects, and small herniae, a bandage, worn a proper time, generally proves a perfect cure. {vol. 2) VMBILICAL HERNIA IN ADULT SUB- JECTS. This case is to be treated on the prin- ciples common to all ruptures. When reducible, the parts should be kept up with a bandage, or truss; which plan, however, at this period of life, affords no hope of a radical cure. Mr Hey has described one ofthe best trusses for the exomphalos, which is applicable to children, when compression is prefer- red, as well as to adult subjects It was invented by Mr. Marrison, an ingenious mechanic at Leeds. " It consists of two pieces of thin elastic steel, which surround the sides of the abdomen, and nearly meet be- hind. At their anterior extremity they form conjointly an oval ring, to one side pf which is fastened a spring of steel of the form represented. At the end c* this spring is placed the pad or bolster that presses upon the hernia. By the elasticity of this spring the hernia is re- pressed in every position of the body, and is thereby retained constantly with- in the abdomen. A piece of callico or jean is fastened to each side ofthe oval ring, having a continued loop at its edge, through which a piece of tape is put, that may be tied behind the body. This contrivance helps to preserve the instrument steady in its proper situa- tion." {Pract. Ob». in Surg. p. 231.) When the exomphalos is irreducible, and large, the tumour must be support- ed with bandages. As Mr. Pott remarks: " The umbili- cal, like the inguinal hernia, becomes the subject of chirurgic operation, when the parts are irreducible by the hand only, and are so bound as to pro- duce bad symptoms. But though I have in the inguinal and scrotal hernia advis- ed the early use ofthe knife, I cannot press it so much in this; the success of it is very rare, and I should make it the last remedy. Indeed I am much inclined to believe, that the bad symptoms which attend these cases are most fre- quently owing to disorders in the intes- tinal canal, and not so often to a stric- ture made on it at the navel, as is sup- posed. I do not say that the latter does not sometimes happen, it certainly does; but it is often believed to be the case when it is not. [On this opinion of Mr. Pott's I take the liberty to remark, that no surgeon ought to undertake an operation for the cure of hernia, unless certain that the hernia exists. If an umbilical hernia be strangulated, it calls as loudly for the operation as any other, and I see no rea- son why it should be longer delayed.] " When the operation becomes ne- cessary, it consists in dividing the skin and hernial sac, in such manner as shall set the intestine free from stricture, and enable the surgeon to return it into the abdomen." {Pott on Ruptures.) The rest of the conduct of the sur- geon is to be regulated by the usual principles. The division of the stricture is pro- perly recommended to be made direct- ly upward, in the course of the linea alba. In consequence of the great fatality ofthe usual operation for the exompha- los, I think the plan suggested, and sue cessfuUy practised by Mr. A. Cooper in HERNIA. 37 two instances, should always be adopt- ed, whenover the tumour is at all large; 1 might', perhaps, safely add, that when the parts admit of being reduced, with- out laying open the sac, this method should always be preferred. It consists in only making an incision sufficient to divide the stricture, without opening the sac at all, or, at all events no more of it, than is inevitable. In umbilical herniae, of not a large size, Mr. C. recommends the following plan of operating: " As the opening in- to the abdomen is placed towards the upper part of the tumour, I began the incision a little below it, that is, at the middle ofthe swelling, and extended it to its lowest part. I then made a second incision at the upper part of the first, and at right angles with it, so that the double incision was in the form of the letter T, the top of which crossed the middle ofthe tumour. The integuments being thus divided, the angles of the in- cision were turned down, which expos- ed a considerable portion ofthe hernial sac. This being then carefully opened, the finger was passed below the intes- tines to the orifice ofthe sac at the um- bilicus, and the probe-pointed bistoury being introduced upon it, I directed it into the opening at the navel, and divid- ed the linea alba downwards, to the re- quisite degree, instead of upwards, as in the former operation. When the omentum and intestine are returned, the portion of integument and sac, which is left, falls over the opening at the umbilicus, covers it, and unites to its edge, and thus lessens the risk of peritoneal inflammation, by more readi- ly closing the wound." {On Crural and Umbilical Hernia.) [Mr. Lawrence remarks that in old umbilical herniae there is generally found a considerable portion of omen- tum adhering to the sac. About two years ago I operated on a case of umbi- lical hernia, in which the sac differed from any I have seen described. Upon cutting into it I found a portion of ili- um, ten inches in length, strangulated in several places, by bands passing in all directions from the sac to the omen- tum forming a cavity much resembling the ventricles ofthe heart. The omen- tum, and sac had been blended together in this way, probably for years. The in- testine was not a part ofthe usual con- tents ofthe sac, but had been forced in- to this singular cavity and become stric- tured in four distinct places by these productions. It was necessary by very careful dissection to divide these baads and liberate the strictured intestine, which was accomplished, and the intes- tine evidently not being gangrenous was returned into the abdomen.] LESS FREQ_UENT KINDS OF HERNIA. The ventral hernia, described by Cel- sus, is not common; it may appear at almost any point of the anterior part of the belly, but, is most frequently found between the recti muscles. The portion of intestine, &c. is always contained in a sac, made by the protrusion ofthe pe- ritonaeum. Mr. A. Cooper imputes its causes to the dilatation of the natural foramina for the transmission of vessels, to congenital deficiencies, lacerations, and wounds, ofthe abdominal muscles, or their tendons. In small ventral her- niae, a second fascia is found beneath the superficial one; but, in large ones, the latter is the only dne covering the sac. When the ventral hernia is reduced, it should be kept in its place by a band- age, or truss. When strangulated, it admits, more frequently than most other cases, of being relieved by medi- cal treatment. If attended with stric- ture, which cannot otherwise be reliev- ed, that stricture must be carefully di- vided. Mr. A. Cooper recommends the valvular incision, and the dilatation to be made, either upward, or downward, according to the relativ e situation ofthe tumour and epigastric artery, which crosses the lower part ofthe linea semi- lunaris. Pudendal Hernia.—This is the name, assigned by Mr. A. Cooper, to that which descends between the vagina and ramus ischii, and forms an oblong tumour in the labium, traceable within the pelvis, as far as the os uteri. Mr. C. thinks this case has sometimes been mistaken for a hernia of the foramen ovale. When reducible, a common fe- male bandage, or the truss used for a prolapsus ani, sliould be worn. A pes- sary, unless very large, could not very well keep the parts from descending, as the protrusion happens so far from the vagina. Mr. C. is of opinion, that, when strangulated, this hernia, in con- sequence of the yielding nature of the parts, may generally be reduced, by pressing them with gentle and regular force, against the inner side of the branch of the ischium. If not, the warm 38 HERNIA. bath, bleeding, and tobacco glysters, are advised. Were an operation indis- pensable, the incision should be made in the labium, the lower part ofthe sac carefully opened, and, with a concealed bistoury, directed by the finger, in the vagina, the stricture should be cut di- rectly inward, towards the vagina. The bladder should be emptied, both before the manual attempts at reduction, and the operation. {On Crural Hernia, &c. p. 65, 66.) Vaginal Hernia.—A tumour occurs within the os externum. It is elastic, but not painful. When compressed, it readily recedes, but, is reproduced by coughing, or even without this when the pressure is removed. The inconve- niences produced are an inability to un- dergo much exercise, or exertion; for, every effort of this sort brihgs on a sense of bearing down. The vaginal her- nia protrudes in the space, left between the uterus and rectum. This space is bounded below by the peritonaeum, which membrane is forced downwards towards the perinxum; but, being una- ble to protrude further in that direc- tion, is pushed towards the back part ofthe vagina. Mr. C. advised the use of a pessary in one case; the plan, how- ever, was neglected. These cases, pro- bably, are always intestinal. Some herniae protrude at the anteri- or part ofthe vagina. (See Mr. A. Coo- per on Crural Hernia, &c.fi. 65, 66.) Perineal Hernia.—In men, the parts protrude between the bladder and rec- tum; in women, between the rectum and vagina. The hernia does not pro- ject, so as to form an external tumour, and, in men, its existence can only be distinguished by examining in the rec- tum. In women, it may be detected both from this part, and the vagina. In case of strangulation, the hernia might, perhaps, be reduced by pres- sure from within the rectum. An in- teresting case of perineal hernia, which took place from the peritonaeum being wounded with the gorget in lithotomy is related by Mr. Bromfield; Chirurgical Observations, p. 264. The reducible perineal hernia in wo- men may be kept from descending, by using a large pessary. Both this kind of rupture and the vaginal may prove very 'dangerous in cases of pregnancy. See Smellie's Midwifery, Case 5. Thyroideal Hernia, or Hernia Fora- minis Ovalis. In the anterior and upper part of the obturator ligament, there is an opening, through which the obtura- tor artery, vein, and nerve proceed, ana through which, occasionally, a piece of omentum, or intestine is protruded, co- vered with a part of the peritonxum, which constitutes the hernial sac. In the case, which Mr. A. Cooper met with, the hernia descended above the obturatores muscles. The os pubis was before the neck of the sac; three fourths of it were surrounded by the obturator ligament; and the fundus of the sac lay beneath the pectineus and adductor brevis muscles. The obturator nerve and artery were situated behind the neck of the sac, a little towards its inner side. This species of hernia can only form an outward tumour, when very large. Garengeot, however, met with an instance, in which there was not only a swelling, but, one attended with symptoms of strangulation: he re- duced the hernia, which went up with a guggling noise; the symptoms were stopped, and stools soon followed. The hernia of the foramen ovale, when reducible, must be kept up with a suitable truss; and when strangula- ted, and not capable of relief from the usual means, an operation would be re- quisite, though attended with difficul- ties. The. division ofthe obturator liga- ment and mouth of the sac should be made inwards, to avoid the obturator artery. This vessel, however, woidd even be exposed to injury by following this plan, if it should arise in common with the epigastric artery. (See a pa- per by Garengeot in M£m. de I' Acad, de Chir. tom. 1, and A. Cooper on Crural Hernia, C+cp. 70.) Cystocele.—As Mr. Pott observes; " The urinary bladder is also liable to be thrust forth, from its proper situa- tion, either through the opening in the oblique muscle, like the inguinal her- nia, or under Poupart's ligament, in the same manner as the femoral. " This is not a very frequent specie* of hernia, but does happen, and has as plain and determined a character as any other. " It has been mentioned by Bartho- lin, T. Dom. Sala, Platerus, Bonetus, Ruysch, Petit, Men, Verdier, &c. In one ofthe histories given by the latter, the urachus, and impervious umbilical artery on the left side, were drawn through the tendon into the scrotum, with the bladder: in another he found four calculi. " Ruysch gives an account of one complicated with a mortified bubono- cele. Mr. Petit sa< s he felt several cal- HERNIA. 33 culi in one, which were afterwards dis- charged through the urethra. " Bartholin speaks of T. Dom. Sala as the first discoverer of the disease, and -quotes a case from him, in which the patient had all the symptoms of a stone in his bladder; the stone could never be felt by the sound, but was found in the bladder (which had passed into the groin) after death. " As the bladder is only covered in part by the peritoneum, and must insi- nuate itself between that membrane and the oblique muscle, in order to pass the opening in the tendon, it is plain that the hernia cystica can have no sac, and that, when complicated with a bu- bonocele, that portion of the bladder which forms the cystic hernia must lie between the intestinal hernia and the spermatic cord, that is, the intestinal hernia must be anterior to the cystic. " A cystic hernia may indeed be the cause of an intestinal one; for when so much of the bladder has passed the ring, as to drag in the upper and hinder part of it, the peritoneum which covers that part must follow, and by that means a sac be formed for the reception of a portion of gut or caul. Hence the dif- ferent situation of the two herniae in the same subject. " While recent, this kind of hernia is easily reducible, and may, like the others, be kept within by a proper bandage; but when it is of any date, or has arrived to any considerable size, the urine cannot be discharged, without lifting up, and compressing the scro- tum ; the outer surface of the bladder is now become adherent to the cellular membrane, and the patient must be con- tented with a suspensory Bag. " In case of complication with a bu- bonocele, if the operation becomes ne- cessary, great care must be taken not to open the bladder instead ofthe sac, to which it will always be found to be posterior. And it may also sometimes by the inattentive be mistaken for a hy- drocele, and by being treated as such, may be the occasion of great or even fatal mischief, {vol. 2.) Thecystocele is always easily distin- guishable by the regular diminution of the swelling, whenever the patient makes water. Verdier and Sharp have accurately described the cystocele. Pott has offer- ed two cases, which fell under his ob- servation; vol. 3. Pipelet le Jeune men- tions a cystic herjiiain perinso, and se- veral cases of its occurrence in the fe- male; Acad, de Chir. torn. 4. Pott cut into one*cystocele, by mistake. Men- tion is made {Edinb. Surg. Journ. vol. 4. p. 512.) of a cystic hernia, which pro- truded between the origins of the leva- tor ani, and obturator internus muscles: the tumour made its appearance in the pudendum of an old woman. Gunz and Hoin have also treated of the cystocele. Ischiatic Hernia.—The case is proba- bly very rare. A case, however, which was strangulated, and undiscovered till after death, is related in Mr. A.Cooper's second part of his work on hernia. It is communicated by Dr. Jones, already celebrated for his book on hemorrhage. The disease happened in a young man, aged 27. On opening the abdomen, the ilium was found to have descended on the right side of the rectum into the pelvis, and a fold of it was protruded into a small sac, which passed out of the pelvis at the ischiatic notch. The intestine was adherent to the sac at two points: the strangulated part, and about three inches on each side, were very black. The intestines towards the sto- mach were very much distended with air, and, here and there, had a livid spot on them. A dark spot was even found on the stomach itself just above the py- lorus. The colon was exceedingly con- tracted, as far as its sigmoid flexure. A small orifice was found in the side of the pelvis, in front of, but a little above, the sciatic nerve, and on the forepart of the pyriformis muscle. The sac lay under the glutaeus maximus muscle, and its orifice was before the internal iliac artery, below the obturator artery, but above the vein. Mr. A. Cooper re- marks, that a reducible case might be kept up with a spring truss, and, that if an operation were requisite, the orifice of the sac should be dilated directly forwards. {On Crural Hernia, &c. jb.73.) Phrenic Hernia.—The abdominal vis- cera are occasionally protruded through the diaphragm, either through some of the natural apertures in this muscle, or deficiencies, or wounds, and lacerations in it. The second kind of case is the most frequent: Morgagni furnishes an instance of the first. Two cases, rela- ted by Dr. Macauley in Med. Obs. and Inq. vol. 1. and two others published by Mr. A. Cooper, are instances of the se- cond sort: and another case has been lately recorded by the latter gentle- man, affording an example ofthe third kind. Hildanus, Pare, Petit, Schenck, 40 HERNIA. &c. also mention cases of phrenic her- nia. The disease is quite out of the reach of art. Mesenteric Hernia.—If one ofthe lay- ers ofthe mesentery be torn by a blow, while the other remains in its natural state, the intestines may insinuate them- selves into the aperture, and form a kind of hernia. The same consequence may result from a natural deficiency in one of these layers. Mr. A. Cooper re- cords a case, in which all the small in- testines, except the duodenum, were thus circumstanced. The symptoms du- ring life were unknown. (On Crural Hernia, &c. p. 82.) Mesocolic Hernia.—So named by Mr. A.Cooper, when the bowels glide be- tween the layers of the mesocolon. There is a specimen of this disease, preserved at St. Thomas's hospital. Every surgeon should be aware, that the intestines may be strangulated with- in the abdomen from the following cau- ses: 1. Apertures in the omentum, me- sentery, or mesocolon, through which the intestine protrudes. 2. Adhesions, leaving an aperture, in which a piece of intestine becomes confined. 3. Mem- branous bands at the mouths of hernial sacs, which becoming elongated, by the frequent protrusion and return of the viscera, surround the intestine, so as to strangulate them within the ab- domen, when returned from the sac. (See A. Cooper on Crural Hernia, &c. p. 85.) Pott remarks, that " Ruysch gives an account of an impregnated uterus being found on the outside ofthe abdo- minal opening; and so do Hildanus and Sennertus. Ruysch also gives an ac- count of an entire spleen having passed the tendon of the oblique muscle. And I have myself seen the ovaria removed by incision, after they had been some months in the groin." (vol. 2.) The best sources of information on hernia are the following: Franco, Traite" des Hernies, &c.; Lyon, 1561; Hvo. Littre, Observation sur une Nouvelle Espece de Hernie; Mem. de I'Acad, des Sciences; 1700. Mery; same work; 1701. Littre, sur une Hernie Rare; same work; 1714. Mauchart de Hernia incarceratd; Tubing. 1722. Heister, Instil. Chirurg. et De Hernia Incarceratd Suppuratd non sem- per lethati. Vogel, abhand lung aller ar- ten der bruche,- Lips. 1738. Peyronie, Ob- servations, &C. sur la Cure des Hernies avec Gangrene; .Mem. de I'Acad, de Chir. torn- 1. Gunzius, Observationum Anato- mico-chirurgicarum de Remits libellusi Lips- 1744. Arnaud on Hernias, 1748; al- so his Mem. de Chir. Haller de Hemiis Congenitis, 1749. Garengeot, sur plusieur* Hernies singulieres; Mem. de I'Acad, de Chir. torn 2. Moreau sur les suites d'une. Hernie operie; Mem. de I'Acad, de Chir tom. 3. Benevoli, una Ernia assaiportico- lare; Firenzo, 1750. Haller, Herniarum adnotationes; extant, in opuscul. pathol. 1755. Blanc Nouvelle Methode d'opher les Hernies; avec tin essa! sur les Hernies, par M. Hoin; Orleans, 1767; 8vo Louis, Reflexions sur I'Opiration de la Hernie; Mem. de VAcad, de Chir. tom. 4. Hoin, Essai sur les Hernies rares et peu connues; 1767- Medical Observations and Inqui- ries. Pott's Works, vols. 2. and 3. Gour- saud sur la Difference des Causes de I'i- tranglement des Hernies; Mem- de I'Acad- de Chir. tom. 4. Le Dran, Traite* des Ope- rations de Chir. et Observations de Chir. obs. 57- F. Hildanus, cent. 5. obs. 54. J. L. Petit, Trait/ des Mai. Chir. torn. 2. Sharp on the Operations, and his Critical Inquiry. Bertrandi, Traiti des Opera- tions, et Excmple d'une Hernie formte du cote' droit par I'intestin ileum seule- ment, dont une portion s'Stpit ichapptepar une des echancrures ischiatiques, en se glis- sant sur les ligaments sacro-sciatiques; Mem. de Chir. tom. 2. Saltzmann, Disp. de Vesica Urinaria Hernia; 1712. Mery sur des Descentes de la Vessie; Acad, des Sciences, 1713. J. L. Petit sur les Her- nies de la Vessie; Acad, des Sciences, 1717. Verdier, Recherches sur la Hernie de la Vessie; Mem. de I'Acad, de Chir. torn,. 2 Divoux, Disp. de Hernia Vesica Urina- ria; Argent. 1732. Levret, Obs. sur la Hemic de la Vessie; Mem. de I'Acad, de Chir. tom. 2- P. Petit (le jeune) sur les Hernies de la Vessie, et de I'Estomac; Acad, de Chir. tom. 4. Voter de Lienis Prolapsione; 1746. Peyronie sur un ttran- glement de I'intestin, cause int6rieur%ment par I'adherence de I'ipiploon au-dessus de I'anneau; Mem. de I' Acad, de Chir. torn. 1 Tenon in Acad, des Sciences; 1764. Gun- zius, Obs. de Entero-epiplocele. Callisen, System. Chirurg. hodierna, pars posterior. Richter Von den Br'uchen, in 2 vols. 1778, 1779.- or the French transl. by Rougemont. Also Richter's Bibliothek, and Anfangr. der Wundarzn. Wilmer's Pract. Obs. on Hernia. Schmucker's Chir. Wahrnehmun gen. Desault's (Kuvres Chirurg. par Bi- chat, torn- 2. Hey's Pract. Observ. in Sur- gery. Sandifort's Anat. Pathol. Camper's Demonstrat. Anat. Pathol. 1760,- and his Icones Herniarum, edit, d Sonnmerring, 1801. Dr. Hunter's Med. Comment. 1762, HERNIA 41 1764. Monro in Edinb. Med. Essays; and the edition of his works by his Son. Gim- bernat's Account of a New Method of Ope rating for Femoral Hernia. A Cooper on Inguinal and Congenital Hernia; and on Crural and Umbilical Hernia. Monro on Crural Hernia, 1803. Sabatier, Medicine Op/ratpire, torn. 1. Chopart and Desault, Trait/ des Mai. Chir Desault, Parisian Surgic.il Journal. Wrisberg in Comment. Reg. Societ. Getting, 1778. Schmucker's Vermischte Chir. Schriften. Holler's Ope- ra Minora; and Disputationes Chir. But, above all, the work, which I feel infinite pleasure in recommending, from a convic- tion of its superior merit, and practical utility, is a Treatise on Hernia by W. Lawrence; 1807; 8vo. HERNIA CEREBRI, Fungus Cere- bri. This name is given to a tumour, which every now and then rises from the brain, through an ulcerated open- ing in the dura mater, and protrudes through a perforation in the cranium, made by the previous application of the trephine. Mr. Abernethy has made some observations on this disease, and related some cases. In one of these, the hernia cerebri arose on the tenth day alter trephining, and was as large as a pigeon's egg; the pia mater, covering it, was inflamed; and a turbid serum was discharged at the sides ofthe swel- ling, from beneath the dura inater. On the eleventh day, the tumour was as large as a hen's egg, smooth, and ready to burst. The man died the next day. On examination, the swelling was found larger, than before, and of a dark colour, with an irregularly granulated surface. This appearance was owing to coagulated blood, which adhered to its surface, as the part had bled so much, that the patient's cap was rendered quite stiff with blood. The pia mater was in general much inflamed, and, as «ell as the dura mater, was deficient at the place ofthe tumour. The deeper part of the swelling seemed to consist of fibrous coagulated blood, and it was found to originate about an inch below the surface ofthe brain. Mr. Abernethy explains the particu- lar appearances and progress ofthe dis- ease, as follows: " In consequence of the brain being injured to some depth beneath the surface, disease ofthe ves- sels, and consequent effusion of blood, had ensued; the effusion was, for a time, restrained by the superincumbent brain and its membranes; but, these gradually yielding to the expansive force exerted from within, and at last giving way altogether, the fluid blood oozed out and congealed upon the sur- face ofthe tumour" An organized fun- gus could hardly be produced so rapid- ly as these tumours are. (Essay on In- juries ofthe Head, p. 37) Mr. C. Bell contends, however, that such swellings are vascular and or- ganized. (Operative Surgery, vol. 1.) When the bad symptoms disappear, on the tumour being no longer confined by the dura mater, it is best to interfere as little as possible, as the hemorrhage will probably cease, and the tumour drop off in pieces. (See Edinb. Med. Comment, vol. I. p. 93 Med. Museum, vol. IV. p. 463.) The mildest dressings alone should be employed, and all pres- sure avoided. When the tumour acquires a very great size, it may be'pared off with a knife, as Mr. Hill did several times, with success. (Cases in Surgery.) Should the swelling still increase, and bad symptoms prevail, in conse- quence ofthe irritation and pressure on the brain, die opening in the bone ought to be enlarged. VVere the bleed- ing to continue in a dangerous degree, Mr. Abernethy suggests removing the coagulum, to try whether exposure of the cavity would stop the effusion of blood. Quesnay mentions an instance, in which a patient tore off the co- agulum himself, and the cavity healed up; Mem. de I'Acad, de Chir. torn. I. The danger of applying styptics, and irritating applications, is shown by Hil- danus, Obs. 14, and Mr. Hill, p. 198. (See Abernethy on Injuries of the Head.) One would suppose, that cases of this kind would generally require the em- ployment of every thing at all likely to keep off, and diminish, inflammation of the brain. HERNIA HUMORALIS. Infiam- matio Testis. Swelled Testicle. A very common symptom, attending a gonorr- hoea, is a swelling of the testicle, which is only sympathetic, and not venereal, because the same symptoms follow every kind of irritation on the urethra, whether produced by strictures, injec- tions, or bougies. Such symptoms are not similar to the actions arising from the application of venereal matter, for suppuration seldom occurs, and when it does, the matter is not venereal. The swelling and inflammation appear sud- denly, and as suddenly disappear, or go from one testicle to the other. ThVepi- Vol. II. F 42 HERPES. didymis remains swelled, however, even for a considerable time after- wards. (J. Hunter.) The first appearance of swelling is generally a soft pulpy fulness of the body ofthe testicle, which is tender to the touch; this increases to a hard swel- ling, accompanied with considerable pain. The epididymis, towards the lower end of the testicle, is generally the hardest part. The hardness and swelling, however, often pervade the whole ofthe epididymis. The spermatic cord, and especially the vas deferens.are often thickened and sore to the touch. The spermatic veins sometimes become varicose. A pain in the loins, and sense of weakness there, and, in the pelvis, are Other casual symptoms. Colicky pains; uneasiness in the stomach and bowels; flatulence; sickness; and even vomiting; are not unfrequent. The whole testicle is swelled, and not merely the epididy- mis, as has been asserted. (J. Hunter.) The inflammation of the part most probably arises from its sympathizing with the urethra. The swelling of the testicle coming on, either removes the pain in making water, and suspends the discharge, which do not return, till such swelling begins to subside; or else the irritation in the urethra, first ceas- ing, produces a swelling of the testicle, which continues till the pain and dis- charge return; thus rendering it doubt- ful, which is the cause, and which the effect. Occasionally, however, the dis- charge has become more violent, though thetesticle has swelled; and such swel- ling has even been known to occur after "the discharge has ceased; yet, the lat- ter has returned with violence, and re- mained as long as the hernia humoralis. (J. Hunter.) Irritation at the mouth of the vasa deferentia has been mentioned as a cause; but, were this true, both testi- cles would usually be affected at the same time, and the complaint would occur more frequently, when the irrita- tion ofthe urethra extends far towards the bladder, than when it only reaches about an inch and a half, or two inches, from the orifice of the passage. (J. Hunter.) Hernia humoralis, with stoppage of the discharge, is apt to be attended with strangury. A very singular thing is, that the inflammation more frequent- ly comes on when the irritation m the urethra is going off, than -when it is at its height. (J. Hunter.) The enlargements of the testicle, from cancer and scrofula, are gene- rally slow in their progress; that of a hernia humoralis very quick. (J. Hun- ter.) Rest is the best remedy, and the ho- rizontal position of the body is easiest. At all events, thetesticle must be well suspended; to which expedient the pa- tient will readily have recourse as soon as he knows the case it affords. The case is treated as inflammation in gene- ral, by bleeding and purging, and applying fomentations and poultices. Leeches have often proved serviceable. The swelling not being venereal, mer- cury is only useful in removing the in- duration, continuing after the inflam- mation has subsided. Vomits have been recommended, and found beneficial. They have even been known to cure the complaint in a surprisingly sudden manner. Opiates are useful. When sup- puration occurs, no mercmy is requi- site, only common treatment. As the hernia humoralis often ap- pears to depend on the cessation ofthe discharge, some (Bromfield) have ad- vised irritating the urethra with bou- gies to bring on the gonorrhoea again; but the practice is not followed by the expected good. The introduction of ve- nereal matter into the urethra has also been most absurdly suggested. A hernia humoralis is at first very quick in subsiding; but, some of the swelling remains a long while, and the hardness and swelling of the epididy- mis even continue for years, nay, for life. However, no inconvenience attends the mere induration. In such instances, the vas deferens may occasionally be rendered impervious, though the oc- currence must be by no means frequent. (J. Hunter.) Frictions with camphorated mercu- rial ointment; fumigations with aroma- tic herbs; and electricity; are the best means for promoting the absorption of the superfluous particles, causing the induration in question. (J. Hunter.) The signs, distinguishing a hernia humoralis from a scrotal rupture, are explained in the article Hernia. John Hunter has undoubtedly given the best account of hernia humoralis. HERPES, (from i?xa, to creep.) Se- veral cutaneous, superficial kinds of ul- cerations, having a great propensity to creep, or spread over the skin, are so named. Cullen places this disease in the class locales, and order dialyses; and defines it, phlyctenae, or a great number ol small uicers, crowding together. HOR HOR 4* creeping, and difficult to heal. For an account of one disease, usually consi- dered as a species of herpes, see Noli me tangere. Refer also to Tinea Capitis, which some have classed with herpes The tetter,ring-worm, serpigo,ordarta, consists of clusters of sharp-pointed pustules, of a yellowish white colour, with inflamed bases. The disease is attended with more or less smarting and itching, is sometimes difficult of cure, and apt to recur. When the disor- der is connected with constitutional causes, small doses of mercury are use- ful. One of the best local applications, is a solution ofthe hydrargyrus muria- tus in lime-water. Shingles, Zona aurea, or herpes zoster, is a disease, which appears in large clus- ters on the neck, breast, loins, hips, or thighs, and sometimes spreads all round the body, or limbs. The heads of the little pustules have at first a white watery appearance, and then a small round scab, resembling a millet-seed. Hence the name herpes miliaris. The complaint is often attended with febrile symptoms. The treatment should re- semble that of erysipelas; but, bark and camphor are particularly recommended as useful internal medicines. The lotion of lime-water, and muriated mercury is also said to be frequently an efficaci- ous application. Old persons are subject to a more inveterate, obstinate, and dangerous species of shingles. All the other kinds of herpes, enumerated by writers, are medical cases, as, indeed, »>ome may consider the two latter affec- tions: we shall, therefore, not enlarge on the subject in this work. HORDEOLUM, (dim. of hordeum, barley ) A little tumour on the eye-lid, resembling a barley-corn. A Stye. As Scarpa remarks, the stye is strictly on- ly a little bile, which projects from the edge of the eyelids, particularly often near the great angle of the eye. This little tumour, like the furunculus, is ot a dark red colour, much inflamed, and a great deal more painful than might be expected, considering its small size. The latter circumstance is partly ow ing to the vehemence of the inflamma- tion producing the stye, and partly to the exquisite sensibility and tension of the skin, which covers the edge of the eyelids. On this account, the hordeo- lum very often excites fever and rest- lessness in delicate, irritable constitu- tions; it suppurates slowly and imper- fectly; and, when suppurated, has no tendency to bur ,t The stye, like other furunculous in- flammations, forms an exception to the general rule, that the best mode, in which inflammatory swellings can end, is resolution. For, whenever a furuncu- lous inflammation extends so deeply as to destroy any of the cellular substance, the little tumour can never be resolved, or only imperfectly so. This event, in- deed, would rather be hurtful, since there would still remain behind a greater or smaller portion of dead cel- lular membrane; which sooner or later, might bring on a renewal ofthe stye in the same place as before, or else be- come converted into a hard indolent body, deforming the edge of the eye- lid * The resolution of the incipient hor- deolum may be effected in that stage of it, in which the inflammation only inte- rests the skin, and not the cellular sub- stance underneath, as is the case on the first appearance ofthe disease. Now re- pellent, cold applications are useful; particularly ice. But when the hordeo- lum has affected, and destroyed, any of the cellular membrane underneath, every topical repellent application is absolutely useless, and even hurtful; and the patient should have recourse to emollient anodyne remedies. The hor- deolum and eyelids should be covered with a warm soft bread and milk poul- tice, which ought to be renewed very often. When a white point makes its appearance on the apex ofthe little tu- mour, Scarpa says, the surgeon should not be in a hurry to let out the small quantity of serous matter, which exists between the skin and dead portion of cellular membrane. It is bettter, that he should wait till the skin, within this white point, has become still more ex- tenuated, so as to burst of itself, and give a ready vent, not merely to the lit- tle serous matter, but to all the dead cellular membrane, which constitutes the. chief part of the disease. When the contents of the little tumour are slow in making their way outward, through the opening, the surgeon, gently com- pressing the base ofthe stye, ought to force them out. After this, all the symptoms of the disease will disap- pear, and the cavity, left by the dead cellular membrane, in the centre of the Uttle tumour, will be found quite filled up, and healed, in the course of twen- ty-four hours. Sometimes, though seldom, this pro- cess of nature, destined to detach the dead from the living cellylar mem- 44 HYD HYD brane, only takes place incompletely, and a small fragment of yellow dead cellular substance still continues fixed in the cavity, and hinders the cure. In this circumstance, the further employ- ment of emollient poultices is of little, or no service. The surgeon should dip the point of a camel-hair pencil in sul- phuric acid, and touch the inside ofthe stv e with it, one or more times, until the sloughy cellular membrane comes away. After this, the small cavity re- maining will soon close. Should the eyelid continue afterwards a little swollen and oedematous, this affection may be removed by applying the lotio aqux litharg. acet. containing a little spirit of wine. Soojp persons are very often annoyed with this disease. Scarpa imputes this most frequently to a dis- ordered state of the prima via, often met with in persons who five on acrid irritating food, and drink too much spi- rits. (See Scarpa sulk Malattie degli Oc- chi, cap. 2.) HYDARTHRUS, (from v«ty>, wa- ter, and ccgSgov, a joint.) The white swelling. (See Articulation.) HYDRARGYRUS, (from vfug, wa- ter, and agyvgot, silver.) Quicksilver; mercury. See Mercury. , HYDROCELE, (from iSug, water, andxwXH, a tumour.) The term hydrocele, if used in a literal sense, means any tu- mour produced by water: but surgeons have always confined it to those, which possess either the membranes of the scrotum, or the coats of the testicle and its vessels. The first of these, viz. that which has its seat in the membranes of the scrotum, is common to the whole bag, and to all the cellular substance, which loosely envelopes both the testes. It is, strictly speaking, only a symptom of a disease, in which the whole habit is most frequently more or less con- cerned, and very seldom affects this part only. The latter, or those which occupy the coats immediately investing the testicle and its vessels, are abso- lutely local, very seldom affect the common membrane ofthe scrotum, ge- nerally attack one side only; and are frequently found in persons, who are perfectly free from all other com- plaints. Dr. Monro, the father, professor of anatomy at Edinburgh, and Mr. Sam- uel Sharp, were almost the only wri- ters, before Mr. Pott, who sensibly and rationally explained the true nature of these diseases. ANASARCOUS TUMOUR OF THE* SCRO- TUM. It is most frequently only a symptom of a dropsical habit, and very often ac- companies both the general anasarca, and the particular collection within the abdomen, called the ascites. This being the case, and the true method of cure consisting in an internal medical pro- cess, it has been improperly ranked among the species of hydrocele, though the nature ofthe contents will certainly admit of the use ofthe word. " It is (says Pott) an equal, soft tu- mour, possessing every part ofthe cel- lular membrane, in which both the tes- ticles are enveloped, and consequently is generally as large on one side as on the other; it leaves the skin of its natu- ral colour; or, to speak more properly,. it does not redden or inflame it; if the quantity of water be not large, nor the distension great, the skin preserves some degree of rugosity; the tumour has a doughy kind of feel; easily re- ceives, and for a while retains, the im- pression of the fingers; the raphe, or seam, ofthe scrotum divides the swel- ling nearly equally; the spermatic pro- cess is perfectly free, and of its natural size; and the testicles seem to be in the middle ofthe loaded membrane. Thisis the appearance, when the disease is in a moderate degree. But if the quantity of extravasated serum be large, or the disease farther advanced, the skin, in- stead of being wrinkled, is smooth, tense, and plainly shows the limpid state of the fluid underneath: it is cold to the touch, does not so long retain the impression of the finger, and is always accompanied with a similar distension of the skin ofthe penis; the praeputium of which is sometimes so enlarged, and so twisted, and distcjrted, as to make a very disagreeable appearance.These are the local symptoms: to which it may be added, that a yellow countenance, a loss of appetite, a deficiency of urinary se- cretion, swelled legs, a hard belly, and mucous stools, are its very frequent companions. " The cure of the original disease comes within the province of the phy- sician, and requires a course of internal medicine; but sometimes the loaded scrotum and penis are so troublesome to the patient, and in such danger of mortification, that a reduction of their size becomes absolutely necessary; and at other times a derivation, or dis- HYDROCELE. 45 charge, ofthe redundant extravasated serum from this part is ordered as an assistant to the internal regimen. " The chirurgical means in use for this end is called in general scarifica- tion; a term, whose precise sense has by no means been settled; by which it has now and then happened, that a ge- neral order being given, and the parti- cular method of executing it being left to the choice of those who have not been sufficiently acquainted with this kind of business, much hazard has been incurred, and considerable mis- chief done, which might have been avoided. " The means of making this dis- charge are two, viz. puncture and inci- sion: the former is made with the point of a lancet; the latter with the same in- strument, or with a knife. "The generality of writers on this subject have spoken on the two me- thods in such a manner, that a practiti- oner, who had seen but little of either, would be inclined to think, that it was a matter of great indifference, which we should make use of; and that the safety and utility of each were equal: which is by no means the case. " The intention of the use of either is, by a discharge of extravasated se- rum, to alleviate the present uneasi- ness; and, by reducing the size ofthe scrotum, to render it less troublesome, and less likely to mortify. In some few instances, it has indeed happened, that this drain has proved a radical cure of the original disease; but that has been accidental, and is not in general to be expected. The intention is generally palliative; and if the patient lives, is most likelv to require repetition: there- fore, if there be anydifference between the two methods, with regard either to ease or safety, there can be no doubt which ought to be preferred. " All wounds of membranous parts, in anasarcous or dropsical habits, are necessarily both painful and hazardous; they are apt to inflame, are very diffi- cultly brought to suppuration, and will often prove gangrenous in spite of all endeavours to the contrary. But the larger and deeper the wounds are, the more probable are these bad conse- quences. Simple punctures, with the point of a lancet, are much less liable to be attended by them than any other kind of wound; they generally leave the skin easy, soft, cool, uninflamed, and in a state to admit a repetition of the same operation, if necessary. Inci- sions create a painful, crude, hazardous sore, requiring constant care. Punc- tures seldom produce any uneasiness at all; and stand in need of only a superfi- cial pledget, for dressing. " Now, although there is so very material a difference in the symptoms and trouble attending the two methods, yet is there none in their effect: the communication ofthe cells of tlie dar- tos with each other is so free, through every part of it, that punctures made with the fine point of a bleeding-lancet, into the most superficial of them, will, as certainly and as freely, drain off' all the water, as a large incision, without any of its inconveniences or its hazard. Neither the one nor the other will cure the original disease, unless by mere ac- cident: they are both made, with a de- sign to cure only the local one. The same habit and constitution remaining, the same effect will in general follow, and the same relief be again necessary. The ease, the freedom from bad symp- toms, or from danger, and the state in which the parts are left, render one method practicable at all times, and ca- pable of being repeated as often as may be thought necessary: the fatigue, pain, confinement and hazard, which most frequently attend the other, make one experiment in general as much as most people chuse to submit to, or indeed have an opportunity of complying with." Mr. Pott afterwards remarks: " If we consider the preceding complaint as merely symptomatic, and do not rank it among the different kinds of hydro- cele, there will then remain only three, viz. '« 1. That which consists of a collec- tion of water in the cells of the tunica communis, or cellular membrane, en- veloping and connecting the spermatic vessels. " 2. That which is formed by the ex- travasation of a fluid, in the same coat as the former, but which, instead of being diffused through the general cel- lular structure of it, is confined to one cavity or cyst, in which all the water constituting -this species of disease is contained; the rest of the membrane being in its natural state. " 3. That which is produced by the accumulation of a quantity of water, in the cavity ofthe tunica vaginalis testis. " These three are distinct, local, and truly within the province of surgery. They may accidentally be combined or •6 HYDROCELE. connected with other disorders, but not necessarily; and are frequently found in persons whose general habit is good, and who are perfectly free from all other complaints. THE HYDROCELE OF THE CELLS OF THE TUNICA COMMUNIS. " The spermatic vessels, from their rrigin quite down to the insertion into the testicle, are enveloped in, and con- nected together by, a membrane, call- ed formerly tunica vaginalis vasorum spermaticorum, but now (more proper- ly) tunica communis. This membrane, so enveloping the spermatic vessels, has no one particular cavity, (as its old name would seem to imply;) but is merely cellular, as either the inflation of air, or the extravasation of a fluid, will always prove. While it is within the cavity of the belly, its cells are lax and large; and when it has passed out from thence, and has formed a part of the spermatic process, by enveloping its vessels, its cells are rather smaller, and the membrane composing them, firmer. It is included within that thin expansion of muscular fibres, called the cremaster. And a great number of lym- phatics, passing from the testicle to the receptaculum chyli, are always to be found in it. " An attentive consideration of these circumstances in the structure of this part will show us, (continues Pott) why either obstruction or breach in the lymphatic vessels, considerable pres- sure by means of diseased indurations within the abdomen, or a morbid state of the parts which should receive the lymph from the vessels ofthe spermatic cord, may induce the disease in ques- tion; and also, when it is produced, that its appearance, and the nature of the extravasation, must make the term cellular a very proper one, as expres- sive of its true state. " When the disease is simple, it is perfectly local; that is, it is confined entirely to the membrane forming the tunica communis; and does not at all effect, either the scrotum, the tunica vaginalis testis, or any other part." According to Pott, it does not give a great deal of trouble, unless it arrives to a considerable size; and, being by no means so frequent as either of the other two kinds of hydrocele, it is m general but little known or attended to. With some, it passes for a varix ofthe spermatic cord; with oi.iiei'9, for the descent of a portion of omentum, which, having contracted an adhesion, cannot be returned. Thus, its true na ture not being in general rightly under: stood, and it giving but little trouble or uneasiness while it is within moderate bounds, and neither hindering any ne- cessary action or faculty, they who have it are most frequently advised to be contented with a suspensory bandage, and find very little inconvenience from it. " Sometimes it arises to so large a size, and gets into such a state, as to become an object of surgery, and to re- quire our very serious attention. " In general, (says Pott) while it is of moderate size, the state of it is as follows. The scrotal bag is free from all appearance of disease; except that when the skin is not corrugated, it seems rather fuller, and hangs rather lower on that side than on the other, and if suspended lightly on the palm of the hand, feels heavier: the testicle, with its epididymis, is to be felt per- fectly distinct below this fulness, nei- ther enlarged, nor in any manner alter- ed from its natural state: the spermatic process is considerably larger than it ought to be, and feels like a varix, or like an omental hernia, according lo the different size of the tumour: it has a pyramidal kind of form, broader at the bottom than at the top-, by gentle and continued pressure it seems gradually to recede or go up, but drops down again immediately upon removing the pressure; and that as freely in a supine, as in an erect, posture: it is attended with a very small degree of pain or un- easiness; which uneasiness is not feltin the scrotum, where the tumefaction is, but in the loins. " If the extravasation be confined to what is called the spermatic process, the opening in the tendon ofthe abdo- minal muscle is not at all dilated, and the process passing through it may be very distinctly felt; but if the cellular membrane, which invests the spermatic vessels within the abdomen, be affect- ed, the tendinous aperture is enlarged; and the increased size ofthe distended membrane passing through it, produ- ces to the touch, a sensation, not very unlike that of an omental rupture. " While it is small, it is hardly an ob- ject of surgery; the pain or inconve- nience which it produces being so lit- tie, that few people would chuse to submit to an operation to get rid of it; HYDROCELE 4? and it is very seldom radically curable without one: but when it is large, or affects the membrane within the cavi- ty, as well as without, it becomes an apparent deformity, is very inconve- nient both from size and weight, and the only method of cure which it ad- mits is far from being void of hazard. The plan is to make a free incision into the swelling. (See Pott on Hydrocele.) THE ENCYSTED HYDROCELE OF THE TUNICA COMMUNIS. " This species of hydrocele (Pott re- marks) has its seat in the same part as the preceding, viz. the tunica commu- nis, or cellular membrane, which in- vests the spermatic vessels; with this difference, that, in the former, the wa- ter is diffused in general through all the cells of the membrane; whereas, in this, it is contained in one cavity on- ly. If any ofthe three kinds of hydro- cele deserves the name of encysted, it is this. The water, which constitutes it, being all contained in a bag, formed in the same manner as all the coats of all encysted tumours are, viz. by mere pressure and condensation of the com- mon membrane. " It is a complaint by no means in- frequent, especially in children. It was very well known to many of the an- cients, and has been very accurately de- scribed by Albucasis, Celsus, Paulus jfgineta, &c; but later writers have often mistaken it for, and represented it as a species of wind-rupture, or pneu- matocele; a disease existing in their imaginations only. It most frequently possesses the middle part of the pro- cess, between the testicle and groin, and is generally of an oblong figure; whence it has by some people been compared to an egg, by others to a fish's bladder. Whether it be large or small, it is generally pretty tense, and consequently the fluctuation of the water within it, not always immediate- ly or easily perceptible; for which rea- son it has been supposed to contain air only. It gives no pain, nor (unless it be very large indeed) does it hinder any necessary action. It is perfectly circum- scribed; and has no communication, ei- ther with the cavity ofthe belly above, or that of the vaginal coat ofthe testi- cle below it. The testis and its epididy- mis, are perfectly and distinctly to be felt below the tumour, and are abso- lutely independent of it. The upper part of the spermatic process in the groin is most frequently very distin- guishable. The swelling does not re- tain the impression of the fingers; and when lightly struck upon, sounds as if it contained wind only. It undergoes no alteration from change of the pa- tient's posture; nor is affected by his coughing, sneezing, &c. and has no ef- fect on the discharge per anum. " These marks (while the disease is simple and uncombined with any other) are sufficient to distinguish it by, from all others which may affect the same part; but it sometimes happens, that the present complaint is found connect- ed either with a true hernia, or with a hydrocele of the tunica vaginalis; by which the case is rendered complex, and less easy to be understood. " In this, as in every other case where, from a complication of symp- toms and appearances, a combination of diseases may be suspected, there is but one method of investigating the truth; which is, to consider carefully what disorders the part aggrieved is natural- ly liable to; what the distinct symptoms and appearances of each of those are; and what are the effects ofthe present complaint. The two diseases with which this kind of hydrocele is most likely to be combined are, a hydrocele ofthe tunica vaginalis testis, and a true hernia; the parts within the groin, the spermatic process, and the scrotum be- ing the seat of all three. " One mark, or characteristic of an hydrocele of the tunica vaginalis testi9 is, that it possesses and distends die inferior part of the scrotum; and that the testicle being nearly (though not absolutely) surrounded by the water, it very seldom happens, that the former can be clearly and plainly distinguished by the fingers of an examiner; whereas, in the encysted collection, in the mem- branes of the cord, the tumour is al- ways above the testicle, which is ob- vious and plain to be felt below it. '* Another circumstance worth at- tending to is, that although the fluid in a hydrocele of the vaginal coat does so nearly surround the testis as to render it often not very easy to be distinguish- ed, yet the different parts of the tumour have always a very different feel: for instance, in all those points where the vaginal tunic is loose, and unconnected with the tunica albuginea, the tumour is soft and compressible, and gives a clear idea of the contained fluid; but 48 HYDROCELE. when these two coats are continuous, or make one and the same membrane, and have no cavity between them (which is the case on the middle and posterior part) there will always be found a hardness and firmness very un- like to what is to be found in all those places, where the distance between the two tunics leaves room for the col- lection of a fluid: now the hydrocele of the cord being formed in the mere cellular membrane of it, is the same to the touch in all the parts ofthe tumour, and feels like a distended bladder through every point of it. " The free state ofthe upper part of the spermatic process, while the tu- mour is forming below; the gradual ac- cumulation ofthe fluid, and consequent- ly the gradual growth of the swelling; the indolent and unaltering state of it; its being incapable of reduction, or re- turn into the belly from the first; its be- ing always unaffected by the patient's coughing, or sneezing; and the unin- terrupted freedom of the faecal dis- charge per anum, will always dis- tinguish it from an intestinal hernia; and he who mistakes it for an omental one, must be very ignorant, or very heedless. " Now, although there may not al- ways be such external marks as may, to the eye, explain the combination of these diseases with each other; yet the particular seat and symptom of each being known, and the sensations which they produce to the fingers of an intel- ligent examiner being well understood, when such mixed characteristics are found in the same subject, we may rea- sonably conclude the case to be com- plex, and act accordingly. " I have indeed seen an encysted hy- drocele, situated so high toward the groin, as to render the perception of the spermatic vessels very obscure, or even impracticable; but then, the state and appearance of the testicle, and the absence of every symptom proceeding from confinement of the intestinal canal, were sufficient marks of the true nature ofthe complaint. " Infants are much more subject to this disease than adults; though it often affects the latter. " In young children, it frequently dissipates in a short time, especially if assisted by warm fomentation, and an open belly. " If it does not disperse, that is, if it be not absorbed, the point of a lancet will give discharge to the water; and, in young children, will most frequently produce a cure: but in adults, the cyst formed by the pressure of the fluid does sometimes become so thick, as to re- quire division through its whole length; which operation may in general be per- formed with great ease, and perfect safety." Mr. Pott says, in general, be- cause it is most frequently so: though he has seen even this, slight as it may seem, prove troublesome, hazardous, and fatal. (See Pott on Hydrocele.) Sir James Earle has proposed curing this case, in the same way as the hydro- cele of the tunica vaginalis, viz. by an injection of red wine and water. This gentleman has succeeded in this man- ner himself. (See Earle on Hydrocele, p. 154. edit. 2.) HYDROCELE OF THE TUNICA VAGI- NALIS TESTIS. " The third species of this disease, (as Pott describes) is that which is confined to the vaginal coat, or bag, which loosely envelopes the testicle. In a natural, healthy state, its cavity always contains a small quantity of a fine fluid, exhaled from capillary arte- ries, and constantly absorbed by vessels appointed for that purpose. " This fluid, in the natural small quantity, serves to keep the tunica al- buginea moist, and to prevent a cohe- sion between it and the vaginalis; a consequence, which almost necessarily follows any such diseased state of these parts, as prevents the due secretion of it. On the contrary, if the quantity de- posited be too large, or if the regular absorption of it be by any means pre- vented, it will be gradually accumulat- ed, and, by distending the containing bag, will form the disease in question." It is a disease from which no time of life is exempt; not only adults are sub- ject to it, but young children are fre- quently afflicted with it; and infants sometimes born with it. What is the immediately producing cause, Mr. Pott will not take upon him to affirm. Ruysch is of opinion, that it proceeds from a varicose state of the spermatic vessels. What real foundation there may be for such conjecture, Mr. Pott cannot say; certain it is, that the spermatic vessels are very frequently found varicose, in persons afflicted with this kind of hy- drocele; but whether such state of these parts ought to be regarded as a cause, HERNIA. 4-V* or as an effect of the disease, is a mat- ter worth inquiring into. " In Morgagni, are some observa- tions on the state of the parts concern- ed, particularly the inside ofthe tunica vaginalis, and outside ofthe albuginea; which, if repeated and confirmed, may possibly lead us on to farther informa- tion. " Whatever tends to increase the secretion ofthe fluid into the sacculus, beyond the due and necessary quantity, or to prevent its being taken up, and carried off, by the proper absorbent vessels, must contribute to its produc- tion; which is so slow, and gradual, and it the same time so void of pain, that the patient seldom attends to it, until it has irrived to some size. Not but that it sometimes is produced very sudden- ly; and in a very short space of time at- tains considerable magnitude. " The size and figure of the tumour (continues Pott) are various in different people, and under different circum- stances. In general, at its first begin- ning, it is rather round; but as it in- t-reases, it frequently assumes a pyri- form kind of figure, with its larger extremity downward: sometimes it is hard, and almost incompressible; so much so, that, in some few instances, it has been mistaken for an induration of the testicle.- at other times, it is so soft and lax, that both the testicle, and the fluid surrounding it, arc easily dis- coverable. It is perfectly indolent, in it- self; though its weight does sometimes produce some small degree of uneasi- ness in the back. The transparency of the tumour, the great characteristic (as it is called) of this disease, and on which almost all writers have agreed to lay the greatest stress, and to rest their proof of the nature ofthe disorder, is, according to Pott, the most fallible, and uncertain sign belonging to it: it is a circumstance which does not de- pend upon the quantity, colour, or con- sistence of the fluid constituting the disease, so much as on the uncertain thickness, or thinn ss ofthe containing bag, and of the common membranes of the scrotum. " If (adds this celebrated writer) they are thin, the fluid limpid, and the accumulation made so quick as not to give the tunica vaginalis time to thick- en much, the rays of light may some- times be seen to pass through the tu- mour: but this is accidental, and by no means to be depended upon. Whoever would be acquainted with this disorder, must learn to distinguish it by other, and those more certain marks; or he will be apt to fall into very disgraceful, as well as pernicious blinders. The colour ofthe fluid is very different and uncertain: sometimes it is of a pale yel- low, or straw colour; sometimes it is inclined to a greenish cast; sometimes it is dark, turbid, and bloody; and sometimes it is perfectly thin and lim- pid. " In the beginning of the disease, if the water be accumulated slowly, and the tunica vaginalis thin and lax, the testicle may easily be perceived; but if the said tunic be firm, or the water ac- cumulated in any considerable quantity, the testis cannot be felt at all; and other symptoms, or marks must be attended to. In most cases, the spermatic vessels may be distinctly felt at their exit from the abdominal muscle, or in the groin; which will always distinguish this com- plaint from an intestinal hernia, the disease which it is most likely to be confounded with. It does indeed now and then happen, that the vaginal coat is distended so high, and is so full, that it is extremely difficult, nay, almost impossible, to feel the spermatic pro- cess: and it also sometimes happens, that the same kind of obscurity is occa- sioned by the addition of an encysted collection of water in the membrane of the chord; or by the case being com- bined with a true enterocele. These circumstances are not very frequent, but yet do occur often enough to render it well worth while to mention them; and to signify that, when they are met with, recourse must be had to other marks. " The two coats of the testicle, the tunica vaginalis and tunica albuginea, are so inseparably united at the poste- rior and superior, or rather the poste- rior and middle part ofthe tumour, that no fluid can collect between them; and, in operating, a puncture, or incision, made here, cannot only do no service, as it cannot reach the water, but must injure the testicle, or epididymis, and do great mischief. "This natural connexion, between the two tunics, at the upper and hinder part, is the reason (says Pott) why, in a simple hydrocele, that part ofthe tu- mour feels so very unlike to every other. In that, the tunica albuginea, and vaginalis, being immediately continu- ous, no water can get between them, Vol. II. G 50 HYDROCELE. and therefore, the fingers of an intelli- gent examiner must immediately dis- cover the firmness and hardness arising from the union of these parts: in all others, the two membranes being un- connected, and affording a void space for the collection of water, the fluctua- tion of it will always be distinguisha- ble. " This must for ever discriminate the simple hydrocele of the tunica va- ginalis, from the anasarcous swelling of the scrotum; from the encysted hy- drocele of the chord; and from the in- testinal hernia. The first is every where equal, tumid and soft; and every vv here equally receives and retains the im- pression of the fingers: the second, though circumscribed, not very com- pressible, and affording the sensation of fluctuation, yet does not pit, and is alike to the touch in all parts of it: and in the third, if the testicle be distin- guishable at all, it is found at the infe- rior part ofthe whole tumour. " An indurated or scirrhous testicle (continues this author) has indeed, very frequently, a quantity of fluid lodged in its vaginal coat (hydro sarcocele;) which is a circumstance (says Pott) not to be wondered at; the diseased state of the gland being sufficient to account for the non-execution of the absorbent fa- culty, and consequently, for the collec- tion ofthe water. But although part of this mixed tumour is undoubtedly ow- ing to a fluid, and ..s such fluid is lodg- ed within the vaginal coat; yet it is a very different disease from the true sim- ple hydrocele, and ought not to be con- founded with it; one of these marks of the latter being the natural, soft, healthy state of the testicle; and the charac- teristic of the former, being its dis- eased and indurated enlargement." Mr. Pott does not mean that, in a true simple hydrocele, the testicle is never altered from its natural state. He knows the contrary, and that it is often enlarged in size, and relaxed in struc- ture, and th.it the spermatic vessels are frequently varicose. But, the testicle is never indurated. These two diseases are extremely unlike each other, and require very different treatment. That which would cure a simple hydrocele weuld dangerously aggravate the hv- dro-sarcocele. Mr. Pott observes, that " It may, and does sometimes become necessary to let out the water from the vagin..l coat of a testicle, in some degree diseased; but this should always be done with caution, and under a guarded prognos- tic; lest the patient be not only disap- pointed, by not having that permanent relief, which, for want of better infor- mation, he may be induced to expect; but be also (possibly) subjected to other unexpected inconveniences from the attempt. " When the disease is a perfect, true, simple hydrocele, the testicle, though frequently somewhat enlarged, and perhaps loosened in its va cular texture, is nevertheless sound, healthy, and capable of executing its proper of- fice; neither is the spermatic chord any way altered from a natural state, ex- cept that its vessels are generally some- what dilated; neither of which circum- stances are objections either to the pal- liative or radical cure of the disease. But in those disorders, which in some degree resemble this, the case is dif- ferent; either the testicle, or spermatic chord, or both, bearing evident marks of a diseased state. METHODS OF CURING THE HYDRO- CELE OF THE VAGINAL COAT. " The methods of cure (says Pott) though various, are reducible to two, (viz.) the palliative, or that which pre- tends only to relieve the disease in pre- sent, by discharging the fluid; and the radical, or that which aims at a perfect cure, without leaving a possibility of relapse. The end of the former is ac- complished by merely opening the con- taining bag in such manner as to let out the water: that of the latter cannot be obtained, unless the cavity of that bag be abolished, and no receptacle for a future accumulation left- One may be practised at all times of the patient's life, and in almost any state of health and habit: the other lies under some re- straints and prohibitions; arising from the circumstances of age, constitution, state ofthe parts, &e. " The operation by which the fluid is let out, is a very simple one. The on- ly circumstances requiring our atten- tion in it, are the instrument where- with we would perform it; and the place or part of the tumour, into which such instrument should be passed. " The two instruments in use, are the common bleeding-lancet, and the tiocar. " The former having the finer point, may possibly pass in rather the easier, HYDROCELE. 51 fthough tlie difference is hardly per- ceptible) but is liable to inconveniences, to which rlie latter is not. The trocar, by means of its cannula, secures the exit ofthe whole fluid without a possi- bility of prevention; the lancet cannot. And therefore it frequently happens when this instrument is used, either, that some of the water is left behind; or that some degree of handling and squeezing is required for its expulsion; or, that the introduction of a probe, or a director, or some such instrument, becomes necessary for the same pur- pose. The former of these may in some habits be productive of inflammation. the latter prolongs what would other- wise be a short operation, and multi- plies the necessary instruments; which, in every operation in surgery, is wrong. To which it may be added, that if any of the fluid be left in the vaginal coat, or insinuates itself into the cells ofthe scrotum, the patient will have reason to think the operation imperfect, and to fear that he shall not reap even the temporary advantage which he expect- ed. The place where this puncture ought to be made, is a circumstance of much more real consequence; the suc- cess ofthe attempt, the ease, and even sometimes the safety of the patient, de- pending upon it. " All the anterior and lateral parts of the vaginal coat are loose and detached from the albuginea; in its posterior and superior part, these two tunics make one; consequently, the testicle is, as it were, affixed to the posterior and supe- rior part ofthe cavity ofthe sac of an hy- drocele; and consequently, the water or fluid can never get quite round it. This being the state ofthe case, the operation ought always to be performed on that part of the tumour, where the two coats are at the greatest distance from each other, and where the fluid must therefore be accumulated in the largest quantity; and never on that part of it where the fluid cannot possibly be. Tin consequence of acting otherwise, must not only produce a disappoint- ment, by not reaching the said fluid; but may prove, and has proved, highly and even fatally mischievous to the pa- tient. " After performing this operation, present practitioners content them- selves with a bit of lint, and a plaster; and if the scrotum has been considera- bly distended, they suspend it in a bag truss; and give the patient no farther trouble " In most people, (continues Pott) the orifice thus made heals in a few hours, (like that made for blood-let- ting;) but in some habits and circum- stances, it inflames and festers: this festering is generally superficial only, and is soon quieted by any simple dress- ing; but it sometimes is so considerable, and extends so deep, as to affect the vaginal coat, and by accident produce a radical cure. Mr. Pott has also seen it prove still more troublesome, and even fatal: but then the circumstances both of the patient, and of the case, have been particular. " Wiseman and others have advised deferring the puncture, till a pint of fluid has collected. When there is a sufficient quantity, however, to keep the testicle from the instrument, there can be no reason for deferring the dis- charge; and the single point on which the argument ought to rest, is this: Whether the absorbent vessels, by which the extravasation should be pre- vented, are more likely to reassume their office, while the vaginal coat is thin, and has suffered but little violence from distension; or after it has been stretched and distended to ten or per- haps twenty times its natural capacity; and by such distension is (like all other membranes) become thick, hard, and tough? Mr. Pott thinks the probability so much more on the side of the former, that he should never hesitate a moment about letting out the water, as soon as he found, that the puncture could be made securely. And from what ha£ happened within the small circle ot his own experience, he is inclined to believe, that if it was performed more early than it generally is, it might sometimes prevent the return of the distase." The palliative cure should in general be performed at least once on those, who determine to undergo a radical one, as it gives an opportunity of ex- amining the state ofthe testis, and also of permitting the cavity to be filled again only to such a size, as may be thought to be best calculated to insure success in any future operation. (Si* James Earle on the Hydrocele, p. IS. edit. 2.) RADICAL CURE OF THE HYDROCELE. Six different operations have been practised fortius purpose; viz.the inci- sion, the excision, the application of caustic, the introduction of a tent, the employment of a seton, and injecting ,52 HYDROCELE. some stimulating fluid into the cavity ofthe tunica vaginalis. The principle, on which the success of every plan of this kind depends, is the excitement of such a degree of in- flammation in the tunica vaginalis, and tunica albuginea, forming the cavity which contains the water, as shall end in a mutual and general concretion of those membranes with each other, by which, it is evident, the receptacle for a future accumulation of fluid is com- pletely obliterated. All the above plans are not equal- lyel igible. Some of them, indeed, are now quite exploded; some, which are still practised by a few, are not more successful, though certainly more se- vere, than one, which will be presently recommended; others are very uncer- tain in their effect, as well as painful. Incision. Making an incision, so as to lay open the cavity containing the fluid, is the most ancient method, being described by Celsus Paulus jEgineta says, the in- cision is to commence at the middle of the tumour, and be carried to the up- per part of it, in a line parallel to the r-aphe. This incision is only to go through the integuments; the bag, which con- tains the water, is then to be opened, and part of the sides of the sac taken away. A director is next to be introduc- ed, and a division ofthe tunica vaginalis made to the bottom of the swelling. The cavity is afterwards to be dressed with lint, and healed by granulations. Hildanus, Dodonaeus, Wiseman, Che- selden, Heister, and Sharp, all coincide in stating the dangerous and even fatal consequences sometimes following this mode. Mr. B. Bell, who preferred this operation to every other one, acknow- ledges that he has seen it produce great pain and tension ofthe abdomen, inflammation, and fever. Pott observes, that it can never be said to be totally void of danger, and that it bears the ap- pearance of an operation of some seve- rity. This eminent surgeon abandoned the method, during the last twenty-six years of his life. Severe as it is, it has also been known to fail, as Sabatier and Earle have confirmed. Excision. Albucaeis gave the first clear account of this operation, though Celsus has certainly mentioned removing some of the sac. White and Douglas used to adopt this method. The latter advises making two incisions, so as to form an oval, from the upper to the lower part of the tumour; dissecting off" the oval piece ofthe scrotum, and then making an opening into the sac, and enlarging it with scissors. The tunica vaginalis was next to be entirely cut away, close to where it is connected with the sper- matic vessels. The cavity was after- wards filled with lint. Sir James Earle justly notices, that this plan must have been tedious, exquisitely painful in the performance, and, as subsequently treated, attended with violent and dan- gerous symptoms. Caustic. Paulus jtgineta advises destroying the skin with a cautery of a particular form, dissecting off the eschar, and then cauterizing the exposed mem- brane. Guido de Caulico is perhaps, the first who described the application of caustic for the cure of the hydrocele. Wiseman practised this method. Dio- nis advises it; but, De la Faye and Garengeot make objections to it. Mr. Else has left the best account of the manner' of using caustic. He recom- mends laying "a small caustic upon the anterior and inferior part of the scro- tum, which is intended to affect, and, if possible, penetrate through the tuni- ca vaginalis." The objections to the employment of caustic are, its causing an unnecessary destruction of parts, and producing a tedious painful sore. The action of caustic can never be so regulated as to make an opening with certainty through the tunica vaginalis, so that either its application must sometimes be repeat- ed, or else a lancet, or trocar used after all. Its success is also less sure than that of an injection; but, it is preferable to all the other methods, except this latter, and, perhaps, the seton. Tent. This is first mentioned by Franco. We shall only state, that the operation consists in making an opening into the tunica vaginalis, andkeepingthe wound open with atent of lint, linen, or sponge, so as to make the cavity suppurate, in which the water was contained. Pare, Guillemeau, Covillard, Ruysch, Heis- ter, and Marini, have all described the plan, with some variations, one of which consisted in smearing the tents with irritating substances. The famous Mon- HYDROCELE. ro devised the plan of keeping a cannu- la in the tunica vaginalis; so as to bring on a cohesion ofthe parts, without sup- puration. F..bricius ab Aquapendente, however, has made allusion to some surgeons before him, who used to keep the wound open a few days with a can- nula. Mr. Pott tried the cannula, but found it very inconvenient, as its inflex- ibility hurt the testis whenever the pa- tient moved with inattention, and, con- sequently, he preferred a tent, or bou- gie, though he speaks of the plan as a very uncertain one. Seton Is first mentioned by Guido de Cauli- co, 1363, as a means of curing the hy- drocele. In modern times, Pott pre- ferred it to every other method, if we except injection, of which, according to Sir J. Earle, he expressed his appro- bation before his decease. Mr. Pott found, that the best mode of making the seton was, as follows. He employ- ed three instruments: the first was a trocar, the cannula of which was about one-fourth of an inch broad. The se- cond w..s what he called the seton-can- nula, which was made of silver, was just small enough to pass with ease through the cannula of the trocar, and five inches long. The third instrument was a probe 6^ inches long, having at one end a fine steel trocar point, and, at the other, an eye, which carried the seton. The seton consisted of so much white sewing-silk, as would just pass easily through the cannula, and yet fill it. The thickness of 4he seton, howe- ver, was not so great in the latter part of his practice. Having pierced the in- ferior and anterior part of the tumour with the trocar, withdrawn the perfo- rator, suid discharged the water, Mr. Pott used to pass the seton-cannula through that of the trocar, to the upper part of the tunica vaginalis, so as to be felt there. The probe, armed with the seton, was next conveyed through the latter cannula, and its point pushed through the upper part of the tunica vaginalis and scrotum. The silk was then drawn through the cannula, until a sufficient quantity was brought out of the upper orifice. The two cannulae being withdrawn, the operation was finished. Injection. Div Monro attributes the first use of injections for the radical cure of hydroceles to an army-surgeon of his own name, who first used spirits of wine. This produced a cure, but, the inflammation was so violent, that he afterwards tried a milder injection, which consisted of wine. However, M. Lambert, above a century ago, in his (Euvrcs Chirurgicaks, publish- ed at Marseilles, advised injecting a solution of sublimate in lime-water, and he has related cases of success. Mr. Sliarp also made trial of spirit of wine, which cured the hydrocele, but, not without causing dangerous symp- toms, and two subsequent abscesses in the scrotum. (Operations of Surgery.) Douglas, Le Dran, and Pott, all disap- prove of injections, in their worksj though Sir James Earle informs us, that the latter lived to alter his opinion on the subject. The violence of the inflammatory- symptoms, consequent to the first em- ployment of injections for the radical cure of hydroceles, arose from the flu- ids used being too irritating-. Sir J ames Earle, at last, preferred wine for se- veral reasons. He found, that it had been used with success in France; its strength is never so great as to render it unsafe; and it may be readily weak- ened. This injection, in short, produ- ces less pain, than any other mode of cure, does nothing more than is intend- ed, and is as certain as any plan. " I have commonly used (says Sir James Earle) about two-thirds of wine to one-third of water; if the parts ap- peared insensible, and no pain at all was produced by the first quantity thrown in, I have withdrawn the syringe, and added to the proportion of wine; on the contrary, if the complaint was recent, and the parts irritable, I have increased the proportion of water, so that 1 have hitherto been principally guided by the degree of sensation, which the patient has expressed. 1 have lately used pure water mixed with wine, and found it answer as well as when astringents were added." P- 103. Treatise on the Hydrocele, Edit. 2 In the preface, the Ttuthor says, that he has long disused the pipe with a stop-cock, which he once employed, on account of not being well able to spare a hand, during the; operation, to turn it, and its consequent- ly being found awkward. A pipe, one end of w! ich is made to fit into the can- nula of a trocar, the other adapted to receive the neck of an elastic bottle. with a valve, or hall, in the centve e»t 54 HYDROCELE Lhe pipe to permit the entrance, and prevent the exit of the injection, will be found infinitely more convenient and Useful. (Earle.) "When the hydrocele is very large, Sir James recommends simply letting out the fluid, and wait- ing till the tumour acquires a -more moderate size, before attempting the radical cure by injection. It appears from Sir James Earle's in- teresting cases, that a cure may be ac- complished in this manner, even when the tunica vaginalis is considerably thickened. The following is the com- mon mode of operating: the hydrocele is to be tapped with a trocar at its ante- rior and inferior part, and, when the whole ofthe fluid is evacuated, the ca- vity ofthe tunica vaginalis is to be dis- tended to its former dimensions with the above injection. This is to be allow- ed to remain in the part about five mi- nutes, upon the average, after which it is to be discharged through the cannu- la. The patient usually feels some pain in the groin, and about the kidneys, on the injection being introduced; which .symptoms are rather desirable, as they evince, that the stimulus ofthe fluid is likely to have the wished-for effect of exciting the necessary degree of in- flammation. This plan, now brought to so high a pitch of perfection by Sir James Earle, may be deemed almost an infallible means of obtaining a perma- nent cure, and being the mildest me- thod, also, is, of course, universally pre- ferred. The treatment after the operation is exactly like that of the common swel- led testicle (see Hernia Humoralis), consisting of the use of fomentations, poultices, saline purges, and, above all, of a bag truss for keeping up the scro- tum. There is a particular case, that has been called the congenital hydrocele, by which is implied a collection of wa- ter in the tunica vaginalis, in conse- quence of there being a preternatural communication between it and the ca- vity of the peritonaeum. Desault used to cure this disease by a red-wine injec- tion. Any protruded viscera being re- turned into the belly, and the opening between that and the inside of the tu- nica vaginalis being carefully compres- sed and closed by a trusty assistant, this celebrated surgeon, after letting out Che water in the common way, used to throw in the injection. The method is said to succeed, without causing the perilous consequence, one might a pn ori expect, viz. inflammation ofthe pe- ritonaeum. (See Dtsauitpar Bichat.) This kind of hydrocele, has not been described by most writers. t he case is easy of discrimination from the fluid being capable of being pushed into the belly. The French state, that this dis- ease admits of cure by injections, first taking care to press the upper part of the chord, so as to keep the injection from coming into contact into the peri- tonaeum. A successful instance of this practice is related, by which a boy was cured both of a congenital hydrocele and hernia. The patient was nine years old, and had in his scrotum, ever since he was born, a fluctuating semi-transpa- rent tumour, which was free from pain, ofthe size of a large egg, and disap- peared, when compressed, and in a ho- rizontal posture. (See Quuvrts Chir. de Desault, tom. 2. p. 442.) The success of the vinous injection in hydroceles ofthe t mica vaginalis, in encysted ones ofthe chord, and in other cases, in which Sir James Earle has tried it, particularly in a large gangli- on, and a collection on the patella, makes it probable, that it will be found extensively useful in all cavities, where we wish to procure an adhesion, with- out destruction of parts. (Earle, p. 158, edit. 2.) One caution it is necessary to offer, before taking our leave of this subject; it has sometimes happened, during the operation, that the cannula has slipped out of the tunica vaginalis, and its inner mouth become situated in the sub- stance of the scrotum, in which event, the operator, if he persists in propelling in the injection, will fill the cellular texture of the part with a stimulating fluid, which may cause sloughing, and other unpleasant symptoms, without entering the cavity of the tunica vagi- nalis, or affording the least prospect of a radical cure of the hydrocele. When such an accident happens, it is best to defer the operation, till a sufficient quantity of fluid has collected again. Hydroceles have been cured by apply- ing to the scrotum a solution of sal am- moniac in vinegar and water. (Keate.) But the application frequently creates a good deal of pain and irritation, and does not often succeed, to say the best of it. (Earle) For information, relative to the hy- drocele, the reader is particularly re- ferred to Monro on the Tumours of the HYDROPHOBIA. 55 Scrotum, in the Edinb. Med- Essays, vol. V. Pott on the Hydrocele; Else on the Hydrocele; Keate; B. Bell; Doug/as; and Sir James Earle on the same. Memoire sur I'Hydrocele par Bertrandi, in Mem. de I' Acad de Chirurgie, tom. III. Also the same author in Trattato dellt Opera- Zioni di Chirurgia, Nizza, 1763- Re- marques, &c. sur diverses especes d'Hy- drocele, en (Euvres Chirurgicaks de De- sault, torn. II. Sharp's Treatise on the Operations, and his Critical Inquiry. Also Sabatier in Medecine Operatoire, tom. I. The mode of distinguishing a hydro- cele from a scrotal hernia, as explained by Pott, is described in the article Her- nia. HYDROPHOBIA, (from iUp, wa- ter, and foQio, to fear.) A dread of water. This being a striking symptom of that species of madness, which results from the bite of a mad dog, and some other animals affected in the same way, the disease itself has been named Hydro- phobia. It is also called rabies canina, or canine madness. Dr. James observes, that this peculiar affection properly be- longs to the canine genus, viz. dogs, foxes, and wolves, in which animals only it seems to be innate and natural, scarcely ever appearing in any others, except when communicated from these. When a dog is affected with madness, lie becomes dull, solitary, and endea- vours to hide himself, seldom barking, but making a murmuring noise, and re- fusing all kinds of meat and drink. He flies at strangers; but, in this stage, he remembers and respects his master; his head and tail hang down; he walks as if overpowered with sleep; and a bite, at this period, though dangerous, is not so apt to bring on the disease, in the animal bitten, as one inflicted at a later period. The dog, at length, be- gins to pant; he breathes quickly and heavily; his tongue hangs out; his mouth is continually open, and discharges a large quantity of froth. Sometimes he walks slowly, as if half asleep, and then runs suddenly, but, not always direct- ly forward. At last he forgets his mas- ter; his eyes have a dull, watery, red appearance; he grows thin and weak, often falls down, gets up, and attempts to fly at every thing, becoming, very soon, quite furious. The animal seldom lives in this latter state longer than thirty hours, and, it is said, that his bites towards the end of his existence are the most dangerous. The tliroat of a person suffering hydrophobia is al- ways much affected, and, it is asserted, that the nearer the bite is to this part, the more perilous. Hydrophobia may be communicated to the human subject from the bites of cats, cows, and other animals not of the canine species, to which the affection has been previously communicated. However, it is from the bites of those domestic ones, the dog and cat, that most cases of hydrophobia originate. It does not appear, that the bite of a person affected can communicate the disease to another; at least the records of medicine furnish no proof of this cir- cumstance. Dr. Heysham has defined hydropho- bia to be an aversion and horror at li- quids, exciting a painful convulsion of the pharynx, and occurring at an inde- terminate period after the canine virus has been received into the system. Dr Cullen places it in the class neuroses, and order spasmi, and defines it a loath- ing and great dread of drinking any liquids, from their creating a painful convulsion of the pharynx, occasioned most commonly by the bite of a mad animal. Others have suggested the fol- lowing definition, as more complete: melancholy, dread of cold air, of any thing shining, and particularly of water; often arising from the bite of a mad ani- mal. (London, Med. Diet.) However, the latter definition is, perhaps, equally objectionable, because there is not in- variably a dread of shining bodies. (Sea Dr. Powell's Case, p. 8.) Writers in general have divided hy- drophobia into two stages, viz. the melancholy, and the raving; the hydro- phobia simplex, and rabiosa, of Cullen. With regard to the symptoms of hy- drophobia, they are generally tardy in making their appearance, a considera- ble, but a very variable space of time usually elapsing between their com- mencement and the receipt ofthe bite The wound, if treated by common mev thods, usually heals up at first in a fa- vourable manner. At some indefinite period, and, occasionally, long after the bitten part seems quite well, a slight pain begins to be felt in it, now and then attended with itching, but gene- rally resembling a rheumatic pain. L soon extends from the wound up the arm, and affects the situation of the trapezius muscle, and the neck, on the same side as the bite. The cicatrix, in the mean while, begins to swell, in? 56 HYDROPHOBIA. flames, .and, at length, discharges an ichorus matter. There are often pains of a more flying, convulsive kind, felt in various parts ofthe body. As the dis- ease advances, the patient complains of the pain shooting, from the situation of the bite, towards the region of the heart. A lassitude, a dull pain in the head, and a vertigo, soon come on: the patient is commonbymelancholy, though not always; mutters, is forgetful, and drowsy; his mind seems disordered; his temper irritable and irregular; his slumbers disturbed, and convulsive agi- tations immediately follow his waking; a deafness is sometimes complained of; the eyes are watery; the aspect sorrow- ful; the face pale and contracted; sweat breaks out upon the temples; and an unusual discharge of* saliva is made from the mouth. From the beginning, a peculiar stricture and heaviness on the breast, occasional involuntary sigh- ing, and nausea, take place. There is often a bilious vomiting. The idea of drinking any kind of fluids creates con- siderable alarm and agitation, and the attempt to do so generally brings on most afflicting pains and convulsions, attended with a dreadful sense of suf- focation, and choaking. Even the splash- ing, or running, of any liquid causes a great deal of inconvenience. As the sys- tem becomes more and more affected, the patient loses his sleep entirely, and has frequent and violent fits of anxiety and loud screaming from slight causes. The woman, whom Dr. Powell attend- ed, was often attacked in this way, in consequence of so trivial a circumstance as a fly settling on her face. The noise of tea-cups, or the mention of any sort of drink greatly disturbed her, though she was not at all agitated by the sound of her urine. The currents of air enter- ing her room, whenever the door open- ed, became very distressing to her, and this more and more so. The pain in her neck became so great, that she could scarcely bear it to be touched; but she made use of a looking-glass without the inconvenience which hydrophobic pa- tients usually suffer from the sight of shining bodies. Dr. Powell states, that the paroxysms which this poor woman suffered, resembled those of hysteria, and increased in duration as the disor- der lasted. " She described their com- mencement to be in the stomach, with a working and fulness there, and that a pricking substance passed up into her throat and choaked her; she screamed suddenly, and grasped firmly hold of her attendants, as if voluntarily; and muscular convulsions came on, which were sometimes more, sometimes less general and v iolent." The causes from which these paroxysms arose, were extremely slight; the passage of a fly near her "face, the attempt to swallow a pill, a stream of air, the sight of oil or wine, or any other liquids, even the sound of water, and other such circum- stances, were sufficient; she now also complained of inconvenience from light, which was accordingly moderated. The effect of sounds was peculiar; for, though in the subsequent stages, their influence became more general, at this period the effect was rather proportion- ate to the ideas they excited in her mind, than to their violence. Bells, and other strong noises, did not agitate her, but the clatter of earthenware, the noise of a distant pump, or any tliinjj connected with liquids, produced the paroxysms in all their violence. She could swallow fresh currants with less resistance than any thing else, taking- care that they were perfectly dry. Her mind had, till now, been quite calm and composed, and her conversation and behaviour proper, during the intervals of the convulsive attacks. But Dr Pow- ell was obliged to discontinue the pills of argentum nitratum, in consequence of the sufferings which the attempt to swallow them regularly brought on. Fifteen grains of this substance had been given without any s: nsible effect. The fits and the irritability to external objects, increased. The pain shot from the back ofthe neck, round to the angles of the jaws, the chin, and throat. At length, the paroxysms became more frequent, and, indeed, might be said to come on spontaneously: seven occurred in one hour. She looked pale and ex- hausted, and a tremor and blueness of her lips and fingers were observable; her pulse became weaker and more rapid, and her scalp so tender, that touching it brought on convulsions. She- had, latterly, eructations of wind, and spit up some thick viscid saliva. Her urine now came away involuntarily, and she was more and more irritable and uncontrollable. She now passed two hours in almost constant convulsions; became extremely irritable and impa- tient of every thing about her, com- plained of failure of her sight; wished to be bled to death; her words were fewer and interrupted; she struck, and HYDROPHOBIA. 57 threatened to bite, her attendants; had copious eructations of air; discharged an increased quantity of viscid saliva with much convulsive effort; said the affection of her throat and stomach had quite left her; and continued in a gene- ral perspiration, with a weak pulse from 140 to 150. She afterwards bit some ofthe attendants, and was there- fore confined with a waistcoat. From this period, she had lost all control over her mind, and continued for almost four hours in a paroxysm of furious insanity. She now swallowed, with an effort, near half a pint of water; but this was, in a few seconds, vomited up, with some mucus and a greenish fluid. In this violent raving state she continued till within two hours of her death, which took place forty-seven hours after the first marked occurrence of hydrophobia. In the course of the case, she swallowed once, or twice, a little porter; and also some cinnamon-water, with tinct. opii; but they were always vomited up. On opening the body, the most remarkable appearances were, a turgid state ofthe vessels ofthe brain; great distension of the intestines with air; the oesophagus rather redder than natural, and covered with a thin layer of coagulating lymph; nearly half a pint of greenish fluid in the stomach, which was rather redder than natural, and had under its internal coat, near the cardia, a few spots of extravasated blood. (Dr. Powell's Case of Hydropho- bia.) The dread of water is said to be sometimes a symptom of some fevers, from topical inflammations of the tho- rax, or neighbouring parts. (Edinb. Med. Comment, vol. 11. p. 331.) A spe- cies of hydrophobia has been known to originate from an inflammation of the stomach. (Med- Essays, vol. 1.) Also from the bite of an epileptic patient, or of persons in violent fits of passion; and from the accession of epilepsy. An inferior degree of it is said to be observ- able in some hysteric cases, when, from the difficulty of swallowing, patients are fearful of taking liquids. In the lat- ter cases musk and opium are recom- mended. (Lon. Med. Diet.) With respect to the treatment of hy- drophobia, arising from the canine poi- son, little is necessary to be said in this work, because the subject is rather me- dical than surgical. The reader will re- gret my brevity the less, when he is in- formed, that, after hydrophobia has once begun, it has always pursued its dreadful course to a fatal termination, without any one well authenticated in- stance to the contrary, notwithstanding the trial of every medicine, and method, which the ablest practitioners have suggested. The same observation might, perhaps, be accurately extended to every internal remedy, mercurial frictions, plunging the patient for a con- siderable time under water, &c. as pre- ventives. The instances, in which a prevention has been inferred to have ta- ken place by different writers, in conse- quence of such means, may all be very rationally ascribed to other circum- stances. It is well known, that, out of the great number of persons, frequent- ly bitten by the same dog, only a few are commonly affected. The hydropho- bic poison is known to reside in the sa- liva of the animal; consequently, the chance of being affected must greatly depend upon the quantity of this fluid which may be insinuated into the wound; and, if the teeth ofthe animal should have previously pierced a thick boot, or other clothing, before enter- ing the skin,, the danger must obviously be in general much diminished. Many patients wash and suck the wound, im- mediately after its occurrence, and thus, no doubt, very often get rid ofthe poison. Even when it has lodged in the wound, it may not be directly absorbed, but be thrown oft'with the discharge. All prudent patients submit to excision ofthe bitten part. Now, under each of the above circumstances, escapes have frequently occurred, while internal me- dicines, half drowning, or salivating the patients, had also not been neglected, so that all the efficacy of preventives has too often been most unjustly ascrib- ed to means which, probably never yet had, nor ever will have, any beneficial effect whatever. What confirms the truth of the preceding statement are these facts; that persons bitten by the same animal have sometimes been treated exactly on the same plan; some of them have escaped having the dis- ease; others have had it, and, of course, perished: on other occasions, some of the patients, bitten by the same animal, have been treated in a particular way, and have escaped hydrophobia, while others bitten at the same affie by the ani- mal also, never had any constitutional ef- fects, although they took no medicines, nor followed any other particular plan. [Dr. Physick, from an opinion that death in hydrophobia often results from Vol. It H 58 HYDROPHTHALMIA. a spasmodic closure of the glottis, has recommended the operation of tracheo- tomy. Vid. " Medical Repository of New-York."] Happily, there is, in surgery, one means of preventing hydrophobia, when it is practised in time, and in a complete manner. Every reader will knowr, that the excision of the bitten parts is the operation to which I allude. Indeed, as hydrophobia is often several months before it begins, the wounded parts should, perhaps, >lways be cut out, even though they are healed, and some weeks have elapsed since the ac- cident, provided no incipient symptoms of hydrophobia have already commenc- ed. The operation should be done com- pletely; for a timorous surgeon, who should fear to cut deeply enough, or to cut a sufficient quantity ofthe surround- ing flesh away, would be a most danger- ous one for the patient. All hopes of life depend on the prevention of the dis- order; for, in the present state of medi- cal knowledge, none can rest upon the efficacy of* any plan, except the extirpa- tion ofthe part. This some have done 'with caustics. However, as their action can never be regulated with the same precision as that of the knife, and, con- sequently, they will not always destroy the flesh to a sufficient depth, excision should always be preferred. The latter method is also the safest, for another important reason, viz the part, and poi- son lodged in it, are removed from the body at once; but, when caustic is used, the slough will not be thrown off for some d;ys afterwards. Some surgeons of the present day are not content with cutting out the part; they recommend, after the operation, filling the wound with the aqua am- moniac purae, so as to produce a general sloughing of its surface, by way of greater security. I shall conclude this article with re- ferring my readers to the following works, for farther information on hy- drophobia: Sauvages sur la Rage; James on Canine Madness; Mead on the Bite of a Mad-dog; Seleg, Nugent, and Hamilton on Hydrophobia; Medical Mu- seum, vol. 2; London Medical Transac- tions, jpol. 2-^OIed. Obs. and Inq. vol. 3; Edinb. Me(fWComment. vol. 5, p. 42; Vaughan's Two Cases of Hydrophobia; Dr. Powell's Case of Hydrophobia; Lot- to's System of Surgery vol. 3; Cullen's First Lines, vol. 4; Memoirs ofthe Med. Society of London, vol. 1, p. 243; Medical Communications, vol. 1; Mem- of the Royal Society of Medicine in Paris; Sup- plement to vol. 4. Ferriar's Med. Factt and Observations. HYDROPHTHALMIA, (from vSut>, water; and opSax^or, the eye.) Dropsy of the eye. In all the cavities of the animal body (says Scarpa) which are continually moistened by a serous vapour, as well as in those destined to contain a determinate quantity of an aqueous, limpid fluid, there is such a reciprocalness of action, between the secerning extremities of the arteries, and the minute mouths ofthe absorbent vessels, that the fluid effused in these cavities is always in circulation, being incessantly renovated, but never accu- mulating beyond a certain degree and determinate measure. When this mutu- al action, existing between these two vascular systems, is interrupted, in con- sequence of a general or local indispo- sition, the above cavities, being no longer moistened by a serous vapour, shrivel and become obliterated; or, on the contrary, being unusually distended by the excessive quantity of" fluid, they acquire an enormous magnitude, much beyond what a person, unacquainted with these things, would suppose. As Scarpa continues, the eye, consi- dered simply as a cavity destined to contain a certain quantity of limpid fluid, is occasionally subject to both these infirmities. The first is termed at- rophy; the second, dropsy of the eye, or hydrophthalmia. In the first case, the globe of" the eye gradually becomes smaller; and, as the absorbent system does not cease acting, when there is no more fluid to be absorbed, it gradually consumes the solid parts of this organ, which it insensibly diminishes, and in time destroys. I:i the second case, the eye assumes a greater bulk than is na- tural to it; sometimes acquiring such an extraordinary magnitude, that it pro- jects out of the tye-lids, at first with great weakness, and afterwards with total loss of sight. Surgeons generally state, that the immediate cause of the dropsy of the eye, is sometimes an increase of the vitreous humour, sometimes of the aqueous. In every case of this kind, on which Scarpa has performed the opera- tion, and in other examinations of the different stages ofthe disease, made on tiie dead subject, he has constantly found the vitreous humour, more or less, altered in its organization, liquifi- ed, and converted into water, according as the disease was ancient, or recent. HYDROPHTHALMIA. 59 In some instances, he could not distin- guish whether the increased quantity of the vitreous or the aqueous humour had most share in the formation of the disease. Some of the most celebrated modern oculists believe, that the prin- cipal cause of this complaint is referri- ble to the closure ofthe inorganic pores ofthe cornea, through which the aque- ous humour can no longer transude, and consequently collects in the interi- or of the eye, so as to occasion dropsy. By this assertion, they evince, that they are not sufficiently acquainted with the activity of the absorbent system in the animal economy; and they do not seem to have adverted that, in conformity with their theory, the dropsy of the eye ought invariably to follow a thick- ening of the conjunctiva spread over the organ, as well as the leucoma and ex- tensive scars of the whole cornea; a thing that is contradicted by daily ob- servation and experience. Scarpa has also dissected a dropsical eye, taken from the body of a child, three years and a half old, who died of marasmus. The vitreous humour was not only wanting in this eye, and the cavity destined for its reception filled with water, but the vitreous tunic was converted into a substance, partly of a spongy, partly of a lippomatous nature. This dropsical eye was one third larger than the sound one. The sclerotica was not thinner than that ofthe other eye; but, in consequence of being yielding, flaccid, and separated from the cho- roides, it had lost its plumpness, and globular shape. The cornea formed a disk, one third larger than that of this membrane in a sound state; it did not retain its natural pulpousness, and was obviously thinner than the cornea of the healthy eye. There was a considerable quantity of an aqueous, reddish fluid, between the cornea and iris. The crys- talline lens, with its opaque capsule, had been pushed forward a little way into the anterior chamber, but could not advance further, on account of a firm adhesion, which the capsule had con- tracted with the iris, around the edge of the pupil. As soon as the capsule was opened, the lens issued from it, half dissolved, the rest exceedingly soft. It was impossible to detach the whole of the posterior layer of the capsule from a hard substance, which seemed to be the altered membrane of the vitreous humour. Scarpa, therefore, slit open the choroides, from the ciliary liga- ment to the bottom ofthe eye, when a considerable quantity of a reddish aque- ous fluid gushed out, without, howe- ver, one particle of the vitreous hu- mour. In lieu ofthe latter body, there was found a small cylinder of a sub- stance, partly of a fungous, partly of a lippomatous nature, surrounded with a good deal of water, which was effused in the longitudinal axis of the eye, from the entrance of the optic nerve, as far as the ciliary ligament, or that hard substance to which the posterior layer of the capsule firmly adhered. This lit- tle cylinder was covered, for the extent of two lines and a half forwards from the entrance of the optic nerve, by a stratum of whitish matter, reflected on itself, like the epiploon, when raised towards the fundus of the stomach. Scarpa conceived, that this stratum of whitish matter was nothing else than the relics of the unorganized retina; for, on pouring rectified spirits of wine on the whole inner surface ofthe cho- roides, and the little cylindrical body, he found no vestiges of the retina on this membrane, and that the whitish substance, which was reflected on it- self, became very firm, just as the reti- na does when immersed in spirit of wine. Both the cylinder and the indu- rated substance, occupying the place of the ciliary body, were manifestly no- thing else than the membrane of the vitreous humour, destitute of water, and converted, as was described, into a substance, partly of a spongy, partly of a lippomatous nature. It is not easy to determine whether this fungous and lippomatous degeneration ofthe vitre- ous tunic had preceded, or was a con- sequence of the dropsy of the eye. However, it may be, this fact, in con- junction with seve r al oth e r similar on es, that Scarpa has met with, in which he found no vitreous humour in the poste- rior cavity of the eye, but only water, or a bloody lymph, tends very much to confirm that this disease principally consists of a morbific secretion of the vitreous humour, and occasionally, also, of a strange degeneration of the alveo- lary membrane, by which this humour is formed. Scarpa refers to a similar case in Med. Obs. and Inq. vol. 3, Art. 14. The augmentation in the secretion of the aqueous fluid, both in the cells of the vitreous humour and out of them, after they have been ruptured from ex- cessive distension; together with a de- bilitated action of the absorbent 6yste*ir> 60 HYDROPHTHALMIA. of the eye affected, are, most probably, continues Scarpa, the causes of every species of dropsy, and, consequently, of the morbific accumulation of humours in the eye. From such a lodgment, and successive increase, of the vitreous and aqueous humours, the eye-ball at first necessarily assumes an oval shape, end- ing at the point ofthe cornea; then, as the organ enlarges in all dimensions, it acquires a larger size than that of its fellow; so that, in the end, it projects from the orbit in such a manner, that it cannot be covered by the eye-lids, and disfigures the patient's face as much as if an ox's eye were placed in the orbit, instead of" his own natural one. This disease (says Scarpa) is some- times preceded by blows on the eye, or adjoining temple; sometimes by an ob- stinate internal ophthalmy. In other in- stances, it is preceded by no other in- convenience except an uneasy sensation of tumefaction and distension in the or- bit, a difficulty of moving the eye-ball, and a considerable impairment of sight. Lastly, it is sometimes preceded by none of these causes, or no other obvi- ous one whatever, especially when the complaint occurs in children, of very tender age, from whom no information can be obtained. As soon as the eye has assumed an oval form, and the ante- rior chamber has become preternatu- rally capacious, the iris seems situated further backward than usual, and tre- mulates, in a very singular way, on the slightest motion of the eye-ball. The pupil remains dilated in every degree of light, while the crystalline is some- times brownish from the very begin- ning of the disease; and sometimes it does not become cloudy till the affec- tion has arrived at its highest pitch. The complaint then becomes stationa- ry; and, as the crystalline is not deeply opaque,the patientcan distinguish light from darkness, and, in some degree, the contour of objects, and brilliant co- lours. But, when the eye has acquired a larger volume, and the whole crystal- line has become opaque, the retina at last remains in a state of paralysis, from the excessive distension, and, conse- quently, is no longer sensible to such few rays of light as reach the bottom of the eye, by insinuating themselves at the sides ofthe lens. In the last stage ofthe disease, (con- tinues the above celebrated surgeon) when the dropsical eye projects from :bc orbit, <-o as not to admit of being covered by the eye-lids, with the incon- veniences already enumerated, others associate themselves, arising from the friction of the alia, the secretion of gum, the flux of tears, the ulceration ofthe lower eye-lid, on which the eye rests, and the excoriation ofthe eye it- self. Hence, the dropsical eye is gradu- ally attacked by violent ophthalmies, attended with intolerable pains of the the part affected, and of the whole head. The ulceration, also, does not al- ways confine itself within certain limits; but continues to spread, first depriving the cornea of its transparency, next consuming the sclerotica, and lastly, destroying progressively the other com- ponent parts ofthe eye-ball. At the first apptarance ofthe dropsy of the eye, the masters of the art re- commend the internal administration of mercurials, the extract of cicuta, and of Pulsatilla nigricans; and the exter- nal employment of astringent and cor- roborant collyria, making a seton in the nape of the neck, and compressing the eye, which forms a preternatural pro- jection out of the orbit. As far, howe- ver, as Scarpa can judge, from the events ofthe observations made by the best practitioners on this point, he has never yet met with a single well-de- tailed history of a dropsy of the eye cured by means ofthe above-mentioned internal medicines. With regard to ex- ternals, he has learnt, from his own ex- perience, that, when the disorder is manifest, astringent, and corroborant collyria, as well as compression on the protuberant eye, are highly prejudicial. In such circumstances, making a seton in the nape of the neck, frequently bathing the eye in a lotion of mallows, and applying to it a plaster composed ofthe same plant, have enabled him to calm, for a time, that disagreeable sense of distension in the orbit, and over the forehead, and temple of the same side, of which patients in this state make so much complaint, espe- cially when they are affected with a re- currence of ophthalmy. But, as soon as the eye-ball begins to protrude from the orbit, and project beyond the eye- lids, there is no means of opposing the very grievous dangers, which the drop- sy ofthe eye threatens, except an ope- ration, which consists in evacuating by an incision, the superabundant hu- mours from the eye, then exciting jren- tle inflammation ofthe membrane and suppuration on the interior of this or HYDROPHTHALMIA. 61 gau, so as to make it contract, and shrink into the bottom ofthe orbit. To defer the operation any longer, would be abandoning the patient to the con- stant inconvenience of an habitual oph- thalmy, the danger of an ulceration of the eye-ball and subjacent eye-lid, and, what is worse, of carcinoma of the whole eye, with great peril to the pa- tient. Scarpa next states, that, in order to fulfil the preceding indication, of evac- uating the superabundance of aqueous .humours lodged in the eye, the para- centesis ofthe eye-ball has been great- ly extolled in past times.—Nuck, one ofthe promoters of this operation, punc- tured the eye with a trocar, exactly in the centre of the cornea. (De Duct. Ocul. Aquas, p. 120.) It has since been thought better to puncture the eye-ball in the sclerotica, at about two lines from the junction of this membrane with the cornea, that such a simdl quan- tity of the vitreous humour may be more easily discharged at the same time with the aqueous, as may be deemed adequate to effect a diminution in the morbific enlargement ofthe eye- ball. Notwithstanding the approbation, says Scarpa, which the most celebrated surgeons have conferred on this method of operating for the dropsy of the eye, it has at present fallen into disuse, as insufficient, and ineffectual for the pur- pose. This will not appear surprising to such as are acquainted with our pre- sent knowledge of the animal econo- my, particularly in regard to the lym- phatics, and are not ignorant how little reliance can be put in paracentesis, as a means of curing chronic dropsy in general, especially that of the tunica vaginalis, termed hydrocele. Indeed, the radical cure of the latter is never accomplished, except when the adhe- sive inflammation takes place in the tu- nica vaginalis and albuginea, after the evacuation of the fluid, or when these membranes suppurate, ulcerate, or con- tract an intimate adhesion together, which remove every opportunity, every possibility of a fresh accumulation of water in the scrotum. If it has some- times happened, that the puncture has radically cured the hydrocele, it is be- cause it has, by some unexpected inci- dent, excited inflammation ofthe vagi- nalis and albuginea, so as to produce a coalescence of these two membranes. In consequence of these principles, (continues Scarpa) the paracentesis of the eye, directed wholly for the dis- charge of the superfluity of humours in this organ, can never be a means of curing the dropsy of the pail, unless the puncture, made by the trocar, ex- cite, at the same time, inflammation and suppuration, and afterwards a con- cretion of the membranes composing the eye-ball. Indeed Nuck relates, that in a young man at Breda, on whom he had operated, he was obliged to punc- ture the eye five several times; that, on the fifth time of doing this, it was ne- cessary to suck through the cannula of the trocar, in order to evacuate the greatest possible quantity of the vitre- ous humour; and, lastly, that it seemed proper to introduce a plate of lead, be- tween the eye-lids and eye-ball, for the purpose of making a continual pressure. on the eye, in its empty, shrivelled state. In a woman of the Hague, he mentions that he twice punctured the eye in vain; and that this person sub- mitted, two or three other times, to the same operation, but he omits adding with what degree of success. Scarpa has no difficulty in believing, that a ra- dical cure of the dropsy has sometimes been accomplished by means of the puncture, after the trocar, and other similar hard substances, have been repeatedly introduced into the eye, through the cannula of that instrument; but this success can never be attributed to the mere evacuation of the supera- bundance of the vitreous and aqueous humour; though it may be referred to that, conjoined with the irritation pro- duced by the cannula, and, consequent ■ ly, to tlie adhesive inflammation or sup- puration excited in the internal mem- branes of the eye. It is by no means un- likely, that, after having learnt thisi practical point from experience, and wishing to insure the success of the paracentesis in the radical cure of the dropsy of the eye, Woolhouse may have directed that, when the cannula is in- troduced in the eye, it should be rolled at least six times between the fingers; and that Platner, following the same steps, may have proposed to inject a warm fluid through the cannula into the cavity ofthe eye, after having eva- cuated the humours, by means of a tro- .car; and that Mauchart may have di- rected keeping open the wound made in the eye by the trocar, by means of a small tent of lint. If all these < ircum stances prove, on one side, thr incfli 62 HYDROPHTHALMIA. cacy of the paracentesis in the radical necessarily happen when a circular in- J - . r n. ■ __ a____ _ • „:„:«« \c mr,Ac in tlir. crlprntica. anil cure ofthe dropsy ofthe eye, they ev dently show, on the other, that the per- fect cure of this infirmity can only be achieved by evacuating the humours contained in the eye, and exciting, at the same time, a certain degree of in- flammation, and suppuration, of the in- ternal membranes ofthe organ. The most easy and expeditious way hitherto known, of obtaining all these advantages, is undoubtedly that -which is explained in the account of the radical cure of the inveterate sta- phyloma, protruding out of the eye-lids. (See Staphyloma ) With respect to this subject, Scarpa cannot refrain from re- peating, at this opportunity, that it is exceedingly disadvantageous, and even dangerous, to make the circular section of the dropsical eye-ball in the sclero- tica. In fact, this circular recision, when performed in the sclerotica, is constant- ly followed by the most aggravated symptoms, particularly, frequent he- morrhages, an accumulation of gru- mous blood at the bottom of the eye- ball, vehement inflammation ofthe eye, eye-lids, and head, obstinate vomitings, convulsions, delirium, and the most im- minent danger to the patient's life. Such modern surgeons, as have faithfully published the results of their practice on this point, among whom, Marchan* and Terras,f next to Louis,t merit in- finite praises, have ingenuously declar- ed that, after performing the circular recision of dropsical eyes in the sclero- tica, they have had the greatest motives fin- repenting of what they had done. The circular section* as broad, or rather broader than a large lentil-seed, performed at the summit or centre of the cornea ofthe dropsical eye, accord- ing to Celsus's direction relative to the staphyloma, is exempt from the serious consequential symptoms that Scarpa has just mentioned. By means of this operation, which is by no means pain- ful, an opening is made for the evacua- tion ofthe humours of the eye, and in- ternal inflammation is, at the same time, excited. These objects are accomplish- ed, also, without occasioning such a sudden subsidence, and emptiness, of the membranes of the whole eye, as cision is made in the sclerotica, and greatly affect the nerves of this organ, and the parts sympathizing with it, particularly the head and stomach. This intimate sympathy, perhaps, is not the least of the causes producing the fatal consequences above specified; besides those very serious ones, which neces- sarily result from the almost sudden ex- posure of a large surface ofthe deeper part ofthe eye to the contact ofthe air, and from the lotions which are, in these circumstances, often employed. With regard to the manual of the operation, it is exactly the same as what is detailed in the article Staphyloma. In the dropsical eye, whether the cornea be transparent or not, since the func- tion of the immediate organ of sight is irrevocably lost, as Scarpa has already stated, the surgeon must introduce a small bistoury across the apex, or mid- dle of the cornea, at one line and a half from its central point; and then, by pushing the instrument from one to- wards the other canthus ofthe eye, he will cut the lower part ofthe cornea in a semicircular manner. The segmentof the cornea being next elevated with the forceps, the operator is to turn the edge of the knife upward, and complete the work by a circular removal of as much of the centre ofthe cornea as is equal, in size, to a large lentil-seed, or three lines in diameter, supposing the patient to be in the adult state. Through this circular opening, made in the centre of the cornea, the surgeon may, by means of gentle pressure, discharge as much of the superabundant humours in the eye, as is requisite to make the eye-ball diminish, and return into the orbit, so as to be covered by the eye-lids. As for the rest of the humour lodged in the eye, it will gradually escape of itself, through the circidar opening in the cornea, without any more pressure be- ing made. Until the appearance of the inflam- mation, that is, until the third or fifth day after the operation, the dressings are to consist of the application of a pledget of dry lint, supported by a re- tentive bandage. As soon as the inflam- mation and tumefaction invade the eye * Journal de Med. de Paris. Janvier, 1770. Sur deux Exophthalmies, ou gros* seurs contre nature du Globe de 1'Oeil. | Ibidem; Mars, 1776. Sur I'Hydrophthalmie. Memoires de Chirurg. 1.13. p. 289—90, HYD HYP 63 operated on, and the eye-lids, the sur- geon is to employ such internal reme- dies as are calculated to moderate the progress of iuflummation; and he is to cover the eye-lids with a bread and milk poultice, which must be renewed at least once every two hours It is a very frequent phenomenon, both in the staphyloma and dropsy of the eye, that, on the first appearance of inflammation, the eye-ball on which the operation has been done, augments, and protrudes again from the eye-lids, in the same way as before the operation. In this cir- cumstance, it is proper to cover the projecting part of the eye-ball with a piece of fine linen, smeared with a lini- ment of oil and wax, or the yolk of an egg, and oleum hyperici; the applica- tion of the bread and milk poultice be- ing continued, as before mentioned, over this other dressing. Scarpa next states, that when suppuration of the interior of the eye manifests itself, the swelling of the eye-lids at the same time decreases, and the eye-ball dimi- nishes in size, returns gradually into the orbit, and continues to contract it- self. This state of suppuration may be known by observing, that the dressings are smeared with a viscid lymph, blended with a portion of the humours ofthe eye, which incessantly issue from the centre of the cornea; and by notic- ing the appearance ofthe margin ofthe recision, which is changed into a circle of a whitish substance, resembling the rind of bacon. In the progress of the case, this whitish circle, surrounding the place of the recision ofthe cornea, becomes detached, like a slough, so as to leave a small ulcer, of a very healthy colour. This ulcer, as well as the whole eye-ball, contracts, so as to become en- tirely closed, and cicatrized, leaving every opportunity for the placing of an artificial eye between the eve-lids and the stump ofthe eye-ball. Although, in the majority of cases, the circular recision of the centre of the cornea, equal in size to a large len- til-seed, proves sufficient to excite a mild inflammation, and suppuration, in the interior of the eye of an adult sub- ject, yet, if this occurrence does not take place on the fifth day, it is useful to expose the eye, on which the ope- ration has been done, to the air; or, as is stated in the article Staphyloma, it is useful to remove a circular portion of the cornea, half a line in breadth, or little more, by means of the forceps and curved scissars. This gives the patient neither pain nor any other inconve- nience, and produces the desired ef- fect, viz. it makes the interior of the eye, at length, inflame and suppurate mildly, without which it is impossible to effect a perfect cure. (Scarpa sulle Principali Malattie degli Occhi, cap. 18;) HY DROPS, (from itag, water.) A dropsy, or morbid accumulation of wa- ter. For hydrops articuli, refer to Articu- lation. With regard to hydrops pectoris, hydrothorax, or dropsy of the chest, as it is altogether a medical case, an account of" its symptoms and treatment will hardly be required in this Dictionary The only concern which a surgeon has with the disease, is being occasionally required to make an opening for the discharge of the water: this operation is described in Paracentesis Thoracis. HYDROSARCOCELE, (from ifag, water; cpopium (says Scarpa) I imply, with all surgeons, that accumulation of a glutinous, yellowish fluid, like pus, which takes place in the anterior chamber of the aqueous humour, and. frequently, also in the posterior one, in consequence of severe, acute oph- thalmy, particularly the internal spe- cies. I have explained, in speaking of inflammation of the eyes, that, though the severe, acute ophthalmy particular-' ly affects the external parts of the eye, in the majority of instances; yet, it oc- casionally invades, with equal violence, both the external and internal coats of this organ, especially thechoroides and uvea. In this last circumstance, if the inflammatory diathesis, affecting the interior of the eye, be not promptly cheeked and subdued, by the most ef- fectual chirurgical means, coagulating lymph is extravasated from the hig-hly inflamed choroides and uveaj and gra- dually, as it is effused into the cavity of the eye, it passes through the pupil, into the chambers of the aqueous hu- mour, and descends to the bottom of the anterior one, so as to fill sometimes one third, sometimes one half of this space; and, occasionally, to occupy it to such a heighth, as totally to conceal the iris and pupil.. This viscid matter of the hypopium is commonly called pus; but Scarpa 64 HYPOPIUM. contends tliat it is only coagulating lymph. The symptoms portending an extravasation of coagulating lymph in the eye, or an hypopium, are the same as those which occur in the highest stage of violent acute ophthalmy: viz. prodigious tumefaction of the eye-lids; the same redness and swelling of the conjunctiva, as in chemosis; burning heat and pain in the eye; pains in the eye-brow and nape of the neck; fever, restlessness, aversion to the faintest light, and a contracted state'of the pupil. As soon as the hypopium begins to form (says Scarpa) a yellowish semi- lunar streak makes its appearance at the bottom of the anterior chamber, and, regularly, as the glutinous fluid is secreted from the inflamed internal membranes of the eye, so as to pass through the pupil, and fall into the aqueous humour, it increases in all di- mensions, and gradually obscures the iris, first at its inferior part, next, where it forms the pupil, and lastly, the whole circumference of this mem- brane. As long as the inflammatory stage of the violent ophthalmy lasts, the hypopium never fails to enlarge; but, immediately this stage ceases, and the ophthalmy enters its second period, or that dependent on local weakness, the quantity of coagulating lymph, forming the hypopium, leaves off" in- creasing, and, from that moment, is dis- posed to diminish. This fact sufficiently evinces (con- tinues this eminent Professor) how important it is, in order to check the progress of the hypopium, to employ, with the utmost care, the most effectual means for checking and resolving the attack of violent ophthalmy, in its first stage. Copious evacuations of blood, both generally and topically, ought to be speedily put into practice; and when chemosis exists, the conjunctiva should be divided; mild aperients, blisters to the nape of the neck, little bags of emollient herbs, ap- plied tt> the eye, and other measures of this kind, described on the subject of the first stage of severe acute ophthal- my, ought to be employed. It will be known that they have fulfilled the indi- cation, by noticing that, some days after the adoption of such treatment, though there may still be redness of the con- junctiva and eye-lids, the lancinating pains in the eye abate, the heat consi- derably diminishes, the fever subsides, quietude and sleep are restored, the motion of the eye becomes free,,and, lastly, the collection of viscid matter forming the hypopium, becomes sta- tionary. It is not unfreqnent to see, es pecially among the lower orders of peo- ple, persons affected with the second stage of severe acute ophthalmy, bcar- ingthis collection of coagulating lymph, in the chambers of the aqueous hu- mour, with the greatest indifference, and without complaining of any of those sv mptoms which characterize the acute stage of ophthalmy. It is only at this crisis, or at the termination ofthe acute stage ofviolent inflammation ofthe eye, that the enlargement of the hypopium ceases, and the coagulating lymph be- gins to be absorbed, provided this salu- tary operation of nature be not im- peded, nor retarded, by any injudicious regimen. Scarpa states, that persons, little versed in the treatment of diseases of the eyes, would fancy that the most ex- peditious and efficacious mode of cur- ing an hypopium, after it has become stationary in the second stage of severe acute ophthalmy, would be that of opening the cornea at its most depend- ing part, in order to procure a speedy exit for the matter collected in the chambers ofthe aqueous humour; espe- cially, as this is also the common doc- trine. But experience shows, that di- viding the cornea, in such circum- stances, is seldom successfur, and most frequently gives rise to evils, worse than the hypopium itself, notwithstand- ing the modification suggested by Richter, (Obs. Chir. Fate. 1. Cap. 12.) not to evacuate the whole ofthe matter at once, nor to promote its discharge by repeated pressure, and injections, but to allow it to flow slowly out of itself. The wound made at the lower part of the cornea, for cvacuting the matter of the hypopium, how small soever the in- cision may be, most commonly repro- duces the severe acute ophthalmy, and occasions a greater effusion of coagulat- ing lymph into the chambers of the aqueous humour, than existed before. Besides, after opening the cornea, the matter of the hypopium, if allowed to escape gradually, and in drops, of its own accord, would be several days in becoming completely discharged, on account of its viscid quality. During this space of time, the glutinous lymph would keep the edges ofthe wound of the cornci dilated, and make them sup puratc. Thus the incision would be con HYPOPIUM. 65 verted into an ulcer, through which the aqueous humour, situated behind the coagidating lymph, would escape, and next even a fold ofthe iris. Opening the cornea, therefore, only converts the hy- popium into an ulcer of that membrane, attended with a prolapsus of the iris, and occasionally ofthe crystalline itself. Nor can any inference be drawn in fa- vour of making an artificial opening during the stationary state of an hypo- pium in the second stage of severe acute opthalmy, from the matter of hy- popium having sometimes made its way spontaneously through a narrow aper- ture in the cornea, with a successful re- sult. For, there is a wide difference, be- tween the effects of a spontaneous opening into a natural, or preternatural cavity of the animal body, or of one made with caustic, and the conse- quences of an opening, made with a cutting instrument. In the two first me- thods, the subsequent symptoms are constantly milder, than in the last. Be- sides, even in the instance, in which a spontaneous exit ofthe hypopium takes place through the cornea, an escape of the aqueous humour, and a prolapsus ofthe iris not unfrequently ensue; con- sequently, the spontaneous evacuation of the hypopium cannot justly form a rule for the treatment of the disease. There is only one case, in which divid- ing the cornea, in order to discharge an hypopium, is not only useful, but indis- pensable: this is, when there is such an immense quantity of coagulating lymph, extravasated in the eye, that the excessive distension, which it produces uf all the coats of this organ, occasions such vehement symptoms, as.not only threaten the entire destruction ofthe eye, but, even endanger the life ofthe patient. But, this particular case cannot serve (says Scarpa) as a model, for the treatment ofthe hypopium, usually met with in practice. Besides, if it be certain, that blood extravasated in the eye in consequence of blows, and what is still more remark- able, that even the membranous flakes ofthe capsular cataract, pushed by the needle from the posterior into the ante- rior chamber, are insensibly dissolved, and, at length, entirely absorbed, if it be the same with milky, and caseous cataracts, that have been lacerated as much as possible; and even with the crystalline lens itself, when deprived of its capsule, and depressed into the vi- treous humour by the operation; (see Cataract;) there cannot be a doubt, as Scarpa states, that absorption will take place, in the case of coagulating lymph extravasated into the chambers of the aqueous humour, as soon as the source ofthe extravasation of glutinous fluid no longer exists, and the lympha- tics ofthe eye have recovered their ori- ginal energy. Hence the resolution of the hypopi- um, by means of absorption, forms the primary indication, at which the surgeon should aim in the treatment of the complaint. We have already observ- ed, that, in order to stop its progress, the only truly efficacious method is to subdue the first shock ofthe inflamma- tion, and to shorten the acute stage of the severe ophthalmy, by the free em- ployment of the antiphlogistic treat- ment, and the use of mild, emollient, topical remedies. If this plan of treatment answer the wishes of the practitioner, (continues Scarpa) as in the majority of cases it does, the incipient collection of coagu- lating lymph, at the bottom of the ante- rior chamber of the aqueous humour, not only ceases to augment, but, also, in proportion as the severe ophthalmy dis- appears, the absorbent system takes up the heterogeneous fluid extravasated in the eye, and the white, or yellow speck, shaped like a crescent, situated at the bottom of the anterior chamber, gradually diminishes, and is at last en- tirely dispersed. Janin considered the infusion ofthe flowers of mallows, ap- plied to the eye that is inflamed and af- fected* with this disease, as a specific resolventin these circumstances (Mem. et Obs. sur l'(Eil, p. 405); but, it is now known, that every topical emollient ap- plication, provided it be conjoined with such internal antiphlogistic treatment, as is the most proper for repelling the acute stage of the severe ophthalmy, produces quite as good an effect as this infusion. Simple warm water produces the same benefit. " A young girl, " (writes the celebrated practitioner " Nannoni) was struck in the eye by an " ear of corn. An inflammation was " the conseouence, which produced a " white pus of a semilunar shape, appa- " rently behind the cornea, without any "possibility of judging, whether the " matter was actually situated between " the laminae of that membrane, or in " the anterior chamber. Hence, I was. "asked whether it might not be eva- " cuated by an incision, particularly, as Vol. II. I 66 HYPOPIUM "the patient complained of great pain " in the eye, and eye-brow. She was in " the hospital; and in the presence of " Dr. Lulli, and several students in " surgery, I said that the pain of which " the patient complained, was notocca- " sioned by the pus itself, but the cause " which produced it. This cause was " inflammation, which probably would " be increased by making a larger open- " ing for the external air, than what it •' has to the internal parts, while the " external ones remain entire. By fo- " menting the eye and forehead with " warm water, the inflammation sub- " sided, and the pus disappeared. We " have so often witnessed the fact sub- " sequently, that we can also extol the " simplicity of the treatment." Such, in short, is the happy termination of an hypopium, whenever the disease is properly treated at its commencement, and the acute stage ofthe severe oph- thalmy has been properly checked, and repelled by internal antiphlogistic means, and emollient applications to the eye. But, in consequence ofthe in- flammatory period of the severe oph- thalmy having resisted in an uncom- mon manner the best means, or because such means have been employed too late, it sometimes happens, that the co- agulating lymph, effused in the eye, and collected in the anterior chamber, is so abundant, even after the acute Stage ofthe ophthalmy, that it continues for a long time to cloud the eye, and in- tercept vision. Scarpa has often seen patients, especially paupers, who from indolence, negligence, or ill treatment, have remained, a long time after the cessation of the inflammatory stage of ophthalmy, with the anterior chamber almost entirely filled with the glutinous matter of hypopium. When the inflam - mation ceases, these unhappy persons wander about the streets almost quite indifferent, and without complaining of pain, or any other inconvenience, than the difficulty of seeing with the eye af- fected. In this second stage ofthe oph- thalmy, the resolution ofthe hypopium obviously cannot be accomplished by the same means, nor with equal celeri- ty, as in the first. At this crisis, the great quantity, and density ofthe glutin- ous matter extravasated, and the atony ofthe vascular system ofthe eye, make it necessary to give nature sufficient time, to dissipate the thick, tenacious matter ofthe hypopium, and, at length, to dispose it to be insensibly absorbed with the aqueous humour which is continually undergoing a renovation" Hence, it is right, (says Scarpa) to adopt those means, which are best cal- culated to invigorate the debilitated tone of the vascular system ofthe eye, more especially the lymphatics. This requires more or less time according as the patient is advanced in years, of a relaxed fibre, and weak; or a young man of good constitution. However, in the second stage of vi- olent acute ophthalmy, complicated with hypopium, the surgeon, according to Scarpa, should limit his efforts to the removal of every thing, which may ir- ritate the eye,or be likely to renew the inflammation; and he sliould only em- ploy such means, as are conducive to the resolution of the second inflamma- tory stage, depending on relaxation of the conjunctiva and its vessels, and such remedies as tend, at the same time, to invigorate the action ofthe ab- sorbents. Therefore, in this state, he ought first to examine carefully the de- gree of irritability in the eye affected with the hypopium, by introducing, be- tween the eye and eye-lids, a few drops of vitriolic collyrium, containing the mucilage of quince-seeds. Should the eye seem too strongly stimulated by this application, it must not be used, and little bags of warm mallows with a few grains of camphor are to be substituted for it. In the intervals, the vapours of the spir. ammon. conip. mentioned in the article Ophthalmy, may be applied, and recourse had again to a blister on the nape of the neck. When the ex- treme sensibility of the eye is overcome, the simple vitriolic collyrium must be used again, strengthening it afterwards by the addition of a few drops of cam- phorated spirit of wine. Under such treatment, proceeds Scarpa, the sur- geon may observe, that, in proportion as the chronic ophthalmy disappears, and the action of the absorbents is re- excited, the tenacious matter of the hypopium divides first into several small masses; then dissolves still fur- ther; and, afterwards, decreases in quantity; depending towards the infe- rior segment of the cornea; and, final- ly, vanishing altogetiier. But Scarpa accurately observes, that the surgeon cannot always expect to be equally suc- cessful, whether the disease occur du- ring the first, or second stage of vio- lent acute ophthalmy, if the tenacious lymph, suddenly extravasated in the interior ofthe eye, prevail in such quan- tity, as cot only to fill, but strongly dis« HYPOPIUM. 57 >end, the two chambers ofthe aqueous humour, and the cornea in particular. Notwithstanding the most skilful treat- ment, in this state ofthe complaint, the unpleasant complication is often follow- ed by another inconvenience, still worse than the hypopium itself; viz. ulcera- tion, opacity, and bursting of the cor- nea, at that point of its circumference, or centre opposite the pupil, where there is the smallest resistance to the pressure. The ulceration of the cornea ordina- rily takes place with such celerity, that the surgeon seldom has time to prevent it. As soon as an aperture has formed, the excessive abundance of coagulating lymph, contained in the eye, (some- times named empyema oculi) begins to escape through it, and a degree of re- lief is experienced. But, this meliora- tion is not of long continuance; for, scarcely is the glutinous fluid evacua- ted, that distended the whole eye, and especially the cornea, when it is follow- ed by a portion of the iris, which glides through the ulcerated aperture, pro- trudes externally, and constitutes the disease termed, prolapsus of the iris. (See Iris, Prolapsus of.) But, if in such an emergency, the cornea already ul- cerated, opaque, and greatly deranged in its organization, should not immedi- ately burst, the surgeon is then con- strained by the violence of the symp- toms, depending on the prodigious dis- tension ofthe eye-ball, to make an arti- ficial opening in this membrane, in or- der to relieve the immense constric- tion, and even the danger in which life is placed. The practitioner will do this the more readily, as, in such circum- stances, there is little hope of preserv- ing the organ of vision. Scarpa adds, that the pain in the eye, and whole head, is often so severe in this case, as to cause delirium. Were there the least chance of re- storing, in any degree, the transparen- cy of the cornea and the functions of the organs of vision, after opening the cornea, it would certainly be more pru- dent to make the opening at the lower part of this membrane, as is practised in the extraction of the cataract. But, in the case of empyema ofthe eye, now considered, in which the corneals uni- versally menaced with ulceration and opacity, and seems ready to slough, there is no hope of its resuming its (transparency at any point. The best, and most expeditious, method of re- lieving the patient from the terrible pain, which he suffers, is, according to Scarpa, to divide the centre of the cor- nea with a small bistoury to the extent of a line and a half; then to raise with a pair of forceps the little flap, and cut it away all round with one stroke ofthe scissors, so as to make in the middle of this membrane an opening of about the size of a lentil-seed. The most fluid part of the matter, distending the eye, immediately es- capes through this opening, the lips of which cannot close, like those of a sim- ple incision. Successively afterwards, the coagulating lymph, and the crys- talline lens, take the same course, and also, in a few days, the vitreous hu- mour. The surgeon should refrain from promoting the escape of the latter by strong pressure on the eye-ball; experi- ence proves, that, in such cases, it is best to allow it to flow out spontaneously. Immediately after the operation, the surgeon must cover the eye with a bread and milk poultice, which is to be renewed every two hours, not neglect- ing the use of such general remedies, as are calculated, to check the progress" of acute inflammation, and to quiet the alarm of the nervous system. In pro. portion as the interior of the eye sup- purates, the eye-ball gradually dimin- ishes, shrinks into the orbit, and at length cicatrizes, leaving things in a favourable state for the application of an artificial eye. However, Scarpa infers from the whole of what has just been said, that making an incision into the cornea is as dangerous, and useless, in the case of hypopium ordinarily met with in prac- tice, as it is necessary in the instance of empyema ofthe eye, attended with the aggravating symptoms above-mention- ed, and irremediable opacity of the cor- nea. The foregoing remarks, which are some of the best ever offered on the subject, were first published by Pro- fessor Scarpa in Saggio di Osservazioni e d'Esperienze, sulk Principali Jtalattie degli Occhi; Venezia, 1802. Another ex- cellent writer on hypopium is Richter: (see Anfangsgrunde der Wandarzney- kunst, Band. 3. 1795. Consult also Es- says on the morbid Anatomy of the Hu- man Eye.- by J. Wardrop. Chap. 6 Edinb. 1808. HYSTEROTOMIA, (from fartg* the womb, and r^vw, to cut.) See Cesarean Operation. 68 INFLAMMATION I Incision, (from inddo, to cut.) a wound made with a sharp cutting in- strument. INCONTINENCE OF URINE. An inability of the bladder to retain this fluid, which should not be discharged without the concurrence of the will. See Urine, Incontinence of. INDURATION, (from induro, to harden.) A morbid hardness of any part. INFLAMMATION, (from inflam- mo, to burn.) By the term, inflamma- tion, is generally understood, that state of a part, in which it is painful, hotter, redder, and somewhat more turgid, than it naturally is; which topical symp- toms, when present in any considera- ble degree, or when they affect very sensible parts, are attended with fever, or a general diseased action of the sys- tem. (Burns.) The susceptibility ofthe body for in- flammation is of two kinds; the one ori- ginal, constituting a part of the animal economy, and beyond the reach of hu- man investigation; the other acquired from the influence of climate, habits of Kfe, and state of the mind over the con- stitution. (Hunter.) The first kind of susceptibility, being innate, cannot be diminished by art; the second may be lessened by the mere avoidance of the particular causes, upon which it de- pends. ' Inflammation may, with great pro- priety, be divided into the healthy and unhealthy. Of the first, there can only be one kind; of the second, there must be an infinite number of species, accor- ding to the peculiarities of different constitutions, and the nature of* disea- ses, which are numberless. (Hunter.) Inflammation may also be divided into the acute and chronic. This division of the subject is one ofthe most ancient, and seems to have obtained the sanction of all the best surgical writers. Healthy inflammation is invariably quick in its progress, for which reason, it must al* ways rank as an acute species of the af- fection. However, there are numerous inflammations, controlled by a diseased principle, which are quick in their pro- gress, and are, therefore, to be consi- dered as acute. Chronic inflammation, which we shall treat of, when we come to the subject of tumours, is always ac- companied with a diseased action. PRINCIPLES OF INFLAMMATION. There is much foundation for believ- ing, that healthy inflammation is inva- riably an homogeneous process, obedi- ent to ordained principles, and, in simi- lar constitutions,* similar structures, and similar situations, uniformly assu- ming the same features. If experience reveals to us, that here it is commonly productive of certain effects, and there it ordinarily produces different ones, the same unbounded source of wisdom communicates to the mind a know- ledge, that there is some difference in, the tone of the constitution, or in the structure or situation of the parts af- fected, assignable as the cause of this variety. The nature of the exciting cause can have no share in modifying the appearances of phlegmonous inflam- mation, whether this be occasioned by the application of heat, or of mechanic- al violence to the body. Healthy inflam- mation is always the same in its nature, and all the influence, which the excit- ing causes can have, is proportioning the degree of inflammation to their own violence. A modern author (Dr. Smith, in Med. Communications, vol. II.) makes the nature ofthe exciting cause one principal ground of the specific dis- tinctions in inflammation, and, with good reason, when he takes into the account the action of morbid poisons, and the qualities of disease in general. The attentive observation of expe- rience, the only solid basis of all medi- * Here strength and weakness are alluded to; for, it is impossible that health v inflammation should prevail in a diseased constitution. INFLAMMATION. 69 cal, as well as other, knowledge, has informed the practitioner, that parts, which from their vicinity to the source of the circulation, enjoy a vigorous cir- culation of blood through them, under- go inflammation more favourably, and resist disease better, than other parts, of similar structure, more remote from the heart. The lower extremities are more prone to inflammation, and dis- ease in general, than parts about the chest; when inflamed, they are longer in getting well; and the circumstance of their being depending parts, which retards the return of blood through the veins, must also increase the back- wardness of such parts in any salutary process. (Hunter.) Healthy inflamma- tion is of a pale red; when less healthy, it is of a darker colour; but, the inflam- ed parts will, in every constitution, partake more of the healthy red, the nearer they are to the source ofthe cir- culation. (Hunter:) Inflammation, when situated in high- ly organized and very vascular parts, is more disposed to take a prosperous course, and is more governable by art, than in parts of an opposite texture. The nearer also such vascular parts are to the heart, the greater will be their tendency to do well in inflammation. (Hunter) Hence, inflammation ofthe skin, cellular substance, muscles, &c. more frequently ends favourably, than the same affection of bones, tendons, fasciae, ligaments, &c. It is also more manageable by surgery; for those parts of the body, which are not what ana- tomists term vascular, seem to enjoy only inferior powers of life, and, con- sequently, when excited in a preter- natural degree frequently mortify. But, inflammation of vital parts, though these may be exceedingly vas- cular, cannot go on so favourably, as in other parts of resembling structure, but, of different functions; because, the natural operations of universal healtli depend so much upon the sound condition of such organs. (Hunter.) The truth of this observation is illustrated in cases of gastritis, peripneumony, &c. All new formed parts, not originally entering into the fabric of the body, such as tumours, both of the encysted and sarcomatous kinds, excrescences, 8cc. cannot endure the disturbance of inflammation long, nor in a great de- gree. The vital powers of such parts arc weak, and when irritated by the presence of inflammation, these adven- titious substances are sometimes re- moved by the lymphatics, but more commonly slough. This remark applies also to substances generated as substi- tutes for the original matter of the body; for instance, granulations and callus. The knowledge of this fact leads us to a rational principle of cure in the treat- ment of several surgical diseases. De we not here perceive the cause, why very large wens are occasionally dis- persed by the application of urine, brine, and similar things, which are now in great repute, on this account, with almost every one out of the pro- fession? How many verrucae, wrongly suspected to originate from a syphili- tic cause, are diminished and cured by a course of mercury! It is the stimulus of this mineral upon the whole system, that accomplishes the destruction of these adventitious substances—not its antivenereal quality. Topical stimulants would fulfil the same object, not only with greater expedition, but with n» injury to the general health. In strong constitutions, inflammation, cateris paribus, always proceeds more propitiously, than in weak ones; for, when there is much strength, there is little irritability. In weak constitutions, the operations of inflammation are back- ward, notwithstanding the part, in which it is seated, may, comparatively speaking, possess considerable organi- zation, and powers of life. (Hunter.) Healthy inflammation, wherever si- tuated, is always most violent on that side ofthe point of inflammation, which is next to the external surface of the body. When inflammation attacks the socket of a tooth, it does not take place on the inside of the alveolary process, but towards the cheek. When inflam- mation attacks the cellular substance, surrounding the rectum, near the anus, the affection usually extends itself to the skin ofthe buttock, leaving the in- testine perfectly sound, though in con- tact with the inflamed part. (Hunter.) We may observe the influence of this law in the fistula lachrymalis, in dis- eases ofthe frontal sinuses, and antrum, and, particularly, in gun-shot wounds. Suppose a ball were to pass into the thigh, to within an inch ofthe opposite side of the limb, we should not find, that inflammation would be excited along the track of the ball, but, on the side next the skin which had not been hurt. If a ball should pass quite through a lin>h.. and carry into the wound a piec: to INFLAMMATION. of cloth, which lodges in the middle, equidistant from the two orifices, the skin, immediately over the extraneous body, would inflame, if the passage of the ball were superficial. (Hunter.) Mr. Hunter compared this law with the principle, by which vegetables approach the surface of the earth; but, the solu- tion of it was even too arduous for his strong genius and penetration. We see three very remarkable ef- fects follow the prevalence of inflam- mation; viz. adhesions of parts of the body to each other; the formation of pus, or suppuration; and ulceration, a process, in which the lymphatics are more concerned, than the blood vessels. Hence, Mr. Hunter termed the differ- ent stages of inflammation, the adhesive, tile suppurative, and the ulcerative. All parts of the body are not equally liable to each of the preceding conse- quences. (Hunter.) In the cellular membrane, and in the circumscribed cavities, the adhesive stage takes place more readily, than the others; suppuration may be said to follow next in order of frequency", and lastly ulceration. In internal canals, on the inner sur- faces of the eye-lids, nose, mouth, and trachea, in the air-cells ofthe lungs, in the oesophagus, stomach, intestines, pelvis ofthe kidneys, ureters, bladder, urethra, and in all the ducts and out- lets of the organs of secretion, being what are termed mucous membranes, the suppurative inflammation comes on more readily, than either the adhesive, or the ulcerative, stage. Adhesions, which originate from the slightest de- gree of inflammation in other situations and structures, can only be produced by a violent kind in the above mention- ed parts. Ulceration is more frequently met with upon mucous surfaces, than adhesions. (Hunter.) The cellular mem- brane appears to be much more suscep- tible ofthe adhesive inflammation, than the adipose, and much more readily passes into the suppurative. (Hunter.) Thus we see the cellular substance, connecting the muscles together, and the adipose membrane to the muscles, inflaming, suppurating, and the matter separating the muscles from their late- ral connexions, and even the fat from the muscles, while the latter substance and the skin are only highly inflamed. (Hunter) But, it must be allowed, that in situations where fat abounds, we very frequently meet *ith abscesses This is so much the case,that fat has been ac- counted a more frequent nidus for col- lections of matter, than the cellular substance. (Bromfleld.) Abscesses are particularly liable to form in the neigh- bourhood of the anus, mamma, &c. We have mentioned above the fat's be- ing highly inflamed; an expression not strictly true. Fat has 116 vessels, princi- ple of life, nor action of its own; conse- quently, we cannot suppose it can itself either inflame, or suppurate. We know, that it is itself a secretion, and, when an abscess forms in it, we understand, that the mode of action in the vessels, naturally destined to deposit fat, has been altered to that adapted to the formation of pus. When we speak of the fat being inflamed, we imply, that the membranous cells, in which it is contained, and by which it is secreted, are thus affected. The deeply situated parts of the body, more especially the vital ones, very readily admit of the adhesive stage of inflammation. The circumstance of deeply seated parts not so readily tak- ing on the suppurative stage of inflam- mation, as the superficial ones do, is strikingly illustrated in cases of extra- neous bodies, which, if deeply lodged, only produce the adhesive inflamma- tion. By this process a cyst is formed, in which they lie without much incon- venience, and they may even gradually change their situation, without disturb- ing the parts, through which they pass But, no sooner do these same bodies approach the skin, than abscesses im- mediately arise. (Hunter.) All inflammations, attended with dis- ease, partake of some specific quality, from which simple inflammation is en- tirely free. When the constitution al- lows the true adhesive and suppurative stages to occur, it is to be regarded as the most healthy. Were it in an oppo- site state, we should see the very same irritation excite some other kind of in- flammation, such as the erysipelatous, scrofulous, &.c. (Hunter.) In specific inflammations, the posi- tion, structure, and distance ofthe part affected from the source ofthe circula- tion, as w ell as from the surface of the body, seem also to have as much influ- ence as in cases of common inflamma- tion. Upon this point, I feel conscious of being a little at variance with what Mr. Hunter has stated; but, the unde- cided manner in which he expresses himself, not less than the following re- INFLAMMATION 71 flections, encourages me not to desert my own ideas. We see, that venereal eruptions sooner make their appearance upon the chest and face, thsn upon the .vtivmities. No organized part can be deemed exempt from the attack of common inflammation; many appear to be totally insusceptible of the venereal. We know, that scrofulous diseases of the superior extremities take a more favourable course, require amputation less frequently, and get well oftener, than when situated in the inferior ones. (Ford.) The venereal disease makes more rapid advances in the skin and throat, than in the bones and tendons; we often see it producing a specific in- flammation, and an enlargement of the superficial parts of the tibia, ulna, cla, vicle, cranium, &c. while other bones, which are covered with a considerable quantity of flesh, are very rarely affect- ed. Gouty inflammation is prone to in- vade the small joints; the rheumatic the large ones. SYMPTOMS AND NATURE OF HEAL- THY INFLAMMATION, OR PHLEG- MON. Redness, swelling, heat, and pain, the four principal symptoms of phleg- monous inflammation, have been accu- rately noticed by Celsus.' If we refer to any writer on this interesting part of surgery, we shall find the above symp- toms enumerated as characterizing phlegmon. In short, this term is usually applied to a circumscribed tumour, at- tended with heat, redness, tension, and a throbbing pain. These are the first appearances observed in every case of phlegmon; and when they are slight, and the part affected is of no great ex- tent, they have commonly very little, and sometimes no apparent, influence on the general system. But, when they are more considerable, and the inflam- mation becomes extensive, a full, quick, and generally a hard pulse, takes place, and the patient, at the same time, com- plains of universal heat, thirst, and other symptoms of fever. (B. Bell.) While the inflamed part becomes red, painful, and swelled, its functions are also impaired. The same degree of in- flammation is said to produce more swelling in soft parts, and less in harder ones. (Burns.) Though the redness, swelling, throb- bing, tension, and other symptoms of phlegmonous inflammation, are less manifest, when the affection is deeply situated, yet they certainly exist. When persons die of peripneumony, or inflam- mation of the lungs, the air-cells of these organs are found crowded with a larger number of turgid blood-vessels, than in the healthy state, and of course the parts must appear preternaturally red. Coagulating lymph, and even blood, are extravasated in the sub- stance of these viscera, which become heavier, and feel more solid. (Baillie.) The extravasation of coagulating lymph, which is one ofthe chief causes ofthe swelling, is also one ofthe most characteristic signs of phlegmonous in- flammation. Some writers (Smith, Med. Com- mun.) have confined the seat of phleg- mon to the cellular membrane; but, this idea is probably an erroneous one. Had such authors duly discriminated the na- ture of common inflammation, they would have allowed, that this affection existed, wherever the blood-vessels ap- peared to be more numerous, and en- larged, than in the natural state, accom- panied with an effusion of coagulating lymph, whether upon the surface of a membrane, or a bone, or into the inter- stices of the cellular substance, and at- tended with acute pain, andathrobbing pulsation in the part affected. Before proceeding further into the consideration of inflammation, it seems proper to treat of causes. REMOTE CAUSES. The remote causes of inflammation are infinite in number; but, very easy of comprehension, because only divisible into two general classes. The first in- cludes all such agents as operate by their stimulant, or chemical qualities"; for instance, cantharides, heat, &c. The second class of causes are those wliich act mechanically, such as bruises, wounds, &c. After this statement, it seems quite unnecessary to give a de- tail of each particular remote cause.f ,-. * oNot!E Verd innammationis sunt quatuor; rubor, et tumor, cum calore et dolore lib. 3. cap. 10. ^t Those who are curious, may see a list of remote causes in Pearson's Prinei- r2 INFLAMMATION. Fevers often seem to become the re- mote causes of local inflammation. In other instances, inflammation appears to arise spontaneously, or, as I should rather say, without any perceptible ex- citing cause. The principle on which the applica- tion of cold to a part becomes the re- mote cause of inflammation, is not de- cidedly known. A modern author offers the following explanation, in lieu of those founded on the doctrines of cold being a stimulus and a sedative: Cold may operate on a part in three differ- ent ways. First, it may be applied in such a degree, and for such a length of time, as to destroy the vitality of the part directly; in which case, sloughs are formed. Secondly, it may be applied in a less degree, or for a shorter time; and afterwards a stimulant, such as heat, may be applied, which will excite inflammation. The production of inflam- mation, by any agent, depends in a great degree upon the suddenness of the ope- ration of the agent, which excites it; for, a quantity of stimulus, which, if suddenly applied, would produce in- flammation, maybe applied slowly with impunity. Hence, it results, thatany giv- en stimulant must more easily produce inflammation in apart, which has a low action, &c. than in one having a vigo- rous action, &c. Hence, very slight sti- muli will induce inflammation in parts, which have been weakened by cold. Thirdly, a part sympathizes very much with the contiguous ones. Ifapartbe weakened by having its action reduced, and if then the debilitating cause be re- moved, the action of the part will be increased from sympathy with the neighbouring acting parts. But, as the action ought to be very little, the power being small, inflammation must arise from the action being increased beyond the power. We ought, therefore, in this case, to diminish the action of the neighbouring parts, in order to prevent their extending their action to a part, which is not able to bear it without be- coming diseased. (Burns.) PROXIMATE CAUSE. Numerous opinions have been enter- lained upon this subject; but, almost every theory has been built upon the supposition of there being some kind of obstruction in the inflamed part. While the circulation of the blood was unknown, and the hypothetical no- tions of the power ofthe fiver, in prepar- ing and sending forth, this fluid, con- tinued to prevail, it is not astonishing, that the theories of physic should be exceedingly imperfect. So fully per. suaded were physicians of the exist- ence and influence of different humouri and spirits, and so little did they know of the regidar and constant motion of the blood, that they believed in the possibility of depositions and conges- tions of the blood, the bile, or lymph; and acknowledged these as the cause of inflammation. Their anatomists taught them, and their professors of physic supported the opinion, that the fiver was the centre ofthe vascular sys- tem, from which the blood went forth by day to the extremities, and return- ed again by night. If then any peccant matter irritated the liver, the blood was sent out more forcibly; and if, at the same time, any part of the bodv were weakened, or otherwise disposed to re- ceive a greater quantity of fluid than the rest, then a swelling was produced by the flow of humours to this place. Fluxions, or flows of humour to a place, might happen either from weak- ness ofthe part which allowed the hu. mours to enter more abundantly, or from the place attracting the humours, in consequence of the application of heat or other agents. (Burns.) The peculiar nature of the swelling thus occasioned was supposed, by the ancients, to depend upon the kind of hu- mour Blood produced the true phleg- mon, bile, erysipelas, &.c. The ancient physicians also enter- tained an idea, that the blood and hu- mours might slowly stagnate in a part, from a want of expulsive power, and this affection was termed a congestion, while the exoressionfluxion or defluxion was used to denote any swelling arising from the sudden flow of humours from a distant part. The first was formed gradually without much pain, or the feeling of pulsation, and run its course slowly; the second appeared suddenly, was very painful, had a pulsatory feel, and was rapid in its progress. The an- cients, who supposed that the blood had very little motion, and that its course could be easily directed or changed, recommended bleeding from some part which was remote from a recent in- flammation, by which they imagined that the current of blood was altered, and a revulsion made. A revulsion was also made by raising a tumour in some other part, by means of ligatures, cup- ping-glasses, &c. or by giving nature an opportunity of discharging the humours INFLAMMATION 73 from distant parts, by applying leeches or blisters. Hence sinapisms were ap- plied to the feet, in disease of the su- perior parts. (Burns.) When blood was drawn from the vi- cinity ofthe fluxion, or congestion, the mode was called derivation, which only differed from revulsion in the distance to which the humour was drawn being less. (Burns.) I shall not enter further into an ac- count ofthe practice ofthe ancients in the treatment of inflammation; but shall refer the reader to what Mr. Burns has written on the subject. Our present ob- ject is only to trace the leading doc- trines, which have at different times prevailed, respecting the proximate cause of inflammation. From the theories of fluxion and con- gestion, which were quite incompatible with the laws ofthe circulation ofthe blood, we turn our attention to the doc- trine of obstruction. Boerrhave inculcated, (Aph. 375 et seq.) that inflammation was caused by an obstruction to the free circulation of the blood in the minute vessels, and this obstruction, he supposed, might be caused by heat, diarrhoea, too copious flow of urine, and sweat, or whatever could dissipate the thinner parts of the blood and produce a hickness or visci- dity of that fluid. When the lentor did not exist before the production of in- flammation, he imagined, that the larg- er globules ofthe blood, got into the small vessels, and thus plugged them up. When, for instance, the perspira- tion was stopped, the fluid being re- tained, dilated the vessels, and allowed some of these mischievous globules to enter, and produce a more permanent obstruction. This circumstance was termed an error loci, and was one ofthe chief causes assigned for inflammation. The obstruction, whether caused by viscidity or an error loci, was imagined to occasion a resistance to the circula- tion in the part affected; hence increased it in the other vessels, proving an irri- tation to the heart, and augmenting the force or attraction ofthe blood in that part of the vessel which was behind the obstruction. This caused heat and pain, while the accumulation of the blood produced redness; which three symptoms are the essence of the dis- ease. Besides obstruction, Boerrhave al- so brought into the account an acrimo- nious state of the fluids, which rendered resolution out ofthe question, and gan- grene likely to follow. (Aph. 388.) The viscidity ofthe blood cannot be admitted as the proxim-ite cause of in- flammation; because we have no proof, that this state ever exists; or, granting that it did, it would not explain the phenomena. Were a viscidity to occur, it would exist in the whole mass of blood, would affect every part of the body alike, and could not be supposed to produce only a local disorder. How also could such a lentor be produced by causes which bring on inflammation suddenly, without there being time for changes of the fluids to take place? (Burns.) With regard to the doctrine of error loci, or of red globules going into'ves- sels, which did not formerly transmit them, the fact must be admitted, at the same time, that the conclusion is deni- ed. When the eye becomes inflamed, the tunica conjunctiva is seen with its vessels full of red blood, which in health is not the case; but this redness never appears until the inflammation has commenced, and must, therefore, be considered as an effect, not a cause. Nor can this error loci occasion any ob- struction in these vessels; for, if they be divided, the blood flows freely, which shows, that they are large. enough to allow an easy circulation. (Burns.) Boerrhave's theory of obstruction was too circumscribed, and too mechanical; it reduced all inflammations to one spe- cies. The only distinctions which could have arisen, must have proceeded from the nature of the obstruction itself. This doctrine could never account for the action of many specific diseases and morbid poisons. (Hunter.) As for the supposition ofthe co-ope- ration of an acrimony of the fluids, the proportion of the saline matter of the blood has never been proved to be greater in this, than in any other state ofthe body. (Burns.) Even were a ge- neral disorder of this kind to be admit- ted, no rational explanation ofthe prox- imate cause of local inflammation could be deduced from it. Dr. Cullen attributed the proximate cause of inflammation to a " spasm of the extreme arteries supporting an in- creased action in the course of them." This theory only differs from that of Boerrhave in the cause which is assign- ed for the obstruction. Some causes of inequality in the distribution of the blood, may throw an unusual quantity of it upon particular vessels, to which Vol. II K 74 INFLAMMATION. it must necessarily prove a stimulus. But, farther, it is probable that, to re- lieve the congestion, the vis medica- trix naturae increases still more the ac- tion ofthe vessels; and which, as in all other febrile diseases, it affects, by the formation of a spasm on their extreme- ties." " A spasm of the extreme arte- ries, supporting an increased action in the course of them, may, therefore, be considered as the proximate cause of inflammation; at least, in all cases not arising from direct stimuli applied; and, even in this case, the stimuli may be supposed to produce a spasm ofthe extreme vessels." (Cullen.) The inconsistencies in Cullen's the- ory are very glaring. The congestion or accumulation of blood, which is only an effect or consequence of inflamma- tion, is set down as the cause of the spasm ofthe vessels, to which spasmo- dic constrictions, Cullen, strangely enough, assigns the name of proximate cause. The spasmodic contraction of the extremities of the vessels, instead of propelling the accumulated quantity of blood, would render the passage of the blood from the arterial into the ve- nous system still more difficult. Spas- modic constriction ofthe small vessels is so far from being a satisfactory ex- planation of the proximate cause of in- flammation, that even tying a large vessel does not of itself bring on the af- fection. Phlegmon is also attended with an effusion into the cellular substance from the extremities of the arteries; a circumstance not easily explained upon the principle of obstructed circulation. (Burns.) We shall now notice the celebrated, and very original, opinions, promulga- ted on this subject by the famous John Hunter. Accordingto him inflammation is to be considered only as a disturbed State of parts, which requires a new, but salutary, mode of action, to restore them to that state, wherein a natural mode of action alone is necessary. From such a view of the subject, therefore, inflammation, in itself, is not to be con- sidered as a disease, but as a salutary operation, consequent either to some violence, or some disease. Elsewhere, the author remarks, the act of inflam- mation is to be considered as an increas- ed action ofthe vessels, which, at first, consists simply in an increase or dis- tension beyond their natural size. This increase seems to depend upon a dimi- nution of the muscular power of the vessels, at the same time that the elas- tic power of the artery must be dilated in the same proportion. This is, there- fore, something more than simply a common relaxation; we must suppose it an action in the parts to produce an increase of size, to answer particular purposes, and this Mr. Hunter would call an act of dilatation. The whole is to be considered as a necessary ope- ration of nature. Owing to this dilata- tion, there is a greater quantity of blood circulating in the part, which is accor- ding to the common rules ofthe animal economy; for, whenever a part has more to do than simply to support it- self, the blood is there collected in larger quantity. The swelling is pro- duced by an extravasation of coagulable lymph, with some serum; but, this lymph differs from the common lymph in consequence of p. ssing through in- flamed vessels. It is this lymph which becomes the uniting medium of inflam- ed parts; vessels shoot into it; and it has even the power of becoming vascu- lar itself. The pain proceeds from spasm. The redness is produced either by the arteries being more dilated than the veins, or because the blood is not changed in the veins. When a part cannot be restored to health, after inju- ry, by inflammation alone, or by adhe- sion, then suppuration, as a preparatory step to the formation of granulations, and the consequent restoration of the part takes place. The vessels are near- ly in the same state as in inflammation; but they are more quiescent, and have acquired a new mode of action. An increased action of the vessels is now almost universally regarded as the proximate cause of inflammation. This opinion is greatly supported from a re- view of the several exciting causes of the affection, which, being in general of an irritating nature, must, when ap- plied to any livingor sensible pails, oc- casion a preternatural exertion of the vessels. The method of cure, as we shall presently see, tends also to con- firm the general doctrine with respect to the cause of inflammation. SYMPTOMS OF PHLEGMONOUS IN- FLAMMATION FURTHER CONSI- DERED. The essential symptoms are redness, swelling, heat, and pain. Redness.—This is manifestly owing to the increased quantity of blood in the INFLAMMATION. 7$ mflamed part. More blood must neces- sarily be contained there, because the vessels, which previously conveyed this fluid, are preternaturally distended, and the small vessels, which naturally contained only lymph, are now so en- larged as to be capable of receiving red blood. Many have supposed, that the redness of common inflammation is partly occasioned by the generation of new vessels. This doctrine, however, seems very questionable. When coagu- lating lymph is extravasated upon the surface of a wound, an inflamed mem- brane, &c. I think no one can doubt, that the lymph often becomes vascular, mother words, furnished with new ves- sels. But, in the extravasated lymph of a phlegmonous tumour, we have no evi- dence showing, that there is any genera- tion of new vessels. Were the lymph to be rendered organized and vascular, the swelling and redness would probably be more permanent, and not admit, at least so easily, of resolution. When ad- hesions form between two inflamed sur- faces, the organized substance, form- ing the connexion, lives after the subsi- dence of the inflammation, and is a permanent effect. It was probably the enlargement ofthe small vessels, which led to the theory, that new vessels are formed in inflammation. It has, howe- ver, been justly observed, that the sup- position easily admits of refutation; for heat, and many other causes of inflam- mation, operate so quickly, that there can be no time for the formation of any new vessels; and yet, the redness is as great, and the inflammation as perfect, in a minute as in an hour or a day after the application of the exciting cause. (Burns.) Another reason, assigned for the redness of inflammation, is that the blood, after it has become venous, re- tains, more or less, its bright scarlet colour. (Hunter.) Swelling.—This effect arises from se- veral causes. 1. The increased quantity of blood in the vessels. 2- The effusion of coagulating lymph, and deposition of new matter. 3. The interruption of ab- sorption, of late particularly noticed. (Soemmering de Morb. Vas- Absorb.) Pain.—This is observed to be great- est during the diastole of the arteries. The affection is probably owing to the unnatural state of the nerves, and not to mere distension, as many have as- serted. Were the latter cause a real one, the pain would always-be propor- tioned to it Heat.—It was formerly imagined by many, (Boerhaave, Sauvage, Cfc.) who wrote after the discovery of the circu- lation of the blood, that the heat was produced by the attrition of the red globules against the sides of the ves- sels. Modern philosophy now, howe- ver, teaches us, that a fluid may flow, with the utmost velocity, through a pipe, for a thousand years, without pro- ducing a single degree of heat. The most commonly received opinion now is, that the production of animal heat depends upon the difference in the ca- pacity of arterial and venous blood for combining with caloric; and that in the minute arteries, the blood is combined with certain substances, inconsequence of which its capacity is diminished, and heat is given out. But, when the ve- nous blood has been freed from such substances in the lungs, its capacity is increased, and the heat, which is given out by the decomposition of the air which we inspire, is absorbed. Now, if these things be admitted as facts, the augmented heat of inflammation may be conceived to arise from the increas- ed velocity of the circulation in the part affected. More blood is transmit- ted into the minute arteries; the capa- city of a greater quantity of this fluid for heat is of course there necessarily diminished, and more caloric is ex- tracted. APPEARANCES OB THE BLOOD IN IN- FLAMMATION. The blood, when taken out of the li- ving vessels, spontaneously separates into two distinct parts, the serum and the crassamentum. The last is a com- pound substance, consisting chiefly of coagulating lymph, and red globules, the most heavy ingredients in the blood. Blood, taken away from persons affect- ed with inflammation, is longer in coa- gulating, and coagulates more firmly, than in other instances. Hence, the red globules, not being so so^on entangled in the lymph, descend, by their gravi- ty, more deeply from its surface, which, being more or less divested of the red colouring matter, is from its appear- ance termed the iuffy coat or inflamma- tory crust. The firmer and more com- pact coagulation of the lymph com- presses out an unusual quantity of se- rum from it, and the surface of the si zy blood is often formed into a hollow, the edges being drawn inward. (Hunter) 76 INFLAMMATION. These changes in. the blood are, in Bome cases, a more infallible proof of the existence of inflammation, than the state of the pulse itself. At the same time, it is probably only a criterion of some unusual operation going on in the system; for the blood taken from preg- nant women is always found to exhibit the above appearances. In peritoneal inflammation, the patient sometimes seems to be in the most feeble state, and the pulse, abstractly considered, would rather induce the practitioner to employ tonics and stimulants, than eva- cuations; but, should the continuance or exasperation of the disorder, or any other reasoii, lead the surgeon to use the lancet, then the buffy coat, and the concave surface ofthe blood, clear away all doubt concerning the existence of inflammation. In a few anomalous constitutions, the blood, when drawn, always exhibits the above peculiarities. TERMINATIONS OF INFLAMMATION. Inflammation is said to have three different terminations; or, in more cor- rect language, we may say, that, after this process has continued a certain time, it either subsides entirely, induces a disposition in the vessels to form pus, or completely destroys the vitality of the part- When the inflammation is to end in the first manner, which is the most fa- vourable, the pain becomes less, the swelling subsides, the fever, and every other symptom, gradually abate, till at last the part is wholly restored to its natural size and colour. There is no formation of pus, nor any permanent in- jury of structure. This termination of inflammation is termed by surgeons re- solution. It is fortunately the most com- mon, as well as the most desirable man- ner, in which the affection ends. If, however, notwithstanding the ap- plication ofthe usual remedies, the se- veral symptoms of heat, pain, and red- ness, instead of diminishing, rather increase; if the febrile symptoms are likewise augmented, and the tumour gradually acquires a larger size, turns soft, somewhat prominent in the mid- dle, or towards its most depending part; if it should next acquire a clear shining appearance, and become less painful, the different symptoms of fever being at the same time diminished, and a Huctuation perceptible in the tumour; the inflammation has ended in suppura tion. The worst, but, happily, the least frequent consequence of common in- flammation, is the death, or mortifica- tion, of the part affected. The signs of this disastrous event are a change of colour in the part, which, from being of a bright red, becomes of a livid hue; small vesicles, filled with a thin fetid serum, arise on its surface, and air is plainly felt to exist in the disordered situation. The pain is, indeed, diminish- ed; but the pulse sinks, while the tu- mour is gradually changed into a black, fibrous mass. These are the three most usual ter- minations of inflammation. By many au- thors, however, another disorder has been treated of, as one in which inflam- mation is apt to end, viz. scirrhus. But, although that complaint may, per- haps, in a few instances, follow inflam- mation; yet, it is far from being a com- mon consequence of it. Hence, although inflammatory affections may justly enough be mentioned as one ofthe ma- ny exciting causes of scirrhus, yet the consideration of this disorder can never with propriety, it is presumed, be in- troduced into an account of inflamma- tion. (B. Bell.) Common inflammation, particularly when it affects glandular parts, is often observed to leave an induration in the part. We know very well, that, when the testis has been inflamed, a hard- ne s of the epididymis frequently re- mains afterwards during life. Such in- durations, however, are not at all ma- lignant, and, consequently, are very dif- ferent in their nature from what is im- plied by a real scirrhus. TREATMENT OF INFLAMMATION Removal of the Exciting, or Remote Cause. After the description, which we have given of inflammation, the reader may easily guess, that the grand principle to be observed in the treatment is to en- deavour to lessen that immoderate ac- tion of the arteries, which is now commonly set down as the proximate cause. The first circumstance to be attended to in all cases, in which resolution is to be attempted, is the removal of all such exciting causes of the disorder as may- happen to present themselves. If the irritation of a splinter should excite INFLAMMATION. 77 phlegmonous inflammation, who would not of his own accord extract the ex- traneous body? Foreign substances in wounds fre- quently excite inflammation, and ought to be taken away as speedily as possi- ble; splintered pieces of bone often give rise to the affection, and require remo- val; the head of a bone, being out of its place, may press and inflame the parts on which it lies; and who does not im- mediately see the propriety of putting it back into its natural situation? Such ex- citing causes as these may oftentimes be detected and removed at once, and this is doing a great deal towards the cure of the inflammation. Many of the exciting causes of this affection are only of momentary application; yet, though they no longer exist, the pro- cess of inflammation must follow the violence and irritation, which were suddenly produced, and still remain. Hence, besides taking away, if possi- ble, the remote cause, it is proper to moderate, by other means, the increas- ed action of the vessels. Bleeding. If the doctrines which we have ad- vanced be true, viz. that inflammation depends upon an increased action ofthe vessels, and that a greater quantity of blood is impelled into, and circulates through the inflamed part, than,in the natural state; it follows, that bleeding must be a principal means of relieving inflammation; because it lessens the ac- tion of the whole arterial system, and, of course, of that part which is under- going inflammation; and because it di- minishes the quantity of blood trans- mittedto the part affected, by lessening the whole mass in the circulation. Bleeding, however, is often misem- ployed, especially, when regarded as the only remedy for inflammation, and other steps are neglected. The obstina- cy and vehemence of the process in weak constitutions prove, that bleeding is not invariably proper. When inflam- mation is complicated with an unheal- thy state ofthe aliamentarycanal, blood should be taken away with great cir- cumspection. A great deal of indura- tion, with little pain and heat in the in- flamed part; the probability of a long and copious suppuration, as is the case in many compound fractures; and the dependence ofthe inflammation on local weakness; are particular instances, in which the practitioner should be spar- ing of this evacuation. Bleeding is quite unnecessary when the local inflamma- tion and symptomatic fever are trivial, when the patient is feeble or very old, and when the cause ofthe affection can be entirely removed (Richter.) On the other hand, bleeding is highly beneficial in all cases, in which the in- flammation is uncomplicated with amor- bid state ofthe gastric system, is con- siderable in extent and degree, and at- tended with a good deal of febrile dis- turbance. The same is also strongly in- dicated, when the part affected is very sensible, and highly important, in re- gard to its office in the system. Hence, ophthalmy or inflammation of the eye, which is a most sensible part, particu- larly requires a free evacuation of blood. Hence, inflammation ofthe lungs, brain, or stomach, which are organs, the sound state of which is intimately essential to the regular continuance of all the various operations in the animal machine, particularly demands the em- ployment ofthe lancet; for, if a success- ful effort be not promptly made to stop such inflammation, death itself will, in all probability, be the result. Bleeding is likewise indicated, when the patient is young, robust, and ple- thoric; when the cause ofthe disorder can neither be removed nor diminished, and when there is a very strong motive for wishing to avoid the formation of matter. Inflammation of the eye affords an instance illustrative of the truth of the last observation; for, if suppuration be allowed to take place in this organ, the common consequence is so serious a destruction of its internal structure and organization, that the future restora- tion of sight is totally impossible. Un- der such circumstances as we have specified, it is frequently necessary to repeat bleeding several times. The efficacy of bleeding is greater, the sooner it is practised, and the more suddenly the blood is evacuated. Bleed- ing near the part affected is usually- more effectual, than when done in are- mote situation. Hence, in inflammation ofthe eye, or brain, it is deemed most advantageous to take blood from the temporal artery. The preceding remarks chiefly relate to general bleeding; for, in phlegmon- ous inflammation, topical bleeding is scarcely ever improper. It is always a point highly worthy of the surgeon's consideration, whether bleeding in or near the part will answer better, than 78 INFLAMMATION. taking the blood from the general habit; for,certainly, less may be removed in this way, so as to have equal effect up- on the part inflamed, and probably, up- on every other disease that is relieved by bleeding, and yet affect the constitu- tion less. Although, in many cases, the general habit may be relieved by bleed- ing, yet the part affected will always re- quire this evacuation most. That local bleeding has very considerable effects on the inflamed part, is proved by the sudden relief, which leeches, applied in cases of gout, produce. Bleeding by leeches alone will also remove a tumour in the breast, having all the appearances of a scirrhus, which cannot be consi- dered as inflammatory, so that topical bleeding extends its power further than the mere checking of inflammation. Some part of its effect has been imput- ed to sympathy. (Hunter.) There are three modes of performing topical bleeding; by cupping; by leeches; and by dividing, or scarifying, the dilated vessels leading to the inflamed part. Upon the head and face, leeches are commonly employed; upon the chest, either leeches or cupping; upon the ab- domen, leeches; and upon the joints, either cupping or leeches. When the eye is inflamed, leeches may either be applied to the adjoining temple; or the dilated vessels of the conjunctiva may be scarified; or both methods may be adopted. When the inflammation ex- tends quite to the surface of the body, leeches are always most eligible, as their bite causes less irritation in in- flamed parts, than the punctures ofthe scarificator, or the pressure ofthe cup- ping glasses. Purging. The exhibition of* mild laxative medi- cines, and saline purgatives, is a prin- cipal means of diminishing inflamma- tion. Purging does not produce such lasting weakness as is the consequence of bleeding, and, consequently, it is scarcely ever omitted, even when ta- king away blood is deemed improper. Saline purges must lessen the quantity of circulating blood, inasmuch as they increase the secretion from the intes- tinal arteries. Hence, they must ope- rate beneficially in the cure of local in- flammation, much upon the same prin- ciple, as bleeding does. Mr. Hunter was of opinion that purging lowers ac- tion, without diminishing strength, by which we are probably to understand, without producing a very lasting or permanent loss of strength. With re- spect to mild laxative medicines, none are superior to manna, rhubarb, oleum ricini, and the like; and of the saline purgatives, which are in general prc- fert'-ble to the former ones, the natron vitriolatum, kali tartarizatum, soda phosphorata, and magnesia vitriolata, are the best. We may here remark, that besides the benefit, which the lo- cal inflammation derives from the judi- cious administration of purgatives, the costiveness and heat, which usually at- tend the symptomatic fever, are also relieved by the same means. Nauseating Medicines. Medicines, which have the power of producing sickness, lessen, for a time, the action, and even the gene- ral powers of life. This is in conse- quence of every part ofthe body sym- pathizing with the stomach; and the effect may be very quickly excited. Sickness lowers the pulse, makes the small vessels contract, and rather dis- poses the skin for perspiration. But no- thing more than nausea should be caus- ed: for vomiting rather rouses than de- presses. (Hunter.) Nauseating medi- cines, employed after bleeding has been practised once or twice, are often productive of considerable benefit; but there are some affections, in which they cannot be used, such as inflamma- tion of the stomach and intestines. In all superficial inflammations, however, they may be safely ar.d advantageously exhibited, as well as in most inflamma- tory affections internally situated. In inflammation of the dura mater and brain, and, indeed, in every instance, in which there is an urgent reason for put- ting as sudden a check as possible to the continuance of the affection, the employment of nauseating doses of an timony is most strongly indicated. The antimonium tartarizatum, (emetic tar- tar) is the one, on which practitioners place the greatest reliance, and it is to be prescribed for the purpose of excit ing nausea, as directed below.* * R. Antimonii tartarisati grana duo; Aquae distillatae uncias quatuor. Misco et cola. Dosis. -Uncia dimidia sexta quaque hora INFLAMMATION. fB Opium. The majority of surgeons entertain an insuperable objection to the administra- tion of opiates in almost all cases of inflammation, and the aversion to this practice is for the most part deducible from the recollection of opium being a potent stimulant. The plan however, has its advocates. (B. Bell, Richter.) One of its strongest partisans tells us, that opium particularly lessens the dis- turbance of inflammation, and it allays pain, which is at once a principal symp- tom of the process, and a cause of its augmentation, as well as that ofthe fe- ver. Opium also quiets the inordinate action of the solids, the mental agita- tion, and restlessness so powerfully, that it well deserves the name of the grand antiphlogistic remedy. It likewise occasions a moisture on the surface of the body, wliich experience shows is eminently serviceable in all inflamma- tions affecting the skin. When given with this view, it is usually conjoined with antimony, camphor, calomel, or ipecacuanha. The administration of opi- um is a general practice in all painful inflammations arising from external causes, and it is attended with perfect safety when evacuations from the bow- els and bleeding have been previously put in practice Care must only be ta- ken to give it in sufficient doses; for small quantities not only fail in fulfilling the object, but frequently produce quite an opposite effect. During its employ- ment, the bowels should be kept open by glysters. The efficacy of opium chief- ly manifests itself in the early stage of the affection; for, as soon as the inflam- matory fever has extended itself to the whole system, it loses its beneficial vir- tues. Hence, in cases of external inju- ries, it is to be given the two first days, immediately after bleeding. It is to be given as soon after the accident as pos- sible, in order to tranquillize the men- tal alarm, and, if convenient, towards the evening, for the sake of procuring for the patient a quiet night. (Richter.) Evacuations being premised, says the other advocate for this medicine, the next object of importance is to procure ease and quietness to the patient, which, in cases of inflammation, are often of more real service, than any other cir- cumstance whatever. The most effec- tual remedy for this purpose is opium, which, when the pain and irritation are considerable, as very frequently hap- pens in extensive inflammations, should never be omitted. In large wounds, es- pecially after amputations, and other capital operations, and in punctures of all kinds, large doses of opium are al- ways attended with remarkably good effects. In all such cases, however, opium, in order to have a proper influ- ence, should be administered in very large doses; otherwise, instead of pro- ving serviceable, it seems rather to have the contrary effect. This circum- stance is, perhaps, the chief reason why opiates in general have been very unjustly condemned in every case of in- flammation. (B. Bell.) On the contrary, they who are averse to the use of opium, remark, that, in acute inflammation, daily experience shows, independently of every theory, that the exhibition of this medicine in- creases the general fever, and aggra- vates the local action. Even given as a preventive of inflammation, after ope- rations, anodynes are almost uniformly hurtful, producing restlessness, heat, thirst, and afterwards headach, sick- ness, and, frequently, troublesome vo- miting. (Burns.) Upon the whole, candour obliges me to own, that the votes of the majority of surgeons in this country are decided- ly against the general use of opium in inflammation; but, after the perform- ance of severe operations, and in all in- stances, attended with excessive pain, truth, I believe, will justify my saying, that the voice of most practitioners is in favour of the exhibition of this re- medy. DIET AND REGIMEN. In all cases, the surgeon is to forbid taking wine and spirits; and, when the inflammation is in the least considera- ble, the same prohibition is to be made in regard to animal food. Watery, cooling, mucilaginous drinks, taken in a lukewarm state, are proper; for they keep off thirst and heat, and tend to sooth the increased action ofthe whole arterial *ystem. For this purpose, whey, buttermiik, barley-water, decoction of dried fruits, water-gruel, &c. are the best. The chamber, in which the patient lies, should not be kept warmer than his comfort requires; for, of all things, heat keeps up any increased action in the body, in the most powerful manner. For the same reason, the patient should not be covered with a superfluous quan- tity of bed-clothes. 80 INFLAMMATION The whole body, but more especially the inflamed part', should be preserved as free as possible from every kind of motion. Every one knows, that all mo- tion, exercise, and muscular exertion, accel rate the circulation, and hence they must have a pernicious effect on inflammation, by determining a larger quantity of blood to the part af- fected. f OPICAL APPLICATIONS—COLD ONES. "• With the exception of what has been stated, concerning topical bleeding, all the foregoing remarks relate to the ge- neral treatment of inflammation: we shall next consider the local. It has been already observed, that phlegmon is attended with an increase of heat in the part affected, and it is an acknowledged and well known fact, that the action of the arteries, as well as every other operation in the animal economy, is promoted and increased by the influence of heat. For this reason an obvious indication arises, viz. to re- duce the temperature of the inflamed part, by the topical application of cold, and, in particular, by continually ab- stracting the heat generated in the part, by keeping up a constant evaporation from its surface. Preparations of lead, and other seda- tive anil astringent substances, are such as are in the greatest repute for bringing about the resolution of inflam- mation. I am decidedly averse to entering in- to minute discussions, concerning the modus operandi of such medicines as are recommended. These disquisitions would only extend our remarks to an unnecessary length, and probably fail in conveying satisfactory information to the reader. However, I am firmly of the same sentiment with a preceding systematic writer (B. Bell) that, in some circumstances, it may not be im- proper to deviate so far from the gene- ral plan, as to render, as obvious as pos- sible, the propriety of what at any time may be advanced; for mere practical as sertions, unsupported by some founda- tion in reason, can never prove either so useful or agreeable as they might other- wise be rendered. We have remarked, that the cold applications, used in the resolution of in- flammation, are commonly such as are nf an astringent and sedative quality. But the whole class of medicines, which are found to possess these pro- perties, can never be recommended as topical remedies for phlegmonous in- flammation. Opium is one of the most powerful of all sedatives; yet, when ap- plied to the surface ofthe human body, (if the cuticle intervene,) it has- little virtue; and, if the part be excoriated, it is always productive of some degree of" irritation. Hence, however useful opium may be as a topical application to some particular species of inflammato- ry affections, which will be specified in the course of this work, we may cer- tainly conclude, that it will never come into general use, as an external local application in inflammatory cases. Simi- lar objections might, perhaps, be made to the employment of nearly all seda- tives, in cases of acute inflammation. The zincum vitriolatum, cerussa ace7 tata (sugar or acetite of lead,) and vine- gar, are the only medicines of the astringent and sedative class, which seem to have acquired permanent cele- brity for their efficacy in resolving in- flammation. Extensive experience, and long es- tablished trials, have now fully confirm- ed the virtue of all those local remedies, in which the acetite of lead is the ac- tive ingredient. M. Goulard, and nu- merous other French surgeons, found, that the objections to the employment of many other sedative applications in the treatment of inflammation, did not exist against the use of the preparation of lead. The universal assent of modern practitioners proves, indeed, that the acetite of lead, as a local application for genuine phlegmonous inflammation, is certainly unsurpassed, if not unrival- led, in point of efficacy. Although M. Goulard, in extolling a favourite remedy, has been induced to assert its effects to be more general and considerable than they probably will ever be found to be; yet the world is much indebted to him; not, however, for a new medicine, as every prepara- tion of lead, recommended by him, was formerly, in some form or other, known to every practitioner; but, for introduc- ing into more general use a very effectual remedy for the discussion of inflamma- tory swellings. (B. Bell.) The preparations of lead certainly me- rit the appellation of sedatives. When taken internally, many ofthe most strik- ing effects of this mineral are of a seda- tive kind. The propriety of the term, INFLAMMATION. 81 however, is more particularly evinced by the immediate and obvious operation of lead, when any of its preparations are outwardly applied to the surface of an inflamed part. An abatement of the dif- ferent symptoms of pain, and tension, and the communication of an agreeable soothing sensation to the part, are al- most always its direct palpable effects. The preparations of lead are recom- mended by M. Goulard, as almost equally applicable to every stage of in- flammation. When swellings have fully suppurated, the employment of, what he calls, the extractum Saturni, will al- most always render it unnecessary to open them. Even in gangrene, the so- lution of lead is represented by this zealous writer, as a remedy, deserving ofthe greatest confidence. But, notwithstanding the above ex- aggerations, every man of experience and observation will allow, that, while there is a chance of accomplishing re- solution, no local applications to phleg- monous inflammation, are in general so proper, as cold lotions, containing the acetite of lead. From the poisonous qualities of lead, when taken into the system, and from the possibility of this mineral being ab- sorbed from the surface of the body, objections have arisen against the free use of its preparations, even as outward remedies in cases of inflammation. Cer- tain it is, however, that, though the possibility of such absorption is proved "by the occurrence of the disorder called the colica pictorum, which originates in painters from the white lead absorbed into the system, yet, any ill effects from the use of lead, as an application to inflamed parts, are so exceedingly rare, that they can hardly form a serious objection to the practice. It is a fact, that, in inflamed parts, there is an im- pediment to absorption, and this cir- cumstance may tend to render the em- ployment of lead a matter of safety. Mr. B. Bell observes, that in all the experi- ence, he has had, ofthe external appli- cation of lead and its preparations, and in many cases, particularly of burns, he has known the greatest part of the sur- face ofthe body covered with them for days, nay, for weeks together, he does not recollect a single instance of any disagreeable symptom being ever pro- duced by them. A lotion composed of cerussa acetata (sugar of lead), vinegar and water, is one very commonly employed.* Occa- sionally, bread-crumb is moistened in the fluid, and applied to the part affect- ed, in the form of a poultice; but, linen wet in the lotion, and kept constantly so, is now almost always preferred. Thus a continual evaporation is main- tained, and of course a continual ab- straction of heat. The aqua lithargyri acetati is prefer- red by most surgeons. About a tea-spoonful of this prepara- tion, mixed with a pint of water, makes a very proper lotion for all ordinary cases. When the surgeon is afraid to em- ploy a solution of lead, he may try one containing the zincum vitriolatum. For this purpose, one drachm of this metallic salt is to be dissolved in a pint of water, and linen, well wet with the lotion, is to be applied to the inflamed part. Many practitioners impute very little real efficacy either to the acetite of lead, or sulphate of zinc, contained in the above applications; and, they attri- bute all the good, that is produced, en- tirely to the evaporation kept up from the surface ofthe inflamed part, and to the coldness ofthe fluid, in which tne metallic salts are dissolved. Those, who entertain these sentiments, think the application of cold water alone quite as efficacious, as that of any medicate lotion whatsoever. There are particular cases of inflam- mation, in which the extravasation of blood and lymph, into the interstices of the inflamed part, is exceedingly copi- ous, while the swelling is considerable, and the pain and redness not particu- larly great. In such instances, it is a grand indication to rouse the action of the absorbents, in order to remove the extravasated fluid, and with this view, a more powerful discutient lotion, than the saturnine one, should be employed. Sometimes, it is better to use embro- cations and liniments, than any sort of * R. Cerussx Acetatae^ss. Solve in Acet. pur. $iv. Et adde Aq. Fontanae distill. Ifeij. The vinegar makes the solution more complete. Vol. II. L 82 INFLAMMATION lotion. A verv excellent discutient lo- tion is one of* those mentioned below.* Wrhen the part affected with inflam- mation is not very tender, or when it lies deep, applications of the vegetable acid are often had recourse to with con- siderable advantage; and the most ef- fectual form of using it seems to be a poultice made with vinegar and crumb of bread. In such cases, it has been thought, that an alternate use of this remedy, and the saturnine lotion, has produced more beneficial effects, than are commonly observed from a continu- ed use of one of them. (B. Bell.) How- ever, surgeons ofthe present day seem to think, that vinegar can be as advan- tageously applied in the form of a lo- tion, as in that of a poultice, and, cer- tainly, with less trouble. Alcohol and aether have acquired some celebrity, as local remedies for inflammation. Perhaps, one great rea- son, why they are not more extensively used in this way, is the expense attend- ing such treatment, as these fluids eva- porate with great rapidity. Alcohol may possibly prove useful from its astringent qualities; but, it seems much more ra- tional to impute both its virtue, and that of aether, to the powerful manner, in which the evaporation of such fluids deprives the inflamed part of its heat. WARM APPLICATIONS, EMOLLIENT POULTICES AND FOMENTATIONS. The absurdity of attemptingto recon- cile every useful practice with a philo- sophical theory is, in no instance, more strikingly shown, than in the opposite sorts of local applications, which are of service in inflammation. The generality of cases undoubtedly receive most relief from the use of cold sedative astringent lotions; but, there are constitutions and parts, which derive most service from the local employment of warm emollient remedies. Were 1 to endeavour to define the particular instances, in which the lat- ter applications avail most, I should take upon me a task, which has baffled all the most able surgical writers. The first stage of the acute ophthalmy, and the hernia humoralis, or inflamed testi- cle, may be specified, however, as ex- amples, in which, generally speaking, warm emollient applications are better, than cold astringent ones. If we may judge by the feelings of certain pati- ents, there are undoubtedly particular constitutions, in which the local use of warm remedies produces greater relief, than that of cold ones. This circum- stance, however, does not generally hap- pen; and, as warm emollient applica- tions of all kinds have the most power- ful influence in promoting suppuration, a fact admitted by every experienced practitioner, the use of such remedies, while the resolution of inflammation is practicable, must be highly censura- ble. But, 1 am ready to grant, that in all cases of inflammation, which manifest- ly cannot be cured without suppura- tion, the emollient plan of treatment ought to be at once adopted; for, the sooner the matter is formed, the sooner the inflammation itself is stopped. The inflammation attending contused and gun-shot wounds, and that accompany- ing boils, and carbuncles, are of this de- scription. The inflammation, originating in fevers, commonly ends in suppura- tion, and, perhaps, it might be advan- tageous, in such instances, also, to em- ploy at once the emollient treatment. Warmth and moisture together, in other words, fomentations, are com- monly had recourse to in cases of in- flammation; but, when the warmth is as much as the sensitive principle can bear, it excites action. "Whether it is the action of inflammation, or the ac- tion of the contraction of the vessels, is unknown. We see that many patients cannot bear warmth, and, therefore, it might be supposed to increase the ac- tion of dilatation, and do harm. But, if the pain should arise from the contrac- tion of the inflamed vessels, benefit would be the result; though we must doubt that this change is produced, as R Ammoniae Muriatae ^ss. Aceti.; Spirittis Vini rectificati; sing. ILj. M. Aq. Ammon. Acet. Spir. Vini rectif.; Aq. Distillatx; sing. ijiv. M. The Aqua Ammoniae Acet. alone also does verv, well R INF INJ 83 making the vessels contract would pro- bably give ease. (Hunter.) From the preceding observations, we must perceive how vain it is to theorize »n this subject, which even puzzled the genius and penetration of a Hunter. In addition to what has been already observed, I feel totally incapable of giv- ing any useful practical advice, with respect to those cases, in which warm emollient applications should be used in preference to cold astringent ones. I can, however, with confidence remark, that the surgeon, who consults the feel- ings and comfort of the patient on this point, will seldom commit any serious error. Hence, in all cases, in which the first kind of topical applications seem not to produce the wonted degree of relief, let the second sort be tried. From the opportunity of comparison, a right judgment may then be easily formed. The poultice made ofthe powder of linseed is so easily prepared, that the old bread and milk poultice is now sel- dom made. As' much hot water is to be put into a basin, as the size of the poultice requires, and then the linseed powder is to be gradually mixed with the water, till the mass is of a proper consistence. Very frequently, a little sweet oil is also added to keep the ap- plication longer soft and moist. Fomentations are only to be consider- ed as temporary applications, while the emollient poultices are the permanent ones. The former are, at most, never used more than three times a day, for the space of about half an hour each time. Two ofthe best are directed be- low.* By pursuing the treatment, recom- mended above, the resolution of the in- flammation will in general begin to take place, either in the course of three or four days, or in a shorter space of time. At all events, it may usually be known before the expiration of this period, how the disorder will terminate. If the heat, pain, and other attending symptoms abate; and, especially, if the tumour be- gins to decrease, without the occur- rence of any gangrenous appearances; we may then be almost certain, that, by a continuance of the same plan, a total resolution will in time be effected. On the other hand, when all the dif- ferent symptoms increase, and, parti- cularly, when the tumour becomes larger, and softish, attended with a more violent throbbing pain, we may conclude, that the case will proceed to suppuration. Hence, an immediate change of treatment is indicated, and such applications, as were proper, while resolution seemed practicable, are to be left off, and others substituted. This remark relates to the employment of cold astringent remedies, which, when suppuration is inevitable, only do harm, by retarding what cannot be avoided, and affording no relief of the pain and other symptoms. If the inflam- mation, however, should already be treated with emollients, no alteration of the topical applications is requisite, in consequence ofthe inevitability ofthe formation of matter. Indeed, emollient poultices, and fomentations, are the chief local means, both of promoting suppuration, and diminishing the pain, violent throbbing, &c. which always precede this termination of phlegmon- ous inflammation. But, besides the substitution of warm emollient applications for cold astrin- gentones,to the partitself, practitioners have decided, that it is also prudent, as soon as the certainty is manifest, to re- linquish the free employment of evacu- ations, particularly, blood-letting, and to allow the patient a more generous diet. When the system is too much re- duced by the injudicious continuance of the rigorous antiphlogistic treatment, the progress ofthe ensuing suppuration is always retarded in a disadvantageous manner, and the patient is rendered too weak to support, either a long continu- ed, or a profuse discharge, which, it may not be possible to avoid. On the subject of inflammation, the best works for perusal are; Van Swie- ten's Commentaries on Boerhaave; Cul- len's First Lines ofthe Practice of Physic, vol. 1; John Hunter on Inflammation, &c.; Burns's Dissertations on the same. INGUINAL HERNIA. See Hernia. INJECTION, (from injicio, to cast * R. Lini contusi aj. Chamaemeli afij. Aq. Distill, ifevj. Paulisper coque et cola. or R. Papaveris albi exsiccati £iv. Aq. Purx "tbyj. Coque usque remaneant ftjij. et cola. 84 INTROSUSCEPTION into.) A fluid, intended to be thrown into a part of the body by means of a syringe. Thus port wine and water form an injection, which is used by surgeons for radically curing the hydrocele, and, for this purpose, it is introduced into the cavity of the tunica vaginalis, where it excites the degree of inflammation necessary to produce an universal adhe- sion between this membrane and the albuginea. Thus many fluid remedies are intro- duced into the urethra and vagina for curing the gonorrhoea. In the article, Gonorrheea, will be found an account of the best injections employed for its re- lief. We here subjoin a few particular ones not there noticed. INJECTIO ACIDI MURIATICI. —R. Aquae distil. 5iv Acid. Mur. gutt. viij. Misce.—Useful when the scalding is a very troublesome symptom. INJECTIO ALUMINIS.-R. Alum. 3j- Aq. pur. ^vj. Misce.—Successfully employed by Dr. Cheston, as an injec- tion in affections of the rectum, either when the internal coat is simply relax- ed, and disposed to prolapsus, or when it is studded with loose fungated tu- mours. In such cases, camphor is also of service. The quantity of alum may be increased, if the parts will bear it. INJECTIO CUPRI AMMONIA. TI.—R. Liquoris Cupri ammon. gutt. xx. Aquae rosae j"fiv. Misce.—Strongly recommended by Mr. Foot INJECTIO QUERCUS.--R. Decoc- ti quercusfbj. Alumiuis purificati ^ss. Misce.—May be used, when the rec- tum, or vagina, is disposed to a pro- lapsus from relaxation, or in cases of gleet. INTERRUPTED SUTURES. See Sutures. INTESTINES WOUNDED. See Abdomen, Wounds of. INTROSUSCEPTION, or Intus- susception, (from intus, within, and sus- cipio, to receive.) Called also Volvulus. Is a disease, produced by the passing of one portion of an intestine into ano- ther, and it is commonly from the up- per passing into the lower part. (J. Hunter.) Mr. G. Langstaff has published an interesting paper, on this subject, in the Edinb. Surg. Journal, No. XL; which I shall take the liberty of freely quoting. This gentleman remarks, that the small intestines of children are so often affected with introsusception, in a slight degree, that most practitioner* must have had opportunities of observ- ing the form of the complaint. The greatest pas^of three hundred children, who died either of worms, or during dentition, at the Hospital de la Salpe- triere, and came under the examination of M. Louis, had two, three, four, and even more volvuli, without any inflam- mation of the parts, or any circumstan- ces leading to a suspicion, that these affections had been injurious during life. " These cases (says M. Louis,) seem to prove, that introsusception may be formed, and destroyed again by the mere action of the intestines." (Mem. dePAcad. de Chirurg. 4to, torn. 4. p. 222.) This opinion is confirmed by the authority of Dr. Baillie, (Morbid Anatomy, 2d edit. p. 162.) who observes, that, " in opening bodies, particularly of infants, an intussusceptio is not un- frequently found, which had been at- tended with no mischief; the parts ap- pear perfectly free from inflammation, and they would probably have been easily disentangled from each other by their naturalperistaltic motion." The disease, continues Mr. Lang- staff, assumes a more dangerous, and, indeed, generally a fatal form, when it occurs at the termination of the small intestines in the caecum. A contracted state of the part to be introsuscepted, and a dilatation of that portion of the canal, into which this part must pass, are essential conditions to the formation of a volvulus; and those exist no where so completely as in the situation here alluded to. The extent to which the af- fection proceeds in this situation, would appear almost incredible, if it were not proved by well authenticated facts. A person, who considered the natural si- tuation and connexion of the parts, would of course require the strongest evidence, before he would believe, that the ilium, caecum, ascending, and transverse portions of the colon, may descend into the sigmoid flexure ofthe latter intestine; nay more, that they may pass through the rectum, and be pro- truded in the form of a procidentia ani. Such cases, however, are recorded. (Langstaff in Edin. Med. and Surg. Journal, No. XL) This gentleman next relates the case of a child three months old, the body of which he inspected after death, and found to confirm the truth of the pre- ceding account. The example was par- ticular in there being, in addition to an INTROSUSCEPTION. 85 extensive introsusception in the usual way, a smaller invagination in the oppo- site direction, like what probably oc- curred in the case related by Mr. Spry; Med. and Physical Journal, No. XL Mr. Home,, in the Med. and Chirurg. Trans. vol. 1. mentions an example of a retro- grade introsusception, in which a worm was found coiled up round the introsus- cepted part. The disease took place in a boy, who had swallowed some ar- senic. If the following mode of accounting for introsusception, be just, it will most frequently happen downwards, although there is no reason why it may not take place in a contrary direction; in which case, the chance of a cure will be increased by the natural actions of the intestinal canal tending to replace the intestine; and probably from this cir- cumstance it may oftener occur than commonly appears. (J. Hunter.) When the introsusception is down- wards, it may be called progressive, and when it happens upwards, retrograde. The manner in which it may take place is, by one portion of a loose intestine being contracted, and the part imme- diately below relaxed and dilated; un- der which circumstances, it might very readily happen,by the contracted portion slipping a little way into that which is dilated, not from any action in either portion of intestine, but from some ad- ditional weight in the gut above. How far the peristaltic motion, by pushing the contents on to the contracted parts, may force these into the relaxed, Mr. Hunter will not determine, but is in- clined to suppose that it would not. (J. Hunter.) By this mode of accounting for an ac- cidental introsusception, it may take place either upwards or downwards; but if a continuance or an increase of it arises from the action of the intestine, it must be when it is downwards, as we actually find to be the case; yet this does not explain those in which a con- siderable portion of intestine appears to have been carried into the gut below: to understand these, we must consider the different parts which form the in- trosusception. It is made up of three folds of intestine; the inner, whicli passes down, and being reflected up- wards, forms the second or inverted portion, which being reflected down again, makes the third or containing part, that is the outermost, which is al- ways in the natural position. (J. Hun- ter ) The outward fold is the only one which is active, the inverted portion being perfectly passive, and squeezed down by the outer, which inverts more of itself, so that the angle of inversion in this case is always at the angle of re- flection of the outer into the middle portion or inverted one, while the in- nermost is drawn in. From this we can readily see how an introsusception, once begun, may have any length of gut drawn in. (J. Hunter.) The external portion acting upon the other folds in the same way as upon any- extraneous matter, will, by its peristal- tic motion, urge them further; and, if any extraneous substance is detained in the cavity of the inner portion, that part will become a fixed point for the outer or containing intestine to act upon. Thus it will be squeezed on, till at last the mesentery preventing more of the innermost part from being drawn in, will act as a kind of stay, yet without entirely hindering the inverted outer fold from going still further. For it be- ing the middle fold that is acted upon by the outer, and this action continuing after the inner portion becomes fixed, the gut is thrown into folds upon itself; so that a foot in length of intestine shall form an introsusception not more than -three inches long. (J. Hunter.) The outer portion of intestine is alone active in augmenting the disease when once begun; but if the inner one were capable of equal action in its natural direction, the effect would be the same, that of endeavouring to invert itself, as in a prolapsus ani; the outer and inner portions, by their action, would tend to draw in more of the gut, while the in- termediate part only would, by its ac- tion, have a contrary tendency. (J. Hunter.) The action of the abdominal muscles cannot assist in either forming, or con- tinuing this disease, as it must com- press equally both above and below, al- though it is capable of producing the prolapsus ani. (J. Hunter.) When an introsusception begins at the valve ofthe colon, and inverts that intestine, we find the ilium is not at all affected; which proves that the mesen- tery, by acting as a stay, prevents its inversion. (J. Hunter.) From the natural attachment of the mesentery to the intestines, one would, at the first view of the subject, con- ceive it impossible for any one portion of gut to get far within another; as the greater extent of mesentery that is car- 86 INTROSUSCEPTION ried in along with it would render its further entrance more and more diffi- cult, and we should expect this difficul- ty to be greater in the large intestines than in the small, as being more closely confined to their situation; yet one of the largest introsusceptions of any known was in the colon, as related by Mr. Whately. (Vid. Philos. Trans, vol. 76. p. 305.) The introsusception appeared to have begun at the insertion ofthe ilium into the colon, and to have carried in the caecum with its appendix. The ilium passed on into the colon, till the whole of the ascending colon, the transverse arch, and descending colon, were car- ried into the sigmoid flexure and rec- tum. The valve ofthe colon being the leading part, it at last got as low as the anus; and when the person went to stool he only emptied the ilium, for one half ofthe large intestines being filled up by the other, the ilium alone, which passed through the centre, discharged its contents. (J. Hunter.) Two questions of considerable im- portance present themselves to the mind in considering this subject; whe- ther there are any symptoms, by which the existence ofthe affection can be as- certained during life? And whether we possess any means of relieving it, sup- posing, that its existence could be dis- covered? The symptoms attending an introsusception, are common to inflam- mation of the intestines, hernia, and obstruction of the canal, from whate- ver cause, and a volvulus is the least frequent cause of such symptoms. (Langstaff.) In the case, published by this gentleman, and in those related by Mr. Hunter and Mr. Spry, the seat of the disease was clearly denoted by a hard tumour on the left side of the ab- domen. This circumstance, together with the impossibility of throwing up more than a very small quantity of fluid m clysters, (Hevin, Spry, Langstaff,) and the presence of the other symp- toms would lead us to suspect the na- ture of the disorder. If the invaginated portion descended so lowr as to protrude through the anus, and we could ascer- tain, that it was not an inversion ofthe gut, the cause might be considered as clear, and we should have no hesitation in delivering a prognosis, which, by preparing the friends for the fatal ter- mination, would exonerate us from all blame on its occurrence. (Langstaff.) In the treatment of this disease, bleeding, to lessen the inflammation that might be brought on, and quick- silver to remove the cause, have been recommended. Quicksilver would have little effect either in one way or the other, if the introsusception was downward; for it is to be supposed that it would easily make its way through the innermost contained gut, and, if it should be stop- ped in its passage, it (would, by increas- ing its size, become a cause (as before observed) of assisting the disease. In cases of the retrograde kind, quicksil- ver, assisted by the peristaltic motion, might be expected to press the intro- susception back; but even under such circumstances it might get between the containing and inverted gut into the angle of reflection, and, by pushing it further on, increase the disease it is intended to cure. (J. Hunter.) Every thing that can increase the ac- tion of the intestine downwards is to be particularly avoided, as tending to increase the peristaltic motion of the outer containing gut, and thus to con- tinue the disease. Medicines can never come in contact with the outer fold, and, having passed the inner, can only act on the outer below, therefore can- not immediately affect that portion of the outer wliich contains the introsus- ception; but we must suppose that whatever affects, or comes in contact with the larger portion ofthe canal, so as to throw it into action, will also af- fect by sympathy any part that may es- cape such application. Mr. Hunter therefore advises giving vomits, with a view to invert the peristaltic motion of the containing gut, which will have a tendency to bring the intestines into their natural situation. Ifthis practice should not succeed, it might be proper to consider it as a retrograde introsusception, and bv ad- ministering purges endeavour to in- crease the peristaltic motion down- wards. (J. Hunter.) I cannot agree with Mr. Langstaff", that it is to be regretted, Hunter's name should be affixed to the preceding pro- posal, or that it is an absurd one; for pur- gatives and emetics were only recom- mended to increase the peristaltic ac- tion,the former down ward,the latter up- ward, according as the supposed nature ofthe case might require, and this ef- fect they certainly would have, notwith- standing vomiting is an early and con- stant s) mptom of the disease, and an in- IRIS 8" superable constipation an equally inva- riably attendant. The method, I allow, however, is not very hopeful, on ac- count ofthe existence of adhesions. Mr. Langstaff remarks, the Recherches His- toriques sur la Gastrotomie dans le cos de Volvulus, par M. Hevin, (Mem. de" I'Acad, de Chir. tom. 4. 4to.) contain ma- ny interesting facts and much sound reasoning. There we find a very ample discussion of the question, concerning the propriety of opening the abdomen, in order to disentangle the introsus- cepted intestine; a proposal which M. Hevin condemns. If the equivocal and uncertain nature of the symptoms of volvulus, were not sufficient to deter us from undertaking an operation, which, under the most fa- vourable circumstances, could not fail to be extremely difficult, and immi- nently hazardous to the patient, the state ofthe invaginated parts will en- tirely banish all thoughts of such an im- prudent attempt. The different folds of the intestine become agglutinated to each other, so that they can hardly be withdrawn after death; (Simpson, Edinb. Med. Essays, vol. 6. Hevin's 4tA. Obs. Malcolm, Physical and Lit. Essays, vol. 2. p. 360. Hunter, Med. and Chir. Trans, and Soemmering in Trans, of Baillie's Morb. Anat.) the stricture on the introsuscepted part causes it to in- flame, and even mortify. (Soemmering.) It is very clear, that, in this state of parts, the operation of gastrotomy would be totally inadmissible, even if the symptoms could clearly indicate the nature of the case, and the affected part could b« easily reached and exa- mined. (Langstaff, in Edinb. Med. and Surg. Journal.) The forcible injection of clysters was found useless by Dr. Monro, and the agglutination ofthe parts must produce an insuperable obstacle to the bowels being pushed back by this means. (Langstaff.) Some have proposed the employment of a long bougie, or a piece of whalebone, to push back the intes- tine; and this proposal may be adopted, when we are furnished with an instru- ment, adapted to follow the windings of the large intestine to its origin in the right ilium, without any risk of perforating the gut in its course. (Lang- staff.) We must confess, both surgery and medicine are almost totally unavailingin the present disease. Yet here, as in ma- ny other instances, the resources of na- ture are exhibited in a most wonderful and astonishing manner, while those of art completely fail. The invaginated portion of intestine sometimes sloughs, and is discharged per anum, while the agglutination ofthe parts preserves the continuity of the intestinal canal. The annals of medicine furnish numerous instances, in which long pieces of gut have been discharged in this manner, and the patient has recovered. Hence, some hope may be allowed under the most unpromising circumstances. In a case, related in Duncan's Commentaries, 18 inches of small intestine were voided per anum, vol. 9. p. 278. Three similar instances occur in M. Hevin's memoir; twenty-three inches of colon came away in one of these, and twenty-eight of small intestines in another. Other cases occur in the Physical and Litera- ry Essays, vol. 2. p. 361; in Duncan's Annals, vol. 6. p. 298; in the Med. and Chir. Transactions, vol. 2; where Dr. Baillie states, that a yard of intestine was voided. The patients did not, how- ever, ultimately survive in every one of these instances. (Langstaff, in Edinb. Med. and Surg. Journal.) For information concerning intussus- ceptio, I would particularly refer the reader to M. Hevin in Mem. de I'Acad. de Chir. Hunter's Observations, in the Medical and Chirurgical Transactions. L'Encyclopedic Methodique; Partie Chi- rurgicalc; Art. Gastrotomie. And Lang- staff's Remarks in the Edinburgh Med. and Surgical Journal, No. II. INVERSION OF THE UTERUS. See, Uterus, Inversion of. IRIS, PROLAPSUS OF. As long as the humours, which fill the cav ity of the eve, and in which the iris is im- mersed and suspended, remain in perfect equilibrium with respect to each other, that membrane retains its natural position, and a suitable distance from the cornea. While such an equili- brium continues, the iris, although of a very delicate and yielding texture, contracts, and relaxes itself, without ever forming any irregular fold. But, when the aqueous humour has escaped through an accidental, or artificial, opening in the cornea, the iris is press- ed forward by the humours situated be- hind it, and is urged gradually towards the cornea, until aportion of it protrudes from the eye, at the same opening, through which the aqueous humour made its escape. Thus a small tumour ofthe same culoUr as the iris forms on 88 IRIS. the cornea, and is named, by the majo- rity of surgeons, staphyloma ofthe iris; but, for the sake of distinguishing the disease more particularly from another, to which the term, staphyloma is more properly applicable, Scarpa prefers call- ing it, with Galen, procidentia, or pro- lapsus ofthe iris. The causes of this complaint are such wounds and ulcers of the cornea, as make an opening of a certain extent in- to the anterior chamber of the aque- ous humour, and such violent contu- sions ofthe eye-ball, as occasion a rup- ture of the cornea. If the edges of a wound in this situation, whether acci- dental, made for the purpose of extract- ing the cataract, or evacuating the mat- ter of an hypopium (as is the practice of some), be not brought immediately afterwards into reciprocal contact, or continue not sufficiently agglutinated together to prevent the escape of the aqueous humour from the anterior chamber, regularly as this fluid is re- produced; the iris, drawn by its contin- ual flux towards the cornea, glides be- tween the lips ofthe wound, becomes elongated, and a portion of it gradually protrudes, beyond the cornea, in the form of a small tumour. The same thing takes place, whenever the eye-ball un- fortunately receives a blow, or is too much compressed by bandages, during the existence of a recent wound ofthe cornea. Also, if the patient should be affected, in this circumstance, with a spasm of the muscles ofthe eye, with violent and repeated vomiting, or with strong and frequent coughing, a prolap- sus ofthe iris may be caused. When an ulcer of the cornea penetrates the an- terior chamber of the aqueous hu- mour, the same inconvenience happens more frequently, than when there is a recent wound of that membrane; for, the solution of continuity in the cornea, arising from an ulcer, is attended with loss of substance, and in a membrane so tense, and compact, as this is, the edges of an ulcer do not admit of being brought into mutual contact. The little tumour is likewise neces- sarily ofthe same colour as the iris, viz. brown, or greyish, being surrounded at its base by an opaque circle of the cornea, on which membrane there is an ulcer, or a wound of not a very recent description. As it usually happens, that the cor- nea is only penetrated at one part of its r ircumference by a "wound, or ulcer, -. in practice \v< ' ommonly meet with only one prokipsus of the iris in the same eye. But, if the cornea should happen to be wounded, or ulcerated, at several distinct points, the iris may protrude at several different places of the same eye, forming an equal number of small projecting tumours on the sur- face of the cornea. Scarpa has seen a patient, who had three very distinct protrusions of the iris on the same cor- nea, in consequence of three separate ulcers, penetrating the anterior cham- ber of the aqueous humour; one in the upper, and two in the lower segment of the cornea. If we reflect a little on the delicate structure ofthe iris, the great quantity of blood-vessels which enter it, and the numerous nervous filaments, which proceed to be distributed to it, as a common centre; we shall easily con- ceive the nature, and severity of those symptoms, which are wont to attend this disease, how small soever the por- tion ofthe iris projecting from the cor- nea may be, even if no larger than a fly's head. The hard and continual fric- tions, to which this delicate membrane is then exposed, in consequence of the motions ofthe eye-lids; together with the access of air, tears and gum to it, are causes quite adequate to the pro- duction of continual irritation; and the blood, which tends to the point of the greatest irritation, cannot fail to render the projecting portion of the iris much larger, almost directly after its protru- sion, than it was at the moment of its first passingthrough the cornea. Hence, it becomes, soon after the prolapsus, more incarcerated and irritated, than it was at first. In the incipient state of the complaint, the patient complains of a pain, similar to what would arise from a pin penetrating the eye; next he begins to experience, at the same time, an oppressive sensation of a tight- ness, or constriction, over the whole eye-ball. Inflammation of the conjunc- tiva, and eye-lids, a burning effusion of tears, and an absolute inability to en- dure the light, successively take place. As the protruded portion of the irii drags after it all the rest of this mem- brane, the pupil assumes of mechanical necessity an oval shape, and deviates from the centre ofthe iris, towards the seat of the prolapsus. The intensity of the pain, produced by the inflamma- tion, and other symptoms, attendant on the prolapsus ofthe iris, does not, how- ever, always continue to increase Indeed, in practice, cases of old pro- IRIS. 89 Vusions ofthe iris often occur, where, il'ter the disease has been left to itself, the pain and inflammation spontaneous- ly subside, and the tumour of the iris becomes almost rompletely insensible. Scarpa mentions hi.; having s<;en a man, fifty years of age, who had had a pro- lapsus of the iris in the right eye ten weeks; it was as large as two grains of millet seed; the patient bore it with the greatest indifference, and without any other incoi.v rnience, than a little chronic redness of tic conjunctiva, and a difnvul'v of moving the eye-ball free- ly, inconsequence of the friction ofthe lower eye-li'l : '.a'mst the tumour form- ed by the iris. When the extremity of the finger was applied, the little tumour seemed hard and callous to the touch. This phenomenon was partly owing to the, constriction, which the base of the tumour of the iris suffered between the lips of* the wound, or ulcer of the cornea. The protruded portion of the iris loses its natural exquisite sensibili- ty, in consequence of such compres- sion, or strangulation. The phenome- non was also partly ascribablc to the iris being deprived of its vitality by the induration, and callosity, which were occasioned by the long exposure of this membrane to the air, and tears. In the early stage of this disease, some direct the iris to be replaced in its proper situation by means of a whale- bone-probe; and, in case of difficulty, to make a dilatation of the wound, or ul- cer of the cornea, by an incision, pro- portioned to the exigency of the case, as we are accustomed to do, in order to return a strangulated intestinal hernia. Others only recommend stimulating the prolapsed portion of the iris, with a view of making it contract and shrink into the eye; or suddenly exposing the eye affected to a very vivid light, in the belief, that, as the pupil then forcibly contracts, the piece of the iris, engag- ed between the lips of the wound, or ulcer ofthe cornea, will rise to its pro- per place. However, Scarpa strongly contends that all such methods are ab- solutely useless, and even dangerous. Supposing it were possible, by such at- tempts, to reduce the iris to its proper situation, without tearing, or injuring it in any manner whatever, still the aqueous humour would escape as be- fore, through the wound, or ulcer of the cornea, so that the iris, when re- placed, would fall down, the moment afterwards, and project from the cor- nea, in the same way as before the operation. It cannot be denied, that the prolap- sus of the iris is an afflicting accident but, when it is remembered, tliat surge - ry has no means of suppressing at once, or, at least, of suspending the escape of the aqueous humour through a wound, much less through an ulcer of the cor- nea, when either exceeds certain li- mits, the prolapsus ofthe iris, far from being an evil in such unfavourable cir- cumstances, will be found rather use- ful, and, perhaps, the only means of preventing the total loss ofthe organ <t a portion of the vitreous humour, which, from too much pressure being made on the e\ e, either at the time of the operation, or afterwards, or from a spasm of the muscles of the eye, insinuates itself be- tween the edges ofthe wound after the extraction ofthe cataract, ar.ci projects in the form of a transparent vesicle. The same thing also happens after ul- cers of the cornea, whenever the aque- ous humour has escaped, :.nd a portion ofthe vitreous humour is urged by for- cible pressure towards the ulcer facing the pupil; or whenever an elongated piece ofthe vitreous humour, after the recision of a prolapsed portion of the iris, passes by a shorter route, than through the pupil, between the lips of the ulcer ofthe cornea. At length, we understand, why in both these instan- ces a transparent vesicle forms, even after the recision of the tunic of the aqueous humour, or ulceration of the cornea; and why it very often re-ap- pears in the same place, though it has been cut away to a level with the cor- nea. It is because one or more cells of the vitreous humour, constituting the transparent vesicle, are succeeded af- ter their removal by other cells of the same humour, which glide between the lips ofthe wound, or ulcer of* the cor- nea into the situation ofthe preceding ones. The treatment of this species of pro- lapsus consists in removing the trans- parent vesicle, projecting from the wound, or ulcer, by means of a cutting instrument, and bringing the edges of the wound of the cornea immediately afterwards into perfect apposition, in order that they may unite together as exactly as possible. But, when there is an ulcer of the cornea, as soon as the vesicle is removed, the sore must be touched with the argentum nitratum, so that the eschar may resist any new- prolapsus of the vitreous humour, and at the same time dispose the ulcer of the cornea to granulate and heal. In this kind of prolapsus, what pro- trudes through the cornea is only a subtile little membrane, filled with wa- ISCHURIA. 93 ter, and quite destitute of sensibility. Its detachment from the rest of the eye, is a matter of trivial importance; while, on the contrary, its presence oc- casions all the inconveniences of an ex- traneous substance, that would prevent a wound from uniting, and an ulcer from healing. Hence, the detachment of the protruded vesicle is very justly indicated, and the success ofthe plan is confirmed by practice; doubtless, be- cause the little transparent tumour can, in general, be expeditiously removed, by a stroke ofthe curved convex-edged scissors. But if, in some particular ■ ases, the vesicle should not project sufficiently from the wound, or ulcer of the cornea, to be included in the scis- sors, the same object may be accom- plished by puncturing the tumour with a lancet, orcouching-needle; for, when the limpid fluid which it contains is discharged, the membrane forming it shrinks within the edges of the wound, or ulcer, of the cornea, and no longer hinders the union of the former, or the cicatrization ofthe latter. Should the transparent tumour reap- pear in the same situation, the day after its recision, or puncture, it is right to repeat one of these operations, and to adopt further measures for maintaining the wound ofthe cornea in contact; or, if it should be an ulcer, the eschar must be made to adhere more deeply to its bottom and sides, so as to form a great- er obstacle than before to the escape of the vitreous humour. In such circum- stances, the surgeon must take all pos- sible care to obviate such causes as have a tendency to propel the vitreous humour towards the wound, or ulcer, of the cornea; particularly too much pressure of the eyelids, spasms of the muscles ofthe eye, coughing, sneezing, efforts at stool, mid other similar ones; and care mu t also be taken to check the progress of inflammation. Pellier's two eases (Obs. sur /'uA,*7, p. 350.) on the treatment of this species of transparent v i-sicular prolapsus deserve perusal. To these, if it were requisite, Scarpa says he could add several other similar ones, which have fallen under his own observation, in cases of ulcer of the cornea penetrating the anterior chamber of the aqueous humour, and which were attended with as much success as those related by the French oculist. The choroid coat is, likewise, not ex- empt from prolapsus. Scarpa has seen and cured this complaint in M. Bressa- nini, an apothecary at Bescape. A small abscess formed between the sclerotic and choroid coats, at the distance of two lines from the union of the cornea with the sclerotica, in the inferior he- misphere ofthe globe ofthe eye, in con- sequence of a severe internal and ex- ternal ophthalmy, which had been treated, in its incipient state, with re- pellent remedies. The abscess burst, and discharged a small quantity of thick viscid lymph; then a small blackish bo- dy, composed ofthe choroid coat, pre- sented itself on the outside of the little ulcer of the sclerotica. The treatment consisted in applying the argentum ni- tratum several times to the projecting portion ofthe choroide s, until it was con - sumed, and reduced to a level with the bottom ofthe ulcer ofthe cornea. Then the place healed. The eye remained, however, considerably weakened, and the pupil became afterwards, so much contracted, that it was almost entirely closed. (Scarpa sulk Principali Malla- tie degli Occhi. Venezia. 1802.) Consult also, Richter's Anfangsgriinde der Wundarzneykunst. Band. 3. Von dem Vorfalle der Regenbogenhaut. For a description of the manner of dividing the iris, in order to make an artificial pupil, when the natural one is closed, refer to Pupil, Closure of. A wound of the iris is one of the things most to be feared in extracting a cataract. No sooner does any instru- ment penetrate the eve, than the mus- cles of this organ usually contract in a spasmodic manner, so as to make great pressure on the part, and to urge for- ward the cataract and the iris. In this circumstance, we cannot wonder that the latter should now and then be in- jured by the edge of the instrument. When the iris becomes entangled un- der the knife, Wenzel asserts, that it maybe in% ariably disengaged without injury, by gently touching the cornea with the finger. Richter justly observes, however, (Anfangsgr. der Wu-darzn.) that this artifice is not unattended with some risk of pressing out the aqueous humour; especially, if the irritation of touching the eye should make it move, or the operator in the least disturb the knife. See Cataract. ISCHU'RI A, (from ur^u, to restrain; and vgov, the urine.) A suppression, or stoppage ofthe urine. The distinction between a suppres- sion and retention of urine, is practical 9 drams of this, dissolved in a pint of lime, or distilled water, make an excel- lent lotion for the cure ofthe tinea cap- itis. Many other cutaneous affections yield, also, to the same remedy. When arsenic has been swallowed as a poison, it is best to give first, twenty grains of zincum vitriolatum, as an emetic the quickest in its operation; and, after keeping up the vomiting by drinking warm water, and, what is better, sweet oil, it is recommended to make the pa- tient drink as much as possible of a so- lution ofthe kali sulphuratum, the sul- phur of which is known to blunt the ac- tivity ofthe mineral. KNEE, DISEASES OF. See Arti- culation. KNEE-CAP, its effects in relieving the inconveniences resulting from car tilaginous substances in the knee. See Articulator. J OINTS, DISEASES OF. See Arti- JUGULAR VEIN, how to bleed in. culation. See Bleeding. K LAB :.en 9* L liABIA LEPORINA. See Harelip. LAGOPHTHALMIA, OR LA- GOPHTHALMOS, (from x«>af, a hare; and of Jax^of, an eye.) The Hare's Eye. A disease, in which the eye cannot be shut. The following complaints may arise from it; a constant weeping of the organ, in consequence ofthe inter- ruption of the alternate closure and opening (if the eye-lids, which motions so materially contribute to propelling the tears into the nose; blindness in a strong light, inconsequence ofthe ina- bility to moderate the rays, which fall on the eye; on the same account, the sight becomes gradually very much weakened; incapacity to sleep where f here is any light; irritation, pain, and redness of the eye, from this organ be- ing exposed to the extraneous substan- ces in the atmosphere, without the eye- lids having the power of washing them away, in the natural manner. An enlargement, or protrusion ofthe whole eve, or a staphyloma, may obvi- ously produce lagophthalmos. But, af- fections of the upper eye-lids are the common causes. Heister savs, he has seen the complaint originate from a dis- ease of the lower one. Now and then lagophthalmos depends on paralysis of the orbicularis muscle. A cicatrix, af- ter a wound, ulcer, or burn, is the most frequent cause. When lagophthalmos arises from a paralytic affection of the orbicularis palpebrarum, let the eye lids be rubbed with the tinctura cantharidum, and cold water, or the linimentum campho- rs. Electricity is also considered as a principal means of cure, (Chandler) to- gether with the exhibition of bark, the use of the shower-bath, &c. When the affection arises from spasm ofthe levator palpebrs superioris, elec- tricity, a small blister on the neigh- bouring temple, and rubbing the eye- lid and eye-brow with the tinctura opii, are good means. Internal antispasmo- dic medicines may also be tried. When lagophthalmos arises from the contraction of a cicatrix, its relief is to be attempted precisely on the same principles as the ectropium. (See E'c- tropium.) In some cases, it will not be amiss, especially at night, to lay plasters, drawing in contraiy directions upon each lid, and to assist them by a com- press and bandage. (Chandler.) The inconveniences, depending on the eye being unable to shelter itself from the light, are to be obviated by wearing a green shade, till the disor- der is cured. Whoever is acquainted with Ger- man, and is desirous of more minute in- formation on this subject, may find an excellent account of lagophthalmos in R ichter's Anfangsgr. der Wundarnz. Band. 2. Von dem Hassenauge. See also Chandler on the Diseases of the Eye. Chap. 2. LARYNGOTOMY, (from \agvy$, the larynx; and tijj.iv, to cut.) The cut- ting an opening into the larynx. See Bronchotomy.) LATERAL OPERATION. One mode of cutting for the stone is so termed. (See Lithotomy.) LENS CRYSTALLINE OPAQUE. (See Cataract.) LENTICULAR, (from Unticulairc, doubly convex.) An instrument, con- tained in every trephining case, and employed for removing the jagged par- ticles of bone from the edge of the per- foration, made in the cranium with the trephine. One side of its blade is con- vex, the other concave; and one of its edges is sharp. On the end ofthe blade is fixed a little shallow cup, with its concavity towards the handle ofthe in- strument. This part serves the purpo- ses of receiving the little pieces of bone, when detached, keeping the end of the blade from hurting the dura mater, and, when applied under the margin of the opening, enables the operator to guide the edge ofthe instrument all round it, with steadiness and security. [We take the liberty to remark, with- out fear of contradiction from practical surgeons, that this instrument is never necessary, and that the " trephining case" will be sufficiently perfect wi'1i- out it.1 9G LEU LF.L LEUCOMA, (from xvxvi-'.c.-< its organization. In mh- instance, the ni..tter forming the albugo cannot be absorbed; in the other, it leaves the cornea so much injured, after its ab- sorption, that it continues opaque. (Scarpa.) 1 he recent condition of the disease, without disorganization of the struc- ture of the cornea; its occurrence in young subjects, whose absorbents are readily roused by external stimulants; are circumstances very favourable to the cure. The opacity of albugo in children, arising from severe ophthal- my after the small-pox, and remaining insulated in the centre of the transpa- rent cornea, very often disappears in the course of a few months, even with- out the interference of art. Heister, Langguth, and Richter, have made the same observation. The event can only be imputed to the vigorous action ofthe lymphatics in children, and to the or- ganization of the cornea not being de- stroyed. To promote this absorption, Scarpa has found the following collyri- um a most efficacious one: R. Amnion. muriata J")ij. Cupri acetati gr. iv. Aqua Calcis ,?viij. Misce. To be filtered, af- ter standing twenty-four hours. He praises also this ointment; R. Tu- tia prapar.^y Aloes, s. p. gr. ij. calo- mel'anos gr. ij. Adipis suilla t^ss. Mis- ce. And the unguentum ophthalmicumof Janin. He mentions the gall of the ox, sheep, pike, and barbel, applied to the cornea, two or three times a day, with a small h:nd cannot bear the latter applica- tions, Scarpa has found the oil of wal- nuts, when rather rancid, very benefi- cial; two or three drops being insinua ted into the eye, every two hours, for some months. In others, he has found the juice ofthe lesser centaury, mixed with honey, of service. (Scarpa.) It is generally necessary to persevere very strictly, for at least three or four months, before the case can be reckon- ed incurable. (Scarpa.) All the expedients, proposed for the inveterate albugo, or leucoma from a cicatrix, consisting of scraping or per- forating the layers of the cornea, and exciting ulceration there, are unavail- ing. For, though the enlargement of the cornea should be lessened by such means, its diaphanous state could not be restored; or shoidd the patient per- LIN LIP 97 ctxve a ray or two of light immediately after the operation, the benefit would only be transient; for, as soon as the wound had healed, the opacity would recur. The formation of an artificial ulcer might prove useful, did leucoma depend on a mere extravasation of lymph; but, the fact is, the disease ari- ses from the deposition of an opaque substance, and the disorganization of the texture ofthe cornea, conjointly; in this lies the difference between albugo and leucoma! (Scarpa) See Scarpa sulk Malattie degli Occhi, Venezia; 1802. Richter's Anfangsgrunde der Wundorzn. Band 3. Essays on the Morbid Anatomy ofthe Eye, by J. Ward- rop; Edinb. 1808. chap. 11. LIGATURE, (from ligo, to bind.) In the article Hemorrhage, we have notic- ed, that the immediate effect of a tight ligature on an artery, is to cut through its middle and internal coats, a circum- stance, that tends very much to pro- mote the adhesion of the opposite sides ofthe vessel to each other. Hence, the form and mode of applying a ligature to an artery should be such as are most certain of dividing the above coats of the vessel, in the most favourable man- ner. A broad flat ligature does not pro- mise to answer this purpose in the best manner; because it is scarcely possible to tie it smoothly round the artery, which is very likely to be thrown into folds, or to be puckered by it, and, con- sequently, to have an irregular bruised wound made in its middle and internal coats. (Jones.) A ligature of an irregular form is likely to cut through these coats more completely at some parts than others; and if it does not perfectly divide them, no adhesion can take place, and secondary hemorrhage will follow. A fear of tying the ligature too tight may often lead to the same conse- quences. Tliese, and many other impor- tant circumstances, are noticed in the article Hemorrhage. Ligatures are commonly made of inkle, waxed together with white wax. They should be round, and very firm, s.o as to allow being tied with some force, without risk of breaking. (See Jones on Hemorrhage, p. 172.) LINIMENT, (from lino, to anoint.) A very soft kind of ointment, not much thicker than oil, and intended to be smeared, or rubbed on parts. We shall only mention here, a few of the most useful ones for surgical 'nwpot'-* LINIMENTUM AMMONI1 FOR- TIUS—R. Aq. ammon. pur. gj. Olei olivae^ij. Misce. Used for stimulating the surfaces of parts in which it is wished to excite the action ofthe absor- bents. It is serviceable in removing in- durations, stiffness of the joints, 8tc. LINIMENTUM CALCIS.—R. Aqux calcis, Olei olivs, sing. ^viij. Spirit, vinosi rectificati 3J. Misce.—A common application to burns and SCSLlds LINIMENTUM CAMPHOR.* COMPOSITUM—R. Camph. |ij. Aq. ammon. ^vj. Spirit, lavend. 3xvj- Six- teen ounces are to be distilled ofthe two last ingredients, from a glass retort, and the camphor then dissolved in the distilled fluid.—For bruises, Sprains, ri- gidities of the joints, incipient chil- blains, Sec. LINIMENTUM CAMPHOR/E .ETHEREUM.—R. Camphors gj. i£theris une. ss. Olei viperaruni jij. Misce. The camphor is to be dissolv- ed in the aether, and the oil afterwards incorporated with it. This formula, communicated by Mr. Ware, is adapted to those obscure af- fections of the eye, in which it is not easy to determine, whether the imper- fection of the sight proceeds from an incipient cataract, or a defect of sensi- bility in the optic nerve. The mode of applying it is to mois- ten the finger with it, and to rub it for two or three minutes together, morn- ing and evening, on the outside and edges of the eyelids. (Pharm- Chirur- 1 LINIMENTUM HYDRARGYRI COMPOSITUM.—R. Ung. hydrargy- ri fortioris, Adipis suills, sing. ^j. Camph. 3'ij. Spirit, vinos, rectif. gij. Aq. ammon. pur. ^j.—The camphor being dissolved in the spirit of wine, add the aq. ammon. and the ointment, previously blended with the hog's lard. (Pharm. Sancti Barthol.) A truly excel- lent formula for all surgical cases, in which the object is to quicken the ac- tion of the absorbents, and gently sti- mulate the surfaces of parts. It is a ca- pital application for diminishing the in- durated state of particular muscles, a peculiar affection every now and then met with in practice; and it is particu- larly well calculated for lessening the stiffness and chronic thickening often noticed in the joints. LINIMENTUM SAPONIS COM- POSITUM.—R. Sapon. Jiij. Camph. Vol. II N 98 LIP LIP §j. Spirit, rorismar. Ibj. Dissolve the soap in the spirit, and then add the camphor.—Uses the same as those of the linimentum camph. LINIMENTUM SAPONIS CUM OPIO— R. Lin. sapon. comp. ^vj. Tinct. opii ^ij. Misce—For dispers- ing indurations and swellings attend- ed with pain, but no acute inflamma- tion. LINIMENTUM TEREBINTH- IN^E. R. Ung. resins flavae ^iv. Ol. te- rebinthins, q. s. Misce. The celebrated application for burns, recommended by Kentish. (See Burns) LINIMENTUM TEREBINTH- INj£ VITRIOLICUM.—R. Olei olivs "|x. Ol. terebinth, ^iv. Acidi vitriol. 5*iij. Misce.—Said to be efficacious in chronic affections of the joints, and in the removal of long existing effects of sprains and bruises.—(Pharm. Chirur- gka.) LIP, CANCER OF. The lips are subject to ulcers, wliich put on a very malignant aspect, although they are not in reality malignant; and many of" these, occurring just on the inside of these parts, will be found to depend on the bad state ofthe constitution, and the ir- ritation and disturbance which the sores are continually suffering from the in- cessant motion of the parts, and their rubbing against a projecting, or rough tooth. When cancer takes place, it is usual- ly in the lower, and very seldom in the upper lip. The disease sometimes puts on the appearance of an ulcerated, wart-like excrescence, occasionally acquiring a considerable size. Sometimes it is seen in the form of a very destructive ulcer, which consumes the surrounding sub- stance of the lip; and, in other exam- ples, the disease resembles a hard lump, which, at length, ulcerates. The disease, in its infancy, is often no more than a pimple, which gradually be- comes malignant. Whenever there is reason to believe, that the disease is of an unyielding cancerous nature, the sooner it is extirpated the better. For this purpose, some surgeons admit the propriety of using caustic, when the whole disease can be completely de- stroyed by one application. But, as the action of caustic is not capable of being regulated with so much precision as the extent of a wound can be, and as • austic will not allow the parts to be ' iited again, the knife is the only jus- tifiable means, especially as it occasion also less pain. Two incisions are to be made, meeting at an angle below, (sup- posing it to be the lower lip) and in- cluding the whole of the disease. The sides ofthe wound arc then to be unit- ed with the twisted suture. (See Hare- lip.) When the affection is extensive, however, the surgeon is frequently ne- cessitated to remove the whole ofthe lip, or too much of it to admit of the above plan being followed. This cir- cumstance is particularly unpleasant, as the patient's spittle can only be pre- vented from continually running over his chin by some artificial contrivance. The deformity also is very great, and pronunciation aj)d swallowing can only be imperfectly performed. (First Lines ofthe Practice of Surgery, p. 233.) LIPPITUDO, (from lijbpus, blear- eyed.) Blearedness. The ciliary glands, and lining ofthe eye-lids, only secrete, in the sound state, a mere sufficiency of a sebaceous fluid to lubricate the parts in their continual motions. But, it some- times happens, from disease, that this sebaceous matter is secreted in too' great a quantity, and glues the eye-Uds together during sleep, so that, on wak- ing, they cannot be easily separated. Hence, the margin of the eye-lids be- comes red all round, and the sight itself even weakened. The best remedies are the unguen- tum hydrargyri nitrati, smeared, at night, on the edges and insides of the eye-lids with a hair pencil, after being melted in a spoon; the unguentum tu- tis, applied in the same way; and a col- lyrium, composed of "^j. of zincum vi- triolatum in ^viij. of aquaross. When alterative medicines are requi- site, a grain of calomel may be exhibit- ed daily, or a pill containing one grain of calomel, one of sulphur antimonii prscipitatum, and two of guaiacum, put together with soap. Persons, who have lippitudo and ca- taracts together, bear couching much better than one would expect from tiV appearance of the eyes in that disease; and Mr. Hey never rejects a patient on this account, provided such state is ha- bitual. (Practical Observations, p. 51.) Scarpa, however, recommends reliev- ing the lippitudo before undertaking the operation, as we have explained in the article Cataract. See Chandler on the Diseases of the Eyes, chap. 8. Scarpa sulk Malattie degli Occhi,p. 244. LIT LIT 9vi LITHONTRIPTICS, (from m9«, a stone; and $gvxTa, to break.) Medi- i-ines for dissolving stones in the blad- der. (See Calculus.) LITHOTOMY, (from xi8.<, a stone; and ts/jlvu, to cut.) The operation of cut- ting into the bladder, in order to extract a stone. The symptoms of a stone in the blad- der are, a sort of itching along the pe- Viis, particularly at the extremity of the glans; and hence the patient frequently gets a habit of pulling the prepuce, which becomes elongated; frequent propensities to make water, and go to stool; great pain in voiding the urine, and difficulty of retaining it, and often of keeping the feces from being dis- charged at the same time; the stream of urine is liable to stop suddenly, while flowing in a full current, although the bladder is not empty, so that the fluid is expelled by fits, as it were; the pain is greatest towards the end of, and just after, the evacuation; there is a dull pain about the neck of the bladder, together with a sense of weight, or pressure, at the lower part of the pel- vis; and a large quantity of mucus is mixed with the urine; and, sometimes, the latter is tinged with blood, espe- cially after exercise. (Sharp, Earle, Sa- batier.) All these symptoms, however, are exceedingly equivocal, and may be pro- duced by several other disorders. " Pain in making water, and not being able to discharge the urine without the feces, arc common consequences of ir- ritation of parts about the neck of the bladder, from a diseased prostate gland, and other causes. The urine stoppingin a full stream is frequently caused by a stone altering its situation, so as to ob- struct the passage; but the same thing may happen from a tumour, or fungus in the bladder. I have seen an instance of this, where a tumour, hanging by a small pedicle, would sometimes cause obstruction, and, by altering the pos- ture, would retire, and give a free pas- sage. The dull pain at the neck of the bladder, and the sensation of pressure on the rectum, are frequently owing to the weight of the stone, &c. but these may proceed from a diseased enlarge- ment of the prostate gland. Children generally, and grown persons frequent- ly, are subject to a prolapsus ani, from the irritation of a stone in the bladder; but it will likewise be produced by any irritation in those parts." ( Lurk.) The rest ofthe symptoms are equally falla- cious; a scirrhous enlargement ofthe os tines, and disease of the kidneys, may occasion a copious quantity of mucus in the urine, with pain, irritation, Ike. " The least fallible sign (says Sir James Earle) which I have remarked, is the patient making the first portion of urine with ease, and complaining of great pain coming on when the last drops are ex- pelled. This may readily be accounted for from the bladder being at first de- fended from contact with the stone by the urine; and, at last, being pressed naked against it. But, to put the matter out of all doubt, and actually to prove the existence of a stone in the bladder, we must have recourse to the operation of sounding." A stone in the ureter, or kidneys, or an inflammation in the bladder, from any other cause, will sometimes pro- duce the same effects; but if the patient cannot urine, except in a certain pos- ture, it is almost a sure sign the orifice is obstructed by a stone. If he finds ease by pressing against the perinaeum with his fingers, or sitting with that part up- on a hard body, there is little doubt the ease is procured by taking off' the weight of the stone; or, lastly, if, with the other symptoms, he thinks be can feel it roll in his bladder, it is hardly possible to be mistaken; however, the only sure judgment is to be formed from searching. (Sharp on the Opera- tions.) An enlarged prostate gland is attend- ed with symptoms rescmblingthose of a stone in the bladder; but, with this dif- ference, that the motion of a coach, or horse, does not increase the grievances, when the prostate is affected, while it does so in an intolerable degree incases of stone. It also generally happens, that the fits of the stone come on at inter- vals; whereas, the pain from a diseased prostate is neither so unequal nor so acute. (Sharp in Critical Inquiry, p. 165. Edit. 4.) Though, from a consideration of all the circumstances above related, the surgeon may form a probable opinion of there being a stone in the bladder, yet he must never presume to deliver a posi- tive one, nor ever be so rash as to under- take lithotomy, without having greater reason for being certain that there is a stone to be extracted. Indeed, all pru- dent surgeons, for centuries past, have laid it down as an invariable maxim, ne\crto deliver a decisive judgment, 100 LITHOTOMY nor undertake lithotomy, without hav- ing previously introduced a metallic in- strument, called a sound, into the blad- der, and plainly felt the stone. However, were the symptoms most unequivocal, there is one circumstance which would always render it satisfac- tory to touch the stone with an instru- ment, just before venturing to operate; 1 mean the possibility of there actually- being a stone in the bladder to-day, and not to-morrow. It is now a well-known fact, that stones are occasionally forc- ed, by the violent contractions of the bladder, during fits of the complaint, between the fasciculi of the muscular coat of this viscus, together with a por- tion of the membranous'lining of the part, so as to become what is termed encysted. The opening into the cyst is frequently very narrow, so that the stone is much bigger than the orifice of the cyst, in consequence of which it is impossible to lay hold ofthe extraneous body with the forceps, and the opera- tion would necessarily become fruitless. (Sharp's Critical Inquiry, p. 228. Edit. 4*) In the article Calculus, I have noticed the probability of this having occurred in some of the instances, in which Mrs. Stevens's medicine was supposed to have actually dissolved the stone, in the bladder; for, an encysted stone is not likely to be hit with the sound, nor to cause any inconvenience, com- pared with what a calculus, rolling about in the bladder, usually occasions. With perfect impartiality, I shall next concisely describe the various me- thods of cutting for the stone, begin- ning with the most ancient, called the apparatus minor, and ending with the modern proposal of employing a knife in preference to a gorget. Or THE APPARATUS MINOR, CUT- TING ON THE CRIPE, OR CELSUS's METHOD. The most ancient kind of lithotomy was that practised upwards of two thousand years ago, by Ammonius, at Alexandria, in the time of Herophilas and Erasistratus, and by Meges, at Rome, during the reign of Augustus; and, being described by Celsus, is nam- ed, Lithotomia Celsiana. From cutting directly on the stone, fixed by the pres- sure of the fingers in the anus, it has been called, cutting on the gripe, a knife and a hook being the only instruments used. The appellation of the lesser ap- paratus, was given to it by Marianus, to distinguish it from a method which he described, called the apparatus ma- jor, from the many instruments em- ployed. The operation was done in the fol- lowing way. The rectum was emptied by a glyster, a few hours previously; and, immediately before cutting, the patient was desired to walk about his chamber, to bring the stone down to the neck of the bladder; he was then plac- ed in the lap of an assistant, or secured as now, in the lateral operation. The surgeon then introduced the fore and middle fingers of his left hand, well oil- ed, into the anus; while he, at the same time, pressed with the palm of his right hand on the lower part ofthe abdomen, above the pubes, to assist in bringing down the stone. With the fingers, it is next to be griped, pushed forward to- ward the neck of the bladder, made to protrude, and form a tumour on the left side of the perineum. The operator then took a scalpel, and made a lunated incision through the skin and cellular substance, directly on the stone, and near the anus, down to the neck ofthe bladder, with the horns towards the hips. Then, in the deeper and narrower part ofthe wound, is to be made a se- cond incision, also transverse, into the neck ofthe bladder itself, till the flow- ing out ofthe urine shows the incision to exceed, in some degree, the size of the stone. The calculus, being strongly pressed upon with the fingers, next started out of itself, or was extracted with a hook for the purpose. (Celsus, lib. 7. cap. 26. J. Bell's Principles, vol. 2. p. 42. Allan on Lithotomy, p. 10 ) The objections to cutting on the gripe, are, the impossibility of always dividing the same parts; for, those which are cut will vary, according to the degree of force employed in making the stone project in the perinxum. When little exertion is made, if the in- cision be begun just behind the scro- tum, the urethra may be altogether de- tached from the prostate; if the stone be much pushed out, the bladder may be entered beyond the prostate, and both the vesiculs seminales and vasa defe- rentia inevitably suffer. Lastly, if the parts are just sufficiently protruded, the bladder will be cut upon its neck, through the substance of the prostate gland. (Allan on Lithotomy. Burns, in Edinb. Surg. Journal, No. 13. J. Bell, vol. 2. p. 59.) The preceding dangers were known LITHOTOMY 101 to Fabricius Hildanus, -who attempted to obviate them by cutting on a staff, in- troduced along the urethra into the bladder. He began his incision in the perinsum, about half an inch in the side ofthe raphe; and he continued the cut, inclining the knife, as he proceeded, to- wards the hip. He continued to divide the parts till he reached the staff; after which, he enlarged the wound to such an extent, as to permit him easily to ex- tract the stone, whichhe had previous- ly brought into the neck ofthe bladder, by pressure with the fingers in the rec- tum. He employed a hook to extract the stone. (Burns.) In this way, Mr. C. Bell has operated with success. (J- Bell.) The apparatus minor, as practised by Fabricius, with the aid of a staff, is certainly so simple and safe an opera- tion for children, that we must lament its present utter neglected state. You cut, says an eminent writer, upon the stone, and cut, of course, with perfect security, an incision exactly proportion^ ed to its size. There is no difficult nor dangerous dissection; no gorget, nor other dangerous instrument, thrust into the bladder, with the risk of its passing betwixt that and the rectum; you are performing, expressly, the lateral inci- sion of Raw and Cheselden, in the most simple and favourable way. (J. Bell.) The prisca simplicitas instrumentorum seems, indeed, as the latter gentleman remarks, to have been forsaken, for the sake of inventing more ingenious and complicated operations. Celsus has delivered one memorable precept in his description of lithotomy, ut plaga paulo major, quam calculus sit; and he seems to have known very well, that there was more danger from lace- rating, than cutting the parts. The simplicity of the operation em- boldened every quack to undertake its performance; and thus, by diminishing the emolument of regular practitioners, became the grand cause of its downfal. (See Heister on this subject.) It was longer practised, however, than all the other methods; and was performed at Bourdeaux, Paris, and other places in France, on patients of all ages, by Raoux, even as late as 140 years of age. Frere Jacques occasionally had re- course to it; and it was successfully executed by Heister. (Part 2. chap. 140.) A modern author recommends it always to be preferred on boys, under fourteen. (Allan, p 12 ) APPARATUS MAJOR, So named from the multiplicity of in- struments employed: or the Marian me- thod, from having been first published by Marianus Sanctus, in 1524, as the invention of his master, Johannes de Romanis. (See Marianus delapide Vesi- ca per incisionem extrohendo.) This operation, which came into vogue, as we have noticed, from avari- cious causes, was rude and painful in its performance, and very fatal in its consequences. The apology for its in- troduction, was the declaration of Hip. pocrates, that wounds of membranous parts are mortal. It was contended, however, that such parts might be di- lated with impunity; and, on this prin- ciple of dilatation, Romanis invented a complex and dangerous plan of operat- ing; one very incompetent to fulfil the end proposed; one, which, though sup- posed only to dilate, really lacerated the parts. (Burns.) The operator, kneeling on one knee, made an incision, with his razor, along the perinsum, on one side ofthe raphe; and, feeling with his little finger for the curve ofthe staff, he opened the mem- branous part ofthe urethra; and, fix- ing the point ofthe knife in the groove of his staff, gave it to an assistant to hold, while he passed a probe along the knife into the groove of the staff", and thus into the bladder. The urine now flowed out, and the staff' was with- drawn. The operator next took two conductors, a sort of strong iron probes; one, named the female conductor, hav- ing in it a groove, like one of our com- mon directors; the other, the male con- ductor, having a probe point, corres- ponding with that groove. The groov- ed, or female conductor, being intro- duced along the probe into the bladder, the probe was withdrawn, and the male conductor passed albng the groove of the female one, into the bladder. Then commenced the operation of dilating. The lithotomist took a conductor in each hand, and, by making their shafts diverge, dilated, or. in plain language, tore open the prostate gland.—(J. Bell.) It would be absurd in us to trace the various dilating instruments, contrived for the improvement of this barbarous operation, by the Collots, Le Dran, Par£, - LITHOTOMY 105 ed to his new edition of Douglas's Appen- dix. Edinburgh, 1808. The instruments, which Cheselden employed in his third, and most im- proved, mode of cutting for the stone, were a staff", an incision knife, a gorget, a pair of forceps, and a crooked needle carrying a waxed thread. The patient being placed on a table, his wrists are brought down to the outsides of his ankles, and secured there by proper bandages, his knees having first been bent, and his heels brought back near his buttocks. Mr. Cheselden used then to take a catheter, first dipped in oil, and intro- duce it into the bladder, where having searched for, and discovered the stone, he used to give the instrument to one of his colleagues, whom he desired to satisfy himself, whether there be a stone, or not. The assistant, standing on his right hand, held the handle of the staff between his fingers and thumb, inclined it a little towards the patient's right thigh, and drew the convex side close up to the os pubis, in order to re- move the urethra as far as possible from the rectum. The groove of the staff being thus turned outwardly and laterally, Chesel- den used to sit down in a low chair, and, keeping the skin of the perinsum steady with the thumb and forefinger of" his left hand, he made the first, or outward incision, through the integu- ments, from above downwards, begin- ning on the left side of the raphe, be- tween the scrotum and verge of the anus, almost as high up as where the skin of the perinsum begins to form the bag containing the testicles.Thence, he continued the wound obliquely out- wards, as low down as the middle of the margin of the anus, at about half an inch distant from it near the skin, and, consequently, beyond the tubero- sity of the ischium. He was always careful to make this outward wound as large as he could with safety. Having cut the fat rather deeply, especially near the rectum, he used to put his left forefinger into the wound, and keep it there till the internal incision was quite finished; first to direct the point of his knife into the groove of his staff', wliich he now felt with the end of his finger, and likewise to hold down the rectum, by the side of which his knife was to pass, and so prevent its being wounded. This inward incision Cheselden made with more caution, than the former. His knife first entered the groove of the rostrated, or straight part ofthe cathe- ter, through the sides of the bladder, immediately above the prostate, and, afterwards, the "point of it continuing to run in the same groove in a direction downwards, and forwards, or towards himself, he divided that part of the sphincter of the bladder, which lies upon that gland, and then he cut the outside of one half of it obliquely, ac cording to the direction and whole length ofthe urethra, that ran within it, and finished his internal incision, by dividing the muscular portion of the urethra on the convex part of his staff. A sufficient opening being made, Cheselden used to rise from his chair, his finger still remaining in the wound Next he put the beak of his gorget in the groove ofthe staff, and then thrust it into the bladder. The staff was now withdrawn, and, while he held the gorget with his left hand, he introduc- ed the forceps, with the flat side up- permost, sliding them with great cau- tion along the concavity of the gorget. When they were in the bladder, he withdrew the latter instrument, and taking hold ofthe two branches ofthe forceps with both his hands, he search- ed gently for the stone, having them still shut. As soon as this was felt, he used to open them, and try to get the lower blade under the stone, that it may fall more conveniently into their chops, and be laid hold of. This being done, the stone was extracted with a very slow motion, in order to give the parts time to stretch a*hd dilate, turn- ing the forceps gently in all directions. When the stone was very small, and did not lie well in the forceps, Chesel- den used to withdraw them, and intro- duce his finger into the bladder, in or- der to try to turn the stone, and disen- gage it from the folds of the lining of the bladder, in which it is sometimes entangled. Then the gorget was passed in again on the upper side of his finger, and turned as soon as the latter was pulled out; the forceps were introduc- ed, and the stone extracted. To preserve a soft stone from break- ing, during its extraction, he used to put one or more of his fingers between the branches of his forceps, to prevent any greater pressure upon it than what was just necessary to hold it together. But, when it did break, or there were more than one, he used to extract the single stones, or fragments, one after Vol. II. O 106 LITHOTOMY. another, repeating the introduction of his fingers and forceps, as often as there was occasion. Cheselden took care not to thrust the forceps so far into the bladder as to bruise, or wound its opposite side; and he was equally careful not to pinch any folds of its in- ner coat. In this way, Cheselden saved 50 patients out of 52, whom he cut suc- cessively in St. Thomas's Hospital. (Appendix to the History of the Lateral Operation by J. Douglas. 1731.) Cheselden, with all the enthusiasm of an inventor, believed, that he had discovered an operation, which was not susceptible of improvement; yet, he himself changed the manner of his incision no less, than three times in the course of a few years. 1st, He cut into the body of the bladder, behind the prostate, when he imitated Raw. 2dly, He cut another part ofthe bladder, viz. the neck and the thick substance ofthe prostate; this is his lateral mode of in- cision. 3dly, He changed a third time, not the essential form of the incision, but, the direction, in which he moved the knife; for, in his first operation, when imitating the supposed operation of Raw and Frere Jacques, he struck his knife into the body of the bladder, betwixt the tuber ischii and the vesi- culx seminales, and all his incision lay behind the prostate gland. In his se- cond operation, he struck his knife into the membranous part of the urethra, immediately behind the bulb, and ran it down through the substance of the gland; but, his incision stopped at the membranous part, or body, ofthe blad- der. But, in his third operation, he, after very large external incisions, struck his knife deeply into the great hollow under the tuber ischii, entered it into the body of the bladder imme- diately behind the gland, and, drawing the knife towards him, cut through the whole substance ofthe gland, and even a part of the urethra, "cutting the same parts the contrary way." By car- rying the forefinger of the left hand be- fore the knife, in dissecting towards the body of the bladder, he protected the rectum more perfectly, than he coidd do in running the knife back- wards along the groove of the staff; and by striking his knife into the body ofthe bladder, and drawing it towards him, through the whole thickness of the gland, he was sure to make an am- ple wound. (J. Bell's Principles of Sur- gery, vol. II. part 1, p. 152) LATERAL OPERATION AS PERFORM- ED A 1 THE PRESENT DAY WITH CUTTING GORGETS. •The gorget is the same instrument as the conductor used by Hildanus; but, having a cutting edge; and it was used in the Marian operation as a dilator and conductor for the forceps. Sir Cssar Hawkins thought, that, when its right side was sharpened into a cutting edge, it might be pushed safely into the blad- der, guided by the staff, and make the true lateral incision, in the left side of the prostate gland.more easily, and with less risk of injuring the adjacent parts, than Cheselden could do with the knife, and surgeons were pleased with a con- trivance, which saved them from the re- sponsibility of dissecting parts, with the anatomy of which all were not equal- ly well acquainted. (J. Bell. Allan.) When the patient is of a plethoric ha- bit, 16, or 20 ounces of blood should be taken from his arm two days before the operation; a brisk purge administered the day before; and a clyster injected a couple of hours before cutting, in order to empty the rectum, and render it less liable to be wounded. It is to be lament- ed, that these prudent steps are so often neglected. As it is advantageous to have the bladder somewhat distended with urine, the patient should be requested to retain it a certain time before being cut. When this cannot be done, as in children, some advise tying a ligature round the penis, or applying, what is called, a jugum, to prevent the patient from making the evacuation. The best practitioners in London, however, do not commonly adopt this method. Before the operation, the following instruments should all be arranged rea- dy on a table: three grooved staffs, of various sizes; a sharp gorget, with a beak nicely and accurately adapted to the grooves of the staffs, so as to glide easily and securely; a large scalpel for making the first incisions; forceps, of various sizes, for extracting the stone; a blunt-pointed bistoury for enlarging the wound in the prostate, if the inci- sion of the gorget is not sufficiently large, as the parts should never be la- cerated: a pair of Le Cat's forceps with teeth for breaking the stone, if too large to come through any wound reasonably dilated; a syringe for injecting the blad- der, if necessary, to wash out clots of blood, or particles ofthe stone; a scoop LITHOTOMY. 107 for the latter purpose; two garters to tie the patient's hands to his feet After introducing the staff, and feel- ing that the stone is certainly in the bladder, the patient is to be secured in the same position, as we described in the account of Cheselden's latest me- thod of operating. The assistant, holding up the scro- tum with his left hand, is with his right to hold the staff*, inclining its handle to- wards the right groin, to make the grooved convexity of the instrument turn towards the left side of the peri- nsum. Some operators, also, like the assistant to' depress the handle of the staff' towards the patient's abdomen, in order to make its convexity project in the perinsum, while others condemn this plan, asserting, that it withdraws the instrument from the bladder. (Al- lan, &c.) The first incision should always com- mence, below the bulb ofthe urethra, over the membranous part of this canal, at the place, where the operator means to make his first cut into the groove of the staff, and the cut should extend about three inches, obliquely down- ward,to the left ofthe raphe ofthe pe- rinsum, at equal distances from the tu- berosity of the ischium and the anus. In a large man, the first cut should pass the anus an inch and a half or more; for, it is a general rule in surgery to make free external incisions, by which the surgeon is enabled to conduct the re- maining steps of his operation with greater facility, and no where is it so necessary, as where a stone is to be ex- tracted. (Allan.J The next object is to divide the transversalcs perinsi mus- cles, wliich stand, like a bar, across the triangular hollow, out of which alone the stone can be easily extracted. An opening is next to be made into the membranous part of the urethra, and now the operator has to accomplish a very important object, and one which is, for the most part, very much neglect- ed; I allude to dividing the urethra with the knife, as far as possible along the groove of the staff, towards the blad- der. When this is properly done, very little remains to be effected by that rougher instrument, the gorget. Having placed the beak of the gor- get in the groove of the staff, the ope- rator takes hold ofthe latter instrument himself, raises its handle from the right groin, so that it may form nearly aright angle with the body, and he stands up. Before attempting to push the gorget onwards into the bladder, he should slide it backwards and forwards, with a wriggling motion, that he may be sure its beak is in the groove of the staff". The bringing forward the handle of the latter instrument, so as to ele- vate its point, before introducing the gorget into the bladder, is also of im- mense importance, for, it is by this means, that the gorget is introduced, along the groove of the staff in the axis of the bladder, the only direction, un- attended with risk of wounding the rectum. In fact, the gorget should be introduced nearly in a direction, cor- responding to a line drawn from the os coccygis to the umbilicus. As soon as the gorget is introduced, the staffis to be withdrawn. Some ope- rators next pass the forceps, along the concave surface of the gorget, into the bladder; while others, with every ap- pearance of being right, recommend the cutting gorget to be withdrawn imme- diately it has completed the wound; for, then the bladder contracts violently, and its fundus would be veiy apt to be cut, if the gorget were not withdrawn. This should be done in the same direction, in which it entered, pressing it towards the right side to prevent its making a second wound in coming out. If the operator should prefer passing the for- ceps into the bladder, along the gorget, th* latter instrument must be kept quite motionless, lest its sharp edge should do mischief; and, at all events, imme- diately the forceps is in the bladder, the cutting gorget is to be withdrawn. Some operators withdraw the cut- ting gorget, and introduce a blunt one for the guidance of the forceps; a step certainly unnecessary as the latter in- strument will easily pass, when the in- cision into the bladder is ample and di- rect, as it ought always to be. The operator has next to grasp the stone with the blades of the forceps; for which purpose, he is not to expand the instrument, as soon as it has arrived in the bladder; but, he should first make use of the instrument as a kind of probe, for ascertaining the exact situation of the stone. If this body should be lodg- ed at the low er part of the bladder, just behind its neck, the operator is to open the instrument immediately over the stone, and, after depressing the blades a little, is to shut them, so as to grasp it. Certaiuly, it is much more scientific to use the forceps at first, merely to as- 108 LITHOTOMY. certain the position of the stone; for, when this is known, he is much more able to grasp the extraneous body in a skilful manner, than if he were to open the blades of the instrument immedi- ately, without knowing where they ought next to be placed, or when shut. No man can doubt, that the injury, which the bladder frequently suffers, from rough, reiterated, awkward movements ofthe forceps, is not an un- common cause of such inflammation of this viscus, as too often extends to the peritonsum, and occasions death. When the surgeon cannot readily get hold of the stone with the forceps, he should introduce his fore and middle fingers into the rectum, and raise the extraneous body up, when it may gene- rally be easily grasped.The stone should be held with moderate firmness to keep it from slipping from the blades, but, not so forcibly as to incur the risk of its breaking. Sometimes, the extraction of the stone is attended with difficulty, owing to the operator having chanced to grasp it in a transverse position, in which cir- cumstance, it is better to try to change its direction, or let it go altogether, and take hold of it in another manner. When the stone is so large, that it cannot be extracted from the wound, without vio- lence and laceration, the surgeon may either break the stone with a strong pair of forceps, with teeth constructed for the purpose; or he may enlarge the wound with a probe-pointed crooked bistoury, introduced under the guid- ance of the forefinger of the left hand. The latter plan is generally the best of the two; for, breaking the stone is an exceedingly unpleasant circumstance, as it creates such a danger of calcul- ous fragments remaining behind. However, as nothing can justify the exertion of force in pulling out a stone, if the operator should be afraid of mak- ing the wound more ample, (its being already large and direct) he must break the stone, as above described. As many ofthe fragments are then to be extract- ed with the common lithotomy forceps, as can be taken away in this method, after which the surgeon should intro- duce his finger, in order to feel, whe- ther any pieces ofthe stone still remain behind. Perhaps, some of these may be most conveniently taken out with the scoop; but, if they are very small, it is best to inject lukewarm water with moderate force into the wound, for the purpose of washing them out. The stone should always be examin- ed immediately it is extracted; because, its appearance conveys some informa- tion, though not positive, concerning the existence of others. If the stone is smooth on one surface, the smoothness is generally found to arise from the fric- tion of other stones still in the bladder; but, when it is uniformly rough, it is a presumptive sign, that there is no other one remaining behind. In every in- stance, however, the surgeon should in- troduce his forefinger, for the purpose of examining; for, it would be an inex- cusable neglect to put the patient to bed, with another stone in his bladder. After the operation, a simple pledget should be laid on the wound, and sup- ported with a T bandage; the patient should lie in bed on his back, with his thighs closed; folded cloths should be laid under him to receive the urine; and a large opiate administered, as after all grand operations. OF SOME PARTICULAR METHODS AND INSTRUMENTS. M. Foubert, a very eminent surgeon at Paris, devised and practised a plan of his own, which, however, has not been considered by others, as worthy of being imitated. The patient, having re- tained his urine, so as to distend his bladder, an assistant, wi^h a convenient bolster, presses the abdomen a little below the navel, in such a manner, that by pushing the bladder forwards, he may make that part of it protuberate, wliich lies between the neck and the ureter. The operator, at the same time, introduces the forefinger of his left hand up the rectum, and drawing it down towards the right buttock, pushes in a trocar on the left side of the peri- nsum, near the great tuberosity of the ischium, and about an inch above the anus. Then the trocar is to be carried on parallel to the rectum, exactly be- tween the erector penis and accelera- tor urins muscles, so as to enter the bladder on one side of its neck. As soon as the bladder is wounded, the operator withdraws his forefinger from the anus. In the upper part of the cannula of the trocar, there is a groove, the use of wliich is to allow some urine to escape, immediately the instrument enters the bladder, that the trocar may not be pushed in any further; but, its principal use is for guiding the incision. As soon LITHOTOMY. 109 n which death could be imputed to hemorrhage, not- withstanding the bleeding has often been so profuse, and from so deep a source, just after the operationjfcs to leave no doubt, that it proceedecTfrom the internal pudendal artery. Such he- morrhage generally stopped before the patient was put to bed. The majority of patients, who die after lithotomy, perish of peritoneal in- flammation. Hence, on the least occur- rence of tenderness over the abdomen, copious venesection should be put in practice. At the same time, eight or ten leeches should be applied to the hypo- gastric region. The belly should be fo- mented, and the bowels kept open with the oleum ricini. The feebleness ofthe pulse should not deter the practitioner from using the lancet; this symptom is only fallacious; and it is attendant on all inflammation within the abdomen. To- gether with the above measures, the warm bath, a blister on the lower part of the abdomen, and emollient glys- ters, are highly proper. I have seen se- veral old subjects die of the irritation of a diseased thickened bladder, con- tinuing after the stone was extracted. They had not the acute symptoms, the inflammatory fever, the general tender- ness and tension of the abdomen, as in cases of peritonitis; but they referred their uneasiness to the lower part of the pelvis; and, instead of" dying in the course of two or three days, as those usually do, who perish of" peritoneal inflammation, they, for the most part, lingered for two or three weeks after the operation. In these cases, opiate glysters, and blistering the hypogastric region, are the best measures. In some instances of this kind, abscesses form about the neck ofthe bladder. Whoever wishes to acquire a per- feet knowledge of the history of litho- tomy, should consult the "following works: Celsus de Re Medico, lib. 7. cap. 26. Remarques sur la Chirurgie de Chau- liac, par M. Simon de Mingelouzeaux, torn. 2; Bourdeaux, 1663. La Legende du Gascon par Drelincourt; Paris, 1665. Van Home's Opuscula. Marianus de La- pide Vesica per Incisionem extrahendo; 1552. Parallele des Differentes Manieres de tirer la Pierre hors de la Vessk; 1730. Sharp's Operations. Sharp's Critical In- quiry. Le Dran's Operations, Edit. 5; J LOT LOT 117 London, 1781. Franco's Traite des Her- mes,- 1561. Rosetus de Partu Casario. Traite' de la Lithotomie, par Tolct. Heister's Surgery, Part 2. Lithotomia Douglassiana; 1723. Morand de alto Ap- paratu. Observations sur la Maniere de Tailler, lye. pratiquiepar Frere Jacques; par J. Mery. Cours d'Operations de Chi- rurgk par Dionis. Traitt des Operations par Garengeot, tom. 2. .Morand Opuscules de Chirurgie. Bertrandi Traite des Ope- rations. Index Supelkctilis Anatomica Ravidna,- Leida, 1725. Le Cat, Recueil ik Piices sur {'Operation de la Taille, Part 1; Rouen, 1749. Cosme, Recueil de Piece* Anatomiques importantes sur rOptration de la Taille; Paris, 1751— 1753. J. Douglas, Postcript to Hist, of the Lateral Operation; 1726. Cheselden's Anatomy, 1730,- and subsequent editions. J. Douglas, Appendix to Hist, of the La- teral Operation; 1731. A short Historical Account of Cutting' for the Stone, by W. Cheselden, in his own last edition of his Anatomy. John Bell's Principles of Sur- ■gery, vol. 2. part 1. Burns, in Edinb. Med. and Surg. Journal, January 1808. C Bell's Operative Surgery, vol. 1, 1807. Sabatier, dg l& Medecine Operatoire, tom. 2, 1796. Thompson's Observations on Lithotomy;Edinb. 1808. Allan's Trea- tise on Lithotomy; Edinb. 1808. Mark's Practical Observationt>m the Stone; 1796, Edit. 2. (Euvres Chirurgicaks de Desault par Bichat; tom. 2.—For a minute de- scription and delineations of the parts concerned in the operation, see Cam- per's Demonstrationes Anatomico-patho- logica, lib. 2. LOTION, (from lavo, to wash.) Lo- tio. An external fluid application. Lo- tions are usually applied by wetting linen in them, and keeping it on the part affected. The following are some of the most useful in the practice of surgery. LOTIO ALUMINIS.—R. Alumi'- nis purif. ^ss. Aqus distillats lbj. Misce.—Sometimes used as an astrin- gent injection: sometimes as an appli- cation to inflamed parts. LOTIO AMMONIA ACETATE. —R. Aqus ammon. acetats; Spirit, vin. rectif.; Aqus distillats; sing. giv. Misce.—Properties discutient. LOTIO AMMONIA MURIATE. —R. Amnion, muriate §j. Spirit, roris- marini lbj.— Has the same virtues as the preceding. Justamond recommend- ed it in the early stage of the milk- breast. LOTIO AMMONIA MURIATA CUM ACETO.—R. Ammon. Mur. |ss. Aceti, Spirit, vinos, rectif. sing. mi. Misce. This is one of the most effica- cious discutient lotions. It is, perhaps, the best application for promoting the absorption of extravasated blood, in cases of eccthymosis, contusions, sprains, 8uw LOTIO \MMONIA OPIATA.— R. Spiritus ammon. comp. ^iiiss. Aqus distillats 3iv. Tinct. opii £ss. Misce.— Applied by Kirkland to some suspicious swellings in the breast, 'Soda and bark being also given internally. LOTIO CALCIS COMPOSITA. —R. Aqus calcis lbj. Hydrargyri mu- riati gj. Misce.—Properties strongly astringent. Ring-worms, tetters, and some other cutaneous affections yield to this application, which, however, should generally be dduted. In the lat- ter state, it may occasionally be used as an injection for various purposes. LOTIO GALEA—R. Gallarum contusarum sjij. Aqus ferventis lbj. To be macerated one hour, and strain- ed.—This astringent lotion is some- times used with a view of removing the relaxed state of the parts, in cases of prolapsus ani, prolapsus uteri, &c. LOTIO HYDRARGYRI AMYG- DALINA.—R. Amygdalarum amara- rum Sij. Aqus distill, ifeij- Hydrarg. mur. ^j. Rub down the almonds with the water, which is to be gradually poured on them; strain the liquor, and then add the muriated mercury. This will cure several cutaneous herpetic affections. LOTIO HYDRARGYRI MURIA- TI.—R. Hydrargyri muriati gr. ijss. Arabici gummi 3SS. Aqus distillats lbj- Misce.—This is the injection of corrosive sublimate in use at St. Bar- tholomew's Hospital. LOTIO HYDRARGYRI MURIA- TI COMPOSITA— R. Hydrarg.mur. gr. x. Aq. distillat. bullientis §iss. Tinct. canthar. ijss. Misce.—This was ordered, by Dr. H. Smith, to be ap- plied every night to scrofulous swel- lings. LOTIO HELLEBORI ALBI—R. Decocti hellebori albi lbj. Kali sulphu- rati ^ss. Misce.—This is occasionally employed as an application for curing tinea capitis, and some other cutaneous diseases. LOTIO KALI SULPHURATI — R. Kali sulph. Jij. Aqus distill, lbj. Misce.—It is used in the same cases as the preceding one 118 LUMBAR ABSCESS. LOTIO LITHARGYRI ACETA- TL—R. Aqus litharg. acet. 31}. Aq. distill. Ibij- Spirit, vinos, tenuioris 3y. —The first and the last ingredients are to be mixed before the water is added. This is the common whitewash, an application, that is so universally known as the usual saturnine amplication in cases of inflammation, &.c.Tnat we need say nothing more concerning it. LOTIO OPII— R. Opii purif. Sjss. Aqus distillats lbj. Misce.—A very excellent application to irritable pain- ful ulcers of every description. It is best to dilute it, especially at first. LOTIO PICIS—R. Picis liquids 3*iv. Calcis^vj. Aqus ferventis Ibiij-— To be boiled till half the water is eva- porated. The rest is then to be poured off for use. This application is some- times employed for the cure of tinea capitis; it is also of singular service in removing an extensive scorbutic red- ness, frequently seen on the legs, toge- ther with old ulcers. LOTIO ZINCI VTTRIOLATI — R. Zinci vitriolati 3J. Aq. ferventis ibj. Misce. This is sometimes used by prac- titioners in lieu of the lotio aq. litharg. acet. The free external application of lead has sometimes been suspected of bringing on bad effects, in consequence of absorption; and some surgeons, therefore, advise the employment of this lotion instead of it, which, in all probability, also, is equally efficacious. When diluted, by adding two pints more water, it forms the common injec- tion, so much recommended in cases of gonorrhoea. LUES VENEREA. Venereal Disease. See this article. LUMBAR ABSCESS. Psoas Ab- scess. By these terms are understood chronic collections of matter, which form in the cellular substance of the loins, behind the peritonsum, and de- scend in the course of the psoas mus- cle. Patients, in the incipient stage of the disease, cannot walk so well as usual; they feel a degree of uneasiness about the lumbar region; but, in gene- ral, there has been no acute pain, even when the abscess has acquired such a size as to form a large tumour, pro- truding externally. In short, the psoas abscess is the best instance, which can possibly be adduced, in order to illus- trate the nature of those collections of matter, which are called chronic, and •vhich form in an insidious manner, without serious pain, or any other at- tendant of acute inflammation. The abscess sometimes forms a swel- ling above Poupart's ligament; some- times below it; and frequently the mat- ter glides under the fascia ofthe thigh. Occasionally, it makes its way through the sacro-ischiatic foramen, and as- sumes rather the appearance of a fistu- la m ano. When the matter gravitates into the thigh, beneath the fascia, Mr. Hunter would have termed it a disease in, not of, the part. The uneasiness in the loins, and the impulse communicat- ed to the tumour by coughing, evince, that the disease arises in the lumbar region; but, it must be confessed, that we can hardly ever know the existence of the disorder, before the tumour, by presenting itself" externally, leads us to such information. The lumbar abscess is sometimes connected with diseased vertebrs, which may either be a cause, or an effect, of the collection of mat- ter.—The disease, however, is fre- quently unattended with this complica- tion. The disease ofthe spine, we may in- fer, is not of the same nature as that treated of by Pott, as there is usually no paralysis. When the bodies of patients with lumber abscesses are opened, it is found, that the matter is completely enclosed in a cyst, which, in many cases, is, of course, very extensive. If the contents of such abscesses were not circumscribed by a membranous boun- dary in this manner, we should have them spreading among the cells ofthe cellular substance', just like the water ii» anasarca. The cysts are both secret- ing and absorbing surfaces, as is proved by the great quantity of matter, which soon collects again after the abscess has been emptied, and by the occasional disappearance of large palpable collec- tions of matter of this kind, either spon- taneously, or in consequence of means which are known to operate by exciting the action of the absorbents. In short, the cyst becomes the suppurating sur- face, and suppuration is now well as- certained to be a process, similar to glandular secretion. While the abscess remains unopened, its contents are al- ways undergoing a change; fresh mat- ter is continually forming, and a portion of what was in the cyst before is under- going an incessant removal by the ab- sorbents. This is not peculiar to lum- bar abscesses; it is common to all, both LUMBAR ABSCES . 119 chronic and acute, buboes and suppu- rations in general. It is true, that, in acute abscesses, there often has not been time for the formation of so dis- tinct a membrane as the cyst of a large chronic abscess; but its matter is equal- ly circumscribed by the cavities of the cellular substance being filled with a dense coagulating lymph; and, though it generally soon makes way to the sur ■ face, it also is occasionally absorbed. The best modern surgeons make it a common maxim to open very few acute abscesses; for, the matter naturally tends with great celerity to the surface ofthe body, where ulceration allows it to escape spontaneously; after which, the case generally goes on better, than if it had been opened by art. But, in chronic abscesses, the matter has not that strong tendency to make its way out- ward; its quantity is continually increas- ing; the cyst is, of course, incessantly growing larger and larger; in short, the matter, from one ounce, often gradual- ly increases to the quantity of a gallon. When the disease is at length opened, or bursts by ulceration, the surface of the cyst, irritated by the change, in- flames; and its great extent, in this cir- cumstance, is enough to account for the terrible constitutional disorder, and fa- tal consequences, which too frequently soon follow the evacuation ofthe con- tents of such an abscess. Hence, in cases of chronic suppurations of every kind, and not merely in lumbar ones, it is the surgeon's duty to observe the op- posite rule to that applicable to acute cases; and he is called upon to open the collection of fnatter, as soon as he is aware of its existence, and its situation will allow it to be done. Certainly, it would be highly advan- tageous to have some means of ascer- taining whether the vertebra are also diseased; for, as in this instance, the morbid bones would keep up suppura- tion, until their affection had ceased, and there would be no reasonable hope of curing the abscess sooner, it might be better to avoid puncturing it under such circumstances. The propriety of, this conduct seems the more obvious, as issues, which are the means most likely to stop and remove the disease of the spine, are also such as afford most chance of bringing about the absorption of the abscess itself. However, if the collection cannot be prevented from dis- charging itself, and ulceration is at hand, it is best to meet the danger, make an opening with a lancet, in a place at some distance from where the pointing threatens, and afterwards heal it, in the way we shall presently de- tail. Though we have praised the pru- dence of opening all chronic abscesses while small, the deep situation of the lumbar one, and the degree of doubt always involving its early state, unfor- tunately prevent us from taking this be- neficial step in the present case. But, still the principle is equally praisewor- thy, and should urge us to open the tu- mour as soon as the fluctuation of the matter is distinct, and the nature ofthe ease is evident. For this purpose, Mr. Abernethy employs an abscess lancet, which will make an opening large enough for the discharge of those flaky substances so frequently found blended with the matter of lumbar abscesses, and by some conceived to be an em- blem of the disease being scrofulous. Such flakes seem to consist of a part of the coagulating matter of the blood, and are very commonly secreted by the peculiar cysts of scrofulous abscesses. The puncture must also be of a certain size to allow the clots of blood, occa- sionally mixed with the matter, to es- cape. Mr. Abernethy considers the opening of a lumbar abscess, a very de- licate operation. Former surgeons used to make large openings in these cases; let out the contents; leave the wound open; the usual consequences of which were, great irritation and inflammation of the cyst; immense disturbance ofthe constitution; putrefaction of the con- tents ofthe abscess, in consequence of the entrance of air into its cavity; and, too often, death. While such practice prevailed, very few afflicted with lum- bar abscesses, were fortunate enough to escape. The same alarming effects resulted from allowing the abscess to attain its utmost magnitude, and then burst by ulceration. If then a more hap- py train of events depend upon the man- ner, in which lumbar abscesses are punctured^, the operation is certainly a matter of great delicacy. Until the collection is opened, or hursts, the patient's health is usually lit- tle, or not at all impaired; indeed, we see in the faces of many persons with such abscesses, what is usually under- stood by the picture of health. Hence, how likely our professional conduct is to be arraigned, when great changes for the worse, and even death, occur 120 LUMBAR ABSCESS. very soon after we have let out the matter, seemingly, and truly, in conse- quence of the operation. Every plan, therefore, which is most likely to pre- vent these alarming effects, is entitled to infinite praise; and such, I conceive, is the practice recommended by Mr. Abernethy. This gentleman's method is to let out the matter,Kand heal the wound im- mediately afterwards by the first inten- tion. He justly condemns all introduc- tions of probes, and other instruments, which only irritate the edges of the puncture, and render them unlikely to grow together again. The wound is to be carefully closed with sticking plas- ter, and it will almost always heal. Doing this, does not put a stop to the secretion of matter within the cavity of the abscess. Of course, a fresh accu- mulation takes place; but, it is obvious that the matter, as fast as it is produc- ed, will gravitate to the lowest part of the cyst, and, consequently, the upper part will remain for a certain time un- distended, and have an opportunity of contracting. When a certain quantity of matter has again accumulated, and presents it- self in the groin, or elsewhere, which may be in about a fortnight after the first puncture, the abscess is to be punctured again, in the same manner as before and the wound healed in the same way. The quantity of matter will now be found much less, than what was at first discharged. Thus the abscess is to be re- peatedly punctured at intervals, and the wounds as regularly healed by the first intention, by which method, irritation and inflammation ofthe cyst will not be induced, the cavity of the matter will never be allowed to become distended, and it will be rendered smaller and smaller, till the cure is complete. In a few instances, you may, per- haps, be unable to persevere in healing the repeated punctures it may be ne- cessary to make; but, after succeeding once or twice, the cyst will probably have enjoyed sufficient opportunity to have contracted itself so much, that its surface will not now be of alarming ex- tent. It is also a fact, that the cyst loses its irritability, and becomes more indo- lent, and less apt to inflame, after the contents have been once or twice eva- cuated, in the above way. Its dispo- sition to absorb becomes also stronger. The knowledge ofthe fact, that the cysts of all abscesses are absorbing sur- faces, should lead us never to neglect other means, which Mr. Abernethy suggests, as likely to promote the dis- persion of the abscess, by quickening the action of the absorbents. Blisters kept open with savine cerate, issues, electricity, occasional vomits of zincum vitriolatum, are the means most con- ducive to this object. When the verte- brs are diseased, issues are doubly in- dicated, In the latter complication, the case is always dangerous. If an opening should have been made in the abscess, the cyst is at first more likely to be irri- tated, than when the bones are not diseased, and the affection ofthe spine is rendered much less likely to under- go any improvement, in consequence of the mere formation of an outward com- munication. The same bad effect at- tends necrosis; in which case, the ab- sorption of the dead bone is always re- tarded by the presence of unhealed fis- tuls and sores, which lead down to the disease. Mr. Crowther has succeeded in dis- persing some large lumbar abscesses without opening them. Large blisters, applied to the integuments covering the swelling, and kept open with the sa- vine cerate, effected the cure. When this gentleman punctures such collec- tions of matter, he uses a small trocar, which he introduces at the same place as often as necessary. He observes, that the aperture so made does not ul- cerate, and allows no matter to escape after being dressed. I cannot, how- ever, discover any reason for his pre- ferring the trocar to the abscess lancet, except that the cannula enables the surgeon to push back with a probe any flakes of lymph, &x. which may obstruct its inner orifice. But, this is scarcely a reason, when Mr. Abernethy informs us, that the opening, made with an ab- scess lancet, is large enough to allow such flakes to be discharged; and, when they stop up the aperture, a probe might also be employed to push them back. A wound made with a cutting instrument will, cater is paribus, always more certainly unite, by the first inten- tion, than one made with such an in- strument as a trocar. Mr. Crowther may have succeeded in always healing the aperture; but, I do not believe, that other practitioners would experience equal success. Were the tumour not very prominent, from the quantity of matter being small, suddenly plunging LUM LUX 121 in a trocar might even endanger parts, which should, on no account, be in- jured. Some writers recommend opening lumbar abscesses with a seton. The matter being made to form as promi- nent a swelling as possible, by pressing the abdomen, and putting the patient in a position, which will make the con- tents of the abscess gravitate towards the part where the seton is to be intro- duced, a transverse cut is first to be made in the integuments down to the fascia. Aflat trocar is next to be intro- duced within the incision, wliich should only be just large enough to allow the instrument to pass freely up under the skin, for at least three quarters of an inch; when the hand is to be raised, and the trocar pushed obliquely and gently upwards, till the cannula is within the lower part of the sac. The trocar must now be withdrawn, and the matter al- lowed to flow out gently, stopping it every now and then for some minutes. The assistant must now withdraw his hand, to take away the pressure, and the thumb of his left hand upon the opening of the cannula, holding it be- tween his fore and middle fingers. It must then be pushed upward, nearly to the top of the tumour, where its end may be distinctly felt with the fore-fin- ger ofthe right hand. As soon as it can be plainly felt, it must be held steadily in the same position, and the trocar is to be introduced into it again, and push- ed through the skin, at the place where it is felt, and the cannula along with it. The trocar being next withdrawn, a probe, with a skein of fine soft silk,*lip- ped in oil, must be passed through the cannula, which being now taken away leaves the seton in its place. A pledget of a mild ointment is then to be applied over the two openings, the more com- pletely to exclude the air. A fresh piece of the silk is to be drawn into the ab- scess, and that which was in before, cutoff, as often as necessary. (See Lat- •a's System of Surgery, vol. 3. p. 307.) Mr. Crowther states, that Deckers, who wrote in 1696, discharged a large abscess, in a gradual manner, with a trocar, the cannula of which was not withdrawn, but was stopped up with a cork, and the latter let out at intervals. B. Bell also advises the cannula not to be taken out. I cannot quit this subject without mentioning a remarkable case of lumbar abscess, which I lately saw in Christ's Hospital, under the care of Mr. Rams* den. The tumour extended from the ilium and sacrum below, as high up as the ribs. The diameter ofthe swelling, from behind forward, might be about six or eight inches. It was attended with so strong a pulsation, correspond- ing with that ofthe other arteries, that several eminent surgeons in this city considered the case as an aneurism of the aorta. After some weeks, as the tumour increased in size, the throbbing of the whole tumour gradually became fainter and fainter, and, at length, could not be felt at all. The tumour was near- ly on the point of bursting. Mr. Rams- den suspected, that it was an abscess, and determined to make a small punc- ture in it. The experiment verified the accuracy of his opinion; a large quanti- ty of pus was evacuated at intervals; but, the boy's health suffering, he went to his friends at Newbury, and I have not yet heard the event. I have never seen any popliteal aneurism, whose pulsations could be more plainly seen and strongly felt, than those of the ab- scess we have just been describing. The rationale I must leave to the spe- culative reader. I shall conclude with expressing my decided preference to Mr. Abernethy's plan of treating lumbar abscesses. Consult Abernethy's Surgkal and Phy- siological Essays, Part I. and II. Crow- ther's Observations on White Swelling, Crc. 1808. Latta's System of Surgery, vol. 3. LUNAR CAUSTIC. See Argentum Nitratum. LUXATION, (from luxo, to put out of joint.) A dislocation. See this word. Vol. II. Q. 122 MAMMA, M Mamma, removal of. The operation of cutting away a diseased breast, is done nearly in the same man- ner as the removal of tumours in gene- ral, and is indicated whenever the part is affected with an incurable disease, which admits, however, of being en- tirely removed with the knife. When the breast is affected with scirrhus, or ulcerated cancer, the imprudence of tampering with the disease cannot be too severely censured. Were the dis- order unattended with acontinual ten- dency to increase, some time might properly be dedicated to the trial of the internal remedies, and external appli- cations, which have acquired any cha- racter for doing good in these unpro- mising cases. But, unfortunately, by endeavouring to cure the disease by medicine, we only afford time for it to increase in magnitude, and, at length, to attain a condition, in which even the knife cannot be employed so as to take away the whole of the diseased parts. When the case is marked by those cha- racteristic features of scirrhus, which are noticed in the article Cancer, the sooner the tumour is cut out,the better. There are also some malignant kinds of Sarcoma, to which the female breast is subject, (as will be explained in the article Tumour,) which cannot be re- m6ved at too early a period after their nature is suspected, or known. Indeed, though there is not equal urgency for the operation when the tumour is only an indolent, simple, fatty, or sarcoma- tous disease, yet, as all these tumours are continually growing larger, and lit- tle success attends the attempt to dis- perse them, the practitioner should ne- ver devote much time to the trial of un- availing medicines and applications, and let the swelling attain a size, which would require a formidable operation for its excision. Besides, every simple, fleshy, or fatty tumour, is always ac- companied with a certain hazard of changing into a malignant, or cancer- ous one. Certainly, there are many swellings and indurations of the breast, which it would be highly injudicious and unne- cessary to extirpate, because they ge- nerally admit of being discussed. Such are many tumours, which are called scrofulous, from their affecting patients of this peculiar constitution; such are nearly all those indurations, which re- main after a sudden and general inflam- matory enlargement of the mamma; such are most other tumours, which acquire their full size in a few days, attended with pain, redness, 8cc; and, of this kind, also, are the hardnesses in the breast, occasioned by the mam- mary abscess. In the removal of all tumours, their malignant or cancerous nature makes it necessary to observe one important caution in the operation, viz. not to rest satisfied with cutting away the tumours just attheir circumference; but to take away also a considerable portion ofthe substance, in which they lie, and with which they are surrounded. In cutting out a cancerous breast, if the operator were to be content with merely dissect- ing out the disease, just where his eyes and fingers might equally lead him to suppose its boundary to be situated, there would still be left behind white diseased bands, which radiate from the tumour into the surrounding fat, and which would inevitably occasion a re- lapse,. In a vast proportion ofthe cases also, in which cancer of the breast un- fortunately recurs after the operation, it is found, that the skin is the part, in which the disease makes its reappear- ance. Hence, the great prudence of taking away a good deal of it in every case suspected to be a truly scirrhous or cancerous disease. This may also be done so as not to prevent the important objects of unitingthe wound by the first intention, and covering the whole of its surface with sound integuments. So frequently does cancer recur in the nip- ple, whenever it does recur any where, that many of the best modern operators always make a point of removing this part in every instance, in which it is judged expedient to take away any por- tion of the skin at all. The surgeon, in- deed, would be inexcusable, were he to neglect to take away such portion of the integuments covering scirrhous tn- MAMMA 123 mours, as is evidently affected, appear- ing to be discoloured, puckered, and closely attached to the diseased lump beneath. Nor should any gland, in the axilla, at all diseased, nor any fibres of the pectoral muscle, in the same state, be ever left behind. There is no doubt, that nothing has stamped operations for cancers with disrepute, so much as the neglect to make a free removal of the skin, and parts surrounding every side ofthe tumour. Hence the disease has frequently appeared to recur, when, in fact, it had never been tho- roughly extirpated; the disease, though entirely a local affection, has been deemed a constitutional one: and the operation frequently rejected as inef- fectual and useless. But, strongly as I have urged the prudence, the necessity of making a free removal of the skin covering, and ofthe parts surrounding, every cancer- ous or malignant tumour, the same plan may certainly be regarded as unneces- sary, and, therefore, unscientific, in most operations for the removal of sim- ple, fatty, or fleshy tumours. However, even in the latter cases,when the swell- ing is very large, it is better to take away a portion of skin; for, otherwise, after the excision of the tumour, there would be a redundance of integuments, the cavity of which would only serve for the lodgment of matter. The loose superfluous skin also would lie in folds, and not apply itself evenly to the parts beneath, so as to unite favourably by the first intention; nor could the line of the cicatrix itself be arranged with such nice evenness as it might be were a part of the redundant skin taken away at the time of operating. The best method of removing a dis- eased breast is as follows:—The pa- tient is usually placed in a sitting pos- ture, well supported by pillows and as- sistants; but the operator would find it equally convenient, if not more so, to remove the tumour with his patient in a recumbent position; and it certainly is better whenever the operation is likely to be long, or much blood to be lost, which circumstances are very apt to bring on fainting. I remember that Mr. Abernethy, in his lectures, used to recommend the latter plan; which, however, without the sanction of any great name, or authority, possesses such obvious advantages, as will always entitle it to approbation. The arms should be confined back, by placing a stick between them and the body, [or by an assistant,] by which means, the fibres of the great pectoral muscle will be kept on the stretch, a state most favourable for the dissection of the tumour off its surface. The stick [or assistant] also prevents the patient from moving her arm about, and inter- rupting the progress ofthe operation. When the tumour is not large, and only a simple sarcoma, free from malig- nancy, it will be quite unnecessary to remove any ofthe skin, and, of course, this need only be divided by one inci- sion, of a length proportionate to the tumour. The cut must be made with a common dissecting knife; and, as the division of the parts is chiefly accom- plished with the part of the edge to- wards the point, the instrument will be found to doits office best when the ex- tremity ofthe edge is made of a convex shape, and this part ofthe blade is turn- ed a little back, in the way in which dissecting knives are now often con- structed. The direction of the incision through the skin should be made ac- cording to the greatest diameter ofthe tumour to be removed, by which means it will be most easily dissected out. The direction of the incision is vari- ous with different practitioners; some making it perpendicular, others trans- verse. In general, the shape ofthe tu- mour must determine which is the best. In France, it has been said, that when the incision follows the second direc- tion, it heals more expeditiously, be- cause the skin is more extensible from above downward, than laterally, parti- cularly towards the sternum, and, con- sequently allows the sides ofthe wound the more readily to be placed in con- tact; and that the action ofthe pectoral muscle tends to separate the edges of the wound, when it is perpendicular. On the other hand, it is allowed, that the wound, made in the latter manner, is the most favourable for the escape ofthe discharge, if suppuration should occur. (See Desault par Bichat, p. 312. tom. 2.) The cut through the skin should al- ways be somewhat longer than the tu- mour; and as it is, perhaps, the most painful part of the operation, and one attended with no danger whatever, it should be executed with the utmost ce- lerity. Pain is certainly more or less to be dreaded, accordingto its duration. The fear, however, of giving pain has probably led many operators to err, by not making their first incision through the integuments large enough, the con- sequence of which has often been, that there was not room enough to get at 124 MAMMA the tumour so as to dissect it out with facility; the patient has been kept near- ly an hour in the operating room, in- stead of five minutes, and the surgeon censured by the spectators, as awk- ward and tedious. It is clear, also, that, besides the great deal more blood lost, from this error, than would otherwise happen, the vessels being commonly not tied till all the cutting is finished, the avoidance of pain, that fear, which led to the blunder, is not effected, and the patient suffers much more, and for a much longer time, in consequence of the embarrassment and obstacles in the way of the whole operation. When the disease is of a scirrhous or malignant nature, the skin coveringthe tumour should, at all events, be in part removed. As 1 have said before, ail that portion which is discoloured, puck- ered, tuberculated, or otherwise alter- ed, should be taken away. Some must also be removed, in order to prevent a redundance, in all cases in which the tumour is large. We have said too, that in cases of scirrhus and cancer of the breast, the nipple is considered a dangerous part to be left behind. For the purpose of removing the necessary portion of skin, the surgeon must obvi- ously pursue a different mode from that above described; and, instead of one straight incision, he is to make two se- micircular ones, one immediately after the other, and which are to meet at their extremities. The size of these wounds must be determined by that of the disease to be removed, and by the quantity of skin, which it is deemed prudent to take away; for, the part, which is included in the two semicircu- lar cuts, is that which is not to be se- perated from the upper surface of the swelling, but taken away with it. The shape ofthe two cuts together may ap- proach that eiSher of a circle or oval, as the figure of the tumour itself may in- dicate, as most convenient. The direc- tion ofthe incisions is to be regulated by the same consideration. In the above ways, the first division of the integuments is to be made in re- moving tumours of every description, covered with skin. The same princi- ples and practice should prevail in all these operations; and, whether the swelling is the mamma, or any other diseased mass, whether situated on the chest, the back, the head, or extremi- ties, the same considerations should al- ways guide the operator's hand. The incision, or incisions, in the skin having been made, the next object is to detach every side of the tumour from its connexions, and the separation of its base will then be the last and only thing remaining to be done. When the tu- mour is a scirrhus, or other malignant disease, the operator must not dissect close to the swelling, but make his in- cisions on each side, at a prudent dis- tance from it, so as to be sure to re- move, with the diseased mass, every atom of morbid mischief in its vicinity. But, when the tumour is only a mere fatty, or other mass, perfectly free from malignancy, the cellular bands and ves- sels forming its connexions, maybe di- vided close to its circumference. It is astonishing with what ease fatty tu- mours are removed, after the necessary division is made in the skin; they may almost be turned out with the hngers, without any cutting at all. When they have been inflamed, however, they are then more adherent to the surround- ing parts. Thus we see, that the first stage of the operation of removing a tumour, is • the division ofthe skin; the second, the separation of the swelling from the surrounding parts on every side; the third and last stage is the division of the parts to which its under surface, or base, is attached. The latter object should be accomplished by cutting re- gularly from above downward, till eve- ry part is divided. It is a common thing to see many operators constantly embarrassed and confused, whenever they have to re- move alarge tumour, on account of their having no particular method in their proceedings. They first cut a fewfibres on one side, then on another; and, turn- ing the mass of disease now to this side, now to that, without any fixed design, they both prolong the operation very te- diously, and present to the by-standers a complete specimen of surgical awk- wardness. On the contrary, when the practitioner divides the cutting part of the operation into the three methodical stages, above recommended, in each of which there is a distinct object to be fulfilled, he proceeds with a confidence of knowing what he is about, and soon effects what is to be done, with equal expedition and adroitness. Having taken out the tumour, the operator is immediately to tie such large vessels as may be pouring out their blood; indeed, when the removal ofthe swelling will necessarily occupy more than three, or four minutes, it is MAMMA. 125 better to tie all the large arteries as soon as they are divided, and then pro- ceed with the dissection. This was the celebrated Desault's plan, and it is highly deserving of imitation in this country, not only because many sub- jects cannot afford to lose much blood, but also because the profuse effusion of this fluid keeps the operator from see- ing what parts he is dividing. The largest arteries being tied, the surgeon should not be immediately so- licitous about tying every bleeding point which may be observed. Instead of this, let him employ a little while in examining every part of the surface of the wound, in order to ascertain that no portion of the swelling, no harden- ed lump, nor diseased fibres, remain behind. Even if any part ofthe surface ofthe pectoral muscle should present a morbid feel, or appearance, it must, on every account, be cut away. Also, if any of the axillary glands are diseased, the operator should now proceed to re- move them. After the time spent in such measures, many ofthe small ves- sels, which bled just after the excision ofthe swelling, will now have stopped, the necessity for several ligatures will be done away, and, of course, the patient saved a great deal of pain, and more ofthe wound be likely to heal by the first intention. Some information may be derived, respecting whether any ofthe tumour is left behind, by examining its surfaces, when taken out, and observing whether any part of them is cut off; for if it is, it may always be found in the correspond- ing part ofthe wound. The axillary glands may always be taken out, without the least risk, if the plan pursued by Desault in France, and Sir Charles Blickc, and other eminent surgeons in this country, be adopted. The method, alluded to, is, after divid- ing the skin covering the gland, and freeing the indurated part from its la- teral connexions, to tie its root, or base, with which it is connected with the parts on the side towards the axillary artery. Then the indurated gland itself may be safely cut off", just above the li- gature. Were the gland cutoff in the first instance, the artery which supplies it with blood, would be exceeding dif- ficult to tie, on account of its deep situ- ation; and, by reason of its shortness and vicinity to the heart, it would bleed almost like a wound ofthe thoracic ar- tery itself. In this way, there is also not the least hazard of injuring the lat- ter vessel. It would be a great improve- ment in the mode of operating for the removal of these glands, if surgeons were always to make the patient lie down, with the arm placed in such a position as would let the light fall into the axilla. How much the steps of the operation would be facilitated in this way, I need not attempt to explain. The above directions will enable a surgeon to remove tumours in general. They apply also in a great measure to encysted tumours; but, a few particular rules how to operate in the latter cases, will be found in that article. One half of each ligature is always to be cut off be- fore dressing the wound. The edges ofthe incision are to be brought toge- ther with strips of adhesive plaster; and, before this can be done with ease, the stick confining the arm back must be removed, and the os brachii brought forward, so as to relax the pectoral muscle, and integuments ofthe breast. No sutures should ever be employed, as they are useless, painful, and irritat- ing. The wound being closed with sticking plaster, and a pledget of sim- ple cerate, a compress of folded linen, or flannel, may be put over the dres- sings; these are to be secured with a broad piece of linen, which is to en- circle the chest, be fastened with pins, or stitches, and kept from slipping down by two tapes, one of which is to go from behind forward, over each shoulder, and be stitched to the upper part ofthe bandage, both in front and behind. The arm on the same side as that on which the operation has been done, should be kept perfectly motion- less, in a sling; every motion of the limb must evidently disturb the wound, by putting the great pectoral muscle into action, or renderingits fibres some- times tense, sometimes relaxed. It is scarcely necessary to say, that, after so considerable an operation as the remo- val of a large breast, or any other tu- mour of magnitude, the patient should be given about thirty drops ofthe tinc- tura opii. A smaller dose always cre- ates restlessness, head-ach, and fever, after operations, instead of having the desired effect. Here it becomes me to state, that as I could not find, in any surgical book, with which I am acquainted, what I conceived to be a proper description of the mode of removing a diseased breast, and tumours in general, the foregoing 126 MAMMARY ABSCESS. remarks are given chiefly on my own authority. Whether they are just, or not, must be decided by the profession. The principal writers on the remo- val ofthe mamma are, Garengeot, Dio- nis, Le Dran, Bertrandi, Sharp, and Sabatier, in their respective treatises on the operations. B. Bell, Latta, &.c. have also treated of the subject in their Systems of Surgery; and there is a me- moir Sur I'Operation du Cancer au Sein, in Les (Euvres Chirurgicales de Desault par Bichat, tom. 2. MAMMARY ABSCESS. Milk Ab- scess. Women who suckle, are parti- cularly subject to inflammation and suppuration in the breast. The part en- larges, becomes tense, heavy, and pain- ful. The integuments of the breast sometimes assume a uniform redness; sometimes they are only red in parti- cular places. The inflammation may af- fect the mammary gland itself, or be confined to the skin and surrounding cel- lular substance. In the latter case,the in- flamed partis equally tense; but, when the glandular structure of the breast is also affected, the enlargement is irregu- lar, and seems to consist of one or more large tumours,situated in the substance of the part. The pain often extends to the axillary glands. The secretion of the milk is not always suppressed, when the inflammation is confined to the integuments, and suppuration is said to come on more quickly, than in affections ofthe mammary gland itself. When the symptoms of inflammation continue to increase for four or five days, suppuration may be expected; unless the progress ofthe inflammation be slow, and its degree moderate, in which circumstances, resolution may often be obtained, even as late as a fort- night after the first attack. Inflamma- tions of the breast, are almost always attended with symptoms %f the sym- pathetic inflammatory fever. (See Fe- vers, Surgical.) I think authors err, who describe the febrile disorder as gene- tally preceding the local complaint. Women are most liable to mammary abscesses within the first three months after parturition; but they are also very much exposed to the disorder as long as they continue to suckle. The most common causes occasion- ing the mammary abscess, as enume- rated by writers in general, are, re- pressing the secretion of milkatjm ear- ly period, mental disturbance, fright, Ste.; exposure to cold, moving the arms too much while the breasts are very large and distended, bruises, and other external injuries. The causes are not always assignable. The matter is sometimes contained in one cyst, or cavity, sometimes in se- veral; but the abscess generally breaks near the nipple. As all inflammations of the mamma are attended with considerable indura- tion, these cases should be carefully distinguished from other swellings of a more incurable kind. It is said, that scrofulous tumours of the mamma, which have existed a long while, often disappear after the occurrence of a milk-abscess. Women who have never been pregnant, are sometimes affected with suppurations in the breast, not es- sentially different from those above de- scribed. Even men are said to be liable to similar complaints. In the early period of the affection, resolution should be attempted. The following are the principal means for this purpose:—topical blood-letting, sa- line purges, low diet, keeping the in- flamed breast from hanging down, gen- tie friction of the breast, with a soft sponge, wet with some warm emol- lient liquor, having the milk tenderly sucked out at proper intervals; satur- nine applications, or lotions containing sal ammoniac. When matter cannot be prevented from forming, an emollient poultice is the best application, and the abscess should in general be allowed to break of itself, unless of a somewhat chronic nature, in which case, it should be open- ed in a depending part, with a lancet. Sinuses sometimes form, in conse- quence of abscesses in the breast, and will not heal till freely opened with a director and curved bistoury. When the cavity ofthe abscess begins to fill up with granulations, the poultice may be left off", and superficial dressings applied. The indurations, often remaining in the breast, in consequence of acute in- flammation and abscesses, generally yield to frictions with camphorated mercurial ointment, the application of a piece of" soap-plaster,and giving calo- mel,cicuta, and,as some advise,emetics. Mr. I-Ljy describes a very deep-seat- ed abscess of the breast, not of frequent occurrence, nor confindd to pregnant nor suckling women. Its situation ren- ders all superficial applications ineffec- tual. The inflammatory stage is te- MEL dious; and when the matter has made its way outward, the discharge conti- nues, and there is no tendency to heal- ing. Sometimes the matter lodges be- hind the mamma, as well as in the sub- stance of the gland, and breaks out in different places, the intermediate parts ofthe breast feeling as if affected with a scirrhous hardness. There are nu- merous sinuses running in different di- rections, and, when opened, a soft pur- ple fungus appears within them. The disease goes on in this state, for a long while, keeping up hectic symptoms. Mr. Hey's practice is to trace the course of all the numerous sinuses, and lay them open, and unless this is done, with respect to every one of them, the cure cannot be accomplished. If he finds any two sinuses running in such directions, that when fully opened, they leave a small part of the mamma in a pendulous state, he removes such part entirely. As the sinuses are filled with fungus, their continuations pre- sent no visible cavity, and can only be detected by the greater softness of parts ofthe wound, where, on breaking down the fungus, the orifice ofthe col- lateral sinus may be found. Mr. Hey has found, that even in the most unfa- vourable subjects, the wounds heal quickly, and the natural shape of the breast is preserved. Consult Pearson's Principles of Surge- ry, Chap. 3. Hey's Practical Observations, p. 604. Kirkland has also treated of* se- veral kinds of abscesses of the breast, in his Inquiry into the Present State of Medical Surgery, vol. 2. p. 161. The German reader may refer to Richter's Anfangsgr. der Wundorzn. Band. 4. Chap. 16. MARASMUS, (from ftxgaiva, to grow lean.) An atrophy, or wasting of the bulk and strength. MATURANTIA, (from maturo, to ripen.) Medicines for promoting sup- puration. MATURATION. (Same deriva- tion.) Maturatio. The old surgeons were accustomed to call the comple- tion of the suppurative process in in- flammatory tumours their maturation, in which state they were deemed fit to be opened. The word is still frequent- ly found in modern surgical works. MELICERIS, (from pt\i, honey, and x»foc, wax.) A tumour of the en- cysted kind, filled with a substance re- sembling wax and honey in consistence. (See Tumours Encysted). MER 127 MENINGES, (from ftwu, to re- main.) The membranes covering the brain. MENINGOPHYLAX,(from /wwy?, a membrane, and \», a tumour.) A femoral or cru- ral hernia. See Hernia. METACINEM A, (from una., after, and y.ivicj, to remove.) A removal of the pupil ofthe eye from its natural situation. METASTASIS, (from p&tn/H, to transfer.) A transportation of a disease from one part to another. MEZEREON, (said, by Blanchard, to be derived from some barbarous dia- lect.) This medicine was recommended by Dr. A. Russell for a particular class of venereal symptoms, in the following terms: " The disease, for which I principally recommend the decoction ofthe mezereon root as a cure, is the venereal node that proceeds from a thickening of the membrane of the bones. In a thickening ofthe perioste- um, from other causes, I have seen ve- ry good effects from it: and it is fre- quently of service in the removal of those nocturnal pains, with which vene- real patients are afflicted; though, in this last case, excepting with regard to the pain that is occasioned by the node, I own I have not found its effects so cer- tain, as I at first thought I had reason to believe. I do not find it of service in the Vol. II. S 1SS MOL MOL cure of any other symptom ofthe vene- real disease." (Med. Obs. andInq. vol. 3.p. 194—195.) Mr. Pearson, however, asserts, unequivocally, that mezereon has not the power of curing the vene- real disease in any one stage, or under any one form, and if the decoction should ever reduce a venereal node, yet there will be a necessity for taking mercury in as large quantity, and for as long a time, as if no mezereon had been exhibited. Cullen found this medicine of use in some cutaneous affections, but, excepting an instance or two of lepra, Mr. Pearson has very seldom found it possessed of medicinal virtue, either in syphilis, or the sequels of that disease, scrofula, or cutaneous affec- tions. (Pearson on Lues Venerea, p. 55— 59.) MIASMA, (from ^latva, to pollute.) The matter, or effluvia producing con- tagion. MODIOLUS, (dim. of modius, a measure.) The crown, or saw of a trepan, so called, because it was for- merly contrived to enter only to a cer- tain depth. MOLLITIES OSSIUM. A morbid softness of the bones, which become preternaturally flexible, in consequence either of the inordinate absorption of the phospate of lime, from which their natural solidity is derived, or else of this matter not being duly secreted and deposited in their fabric. In rickets, the bones only yield and become dis- torted by slow degrees, and retain their natural inflexibility; but, in the present disease, they may be at once bent in any direction. The mollities ossium is rare, and its cause not understood. To give an idea of the disorder, I shall quote the case of Madame Supiot in the words of Mr. Latta.—" In the year 1747 she had a fall, which occasioned her to keep her bed for some time, and left great pain and weakness in her loins and lower extremities. In about a year and a half afterwards, she began to perceive her left leg particularly af- fected. Along with this weakness, she had violent pains over her whole body, which increased after a miscarriage, and still more after a natural delivery, in the year 1751. She was now seized with startings, great inquietude, and such violent beats, that she was almost continually in a sweat, and could not bear the least covering even in the coldest weather, and while her pains continually increased, she took notice that her urine precipitated a white se- diment. Her pains abated on the ap- pearance ofthe sediment, but she now observed that her limbs began to bend, and from this time the softness of them instantly increased till her death. In the month of April 1752, the trunk of tile body did not exceed 23 inches in length; the thorax exceedingly ill form- ed, and the bones ofthe upper part very much distorted; those ofthe lower part were very much bent, and the thigh bones became so pliable, that her feet might easily be laid on each side of her head. The right side did not, till after some time, become so deformed as the left; but it was surprising to observe the alterations which daily took place, and the different figures assumed by the limbs, in consequence of the in- creased softness of the bones; so that when the sediment in the urine was considerable, the disease ofthe bones seemed to be at a stand, increasing considerably, when it was suppressed. Besides this, she had violent pains, startings, difficulty of breathing, spit- ting of blood, and, lastly, a fever, with convulsions. She died in the beginning of November 1752, and, on dissecting her body, the following appearances were observed: 1. The muscles in ge- neral w ere of a very soft and pale con- sistence, the vastus externus, fascialis, quadriceps, biceps, and external parts ofthe gracilis, were much shorter than in their natural state, and more firm and tense; while those on the opposite side were much elongated, thin, and very tender; in short, the whole muscular system had suffered more or less, ac- cording to the action of the muscles in her lifetime. 2. The bones were entire- ly dissolved, the periosteum remaining unhurt, so that they exhibited only the form of a cylinder. 3. The heart and large blood vessels, both veins and ar- teries, contained large black polypi, of a viscid consistence, and very unlike those usually found in dead bodies. " A case of softness of the bones is Telatedby Mr. Gooche, but considerably different from the above, as it was at- tended with a remarkable fragility of the bones before they became soft. It likewise began with pains through the whole body, attended with feverish symptoms; but, after some weeks, they became confined chiefly to the legs and thighs, though they were not increas- ed by pressure. This fragility of the bones does not appear to have been MOL MOR 139 the case with Madam Supiot. In the month of June, 1749, Mr. Gooche's pa- tient broke her leg, in walking from her bed to a chair, and heard the bone snap. No callus, however, formed, though the fracture was instantly re- duced, and treated by one of the best surgeons in that part of the country; but, instead ofthis, the bones began to grow flexible, and, in a few months, were so from the knee to the ankle. The disease still continued to increase, so that, in a short time, the other leg and thigh were affected in the same manner, after which both legs and thighs became ocdematous, liable to excoriations, and to discharge a thin yellow ichor. Scorbutic symptoms be- gan to appear in the winter after her leg was broken, and her gums began to bleed. Tonic medicines were exhibited without any success, only that her menstruation became more regular, and her appetite and digestion better than before; but, towards the end of her life, her breathing became difficult, the spine distorted, and a pain in the loins took place upon every motion of the vertebrs; and, as her limbs were now quite useless, she was obliged to sit upright in bed. At last, the ends of the bones, on which she sat, having be- come also very soft, spread much, and the ends of her fingers and thumbs, by frequent endeavours to raise herself, became also very broad, and the pha- langes crooked. The flexibility of the bones gradually increased, and became more general, attended with the wast- ing of the flesh, and excessive difficulty ofbreathing. The menstrual flux total- ly ceased four months before her death; her legs, which were very anasarcous, and excoriated almost all over, became erysipelatous, but she retained her senses to the last. She expired sudden- ly, having talked in a composed manner concerning her miserable situation and approaching end only a few moments before. " On examining the body, she was found to have lost two feet two inches of her natural stature. The heart and lungs appeared sound, but had been much confined, principally by the liver, which was enlarged to an extraordi- nary degree; it was not, however, scirrhous, or in any other way diseased. The spleen was very small, and the mesentery had one large scirrhous gland. All the bones, except the teeth, were softened, so that scarce any of them could resist the knife; but those ofthe lower extremities were the most dissolved, being changed into a kind of parenchymous substance, like soft dark coloured fiver, without any offensive smell. So completely, indeed, were they decomposed, that the knife met with less resistance in cutting through them, than in sound muscular flesh, though some bony lamella were here and there to be met with, butas thin as an egg-shell. The most compact bones, and those which contained the greatest quantity of marrow, were the most dis- solved;" and it was observable, that the dissolution began internally, for the bony lamins remained here and there on the outside, and no where else. The periosteum was rather thicker, than ordinary, and the cartilages thinner; but, not in a state of dissolution. The bones were found to contain a great quantity of oily matter and little earth. No cause could be assigned for the dis- ease; and in the case of Madame Supi- ot, the one assigned, viz. that of her eating too much salt, seems totally in- adequate to explain the origin of the disorder. All the cases of mollifies os- sium on record have proved fatal, and no means of cure are yet known. (Sys- tem of Surgery, vol. 1. chap. 6.) MONOCULUS, (from ^ovor, single, and oculus, the eye.) A bandage former- ly applied to the fistula lacrymalis, and diseases of the eye. It consists of a single headed roller three ells long. To apply it to the right eye, it is to be held in the right hand, and its end in the left, et vice versd. This end is to be put on the back of the neck, and one turn of the roller is to be carried round, over the forehead, so as to meet the extremity ofthe bandage. The roller is then to descend under the ear of the side af- fected, and to pass obliquely over the cheek underneath the eye, and next over the root of the nose, and opposite parietal bone, to the nape of the neck. The third turn ofthe roller is to overlap the second a little; the third the fourth; making what the French call doloires; and the application of the bandage is completed by making turns round the head. The use of the monoculus was only to retain dressings. (Encyclopedic MSthodique; Partie Chirurgicak.) MORTIFICATION, (from mors, death, and JJo, to become.) Mortificatio. The death of a part ofthe body. Mortification is of two kinds, the one without inflammation, the other pre- 140 MORTIFICATION. ceded by it Inflammation is an increas- ed action of that power, which a part naturally possesses; and in healthy in- flammations, at least, it is probably at- tended with an increase of power. In cases however, which are to terminate in mortification, there is no increase of power; but, on the contrary, a diminu- tion of it. This, when joined to an in- creased action, becomes a cause of mortification, by destroying the ba- lance, which ought to subsist between the power and action of .every part. There are, besides, cases of mortifica- tion, preceded by inflammation,which, do not arise wholly from that, as a cause: of this kind are the carbuncle and the slough formed in the small- pox pustule. (Hunter.) When any part ofthe body loses all motion, sensibility, and natural heat, and becomes of a brown, livid, or black colour, it is said to be affected with sphacelus, that is, complete mortification. As long as any sensibility, motion, and warmth, conti- nue, the state of the disorder is termed gangrene. This word is here made use of to signify only a degree of sphacelus, or rather the process, by which any lo- cal disorder falls into the state of com- plete mortification. Many authors use both terms synonymously; but, it is to be observed, that gangrene does not invariably end in sphacelus; nor is the latter always preceded by the former. (Richter.) The causes of mortification are very numerous, and many of them involved in impenetrable obscurity. Hence, the cure is frequently very diffi- cult, and even impossible. Such causes, as are at all understood, may, very pro- perly, be distinguished into four clases; inflammation; the impeded return of blood from a part; the stoppage ofthe flow of blood into the same; and a dis- turbed state of this fluid and of the nerves. Inflammation is one of the most fre- quent occasional causes of mortifica- tion. But, as we have already remark- ed, the death of a part may take place without any previous inflammatory dis- order; and the latter, even when pre- sent, has frequently less share in the mischief, than other incidental circum- stances, and is, in reality, only an effect ofthe very same cause, which produces the sphacelus itself. It is oftentimes a matter of doubt, whether actual in- flammation precedes the occurrence, or not; for, a part, before it mortifies, is eften only affected with pain, and with no degree of preternatural redness Lastly, when mortification is, unques- tionably, preceded by inflammation, there are so many varieties ofthe disor- der, depending on incidental causes, that these latter demand more atten- tion, than the inflammation itself.— (Richter) Healthy phlegmonous inflammation seldom ends in mortification, though it occasionally does so, when very ex- tensive and vehement. Of all the inflammatory complaints, to which the system is liable, erysipe- las is observed most frequently to ter- minate in gangrene, and whenever phlegmon is, in any degree, conjoined with an erysipelatous affection, which it not unfrequently is, it seems thereby to acquire the same tendency, being more difficult to bring to resolution, or suppuration, than the true phlegmon, and more apt to run into a mortified state. (B. Bell.) ■ The symptoms of mortification from inflammation take place variously, yet, generally, as follows. The pain and sympathetic fever suddenly diminish, the part affected becomes soft, and of a livid colour, losing, at the same time, more or less of its natural warmth and sensibility. In some places, the cuticle is detached; while, in other situations, vesicles arise, filled with a clear, or turbid fluid. Such is the state to which we apply the term, gangrene, and which stage of the disorder too often rapidly advances to sphacelus, when the part becomes a cold black, fibrous, sense- less substance, called in technical lan- guage a slough. The second class of causes, produ- cing mortification, are such as impede the return of blood from the part affect- ed, and, for the most part, operate by making pressure on the trunk, or prin- cipal branches, of a vein. In these in- stances, there is always an accumula- tion of blood in the part, which first swells, becomes of a livid colour, tense, and very painful. Soon afterwards, blisters arise, and the part becomes soft, edematous, cold, insensible, em- physematous, black, and fetid. Such are the circumstances, which happen in strangulated hernis, in tied polypi, and in a limb, in which the veins have been so compressed by any hard swell- ing, such as the head of a dislocated bone, as to excite mortification. The third class of causes of mortifi- cation prevent the entrance of arterial MORTIFICATION 141 blood. The application of a ligature to an artery, as practised in several surgi- cal cases, and all external pressure, that closes the artery, or arteries, on which a part entirely depends for its supply of blood, have this effect. Mor- tification does not, however, always take place, when the trunk of an arte- ry is rendered impervious, because na- ture furnishes the necessary supply of blood, through collateral ramifications. But, when the disorder does happen, the part commonly first becomes pale, flaccid, and cold, and soon after wards shrinks, loses its sensibility, grows black, and perishes. The fourth set of causes are such, as are said to proceed from a mere lessen- ing ofthe communication of blood and nervous energy to a part. However, it is to be observed, that parts, deprived of all connexion with the sensorium, by the division, or paralytic state, of their nerves, do not frequently perish on this account. But, as their functions are car- ried on with less vigour, and their vi- tality is weakened, the same causes, which sometimes produce mortifica- tion in parts differently circumstanced, must much more readily occasion it in these. Among the causes of the pre- sent species of mortification, may be mentioned great universal debility; ex- treme old age; a thickening and ossifi- cation of the coats of the arteries, and a consequent diminution of their capa- city, and of their muscular and elastic power. The mortification, arising from long continuance in the same posture, is chiefly attributable to the unremitted pressure, which parts sustain, and which obstructs the circulation. Sur- geons have frequent occasion to see melancholy examples of this kind of mortification, particularly in cases of fractures, paralysis from disease of the vertebrs, &c. The mischief most rea- dily occurs, where the bones have the least flesh upon them, and, consequent- ly, where all external pressure has the most effect; as, for instance, about the os sacrum, os ilium, spines of the sca- puls, &c. The disordered part always first becomes soft, livid, red at the cir- cumference, and oedematous, after- wards losing its sensibility, and acquir- ing a black appearance: at length, it is converted into a foul sloughing ulcer. Though long continuance in the same posture is the grand cause of this kind of mortification; yet, incidental circum- stances are frequently combined with it, and have great influence over the disorder. These are, great debility, the same state of the system as exists in typhus fever, impure air, unclean bed- ding, &c. There are some causes,which produce death in a part at once, by the violence of their operation. A blow, struck very forcibly, on any situation of the body, may destroy the vitality of the fibres and vessels in this sudden manner. When a ball enters the sub- stance of parts with great force and ra- pidity, it always kills at once many of the fibres, which are in the way of its track, and these must be thrown off in the form of sloughs, before the wound can granulate and heal. There are other causes, which kill parts of the body, by actually decom- posing them; such is the way, in which caustics act. Cold is often another cause of mor- tification, and, when parts, which have been frozen, or frostbitten, are sud- denly warmed, they are particularly apt to slough. Sometimes, mortification seems to depend on epidemic causes. Instances have been known, in which almost all the ulcers and wounds in large hospitals have become nearly at the same time affected with gangrenous mischief. Mortification is very frequently oc- casioned by the injury, which parts sustain from the application of fire, and heated substances to them. When the heat is very great, the substance ofthe body is even decomposed, and of course killed at once On other occasions, when the heat has not been so violent, nor sufficiently long applied, inflamma- tory symptoms precede the sloughing. It is a curious fact, that the blood coagulates in the large arteries, which lead to a mortified part. This occur- rence takes place for some distance from the slough, and is the reason,why the separation of a mortified limb is seldom followed by hemorrhage. When gangrene and sphacelus take place, the patient is usually troubled with a kind of hiccough. The constitution also suffers imme- diately a considerable dejection. The patient's countenance suddenly as- sumes a wild, cadaverous look; the pulse becomes small, rapid, and some- times irregular; cold perspirations come on, and the patient is often affect- ed with diarrhoea and delirium. The generality of writers have dis 142 MORTIFICATION. tinguished gangrene and mortification into the dry and humid kinds, accord- ing as the disordered part is found free from much moisture, or not. It does not appear, however, that such distinc- tions lead to any useful objects in prac- tice. Cases, of what have been termed dry gangrene, never occur from inflam- mation. They commonly happen from the flow of blood to the parts affected being stopped by some kind of" com- pression, or another, as by tumours, ligatures, or other similar causes, ob- structing the principal arteries, which used to supply the parts now in a mor- tified state. Such causes, when the stoppage ofthe circulation is complete, always occasion a very slow mortifica- tion; and, as the parts in such instances, are no longer supplied with fresh quan- tities of fluids, while a considerable evaporation must be going on, there must be less humidity, than in other cases of mortification. (B. Bell.) Authors have enumerated other va- rieties of mortification, as for instance the white gangrene, in which the parts, supposed to be mortified, do not turn black, but retain nearly their former colour, (^uesnay.) All mortifications spread in one of the following ways: either the living circumference sphacelates,without un- dergoing any previous perceptible changes, or the part first inflames, and then dies. The difference, in regard to the quickness, or slowness,with which sphacelus spreads,is exceedingly great, in different cases. In cases of sphacelus, the prognosis chiefly depends on the nature of the cause of the disorder. The more easy the cause is of removal, the less room is there for alarm. It is an erroneous supposition, that mortification arising from an external local cause, is more easy to be stopped and cured, than that originating from an internal one. The local cause is sometimes exceedingly difficult, or even incapable, of removal; and a sphacelus,which is at first entirely local, may afterwards become a general disorder, by the universal debility, and derangement of the system, resulting from the absorption of putrid matter. Hence, it is obvious; that a sphacelus may easily extend beyond the bounds of its outward local cause. On the other hand, a mortification may be reduced to one of a nature entirely local, though it arose at first from constitutional causes. Sphacelus from extreme debi- lity, or from such a state ofthe system, as attends the scurvey, typhoid fevers, &c. is constantly perilous, because these causes are very difficult to re- move. It is also a fact, that, when nu- merous causes are combined, it is an unfavourable occurrence, not merely because the surgeon is apt to overlook Borne of them, but, because there are in reality more obstacles to the cure. There is a species ofsphacelus, which spreads with very great rapidity, and, as the surgeon has scarcely time to em- ploy the necessary means, the case is exceedingly dangerous. Sometimes, a mortification spreads so slowly, that it does not occupy much extent at the end of several months, or even a whole year. The case, however, is often not the less fatal on this account. The dan- ger is never altogether over, until the dead part has completely separated. The entrance of putrid matter into the circulation is so injurious, that pa- tients sometimes perish from this cause long after the mortification has ceased to spread. (Richter.) The danger of sphacelus is also pro- portioned to the size and importance of the part affected. The event ofthe dis- temper likewise depends very much on the patient's age and constitution. Parts, affected with gangrene, do not immediately lose the whole of their sensibility; the circulation is still con- tinued in a certain degree; and when the progress ofthe distemper does not surpass certain bounds, the functions of such parts may be completely reesta- blished. Gangrene, strictly speaking, is not a decided mortification; but, only the forerunner of this latter mischief, and may be regarded, as the interme- diate link, between the most violent stage of inflammation and sphacelus. The presence of this last implies the to- tal loss of life in the part affected, the destruction of its organization, the abo- lition of all its functions, and an abso- lute inability to resume them again. However, even when we see a part ma- nifestly sphacelated, we must not al- ways conclude, that its entire destruc- tion is certair; for, in many cases, the disorder only affects the skin and cel- lular substance. The integuments fre- quently slough away, and we have the happiness to perceive that the tendons, muscles, and other organs, which they cover, remain perfectly sound, and leave room to entertain hopes of a cure. MORTIFICATION. 143 It is easily comprehensible, that it is only in external affections of the body, that the progress of inflammation to gangrene and sphacelus can be marked with any degree of precision. But, as we have indeed already observed, the approaches of the latter are not invari- ably announced by the distinct and ma- nifest symptoms of gangrene, even when the disorder is quite superficial. There are cases, which justify the con- clusion, that a small part of the body may be affected with sudden death, just in the same manner as the whole machine. Sphacelus is often seen mak- ing its appearance in a part, which is apparently quite healthy, without being preceded by any other symptom, than a sudden acute pain in the seat of the mischief. Sometimes, in the earliest period of the complaint, a black spot, which rapidly spreads on every side, may be observed. In order to be able to form a just prognosis, all the above circumstances must be taken into consideration, and, in particular, we must never deliver an opinion, without having closely exam- ined the progress of the disorder; for, should we make a favourable prognosis from such appearances, as might justi- fy us as much as possible in so doing, there is always great risk of finding ourselves most miserably mistaken by the event of the case. In all cases of considerable mortification, even when arising from an external cause, the pa- tient cannot be deemed exempt from danger, not only, while no separation of the mortified parts has begun, but, also, not before such pails have been completely detached from the sound ones. After the progress of mortifica- tion has ceased, patients have been known to perish suddenly, without there being a possibiUty of suspecting any other causes of this catastrophe, than the operation of putrid matter on the animal economy and nervous sys- tem after absorption. TREATMENT OF MORTIFICATION. We shall arrange under two heads what we have to say on the treatment of mortification. Under the first, we shall comprehend every thing, which relates to internal remedies, and such other general means, as are indicated by the general state ofthe system. Un- der the second, we shall speak of topi- cal remedies, and of the local treatment ofthe parts affected. GENERAL MEANS. 1. Evacuations and Antiphlogistic Re- medies. When mortification seems to depend on the violence of inflammation, the first indication is to moderate the inor- dinate action of the sanguiferous sys- tem, by the prudent employment of such means as are proper for counter- acting inflammation. This subject is treated of in Inflammation, and it is not necessary to enter here into any repetitions. When bleeding has not been sufficiently practised, during the state ofthe inflammation antecedent to the mortification, and when the general symptoms, which point out the exis- tence of this state, continue violent, and, especially, when the pulse is still quick, hard, or full, it is absolutely ne- cessary to empty the vessels a little more, even though mortification has begun, particularly if the patient be young and plethoric. Bleeding, by di- minishing the fever, and abating the general heat, is frequently the best means of all. It may then be consider- ed better than all antiseptics, for slop- ing the progress of the disorder. But, this evacuation is to be employed with a great deal of circumspection; for, should it be injudiciously resorted to, from the true state of the system not being understood, the error may bo followed by the most fatal conse- quences. It should also be well remem- bered, that how strongly soever bleed- ing may be indicated, the moment is commonly not long in coming, when this evacuation is totally inadmissible, especially when the mortification makes much progress. What we have observed, concerning bleeding, is equally applicable to other evacuations, particularly those which are obtained by purgative medicines; and which become dangerous when they lower the patient's strength to a certain point, or when they are accom- panied by too violent an irritation ofthe intestinal canal, operating sympatheti- cally on the whole system. Emetics, the effects of which are always apt to be confounded, or compared, with those of purgatives, act in a very diffe- rent and much more advantageous manner in cases of mortification, espe- cially that species of the distemper. 144 MORTIFICATION. which arises in consequence of erysi- pelatous inflammation. Such, for ex- ample, is the inflammation, often seen in hospitals, in consequence of com- pound fractures, or other kinds of wounds. When this kind of inflamma- tion makes its appearance, and even after the symptoms of mortification have begun to appear, an emetic, given in small repeated doses, so as to excite vomiting, is one of the best means of resisting the progress of the disorder. But, if, instead of occasioning vomiting, the medicine should only produce eva- cuations per anum, as sometimes is the case, we must not persist in exhibiting it, lest it should prove, like every other cathartic, pernicious to the patient. A strict regimen, which may have been useful and even necessary, during the inflammatory stage, may also have a very bad effect, if continued too long, by diminishing the patient's strength, wliich, on the contrary, should be sup- ported by the most nourishing food. 2. Tonic and Antiseptic Remedies. This leads us to a second veiy essen- tial and important indication to be ful- filled, as soon as the symptoms, an- nouncing the existence of the inflam- matory state, appear to abate, and the patient begins to be debilitated. This indication is to prevent excessive weak- ness by the suitable employment of cor- dials, and, particularly, oftonics. These same means also contribute to place the system in a proper state for freeing itself from the mortified parts, or, in other words, for detaching them. For, inflammation is the preparatory step, which nature takes to accomplish the separation of mortified parts from the living ones, and, such salutary inflam- mation cannot take place, if the ener- gies of life be too much depressed in the rest of the system. In order to fulfil the above indica- tion, it is necessary to prescribe a nou- rishing diet, with a certain quantity of good wine, proportioned to the pati- ent's strength, and the symptoms of the complaint. This diet is generally productive of more real benefit, than the whole class of cordial and stimulat- ing medicines. However, when the pa- tient is very much weakened, when the mortification of* the part affected is complete, and the disorder is spreading to others, some of the following reme- dies may be ordered: volatile alkali; aromatic confection, &c. In general, however, wine is best; because more agreeable than cordials, and, for this purpose one ought to prefer the most perfect wines, such as those of Spain and Madeira. Of all the medicines, hitherto recom- mended for the cure of mortification, there is certainly not one, that has ac- quired such a character for efficacy,\as the Peruvian bark. It is said, that this remedy often stops, in a very evident and expeditious manner, the course of the disorder. Being a very powerful tonic, it probably operates by strength- ening the system, and thus maintaining in every part the necessary tone for re- sisting the progress of mortification. But, whatever may be its mode of act- ing, the advocates for this medicine contend, that it is now a well-known fact, that it ought to be employed in al- most all cases of mortification, as soon as the violence of the inflammator) symptoms has been appeased It was Mr. Rushworth, a surgeon at Northampton, who made this discove- ry in the year 1715. Amyand and Dou- glas, two surgeons in London, soon af- terwards confirmed the virtue of this remedy. Mr. Shipton, another English surgeon, has also spoken, in the Philo- sophical Transactions, of the good ef- fects, which he has produced by this medicine. In the Medical Essays, of Edinburgh, we find several cases, il- lustrative ofthe efficacy of bark in cases of mortification. We there are inform- ed, that when its exhibition was inter- rupted, the separation of the eschars was retarded, and that, on the medi- cine being resorted to again, such a se- paration went on again more quickly. Since this period, all practitioners, both in England, and elsewhere, have had recourse to this remedy, which has every where obtained the highest praises. Unfortunately, these praises have induced surgeons to employ it in-, discriminatory, and with equal confi- dence, in all cases. Hence, the partial want of success, which occurred, led some to decry the Peruvian bark almost generally; until observations, made with the greatest care and circum- spection, reestablished its credit, by showing the limits, beyond which, its efficacy is not to be depended upon. We cannot indeed doubt, that bark has frequently had the most salutary effect, in cases of mortification, though sometimes it may probably have had imputed to it effects, which were en MORTIFICATION. 145 tirely produced by nature. In many cases, however, bark is evidently hurtful, when exhibited prematurely. There are other instances, in which it is impossible to employ it in suffi- cient quantity, the stomach not being able to bear it in any form. In gene- ral, it should never be administer- ed, when the pulse is high, and other inflammatory symptoms exist; but, when the tension ofthe part diminishes, the pulse sinks, when symptoms of weakness commence, and, particular- ly, when with these circumstances, we perceive a separation beginning to take place between the dead and living part, bark hardly ever fails to support the strength of the constitution, and powerfully to accelerate the separation of the mollified parts. (Encyclop. .Me- thod.) However, as we have already re- marked, it is quite wrong to prescribe bark, in every instance, as the sole reme- dy; for, there are many cases, in which it is unnecessary; some, in which it does harm; and others, in which it is totally inefficacious. It is a medicine obvious- ly of no service, when the mortification arises from an external cause, and is the only complaint, in a healthy, strong constitution. It is equally unnecessary, when the sphacelus is of the diy sort, and has ceased to spread, at the same time, that the living margin appears to be in a state of inflammation, without any universal debility. But, it deserves particular .notice, that the circum- stances of each individual case are lia- ble to such considerable variation, that though bark may be at first un- necessary, it may afterwards be indi- cated, v In some cases of sphacelus, bark is hurtful The disorder is generally at- tended with fever, which may be of three kinds; inflammatory; typhoid; or one connected with a disordered state ofthe abdominal viscera. In the latter case, which is far more common, than is supposed, bark is ob- viously pernicious. Here, the indica- tion is to empty the stomach and bow- els, as quickly as possible. When this has been done, and bark should now be indicated by any of the circumstances, already pointed out, it may be safely administered. But, there is a great necessity, for procuring evacuations, as speedily as possible, before great debi- lity has come on. Sometimes, mortification is accom- panied by a low typhoid kind of fever, which, whether the cause, or the con- sequence ofthe local mischief, demands the exhibition of bark. As we have above stated, the com- mon inflammatory fever may attend a mortification, and then the living mar- gin is generally inflamed and painful. This is particularly the case, when mortification is the consequence of genuine acute inflammation, or of an external injury, in a healthy subject. Here, bark must obviously be injurious. Still, it is wrong to regard this medi- cine, as invariably hurtful, whenever sphacelus is the effect of inflammation. It has already been observed, that the inflammation frequently has less share in the origin ofthe disorder, than some incidental cause, which oftentimes re- quires the exhibition of bark. It is also to be noticed, that even when mortifica- tion is the pure effect of inflammation, great prostration of strength may sub- sequently arise, or else constitutional symptoms in consequence of the ab- sorption of putrid matter, and, in both these instances, the voice of experi- ence loudly demands the employment of bark, though its exhibition might have been at first useless, or hurtful. While the genuine inflammatory fever, and local inflammation, attend mortifi- cation, antiphlogistic means are un- doubtedly useful. However, great cau- tion is requisite in employing them, as, in cases of humid gangrene, as it is termed, the inflammatory state very soon changes into one, resembling that of typhus fever, &c. Sometimes, there is mere prostra- tion of strength, without any symptom of disorder in the gastric system, or of inflammation, or typhoid fever. A ner- vous fever is of this kind. In this in- stance, bark is plainly proper, though seldom effectual alone. Volatile, dia- phoretic, and nervous medicines, are commonly at the same time proper, and opium, wine, and the volatile al- kali, are such as experience has select- ed, together with the application of blisters. From the preceding observations, it becomes evident, that though the me- thod of treatment in cases of sphacelus, depends on the occasional cause, yet, it must also be regulated by the kind of fever, which, as we have described, may be either inflammatory, typhoid, one connected with gastric disorder, or nervous. Consequently, there are four Vol. II." T 146 MORTIFICATION. plans of constitutional treatment, and it is easy to determine the particular cases, in which bark is unnecessary, hurtful, or inefficacious. We meet with one species of morti- fication; in which the patient experi- ences severe pain in the part, without the smallest appearance of inflamma- tion. Here bark is never of any use, and opium is probably the only medicine of any efficacy. We shall consider this subject more fully presently, when we introduce Mr. Pott's remarks on a peculiar mortification of the toes and feet. Bark sometimes occasions purging, and then it also proves inefficacious, and hurtful. This effect, however, may frequently be prevented by adding a few drpps of laudanum to each dose. Bark may disagree with the stomach; but, it very seldom does so, when giv- en in an exceedingly fine powder, which also generally proves more effi- cacious, than a coarse one. Adminis- tering it with wine, some aromatic wa- ter, or in the form ofthe cold infusion, makes the medicine likewise less like- ly to disorder the stomach. (Richter.) The vitriolic acid may frequently be advantageously given at the same time with the bark, and the best method of exhibiting it is to acidulate with it eve- ry thing, which the patient drinks. Other acids are also sometimes used for the same purpose. Carbonic acid gas is another remedy of the highest efficacy in all cases of mortification. It has even been known to have the most beneficial effects when bark has failed in doing good. Water impregnated with this gas should be recommended, as a most beneficial kind of drink. Such are the remedies, which have acquired the greatest confidence of practitioners, when the indication is to support and strengthen the constitu- tion, with a view of resisting the pro- gress of mortification. A great many others have been recommended, but, there are none, which, in point of efli- eacy, can be compared with those abovementioned. 3. Anodyne Remedies. A third indication which should be •bserved together with the second, or which should even precede it in many instances, is to lessen the irritability and sufferings of the patient, by the use of opium. Attention to this deside- ratum frequently contributes more than any thing else, to stop the progress of the disorder, and is often indispensable in order to promote the operation of other remedies. In all cases of mortifi- cation, everv thing, which heats, irri- tates, or adds to the patient's suffer- ings, appears, in general, to augment the disorder, and increase the rapidity of its progress. On the other hand, every thing which tends to calm, as- suage, and relax, almost always re- tards the progress of mortification, if it produce no greater good. The pain al- so, which is a constant mark of too much irritation, contributes of itself to increase such irritation, and, in this double point of view, we cannot do bet- ter, in the majority of cases, than en- deavour to appease it by the more or less liberal use of opium. When the in- flammatory stage evidently prevails, this medicine may be conjoined with antiphlogistic remedies, such as neu- tral salts, and particularly, nitre. In other instances, attended with debili- ty, it may be given with bark and cor- dials. The following observations on the efficacy of opium in a particular, and not unfrequent case, are highly enti- tled to the attention of every surgical practitioner. The disease is also de- scribed with that accuracy and ele- gance, which always distinguish the writings of Mr. Pott. " The powers and virtues of the Pe- ruvian bark are known to almost every practitioner in physic and surgery.— Among the many cases, in which its merit is particularly and justly cele- brated, are the distempers called gan- grene and mortification; its general power of stopping the one, and resist- ing the other, have made no inconsi- derable addition to the success of the chirurgie art; but still there is a parti- cular species even of these, in which this noble medicine most frequently fails: I mean that particular kind, which, beginning at the extremity of one or more of the small toes, does, in more or less time, pass on to the foot and ankle, and sometimes to a part of the leg, and, in spite of all the aid of physic and surgery, most commonly destroys the patient. " It is very unlike to the mortifica- tion from inflammation, to that from ex- ternal cold, from ligature, or bandage, or to that which proceeds from any known and visible cause, and this as MORTIFICATION. 147 well in its attack as in its process. In some few instances, it makes its ap- pearance with little or no pain; but, in by much the majority of these cases, the patients feel great uneasiness through the whole foot and joint of the ankle, particularly in the night, even before these parts show any mark of distemper, or before there is any other, than a small discoloured spot on the •nd of" one of the little toes. " It generally makes its first appear- ance on the inside, or atthe extremity, of one ofthe smaller toes, by a small, black, or blueish spot: from this spot the cuticle is always found to be de- tached, and the skin under it to be of a dark red colour. " If the patient has lately cut his nails, or corn, it is most frequently, though very unjustly set to the account of such operation. " Its progress in different subjects, and under different circumstances, is different; in some it is slow and long in passing from toe to toe, and from thence to the foot and ankle; in others its progress is rapid, and horridly pain- ful: it generally begins on the inside of each small toe, before it is visible either on its under or upper part; and when it makes its attack on the foot, the upper part of it first shows its dis- tempered state, by tumefaction, change of colour, and sometimes by vesication; but wherever it is, one of the first marks of it is a separation or detach- ment ofthe cuticle. " Each sex is liable to it; but for one female in whom I have met with it, I think I may say, that I have seen it in at least twenty males. I think, also, that I have much more often found it in the rich and voluptuous, than in the labouring poor; more often in great eaters, than free drinkers. It frequently happens to persons advanced in life, but it is by no means peculiar to old age. It is not, in general, preceded or accompanied by apparent distempera- ture either of the part, or of the habit. I do not know any particular kind of constitution which is more liable to it than another; but as far as my observa- tion goes, I think that I have most fre- quently observed it to attack those, who have been subject to flying uncer- tain pains in their feet, which they have called gouty, and but seldom in those who have been accustomed to have the gout regularly and fairly. It has, by some, been supposed to arise from an ossification of vessels; but for this opi- nion I never could find any foundation but mere conjecture. " The common method of treating this distemper is, by spirituous fomen- tations, cataplasms actually and poten- tially warm, by dressings of the diges- tive kind, as they are called, animated with warm, pungent oil and balsams, &c. and, internally, by the Peruvian bark. " I wish I could say that this, which, with little alteration, has been the ge- neral practice, had been most frequent- ly, or even often successful; but I am, from long and repeated experience, obliged to say, that it has not. " I am sensible, that many of my readers will be surprised at my affirm- ing, that the Peruvian bark will not stop a mortification, a distemper in which, for some years, it has been re- garded as specific; but I must beg not to be misunderstood: I mean to confine my observation and my objection to this particular species of mortification, which I regard as being sui generis: and under this restriction 1 must re- peat, that I have seldom, if ever, seen the bark successful: in all other cases, wherein it is used or recommended, no man has a higher opinion of it; but, in this I cannot give it a praise, which it does not deserve. " I believe 1 may venture to say, that I have tried it as fairly, as fully, and as variously as any man has or can: I have given it in the largest quantity, at the shortest intervals, and for the longest possible space; that is, as long as the patient's life would permit: I have given it by itself in decoction, extract, and substance; I have combined all these together; I have joined it with nitre, sal. absynth. with snake-root, with confect. cardiac, with volatile salts, and with musk, as different cir- cumstances seemed to require, or ad- mit: I have used it as fomentation, as poultice, as dressing; I have assisted it with every thing which has been usu- ally thought capable of procuring, or assisting digestion; still the distemper has continued its course, perhaps a little more slowly, but still it has ended in death. " I am sorry to rob one of our great medicines of any part of its supposed merit, but as on the one hand, its claim, in this instance, is unjust, and as 148 MORTIFICATION on the other, I hope to add as much to the character of* another, the res me- dica will be no sufferer. " Some time ago, I had a patient la- bouring under this complaint, who, from antipathy, obstinacy, or some other cause, could not be prevailed on to take bark in any form whatever. I made use of every argument, but to no purpose: fomentation, poultice, and the usual dressings were applied in the usual manner; the disease advanced some days more, some days less, and at the end of a fortnight, the small toes were all completely mortified, the great one become blackish, the foot much swollen, altered in colour, and the dis- ease seeming to adv. nee with such hasty strides, that I supposed a very- few days would determine the event. The pain in the foot and ankle was so great, and so continual, as totally to de- prive the patient of sleep. On this ac- count, and merely to procure some re- mission, I gave two grains of opium at night, which not having the desired effect, I repeated it in the morning. Finding, during the following day, some advantage, I repeated the same dose night and morning, for three days; at the end of which time the patient became quite easy, and the appearances on the foot and ankle were visibly more favourable Encouraged by this, I in- creased the quantity of the medicine, giving one grain every three or four hours, taking care to watch its narcotic effect, and to keep the belly empty by glysters. In nine days from the first administration of the opium, all the tu- mefaction of the foot and ankle totally subsided, the skin recovered its natu- ral colour, and all the mortified parts plainly began to separate; in another week they were all loose, and casting off, the matter was good, and the in- carnation florid. During the whole of this time I continued the use of the opium, varying its quantity as circum- stances required, but never gave less than three or four grains in twenty-four hours. . %* " When the sloughs were all cast off, the bones separated, and I had only a clean sore to dress and heal, I gradu- ally left off the medicine. " I am very willing to acknowledge, that however well-pleased I might be with the event of this case, yet I really regarded it as accidental; so much so, that having very soon after another op- portunity, I did not care to trust to opium alone, but joined the bark with it. The event was equally fortunate But although I had joined the cortex with the extractum thebaicum, and did therefore attribute the success to their united powers, yet the effect was so very unlike to what I had ever seen from the bark without opium, that I could not avoid seriously, and often re- flecting on it, and determining to use it by itself, whenever another opportunity should offer. 1 did so, and succeeded in the same happy manner, though under the very disagreeable circum- stances of seventy years of age, a broken, distempered constitution, and the disease making a hasty progress. " To relate cases which are nearly, or at least materially similar, is of no use: I shall therefore only say, that every opportunity, wliich I have had since of making the experiment, has still more and more convinced me of the great value and utility of this me- dicine, and of its power of rescuing from destruction, persons under this affliction. " I cannot say that it has never failed me: it certainly has; but then it has been under such circumstances, as I think would fairly account for the failure. " I should be exceedingly sorry to be misunderstood; 1 should be still more so to mislead any body; and there- fore I beg it may be noticed, that I do not propose the extractum thebaicum, in this case, as a universal, infallible specific; I know, from experience, that it is not; but as I also know, from re- peated experience, that it will^ under proper management and direction, do more than any, or than all other medi- cines; and that I have, by means of it, saved some lives, which, I am very sure, would, under the common, and most approved method of treatment, without it, have been lost, I could not answer to myself the not communicat- ing what I had observed. " If this was an experiment, in which the life or limb, or health ofthe patient, was in any degree endangered, or by which the person, on whom it may be tried, could, in any degree, be injured, I should have withheld what I now publish, until a greater length of time, and more experience, had ren- dered it still more absolutely certain; and I should have thought myself strictly vindicable in so doing: but as this is a medicine, whose general ef- MORTIFICATION. 149 fects are well known, and which is, at the same time, so capable of direction and management, that it is almost im- possible for any person who deserves to be trusted with medicine at all, to do any material harm with it, I thought it would be wrong and unjust to con- ceal what had occurred to me, lest I might thereby deprive the afflicted of an assistance which, I verily believe, is not to be obtained from any other quarter. " In short, from what I have seen and done, I am perfectly convinced that, by its means, and by its means solely, I have saved lives which, with- out it, must have been lost. " If it preserves a few of those, who are so unfortunate as to labour under this nasty, painful, lingering, and destructive disorder, to which we are all liable, and which has hitherto, most frequently, foiled all attempts of art, I shall be sincerely glad to have contributed to so good an end: if it should prove in other hands as success- ful as it has with me, 1 shall be still more so; but, on the other hand, if, after several times giving me reason to believe and hope that it would prove an instrument for the preservation of many, it should, upon more repeated trial, be found to fail, I shall be sorry for the event, but shall still think, that I did right in communicating what I had seen, and thereby endeavouring to be useful to mankind. Hoc opus, hoc studi'um, pan i propere- mus et ampli, Si patris volumus, si nobis vivere cart. " If I am right in my conjecture concerning this hazardous and destruc- tive malady; and if the method wliich I have proposed and practised, should prove as successful in the hands of others as it has in mine, I cannot help thinking, that the external or chirurgie treatment of the disorder might be amended; that is, might be made to coincide more than it does at present, with such soothing kind of plan. " Since I have had reason to em- brace this opinion, and to act in con- formity to it, I have found more ad- vantage from frequently soaking the foot and ankle in warm milk, than from any spirituous, or aromatic fomenta- tions whatever; that is, I have found the one more capable of alleviating the pain, which such patients almost al- ways feel, than the other; which cir- cumstance I regard as a very material one. Pain is always an evil, but, in this particular case, I look upon it as being singularly so. Whatever heats, irritates, stimulates, or gives uneasi- ness,'appears to me always to increase the disorder, and to add to the rapidity of its progress; and, on the contrary, I have always found, that whatever tended merely to calm, to appease, and to relax, at least retarded the mis- chief, if it did no more. " The whole plan of the chirurgie treatment of this disease is founded on a general idea of warming, invigora- ting, stimulating, and resisting putre- faction; and the means generally made use of are very proper for such pur- pose: but I must own that I think the purpose, or intention, to be improper. " Upon this principle, the old theri- aca Londinensis, and the present cata- plasma e Cymino, have been, and still are, so freely used on this occasion. A composition of this kind, if it does any thing, must heat and stimulate, and it is by heating and stimulating the skin, to which it is applied, that it so fre- quently does that mischief which I am confident it often does, though such mischief is set to the account ofthe na- ture of the disorder. Cases exactly si- milar, in all circumstances, are not to be met with eveiy day, but I am from experience convinced, that of two, as nearly similar as may be, in point of pain, if the one be treated in the usual manner, with a warm, stimulating ca- taplasm, and the other only with a poul- tice made of the fine farina seminis lini, in boiling milk or water, mixed with ung. sambuc. or fresh butter, that the pain, and the progress of the distem- per, will be much greater and quicker in the former than in the latter. " When the black or mollified spot has fairly made its appearance on one or more of the toes, it is the general practice to scarify or cut into such al- tered part with the point of a knife or lancet. If this incision be made merely to learn whether the part be mortified or not, it is altogether unnecessary, the detachment of the cuticle, and the co- lour of the skin, render that a decided point: if it be not made quite through the eschar,it can serve no purpose atail; if it be made quite through, as there i* no confined fluid to give discharge to, it can only serve to convey such medi- cines as may be applied for the purpose of procuring digestion to parts, capable 150 MORTIFICATION. of feeling their influence, and on this account they are supposed to be bene- ficial, and therefore right. " When the upper part of the foot begins to part with its cuticle and to change colour, it is a practice with many to scarify immediately; here, as in the preceding instance, if the scari- fications be too superficial, they must be useless; if they be so deep, as to cause a slight hemorrhage, and to reach the parts which have not yet lost their sensibility, they must do what indeed they are generally intended to do, that is, give the medicines, which shall be applied, an opportunity of act- ing on such parts. " The medicines most frequently made use of for this purpose arc, like the theriaca, chosen for this supposed activity; and consist of the warm, pun- gent oils and balsams, whose action must necessarily be to stimulate and ir- ritate: from these qualities they most frequently excite pain, which, accord- ing to my idea of the disease, is dia- metrically opposite to the proper cura- tive intention; and this lam convinced of from repeated experience. " The dressings cannot consist of materials which are too soft and leni- ent; nor are any scarifications necessa- ry for their application. But I would go farther and say, that scarifications are not only useless, but, in my opinion, prejudicial, by exciting pain, the great and chiefly to be dreaded evil in this complaint The poultice should be al- so soft, smooth, and unirritating; its intention should be merely to soften and relax; it should comprehend the whole foot, ankle, and part of the leg; and should always be so moist or greasy as not to be likely to become at all dry or hard, between one dressing and ano- ther. " I will trouble the reader with only one remark more. " When the toes are, to all appear- ance, perfectly mortified, and seem so loose as to be capable of being easily taken away, it is, in general, thought right to remove them. However rotten and loose they may seem to be, or real- ly are, yet while they hold on, they hold by something which is still endu- ed with sensation, as may always be known, if they be bent back or twisted with any degree of violence. " I will not enter into a dispute about the sensibility or insensibilty of ilaments, nor undertake to determine whether they be ligaments or any other kind of parts which still maintain the connexion of the toes with their own respective joints, or with the metatar- sal bones; it is sufficient for me to know, and to inform the young practitioner, that however loose they may seem, yet if they be violently twisted off, or the parts, by which they hang, be divided, a very considerable degree of pain will most commonly attend such operation, which therefore had much better be avoided; and that 1 have seen this very pain, thus produced, bring on fresh mischief, and that of the gangrenous kind. " If the patient does well, these parts will certainly drop off; if he does not, no good can arise from removing them."— (Pott's Works.) Other practitioners have confirmed, by their experience, the efficacy of opi- um, in cases, in which the disorder is attended with a great deal of irritation, though it may not always have had the same success in their hands, when the mortification has appeared to depend chiefly on constitutional debility. Mr. Kirkland observes, that we must be careful not to force the doses, especial- ly at first; and that the medicine does more harm, than good, when its sopo- rific effects go so far as to occasion de- lirium, take away the appetite, or cause affections ofthe heart. Some authors have also recommend- ed the use of camphor, which, by rea- son of its narcotic virtue,has sometimes produced good effects. M. Pouteau at- tributes considerable efficacy to it, especially, in the erysipelatous gan- grene arising from wounds. In such cases, he recommends it to be given in the dose of five grains, with a double quantity of nitre, every four hours.— (Encyclopedic Methodiquej Partie Chi- rurgicale.) LOCAL MEANS. 1. Suppression of Irritating Causes. With respect to the external, or lo- cal treatment of mortification, the first indication consists in removing, if pos- sible, such external causes,as may have occasioned, or kept up the disorder. Such are all those causes, which origi- nate from the compression of ligatures, tumours, &c. Of this kind, also, are all irritating, and poisonous substances, which by their presence stimulate the parts, more or less violently, according to their particular nature. MORTIFICATION. 151 2. Topical Applications. When mortification arises from in- flammation, which still prevails in a considerable degree, it is evident, that the dead part itself only claims second- ary consideration, and that the princi- pal desideratum it to prevent the mor- tification from spreading to the living circumference, by lessening the inflam- mation present. Hence, under such circumstances, the application of linen, wet with the saturnine lotion, and the maintenance of a continued evapora- tion, from the inflamed parts surround- ing the mortified ones, must be just as proper as if the mortification itself did not exist, and were quite out of all con- sideration. It has been justly remarked by a most eminent man, (Hunter) that the local treatment of mortification, (mean- ing that in consequence of inflamma- tion) has been as absurd as the consti- tutional; scarifications have been made down to the living parts, that stimulat- ing and antiseptic medicines might be applied to them; such as turpentines, the warmer balsams, and sometimes the essential oils. Warm fomentations have been also applied, as being con- genial to life; but, warmth always in- creases action, and should, therefore, be well adjusted to the case; for on the other hand, cold debilitates or lessens powers, when carried too far, though it first lessens action. Stimulants are likewise improper, as the actions are already too violent. It is proper to keep the parts cool, and all the applications should be cold. In cases of mortification from inflammation, good effects have also been seen to arise from the topical, as well as internal employment of opium. But it must be acknowledged, that how proper soever the employment of cold applications is, in cases of mortifi- cation, attended with inflammation, fomentations and emollient poultices are most commonly preferred. Besides common poultices, there are several others, which have acquired great celebrity, as topical applications in cases of mortification. Of this kind are the cataplasma carbonis,* cataplas- ma cerevisis.f and the cataplasma ef- fervescens*. These local remedies are, perhaps, in nine cases out of ten, su- perior to all others. With respect to stimulating, and spi- rituous applications, such as brandy, spirit of wine, balsams, resins, and aromatic substances, which have been recommended by a vast number of au- thors.they are at present almost entirely laid aside by practitioners. Though such things are indeed really very use- ful in preserving dead animal substan- ces from becoming putrid, very little knowledge of the animal economy is requisite to make us understand, that they cannot act in this manner on parts still endued with vitality; but, on the contrary, that they must have very prejudicial effects, in the cases under consideration, by reason of the violent irritation, which they always excite, when applied to the living fibres. It may now and then, however, be justifi- able to apply spirituous applications to the dead parts themselves with a view of diminishing the fetid effluvia, which, by contaminating the air, have some ' share in injuring the patient's health; but the greatest care is requisite to keep these stimulants from coming into contact with the living surfaces around, and beneath the sloughs. When mortification arises from cold, every sort of warm emollient applica- tion must be avoided, and cold water, or even snow or ice, made use of. For this subject, however, See Chilblains. The local treatment ofthe mortifica- tion of the toes and feet, described by Mr. Pott, has been already considered. 3. Scarifications, and Removal of the mortified Parts. Another grand indication is to give vent to putrid matter, extravasated in the cellular substance, by making deep scarifications in the integuments. The majority of authors who have treated of mortification, have very much in- sisted upon this plan, which they re- commend in all kinds of cases. They even advise the incisions to be made * Prepared by mixing about Jij of finely powdered wood-charcoal with half a pound ofthe common linseed poultice. f Prepared by stirring into the grounds of strong beer as much oatmeal, as will make the mass of a suitable consistence. t Prepared by stirring into an infusion of malt as much oatmeal, as will render the substance of a proper thickness, and then adding about a spoonful of yeast. 152 MORTIFICATION down to the sound parts, in order to facilitate the application of topical sti- mulants, and to favour the operation of the supposed antiseptic qualities of such applications. But, with the ex- ception of cases, in which gangrene affects some aponeurotic membrane, and others, in which the integuments, already mortified, are exceedingly dis- tended with putrid matter collected in the cellular substance, either in conse- quence of foregoing inflammation, or any other cause, such as the extravasa- tion of urine in the scrotum, all scarifi- cations, which penetrate as far as the living parts, are often productive of most serious mischief, instead of ad- vantage. Such incisions cannot be prac- tised, without occasioning a great deal of pain, and producing inflammation, which itself often powerfully contri- butes to make the mortification spread. But, as parts, which are in a complete state of sphacelus, are absolutely ex- traneous substances, in regard to those, wliich still retain their vitality, they require no concern, and when their mass is considerable, it is not only pro- per to scarify them, but, also to re- move a portion of them. By lessening the size of the putrid mass of matter, the fetor is diminished, which, in this case, is always considerable; we also make way for the escape of a great .deal of putrid discharge, which, being confined, might have a bad effect on the neighbouring living parts; and we enable these latter to free themselves more easily from the rest of the sloughs. From what has been already said, it must appear, that scarifications are only to be employed with the greatest prudence, lest they should increase the disorder, which they are intended to benefit. The same may be said of the too common practice of accelerating, with a cutting instrument, the separation of the mortified parts, which process na- ture tends to accomplish. It is always dangerous to irritate parts, which are affected with inflammation, in cases of sphacelus, before they are completely restored to their natural state, and in having recourse to the abovementioned operation, while there is any adhesion remaining, between the slough and the living parts, it is impossible to avoid producing irritation in the latter. We have already given Mr. Pott's senti- ments, with respect to the danger and inutility of cutting the tendons and li- gaments, in the mortification of the toes and feet. If the surgeon prudently wait the event of things, the separation of the mortified from the living parts, will in general be soon effected, when an in- flammation and suppuration at the edges of the slough, have set bounds to the expansion of the sphacelus, and which inflammation and suppuration will also contribute to the-detachment of the slough. The other mode of prac- tice is the above one, viz. the amputa- tion of what is mortified. Although the certainty and expedi- tion ofthe knife have the semblance of being infinitely preferable to the uncer- tain, and tedious, mode of procuring a detachment of a mortified part, by the occurrence of suppuration and the ac- tion of the absorbents, which remove the particles, connecting the dead and living matter together, yet cutting away parts, in cases of sphacelus, is not, very frequently, proper. The inci- sion can only be performed in the liv- ing, or dead part. In attempting the latter, we are ignorant of the precise extent of the disorder. Sometimes the sphacelus is more extensive towards the surface, than in a deeper situation. There is also a constant risk of injuring the living parts, and thereby occasion- ing very unfavourable symptoms. If this should not occur, still there will remain, after the operation, a vconsi- derable portion of the mortified part, for the detachment of which as much inflammation, suppuration, and time, will be requisite, as if no operation had been undertaken. If the operation have any use, it is that of lessening the bulk of t*he slough, and thereby diminishing the fetid effluvia. Amputation, performed in the living part, removes one danger by incurring a still greater one. Of this no doubt can be entertained, when we reflect, that this important operation has often a fatal event, even when performed under the most propitious circum- stances, and that, in the cases now under consideration, it must commonly be undertaken on a subject, in a state of extreme debility. Besides, there is never any certainty, that we are ampu- tating in living parts. Mortification ra- pidly ascends along the cellular sub- stance, surrounding the large blood- vessels, and is frequently much more extensive internally, than external ap- MORTIFICATION. Jj3 -pearances would lead one to suppose. The adjacent surface, still apparently alive, is often so affected, that it must inevitably slough, though, at present, it may not actually have sphacelated. The surgeon imagines, that amputa- tion is performed on living parts; but, soon afterwards discovers, that he has been dividing those, which are dead. (Richter.) The operation can do no good, while the mortification is in a spreading state, nd it may do considerable mischief. The disorder enlarges its limits, be- cause its cause still operates, and this is not removable by amputation. If the operation be now injudiciously under- taken, the sphacelus invades the wound, and is the more certainly mor- tal, as the patient has now been further ■weakened by amputation, and its con- sequences. Many mortifications, especially those, which arise from external causes, very often spontaneously stop, and separate. But, the place, where this will hap- pen, can never be foreseen. By amputa- ting in this circumstance, we run a risk of disturbing nature in her salu- tary work, and rendering the disorder fatal: and the operation, considered in the most favourable point of view, is a most useless one. It is rational to be- lieve, that, whenever amputation has been successfully practised in the liv- ing part, while a sphacelus was in a spreading state, the complaint would have stopped of its own accord, and the patient been preserved without the operation. Since amputation, also, plainly renders the patient's condition unfavourable, we may infer, that many persons have died after its perform- ance, who might have been saved without it. / As soon as a sphacelus leaves off spreading, and begins to separate, the greatest danger is over. To practise amputation now in the living part, is manifestly hurrying the patient unne- cessarily into fresh peril, just after he has escaped from a most dangerous si- tuation. However, should the opera- tion be done, and the patient live, the cure is not in the least accelerated, as the healing of the wound will require as much time, as the detachment, and perfect cure of the mortification. The following are cases, in which, perhaps, the use ofthe knife is justifia- ble and proper. There exists a species of sphacelus, which rapidly occasions death, before it is yet of great extent. Here, indeed, amputation might be really advisable; but, the nature of ths case is unfortunately never disclosed, before the fatal catastrophe. Some ex- ternal injuries are inevitably followed by mortification. In such cases, ampu- tation is evidently proper; for, the sim- pie incision is attended with less dan- ger, than the sphacelus would be. The surgeon, however, seldoms knows be- forehand, that mortification will inevr. tably ensue. When the mortification has already ceased spreading, or begun to sepa- rate; or, when the cause of the disor- der is removed; one may, at all events, cut off some of the slough. By this means, we shall succeed in diminishing the nuisance and unwholesomeness arising from the putrid effluvia. It is only necessary to be careful, not to in- jure the living parts, so as to occasion pain and hemorrhage. In cases, in which a whole limb has mortified, and the soft parts have al- ready been detached, the separation of the denuded bone is the only thing re- maining to be done; and this may be accomplished in the usual way with a saw. But, we are to remember, that we thus only free the patient from the fetor of the sphacelated limb, and nei- ther accelerate the cure, nor obtain any other essential advantage. The death of the bone generally extends rather far upward, and, consequently, the saw" can seldom remove the whole of the dead portion, some of which must re- main for nature to detach. The same length of time will be requisite for this exfoliation to be effected as if none of the bone had been sawed off. When the sphacelus is of the dry de* scription, and produces no inconveni- ence from fetor, the employment of the saw is even unadvisable. From what has been said, it appears, that in the majority of cases, the sur- geon must abandon the separation of a mortified part to nature, and confine his endeavours to checking the progress of the disorder. Sometimes, asphacelus spontaneous- ly ceases to spread. This happens most frequently in cases which originate from an external cause, such as a vio- lent contusion, burn, &c. But, the oc- currence is not restricted to this kind of case, nor is it invariably attendant on it. When there are no other occa- sional causes present, the mortification Vol. n. r 154 MORTIFICATION does not readily go beyond the limits of the contusion, or violent burn; but the interference of surgery can hardly ever put a stop to its progress, before it has spread as far as the extent ofthe local injury. (Richter.) 4. Application of Caustic Substances, and ofthe Actual Cautery. Having explained the chief indica- tions in the treatment of mortification, we proceed to notice some particular means, which have been recommended by practitioners of eminence, as being in certain cases very efficacious. We allude to some caustic substances, and even the actual cautery, which have sometimes been successfully employed in this disease. One of these applications is the mu- riatic acid, more or less diluted with water. It was Van Swieten, who parti- cularly recommended this remedy; he mixed the acid with six times its quan- tity of water, and applied it as a fo- mentation to the moi-tified part, after making deep scarifications. In this manner he stopped, or seemed to stop, a mortification, arising from a violent inflammation ofthe scrotum and penis, and which extended all over these parts. The same author strongly re- commends this same topical application to the sloughy state of the gums in cases of scurvy. In this kind of case, lie mixed the muriatic acid with honey, in various proportions; sometimes, he even employed the pure acid itself for touching the parts, which were likely to slough. It is easy to comprehend, that the muriatic acid as well as other mineral acids, and vinegar, weakened with a sufficient quantity of water, may act as an antiphlogistic, and antiseptic, but, when it is concentrated, its man- ner of acting is then very different, as it is a real caustic, and its salutary ef- fects can only be explained by the change, which it produces in the na- ture of the inflammation, which now becomes favourable to the formation of healthy pus. It is only in the same way, that we can account for the good effects, attri- buted to another, much more active caustic, than the muriatic acid, namely, a solution of mercury in the nitrous acid, with which solution the edges of the mortified part are recommended to be wetted. This, it is said, stops the progress of mortification. We are not, however, possessed of a sufficient num- ber of facts in support of such prac- tice. An example, however, mentioned by a judicious author, Mr. Kirkland, deserves attention. A man met w ith a fracture of the fore-arm, and the ends of the bones projected through the integuments. The fracture was very expeditiously reduced; but, at the end of five, or six days, the whole arm seemed to be com- pletely mortified up to the shoulder. Amputation was performed as near th« joint as possible, and the stump, which had mortified as far as the acromion, was cauterised. The following dav the mortification had reached the inferior extremity of the scapula. A little of the solution of mercuiy in nitrous acid was now applied, by means of a probe, along the edges of the parts affected, and from this moment the disorder made no further progress. This cau- terisation was repeated every day, for seventeen, or eighteen days. The sloughs, and, especially, the scapula, were detached, and the patient got well. With respect to the actual cautery, Celsus has recommended it to be ap- plied to the line, which separates the dead parts from those which are still living, whenever medicines, and, par- ticularly, topical emollient applications fail in stopping the progress ofthe dis- order. M. Pouteau has ventured to re- vive this practice, which had been en- tirely exploded from modern surgery, and he was opinion, that the method might have the most beneficial effects, in cases of erysipelatous gangrene, which is so often seen in hospitals in consequence of wounds. For this pur- pose, he recommends cauterising chiefly the edges of such parts, as are of a dark red colour, and are on the point of perishing; and he advises this to be done with a heated iron, or boiling oil, and to repeat the cauterisation of the dead parts, at every time of dressing them, until the sensation of heat is even felt with a certain degree of force in the sound parts. The whole of the af- fected part is afterwards to be covered with a large emollient poultice. M. Pouteau relates a very interesting case of an anthrax, which took place on a woman's cheek, and which he cured in the above manner. The tumour, which, on the third day, was quite black, and as large as a walnut, was accompanied by an erysipelatous oede- ma, which extended over the whoh? MORTIFICATION. 155 cheek, eyelid*, and front of the neck. M. Pouteau, after having- opened the tumour in different directions with a lancet, introduced the red-hot caute - ry, and repeated the application se- veral times, until the heat was fi.lt by the sound flesh. The patient felt her- self very much relieved immediately after this had been done; an oppressive head-ach, and a very afflicting sense of strangulation, which she before expe- rienced, were got rid of, and, in ten days more, the slough was detached by the occurrence of suppuration. (Ency- clopedic Methodique; Partie Chirurgicak, Art. Gangrene.) The foregoing observations are in- troduced into this work, that the rea- der may ndt be left entirely ignorant of What violent measures the old surge- ons adopted in cases of mortification, and the account is not given, in order that such practice may be again imitat- ed. The employment of such terrible implications, as the actual cautery, and boiling oils, is as unscientific, and un- necessarily painful, as it is unproduc- tive of any essential good. The grand object in almost every case of mortifi- cation, is to diminish the irritation of the parts in immediate contact with those already dead. This is indicated, lest the parts still alive, and so situated, should experience the same fate, as the contiguous ones. Some who have re- probated the application of spirituous, and resinous substances to parts, affect- ed with mortification, and who have also condemned incisions and scarifica- tions, give their approbation to the use of the cautery. They assert, that the manner, in which the latter acts, is es- sentially different from that, in which spirituous and resinous applications operate, and that while these, by irri- tating the affected pails, tend to in- crease and propagate the inflammation, that leads to mortification, the lively action of the cautery changes the na- ture of such inflammation, and esta- blishes that state of the vessels, which is necessary for a favourable suppura- tion. They state, also, that the cautery gives a tone to the vessels, in the vicini- ty of the parts to which it is applied, and, in proof of this remark, they refer to the effects of the application on dif- ferent ill-conditioned ulcers, and par- ticularly, on carious bones. (Encyclopi- die Methodique; Partie Chirurgicak, Art. Gangrene.) . Notwithstanding these assertions, 1 shall venture to congratulate the sur- geons of this country in particular, on the total rejection of the use of the ac- tual cautery and boiling oils, in cases of mortification. £From repeated disappointments in the use of the various remedies which have been recited, and from having ob- served the efficacy of blisters in arrest- ing the progress of erysipelas, Dr. Phy- sick was induced some years ago to try the effect of epispastics in the treatment of gangrene. " The first opportunity," says the Doctor, " I bad of applying a blister with this intention, was in the case of Captain Stokes, a gentleman between forty and fifty years of age, whom I was desired to visit in consultation with Dr. Rush, in January 1803. After an inflammation about the anus, which had been supposed for several days by the patient, an attack of piles, a morti- fication was observed to have com- menced in the perinsum, and on the side ofthe scrotum. At my first visit I proposed a blister, to extend from the edge ofthe mortification in the perins- um, backwards over the buttocks; this being agreed to, was immediately ap- plied; the following day, when the blis- ter was dressed, we were both well satisfied with its effect, as it had pre- vented the mortification from spread- ing backwards; but so extensive was the mortification of the skin and an- terior part of the scrotum, which ap- peared to extend upwards in the course of the spermatic chords towards the abdomen, that his recovery was not to be expected. After a few days he died." Dr. Rush being struck with the good effect of the blister in the preceding instance, has lately employed the re- medy in a case of mortification, the his- tory of which is contained in the fol- lowing letter. Dear Sir, I was called upon by Dr. Bleight, on the 29th of last July, to visit with him Captain R. A. who in consequence of applying a handful of the polygonum persicaria, instead of paper, to a com- mon use, after going to stool, was affect- ed with an inflammation in the extre- mity of the rectum, which extended around the adjoining parts, and along the perinsum, so as to affect the in- teguments of the scrotum. Bleeding andotheT depleting Temedie shad been 156 MYO Nl used to no purpose, in order to cure it: a partial mortification had taken place. I concurred with Dr. Bleight in ad- vising leeches to the sound parts; and recollecting the high terms in whieh you spoke of the efficacy of blisters in preventing the progress of mortifica- tion in our consultation, in the case of Captain Stokes, in January 1803, I ad- vised their application to all the dis- eased parts which had not put on a gan- grenous appearance. They had the wished-for effect; the mortified parts were afterwards cut away, or gradual- ly sloughed off; and, under the faithful and patient subsequent attendance of Dr. Bleight, the Captain happily reco- vered, and now enjoys his usual health. In the most dangerous state of his disease, we gave him bark; but its dis- tressing effects upon his system oblig- ed us to lay it aside. From, dear, sir, your sincere friend, Benjamin Rush. Dr. P. S. Physick. Nov. 15th, 1804. The next case in which the remedy was employed was that of a gentleman who had been attacked with " a mor- tification of the foot, which was ad- vancing daily upwards, unchecked by the liberal use ofthe bark;" a blister in this case was applied round the leg be- low the knee, in the evening—next morning it was dressed, and it was ob- served that the mortification had not increased: the application of a second blister effected a cure. Since the publication of these facts a variety of respectable testimonials have been forwarded to Dr. Physick, of the efficacy of blisters in arresting the progress of mortification. I have my- self experienced the advantage of the practice in several cases of gangrene, i^i AVUS. A mole, or freckle on the skin. Navi materni signify the little spots, excrescences, or swellings,with which many children are born. There are two kinds, viz. small red tumours, which gradually increase to a large size; or brown flat marks, not rising in the least above the surface ofthe skin. and have no hesitation in recommend- ing it, in preference to every local re- medy hitherto in use.J* I Consult B. Bell's System of Surgery. i Encyclopedic Methodique; Partie Chirur- l gicale, Art. Gangrene. Kirkland on Gan- - grene, and on the Present State of Medi- f cal Surgery. Richter's Anfangsgr'unde - der Wunderzneykunst, Band. 1. Various - parts of Hunter on Inflammation, &c. MOXA(Jupanese.)A soft lanuginous ; substance prepared from the young > leaves of a species of mugwort. It is used in the following way: A little I cone ofthe moxa is laid upon the part, f previously moistened, and seton fire at the top. It burns down with a tempe- rate glowing heat, and produces a i dark-coloured spot, the exlilceration of which is promoted by applying a little garlic. The ulcer is left to discharge, , or is healed up according to the object in view. The moxa is famous in the East for curing several diseases; and the French are in the habit of using it; but, whenever English surgeons wish r to produce a slough, they have recourse i to caustics, in preference to actual fire. MUNDIF1CATIVES, (from mun- diflco, to cleanse.) Mundicativa, Mun- r dtflcantia, Mundificativa. Applications, 1 which make sores put on a cleaner ap- pearance. t MYDRIASIS, (from Moiao, to abound in moisture.) A preternatural dilatation of the pupil; so named, be-' L cause it was thought to originate in re- dundant moisture, or too great an in- l flux of humours. It is often a symptom of an amaurosis. MYO'PIA, (from /jlw to wink, and uvj, the eye.) That kind of shortsight- edness, in which the eyes are half : shut, and always winkings Mr. Latta says, he once saw in a child two years old, a tumour of this kind weighing fourteen ounces, which, at the time of birth, was only equal in size to a large bean, and which for a year afterwards did not enlarge much; but, then grew to the magnitude alrea- dy specified. The other species of ns- vi materni, or such as rise but little N NECROSIS, 157 above the skin* are of various forms, and have been compared with cherries, grapes, &c. and have all been supposed to arise from some impression made on the mind of the mother during preg- nancy, or at the time of conception. The settlement of this disputed point, I shall leave to speculative writers. Those nsvi materni, which are mere spots, or marks, give no inconvenience, and of course do not require the inter- ference of surgery. But such nsvi ma- terni as elevate themselves above the surface ofthe body, increase in size, and seem likely to become trouble- some, should be entirely removed with a knife. Many of them seem to consist of a congeries of dilated vessels, and, after they have acquired a certain size, are apt to burst and bleed profusely. John Bell has named this kind of dis- ease aneurism by anastomosis; the de- scription, and proper treatment of which are to be found in the article Aneurism. Mr. Abernethy cured an extensive nsvus maternus, of a child's arm, with a bandage. (See Lotto's System of Sur- gery, vol. 2, chap. 22/ John Bell on Aneu- rism by Anastomosis, in his Principles of Surgery, vol. 1; Abernethy's Surg. Obser- vations.) NATRON PRvEPARATUM, in surgery, is chiefly given in cases of bronchocele, and scrofula. The com- mon dose is a scruple. NEBULA, (from wptiKn, a little cloud.) A cloudiness ofthe cornea of the eye. See Cornea, Opacity of. NECROSIS, (from nxgou, to de- stroy.) This word, the strict meaning of which is only mortification, is, by the general consent of surgeons, con- fined to this affection of the bones. The death of parts of bones was not distinguished from caries by the an- cients. However, necrosis and caries are essentially different; for, in the first, the affected part of the bone is deprived ofthe vital principle; but this is not the case when it is simply cari- ous. Caries is very analogous to ulcera- tion, while necrosis is exactly similar to mortification, ofthe soft parts. The subject of necrosis is a peculiar- ly interesting one; for, it introduces us to a knowledge of reparations accom- plished by nature, which would excite admiration and wonder even in men whose feelings are the most thoroughly chilled with apathy. What man, unac- quainted with the facts, which the rich records of surgery now present, would ever suppose, that so large a bone as that of the thigh might perish, a new- one be afterwards generated, and the old dead one in time removed by ab- sorption, so as to leave the functions and power of the limb quite unimpair- ed!—We shall first explain the most remarkable circumstances, relative to the nature of necrosis, next mention a few important cases, and lastly speak of the treatment. It is a remarkable circumstance, in the history of necrosis, that, in favour- able instances ofthe disease, the inflex- ibility and firmness of the limb are pre- served, during the whole of the pro- cess, by which the new bone is formed. Consequently, the new bone must have begun to gro w, and must have acquir- ed firmness before the old bone sepa- rates, or is absorbed. Were this not the case, the limb must become flexible and useless, the moment the dead bone is removed. Another consequence of the new bone being formed, before the removal of the old one, is that the for- mer must surround and include the lat- ter. For, since the lifeless portion of bone completely occupies the space be- tween the two living ends, these can- not be immediately connected by the new bony matter. The connexion can alone be completed by the new bone being deposited on the outside of the old one, from one end to the other, and attaching itself to the portions which still remain alive. The new bone must also be necessarily larger, than the old one, because externally situated, and hence the affected limb, after cure is complete, will always continue larger, clumsier, and less shapely, than the other. The length of it, however, re- mains unaltered, because the old bone retains its attachments, while the rudi- ments ofthe new*bone are lying on its outside, and connect the living ends of the old one, by an inflexible mass, equal in length to the portion, which is de- stroyed. Thus we see, that, in the process, which nature follows in the formation of the new osseous shell, the old bone serves as a mould for the new one; and the first step ofthe process is to sur- round the old bone with an effusion of coagulating lymph. (Russell on Necro sis, p. 2—7.) This author adduces many argu ments to prove, that the pulpy mass. which extends from one portion ofthe 158 NECROSIS. bone to the other, and is itself at last converted into bone, is formed quite independently of the original bone, Or the periosteum. (P. 27.) On the other hand, Mr. Crowther has published a letter, written by Mr. Macartney, in which the periosteum is described, as being the organ produc- ing the new bony matter. Mr. Macart- ney remarks, " that the first and most important circumstance is the change, which takes place in the organization ofthe periosteum; this membrane ac- quires the highest degree of vasculari- ty, becomes considerably thickened, soft, spongy, and loosely adherent to the bone. The cellular substance, also, which is immediately connected with the periosteum, suffers a similar alter- ation: it puts on the appearance of being inflamed, its vessels enlarge, lymph is shed into its interstices, and it becomes consolidated with the periosteum.— These changes are preparatory to the absorption ofthe old bone, and the se- cretion of new osseous matter, and even previous to the death of the bone, which is to be removed. In one in- stance, I found the periosteum vascular and pulpy, when the only affection was a small abscess of the medulla, the bone still retaining its connexion with the neighbouring parts, as it readily re- ceived injection. The newly organized periosteum, &c. separates entirely from the bone, after which it begins to re- move the latter by absorption;" and, ^rhile this is going on, its inner surface becomes covered with little eminences, resembling granulations. " In propor- tion as the old bone is removed, new osseous matter is dispersed in the sub- stance ofthe granulations, whilst they continue to grow upon the old bone, until the whole, or a part of it, is com- pletely absorbed, according to the cir- cumstances ofthe case. What remains ofthe investment, after the absorption of the old bone, and the formation of the osseous tube, which is to replace it, degenerates, loses its vascularity, and appears like a lacerated membrane. I have never had an opportunity of exam- ining a limb, a sufficient time after the termination of the disease, to ascertain, whether the investment be at last to- tally absorbed, but, in some instances, I have seen very little remaining. During the progress ofthe disease, the thick- ened cellular substance, which sur- rounded the original periosteum, be- comes gradually thinner; its vessels di- minish, and it adheres strictly to the new formed bone, to which it ultimate- ly serves as a periosteum." Mr. Ma- cartney states, that the anatomical pre- parations, which authenticate the above observations, are preserved at St. Bar- tholomew's Hospital. See Cr&ivther on White Swelling, p. 183. Edit. 2- With respect to the symptoms of lie- crosis, an incipient case is characteris- ed by a deep seated excruciating pain, not at first aggravated by pressure, and which is soon followed by a rapid en- largement ofthe parts alongthe course of the bone. Soon, however, after the commencement of the attack, an ex- ternal inflammation succeeds, which quickly ends in the formation of mat- ter. The abscess, at length, bursts by a small opening. The extent of this in- flammation is not in general great. Most commonly several inflammations, of a circumscribed kind, occur about the same time, the abscesses burst by small openings, which do not close, but, continue discharging matter, as fistulous sores. The apertures are ge- nerally situated over the most superfi- cialpartof the affected bone. The pus is usually of good quality, and large in quantity, issuing from extensiv e cavi- ties, into which the fistuls lead. Such abscesses, being situated within the newly formed osseous shell, cannot be discharged by pressure, nor can any fluctuation be felt. A probe can seldom be introduced far into the fistulous openings, or discover any loose piece of bone. In this stage, the dead bone, technically called the sequestrum, can seldom be felt, though, in a few in- stances, small speculs make their way outward, together with the discharge. Fistulous openings may be regarded, as necessarily attendant on all cases of ne- crosis; though so mild a case may be conceived, that the new bone may be generated without any outward ulcera- tions. No such instance, however, is on record. (Russell.) After the openings have formed, the case may take one of the following courses. The ulcerations may in time heal up, the sequestrum never be seen, and no vestige of the disease remain, except a permanent enlargement and induration alongthe course ofthe bone. This is the most favourable manner, in which a necrosis may terminate. In the other one, the sequestrum makes its appearance extei aally, through the new byne and the integuments attended Mfith NECROSIS. 159 different degrees of pain, inflammation, and suppuration, in different cases. The sequestrum may at first be moved by shaking it; but, is too firmly wedged in the surrounding parts to be com- pletely taken out In time, however, it becomes loose enough to be removed. Sometimes, the middle portion ofthe sequestrum presents itself externally, while its sides are every where wedged in the subst nee of the new bone. The natural end of such a case would be very tedious of accomplishment, and the interference of art is essentially serviceable in accelerating the separa- tion of the dead bone, thus circum- stanced. After the sequestrum has been either absorbed, or thrown off, in one ofthe above ways, the cavity of the new bone becomes filled up with gran- ulations, which are, at length, convert- ed into bony matter. Thus the new bone differs from the original ope, in being solid, instead of hollow. (Rus- sell.) When the sequestrum is thrown off slowly, the inflammation is moderate; but, when it separates quickly, while the new bone is in a soft state, the de- tachment is always preceded by severe inflammatory symptoms, and followed by a temporary loss ofthe natural firm- ness ofthe limb. This premature sepa- ration ofthe sequestrum often occurs in necrosis of the lower jaw, and the chin consequently falls down on th» neck. • In certain cases, the sequestrum sepa- rates at each end from the living por- tions of the old bone, before the new osseous shell has acquired firmness, so that the limb feels as if it were broken in two places. (Russell.) When the dead bone is removed by absorption., the process is tedious, and attended with a profuse discharge of matter, which gradually ceases, and at last stops altogether. In young sub- jects, this work is more quickly per- fected, than in old ones. There are some chronic cases of necrosis, in which the sequestrum remains unab- solved, for an indefinite length of time, producing no violent irritation, yet, al- ways enough to teaze the patient, and disturb his health. . In necrosis of the long bones, there are always round apertures in the new osseous shell, corresponding with the external fistulous openings, as long as the sequestrum remains enclosed in it. (Russell.') The tibia, femur, lower jftw, clavicle, humerus, fibula, radius, and ulna, are most frequently affected with necrosis. Excepting the lower jaw and scapula, the process of regeneration has only been noticed, in the cylindrical bones. From twelve to eighteen years of age, is the time of life, most subject to necrosis. The necrosis of the lower jaw, how- ever, seldom occurs before the age ef thirty. In some persons, two bones are affected at once, owing to constitution* al causes. The process of cure is said to take place with more celerity in the lower jaw, than any other bone, and may be completed in three months. Mr. Rus- sell has never known a necrosis of the tibia get well in less than a year; but, in general, nearly two years elapse first; sometimes, the cure is protracted to a much greater length of time. When the constitution is predispos- ed to necrosis, any cause, capable of exciting inflammation, may occasion an attack of it. Often, however, the dis- ease is purely sporadical, and not re- ferrible to outward causes. Cases, which occur from external injury, are generally those of the lower jaw, which are frequently imputable to blows, the application of acrid sub- stances to carious teeth, effects of mer- cury, &c. Necrosis of the lower jaw and clavi- cle never proves fatal: that ofthe lower extremities, which is the worst case, does so very seldom, and only, from the violence ofthe first inflammatory symp- toms, which rapidly bring on a hectic fever, which proves incurable, without removing its local cause by a timely amputation. When the violence ofthe first stage, however, has abated, the ir- ritation ceases, and the hectij symp- toms, if there are. any, are generally moderate. Nor is this state of tranquil- lity disturbed, till the sequestrum, in making its way outward, again pro- duces irritation. At this second period of urgency, extensive inflammation may originate, ulcerations spread all over the surface ofthe limb, assume an un- healthy appearance, violent fever suc- ceed, and the patient either perish, or sink into a state, in which he must con- sent to amputation, as the only means of saving his life. This is the last crisis of imminent danger; but, in general it is less perilous, than when the inflam- mation comes on in the incipient stage of necrosis. (Russell.) The following case of necrosis of the J 60 Vecrosais thigh bone is related by Dr. Macken- zie. William Baxter, a boy thirteen years old, received a blow on his thigh at school, of which he at first hardly complained; but, in a few months, he began to have pain in the thigh, which inflamed, swelled, and appeared to have matter in it. The parents being poor, no surgeon was called, and the boy was allowed to linger for a great while. At length, the matter made its way through the skin by a small opening on the interior part ofthe thigh, about three inches above the knee, and a thin sanies continued to be discharged for eighteen, or twenty months. At length, the hole in the skin enlarged, and the point of a bone began to protrude, and give a good deal of pain, when the clothes rubbed against it. After suffer- ing in this manner for two years and a half, the boy, as he lay in bed one morning felt the bone looser, and pro- jecting more, than ordinary. He gave it a strong pull, and brought the piece away entirely, which proved to be se- ven inches and a half of the thighbone. A good deal of bleeding followed; but the wound soon healed, and he has ne- ver since found the least inconvenience. Dr. Mackenzie, hearing of this singu- lar case, sent for the boy, carefully ex- amined his thigh, and found it as firm as the other. The only difference was, that it was somewhat thicker, and a little more curved. The muscles re- tained their natural softness, and looseness on the bone. The detached piece of bone was a portion of its whole circumference. In confirmation of this case, Dr. Hun- ter mentions a tibia, which was sent to him by a Mr. Inett, after amputation. On examination, the case at first sight seemed to be a swelling of the whole bone, with a loose external exfoliation. However, it proved to be a remarkable instance ofthe separation ofthe great- est part of the original bone whose place was supplied by a callus. The ex- ternal surface of the inclosed loose piece of the bone was smooth. A small part ofthe surrounding bony substance beingremoved,the contained piece was taken out, and found to be the whole body ofthe tibia. It had separated from the epiphysis at each extremity. The middle part of the bone had perished, consequently, had lost its connexion with the periosteum, and was gradual- ly thrown off from the living parts of tlfe bone at each end. A c;;litis extend- ed from end to end, united the two ex- tremities of the original tibia, preserved the length, and gave firmness and in- flexibility to the part. The exfoliation was so encompassed by the new bony case, that, though quite loose, it could not be thrown out. (Med. Obs. and In- quiries, vol. 2.) In the 5th vol. of the Mem. de I'Acad, de Chirurg. is the his- tory of a man, the whole of whose cla- vicle came away, without his being de- prived of any of the motions ofthe arm. The death of this patient, which hap- pened shortly afterwards, afforded an opportunity of examining how nature had repaired the loss. Another clavicle was found regenerated, which neither differed from the original one in length, or solidity; but, only in shape, being flatter, and not so round. It was con- nected with the acromion and sternum, just like the primitive bone. Though necrosis mostly attacks the cylindrical bones, the flat ones are not exempt from the disease. Pott makes mention of a parietal bone, the whole of which was detached, and of an os frontis, the greatest part of which came away. In a thesis on necrosis, in 1776, aux ecoles de chirurgie, may be found the case of a young man, a very large part of whose scapula perished and came away. Chopart, who relates the case, mentions, that he saw the patient quite recovered, and felt a new trian- gular moveable bone, firmly supporting the clavicle, but, smaller and flatter, than natural, and without any spinous process. The same has happened to the lower jaw, as may be seen by referring to the Ephemerides Germania, and Mem. de I'Acad, de Chirurgie. In the fifth vol. of the latter work, is an ac- count of a woman, who applied to be relieved of some venereal complaints. From the beginning of the treatment, the bone was discovered to be loose just under the gums, and seemed, shortly afterwards, to move backwards and forwards with a tooth. Mr. Guer- nery took hold ofthe tooth with a key instrument, and found itfirmly inserted in the moveable piece of the jaw; he made with caution the necessary ma- noeuvres for extracting the portion of bone; but was greatly surprised on finding what an extensive part yielded to his very moderate efforts. It was the whole ofthe lower jaw, above its right angle, from its division into the coro- noid and condyloid processes to the space between the first and second of NECROSIS. 161 the front grinders of the left side. On the right, there only remained the con- dyle in the articular cavity of the tem- poral bone. This destruction left a con- siderable empty space, from which great deformity was apprehended, in consequence of the unsupported soft parts falling down. The woman, how- ever, got well in two months, and had the most perfect use of a new jaw. A similar fact is recorded in the Journal de Medicine, 1794. In cases of necrosis, the surgical in- dications are few and obvious; viz. 1. When inflammation attends any stage ofthe disease, to have recourse to com- mon antiphlogistic means;—2. To pro- mote the separation, or absorption, of the dead bone, according as it tends to make its way outward, or to become completely incased with new bony mat- ter; and, in this situation, to be invisi- bly and gradually removed by a natu- ral process. 3. When the constitution seems unable to sustain any longer the effects of the local disease, to ampu- tate, if the situation ofthe affection will permit. During the first inflammatory attack, the patient's life is often endangered from the extent and violence of the in- flammation, before the new shell is formed, or the sequestra loose, and ready to separate. In this state, art can do little more, than employ topical bleeding, and fomentations, and poul- tices. If, notwithstanding such treat- ment, the patient should seem likely to perish of the hectic symptoms, which rapidly follow, unless the limb be immediately removed, the operation should then not be delayed. But, if the patient get over the first inflammatory stage, the grand object is to get rid of the sequestra. When they, however, are undergoing a gra- dual absorption, without ever making their appearance externally, or giving any considerable disturbance to the constitution; or, when the dead bone is making its way outward, without oc- casioning urgent inconveniences; the surgeon should interfere very little with the natural progress of the case. When the dead bone does not tend to make its way through the skin, but lies quietly incased in the new osseous shell, the occurrence of extensive sup- purations may be prevented, by occa- sionally applying leeches, and keeping open a blister with the savine cerate, as recommended bvMr. Abernethy in his lectures, and Mr. Crowther in his work on the White Swelling. The blis- ter will, at the same time, have great effect in promoting the absorption of the sequestrum, and, of course, in ac- celerating the process of cure. When the dead bone, however, creates considerable irritation, when its middle portion is very superficial, or quite exposed, while its ends, or edges, are overlapped by the surrounding new bony matter, consequently the piece so wedged in, that its separation cannot be expected in any moderate time, the operation of cutting it out, is, certainly, not only feasible, but highly proper and commendable. In this kind of case, Mr. Hey's saws would be found the most convenient instruments. Also, were the dead bone, though quite covered and incased in the new one, to be tediously long in being ab- sorbed, productive of great irritation and impairment ofthe health, and the affected bone superficial, like the tibia, no candid man could condemn making an incision, and removing a pail of the osseous shell, in order to take the chance of being able at once to extract the sequestrum lodged in its cavity.— Mr. Russell mentions successful at- tempts of this kind, which fully justify the practice. The state ofthe bone may- be examined, without proceeding to any severe operation, by laying bare small portions ofthe bone in the vicini- ty of the fistulous openings, introduc- ing a probe, if possible; or, if that be impracticable, drilling small holes witlv a perforator, for the purpose of explor- ing the state ofthe cavity. If the cavity should still seem extensive, and to con-. tain a sequestrum of considerable size, the necessity of operating is apparent. On the contrary, if the whole cavity be filled up with osseous matter, and no dead bone be found there, the progress of the case must, of course, be left to nature. (Russell.)—When the surgeon knows, that his object is to make an opening large enough to allow the dead piece to be extracted, he scarcely needs directions how to set about making it. The skin must be divided with a com- mon scalpel, and the bone cut with small trephines, a gouge and mallet, or, what are in most cases best, Mr. Hey's saws. Consult Russell on Necrosis, 1794. Mem. de CAcad, de Chirurgie, tom. 5. Boyer on the Diseases of the Bones, vol. 1. Encyclopedic Mithodique; Partie Chirur- VOL. II. X 162 NOLI ME TAN GERE. gicak; Art. Necrose. Thesis de Ossium Necrosi, 1776. Crowther on White Swel- ling, &c. Edit. 2. NEPHELA, (dim. of vipof, a cloud.) A cloud-like spot on the cornea. NEPHRITIS, (from npgo;, a kid- ney.) Inflammation ofthe kidneys. NEPHROTOMY, (from vapgoc, a kidney; and n^a, to cut.) Nephroto- mia. The operation of cutting a stone out of the kidney; a proceeding which, perhaps, has never been actually put in- to practice. In the Abrege Chronologique de I'Histoire de France par Mezerai, and in the Philosophical Transactions for 1696, two cases of what is called ne- phrotomy are mentioned; but several circumstances in the accounts led Hal- ler and others to conclude, that the operation alluded to in the first work, was nothing more than the high opera- tion for the stone. With respect to the example in the latter work, the parti- culars are not detailed enough to show that an incision was really made into the kidney. There is no doubt that stones have often been extracted from abscesses about the region of the kid- neys, after their presence has been de- tected with a probe. But, with regard to cutting into the kidney, the deep si- tuation of" this viscus, and the want of symptoms, by which the lodgment of a stone in it can be certainly discovered, will always be strong objections to the practice. NITROUS ACID. See Acidum Ni- trosum. NODE. Nodus. A swelling of abone; a thickening of the periosteum, or a fas- cia; or a tumour on a tendon, from a venereal cause. See Venereal Disease. NOLI ME TANGERE. By this ex- pression, surgeons commonly imply an herpetic disease, affecting the skin and cartilages ofthe nose. Mr. Home says, that the ulcers, for which he has been led to employ arsenic, are named, from the virulence of their disposition, noli me tangere, and are very nearly allied to cancer; differing from it in not con- taminating the neighbouring parts by absorption, but, only spreading by im- mediate contact Ulcers of this kind differ exceedingly from one another in their degree of virulence, but, they are all so far of the same nature, that arse- nic in general agrees with them, and puts a stop to their progress, while they are aggravated by milder dres- €»igs. (IRmeon Ulcer, edit. 2. p. 267-) The disease generally commences with small, superficial, spreading ulce- rations on the als of the nose, which become more or less concealed be- neath furfuraccous scabs. The whole nose is frequently destroyed by the pro- gressive ravages of this peculiar disor- der, which sometimes cannot be stop- ped or retarded by any treatment, external or internal. The specific ulcerations do not gene- rally extend to the parts far within the nostrils; but, at the time that I am writing this article, there is, under Mr. Harvey, in St. Bartholomew's Hospital, a curious example, in which the great- est part of the nose is destroyed, and the ulceration proceeds even through the front part of the palate into the mouth. The morbid process sometimes stops for a considerable time, and then is renewed with increased violence. The following case illustrates the na- ture of noli me tangere, and one mode of treatment, to wliich it yielded: Jane Chatillon, 45 years of age, was attack- ed, in the course of September, 1788, with an inflammation on the left ala of the nose. Some time afterwards the part ulcerated, which occasioned a troublesome and sometimes a painful itching: different means were unsuc- cessfully employed, and the case re- mained nearly in the same situation till the month of September in the follow- ing year. At this period, the ulcer spread very fast; the septum nasi, the muscles, and cartilages of both sides, were, in a short space of time, de- stroyed. The ulceration extended on the left side, on the loose edge of the upper-lip. This was the state of her case on her admission into the Hospi- tal of St. Louis, in the month of Octo- ber, 1789. A poultice, moistened with aq. veg. was applied twice a day to the ulcer; a sudorific ptisan prescribed, and a pill, composed of one grain of calomel, and one grain of sulph. aurat. antimonii, ordered to be taken every day. From the fifth day, the inflammation lessen- ed. No other sensible alteration took place till the 21st. The suppuration, that, till this time, had been black and putrid, now became white and inodo- rous. On the 37th, the discharge was tri- fling, and the ulcer, being well deterg- ed, was dressed with pledgets, dipped in a solution of verdegris and corrosive NOL NYC 163 sublimate, in the proportion of six grains of each to a pint of water. On the 40th day, cicatrization began to take place, and was finished by the 60th. J Some time before it was completely cicatrized, an issue was made in the arm, which was healed up, without any inconvenience to the patient, six months after the cure. (Parisian Chi- rurgical Journal, Vol. 1.) One ofthe best external applications to noli me tangere is the following lo- tion : r£. Kali arsenicati, gr. iv. Aq. menths sativs giv. Spiritus v ini tenui- oris "^j. Misce et cola. I have seen se- veral cases in St. Bartholomew's Hos- pital, very lately, which were either cured, or seemed disposed to get well, with this application. The solution of arsenic, which Mr. Home has always used, is made by boiling white arsenic in water for several hours, in a sand- heat. When given internally, the dose is from three to ten drops; when for external application, a dram is to be diluted with Ifeij. of water; and this solution is gradually made stronger, as the parts become accustomed to it, till it is of double strength. However, this mode of using arsenic is by no means a well regulated one; and Plun- ket's caustic (see Arsenic) for outward employment, is not nearly so neat an application as the abovementioned lo- tion. At St. Bartholomew's Hospital, arsenic is administered internally in the following formula: R. Kali arseni- cati gr. ij. Aqus menths sativs ^iv. Spiritus vin. ten. ^j. Misce et cola. Dosis ttij. ter quotidie. In this way, the quantity of arsenic is nicely determin- ed. We shall only just add, with re- gard to this medicine, that, both as an external application and an inward re- medy, in cases of noli me tangere, it perhaps deserves the highest rank. One scruple ofthe argentum nitratum, dissolved in half an ounce of distilled water, makes a very good application, which, although generally inferior, in point of efficacy, to arsenical ones, in the present disease, occasionally does good, when nothing else seems to pro- duce any benefit. The case above, makes us acquainted with another lo- tion, which deserves further trial. All fluid remedies must be applied to the part, by dipping little bits of lint in them, placing these on the ulcerations, and covering the whole with a pledget. The ointments, which seem most likely to prove useful applications to noli me tangere, are the unguentum hy- drargyri nitrati, the unguentum picis, and unguentum sulphuris. As far as my experience extends, they are gene- rally less efficacious than lotions in the present cases; but, in particular in- stances, they prove superiorly useful, and, it deserves particular notice, that surgeons can often make no progress against this inveterate disease, unless they apply a different sort of dressing every day; sometimes, a lotion; at other times, an ointment. The little ulcers may occasionally be touched with the argentum nitratum. The small furfuraceous scabs, which are continually forming on the part affect- ed, should be softened with a little of the unguentum spermatis ceti, and re- moved with as much tenderness as possible. We have already remarked, that ar- senic is a good medicine to give as an internal medicine, and the best mode of exhibiting it is already explained. Another medicine, which is often use- ful in these cases, is what is known by the name of Plummer's pill, or the compound calomel pill. R. Calomela- nos, Sulphuris Antimonii prscipitati, singulorum gr. xii. Guaiaci gummi re- sins, gr. xxiv. Saponis quod satis sit. Misce; fiant piluls duodecim. Dosis una bis quotidie.—In other instances, we may try the decoctum ulmi, or sar- saparilla, with one of" the following pills thrice a day: R. Calomelanos gr. vj. Succi spissati cicuts jj. Misce; fiant piluls duodecim. The hydrargy- rus sulphuratus has occasionally been given, as an alterative medicine, for the relief of noli me tangere; with what good effect I cannot pretend to say. NYCTALOPIA, (from vu$ night; and mj, the eye; or ?rri> to see.) An affection of the sight, in which the patient is blind in the day-light, but sees very well at night. The Greek physicians are divided in their opinions concerning the now un- common disease of nyctalopia. Hippo- crates expressly says, " we call those nyctalopes who see by night." The au- thor of Defin. Medic. " that they see nothing in the day-time, but have their sight by night." On the contrary, Pau- lus jtgineta, and Actuarius are as ex- plicit in asserting, that they have their sight perfect in the day-time, but are blind by night. £tius is of the same mind, though he is thought to favour 164 OEDEMA the contrary opinion, when he says, *' they see better by night than in the day, and if the moon shines they are blind." The author of Isagoge em- braces both opinions, when he says, " they call those nyctalopes, who, in the day time, see more obscurely, at the setting of the sun more clearly, but, when it is night, much better; or, on the contrary; by day they see a lit- tle, but, in the evening, or at night, they are blind. Galen explains the word by a night-blindness. Pliny, Varro, No- nius, Festus, Celsus, and other Latin writers, gave equally opposite defini- tions of the disorder. Dr. Pye ques- tions, whether these two descriptions of nyctalopia, so diametrically opposite to each other, may not be reconciled by considering the disorder as an inter- mittent one. The difference then will only consist in the different times of the approach of the disease; that of Hippocrates came on in the morning; that of vEgineta, in the evening; both were expressly periodical, and the dis- tance of time between the paroxysms, in both, was respectively the same; a whole day, or a whole night. The various shapes, in which intermittents appear, very much favour, says Dr. Pye, such an opinion; and the appa- yeiv£ success of bark in the case, which he has related, notwithstanding the unfavourable circumstances ofthe eva- cuations his patient laboured under, and the consequent necessity of its dis- use, seem to confirm it in this gentle- man's mind. (Med. Obs. and Inq. Vol. 1.) If this opinion be true, we need only refer the reader to Amaurosis and He- meralopia, for the best mode of treat- ment. But, certainly there are in- stances of nyctalopia, every now and then met with, in which the affection seems to depend on a peculiarity in the structure and organization of the eye; by reason of which, the quantity of light, which only suffices for vision in an eye of natural formation, proves too abundant for a nyctalops, and absolute- ly prevents him from seeing at all. We know, that in the eye there is a black substance, named the pigmentum ni- grum; one supposed use of which is to absorb the redundant rays of light, which enter the pupil. A deficiency of this, may certainly account for a nycta- lops being blinded with the day-fight, and seeing best at night. On the whole, however, there can be no doubt, that amaurosis is occasionally a periodical disease, like an intermittent; and a specieKof nyctalopia may also be thus inducedv o Oedema, (from m&to to swell.) The ancients understood, by this term, all kinds of tumours; but, it is now re- stricted to a swelling arising from an extravasation of an aqueous fluid in the cellular substance of a particidar part; for, when the affection is more exten- sive, and especially when it is also ac- companied with a general dropsical tendency, it then becomes a medical case, and receives the name of ana- sarca. An oedematous part is usually cold, and of a pale colour; and, as it is little, or not at all elastic, it pits, as surgeons express themselves, or, in other words, it retains for some time, the mark of the finger, after being handled, or pressed.—Oedematous swellings are often connected with constitutional causes. In many cases, however, they seem to be entirely local affections, arising from such causes as only act upon the parts, in which the swelling is situated. Thus we observe, that after violent sprains of the wrist, or ankle-joint, the hands and feet often become oedematous, and limbs are frequently affected with oede- ma, in consequence of the return of blood through the veins being obstruct- ed by the pressure of tumours on them, or that of splints, bandages, &c. Preg- nant women are known to be particu- larly subject to oedema of the legs, owing to the pressure of the gravid uterus on the iliac veins. Persons who have been confined in bed, with frac- OESOPHAGOTOMY. 165 tured thighs, or legs, generally have more or less oedema of their feet and ankles, on first getting up again; and the affection, in these cases, is proba- bly quite dependent on loss of tone in the vessels of the limb. In the treatment of oedema, great at- tention must always be paid to the na- ture of the cause, in order to determine whether the disease originates from a mere local, or a general constitutional affection. When it depends on the pressure of a tumour on the veins, as we often see happen in cases of aneu- risms, the effect cannot be got rid of till the cause is removed; and the aneu- rismal swelling must be lessened, be- fore the oedematous one can admit of the same beneficial change. When oedema is the effect of vascular weak- ness in a limb, in consequence of sprains, contusions, &c. the best means of relief is, to support the parts affect- ed with a laced stocking, or a flannel roller, while they are also to be rubbed with liniments, and bathed with cold spring water, till they have perfectly recovered their tone. With regard to the oedema attendant on the advanced stage of pregnancy, a complete cure cannot be expected till after delivery. The affection is general- ly more considerable in the afternoon, than in the morning, owing to the dif- ierent effects of an erect and a recum- bent position. Some relief may be ob- tained by keeping as much as possible in a horizontal posture; and when much inconvenience and pain are felt, the parts maybe fomented with any aroma- tic and spirituous application. Oedema is often one ofthe symptoms of suppuration; and, when the matter is very deeply situated, sometimes leads to its discovery. The truth of this remark is often seen in cases of empy- ema. There is a species of oedema accom- panied with a degree of heat, pain, &c. in the part, and which, in short, seems combined with phlegmon. In this case saturnine lotions, the application of leeches, and the exhibition of saline purgatives, are proper. An erysipela- tous oedema is also met with, in which the treatment should very much re- semble what is explained in the article Erysipelas. OESOPHAGOTOMY, (from oeso- phagus, and TtAtvcj to cut.) (Esophagoto- mia- This operation consists in making an incision into the oesophagus, in order to take out of this tube foreign bodies, which lodge in it, and which can nei- ther be extracted through the mouth, nor pushed down into the stomach, and whose continuance in the oesophagus would occasion fatal symptoms. As the oesophagus is deeply situat- ed, and covered by very important parts, such as the trachea, nerves, and considerable blood-vessels, every ope- ration, the object of which is to make an opening into this tube, has always been regarded as exceedingly danger- ous, and was even, for a long while, quite proscribed. However, although every rational practitioner agrees, that this proceeding should never be resort- ed to, without some most urgent cause, yet, if a case were to present itself, in which the oesophagus was so obstruct- ed, by some extraneous substance, that no food could absolutely pass into the stomach, or if, in consequence of an accident of the same nature, respira- tion were impeded in a manner immi- nently dangerous to life, doubtless the uncertain chance of the operation should be preferred to the certainty of a fatal event. Many instances of the oesophagus being accidentally wound- ed, have been known to end well. Mr. B. Bell saw a man, who, in attempting to kill himself, by cutting his throat, cut through a great part ofthe trachea into the oesophagus. Bohnius relates the case of a man, wounded in the same way, whose wound in the oeso- phagus was quite manifest, as every thing which the patient attempted to swallow came out of it. Both the pa- tients, just mentioned, got well, and many similar examples are on record. Guattani, a surgeon at Rome, pub- lished, in the third volume ofthe Mem. de I'Acad, de Chirurgk, a dissertation on the present subject. After explaining the manner of performing this opera- tion, he relates some experiments made on dogs, which succeeded very well. He practised the plan also on the dead subject, in such a manner as to make it demonstrable, that the method was practicable on the human body. What is still more conclusive, the ope- ration was actually done twice, on liv- ing subjects with perfect success. The following is the account of these facts, as recorded in the Mem. de CAcad. de Chirurgie. « In the month of May, 1738, M. Goursauld, a surgeon at Coussat-Bou- neval, in Limousin, was called to a 166 OESOPHAGOTOMY. man, who had swallowed a bone, an inch long, and six lines broad. M. Gour- sauld made various attempts to make this foreign body pass down into the stomach. Not being able to succeed, however, and the bone being felt on the left side, he determined to cut up- on it, and try to extract it. An incision having been made, the bone was easily extracted, no bad symptoms followed, and the wound healed, with the aid of an uniting bandage. Care was taken to give the patient no food for six days, but to nourish him with glysters. A similar operation was performed, with equal success, by M. Rolland, surgeon- major of the regiment of Mailly."— (Memoires de I'Academie de Chirurgie, tome 3 ) Guattani, in this memoir, observes, with several other anatomists, that the oesophagus is always situated, not di- rectly between the trachea and verte- brs, but rather more towards the left than the right. This fact would always lead a surgeon, when he deems oeso- phagotomy necessary, to undertake it on the left side ofthe neck. The parts, which cover the oesophagus, from the middle and external part of" the neck, to the upper part of the sternum, are the skin, fat, cellular substance, mus- cles proceeding from the sternum to the larynx, the thyroid gland, the thy- roid arteries and veins, the trachea, the recurrent nerve, &c. Things thus circumstanced, Guattani recommends the following mode of operating. " The patient is to sit on a chair, witli his head inclined backward, as far as may be thought proper, and held by an as- sistant, so that it can neither move backward nor forward. The operator, placed before the patient, after pinch- ing up the skin on the right side, into a transverse fold, with the fingers of his left hand, while an assistant does the same to that on the left, is to make, with a straight bistoury, a longitudinal incision in the integuments, from the upper part of the sternum. He is next to divide the cellular substance, fat, he. which he will find between the left sterno-hyoideus, and sterno-thyroideus muscles, and the trachea. By means of two double blunt hooks, he is to keep the edges of the wound asunder, and, on dividing the cellular substance at the side ofthe trachea, with his finger and a few strokes of the knife, he will see the oesophagus. A longitudinal in- cision is then to be made into the low- est part of it, with a straight knife; and this wound must afterwards be dilated upwurds, with curved, blunt-pointed scissors. If any difficulty should be ex- perienced, the surgeon may employ a director, to facilitate the last object. Small curved forceps, similar to those used for extracting polypi, are then to be introduced into the oesophagus, for the purpose of extracting the extrane- ous substance. This canal having been opened in the place above specified, the foreign body may be extracted with these forceps, whether it be situated above or below the aperture made for the purpose. This kind of opening will even be useful, when the extraneous substance has passed so far that it can- not be extracted with forceps; for, with a bougie, or some other instrument, it may now be easily pushed down into the stomach. " The operation finished, the dress- ing the wound is a point, which me- rits a great deal of attention, in regard to the method pursued to unite it. This object has always been accomplished, in the animals on which my experi- ments were made. If comparative sur- gery have any weight, it is certainly in such cases as the present one, in which the structure of the part seems to be almost the same. It is also proved by my experiments, that the oesophagus cicatrizes very well, without contract- ing any adhesion to the adjacent parts. It is proper to observe, 1. That the in- teguments being cut, and the parts dis- engaged, if, by chance, the vein, which brings back the blood from the inferi- or part of the thyroid gland, andTruns into the left subclavian, should be cut, the hemorrhage may be stopped with a dossil of lint, which is to be com- pressed by an assistant's finger, during the operation. The vein will afterwards be compressed by the uniting band- age, employed for healing the wound; but, otherwise, a ligature is to be used. 2. That, on separating the lips of the wound, the recurrent nerve may be seen, at a greater or lesser distance from the trachea. If, then, it should be foreseen, that it would be injured in separating the cellular substance, and making the incision into the oesopha- gus, it must be drawn out of the way, with the same hook which is employed for pulling aside the left lip of the wound. In the same manner, the tra- chea may be carefully drawn to one side with the tight hook, if it should OESOPHAGUS. 167 embarrass the operator in finding out the oesophagus; a thing which may be done, without fear of seriously inter- rupting respiration. 3. That the oeso- phagus is to be opened, as near as pos- sible to the trachea, especially at its upper part, where the arterial branch, which goes from the subclavian, to be distributed into the thyroid gland, sometimes runs. 4. That, if thought proper, the thyroid gland is to be se- parated from the left side of the tra- chea, when the foreign body, lodged in the oesophagus, requires a large inci- sion, and, particularly,when this gland is very much swollen, as it would pre- vent a free view of the oesophagus. 5. That the oesophagus will be known to be opened, when the internal membrane, which is whitish, has been divided. 6. That the operation should be done with promptitude, when it is thought neces- sary, in order to avert the afflicting consequences of inflammation of the oesophagus. 7. That the operation be- ing done, the reunion ofthe parts is to be promoted, by simple dressings, and the uniting bandage. " With regard to regimen, besides all the general remedies required in such cases, and eve»y thing which a judicious practice indicates, I am of opinion, that it would be proper (as far as possible) only to give the patient, at intervals, a little broth, for the first three or four days after the operation, so as not to disturb the healing of the parts. And, as broth might cause some little disturbance of the wound, even nourishing glysters, which we know, would suffice for the support of the pa- tient this short time, who, in such cases, is not much reduced." (Guattani in Mem. de I'Acad.de Chirurgie, tom. 3.) Whenever nourishment is to be con- veyed into the stomach, through a wounded oesophagus, the hollow bougie should be introduced, from one of the nostrils, down the passage, and the li- quid food injected through it, with a syringe. OESOPHAGUS, FOREIGN BO- DIES IN. There are few situations in which foreign bodies lodge more fre- quently, than in the oesophagus. The function of this tube explains the rea- son of this occurrence, and its great sensibility is a ground for the appre- hension of many bad effects, which may result from the lodgment of extra- neous substances in it. Foreign bodies, liable to stick in the oesophagus are not only food, such as pieces of crust, or meat imperfectly chewed, but also various substances which are accidentally swallowed alone, or with the food, such as little bones, stones, pins, pieces of money, &.c. These latter things, by lodging in the pharynx, or oesophagus, may occa- sion very bad symptoms; and, if forced down into the stomach, may produce still worse effects. Hence, we should immediately try to extract them. For this purpose, the .fingers are to be us- ed, and if they cannot reach them, for- ceps must be employed. Some have re- commended hooks, for the accom- plishment of the object in view; others, various instruments adapted to particu- lar circumstances. The excitement of vomiting has been tried, and occasion- ally with success; but, it is not free from danger, and the most distressing symptoms have been brought on by it. [A solution of emetic tartar is a very useful remedy in cases of foreign bo- dies in the oesophagus. The nausea produced before its emetic operation commences, relaxes, so completely all spasm in the part, that the substance is allowed to escape. A boy in attempting to swallow a peach stone had it to lodge in the oesophagus, the probang was tried without effect; it remained immoveable; he was directed to swal- low a solution of emetic tartar; whe- ther any passed into the stomach, or whether nausea was produced by its impression on the parts, it is difficult to decide. Nausea however came on, and immediately the peach stone was libe- rated and passed into the stomach."] When such extraneous substances cannot be extracted, they must be pushed down into the stomach, with some such instrument as a large bougie, or a whale-bone probang, fif- teen or sixteen inches long; and, on the end of which, a piece of fine sponge, is firmly fastened. Small bits of sponge tied on the ends of some string, have also been used; the patient is to swal- low them, and then drink something. The sponge, expanded with the fluid, dilates the passage, and facilitates the descent of the extraneous substances into the stomach. But, when, such bo- dies are, from their sharp pointed, an- guL.r shape, or hurtful nature, likely to occasion perilous consequences, by be- ing pushed down into the stomach, the plan must not be attempted. Hard, angular substances, and suc|i things a* 168 OESOPHAGUS. pins and needles, which surgeons have not chosen, or not been able, to force down into the stomach, have often, af- ter a time, made their way to the sur- face of the body, where an abscess has formed, out of which they have been discharged. When hard bodies have been push- ed, or have got of themselves, down into the alimentary canal, their ill ef- fects should be counteracted, and their passage through the bowels promoted by giving the patient frequent draughts containing the oleum amygdalarum. When foreign bodies, in the oesopha- gus, resist the different means employ- ed for their extraction, or for propel- ling them into the stomach, when such method has been judged to be proper; when, at the same time, the pain, which they occasion, is not considera- ble; when they do not too seriously in- terrupt respiration, and leave sufficient room for the passage of aliment and drink; it is prudent to abstain from fur- ther attempts to displace them. They should be left to natiu-e, while the practitioner should content himself with bleeding the patient a few times, exhibiting draughts containing the ole- um amygdalarum, and employing glys- ters. But, when the lodgment of such foreign bodies dangerously obstructs respiration, by the pressure made on the larynx, an opening must be quickly made in the trachea, in order to serve for a time the office ofthe natural pas- sage for the air. (See Bronchotomy.) As soon as the swelling subsides, ano- ther attempt may be made to move the extraneous substance. (See VEncyclo- pedk Method. Partie Chir. Art. Corps Etrangers.) There may be cases, in which death would certainly result from the contin- uance of a foreign body in the oesopha- gus, and as it could neither be extract- ed nor removed by common means, perhaps cutting into the oesophagus woidd be proper. (See (Esophagotomy.) When some extraneous substances have been left to themselves, nature has sometimes succeeded in expelling them. They have excited a trivial sup- puration, where they were lodged, by which they have been loosened, so as then either to be ejected by vomiting, or, after descending into the sto- mach, to be discharged by stool. In passing- any instrument into the oeso- phagus, the great skill lies in putting it at once directly against the posterior part of the pharynx, so as to avoid touching the epiglottis, and keeping it closely against the vertebrs all the way- down. The knowledge of this circum- stance may be of infinite service in passing probangs, bougies, &c. but, hollow bougies are introduced in a dif- ferent way, viz. through one ofthe nos- trils, down the phaiynx. When thus employed, they may sometimes be al- lowed to remain in the passage very ad- vantageously. They are extremely use- ful for the conveyance of food and me- dicines into the stomach, when the oesophagus has been wounded; and as the elevation and depression of the larynx, in the action of swallowing, produces immense disturbance of" wounds of the trachea, they promise to be of infinite service in the latter cases. OESOPHAGUS, STRICTURES OF. As the oesophagus is required to be wider at one time and narrower at another, in order to be fitted for con- veying the different kinds of food into the stomach, it is nearly under the same circumstance with respect to the formation of stricture, as the urethra. Strictures in the oesophagus are, for very obvious reasons, much less fre- quent, than in the urethra. However, they are by no means uncommon, and produce symptoms even much more distressing and dangerous, than those, which ordinarily arise from analogous obstructions in the passage for the urine. Of course, the most remarkable symptom of a stricture in the oesopha- gus, is the difficulty of swallowing, which must be greater or less, accord- ing as the obstruction is more or less complete. Sometimes no solid food whatever can pass down into the sto- mach, and fluids can only descend with great difficulty, and in very small quan- tities. This is, in some instances, at- tended with considerable pain, which extends along the fauces to the basis of the skull, and through the eustachian tube to the ear. The pain sometimes returns at intervals, and lasts a consi- derable time, even -when no effort is made to swallow. If a bougie of proper size be introduced down the pha- rynx, it will often be stopped by the stricture just behind the thyroid, or cri- coid cartilage; for, from Mr. Home's remarks, it appears that the obstruction is generally as high up as this situation However, there are other cases, in t which the obstruction is only of a spas- modic nature, and in such, a bougie may be passed quite down. It is curi- ous, that strictures high up in the oeso- phagus, often occasion ulceration in this tube very low down towards the stomach, just as strictures in the ure- thra occasion ulceration in that passage towards the bladder. This is most apt to occur, when strictures of the oeso- phagus have been of long continuance, and may arise from the efforts in retch- ing, which frequently comes on, and must strain the parts already deprived of their natural actions, and of the be- nefit of the secretions, wiith which they are lubricated in a healthy state. When such ulceration takes place, the cha- racters ofthe original disease arc lost; and when the ulceration extends up- wards, the stricture itself may be de- stroyed. A bougie, introduced under such circumstances, will, in general, have its point entangled in the ulcer; and when so skilfully directed as to go down into the oesophagus, it will meet "with a difficulty while it is passing the commencement ofthe ulcerated part of the oesophagus, and another impedi- ment where it leaves the ulcer, and en- ters the sound portion of the oesopha- gus below. These two resistances may lead to the supposition, that there are two strictures, while in fact there is not one, only ulceration as above de- scribed. Strictures in the oesophagus are sometimes so complete, that swallow- ing even fluids is utterly prevented; the patient is obliged to have all nou- rishment injected intra anum, and in general soon perishes in a most emaci- ated condition. Though any part ofthe oesophagus is liable to the kind of contractions form- ing strictures, the part immediately behind the cricoid cartilage, where the pharynx ends, and the oesophagus be- gins, is the most frequent seat of the obstruction. Those which are situated further down, do not so easily admit of being examined, and relieved by any surgical operation. Strictures of the oesophagus occupy very little extent, of the passage, consist of a transverse fold of the internal membrane, and are at- tended with little thickening of the ad- jacent parts. These latter circumstances are such as render the disease capable of receiving relief either from simple or atmed bougies. •OESOPHAGUS. 1§9 There are two other diseases of the oesophagus, which have symptoms si- milar to those of strictures. One is a thickening of the coats of the oesopha- gus, which extends to the surrounding parts, and generally ends in a cancer, or an incurable disease. The other af- fection is an ulcer of the lining of the passage, commonly situated a little be- low the seat of the stricture, on the back part of the tube. In the early state, these diseases can only be distin- guished from a stricture, by an exami- nation with a bougie; afterwards their nature becomes clear enough from other symptoms which arise. Stric- tures also take place more common- ly in young subjects; the other two diseases in the more advanced periods of life. Mr. Home has found, that a bougie can be more easily introduced into the oesophagus, when the tongue is brought forwards out of the mouth. This gen- tleman remarks, that when a bougie is passed, with a view of learning the na- ture ofthe case, and it passes down tt> the distance of eight inches, measuring from the cutting edge of the front teeth in the upper jaw, its extremity has gone beyond the usual seat of stric- ture. If it be withdrawn without any resistance, the aperture in the oesopha-- gus must then be larger than the bou- gie employed. But if the bougie stops at the distance of six inches and a half, or even lower, it must be retained there with a uniform pressure for half a minute, so as to receive on its point an impression ofthe surface by which it was opposed. If the end ofthe bougie retains its natural form, or nearly so, and there is an indentation on one side of it, or all round it, the surgeon may conclude there is a stricture. On the other hand, should the bougie de- scend without impediment, as far as seven inches and a half, and, when withdrawn, the surface of its point ap- pear irregular and jagged, the disease is an ulcer on the posterior part ofthe oesophagus. The mode of treatment, adopted by Mr. Home, consists either in occasion- ally passing a common bougie through the stricture, and employing one of larger size, in proportion as the dilata- tion of the obstruction will allow: or else in introducing an armed one at convenient intervals. Consult Practical Observations on the Treatment of Strio Vol.. II Y 170 OLifi OPH tures in the Urethra and Oesophagus, Vol. 1. Edit. 3. 1805. Vol. 2. 1803/ by E. Home, F. R. S. In spasmodic strictures of the oeso- phagus, blisters have been known to do good, and I have heard a most emi- nent surgeon express a strong expec- tation, that other strictures of this pas- sage would be benefited, by feeding the patient through hollow bougies. OESOPHAGUS, POLYPI OF. (See Polypus.) OLEUM CAMPHOR AJUM. R. Olei Olivs lbj. Camphors Jiv. Misce ut solvatur camphora. Some practitioners employ this for promoting the suppuration of indolent, particularly scrofulous swellings,which are to be rubbed with the application once, twice, or thrice a day, according to circumstances. OLEUM LINI. In surgery, linseed oil is often used as an application to burns, either alone, or mixed with an equal quantity of the aqua calcis. It has also been applied to cancerous ul- cers, as some assert, with considerable benefit. OLEUM ORIGANI. The oil of marjoram is often used by surgeons for discussing ganglions: the tumours are to be rubbed with it two or three times a-day. OLEUM PALM.E CAMPHORA- TUM. R- Camphors ^ij. Olei palms lbj. The camphor is to be reduced to powder, and the palm oil, being melt- ed, and suffered to become almost cold, is to be mixed with it in a mor- tar. This application is a mild topical stimulant: it has been used for promot- ing indolent suppurations, especially those of a scrofulous nature, which take place under the jaw, and are at- tended with a good deal of chronic in- duration at their circumference. OLEUM RICINI. In such surgical cases as require the bowels to be open- ed with the slightest degree of irrita- tion possible, the oleum ricini is the best and safest medicine that can be 'given. The usual dose is one large ta- ble-spoonful, which must be repeated every two or three hours, till the de- sired effect is produced. OLEUM TEREBINTHINjE. Oil of turpentine is employed externally as a stimulating liniment, and a styptic. In the article Liniment may be seen some formuls, in which turpentine is the most active ingredient. It is sometimes exhibited by surgeons internally, for the cure of gleets. OLEUM TEREBINTHINATUM R. Olei Amygdals j§ss. Olei Terebin- thins gutt. xl. Misce. In deafness, occasioned by defective, or diseased actions of the glanduls ce- rumenes, Mr. Maule directs a little of this oil to be dropped into the patient's ear, or applied at the end of a small dossil of cotton. When a thin secretion takes place, the cure is also promoted by a small blister, which he orders to be placed as near the ear as convenient, and kept open by the common means. Of course, the savine cerate would now be prefer- red for this purpose. The meatus audi- toribus externus must also be cleansed every day with a lengthened bit of soft cotton affixed to a probe. This is to be introduced into the passage, and twist- ed gently round, so as to wipe away the discharge. (See Pharmacop. Chi- rurgica.) OMPHALOCELE, (from o^axoc, the navel, and x»xx, a rupture.) A rup- ture, or hernia at the navel. See Hernia. ONYCHIA, (from ow?, the nail.) An abscess near the nail of the finger. See Whitlow. ONYX, (from ow\, the nail.) A small collection of matter, situated un- der the cornea, in the anterior cham- ber of the aqueous humour, and so named from its being shaped like a nail. It is of the same nature as Hypopium, to which word I must refer the reader. Maitre-Jean, Monchart, and several other oculists, imply, however, by the term onyx, a small abscess between the lavers of the cornea. OPHTHALMY, (from of&akfuc, the eye.) Ophthalmia. Inflammation of the eye. Ophthalmy is not only a consequence of several affections of the eye and ad- jacent parts, on the existence of which its continuance entirely depends; it is frequently, also, the primary complaint, and too frequently the fore-runner, of those irreparable diseases which de- prive the patient of vision. Redness of the tunica conjunctiva: tumefaction of the eye-lids; aversion to light; lanci- nating pain in the orbit; an itching, conjoined with a sensation of heat; and an uneasiness, seeming as if it arose from particles of sand in the eye; are symptoms forming the general incon ve OPHTHALMY 171 uicnces attendant on inflammation of the eye. No part ofthe eye-ball can be considered as exempt from the attack of inflammation. Hence, in ophthalmy, not only the conjunctiva, the sclerotica, and the choroides, but the retina itself, may also be inflamed, as well as the surrounding parts, the palpebrs, the muscles in the orbit, and the lachrymal gland. The grand distinctions of ophthalmy are into two species, viz. acute and chronic; the one arising, as Scarpa says, from an excess of stimulus, and re-ac- tion of the living solid; the other con- nected with debility, which is general- ly limited to the vessels of the parts affected, but sometimes extends to the whole system. The Arabian authors termed the one calida, the other frigi- da. It should be well known, however, that every acute ophthalmy, though treated in the best possible manner, is never so completely resolved, but that beyond a certain period, at which all active disturbance ceases, there yet re- mains in the conjunctiva, or lining of the eye-lids, a degree of chronic oph- thalmy, either from local weakness in the vessels, or from a morbid irritabi- lity continuing in the eye, after the cure of the acute inflammatory stage. As it occasions a diseased secretion in the organ, and a slow accumulation of blood and coagulating lymph in the part, the inexperienced are apt to sup- pose, that the acute ophthalmy is not yet subdued, while it is completely so. Immediately the critical moment ar- rives, when the acute ophthalmy changes into the chronic one, attended with local weakness, it is highly im- portant, in the treatment, to substitute for topical emollient, relaxing applica- tions, such as partake of an astringent, corroborant quality. Those surgeons who now continue to employ the first remedies, only protract the turges- cence of the vessels, and the redness of the conjunctiva. §>uo major autem fuit inflammationis vehementia (says Richter), eo major plerumque sequitur partium affeetarum atonia, eoque major opus est adstringentium et roborantium longo usu, ut auferantur penit&s reliquia morbi, &e. Fascieul. I. p. 109, 110. Mild acute obhthalmy is characterized by redness ot the conjunctiva and lin- ing ofthe eye-lids, an unnatural sensa- tion of heat in the eyes, uneasiness, itching and shooting pains, as if sand had got between the palebrs and eye- ball. At the place where the pain seems most severe, some blood-vessels appear more prominent and turgid, than other vessels of the same class. The patient of his own accord keeps the eye-lids closed, for, he feels a wea- riness and restraint in opening them, and by this means, also, he moderates the action of the light, to which he cannot expose himself, without in- creasing the burning sensation, lanci- nating pain, and effusion of tears from the eye. If the constitution is irritable, the pulse will be a little accelerated, particularly towards the evening; the skin will be dry; slight shiverings will occur, and, in some instances, nausea, and inclination to vomil- (Scarpa.) This complaint is often the conse- quence of a cold, in which the eyes, as well as the pituitary cavities, fauces, and trachea, are affected. It is not un- frequently occasioned by change of weather, sudden transitions from heat to cold, the prevalence of easterly winds, journeys through damp, un- healthy, sandy countries, in the hot season of the year, exposure of the eyes to the vivid rays of the sun, &c. Hence, it does not seem extraordinary, that it should often make its appear- ance as an epidemic, and afflict persons of every age and sex. Besides the pre- ceding remote causes of ophthalmy, authors have enumerated the suppres- sion of some habitual evacuation, such as bleedings from the nose, or piles, the menses, 8tc. affections of the pri- ms vis, worms, dentition, &c. How- ever, though persons thus circum- stanced, are unquestionably subject to inflammation of the eyes, it may be doubted whether they are more so than other people, and when afflicted with ophthalmy, whether the alleged causes have any share in the origin of the latter complaint. The mild acute ophthalmy is in gene- ral easily cured by means of low diet, gentle purging, with small repeated doses of the antimonium tartarizatum, and after making search for any extra- neous body that may have insinuated itself beneath the eye-lid, repeatedly washing the eye with a warm decoc- tion of mallow leaves, and covering it with any very soft emollient poultice, included in appropriate little bags of exceedingly fine muslin. The fluid re- medy may be most conveniently applied by means of an eye-glass. Scarpa or- 172 OPHTHALMY. ders the antimonium tartarizatum to be taken as follows: R Antim. tart. gr. j. Decocti Hordei ftiss. Crystall. tart. gj. Sacchari Purif. ^vj. Misce. To be taken in divided doses every day. I have substituted the barley-water for the decoction of dog-grass, which is certainly not essential. With this treatment, the inflamma- tory stage of the mild acute ophthal- my, commonly ceases in the course of four or five days. The patient no lon- ger complains of that oppressive sense of heat, tension, throbbing, &c. expe- rienced at first, and he can now bear a moderate light, without such an effu- sion of tears as was previously occa- sioned. In this state, how red soever the tunica conjunctiva may appear, it is no longer affected with acute inflam- mation, and the ophthalmy has relaps- ed, from its acute stage, into that at- tended with relaxation and weakness of the vessels of the conjunctiva, and membranous lining of the eye-lids. Emollients are now improper; in lieu of them, astringent, corroborant colly- ria should be used, by means of which the relaxed vessels of the conjunctiva and eye-fid, will recover their original tone, and the ophthalmy be totally re- moved. One of the following eye-wa- ters, which are similar in quality to those directed by Scarpa, may be em- ployed: R. Zinci Vitriolati gr. v. Aqua Rosa, %iv. Misce. Or, R. Cerussa Ace- tata gr. viij. Aqua Faniculi £vj. Spirittis Vini Camphorati gutt. x. Misce. The mild ophthalmy, originating from causes which render it an epidemic, so quickly passes over the first inflamma- tory stage, that it is scarcely observa- ble, and is, according to Scarpa, the only case in which cold astringent ap- plications prove in the first instance beneficial. Surgeons in this country certainly very often employ vitriolated collyria at first, in almost all cases of opthalmy, and with great benefit; but, it is to be observed, that in general some days have usually elapsed before they are consulted. If the continental surgeons are accurate in their remarks, astrin- gents must be very wrong in the first instance. Richter says:—Quotidie ob- servo quantum damni adferant oculis in- flammatis sueta ilia collyria adstringen- tia, quantum emolumejiti emollkntiu.— Fascicul, 3. p. 101. The Severe Acute Ophthalmy is at- tended with the same kind of symp- toms as the mild, but in a more aggra- vated form. The sensation of heat in the eyes is burning; the constriction of the whole eye and eye-lid spasmo- dic; the presence of even a faint light intolerable. Sometimes the effusion of tears is continual, very copious, and blended with mucus, which is apt to make the eye-lids adhere together.— Sometimes this secretion is almost suppressed, and the eyes become pre- ternaturally dry. The sympathetic fe- ver is considerable, with restlessness, and intolerable pain at the back part of the head. The pupil is contracted, the conjunctiva of an uniformly deep red colour. On the anterior hemisphere of the eye, among the most prominent fasciculi of vessels, may be distinguish- ed a delicate vascular net-work, con- tinued from one fascilus to another; but, all being equally turgid with blood, and coiled as it were together, seem to form a kind of excrescence, which rises above the surface of the eye, and has a tendency to project for- wards, beyond the eye-lids. (Scarpa.) From the immoderate action of the inflamed vessels, blood is occasionally extravasated into the cellular sub- stance, connecting the tunica conjunc- tiva with the sclerotica; inconsequence of which the first of these coats, which is naturally loose, becomes enormously distended, and elevated in front ofthe eye, so as to make the transparent cor- nea seem quite sunk, and prevent the eye from being completely shut. Che- mosis is the term usually applied to this sort of case. The severe acute ophthalmy com- monly affects the other part of the eye- ball; but, sometimes the interior ofthe eye is alone affected, or, at all events, more so than the outer parts. There is little change in the external parts, the patient has immense aversion, even to the faintest light, the iris has a red ap- pearance, the pupil is exceedingly contracted, and the aqueous humour is occasionally red and turbid. From these circumstances, Scarpa thinks it not irrational to suspect, that, in the highest pitch of internal ophthalmy, there may be an extravasation of blood into the chambers ofthe eye, especial- ly betwixt the choroid and sclerotic coats. Hence may arise the termina- tion ofthe internal ophthalmy in amauro - sis, so common, when the case does not end in suppuration. The severe acute ophthalmy require s OPHTHALMY. 173 the antiphlogistic treatment, in the most rigorous degree. Tardiness in procuring evacuations, especially of blood, too often gives the disease time to advance to the state of chemosis; or else to a condition, in which suppura- tion, or an extravasation of lymph with- in the eye, is threatened; while, in other instances, the inflammation dege- nerates into an obstinate chronic oph- thalmy from the extreme weakness produced in the vessels ofthe conjunc- tiva. Both general and topical blood letting should, therefore, be speedily put in execution. Leeches should be applied to the vicinity of the eye-lids, especially about the inner canthus, on the vena angularis, where it joins the frontal, deep orbital-, and transverse vein of the face. (Scarpa.) Mr. Ware objects to leeches being put on, or very near, the eye-lids, as they have sometimes caused a consi- derable swelling of the lids, and in- creased, instead of lessening the irrita- tion. In ordinary cases, this gentleman recommends applying three in the hol- low of the temple, about an inch and a half from the outer part of the orbit. There is one mode of bleeding, in cases of ophthalmy, perhaps productive of more benefit than any other, and this probably on account of its acting at once both as a general and topical eva- cuation; I mean opening the temporal artery. In some instances, it is true, I have seen the surgeon fail in procuring from this source a sufficient quantity of blood; but I have never seen a con- tinuance of bleeding from the wound any longer than the practitioner him- self wished. There is one particular mode of tak- ing blood from the eye, which, in acute inflammations, has sometimes been very useful. The visible blood-vessels on that part ofthe conjunctiva, which covers the inside of the eye-lids, are much more numerous, than those which are observable on the white of the eye. Hence, in ophthalmy, the in- flammation seems greatest on the in- side of the eye-lids, where the blood- vessels are often not only much in- creased in number, but also extremely full and turgid. Sometimes, also, the whole inside ofthe eye-lids, particular- ly, of the lower one, is so much en- larged, as to be constantly turned out. In Doth these cases, great benefit has been derived from scarifying the inner ■surface of these parts with a lancet, by means of which a considerable quantity of blood has been removed. When the upper eye-lid is very oedematous in ophthalmy, and its thickness prevents the application of remedies to the eye, a few punctures made on the outside of the lid, near its edge, will cause the discharge of a bloody water, and a very quick subsidence of the "swelling.— When the tumefaction of the everted eye-lids is very considerable, great and speedy relief has been given, by cut- ting off'a piece from the inside of each of them with a pair of curved scissars. (Ware, p. 39, 40.) General bleeding, though copious, and assisted by the topical application of leeches, does not always prove ade- quate to remove the high degree of in- flammation, attendant on chemosis. It is expedient to employ additional means, in order to give exit to the blood effused in the cellular substance, between the conjunctiva and scleroti- ca, by which the former is raised so much above the level of the cornea. Scarpa recommends, for this purpose, making a circular incision in the con- junctiva, near the margin ofthe cornea, with a pair of curved scissors. As a lancet, however, makes a cleaner cut than these instruments, it is perhaps preferable for the operation, and scari- fications might suffice, both for the dis- charge ofthe extravasated blood, and of that distending the vessels of the conjunctiva itself. In chemosis, Mr. Ware says, there cannot be an easier or a more effectual remedy than sther. A few drops are to be poured into the palm of the hand, and diffused over it, which may be immediately done by pressing the other hand against it. The hand is then to be applied to the eye, and kept so close to it that the spirit, as it evaporates, may insinuate itself in- to the part affected, and act on the ex- travasated blood, so as to disperse it In a few instances of chemosis, in which the swelling and inflammation have been considerable, this gentleman has found the following application of singular service; R. Interiorum folio- rum recentium Lactucs Sissilis §iij. Coque cum aq. pur. 5SS. in balneo ma- ris pro semiliora; tunc exprimatursuc- cus, et applicetur paululum ad ocu- los et ad palpebras sspe in die. (Ware, p. 54.) After general and topical bleeding, aperient medicines, ofthe most gentle nature, should be administered; soda 174 OPHTHALMY. phosphorata, pulp of tamarinds, cream of tartar, and magnesia vitriolata, are the most proper. When the stomach is affected, Scarpa also recommends an emetic, as being peculiarly benefici- al to inflamed eyes. When bleeding and other evacua- tions have been practised, the next most useful measure is the application of a blister to the nape of the neck.— Scarpa observes, that the skin in this situation, and that behind the ears, sympathise more closely with the eyes than any other part ofthe integuments. —Many practitioners, however, and among them Mr. Ware, prefer blister- ing the temples. The latter says: " When the leeches have fallen off, and the consequent hemorrhage has ceased, I would advise a blister of the size of half a crown, to be applied on the temples, directly over the orifices made by the leeches; and I have found, that the sooner the blister has followed the bleeding, the more efficacious both have proved." When the ophthalmy has been very violent, and resisted the common method, Mr. Ware adds, that the most beneficial effects have also been sometimes produced by the ap- plication of a blister large enough to co- ver the whole head. (P. 43, 44.) At first, topical emollient applications to the eye are most beneficial; such as mallows boiled in new milk; bread and milk poultices; or the soft pulp of a baked apple; all included in fine little muslin bags. Remedies of this descrip- tion should be renewed at least every two hours. The patient should be di- rected to observe perfect quietude, and to lie with his head in an elevated posi- tion. To keep the eye-lids from adher- ing together, in the night time, the spermaceti cerate is proper. When the ophthalmy is accompanied with a vio- lent pain in the head, Mr. Ware re- commends a strong decoction of poppy heads to be applied as a fomentation. (P. 51.) Under the preceding plan of treat- ment, the acute stage of severe oph- thalmy commonly abates in about a week. The burning heat, and darting pains in the eyes, and the febrile dis- turbance of the constitution, subside. The patient is comparatively easy, and regains his appetite. The eye-lids lose their tension and wrinkle. A discharge of thick matter takes the place of a se- cretion of thin serum, or of a preterna- turally dry state ofthe eyes. These or- gans can now be opened, without ex- periencing vast irritation from a mode- rate light. In this state, notwithstand- ing the eyes may continue red, and the conjunctiva swollen, all evacuations are to be left off, as well as the use of topi- cal emollients, for which latter astrin- gent, corroborant collyria arc to be substituted. Scarpa recommends the followingapplication:R.Zinci vitriolati gr. vj. Aqus distillats 3yj. Mucil. sem. cydon. mali §j. Spiritus vini camphor guttas paucas. Misce et cola. This col- lyrium may be injected, with a syringe, between the eye and eye-lids, once every two hours; or the eye may be bathed in it, by means of an eye-cup. Such persons as cannot bear cold appli- cations to the eye, must have the same kind of collyrium a little warmed; but as soon as the irritability has lessened, they may be used cold. The tinctura thebaica ofthe old Lon- don Dispensatory proves a most ef- ficacious remedy for the second stage of acute ophthalmy, or that connected with weak vascular action in the part affected. Two or three drops may be insinuated, between the eyelids and globe of the eye, twice a day, in com- mon cases; but in others, attended with more sensibility, once will at first be sufficient. Mr. Ware, who brought this application into repute, has found, that introducing two or three drops of this medicine at the inner canthus, and making them glide gradually over the eye, by gently drawing down the low- er eye-lid, proves equally beneficial and less painful than dropping them at once on the eye-ball. Immediately the application is made, it commonly cre- ates a copious flow of tears; a smart- ing pain, and a sense of heat in the eyes, which inconveniences, however, soon cease, and the eyes become clear- er, and feel evidently improved. But, notwithstanding every exaggerated as- sertion, unbiassed surgeons are now quite convinced, that the tinctura the- baica is only a proper application, when the inflammatory action has been pre- viously diminished by blood-letting, aperient medicines, and blisters, and when the action ofthe vessels has been weakened by the continuance of the disease. Mr. Ware, in recommending it, as a most effectual application, in every species and stage of the disor- der, from the most mild and recent, to the most obstinate and inveterate, (p. 51.) has certainly been rather too OPHTHALMY. 175 zealous. Scarpa has seen the necessity of limiting the use of the remedy in question, and he has expressly pointed out, that it is only useful, when the violence of the pain, and the aversion to light have abated. Indeed, Mr. Ware himself has acknowledged, a little be- fore sanctioning its unlimited employ- ment in all cases, that, in certain in- stances, in which the complaint is gene- rally recent, the eyes appear shining and glossy, and feel exquisite pain from the rays of light, no relief at all was obtained, (p. 48,49.) See Tinctura The- baica. Whenever the patient can easily bear a moderate degree of light, ail coverings should be removed from the eyes, except a shade of green or black silk. A brighter light 'should be gra- dually admitted every day into his chamber, so that he may become habi- tuated, as soon as possible, to the open day-light. Nothing has a greater ten- dency to keep up and increase the mor- bid irritability of the eyes, than keep- ing them unnecessarily long in a dark situation, or covered with compresses and bandages. (Scarpa.) There is a particular species of se- vere acute ophthalmy, which differs from the common, in appearing with vehement inflammation and swelling of the conjunctiva and eye-lids, and be- ing followed by an extraordinary dis- charge of pus from the eye. It is very common in children at the breast, and is described as attacking adults on the sudden suppression of a gonorrhoea, or on the inadvertent application of the matter of clap to the eyes. These cases must be regarded as complicated with specific morbid action, and not in the light of simple inflammation, free from any diseased principle. The Purulent Ophthalmy of children produces such tumefaction of the eye- lids, as almost prevents them from be- ing separated. Should the surgeon suc- ceed in gaining a view of the mem- brane lining them, it appears wrinkled, and converted into a red villous surface, somewhat like the inner coat of the rectum, when protruded in young chil- dren. (Warner on the Human Eye, page 42.) Sometimes in the child's fits of crying, the eye-lids become everted, and continue so, until rectified by an attendant. No sooner is the first short attack of inflammation past, than there succeeds a discharge of thick yellow matter, truly surprising in quantity, partly secreted from the meibomian glands, but chiefly from that villous fungus-like surface, into which the li- ning of the palpebrs seems converted. If the eye-lids can be opened, the mat- ter may be seen diffused over the whole surface of the eye, and its confinement, between the swollen eye-lids, and the eye-ball, contributes still more to ag- gravate the pain, increase the inflam- mation, and often to induce ulcers, or specks, either over a part or the whole of the cornea. If a speedy check be not soon put to this distressing malady, it renders the cornea so opaque and thickened, as often to form what is termed staphyloma. The cornea has even been known to burst, the humours to be discharged, and the eye to sink in the orbit. The febrile symptoms are at first severe; the infant is continually fretful and restless, and a diarrhoea is not unfrequently concomitant. The af- fection of the eyes is occasionally ac- companied with eruptions on the head, and with marks of a scrofulous consti- tution. (See Ware, p. 138. Crc.) The antiphlogistic treatment should be quickly opposed to the progress of the disease. The temporal arteries should be opened, or leeches applied to the temples, or neighbourhood of the eyelids, and a blister put on the nape ofthe neck, or temples. The child should be kept in a cool room, and not covered with much clothes. If no diar- rhoea should prevail, it is proper to purge with a little rhubarb or magne- sia in syrup of violets. A surgeon, however, is seldom call- ed in before the first short inflammato- ry stage has ceased, and an immense discharge of matter from the eyes has commenced. Of course emollient ap- plications must generally not be used. On the contrary, astringents and cor- roborants are immediately indicated, in order to restore to the vessels ofthe conjunctiva and eyelids their original tone, to rectifv the villous and fungous appearance of' the lining of the palpe- brs, and thus finally to check the mor- bid secretion of matter. For this pur- pose Mr. Ware strongly recommends the aqua camphorata of Bates's Dispen- satory: R. Cupri vitriolati, Bol. Armen., aa^iv. Camphors ,fj. M. & f. pulvis, de quo projice Jj. in aqus bullientis Rjiv. amove ab igne, et subsidant f'sces. Mr. Ware, in his late Remarks on Pu- rulent Ophthalmy, 1808, observes, that he usually directs the aqua eampho- 176 OPHTHALMY rata, as follows: R. Cupri vitriolati, Bol. Armen. a a gr. viij. Camphors gr. ij. Misce, et aflundc aqus bullientis jfviij. Cum lotio sit frigida, eftimdatur limpidus liquor, et sspissime injiciatur paululum inter oculum et palpebras. This remedy possesses a very styptic quality; but it is much too strong for use before it is diluted; and the degree of its dilution must always be deter- mined by the peculiar circumstance of each case. Mr. Ware ventures to re- commend about one drachm of it to be mixed with an ounce of cold clear wa- ter, as a medium or standard, to be strengthened or weakened as occasion may require, (p. 143) The remedy must be applied by means of a small ivory or pewter syringe, the end of which is a blunt-pointed cone. The ex- tremity of this instrument is to be pla- ced between the edges of the eye-lids, in such a manner, that the medicated liquor may be carried over the whole surface of the eye. Thus the matter will be entirely washed away, and enough ofthe styptic medicine left be- hind to interrupt and diminish the ex- cessive discharge. According to the quantity of matter, and the rapidity with which it is secreted, the strength of the application, and the frequency of repeating it, must be regulated. In mild recent cases, the lotion may be used once or twice a-day, and rather weaker than the above proportions, but, in inveterate cases, it is necessary to apply it once or twice every hour, and to increase its styptic power in propor- tion; and when the complaint is some- what relieved, the strength of the lo- tion may be lessened, and its applica- tion be less frequent. " The reasons for a frequent repeti- tion of the means just mentioned, in bad cases, are, indeed, of the most ur- gent nature. Until the conjunctiva is somewhat thinned, and the quantity of the discharge diminished, it is impossi- ble to know in what state the eye is; whether it is more or less injured, to- tally lost, or capable of any relief. The continuance, or extinction, ofthe sight frequently depends on the space of a few hours: nor can we be relieved i'rom the greatest uncertainty, in these respects, until the cornea becomes visi- ble." (Ware, p. 145.) This gentleman, with every appear- ance of reason, condemns the use of emollient poultices, which must have a tendency to increase the swelling and relaxation of the conjunctiva. If poul- tices are preferred, he particularly re- commends such as possess a tome or mild astringent property; as one made ofthe curds of milk, turned with alum, and an equal pail of unguentum sam- buci, or axungia porcini. This is to be put on cold, and frequently renewed, without omitting the use of the injec- tion. (Ware, p. 147.) When the secreted matter is glutin- ous, and makes the eye-lids so adlierent together that they cannot be opened, after being shut for any length of time, the adhesive matter must be softened with a little fresh butter mixed with warm milk, or by means of any other soft oleaginous liquor, after the poul- tice is taken off", and before using the lotion. (P. 147.) If the eversion ofthe eyelids only oc- curs when the child cries, ami then goes off, nothing need be done in addi- tion to the above means. When, how- ever, the eversion is constant, the in- jection must be repeated more fre- quently than in other cases; the eye-lids put in their natural position, after its use; and an attendant directed to hold on them, with his finger, for some length of time, a compress dipped in the diluted aqua camphorata. (P. 148.) In some cases, when the inside of the eye-lids has been very much inflam- ed, the tinctura thebaica, insinuated between the eye and eye-lids has been useful. If, after the morbid secretion is checked, any part of the cornea should be opaque, the unguentum hy- drargyri nitrati, melted in a spoon, and applied accurately on the speck, with a fine hair pencil; or Janin's ophthalmic ointment, lowered and used in the same manner; may produce a cure, if the opacity be not of a deep kind. When the local disease seems to be kept up by a bad habit, alteratives should be exhibited, such as the oethiops mineral- is, or small doses of calomel. The Purulent Ophthalmy, arising ei- ther from suppression of gonorrhoea, or from the inadvertent conveyance of go- norrhoea matter to the eyes, is said to produce rather a swelling of the con- junctiva, than of the eyelids, which is followed by a discharge of a yellow greenish matter, similar to that of clap. The heat and pain in the eyes are con- siderable; an aversion to light prevails, and, in some instances, an appearance ofhypopion is visible in the anterior chamber of the aqueous humour. When OPHTHALMY. 177 the complaint proceeds from the se- cond cause, it is described as being less severe. If it be actually true, that, in adults, a species of purulent ophthalmy does originate from the sudden suppression of a gonorrhoea, are we to consider the complaint so produced as a metastasis of the disease from the urethra to the eyes? This ophthalmy does not regu- larly follow the suppression of gonor- rhoea; nay, it is even a rare occurrence: also, when it is decidedly known, that the purulent ophthalmy has arisen from the infection of gonorrhoea, namely, in those instances, in which the matter has been incautiously communicated to the eyes, it appears, that such an affection of these organs, so produced, is different from the one alluded to, in- asmuch as it is slower in its progress, and less threatening, in its aspect. Hence, there is good reason for sup- posing, that no metastasis takes place in this species of purulent ophthalmy, supposed to be connected with a sup- pressed gonorrhoea; but, we must be content with inferring that, if it really has such a cause, it originates from a sympathy, prevailing between the ure- thra and eyes, and, that the variation of irritability, in different people, is the reason, why it is not an invariable con- sequence of the sudden stoppage of a gonorrhoea. The injection of warm oil, the intro- duction of a bougie into the urethra, and the application of cataplasms to the perinsum, with a view of renewing the discharge from the urethra, form the outline of the practice of those, who place implicit reliance in the sup- pression of gonorrhoea being the cause of the complaint. The rarity of the oc- currence; the frequency of the sudden cessation of the urethral discharge; the possibility of an ophthalmy arising, as well at this particular moment, as at any other, totally independently of the other complaint; cannot fail to raise in a discerning mind a degree of doubt, concerning the veracity ofthe assigned cause. Besides, admitting, that there is a sympathy, between the urethra and eyes, how are we to ascertain, whether the suppression of gonorrhoea be the cause, or the effect of the ophthalmy, supposing that the one ceases, and the other commences, about the same time? Actuated by such reflections, I am induced to dissuade surgeons from adopting any means calculated to re- new a discharge of matter from the urethra. When the purulent ophthal- my, in adult subjects, is decidedly oc- casioned by the actual contact, and in- fection of gonorrhoeal matter, applied accidentally to the eyes, no one has re- commended this unnecessary and im- proper practice. The first indication, in the treatment of the disease from either cause, is to oppose the violence of the inflamma- tion, and thus resist the destruction of the eye and opacity of the cornea. A copious quantity of blood should be taken away both topically and general- ly; mild laxatives should be exhibited, and a blister applied to the nape of the neck, or temples. The eyes ought to be often fomented with a decoction of white poppy-heads, and warm milk re- peatedly injected beneath the eye-lids. To prevent the palpebrs from be- coming agglutinated together, during sleep, the spermaceti cerate should be smeared on the margins of the tarsi, every night. When the heat and pain in the eyes, and febrile symptoms have subsided; when an abundant discharge of pus has commenced; all topical emollients are to be relinquished, and a collyrium of Aq. ross ^x. containing Hydrarg. mur. gr. j. used in their place. Scarpa states, that in the ophthalmy, originat- ing from the inadvertent communica- tion of the matter of gonorrhoea to the eyes, applications, in the form of oint- ment, such as the ung. hydrarg. the unguentum ophthalmicum of Janin, to which might be added the ung. hyd. nitrat. avail more than fluid remedies. (Scarpa.) Epidemic, Purulent, or Egyptian, Oph- thalmy. The latter name has been given, inconsequence ofthe very close resemblance, which this inflammation bears to that, which destroyed the sight of a considerable number of our soldiers in Egypt in 1801. Mr. Ware, however, objects to the appellation, because an ophthalmy, precisely simi- lar in its symptoms and progress, has appeared long ago in this and other countries, and, in Egypt, as well as England, several varieties of ophthal- my prevail. This gentleman prefers calling the late epidemic affection of the eyes a purulent ophthalmy, since one of its chief symptoms, and that which distinguishes it from every other, is the profuse discharge of a pu- rulent coloured fluid__Some valuable Vol. II. Z 178 OPHTHALMY. practical remarks have been published in the Edinburgh Surgical Journal for January 1807, by my worthy friend Mr. Peach, who has enjoyed great opportu- nities of observation, from his situation as surgeon to the 2d battalion of the 52d regiment, in which the disease has prevailed, perhaps, to an extent not witnessed in any other corps. The total strength of this regiment was 691 men, and, including relapses, Mr. Peach had 733 cases, without taking into the account some slight returns of the disease, which were obviated by venesection. Fifty men had lost the sight of both eyes, though Mr. Peach thought, that several of these would ultimately recover; for, he had already had some instances, in which the cornea recovered its transparency, after hav- ing been opaque for six months. Forty men had lost the sight of one eye. The perfect cures amounted to 404; and, when Mr. Peach's letter to Dr. M'Gri- gor was written, he lid 213 cases under treatment. (Edinb. Surg. Jovrn. for January 1807.) The epidemic, now under consideration, is very different from an ophthalmy, which, at various times, has been epidemic in this, and other countries, without any purulent discharge from the eyes, which is seldom dangerous to sight, and, in a few days, generally yields to internal antiphlogistic means, and mildly astrin- gent applications. (Ware on the Epide- mical Purulent Ophthalmy, Note p. 3; 1808.) According to Mr. Peach, the patient complains, in the first stage ofthe dis- ease, of being suddenly seized with a rolling of sand in his eye; the vessels on the albuginea become suddenly tur- gid with blood, and the lower palpe- brsvery vascular. The cases treated in this recent state, generally yield. But, if very active measures do not arrest the progress ofthe disease, the second stage appears, when the palpebrs su- periores become much enlarged; the eye-lids can only be opened with ex- treme difficulty, and then either a scalding fluid is discharged and exco- riates the face, or a flux of thick yel- low matter takes place. In this state, it is frequently in our power to stop the progress of the evil; but, if the most decided and active practice be not adopted, the disease reaches the third stage, in which every thing is seldom of any avail in relieving the most distressing symptoms. The cor- nea now too often becomes ulcerated, and the eye ruptured. On the first appearance of the dis- ease, Mr. Peach had recourse to vene- section, and the antiphlogistic treat- ment. Being unsuccessful, he tried bark and stimulants; but, being still more unsuccessful with this mode of treatment, he reverted to the antiphlo- gistic plan in its fullest extent, and with the greatest success, and he found, that he did not formerly suc- ceed, because he did not carry this mode far enough. It is in the com- mencement of the disease, that a very large quantity of blood should be taken away: in that stage, large venesection, even ad deliquium animi, is almost an infallible remedy. It is not sufficient to take away twenty or thirty ounces of blood. Mr. Peach has often taken away sixty, at the same time enjoining per- fect rest, the avoidance of all animal food, and putting in practice every other part of the antiphlogistic treat- ment. -The complaint is naturally dis- posed to relapse, and, as often as the disease, or even the slightest pain, or uneasiness in the eye, returns, so often did this gentleman return to the lancet. Such practice, Mr. Peach confesses, is likely to excite astonishment; but the fullest trial of it has demonstrated to him its utility. In many of the cases, which occurred to him, the progress of the inflammation was so rapid, that it probably would have totally destroyed the eye, if only the ordinary mode of treating ophthalmy had been resorted to. He advises particular attention to be paid to the first sensation of sand in the eye: He never defers venesection, when this is complained of; and the patient, in general, finds so much ad- vantage during the operation, that he says, "the sand is removed." Mr. Peach has occasionally found advan- tage arise from dropping the undiluted aqua litharg. acetat. into the eye, though great pain was the immediate effect of its application. On the whole, however, he concludes, that dropping substances into the eye is not service- able, and says, that, since this practice was relinquished, the eye-lids have not been so often inverted. The bowels must be kept open. Benefit has often been derived from shaving the head, and keeping it continually wet with water, or vinegar. Blisters are also sometimes indicated; but, the great reliance is to be put in the striotest OPHTHALMY. XJ-g antiphlogistic regimen, and copious part of the discharge, which issues venesection. (See Edinb. Med. and either from the conjunctiva of an af- **rg'Journal, for January, 1807.) fected eye, or from some other mem- With regard to the causes of the brane secreting a similar poison, to the epidemic purulent ophthalmy, Mr. conjunctiva of the eye of another per- Ware seems to think, that the com- son. In schools and nurseries, in con- plaint is commonly communicated by sequence of children using the same contact. Some of the worst cases of basins and towels, as others who had the purulent ophthalmy of children the complaint, the disease has been have happened in those, whose mo- communicated to nearly twenty in one there were subject to an acrimonious academy. Hence, Mr. Ware censure* discharge from the vagina at the time the indiscriminate use of those arti- of parturition. Some of the worst cles, in schools, nurseries, hospitals, forms of the purulent ophthalmy in ships, and barracks. (P. 14,15.) adults have occurred in those, who, The principal difference, between either shortly before the attack of the the purulent ophthalmy of infants, and ophthalmy, or, at that very time, la- that of adults, consists in the differ- boured either under a gonorrhoea, or a ent states of the tunica conjunctiva. gleet. Mr. Ware does not mean to im- In the former, notwithstanding the pute every purulent ophthalmy to such quantity of matter, confined within the a cause; but, in the majority of adults, lids, is often profuse, the inflammation whom he has seen affected, if the dis- of the conjunctiva is rarely considera- order had not been produced by the ble, and whenever the cornea becomes* application of morbid matter from a impaired, it is rather owing to the lodg- diseased eye, it could be traced to a ment of such matter on it, than to in- conne,xion, between the ophthalmy, flammation. But, in the purulent oph- and disease of the urethra. Other thalmy of adults, the discharge is al- causes, Mr. Ware acknowledges, may ways accompanied with a violent in- contribute to aggravate, and, perhaps, flammation, and generally with a tume- produce the disorder, and the purulent factionof the conjunctiva, by which its ophthalmy in Egypt has been attribut- membranous appearance is destroyed, ed to a great number. The combined and the corneals made to seem sunk in- influence of heat and light, of a burn- the eye-ball. (Warep. 23.) ing dust continually raised by the wind, We have already detailed the suc- and of the heavy dews of the night, cessful plan of taking very large quan- may powerfully tend to excite inflam- tities of blood from the arm, as practis- mations of the eyes. Yet something ed by Mr. Peach. Mr. Ware speaks al- more must operate in causing the ma- so in favour of bleeding; but has rarely lignant ophthalmy now under conside- carried it to the extent, it has been in- ration; for, the same causes operate the army. In weak persons, this gen- with equal violence in some other tleman prefers, instead of repeating countries, besides Egypt, and yet do venesection, topical bleeding, either not produce the same effect; and, in from the vein, that passes on the side this country, (continues Mr. Ware) the of the nose, or by means of five or six disorder prevailed during the last sum- leeches put on the temple. Sometimes^ mer, to as great a degree, and upon as he thinks it better to scarify the inside great a nsmber of persons, within a ofthe lower eye-lid, with the point of a small district of less than a mile, as it lancet, carried along parallel to, and ever did in Egypt; and, yet, beyond very near the margin of this part. Mr. this space, on either side, scarcely a Ware objects to pricking the eye-lid in person was affected with it. The dis- an infinite number of places, as very order was certainly brought into this painful, and likely to increase the irn- countrybythe soldiers, who returned tation. The lancet never need be appli- from Egypt, and was probably commu- ed more than twice, and rarely more, nicated from them to many others, than once; and, perhaps, less pain will Now as the action of the atmosphere be occasioned by making the incision alone cannot account for the spreading with the edge, rather tiianthe point of of the disease, &c. Mr. Ware is led to the lancet. After taking away blood, believe, that this particular disorder Mr. Ware says, a large blister on the is only communicable by absolute con- head, or back, is often useful. Ano-. tact; that is, by the application of some dynes should be given, with occasional 180 OPHTHALMY purgatives, and an antiphlogistic regi- men. (Ware on Purulent Ophthalmy, 1808; p. 26, &c.) Dr. Vetch, on the subject of local ap- plications in the present disease, ad- vises keeping the eyes continually co- vered with linen, dipt in some cooling lotion. In the first stage, he gives the preference to dropping the aqua sap- phirma into the eye; afterwards, when the swelling of the eye-lids has come on, he' prefers the aqua litharg. acet. While the patient is subject to a recur- rence of pain, he thinks, the injection of warm water the best application. For the purpose of lessening the swelling ofthe eye-lids, he advises compresses, dipt in the aqua litharg. acet. to be ap- plied with a moderately firm pressure. When the swelling, and other symp- toms of the second stage have subsid- ed, Dr. Vetch recommends more as- tringent applications, such as the aqua lithargyri acet. Bates's camphorated water, solutions of alum, and the mu- riate of mercury. (See An Account of the Ophthalmia, as it appeared in En- gland since the return ofthe British Army from Egypt; by John Vetch, M. D. 1807;p. Ill) Mr. Ware gives the preference to the aqua camphorata, which is to be used exactly in the same way, as was described above, in speaking ofthe pu- rulent ophthalmy of children. I cannot help thinking, that, if army surgeons had been careful to inject their applica- tions under the eye-lids, as advised by Mr. Ware, great benefit would have* been produced. In other ways, the ef- fect ofthe remedies is often lost When the inflammation has been very great, Mr. Ware has only put four, or five grains, instead of eight, ofthe cuprum vitriolatum to eight ounces of water; and, while the inflammation is great, he would never advice more than eight grains to this quantity of water. He usually employs the lotion cold, especi- ally in children; but, in some adults, in whom the general fever, and local in- flammation have been considerable, he has been obliged to use it warmed. In cases of great pain and swelling, it should be very weak, less often appli- ed, and sometimes only warm water in- jected. In such circumstances, Mr Ware also sanctions fomenting the eye with a flannel, or sponge, wet with a hot decoction of poppy-heads, or mere hot water. When the cornea threatens to burst, this gentleman approves of opening it, in order to discharge the aqueous humour, by making an incision in a place, where the scar will not ob- struct vision. Having now treated of all the princi- pal species of acute ophthalmy, 1 shall finish this part ofthe subject, with no- ticing Mr. Wardrop's proposal to punc- ture the cornea, and let out the aque- ous humour in particular states of in- flammation of the eyes. This gentle- man remarks, that if the eye of a sheep, or ox, be squeezed in the hand, the whole cornea becomes instantly cloudy, and whenever the pressure is removed, this membrane completely regains its transparency. From this curious phs- nomenon in the dead eye, it was evi- dent, that, in the living body, the trans- parency of the cornea might vary ac- cordingto the degree of its distension; and that, in cases of opacity ofthe cor- nea, accompanied with fulness of the eye-ball its transparency might be re- stored by the evacuation of the aqueous humour. The cornea is little sensible, and, as every body knows, its wounds are free from danger. Mr. Wardrop soon met with a case, favourable for making the experiment; the cornea was milky and opaque, and the eye- ball distended and prominent, attended with acute inflammatory symptoms.— The aqueous humour was discharged by a small incision, and the operation produced not only a removal of the cloudiness ofthe cornea, but an abate- ment of the pain, and a sudden check to all the inflammatory symptoms. From the success of this case, Mr. Wardrop was led to perform the ope- ration on others, not only with a view of diminishing the opacity of the cor- nea, but, also, of alleviating the inflam- mation. Four interesting cases are re- lated by this gentleman, very much in favour of the practice, when the eye is severely inflamed, attended with ful- ness of the organ, a cloudy state of the cornea, and aturbidness ofthe aqueous* humour. Mr. Wardrop also advises the operation, whenever there is the smallest quantity of pus, in the anterior chamber, accompanied with violent symptoms of inflammation. He thinks, that, the great and immediate relief, which the method affords, is imputable to the sudden removal of tension; and he performs the operation with a small knife, such as is used for extracting the cataract. The instrument is to be oiled, and introduced, so as to make a wound OPHTHALMY. 181 of its own breadth, at the usual place of making the incision in the extraction of the cataract. By turning the blade a little on its axis, the aqueous humour Hows out. (See Edin. Med. and Surg. Journal, Jan. 1807.) Mr. Ware seems to approve of Mr. Wardrop's operation in the epidemic, purulent, or Egyptian Ophthalmy, when, notwithstanding, general evacuations, topical bleeding, mildly astringent lo- tions, and a strict antiphlogistic regi- men, the symptoms still continue, and, especially, if the cornea begin to lose its transparency, and a white rim ap- pear round its circumference. Mr. Ware does not object to using a small knife, ofthe kind, employed in extract- ing the cataract; but, thinks a lancet will safely answer the purpose, or, what is better, a sharp pointed couch- ing needle, having a blade somewhat wider than usual, and a groove in its middle. The instrument, he advises,to be introduced about one-tenth of an inch before the connexion of the cor- nea with the sclerotica, and pushed gently on, parallel to the plane of the iris, until the aqueous humour make its escape. (Ware on the Purulent Ophthal- my, p. 41; 1808.) CHRONIC OPHTHALMY. Unfavourable peculiarities are met with in practice, which prevent the complete cure of the second stage of acute ophthalmy, br that connected with a weak vascular action in the part affected; whence the protract- ed disease becomes purely chronic, and threatens the slow destruction of the eye. Thes^peculiarities may be chiefly referrecrro three causes: 1. To an in- creased irritability continuing in the eye after the. cessation of acute inflam- mation. 2. To some other existing af- fection of the eye, or neighbouring parts, of which the chronic ophthalmy is only an effect. 3. To constitutional disease. 1. That chronic ophthalmy may de- pend upon a morbid irritability of the eye is evinced, not only from its resist- ing topic.d astringents and corrobo- rants, to which the disease from sim- ple relaxation and weakness yields, but, from its being exasperated by them, and even by cold water. The pa- tient complains of a sense of weight in the upper eye-lid, and restraint in open- ing it; the conjunctiva has a yellowish cast, and when exposed to the-damp cold air, or a brilliant light, or when the patient studies by candle light, its ves- sels become injected and turgid with blood. If, in combination with such symptoms, the habit of body be weak and irritable; subject to spasms; hypo- chondriasis, Stc. then it is manifest, that the chronic ophthalmy is connect- ed with a general impairment of the nervous system. 2. Besides extraneous bodies, lodged between the palpebrs and eye-ball, the inversion of the cilis, and hairs, grow- ing from the caruncula lachrymalis; ul- cers of the cornea; prolapsus of the iris; herpetic ulcerations ofthe margins ofthe eye-lids; a morbid secretion from the meibomian glands; a diseased en- largement of the cornea, or of the whole globe of the eye, &c. may occa- sion and maintain chronic ophthalmy. It is only my part here to mention such remote causes; for, the particular treat- ment of them is described in other ar- ticles. See Cornea, Ulcers of; Iris, Pro- lapsus of; Lippitudo; Staphyloma; Hy- drophthalmy; Trichiasis; &c. 3. The cure ofthe second stage of acute ophthalmy may be retarded by the prevalence of scrofula in the sys- tem; or by the small-pox affecting the eyes. Chronic ophthalmy is also sometimes a consequence of Lues Ve- nerea. When chronic ophthalmy depends upon preternatural irritability, the in- ternal exhibition of bark with valerian is proper; animal food of easy digestion; gelatinous and farinaceous broths; wine in moderation; gentle exercise; living in salubrious and mild situations; are all severally productive of benefit Ex- ternally, the applications should be of the sedative and corroborant kind; such as aromatic spirituous vapours (from the spiritus ammon. Comp,) ap- plied to the eye through a funnel, for half an hour, three or four times a day; and the eye-lids and eye-brows may also be rubbed with the linimentum camphors. Patients, both during the treatment and after the cure, must refrain from straining the eye, and, immediately the least uneasiness is felt, must desist from exercising it. When they write, or read, it should be constantly in a steady, uniform light, and too little, as well as too much, aggravates the dis- ease. Having once begun to use spec- 182 OPHTHALMY. tacles, they should never study, or sur- vey minute objects, without them.— (Scarpa.) I shall conclude the subject with a few remarks upon the cure of ophthal- my, when connected with constitution- al disease. SCROFULOUS OPHTHALMY. No specific being known for scrofu- la, the treatment, in this instance, ra- ther consists in preventing the aggra- vation, than in attempting the radical cure ofthe complaint. Every thing de- bilitating is hurtful, as all evacuations; indigestible food; intense study; a se- dentary'life; damp marshy habitations; uncleanline ss; frequent transitions from heat to cold. On the other hand, ob- serving to regulate the action of the bowels with the mildest laxatives; and the administration of bark, either alone or conjoined with the tinct. guaiaci am- moniata, do good. Alterative medicines, and especially jfcthiops mineralis, from gr. ss. to gr. xx. in the day, taken for a few weeks uninterruptedly, aquacalcis, in broth or gruel, at first, in the dose of §iij. at breakfast, and afterwards the same quantity, twice daily for a few months, uniformly adhering to a good regimen in diet; may tend much to ab- breviate the duration of this obstinate species ofthe disease. (Scarpa.) Mr. Ware has found, that the addi- tion of xx to xxx gr. of the sal poly- chrestus ofthe Edinb. Dispensatory, to each dose of bark, suffices to keep the bowels in a regular state, when there is tendency to costiveness. In some cases, in which there was little appear- ance of inflammation, this gentleman found the eye-lids so relaxed, and the eyes so irritable, that children would not open their eyes, even in the dark- est room. In some such relaxed cases, very beneficial effects were produced by administering internally small doses of opium, night and morning, to abate the irritability. Sea-bathing is always serviceable in scrofulous ophthalmy, and, probably the mere residence on the sea-coast, and the respiration of the sea-air, may bring about some of those advantages, which have been exclu- sively attributed to bathing. Friction of the body with a flesh-brush, or flannel, shoidd be employed morning and even- ing. With regard to topical triplications, those of a soft relaxing kind prove in- jurious, as also retirement into dark situations. Slightly astringent collyria; the ung. tutis, and the ung. hyd. ni- trat. are proper when there are excori- ations upon the eyelids, and when, from their occasional adhesion to each other, there is reason to suspect, that the sebaceous glands secrete an acri- monious fluid. Mr. Ware has also found that one drop of the thebaic tincture, dropped into the eye, once or twic% in the course ofthe day, contributes great- ly, both to abate the irritability and to increase the strength of the relaxed vessels. (On Scrofulous Ophthalmy, p. 26.) The same gentleman has occa- sionally mixed old verjuice with cold spring-water, at first, in the proportion of one part of the former to six of the latter, and increasing the quantity of verjuice, until, sometimes there has been an equal quantity of that and wa- ter. All coverings should be removed from the eyes, except a shade of green silk, and patients should be gradually habituated to a stronger light. Good air and exercise always tend to im- prove scrofulous constitutions, and thus, indirectly, the disease under con- sideration. Scrofula often disappears spontaneously, as children approach the adult slate, and, if we only have it in our power to check its progress in the early stage of life, it seems to wear itself out afterwards, and whatever lo- cal effects, it may have produced, often disappear. As the small-pox inoculation has now almost generally been abandoned by the faculty in favour of the vaccine disease, there seems less occasion now for detailing circumstantially a very obstinate species of ophthalmy, indu- ced by the former complaint. When the small-pox eruption is very ahwdant in the face, it causes a considerame swell- ing of this part ofthe body; the eye-lids become tumefied, the eyes redden, and there ensues a discharge of a very thick adhesive matter, which agglutinates the palpebrs together; so that, if no steps be taken, the eyes will continue closed for several days in succession. The matter, confined between the eye- lids and globe of the eye, being per- haps of an irritating quality, and injuri- ous from the pressure it occasions on the surrounding parts, seems capable of exciting ulceration of the cornea, and even of irremediably destroying vision. When the pustules of the small- pox in other parts of the body have suppurated, they cicatrize; but, those, OPHTHALMY. 183 which happen within the margin ofthe cartilage ofthe eye-lids, are prevented from healing by the diseased secretion, which is then secreted from the mei- bomian glands, and such ulcers result, as will sometimes last for several years, and even during life, if unremedied by art. (St. Tves sur les Mais des Teux, p. 218, edit. 12mo.) After the employ- ment of the antiphlogistic treatment, shoidd the disease, when treated with topical astringents and corroborants, yet baffle the efforts of the surgeon, se- tons in the nape of the neck, kept open for along while, prove one of the most useful remedies. Scarpa has experien- "■** ced much advantage from giving, every morning and evening, to a child, ten years old, a pill, containing one grain of calomel, one grain ofthe sulph. aur. antim. and four grains of cicuta in pow-. der. It is obvious, that such a potent alterative, if ever serviceable in this case, will soon evince its efficacy, nor would it be justifiable to sport with the patient's constitution by continuing its use beyond a certain period, unless sanctioned by evident signs of its salu- tary effects on the disease ofthe eyes. When great irritability prevails, a mixture of three drachms ofthe vinum antimoniale, and one drachm of the tinctura thebaica, given in doses, of five, or six drops, in any convenient ve- hicle, and, at the same time, applying externally the vapours of the spiritus ammon. comp. to the eye, constitute an excellent plan of treatment. In other cases, saturnine collyria, with a little camphorated spirit of wine, or white wine, in which a little sugar is dissolv- ed, tinct. thebaica, Janin's ointment, &c. avail most. This treatment is also applicable to the chronic ophthalmy from measles. When inveterate ulcers remain upon the edges of the palpebrs, the disease may then be regarded as the psoroph- thalmy, described by Mr. Ware, and will demand the same method of cure. See Psorophthalmy. VENEREAL CHRONIC OPHTHALMY. Mr. Hunter entertained doubts,whe- ther any inflammation of the eyes are syphilitic, and he appears to build his opinion upon two circumstances; one is, that if such cases be venereal, the disease is very different from what it is when it attacks other parts, and is at- tended with more pain, than venereal inflammation arising from an affection of the constitution: the second is, that he never saw these cases attended with such ulceration, as occurs when the disease invades the mouth, throat, and tongue. (Hunter on the Venereal, p. 324.) In regard to the first circumstan- ces, I can accurately state, that in se- veral cases, reputed to have been ve- nereal ophthalmy, which I have seen in St. Bartholomew's Hospital, the pain was by no means severe, or the chief part ofthe mah.dy. The disorder seem- ed rather to consist in an impairment of vision, with here and there little dis- tinct plexuses of dilated blood-vessels. If the pain should be actually more se- vere, than that accompanying other local symptoms of Lues Venerea, will not the natural sensibility of the eye sa- tisfactorily explain this semblance of a well-marked disease deviating from its determinate character? In support of this observation, may I not remark, that the progress of a venereal bubo in the groin causes greater pain, than the for- mation of a node on the ulna, or tibia. As to the second reason for supposing no inflammation of the eyes are truly venereal, it cannot be considered as conclusive. Syphilis does not seem in- variably to produce ulceration, in every situation, where it invades the human frame, and, in the bones, indeed, it would rather seem, in general, to give rise to a process of a directly different tendency, namely, the formation of nodes; nor does it, according to Mr. Hunter's own sentiments, produce ul- ceration upon mucous membranes. Scarpa says, the venereal ophthalmy is peculiar in not discovering manifest signs of inflammation, stealingly on clandestinely, without much uneasiness. It afterwards relaxes the vessels ofthe conjunctiva and lining ofthe palpebrs, and changes the secretion of Meibomi- us's glands. In time it causes ulceration of the margins of the eye-lids; the ci- lis fall oft*, and the cornea grows opaque. In the worst stage, it excites itching in the eyes, which is exaspe- rated at night, and abates in violence towards morning, as do almost all the effects of syphilis. It never attains the state of chemosis. (Scarpa.) In the few cases, which have fallen under my own observation, the decoct sarsap. and hydrarg. mur. have con- stantly improved the condition of the eye, and, when taken, for a sufficient time, have cured the disease. 1 do not 184 ORC OZA mean to assert, that these instances were unequivocally venereal ophthal- mics, lean only say, that they were re- puted to be such, and yielded to the above medicines. In some cases, me- zereon guaiacum, and mercurial fric- tions, might be tried, and, I believe, in all cases, the use of a collyrium, con- taining hydrarg. muriatus, as Scarpa recommends,would assist the operation of internal medicines, in the cure ofthe disease. When the eye-lids are ulcera- ted, the ung. hydrarg. nitrati, weaken- ed at first by the addition of twice, or thrice its quantity of hog's lard, is the best topical application. INTERMITTENT OPHTHALMY. There is a description of ophthalmy, the symptoms of which intermit, or at least remit, at stated periods. Mr. Ware has not found bark so useful in this, as in scrofulous ophthalmy; but, he has known the hydrar. mur. pro- duce the most beneficial effects, and, sometimes, he has conjoined with its internal exhibition the decoct, sars. com. (See Ware on Intermittent Oph- thalmy.) On the subject of Ophthalmy, the read- er may consult with advantage, Maitre- Jean, and St. Yves sur les Mai. des Teux. Ware on Ophthalmy, Psorophthal- my, and Purulent Eyes if new-born Chil- dren: on Scrofulous and Intermittent Oph- thalmy; also, Additional Remarks on Ophthalmy; and Remarks on the Puru- lent Ophthalmy lately epidemical in this country There is a masterly account of Ophthalmy in RJchter's Anfangsgr. der Wundorzn. BaM. 3. The Edinb. Med. end Surg. Journal for January, 1807, contains Mr. Peach's and Mr. Wardrop's remarks. See also, An Account of Oph- thalmia, as it appeared in England, since the return of the British Army from Egypt; by John Vetch, M. D. IS )7 But in particular, the Observations of Scarpa, in cap. 7. of his work Sulk Principali Ma- latti degli Occhi, V6nez. 1802, merit no- tice: they have been ably translated by Mr. Briggs- OPISTHONOTOS, (from or/r«iv, backward, and tuvu, to extend.) A spasmodic disease,, in which the trunk is drawn backwards, with the head to- wards the shoulders: it is one of the varieties of tetanus. ORCHOTOMIA, from oeXict a tes- ticle, and Tf.tcvw, to cut.) The operation of removing a testicle. See Castration. OSCHEOCELE, from oo-^iov, the scrotum, and x»x>», a tumour.) A hernia situated in the scrotum. OSTEOSARCOMA, or OSTEO- SARCOS1S, (from oo-ltov, a bone, and o-apj;, flesh.) This term signifies the change of a bone into a substance, of the consistence of flesh. Bones are sometimes converted into a soft, lardy, homogeneous substance, resembling a cancerous gland, and it is this affec- tion, which has most claim to the ap- pellation. Authors seem to apply the term os- teosarcoma too much at random, as may be seen by referring to Boyer on the Diseases of the Bones, vol. 1, chop. 22. The disease, called mollifies ossium certainly renders the bones soft and flexible, and the heads become soften- ed, in cases of white swellings. There is not much propriety, and, certainly, no necessity for calling these diseases osteosarcoma. The bones are also occasionally converted into a com- plete gelatinous mass. Boyer relates a very remarkable example, in which the whole humerus was destroyed in this way, nearly down to the elbow. (See vol. 1, chap. 22.) OTA'LGIA, (from «?, an ear, and «\yo(, pain.) The ear-ach. OTITIS, (from «f, the ear.) Inflam- mation of the ear. OZvENA, (fom »J», a stench.) An ulcer situated in the nose, discharging a fetid, purulent matteivand sometimes accompanied with caries of the bones. Some authors have signified by the term, an ill-conditioned ulcer in the antrum. The first meaning is the origi- nal one. The disease is described, as coming on with a trifling tumefaction and redness about the ala nasi, accom- panied with a discharge of mucus, with which the nostril becomes ob- structed. The matter gradually as- sumes the appearance of pus, is most copious in the morning, and is some- times attended with sneezing, and a little bleeding. The ulceration occa- sionally extends round the ala nasi to the cheek, but, seldom far from the nose, the ala of which, also, it rarely destroys. The ozsna is often connected with scrofulous and venereal com- plaints. In the latter cases, portions of the ossa spongiosa often come away. After the complete cure of all venereal complaints, an exfoliating dead piece of bone will often keep up symptoms, similar to those ofthe ozsna, until it is PARACENTESIS. 185 detached. Mr. Pearson remarks, that the ozsna frequently occurs, as a symp- tom of the chachexia syphyloidea. It may perforate the septum nasi, destroy the ossa spongiosa, and even the ossa nasi. Such mischief is now more fre- quently the effect of the chachexia sy- phyloidea, than of lues venerea. The ozsna must not be confounded with abscesses in the upper jaw-bone. (See Antrum.) The constitutional disease, on which the ozsna generally depends, and which acts as the remote cause, must X ANA'RIS, (from o-apa, near, and ow%, the nail.) See Whitlow. PANNUS, (from ortva, to labour.) When two, or three pterygia, of diffe- rent sizes, occurred on the same eye, with their points directed towards the centre of the cornea, where they met, and covered all the surface of this transparent membrane with a dense pellicle, the ancients named the dis- ease, pannus. (Scarpa, chap. 14.) PA'PULA, (dim. of pappa, a nip- ple.) A pimple, or ulcerous tubercle. P AR ACENTE'SIS,(from u«p««,tib, to perforate.) Surgeons, at present, re- strict the meaning of this word to two operations; viz. tapping the abdomen, and making an opening into the chest. The first is called paracentesis abdomi- nis, and is often necessary in cases of dropsy. The second is named paracen- tesis thoracis, and is sometimes proper in cases of emphysema, empyema, hy- drops pectoris, and extravasations of blood in the chest. TAPPING, OR PARACENTESIS ABDO- MINIS. When the swelling extends equally over the whole abdomen, the fluid is usually diffused among all the viscera, and is only circumscribed by the boun- daries of the peritonsum. The water is occasionally included in different cysts, which are generally formed in one of the ovaries; and, in this case, the tumour, which is produced, is not be relieved, before a cure of the local effect can be expected. The internal medicines, which may be necessary, are preparations of mercury, and anti- mony; sarsaparilla, elm bark, Peruvian bark, muriated baiytes, and muriate of lime. Sea-bathing may also do good, by improving the health. The best ex- ternal applications are said to be, pre- parations of copper, zinc, arsenic, mer- cury, the pulvis sternutatorius, and diluted sulphuric acid. (Pearson's Prin- ciples of Surgery, chap. 12) so uniform, the fluctuatiqn is not so distinct, as in the former instance; at least, this is the case while the disease has not made very great progress. The difference, also, in the consistence of the fluid, may render the fluctuation more, or less difficult of detection. When the water is contained in diffe- rent cysts, it is frequently thick and gelatinous; but, when it is uniformly diffused all over the cavity of the peri- tonsum, it is generally thinner, and even quite limpid. Sometimes a consi- derable number of hydatids are found floating in the fluid, discharged in cases of ascites. Whatever may be the efficacy of di- gitalis, mercuiy, diuretics, and other evacuantfc in ascites, they are rarely of any serviceJnn cases of local and en- cysted dropsies. When such swellings continue to enlarge, notwithstanding the adoption of a few measures, which will presently be suggested, the sooner the fluid is evacuated, the better. It is also well known, that all efforts to pro- duce a radical cure even of dropsies, which are not encysted, too frequently fail. I am decidedly of opinion, how- ever, with Dr. Fotliergill, that physi- cians would meet with much more success, in the treatment of ascites, if , they would recommend paracentesis - to be done sooner, than they generally r do. This operation is, for the most t part, much too long delayed; and dur- l ing a long space, the bowels are conti- , nually suffering, more and more, from t the effect of the large quantity of fluid, Vol. II. 2 A P 186 PARACENTESIS. which oppresses them. What ought to render the practice of early tapping more entitled to approbation, is, that the operation, when done in the situa- tion, we shall presently advise, is per- fectly free from danger, attended with very little pain, and need not interrupt the.further trial of such medicines, as the physician may place confidence in. Paracentesis only becomes a serious measure, when the disease has existed for a great length of time, and the pa- tient has been much weakened by it. Indeed, there seems much reason to suspect, that the operation should be done, as soon as the tension of the ab- domen, and the fluctuation, leave no doubt, concerning the nature of the malady; especially, when the first trials, which have been made of inter- nal remedies, seem to promise no suc- cess. Dr. Fothergill has demonstrated by facts, the advantages of this me- thod. On the commencement of an as- cites, this celebrated practitioner ad- vised the trial of diuretics and other evacuants. He then adds, that, " if by a reasonable perseverance in this course, no considerable benefit accrues; if the viscera do not evidently appear to be obstructed, and unfit for the pur- poses of life; if the complaints have not been brought on by a long habitual train of intemperance, and from which there seems little hope of reclaiming the patient; if the strength and time of life are not altogether against us; I de- sist from medicine, except of the cor- dial kind; and let the disease proceed, till the operation becomes safely practi- cable. When this is done, by the mode- rate use of the warmer diuretics, cha- lybeates and bitters, alsoVthe prepara- tions of squills, in doses below that point, at which the stomach would be affected, I endeavour to prevent the abdomen from filling again." (Med. Obs. and Inq. vol. 4. p. 112.) The same au- thor remarks, with regard to encysted dropsies, that tapping sometimes ef- fects a radical cure. Whenever a considerable quantity of fluid is suddenly let out ofthe abdomen by tapping, the quick removal of the pressure of the water off the large blood-vessels, and viscera, may pro- duce swooning, convulsions, and even sudden death. These consequences led the ancients to consider paracentesis, as a very dangerous operation, and, when they ventured to perform it, they only let out the water gradually, and at intervals. Dr. Mead, after considering what might occasion the bad symptoms re- sulting from too sudden an evacuation of a large quantity of fluid from the abdomen, was led to try what effect external pressure would have in pre- venting such consequences. This prac- titioner thought, that, in this way, he might keep up the same degree of pressure, which the fluid made on the viscera. The success, attending some trials of this plan, fully justified the opinion Dr. Mead had conceived; for, when the compression is carefully made, the whole of the water, con- tained in the abdomen of a dropsical patient, may be safely discharged, as quickly as the surgeon chooses. For this purpose, however, the whole ab- domen must be equally compressed, the pressure increased in proportion as the evacuation takes place, and kept up, in the same degree, for several days afterwards. In St. Bartholomew's Hospital, while the water is flowing out, the necessary degree of pressure is usually made with a sheet, which is put round the abdomen. Two assist- ants, who hold the ends of the sheet, gradually tighten it, in proportion, as the fluid is discharged. Immediately, after the operation, some folded flannel, sprinkled with spirit of wine, is laid over the whole anterior part of the belly, and covered with a broad linen roller, applied with due tightness round the body. Dr. Monro invented a particular kind of belt, for the purpose; but, though it may be well adapted to the object in view, it is, perhaps, unne- cessary, as the above method seems to answer every end. The instrument used for tapping the abdomen, is called a trocar. See Trocar. The most convenient position for the operation, is certainly when the patient is sitting in an arm-chair. However, weakness and other circumstances, fre- quently make it necessary to operate on the patient, as he lies in bed. Until of late, the place, in which surgeons used to puncture the abdo- men, in cases of ascites, was the centre of a line, drawn from the navel to the anterior superior spinous process of the ilium, and, on the left side, which was preferred, in consequence of the liver not being there. The place, for PARACENTESIS. 187 the puncture, was usually marked with ink, and was supposed to be always si- tuated just over a part ofthe linea semi- lunaris, where there is no fleshy sub- stance, nor any large blood vessel, ex- posed to injury. This calculation, how- ever, was made, wi.hout considering, that, in dropsy, the parietes of t;ie ab- domen do not yield equally in every si- tuation. On the contrary, it is known, that the front part is always more dis- tended, than the lateral ones, and, that the recti muscles, in particular, are sometimes very much widened. In consequence of these alterations, indu- ced by the disease, no dependence can be put on any measurement, made with a view of ascertaining the precise situ- ation ofthe linea semilunaris. The sur- geon, who trusts to his being able to in- troduce the trocar exactly in this place, from any calculation of the above kind will frequently wound a great thick- ness of muscle, instead of a part, where the abdominal parietes are thinnest.— But, a still stronger objection is to be urged against the practice of attempt- ing to tap in the linea semilunaris. Men, well acquainted with anatomy, have frequently been deceived in their reckoning, and, instead of hitting the intended line with their trocars, they hav<. introduced these instruments through the rectus muscle, and wound- ed the epigastric artery. Patients have died from this error, with large extra- vasations of blood in the cavity of the peritonsum. In a dropsical person, who has been tapped, it is to be observ- ed also, that, an effusion of blood in the abdomen will of course more readily take place, in consequence ofthe parts not being in the same close, compact state, in which they are in the healthy condition. Let every prudent practitioner, therefore, henceforth abandon the plan of tapping in the linea semilunaris, and, he may the more easily make up his mind to do so, as there is another place, where the operation may be done with the utmost facility and safety. The li- nea alba is now commonly preferred by the best surgeons; because, here no muscular fibres need be wounded, the place can be hit with certainty, and no large blood vessel can be injured.— About the middle point, between the navel and pubes, is as good a situation for making the puncture, as can possi- bly be chosen. The surgeon should in- troduce the trocar in a steady, firm manner, never in an incautious,audden way, lest parts contained in the perito- nsum should be rashly wounded. For the same reason, immediately the point of the trocar has entered the abdomen, a thing always known at once, by the sudden cessation of resistance to its passing inward, it should be introduc- ed no further, and its office of making a passage for the cannula is already ac- complished. The surgeon, consequent- ly, is now to take hold of the cannula with the thumb and index-finger of his left hand, and gently insinuate it fur- ther into the cavity ofthe peritonsum, while, with his right hand, he is to withdraw the stilette. The fluid now gushes out, and regularly as it escapes, the sheet, which is round the patient's body is to be tightened. All the water having been evacuated, a piece of flan- nel and a roller are to be immediately applied, as above explained, after put- ting a piece of lint and soap-plaster on the wound. It is not uncommon for the water' suddenly to stop, long before the full quantity is discharged. Sometimes, this happens from a piece of intestine, or omentum, obstructing the cannula. This kind of stoppage may be removed by just introducing a probe or director, and holding the portion of viscus back. When the water is very viscid, the on- ly thing we can do is to introduce a larger trocar, if doing so should pro- mise to facilitate the evacuation. Also, when hydatids obstruct the cannula, a larger instrument might allow them to escape. In encysted dropsies, the prac- titioner, of course, can only let the fluid out of such cavities, as he can safely puncture. When a dropsy of the ovary is very large, it also admits of being tupped in the linea alba; but, in this particular case, it is generally best to make the puncture where the swelfing is most prominent. In this disease, the ovary is, either converted into one large cavi- ty, filled with fluid, or else it contains several distinct cells. The contents are sometimes exceedingly viscid. In early stages of the case, the tumour is situ- ated towards one side ofthe abdomen, and seems to ascend out of the pelvis. This kind of progress at once distin- guishes the disease from a common as- cites, which is attended, from the first, with an equal, gradual, universal swel- ling of the abdomen. The cyst of the ovary, when it has attained a large size, 13$ PARACENTESIS. generally adheres, in different places, to the inner surface ofthe peritonsum, and, in this state, the whole abdomen often seems uniformly swollen, in con- sequence ofthe immense magnitude of the disease. The impairment of the health, arising from the pressure on the viscera, and interruption of their func- tions, and the great difficulty of breath- ing, produced by the pressure on the diaphragm, make it necessary to let out the fluid, and paracentesis must be done, in the way already related. The disease is often attended with an al- most total stoppage ofthe secretion of urine. Sometimes, the urine is duly se- creted; but a retention occurs, so that the use of the catheter becomes indis- pensable. Tapping, however, can only be regarded as a palliative measure; the water collects again, the same grievances recur, and the operation must be repeated. While an ovarial dropsy is recent, and even after it has been tapped, some attempts may be made to effect a radical cure. Blister- ing the surface of the abdomen, keep- ing up a discharge with the savine ce- rate, and applying a tight roller, have been known to do good. In France, the celebrated Le Dran laid open the cysts of ovarial dropsies. His patients did not die of the consequent inflamma- tion, and the dropsy, indeed, was cur- ed; but, there remained either a sarco- matous enlargement of the ovary, which continued to increase till death, or else incurable fistuls, leading into the cyst, were the consequences. The large size of a wound, necessary for this purpose, the danger of inducing in- flammation in so extensive a surface, as the cyst of a large ovarial dropsy, and the events of Le Dran's cases, are circumstances, on the whole, quite enough to keep the practice from ever being revived. A still more absurd plan has been attempted, viz. to cure the disease, by injections, just as hydroceles. I have seen two cases, in which red wine and water have been injected: one patient died very soon afterwards ofthe in- flammation, and the other perished more lingeringly from the same cause. Setons have been tried, without suc- cess. Sometimes, though very seldom, the operation of paracentesis is necessary for giving vent to collections of air in the abdomen. Air, when confined in this manner, is generally contained in the bowels, which it inflates to an enormous size. Instances, however, are related of quantities of air being confined between the peritonsum and intestines; but, in some of these cases, it is said, that the air was known to have escaped through a small hole in some part of the intestinal canal, and, it is probable, that all the other examples were ofthe same kind. This disease is named tympanites, and may render making an opening into the abdomen necessary. Notwithstanding authors generally recommend a small trocar for the purpose, there can be no doubt, that dividing the skin, and making a cautious puncture with a lancet through the linea alba, and peritonsum, would be a preferable mode of proceeding. The abdomen must also be compressed with a sheet, while the air is escaping, and, afterwards, with a roller, just as if the case were an ascites. Even when the air is contained in the bowels, if it should be enormous in quantity, occa- sion urgent symptoms, and cannot be got rid of in other ways, authors re- commend paracentesis. PARACENTESIS OF THE THORAX. The necessity for this operation is indicated, when the heart, or lungs, are oppressed by any kind of fluid con- fined in the cavity of the chest. Every body knows, that the free and uninter- rupted performance ofthe functions of these organs is essential to the support of life. When the action of these visce- ra is disturbed by the lodgment of a collection of any kind of fluid in the tho- rax, no internal medicines can be much depended upon for procuring relief. The only means, from which benefit can be rationally expected, is letting out the fluid, by making an opening in the parietes ofthe chest. The nature of the effused fluid can make no difference, in regard to the propriety of discharging it in this man- ner; and, though some authors have on- ly treated of this operation, as applica- ble to cases of hydrops pectoris, and empyema, it may also be ofthe great- est service when air is confined in the chest, (see Emphysema,) or blood ex- travasated there (see Thorax, Wounds of,) so as to make dangerous pressure on the lungs and diaphragm. In this place, I shall content myself with describing the best method of per- forming paracentesis thoracis, refer- PAROTID DUCT. 189 ring the reader to the articles just mentioned for information, concern- ing the particular symptoms and cir- cumstances which may render the ope- ration proper, and the rest of the sur- gical treatment peculiar to each affec- tion . ' The safest, and most convenient si- tuation, for making an opening into the chest, is between the sixth and seventh true ribs, on either side, as circum- stances may render necessary. The surgeon should only recollect, that the two cavities of the pleura are com- pletely distinct from each other, and have no communication whatsoever, so that, if fluid were contained on the left side of the thorax, making an opening into the right cavity would not serve for discharging the accumulated mat- ter. The practitioner should also re- member, that, when there is a fluid on both sides of the chest, paracentesis must never be done for the relief of the two collections at the same time; be- cause, there is great reason to believe, that, as the lungs on one side usually collapse, when there is a free commu- nication between the air and inside of the thorax, they would do so on both sides, were an opening made at the same time into each bag of the pleura. It is hardly necessaiy to remark, that, in this condition, the patient could not breathe, and would die suffocated. The operation consists, in making an inci- sion, about two inches long, through the integuments, which cover the space between the sixth and seventh true ribs, just where the indigitations of the serratus major anticus muscle meet those of the externus obliquus. Here it is unnecessaiy to divide any muscular fibres, except those ofthe in- tercostal muscles, and, by putting the patient in a proper posture, the opening that is to be made, will be depending enough for any purpose whatsoever. The surgeon, avoiding the lower edge of the upper rib, where the intercostal artery lies, is then cautiously to divide the layers of the intercostal muscles, till he brings the pleura into view; when the membrane is to be very care- fully divided with a lancet. The instru- ment should never be introduced in the least deeply, lest the lungs should be injured. The size ofthe opening in the pleura should never be larger than ne- cessary. The discharge of blood and matter will of course require a freer aperture, than that of air, or water. If requisite, a cannula may be introduced into the wound, for the purpose of fa- cilitating the evacuation of the fluid, and it may even in some cases, be pro- per to let this instrument remain in the part, in order to let the water, or pus escape, as often as another accumula- tion takes place. It is obvious, however, that a cannula, for this object, should only be just long enough to enter the cavity of the pleura, and should have a broad rim to keep it from slipping into the chest. A piece of sticking plaster would easily fix the cannula, which might be stopped up with a cork, or any other convenient thing, or left open, according as the circumstances of the case, and the judgment of the surgeon, should direct. The paracentesis of the abdomen, and that of the thorax, are described in all treatises on the operations, and systems of surgery. The works of Sharp, Le Dran, Bertrandi, and Saba- tier, are particularly deserving of at- tention. PARA'LYSIS, (from va.ga.\w», to weaken.) A palsy. It is a symptom of several surgical disorders; as, for in- stance, of pressure on the brain, from blood, matter, or a depressed portion of bone; of injuries of the vertebra and spinal marrow; of disease of these latter bones, &c. (See Head, Injuries of; Dislocations; Fractures, and Verte- bra, Disease of.) PARAPHYMO'SIS, or PARA- PHIMOSIS, (from traga, back, and fujK^, to bridle.) This signifies the case, in which the prepuce is drawn quite behind the glans penis and cannot be brought forward again. See Phymo- sis, with which it will be considered. PARONYCHIA, (from tsmcfa, near, and «vu£, the nail.) An abscess at the end of the finger, near the nail. See Whitlow. PAROTID DUCT. Every one ac- quainted with anatomy, is aware, that, behind the jaw, on each side, there is situated a large conglomerate gland, being the principal one of such as are destined to secrete the saliva, with which the cavity of the mouth, and the food, which we swallow, are conti- nually moistened. The parotid duct crosses the cheek, being situated about one-third from the zygoma, and two- thirds from the basis of the jaw. After passing over the masseter muscle, it pierces the buccinator, and terminates in the mouth by a considerable orifice, 190 PAROTID DUCT. opposite the space, between the second and third bicuspid grinders of the up- per jaw. As soon as it has passed the masseter, it dives deeply into the fat of the cheek, and, as M. Louis observes, makes an angle before it opens into the mouth. (Mem. de I'Acad, de Chir. tom. 3. p. 457.) From the situation of the parotid duct, it is liable to be wounded, and this has even been done, by the sur- geon's lancet, through ignorance. (See Monro's Works, p. 520.) In cases of this kind, the continual escape of the saliva is apt to keep the wound from healing, and, what is called a salivary fistula would be the perpetual consequence, if no steps were taken to afford relief. The parotid duct has sometimes been ruptured by blows. ((Euvres Chir. de De- sault, tom. 2. *. 221) Cases also occur, in which the face becomes considerably swollen, in consequence of the saliva insinuating itself into the cellular sub- stance, just as the air does in emphy- sema. On the last circumstance, I shall only just mention, that mischief of this kind must always be prevented from becoming very extensive, by making a depending opening for the ready es- cape of the fluid. With regard to the treatment of sa- livary fistuls, if the division of the parotid duct is recent, the sides of the wound should be brought into contact, and a steady pressure maintained on that part of the cheek, by means of suitable compresses, and a roller. In this manner a salivary fistula may often be prevented altogether: Either the di- vided ends of the duct reunite, and the spittle resumes its original course into the mouth; or, what is more probable, the wound in the face heals at every part, with the exception of a small fis- tulous track, which serves as a conti- nuation of the duct into the inside of the mouth. The latter kind of cure, however, can only take place when the wound extends quite through the cheek; but, the chance of the two por- tions of the duct uniting, and becom- ing continuous again, should always be taken in recent cases. When a salivary fistula has actually formed, a seton, introduced from the external fistulous orifice into the mouth, is a method which seems to have, with justice, the greatest share of approbation. The celebrated Monro adopted this plan with success: he kept in the seton till the channel, wiich it had formed, had become fistulous, after which it was withdrawn, the ex- ternal orifice being touched with the argentum nitratum, healed up, and the saliva in future flowed through the ar- tificial fistulous channel into the mouth Desault used to practice the st ton as follows:—He introduced two fingers of his left hand into the patient's mouth, and placing them between the teeth and the cheek, opposite the fistula, thus kept the integuments tense, and the gums from being injured. He then introduced a small hydrocele trocar, with its cannula, just before the open- ing of the posterior part of the duct, and pushed through the cheek, in a di- rection a little inclined forward. An assistant now took hold ofthe cannula, while Desault withdrew the perfora- tor, and passed through the tube a bit of thread, into the cavity of the mouth. The cannula was next taken out, and a seton, which was then fas- tened to the end of the thread in the mouth, was drawn from within out- ward; but not so far as to come be- tween the edges of the external open- ing, where the thread alone lodged, and this was fastened with sticking- plaster to the out-side of the cheek. The outer wound was dressed with lint and compresses. Desault used to change the seton daily, introducing re- gularly rather a larger one, and taking especial care not to bring it between the edges of the wound, which was afterwards covered with sticking-plas- ter. He enjoined the patient not to move the jaw much, and only allowed him, for some time, liquid food. In about six weeks he used to leave off the seton, leaving in the thread, how- ever, for a little while longer. This being taken away, he used to finish the cure, by touching the little aperture remaining, with caustic. The making of an artificial passage is one of the most ancient plans of curing salivary fistuls. Every author has had his particular method of doing it, and numerous variations are to be met with, either in the instrument em- ployed for piercing the cheek, or in the substance intended for maintaining the opening. For the first step of the ope- ration, surgeons sometimes used the actual cautery, as Saviard furnishes us an instance of; sometimes an awl, as Monro did; sometimes a common knife, or lancet; sometimes a straight needle, which drew in the thread after it; but, Desault's trocar generally me- rits the preference, because the cannu- PENIS. 191 la, by remaining in the wound, after the perforator is withdrawn, allows the thread to be introduced, which, in every other way, is either difficult to accomplish, or requires the use of se- veral instruments. For the second step ofthe operation, viz. keeping the opening distended, cannuls were employed by Duphenix, who used to make a suture over them; a plan objectionable, inasmuch as it was attended with the inconvenience of a solid body left in the parts, and also that of the instrument being apt to slip into the mouth. The seton, therefore, ought to be preferred, and there can be no doubt that Desault's method is better, than the one followed by Monro. See on this subject, Mon- ro's Works; (Euvres Chir. de Desault, par Bichat, tom. 2. p. 221. Also Mem. de I*Acad, de Chir. tom. 3. PARU'LIS, (from -aagx, near, and wxov, the gum.) An inflammation, boil, or abscess in the gums. PEDILU'VIUM, (from pes, the foot, and lavo, to wash.) A bath for the feet. PE'NIS, AMPUTATION OF. No part of the penis should ever be ampu- tated, on account of a mortification, be- cause the dead portion will be naturally thrown off, and the ulcer heal, without the least occasion for putting the pa- tient to any pain from the employment ofthe knife. Some cancerous, and fun- gous diseases, are the cases, in which it is often really proper and necessary to amputate more or less of this part of the body. The old surgeons, fearful of hemor- rhage, used sometimes to extirpate a part of the penis, by tying ligatures round it with sufficient tightness to make it mortify and slough off*. Thus, Ruysch removed the penis in one in- stance. (See Observ. 30.) The plan, however, is exceedingly painful, and quite unnecessary, notwitlistanding what Heister states in its favour. The amputation may be done in the following manner:—A circular incision is to be made through the skin, about a finger-breadth from the cancerous part. The integuments are then to be drawn back, so as to expose the cor- pora cavernosa, which are to be divid- ed with one stroke of the knife, on a level with the cut edge of the skin, in such a manner, that the extremity both of the skin and corpora cavernosa, is t© form one wound, or surface. The bleeding arteries are now to be imme- diately tied: the chief are, one on the dorsum of the penis, and one in each corpus cavernosum. When a general oozing from the wound still continues, some recommend (White, Hey, &c.) applying sponge to its surface; others (Latta) finely scraped agaric, with a small proportion of pounded white sugar, or gum arabic. Perhaps, how- ever, finely scraped lint, supported with compresses, would be quite as effec- tual as any styptics, and, certainly, the latter applications should be avoided, if possible, because stimulating, and productive of pain and inflammation. A surer and preferable method of stopping the oozing of blood, and at the same time of healing the wound, might be to bring the skin forward, over the end of the stump, with two strips of sticking-plaster, after intro- ducing a flexible gum catheter into the continuation of the urethra, so as to keep its orifice unobstructed, and the urine from coming into contact with the wound, whenever the evacua- tion is made. There can be little doubt, that the gum catheter would be better than a silver one, or any metallic can- nula, commonly advised for the above purposes, because it lies in the passage with less irritation. In one case, in which Mr. Hey operated, he made a longitudinal division of the integu- ments, at the inferior part of the penis, so as to make them cover its extremi- ty, without puckering, or lying over the orifice of the urethra. The corpora ca- vernosa, however, do not readily gra- nulate and unite to the skin by the first intention. (Hey, p. 452.) After the first dressings are removed, the part should be dressed with the unguentum sper- matis ceti, or any mild unirritating salve. In consequence ofthe introduction of a cannula being neglected, Le Dran mentions his having seen the orifice of the urethra become closed a few hours after the operation, so that the patient could not make water. The orifice of the passage could not be discovered without great difficulty. A lancet being introduced at the point, against which the urine seemed to be forced, a quan- tity of it gushed out, and, as a cannula was not at hand, a sound was introdu- ced, till one could be procured. (Traite" des Oper.de Chirurgie.) Pearson, in his Practical Observations on Cancerous Complaints, has treated of 192 PEN PES this operation: he particularly advises the skin not to be drawn back, be- cause, when saved in thi6 manner, it impedes the free exit of the urine. He likewise disapproves of introducing cannuls, as creative of pain, and spasms ofthe urethra, and being moreover un- necessary, since the stream of urine will always preserve the urethra in a permeable state. (P. 103.) Sharp, Le Dran, Bertrandi, and Sa- batier's books on the operations, may be consulted. Also, I'Encyclopedic Mitho- dique; Partie Chir. Art. Verge. Hey's Practical Observations in Surgery, p. 445. Pearson on Cancerous Complaints, p. 103, PENIS, CANCER OF. A wart, or a tubercle, on the prepuce, the frsnum, or the glans penis, is generally the first symptom, and it often remains in a quiet state for many years. When irri- tated, however, it becomes painful, and enlarges, sometimes enormously, in a very short time. At the same time, ul- ceration, and a discharge of sanious foe- tid matter, take place. The disease sometimes also occasions in the ure- thra fistulous openings, out of which the urine escapes, and the lymphatic glands in the groin may become affected as the disease advances. Mr. Pearson says, that " cancerous excrescences have a broad base, often more extensive, than their superficies; they seem to germi- nate deeply from within, or rather to be a contmuation of the substance of the part; and, in their progressive state, the contiguous surface has a morbid appearance." What Mr. P. considers as a venereal wart, has a basis smaller, than its surface; its roots have rather a superficial attachment, and the conti- guous paits have a natural appearance: p. 97. Such are this gentleman's marks of disci'imination. We might question, however, whether Mr. Pearson, not- withstanding his great opportunities, ever saw a real venereal wart. For many years past I have never seen any ex- crescences of this kind, in St. Bartho- lomew's hospital, which truly required mercury for their cure, or which, when cured without it, were followed by any inconvenience. If my memory does not fail me, Mr. Abernethy also disbelieves in the doctrine of venereal warts. Foul, spreading, sloughy ulcers of the penis, should be discriminated from cancer. It is worthy of attention, that almost all the cases of cancer of the pe- nis, recorded by Mr. Hey, were attend- ed with a congenital phymosis. (See Pearson on Cancerous Complaints, and Hey's Practical Observations in Surgery.) PERINEUM, FISTULA OF. See Fistula in Perinao. PERITONITIS. An inflammation of the peritonsum. Surgeons have chiefly to combat this dangerous af- fection, in cases of hernia, lithotomy, wounds of the abdomen, fractures of the pelvis, &e but as the necessary treatment is detailed in the particular articles of this dictionary, we need not here enlarge upon this subject. PE'RNIO, (from tsigtm, or ■angw, the heel.) A chilblain, especially one on the heel. See Chilblain. PESSARY, (from *»\t±, a vein, and rt^a, to cut.) The operation of opening a vein, for the purpose of taking away blood. See Bleeding. PHLE'GMON, PHLEGMONE, (from *, the membrane lining the chest.) A pleu- risy, or inflammation of the pleura. PLEUROSTHOTONOS, (from erxti/pov, the side, and t»v», to stretch.) A spasmodic disease, in which the body is drawn to one side; a species of tetanus. (See Tetanus.) PLICA POLONICA, (from plico, to entangle.) A peculiar disease, to which the inhabitants of Poland and Lithuania are subject: in this singular affection, the hairs ofthe head become adherent together, probably, in conse- qaence of some morbid secretion from the scalp. It may be cured by the same means, which cure the scald-head. (See Tinea Capitis.) PNEUMATOCELE, (from enzvftai wind, and k«\h, a tumour.) The wind- rupture; a case, which only existed in the imaginations of the old sur- geons. POLYPUS, (from rntoc, many, and tax, a foot.) A kind of tumour, which is generally narrow where it originates, and then becomes wider, somewhat like a pear; which most commonly is met with in the nose, uterus, vagina, and antrum; and which received its name from an erroneous idea, that it usually had several roots, or feet, like polypi, or zoophytes. POLYPUS OF THE NOSE. Polypi more frequently grow in the cavity of the nose, from the Schneide- rean membrane, than any other situa- tion. Nasal polypi are visibly of differ- ent kinds; some being red, soft, and sensible; but, free from pain, and ex- actly like a piece of healthy flesh. This, which has been termed the fleshy polypus, is the most common, and for- tunately the most easy of cure. Other polypi are called malignant, being hard, scirrhous, and painful: some are said to be even capable of conversion into carcinoma. Richter describes another kind of nasal polypus, which is pale, very tough, and secretes a viscid dis- charge; which undergoes an alteration of its size with every change if the weather; and which is rather a relaxa- tion, or elongation, of a part of the Schneiderean membrane, than a poly- pus excrescence. The whole membran- ous lining of the nostrils is sometimes relaxed, and thickened in this manner, so as nearly to fill up the whole cavity of the nose. (Ansfangr. der Wundarzn. Band 1. Cap. 21.) Mr. Pott has taken great pains to show, that there is one kind of poly- pus, originally benign; another origin- ally malignant. He states, that those, which begin with, or are preceded by considerable, or frequent pain in the forehead and upper part of the nose, and which, as soon as they can be seen, are either highly red, or of a dark pur- ple colour; those which, from the time of their being first noticed, have never been observed to be sometimes bigger, sometimes less, but have constantly ra- ther increased; those, in which cough- 198 POLYPUS. ing, sneezing, or blowing the nose, gives pain, or produces a very disa- greeable sensation in the nostril, or forehead; those which, when within reach, are painful to the touch, or which, upon being slightly touched, are apt to bleed; those which seem to be fixed, and not moveable by the action of blowing the nose, or of driving the air through the affected nostril only (when the polypus is only on one side); those which are incompressibly hard, and which, when pressed, occasion pain in the cornea ofthe eye, and fore- head, and which, if they shed any thing, shed blood; those which, by ad- hesion, occupy a very considerable space, and seem to consist of* a thick- ening, or of an enlargement of all the membrane covering the septum nari- um; those which sometimes shed an ichorous, offensive, discoloured dis- charge; and those, round whose lower part, within the nose, a probe cannot easily and freely be passed, and that, to some height, ought not to be at- tempted, at least by the forceps, nor indeed by any other means; and this for reasons obviously deducible from the nature and circumstances of the polypus. On the one hand, the very large extent and quantity of adhesion will render extirpation impracticable, even if the disease could be compre- hended with the forceps, which it very frequently cannot; and on the other, the malign nature of the dis- temper may render all partial removal, all unsuccessful attacks on it, and in- deed any degree of irritation, produc- tive of the most disagreeable conse- quences. But, the polypi, which are of a pal- ish or grayish light-brown colour, or look like a membrane just going to be sloughy; which are seldom or never painful, nor become so upon being pressed; which have appeared to be at one time larger, at another less, as the air has happened to be moist or dry; which ascend and descend freely by the action of respiration through the nose; which the patient can make to descend by stopping the nostril which is free, or even most free, and then driving the air through that which the polypus possesses; wliich when press- ed give no pain, easily yield to such pressure, become flat thereby, and dis- til a clear lymph; and round whose lower and visible part a probe can easi- ly, and that to some height, be passed, are fair and fit for extraction; the po- lypus,- in these circumstances, fre- quently coming away entire; or if it does not, yet it is removable without pain, hemorrhage, or hazard of* any kind; the second of which circum- stances Mr. Pott can with strict truth affirm, he never yet met with when the disease was at all fit for the opera- tion. Ofthe benign kind of polypus, fit for extraction, there are (says Mr. Pott) two sorts, whose principal difference from each other consists in their differ- ent origin or attachment. That which is most freely moveable within the nos- tril, upon forcible respiration; which has been found to be most liable to change of size, at different times and seasons; which has increased the most in the same space of time; which seems most limpid, and most freely yields lymph upon pressure, has its ori- gin most commonly by a stalk, or kind of peduncle, which is very small, com- pared with the size of the polypus. The other which, although plainly moveable, is much less so, than the one just mentioned, which has been less liable to alteration from air and seasons; and which has been rather slow in arriving at a very troublesome size, is most frequently an elongation of the membrane covering one of the ossa spongiosa. These latter may be extracted with no kind of hazard, and, with very little pain, and hemorrhage; but, the former require the least force, and mostly come away entire; while the others often break, come away piecemeal, and stand in "need of the repeated use of the forceps. (Potts on the Polypus of the Nose.) Mr. John Bell criticises the distinc- tions drawn by the preceding writer, and he says, that a polypus is never mild, nor ever malignant; time, and the natural growth ofthe tumour, and the pressure it occasions within the soft and bony cells ofthe nostrils and jaws, must bring every polypus to one invari- able form, in its last and fatal stage. Polypus, says Mr. John Bell, is indeed a dreadful disease; but, it becomes so by a slow progression, and advances by gradations easily characterised. Every polypus in its early stage is, according to this writer, a small moveable tumour, attended with sneezingand wateringof the eyes; swelling in moist weather; descending with the breath, but, easily repressed with the point of the fin- ger. It is void of pain, and not at all alarming, it may also be easily POLYPUS. 199 extracted, so as to clear for a time the passage for the breath. Yet this little tumour, simple as it may appear, is the germ of a very fatal and loathsome dis- ease, and this easy extraction often the very cause of its appearing in its most malignant form. The more easily it is extracted, (says Mr. J. Bell) the more easily does it return; and whether carelessly extracted, or altogether ne- glected, it soon returns. But, when it does return, it has not really changed its nature; it has not ceased to be in it- self mild, it is then to be feared, not from its malignity, but from its pres- sure, among the delicate cells and membranes of the nose. It soon fills the nostrils, obstructs the breathing, and causes indescribable anxieties. The tears are obstructed, and the eyes be- come watery from the pressure on the lachrymal sac; the hearing is in like manner injured, by the pressure ofthe tumour against the mouth of the eu- stachian tube; the voice is changed, and its resonance and tone entirely lost, by the sound no longer passing through the cells of the nose and face. The swallowing is in some degree affected by the soft palate being depressed by the tumour. The' pains, arising from such slow and irresistable pressure, are unceasing. From the same pressure, the bones become carious, and the cells of the face and nose are destroyed by its slow growth. It is not long, before the tumour begins to project from the nostril in front, and over the arch of the palate behind. One nostril becomes widened and thickened; the nose is turned towards the opposite side ofthe face, and the whole countenance seems distorted. The root ofthe nose swells, and becomes puffy, the features tumid and flabby, the face yellow, and the parts round the eye livid. The patient is affected with head-achs, which seem to rend the bones asunder, and with perpetual stupor, and dozing.— The bones are now absorbed, and the membranes ulcerate; a foul and fetid matter, blackened with blood, is dis- charged from the nostrils, and exco- riates them. The blood-vessels next give way, and sudden impetuous he- morrhages weaken the patient; the teeth fall from the sockets, and, through the empty sockets, afoul and fetid mat- ter issues from the antrum. Now the disease verges to its con- clusion. The patienthas terrible nights, and experiences a sense of suffocation. The repeated loss of blood renders him so weak, that he cannot quit his bed for several days together; and when he does get up, lie is (to use Mr. J. Bell's words) pale as a spectre, his lips co- lourless, andhis face like wax, yellow, and transparent. He now suffers into- lerable pain, while his saliva is continu- ally dribbling from his mouth, and the fetid discharge from his nose. In this state, he survives a few weeks; during the last days of his illness, lying in a state of perpetual stupor, and dying le- thargic. Mr. J. Bell, afterwards, ob- serves, that, " if horrid symptoms could establish the fact of malignity, there is not to be found in all nosology a more malignant disease, than this: but, aneurism, though it destroys the thigh-bone, the sternum, or the crani- um, is not accounted malignant; iiei* ther is polypus malignant, though it destroys the cells of the face, and pe- netrates even through the ethmoid bone to the brain. These consequences result merely from pressure." (John Bell's Principles of Surgery, vol. 3. part 1. p. 90—92.) The celebrated professor Richter has also denied the validity of the ob- jections, urged by Pott against at- tempting to relieve the patient: neither the malignant nature of a polypus, its adhesions, immoveableness, ulcera- tions, nor disposition to hemorrhage, gx, the itch, and o?5rx\fe.ia, an inflammation ofthe eye.) An inflammation ofthe eye- lids, attended with ulcerations, which itch very much. By psorophthalmy Mr. Ware means a case, in which the inflammation ofthe eye-lids is attended with an ulceration of their edges, upon which a glutinous matter lodges, in- erusts, and becomes hard, so that, in sleep, when they have been long in contact, they become so adherent, that they cannot be separated without pain. Mr. Ware remarks, that " the ul- ceration in the psorophthalmy is usual- ly confined to the edges ofthe eye-lids; but, sometimes, it is seen to extend over their whole external surface, and even to excoriate the greater part of the cheek. In cases of the latter kind, the inflammation which accompanies, has often much the appearance of an erisypelas, and will receive most relief from cooling applications. The use of the citrine ointment, which will here- after be recommended, must, in such instances, be deferred until the irri- tability ofthe skin is in a good degree abated. " This disorder is also, sometimes, attended with a contraction ofthe skin ofthe lower eye-lid; in consequence of which, that lid is drawn down, and the inner part turned outward, so as to form a red, fleshy, and most disagreea- ble appearance, called ectropium.— Whenever this happens, it proves the complaint to be of the most obstinate nature; though it is generally removed by the cure of the psoraphthalmy, which is the occasion of it." (Remarks «« Ophthalmy, &c. P. 112.) Mr. Ware recommends, for the cure of this dis- ease, the unguentum hydrargyri nitra- ti. This is to be melted into an oil, and rubbed with the end of the forefinger, or the point of a small pencil-brush, into the edges of the affected eye-lids, once every night, on going to bed. A plaster of ceratum album is then put over the eye-lids to keep them from ad- hering together. If they should still ad- here in the morning, he advises clean- ing them with milk and butter, well mixed together. In a few cases, it is necessary to touch ulcers, formed on the edge ofthe eye-lid, after the small- pox, with the argentum nitratum. When the globe ofthe eye is inflamed, use the thebaic tincture, as directed in the article Ophthalmy. In scrofulous subjects, alterative medicines; an is- sue, or perpetual blister; and attention to diet, &c. are proper. (See Ware on Ophthalmy, &c.) PTERYGIUM, (dim. of &rfg^, a wing ) Scarpa accurately remarks, that surgeons apply the term "pterygium" to that preternatural, reddish, ash-co- loured, triangular little membrane, which most frequently grows from the internal angle of the eye, near the ca- runcula lachrymalis, and gradually ex- tends over the cornea, so as to cause considerable impediment to vision. Though the pterygium most com- monly proceeds from the internal an- gle, it is observed to arise sometimes from the external one, and, in some instances, from the superior, or infe- rior hemisphere of the eye-ball. But, whatever be its origin, its figure is in- variably that of a triangle, with its base on the white of the eye, and its apex more or less advanced over the cornea, towards its centre, and that of the pu- pil. Indeed, there are a few cases, in which two, or three pterygia of diffe- rent sizes occur on the same eye, and are arranged round its circumference at interspaces of various breadths.Their points are directed towards the centre ofthe cornea, and if they should unfor- tunately conjoin there, the whole of that transparent membrane becomes covered with an opaque veil, and a to- tal loss of sight is the consequence. It seems to Scarpa, that the term " pan- nus" was applied by the ancients to ex- actly this sort of complication. Strictly speaking, chronic varicous ophthalmy, with relaxation, and thick- ening ofthe conjunctiva; opacity of the cornea; and the pterygium; only differ in the degree ofthe disease. In reality, all the three complaints consist of a more, or less extensive varicous state of the vessels of the conjunctiva, com- bined witli a degree of preternatural relaxation, and thickening, of that membrane. Inchronic varicous ophthalmy, theex- traordinary amplitude, and knottiness of the vessels; the flaccidity, and thicken- ingof the conjunctiva; are limited to the white ofthe eye. In opacity of the cor- nea, certain veins'even dilate, and be- come knotty, for some way, over that delicate layer of the conjunctiva, which is continued over the surface of the cornea. In the pterygium, an extraor- PTERYGIUM. 215 dinary swelling of this subtile membra- nous expansion is added to the varicous state of its veins. Hence, the pterygi- um seems atfirst like a new membrane formed on the cornea, while it is really nothing more than the delicate conti- nuation ofthe conjunctiva just mention- ed, deprived of its transparency, and degenerated, in consequence of chro- nic ophthalmy, into a thick, opaque membrane, on which there is a plexus of varicous blood-vessels. Consequent- ly, in the case of pterygium, there is no new production on the eye, but only an alteration of one of the thin, trans- parent membranes, which naturally cover it. The following circumstance, as will be more fully explained pre- sently, illustrates, says Scarpa, the ve- racity of the preceding statement. The incipient pterygium may be cured in the same manner as opacity of the cor- nea, viz. by merely cutting off that portion of it, which is situated at the junction ofthe cornea with the sclero- tica, without detaching the whole of it from the surface of the former mem- brane; just as is practised in opacity of the cornea, in order to destroy the communication ofthe varicous veins of the conjunctiva with their trunks, the ramifications of which produce, and maintain the disease. Scarpa observes, that the pterygium would be as common a complaint as the varicous chronic ophthalmy, so of- ten occupying the white ofthe eye, if the delicate continuation of the con- junctiva, over the surface of the cor- nea, were not naturally of a denser, and more compact texture, than the rest ofthe membrane, from wliich it is produced, and if its vessels were not very minute, and delicate, and not so dilatable as those of the other part of the conjunctiva. This is the reason why the pterygium is comparatively a rare cace, in respect to the great frequency of varicous, chronic ophthalmies. But, should the vessels of the transparent layer of the conjunctiva once yield to the impulse of the fluid propelled into them; should they once become vari- cous; the cellular texture, in which they are enveloped, never fails to swell gradually, and, thus, the delicate, diaphanous membrane in question, changes into a pulpy, reddish tunc, precisely similar to the pterygium. That the pterygium is truly nothing else, but the natural, delicate, transpa- rent expansion of the conjunctiva, on the cornea, converted, for a certain ex- tent, into a pulpy, flaccid, varicous membrane, may be inferred (continues Scarpa) from the folds, wliich the pterygium and conjunctiva form at the same time, when the morbid eye is turned towards the origin of the dis- ease. The same inference is equally deducible from the tension occasioned in both these parts, whenever the eye is moved in the opposite direction. We become still more convinced ofthe fact on observing, that in the first position ofthe eye, both the pterygium, and the corresponding portion of the conjunc- tiva (which is equally relaxed, vari- cous, and reddish),may be easily taken hold of with a small pair of forceps, and raised together in the form of a fold. When the pterygium is met with iir the dead subject, on carefully cutting off, and detaching, that flaccid, and thickened portion ofthe conjunctiva, in the white of the eye, which corre- sponded to the part ofthe cornea in the state of opacity from the pterygium, Scarpa has constantly found, that the pterygium might be separated, with equal facility, both on the white ofthe eye, and the cornea. The latter mem- brane was evidently denuded at the seat ofthe disease, being no longer co- vered with the transparent continua- tion of the conjunctiva. But, Scarpa* has never been able to deprive the cor- nea of its natural' covering, beyond the limits ofthe pterygium. Also, when se- veral pterygia occur on tbe same eye, with interspaces between them, as ma- ny flaccid, varicous, pulpy places ap- pear in the conjunctiva on the bulb, and constitute the basis of the pterygia; while the rest of this membrane, cover- ing the white of the eye, continues smoothly spread over tbe ball, and no varicous blood-vessel is perceptible on the anterior hemisphere of the eye, except where the relaxation of the conjunctiva, and the knottiness of tlte vessels, have implanted, as it were, the distant roots, and rudiments ofthe pterygium. The pterygium, whether large, or small, and whatever its situation may be at the circumference ofthe eye-ball, constantly retains its triangular shape, with its base on the white of the eye. and its apex on the cornea. The con- stancy of this fact seems to Scarpa at- tributable to the increasing degree of firmness, withjwhich the subtile, trans- parent layer of the conjunctiva ad- heres to the surface ofthe cornea, as it 216 PTERYGIUM. proceeds from the circumference to the centre of that membrane. The follow- ing consequences must necessarily re- sult from this sort of structure, and the different degree of cohesion, actually existing in healthy eyes. 1. The pro- gress ofthe pterygium must be slower in every instance on the cornea, than on the white of the eye. 2. As the ptery- gium always meets with augmented resistance, in proportion as it endea- vours to approach the centre ofthe cor- nea, it must from mechanical necessity assume the form of a triangle, with its base on the" white of the eye, and its apex directed towards the centre ofthe cornea. Forestus (Oper. Med.) has ac- curately noticed the circumstances of this appearance, and, he continues: non cooperit oculum nisi in forma sagit- ta. From this invariable appearance, and figure of the pterygium, one of its principal diagnostic characters results, by which the true disease may be dis- criminated from false instances, and from every other soft, fungous, reddish excrescence, that obscures the cornea. For, on this membrane, excrescences sometimes form, which, from having the colour and consistence of a soft membrane, bear a very great resem- blance to the pterygium, though they are really widely different, and, strictly speaking, consist ofthe texture ofthe cornea itself, degenerated into a soft, fungous substance. Such pellicles, how- ever, not only almost always create a greater prominence on the cornea, than what accompanies the pterygium, but they are constantly of an irregular tu- berous form, and never represent a tri- angle, with the apex pointing towards the centre ofthe cornea, like the genu- ine pterygium. Another distinguishing character of the pterygium (continues Scarpa) con- sists in the facility, with which the whole of it may be taken hold of with a pair of forceps, and raised into a fold on the cornea. Every other kind of excre- scence, attached to this membrane, continues firmly adherent to it, and cannot be folded, and raised from the surface of the cornea, in any manner whatever. This particularity is of the highest importance in the treatment of the disease; for, the genuine pterygium may be cured by simple means, while fungous excrescences ofthe cornea.'can only be radically removed, and perfect- ly cicatrized with the utmost dttnciu- ty. Plenck very properly observes, on this head: Pterygia, qua filamentis so- lummodd adheerent, facile* abscinduntur, dijficillimd qua ubique accreta sunt cor^ nece, et in plicam elevari non possunt. If this excrescence should adhere firmly to the cornea, be of a deep red colour, easily bleed on being touched, and, cause shooting pains in the whole eye, and temple, though it be of a triangular figure, and constitute the true pterygi- um, it now threatens to assume a ma- lignant cancerous nature, or has done so already. Hence, in the treatment, it is necessary only to adopt a palliative plan, or else extirpate the whole eye- ball. The true, benign pterygium, says Scarpa, which has a triangular figure, is ash-coloured, or pale-red, is free from pain, and admits of being raised in the form of a fold on the surface of the cornea, may be cured by cutting the opaque triangular little membrane accurately from the surface of the cor- nea, which is in part covered by it. But, as it appears, from what has been said, that the pterygium is nothing, but a portion of the delicate, transparent layer of the conjunctiva, converted by chronic varicous ophthalmy into a thick, opaque tunic, it follows, that the pterygium cannot be removed in any way, without the spot, which it occupies on the cornea, being bereft of its natural external covering. Also, as. this denudation of the cornea renders a cicatrix unavoidable at the place, it equally follows, that the knife cannot be employed in the cure ofthe disease, without the cornea being rendered more or less opaque at the part, where the pterygium was before situated. Hence, Scarpa cautions young sur- geons not to allow themselves to be de- ceived by the specious accounts of au- thors, who assert, that they have re- moved pterygia with the scalpel, Aid entirely restored to the cornea its for- mer natural transparency. It is true (says he) that, after the removal, and cure, of the pterygium, the cornea at the part affected becomes less opaque, than it was before; but, the place al- ways continues dim, and clouded with an indelible, though a superficial cica- trix. The amendment, derived from the operation, cannot but be considera- ble; by means ofthe incision, and firm cicatrix, a stop is put to the progress of the complaint, or rather to the increase ofthe varicous affection, and swelling, PTERYGIUM. 217 of the thin, transparent layer, of the conjunctiva, sitmted on the cornea; the local cause of irritation, and inflamma- tion of the eye, is entirely obviated; and, thus, complete opacity ofthe cor- nea is prevented. But, should it ever have happened after the recision of a large pterygium, that the patient re- gained his sight, we are to understand a certain degree of vision; in that pro- portion (Scarpa wishes to signify) which exists between a dense mem- brane, which entirely obstructs the passage ofthe light, and a slight, super- ficial cicatrix ofthe cornea, which does not intercept it altogether. Scarpa's experience enables him to state, however, that the superficial, in- delible speck, remaining on the cornea, after the recision ofthe pterygium, is always less extensive, than the space previously occupied by the disease.— This fact, says he, is a constant one, and, in the vast number of pterygia, for which he has operated, some had ad- vancedover the cornea two lines, others two and a half, towards its centre. In all, the scar, and opacity, of the cor- nea, diminished after the cure was perfected, and never exceeded a line and a half, or a little more, in cases, in which the pterygia had been two lines in length. The recision of the pterygium is a very easy operation. For this purpose, there is no occasion for a needle threaded with silk, which most sur- geons recommend to be passed through the little membrane, in order to make a noose for raising the pellicle, which must be divided at its base. The plan is disadvantageous, as it prolongs the operation considerably, and, particu- larly, as the bleeding from the punc- tures prevents the operator from dis- tinguishing, with the necessary clear- ness, the margin of the parts designed for removal. A pair of dissecting for- ceps, and a pair of sharp scissors, suf- fice for this operation. It is customary (continues Scarpa) to remove the pterygium by making the incision on the cornea, and extend- ing it over the white ofthe eye, as far as the base of the disease reaches on the conjunctiva; so that when the pte- rygium grows from the internal angle ofthe eye, most surgeons continue the section as far as the caruncle. This practice is disadvantageous, first, be- cause it denudes too much ofthe white of the eye-, secondly, because, in con- sequence of the large portion of the conjunctivaremoved at the base of the pterygium, and, in consequence ofthe direction ofthe wound, the cicatrix in the white ofthe eye, forms an elevated frsnum, which, like a little cord, keeps the eye-ball approximated to the caruncula lachrymalis, and destroys the freedom of its motions, particularly, to- wards the external angle. To avoid this inconvenience, Scarpa says, he has found it useful, in the treatment of pterygia with bases ex- tending far in the white ofthe eye, to detach them at their apex, as far as the junction of the cornea with the sclero- tica, and then to separate them at their base by a semicircular incision, com- prehending one line in breadth ofthe substance ofthe conjunctiva, and made in a direction concentrical with the edge ofthe cornea. Scarpa has observ- ed, that, in this mode of operating, the subsequent cure takes place sooner, than when the common method is adopted; the cicatrix occasions no sort of frsnum, and the conjunctiva, circu- larly stretched by the cicatrix, lies smoothly over the white of the eye, and loses that relaxation, and varicous state, which are the groundwork of the pterygium. Such attention, however, is not requisite, when the pterygium is small, and its base does not extend far in the white ofthe eye. Scarpa describes the operation, as follows: The patient being seated, an assistant behind him is to elevate the up- per eye-lid with the index and middle fingers of one hand, while he depresses the lower eye-lid with the correspond- ing ones ofthe other. Supposing it the right eye, the operator is to stand, or sit down, just as he prefers, in front ofthe patient; and the former, after di- recting the latter to move his eye-ball towards the part corresponding to the base of the pterygium, is to seize the morbid membrane with a pair of for- ceps held in his left hand, and pinch it into a fold, at about one line from its apex. The duplicature is now to be raised, and drawn out gently, until a sensation of something giving way is felt, which indicates the detachment of the pterygium from the delicate cellu- lar texture, by which it is connected with the subjacent cornea. Next, by means of a pair of scissors in the right hand, the surgeon must dissect this fold, as closely as possible, from the cornea, proceeding from the apex to- Vol. II. 2 E 218 PTERYGIUM. wards the base ofthe pterygium. The section being completed to where the cornea and sclerotica meet, the fold is to be again elevated still more, and, with one stroke of the scissors, the pterygium, and the relaxed portion of the conjunctiva, forming its base are to be detached, as concentrically, and closely to the cornea, as possible. This second incision will have a semilunar shape, the horns of which ought to ex- tend two lines beyond the relaxed part of the conjunctiva in following the cur- vature ofthe eye-ball. When the operation is finished, the surgeon must promote the hemor- rhage, by washing the part with warm water, and then cover the eye, that has been operated on, with a pledget of dry lint, or lint moistened in the aqua vegeto-mineralis, supported by a ban- dage, that does not make too much pressure on the part. If no particular symptoms arise, (continues Scarpa) such as pain, ten- sion ofthe eye, considerable tumefac- tion of the eye-lids, it is sufficient to wash the eye, and inside of the eye- lids, three or four times a day with a warm lotion of mallows, and carefully keep these parts from being exposed to the air, without compressing them. If the symptoms just mentioned should afterwards occur, the antiphlogistic treatment must be adopted in its full extent, &c. On the fifth or sixth day, at latest, after the operation, all the surface, from which the pterygium was cut, appears yellowish, and covered with a fluid, like mucus. This is a mode of suppuration (says Scarpa) peculiar to membranes in general, and particular- ly, to those ofthe eye. The edges ofthe wound, and the adjoining pail of the conjunctiva, assume a reddish colour. Afterwards, the surface of the wound contracts more and more daily, so that, at length, it completely closes, and the cicatrix forms. During the whole treatment, subse- quent to the operation, there is no oc- casion to employ any other topical appli- cations, but the warm lotion of mal- lows, three or four times a day. Nu- merous cases have convinced Scarpa, that astringent collyria, and the boast- ed powders of the florentine iris, and alum, cause great irritation to the eye operated on, and give rise to tumefac- tion, and a fungus like state of the con- junctiva, which are impediments to the cure. What is .still more incommodi ous, is, that such means produce fun- gous excrescences on the middle ofthe wound itself, which only admit of be- ing repressed and cicatrised with diffi- culty. Scarpa has seen all these incon- veniences arise from one single unne- cessary application of the argentum ni- tratum. On the other hand, when a mere lotion of mallows is the only re- medy employed in the treatment, the cure proceeds regularly; the yellowish surface of the incision diminishes dai- ly, and in three, or, at most, four weeks, the wound is quietly healed. The vi- triolic collyrium, containing a few drops of camphorated spirit of wine., can only be prudently instilled, three or four times a day, into the eye, for the purpose of strengthening the conjunc tiva and its vessels, after the wound is perfectly cicatrised. We have already repeated Scarpa's sentiment, that the incipient pterygi- um, strictly speaking, is nothing more, than an opacity ofthe cornea, in which the venous vessels of the conjunctiva covering that part of the cornea, which is the seat of the disease, are some- what more dilated, than in the case, to which the term, " opacity" is usually assigned; and, also that the density, and opacity, of the delicate layer of the conjunctiva are much more considera- ble, at the part affected, in the instance of pterygium, than in that of simple opacity ofthe cornea. The incipient pterygium (adds this author) is not a dense, opaque mem- "*■ brane, but a pellicle as fine as a cobweb, * interwoven in different places with va- ricous blood-vessels, the iris continu- ing tolerably visible behind it. In tins early state of the pterygium, it is un- necessary to deprive the cornea of its natural covering; it is quite enough to cut off a portion of it, in order to inter- cept all communication between the dilated venous ramifications of the pte- rygium, and the varicous trunks in the white ofthe eye. The recision, says Scarpa, is accom- plished by cutting out, with a pair of forceps and scissors, a semilunar piece of the conjunctiva, at the point where the cornea and sclerotica conjoin, and exactly at the base of the incipient pterygium, just as is practised for opa- city ofthe cornea. The recent pterygi- um is observed to disappear gradually after the operation, or to change into a slight dimness ofthe cornea, extending PUPIL. 219 over a part of the space previously oc- cupied by the disease. This opacity is commonly much more trivial, than what follows a cicatrix. Acrell, in his Surgical Observations, mentions having successfully treated an incipient ptery- gium in this maimer. Scarpa has also tried the plan several times with suc- cess. Scarpa sulk Malattie degli Occhi, cap. 11. PTO'SIS, (km wtto, to fall down.) An inability of raising the upper eye- lid. The affection may be owing to se- veral causes, the chief of which are a redundance of skin on the eve-lid; a paralytic state of the levator muscle, and a spasm of the orbicularis. Ptosis from the first cause may be cured by cutting away the superfluous quantity of skin. When the case depends on pa- ralysis, the surgeon may try bathing the eye and surrounding parts with cold spring water, and rubbing the eye-lid and eye-brow with any liniment con- taining a little ofthe tincture of cantha- rides. The linimentum camphors; the shower bath; and bark; may also be oc- casionally tried. The spasmodic ptosis requires antispasmodic medicines; the application of a blister to the temple; and fomenting and bathing the eye and eye-lids with a decoction of cicuta, or poppy-heads. PTYALISMUS, (from ■arvx^a, to spit.) A copious discharge of saliva. PUNCTURED WOUNDS. See Wounds. PUPIL, CLOSURE OF. An incon- venience, not frequent indeed, but which however sometimes follows the operations ofdepression, and extraction, is a closure of the pupil in such a de- gree, that it becomes almost, or quite shut, attended at first with a diminu- tion, and afterwards with an entire loss, of sight. This unpleasant occurrence, says Scarpa, is most frequently the conse- quence of a vehement inflammation of the internal membranes ofthe eye, es- pecially, the iris, occasioned by the ex- traction, or depression, ofthe cataract. In some particular instances, this in- convenience follows one of these oper- ations, but without the inflammation of the internal parts ofthe eye, and espe- cially ofthe iris having any share in its origin, at least, as far as we can judge from appearances. In such circum- stances, after an indeterminate time from the operation of depression, or extraction, the pupil is perceived to di- minish in diameter daily, without any evident cause, so that at last it becomes, as it were, entirely obliterated, and that without the patient complaining of any uneasiness in the eye, if we ex- cept, in a few individuals, a greater sen- sibility, than is natural, in the immedi- ate organ of vision, even to a very mo- derate degree of light. In both cases, the pupil ordinarily closes so much, that it can hardly admit a small pin's head, and continues motionless; while within the situation of the pupil itself, the iris assumes a stellate, rugose ap- pearance, with a little irregular aper- ture in the centre, behind which, when the cataract has been extracted, or de- pressed, the deeper part of the eye seems black; or, if a portion ofthe an- terior convexity of the opaque crystal- line capsule, should chance to remain behind after one of these operations, and has subsequently come into con- tact with, and adhered to, the poste- rior surface ofthe iris, a small whitish speck, or veil, maybe seen there. Theory has induced some to sup- pose, that, when this morbid closure of the pupil originates from an excessive distension ofthe vessels ofthe iris, in consequence of severe inflammation af- fecting that membrane, it may be cured by means of local and general bleeding, purgatives, blisters, and a seton in the nape ofthe neck. On the other hand, they have deemed emollients, and in- ternal and external antispasmodics, ser- viceable, in the instance of constriction of the pupil arising from spasm of the iris, and increased morbid sensibility of the immediate organ of sight, in consequence of the sympathy of the latter with the iris. But, how plausi- ble soever these curative indications may seem to be for the closiu-e of the pupil, practice has not admitted their efficacy. Onthe contrary, says Scarpa, it has clearly evinced, that this disease cannot be.remedied, except by making an artificial opening in the iris, as a substitute for the natural pupil, now wholly, or partly obliterated, and as an aperture, which is to do the functions of the original one. To the best of Scarpa's knowledge, Cheselden was the first, who ventured to devise, and execute, a section of the iris, for the purpose of forming an arti- ficial pupil. He introduced a couching needle, having a sharp edge only on one side, through the sclerotica, at the distance of a line and a half from the 220 PUPIL. cornea, into the interior of the eye. After perforating the iris towards the external angle, and then pushing the point of the needle through the ante- rior chamber of the aqueous humour, as far as that side of the iris, which is nearest the nose, he turned the edge of the instrument backward, and with- drew it, so as to make a transverse di- vision ofthe iris. It is related, that this operation was attended with the greatest success. However, Janin (Mem. sur I'QLil) as- sures us, that, having performed it on two subjects with the utmost care pos- sible, he didnot find the smallest bene- fit follow it; for, in these two patients, as soon as the symptoms, produced by the operation, subsided, he found the transverse section, made in the iris by the edge of the needle, reunited, and consolidated. Sharp had experi- enced the same thing, before Janin. (On Operations, chap~T29.) An accident occurred to Janin, in the act of extracting a cataract; viz. he included the iris together with the cor- nea, in Daviel's scissors, and cut it perpendicularly. This circumstance taught him, as he expresses himself, that a perpendicular section, made in this membrane, on one side of the. pu- pil, was the only truly efficacious me- thod of preventing the edges of the wound of the iris from growing toge- ther again, so as to form a durable ar- tificial pupil. This is exactly what led this oculist to make it an operative method, and to propose it, as the best expedient for making an artificial pu- pil. His plan consisted in opening the cornea, as is practised for the extrac- tion of the cataract, and in dividing the iris perpendicularly with scissors, near that part ofthe pupil, which is next to the nose, and he affirms, that he has seen strabismus result from making the section towards the external side, on account of the'too great divarication of the optical axes. In the small number of cases of clo- sure of the pupil, which Scarpa has seen and treated, as consequences of the operation ofthe cataract by extrac- tion, or depression, he has never been able to make up his mind to open the cornea, in order to accomplish with scissors the perpendicular section of the iris, as proposed by Janin, or with the knife, as recommended by any other person. He has felt conscious of t'ye frequent severe symptoms, which arise from making an opening into the cornea, when the eyes have already been affected, after -the first operation, with violent internal ophthalmy, spasm, and morbid increase of sensibility in the im- mediate organ of sight. He says, he will never cut the cornea again after the extraction of the cataract, lest an irregular cicatrix sliould be the conse- quence. He is the less inclined to do so, as he is convinced, that it is not so easy, as some may conceive, to divide the iris, with scissors, when it has be- come flaccid in consequence of the escape ofthe aqueous humour. Scarpa had had occasion to see more frequent- ly, than once, the edge ofthe iris de- tached, by blows on the eye-ball, from the ciliary ligament, to the extent of two lines, and without any laceration of the body of this mem- brane. At the place where the iris had been separated from the ciliary ligament, he says, he had seen an oval fissure remain during the rest of the patient's life, and it might have an- swered every purpose of an artificial pupil, had not the immediate organ of vision, and the crystalline, in the in- stances alluded to, suffered too severe- ly from the violence of the blow. In a case of prolapsus of the iris, through a small ulcer of the cornea, where the former part was very much dragged, in consequence of the large portion of it protruded, and the adhesion, which it had contracted with the edges ofthe ulcer ofthe cornea, Scarpa had remem- bered, that this same part, the iris, in- stead of being lacerated at its middle, had rather been detached, for a certain extent of its circumference, from the ciliary ligament, so as to produce there an artificial pupil, which was very ser- viceable to the patient after the cure of the prolapsus of the iris. Scarpa like- wise called to mind, that in depressing a cataract, he had seen a similar sepa- ration of" the margin of the iris from the ciliary ligament take place, in con- sequence of having merely pushed the opaque crystalline inadvertently against the internal edge of this membrane, at the moment, when the lens continually rolled round the spear of the straight needle, without his being able to seize it, so as to immerse and depress it deeply in the vitreous humour. Besides these circumstances, it had often oc- curred to him to observe, in frequent dissections of the eye, that on taking hold of the iris with forceps.and pulling PUPIL. J5?2f it, not only at a little distance from its greatest disk, but also at the veiy edge of the pupil, this delicate membrane more readily became detached from its junction with the ciliary ligament, than lacerated at its middle, although it i9 certainly of a very soft nature. Lasily, it cannot be doubted*, that the iris is a membrane perfectly distinct from the choroides, and has a proper, though feeble, connexion with the ciliary liga- ment, independently of the union of the choroides with the same ligament. All these considerations taken toge- ther, especially that of the feeble union of the iris with the ciliary ligament, and, consequently, ofthe greater facili- ty of detachingthe edge of the iris from the ligament, with which it is connect- ed-, than of lacerating the body of this membrane, have induced Scarpa to try a new method of forming an artificial pupil, when the natural one has be- come too much contracted, or quite obliterated, after the extraction, or de- pression ofthe cataract. This method of operating, consists in detaching, by means of a couching needle, a certain extent of the circumference ofthe iris from the ciliary ligament, without ever preceding this operation by a section of the cornea. The attempt met with suc- cess. The patient being seated, and sup- ported, as if he were about to have the operation for the cataract perform- ed, a straight couching needle, not so large as that which most surgeons use, but slender, like that which Scarpa prefers, (see Cataract,) is then to be introduced through the sclerotica, at the external angle of the eye, about two lines from the union of this mem- brane with the cornea; and its point is to be pushed as far as the upper and inner edge of the iris; in other words, as far as that side of the iris which is nearest the nose. The needle advances nearly to the ciliary ligament, and the surgeon perforates the internal edge of the iris, at its upper part, so that the point ofthe instrument scarcely appears in the anterior chamber ofthe aqueous humour, because, that part of the an- terior chamber being very narrow, the point of the instrument, how little so- ever it might advance beyond the iris, would enter the substance of the cor- nea. The moment the needle appears in the anterior chamber, the instrument must be pressed on the iris from above downward, and from the internal to- wards the external angle, so as to bring it in a parallel line to the anterior sur- face of the iris, for the purpose of de- taching a portion of the edge of this membrane from the ciliary ligament. This separation being effected, the operator (continues Scarpa) must de- press the point of the needle, in order to apply it to the inferior angle of the slit, that he has begun to make. Than the aperture may be enlarged at plea- sure, by pushing the iris towards the temple, and withdrawing the needle from before backward, parallel to the anterior surface of the iris, and the greatest axis of" the eye. If, when this detachment has been accomplished, no opaque body should appear at the bot- tom of the eye, the needle is to be withdrawn altogether. If any portion of opaque capsule, left behind after the depression or extraction ofthe cataract, should afterwards advance, and pre* sent itself in the vicinity of the new pu- pil, the little opaque membrane must be reduced to fragments, and pushed through the artificial opening into the anterior chamber, where, as we have shown in the article Cataract, such membranous portions, or flakes of the capsule, are, in time, dissolved and ab- sorbed with the aqueous humour, which is continually undergoing a re- novation. This separation of the iris from the ciliary ligament invariably occasions an extravasation of blood, which always renders the aqueous humour more or less turbid; but the turbidness is after- wards absorbed, and the eye recovers its original transparency. The patient, says Scarpa, complains, during the operation, of a vast deal more suffering, than at the time when he undergoes the extraction ordepres- sion of a cataract. It cannot be other- wise; for, in detaching a part of the edge of the iris from the ciliary liga- ment, some filaments of the ciliary nerves, which proceed to be distribu- ted in the iris, must at least be drag- ged, or lacerated. However, on the whole, the symptoms consequent to this operation, have neither been obsti- nate nor fatal in the two cases which Scarpa has seen. From some experi- ments made on the dead subject, Scar- -pa thinks the curved needle, which he 222 RAN uses for the depression of the cata- ract, would also be better than the straight one for making an artificial pupii; a thing which he intends to as- certain the first favourable opportunity. RAN (Scarpa sulk Malattie degli Occhi, Ca- po 16.) PUS, (from -n-uov, matter.) The fluid formed by the process of suppuration. See Suppuration. R JLVACHITIS, (from gx^s, the spine of the back, because the disease was once supposed to depend on disease of the spinal marrow.) The rickets. See this word. RANULA, (dim. of rana, a frog.) A whimsical name applied to a tumour under the tongue, arising from an ac- cumulation ofthe saliva in the ducts of *he sublingual gland. The term has either been derived from an imaginary resemblance of the swelling to a frog, or from the disease making the patient, as it were, croak when he attempts to articulate. The writers, who have treated of this disease, before it was known that the parts affected by it were destined for the secretion of the saliva, have had no accurate notions of its true nature. Celsus has been sup- posed to have alluded to the ranula, in the fifth section of his seventh book, where, after treating of the diseases of the tongue, he continues with the fol- ldwing passage: sub lingua quoque inter- dum aliquid abcedit, quod fere consistit in tunicd, doloresque magnos movet. The latter circumstance, however, renders it probable, that some other affection was alluded to, as a ranula is rather at- tended with a sense of restraint, than of pain. Various erroneous sentiments were entertained, concerning ranula, by authors, who treated of it subse- quently to Celsus. Pare thought it pro- ceeded from an accumulation of a pi- tuitary, cold, viscid matter, which de- scended from the brain beneath the tongue. Fabricius ab Aquapendente considers the ranula as an encysted tu- mour of the ineliceris kind. Dionis is of a similar opinion. Munick, better acquainted with the modern discove- ries of anatomy, does not mistake the nature of the present disease; and he expressly says, that the affection origi- nates from a thick, acrid saliva, which, TK,>t being able to pass out ofthe saliva- ry ducts, accumulates under the tongue, so as to cause a swelling in that situation. Far from adopting the opini- on of Munick, Heister fell back to that of Fabricius, and borrows every tiling from this author. Lastly, De la Faye, in his notes on Dionis, has taken up Munick's sentiments; he says, that " there are two sorts of ranuls; some, which are round, and situated be- neath the tongue, seem only to be produced by a dilatation of the excre- tory duct of the sublingual gland; the others are longer, than they are round; are situated at the side of the tongue, and are formed by a dilatation of the excretory duct ofthe inferior maxillary gland. The fluid, which fills such tu- mours, is the saliva which lodges and gradually accumulates in them, in con- sequence of its viscidity and atony of the duct. The ranula is said to be frequently met with in persons who move their tongue a great deal, and in those who sing. The fluid in the tumour is pre- cisely like white of egg; but, it is thicker after having remained a long while in the swelling; it is occasionally of a calcareous, and even stony nature. Modern surgeons are of opinion, that the ranula does not proceed from an inspissation of the saliva, but from an obliteration of the duct, or orifice, of this tube. The collection of saliva often produces a tumour of very large size; but, it generally bursts when it has at- tained the dimensions of a walnut, and then leaves an ulcer, which cannot be healed while the real cause of the dis- order remains unknown. Mr. B. Bell mentions his having seen an ulcer of this kind treated with the utmost care for several months; va- rious detergent and corrosive applica- tions had been employed; and even a mercurial course was resorted to; but all in vain. At length, the true cause of the disease having been ascertained, u RANULA. 223 cure was accomplished in a few days, by removing a piece of calcareous mat- ter, which, by obstructing the ducts, had first caused a swelling, and then the ulceration which ensued. The edges of the opening very often close again, especially when it has been made with a lancet, and not of sufficient size. In this case, the swell- ing makes its appearance again, some time afterwards. M. Louis observes, that the ancients have made the same remark; and hence, Pare preferred the actual cautery to the lancet. Dionis also mentions his having seen ran ids, which recurred in consequence of a mere opening having been made with a lancet; and he recommends, for the prevention of this, applying a mixture of honey of roses and vitriolic acid to the inside of the cyst, so as to destroy it M. Louis remarks, that all authors seem to regret, that the situation of the tumour should prevent the sac from being totally dissected out. The success, which Fabricius ab Aquapen- dente experienced, when he merely opened the tumour its whole length, did not free him from this prejudice; and Heister says, he should prefer ex- tirpation, if the nature of the adjacent parts, which would be wounded, were not a formidable objection. But, if this pretended cyst, this pouch, is nothing else than the gland itself, or its duct, dilated by the retention of the saliva, its inside should not be irritated. Whenever a sufficient opening is made, no relapse takes place. Munick parti- cularly advises such an incision, and Rossius mentions the smallness of the opening, among the defects in the treatment, and as being a cause of the disease returning. However, he does also recommend destroying the sac; but, specifies for the purpose, only as- tringent drying applications, wliich did not act in so powerful a manner. In a ranula, there is nothing like a cyst which ought to be extirpated. It is enough to lay the cavity open, and occasionally to cut off the edges ofthe incision, when they will not otherwise unite. M. Louis always observed, that the radical cure depended on a fistu- lous aperture, through which the sa- liva continued to flow; and that, when this opening was situated behind the lower incisor teeth, a very annoying ejaculation of the saliva took place, in certain motions ofthe tongue. This in- convenience must be obviated, to ren- der the cure complete. For this pur- pose, such an opening for the saliva must be made, as will not close. The perforation of the tumour with the actual cautery, was Pare's method; and thus a durable opening might cer- tainly be obtained, for the excretion of the saliva, in a part of" the mouth more backwards, so that patients would be freed from the disagreeableness of con- tinually slobbering, or having their spittle ejected from their mouths in talking. The ranula, when of long standing, is sometimes so large as absolutely to hinder a person from articulating. M. Le Clerc has recorded a case, in which the root of" the swelling extended un- der the tongue; the tumour filled the whole mouth; the prominence it form- ed outwardly, was as large as a duck's egg; and the disease, in its progress, had made the teeth of both jaws pro- ject outward. At some parts of its sur- face, a fluctuation was perceptible; other places were exceedingly hard. The patient, who could hardly breathe, demanded assistance: and a puncture was made in the softest part of the outside of the swelling. A thick yel- lowish fluid issued out of the cannula. The opening was enlarged with a knife; and about a pint of gritty, ino- dorous matter was extracted. There was no hemorrhage from the cut; and, no sooner had the contents of the swelling been taken out, than the pa- tient began to articulate, which he had not been able to do for a long while. The sides of the tumour having been so prodigiously distended, M. Le Clerc thought it proper to destroy the inside of the cavity with a tent, dipped in a mercurial solution. The cure was completed in a month, and the tongue gradually regained its original size, a part of which it had lost. But, as M. Louis observes, fortunate as the termination of this case was, it must not be indiscriminately set down, that destroying the cyst, or even open- ing the tumour, is always requisite. A more simple method will sometimes succeed. In a particular case, which this gentleman has related, a sinuosity, which divided the swelling into a right and left portion, made him suspect that it consisted of two sacs, in con- tact with each other. On each side, in front, and in the same line, there was a point, which was the orifice of the sa- livary duct, somewhat dilated, and 224 RECTUM. blocked up with a viscid matter. Hav- ing very easily passed a small probe into the orifices, a matter, similar to white of egg, made its escape. A small leaden probe was passed into each opening, and, two days afterwards, the sacs were emptied again, and two pieces of lead, somewhat larger, intro- duced. The man was advised to take ©ut the piece of lead every morning, empty the swelling, and then replace them. In a fortnight, the openings, hav- ing been kept continually dilated, had bo tendency to close; the saliva has not accumulated since, and the ranuls have not appeared again. In certain cases, the above menus are quite inadequate, and the turnout- must be totally extirpated. M. Boinct has related, to the French academy, a case in which the swelling not only filled the whole mouth, but one half of the tumour projected out, and a cure could only be accomplished in the lat- ter manner. The two upper incisor teeth, on the left side, were lodged in a depression observable there; and the canine tooth, of the same side, forced outward by tbe mass of disease, had pierced the lip near its commissure. A fluid, resembling mucus, flowed from a narrow aperture, at the lower part of tiie swelling. The tongue could not be seen, so much was it pushed back- ward; and, for some time, the patient bad only subsisted on liquid food, which he was first necessitated to con- vey to the back of the throat, with some mechanical contrivance. The four incisor teeth, two canine, and first grinders of the lowrer jaw, had been pushed out of their sockets, by the pressure ofthe swelling. I'he patient's aspect was alarming, and he was threatened with suffocation. Extirpa- tion was deemed necessary, and it was performed, with all the caution, which the situation of the tumour demanded. The large cavity occasioned, was filled with lint. The lower jaw being found diseased, M. Boinct scraped some of its surface off, and covered the places with lint, either dry, or dipped in spi- rit of wine. Some exfoliations followed, and the fungous granulations which grew, were repressed with proper ap- plications. In three months, the parts were healed in so regular a manner, that the motion of the tongue was not in the least obstructed, and no change continued, except the alteration of the voice, occasioned by the loss of teeth. This t *•' is very interesting,and sliowi how much nv.'.y he hoped for in difficult cases, from prudent and judicious mea- sures. (Encyclopedic Methodique; Art Grenouilktte. Mem. de I*Acad, de Chi- rurgie, torn. 3-) RASP.ATORIUM, (from rado, to scrape.) A kind of rasp formerly em- ployed by surgeons. RECTUM. The last large intestine, terminating in the anus, is so named, from an erroneous opinion that, it was straight, while, in fact, it is semilunar, being adapted to the concavity of the sacrum. Piles, which are a disease of the veins of this bowel, are treated of at Hemorrhoids. I'he rectum is also subject to have tumours formed in it. Mr. Hey men- tions a young man, who had had, for two years, a swelling in this bowel. The tumour protruded from the anus, whenever the patient went to stool, and generally bled on the same occa- sion. The disease had been, from the first, attended with pain in the loins. On examination, Mr. Hey found the swelling to be ofthe size of a nutmeg, adhering to the intestine by a narrow basis. It was firmer in its texture than piles usually are, except when inflam- ed. The apprehension of a troublesome hemorrhage, led Mr. Hey to prefer tying the base of the swelling to cut- ting it away, and thus he successfully extirpated the disease. (Practkal Ob- servations in Surgery, p. 443.) The scirrho-contracted rectum is what we have chiefly to consider in the pre- sent article. Scirrhus of the rectum is not uncommon at an advanced period of life. Sometimes it extends over a considerable length ofthe gut, but ge- nerally it is more circumscribed. The coats of the bowel become much thicker and harder than in the natural state. The muscular is subdivided by membranous septa, and the internal coat is sometimes formed into hard, ir- regular folds. The surface of the inner membrane is occasionally ulcerated, so as to form a cancerous diset.se.. Every vestige of the natural structure is oc- casionally lost, and the gut is changed into a gristly substance. The cavity of the bowel is always rendered narrow at the scirrhous part, and is, some- times, almost obliterated. When the passage through the gut is very much obstructed, the bowel is always a good deal enlarged just above the stoppage, RAN or stricture, from the accumulation of the feces there. As the disease ad- vances, adhesions form between the rectum and adjacent parts, and ulcera- tions produce communications between them. The disease is usually not much no- ticed till somewhat advanced, not be- ing at first very painful. The patient on- ly thinks, that he is costive, and that he voids his stools with a little difficulty. In time, a good deal of pain is felt in the part affected, especially at stool, after which, some relief is experienc- ed. Pus and blood may sometimes be noticed with the excrement, particu- larly when the disease has advanced to the ulcerated state. The patient at length becomes sallow, the constitution suffers, and dissolution follows. Se- vere tenesmus attends the whole course ofthe disease. Desault has often seen the disease form a communication between the rectum and vagina, and the feces have passed through the latter part. In the latter stage of the affliction, the rec- tum, bladder, vagina, uterus, and adja- cent parts, are all involved in one com- mon ulceration. When the disease has attained the ulcerated state, it is probably always in- curable. Palliatives can now only be re- sorted to, such as anodyne andemollient glysters, the warm-bath, &c. with the exhibition of medicines like opium, ci- cuta, uva ursi, &c. Claudius applied his remedies to the inside ofthe bowel, by means of tents, and did not employ the latter as a mode of curing the dis- ease, when less advanced. Valsalva used to introduce a cannula, pierced with numerous holes, when his pa- tient got into the bath, so as to let the fluid enter the intestine. Numerous practitioners, among them Morgagni, made mercurials the base of their treat- ment, from a supposition that the com- plaint was of venereal origin. When the disease is not attended with ulceration, the contraction and thickening of the gut may be diminish- ed, by introducing bougies, keeping them, for a certain time, every day, so introduced, and increasing their size gradually. The pressure of these in- struments seems to lessen the disease, and stop its progress; a proof that its nature differs from that of what is usu- ally understood by scirrhus. Desault used to employ long tents, made of lint, smeared with cerate, and passed into RIC 522 the bowel by means of a probe, with a forked end. This surgeon gradually in- creased the size of the tents, so as to continue the compression, to which he conceived all the good was owing. Their length was also augmented, by degress. Fresh ones were, at first, in- troduced twice every day. When any hardnesses were situated on the out- side of the anus, Desault cured them on the same principle, viz. by making pressure on them, with compresses and a bandage. This eminent surgeon ef- fected a cure of a scirrho-contracted rectum by this method. The woman was taught to pass occasionally the tents herself, so as to prevent a relapse. The disease is said to afflict women more frequently than men: from a com- parative table kept at the Hotel-Dieu, this hasjbeen the case there in the pro- portion often to one. See Baillk's Morbid Anatomy. (Euv- res Chirurgicales de Desault par Bichat',' tom. 2. p. 422. REFRIGERANTS, (from refrigero, to cool.) A term often appfied by sur- geons to such remedies and applica- tions as cool the whole body, or any part of it REGIMEN, (from rego, to govern.) The regulation ofthe diet. REPELLENTS, (from repello, to drive back.) Applications are some- times so named which make diseases recede, as it were, from the surface of the body. RESOLVENTS, (from resolvo, to loosen.) Medicines which disperse swellings, inflammations, &c. The term originated from the idea that the tena- cious humours were loosened. RESOLUTION (from resolvo.) The subsidence of inflammation, without any abscess, ulceration, mortification, &c. being occasioned, is so named.— The dispersion of swellings, indura- tions, &c. RETENTION OF URINE. See Urine, Retention of. RETROVERSIO UTERI. A turn- ing backward ofthe womb. See Uterus, Retroversion of. REVULSION, (from revello, to draw away.) An old term, used by the humoral pathologists, signifying the drawing of humours a contrary way. RHACOSIS, (from gxxo<;, a rag.) A ragged excoriation ofthe scrotum. RICKETS. Raehitis. Is mostly met with in young children; seldom in adults. Morand, however, (Acad, des Vor.. II. 2 F 226 RIC Scknces, 1753,) mentions an instance m which an adult became affected. Pinel has given a description ofthe skeleton of a ricketty foetus. (Fourcroy's Jour- nal.^ The disease seems to consist of a want of due firmness in the bones, in consequence of a deficiency of the phosphate of lime in their structure. The causes ofthe affection are involved in great obscurity, and authors have re- ferred them to scrophula, scurvy, lues venerea, difficult dentition, &c; mere conjectures, which it is not worth while to inquire into. Ricketty subjects are often at the same time scrophulous; but, this is, probably, the only reason for scrophula being accounted a cause of the other affection. The particular appearances of ricketty children, we need not detail, as every one is familiar- ly acquainted with them: such chil- dren are usually of a bad, weak consti- tution, and their limbs and bones be- come bent in such directions as the ac- tions of the muscles, the weight and pressure, &c. which they sustain, de- termine. When the affection is very general, the spine becomes shorter, and is curved in various directions; the breast becomes deformed, not only in consequence of the curvature of the spine, but by the depression ofthe ribs, and projection of the sternum. The bones of the pelvis fall inwards, and the os pubis generally approaches the sacrum. The latter circumstance is one of the causes of difficult parturition. The clavicles become more bent and prominent forward; the os humeri is distorted outward; the lower ends of the radius and ulna are twisted in the same direction; the thighs are curved forwards, or outwards; the knees fall inwards; the spine and front surface of the tibia become convex; and the feet are thrown outwards. When the thoracic viscera are con- siderably oppressed by the alteration in the figure ofthe che st, produced by the rickets, the disease may bring on fatal consequences. Many infants, which are very ricket- ty and deformed, improve as they grow up, and their constitutions acquire strength. The deformity of the bones RUP of their limbs spontaneously dimi- nishes, and these parts gain a due de- gree of firmness, resulting from a pro- per deposition ofthe phosphate of lime in their texture. The restoration of the proper figure of the bones may sometimes be pro- moted by the constant pressure of ban- dages and mechanical contrivances, sold in the shops. (See Distortion.) Some authors, however, contend, that in very young children machines are useless, as the confinement and inacti- vity of the muscles, necessarily occa- sioned by such contrivances, must in- crease the general debility, and conse - quently the disease. But, all writers al- low, that, after a certain age, and when the strength is not too much exhaust- ed, mechanical aid is proper. Were I to offer my own sentiments on this sub- ject, they would be in favour ofthe em- ployment of proper machines and ban- dages, at an early age. No medicine is known, which pos- sesses any direct efficacy in cases of rickets. Tonics are indicated, and should be employed. More good, how- ever, may be effected by keeping chil- dren in healthy situations, and in a sa- lubrious air, than by any medicines whatever. Light, wholesome, nutri- tious, easily digestible food; cold bath- ing; the use of the flesh-brush, &c. are also highly serviceable. The constitu- tional treatment of rickets belongs more properly to the physician than the surgeon; and it is not necessary to in- troduce more of the subject in a Dic- tionary expressly allotted to surgery The reader may consult Bayer's Lec- tures on the Bones, vol. 2, chap. 2, if he wishes to see the various absurd no- tions many have entertained concern- ing rickets. RIGOR, (from rigeo, to be cold.) A cold chill. A shivering. RUBEFACIENTS, (fromrubefacio, to make red.) Applications which make the skin red. RUBINUS, (from ruber, red.) A car- buncle, named from its colour. RUPTURE. A protrusion of some of the abdominal viscera. A hernia See Hernia. SAN SAR 227 J^ABINA, (said to be named from the Sabines, whose priests used it in their religious ceremonies.) Savine. The use ofthe leaves of this plant, in forming the active ingredient in the ointment commoidy preferred for keeping open blisters, we have explained in the arti- cle Blisters. The other chief surgical use of savine, is as a stimulating appli- cation for destroying warts, and other excrescences. For the latter purpose, it is generally powdered, and mixed with an equal proportion ofsrugosris. The same powder is also sometimes employed by surgeons for maintaining the hollows in which peas are inserted in issues. The best plan is, first to wet the peas, then roll them in the powder, and put them, in this state, on the issue. But, when the whole surface ofthe is- sue has risen high, above the level of the skin, the powder must be sprinkled all over the sore, so as to produce an absorption ofthe high granulations. In- deed, even in this manner, a good cavi- ty often cannot be obtained; and, it be- comes necessary to destroy the surface of the issue, by rubbing it with the kali purum, or kali purum cum calce viva. SACCHARUM SATURNI. Sugar of lead. Cerussa Acetata. Acetite of Lead. This is very extensively used in surgery, chiefly as a local application to inflamed parts, and in the form of a lo- tion. See Inflammation, Collyrium, Lo- th, Gonorrhoea, Ophthalmy, and nume- rous other articles of this Dictionary, for an explanation of the uses of acetite of lead. SAL-AMMONIAC. Ammonia Mu- riata. Muriate of Ammonia. Employed a good deal by surgeons, as an ingredi- ent in discutient lotions. See Lotio Am- mon. Mur. SALIVARY FISTULA. See Paro- tid Duct. SALIVATION. An increased se- cretion of the saliva, excited by mer- cury. SA'NIES, (Latin.) A thin, serous matter, discharged from fistuls, un- healthy sores, &c. It is sometimes tinged with blood. SAPO TEREBINTH IN A Star- key's Soap. R. Kali prspar. calidi §j. Olei Terebinth, giij.—The hot kali prsparatum is to have the oil of turpen- tine gradually blended with it, in a heated mortar. Indolent swellings were formerly rubbed with this application, and, perhaps, some chronic affections of the joints might still be benefited by it. SARCOCE'LE, (from o-aS%, flesh; and kox», a tumour.) A fleshy enlarge- ment of the testicle. (See Testicle, Diseases of.) SARCO'MA, SarcSsis, (from cxtg%, flesh.) A fleshy tumour on any part of the body. (See Tumours, Sarcoma- tous.) SARCO'TICS, (from , to twist.) A distortion of the spine. SCORBU'TUS, (from schorboet, Germ.) The scurvy. SCRO'PHULA, OR SCROFULA, (from scrofa, a sow.) The king's evil, so named, because swine are said to be subject to it; called also, struma. A disease, the chief, or at least, the most palpable symptom of which is a swell- ing of the absorbent glands, in various parts of the body, which glands tend very slowly to a state of suppuration, that is almost always imperfect. Scro- fula generally shows itself during in- fancy, between the age of three and seven; sometimes rather sooner; but, frequently, as late as puberty; and, in some instances, though a very few, not till a much more advanced period of life. In the latter cases, the disease is said to be rarely so complete, or well marked, as it is in young subjects. Scrofula is also as hereditary as any disease can be; that is to say, it is so as far as any particular kind of tempera- ment, or constitution, can descend, more or less completely, from parents to children. Mr. White, in his treatise on struma, has strongly censured call* ing the disease hereditary; but, his ob- servations only lead to these conclu- SCROPHULA. 229 nons, that children, born of scrofulous parents, are not invariably affected with scrofulous diseases; and that, some- times, one child has some strumous af- fection, while the parents, and all the rest of the family, have no appearance of scrophulous habits. However, I should conceive, that neither Mr. White, nor any other writer, will main- tain the opinion, that scrofula does not much more frequently afflict the chil- dren of scrofulous parents, than the offspring of persons, who have always been perfectly free from every tenden- cy to any form of this affliction. Too numerous are the facts, which occur to my own mind, to allow me to entertain the smallest doubt, that scrofula runs very much in certain families. In this sense, I think the term hereditary per- fectly accurate and allowable. But, at the same time, I beg the reader to un- derstand, that I have no intention of questioning what seem to be irrefraga- ble truths, viz. that the children of scrofulous parents often continue, as long as they live, entirely free from the disease; and that one child is some- times afflicted, while its father, mo- ther, brothers, sisters, and all the rest of its relations, have never had any ten- dency to strumous disorders. When scrofula does not actually take place at a very early period of life, it is generally stated by writers on the sub- ject, that the particular constitutions, in which there is a disposition to the disease, are, in a certain degree, dis- tinguishable. In the individuals, pos- sessing the disposition in question, a peculiar softness and flaccidity of fibre are remarkable; their hair is more fre- quently light coloured than dark; and their eyes are said to be more often of a blue, than any other colour. Their skin is generally very fine, and even handsome, both in regard to its out- ward texture and complexion. Subjects with scrofulous constitutions, frequent- ly have a kind of thickening of the up- per lip; this swelling is sometimes very considerable, and occasionally ex- tends as far as within the nostrils. Scro- fula is also very often complicated with rachitis, or follows the latter affection; but, there is as little real reason for supposing rickets to arise from scro- fula, as this latter from rickets. In some instances, however, the com- plexion is dark, and the skin coarse; but, in these subjects, at least when young, the face is generally tumid, and the look unhealthy. (Burns on Inflam- mation, Vol. 2, p. 332.) Mr. White seems, as I think, witli some appearance of truth, to deny that gray, or blue eyes, light hair, and a fair complexion, ought to be consider- ed as marks of a scrofulous predisposi- tion; for, the majority of children in this country have light hair, and eyes, while young, which become darker as they advance in life. Now, as the ma- jority of scrofulous patients are chil- dren, and young subjects, and as most children in this country have naturally the kind of hair and eyes above de- scribed, it seems inaccurate to lay any stress on persons affected with struma, or predisposed to this disease, having such appearances. (See White on thw Struma, or Scrofula, p. 38. Edit. 3.) I believe the fact is now almost gene- rally admitted, that females are rather more subject, than males, to scrofulous disease. Struma, according to Mr. White, is as universal a complaint as it is an- cient; but it prevails more extensively in temperate latitudes, than in very hot or very cold climates. It is also more frequent in some parts of Europe than others; and, in this country, it has been found to be most general in the counties of Suffolk and Lancashire. At all periods, it seems to have been a very common complaint in this island. From history, we learn, that it was de- nominated the king's evil in the time of Edward the Confessor, who is suppos- ed to have been the first that attempt- ed to cure it by the royal touch. From a register kept in the royal chapel, we find that Charles the Second touched 92,107 persons, in a certain number of years; and this equally bigoted and useless practice w;;s not discontinued till a recent period, when kings were found to be, as well as their poorest subjects, totally destitute of all super- natural power. Scrofula is not communicable from one person to another; neither can it be conveyed into the system by inocu- lation. The opinion also, that scrofulous nurses may infect children, seems also to rest on little foundation. (See White, p. 56, 57.) The parts, which are most frequent- ly affected by scrophula, next to the lymphatic glands, are the spongy heads ofthe bones, and the joints. The form, which the disease assumes in the latter situations, is particularly described in 230 SCROPHULA the article Articulation. The disorder of the spine, attended with a paralytic af- fection ofthe lower extremities, is, no doubt, very frequently of scrophulous origin. (See Vertebra.) The abscess, which forms in the cellular substance, between the peritoneum and psoas muscle, is,oftcn regarded as a strumous disease; and when the contents of the abscess are found to contain flakes of a curdy mattter, somewhat resembling white of egg, a substance peculiar to scrophulous abscesses, no one can doubt, that the complaint is connected with this constitutional affection. (See Lumbar Abscess.) The chronic enlarge- ment of the thyroid gland, is by many considered as scrophulous; and, the opinion seems to be strengthened by the fact, that patients, with this afflic- tion, very often have, at the same time, other complaints, which are unequivo- cally strumous. It might also be notic- ed that this enlargement ofthe thyroid gland most frequently commences at an early period of life, like other scrophu- lous diseases; and, like them, is bene- fited by the mineral alkali. (See Bron- ckocek.) Scrophula also frequently makes its appearance in the form of imperfect suppurations, in various parts ofthe body; the contents of such abscesses being a curdy kind of matter, and the skin covering them, having an unhealthy red appearance, and a thick- ened, doughy feel. The mesenteric glands are particularly often found uni- versally diseased, and enlarged, in scrophulous subjects; and, as all nutri- ment has to pass through these parts, before it can get into the circulation, we cannot be surprised at the many ill effects, which must be produced on the system, when such glands are altered, and, no doubt, obstructed, in the way in which they frequently are. Scrophu- la also frequently makes its attack on thetesticle. (See Testicle, Diseases of.) The female breast not unfrequently becomes affected with scrophulous tu- mours, and abscesses. The scrophulous inflammation (says Mr. Burns) is marked by a soft swelling of the affected part, which, very fre- quently, is one ofthe lymphatic glands. The covering, or coat ofthe gland, be- comes slightly thickened, and its sub- stance more porous and doughy. The swelling increases, and the doughy feel changes by degrees into that of"elasti- city, or fluctuation, and a firm, circum- scribed, hardened margin, can be felt round the base ofthe tumour. The skin is slightly red. If, at this time, an inci- sion, or puncture, be made, either no matter, or very little, is evacuated, the lips ofthe wound inflame and open,dis- playing a sloughy-looking substance within; and, betwixt this and the skin, a probe can often be introduced for some way all round. If, however, the disease should have advanced further, then there is very little elasticity in the tumour; it is quite soft, rather flaccid, and fluctuates freely; the skin becomes of a light purple colour, and small veins may be seen ramifying on its surface. Some time after these appearances, the skin becomes thinner at one particular part, and here it also generally be- comes of a darker colour. It afterwards bursts, and discharges a thin fluid, like whey, mixed with a curdy matter, or thick white flocculi. The redness of the skin still continues; but the aper- ture enlarges as the tumour subsides, and thus a scrophulous ulcer is produc- ed. The margins of this kind of sore are generally smooth, obtuse, and over- lap the ulcer; they are of a purple co- lour, and rather hard, and tumid. The surface of the sore is of a light red co- lour; the granulations are flabby and in- distinct; and the aspect is of a peculiar kind, which, says Mr. Burns, cannot be described The discharge is thin, slightly ropy, and copious, with curdy flakes. The pain is inconsiderable.— When this ulcer has continued for some time, it either begins slowly to cicatrize, or, as more frequently hap- pens, the discharge diminishes, and be- comes thicker. An elevated scab is next formed, of a dirty white, or yellowish colour. This continues on the part a good while; and, when it falls off, leaves the place covered with a smooth purple cicatrix. Mr. Burns adds, that the preceding description corresponds to the mild scrophula, or the struma mansueta, of the old writers. This gen- tleman next remarks, that, occasional- ly, especially if a bone be diseased be- low the ulcer, the sore has a more fiery appearance, the surface is dark-colour- ed, the margins soft, elevated, and in- flamed, and sometimes retorted. The discharge is watery, the pain very con- siderable, and the surrounding skin in- flamed. This has been called the stru- ma maligna. Such overacting scrophu- lous sores are most frequently met with over the smaller joints, particular- ly those of the toes. (Burns.) Some- SCROPHULA. - 231 times ft scrophulous abscess, after it has Burst, forms a sinus; the mouth of which ulcerates, and assumes the spe- cific scrophulous appearance, while the track of the sinus still continues to emit a discharge. Mr. Burns also re- marks, that scrophulous swellings are often disposed to subside in winter, and recur on the approach of summer; but, he adds, that this is not an invariable law. The glandular enlargements are very apt to become smaller, in a short time, in one place, while other glandu- lar swellings originate with equal sud- denness, somewhere in the vicinity of the former ones. Ulcers1, also, very of- ten heal, upon the appearance of the disease in other parts. (See Dissertations on Inflammation, by John Bums. vol. 2, 1800.) With regard to the proximate cause of scrophula, medical men may be said to remain, even at the present day, in entire ignorance. Of the exciting causes, very little is also known. Mr. John Hunter remarks, that" in this country, the tendency to scrophula arises from the climate, which is in many a predisposing cause, and only re- quires some derangement to become an immediate cause and produce the whole disease." (Treatise on the Venereal Dis- ease, p. 26.) In the same part ofthe work this celebrated writer takes notice of slight fevers, colds,small-pox, and mea- sles, exciting scrophulous diseases. He observes also, that, in particular coun- tries, and in young people, there will sometimes be a predisposition to scro- phula; and that, in such subjects, buboes will more readily become scrophulous. (P. 27.) In short, it was one of Mr. Hunter's opinions, and probably a most correct one, that the venereal disease is capable of calling into action such susceptibilities as are remarkably strong, and peculiar to certain constitu- tions and countries; and that, as scro- phula is predominant in this country, some effects of other diseases may par- take of a scrophulous nature. (P. 96.) Mr. Hunter, speaking of venereal bu- boes, mentions his having long suspect- ed a mixed case, and adds, " I am now certain that such exists. I have seen eases, where the venereal matter, like a cold, or fever, has only irritated the glands to disease, producing in them scrophula, to which they were predisposed. In such cases, the swel- lings commonly arise slowly, give but little pain, and seem to be rather has- tened in their progress, if mercury is given to destroy the venereal disposi- tion. Some come to suppuration while under this resolving course; and others, which probably had a venereal taint at first, become so indolent, that mercury has no effect upon them; and, in the end, they get well of themselves, or by other means." (P. 269.) For such buboes, Mr. Hunter used to re- commend sea-bathing; and, in case of suppuration, poultices made with Sea- water. It would be tedious and useless to expatiate on the many absurd notions, which have been entertained, concern- ing the proximate cause of struma. All that we need add in this work, is, that certain constitutions probably have a congenital disposition to the diseases that such disposition may probably be increased, or diminished, by the opera- tion of climate, mode of life, age, &c; and that irritations of a thousand kinds may excite the disease into action, when the system is predisposed to it, by inexplicable causes. That climate has great influence, cannot be doubted, when we reflect, that the inhabitants of certain countries, in which the tempe- rature is invariably warm, never suffer from scrophula. There can also be no doubt that, with age, the disposition to scrophula diminishes; for, chil- dren, much afflicted while young, fre- quently get quite well when they ap- proach the adult state; and, if a person has remained perfectly free from any mark of a scrophulous constitution, till the age of twenty-five, he may be con- sidered as almost entirely exempt from the disease. TREATMENT OF SCROPHULA. " For the cure of scrophula, (says the celebrated Cullen,) we have now yet learned any practice that is certain- ly, or even generally successful. The remedy which seems to be the most successful, and wliich our practitioners especially trust to, or employ, is the use of mineral waters." " But, (adds this eminent physician,) in very many instances ofthe use of these waters, I have not been well satisfied, that thev had shortened the duration of the dis ease more than had often happened when no such remedy had been em- ployed. With regard to the choice of the mineral waters most fit for the pur- pose, (says Cullen,) I cannot, with any confidence, give anopinion. Almost aft kinds of mineral waters, whether ciia- 232 SCROPHULA. lybeate, sulphureous, or saline, have been employed for the cure of scrophu- la, and, seemingly, with equal success and reputation; a circumstance, which leads me to think, that if they are ever successful, it is the elementary water that is the chief part ofthe remedy. Of kite, sea-water has been especially re- commended, and employed; but, after numerous trials, I cannot yet discover its superior efficacy." Dr. Cullen next speaks of bark; but seems to consider its efficacy in scrophula, as very dubi- ous and trivial. He mentions that, in se- veral instances, the leaves of colts- foot appeared to him to be successful. He used it frequently, in a strong de- coction, and even then with advan- tage; but he found more benefit from the expressed juice, when the plant could be had in rather a succulent state, soon after its first appearance in the spring. Dr. Cullen observes, that he had frequently employed the hem- lock, and sometimes found it useful in discussing obstinate swellings; but, that it also frequently disappointed him, and he never remarked that this medicine disposed scrophulous ulcers to heal. The sentiments of Cullen are decidedly against the use of antimony, and mercury, in scrophulous cases. (See First Lines ofthe Practice of Phy- sic, vol. 4.) Dr. Fordyce extolled bark for its ef- ficacy in scrophulous diseases; he en- deavours to prove, by some cases which are adduced, that, in cases of tumefied glands, attended with a feeble habit, and a weak circulation, it is a most efficacious medicine, and acts as a resolvent and discutient. He also brings forward a case, in support of bark being a means of cure for the oph- thalmia strumosa. (See Med. Obs. and Inq. vol. 1. p. 184.) Dr. Fothergill, in the same work, p. 303, writes in fa- vour of the good effects of bark in simi- lar cases; the latter sometimes gave, at the same time, small doses of ca- lomel. Mr. Burns remarks, that bark has been frequently found useful in the cure of scrofulous inflammation, but more often of ulceration, than tume- faction of the glands. But, adds this gentleman, it does not appear to pos- sess, by any means, that certain power of curing scrofulous affections, which is attributed to it by Dr. Fothergill, and several other authors. He observes, that we are not to suppose, that it will infallibly cure scrofulous inflammation; or ulceration of parts, which, even when affected with simple inflamma- tion, are very difficult of cure. If it be difficult to cure a simple inflammation, or ulceration of a tendon, cartilage, or bone, we must not be disappointed if even a specific remedy for scrofula (were such ever discovered) should prove ineffectual in procuring a speedy restoration to health. Mr. Burns con- tends, that bark is often ineffectual, be- cause improperly administered. Given in small quantities, once or twice a-day, it may prove a stomachic, and increase, like other toniu bitters, the power of the stomach, or the functions depen- dent on it; but, in order to obtain the benefits of the specific action of bark, he maintains, that it should be given in large quantities, for several weeks, with a good diet, air, and proper exer- cise. (Dissertations on Inflammation, vol. 2. p. 371.) As far as I can judge, Mr. White has, with much reason, recommended paying attention to such circumstances as may have effect in preventing the disease, viz. air, cleanliness, exercise, and diet. He mentions cold bathing among the preventives of struma, and speaks of sea-bathing as being the best. He advises attention, also, to be paid to the manner of clothing children, keeping them more covered in winter than summer. Mr. White thought, that allowing children to sleep a great deal was prejudicial; but, this seems to me only conjecture. In noticing the treatment ofthe dis- ease, Mr. White states, that " the ge- neral idea of the struma is, that it is a disease of debility; and, therefore, the great object is, to invigorate the habit by every possible means; the chief of which are tonic medicines, and sea- bathing. Some are of opinion, that, in the case of young patients, this should be continued, during the summer months, every year, to the age of four- teen or sixteen. Many recommend it, not only in the summer, but through- out the year: whilst others are for ad- ministering alteratives, principally the alkaline salts, with or without antimo- nials, and the different tonics, during the winter; and the sea-water, and sea- bathing, or cold bathing, during the summer, for a continuance of two or three years from the commencement of the disease; with this general observa- tion, that they will outgrow the com- SCROPHULA. 233 plaint." Mr.White adds, that the chief external means are fomentations of sea- water, and cataplasms, made with the same. As to regimen, some recommend a milk and vegetable diet; others, ani- mal food, and fermented liquors. Mr. White maintains, that the pre- ceding plans of treatment are not, in general, efficacious, though, in some in- stances, they may prove useful. " In early affections ofthe lymphatic glands, (says this gentleman,) and from the wantof a pure air, and proper exercise, where children arc delicate and irrita- ble, a change of situation to the sea- side, together with bathing,when they have acquired some strength, must be exceedingly proper; and in gross pletho- ric subjects, who have diseased lym- phatics, from improper feeding, and want of necessary exercise, a journey to the sea-coast may be very useful, particularly if the salt water is drank often, and in a sufficient quantity to be- come purgative. This, with the novel- ty of their situation, which may natu- rally produce an increase of exercise, might answer every expectation; but, these are the kind of cases that, with a very little attention, are easily cured. (White on the Struma, Edit. 3. p. 104.) The conclusion to which Mr.White's remarks upon this part of the subject tend, is, that sea-bathing only deserves praise as a preventive, and in the early stages of the disease. He particularly condemns cold-bathing, for poor, weak- ly, debilitated children, whose thin vis- age, enlarged belly, and frequent tick- ling cough, sufficiently indicate diseas- ed viscera; such do not recover their natural warmth, after cold-bathing, for hours, and their subsequent head-ach, livid lips, and pale countenance, are sufficient marks of its impropriety. (P. 107.) With regard to electricity, Mr. White thinks it is useful, when, from length of time, the enlarged glands have acquired a degree of hardness and insensibility. Mr. White, after enjoining attention to air, exercise, and diet, as promotive of a recovery, as well as preventive of the disease, proceeds to explain his own practice. The internal cases, which properly belong to the physi- cian, we shall dismiss from considera- tion. The first external symptoms, such as swellings of the lips, side ofthe face, and of glands under the chin, and round the neck; also, other symptoms, usually considered as strumous, viz. roughness of the skin, eruptions on the back of the hand, and different parts of the body, redness, and swelling of the eye-lids, and eyes; are accompanied, according to Mr. White's conceptions, with an inflammatory diathesis, though seldom such a one, as to require bleed- ing. Calomel is the medicine, which this gentleman recommends for the re- moval of the foregoing complaints. It is not to be given in such quantities, as to render it a powerful evacuant, either by the intestines, or any other way; but, in small doses, at bed-time. Thus, says Mr. White, " it remains longer in the intestinal canal, a greater quan- tity is taken into the habit, and the pa- tient is less susceptible of cold, than when taken in the day-time. The first, and, perhaps, the second dose may -prove purgative, which is, in general, a salutary effect; but, afterwards, the same quantity will seldom do more, than is sufficient to keep the body open; and should it fail of answering that pur- pose, 1 have usually recommended some gentle purgative, every third, or fourth morning, according to circum- stances. If there should be a prevailing acidity, a few grains of the sal sods, magnesia, or some testaceous powder, may be added to the medicine. By this simple method (continues Mr. White) most of the symptoms before-men tion- ed will, in a short time, disappear; but if the tumours should continue hard, and retain their figure, without divi- ding into smaller ones, we may derive some benefit from external applications, particularly the steam of warm water. I have used a variety of medicinal herbs with success; but, am inclined to believe, that the advantage was princi- pally derived from the warm water, 8tc. At other times, I have stimulated the part affected by electricity, insula- ting the patient, and drawing sparks from the tumour, until a slight degree of inflammation was excited. After the application of the steam, or the use of the electrical machine, I have some- times rubbed a little ofthe unguentum mercuriale into the tumour, and neigh- bouring parts, or applied the emplas- trum saponaceum, or mercuriale cum ammoniaco, over the swelling, or a lini- ment with camphor, ol. olivarum, and sp. terebinth." Mr. White adds, that in such cases, if the tumours should suppurate, and burst, the parts will, in most instances, heal without much Vol. II. 2 G 234 SCROPHULA. trouble. For eruptions on the head, he recommends applying the ung. saturn. album camphoratum, or the cerat. alb. cum hydrarg. prscip. alb. For the roughness of the skin, which is gene- rally followed by eruptions, he also ad- vises the aqua-vegeto-mineralis, aqua calcis, solutions of sal. tartar, or of the hydrarg. mur. as outward applications. " This last (says Mr. White) will sel- dom fail to check the progress of the complaint, and dry the sores; and in the quantity often or twelve grains, to a quart of warm water, the use of it will not be productive of any pain. If the eruption should ulcerate, and re- quire any unctuous application, to pre- vent the adhesion ofthe linen, the oint- ment beforementioned may be applied; the best remedy will be warm-bath- ing, and,when practicable, the sea-wa- ter claims a preference." (P. 114.) The author next mentions his having occa- sionally recommended the vinum anti- moniale, tartarum emeticum, decoc- tum Lusitanicum, decoctum lignorum, or sarsaparills; and that he sometimes found advantage derived from artificial drains. We need not detail this gentle- man's mode of treating affections ofthe eye-lid, as the reader may find all the necessary instruction, concerning scro- fulous diseases of the eye and e)e-lids, hy referring to Ophthalmy and Psoroph- thalmy. For the cure of indurations in the breast, remaining after mammary ab- scesses, Mr. White speaks very highly ofthe effects ofthe steam of warm wa- ter; and cautions us against indiscrimi- nately employing calomel, which will often affect the mother little, but the child violently. Mr. White mentions his employing a small tin machine, large enough to hold a pint and a half, or two pints of boiling water. From the top proceeded a narrow tube, ten, or twelve inches long, through which the steam passed. Near its end, which was movable and curved, was a joint, for the greater convenience of directing the steam to the diseased parts. The Water was easily kept boiling, by means of a lamp under the machine. Mr.White says, that the steam should be employ- ed, twice, or thrice a-day, and a piece of flannel, or skin, afterwards applied. The body should also be kept open. In obstinate, neglected cases, mercurial preparations, according to Mr. White, must likewise be given, and, if they af- fect the child much, suckling should be suspended. (P. 117, 118.) Mr. White treats largely ofthe treat- ment of cases, in which the mesenteric glands are diseased; but, this subject strictly belongs to the physician. When, in these instances, the glands of the neck, or other parts ofthe body, tend to a state of suppuration, it is very slow- ly, the skin appearing uniformly thin, and of a deep red colour, and the tu- mour seeming flaccid. In such cases, Mr. Whhe recommends the use ofthe lancet, or caustic; for, if no artificial opening is made, it will be a long time, before the skin gives way; and, when it does, the aperture will not only be very small, but often unfavourable in its si- tuation. Mr. White adds, that the con- tents will often be more like mucus, than pus, or like a mixture of both; and the discharge will continue, for a great length of time, if no remedy is applied. This gentleman mentions his having found a solution of gum myrrhs in aqua calcis, used as a lotion, and the cera- tum saponaceum, or some similar out- ward application, the best method of treating this symptom. We need not describe Mr. White's practice in the treatment of scrofulous joints, as the subject is fully considered in Articulation. It appears, however, that he confirms the efficacy of stimu- lating applications, and pressure with bandages, when the fingers and toes are affected with strumous disease. (P. 143.) Dr. Crawford, M. Pinel, and others, have tried the muriated barytes, as a remedy in scrofulous cases. (Med. Com- munications, vol. 2. Nosographie Philo- sophique, vol. 2. p. 238.) Mr. Burns says, that the muriate of barytes has no effect on diseased glands; but, that it is occasionally serviceable in scrofu- lous ulceration, though, he adds, that it deserves little dependence. (Dissert on Inflamm. vol. 2. p. 372.) This gen- tleman recommends the following for- mula: R. Terra Ponder. Salit. Chryst. gr. x. Aq. Font. Aq. Cassia, utriusque ifiij. Syrup. Aurent. §ij. Half an ounce of this may be given at first, twice, or three times a day, and gradually in- creased to such quantity, as the sto- mach can bear without sickness. Fourcroy proposed trying the muri- ate of lime; but, its efficacy is very doubtful, and inconsiderable. The same may be said of iron given either alone, SCROPHULA. 235 *r joined with the fixed, or volatile alkali. Burnt sponge, millipedes, and kali vitriolatum, have all been exten- sively tried: the first of these is, in my opinion, sometimes useful in diminish- ing enlarged scrofulous glands: that it has this effect on bronchoceles, is in- disputable. The Marischal de Rougeres em- ployed a remedy, composed of iron filings, muriate of ammonia, kali prs- paratum, &c. (Journ. de Med. tom. 40. p. 219.) Fothergill praised cicuta, and, per- haps, it is as good an internal medicine as can be tried; but, it is far from being generally efficacious. It is highly de- serving of recommendation for irritable scrofulous ulcers. With regard to mercury, we have already noticed, that calomel was much employed by Mr. White. Some hare exhibited the sublimate; others the acetite of mercury. All these prepara- tions have been at times conjoined with cicuta, antimony, &c. Calomel is, perhaps, the best mercurial prepara- tion in scrofulous cases; but, mercury, given internally with any view of ex- citing a salivation, is justly deemed hurtful by all the best practitioners. As an alterative, and an occasional purga- tive, it is undoubtedly a good medicine for strumous patients. Mr. Burns thinks the nitrous acid has some effect in promoting the sup- puration of scrofulous glands, and tu- mours, and disposing ulcers to heal. He says, two, or three drachms may be given every day, for a fortnight; but, if in this time, it should do no good, its employment ought to be discontinued. The pills containing natron prspara- tum (see Pilula), and the different soda waters, sold at the shops, have repute, for their good effects on scrofulous con- stitutions, and diseases. Eight, or ten drops ofthe hepatized ammonia, given thrice a day, arc use- ful, according to Mr. Burns, in irrita- ble strumous ulcers. The breathing of oxygen gas has been proposed; but, of this plan, I can say nothing myself. Dr. Cullen mentions, that cold bath- ing seemed to produce more benefit, than any other renredy, which he had occasion to see employed. (First Lines of the Practice of Physic, vol. 4.) The local treatment, preferred by Mr. White, has been already described. I have only a few words to add, con- cerning this part of the subject. Dr. Cullen states, that, in his practice, he had very little success in discussing in- cipient scrofulous tumours by topical applications; and that a solution of the saccharum saturni, though sometimes usefid, more frequently failed. Dr. Cullen found the aqua ammonis acet. hot more successful. " Fomentations of every kind (says he) have been fre- quently found to do harm; and poul- tices seem only to hurry on a suppura- tion. I am doubtful, if this last be ever practised with advantage; for, scrofu- lous tumours sometimes spontaneously disappear, but never after any degree of inflammation has come upon them; and, therefore, poultices, which com- monly induce inflammation, prevent that discussion of tumours, which might otherwise have happened." Even when scrofulous tumours have advanced towards suppuration, Dr. Cullen thought, that hastening the spontaneous opening, or making one with a lancet, was hurtful. With respect to ulcers, Dr. Cullen remarks, that escharotic preparations, of cither mercury, or copper, have been sometimes useful in bringing on a proper suppuration, and thereby dis- posing the ulcers to heal; but, they have seldom succeeded, and, more commonly, they have caused the ulcer to spread more. The escharotic, from which Cullen saw most benefit result, is burnt alum, mixed with some mild ointment. But, this celebrated writer gives the preference to keeping the sores continually covered with linen wet with cold water in the day-time, and some ointment, or plaster at night Cullen says, that he usually found sea- water too irritating, and no mineral water better, than common water. (First Lines of the Practice of Physic, vol. 4.) Formerly the extirpation of scrofu- lous tumours was advised; but, this method is now considered as, even for the most part, injudicious, and unne- cessary, with the exception of diseased joints, and a few other parts, which frequently require being amputateda for the sake of saving the patient's lifo. Certainly, no particular danger (gene- rally speaking) would attend cutting out scrofulous glands, and tumours; the objections to the plan are founded on the pain of the operation; on the number of such glands frequently dis- eased; on their often subsiding either spontaneously, or by; surgical treat- 236 SCROPHULA ment; on the operation doing no good to the general affection of the system, &c. When, however, a scrofulous tes- ticle, breast, or joint, seriously impairs the health, and endangers life, the very existence of the patient demands the immediate removal of the diseased part. Wiseman relates, that he was in the habit of cutting out scrofulous glands, and tumours, with great suc- cess; but, for reasons, already alleg- ed, most of the moderns think such operations in general at least unneces- sary. Caustics have been employed for the same purpose, instead of the knife; but, as they effect the object in view less certainly, more painfully and te- diously, and cause extensive ulcers, they are disused by all the best sur- geons of the present day. Some authors have advised making issues, and keeping them open, in or- der to prevent any ill effects from heal- ing scrofulous ulcers. Issues are cer- tainly quite unnecessary for any pur- pose of this kind: but, they are emi- nently useful as a part of the local treatment of scrofulous joints and ab- scesses, (as we have more particularly explained in the articles Articulation, Lumbar Abscess, and Vertebra.) Mr. Burns notices, that issues have hitherto been chiefly used in diseases of the bones and joints; but, he adds, that it is reasonable to suppose, that they ought likewise to be useful in the cure of enlargements of the glands, and other scrofulous tumours, if insert- ed in the immediate vicinity of the part. The only objection to their use is the scar, which they leave, and which, in certain situations, one would parti- cularly wish to avoid. When the tu- mour is thickly covered with the inte- guments, the issue may be made direct- ly over it, and kept open with the savine ointment. In other cases, a small pea issue, or seton, may be inserted by the side of the tumour. This method would be objectionable, for scrofulous glands in the neck, in consequence of the scar; but, it might be employed, when the mamma is diseased. (Disser- tations on Inflammation, vol. 2.) Preparations of lead; cloths dipped in cold water, sea-water, or weak vege- table acids; sther; sea salt mixed with bile; the linimentum camphors; a mix- ture of sther and the linimentum opia- tum; and hemlock poultices; form a long list of applications, which havfe been employed for scrophulous tu- mours. According to Mr. Burns, moderate pressure, by means of adhesive plaster, conjoined with the application of cold water, is one of the best plans of treat- ing mild scrophulous ulcers, when their situation admits of it. In other cases, he recommends applying a powder, five parts of which consist of cerussa acetata, and the sixth of" burnt alum. A piece of dry lint is next to be applied, and a compress, with such pressure as can be used. Benefit occasionally re- sults from dipping the compress in cold water. The ceratum e lapid. calamin. is a good common dressing, when it is wished not to interfere much with the progress of the ulcer. The ung. hy- drarg. nitrat tub. and the ung. hydrarg. nitrat are the best stimulating oint- ments. Poultices of bread and sea-wa- ter; solutions of alum, cuprum vitriola- tum, and the hydrarg. mur.; solutions of the nitrites of copper, bismuth, and sil- ver; the recent leaves ofthe wood-sor- rel bruised; lint dipped in lemon juice, or vinegar and water: are among the applications to common scrophulous ulcers. For irritable ones, dilated hepatized ammonia; ointments containing opium; carrot and hemlock poultices; a solution of opium; and carbonic acid gas, are commonly recommended. I shall not enlarge upon this endless subject, which still stands in need of elucidation, as much as any disease, that can be instanced. The scrophulous affections of the joints are explained in Articulation. Bronchocek; Lumbar Ab- scess; and Vertebra, are other articles, containing matter connected with the preceding observations. With regard to sources of informa- tion, concerning scrophula, I profess myself totall) unacquainted with any, which are even moderately respectable. The reader may consult Wiseman's Chi- rurgical Treatises; Heister's Surgery; Cullen's first Lines ofthe Practice of Phy- sic, vol. 4; Feme on the King's Evil; Cheyne on the King's Evil; B. Bell's Sur- gery, vol. 5; B. Bell on Ulcers; Kirk- land's Med. Surgery, vol. 2; White on the Struma, edit. 3, 1794; A. G. Kortum's Comment, de Vitio Scrophuloso, in 2 vol. 4to. Lemgovia, 1789; London Med. Obs. and Inq. vol. 1; Encyclop4dk Mtthodique, art. Ecrouelks,- Dissertations on Inflam- mation, by John Burns, vol. 2; Crowther's bCR SCR 237 Obs. on the Disease of the Joints, com - monly called White Swelling; with re- marks on Curies, Necrosis, and Scrophu- lous Abscesses, C*c. edit. 2, 1808. Ofthe preceding works, Cullen's First Lines, White's Treatise, and Mr. Burn's Dis- sertation in vol. 2, have been most use- ful to me, in the compilation ofthe pre- sent article. A Treatise on Scrophula bus just been published by Mr. James Russell of Edinburgh. SCROTOCE'LE, (from scrotum, and x>i\»), a tumour.) A rupture, or hernia in the scrotum. SCROTUM, CANCER OF. Chim- ney-Sweeper's Cancer. Mr. Pott gives the following account of this peculiar dis- order. " It is a disease,which always makes its first attack on, and its first appear- ance in the inferior part of the scrotum; where it produces a superficial, painful, ragged, ill-looking sore, with hard and rising edges: the trade call it the soot-wart. I never saw it under the age of puberty, which is, I suppose, one reason why it is generally taken, both by patient and surgeon, for venereal, and being treated with mercurials, is thereby soon and much exasperated: in no great length of time, it pervades the skin, dartos, and membranes of the scrotum, and seizes the testicle,which it enlarges, hardens, and renders truly and thoroughly distempered; from whence it makes its way up the sper- matic process into the abdomen, most frequently indurating and spoiling the inguinal glands: when arrived within the abdomen, it affects some ofthe vis- cera, and then very soon becomes pain- fully destructive. " The fate of these people seems singularly hard: in their early infancy, they are most frequently treated with great brutality, and almost starved with cold and hunger: they are thrust up narrow, and sometimes hot chim- neys, where they are bruised, burned, and almost suffocated; and when they get to puberty, become peculiarly lia- ble to a most noisome, painful, and fa- tal disease. " Of this last circumstance there is not the least doubt, though perhaps it may not have been sufficiently attended to, to make it generally known. Other people have cancers of the same parts; and so have others beside lead-work- ers, the Poictou colic, and the conse- quent paralysis: but it is nevertheless a disease to which they are peculiarly liable; and so are chimney-sweepers to the cancer ofthe scrotum and testicles. " If there be any chance of putting a stop to, or preventing this mischief, it. must be by the immediate removal of the part affected; I mean that part ofthe scrotum where the sore is; for if it be suffered to remain until the virus has seized the testicle, it is generally too late even for castration. I have many times made the experiment; but though the sores, after such operation, have, in some instances, healed kindly, and the patients have gone from the hospital seemingly well, yet, in the space of a few months, it has general- ly happened, that they have returned either with the same disease in the other testicle, or in the glands of the groin, or with such wan complexions, such pale leaden countenances, such a total loss of strength, and such fre- quent and acute internal pains, as have sufficiently proved a diseased state of some of the viscera, and which have soon been followed by a painful death. " If extirpation ever bids fair for the cure of a cancer, it seems to be in this case; but then the operation should be immediate, and before the habit is tainted. The disease, in these people, seems to derive its origin from a lodg- ment of soot in the rugs ofthe scrotum, and at first not to be a disease of the habit. In other cases of a cancerous nature, in which the habit is too fre- quently concerned, we have not oftet so fair a prospect of success by the- re- moval ofthe distempered part; and are obliged to be content with means, which I wish I could say were truly- palliative: but here the subjects arc young, in general in good health, at least at first; the disease brought on them by their occupation, and in all probability local; which last circum- stance may, I think, be fairly presum- ed from its always seizing the same- part: all this makes it (at first) a very different case from a cancer, which ap- pears in an elderly man, whose fluids have become acrimonious from time, as well as other causes; or from the same kind of complaint in women who have ceased to menstruate. But be all this as it may, the scrotum is no vital organ, nor can the loss of a part of it ever be attended with any, the small- est degree of inconvenience; and if a life can be preserved by the removal of all that portion that is distempered, it will be a very good and easy compos, 238 SET SOU tion; for when the disease has got head, it is rapid in its progress, pain- ful in all its attacks, and most certainly destructive in its event." (Pott's Works, vol. 3.) SEARCHING. The operation of introducing a metallic instrument, through the urethra into the bladder, for the purpose of ascertaining whe- ther the patient has a stone, or not. SE'DATIVES, (from sedo, to ap- pease.) Sedantia. Sedativa. Medicines, which diminish irritability. SEMICU'PIUM. Strictly a bath for about one half of the body: medical men, however, now frequently mean by the term only a warm bath, especi- ally, the slipper-bath. SERPI'GO, (from scrpc, to creep, because it gradually creeps 6ver the surface of the skin.) A ring-worm, or tetter. See Herpes. SETON, (from seta, a bristle, be- cause horse-hairs were formerly used for keeping open the wound.) Setacc- •tin. A kind of issue. It is usually made by means of a particular needle, which is of various breadths, from half an inch to a full inch. The needle is commonly a little curved; but, if straight, it would be better calculated for the pur- pose. From the point, to its broadest part, it is double-edged, and behind, it has a transverse eye, through which a skein of thread, or silk, of exactly the same breadth as the needle, is placed. A fold of skin is to be pinched up, at the part where the seton is designed to be made, and the needle is to be pushed throught it, together with the skein of thread, which is to be dipped in sweet-oil. The instrument is not to be introduced too low into the base of the fold, nor too high near its edge. In the first case, the muscles, and parts, which ought to be avoided, might be wounded; in the second, the inter- space, between the two wounds, would be very narrow, and the seton soon m:Jce its way through it. When no seton-needle is at hand, the fold of the skin may be punctured with a lancet, and the skein of thread introduced by means of an eye-probe. A seton may be applied almost to any part ofthe surface of the body, when circumstances require it; but, one of its openings should always be made i^wer, than the other, that the matter may readily flow out. The skein of ''.read is to remain u: touched, for a few d::ys a'"tor the operation, until the suppuration loosens it. Afterwards the ;,. :l ofthe thread, nearest the wound. is to be smeared with oil, white cerate, or any digestive ointment, and drawn under the fleshy interspace between the two wounds, and what was there before is tobe cutoff. The seton is to be drawn in this manner once, or twice, a- day, according as the quantity of matter may require. A new skein of silk, or thread, is to be attached to the preced- ing one, as often as necessary. Care is to be taken to keep the thread on the outside ofthe wound well covered, and free from the discharge, which would make it stiff and hard, and apt to occa- sion pain and bleeding on being drawn into the wound. If the discharge should be deficient in quantity, powdered can- tharides may be mixed with the diges- tive ointment. SINGULTUS, (a sono vocis, from its peculiar noise.) The hiccough. SINUS, (a gulf, from xtvor, void.) This term in surgery means a long, narrow, hollow track, leading from some abscess, diseased bone, &c. SIPHILIS, (from «pxof,filthy.) The venereal disease.(See Venereal Disease.) SOLUTIO ARGENTI N1TRA- TI.—R. Argenti Nitrati"^]. Aq. Distillat. ,5ss. M. This is a very good application for sores, which are frequently met with round the roots of the nails, both ofthe fingers and toes. It is also useful in herpetic affections, noli me tangere, and several kinds of ulcers. The pro- portion of the argentum nitratum may be lessened, or increased, as occasion requires. A strong solution of this sub- stance is a good application for destroy- ing warts, to which it must be applied by means of a hair-pencil. When used for sores, it is best to dip little bits of soft lint in it, lay them on the part af- fected, and cover them with a common pledget. SOLUTIO FER*RI VITRIOLA- TI.—R. Ferri Vitriolati ad albidinem cal- cinati t^j. Aq. Distillat. ^viij. Misce, Has been recommended as an applica- tion for sores on the nipple, and other ulcers. SOLUTIO HYDRARGYRI CUM PLUMBO.—R. Hydrarg. ^ij. Plumbi 3;iss. Acidi Nitrosi£'y The two metals are to be dissolved in the acid, in a glass vessel, placed in a sand heat— Plenck employs this caustic solution for destroying warts, and excrescences. SORDi'TIES, (from sordeo, to be filthy.) Putrid pus of bad quality; any fetid discharge. SOUND, An instrument, which siu-gcons introduce through the ure- thra into the bladder, in order to dis- SPI SPI 23» coyer, whether there is a stone in this viscus, or not. The sound is usually made of very highly polished steel, that it maybe well calculated for conveying to the surgeon's fingers the sensation of any thing, against wliich its end may strike. It is also generally rather less curved, than a catheter, so that its ex- tremity may be more easily inclined to the lower part of the bladder, where the stone is most frequently situated. SOUNDING. The operation of in- troducing the foregoing instrument. SPARGANO'SIS, (from rragyxa, to swell.) An enlargement of the breast from a redundancy of milk: the mam- mary abscess. SPA'TUL A,(dim. of spatha, a broad instrument.) An instrument for spread- ing salve. SPECILLUM, (from speck, to ex- amine.) A probe. SPE'CULUM. An instrument in- tended for facilitating the examination of parts, and also operations on them: thus we have specula ani, specula ocu- li, auris, Ike. SPERMATOCE'LE, (from o-xigpx, and x»a.», a tumour.) The old writers seem to signify, by this term, a swell- ing caused by a stagnation of the se- men. I am acquainted with no real dis- ease, which answers to any meaning of this kind. SPHACELl'SMUS, (from o-paxtxi- ?u, to mortify.) A mortification. SPHA'CELUS, (from o-fx^a, to de- stroy.) Surgeons imply, by this word, complete mortification, which is most- ly preceded by a stage of the disorder, termed gangrene. See Mortification. SPICA, (from o-xxxyc, an ear of corn.) A name, given to a kind of ban- dage, in consequence of its turns being thought to resemble the rows of an ear of corn. Of spica bandages there are several kinds: but, we shall here only mention a few. In order to apply the spica bandage, employed in dislocations ofthe shoulder we are to take a common single-headed roller, and place the end of it under the opposite arm-pit. After conveying the bandage backward, obliquely over the shoulders, we are then to bring it for- ward over the head of the dislocated bone. The roller is next to descend un- der the arm-pit, then be carried up- ward again, and made to cross on.the deltoid muscle. The roller is now to be carried obliquely downward over the fryjit ofthe chest, and under the oppo- site arm-pit, where the end of it ia to be pinned, or stitched. The bandage is next to pass across the back, over the part of the roller previously applied in this situation, and is to be conveyed round the head of the os brachii, so as to form a turn, or doloire, with the first circle ofthe roller. Three, or four do- loires, or turns, each of which covers ahout one-third of the preceding one, are to be made, and then the upper part of the arm is to be once surrounded with a plain circle ofthe bandage. Thiff last circular application leaves between it, and the cross previously made, a triangular, equilateral, space technical- ly named by writers geranis. The roller is now to be carriedupward in a spiral manner; its head is to be brought to the opposite arm-pit, and the application of the whole concludes with a few turns round the body. The bandage is to be fastened with pins at the place, where it commenced. Before putting on the spica, the in- jured part, and margin of the axills, must be guarded from the effects ofthe pressure by compresses. The spica bandage for the broken clavicle is applied in the same man- ner, with the exception, that the cros- sings are made over this bone. It is proper to state in this place, that the spica is a very ineffectual bandage for this kind of case. (See Fractures of the Clavicle) In order to apply, what is named, the spica inguinis, the end of the roller is to be placed on the spine of the os ilium, of the affected side. The bandage is then to be carried obliquely over the groin, and under the perinsum. Then it is to pass over the back ofthe thigh, and next forward, so as to cross the part previously applied, on the front of the groin. The application is continued by carrying the roller over the pubes, over the opposite os ilium, and next round the body above the buttocks.— The bandage thus returns to the place, where it began. Its application is com- pleted by making a few doloires, and turns, like the preceding ones, and lastly, a few turns round the body. The spica for the thigh is applied in the same way; only the crossings are to be made on the upper and outer part of the limb. (See Encyclopedic Metho- dique. Part. Chir. Art. Spica.) SPINA BIFIDA, (i.e. the Cloven Spine.) Hydro-Rachitis. A disease, at- tended witb an incomplete state of 240 SPINA some ofthe vcrtebrs, and a fluid swel- ling, wliich is most commonly situated over the lower lumbar vertebra, some- times over the dorsal and ccrvicle ones, and, in some instances, over the os sa- crum. The same name has also been given to an analogous tumour, which sometimes occurs on children's heads, attended with an imperfect ossification of some part ofthe cranium. The Arabians, who first treated of this disease, erroneously imputed the deficiency of one, or more of the spi- nous processes to the tumour, while it is now well known, that the incomplete state ofthe affected vertebrs is a con- genital malformation, and that the swelling is only an effect. In fact the tumour generally becomes larger and larger, the longer it continues. The spina bifida may be regarded as an af- fliction only met with in children: few, very few, live to the adult age with this incurable affection. Warner, however, has related a case, in which the patient lived till he was twenty. (Cases in Surgery.) As I have remarked, the swelling is most frequently situated towards the lower part ofthe spinal canal, particu- larly at the place, where the lumbar vertebrs join the sacrum. The fluid, which it contains, resembles serum, be- ing somewhat more liquid, than the whiU of egg, and, like the latter, fre- quently coagulable. It is in general lim- pid and colourless; but, occasionally, it is turbid, and tinged with blood. On pressing the tumour, a fluctuation is very perceptible, and a preternatural space may also be felt existing between some of the spinous processes. The fluid is contained in a, kind of cyst, which is composed ofthe continuation ofthe dura mater, investing the spinal canal, and is usually closely adherent to the integuments. Spina bifida is sometimes attended with hydrocephalus. It has even been recorded, that the enlargement of the head has undergone a considerable di- minution, when the tumour ofthe spine casually burst, and discharged the fluid, which it contained; a proof of some communication between the two parts. (Ephem. Cur. Nat. Decad. 3. Art. 1. Decad. 2. Art. 2.) The fluid, which was lodged in the lateral ventricles, and third ventricle, passed into the fourth, through the aquaductus Sylvii, ruptured the calamus scriptorius, and thus got into the spinal canal. BIFIDA Spins bifids usually occur on the lower part of the spine; but, they occa- sionally teke ph.ee on the cervical ver- tebrs, in which latter situation, the tu- mours have the s me characteristic marks, as those which form near the sa- crum. Many facts, recorded by Ruysch, in his Anatomical Observations, con- firm the preceding-account The present affliction is one of a most incurable nature: at least, there is not, I believe, in all the records of me- dicine, or surgery, any case, which ei- ther got well of itself, or was benefited by any mode of treatment. Opening the tumour, either with caustics, or cutting instruments, has hitherto only tended to hasten the fatal event ofthe disease. Death soon follows an operation of this kind, and, it is said, that the child sometimes dies immediately. Tulpius observes on this subject: quam calami- tatem si quidem reformides, chirurge, care sis improvide aperias quod tarn fa- cile occidit hominem. Observ. Med. But, whether the tumour be open- ed, or not, still the disease is one ofthe most fatal, to whicli children are expos- ed. When afflicted with it, they very seldom live till three years of age; but, after lingering several months from their birth, suddenly die. It has been said, that children, with spina bifida, always have their legs in a paralytic state. This, however, is not true; for, the largest spina bifida I ever saw, was under my friend Mr. Maul, lately resi- dent at Newbury, and was unattended with any weakness ofthe legs. Indeed, the child was, to all appearances, as stout, healthy, and fidl of play, as possi- ble. The fatal event, however, took place after a time, as usual; and, if my memory does not fail me, Mr. Maul no- ticed, that, a little before death, a re- markable subsidence of the* swelling occurred, though it never burst ex- ternally. It is a fact, notwithstanding, that many infants, with spina bifida, have paralytic legs, and can neither re- tain their feces, nor urine. If we draw our inferences from the cases, and remarks, offered by almost every writer on spina bifida, we must regard all attempts to cure the disor- der, by making any kind of opening, as exceedingly perilous, if not positively fatal. It is to be observed, at the same time, that some very eminent surgical authors have not altogether abandoned the idea of devising a mode of accom- plishing a cure, at least, in a few In- SPINA VENTOSA. 241 stances. Mr. B. Bell says, that if the tu- mour proceeded from disease of the spinal marrow, or its membranes, no means of cure would probably ever be discovered. But if the deficiency in the spinous processes of the vertebrs, with which the disease is always ac- companied, is not an effect of the com- plaint, as was commonly imagined, and if the collection of fluid takes place from the want of resistance in the dura mater, in consequence ofthe imperfec- tion ofthe bones, Mr.B. Bell questions, whether it would not be proper to tie the base ofthe tumour with a ligature, not merely with a view of removing the swelling, but in order to resist the propulsion ofthe cyst further outward. Mr. Bell acknowledges, that the event of this practice must be considered as very dubious; but, expresses his wish to devise any plan, that would afford even the least chance of success, in a case which must terminate in an unfa- vourable manner. Mr. Bell mentioned his design of putting the method to a trial, on the first opportunity, and, after the detachment ofthe swelling on the outside of the ligature, intended to keep a soft compress on the part with a proper bandage I do not know, whe- ther this gentleman ever put the above scheme in practice; but, suppose not. It is properly objected to by the author of the article Spina Bifida, in the En- cyclopedic Methodique, Part. Chir. be- cause the disease is often attended with other mischief of the spinal mar- row and brain, and the base of the swelling is almost always too large to admit of being tied at all, or not without hazard of dangerous conse- quences. Mr. Abernethy has suggested trying a gentle degree of pressure on the tu- mour from its commencement, with a view of producing absorption of the fluid, and pre venting the distension ofthe unsupported dura mater. Were the fluid to continue to increase, not- withstanding such pressure, Mr. Aber- nethy thinks, that, as death would be inevitable on the tumour bursting, it would be vindicable to let out the fluid, by means of a puncture, made with a finely cutting instrument The wound is to be immediately afterwards closed with sticking plaster, and, if possible, healed. Another accumulation is then to be prevented, if practicable, with bandages and topical applications. Mr. Vbernethy actually made t by inflamma- tion; no pus is ever formed but in con- sequence of it. In abscesses, a suppu- ration is an immediate effect of inflam- mation; and when internal cavities re- main exposed, no suppuration comes on, till inflammation has formed the disposition and action. Violence done to parts is one of the great causes of suppuration; but, sim- ply, violence does not always occasion it. The violence must be followed by a prevention of a cure in a more simple way, viz. by a restoration of the struc- ture, so as to carry on the animal func- tions of the part. The parts must be kept long enough in that state, into which they were put by the violence. Or, what is somewhat similar to this, the violence must be attended with death in apart, as, in many bruises, all mortifications and all sloughs, in conse- quence of the application of caustic, which, when the dead parts separate, leave internal surfaces exposed. (Hun- ter.) As every violence, committed from without, under the above circum- stances, is more or less exposed to the surrounding air, its application to in- ternal surfaces has been assigned as a cause of suppuration; but, certainly, the air has not the least effect on parts, circumstanced as above, for a stimulus would arise from a wound, were it even contained in a vacuum. In cir- cumscribed abscesses, the air cannot possibly get to the parts, so as to have any share in making them suppurate. In cases of emphysema, when the air is diffused over the whole body, no suppuration is the consequence, unless an exposure, or imperfection of some internal surface should be made, for the purpose of allowing the air to es- cape. A stronger proof, that it is not the admission of air, which makes parts inflame, is, that the cells in the soft parts of birds, and many of the cells and canals of their bones, com- municating with the lungs, and always containing air, never inflame; but if these cells are exposed in an unnatural way, then the stimulus of imperfection is given, these cavities then inflame, and their surfaces either form adhe- sions together, or produce pus. (Hun- ter.) QUALITIES OE PUS. True pus has certain properties, which when taken singly, may belong to other secretions, but, which, con- jointly, form the peculiar character of this fluid, viz. globules swimming in a fluid, which is coagulable by . solution of sal ammoniac, which no other animal secretion is, and, at the same time, a consequence of inflammation. The colour and the consistence of pus are the two qualities which first at- tract the notice of every, the most su- perficial, observer. The colour arises from the largest portion of this fluid being composed of very small round bodies, very much likethose little globu- les, which, swimming in a fluid, make cream. The fluid, in which the globules of pus swim, we might at first suppose to be the serum of the blood, for it coagulates with heat like the latter fluid. Pus is also probably mixed with a small quantity of coagulating lymph; as it partly coagulates, after it is se- creted. The fluid part of pus, however, is known to have properties, which serum has not. There being a similarity be- tween pus and milk, experiments have been made to ascertain whether the fluid of pus could be coagulated with the gastric juice of animals; but, no coa- gulation could be effected in this man. ner; a solution of sal ammoniac made the fluid part of pus coagulate; but, not any other secretion, or natural fluid; and", hence, it was concluded, that whenever globules were found swimming in a fluid, coagulable by sal ammoniac, the matter was to be considered as mr- (Hunter.) 254 SUPPURATION; The proportion, which the white glo- bules bear to the other parts of pus, depends on the health of the parts pro- ducing the discharge. When the glo- bules are very abundant, the matter is thicker and whiter, and is called heal- thy pus; the meaning of which is, that the solids, which produced it, are in good health; for, these appearances in the matter are no more, than the result of certain salutary processes going on in the solids, the effect of which processes is to produce the disposition, on which both suppuration and granulation de- pend. (Hunter.) Pus is specifically heavier than wa- ter, and is probably about as heavy as blood. Besides the above properties, pus has a sweetish mawkish taste, very differ- ent from that of most other secretions, and the same taste takes place, whe- ther it is pus from a sore, or an irritat- ed inflamed surface. Pus has a smell, in some ("■.cgree pe- culiar to itself; but this differs in differ- ent cases. Some diseases, it is said, may be known by the smell, as for in- stance, a gonorrhoea. Pus sinks in water; mucus floats. Pus communicates to water an uniformly troubled white colour; mucus gives the appearance of stringy portions floating in it. Mucus is said to be more readily dissolved by sulphuric acid, than pus is. It has also been asserted, that if water be added to such solutions, the pus is precipitated to the bottom ofthe ves- sel; while the mucus, instead of being completely precipitated, forms swim- ming flakes. A solution of caustip alkali dissolves both pus and mucus; but, when water is added, the pus is said to become separated, but not the mu- cus. Though solutions in chemical men- strua and precipitations, have been thought a test of the distinction, be- tween these two fluids; yet, the me- thod has been thought absurd and un- philosophical. It has been conceived, that all animal substances whatever, when in solution, either in acids, or al- kalies, would be in the same state, and therefore, that the precipitation would be the same in all. Calcareous earth, when dissolved in muriatic acid, is in that acid in the same state, whether it has been dissolved from chalk, lime- stone, marble, or calcareous spar, and precipitations from all are the same. Hence, experiments were nu.de on or- ganic, animal matter, such as muscle, tendon, cartilage, liver, and brain; and on inorganic, such as pus and the white of an egg. All these substances were dissolved in sulphuric acid, and precipitated with the vegetable alkali- Each precipitation was examined with such magnifiers, as plainly showed the forms of the precipitates, all which ap- peared to be flaky substances. The pre- cipitate by the volatile alkali had exact- ly the same appearance. The same ap- pearances were seen, when the above kinds of animal matter were dissolved in the vegetable caustic alkali, and pre- cipitated with the muriatic acid. A flaky substance, void of any regular form, composed each precipitate.— (Hunter.) Pus does not irritate the particular surface, which secretes it, though it may be very irritating to any other. Hence, no suppurating surface, of any specific kind, can be kept up by its own matter. If this had not been the case, no sore of a specific quality, or produc- ing matter of an irritating kind, could ever have been healed. This is similar to every other secretion of stimulating fluids, as the bile, tears, &.c. which fluids do not stimulate their own glands, or ducts, but are capable of sti- mulating any other part ofthe body.— (Hunter.) Whenever a real disease attacks, ei- ther the suppurating surface, or the constitution, the production of true pus ceases, and the fluid becomes changed in some measure, in proportion to these morbid alterations. In general it be- comes thinner and more transparent, and it partakes more of the nature of the blood, as is the c.se in most other secretions under similar circumstances. Sanies is the term usually applied by surgeons, to pus, in this degenerated state. This unhealthy sort of matter has morcof the serum, and, frequently, more of the coagulating lymph in it, and less ofthe combination, which ren- ders it coagulable by a solution of sal ammoniac It has also a greater propor- tion of the extraneous parts of the blood, which are soluble in water, such as salts; and it has a greater tendency, than true pus, to become putrid. Such u, healthy matter may even be irri- tating to the surface, which produces it. The discharge, when of an irritating sort, is more stimulating to the adjoin- ing parts, with which it comes in con- SUPPURATION. 25j tact, than to its own secreting surface. In this manner, it frequently produces excoriation of the skin, and ulceration. Thus the tears excoriate the skin of the cheek, in consequence of die quantity of salts, which they contain. From this effect, matter has been called corro- sive, a quality, which it has not; the only property, which it possesses, be- ing that of irritating the parts, which it touches, so as to cause their absorp- tion. (Hunter.) When the vessels thus lose the pow- er of producing good pus, they also lose more or less the power of forming gra- nulations. This may depend on some deviation from the due structure and action, which such vessels should pos- sess, in order to be qualified for the performance of these two operations. Pus, from several circumstances, would appear in general to have a greater tendency to putrefaction, than the natural juices have; but, perhaps, this is not the case with pure pus, which, when first discharged from an abscess, is commonly perfectly sweet. There are, however, some exceptions to this, but these depend on circum- stances entirely foreign to the nature of pus itself. Thus, if the abscess had any communication with the air, while the matter was confined in it; or if the col- Lection has been so near the colon, or rectum, as to have been infected by the feces, then we cannot wonder, that the matter should become putrid. When blood is blended with pus; when sloughs are mixed with it; when the parts forming the seat of the abscess, are in a gangrenous state from an ery- sipelatous affection; the matter has a greater tendency to putrefy, than the pure pus, discharged from sound ab- scesses, or healing sores. Pure matter, though easily rendered susceptible of change, by extraneous additions, is in its own nature tolerably uniform and immutable. It appears so unchangea- ble, that we find it retained in an ab- scess for weeks, without having under- gone any alteration. These qualities, however, only belong to perfect pus. If a healthy sore inflames, the matter, now produced from it, though unmix- ed with extravasated blood, or dead solids, becomes much sooner putrid, and much more irritating, than the dis- charge, formed before this alteration of the ulcer. (Hunter.) In the preceding paragraph, it is stated, that matter remains very often unchanged in abscesses for weeks.— This expression of Hunter's is not strictly correct; for, it is well known, that the surfaces ofthe cavities of ab- scesses are always absorbing, as well as secreting ones; consequently, there" must be a continual mutation going on in the contained matter. When there are diseased bones, or other extraneous^ bodies, exciting irri- tation, sometimes even to so great a de- gree as to make the vessels bleed, and ' often wounding the vessels ofthe part, the matter is always found to be very offensive. This state ofthe discharge is one mark of a diseased bone. The discharge of an unhealthy sore blackens silver probes, and preparations of lead. This effect is imputed by Dr. Crawford to the sulphurated hydrogen gas, generated in the matter. (Phil. Transact, vol. 80. Year 1790. p. 385.) USE OF PUS. By some it is supposed to carry off" humours from the constitution. Sup- puration is sometimes regarded as a constitutional disease, changed into a local one, which constitutional ma- lady is discharged, or thrown out of the body, either in the form of pus, or together with this fluid.— Critical abscesses have been thought to be cases of this sort. Suppuration has also been imagined to carry off' lo- cal complaints from other parts of the body, on the old principle of derivation, or revulsion. For this reason, sores or issues are made in sound parts before allowing other sores to be dried up. Suppuration is Sometimes excited with a view of making parts, such as indu- rated swellings, dissolve into pus; but, we have endeavoured to show, that no dissolution of the solids is concerned in the production of pus. A secretion of pus is looked upon as a general prevention of many, or of all, the causes of dise.se. Hence, issues are made to keep off both universal as well as local diseases. However, the use oi pus is perhaps unknown; for, it is formed most perfectly from healthy sores, and in healthy constitutions; and large discharges from parts not very essential to life, produce very little change in the constitution, and as liul. upon being healed up, whatever some may suppose to the contrary.—(Hun- ter.) This is certainly the case With many old ulcers, the suppuration from which seems to have little, or no effect, in 256 s SUPPURATION. impairing the health. Nor is there any real reasonto be afraid of healing such ulcers, when possible, lest a worse dis- ease should follow from the stoppage of the discharge, to which the system is supposed to be habituated so much, that the continuance of such discharge is essential to health. Every one knows, that when there is no interference of art, that is, when the surface of a sore is left uncovered, the thin part of the skin evaporates, and the thick part dries and forms a scab. Nature, therefore, seems to have designed, that one use of pus should be to make a cover, or protection, for ul- cerated surfaces. But I cannot agree with what has been asserted, (Hunter) that the natural healing of a sore under a scab takes place more quickly, then when surgical dressings are employed. Among the secondary uses of sup- puration, may be mentioned, opening a communication, between a disease, and the external surface ofthe body; form- ing a passage for the exit of extraneous bodies, &c. fr.EATMES I WHEN SUPPURATION MIST TAKE PLACE. In cases of inflammation, arising Trt»Yi accident, but so circumstanced, that we know suppuration cannot be prevented, the indication is to mode- rate the inflammation, which, if the powers are great, and the injury done considerable, will probably be very violent. If the constitution should also be much affected, certain general means are proper, such as bleeding, purging, and nauseating medicines. While the constitution continues to be disturbed, suppuration cannot take place in the most favourable manner. In these cases, also, such medicines as produce a gentle perspiration, greatly relieve the patient, for instance, the pulv. ipecac, comp.; antimonials; aq. ammon. acet.; saline draughts, &c. Opi- ates may produce a temporary diminu- tion of action; but, this is not always the consequence of this medicine, as there are constitutions, which it ren- ders more irritable, and of course it aggravates the inflammatory action. 'i'he applications to inflammations, which are to suppurate and form an abscess, commonly used, are poultices and fomentations. These, however, ap- pear to be applied without much criti- cal exactn'-^s, or discrimin.'lion; for they are applied before suppuration has taken place, and when this event is not desired; and they are also applied after suppuration has taken place With respect to suppuration itself, ab- stracted from all other considerations, the indication cannot be the same in every state; but, if poultices and fo- mentations are found to be of real ser- vice in the two stages of the disease, there must be something common to both; for which they are of service, independently of simple suppuration. Poultices are useful, when the inflam- mation "attacks the skin, either in the first instance or after an abscess has approached so near the skin, that this becomes secondarily affected. This be- nefit appears to arise from the skin be- ing kept soft and moist. Such is the use of a poultice in inflammation, ei- ther before, or after suppuration, un- til the abscess is opened. But, when poultices and fomentations are applied to inflamed parts, in which we wish to avoid suppuration, reason and principle will not justify the practice, though such applications may be proclaimed by experience to be very proper.— (Hunter.) TREATMENT AFTER SUPPURATION HAS TAKEN PLACE. When suppuration cannot be stop- ped, or resolved, it is in general to be promoted. How far suppuration can be increas- ed by medicines, or applications, is doubtful; but attempts are generally- made, and, for this purpose, suppura- ting cataplasms and plasters, compo- sed ofthe w:um gums, seeds, &e. have been recommended. Mr. Hunter doubted, whether such applications had any considerable effect in the way intended; for, if they were put on a sore, they would hardly increase the discharge from it, and, perhaps, even diminish it. However, in many cases, in which the parts are indolent, and hardly admit of true inflammation, in consequence of which a perfect sup- puration cannot take place, stimulating the skin brings on a more salutary in- flammation, and of course a quicker inflammation. These applications have been found, however, to bring the matter more quickly to the skin, even in most rapid suppurations. This effect has been mistaken for an increased forma- SUPPURATION. 257 tion of pus; but, this consequeno«^an only follow in cases, in which the inner surface ofthe abscess is within the in- fluence of the skin. The accelerated progress of the matter to the surface of the body arises from another cause, viz. the promotion of ulceration in the parts, between the collection of mat- ter, and the cuticle. Emollient poultices are commonly applied to inflamed parts, when sup- puration is known to have taken place. These can have no effect upon suppu- ration, except that of lessening the in- flammation, or rather making, the skin more easy. The inflammation must have reached the skin before poultices can have much effect, for they can only affect that part. The ease of the pa- tient, however, should be considered, and we find, that fomentations and poultices are often beneficial in this way. By keeping the cuticle moist and warm, the sensitive operations of the nerves of the parts are soothed. On the contrary, if the inflamed skin is allow- ed to dry, the inflammation is increas- ed, and as suppuration is probably not checked by the above treatment, it ought to be put into practice. As warmth excites action, the fomenta- tion should be as warm as the patient can bear, without inconvenience.— (Hunter.) < OF THE TIME WHEN ABSCESSES SHOULD BE OPENED. As abscesses, wherever formed, must increase that part of their cavity, which is next to the skin, more quick- ly than the bottom, they must become, in some degree, tapering towards the latter part, with their greatest breadth immediately under the skin. This shape of an abscess, when allowed to take place, is favourable to its healing, for it puts the bottom, which is the seat of the disease, more upon a foot- ing with the mouth of the abscess, than it otherwise could be. As the bot- tom, or part, where the abscess began, is more or less in a diseased state; and as the parts between the seat of the abscess and the external surface are sound parts, having only allowed a pas- sage for the pus, they, of course, have a stronger disposition to heal, than the bottom has. To keep the mouth of an abscess from healing before its bottom, the col- lection of matter should be allowed to break of itself; for, although abscesses in general only open by a small orifice, more especially when sound, yet, in such cases, the skin over the general cavity of the matter is so thinned, that it has very little tendency to heal, and often ulcerates and makes a free open- ing. If the latter event should not spon- taneously occur, it may now be more easily obtained by the interference of the surgeon. . Abscesses, which are the most dis- posed to heal favourably, are the quick- est in their progress to the skin, and the matter comes to the surface almost at a point; the swelling is not so conical as in other cases, and when it bursts, the orifice is exceedingly small. On the other hand, when there is an indolence in the progress of the abscess, the col- lection spreads more, or distends the surrounding parts in a greater degree, in consequence of their not being so firmly united by inflammation, in the one as they are in the other instance; nor will ulceration so readily take the lead, and the matter will come to the skin by a broad surface, so as to thin a large portion ofthe cutis. (Hunter.) It may certainly be set down as a ge- neral axiom, that all phlegmonous ab- scesses should be allowed to break, and not be opened by the surgeon. When punctured unnecessarily, or prematurely, they never heal so fa- vourably as when left to themselves. Particular cases, however, should be opened, as soon as the existence of matter is ascertained. Abscesses should only be allowed to burst of themselves, when the confinement of the matter can do no mischief. Abscesses in the abdomen, or thorax, under the crani- um, in the eye, and joints, should be mostly opened very soon. When sup- puration takes place beneath ligamen- tous expansions, or aponeuroses,which invariably retard the progress of the matter to the surface of the body, an early opening should be made. If this be not done, the matter spreads to a great extent, separating such ligamen- tous expansions from the muscles, and the muscles from each other, and, as the pus cannot get to the surface of the body, the length of the disorder is of course increased. When matter is so situated, as to be liable to insinuate itself into the chest, or abdomen, or into the capsular ligaments of the Vol. II. 2 K 258 SUPPURATION. joints, it is highly proper to prevent this extension of mischief, by making a timely opening into the abscess. OF THE PLACE WHERE THE OPEN- ING SHOULD BE MADE. If a free opening is not required, or making one is not practicable, it is at least | roper to make whatever opening can b made in a depending situation. By this means, the matter will more readily escape, and all pressure arising from the confinement or lodgment of pus, will be prevented. A very small degree of pressure on that side ofthe abscess which is next to the skin, may produce ulceration there; and although such pressure might not, in many cases, be so great as to produce ulce- ration at the bottom ofthe abscess; yet it may be sufficiently great to prevent granulations from forming on that side, and thereby retard the cure, as no union can take place, but by means of granulations. The pressure is always most, and retards the formation of granulations in the greatest degree, at the most depending part ofthe abscess. Hence, if no opening be made in this si- tuation, the upper part of the abscess readily heals to a small point, which becomes a fistula. When circumstances forbid making an opening at the most depending part of an abscess, perhaps, nothing more can be done, than to evacuate the mat- ter as often as necessary, and gently to compress the sides of the abscess to- gether, when the situation ofthe case admits of the practice. But abscesses are not always to be opened at the most depending part. The distance between the matter and the skin at this part is the common reason against the method. If an ab- scess is rather deeply situated, and points in a place which is higher than ■where the collection lies, it is proper to make the opening where the conical eminence, or, as it is termed, the point- ing, appears. Thus, if an abscess should form in the centre of the breast, and point at the uppermost part, which is often the case, it would be improper to cut through the lower half of the mam- ma, in order to make a passage for the matter in that direction. If an abscess should form on the upper part of the foot, it would be wrong to make an opening through the sole ofthe foot to get at the most depending part of the abscess; for, besides cutting such a depth of sound parts, a great many use- ful ones would be destroyed. When the abscess does not point in a depending situation, as in the instances just cited, since the place where the matter threatens to open a passage, is likely to be tbe future opening, and this situation is disadvantageous to the heal- ing of the deep part of the abscess, it is generally best to let the collection of matter first burst of* itself, and then di- late the opening as freely as necessary. By allowing abscesses to burst sponta- neously, the opening is not so apt to heal as if made by art, and, therefore, is better in such situations. (Hunter.) * in some cases, it is more advantage- ous even to cut through a certain thick- ness of parts, for the sake of obtaining a depending opening, than to make an, opening, where the pointing appears, as the parts are most extenuated, and the matter nearest the surface. This remark is highly worthy of remem- brance, when there is no doubt of the existence of matter at the depending place, and when the parts to be divided are not important ones. Collections of matter beneath the fasciae of the fore- arm and thigh, particularly demand at- tention to this direction, as they com- monly point where those ligamentous expansions are most attenuated, not where the matter can most readily es- cape. Abscesses in the sheath of the rec- tus abdominis should also be opened in a low situation. DIFFERENT METHODS OF OPENING ABSCESSES. All abscesses will burst of them- selves, unless the matter should be ab- sorbed, and, in general, they ought to be allowed to take this course. There are, however, as we have already ex- plained particular circumstances which require an early opening; but, when the skin over the abscess is very thin, it is not of so. much consequence, whe- ther the case be permitted to burst of itself, or it be opened by the surgeon. When abscesses are large, it is ge- nerally necessary to open them by art, whether they have burst of themselves or not; for, the natural opening will seldom be sufficient for the completion of a cure; and, although it may be suf- ficient for the free discharge of the matter, yet these abscesses will heal SUPPURATION. 259 much more readily when a free open- ing is made; for, the thin skin over the cavity granulates but indifferently, and therefore unites but slowly with the parts underneath. (Hunter.) Abscesses may be opened either by an incision, or by making an eschar with caustic. To the latter plan, how- ever, many urge strong objections: the use of caustic is not usually attended with any advantage which may not be obtained by a simple incision; upon a tender inflamed p»rt it gives much more pain; it is more slow in its ef- fects; and the surgeon can never direct the operation of the caustic so accu- curately as to destroy exactly the parts which he wishes, and no more. If the eschar be not made deeply enough, the lanpet must, after all, be used. Caustic also leaves, after its application, a dis- agreeable scar, a consideration ofsome importance in opening abscesses about the female neck or face. To these nu- merous objections we have to add, that the eschar is, very frequently, ten or twelve tedious days in becoming de- tached. When there is a redundance of skin, or when there is a good deal of it thin- ned, however, an opening made with caustic will answer, perhaps, as well as an incision. The application of a caustic may also sometimes be advan- tageously resorted to when there is a good deal of indolent hardness around a small abscess. The calx viva cum kali puro, or the kali purum alone, is the best caustic for opening abscesses. The part is first to be covered with a piece of adhesive plaster, which has a portion cut out ex- actly ofthe same figure and size as the opening intended to be made in the ab- scess. The best way of making the es- char, is to dip the end of the caustic in water, and to rub it on the pail till the skin becomes brown. The active sub- stance is then to be immediately wash- ed off with some wet tow, the plaster is to be removed, and an emollient poultice applied. In almost all cases, it is better to use the lancet or double-edged bistoury. Either of these instruments opens the abscess at once, and with less pain, than results from the use of caustic: it occasions no loss of substance, conse- quently a smaller cicatrix; and, by us- ing it, the opening maybe made in the most advantageous direction, and of the exact size required. DRESSINGS AFTER OPENING AB- SCESSES. When an abscess has burst of itself, and it is unnecessary to enlarge the opening, all that is requisite is to keep the surrounding parts clean. The conti- nuation of the same kind of poultice, which was before used, is, perhaps, as good an application as any; and when the tenderness, arising from the in- flammation is over, lint and a pledget may be made use of, instead of the poultice. But, an abscess, opened by a cutting instrument, is both a wound and a sore, and partakes more of the nature of a fresh wound in proportion to the thickness of the parts cut. Hence, it is necessary that something should be put into the opening to keep it from heafing by the first intention. If it is lint, it should be dipped in some salve, which will answer better than lint alone, as it will allow of being taken out sooner. This is advantageous, because such sores should be dressed the next day, or, at latest, on the se- cond day, in order that the pus may be discharged again. When the cut edges ofthe opening have suppurated, which will be in a few days, the future dress- ings may be as simple as possible, for nature will, in general, complete the cure. If the abscess has been opened by caustic, and the slough has either been cut out or separated of itself, the case is to be regarded as an entire suppurat- ing sore, and dressed accordingly. Perhaps, dry lint is as good a dress- ing as any, till the nature of the sore is known. If it should be of a good kind, the same dressing may be continued; but, if not, then it must be dressed ac- cordingly. Parts, which at first appear to be sound, sometimes assume everv species of disease, whether from indo- lence, from irritability, from scrofulous, and other dispositions. This tendency to disease arises, in some cases, from the nature of" the parts affected, as, for instance, bone, ligament, &c. (Hunter.) It is impossible to refer the reader, in a satisfactory manner, to any particular works for information concerning ab- scesses and suppuration, because some- thing is to be met with on the^subject in almost every surgical book, ancient as well as modem. The author of the article. Abscess in Rees's Cyclopoedia, makes particular mention ofthe follow- 260 SURGERY. ing writers: Severinus, Hildanus, Wiseman,Heister,Van Swieten.Sharp, Pott, B. Bell, and Kirkland. Some curi- ous cases are said also to be related, or referred to, in the Bibliotheque Choisie de Medecine, the compilations of Mauge- tus, Bernstein, and James; the Me- moirs and Transactions of different learned Societies (the Mem. de I'Acad. de Chir. might be especially mentioned); and in the works of Bonetus, Forestus, Lusitanus, Tulpius, Morgagni, Hors- tius, Stalpart, Vander Wiel, &c. I am rather surprised, that the au- thor of the article above alluded to, should have neglected to notice John Hunter's Treatise on the Blood, Inflam- mation, £*c. a work, in which, perhaps, more interesting knowledge, respect- ing abscesses and suppuration, is con- tained, than in any other one ever pub- lished. The Traite" de la Suppuration de F. ^uesnay, 1749, is also entitled to some attention; so are the Dissertations on Inflammation by J. Burns. Richter has written a tolerable chapter on the subject, in his Anfangsgr. der Wun- dorzn. band. 1. Consult also Home on Pus, and I'Encyclopedic Methodique. SURGERY, (Chirurgery; from ^tif, the hand, and tgycn, labour.) A branch of the science of Medicine, having for its principal object the cure of external diseases. The etymological meaning of the word surgery reduces this part of the medical profession to a very de- graded condition, and, by no means conveys an adequate idea-of what it really is at the present day. They who consider Surgery merely as the mecha- nical part of medicine, or as that branch of it which consists entirely in the per- formance pf manual operations, must either be very ignorant, or very preju- diced and illiberal. In order to remove these foolish notions, it is only necessa- ry to ask, by what dexterity ofthe hand could the surgeon accomplish the cure of the various forms of the venereal disease, and of numerous scrofulous af- fections? Yet these, and many other disorders, equally incurable by the hand alone, fall to the province of the surgeon, and by him are oftentimes successfully treated. A modern author observes, that " many people have imagined, that when a man has learnt the art of dress- ing sores, of applying bandages, and performing operations with a little dex- terity, that he must necessarily be an accomplished surgeon. If a conclusion so gross and fallacious had been confin- ed to the vulgar and illiterate, the pro- gress of scientific Surgery would have suffered little interruption; but, if young minds are directed to these ob- jects, as the only important matters upon which their faculties are to be exercised; if the gross informations of sense constitute the sum of their knowledge, little more can be expected from such a mode of study, than servile imitation, or daring empiricism. In- deed, some people have affected to op- pose Surgery as an ttrt to Medicine as a scknee; and if their pretensions were justly founded, the former would cer- tainly be degraded to a mere mechani- cal occupation. But, it is not very easy to comprehend the grounds of such a distinction. The internal and external prjls of the body are governed by the same general laws during a state of health; and, if an internal part be at- tacked with inflammation, the appear- ances and effects will bear a great si- milarity to the same disease situated externally; nor are the indications of cure, in general, materially different. If by science, therefore, be meant " a knowledge of the laws of nature," he who knows what is known of the order and method of nature, in the produc- tion, progress, and termination of sur- gical diseases, merits as justly the title of a scientifical practitioner, as the well- educated physician. The practical parts of Physic and Surgery are very fre- quently disunited; but, their theory and principles are indivisible, since they truly constitute one and the same, sci- ence." (Pearson's Principles of Surgery, Preface.) We shall next introduce a short ac- count of the rise and progress of Sur- gery, as given by Mr. Gooch, in the first volume of his Chirurgical Works. Writers have divided Surgery into these six branches: Synthesis; Diaere- sis; Exxresis; Aphseresis; Prosthesis; and Diorthrosis: the first signifies unit- ing parts divided; the second, dividing parts united; the third, removing, or extracting extraneous, or other noxious substances, lodged in any part of the body; the fourth, taking away what is superfluous; the fifth, supplying defi- ciency; the sixth, restoring parts to their proper places. The daily instances of the relief, which Surgery brings the afflicted, un- der the various circumstances of dis- tress, even delivering them from the jaws of death, sufficiently proclaim its excellence; and it appears to be of SURGERY. 261 much earlier date, than the other parts of the medical art. We see, by the antediluvian histoiy, that soon after the creation of the world, feuds and animosities, envy and malice, possessed the minds of men, productive of rapine and war, which inevitably exposed the contending par- ties to wounds, and other external in- juries. Reason, implanted in man for his preservation, as the first principle in nature, directed him, on various occa- sions, to seek a remedy; and this ne- cessity gaye rise to Surgery, which, at first, was rude and imperfect, gradually growing, in successive ages, like other ingenious arts and sciences, to a state of perfection. The inhabitants of the earth, in the primitive ages of the world, lived fru- gally, upon plain simple food, accord- ing to the dictates^ of nature and right reason; and enjoying a pure serene air, and temperate climate, their lives were protracted to a great length, without being so subject as we are to diseases, which have been much increased since that time by luxury and intemperance. They were peculiarly happy in the en- joyment of robust and vigorous consti- tutions, raised from good original sta- mina; and, when attacked with dis- eases, nature wanted little or no assist- ance from art, to restore their health; consequently Surgery was then looked upon, as almost the only necessary branch of medicine.* Ancient history informs us, though there may be something fabulous and allegorical in it, that Apollo communi- cated his skill in this science to his son y€sculapius, who then profited under the tuition of Chiron the Centaur; and for his great improvement and know- ledge of Surgery in particular, he was deified, and had temples dedicated to him in several parts of the world. Ma- ny countries contended for the honour of his birth, and, according to the learned, his name signifies a man of the knife, in the Phenician language; whence some writers conclude he was a native of Phenicia; but this contro- verted point, whether he was by birth a Phenician, an Egyptian, or a Gre- cian, is not material to our purpose. In those early days, there were no regular professors ofthe medical art, the know- ledge of which was then conveyed by oral tradition, or recorded upon pillars in the most public places, or on the walls of temples, dedicated to the god of Health; and afterwards registers of cures were kept in those consecrated places for the general good of mankind. Machaon and Podalirius, the sons of .tsculapius, were both medical and mi- litary men, and being particularly skil- ful in surgery, they proved very useful to the soldiers in curing their wounds, in the Trojan war; on which account, when Machaon himself was danger- ously wounded with a dart, greater la- mentation was made for him than for any other hero. From the destruction of Troy to the Peloponnesian war, which was an in- terval of more than seven hundred years, the Asclepiadae, descendants of /Esculapius, and their disciples, were the only noted professors of the heal- ing art. About the conclusion of this period of time, the immortal Hippocrates be- gan to be famous in the world, who was also of the jEsculapian family, and lived between four and five hundred years before our Saviour. He was en- dowed with the greatest sagacity, ex- celled all his predecessors and contem- poraries, and reduced this science into better order, compiling, and laying down for posterity, rules founded upon his own observations, confirmed by ex- perience, and was deservedly called the father of physic. In his writings he also treats of wounds, ulcers, frac- tures, &c. interspersing observations and remarks through the whole, to di- rect the judgment and practice of suc- ceeding ages. He was the ablest sur- geon, as well as physician, of his time. The other Greek physicians, whose writings have been transmitted to us in a more universal language, treating also professedly of Surgery, are Oriba- siuy, Alexander, Trallianus, /Etius, and Paulus /Egineta, and the great Galen, who flourished more than a century be- fore Oribasius.f * Vid. Dissertat. physico-med. Fred. Hoffmanni de Methodo acquirendi Vitam Longam. The great luxury of the Romans in Seneca's time made him say, Non ad rationcm, sed ad similitudinem- vivimus. f Oribasius was a practitioner of great note at Sardis, in Cent. IV. M. C.— What he has said, de Laqueis et Machinamentis, in his^voluminous works, i» 262 SURGERY. Among the Romans, Celsus, a man of a sublime and penetrating genius, is the only author we have in his time, though he mentions several; but, there is no other record, or monument, of them left. Both he and Galen, who was a practitioner of great repute at Rome, though a native of Pergamus, in Asia Minor, speak of some ancient surgeons, as well in Egypt as in other parts of the world, whose works have perished. When the knowledge of arts and sciences was transferred from Egypt to Greece, it received great improve- ments, and Athens was looked upon as the seat of all kinds of learning, till the death of Alexander the Great; after which aera, the Ptolemies ruled in Egypt, and Alexandria became the most renowned school in the world, for physic, surgery, and anatomy, which flourished near a thousand years: and, in those days, physicians boasted of.re- ceiving their education in that univer- sity. Then the different branches of medicine were practised together, and not separated till the time of Herophi- lus and Erasistratus, who were educat- ed at Alexandria, and lived in the reign of Seleucus Nicanor, king of Syria, as appears by a memorable incident, in' respect to the latter of those illustrious men, who shewed his great penetration in discovering Antiochus's distemper, when fallen desperately in love with his mother-in-law, the young and beau- tiful Stratonice, Seleucus's second wife, whom he had married in his old age.-J- In the year 640 of the Christian aera, the caliph of the Saracens, professed enemies to literature, as well as to the Christians, took Alexandria, destroyed the university, and burnt the library of Ptolemy Philadelphia, which was the greatest magazine of learning in the world, said to contain 700,000 vo- lumes;:): however, some books might be saved out of that lamentable confla- gration. In the same century, that this dread- ful catastrophe happened at Alexan- dria, Europe was overrun with Goths and Vandals, by which calamitous event, the liberal arts and sciences also suffered very much; and undoubtedly Medicine shared the same fate. After the fall of Alexandria, and the irruptions of those barbarous people, the Arabians, having collected libra- ries, and probably possessed them- selves of some books, that were saved out ofthe flames at Alexandria, be- came more conspicuous and considera- ble in this science, than any other na- tion; of which, the most eminent, who blended Surgery with their other medi- cal writings, were Rhazes, Avicenna, Avenzoar, Averrhoes, and Albucasis. Rhazes probably was born in the province of Chorasan in Persia; he was superintendant of an hospital there, and died advanced in years, A. C. 932. Avicenna was the next writer of note among the Arabians; he was born at Bochara in Chorasan, towards the end of the 9th century. He resided and practised at Ispahan. He was a man of extraordinary talents; but, shortened his days by intemperance and indulg- ence in pleasures; he was buried at Hamadan. Avenzoar succeeded Avicenna; if not born, he resided much at Seville, the capital of the province of Andalusia in Spain, then the seat of the Mahomet- an caliph. He lived and enjoyed good health to 135 years. Averrhoes followed Avenzoar; he was a native of Corduba in Spain, and died at Morocco. Of Albucasis the place and time of nativity do not certainly appear; but he comes after Averrhoes, and was the best acquainted with Surgery of any of the Arabians. There is reason to sup- pose that he lived in the 11th or 12th century of the Christian aera. These Arabians were favourers of Galen's doctrine, and their authority prevailed unrivalled for many ages. Afterwards the chemists opposed the Galenists, each of which had zeal- ous partisans, who were bigoted to the opinion of their chiefs, and combated each other's notions with great vehe- chiefly taken from Heliodorus.—It appears, that Paulus was a more considera- ble surgeon, having improved upon his predecessors. f Seleucus began his reign Ao. Mdi.3684. Erasistratus resided at his court, and was archiatcr. t Great part of the Ptolemean library having been burnt in the wars between Caesar and Pompey, the loss was supplied, as far as possible, by Cleopatra, queen of Egypt, -v.id her successors, at an immense expense. SURGERY. 263 mence, whence a kind of schism arose in the province of physic; but the wiser moderns have freed themselves from implicit faith, and the embarrass- ments of hypotheses, and fine specula- tive systems, more curious than useful, regarding only what is foimded upon rational experience, to which theory they must be subordinate. In the 13th century, learning emerg- ed from the dark clouds of ignorance, under which it had long been veiled; and about this period of time, the refor- mation of Surgery was begun in Eng- land by Arden,* originally a practi- tioner of great fame at Newark, and afterwards in London: and it was be- gun rather earlier in France, by Pitard and Lanfranc.f By a succession of men of genius, learning and application here, such as Gale, Clowes, Woodall, Banister, Wiseman, and many others; and there, by Vavasseur, Mondeville, Guido de Cauliaco, Pare, Guillemeau, &c, Surgery was gradually advanced, in both countries, to its present state of perfection. Pitard was a Parisian by birth, but Lanfranc was a native of Mi- lan, educated at Salernum, the most fa- mous university for Physic and Surge- ry in those days, as its motto, Civitas Hippocratica, emphatically expresses. He was driven from Italy, with many other learned men, by the dreadful fac- tions ofthe Guelphs and Gibelines, at the conclusion ofthe 12th century, and found an asylum at Paris, where he met with a very honourable reception. His acquaintance with Pitard was soon im- proved into a strict friendship, which was inviolably preserved, for the pub- lic good, between these eminent men, who, co-operating, supported with great credit and dignity, the college of St. Come, founded by Lewis the Ninth, who was sainted for engaging in the crusades; and there public lectures ap- pointed to be read, and demonstrations made, in Anatomy and Surgery, by the royal founder. Pitard having given ear- ly proofs of his extraordinary talents and abilities in his profession, was ho- noured, before he was thirty years of age, with the appointment of first surgeon to the king, and standing in highest esteem, attended him in his expedition to the Holy-Land, where he gathered laurels, and returned loaded with honours. Our neighbours having had for some ages, better opportunities, from royal patronage, of acquiring knowledge in their profession, than other countries, and being regular in giving lectures, and making demonstrations in Anato- my and Surgery, they distinguished themselves, and were deservedly ex- tolled throughout Europe: and from every part of it, surgeons used to resort to Paris, to complete their education; which city now can no longer claim the superiority to London. In the foreign universities, the pro- fessors of physic generally adopted sur- gery; and now, at the famous universi- ty of Edinburgh, and others, there are professorships appropriated to Surgery and Anatomy conjointly. Marianus Sanctus, a celebrated lithotomist, was a doctor of Padua. Marcus Aurelius Severinus, Vigo, Fabricius ab Aqua- pendente, Caesar Magatus, Marchetti, and many other practical surgeons, that might be enumerated, were doctors of physic. Mons. Le Cat, at Rouen, and Mons. Pouteau, at Lyons, chief surge- ons to the great hospitals in those ci- ties, are styled doctors of physic and surgery. The late illustrious M. De La Peyronie, who was first surgeon to the king, and to whom the whole faculty is greatly indebted, was bred, and took a doctor's degree in the university of Montpelier. Some ofthe physicians to the kings of France were originally surgeons, in which country singular marKs of royal favour have, for many ages, been conferred upon surgeons, as we have observed; and by a late edict, upon the establishment of the Royal Academy of Surgery at Paris, no sur- geon is allowed to practise, and be master of his company, without having taken a master of arts' degree in some university of that kingdom.^ The great Fabricius Hildanus, who flourished in the 15th century at Bern, in Switzer- land, w.-.s physician and surgeon in or- dinary to that illustrious republic, and to the marquis of Baden. He stands at * Vid. Opera I. Friend, M. D. de Historia Medicinnc. f See Histoire de l'Origine & des Progres de la Chirurgie en France. + See Histoire de l'Origine & de Progres de la Chirurgie en France; where great encouragement for the improvement of surgery appears to have been given by royal edicts, in different ages. 264 SURGERY. the head ofthe first class of observators, and should be in the hands of every practitioner. (Chirurgical Works of B. Gooch, vol. 1.) Perhaps, nothing contributed so ma- terially to the improvement of surgical knowledge, as the establishment of the Royal Academy of" Surgery in France; a noble institution, which for a long while gave the French infinite advan- tage over us, in the cultivation of this most useful profession. Indeed, every bne, truly interested in the improve- ment of Surgery, cannot fail to regret the discontinuance of a society, in which emulation and talents were so long united for the benefit of mankind. The various dissertations, published by the illustrious members ofthe acade- my, will serve as a perpetual memorial ofthe spirit, ability, and success, with which the objects of the institution were pursued; and, centuries hence, practitioners shall reap from the pages of its memoirs the most valuable kind of surgical information. Unfortunately, this celebrated establishment, which was overthrown by. the agitation of the French revolution, has had only a very inferior substitute in the Ecole de Sante. Were I to name any one thing, which, in my opinion, would have the greatest influence in giving life to the study and cultivation of Surgery in this country, I should certainly assign such importance to the establishment of an institution in this metropolis, on the same grand, and encouraged plan, as the late Royal Academy of Surgery in France. Within the last twenty, or (hilly years, most important improvements have certainlybecn made in almost every branch of surgery; and, it must gratify eveiy Englishman to find, that his own countrymen have acted a very leading part in effecting an object, in which the interests of mankind in general are so deeply concerned. External aneurisms, which formerly used to prove nearly as fatal as internal ones, are now treated with immense success, by operating upon the plan first suggested by Mr. Hunter, and of late very materially improved by Mr. Abernethy. The doctrines of this dis- ease have also been recently elucidat- ed, with great ability, by professor Scarpa, of Padua. The diseases of the eyes, to which affections English surgeons seemed to pay much less attention, than was be- stowed by foreign practitioners, seem now to obtain due attention in this country. Although we have generally had some distinguished oculists, our surgeons at large have been wonderfully ignorant of this part of their profession, and, uninformed in the subject, they have given up to professed oculists, and quacks, one of the most lucrative and agreeable branches of practice. How- ever, the able writings of Wenzel and Ware begin now to be familiarly known among practitioners: and the observa- tions of Scarpa, Richter, Wardrop, &.c. will soon have immense effect in diffusing in the profession a due know- ledge of the numerous diseases, to wliich the organs of vision are liable. Before Mr. Hunter, our ideas ofthe venereal disease were surrounded with absurdities; and it is to this luminary that we are in an eminent degree in- debted, for the increased discrimina- tion, and reason, which now prevail, both in the doctrines and treatment of the malady. Strictures in the urethra, an equally common and distressing complaint, were not well treated of, before Mr. Hunter published on the venereal dis- ease; and the infinite advantage of armed bougies, in the treatment, has been subsequently described by Mr. Home. I must not omit to mention, among the most modem improvements in sur- gical science and practice, the disco- veries of Dr. Jones, relative to the sub- ject of hemorrhage. Very important practical inferences are to be drawn from his experiments. Ruptures, those common afflictions, in every country, have in modem times received highly interesting elucidations from the labours of Camper, A. Cooper, Hey, Gimbernat, &c. The treatment of injuries ofthe head has been materially improved by Ques- nay, Le Dran, Pott, Abernethy, 8tc. The disease of the vertebrae, which occasions paralysis ofthe limbs, form- erly always baffled the practitioner; but, the method piop>sedby Mr. Pott, is now frequently found productive of considerable relief, and sometimes of a perfect cure. The mode of treating lumbar ab- scesses has been rendered much more successful, than formerly, and, for this change, the world is greatly indebted to Mr. Abernethy. SUTURES. 265 The almost infallible plan of curing hydroceles, by an injection, in the way described by Sir James Earle, may also be enumerated among the recent im- provements. I shall conclude this article with no- ticing the increasing aversion to the employment of the gorget in litho- tomy, and the many distinguished ad- vocates for the use of a common scalpel in this operation. These latter circum- stances I hail as propitious omens of very beneficial changes in this part of Surgery. SUPPURATIVES, (from suppuro, to suppurate.) Suppurantia. Medicines, or rather applications, which promote the formation of good pus. SUSPENSORY, (from suspendeo, to suspend.) Suspensor. A bandage for containing, and supporting the scro- tum; a bag-truss. Bandages of this kind are now usually sold at the shops, and seldom made by surgeons themselves; therefore, a particular description of them is not essential in this work. In cases of hernia humoralis, varicocele, cirsocele, some particular ruptures, and several other affections of the testicle, and spermatic chord, a suspensory ban- dage is of infinite service. SUTURES, (from suo, to sew.) A suture, in surgey, means a mode of uniting the edges of a wound, by keep- ing them in contact with stitches. Mr. Sharp remarks, that, " when a wound is recent, and the parts of it are divided by a sharp instrument, with- out any further violence, and, in such manner, that they may be made to ap- proach each other," by being returned with the hands, they will, if held in close contact for sometime, reunite by inosculation, and cement, like one branch of a tree ingrafted on another. To maintain them in this situation, se- veral sorts of sutures have been invent- ed, and formerly practised, but the number of them has, of late, been very much reduced. Those now chiefly de- scribed are the interrupted, the glover's, the quilled, the twisted, and the dry, su- tures; but,-the interrupted and twisted are almost the only useful ones, for the quilled suture is never preferable to the interrupted; the dry suture is ri- diculous in terms, since it is only apiece of plaster, applied in many different ways, to reunite the lips of a wound. And the glover's, or uninterrupted stitch, which is recommended in super- ficial wounds, to prevent the deformity of a scar, does rather, by the frequency of the stitches, occasion it, and is therefore to be rejected, in favour of a compress and sticking plaster." (Oper. of Surgery.) The twisted suture is de- scribed in speaking of the harelip; and gastroraphe, which also properly belongs t& the present subject, forms a distinct article in this Dictionary. INTERRUPTED SUTURE. The wound being cleansed from all clots" of blood, and its lips being brought evenly into contact, the nee- dle, armed with a ligature, is to be *" carefully carried from without, inwards to the bottom, and so on from within outwards. Care must be taken to make the puncture far enough from the edge of the wound, lest the ligature sliould tear quite through the skin and flesh. This distance, accordingto Mi Sharp, may be three, or four tenths of an inch. The other stitches required are only repetitions of the same process. The threads having been all passed, you are in general to begin tying them in the middle of the wound; though, if the lips be held carefully together, (says Mr. S ha >•;->,) it will not tie of great consequence, which stitch is tied first. (See Operations of Surgery, chap. 1.) Surgical writers in general state, that the number of stitches must, in a great measure, depend upon the ex- tent of the wound. The common rule is, that one suture is sufficient for every inch of the wound; but, that, in some instances, a stitch must be more frequently made, particularly when a wound gapes very much, in conse- quence of a transverse division of mus- cles. As we have already explained^ it is necessary to pierce the skin, at a sufficient distance from the sides of the wound, lest the thread should cult through the flesh in a short time: but, though Mr. Sharp lays down the ne- cessary distance, in general, as three, or four tenths of an inch, and others advise the needle to be always car- ried through the deepest part of the wound, we must receive these direc- tions, particularly the last, as subject to numerous exceptions. When a wound is very deep, it would be con- spicuously absurd, and even, in many instances, dangerous, to drive the nee- dle through a vast thickness of parts. Other wounds, of considerable length, might not be, in some places, four Vol. II. 2 L 266 SUTURES. tenths of an inch deep; though it is true, sutures could never be requisite at such points. The needles for making the inter- rupted suture will pass, with the greutest facility, when their shape cor- responds exactly with the segment of a circle, and they should always form a track, of sufficient size, to allow the ligatures, which they draw after them, to pass through the flesh with the ut- most ease. The interrupted suture obviously re- ceives its name from the interspaces between the stitches; and it is the one most frequently employed. Its action is always to be assisted, and supported, either with the uniting bandage, (see Bandage,) or with strips of adhesive plaster, compresses, 8cc. QUILLED SUTURE. As Mr. John Bell has observed: " when the wound was deep among the muscular flesh, the old surgeons imagined, that so large a wound could not be commanded by the common in- terrupted suture; however deep the stitches might be driven among the flesh; they were, besides, fearful of using the continued (glover's) suture in deep gashes, lest the wound should be made to adhere superficially, while it was still open within, forming perhaps a suppuration, or deep collec- tion of matter. They believed, that a deep muscular wound could not be safely healed, without a degree of sup- puration; while they wished to bring it together at the bottom, they were afraid to close it very exactly at the mouth, lest the matter should be col- lected in the deeper parts of the wound; it was, for this purpose (says Mr. John Bell) that they used, what they called the compound, or quilled su- ture. It is merely the interrupted su- ture, with this difference, that the li- gatures are not tied over the face of the wound, but over two quills, or rolls of plaster, or bougies, which are laid along the sides of the wound. In per- forming this suture, we make first two, three, or four stitches, of the in- terrupted suture very deep, and then, all the ligatures being put in, we lay two bougies along the sides of the wound, then slip one bougie into the loop ofthe ligatures on one side, draw- ing all the ligatures from the other side, (Mr. Bell should rather have said towards the other side,) till that bou- gie is firmly braced down. Next we lay the other bougie, and make the knots of each ligature over it, and draw it also pretty firm; and thus the li- gatures, in form of an arch, go deep into the bottom ofthe wound, and hold it close, while the bougies, or quills, keep the middle ofthe wound, and lips of it pressed together, with moderate closeness, and prevent any strain upon the threads, or any coarse and painful tying across the face of the wound." In a note Mr. J. Bell says, that Dionis violently reprobates the quilled suture; but, that De la Faye (the annotator on Dionis) says, it is good for deep mus- cular wounds. The quilled suture is now scarcely ever employed; nor has it any advantages, except, perhaps, in some wounds of the belly. (See Prin- ciples of Surgery, vol. 1, p. 50.) I think the reader will more easily comprehend the manner of making the quilled suture, by directing it to be done as follows: Take as many nee- dles, as stitches intended to be made; arm them with a double ligature, or one capable of being readily split into two; introduce the ligatures through the wound; cut off the needles; lay a piece of bougie along one side of the wound, and tie the ends of the liga- tures over it. Next draw the other ex- tremities ofthe ligatures, so as to bring the first piece of bougie into close contact with the flesh; lay the second piece of bougie along the opposite side of the wound, and tie the other ends of the ligatures over it, with sufficient tightness. GLOVER'S SUTURE. This had also the name of the con- tinued suture. It was executed by in- troducing the needle first into one lip of the wound, from within outwards, then into the other in the same way; and, in this manner fhe whole track of the wound was sewed up. The glover's suture has long been rejected by all good surgeons, as im- proper to be employed in cases of com- mon wounds. It was not, however, till very lately, that this suture was totally abandoned; for, Mr. Sharp, and seve- ral eminent writers, since his time, have advised its adoption in wounds of the stomach and intestines. From what we have said in the articles Abdomen and Hernia, the reader will perceive, SUTURES. 267 that even in such particular instances, the glover's suture would not be ad- visable; so that it may, in every point of view, be now considered as totally disused in every case of surgery,which can possibly present itself. When We remember, in making this suture, how many stitches are unavoidable;- how unevenly, and in what a puckered state, the suture drags the edges ofthe skin together; and what irritation it must produce; we can no longer be surpriz- ed, at its now being never practised on the living subject. It is commonly em- ployed for sewing up dead bodies; a purpose for which it is well fitted; but, for the honour of surgery, and the sake of mankind, it is to be hoped, that it will never again be adopted in prac- tice. FALSE, OR DRY SUTURE.. This term signifies the retaining of the edges of wounds in contact, by means of sticking plaster, in various manners, and the expression, as Mr. Sharp has justly remarked, is highly ridiculous, as no kind of sewing is con- cerned with the method. The proper plan of dressing wounds with adhesive plaster, is detailed in describing the treatment of incised wounds. (See Wounds.) Besides the common way of using strips of sticking plaster, some surgeons have been partial to little par- ticularities. Mr. Petit used adhesive plasters, which had in the middle, one, or two holes, or even more, according to the extent ofthe wound. Such open- ings enabled the surgeon not only to see, whether the edges of the wound were in accurate contact, but also in what state they were; and the aper- tures afforded an opportunity for ap- plying to the wound such remedies, as were deemed expedient. However, as when common strips of" adhesive plaster are properly applied, there should generally be left a certain un- covered interspace, between every two, Petit's plan had no particular ad- vantage in this respect. Another method was to take two pieces of adhesive plaster, of a breadth and length proportioned to the extent and depth of the wound. Three, or four ligatures, or tapes, were then fas- tened to one of the edges of each piece of plaster. Both pieces were then warmed, and put on the skin, along the sides of the wound. Then the edges of the cut were evenly brought into contact, and held so by an assistant, until the surgeon confined them per- manently in this position, by tying each two corresponding ligatures, or tapes. A pledget was next applied over the wound, and a longitudinal compress over each plaster. Over these, a large square compress was put, and the whole of the dressings were covered, and supported with a bandage. The following day, it was usual to inspect the wound, and, if the ligatures seem- ed lax, they were tightened; but, if in a proper condition, they were not med- dled with. Sometimes, when much in- flammation and swelling had come on, the ligatures were loosened; and, when these symptoms had abated, the ligatures were tightened again, if ne^- cessary. REMARKS ON THE EMPLOYMENT OF SUTURES. Sutures, by which I mean such as were made with a needle and ligature, were much more frequently employed by the old surgeons, than they are by the moderns. All the best practitioners of the present day, never resort to this method of holding the sides of a wound in contact, except in cases, in which there is a real necessity for it, and other modes will not suffice. There were, indeed, certain in- stances, in which the employment of sutures was long ago forbidden. Of this kind were envenomed wounds, in which accidents, the destruction ofthe poison always formed a principal indi- cation in the treatment. Wounds, ac- companied with considerable inflam- mation, were not deemed proper for the use of sutures, as the stitches have a tendency to increase the inflammato- ry symptoms. Also, as contused wounds necessarily suppurated, and, conse- quently, could not be united, sutures were not recommended for them; nor were they judged expedient for wounds, attended with such a loss of substance, as prevented their lips from being placed in apposition. Wounds, penetrating the chest, were not united by sutures; nor were those, in wfuch large blood-vessels were injured; at least, until all danger of hemorrhage was removed by such vessels being tied. Dionis believed, with several other authors, that wounds should not be united, when bones were exposed, on 268 SUTURES. account of the exfoliations! which might be expected. This precept is no longer valid; for, when bones are nei- ther altered, nor diseased, and are only simply denuded, or divided with a cut- ting instrument, no exfoliations will commonly follow, if the surgeon take care to replace the fresh cut soft parts, so as to cover the exposed portion of the bone. The practicableness of uniting wounds, attended with a division of a bone, is confirmed, by numerous facts. M. de la Peyronie communicated to the Academy of Surgery, in France, a case, which is very conclusive on this point. A man was wounded with a cut- ting instrument, in an oblique direc- tion, on the external and middle part of the arm. The bone was completely cut through, together with the integu- ments and muscles, in such a manner, that the arm only hung by an undivided portion ofthe skin, about an inch wide, under which were the large vessels. M. de la Peyronie tried to unite the parts, being convinced, that it would be time enough to amputate after- wards, if the case should require it. He placed the two extremities of the divided bone in their natural situation; made several sutures for promoting the union of the soft parts; and applied a bandage to the fracture. In this band- age, there were slits, or apertures, over the wound, to allow the dressings to be applied. Spirit of wine, contain- ing a little sal ammoniac, was used as a topical application, and the fore-arm, and hand, which were cold, livid, and insensible, were also fomented with the same. By these means, the natural warmth was restored, and the wound was dressed. In a week, the dressings were removed, through the opening in the bandage; in a fortnight, they were changed, a second time, and the wound seemed disposed to heal. On the eigh- teenth day, the healing had made pro- gress; the part had a natural appear- ance; and the beating of the pulse was very perceptible. M. de la Peyronie qpw substituted a common roller, for the preceding kind of bandage. Care was taken to change the dressings, every ten days. In about seven weeks, all applications were left off, and, at the end of two months, the patient was quite well, with the exception of a Ut- ile numbness in the part. This case is one ofthe most important in all the re- cords of surgery; for, it displays, in a most striking manner, what very bad wounds it is the duty of the surgeon to attempt to unite; and, above all, lt shews us the propriety of attempting to save many compound fractures, which, judged of only from, first ap- pearances, would lead almost any one to resort to amputation. When the di- vided parts, m such cases, have been put into contact, the appearances are quite altered. From what has been already stated; it appears, that surgeons, a considera- ble time back, did not at once sew up every sort of wound- The best modern practitioners employ sutures much less. frequently, than their predecessors. M. Pibrac's dissertation on the abuse of sutures, inserted in the third volume of the Memoirs of the Academy of Surgery, has had considerable effect in producing this change, and I may safe- ly add, this improvement in practice. This judicious, and enlightened practi- tioner opposed the method of uniting wounds by means of sutures, which, he contended, ought never to be adopt- ed in practice, except in certain cases, in which it was absolutely impossible to keep the sides of the wound in con- tact, by the adoption of a proper pos- ture, and the aid of a methodical band- age. Such circumstances M. Pibr.c re- presents, as exceedingly rare, if they can occur at all. He speaks of sutures, as very seldom fulfilling the intention ofthe surgeon, who, in the majority of cases, in which he employs them, finds himself necessitated to remove them, before they have accomplished the wished-for end. M. Pibrac believes, that sutures are generally more hurtful to, than promotive of, the union of wounds; and, that when they succeed, they do not effect a cure more speedi- ly, than a proper bandage. He cites nu^ merous cases of very extensive wounds of the abdomen, neck, &c. for the cure of which a bandage proved effectual, and this even in many instances, in which sutures had previously failed, and cut their way through the flesh. M. Louis adopted the opinions of M. Pibrac, and published, in the fourth volume of the Mem. de I'Acad, de Chi- rurgie, a dissertation, in which he en- deavours to show, that the hare-lip can be better united, by means of the unit- ing bandage, than when sutures are used for the purpose. As far as 1 can judge, the fair state- ment of the matter is, that sutures are, by no means, requisite in the ge- SUTURES. 269 nerality of wounds; but, that there are particular cases, in which, either their greater convenience, or superior effi- cacy, still makes them approved, and employed, by all the most eminent practitioners of the present day. Since sutures cannot be practised, without making additional wounds, and occa- sioning pain, and since the ligatures al- ways act as extraneous bodies in the parts, in which they are introduced, exciting more or less inflammation, and suppuration round them; there can be no doubt, that their employment is invariably wrong, whenever the sides of a wound can be maintained in con- tact by means less irritating. For, what is it which generally counteracts the wishes of the surgeon in such cases, and makes his attempts, to make the opposite surface of wounds grow toge- ther, prove unavailing? Is not the gene- ral cause too high a degree of inflam- mation, which necessarily ends in sup- puration? Are not sutures means ex- ceedingly likely to augment inflamma- tion, both, by the additional wounds of the needles, and the still more pernici- ous irritation of the threads, which al- ways act as foreign bodies, sometimes producing not merely an increase of in- flammation, and suppuration in their track; but, frequently, such ulceration as enables them to cut their way out, or else sloughing of the parts; or, in particular constitutions, a very exten- sive erysipelatous redness round the wound. By the ulcerative process, just men- tioned, sutures very often cease to have the power of any longer keeping the edges of wounds in contact; as the ob- servations of M. Pibrac, and, indeed, what every man may daily remark in practice, fully testify. The violent in- flammatory symptoms, which they ex- cite, frequently obliges the surgeon to cut them, and withdraw them altoge- ther. But, even admitting, that, in the ge- neral adoption of sutures, some wounds would be united, which would not be so, were this means of accomplishing an union (generally speaking) abandon- ed, still it must be allowed, on the other hand, that the cause of some wounds not uniting, is entirely ascriba- ble to the irritation, occasioned by the sutures themselves. Hence, if it be only computed, that as many wounds are prevented from uniting by the irri- tation of sutures, as other wounds. which are united by their means, and could be united by no other methods, we must perceive, that mankind would be no sufferers, and surgery undergo no deterioration, were sutures altoge- ther rejected from practice. I believe, however, that every man, who has had opportunities of observation, and has made use of them, with an unprejudic- ed mind, will feel persuaded, that more wounds are hindered from unit'u.g by sutures, than such as are healed by them, and could not be united by other means. But, prudent practitioners are not obliged, either to condemn or praise, the use of sutures, in every instance, without exception. Men of independ- ent principles will always adopt the line of conduct, which truth points out to them as that which is right; nor will they obstinately side with M. Pibrac and M. Louis, in contending, that su- tures are always improper and disad- vantageous, nor, with other bigoted persons, wbo may use sutures in every kind of wound whatever. Sutures are, perhaps, still rather too much employed, and, in all probability, will long be so. It will be difficult en- , tirely to eradicate the prejudices, on which their too frequent use is found- ed, as long as we see, what may be called, the Maitres de I'Art, holding up the practice for imitation, in every prin- cipal hospital in the kingdom. Such surgeons, however, as are ready to im- bibe fair and candid sentiments on the subject, and to qualify themselves for practising this part of surgery, with judgment, should by no means, neglect to read, both what M. Pibrac and M. Louis, have written on the subject. I know, that the latter authors are a lit- tle too sanguine, in their representa- tions; but, as I have already remarked, sutures are still rather too much used, and something is yet necessary to do away a certain unwarranted habit of" having recourse to them in several par- ticular cases. Nothing will tend to pro- duce this desirable change so much, as the perusal of every argument against the employment of sutures. I am decidedly of opinion, not from what I have read, but, what I have ac- tually seen, that the sides of the gene- rality of wounds are capable of being effectually kept in contact, by means of" a proper position ofthe part, the aid of strips of adhesive plaster, and that of compresses, and bandages. I believe, 270 SUT SYP that such success can be obtained, with every advantage, which can be urged in favour of sutures, and without their disadvantages; such as greater pain, inflammation, &c. I even think, with M. Louis, that the hare-lip could in ge- neral be united very well, by means of a bandage; but, still, I am of opinion, that the twisted suture is attended with least trouble, is most suited for universal practice, and, that, unless such pains were taken, as many practi- tioners would not, and others could never take, the method by bandage would frequently fail. I find it exceedingly difficult to lay down any fixed principles for the guid- ance ofthe surgeon, in respect to when he ought, and when he ought not, to use sutures. Perhaps, sutures should be made use of, for all cuts and wounds, which oc- cur in parts, which are subject to an unusual degree of motion, such as would be apt to derange the operation of bandages, sticking plaster, and com- presses. Hence, the propriety of using the twisted suture for the hare-lip. Sutures are probably, for the most part, advantageous, in all weunds of the abdomen, of a certain length, and attended with hazard of the viscera making a protrusion. In this situation, the continual motion and action of the abdominal muscles, in carrying on re- spiration, besides the tendency of the viscera to protrude, may be a reason in favour of the use of sutures. When two fresh-cut surfaces posi- tively cannot be brought into contact, by sticking plaster, bandages, the ob- servance of a proper posture, &c. there can be no doubt ofthe advantage of us- ing sutures, if they will answer the purpose. Some wounds of the trachea; some wounds made for the cure of cer- tain fistulous communications between the vagina and bladder; or others for the cure of similar affections in the pe- rinsum; afford instances of cases, to which I allude. I observe, that many ofthe best ope- rators in this metropolis, use sutures for bringing the sides ofthe wound to- gether after several operations; such as that of removing a diseased breast; cas- tration; and operations for strangulated hernia. The reason for using sutures in tiie scrotum, I suppose, arises from the difficulty of keeping the edges of the wound in contact, owing to the great quantity, and looseness of the part I cannot pretend to determine, whether, in this case, sutures are really necessa- ry, or not; but, after the amputation of the breast, 1 have no hesitation, in pro- nouncing their employment wrong and injudicious. I shall conclude with referring to what M. Pibrac and M. Louis have written on the above subjects, in Mem- de I'Acad, de Chir. torn. 3 6-4. Sharp, Dionis, Gooch, Le Dran, Bertrandi, Sa- batier, B. Bell, and J. Bell, have all treated of sutures. SYCOMA, (from cn>x»>,afig.) A wail, or excrescence, resembling a fig. SYCOSIS. The same. SYMPATHETIC BUBO. (See Bu- bo.) SYNCHYSIS, (from o-vyxyu, to con- found.) Saint-Yves, and Maitre-Jean, signify by this term a conversion ofthe vitreous and crystalline humours ofthe eye into a viscid, purulent matter, which, in the course of time, assumes the appearance of a yellowish serum. Since the time of the preceding ocu- lists, the term synchysis has been used to denote the confusion ofthe humours of the eye, occasioned by blows, and attended with a rupture of the internal membranes and capsules. (See Ency- clopedic Methodique; Part. Chir. Art. Synchyse.) SYNCOPE, (from o-vywrru, to cut down.) A sudden prostration of the vi- tal powers; a fainting fit. SYNOVIA, (a term of no radical meaning, and invented by Paracel- sus.) The fluid, secreted in joints, for the purpose of lubricating the articular surfaces. SYNTASIS, (from trvvruvu, to ex- tend.) A distension of parts by a swel- ling. SYNTHESIS, (from o-w, together; and 6f position, situation.) A gene- ric term, formerly much used in the schools of surgery, and comprehend- ing every operation, by which parts, which had been divided, were reu- nited. SYNTHETISMUS, (from e-wBfa to concur.) The reduction of a fracture. SYNULOTICA, (from o-i/mxoa, to cicatrise.) Medicines, or applications, which promote the cicatrization of wounds. SYPHILIS, (is fabulously said to be derived from the name of a shep- herd, who fed the flock of King Alci- nous, and who from pride insulted the Sun, whence the disease was sent on TAL earth as a punishment) Lues Venerea.' The venereal disease; others write Si- philis, and derive the term from o-iifxos, filthy. (See Venereal Disease.) SYR1NGOTOMUM, (from cvgiyl, a fistula, and n^a, to cut.) A kind of concealed knife for dividing fistulae, and sinuses. Figures of it may be seen in Scultetus, and Fabricius ab Aquapen- TER 271 dente. It was constructed in various ways; but, as it is not at present em- ployed by surgeons, it would be a waste of time to introduce a description of its different forms. SYSTOLE, (from ow7ix*«, to con- tract.) The contractile motion of the heart and arteries. X BANDAGE. A bandage, so nam- ed from its figure. It is principally used for supporting the dressings, after the operation for the fistula in ano, in dis- eases of the perinaeum, and those of the groins, anus, &c. It is composed of two longitudinal pieces of cloth, of greater, or lesser breadth, according as occasion requires. The transverse piece of cloth serves to go round the body above the hips; the perpendicular piece is sewed, at one of its ends, to the mid- dle ofthe latter; and in general, its other is slit into two portions, or tails, about six, or eight inches long. The perpendi- cular piece of the T bandage applies it- self between the glutaei muscles, and to the perinaeum; while its two ends, just described, are to be carried be- tween the thighs and the pudenda, to the right and left, and fastened to the transverse piece, surrounding the body. Besides the common T bandage, there is another one named double, which has two perpendicular pieces, sewed to the transverse one, about four inches ap;'rt The double T bandage is said to be more particularly applicable after li- thotomy, and for diseases ofthe peri- naeum; because, one may make the two perpendicular pieces cross each other on the part affected, and leave the anus uncovered; an advantage, which the simple T bandage certainly has not.— The T bandage may be used in some other ways, as we have noticed, in making mention of it in the article Bandage. TABES, (from tabeo, to consume.) A wasting of the body, attended with extreme debility and hectic fever. TALPA, (amole.) A tumour, which creeps under the skin, as a mole under the surface ofthe ground. Such is the etymology. It is often applied to an encysted tumour, which forms on the head, and contains a paplike matter.— (See Atheroma and Tumours Encysted.) TALPARIA. The same. TAPPING. See Paracentesis. TARAXIS, (from rxgxa-a-u, to dis- turb.) A slight ophthalmy, or inflamma- tion of the eye. TAXIS, (from rxo-o-a, to put in or- der.) The operation of reducing a her- nia with the hand. (See Hernia.) TELEPHIUM. In surgery means a malignant, dangerous ulcer, difficult of cure. The word is derived from Tele- phus, who received a mortal wound from Achilles, which injury, it is said, became, before death, a disease of the above description. TENDO ACHILL1S. See Achilles, Tendon of. TENESMUS, (from Tt.-v», to stretch.) A painful, ineffectual, and repeated, effort to go to stool. TENT. A roll of lint for dilating openings, sinuses, &c. (See Spongia Praparata.) TEREBELLA, (dim. of terebra, a perforating instrument) A trepan, or instrument for sawing out circular por- tions of the skull. A trephine. TEREBRA, (from rtgta, to bore.) A trepan, or trephine. Also an instru- ment called a perforator, such as is contained, in the generality of cases of trephining instruments, and is used for making a hole, in which the centre-pin ofthe trephine is to work. TERETRUM. The same. TERMINTHUS, from rtgftnBoe, a pine-nut.) A large tumour, or painful pustule on the skin, resembling a pine- nut. 272 TESTICLE. TESTICLE, DISEASES OF. For an account of many of these affections, I must refer the reader to distinct arti- cles in this Dictionary; for instance, Cirsocele, Hernia Humoralis, Hamato- eek, Hydrocele, &c. I shall next insert Mr. Pott's account of Sarcocek; but, before I do so, it seems proper to ob- serve, that, when this author uses the epithet scirrhous, he frequently seems to attach no other signification to it, than indurated. Indeed, any one, in the least acquainted with the subject, would readily discern, that Mr. Pott could not always mean the malignant tumour, or hardness, which is often named the occult cancer. SARCOCELE. " This (says Pott) is a disease ofthe body of the testicle; and, as the term implies, consists, in general, in such an alteration, made in the structure of it, as produces a resemblance to a hard fleshy substance, instead of that fine, soft, vascular texture, of which it is, in a natural and healthy state, com- posed. " The ancient writers have made a great number of distinctions ofthe dif- ferent kinds of this disease, according to its different appearances, and ac- cording to the mildness or malignity of the symptoms, with which it may chance to be attended. Thus, the sar- cocele, the hydro-sarcocele, the scir- rhus, the cancer, the caro adnata ad tes- tem, and the caro adnata ad vasa, which are really little more than descrip- tions of different states arid circum- stances of the same disease, are reck- oned as so many different complaints, requiring a variety of treatment, and deriving their origin from a variety of different humours. " Every species of sarcocele consists primarily in an enlargement, indura- tion, and obstruction of the vascular part of the testicle; but this alteration is, in different people, attended with such a variety of circumstances, as to produce several different appearances; and to occasion the many distinctions which have been made. " If the body of the testicle, though enlarged and indurated to some de- gree, be perfectly equal in its surface, void of pain, has no appearance of fluid in its tunica vaginalis, and produces very little uneasiness, except what is occasioned by its mere weight, it is usually called a simple sarcocele, or an indolent scirrhus. If, at the same time that the testis is enlarged and harden- ed, there be a palpable accumulation of fluid in the vaginal coat, the disease has by many been named a hydro-sarco- cele. If the lower part ofthe spermatic vessels and the epididymis were en- larged, hard, and knotty, they supposed it to be a fungous or morbid accretion, and called it the caro adnata ad vasa: if the testicle itself was unequal in its surface, but at the same time not pain- ful, they distinguished it by the title of caro adnata ad testem: If it was tolera- bly equal, not very painful, nor fre- quently so, but at the same time hard and large, they gave it the appellation of an occult or benign cancer: if it was ulcerated, subject to frequent acute pain, to hemorrhage, &c. it was known by that of a malignant or confirmed can- cer. These different appearances, though distinguished by different ti- tles, are reatly no more than so many stages (as it were) ofthe same kind of disease: and depend a great deal on se- veral accidental circumstances; such as age, habit, manner of living, &c. It is true, that many people pass several years with this disease, under its most favourable appearances, and without encountering any of its worst; but on the other hand, there are many, who, in a very short space of time, run through all its stages. They who are most conversant with it, know how very convertible its mildest symptoms are into its most dreadful ones; and how very short a space of time often intervenes between the one and the other. " There is hardly any disease, af- fecting the human body, which is sub- ject to more variety than this is, both with regard to its first manner of ap- pearance, and the changes which it may undergo. " Sometimes the first appearance is a mere simple enlargement and indu- ration of the body ofthe testicle; void of pain, without inequality of surface, and producing no uneasiness, nor in- convenience, except what is occasioned by its mere weight. And some few people are so fortunate, to have it re- main in this state for a very considera- ble length_ of time, without visible or material alteration. On the other hand, it sometimes happens, that, very soon after its appearance in this mild man- ner, it suddenly becomes unequal, and TESTICLE. 27 J knotty, and is attended with very acute pains, darting'up to the loins and back; but stUl remaining entire, that is, not bursting through the integuments. Sometimes the fury of the disease brooks no restraint; but making its way through all the membranes which envelope the testicle, it either pro- duces a large, foul, stinking, phage- denic ulcer with hard edges; or it thrusts forth a painful gleeting fungus, subject to frequent hemorrhage. " Sometimes (as I have already ob- served) an accumulation of water is made in the tunica vaginalis, produ- cing that mixed appearance, called the hydro-sarcocele. " Sometimes there is no fluid at all in the cavity of the tunica vaginalis; but the body of the testicle itself is formed into cells, containing either a turbid kind of water, a bloody sanies, or a purulent, fetid matter. " Sometimes the disorder seems to be merely local, that is, confined to the testicle, not proceeding from a tainted habit, nor accompanied with diseased viscera; the patient having all the ge- neral appearances and circumstances of health, and deriving his local mis- chief from an external injury. At other times, a pallid, leaden countenance, indigestion, frequent nausea, colic pains, sudden purgings, &c. sufficient- ly indicate a vitiated habit, and diseas- ed viscera; which diseased viscera may also sometimes be discovered and felt. " The progress also which it makes from the testis upward, toward the process, is very uncertain; the disease occupying the testicle only, without affecting the spermatic process, in some subjects, for a great length of time, while in others, it totally spoils the testicle very soon; and almost as soon seizes on the spermatic chord.* " These, and some other circum- stances to be mentioned hereafter, are materially necessary to be observed; as they characterise the disease, point out its particular nature and disposi- tion, and serve as marks whereon to found our judgment and prognostic of the most probable event, as well as the mosfy>roper method of treatment. Va- rious have been the causes, to which theoretic and whimsical people have assigned this disease; but as a recital of conjectures can convey no instruc- tion or useful information, 1 shall pass them over; and only take notice, that among the great number which have been mentioned, there are two which, though equally groundless with tho rest, have yet obtained a degree of cre- dit, that may mislead: these two are the hernia humoralis, and the hydro- cele ofthe vaginal tunic. " The hernia humoralis (continues Pott) is a defluxion of the inflammato- ry kind, proceeding most frequently from an irritation in that part of the urethra, where the vasa deferentia, or vesiculac seminales terminate/"" It is at- tended with pain and heat, and most frequently fever: during the first, or inflamed state ofthe disease, the whole compages of the testicle is enlarged; but when by rest,e vacuation, and proper applications, that inflammation is calm- ed, there seldom or never remains, ei- ther fulness,hardness,or any other mark of disease in the glandular part of the testis. The epididymis indeed seldom escapes so well; that often continues enlarged and indurated for a consider- able space of time, but without produ- cing either pain or inconvenience; and without occasioning any alteration in the figure or structure of what is call- ed the body of the testicle; whereas the true sarcocele, or hernia carnosa, most commonly^ begins by an indolent induration of that part of the testis, and affects the epididymis secondarily; or after it has already spoiled the vas- cular part of the gland. " I would not be understood to mean, (says Pott) that a sarcocele * This is the common language, and therefore I use it; but I would not be un- derstood to mean, that the progress ofthe disease is always and invariably up- ward, from the testis into the process. I have seen the spermatic process truly cancerous, when the testicle has been free from disease; and am well satisfied from experience, that a diseased state of the vessels within the abdomen, or of the parts in connexion with those vessels, may produce a morbid state of the process, proceeding downwards from thence: but the other is by much the most frequent. (Pott.) \ This may be doubted.—5*. C. ■ I say most commonly, because it is neither necessarily, nor always. Vol. II. 2M 274 TESTICLE. never follows a hernia humoralis; there is no reason in nature why it should not: a hernia humoralis does not, nor can prevent the testicle, in any future time, from becoming scir- rhous: I only say, that it does nrt, at any time, necessarily cause or produce it. So also with regard to the epididy- mis, 1 do not mean to say, that it never is the primary and original seat of a scirrhus: I know that it is, and shall produce some instances of it; neither do I intend to say, that a scirrhus never attacks an epididymis, which has been previously hardened by a hernia humo- ralis; there can be no reason why it should not: I only mean to signify, that it is my opinion, that the induration caused by a venereal hernia humoralis does not, at any time, necessarily pro- duce a scirrhus. A scirrhus indeed may fall on that part, after it has been so diseased; but it would as certainly have attacked it, if there had been no pre- ceding affection of it " There is also a venereal affection ofthe testicle, independent of a gonor- rhea, or of any disease ofthe urethra. " This is seldom an early symptom; and I do not remember (observes Pott) ever to have seen an instance, in which it was not immediately preceded, or ac- companied, by some other appearance, plainly venereal. It has neither the in- equality, nor darting pains of the scir- rhus, and always gives way to a mer- curial process properly conducted. " A quantity of water is frequently collected in the vaginal eoat of a truly scirrhous testis. This has given rise to the supposition, that the testicle often becomes diseased, from its being sur- rounded by, or swimming in the same fluid: a supposition entirely ground- less. " That scirrhous and cancerous tes- tes very frequently are found to have a quantity of fluid accumulated in the tunica vaginalis of them, is beyond all doubt; but that such testicles become diseased, in consequence of being sur- rounded by such fluid, or, in other words, that a simple hydrocele may produce a scirrhous testicle, is by no means true. " The simple lrydrocele is a collec- tion of water in the tunica vaginalis: this fluid, in a natural and healthy- state of the parts, is small in quantity, and, by being constantly absorbed, does not distend the cavity of the tu- nic, but only serves to keep that mem- brane from contracting any unnatural cohesion with the tunica albuginea.— The regular absorption of this fluid be- ing by some means prevented, the quantity soon becomes considerable, and distending its containing bag, con- stitutes the disease called a hydro- cele; but makes no morbid alteration in the structure of the testicle.-"- (See Hydrocele.) " When the testicle becomes en- larged in size, hardened in texture, cr:>ggy and unequal in its surface, pain- ful upon or after having been handled, attended with irregular pains shooting up the groin toward the back, and this without any previous inflammation, dis- ease, or injury from external violence, it is said to be affected with a scirrhus. This, as I have already remarked, is of different kinds anddegrees,and appears under different forms; but, although the appearances, which the disease makes, are various, according to the alteration produced by it in the testi- cle, yet, every such morbid alteration may obstruct or prevent the regular absorption ofthe fluid deposited in the vaginal tunic, and Occasion a species of hydrocele; that is, a tumour from water. " This is that kind of disease,which, by Fabricius ab Aquapendente, is call- ed hydro-sarcocele; but which is so very unlike to a simple hydrocele, that whoever mistakes the one for the other, will commit an error, which may prove very mischievous to his pa- tient, and very detrimental to him- self. " In the true, simple hydrocele, the testis, though somewhat loosened in its texture, and a little enlarged, yet preserves very nearly its natural form; the collection is made without pain or uneasiness, and very soon becomes suf- ficient to hide, or conceal, the testicle; nor is the examination of such tumour I That is, no such alteration as renders it painful, or incapable of executing its Office; and consequently, no such alteration as can ever require extirpation or' any other chirurgical operation on the testicle itself. TESTICLE. 275 attended with any pain: but the in- creased size, and hardened state, of the scirrhous testis, renders it disco- verable, through a much larger quan- tity of fluid than will totally conceal the former. When felt, it will be found to be hard, and somewhat unequal, and not unfrequently attended with irregu- lar shooting pains, especially after hav- ing been examined. " In the simple hydrocele, the fluid distends the tunica vaginalis so equally, that, although it does not surround the testicle, (nor indeed can) yet it seems so to do: whereas in the hydro-sarco- cele, though the anterior part of the tumour may, in some measure, bear the appearance of a simple hydrocele; yet, an examination of its posterior part will always discover the true nature of the case: to which may be added, that, under the same apparent magnitude, the latter will always be found to be considerably heavier than the former. " In short, the name of this species of disease (hydro-sarcocele) is un- doubtedly a very proper one, and capa- ble of conveying a very just idea of its true nature, viz. an accumulation or collection of water in the vaginal coat of a scirrhous or diseased testicle; but the majority of writers have, by sup- posing the water to be the cause, in- stead of the consequence of the dis- eased state of the testis, committed a very material blunder, and endeavour- ed to establish and authorise a very prejudicial and destructive method of practice. For, by conceiving, that the noxious quality of the fluid produces a fungous or fleshy excrescence on the surface of the testicle, they have sup- posed, that, after having discharged the said fluid from its containing bag, they could, either by establishing a suppuration, or by using escharotic me- dicines, waste or destroy the said-ex- crescence, and obtain a radical cure of the whole disease. Now the scirrhosity of the testicle being the original dis- ease, and the extravasation a mere ac- cident, such treatment can never do any material good, and may often be the cause of very essential evil. " Fabricius ab Aquapendente has given a particular description of this method, which he recommends, from having practised it with success: his words are; ' Modus singular is est quan- do hernia aquosa cum carnosd mista est; tuncenimprimum incide, et facforamen in parte scroti qua non sit declivis, neque in fundo scroti, sed circa medium; nee fac admodum latum: et extracta aqua, turundam impone quam longissimam, medicamento, pus moventi infect am, ut resina terebinthina, cum thure, ovi vitello, et butyro; emplastrum emolliens, et pus movens applka, ut diachylon cum gum- mis, et axungia porci: genitum autem, pus, non evacuetur per foramen, sed data opera intus servetur, ut contactu suo, car- nem sensim putrefaciat. Neque innovanda medicamenta, nisi tota caro fuerit in pus conversa; id quod longo fit tempore."* " Now, to pass over the absurdity of the doctrine of removing or dissolving a fungous excrescence, by means ofthe putrefying quality of matter: as well as the great disturbance, which must be the consequence of confining it within the tunica vaginalis; it is very clear from these, and from every other circumstance attending the disease in question, that the cases, which Fabri- cius had successfully made his experi- ments upon, must have been mere sim- ple hydroceles, attended with a small degree of enlargement; but without any diseased state of the testicle. " There is one method of procuring a radical cure of the said disease: a me- thod in use, before Fabricius practised it; and still in some measure employed: a method, which, in some instances, has always been successful; and which may, in general, be tried on any simple hydrocele, in a young and healthy sub- ject. The cure (when it effects one) is not brought about by the destruction of an excrescence from the testicle, or the dissolution of its supposed indura- tion; but merely by exciting such an inflammation, as shall occasion an ad- hesion of the tunica vaginalis to the tunica albuginea; by which means, the cavity of the former is obliterated; the testicle remaining, as to size and con- sistence, just as it was before such operation was performed. But this, * " Si carnosa, et aquosa sit hernia, ego talem adhibeo curam: Seco cutem, et incisionem facio exiguam, et in loco potius altiore, quam in fundo: inde turunda imposita cum digestivoet pus movente medicamento diutius procedo, neque un- quam pus extraho, sed perpetuobonam partem intus rclinquo; quod sensim caT nem corrodit, et ita sanat" 276 . TESTICLE. though practicable, and sometimes successful in the hydrocele, is not to be thought of* in the diseased or scir- rhous t-stlcle. The operation, as de- scribed by'Aquapendente, consists of two points; first to let out the water, and then to cause a plentiful suppura- tion. When the testicle is really and prim.irily diseased, and the extravasa- tion is a consequence of such disease, the discharge of the water from the cavity of the tunica vaginalis, whether by puncture, or by incision, can contri- bute nothing material toward a cure of the principal complaint, and is therefore useless; but it may, in many cases, do harm, by creating a disturbance in parts, whose state requires the- most perfect quietude; and is therefore wrong. When the disease is a mere simple hydrocele, the palliative cure, as it is called, by puncture, is right and necessary; it renders the life ofthe pa- tient easy; rids him, every now and then, of a very troublesome burden; is perfectly safe; may be performed and repeated occasionally, at any time of the patient's life, or in almost any state of the disease: but the introduction of tents or setons, or the endeavour by any means to excite inflammation, or to es- tablish suppuration within the tunica vaginalis, requires (even in the simple hydrocele, where the testicle is unaf- fected) some little consideration, and ought not to be hastily or unadvisedly put in practice. " In some ages, habits, &e. the symptoms will ri6e very high, and oc- casion both trouble and hazard: and if this be the c.se, when the testis is not at all diseased, and when there is no malignity, either in the local complaint, or in the habit of the patient; what have we not to fear where there is both? where the parts are already spoiled by disease, ai.d where irritation and inflammation may (and do) excite the most fatiguing symptoms, and the most direful consequences? " Beside the hydro-sarcocele, or lim- pid extravasation of fluid, in the cavity of the vaginal coat, (and wliich must therefore always be external to the testicle) scirrhous and cancerous testes are liable to collections of fluid, within the substance of them, under the tuni- ca albuginea. These are sometimes large, and in one cavity; sometimes small, and in several distinct ones. They are also very different in nature, in different cases; sometimes serous. sometimes sanious; sometimes puru- lent, sometimes bloody. These are very apt to impose on the inadvertent and injudicious; (especially if they be at- tended with some degree of inflamma- tion in the skin;) and to induce an opi- nion of an abscess, or imposthumation, which may be relieved or cured by an opening;—but caveat operator. These collections will be found to bear a much smaller proportion to the general size of the tumour, than they who are not conversant with them are inclined to apprehend; the subsidence, after the opening has been made, will also be much smaller than was expected; and, instead of relief and ease, all the symp- toms of pain, swelling, inflammation, &c. will be increased and aggravated: and if the opening be considerable, it not unfrequently happens, that an ill- natured fungus is thrust forth; which, by bleeding, gleeting, and being hor- ridly painful, disappoints the surgeon, and renders the state of the patient much more deplorable than it was be- fore: neither is this sensation, which is thought, like the fluctuation of a fluid within the testicle, to lie at all times depended upon as implying that there is any fluid at all there." The touch, in this case, is subject to great deception; and I have seen a loosened texture of the whole vascular structure, or body of the testicle, produce a sensation so like to the fluctuation of a fluid lying deep, as has imposed on persons of good judgment, and great caution. " Many of the most esteemed wri- ters on this part of surgery, either not being practitioners, or being afraid to differ from those who have written be- fore them, have lazily and servilely co- pied each other, and have thereby fal- len into an obscure jargon concerning this disease, which neither themselves nor tbeir readers have understood. They have talked of the scirrhous tes- ticle, the caro adnata ad testem, and the caro adnata ad spermatica vasa, as so many different diseases, requiring different methods of treatment. " The melancholia, the atra bilis, and a certain inexplicable adust state of humours, are said to be the causes of the different appearances; and the fleshy substance arising from, or ad- hering to, the spermatic vessels, is said to be more benign, than either the fun- gus arising from the testicle, or the true scirrhus. For the first, they have described an operation, which is TESTICLE. 277 coarse, cruet, painful, and (notwith- standing all that they have said about it) unsuccessful; all which they must have known, if they had practised it. I therefore am much inclined to believe, that this is one ofthe many parts of an- cient surgery, which having been de- vised by some one bold, hardy operator, and by him described as practicable, has been related by many of his suc- cessors, as practised. The second, the caro adnata ad testem, they allow to be attended with more difficulty, as well as hazard, and seldom to be attempted with success. " They, who are under a necessity of forming their opinions principally from books, and who have not frequent opportunities of knowing from experi- ence how very little they are (in many cases) to be depended upon, maybe in- clined to think, that all these distinc- tions really exist; and that these ope- rations by fire and sword, by knives and cauteries, so exactly described, must be sometimes necessary; but having never seen the particular cases requir- ing such treatment, have a very imper- fect idea, either of them, or of ihe operations; and are, to the last degree, alarmed and intimidated, when any thing, which they think is like to it, oc- curs to them in practice. To such, it may not be amiss to explain this mat- ter, in as few words as I can; begging pardon of* the more intelligent reader for the digression. " In the short anatomical account which I have given of these parts, I have taken no notice, that the spermatic ves- sels terminate in the testicle: and that, after the semen has been secreted from the blood, it passes from that gland into a body, which seems super- added to, although it be really continu- ous with it. This body is therefore call- ed the epididymis, and is so placed, with regard to the testis, that a heed- less or uninformed observer may sup- pose, that the spermatic vessels termi- nate in it; especially if it be enlarged by disease. It takes its rise from the testicle, by a number of vessels, called, from their office, vasa efferentia: these soon become one tube, which, being convoluted and contorted in a most wonderful manner, forms the greater part ofthe said body: and at last, ceas- ing to be so convoluted, it ends in one firm canal, called the vas deferens; by which, the secreted semen is conveyed from the testicle to the vesiculx semi- nales. " Whoever will attentively consider the epididymis in /its natural position, with regard to the testicle and the sper- matic vessels, will see, that if it be en- larged beyond its proper size, it will extend itself upward, in such-a manner as to seem to be closely connected with them, and to bear the resemblance of a diseased body, springing from them. " This is the case called the caro ad- nata ad vasa spermatica; and is really and truly nothing more, than the en- largement of the epididymis; a circum- stance, which occurs not infrequently, but does not imply any malignity, ei- ther in the part or in the patient's ha- bit; and can never require such a hor- rid operation as our forefathers have directed us to perform upon it; nor in- deed any at all. " The epididymis is frequently en- larged, in venereal cases, either sepa- rately, as in the remains of a hernia hu- moralis, or together with the testicle, in that affection of it, which I have called the venereal sarcocele $ and sometimes from mere relaxation of its natural texture, without any disease at all. But in none of these can it require, or even admit any manual operation of any kind. Indeed, whoever will consider the epididymis, as it really is, as the medium by and through which the se- men is conveyed from the testicle to the vas deferens, must immediately be sen- sible ofthe glaring absurdity of remov- ing* any part of it. '« The scirrhus and cancer do not very often begin in this part; they most frequently make the first attack on the body ofthe testis: and, though, the epi- didymis is often cancerous, yet it most frequently becomes so secondarily, or after the testicle is spoiled; so that the removal of it, if practicable, could serve no good purpose: it would not remove the disease; for that has, before-hand, most commonly taken possession ofthe testicle; and the cutting off any part of a scirrhous or cancerous tumour of any kind, is what no man, who has the least knowledge of what he is about. will ever think of. " In short, these two cases, which by the inattention and misrepresentation of our ancestors, have created such per plexity in the minds of their readers. are either a simple enlargement ofthe epididymis, without any morbid altera- 278 TESTICLE. lion in its structure; or a diseased (that is, a scirrhous") state of the same part; or else, a scirrhous or cancerous testi- cle, with inequality of surface. The first of these requires no manual opera- tion of any kind; and the two last will admit of none: the first is no disease at all; and the two last are such diseases, that every attempt made on them, by knife or caustic, (unless for total extir- pation) must render them worse, and more intractable. " The manner of treating a sarco- cele, or hernia carnosa, depends entire- ly on the particular nature and state of each individual case. In some, it will admit of palliation only; in others, the disease may be eradicated by the ex- tirpation ofthe part: so that, under the article of method of cure, we have only to consider, and point out, as clearly as the nature of the disease will permit, what states and circumstances, both of it, and of the patient labouring under ' it, forbid the operation, and what ren- der it advisable. " On this head, a great variety of opi- nions will be found among writers; so great, that a man, who is under a ne- cessity of forming his judgment from •hem, will find himself under somedif- nculty how to act; and so great, that I cannot help thinking it to be clear, that the majority have not written from practice, but from mere conjecture, or from the works of those, wfio have gone before them. "Some have given it as their opi- nion, that while the testicle is perfectly indolent, (let the alteration in its struc- iure, form, or consistence, be what it may,) it is better to suffer it to remain, than to remove it. In support of this opinion, they say, that although the disease has plainly taken possession of the part, yet, while it causes no pain, ihe constitution receives no damage from it; nor is the health ofthe patient impaired by it; whereas, by removing Uie testicle, the same virus may seize on some part-of more consequence to life. This nu-thod of reasoning takes for granted two things, which do not ap- pear to be strictly or constantly true, viz. that this disease is never perfectly local; and that a scirrhous testicle, though free from pain, will not in time produce any evil to the general habit of the patient. Otiiers advise us to stay until the tumour becomes painful, and manifestly increases in size, or acquires a sensible inequality,of surface; that is (mother words) until it begins to alter from a quiet state, to a malign one; which advice, as well as the preceding, supposes, that the hazard of the mere operation of castration is too great to render it an advisable thing, until the patient is pressed by bad symptoms; and that a scirrhous testicle, which has been quiet and free from pain for some time, may be as successfully extirpated after it has become painful, and has ac- quired a malignant and threatening state, as at any time before such altera- tion. The latter of these will hardly be admitted (I believe) by those, who form their opinions from experience; and with regard to the former, I can, with great truth, affirm, that I never saw the mere operation of castration, when performed in time, and on a pro- per subject, prove fatal. " Many people have I known, who have lived several years, their whole lives, perfectly free from disease, after the removal of quiet, indolent, scirrhous testicle; and several have I known, who having deferred the operation un- til they are urged by pain, increase of size, and inequality of the tumour, have, from the sore becoming cancer- ous, not been able to obtain a cure. That I have seen the same thing hap- pen, after the removal of a testicle, cir- cumstanced in tlie best manner, is be- yond all doubt; but not near so fre- quently, as in those cases, in which the operation has been deferred until the symptoms became alarming, and the disease had changed its appearance, from a benign quiet one, to one that was malign and painful. Indeed, were we capable of knowing with certainty which those scirrhi were, that would remain quiet and inoffensive through life, or for a great length of time, and which would not, we should then be enabled to advise or dissuade the ope- ration upon much better (that is, much surer) grounds, than at present we are able to do. We have no such degree of knowledge; all our judgment is formed upon the mere recollection of what has happened to others in nearly similar circumstances; and experience, though the best general guide, is, in these cases, more fallacious than in manv others. "A few people there certainly have been, who have been so fortunate as to cany a scirrhous testicle through many years, with little or no pain or trouble- but the number of those, in whom time TESTICLE. 279 (and that frequently a short space,) change of constitution, external acci- dental injury, Jkc. do not make such an alteration in this disease, as to render the operation less likely to be success- ful, than it would have been at first, and under more favourable circum- stances, is so small, that I think early castration (that is, as soon as the dis- ease is fairly formed and characteriz- ed) may be recommended and practis- ed by every honest and judicious sur- geon. " Indeed, the circumstances of fre- quent pain, and a manifest tendency to an increase of size, are by some people looked on as such marks of a malignant disposition, that they have been by them reckoned as dissuasives from the operation. " But these* gentlemen carry their fears and apprehensions much too far the other way. Pain and a quick in- crease of size are certainly no favoura- ble symptoms; they show a disposition to mischief; but, they are not such po- sitive proofs of a cancereous habit, as to render all hope of a cure, from the removal of the diseased part, vain: there are many instances to the contra- ry: and though no honest or judicious man will venture to promise success, even in the most favourable of these eases, yet it is well known, that they which have had very unpromising ap- pearances, not only from the state ofthe testicle, but from that of the spermatic 'chord, have succeeded ofteruenough, to make the chance of a cure, by the operation, by no means a desperate one. The state of a man left to his fate in these circumstances, that is, to the fu- ry and progress of the disease, is so truly miserable, that nothing should be left unattempted, which carries with it any probability of being serviceable: and a practitioner is vindicable, in pressing what he has known to be suc- cessful; though, at tlie same time, he ought to make a guarded kind of prog- nostic. " Upon the whole, I think it may justly be said, that the man who has the misfortune to be afflicted with a truly scirrhous testicle, has very little chance (notwithstanding all that has been said and written about specifics) to get rid of it by any means, but by extirpation: and all the time the operation is defer- red, he carries about him a part not only useless and burthensomc, but which is every ady liable, from many circumstances (both external and inter- nal) to become worse, and more unfit for such operation. "While the testicle is small, and free from acute or frequent pain, the ves- sels from which it is dependent, are most frequently soft, and free from dis- ease; whereas, when the testis has been suffered to attain a considerable size, the case is frequently otherwise; the spermatic vessels are often large and varicose; and the cellular mem- brane investing them sometimes be- comes thick, and contracts such con- nexions and adhesions, which, though they may not amount to an absolute prohibition ofthe operation, do yet ren- der it tedious, troublesome, and more hazardous than it would be in other circumstances. Every addition to the original complaint in the body of the gland is against the patient; and if any of these are the consequence of not hav- ing removed it in time, it will follow, that the sooner it is removed, the bet- ter. If we wait for what some call indi- cations of the necessity of operating, we shall often stay until it will do no good. Many a one have I seen lose a very probable chance of a cme by de- lay: but I do not remember ever to have seen a testicle removed, by a man of judgment, which testicle did not, upon examination, fully vindicate the extir- pation. If we were possessed of any medicines, either external or internal, which had been known now and then to have dissolved scirrhi, it would always be right to recommend the trial of them previous to an operation; and it would always be right to defer operating until such trial had been made. But the truth is, we know no such medicine.— The credulous on the one hand, and the designing on the other, have told us many strange stories of cures effected by such applications and remedies; and I do most sincerely wish, that what each of them have said was true: but repeated, faithful experience has prov- ed, that it is not; and that they who have placed their confidence in them, or laid their money out on them, have been disappointed and cheated. " Some circumstances there are now and then attending this disease, which are out of our sight and out of our knowledge, and which will render all our pains abortive: such are tuber- cles, indurations, and other diseased appearances in the cellular membrane enveloping the spermatic vessels with- in the abdomen; scirrhous viscera, kc. If any of these can be known, they 280 TESTICLE constitute a good reason for not at- tempting the cure by the operation; but the mere possibility that such may exist, is certainly no reason for ab- -t..ining from it: the apparent evil, that is, the"diseased testis, is certain; the other mayor may not be the case: the one, if left to itself, is most likely to destroy the patient in a most miserable anil tedious manner; and the other, the suspected mischief, may possibly not exist " But though the timely and proper removal of a scirrhous or cancerous testicle does frequently secure to the patient life, health, and ease, which, in such circumstances, are not attain- able by any other means; yet it must be remarked, that the improper and un- timely performance of the operation is not only not attended with such happy and salutary event, but generally brings on high symptoms, and quick destruc- tion. It therefore behoves every prac- titioner to be perfectly well acquainted, not only with such circumstances as render castration practicable and ad- visable, but with those which prohibit such attempt. " These are of two kinds, and re- late either to the general habit of the patient, and the disorders and indispo- sitions ofsome ofthe viscera, or to the state ofthe testicle and spermatic chord " A pale, sallow complexion, in those who used to look otherwise; a wan countenance, and loss of" appetite and flesh, without any acute disorder; a fever of the hectic kind; and frequent pain in the back and bowels, are, in those who' are afflicted with a scir- rhous testicle, such circumstances as would induce a suspicion of some la- tent mischief, and incline one to sup- pose that the same kind ofvirus.which had apparently spoiled the testis, may also have exerted its malign influence m: some ofthe viscera; in which case, success from the mere removal of the 'esticle is not to be expected. They, whose constitutions are spoiled by de- bauchery and intemperance, previous ■o their being attacked with this dis- ease; who have bard livers, and anasar- cous limbs, are not proper subjects for such an operation. Hard tumours with- in the abdomen in the regions of the liver, spleen, kidneys, or mesentery, implying a diseased state of the said viscera, are very material objections to '.he removal of the local evil in the : VoV-1.11. In short, whenever 1 !:•.■»v are manifest appearances, or symptoms < » a truly diseased state of any of the prin- cipal viscera, the success of the opera- tion becomes very doubtful; more especially, if such symptoms and ap- pearances, upon being properly treated, resist in such manner, as to make it most probable, that a cancerous virus is the real cause of them. When none of these require our attention, the ob- ject of consideration is the testicle and its spermatic vessels. The state of the mere testis can hardly ever be any ob- jection to the operation; the sole consi- deration is the spermatic chord: if this be in a natural state, and free from dis- ease, the operation not only may, but ought to be performed, let the condition of the testicle be what it may: if the spermatic chord be really diseased, the operation ought not to be attempted. For although, on the one hand, a pro- bability of success will vindicate an attempt, even though it should fail; yet, on the other, where there is no- such probability, an operation, though per- formed in the most dextrous manner, will prove only a more ingenious me- thod of tormenting. " This, therefore, (the state of the spermatic chord) is a matter, which may require our most serious conside- ration; since, on this it is (when the disease appears to be local) that we must found our judgment; and by this must form our resolution, either to leave a man to the truly miserable fate of being slowly, though certainly, de- stroyed, by a cruelly painful, and fre- quently very offensive disease; or en- deavour to save, and preserve him in health and ease, by means, which have so often proved successful, as truly to deserve the appellation of probable. " All writers on this subject, agree in saying, that if the spermatic process has partaken of the diseased state of the testicle, that is, has become en- larged and hardened, and such en- largement and induration extends it- self quite to the abdominal muscle, that the operation of castration ought not to be performed, because it will not only prove successless, but will hasten the death of the patient. And this is, in some degree, most certainly true; but not without some limitation. A truly and absolutely diseased state of the spermatic chord, in any part of it, is certainly a very material objection to the operation, as it most commonly proves a bar to the success of it: and a - TESTICLE. 281 morbid state of the same chord quite as high as the abdominal muscle, that is, of all that part of it, which is exter- nal to the cavity of the belly, is a just and full prohibition against such at- tempt. But, on the other hand, it must be observed, that every apparently morbid alteration of the spermatic chord is not really such; and, therefore, that every enlargement, induration, fulness, &c. which seems to alter the spermatic vessels from that state, which is called a healthy and natural one, is not to be regarded as a disease; at least, not as such a disease as is suf- ficient to prohibit the attempt to obtain a cure by extirpation. " The difference between these, it is the duty of every practitioner to be- come perfectly acquainted with, as it is from a consideration of these, that he ought to determine, whether he may, with that firmness and assurance, which the probable expectation of suc- cess will give him, propose and advise castration; or find himself obliged in conscience to dissuade, or refuse, the performance of it. " When the spermatic vessels are not only turgid and full, but firm and hard; when the membrane, which in- vests and connects them, has lost its natural softness and cellular texture, and has contracted such a state, and such adhesions, as not only greatly to exceed its natural size, but to become unequal, knotty, and painful, upon be- ing handled, and this state has possess- ed all that part of the chord, which is between the opening in the oblique muscle and the testicle, no prudent, judicious, or humane man, will attempt the operation; because he will, most certainly, not only do no good to his patient, but will bring on such symp- toms as will most rapidly, as well as painfully, destroy him. Of this, there are so many proofs, that the truth of it is incontestible. " In some modern French books,we have, indeed, miraculous accounts of operations of this kind, performed by dividing the tendon of the oblique mus- cle, by tracing the diseased spermatic vessels within the cavity of the belly, and there making the ligature and in- cision: but these are operations, wliich make a figure in books only, and are performed only by visionary writers; or, if ever they have been practised; serve to show the rashness and insen- sibility of the operators, much more than their judgment, or humanity. Whoever (notwithstandingthese tales) performs the operation in the circum- stances above mentioned, will prove himself much more hardy than judi- cious; and will destroy his patient, without having the satisfaction of think- ing that his attempt, though success- less, was yet vindicable; the only cir- cumstance which can, in such events, give comfort to a man, who thinks rightly. " On the other hand, as I have al- ready said, every enlargement of the spermatic chord is not of this kind, nor by any means sufficient to prohibit or prevent the operation. " These alterations, or enlarge- ments, arise from two causes, viz. a varicose dilatation of the spermatic vein, and a collection, or collections, of fluid in the membrane investing and enveloping the said vessels. In thejfirst place, as there is no reason in nature why a testicle, whose vessels have previously (for some time perhaps), been in a varicose state, should not become scirrhous; so it is also clear, that the scirrhosity seizing such testi- cle will by no means remove, or even lessen such varicose dilatation of the vessels from which it is dependent; on the contrary, will, most probably, and indeed does most frequently, increase such distension: but such mere vari- cose enlargement of the vessels, whe- ther it be previous or consequential to the morbid state of the testis, does not, nor ought to prevent the removal of it, if otherwise fit and right. It is, indeed, an objection to the doctrine of M. Le Dran, and a few other writers, who make no ligature on the chord, and trust to a slight contusion of it be- tween the finger and thumb for a sup- pression ofthe hemorrhage; butis none to the rest of the operation, as I can, from experience, testify. " In the next place, the diseased state of a truly scirrhous testicle, its weight, and the alteration that must be made in the due and proper circu- lation ofthe blood, through both it and the vessels from which it is dependent, may and do concur in inducing a vari- cose dilatation of the spermatic vein, without producing that knotty, morbid alteration and hardness, which forbid our attempts. Between these, a judi- cious and experienced examiner will generally be able to distinguish. " In the former (the truly diseased Vol. II. 2 N 282 TESTICLE. state,) the chord is not only enlarged, but feels unequally hard and knotty; the parts of which it is composed are undistinguishably blended together; it is either immediately painful to the touch, or becomes so, soon after being examined; the patient complains of fre- quent panis shooting up through his groin into his back; and from the dis- eased state of the membrane compo- sing the tunica communis, such adhe- sions and connexions are sometimes contracted, as either fix the process in the groin, or render it difficult to get the finger and thumb quite round it. " In the other (the mere varicose distention,) the vessels, though consi- derably enlarged and dilated, are ne- vertheless smooth, soft, and compres- sible; the whole process is loose and free, and will easily permit the fingers of an examiner to go quite round it, and to distinguish the parts of which it is composed; it is not painful to the touch; nor does the examination of it produce, or occasion, those darting pains, which almost always attend handling a process malignantly indu- rated. " I do not say, that the distinction between these two states is always and invariably to be made; but that it often may, I know from repeated experience: and that the operation may safely be attempted, and successfully be per- formed, I know from the same experi- ence. The state of a man, left to the mercy of a malignant scirrhus, is so truly deplorable, that we cannot be too attentive in examining the precise na- ture of each individual case, and in embracing every opportunity of giving him that relief, which it may at one time be in our power to give, and which, the lucky opportunity missed, it may never.be in his power again to receive. " The other circumstance which I have mentioned as capable of deceiving an operator, and inducing him to be- lieve, that the spermatic chord is much more diseased than it really is, and thereby deterring him from the per- formance of an operation, which might prove successful, is the extravasation, or collection of fluid in the cellular membrane enveloping the spermatic vessels, between the abdominal open- ing and the testis. " In t*be cellular membrane, leading to a diseased testicle, it is no very un- common thing to find collections of ex- travasated fluid. These, as they add considerably to the bulk, and apparent size ofthe process, make the complaint appear more terrible; and, as I have just said, less likely to admit relief. " When this extravasation is gene- ral, through all the cells of the invest- ing membrane, and the spermatic ves- sels themselves are hardened, knotty, and diseased, the case is without re- medy; for, although a puncture, or an incision, will undoubtedly give dis- charge to some, or even 'the greatest part ofthe fluid; vet. this extravasation is so small, and so insignificant acircum- stance ofthe disease, that the parts, in this state, are so little capable of bear- ing irritation, that an attempt of this kind must be ineffectual, and may prove mischievous. " But, on the other hand, collec- tions of water are sometimes made in the same membrane, from an obstruc- tion to the proper circulation through the numerous lymphatics in the sper- matic process, while the vessels them- selves are really not diseased, and therefore very capable of permitting the operation. In this case, the fluid is generally in one cyst, o»bag, like to an encysted hydrocele, and the sper- matic chord, cyst and all, are easily moveable from side to side; contrary to the preceding state, in which the general load in the membrane fixes the, whole process, and renders it almost immoveable. " A discharge of the fluid will, in this case, enable the operator to ex- amine the true state of the process, and, as I have twice or thrice seen, put it into his power to free his patient from one of the most terrible calami- ties which can befal a man. " There is one more circumstance relative to the scirrhous testicle.which appears to me to be worth attending to, as I cannot help thinking that it has misled many, who have not had suffi- cient opportunity of comparing theory with practice. " J It has been confidently asserted and is generally believed, that a scir! rhous testicle never begins in the epidi- dymis of the said testicle. The conse- quence of this doctrine is, that when a disease, which affects a testicle, bv enlargmg and hardening it, makes its first attack on the epididymis only, such disease is not allowed to be a scirrhus nor permitted ta be treated as such ' TESTICLE. 28.3 "' That inflammatory kind of tu- mour, which, in the virulent gonor- rhoea, seizes the testicle, and is called the hernia humoralis, affects the epi- didymis; and, even under the best care, sometimes leaves it too large, and too hard. This is said never to end in, or produce a scirrhus; and, I do not re- collect, that I have ever known it to do so. The disease, which consists in an induration and enlargement of the whole testicle, in the more confirmed lues, affects the epididymis also, as well as the glandular part of the testi- cle; and I do not remember to have seen it, either become cancerous, or not yield to mercury, properly admin- istered. But that a true scirrhus, or cancer, sometimes makes its first at- tack on the epididymis, which it alters and spoils, before it at all affects the testicle, is a truth of which I have not the least doubt. Among others, I for- merly believed the contrary doctrine; and, in the first edition of this book, have given it as my opinion: but I am, from experience, so perfectly convin- ced of the truth of what I have now asserted, that I think myself obliged , to declare it. The mistake, I suppose to have been made by the first propa- gators of this opinion, thus: The her- nia humoralis, and the venereal sar- cocele, always enlarge the epididymis, and generally leave it somewhat too hard: both these have, by adventurous and unknowing people, been mista- ken for scirrhi; but it being found, by experience, that these alterations in the epididymis, were either totally re- moved by medicine, or, if any part re- mained, it continued harmless through life; an inference was drawn, that as true scirrhi are not often either re- moved by medicine, or continue harm- less, therefore an original affection of the epididymis could never be a true scirrhus: a deduction, which the pre- mises do not by any means authorise; and which I am satisfied, is not true." (Extract from Pott's Treatise on the Hydrocele, C-rc.) In the preceding remarks, we find, that Pott considered sarcocele and can- cer of the testicle, only as different stages of the same disease; but, I am of opinion, that the only reason for this doctrine must have been built on the fact now so well established, that every kindof swelling is liable to be eventu- ally converted into cancer. The obser- vations of Mr. Home, particularly il- lustrate the truth ofthe latter remark. SCIRRHUS AND CANCER OF THE TESTICLE. Dr. Baillie has noticed, that the tes: tide is often found much enlarged in its size, and changed into a hard mass, of a brownish colour, which is gene- rally more or less intersected by mem- brane. In this disease, there is no ves- tige ofthe natural structure; but, cells are frequently observable in it, con- taining a sanious fluid; and, sometimes, there is a mixture of cartilage. Dr. Baillie considers this state as the true scirrhous testicle; and, according to the progress of the disease, the epidi- dymis, and spermatic chord, are more or less, or not at all affected. A foul deep ulcer is, at length, frequently formed, or else a fungus is thrown out, when it is called, the true cancer of the testicle. This affection is charac- terized, in the bving subject, by its great hardness; the frequent pain in the part darting from it along the sper- matic chord to the loins. The chord it- self, at last, becomes diseased, and the health impaired. The ulcer and fungus form additional symptoms. (See Baillk's Morbid Anatomy.) SOFT CANCER OF THE TESTICLE. This part is very subject to a disease, which, though of a very malignant and incurable nature, is very different from the true cancer, already described. It has been particularly noticed by Mr. Abernethy, under the name of Medul- lary Sarcoma. In most of the instances, which this gentleman has -seen, the tumour when examined after removal, has appeared to be of a whitish colour, resembling, on a general and distant inspection, the appearance of the brain, and having a pulpy consistence. Mr. Abernethy has also often seen it of a brownish red appearance The follow- ing case is related, to illustrate the nature and progress of the disease. " A tall, thin, healthy-looking man, of about forty years of age, had, about fifteen years before, a swelled testicle from a gonorrhoea; the epididymis re- mained indurated. Six years afterwards it became enlarged, and a hydrocele at the same time formed. Half a pint of water was discharged by a puncture, / 284 TESTICLE. but inflammation succeeded the opera- tion, and this testis became veiy large. An abscess formed, and burst in the front of the scrotum, and the testis subsided in some degree. .Mercury was employed to reduce it, but with- out effect. The part, however, was in- dolent, and gave the patient no trouble but from its bulk. " About a year afterwards, a gland enlarged in the left groin (the same side as the testis:) another then be- came swoln in the right groin, and, in the course of two years, several glands in each groin had obtained a very con- siderable magnitude. At this period, he was admitted into St. Bartholomew's Hospital, under the care of Mr. Long. The testis was, at this time, between four or five inches in length, and about three in breadth; it resembled its natu- ral form, and was indolent in its dispo- sition. The spermatic chord was thick- ened, but not much indurated. Four or five glands were enlarged in the groin on both sides; each of which was ofthe size of a very large orange; and, when observed together, they formed a tu- mour of very uncommon shape and magnitude. " They gradually increased in size for several months, till at last the skin appeared as if unable to contain them any longer. It became thin, inflamed, and ulcerated, first in the left groin, and thus exposed one of the most pro- minent tumours. The exposed tumour inflamed and sloughed progressively, till it entirely came way. As the slough- ing exposed its vessels, which were large, they bled profusely, insomuch that the students endeavoured, but in vain, to secure them by ligatures: for the substance of the tumour was cut through, and torn away in the attempt. Pressure by the finger, continued for some time, was the only effectual mode of restraining this hemorrhage. " The loss of one gland relieved the distended skin, which had only ulce- rated on the most prominent part of the tumour, and had not become dis- eased. It now lost its inflamed aspect granulations formed, and a cicatrix took place. In the opposite groin a si- milar occurrence happened. One gland, exposed by the ulceration of the skin sloughed out, being attended by the circumstances just recited. However, before the skin was cicatrized, ulcera- tion had again taken place in the right groin, m consequence ofthe great dis- tension of the skin from the growth of the tumour; and sloughing had begun in the tumour, when the patient, whose vital powers had long been greatly ex- hausted, died." (See Surgical Observa- tions, Crc 1804, by J. Abernethy, F. R. S- &c.) SCROPHULA OF THE TESTICLE. This part is sometimes converted in- to a truly scrophulous mass. It is usu- ally enlarged, and, when cut into, a white, or yellowish-white curdly sub- stance is seen, which is sometimes, more or less, mixed with pus.This affec- tion may be distinguished from a scir- rhous testicle by its greater softness, by the little pain felt in it, and by its not affecting the health so much. (See Bail- lie's Morbid Anatomy.) Mr. Pott has regarded every kind of sarcocele as demanding an early per- formance of castration;'and the obser- vations which I have had opportunities of making, lead me to agree with this celebrated writer, in the general truth ofthe remark. But (setting out of consi- deration the swelling and hardness aris- ing from the common hernia humoralis) there are a few diseased enlargements ofthe testicle, which certainly do fre- quently diminish and remain m a st-te which does not at all impairtlie health, alter taking cicuta, and other altera- tive medicines, wearing a suspensory, and rubbing mercurial ointment on the scrotum. Many of such cases I have suspected to be scrophulous diseases. Dr. Bailie has noticed some other af- fections ofthe testicle, in which it be- comes bony, cartilaginous, &c.; but, on these it is not necessary for us to dwell in this Dictionaiy. The preceding ob- servations may be considered as relat- ing expressly to the diseases for which castration is generally performed. See Castration. FUNGUS OF THE TESTICLE. In a former wdrk, I described "a particular affection of the testicle, in which a fungus grows from the glan- dular substance of this body, and, in tunica albuginea. This excrescence is "heSt^0-ded by a" -l-iment of TES TET 285 fungus gradually protrudes." I then proceeded to represent how unnecessa- ry and improper it was to extirpate the testicle, on account of this affection, if, after the subsidence of the inflamma- tion, the part should not seem much en- larged and indurated. I recommended the fungus to be cut off", or else destroy- ed with caustic; and I founded my ad- vice on a successful attempt of the first kind, which was made in St. Bartholo- mew's Hospital, by Sir James Earle, a little while before my book was pub- lished. (See First Lines of the Practice of Surgery, p. 399.) Since this period an interesting little paper has been written on the subject, by my friend Mr. Lawrence, who has favoured the public with a more parti- cular account, and nine cases, illustra- tive ofthe causes, symptoms, and pro- gress of the disorder. According to Mr. Lawrence, the patient generally assigns some blow, or other injury, as the cause ofthe complaint; in other in- stances, it originates in consequence of the hernia humoralis from gonorrhoea, and sometimes appears spontaneously. A painful swelling ofthe gland, parti- cularly characterized by its hardness, is the first appearance of the disease. After acertain length of time, the scro- tum, growing gradually thinner, ulce- rates; but, the opening, which is thus formed, instead of discharging matter, gives issue to a firm, and generally in- sensible fungus. The surrounding in- teguments and cellular substance, are thickened and indurated by the com- plaint, so that there appears to be alto- gether a considerable mass of disease. The pain abates, and the swelling sub- sides considerably, when the scrotum has given way. In this state, the disor- der appears very indolent; but, if the fungus be destroyed by any means, the integuments come together, and a ci- catrix ensues, which is inseparably connected with the testicle. Mr. Law- rence next informs us, that if the part be examined while the fungus still remains, the excrescence is found to have its origin in the glandular substance of the testicle itself; that the coats of the part are destroyed to a certain extent; and that a protru- sion of the tubuli seminiferi, takes place through the aperture thus form- ed. Mr. Lawrence says, he has often ascertained the continuity of the excre- scences with tlie pulpy substance of the testicle, of which more or less re- mains, according to the difference in the period of the disorder. The same gentleman thinks, that the glandular part ofthe testicle experiences an in- flammatory affection in the first in- stance, inconsequence ofthe violence inflicted on it; and that the confine- ment ofthe swollen substance, by the dense and unyielding tunica albuginea, sufficiently explains the peculiar hard- ness ofthe tumour, and the pain which is always attendant on this stage ofthe disorder. The absorption of the coats ofthe testis, and ofthe scrotum, obvi- ates the tension ofthe parts, and, there- by, restores ease to the patient, at the same time that the fungus makes its ap- pearance externally. With regard to the treatment, Mr. Lawrence is of opinion, that, if the complaint were entirely left to itself, the swelling would probably subside, the fungus shrink, and a complete cure ensue, without any professional assis- tance; but, he adds, that the disorder is so indolent in this stage, that a spon- taneous cure would not be accomplish- ed till after much time. He says, that the excrescence may be removed with a knife, or, if the nature of its attach- ment permit, with a ligature; or that it may be destroyed with escharotic ap- plications. Mr. Lawrence very judici- ously gives the preference to removing the tumour to a level with the scrotum, by means of the knife, as the most expe- ditious and effectual mode of treatment. He can discern no ground whatever for proposing castration in this malady, since, \n no part of its progress, nor in any of its possible consequences and effects, can it expose the patient to the slightest risk. Mr. Lawrence also mentions the possibility of there being other kinds of funguses, which may be met with, growing from the testicle, and quotes an instance, in which Mr. Macartney found a fungus, of a firm and dense structure, growing from the tunica al- buginea, while all the substance ofthe testicle itself was sound. Mr. Macart- ney was so kind as to show me the pre- paration, affording a clear specimen of the second kind of fungus. The cases drawn up by Mr. Lawrence are, in my opinion, highly interesting^ and may be read in the Edinb. Med. and Surgical Journal for July, 1806. TETANUS, (fromTtivw, to stretch.) A violent spasmodic contraction of the muscles, which are concerned in the 286 TETANUS. elevation ofthe lower jaw, and which extends, more or less, to all the mus- cles destined to perform voluntary mo- tion. This disorder, which may be ex- cited by different causes, is much more common in warm climates .than our own. However, it sometimes occurs among us, especially in consequence of wounds, and, more particularly, after such injuries of tendinous and liga- mentous parts. It is one ofthe most fa- tal symptoms, which can possibly arise in these cases, and, therefore, demands the most assiduous attention ofthe sur- geon. Dr. Cullen remarks, that, " tetanic complaints may, from certain causes, occur in every climate that we arc ac- quainted with; but they occur most frequently in the warmest climates, and, most commonly in the warmest seasons of such climates. These com- plaints affect all ages, sexes, tempera- ments, and complexions. The causes from whence they commonly proceed, are cold and moisture applied to the body while it is very warm, and espe- cially the sudden vicissitudes of heat and cold. Or, the disease is produced by punctures, lacerations, or other lesions of nerves in any part ofthe body. There are, probably some other causes of this disease; but, they are neither distinctly known nor well ascertained. Though the causes mentioned do, upon occa- sion, affect all sorts of persons, they seem, however to attack persons of middle age more frequently than the older or younger, the mate sex more frequently than the female, and the ro- bust and vigorous more frequently, than the weaker. " If the disease proceed from cold, it commonly comes on in a few days after the application of such cold; but, if it arise from a puncture, or other lesion of a nerve, the disease does not com- monly come on for many days after the lesion has happened, very often when there is neither pain nor uneasiness, re- maining in the wounded, or hurt part, and, very frequently, when the wound has been entirely healed up. "* The disease sometimes comes on suddenly to a violent degree; but, more generally, it approaches by slow de- grees to its violent state. In this case, it comes on with a sense of stiffness in the back part of the neck, which, gradually increasing, renders the mo- tion of the head difficult and painful. As the rigidity of the neck comes on, and increases, there is commonly t at the same time, a sense of uneasiness felt about the root of the tongue; which, by degrees, becomes a difficul- ty of swallowing, and, at length, an en- tire interruption of it. While the rigi- dity of the neck goes on increasing, there arises a pain, often violent, at the lower end ofthe sternum, and from thence shooting into the back. When this pain arises, all the muscles of the neck, and particularly those of the back part of it, are immediately affect- ed with spasm, pulling the head strongly backwards. At the same time, the muscles that pull up the lower jaw, which, upon the first approaches ofthe disease, were affected with some spas- tic rigidity, are now generally affected with more violent spasm, and set the teeth so closely together, that they do not admit ofthe smallestopening. " This is what has been named the locked jaw ( Trismus,) and is often the principal part of the disease. When the disease has advanced thus far, the pain at the bottom ofthe sternum re- turns very frequently, and with it, the spasms ofthe hind-neck and lower jaw, are renewed, with violence and much pain. As the disease thus proceeds, a greater number of muscles come to be affected with spasms. After those of the neck, those along the whole ofthe spine become affected, bending the trunk ofthe body strongly backwards; and this is what lias been named the Opisthotonos- " In the lower extremities, both the flexor and extensor muscles are com- monly at the same time affected, and keep the limbs rigidly extended. Though the extensors of the head and back are usually the most strongly af- fected, yet the flexors, or those mus- cles of the neck that pull the head for- ward, and the muscles that should pull down the lower jaw, are often at the same time strongly affected with spasm. During the whole of the dis- ease, the abdominal muscles are vio- lently affected with spasm, so that the belly is strongly retracted, and feels as hard as a piece of board. " At length, the flexors of the head and trunk become so strongly affected as to balance the extensors, and to keep the head and trunk straight, and rigidly extended, incapable of being moved in any way; and, it is to this state the term of Tetanus has been strictly ap- plied. At the same time, the arms, lit- TETANUS. 287 tie affected before, are now rigidly ex- tended; the whole of the muscles be- longing to them being affected with spasms, except those that move the fingers, which often to the last retain borne mobility. The tongue also long retains its mobility;'but, at length, it also becomes affected with spasms, which, attacking certain of its muscles only, often thrust it violently out be- tween the teeth. " At the height of the disease, eve- ry organ of voluntary motion seems to be affected, and, amongst the rest, the muscles of the face. The forehead is drawn up into furrows; the eyes, some- times distorted, are commonly rigid and immoveable in their sockets; the nose is drawn up, and the cheeks are drawn backwards towards the ears, so that the whole countenance expresses the most violent grinning. Under these universal spasms, a violent convulsion comes on, and puts an end to life. " The spasms are every where at- tended with most violent pains. The utmost violence of spasm is, however, not constant; but, after subsisting for a minute or two, the muscles admit of some remission ot their contraction, al- though of no such relaxation, as can allow the action of their antagonists. This remission of contraction gives also some remission of pain; but nei- ther is of long duration. From time to time, the violent contractions and pains are renewed, sometimes every ten, or fifteen minutes, and that often without any evident exciting cause. But, such exciting causes frequently occur; for, almost every attempt to motion, as at- tempting a change of posture, endea- vouring to swallow, and even to speak, sometimes gives occasion to a renewal of the spasms over the whole body. " The attacks of this disease are seldom attended with any fever. When the spasms are general and violent, the pulse is contracted, hurried, and irre- gular; and the respiration is affected in like manner; but, during the remission, both the pulse and respiration usually return to their natural state. The heat ofthe body is commonly not increased; frequently the face is pale, with a cold sweat upon it; and, very often, the ex- tremities are cold, with a cold sweat over the whole body. When, however, the spasms are frequent and violent, the pulse is sometimes more full and frequent, than natural; the face is flushed, and a warm sweat is forced out over the whole body. " Although fever be not a constant attendant of this disease, especially when arising from a lesion of nerves; yet, in those cases, proceeding from cold, a fever sometimes has super- vened, and is said to have been attend- ed with inflammatory symptoms. Blood has often been drawn in this disease; but, it never exhibits any inflammatory crust; and all accounts seem to agree, that the blood drawn seems to be of a looser texture, than ordinary, and that it does not coagulate in the usual man- ner. " In this disease, the head is seldom affected with delirium, or even confu- sion of thought, till the last stage of it; when, by the repeated shocks of a vio- lent distemper, every function of the system is greatly disordered. " It is no less extraordinary, that, in this violent disease, the natural func- tions are not either immediately, or considerably affected. Vomitings some- times appear early in the disease; but commonly they are not continued; and it is usual enough for the appetite of hunger to remain through the whole course of" the disease; and what food happens to be taken down, seems to be regularly enough digested. The excre- tions are sometimes affected, but not always. The urine is sometimes sup- pressed, or is voided with difficulty and pain. The belly is costive; but, as we have hardly any accounts, except- ing of those cases, in which opiates have been largely employed, it is un- certain, whether the costiveness has been the effect of the opiates or of the disease. In several ^instances of this disease, a miliary eruption has appear- ed upon the skin, but whether this be a symptom of the disease, or the effect of a certain treatment of it, is undeter- mined, hi the mean while, it has not been observed to denote either safety or danger, or to have any effect in changing the course of the distem- per."—(First Lines of the Practice of Physic, volt 3-) Besides trismus, or the locked jaw, and opisthotonos, there are two other varieties, or forms, of tetanus, men- tioned by authors, viz. emprosthotonos, in which the body is bent by the spasms forward; and pleurosthotonos, in which it is drawn to one side. Sauvages term- ed the latter case Tetanus Lateralis. 288 TETANUS. With respect to the emprosthotonos, and pleurosthotonos, they are in mo- dern times exceedingly uncommon. The first is so frequently mentioned by ancient authors, however, that there can be no doubt of its having been for- merly seen. Hippocrates has taken notice of te- tanic affections, in several parts of his works, and be seems to regard the dis- order only as a consequence of other diseases, or of wounds or ulcers of the nervous or tendinous pails, of which symptomatic kind of* opisthotonos he gives three remarkable cases in lib. 5. § 7. de Morb. Vulg. and repeats them in another place; but some of the symp- toms, which he relates, are said not to be now observed. Galen, Ccelius Aure- lianus, Aretaeus, &c. seem only to have eopied Hippocrates, with the addition of some suppositious symptoms, which really do not appear. The account given by Bontius is also deemed very defec- tive. Dr. Lionel Chalmers, of Charles- ton, South Carolina, states, that when the disease forms very quickly, and invades the unfortunate person with the whole train of its mischievous symptoms, in a few hours, the danger is proportioned to the rapidity of the attack, and that patients thus seized, generally die in 24, 36, or 48 hours, and very rarely survive the third day. But, when the disease is less acute, few are lost after the ninth, or ele- venth. However, perhaps, this gentle- man's descriptions of the disease in South Carolina may not be altogether applicable to it in our climate. (See Med. Obs. and Inq. vol. 1. p. 92, 93.) Tetanus was generally considered by the ancients as a mortal disease; but, we are now aware, that, until of late years, medical practitioners had no just notions concerning the proper treat- ment, and that since more judicious methods have been practised, many persons, afflicted with tetanus, have recovered. Although the treatment, which has succeeded in some in- stances, has not been found successful in others, yet, the degree of success proves, that the affection is not invaria- bly incurable, and, more modern expe- rience has pointed out additional plans, the efficacy of which entitles them to trial. When tetanus is evidently dependent on the particular state of a wound, practitioners in general agree, that the wounded part should be completely re- moved, whenever such an operation is practicable, or that, at least, all com- munication between the injured place and the brain, should be done away either by making a complete division of the nerves of the part, or destroy- ing them with caustics. However, though such is the precept usually de- livered by surgical authors, there are some strong reasons against the advice being implicitly followed. One of the principal grounds of objection is, that greater success does not attend the treatment of tetanus, when the wound- ed part is amputated or destroyed, than when no operation of this kind is performed. Any man who will take the trouble to consult the cases of te- tanus on record, will find this to be a matter of fact; and, though hypothe- sis may sanction the trial of the plan, experience is not at all in favour of it, when it is judged of, as it ought to be, by the results of numerous cases com- pared together. No practitioner could justifiably amputate, or destroy the wounded part, no one would ever think of such a thing, before the symptoms had, at least, decidedly ev inced the na- ture of the disorder. Could it be known beforehand, that tetanus, which in this country is not a frequent affection, would certainly follow any particular appearances of a wound, then the am- putation, or destruction of it, with caustic, would undoubtedly be proper, and promise to be an effectual preven- tive. But, experience has now fully proved, that such an operation, after tetanus has commenced, does no good whatever, since at least as many have died, when so treated, as others, who have not submitted to the method. If the operation do no good, it must be hurtful, and increase the number of deaths; because limbs must frequently be removed, and a certain proportion of persons, on whom amputation is per- formed on any account, always perish. However, the wounds, which most commonly occasion tetanus, are those of the fingers and toes, and the remo- val and loss of one of these parts is a matter of less importance. Experience has shown, that opium has sometimes been a very efficacious remedy, in cases of tetanus; but, from the same source of knowledge, we also learn, that it can only become a meansof cure, when exhibited in very powerful doses, such, indeed, as would be exceedingly dangerous in any other TETANUS. 289 instances. The common plan has been to give the medicine, at first, in mode- rate doses, and repeat them, every two, or three hours, or, at longer inter- vals, according to circumstances. In this manner, twenty, thirty, forty grains, and even more, have frequently been administered, in the space of four and twenty hours, without any other effect, than that of diminishing a little the spasms and pain; the patient hav- ing neither sleep, nor drowsiness, nor any of the other effects, usually result- ing from this medicine, even when ex- hibited in much smaller quantities. It is, for such reasons, that the doses may be boldly augmented, in proportion as the violence of the symptoms seems to demand. Opium, however, does not fail to have sometimes inconveniences, which prevent its being exhibited as freely as one might wish, under other circumstances. The functions of the stomach and bowels have been Xnown to bt so seriously impaired, in conse- quence ofthe medicine, that its exhibi- tion could be no longer continued, but was left off, before any salutary effects had been produced. Another circumstance, which de- serves particular attention, is, that al- though the first doses of opium may produce some abatement of the symp- toms, the benefit is not of long conti- nuance, and fresh doses of the medi- cine must be administered, some time before the operation of the previous ones ceases. This plan must be perse- vered in, as long as the symptoms have any tendency to re-appear; and it is not, till some time after they have seemed to be subdued, and to have left the pa- tient in a long and uninterrupted inter- val of ease, that one should venture to diminish either the quantity, or num- ber of the doses of the medicine. Opium is sometimes prevented from being taken, in an effectual manner, by the difficulty of swallowiug, which is a common symptom of this disease, and occurs particularly often, when the disorder is in an advanced stage. I once conceived, that medicines might, un- der such circumstances, be introduced into the stomach, by means of a hollow bougie, passed, from one of the nos- trils, down the oesophagus. I have late- ly been informed, however, that using a bougie in this way brings on very in- supportable fits of spasm. Perhaps, the suggestion may at least deserve a little more trial. The occurrence of a diffi- culty of swallowing medicines, when the disease has made some progress, is, at all events, an urgent reason, for having recourse, without delay, to such remedies, as have obtained repute, and of these, opium is undoubtedly one of the principal. Should it be found to be impracticable to convey opium into the stomach, after the difficulty of swal- lowing comes .on, authors advise the medicine to be exhibited in glysters, in such doses as the violence ofthe dis- order demands. The costiveness, which opium usually brings on, may common- ly be obviated by emollient glysters, and laxative medicines, as occasion re- quires. Analagous reasoning has led to the supposition, that the efficacy of opium might be increased, by employing some other medicines of the antispasmodic class, and, with this view, musk and camphor have been given, as being just- ly regarded as among the most power- ful remedies of this kind. But, although some practitioners have thought, that they have seen good effects result from musk, yet the majority of practitioners, who have made trial of both this and camphor, in cases of tetanus, have found no reason to recommend these medicines. Possibly, this may be owing, in some instances, to sufficient doses not having been exhibited, or to the musk not being of a good quality. One hundred and fifty grains of musk, how- ever, have been given in the space of twelve hours, to a young girl, thirteen years old, affected with an incipient te- tanus; but, no salutary effect on the dis- order was produced. Analogy has also led to the employ- ment of the warm bath, as a plan, which seemed to promise great benefit, by producing a relaxation of the con- tracted muscles. But, notwithstanding this means has appeared, in a few in- stances, to occasion some little relief, particularly, when the practitioner has been content with mere fomentations, it generally fails, and, often, has even done mischief. This may perhaps be, in some measure, ascribable to the distur- bance and motion, which the patient must necessarily undergo, in order to get into the bath; for, it is very well known, that every exertion, on t-hepart ofthe patient, is very apt to excite very violent paroxysms of s asm. The au- thor of the article Tetanus, in the En- cyclopedic Methodique, mentions his having seen the warm bath do harm, in Vol. II. 2 O 290 TETANUS. two or three cases, in which it was ex- pected to do good. Though numerous writers have recommended the trial of the plan, it would be difficult to trace, in their accounts, any facts, which de- cidedly show, that its adoption has ever been followed by unequivocal benefit. Dr. Hillary, who practised, a long while, in the warm climate of Ameri- ca, where tetanus is very common, dis- approves of this method of treatment. He observes, that, although the use of the warm bath may appear to be very rational, and promise to be useful, he has always found it much less servicea- ble, than emollient and antispasmodic fomentations; and he also, mentions, that he has sometimes seen patients die, the very moment, when they came out ofthe bath, notwithstanding they had not been in it more than twenty mi- nutes, the temperatureof the water be- ing likewise not higher than 29 or 30 of "Reaumur's Thermometer. (See Hil- lary on the Air and Diseases of Barba- does.) De Haen also relates a similar fact of a patient dying, the instant he was ta- ken out ofthe warm bath. It was, in all probability, the bad ef- fects ofthe warm bath, which induced practitioners to try what might be ef- fected by the cold one. Of all the reme- dies, which have been employed in cases of tetanus, the cold bath seems to be that, which has been attended with the greatest success. Dr. Wright has published, in the Medical Observations and Inquiries, vol. 6, a paper, in which may be found a narrative ofthe first tri- als of this method, which were all suc- cessful. The plan is said to be at present preferred throughout all the West In- dies. The way adopted consists in plunging the patient into cold water, and in that of the sea, when at hand, in preference to any other; or else in throwing, from a certain height, seve- ral pailfuls of cold water over his body. After this has been done, he is to be very carefully dried with a towel, and put to bed, where he should only be lightly covered with clothes, and take twenty or thirty drops of laudanum.— The symptoms usually seem to give way, in a certain degree, but, the re- lief, which the patient experiences, is not of long duration, and it is necessary to repeat the same measures, at the end of three or four hours. They are to be repeated in this manner; that is to say, at such intervals, until those of free- dom from the attacks of the disordef" increase in length. This desirable event generally soon follows, and ends in a perfect cure. Wine and bark were sometimes conjoined with the forego- ing means, and seemed to co-operate in the production ofthe good effects.— Dr. Wright concludes the account with the following remark, sent to him with a case, by Mr. Drummond, of Jamaica. " I am of opinion, that opiates and the cold bath will answer every intention in the tetanus and such like diseases; for, whilst the opium diminishes the irrita- bility, and gives a truce from the vio- lent symptoms, the cold bath produces that wonderful tonic effect, so observa- ble in this, and some other cases. Per- haps, the bark, joined with these, would render the cure more certain. May we not then have failed in many cases by us- ing opiates alone in large doses, or what probably is worse, with the warm bath, instead ofthe cold bath? And have we not reason to suspect, that the increas- ed doses of opium, that seemed requi- site, when the warm bath was used, may have proved pernicious?" (Vol. 6, p. 161.) Another remedy, which is said to have frequently effected a cure in teta- tanus, is mercury. It has been employed in France with the greatest success, as may be seen by referring to the forty- fifth volume of the Journal de Mede- cine. This remedy, however, should be resorted to, in an early period of the disorder. Mercurial frictions are pre- ferred, and these are to be put in prac- tice so as to bring on a quick affection ofthe mouth; taking care, however, not to render the soreness and salivation too violent. Some contend, that it mat- ters not, whether mercury be rubbed into the body, or given internally. It is generally allowed, that opium may be advantageously exhibited at the same time. Dr. Cullen mentions his having been informed, that the Barbadoes tar (Pe- troleum Barbadense) had cured tetanus in all its different degrees. It was an opinion, entertained by this celebrated physician, that the cold bathing had neither been so frequently employed, nor found so commonly suc- cessful, in cases of tetanus from wounds, as in those from the applica- tion of cold. Unctuous, balsamic, and spirituous embrocations; bleedings; and theappli- cation of blisters; which many practV TETANUS. 2*91 tioners have recommended, are not on- ly useless remedies in the majority of cases, but even hurtful. Hence, none of the best physicians or surgeons, of the present day, ever advise them to be adopted. The trial of strong shocks of electri- city, in cases of tetanus, has been sug- gested. We have no fact, however, on record, ofthe method havingdone good in this diorder. (Latta's System of Sur- gery, vol. 3./Mil.) It has also been proposed to exhibit, in cases of tetanus, some other very strong stimulants, besides opium, musk and camphor; for instance, the fixed and volatile alkalies, ardent spirits, spices, &c. Mr. Latta's sentiments are against the employment of opiates and the warm bath, and the great objects, which he seems to be desirous of bring- ing about, are, a certain degree of in- flammation and suppuration in the wounded part, and a general inflamma- tory diathesis. The measures, which he advises, with these views, will be fully understood by the following ex- tract. " Some cases (says this author) have been related, where a cure was evi- dently effected by opium; yet, from the numbers, who have suffered, under this management, we may freely say, that the cures are not only in the pro- portion of one to eight, or nine. There are some cases, related by authors, where the patients have indeed recov- ered from the tetanus, but have soon af- ter been attacked by complaints in their stomach, which quickly put' an end to their fife. Upon opening their bodies, the stomach was always found in a high state of inflammation, and sometimes actually mortified- Not- withstanding, therefore, it appears that the disease has sometimes been cured by. opiates, I am clearly of opi- nion, that, in cases of tetanus, they ought almost to be entirely given up. The warm bath, I am likewise of opinion, ought not to be used; and, indeed, I must recommend a course almost di- rectly opposite to that hitherto recom- mended and practised. Instead of putting the patient into a warm bath, I would plunge him into a tub of cold wa- ter, rendered still colder by the addi- tion of vinegar. This ought to be re- peated as often as the patient could bear it; and, in the mean time, he ought to take the bark in very large doses, not less than two ounces in twenty-four hours, washing down eveiy dose with a gill of port-wine. Thus, a degree of inflammatory diathesis might be pro- duced in the system, without that dan- ger of exciting a local inflammation and mortification in the stomach, which arises from immense doses of opium. I am not, however, for rejecting opiates entirely. A large dose may be given at first, and still farther augmented, if the first has no effect to mitigate the symp- toms, until we have an opportunity of pushing the bark to its full extent. Be- sides this, we ought to endeavour to excite a local inflammation in the wounded part itself, and to raise this in- flammation as high as is consistent with a resolution afterwards. We certainly know, that nothing promotes a general phlogistic diathesis through the sys- tem, more than a wound attended with a high degree of inflammation. In all relaxed habits we find, that, even in this climate, wounds are attended with less topical inflammation in summer than in winter; and, from perusing the best authors that have lately written upon this subject, I find that, in wounds productive of tetanus there is an absolute want of this inflammation, so necessary to the cure and well-being of the pa- tient. Nay, I myself know, from gentle- men of undoubted abilities in their pro- fession, both in America and the East- Indies, that, if inflammation and sup- puration take place, even in these cli- mates, immediately after an injury that might be suspected of inducing a teta- nus, such as, slight wounds or scratches on the fingers, or a splinter driven in below the nail, nothing of the kind takes place. Hence, it is evident, or, at least, very probable, that if in a wound threatening to produce a tetanus, we could induce this inflammation, the dis- ease would certainly be prevented. Our first care, therefore, should be, in warm climates, or in cases where we have reason to fear a tetanus, to dress the wound in such a manner as to bring on the requisite inflammation; and no- thing can do this more effectually, than to enlarge it considerably, and apply a pledget dipped in warm oil of turpen- tine. " It must be observed, however, that though dressings of this kind ap- plied to the wound before a tetanus has come on, may very probably prevent it, yet we have no reason to believe, that they will remove it after it has come 292 TETANUS. on. It is even doubtful, whether, after this dreadful disease has appeared, any application to the wounded part would raise the desired inflammation. In this case, we must do the best we can, instantly to remove, or at least palliate, the violence of the spasms; and, while we do so, an incision made above the original wound, and dressing this incision with warm oil of turpen- tine, might possibly be of service. The misfortune is, that now we have not time to wait for the effect of any ordi- nary medicine. The disease makes such rapid progress, that we are under a necessity of using violent remedies, even though we thereby run the risk of destroying our patients afterwards, as has been remarked of opiates. Mer- cury has been much recommended in tbe tetanus, as well as the hydropho- bia, but has not often been attended with success in either. It is evidently too slow in its operation; but indeed, if we can give it in such quantities as to produce symptoms of salivation in a day or two at most, it has a chance of being useful: for, while it is producing a salivation quickly, it brings on a dia- thesis phlogistica; but I believe that, when it acts slowly, or after a saliva- tion is thoroughly produced, it rather has a contrary effect, viz. that of relax- ing the body, and thus tending to bring on the disease, if the wound be not healed before this happen. To avoid this, we ought to begin the unction with mercury as soon as the disease begins to show itself; to rub in a very considerable quantity at once, and to stop as soon as the breath begins to turn fetid, or \he gums to swell, lest a salivation should be excited, which would be contrary to the intention with which the medicine was exhibit- ed." (Lotto, vol. 3. p. 70, &c.) This gentleman is an advocate for cold bathing, which, he observes, should, like other remedies in tetanus, be pushed to its utmost extent. He recommends placing the patient in a tub, about two feet and a half high, and three feet in diameter, and pouring repeatedly over his head and shoulders, buckets of Water, as cold as can be pro- cured. This plan is to be " repeated, accordingto the urgency ofthe sympt toms; but, not less, than four times, in four and twenty hours. During this time, the patient should be made to drink half a gill ofthe best brandy every hour, with two scruples ofthe powder of bark put into it; and, if his stomach can bear it, from two to three ounces of bark, with a bottle and a half of port-wine in twenty-four hours. If, by these means; the strength of the sys- tem increases, every symptom of the disease will decrease. I have already given my opinion with regard to opi- ates. The smallest dose that can be giv- en, provided it will have any effect in relieving the spasms, ought to be ad- hered to; and if they can be kept under without opium, so much the better; but, if not, no doubt we must give it in large quantities. The dose, indeed, cannot be ascertained; but, we must always remember, that, after the sti- mulant power of opium is gone, it has a very remarkable sedative effect, which, in persons not accustomed to it, is productive of something similar to downright intoxication, and a very great degree of debility consequent thereto. We must, therefore, be as careful as possible not to give immode- rate doses of opium after the spasms are removed; or, at any time, more than is absolutely necessary to keep them under. The strength of the sys- tem cannot be ultimately restored by medicines, which act only for a short time, and then lose their effect. It is evident that these are to be used only with a view to others, which act more permanently, though slowly. " The sedative qualities of one dose of opium may indeed be prevented, by giving another before they have time to manifest themselves; but this would require an endless succession of doses. By far the best method seems to be to counteract them, by giving large quantities of the most nutritious food, as soon as the spasms are mitigated to such a degree as to allow the patient to swallow. This is conformable to the doctrines delivered by the late Dr. Brown, who, after a dose of opium or laudanum, always ordered his patients to be supplied with some strong and solid food, to prevent the debility which would otherwise take place." (Latta, vol. 3. p 75.) ' Dl5?r,Rusl1. professor of medicine in Philadelphia, has lately published, in the Transactions ofthe American Phi- JWhical Society, vol. 2, a paper, in- r V rPbser'"ations on the Cause and Cure of Tetanus." Dr. Rush considers tetanus, as a dise*"e occasioned by a relaxation, and, consequently, recom- mends, for its cure, such medicines, as THORAX. 293 are calculated to remove this relaxa- tion, and to restore tone to the system. Hence, he advises the liberal use of wine, and Peruvian bark, and states, that he has put this plan in practice with success. When the disorder is the consequence of a wound, Dr. Rush recommends stimulants to the part af- fected: the wound is to be dilated, and filled with oil of turpentine. In Spain, however, a very opposite mode is said to be adopted with great success: practitioners there advise the use of mild emollient applications to the wounded part, and, they, in parti- cular, recommend it to be immersed, for an hour, in tepid oil, and to repeat this plan, at short intervals. In this manner, many cases are said to have been relieved, after veiy alarming ap- pearances had taken place. Having now touched upon all the different modes of treating tetanus, it only remains for me to remark, that, among such diversity of practice, it is difficult to pronounce, in positive terms, which method claims the preference. Comparative trials, faithfully and im- partially made, can alone enable us to form an accurate judgment. As the dis- ease is not common in this country, the experience of individuals, concerning it, cannot be extensive enough for this purpose. Medical practitioners, in our settlements abroad, have the best op- portunities of undertaking the investi- gation. From all, that I have read, I conceive, that facts prevail in favour of the following plans, in the order set down. 1. Cold bathing and opium. 2. Cold bathing, and strong stimulants, such as volatile alkali, brandy, wine, and spices, with bark. 3. Mercurial frictions, practised so as quickly to in- duce a salivation. The reader may find some cases, or interesting matter, in Hippocrates de Morb. Popularibus, lib. 5 et 7; Aretai et Galeni Opera; Calius Aurelianus de Mor- bis Acutis; Medical Observations and In- quiries, vol. 1. p. 1 and 87; vol. 6. p. 143; and in Hillary on the Air and Diseases of Barbadoes; Edinb. Physical and Litera- ry Essays, vol. 3. In this last work, Dr. D. Monro describes the mode of cure by salivation, as successfully practised by a gentlenrin in Jamaica. In Medical Transactions, Dr. Carter relates a case, which yielded to a blister, applied be- tween the shoulders the whole length ofthe spine, rubbing the jaw with the oleum lateritium, and repeating the fol- lowing purge, at intervals of three or four days: R. Tinct. Sacra ^ij. Tinct. Jalap. 3j. Syr. £ spina Cerv. Jss. M. fiat haust. purg. On the intermediate days, the oleum succini, the fetid gum, and ol. amygdal. were exliibited. Of the first, the patient took thirty drops; of the gum twenty grains; and of the ol. amygdal. four ounces, in twenty- four hours. Dr. Cochrane first repre- sented the advantages ofthe cold bath ki the Edinburgh Medical Commenta- ries; a plan, which was afterwards more fully explained by Dr. Wright, in the Med. Observations and Inquiries, vol. 6. Dr. Currie, of Liverpool, used the cold bath with success, and his name should not be omitted, in favour of what seems one of the most effica- cious measures in tetanus. The reader should also consult Cul- kn's First Lines of the Practice of Phy- sic, vol. 3; Rush's Observations on the Cause and Cure of Tetanus, in the second volume ofthe Transactions of the Ameri- can Philosophical Society; Latta's System of Surgery, vol. 3. THERIOMA, (from Svgtou, to rage like a wild beast.) A malignant ulcer. THERM*, (from 3^0? warm.) Mineral warm baths. THORAX, (The Chest.) The term* thorax, is said to be derived from the Greek verb, Sagto, to leap, because the heart leaps, or pulsates in it. In the language of anatomy, the tho- rax implies the upper part ofthe trunk, or that portion of the body, wliich is surrounded by the sternum, the ribs, and the dorsal vertebrae. The chest is subject to different kinds of injuries, produced by external causes, and the important nature ofthe organs, which it contains, renders the consideration of such cases of the highest consequence to the practi- tioner. In speaking of Fractures of the Ribs, Emphysema, Paracentesis of the Thorax, &c. an account has already been offered, of some affections ofthe thorax, which are very essential to be known by every surgeon. In the pre- sent article we intend to treat of "the subject of wounds, interesting this part ofthe body; but, before beginning what we have to say, concerning these cases, it seems proper to remind the reader of some anatomical circumstances, re- lative to the thoracic viscera. The thorax is a very large cavity, of an irregularly oval figure, bounded in front by the sternum, laterally by the 294 THORAX. ribs, posteriorly by the vertebrae ofthe back, above by the clavicles, and below by the diaphragm, a very powerful muscle, which forms a kind of" parti- tion between the cavity of the thorax, and that of the abdomen. The diaphragm is not stretched across, in a straight direction, from one side of the chest to the other; but, on the contrary, descends much further in some places, than in others. If the cavity of the thorax be opened, by a transverse section, about the middle of the sternum, the diaphragm appears, on examination, to be very prominent and convex towards its centre, while it sinks downward at its edges, towards all the points, to which the muscle is attached. At its anterior, and most elevated part, it is fixed to the ensi- form cartilage, whence, descending obliquely to the right and left, it is in- serted, on both sides, into the seventh - rib, to all the lower ribs, and, lastly, to the lower dorsal vertebrae. According to this description, it is obvious, that the cavity ofthe thorax has much great- er depth and capacity behind, than be- fore; a circumstance^ which surgeons ought to be well aware of, or else they will be very apt to give most erroneous opinions, concerning such wounds as happen to the chest. For instance, a prac- titioner, deficient in anatomical know- ledge, might imagine, that a weapon struck from above downward, into the front ofthe chest, could never reach the lungs, after having penetrated the ca- vity of the abdomen. It is a fact, how- ever, that no instrument could be pushed in this direction, even some inches below the highest part of the abdomen, without entering into the cavity ofthe chest. The whole cavity of the thorax is lined by a membrane, named the pleu- ra, which is every where adherent to the bones, which form the parietes of this cavity, and to the diaphragm. Each side of the thorax has'a distinct pleura. The two membranes meet in the middle of the chest, and extend from the sternum to the vertebrae. In this manner, two cavities are formed, which have no sort of communication with each other. The way, in which the two pleurae touch, and lie against each other, forms a middle partition, which is called the mediastinum. These two membranes are intimately adher- ent to each other, in front, the whole tengtn of the sternum; but, behind, where they approach the vertebrr, they separate from each other, so as to leave room for the passage ofthe aorta, oesophagus, 8tc. The heart, enclosed in its pericardium, occupies a considera- ble space on the left of the mediasti- num, all the rest of the cavity of the chest being filled with the lungs, ex- cept behind, where the large blood- vessels, nerves, thoracic duct, and oeso- phagus, are situated. In the perfectly healthy state, the lungs do not adhere to the pleura; but, in this climate, at least, the majority of subjects, which are examined after death, are found to have such adhesions in different places. The disease may probably be occa- sioned by a very slight inflammation in the chest; and, as the surface of the lungs is naturally destined to be always in close contact with the pleura, and patients are frequently not suspected to have any thing wrong in the thorax, this morbid change being often acci- dentally discovered after death, in look- ing for something else; we may con- clude, that it does not occasion any in- conveniences. The thorax is subject to all kinds of wounds; but, the importance of these injuries most particularly depends on the depth, to which they extend. Such as do not reach beyond the integu- ments, do not differ from common wounds, and, when properly treated, are seldom followed by any bad conse- quences. On the contrary, those which penetrate the cavity of the pleura, even by the slightest opening, are apt to oc- casion, in some circumstances, the most alarming symptoms. Lastly, such wounds, as injure any of the thoracic viscera, are always to be considered, as placing the patient in a state of con- siderable danger. From what has been said, it appears, that wounds ofthe thorax are very pro- perly divisible into three kinds: viz. 1. such as only affect the skin, and mus- cles; 2. such as enter the cavity of the chest, but injure none of the viscera; 3. others, which injure the lungs, or some other viscus. SUPERFICIAL WOUNDS OF THE THO- RAX. Immediately a surgeon is called to a recent wound of the chest, his first care should be to endeavour to ascer- tain, whether the weapon has penetrat- ed the chest, or not. An opinfon may be formed on this subject, by attending THORAX. 295 to several circumstances. 1. Surgical writers recommend, for this purpose, placing the wounded person in the same posture, in which he was, when he received the wound, and then care- fully examining with a finger, or probe, the direction, and depth of the wound. 2. We are also advised, if possible, to get the weapon, with which the injury was inflicted, and, by the bloody part, judge how far it has penetrated. 3- We are advised to inject some liquid into the orifice of the wound, and to ob- serve, whether it regurgitates immedi- ately, or lodges in the part. 4. The co- lour and quantity of the blood, emitted from the wound, are to be noticed, and whether any is coughed up. 5. We are to examine, whether the circumference of the wound becomes emphysema- tous, or any air escapes from its orifice in respiration. 6. Lastly, the state of the pulse and breathing is to be at- tended to. It is a general precept, that, in order to examine a wound in the best man- ner, the patient should be put, as near- ly as possible, in the same posture, as he was in at the moment of meeting with the accident; but, it is very essential, that this precaution should not be ne- glected, in examining a wound of the chest The great number of muscles, which surround this part, and the con- tinual motion of the ribs, may make a wound appear, in one position of the body, quite superficial, while, in ano- ther posture, it shall be found to ex- tend to a great depth. For, should any part of a rib, or even any of the cellu- lar substance, in consequence of the patient's posture, become situated in the track of the wound, neither the fin- ger, the probe, nor an injection will pass with sufficient ease to make a pro- per examination. Sometimes, the orifice of the wound is so large, that one can easily distin- guish with the eye, whether the injury penetrates into the cavity of the tho- rax, or not; or, one can introduce a fin- ger, which, when this can be used, without bruising, or tearing the parts, is always preferable to any probe. But, when the smallness ofthe opening pro- hibits the employment of the finger, we are necessitated to make use of a probe; and the best instrument, of this kind, is in this case a bougie, which is not so apt, as a silver probe, to pierce parts, which have not been wounded. Howe- ver, a prudent, and experienced, prac- titioner will seldom do any mischief of this sort, whether he uses one instru- ment, or the other. In treating of wounds of the abdo- men, I have cautioned surgeons against being too officious in probing such in- juries, merely, for the sake of gratify- ing their own curiosity. The same ad- vice is equally applicable to the present cases. Surgical authors have, perhaps, dwelt too much on the subject of prob- ing wounds of the abdomen, and tho- rax, and their readers imbibe an opi- nion, that, until they have traced the wound, with their finger, or probe, to its very bottom, and termination, they are not qualified to put in practice any kind of meas'ures. The only advan- tage of knowing, that a wound pene- trates the chest, is that the practitioner immediately feels himself justified in having recourse to bleeding and other antiphlogistic means, and thus averts inflammation of the pleura, and lungs, ' which affection, when it has made pro- gress, often proves fatal. However, there can be little doubt, that if the nature and depth of the wound cannot be readily detected, with the eye, the finger, or a probe, it is much safer to bleed the patient, than to put him to useless pain, irritate the injury with the introduction of instruments, and waste opportunities of doing good, which can often never be recalled. In short, it is better, and more advantage- ous, for all patients, that some of them should lose blood, perhaps, unneces- sarily, than that any of them should die,in consequence of the evacuation being omitted, or delayed. Almost all the writers, who have taken pains in directing, how wounds of* the thorax should be probed, con- clude with remarking, that, however advantageous a knowledge of the di- rection and depth of the wound may be, much harm has frequently been done by pushing the attempts to gain such information too far. It is, perhaps, of greater importance to ascertain, by some kind of examination, the extent of a wound, which does not reach be- yond the integuments, or intercostals, than to know, whether the wound ex- tends into the cavity of the chest. For, even when the pleura is found to be divided, if the wound is attended with no urgent symptoms, the information is of no practical use, if we make it a rule to adopt, without the least delay, a strict antiphlogistic plan of treatment, 296 THORAX. in all cases, in which there is any doubt, or chance of the parts, within the chest, being wounded, and likely to inflame. Besides, very frequently, the symptoms are more urgent and alarming, than they could be, were only parts on the outside of the thorax in- jured; and, in these instances, it is ob- vious, that the employment of a probe cannot be necessary for discovering, that the wound extends into the chest. We have above adverted to inspect- ing the weapon, with which the wound was inflicted, as a mode of gaining some information, concerning tbe pro- bable depth of the wound. Inquiry may also be made, in what direction it was pushed: and, sometimes, the blood on the instrument will denote how deeply it penetrated. It is clear, however, that though information of this kind may be obtained, in a few instances, in gene- ral, it is otherwise. When, by any of the above means, it cannot be learnt, whether the wound penetrates the chest, or not, various authors recommend the injection of lukewarm water. If the water regur- gitates at once, they conclude, that the injury is only superficial; but, when the fluid, either wholly, or in part, con- tinues in the wound,, without produc- ing any external swelling, they infer, with certainty, that an opening has been made in the pleura. This plan of examining the state of parts, however, is much more objectionable, than the employment of a probe; for, if the li- quid be propelled, with a certain de- gree of force, for the purpose of driv- ing it to the bottom of the wound, parts, which were not before hurt, will in this manner become injured. The fluid may also be injected into the cavi- ties of the cellular substance, and may seem to be passing through the track of the wound into the chest, while, in reality, not a drop does so. Besides, is it a warrantable proceeding to try to in- sinuate any quantity, or kind, of liquid, whatever, between the jileura and lungs, into a situation, in which it must necessarily obstruct the important func- tion of respiration, and cause serious inconvenience? When air issues from the wound in expiration, there is ground for suspect- ing, that the lungs are wounded. But, authors have erred in setting down this circumstance, as an infallible cri- terion of the nature of the accident; for, the same symptom may happen, when there is only an opening made into the chest, without any injury of the lungs whatever. The air, which is expelled in expiration, has previously got into the bag of the pleura through the wound, in inspiration. In such cases, the external air insinuates itself, through the opening into the chest, between the pleura and lungs, and, it will be seen to escape, during expira- tion, although the lungs may not be at all wounded. In order to remove all doubt upon this subject, the patient should be requested to expire, as strongly as he can, so as to force out whatever air may have accumulated in the chest At the end of each expi- ration of this kind, care must be taken to bring the skin closely over the orifice of the wound, and to keep it thus ap- plied, during each following inspira- tion, for the purpose of preventing the external air from entering. In this way, if there be no wound of the lung, all the air will soon be expelled; but, when some still continues to come out in expiration, we may conclude, with certainty, that the lungs are wounded. Sometimes, an emphysematous swelling takes place round wounds of the thorax, in consequence of a quanti- ty of air diffusing itself in the cellular substance. This symptom is very un- common in wounds,which are straight, and ample; but is, by no means, unfre- quent, in wounds caused by narrow stabs, more especially oblique ones, and the points of broken ribs (See Emphysema.) When a considerable quantity of blood flows from a wound ofthe chest, there is great cause for conjecturing, not only, that it has pene- trated the cavity of the thorax, but, also, that some of the thoracic visce- ra are injured. Excepting the intercos- tal arteries, which run along the lower edges ofthe ribs, and the trunk of the thoracic arteries, all the other vessels, on the outside of the chest, are very inconsiderable. A proper compression will soon show whether the blood es- capes from an artery on the outside of the cavity of the pleura. The situation, and direction of wounds very frequent- ly denote at once, that the hemorrhage cannot proceed from any of the trunks of the thoracic arteries. Even the appearance of the blood, which comes from the wound, may lead to some conjectures, concerning the depth of the injury. The blood, which flows from wounds of the lungs, THORAX. 297 is of a brighter scarlet colour, and more frothy, than that which is emit- ted from any other part. There can be no doubt of the lungs being wounded, when the patient is observed to spit up blood; but, the ab- sence of this symptom is, by no means, to be regarded as a proof of the con- trary The state of the pulse, and that of respiration, ought to be particularly attendedto by the practitioner. Neither one, nor the other, seems altered, at least at first,when wounds do not reach more deeply, than the integuments; but, those, which penetrate the cavity of the thorax, and, especially, such as injure any ofthe viscera, may frequent- ly be distinguished, from the very first moment of their occurrence, by their effects on the sanguiferous system, and the function of respiration. When the lungs happen to be wounded, at a place where they have contracted an adhe- sion to the pleura, the wound may ex- tend to a great depth, and yet no air may be diffused in the cavity of the thorax, nor the functions of these or- gans be at all disturbed. But, when either air, or blood, has insinuated it- self between the lungs and the pleura, the lungs become immediately oppress- ed, the breathing is attended with dif- ficulty, the pulse is weak, contracted, and intermittent; and no doubt can be entertained, concerning the nature of the injury. Having said enough, relative tp the diagnosis of wounds of the thorax, we shall next consider their treatment. Wounds of the thorax, which only injure the integuments, are not gene- rally attended with any danger; they heal with the same readiness, and by the same means, as common, superfi- cial, wounds in any other part of the body. But, when the surgeon has to treat a punctured, or a gun-shot wound, it is too frequently directed, by writers on surgery, to lay open the track of the injury, from one end to the other with a knife, if its course should not be too extensive, and then to dress the cavity down to the bottom. Such au- thors also add, that when the track of the wound is so extensive, as not to ad- mit of this plan, it is better to intro- duce a seton through it. Their object, in employing these methods, is to pre- vent the outer part of the wound from healing too soon, and thus give time for the whole of it to heaMn an equal degree. Afterwards, they advise the . silk of the seton to be gradually dimi- nished, and, when, at length, the whole of it is removed, a slight degree of compression, kept up for a few days, is deemed sufficient for the completion ofthe cure. The French surgeons have the dis- credit of bringing setons into fashion in this branch of surgery, and I am particularly glad, that an able modern writer has exposed the absurdity ofthe practice. " We find (says Mr. John Bell) the history of it, to be plainly this; that as Guy de Chauliac, Pare, and all the older surgeons, did not know how to dilate gun-shot wounds, they found these1 same setons useful in bringing the eschar sooner away, and in preserving an open wound; and, as they believed the wounds to be poison- ed, they took the opportunity of con-. ducting, by these setons, whatever acrid medicines might, according to the pre- vailing doctrines of that time, have any chance of correcting the poison." Mr. J. Bell notices, how surprizing it is, to see the cruelty, and perseverance, with which some modern practitioners, par- ticularly, French, draw these cords through wounded limbs; and when the roughness of such a cord, or the acrimo- ny of the drugs conveyed by it, pro- duces a copious suppuration, these men are delighted with such proofs of their success. The setons have been introduced by the French surgeons, across the thickest parts of the limbs, along the whole length ofthe fore-arm, and, at the same time, frequently through the wrist-joint. The setons have also been covered with stimula- ting applications. Profuse suppurations, and dreadful swellings of course en- sued; still, as Mr. J. Bell has remark- ed, these cruelties were continued, till the wound healed almost in spite of the pain; or till the coming on of very dreadful pain, great suppurations, con- vulsions, &c. made the surgeon discon- tinue the method, or even amputate the limb. The French have become so fa- miliarized to setons, that they do not restrict their use to flesh wounds, they pass them quite across the thorax, across the abdomen, and even through wounds of the knee-joint When we wish to excite inflamma- tion, in the cavity of the tunica vagina- lis, for the purpose of radically curing a hydrocele, we either pass a seton Vol. II. 2P 298 through the part; lay it open with an extensive incision; cram a tent into it; or inject some irritating fluid into it. While the animal machine continues the same, says Mr. John Bell, the same stimuli will produce the same effects, and a seton, injection, or long tent, if they produce pain and inflammation in the scrotum, will not be easy in the chest; and, unless we can use them in the chest, with the same intentions, with which we use them in the hydro- cele, (in other words) unless we are justified in inflaming- the chest, and causing\ adhesion of all the parts, we cannot use them, with any consistency, or good sense. With regard to the cases, which the French adduce in confirmation of the good effects of their plans, I am entire- ly of opinion with Mr. J. Bell, that the facts only prove, that the patients reco- vered in spite of the setons. " It is like (adds this author) what happened to a surgeon, who was dabbling in the tho- rax with a piece of caustic, which fell directly into the cavity of the chest, where it caused very large suppura- tions, and yet the patient was saved. The patient recovered, in spite of the caustic, just as M. Guerin's patient, and many other poor unhappy souls, have lived in spite of the setons. One would think, that people took a plea- sure in passing setons across the eye- ball, the chest, the knee-joint, &c. merely to make fools stare, when the business might be as effectually done with an abscess lancet." Mr. John Bell, in his usual lively style, makes the employment of tents, in wounds of the chest, seem equally ridiculous and improper. Indeed, he says, he knows of no occasion in all surge- ry, in which tents can be useful, except in the single one of a narrow opening, which we desire to dilate, in order to get at the bottom pf the wound; and where either, on account of some great artery, or the fear- ful temper of our patient, we dare not use the knife. (See J. Bell on Wounds. Dis- course 2, vol. 2.) Having hitherto been engaged, ra- ther in pointing out, what ought not to be done, than what ought, I shall next make some remarks on the line of con- duct, which should be adopted, in cases of wounds of the parietes of the chest When the wound is a common cut, the sides of the division are to be brought into ccnu.et, and maintained THORAX. in this position, by the aid of strips of adhesive plaster, compresses, and a bandage, until they have grown toge- ther. There will very seldom be any occasion to employ sutures in these in- stances, if the surgeon only observe to relax such muscles as happen to be cut, or to be situated immediately un- der the wound of the integuments. As cut wounds seldom, or never penetrate the chest, and there is gene- rally no reason, why they should not unite by the first intention, without be- ing followed by extensive inflamma- tion and abscesses, only a moderate use of antiphlogistic means will usual- ly be necessary. Bleeding will not of- ten be requisite. The grand objects are, to keep the patient in a quiet state, on rather low diet, and to hinder him from taking wine, porter, spirits, or any stimulating beverages. If the wound, instead of healing fa- vourably, should inflame, the treat- ment should be regulated by the prin- ciples, laid down in the article Inflam- mation. If it should suppurate over its whole surface, still the sides should generally be kept approximated by one, or two strips of sticking plaster; for, in this way, the cavity, which must now be filled up by granulations, will be rendered much smaller, than it otherwise would be. The softest particles of lint may be laid in the ca- vity of the wound, which the sticking plaster does not entirely remove, and over the whole a pledget of some mild, unirritating ointment. No pres- sure is now proper, until the inflamma- tion diminishes; and if the matter should be very copious, attended with much surrounding inflammation, the best application would then be an emol- lient poultice. The patient should also be bled, and leeches should be applied, as often as necessary, round the wound- ed part. When the case is a stab, or punctur- ed wound, the fibres of the divided parts are not simply cut, they are also considerably stretched, bruised, and otherwise injured. Hence, they can- not, in general, be expected to admit so readily of being united, as the sides of a clean incision, made with a sharp instrument. However, the possibility of uniting the opposite sides of punc- tured wounds must depend veiy much on the shape of the weapon, and the suddenness, roughness, and violence, with wliich it was driven into the part. ■ THORAX. 299 A prick with a needle is a punctured wound; so is that so often made by sur- geons with their lancets; yet, these in- juries do not so frequently bring on violent inflammation, and abscesses, as those wounds often do, which are in- flicted with bayonets, and pikes. Let us suppose a man has received a thrust of a bayonet, which has run into the skin andmuscles, covering one side of the thorax; what plan can the sur- geon follow, with the greatest advan- tage to his patient? Instead of laying open the whole track of such a wound with a knife, as is barbarously recommended in many of the principal works on surgery; in- stead of drawing a seton through its whole course, or of cramming into the part, a hard, irritating tent; the practi- tioner should take whatever chance there is of uniting the wound without suppuration. For this purpose, he should recollect, that the great degree of violence, done to the parts in punc- tured wounds, is the reason, why they are so apt to inflame and suppurate.— "Hence, the expected inflammation is (to use a vulgar expression) to be knocked on the head, if possible, on the very first instance; and immediately the wound is dressed, the patient should be freely bled, and take some saline purga- tive medicines. With regard to the dressings, the orifice ofthe wound may be closed with sticking plaster, if the circumstance is practicable; if not, it may be covered with any mild superfi- cial applications. Over the track ofthe stab, a compress should be placed, and over this a common roller applied with some degree of tightness. Thus, the sides of the wound will be kept, as much as possible, in universal contact; the chance of union by the first inten- tion taken; and all painful operations avoided. If strict antiphlogistic means, and pressure, are thus put in practice, many stabs unite without abscesses, when surgeons entertain little hope of such success. But supposing, that suppuration fol- lows, and a collection of matter takes place, will the patient suffer more, or be put into greater danger, by having a proper depending opening, of just sufficient size, now made into the ab- scess at a proper place, than if he had submitted to have the formidable oper- ation of laying open the whole extent of a stab, performed in the first in- stance In short, will he suffer ha)/ so much, be half so long in getting well, or have to encounter half the danger? With all this advantage, he will have taken a certain chance, which attends all these cases, of the wound becoming united by, what is called, the first intention, that is to say, without any suppuration. I need not enlarge upon this subject, but re- fer the reader to Punctured Wounds in the article Wounds, and to the treat- ment of abscesses, in the article Sup- puration. Gun-shot wounds, only injur- ing the parietes ofthe chest, are to be treated, according to the principles ex- plained in the article Gun-shot Wounds. OF WOUNDS PENETRATING THE CA- VITYOF THE THORAX. Wounds, which penetrate the chest, are always dangerous, and, consequent- ly, claim the utmost attention of the practitioner. We shall first treat of such wounds, as enter the cavity ofthe thorax, but without injuring any ofthe viscera. In the healthy state, the lungs so completely fill the cavity ofthe thorax, that, both in inspiration and expiration, they are always in close contact with the pleura; and, whenever air, blood, or any other matter, insinuates itself, between the outer surface ofthe lungs, and the inner one of the pleura, more or less oppression, and difficulty of breathing immediately take place. In all wounds, attended with a division ofthe pleura, occurring in a situation, where there happens to be no adhesion between this membrane and the lungs, some of the external air, or a small quantity of blood, or both, can hardly fail to get into the cavity ofthe thorax. If one ofthe intercostal arteries should be wounded, and the external wound be, at the same time, veiy narrow, the blood, furnished by this vessel, is very apt to insinuate itself inwardly into the chest, and immediately occasion an immense oppression of the breathing, and other symptoms of pressure on the lungs. Of what is to be done in this case, we shall presently speak. When a wound is known to have en- tered the pleura, and there is no symp- tom leading to a suspicion, that the lungs, or any large vessel, is wounded, the injury is to be dressed accordingto common principles, and the more su- perficial, the better. Authors also usu- ally direct us, just before we close the opening, to tell the patient to make a 300 THORAX deep inspiration, for the purpose of ex- pelling as much of the air as possible, which may have got into the cavity of the pleura. At the end of such inspira- tion, the edges ofthe wound in the skin are to be brought together; and kept so, wi'.h sticking plaster compresses, and a roller, applied round the body.— The other grand indications, in the treatment, are to avert inflammation of the pleura and lungs, by a rigorous adoption of the antiphlogistic plan copi- ous bleeding, in particular, not being forgotten. Let us now consider such wounds as penetrate the chest, and are complicat- ed with some ofthe following circum- stmces: 1. With the presence of"-fo- reign bodies. 2. \\ ith injury of one of the intercostal arteries. 3. With a pro- trusion of a portion of the lungs. 4. With a considerable emphysema. 5. With an extravasation of blood in the thorax. 1. Almost all wounds, which pene- trate the chest, occasion pain and diffi- culty of breathing. Many of them are also followed by an emphysematous swelling round the wound; the patient is frequently attacked by a spitting of bloody and, after having had, for some time, a small contracted, irregular pulse, with a pallid countenance, and cold extremities, he is too often seized with febrile symptoms. These should be counteracted by bleeding, diluent beverages, a proper regimen, quietude, and external applications ofthe resol- vent kind. If such symptoms should continue longer, than the first few days, without any diminution, writers inform us, that there is ground for sus- pecting, that they depend upon the presence ofsome foreign body. How- ever, it may be doubted, whether Sa- % all the bad symptoms, but a speedy batier's advice, immediately to make recovery. (See M. de la Faye's Nqtes search after the extraneous substance, to the Traite des Opiratiors de Dionis.) coughing, and spitting of blood ensu- ing, M Gerard was consulted. This gentleman found, that the symptoms depended, on the presence of a piece of the blade of the knife, which pierced the rib, and projected, to the extent of about six lines, into the cavity of the thorax. So little of the foreign body was on the outside ofthe rib, audit was so fixed in the bone, that it could nei- ther be extracted with any kind of for- ceps, nor even moved in the least with a leaden mallet, &x. Although, in these urgent circumstances, there seemed to be no other resource, except that of sawing, or cutting out the portion of the rib, M. Gerard, however, thought, that an attempt might first be made to extract the foreign body, by pushing it from within outward. Toi this pur pose, having put a steel thimble on his index finger, he introduced it into the cavity of the thorax, and thus succeeded in pushing out the pice ofthe knife. The foreign body being taken out, M. Gerard next introduced his finger, without the thimble for the purpose of examining, whether the inner surface ofthe rib was not splintered. A snicu- la ofthe bone was in fact detected, ca- pable of pricking the parts within the chest; but, it was too firmly connected with the rest ofthe rib to admit of be- ing completely taken out. Hence, M. Gerard adopted the plan of making the splintered piece of bone continue in close contact with the main portion, by immediately surrounding the whole rib, at the splintered part, with a liga- ture. This was passed by means of" a curved needle, and firmly tied over a thick compress. To these ingenious proceedings, as the French term them, was imputed, not only the cessation of is proper, under these circumstances. For my own part, I cannot think the symptoms, above related, by any means unequivocal, and even were they so, the practice would still be questionable. (See Medecine Operatoire, tom. 2, p. 214.) M. Sabatier has quoted the two fol- io wing cases, for the purpose of showing what may be attempted in these cases. " A man, twenty-seven years of age, was struck very violently with a knife, on the outer part ofthe fourth true rib. Simple dressings were applied for the first few days; but, a considerable M. Sabatier quotes another case, which we next insert in this Dictiona. ry, for the information ofthe reader. An officer was shot in the left side of the chest. The baU entered about where the bone, and cartilage of the seventh true rib unite, and came out in the situation of the angle of the same bone, which was broken in two places. The neighbouring part of the first false rib was also broken behind. Incisions were made, which enabled the surgeon to take away several splinters of bone, and facilitated (that absurd French praet'.ce) the introduction of a seton.— THORAX. 301 Soft mild dressings were put on the wounds. In consequence of the dan- gerous nature of the accident, the pa- tient was bled twenty-six times, with a view of relieving the fever, difficulty of breathing, and spitting of blood. On the fifth day, suppuration had begun to take place, and the seton coidd be easi- ly drawn. In about a fortnight, the pa- tient experienced a considerable abate- ment of his sufferings, and passed some of the ensuing days in a tolerably easy state. Circumstances having made it necessary to move him to another place, on the twenty-fourth day, he had an uneasy night: febrile symptoms took place, and the discharge was not of its usual consistence! Two more bleedings were practised, and the critical state of the patient led the surgeon to examine the wounds again. On passing a finger into the wound, which was situated behind, a foreign body was felt, and easily extracted. It proved to be a piece ofthe patient's coat. A spicula of bone was also felt more deeply lodged, which required the posterior wound to be dilated for its extraction. Some amendment followed the removal of these extraneous substances. On the thirteenth day from the re- ceipt of the wound, the bad symptoms having come on again, two more bleed- ings were practised, and, as fear was entertained, that the seton did harm, it was suppressed. The patient now first made complaint of feeling something, which pricked him, in a deep situation, between the two openings of the wound. It was found impracticable to ascertain the cause of this sensation, without dividing all that intervened, between the two wounds, and which formed a space of seven, or eight fin- ger-breadths. This serious operation was resolved on in a consultation, and M. Guerin set about it by cutting, from within outward, the parts between the two ribs, with the aid of a finger intro- duced into the posterior wound. Care was taken not to cut near the lower edge of the upper rib. In this way, the whole track of the ball was laid open, and, in the middle of it, a very sharp splinter was found, sticking in the sub- stance of the lungs. This was remov- ed, and the wound dressed with simple applications. From this day, all the bad symptoms ceased, and the cure was completed at the end of four months. (Obs. de Guerin in Mem. de I'Acad, de Chirurgie, torn. 2; &to.) Mr. John Bell has taken notice of the preceding case: he observes, that some of M. Guerin's steps were bold and good, as well as successful; but, that the employment of the seton was wrong. The example teaches us seve- ral important circumstances: 1. The propriety of making very free dilata- tions for the extraction of splintered pieces of bone. 2. The utility of re- peated copious bleedings, which, in the above case, indeed, had the great- est effect both in preventing such he- morrhage in the chest, as would pro- bably have .produced suffocation, and also in averting a degree of inflamma- tion in the thorax, which would have proved fatal. Mr. John Bell very judiciously con- demns the seton, used by M. Guerin: " Had M. Guerin (says she) been asked what good it was to do, it would have been difficult for him to have invented even a plausible apology for the prac- tice, which, if it was not doing good, could not fail to do harm. Was this se- ton necessary for keeping the wound open? No, surely; for the wound could not have closed, while it was irritated, and kept in suppuration by splinters of bone, and a piece of cloth within the breast. Was it to draw the piece of cloth out? Surely, in the course of twenty days, a piece of cloth would have had some chance, at least, of be- ing floated towards the wound either by the natural flux ofthe matter, or by the help of a mild injection. Was it useful in supporting the discharge ? This would have been a sore question for M. Gue*» rin; for it supported the suppuration only by inflaming the chest; and where inflammation of the chest, or high cough, or bloody expectoration, or a profuse discharge, were the chief dan- gers, a great seton could hardly be a comfortable inmate in the breast. I think one might very boldly promise to produce bloody expectoration and terri- ble cough, profuse suppurations, and oppression, to any degree, by drawing such a cord across a sound thorax." Mr. John Bell next censures M. Gue- rin for not having discovered the prick- ing piece of bone before the thirty- eighth day; and imputes this, in some degree, to the seton, the pain of draw- ing which across the chest deadened every lesser pain, and, consequently, the patient could not feel the trifling pricking of the bone, till his greater sufferings from the seton were allayed. 302 THORAX " In short, (says Mr. John Bell) M. Guerin passes a great strap of coarse linen across the cavity of the chest, and when it causes inflammation, he thinks to subdue it by bleeding; when M. Guerin continued for thirty days drawing a coarse seton through the breast every morning, and bleeding for the cough every night, what did he do, but raise inflammation with his left hand, to show how well he could cure it with his right?" (See John Bell on Wounds, vol. 2, p. 36—38.) 2- When one of the intercostal arte- ries is wounded in the track of a nar- row, oblique wound, the nature of the accident cannot at first be known. The blood, which the vessel pours out, com- monly makes its Way into the cavity of the chest, where it causes an extrava- sation, which is more, or less conside- rable. But, when the wound is ample, and penetrates in a direct manner, the effused blood, which has all the charac- ters of arterial blood, leaves no doubt, concerning the injury of an intercostal artery. However, should there still be the least uncertainty, it may easily be dispelled, by introducing the end of a finger into the wound, and making pressure with it on the lower edge of the rib, which corresponds to the ves- sel suspected to be injured. Some have recommended introducing, under the rib, a hollow cylindrical piece of paste- board; and they infer, that when the blood flows through its cavity, it comes from the intercostal artery; but, that if it passes out underneath the paste- board, it issues from the cavity of the thorax. However, besides several ob- jections, which might be urged against this method, its adoption cannot be made, unless there be a large, open wound, in which case, the plan may be dispensed with, because the place whence the blood flows, is now vi- sible. Surgeons, long ago, began to exer- cise their industry, in devising some means for suppressing hemorrhage from the intercostal arteries, in wounds »f the chest Gerard first proposed to stop such hemorrhage, by means of a ligature. His plan was to enlarge the external wound, as far as the upper edge of the rib, corresponding to the intercostal artery, which is wounded, and then to introduce into the chest a common curved needle, armed with a ligature, to which is attached a dossil of lint. The needle is to be passed be- hind the rib, rather higher than the su- perior edge of the bone. The point of the instrument is then to be pushed, from within outward, and brought out through the external wound, together with the ligature, which follows it When the dossil has come into contact with the artery, the two ends of the ligature are to be tied over a thick compress, placed on the outside ofthe rib. In this manner, the bone is sur- rounded with the ligature, and the ar- tery compressed. Goulard, a surgeon of Montpelier, having found difficulty in passing a common needle, whose shape little cor- responded to the track, through which it had to pass, being curved towards its point, and straight towards the eye, had a particular one constructed for this operation. He also feared, that the former instrument, which has a sharp point, and edges, might wound the lungs. The one, which Goulard invent- ed, formed three-fourths of a circle, and was fixed on a long handle, which facilitated its being introduced. The eye, in which the ligature is to be put, is situated near the point, which is a little blunted, and the ligature lies also in a groove, constructed along the con- vexity of tlhe instrument. When this needle had passed through the inter- costal muscles, and its point had made its appearance over the rib, which was above the artery, the ligature used to be untied, and held, while the needle was withdrawn at the place, where it had entered. The ligature was then tied, just in the same manner, as in Ge- rard's method. Since the use of the ligature, it has been thought, that compression might answer better. L6ttery, professor of anatomy in the university of Turin, had constructed, for this purpose, a steel plate, which he submitted to the in- spection of the Academy of Surgery, and is both described, and engraved in the second volume, 4to. of the Me- moirs of this Society. This plate, as we have said, is made of steel, and is of a long shape; narrow at one end; broad at the other; curved in two direc- tions at its narrow part; and pierced at this place with some holes, by means of which a compress, calculated for compressing the artery, is fastened on the instrument, an opening having been first made in the situation ofthe wound of the vessel, for the purpose of giving vent to blood, already extravasated in THORAX. 303 the chest. The other end of the steel plate has two long parallel slits,through which a ribband is passed, in order to fasten the instrument. This steel contrivance is used in the following manner: when the wound, corresponding to the intercostal artery, is sufficiently extensive in the trans- verse direction, the narrow, bent end of the instrument is to be introduced, in such a way, that the lower edge of the rib above may lie in the concavity of the curvature, and the compress press on the edge of the bone, and, of course, on the artery. The rest of the instrument applies itself to the side of the thorax, in which situation it is to be fastened. When the wound is not ample enough, a sufficient dilatation of it must be made for the introduction of the instrument. M. Quesnay made use of a piece of ivory, which he covered with lint, &c. and then introduced within the chest. The instrument was then drawn from within outward, by means of a ribband, which was fastened to it, and thus the necessary compression was produced. Quesnay's plan is somewhat like that invented by L6ttery. But, to have in- troduced the compress entirely into the thorax, together with the ivory, which was the basis of it, and then to have drawn the contrivance from within out- ward, as was probably intended, a very large wound would have been indis- pensable. This is also one of the ob- jections to L6ttery's instrument,which, in fact, could only be employed, when there was a free and ample opening. However, there are other objections to this instrument: it obstructs the motion of the thorax; it prevents blood, extra- vasated in the chest, from readily mak- ing its escape, notwithstanding the opening made in the curved part ofthe instrument; and, lastly, it does not ef- fectually stop the bleeding, because it does not hinder the rib from rising, against which the pressure should be made, and, consequently, the hemor- rhage may then take place. Belloque, seeing the inefficacy of all the compressing means, used before his time, and their inconveniences, in- vented an instrument, which, he says, is calculated for making proper pres- sure, and, following the motion of* the ribs, without hindering the escape of extravas:ited blood. The machine is en- graved, and described, in 2 tom. 4to. of the Memoirs of the Roval Academy of Surgery in France. It is composed of two plates, which are wadded, and ca- pable of being approximated, by means of a screw. This instrument, as M. Sa- batier observes, does indeed promise to be completely effectual in its action; but, it is complicated, and awkward, and its utility is founded on the suppo- sition of the wound being larger, than wounds are, which are made with common weapons. As the object is to make pressure on the artery, it is quite unnecessary to have, for this rare accident, numerous instruments, which could seldom be at hand, and which are also liable" to all the above objections. A common dos- sil of lint, (says Sabatier) fastened to a strong ligature, and introduced be- tween the two ribs, or even quite into the chest, and then drawn, from within outward, like Quesnay's compress, would fulfil every desirable purpose. This being done, the external wound should be covered with simple dress- ings, and a bandage applied round the body. The patient should be freely, and repeatedly bled, and treated on the most rigorous antiphlogistic plan; every method being adopted, which seems proper, in cases of wounds pe- netrating the chest, which are almost always attended with symptoms of high inflammation and irritation. The dressings should not be removed, till the wound has suppurated, and then the rest of the treatment resembles that, which becomes necessary in wounds with extravasation, of which we shall presently speak. 3. The protrusion of a portion of the lungs, in consequence of wounds pe- netrating the chest, is a very unusual case; but, there are some instances re- corded by writers. Schenckius relates an example, taken from Rolandus, one ofthe commentators on Albucasis. Ro- landus having been called to a man, who had been wounded in the thorax, six days before, found a portion of the lungs protruded, and in a state of mor- tification, in consequence of the com- pression which it had sustained. This surgeon extirpated the part, and appli- ed astringent powders to the wound: the patient recovered in a very little time, without any indisposition what- ever remaining. Tulpius has recorded a similar fact. A man received an extensive wound, just below his left nipple. His natural- ly gay disposition, however, led him to 304 THORAX. neglect the injury; and, on the third day, a piece of the lungs, three finger- breadths long, protruded at the wound. The patient went to Amsterdam, whence he was distant two days' jour- ney, for the purpose of receiving suc- cour in one of the hospitals of that city. The protruded piece of lung, which was already mortifying, was tied, and cut off with scissors. It weighed three ounces. The wound healed in a fort- night, and the patient experienced no complaint afterwards, except a slight cough, which troubled him from time to time. The man survived the acci- dent six years, leading a wandering, drunken life. After death, nothing particular was observed in the thorax, except that the lungs had become ad- herent to the pleura, in the situation of the wound. Fabricius Hildanus also relates a case, which was communicated to him by Abel Roscius. A man was wound- ed with a knife, between the fifth and sixth ribs, near the sternum. A piece of lung protruded through the open- ing, and it was wished to reduce the part; but, as it seemed to assume a li- vid colour, it was extirpated with the actual cautery. Having dilated the wound, and kept the ribs apart, with a wedge, made of wood, the portion of lung, which had been girt by the open- ing, was returned. The patient, after taking, what were called, pectoral and vulnerary medicines, soon got well, and felt no complaints in his chest af- terwards. A fourth example of a piece of lung, making a protrusion through a wound in the thorax, is among the cases, re- corded by the celebrated Ruysch. The servant of a sea-faring man was wound- ed in the anterior and inferior part of the chest, and was immediately attend- ed by a surgeon, who mistook the pro- truded piece of lung, for a portion of omentum, and applied a tight ligature round it. Ruysch, who was called in to the case, soon detected the error, which had been committed; but, he had no apprehensions, as he was con- vinced, that the wound would heal very well, as soon as the tied piece of lung was detached. The event justified his prognosis, and the patient recover- ed, in the same manner as the above mentioned ones. When the piece of protruded lung is sound, and its small size would admit of its being reduced, the attempt ought to be made, without the least delay. It should be done on the same principles, as those, on which we return into the abdomen a piece of protruded intes- tine, or omentum. (See Abdomen.) A recurrence ofthe accident is to be pre- vented by closing the wound, and pla- cing a compress over it. But, when the piece of lung is already in a mortified state, in consequence of the constric- tion, which it has suffered, or when its large size prevents reduction, Sabatier is of opinion, that the only resource is to extirpate the part, after having ap- plied a ligature round its base. If the latter step were not taken, a dangerous hemorrhage might follow, or else an extravasation of blood in the thorax. (Medecine Operatoire, tom. 2, p. 224.) However, the practice just now recom- mended seems very questionable: in the instance of mortification, extirpa- tion is clearly unnecessary, as the dead part will naturally be thrown off by a spontaneous process; and, when the wound is too small to allow the part to be returned, ought it not to be dilated, rather then cut off a considerable por- tion, or even any, ofthe lung? 4. Emphysema is another symptom, with which wounds penetrating the chest are frequently complicated, espe- cially, when they are small, and do not enter the thorax in a direct manner. When such wounds are small, and not straight in their course; when their track is rendered impervious either by some change in the situation of the muscles, by the swelling, by clots of blood, or by any extraneous substances; air may insinuate itself into the cellular substance, so as to cause a great deal of tumour and distension. The emphy- sema is easily distinguishable by the tumefaction of the part affected, with- out any pain, or change of colour in the skin, and by the crepitation, which is perceptible, on making the air quit the situation which it occupies, and pass into the adjoining cavities ofthe cellu- lar substance. The emphysema may take place, in cases in which the lungs are not wounded, and also in others, in which they are so. In the first in- stance, the emphysematous swelling is caused by the external air, which insi- nuates itself into the cavity ofthe tho- rax, through the wound, during the first inspirations, which follow the oc- currence ofthe accident, and the same air is expelled in the subsequent acts of expiration. In the second case, the THORAX. 305 emphysema arises from the escape of air from the lungs, during inspira- tion, first into the cavity ofthe thorax, and thence, through the inner opening ofthe external wound, into the cellular substance. I should not have deemed it neces- sary to have said any thing in this part of the work, on the present subject, but should have contented myself with referring the reader to the article Em- physema, were not the cause of this symptom rather perplexing, and, did I not hope, that the following extract from Dr. Halliday's late publication will tend to facilitate the comprehen- sion of these cases. This gentleman mentions the following circumstances, under which air may escape from the lungs, oremphysema arise. First, " An injury, or disease of the pleura pulmonalis, causing a wound or ulceration of that membrane, and thus allowing the air to escape from the lungs, as in oblique external wounds/ where the outer opening, and that of the pleura costalis have healed, or clos- ed up, and in ulcers of the surface of the lungs. 2dly. " The pleura pulmonalis, and pleura costalis, maybe wounded, or ul- cerated, when there is no external opening, as when the ends of frac- tured ribs penetrate through both into the substance of the lungs, and it is from this accident, &c. that emphyse- ma most commonly takes place. 3dly. " The common integuments of the parietes ofthe chest, the intercos- tal muscles, and the pleura costalis, may be wounded, while the pleura pul- monalis and the lungs remain uninjur- ed, so that the air admitted from with- out, and collected in the cavity of the thorax, may be pressed into the cellu- lar membrane, so as to occasion emphy- sema." Dr. Halliday shortly afterwards re- marks: " that the lungs in the thorax, have often, and not unaptly, been com- pared to a bladder in a close pair of bellows: but if we suppose the bellows to be divided into two compartments, and each of these to contain a bladder, which mutually communicate with each other, and with the external air, by means of a tube, wbich is exactly adapted to the nozzle of the bellows, and which admits the air only into the cavity ofthe bladders, and not into the space betwixt the bladders and bel- lows, we shall then have a perfect re- presentation of the mechanical struc- ture of the thorax. The bellows will represent the thorax, divided in the middle by the mediastinum; the blad- ders will represent the lungs of the right and left sides; and the tube, which communicates with the bladders and with the external air, will repre- sent the trachea. The only thing,which is wanting to render this mechanical representation perfect, is, that the bladders should exactly fill the bellows, so as to leave no air betwixt them and the bellows." Dr. Halliday notices, that when we lift up the handle of the bellows, the bladders become filled by the external air, which rushes in through the tube, which communicates with both of them. When the handle is depressed, the air is expelled again. In the like manner, the lungs are filled with air, and emptied again, when the capacity of the chest is enlarged by the inspira- tory muscles, and then diminished by the expiratory ones. When emphysema arises from a wound, or ulceration ofthe pleura pul- monalis, on one side ofthe thorax, the case is nearly the same as if an opening were made in one ofthe bladders, which opening would form a communication, as Dr. Halliday observes, with the bel- lows and bladder on one side. If this should happen, while the handle of the bellows is depressed, no sooner is the handle raised, than air rushes into the space, betwixt the bladder and bellows, and, on keeping up the handle a little while, the bladder will become quite collapsed, and tlje place which it occu- pied, while distended, will now be oc- cupied by the air. If now, says Dr. Halliday, " we attempt to force out the air, by depressing the handle ofthe bellows, we shall find that this cannot be done; for, there is no direct commu- nication, between the bellows and the external air; and, as the effused air presses equally on all parts of the col- lapsed bladder, it cannot escape through it." When the thorax is expanded in in- spiration, the pressure is taken off the surface of the wounded lung, and the air, which now enters this organ, in- stead of distending its cells, passes through its wound into the space be- tween the pleura pulmonalis, and pleu- ra costalis. The lung will, indeed, be partially expanded, as long us inspira- tion on that side goes on; the more so, Vol. II. 2 Q. 306 rrioRAX. the smaller its wound is. At eVery ex- piration, however, when the thorax is diminished, the effused air will be com- pressed against the wounded lung; but none of the air, which has escaped, can re-enter the lung again; " because (as Dr. Halliday accurately remarks) the whole of the air contained in the lungs must be forced out, and then the pressure (ofthe air) against every part ofthe collapsed lung being equal, will prevent its separating any part, so as to make a passage for itself into the tra- chea." Thus fresh air accumulates at every inspiration in the space, between the pleurae, while none can escape from the same situation during expira- tion, and the quantity accumulated will, at last, equal that which is receiv- ed into the other lung, during the most powerful inspiration. Dr. Halliday no- tices, that some authors have termed this case thoracic emphysema; it is clear- ly attended with no diffusion of air in the cellular substance, a circumstance, generally implied, when we speak of emphysema. When both the pleura pulmonalis, and pleura costalis are wounded, the same effusion of air between these two mem- branes continues to take place, from the abovementioned causes, till the lung is collapsed. When an attempt is now made to expire, the injured side ofthe thorax must continue distended, not- withstanding every effort of the pati- ent However, when, in this expiratory act, the capacity ofthe thorax is dimi- nished, and the air compressed, a part of it finds its way, through the wound in the pleura costalis, into the common cellular substance ofthe parietes ofthe chest. The passage of air into the cavity of the thorax during inspiration is, as Dr. Halliday observes, now more easy, than the return of that, which is already ef- fused in the cellular membrane, and consequently, the subcutaneous emphyse- ma continues to increase with the ra- pidity, which is remarkable, as long as the patient lives. To explain the origin of emphysema, in cases of wounds, which only enter the chest, and do not injure the lungs at all, Dr. Halliday has recourse to the simile of the bellows, and bladders.— Were an opening made into the bel- lows, without injuring the contained bladders, if the access of air by this opening be more free, than that y the nozzle, communicating with the cavitv ofthe bladder, tnore air will enter by the opening, than by the pipe, on the handle being raised, so that the bladder will not rise as before, when no opening in the side of the bellows existed. If the latter opening be smaller, than that of the pipe, the bladder will only be partially filled, and, on depressing the handle ofthe bellows, the air, contain- ed in the bladder, and that between the bladder and the bellows, will be ex- pelled, in the same proportion to each other, as that, in which they were formerly filled. This process would continue to go on in the same way, did not the bladder naturally collapse more and more from its gravitation. Let us now stop the mouth of" the pipe, while the handle ofthe bellows is raised, and the bladder partially filled. On trying next to depress the handle, it residts, that, as no air can escape from the pipe, that air, which is contained between the bladder and the bellows, must be first evacuated, while that, contained in the bladder of the sound side, will be forced into the bladder on the injured side, and either distend it, so as to rup- ture it, or cause it to protrude. Hence, in the case of a wound, pene- trating the chest, without injuring the lungs, if the air can enter more freely by the wound, than by the trachea, more of it will enter, in the act of inspi- ration, into the cavity of the thorax, than into the lungs. On the contrary, when the opening of the wound is not so large as that of the trachea, less air will enter the thorax, than the lungs. In expiration, the air will be expelled from the two different situations, in proportion to the quantity, which en- ters each of them in inspiration, and, no air at all would accumulate in the tho- rax, did not the lungs always tend to collapse from their gravitation. Should, however, the patient, in making an ef- fort to expire, contract the glottis, the air, contained in the lungs ofthe sound side, may be propelled into the bron- chia and air-cells of the lungs, on the same side as the wound, so as to dis- tend them, and even make them pro- trude at the wound. Dr. Halliday remarks, that such a protrusion often happens, when wounds are made in dogs, and has been errone- ously adduced as an argument against the collapse of the lungs, when an opening is made into the thorax of the human subject. See Observations on THORAX. 307 Emphysema, by A. Halliday, M. D. 1807. This work is highly deserving of perusal. For information, concerning the treatment of the affection, the reader is referred to th\_. article Emphysema, in this Dictionary. 5. We have already noticed, that wounds ofthe thorax may injure one of the intercostal arteries, and when the blood cannot find free vent outward, it may become extravasated in the cavity ofthe chest.The same consequence may follow wounds ofthe pulmonary vessels, those of the heart, or of the heart it- self. When the hemorrhage, however, takes place from vessels above a cer- tain size, the wounded person dies al- most instantaneously; but, when they are not so large, he may live for a grea- ter or less time, and receive the suc- cour of surgery. The following are the symptoms, which denote an extravasation of blood in the thorax. The patient feels great oppression, and such uneasiness as will not let him long continue in one posi- tion. He experiences much difficulty in standing up, or sitting up in his bed, unless he bends his body very much for- ward, in which position, the diaphragm is relaxed, and not so much "dragged by the weight ofthe extravasated fluid.— When the thighs are bent, the patient can lie with tolerable ease on his back; he is also not averse to lying on the side, on which the wound is situated; but, he cannot place himself on the opposite one, without feeling very acute pain in the situation ofthe mediastinum. His respiration is short, frequent, and interrupted by sighs; his veins be- come empty; a mortal paleness spreads over his countenance; his extremities become cold; a viscid perspiration co- vers his neck and temples; his teeth chatter; his pulse becomes weak, and if, as most frequently happens, the lungs are wounded, he spits up frothy blood, and air issues from the wound. Though one might suppose the above class of symptoms were always attend- ant on a considerable effusion of blood in the thorax, yet they are not so. Wound- ed persons have been known to die of such an extravasation, whose respira- tion was tolerably free, and who did not complain of suffering more inconveni- ence in one posture, than another. Sa- batier says, that several facts of tbis kind have fallen under his own obser- vation. Other wounded persons, also, who have suffered most of the com- plaints ascribable to extravasations of blood in the thorax, have been cured by ordinary means. M. Mery gives an ac- count of a young man, wounded in the anterior and superior part ofthe chest, about two o'clock in the morning, who had such difficulty of breathing, and so much fever, five hours afterwards, that M. Mery was of opinion, that an extra- vasation had happened, and he was thinking of making an opening for the evacuation of the blood. A tumour, which originated near the great pecto- ral muscle, and presented, neither the feel of fluctuation, nor that of emphyse- ma, made him suspend his decision.— Some bleedings, and the application to the tumour of compresses, dipt in a mixture of spirit of wine and water, dis- persed the symptoms. This recital shows, as M. Mery has remarked, how equivocal the symptoms of an extravasa- tion in the chest are; how difficult it is to form an opinion; and how liable to failure any operation is. However, even the assemblage ofthe above symptoms, did not lead M. J. L. Petit into a mistake. Having been re- quested to assist at an operation, which was about to be done on a wounded man, about whose arm-pit, pectoralis major, and latissimus dorsi muscles, a prodigious emphysematous swelling had taken place; whose respiration was painful and difficult; and who spit up frothy blood from his mouth; M. Petit gave it as his opinion, that it was unne- cessary to make an opening into the chest. He thought, that it would be suf- ficient to enlarge the wound, which was at a little distance from the arm-pit, near the edge of the latissimus dorsi, so as to give vent to the effused air. This advice having been followed, the emphysema in a little while disap- peared, and the patient soon recover- ed. The equivocal nature of the symp- toms of extravasations of blood in the thorax, has induced practitioners to pay the most scrupulous attention to every circumstance attendant on these cases. Valentine remarked, in several in- stances, that, a few days after the wound, an ecchymosis occurred, at the angle ofthe false ribs, and spread to- wards the loins. The ecchymosis is described as being of clear purple co- lour, like the spots, which sometimes form on the abdomen, a little while af- ter death. Such is the difference, be- tween this ecchymosis and that, which -consists of an extravasation of blood in 308 THORAX. the cellular substance, from the rup- ture of" blood-vessels, wliich makes its appei.vance shortly after the acci- dent,, begins close to the injury itself, and is of a deep colour, commonly spot- ted with some red points. Valentine advised a counter-opening to be made, in a case, in which most of the symp- toms of extravasation were combined with the above sort of ecchymosis. The advice was overruled, and the patient soon afterwards died. More than six pints of blood were found extravasat- ed in the thorax. Sabatier remarks, that we cannot too highly applaud the zeal of those practi- tioners, who endeavour to dispel the doubts, which still prevail in some parts of surgery. At the same time, he thinks, that all, who take interest in the im- provement of this science, should en- deavour to ascertain the truth of any new observations, which are offered. Hence, he deems it proper to relate a case, which was communicated to him by M. Saucerotte (the father) an emi- nent military surgeon, and which shows, that the ecchymosis, observed by Valentine, is, at least, not invaria- bly attendant on extravasations of blood in the chest. A carabinier, who had re- ceived a thrust with a sabre in the right side ofthe thorax, above the ten- don ofthe pectoralis major, appeared to be going on very well for the first four days following the accident. On the fifth, he complained of difficulty of breathing, uneasiness, and an inability of lying on the left side, without ag- gravating his complaints. He com- plained of a great deal of pain in the region of the liver, and at tbe top ofthe shoulder. His pulse was small and con- tracted, and rather hard, than weak. The right side of the chest seemed larger, than the left. On the eighth and ninth day, the symptoms became more urgent, and the patient found no ease, except in leaning on his right side, and supporting himself on a chair, placed across his bed. This assemblage of symptoms indicated an extravasation of blood in the right cavity ofthe thorax; but, as the ecchymosis, which M. Va- lentine has described, was not appa- rent, M. Saucerotte thought that they might be deceitful. Their long continu- ance, however, had made him resolve to make a counter-opening, but in the mean while, the patient died, in the night between the ninth and tenth day. When the operation was done on the dead body, a pint of putrid blood flow- ed out. When the surgeon feels assured, that an extravasation of blood in the tho- rax has really occurred, the only in- dication is to make an opening for its escape. However, before undertaking this operation, the revived state of the pulse, the return of warmth in the ex- tremities, and the cessation of convul- sions, ought to denote, that the hemor- rhage no longer continues from the wounded vessels. If this were not the case, a fresh quantity of blood would soon be extravasated, and the patient die exhausted. Besides, by delaying to make an opening for the discharge of the blood, we give nature time to em- ploy her own resources. Observers have recorded instances, in which ex- travasations of blood in the thorax have got well, without any operation. Fabri- cius ab Aquapendente relates an exam- ple of a man receiving so narrow a wound in the chest, that it was impos- sible to make out, whether it had pe- netrated the pleura, or not. The spit- ting of blood, weight on the dia- phragm, fever, and oppression, with which the patient was soon seized, re- moved all uncertainty. It was deter- mined to make an opening into the chest, when a large glassful of blood came away with the urine; the pain now subsided, the fever and other com- plaints abated; and a speedy recovery followed. Though Fabricius sets this case down as one of extravasation, and that it was cured, in consequence of the evacuation of blood with the urine, both inferences may, at all events, be rationally questioned. Authors make mention of five me- thods of discharging collections of blood in the thorax; viz. 1st. By plac- ing the patient in a posture, which fa- vours the escape ofthe blood; 2dly. By introducing a syringe for the, purpose of sucking it out, or a mere cannula, through which it is to flow; 3dly. By enlarging the wound; 4thly. By em- ploying injections; 5thly. By making an opening into the thorax in a depend- ing situation. 1. Success cannot be expected from merely placing the patient in a pOsture, which is favourable to the escape of the extravasated blood, except when the wound is situated at the inferior part of the chest, and is large and di- rect in its course. Pare successfully THORAX. 309 adopted this method in the case of a soldier, who was stabbed in three places with a sword, one of the wounds, which entered the chest, be- ing situated under the right nipple. The man was first dressed by a sur- geon, who made several sutures. The patient was soon afterwards attacked with considerable difficulty of breath- ing, fever, coughing, spitting of blood, and acute pain in the side. Pare, who was consulted the next day, suspected, that an extravasation had happened; consequently,, he cut out the sutures, and placed the patient in a position, in which his feet jyere much more raised, than his lvead. Pare also recommended him to hold his breath, and then intro- duced his finger into the wound, in or- der to take away some clots of blood, which appeared at its orifice. By these steps, the discharge of Seven, or eight ounces, of fetid, coagulated bjood, was effected. Injections of barley-water, in which were mixed a little honey of roses and sugar-candy, gave the patient ease, and finished the cure. 2. The idea of sucking out ofthe ca- vity of the thorax, by means of a sy- ringe, blood extravasated in this situa- tion, was conceived a long while ago. The pipes of all syringes, for this pur- pose, should have blunt ends, lest they should injure the lungs. Mere tubes, containing a stilet, have also fre- quently been employed. In the cases, related by Scultetus, there is an exam- ple, in which an instrument of the lat- ter sort was successfully made use of. No syringe, nor any suction with the mouth, was requisite; it was only found necessary to introduce the tube, and then withdraw the stilet. Lamotte only used a simple cannula, which he introduced into the centre of the extravasation. Then having placed the patient in what he conceived to be the most favourable posture, and re- quested him to hold his breath, he drew off' the collection of fluid. The cases, numbered 216, 217, 218, show the success which attended this me- thod. Although it. might also have an- swered very well in the case 219, La- motte saw, that the exceedingly high situation of the wound would not have allowed all the blood to be discharged, and, therefore, he made a counter- opening. Thus the thorax was com- pletely emptied, and a recovery the consequence. When a cannula is em- ployed, authors recommend it to be in- troduced every day, till the bad symp- toms cease, and no more fluid escapes through the cavity of the instrument. After having given vent to blood, it al- lows a bloody serous fluid to escape, and at a later period pus, which be- comes of a thicker and thicker consis- tence, the nearer the patient is to a re- covery. 3. The cases, in which an enlarge- ment of a wound, complicated with an extravasation in the chest, should be practised, are those, in which there is reason for thinking, that the situation is favourable for the escape of the blood. The operation is performed by introducing a grooved director, along which the knife is to be guided. The integuments, and external muscles, are to be divided in a perpendicular direc- tion, and the intercostal muscles in a line parallel to the ribs. Care is to be taken not to cut too near the lower edge of the upper rib, lest the inter- costal artery should be wounded. Dio- nis relates, that he practised such an operation on a soldier, wrho was wound- ed at Befort in 1703, by the thrust of a sword below the right nipple, which made a direct opening into the thorax. As the patient was half a league from the town, his chest had become full of blood, before he could be assisted. When the extravasated fluid had been let out, Dionis made the patient lie on the wounded side, during the night, and in proportion as the blood continu- ed to be thus evacuated, the breathing became free from oppression. The next day, the thorax was quite emptied, and the cure was so speedy, that the pati- ent was in a state to join the army a month afterwards. 4. The methods, which have just been explained, may be of use, when the blood retains its natural state of fluidity; but, when it has coagulated, as often happens, they can be of no avail. In this circumstance, the best plan, which can be adopted, is to inject warm water into the chest, which in- jection is the best calculated for loosen- ing, and dissolving the coagula, and washing them out of the wound. A proper opening must of course, be previously made. The French wri- ^ ters, even the modern ones (Sabatier) most absurdly recommend the injection of various detergent vulnerary decoc- tions, and of solutions of honey of roses, soap, salt, &c. What idea these authors can entertain of the great sensibility and tendency to inflammation of the lungs and pleura, or what good they 310 THORAX. ran expect from such applications, is difficult of conception. I am firmly con- vinced, that the meanest scribbler on surgery, in this country, would be ashamed of being an authority for such advice. 5. When the wound is narrow, and situated at the upper part ofthe chest, we cannot expect to be able to give vent to the extravasated blood, without making a counter-opening at the lower part of this cavity. The best place for making the opening, and the proper manner of executing the operation, are explained in the article, Paracentesis of the Thorax. When the opening has been made, the blood makes its escape. Its exit is to be promoted by placing the patient in a posture, which makes the opening as depending as possible, and by desir- ing him to hold his breath. After as much blood, as can be ob- tained, has been taken out, the com- mon plan has been to maintain the opening, and not let it heal, till after a Certain time. For this purpose, the old surgeons used to employ tents, made of lint, which were proportioned to the size of the opening, being short, soft, and flat- tened. They had a sort of head, and a double ligature attached to them, and were often dipped in some kind of ap- plication. Tents have now been quite abandoned, as they are apt to bring on inflammation of the lungs, hinder the escape of whatever fluid is contained in the chest, and cause great irritation in the parts, through which it passes, occasioning pain, inflammation, and even exfoliations from the ribs. Others have recommended introduc- ing the end of a kind of wick, which, they contend, keeps open the wound, without hindering the escape of* fluids. Such advice, however, is not free from objections, nor is the latter reason alto- gether true. Le Dran preferred tents to wicks: he states, that the hemorrhage can only be stopped by the coagulum, which forms over the mouth of the wounded vessel. The clot is elongated, and even continued into the vessel itself, and while it remains there, no more blood is effused. In the mean while, it flows into the collateral vessels; and the mouth of the vessel closes, and in- cludes within its parietes, the portion of the coagulum, which has formed in it. Thus the clot becomes gradually se- parated into two portions, one of which remains in the vessels, and acts as a sort of plug, while the other is dissolv- ed in the suppuration. Hence, conti- nues Le Dran, when a tent is introduc- ed into the opening, which has been made, it must confine a part of the blood, which has been extravasated in the chest, and without which portion being retained, the clot would not be supported, but fall off, before the mouth of the vessel had closed, and the hemorrhage constantly continue. Without entering into an examination of Le Dran's theories of the stoppage of bleeding, a subject, which is fully explained in the article Hemorrhage, we may only remark, that this author's predilection for the use of tents is founded on a supposition, that the counter-opening has been made, before the hemorrhage from the vessels has ceased. Every one, however, agrees, that no steps should be taken for the discharge of the blood, contained in the thorax, before being assured, that the hemorrhage has ceased. Hence, the tent can only be regarded as hurtful. But, dismissing from consideration wicks and tents, the best means of maintaining an opening, (were such thing necessary, which cannot fre- quently be the case,) would be, a short cannula, with a rim to keep it from slipping into the thorax, and two little rings for confining it in its situation with a ribband. This should only just enter deeply enough to have its inner orifice on a level, or very little further inward, than the pleura costalis, and consequently it could not injure, nor irritate the lungs. A plug should be kept in its outer opening, and with- drawn, as often as occasion requires, that is, as often as any material quanti- ty of fluid collects, and requires to be discharged. When the patient has been dressed, he is to be kept in bed, with his head and chest somewhat elevated, and his thighs bent, in which position, the breathing will be found to be less op- pressed. It is usual also to recommend him to lie, as much as possible, on the side on which the operation has been done. He is to keep himself in as still, and quiet, a condition as he can. He is to be put on very low diet, and, if his strength allows, he is to be bled, and this evacuation repeated, with other antiphlogistic means, as often as the urgency of the fever and inflammatory THORAX. 3H symptoms indicates, and the strength of the constitution allows. Bleeding from the arm, besides counteracting inflammation in the chest, which is a principal source of danger, does good by lessening the force of the circulation in the wounded vessels, and thus it di- minishes the tendency to internal he- morrhage. In keeping open wounds ofthe chest, the surgeon must be careful, that no tents, nor any of the dressings, glide into the cavity of the pleura. Nume- rous cases on record show the neces- sity of using great caution, that no ac- cident of this kind occur. Tulpius makes mention of a Danish gentleman, who had been under a careless surge- on, on account of a wound in the tho- rax, and who coughed up, six months afterwards, a large tent. A similar fact is recorded, among the cases collected and published by Fabricius Hildanus. A man was stabbed with a sword in the right side of the chest, near the axilla, between the second and third ribs. A great deal of blood was dis- charged, during the first fortnight, both from the wound, and by the mouth. The wound was successfully healed; but, the patient continued to suffer considerable difficulty of breath- ing, and an incessant cough, and he ' used to spit up a greenish, fetid mat- ter. Three months afterwards, he coughed up two tents, which had slip- ped into the cavity of the thorax, from beneath the dressings, with which the wound had been covered. In whatever condition the patient may be, any change in the antiphlogis- tic regimen must be made with very great circumspection. Too much nou- rishment, talking too frequently, and any exertion, are circumstances, which may induce a renewal of the hemor- rhage, and extravasation, even after a considerable time. Vesalius saw an ac- cident of this nature happen, a fort- night after the wound, and eleven days after the operation for empyema. A Biscayan soldier, who had been stab- bed in two places with a sword above the right nipple, was attacked by fever, difficulty of breathing, restlessness, and acute pain at the bottom of the chest. These symptoms indicated to Vesalius, that an extravasation had ta- ken place; but, he was afraid of making an opening into the chest, for fear the hemorrhage should still continue from the wounded vessels. However, as the patient remained in the same state, the fourth day after the receipt of the wounds, and his strength still lasted, Vesalius undertook the operation, by which a considerable quantity of ex- travasated blood was discharged. The patient felt great relief at the instant. The oozing of blood continued for afew days, after which a favourable suppu- ration took place in all the tiiree wounds, and the case was, therefore, expected to end well. But, the patient having regained his strength, and taken too mucb food, the recurrence of he- morrhage caused his death, at the very time when he seemed to be get- ting well. M. Lombard, well known for some excellent productions on sur- gery, saw a soldier die instantaneously of internal hemorrhage, from throwing a bowl at nine-pins, two months after he had been cured of a wound of the chest and lungs. Authors in general advise us, before we close the wound, for the purpose of healing it, to make the patient expel the air from the chest. For this object, they advise the patient to be requested to make a strong inspiration, with the wound closed, and then a long slow expiration with it open, and so on, till as much of the air as possible is dis- charged, and then the wound is to be accurately closed with sticking plas- ter. From what we have said, however, in the article Emphysema, it will ap- pear, that when there is a direct open- ing into the thorax, so as to admit the external air, the lungs on one side col- lapse, and remain so till the wound is healed, and the air absorbed. When one of these organs is wounded, a col- lapsed state is, indeed, the best condi- tion, in which it can possibly be for a certain time, that is, till the breach of continuity in it has healed. All efforts to make the lung expand, by exhausting the air from the cavity of the pleura, seem unavailing; but, there is certainly no objection to not closing the wound, before as much air has been expelled in the above way, as can be thus got rid of. Fistulae sometimes continue for a long while after wounds of the tho- rax. Felix Platner mentions an in- stance, in which a man had in his chest a fistulous opening, out of which the air rushed with such force as to blow out a candle. He lived a long while with this disease, without suffering any particular inconvenience. 312 THO THR Another occasional consequence of openings made in the chest, is a hernia ofthe lungs, an affection, of which, Sa- batier savs, he is not aware, that any one has s"poken. This gentleman, how- ever has seen such a case. A soldier, thirty years of age, who had been wounded at Rostock with a bayonet, in the right side of the chest, between the middle part of the fifth and sixth true ribs, had several bad symptoms, which he survived. The wound was successfully healed; but, as the inter- costal muscles had been divided to a great extent, and could not be approx- imated with precision, there remained an empty space under the integuments, which allowed a piece ofthe lungs, as large as a walnut, to protrude between the ribs. The swelling enlarged at the time of inspiration, and grew smaller when expiration took place. It only occasioned a slight pain, without any oppression in the chest. The making of an opening into the chest, as already spoken of, is recom- mended, as Sabatier remarks, by all authors, who have treated of wounds ofthe chest. However, it does not ap- pear, that the operation has been often done. Few instances are to be met with on record. J. L. Petit does not make mention of even one. Lamotte, who had the care of an infinite number of pa- tients, never practised the operation, except twice, and, in one of these in- stances, it was done to let out a collec- tion of matter in the thorax, which had occurred after a wound, which injured the lungs. Sabatier notices, that the seven volumes ofthe Journal de Medi- cine Militaire, which contain a collec- tion of the most interesting cases, which have presented themselves in the military hospitals, record no exam- ple, in which it was necessary to resort to the operation in question. No in- stances are related in the Mem. de I'Acad, de Chirurgie. Sabatier says, he has inquired of many army-surgeons; but, none of them have either seen the operation done In others, or performed it themselves. M Saucerotte, observes Sabatier, is the only one, who did it with success in a case, in which the exigency for the operation would not be expected. It was in an instance of a gun-shot wound. The necessary dila- tations, and the extraction of extrane- ous substances, had diminished the in- flammatory symptoms. These were subsiding entirely, when, on the third day, a violent hemorrhage took place from one ofthe branches of the internal mammary artery. This loss of blood, together with repeated venesections, did not hinder a considerable extrava- sation of blood in the chest from hap. pening on the fifth day. The patient was threatened with suffocation. He was made to bend forward, in order to promote the escape of the fluid, of which about a pint, in colour, like wine-lees, and having a disagreeable smell, was discharged. A considerable quantity was in this way evacuated, every morning and evening. The pos- ture, in which the patient was necessa- rily put, and the efforts he was obliged to make to promote the evacuation, fa- tiguing him exceedingly, he consented to have a counter-opening made, at the lower part of the chest, on the eigh- teenth day. The operation gave vent to a pint of blood, ofthe same kind as that which had issued from the wound. The quantity emitted became daily less and less, and, in three months, the patient got quite well. Sabatier questions, from what has been stated, whether we may not conclude, that such extravasations of blood in the thorax, as admit of sur- gical aid, are exceedingly unfrequent cases, and that the symptoms, indica- tive of these instances, are not suffi- ciently clear, so that most of the pa- tients, with such extravastions, die, without it being in the power of sur- geons to make any attempt to save them. Every systematic writer on surgery has treated of wounds of the thorax: John Bell's , Discourses on Wounds, and Sabatkr's Medicine Operatoire, from which latter I have extracted a great deal ofthe preceding account, seem to me to merit attentive perusal. THROAT, WOUNDS OF. Inju- ries of this kind are often attended with considerable danger, on account of the great number of important parts, which are interested; but, mere cuts of the integuments of the throat and neck are not (generally speaking) dan- gerous cases, and do not materially dif- fer from common incised wounds of the skin, in any other part ofthe body. They are not liable to be followed by any particular consequences, and re- quire the same kind of treatment, as cuts in general do. (See Wounds—In- cised Wounds.) In wounds of the throat and neck, however, the larynx and traciiea, pha- THROAT. 313 i-ynx and oesophagus, the trunk of the carotid artery, and all the principal branches of the external carotid, the large jugular vein, the eighth pair of nerves, and the recurrent nerve, are all exposed to injury; some much more so than others; but, all of them occasionally not escaping the edge of the knife, or razor, or the point ofthe 9word, or other instruments. It would certainly amount to absur- dity, to offer an account of what is to be done, in cases attended with some part of the mischief above pointed out; for, no patient, thus wounded, would ever be found alive. Wounds of the eighth pair of nerves are universally considered by all surgeons as certainly fatal. These nerves, we know, proceed down the neck, in the same sheath of cellular substance, which includes the carotid artery, and lie on the outside of this vessel, between it and the in- ternal jugular vein. Wounds, either of the carotid arte- ry, or internal jugular vein, must for the most part prove immediately fatal, in consequence of the great and sud- den loss of blood, which would inevita- bly arise from an open, cut wound, in- terestingthese vessels. However,were any surgeon on the spot at the moment, he should immediately tie the end of the vessel, from which the blood gushes with the greatest force, which end, we know, would be the lower one of the carotid, and upper one of the jugular vein. One caution, however, is highly necessary in tying the caro- tid, viz. always to be sure, that the par vagum is excluded from the liga- ture; for, were this nerve to be tied, this erroneous proceeding alone would remove every possibility ofthe patient's recovery. If the mouth of the vessel could not be got at, pressure must be instantly resorted to, for the purpose of produc- ing a temporary suppression ofthe he- morrhage. The surgeon should then ei- ther make the necessary enlargement ofthe wound in the integuments, with a due and constant recollection of the important parts near the place, or else, in the case ofthe carotid being injured, he should cut down to this vessel on the side towards the trachea, where no parts of great consequence are si- tuated. In lacerated wounds, the carotid ar- tery may be injured, and yet the patient not immediately bleed to death; for, it is the nature of all wounds, attended with much laceration and contusion, not to bleed so freely as clean cuts. Mr. Abernethy has related a case, in which the carotid, and all the chief branches of it were wounded by a man being gored in the neck with a cow's horn; yet, death did not immediately follow, and there was time to have recourse to the ligature. Punctured wounds might obviously injure, either the carotid, or the inter- nal jugular vein, without the patient expiring of hemorrhage at once; be- cause, the smallness of the wound in the skin, would often hinder the fatal effusion of blood. However, when these vessels are wounded, the par vagum is generally wounded also, and J.he case is inevitably mortal, either immediately, from the direct effects both of the injury of the nerve, and sudden loss of blood, orveiy soon afterwards, the bleeding being of a slower, and more interrupted kind, which must depend on the lacerated nature ofthe wound, the small size of the opening in the vessel, or of that in the skin, 8tc. Persons who attempt to commit sui- cide, by cutting their throats, do not often divide the carotid artery, on ac- count of their incision being made too high up. Where the carotid arteries emerge from the chest, they are situ- ated by the side of the trachea, and even a little more forward, than it.— However, as these vessels proceed up the neck, they become more laterally situated with respect to the trachea; and when they have arrived at the up- per part of the neck, where persons, who attempt to commit suicide, al- most always cut, they become situated more backward, than the trachea, in- clining towards the angle ofthe lower jaw. The oesophagus is so deeply situat- ed, lying close to the bodies ofthe ver- tebrae, and behind the trachea, that it is not often interested in any incised wounds, which do not immediately prove fatal, in consequence ofthe divi- sion of other important parts. We read of many cases, in which this tube is said to have been wounded, and, what is usually set down as a criterion of the fact, is the passage of victuals through the wound. The writers of many of these narrations have proved them- selves most grossly ignorant of anato- my, by not knowing, that wounds made Vol. II. 2 R AU THROMBUS. above the os hyoides, as they frequent- ly are, may enter the mouth, and hence the victuals may escape through the cut, without the oesophagus, or pha- rynx, being at all concerned. However, no doubt, the oesophagus has occasionally been wounded, with- out the patient perishing so immediate- ly, as not to be capable of receiving any succour. Stabs, and gun-shot wounds, might obviously injure the oesophagus, and leave other important parts un- touched. Even were the oesophagus known to be wounded, its deep situation would prohibit us from doing any thing to the breach of continuity in the tube itself. The best plan would be to have re- course to antiphlogistic means, and to introduce a hollow bougie, from one of the nostrils, down the oesophagus, for the purpose of conveying nourishment and medicines into the stomach, with- out any risk of their getting out at the wound. An instrument of this kind will lie in the above situation, for any length of time, without occasioning any incon- venience, and, besides being advan- tageous for injecting nourishment and medicines down the passage, and keep-- ingthem from issuing at the, wound,' it prevents all necessity for the wounded oesophagus to act, and become disturb- ed, when there is occasion to take any kind of liquids, whether in the way of medicine, or food. The outer wound should be brought together, and treat- ed on common principles. When persons cut their throats, we have explained, that they do not often divide the carotid artery, owing to their incision being usually made high Up in the neck, where this vessel has attained a very backward situation.— When any serious hemorrhage does arise, it is sometimes from the lower branches of the lingual artery, but most frequently, from the superior thy - roideal arteries. Such arteries may oc- casion a fatal bleeding, which, indeed, would more frequently be the event, than it actually is, did not the patient often faint, in which state the bleeding spontaneously ceases, and gives time for the arrival of surgical assistance. I need hardly tell the reader, that these arteries are to be tied, and that this important object is the first, to which the surgeon should direct his at- tention. The danger of bleeding to death being obviated, as soon as possi- ble, the other requisite measures may be more deliberately executed. With respect to wounds of the tra*- chea, the same plan of conveying food and medicines, into the stomach, through a hollow bougie, introduced from one ofthe nostrils, down the oeso- phagus, is highly proper, though too much neglected. For, nothing creates such disturbance of the wound as the convulsive elevation and depression of the larynx and trachea, which are na- turally attendant on the act of swallow- ing. When the trachea is cut, the pati- ent's power of forming the voice is more, or less, impaired, in consequence ofthe air passing into, and out of, the lungs, chiefly through the wound Be- sides air, a considerable quantity ofthe natural mucus of the trachea is also continually coming out of the wound. The grand means of accomplishing the union of wounds of the trachea, are a proper ppsition of the head, and a rigorous observance of quietude. By raising the patient's head with pillows, and keeping his chin close to his breast, the edges of the wound, both in the skin and trachea, are placed in contact, even without any other assistance, un- less the division of the trachea be ex- ceedingly large. It is proper, however, to assist the agency of a* suitable posi- tion with strips of sticking plaster, and also, according to most authors, with a suture, or two. But, the necessity of sutures must depend on the extent of the division of the trachea; for, unless most ofthe circle of this tube be cut, and position be neglected, the wound in it will not gape. The stitches should never be passed through the lining of the trachea, as this method would be likely to make it inflame, and occasion considerable coughing, and irritation, which would have very pernicious ef- fects on the wound. Should there be much coughing, ap- parently arising from irritation and in- flammation in the trachea, bleeding is proper, if other considerations do not forbid it. The spermaceti mixture with opium, is also frequently of great ser- vice. I never saw a wound of the tra- chea unite entirely by the first inten- tion. THROMBUS, (from ^A, coagu- lated blood.) A clot of blood. The term has also been applied to a tumour, formed by a collection of extravasated, coagulated blood under the integu- ments after bleeding. When such an extravasation, though of some extent, is not considerable, it is usually called. TIC DOULOUREUX. 315 an ecchymosis. (See this word, and also Bleeding; Occasional Ill-consequence of.) A thrombus sometimes depends on the surgeon having totally divided the vein; but, much more frequently on his not having made the opening in the ves- sel, properly correspond to that in the skin. The patient's altering the posture of his arm, while the blood is flowing into the basin, will often cause an in- terruption to the escape of the fluid from the external orifice of the punc- ture; and, consequently, it insinuates itself into the cellular substance in the vicinity of the opening ofthe vein. In proportion as the blood issues from the vessel, it becomes effused between the skin and fascia, covering the muscles, in the interstices ofthe cellular sub- stance, and this, with more, or less ra- pidity, and in a greater, or lesser quan- tity, according as the edges ofthe skin impede more or less the outward es- cape of the fluid. Sometimes, also, a thrombus forms after venesection, when the usual dressings, compress, and bandage, have been put over the puncture, and the patient imprudently makes use of the arm, on which the operation has been done. This is more particularly liable to happen, when a very large opening has been made in the vein. The accident is not attended with any danger, when the extravasation is inconsiderable; for, in this circum- stance, the tumour generally admits of being easily resolved, by applying to it linen, dipped in any discutient lotion! If the swelling should be more exten- sive, applying to it a compress wet with a solution of common sea-salt, is deem- ed a very efficacious plan of promoting the absorption of the extravasated blood. Brandy, and a solution ofthe mu- riate of ammonia in vinegar, are like- wise eligible applications. It sometimes happens, that a throm- bus induces inflammation and suppura- tion ofthe edges ofthe puncture. The treatment is now like that of any little abscess: a common linseed poultice may be applied, and, any considerable accu- mulation of matter should be prevented by making an opening with a lancet in proper time. As soon as the inflamma- tory symptoms have ceased, discutients should be resorted to again, for the purpose of dispersing the remaining clots of blood, and surrounding indura- tion. When the quantity of blood is ex- ceedingly large, authors generally re- commend opening the tumour at once, and, despairing of the power of the ab- sorbents to remove the extravasation, they recommend, as much ofthe blood as possible, to be pressed out through the incision. I believe, however, that making an opening is seldom necessary, and often brings on inflammation, and suppuration, which might be avoided. I have never seen any case, in which there was any real occasion to make an opening for the discharge of the blood. A case of this kind, however, may cer- tainly be conceived. THY'MIUM, (said to be derived from &UMO*-, thyme, because of the co- lour of this herb.) A wart, or kind of excrescence on the skin. THY'MUS, (from Srv/tx, an odour, because of its fragrant smell.) The herb thyme. In surgery, the term is of- ten applied to warty excrescences on different parts ofthe body, particularly, about the pudenda and anus, and erro- neously supposed (as I conceive) to be of a venereal nature. THYROID GLAND DISEASED. (See Bronchocck.) TIBIA, ABSCESS OF. (See Corks, and Spina Ventosa.) TIC DOULOUREUX. A painful affection ofthe nerves ofthe face, par- ticularly, ofthe filaments of that branch of the fifth pair, which comes out of the infraorbitary foramen. A cure has sometimes been accom- plished by cutting down to, and divid- ing, the nerve, at the place where it emerges on the cheek. In other in- stances, this has been done, and the re- lief has only been of a temporary na- ture. Similar affections of the nerves may also take place in other situations, be- sides the face. Mr. Abernethy relates an example, in which a lady became gradually affected with a painful state of the integuments under and adjoin- ing to the inner edge of the nail ofthe ring-finger of the left hand. No injury to the part was remembered which could have brought on this disease. The pain occurred at irregular inter- vals, and was extremely sevrere during the time of its continuance, which was for a day or two, when it usually abat- ed. Accidental slight injuries always occasioned great pain, and frequently brought on those paroxysms, wliich however occasionally occurred sponta- neously, or without any evident eacit- 316 TIC ilN ing cause. In all these particulars, the disease correctly resembled the tic douloureux of the nerves of the face. As the pain increased, the disorder seemed to extend up the nerves of the arm. After the patient had endured this painful affection for seven years, she submitted to have the skin, which was the original seat of the disorder, burned with caustic. This application gave her intense pain, and, on the heal- ing of the wound, she found her suf- ferings rather augmented, than dimin- ished by this experiment. After four more years of suffering, she consulted Mr. Abernethy, when the circum- stances of the case were such as to render an operation indispensably ne- cessary. The pain of the part was in- tolerable, and it extended all up the nerves of the arm; and this general pain was so constant during the night, as to deprive the patient of rest. The muscles of the back of the neck were occasionally affected with spasms. The integuments of the affected arm wTere much hotter, than those of the oppo- site side, and sometimes the tempera- ture was so increased as to cause a burning sensation in them. Under these circumstances, Mr. Abernethy did not hesitate to divide the nerve of the fin- ger, from which all this disorder seem- ed to originate. He laid it bare by a longitudinal incision of about three quarters of an inch in length, from the second joint of the finger, and divided it opposite to that joint, by a curved sharp-pointed bistoury, which was con- veyed under it. He then took hold of the nerve with a pair of forceps, and reflecting it downwards, removed a portion of it, half an inch in length, that the possibility of a quick reunion might be prevented. The wound was brought together by sticking-plaster, and it united by adhesion; but, the up- per part of the wound, opposite to the upper end ofthe nerve, became slight- ly inflamed, and was very painful How- ever, the appearance of inflammation gradually went off in the course of three weeks. After the operation, Mr. Abernethy pinched the originally af- fected integuments sharply with his nails, without causing any sensation; but if, in so doing, he moved the finger, then pain was felt Mr. Abernethy found it difficult to convince the pa- tient, that the skin at that part was ac- tually devoid of sensation, for she still continued to feel similar sensations to those.which formerly occurred, though in a much diminished degree: but she became gradually as perfectly convinc- ed as any medical man could be, that these sensations arose from the irritat- ed state of the end ofthe nerve, above the place where it was divided. The painful affection of the nerves of the arm still continued, though considera- bly lessened in violence; however it was sufficiently severe to make the pa- tient apprehend, that little permanent benefit would arise from the operation. This pain continued occasionally about four months with varying degrees of severity, but the temperature of the skin was not hotter, than that of the opposite side, as it had been before the operation. At the expiration of three months, the patient ascertained, that the integuments at the end of the fin- ger actually felt when any thing wa6 applied to them, and this proved a new source of alarm. Mr. Abernethy adds, that more than nine months have now elapsed, since the performance of the operation, and the general pains in the nerves have become very trivial; but, the sensation ofthe integuments at the end of the finger, has during that time gradually increased, and the skin has now its natural sensibility, so as accu- rately to distinguish the tangible pro- perties of any body applied to it. If also the originally affected part be com- pressed slightly, painful sensations re- sembling those which formerly occur- red, take place. (Abernethy's Surgical Observations.) Mr. Lawrence lately mentioned to me a case resembling the former, and which was the consequence of a wound of the finger. This gentleman also cut down to the nerve, and removed a por- tion of it, with every appearance, at present, of permanent relief. TINCTURA CANTHARIDIS. Surgeons sometimes employ this medi- cine, in cases of gleets, and those of in- continence of urine, arising from a want of proper action in the sphincter vesicae muscle, the due power of which it seems to restore. The usual dose is from ten to forty or sixty drops, twice or thrice a day; but its effects should be vigilantly attended to; for it is apt to occasion dangerous inflammations of the urinary prgans, and violent stran- guries and retentions of urine. Tincture of cantharides has also been sometimes employed as an injection for exciting inflammation, in old, chro- TIN TIN 3i7 nic, callous, fistulous sinuses, with a view of curing them. Laying them open with a knife, however, is now universally preferred by all the best surgeons. Tincture of cantharides has occasion- ally been used as an ingredient in vari- ous liniments, and external applica- tions, when the object has been to sti- mulate the skin, rouse the action ofthe nerves of the part, or that of the ab- sorbents. In tliis manner it has been made use of by surgeons in some cases of ptosis, paralysis, &c. TINCTURA FERRI MURIATI. For an account of the manner of mak- ing it, see the London Pharmacopoeia. The writer of the Pharmacopoeia Chi- rurgica remarks, that the tinctura ferri muriati has sometimes been exhibited " for gleets; but a more important use has been assigned it by Mr. Cline, who orders it in dysuria, when a conse- quence of stricture, in the dose of ten drops every twenty or thirty minutes. This relaxes the spasm, through which the retention is occasioned, by a mode of operation not easily explained. " Mr. Justamond's liquid for exter- nal use in cancers, and which the origi- nal inventor called his panacea antican- crosa, partook considerably of the na- ture of this tincture, which, indeed, with an equal quantity of spirit of wine, was sometimes substituted for it. " Lastly, it is remarkably efficacious in destroying venereal or other warts, either used alone, or diluted with a small proportion of water." TINCTURA THEBAICA. R. Opii purificati ^ij. Cinnamomi, Caryophyl- lorum, sing. "5J. Vini albi Ifcj. These are to be macerated, without heat, for a week, and then filtered. This was one of the formulae of the old London Dispensatory, and though the tinctura opii is now substituted for it in that work, yet, in one particular surgical case, it is found that the tinc- tura thebaica cannot be superseded by the other preparation, without great disadvantage to the patient: I allude to inflammation of the eyes. Mr. Ware has found the tinctura thebaica, in this instance, eminently serviceable. His plan has been to drop one drop of it into the eye, once or twice a day, ac- cording as the symptoms are more or less violent When first applied, Mr. Ware remarks, that it causes, a sharp pain, accompanied with a copious flow of t'-ars, which continues a few mi- nutes, and gradually abates; after which a greater and remarkable de- gree of ease generally succeeds. This gentleman observes, that "the inflam- mation is often visibly abated by only- one application of this tincture; and many bad cases have been completely cured by it in less than a fortnight, after every other kind of remedy had been used for weeks, and sometimes months, without any success. But this speedy good effect is not to be expect- ed in all cases indiscriminately. In some, the amendment is more slow and gradual, requiring the tincture to be made use of for a much longer time; and a few instances have occurred, in which no relief at all was obtained from its first application. In cases of the latter kind, in which the complaint is generally recent, the eyes appear shiny and glossy, and feel exquisite pain from the rays of light. However, notwithstanding these symptoms, the application is sometimes found to suc- ceed; and whether it will or not, can only be determined by making the trial; which is attended with no other inconvenience than the momentary pain it gives. When it is found to produce no good effect, the use of it must be suspended, until evacuations, and other proper means, have diminished the ex- cessive irritation; after which, it may again be applied, and bids-equally fair for success, as in those instances, in which it never disagreed. " If two or three drops of the the- baic tincture are dropped at once on the globe of the eye, the pain they oc- casion will be considerably greater than if they are placed in the inner an- gle of the eye-lids, and made to glide gradually on the eye, by gently draw- ing down the lower lid. At the same time that this latter mode of applying the tincture is much less painful than the former, I have found, in a great va- riety of cases, that it is equally benefi- cial." (See Ware's Remarks on Oph- thalmy, &c. his Additional Remarks on the same subject; and the article Oph- thalmy in this Dictionary, at which part of the book, the particular cases, in wliich the application can be judici- ously made, are pointed out.) The rea- der should be well apprised, that the tinctura thebaica cannot be made indis- criminate use of, for all inflammations of the eyes, without doing serious mis- chief in many instances. TINEA CAPITIS. A disease, so 318 TINEA named, from its eating away the skin, in the manner that a moth (in latin ti- nea) does various substances. The Scaldhead. Termed also Achor, or Acha- tes a Greek word, said to be derived from a^vx, bran, and applied to this disorder, in consequence of the branny scales which are thrown off the part affected. Tinea capitis consists of small ulce- rations which originate on the scalp, more particularly in children, and dis- charge a viscid secretion. The disease begins by small vesicles, which rise above the level ofthe skin, which now becomes very manifestly red. The lit- tle vesicles burst, ulcerate, and emit a secretion, which is at first fluid, but afterwards dries more or less, so as to become of a thicker consistence, and form scabs. Several of these scabs be- coming connected together, form veiy large ones, of various degrees of thick- ness, and when these fall off, others of a similar nature are soon produced in the same situation. Some writers assert, that the seat of this disease is in the sebaceous glands, which now pour out an increased quan- tity of their secretion, which is said to be of a thicker, and more acrimonious nature, than natural. This theory, how- ever, rests unsupported by any evi- dence or facts. There certainly is no relative proportion, between the. pre- ternatural quantity of matter secreted, and the glands to which its secretion is ascribed. Besides, it is well known, that the scabs frequently form in si tuations not remarkable for being fur- nished with sebaceous glands. Authors have distinguished two spe- cies of the tinea capitis. One affects children at the breast, and makes its appearance promiscuously on every part ofthe head, on the forehead, tem- ples, and even the lips. This case is considered as the most benign, and, when cleanliness is attended to, gets well of itself. The other species of tinea is of a more inveterate nature, and the matter which it produces is said to be much more ir- ritating than that of the preceding form of the disease. The ulcerations, attendant on it, have occasionally pene- trated down to the cranium, and even rendered it carious; an event, how- ever, which is described as being ex- ceeding uncommon, except in children of very unhealthy constitutions. One may reasonably infer also, that when- CAPIT1S. ever the disease attains so high a pitch, there must have been great neglect. The second kind of tinea capitis some- times affects children after they have been weaned, and even persons, who have attained the age of puberty. The causes of tinea capitis are very imperfectly understood. Some writers have imputed them to a scrofulous constitution; but, 1 cannot discover any reason for this doctrine, except that some ofthe great number of scrofulous children, always to be met with, are affected with the scaldhead. However, so they may be with many other dis- orders, which no man, in his sound senses, would suspect to be at all con- nected with the scrofula. One of the greatest sources of error among medi- cal men, in the investigation of the causes of disease, is their continually forgetting that two of the kind above- mentioned may happen quite indepen- dently of each oher, in the same per- son, and that there is no reason, why tinea capitis, as well as the itch, a chancre, and many other affections, should not occur in a patient manifest- ly strumous. What I conceive to be a clear proof, that scrofula is not a cause of tinea capitis, though it may certain- ly influence its progress, is, that the latter is a very common disease in coun- tries, in which scrofula is scarcely ever seen. One thing, which is decidedly very conducive to the occurrence of tinea, is uncleanliness, and it is on this- account, that the disease prevails most among children ofthe lower classes of society. Poor-living seems also to have some share in keeping up, at least, if not in inducing the complaint. But, there are some circumstances, relative to the causes of tinea, with which we ai'e not at all acquainted; for, the dis- order now and then happens in chil- dren which are taken the greatest care of, being well fed, and carefully wash- ed and cleaned, every day. The ten- dency ofthe tinea capitis to spread, is easily explained, by the secretion among the roots of the hair, having the power of communicating the morbid action to every part of the surface of the scalp, with which it is allowed to come into contact. The principal objects, in the treat- ment of tinea capitis, are to soften and take away as many of the scabs as pos- sible; to cover the subjacent ulcerations with suitable applications; to keep the scalp closely shaved; and, in very ob- TONGUE, DISEASES OF. 319 stinate cases, or unhealthy subjects, to prescribe proper alteratives. In order to fulfil these indications, the best plan is to have the hair cut, and shaved off the whole of the affect- ed part of the head, and also off a good deal of the surrounding surface. The scabs are next to be softened by rub- bing them well with fresh butter, and as many of them taken away as possi- ble. This being accomplished, let the head be next washed with some strong soap-suds and a flannel; and the com- mon turpentine soap is the best for the purpose. The scalp, having been dried, is af- terwards to have applied to it an oint- ment, consisting ofthe unguentum pi- cis, and the unguentum sulphuris, mixed together in equal proportions, and spread upon a piece of bladder, or green oil-skin, which latter substance alone will, when aided by properly washing the parts, effect a cure of it- self. The dressings are to be changed every day, and the pails shaved, and well washed with strong soap-suds equally often. Cleanliness, indeed, has astonishing effect in curing tinea ca- pitis. I have met with instances, however, which resisted the foregoing plan, and, also, the application ofthe unguentum hydrarg} nitrati, hellebore ointment, &.c. The cases in question, however, always yielded to the employment of a lotion composed of a drachm or two of the kali sulphuratum, dissolved in a pint of lime-water. Linen, wet with tliis solution, was kept constantly ap- plied to the pails, which were shaved and washed as often as is above recom- mended. Some very obstinate cases demand the exhibition of internal medicines. Small doses of calomel-alone, or con- joined with cicuta, may be tried. How- ever, the most successful alterative is Plummer's pill, taken once or twice a-day, according to circumstances. [The application of common sperma- ceti lamp oil has, in Philadelphia, re- lieved and effectually cured several ob- stinate cases of tinea capitis.} • TINNITUS, (from tinnio, to tingle.) A noise or ringing in the ear; a symp- tom of some diseases. TOBACCO. The use of this plant in surgery is for promoting the reduction of strangulated hernia. For this par- pose, it is employed either in the form of a fluid glyster, or of smoke, which latter is introduced up the rectum by- means of an apparatus constructed for this object, and sold in the shops. Ex- cepting the operation, the powder of tobacco, particularly, when assisted with the topical application' of cold to the tumour, is most to be depended upon in bringing about a return of the protruded viscera into the abdomen. (See Htrnia, and also Enema.) TONICS, (from tovou, to strength- en.) Medicines whic.i strengthen. TONGUE, DISEASES OF. This part is subject to various diseases, as ulcers, tumours, and such enlarge- ments of it as sometimes put the pa- tient into imminent danger, and claim the practitioner's utmost attention. Carious teeth, having points, and in- equalities, occasioning incessant irri- tation, arc the most frequent cause of ulcerations of the tongue. The sores, thus produced, often resist every kind of remedy, and ignorance of the cause sometimes leads the practitioner to consider them as incurable; whereas, a cure might easily be effected by ex- tracting the carious tooth, or simply filing off its sharp irregularities and pointed parts. The advice just deliver- ed, is exceedingly ancient, and is the subject of a chapter in Celsus, who has treated ofthe diseases ofthe tongue. The glandular papillae, which are si- tuated on the dorsum, or upper surface of the tongue, are naturally formed with a narrow base, and broad termi- nation or head, like a mushroom. They are capable of becoming considerably enlarged, so as to form preternatural tumours which may be very improper- ly mistaken for cancerous excrescen- ces. A young man, eighteen years of age, had on the middle of his tongue, a cir- cumscribed tumour, about as large as a middle-s'i2ed nutmeg. M. Louis,who was consulted, perceived that the swelling was only of a fungous nature, and he tied its base with a ligature, with the noose of which he contracted the diameter of tbe pedicle, while, with the ends, he kept down the tongue. Then, with one stroke of a pair of curved scissors, he cut off the tubercle. M. Louis afterwards applied caustic, with the requisite precautions, to the base of the tumour, and the pa- tient got perfectly well in five or six 320 TONGUE, DISEASES OF. le, Maladies de la tending the patient, and who h«dalrea- days. (Mem. sur Langue, dans les MCmoires de I Acad, de Chirurgie, torn. 5-) Morgagni speaks of these tubercles, which occasionally form on the tongue; but he had never advised their extirpa- tion, not even when they had become hard and scirrhous; for, though he had not deemed t'-e operation impractica- ble, he had w) confidence in the skill of the surgeons, who would have been employed. (De Causis et Sedibus Mor- borum.) The tongue is occasionally affected with a true cancerous disease; one of the most afflicting cases, indeed, to which mankind are exposed. M. Louis saw a lady, who had an ulcerated can- cerous tubercle on the left edge of the tongue. The little swelling was cir- cumscribed; its size did not exceed that of a filbert; the pains were lancina- ting; the sore had penetrated deeply; and its tuberculated edges were affect- ed with a scirrhous hardness. Extirpa- tion of the disease seemed to present the only chance of freeing the patient from the terrible disorder; but, she re- fused to accede to any thing but pallia- tive plans, and she died in the course of a few months. Forestus makes mention of four wo- men, who were attacked with cancer of their tongues, and died from the ra- vages of the disease, and hemorrhage. In the writifigs of Fabricius Hildanus, there is a description of the origin and progress of a cancerous tubercle on a voting man's tongue, who had a most Intolerable fetor of die breath, and died, suffering the most excruciating pains. The same author informs us of another case, exhibiting the good ef- fects of sedative remedies in palliating a cancerous ulcer of the tongue, and the fatal consequences of an opposite line of conduct. In authors, many other examples, of the same kind, are to be met with. Surgery, however, is not destitute of resources against diseases of so for- midable a nature. The following case will serve to show, what benefit may be effected by this useful profession, when not exercised by men of too timo- rous a character. An elderly woman had on her tongue an idecrated hardness. It had been several times removed with a knife, and as repeatedly returned.— Ruysch was called in to a consultation .vith one ofthe surgeons, who was at- dy extended his incisions very deeply in removing the disease. The result of their deliberations was another attempt to extirpate the tumour, and they also determined, that after it was cut away, the actual cautery should be freely ap- plied, with a view of destroying the roots ofthe fungus. The patient con- sented to the plan, and bore the opera- tions in question with great fortitude. The tongue was taken hold of with a cloth, and Pierre Le Memnonite, a surgeon of eminence, removed the dis- ease with a curved bistoury. The inside of the mouth was then protected with wet cloths, and the actual cautery ap- plied, several times to the wound in the tongue. The pain was appeased, and the separation of the eschar promoted by emollient gargles. The place soon healed, with the aid of what were call- ed vulnerary decoctions, containing ho- ney of roses, and the tincture of myrrh and aloes. It is much easier to cutoff a com- plete portion ofthe tongue, through all its diameter, than to remove a cancer- ous ulceration, situated on one of its edges. In both cases, there is a good deal of difficulty in fixing it; for it is so very moveable, that it is not easy to keep it in a steady position. M. Louis recom- mended, for this purpose, the employ- ment of forceps, with blades which ter- minate in hook-like extremities. With this instrument, the part ofthe tongue to be amputated can be kept from slip- ping away from the operator. Cruel as the operation of removing the tongue may appear, we should not hesitate to perform it, whenever the disease has made a certain progress, and is decidedly of a cancerous nature. It should be noticed, however, that very malignant ulcers on the tongue have sometimes been cured by milder means. Very bad sores of this descrip- tion are reported to have yielded to the repeated application of leeches under the tongue, after a vast number of re- medies had been tried in vain. In the Encyclopedk Methodique, Art. Langue, there is an account of a very alarming affection of the tongue, (reputed to be cancerous, though this may be doubt- ed,) which got completely well under a very simple plan of treatment. A wo- man, thirty-five years of age, subject to cutaneous diseases, and ill-conditioned ulcers, complained, for seven or eight TONGUE, DISEASES OF. 321 months, of little swellings, accompani- ed with heat and pain, which made their appearance on the edge, and to- wards the apex, of the tongue. At length, the part affected began to swell, grow hard, and cause lancinatingpains. Its surface became irregular and rough; and all the side of the tongue was con- siderably swelled. The patient could not put her tongue out of her mouth, nor swallow any thing except liquids; and her breath was intolerably fetid.— Various sedative remedies had been employed without success. Cicuta had been used as a topical application; it had been exhibited internally in large doses; the patient had taken, for a long while the corrosive sublimate; but no- thing proved of any avail. At length, the patient was so tired of trying the ef- fect of medicines and applications, that she gave them up entirely; and con- tented herself with trying the experi- ment of keeping some honey continual- ly in her mouth. As this method seem- ed to give her some ease, she was pre- vailed upon to persist in it, and, in this way, the pains were gradually appeas- ed; the swelling was diminished, and, at the end of two or three months, the woman got quite well, except that an indurated cicatrix remained on the part affected, and considerably ob- structed the extension of the tongue on that side. On this case, however, it might be remarked, that the retardation of the cure seems also ascribable to the inju- ry of the health produced by the hem- lock, mercury, &e. and that the amend- ment, following their discontinuance, might arise from the consequent im- provement ofthe patient's health. Many writers have confirmed the fact, that very inveterate diseases of the tongue are sometimes cured by hemlock. In the work, last cited, is mentioned an instance of a very unheal- thy-looking ulcer, near the apex of the tongue, attended with a considerable thickening ofthe part, and ofsome in- duration, which affection was cured by giving large doses of cicuta. However, notwithstanding many facts of this kind on record, medicines should not be tried too long, that is to say, so as to let the disease extend so far as not even to admit of being cut away. When the disease makes pro- gress, the knife should be employed, before it is too late. When any part ofthe tongue is to be amputated, the surgeon is to be prepar- ed for putting a stop to the hemorr- h; ge. Authors very properly recom- mend the chief vessels to be tied, if pos- sible; but, when this cannot be accom- plished, they advise the employment of astringent gargles, such as a strong solution of alum, distilled vinegar, or diluted sulphuric acid. When these methods fail, the actual cautery is ad- vised as the only resource. Some sur- geons, however, impressed with the horror of red-hot irons, might think it better to tie the trunks ofthe lingual ar- teries, as they pass over the os hyoi- des. A patient should undoubtedly ne- ver be suffered to die of bleeding, and some bold step ought certainly to be ta- ken; but, I cannot presume to decide, which ofthe two latter measures is the best. Perhaps, with a practitioner, well acquainted with anatomy, the last one should be preferred. The whole ofthe tongue sometimes inflames, and becomes considerably enlarged, either spontaneously, and without any apparent cause, or in con- sequence of some other disease; or else from some particular irritation; such as that of mercury, or some poisonous substance. Slegel, a German phy- sician, who was at Paris about the mid- dle of the 17th century, saw a patient in a salivation, whose tongue became so enormously enlarged, that the mouth could not contain it. Pimpre- nelle, an eminent surgeon of that time, was sent for, and finding that all trials to relieve the affection had been in vain, amputated one half of the tongue, with a view of preventing it from mor- tifying. When the wound was healed, it is said that the patient could articu- late as well as before. M. Louis, from whom this fact is quoted, very justly remarks, that the measure resorted to by M. Pimprenelle was an exceedingly violent one; for he has often seen ur- gent symptoms occasioned, during a salivation, by a rapid and enormous swelling of the tongue, very quickly yield to bleedings, purgative glysters, change of air and leaving off mercury. Trincavellius mentions two women, who had considerable enlargements of their tongues. One of these patients, who was young, had been rubbed with mercurial ointment even on her head; and the other, who was about fifty years old, had her tongue attacked with the ravages of the small-pox. The ex- cessive swelling of the tongue, in both Vol. II. 2£ ."22 TONGUE, DISEASES Oi these instances, terminated in resolu- tion, and a separation of its outward membrane. When the urgency is such, that* an immediate diminution of the swelling becomes necessary for the relief of the symptoms, nothing, it is said, is attend- ed with so much success, as at once making one or two deep incisions along the tongue. This, it is added, is parti- cularly proved by the cases, inserted by M. de la Malle, in the fifth volume, 4to, ofthe Mem. de I'Acad, de Chirurgie, and by some others, related by M. Louis in the paper above cited. Such cases are extremely interesting, and seem to merit an insertion in this Dic- tionary. A man, who was recovering from a bad fever, was suddenly attacked with a pain in his tongue, followed by a swelling equally large and rapid in its formation. In less than five hours, the part became thrice as large as it is in its natural state; and, in this space of time, M. de la Malle, who had been consulted, had bled the patient succes- sively in his arm, neck, and foot. The man felt very acute pain; his skin was excessively hot; his face was swelled; his pulse was hard and contracted; and his look wild. He could hardly breathe; the tongue filled all the cavity of the mouth, and protruded out between the lips. In this very urgent case, the sur- geon had recourse to no other expedi- ent, than keeping the mouth a little more open than it was made to be by the swelling ofthe tongue, and making with a knife three parallel incisions along this organ, one along its middle, and the other two between the one in the centre and the edges ofthe part af- fected. The cuts extended through two thirds of the preternatural swelling, and had all the good effect, which could possibly be desired. There was a great deal of hemorrhage, and the enlarge- ment of the tongue subsided so much, that, an hour after the operation, the patient was able to speak. The next day, the incisions had the appearance of being only superficial scarifications, and the tongue was in its natural state. In short, the incisions healed in a few days, the patient having merely made use of a simple gargle. M. de la Malle quotes several other cases, all of which tend to show the success, which he has met with in ap- plying this practice to other similar •as-s. He confirms his own sentiments, by quoting the testimony ofsome au- thors, antecedent to him, who have re- commended the method. The following case is taken from Job a Meckren, an eminent Dutch surgeon, who lived about the middle of the seventeenth century. This author relates, that a sai- lor's wife, who, for three, or four days, had experienced a great dryness of her throat, was suddenly threatened with suffocation by a quantity of humour, which she made efforts to expel. The tongue, the tonsils, and the whole pa- late, soon became swelled. Gargles, poultices, and glysters, produced no effect. It was not deemed advisable to bleed the patient, because the tumefied parts had a whitish appearance, and the swelling did not seem to be of an inflammatory nature. Purgative glys- ters; scarifying andcupping on thenape ofthe neck, and between the shoul- ders; and blisters behind the ears; were recommended, with a view of promot- ing, what the old surgeons implied by the term, derivation. Such remedies did not lessen the disease; on the contrary, it manifestly continued to grow worse, and the livid colour ofthe tongue, and adjacent parts caused a fear of mortifi- cation. Meckren called into consultation Francois de Vicq, a very experienced surgeon, who acknowledged, that he had never seen any similar case in the whole course of his practice. He advis- ed blood to be taken away from the arm, and raninal veins, which latter operation was effected with a good deal of difficulty. The breathing became at first a little more easy; but.as the symp- toms still continued to be alarming, it was determined to make a long and deep incision on the tongue, to the right and left. A good deal of blood was discharged; the respiration was immediately relieved; the swelling di- minished; the facility of speaking re- turned; and, at length, all the symp- toms disappeared in an unexpected manner. The sirop of roses andpurlain served as a liniment for the wounds, which soon got well. It may be concluded from the pre- ceding cases, that making incisions into the tongue would have saved numerous patients, who have been suffocated, in consequence of enormous enlargements of this organ. In the small-pox, the tongue sometimes became immensely swelled; and, it is more than probable, that, in many instances, the employ- ment of the above meth#d would have TONSILS. 323 afforded great relief to patients, whom the disease has been known to have en- tirely bereaved of tbe power of swal- lowing. (See Memoire sur les Maladks de la Langue, dans les Memoires de I'A- cad. de Chirurgie, torn. 5. Mem. de M. Malle; same Work. Encyclopedic Me- thodique; Partk Chirurgicak; Art. Lan- gue.) TONSILS, (dim. of tola, the ker- nels.) Tonsilla. Amygdala. The tonsils, like all the other parts at the back of the mouth, are subject to different kinds of swelling, which vary as much in their nature as their consequences. Some are rapid in their progress, and these are frequently observed to affect persons of, what is termed, a sanguine- ous temperament. They are also prone to attack young people, and such as labour hard, and they have all the es- sential characters of inflammation. Other swellings of the tonsils are slower in their progress, occur in damp cold weather, and in indolent, and what the old physicians used to call, phlegmatic constitutions. Lastly, another kind of enlargement of the tonsils, which is usually conta- gious, readily falls into a sloughing, gangrenous state, sometimes extends to the neighbouring parts, and too often proves fatal. Hence, the various spe- cies of angina have been named by some writers inflammatory, catarrhal, and gangrenous. The two first kinds frequently terminate in resolution; but, sometimes, the affected tonsils after- wards assume a scirrhous hardness, obstruct respiration and deglutition, so that it becomes indispensably necessa- ry, either to extirpate the diseased parts with the ligature, or the knife. The cutting away enlarged tonsils was an operation, which was perform- ed by the ancients, and, in different ways. Sometimes, they tore with their fingers the membrane covering the ton- sil, and then pulled this part out ofthe situation, which it occupies between the two pillars ofthe velum pendulum palati. In other instances, in which they experienced too much resistance, they seized the diseased tonsil with a kind of hook, and then cut it away with a bistoury, which, Paulus ./Egineta informs us, was concave on the side to- wards the tongue. The moderns, who, for a long while, were timid in the employment of both these methods, adopted plans of a more cruel description. The actual cautery was proposed, and some partial suc- cess, which followed its use, at once established its reputation. Caustics were afterwards employed, instead of actual fire; but, the inconvenience of not being able to limit their action, and the hazard of their falling down the oesophagus, soon caused them to be re- linquished by all rational practitioners. Then the operation of cutting away the tonsils was revived, and it was per- formed, sometimes in the manner of the old surgeons, sometimes with vari- ous kinds of curved scissors, or knives. Instead of the simple tenaculum used by the ancients, a sort of double one came into fashion. Every practitioner seemed to regulate the choice of his in- struments, by his own ingenuity; and an operation, which was capable of be- ing done at once, became complicated by being divided into several processes. Bichat describes the following plan, as the common one practised at the pre- sent day. The patient being convenient- ly seated, the surgeon is to open his mouth very wide, and depress the tongue with any flat instrument, which is afterwards to be committed to the care of an assistant. The operator is then to take hold ofthe diseased tonsil with a tenaculum, and with a common scalpel, having the back half of its blade covered with rag, he now re- moves as much of the tonsil, as ought to be taken away. In common cases, it is deemed sufficient to cut on a level witli the pillars of the velum pendulum pa- lati. If any other portion should require removal, this should next be perform- ed. The operation being finished, the patient is frequently to wash his mouth with proper gargles. The preceding plan seems a very simple and easy one, and was, for a long while, adopted by Desault. It is said, however, to be liable to one ob- jection, which is, that, when the end of the knife is conveyed far into the mouth, it may do mischief, not (as has been alleged) to the internal carotid artery, the backward situation of which completely keeps it out of all danger of being wounded, but to the membran- ous covering of the palate, in a place not corresponding to the tonsils. De- sault thought this objection was the more forcible, as when the hook is in- troduced into the tonsil, the danger of the above mischief is considerably in- creased by a general spasm, which seems to affect every part of the mouth. 324 TONSILS. Hence, this eminent surgeon used to employ, for cutting away diseased ton- sils, an instrument, which was first in- vented for dividing cysts ofthe bladder. The contrivance consisted of a sharp- edged blade, which was included in a silver sheath. The latter had at its ex- tremity a kind of notch, in which the gland, which was to be extirpated, was received. The rest of the instru- ments were similar to those used in the operation above described. Desault us- ed to proceed, as follows: 1. The patient being seated on a high chair, with his head supported on an assistant's breast, the surgeon is to make him open his mouth very wide, and the lower jaw is to be kept thus depressed, by any solid body placed between the teeth, and held there by an assistant. 2. The tongue is to be kept down with a broad spatula. 3. The surgeon is next to take hold ofthe tonsil with a double hook, with which he is to raise and draw it a little towards him. He is then to take the above cystitome, and put the tonsil in the notch, on a level with the place, where the incision is intended to be made. 4. When the portion, which is to be cut off, is engaged in the notch, the operator is to draw the part towards him, so as to stretch it, and press the instrument against it from below up- ward. The blade being next pushed across the notch, the necessary section is accomplished. When the division is not complete, which is particularly lia- ble to happen, when the diseased gland is of considerable magnitude, the blade is to be drawn back, and the section completed by applying the instrument to the wound, which it has already made. Even a third application may possibly become requisite on some oc- casions. 5. The patient is to be directed to wash his mouth. Bichat states, that this plan of operating, adopted by De- sault, is equally simple and easy as the method above related, with the advan- tage of being safer. Such is the con- struction ofthe blade ofthe instrument, that when it slides across the notch, it presses against, and steadily fixes the parts, which are to be divided; an ad- vantage which neither the knife nor scissors have, before the action of which the parts are quite moveable.— Hence, there is difficulty in cutting them. When the introduction of the instrument from above downward, is difficult, it is better to withdraw it; and, after turning the notch in the op- posite direction, pass it from below up- ward. In general, however, the first of these methods is preferable, because the gland, when half cut through, can- not now fall back and obstruct the rima glottidis, so as to bring on danger of a sudden suffocation; a circumstance, which Wiseman and Moscati have seen happen. With a view of prevent- ing this occurrence, M. Louis recom- mended the common scalpel to be us- ed, with its edges directed upward, as has been advised for the above instru- ment; which latter contrivance, how- ever, being according to Bichat's ac- count, more easy and safe, merits the preference. Besides the advantage of fixing the soft parts, which are to be cut, it has that of not contusing them, like most other instruments of this na- ture, as, for instance, scissors. The oblique disposition of its blade makes it divide parts, in the manner of a saw. The above contrivance, as Bichat al- lows, is certainly increasing the num- ber of surgical instruments; a thing, which all the best modern surgeons endeavour to avoid. But, as this author remarks, this instrument is not exclu- sively applicable to any particular ope- ration. It may be employed for cutting away the tonsils and uvula; dividing membranous fraena in the rectum, vagi- na, and bladder; amputating fungous excrescences, polypi of the nose, (if this mode of extirpating them were preferred) and various tumours in ge- neral, which are deeply situated in different cavities of the body, where in- struments introduced unguarded might injure parts, which should be avoided, or the base of the tumour should be steadily fixed, when its division is to be accomplished. The latter object cannot safely be effected by scissors.— When the base of the tumour is too large to be received in the notch, one part is first to be divided, and then ano- ther, till its whole thickness is cut through. The ligature, as a means of extirpat- ing enlarged tonsils, is, in general, only proper for timid patients, who will not have the knife employed, or whose fears are such as would baffle the oper- ation with a cutting instrument. Tying the tonsils is more tedious, and not at all less painful than cutting them away, and TONSILS. 325 always creates a vast deal more irrita- tion. Moscati having once adopted this plan, very severe pain and inflammation ensued; the difficulty of swallowing and breathing compelled him to ampu- tate the tumour at the place where the ligature was applied, and all the bad symptoms immediately ceased. Be- sides, when the ligature is used, the oozing of blood cannot take place from the ends of the cut vessels, and which tends so much to diminish the inflam- mation. The base ofthe swelling is al- so commonly broader than its upper part, and does not admit of being pro- perly surrounded with a ligature.— And, when it has a narrow base, it can then be so easily removed with a cut- ting instrument, or with Desault's in- strument, and with such little pain, that one ofthe last modes is always pre- ferable. The ligature, however, has had its advocates. Heister recommends it, in certain cases; Sharp praises it; and others approve its use, and the plans of employing it have been as various as the inventive genius of the different parti- sans ofthe practice. Some make use of Levret's double cannula, which is furnished with a silver wire noose, in which the tumour is to be engaged. By twisting the instrument, the diseased part becomes constricted; and this plan being repeated every day, the circula- tion is intercepted, and the gland mor- tifies, and sloughs away. Some, after putting the noose of a ligature over a kind of tenaculum, hook hold of" the tonsil, push the ligature over the en- larged gland, which they tie, without having any means of increasing the con- striction every day. Some employ Bel- loque's instrument for putting the li- gature over the tonsil. Others require no instrument whatever for the pur- pose, and accomplish the business with their fingers. Passing over a more ample historical detail, we need only observe, that two inconveniences generally attend all the above plans. Some of them do not ad- mit ofthe constriction being afterwards increased, and, therefore, are apt to prove insufficient. Indeed, this is usu- ally the case; and it becomes necessary to apply another lig-ature. Other ofthe above methods, free from this objec- tion, are attended with the inconveni- ence of leaving in the mouth too large a body, which is very annoying. The repeated twisting of the wire, also, sometimes makes it break, and renders another operation indispensable, which is much more painful than the first one. In order to obviate these inconveni- ences, Desault employed an instru- ment, which the French call un serre- nceud, which is an exceedingly simple thing, being, in fact, nothing more than a long, narrow, round piece of sil- ver, terminating at one end in a little ring, or hole, and, at the other, in a kindof groove or notch. Desaultsome- times employed the same instrument for tying nasal polypi, and tumours in the vagina, and rectum. The following was this celebrated surgeon's method of extirpating the tonsils with a ligature. 1. The patient is to be seated on a high chair, with his head held back, on an assistant's breast; his mouth is to be opened very wide, his tongue depress- ed, and the diseased tonsil taken hold of with a double hook. 2. The surgeon takes the serre-nceud, in which a ligature has been passed; so as to form a noose. The noose is to be put over the handle of the hook, which is to be committed to the charge of an assistant, and the noose then pushed over the tonsil, so as to embrace it completely. 3. The surgeon is now to draw the ligature strongly towards him, and push forward the serre-nceud, so as to produce the requisite constriction of the tumour. In general, the ligature should not be made very tight the first day. 4. When the constriction is such as it ought to be, the double hook is to be withdrawn, and the ligature twisted round the notch, at the outwardend of the instrument. 5. The next day, the gland becomes unusually large, in consequence of the impediment to the return of the venous blood. The ligature is to be unfastened from the notched end of the instru- ment, and drawn more out, so as to in- crease the constriction. When this is sufficient, the ligature is to be again twisted round the notch. This plan is to be followed up, till the tumour is detached, which usually happens in the fourth or fifth day. The method just described, is more simple, than those described in Pare, Fabricius, Hildanus, Scultetus, &c; but, as BicUat and Desault recommend - 326 ed the knife, if possible, should always be preferred to the ligature. (Desault par Bichat, tom. 2.) . I shall conclude this article with ob- serving, that the b*st modern practi- tioners in this country, prefer a com- mon knife to any other instrument, for the performance of this operation. TOPHUS, (said to be derived from a Hebrew word.) A swelling, which particularly affects a bone, or the peri- osteum. See Node. TORCULAR, (from torqueo, to twist.) A tourniquet. See this word. TORMENTIL, (from tormentum, pain, because it is said to relieve the tooth-ach.) Tormcntilla Erect. Linn. The root of this plant is exceedingly astringent, and, on this account, is sometimes employed in affections aris- ing from atony, and a relaxation of cer- tain parts. It lias been used for making astringent poultices, in cases of pro- lapsus of* the anus, and also of that of the vagina. In relaxations ofthe uvula, and scorbutic affections of the gums, gargles, made with tormentil, are said to have proved useful. Fomentations, prepared with this plant, have been re- commended, as being very serviceable for relieving the weakness of joints consequent to sprains. TORTICO'LLIS, (from torqueo, to twist; and collum, the neck.) The wry- neck. See Wry-neck. TOURNIQUET. ^French, from tour- ner, to turn.) An instrument used for stopping the flow of blood into a limb, until some requisite operation has been performed, or some more permanent plans of checking hemorrhage, have been put in practice. The old surgeons used to surround the limb with a band, with which they made such a degree of constriction, that the circulation was quite stopped. These practitioners also believed, that the pressure of the band was advan- tageous, by benumbing the limb, and moderating the pain of operations. The violent pain and contusion, however, which this tourniquet occa- sioned, being frequently followed by mortification and abscesses, surgeons, endeavoured to devise some other me- thod of checking hemorrhage. The ap- plication of the circular band was first improved, so that it caused less pain, and less mischief to the skin. The limb was surrounded with a very thick compress, over which the band was placed. Two small sticks were next TOURNIQUET. put under the band; one on the inside, the other on the outside of the limb; and they were twisted till the band was rendered sufficiently tight. It is in this manner, says Dionis, in his Traite d'Operations, that carriers tight- en the cords which fasten the bales of goods in their carts. A French surge- on, named Morel, is said to have made this first improvement in the applica- tion of tourniquets. M. Petit, in 1718, presented to the Academy of Sciences, a tourniquet of his own invention, which was much more perfect, than any one ever con- trived before. It consists of two pieces of wood, one of which is superior, the other inferior. The inferior piece is about four inches and a half long, and nearly two broad. Its under surface is somewhat concave, while its upper one is a little convex, and the ends are hol- lowed out. From its middle part rises a round eminence, about seven lines high, and eight and a half broad. The superior piece is almost the same as the inferior one, just described, but ra- ther shorter. The eminence, which as- cends from its middle part, is six lines high andan inch and a half in diameter. This eminence is hollow within, and calculated to receive a wooden screw, the top of which is a sort of button for turning the screw. The grooves of Pe- tit's screw were about four, or five, and each of them four lines in diameter, in order that a half turn might produce the necessary effect. Lastly, all the pieces of the instrument were fastened together by an iron pin, which went through the middle of the two pieces of wood, and through the whole length ofthe screw. This iron pin is rivetted under the in- ferior piece, and at the top of the but- ton, in such a manner, however, that the screw is capable of turning on it, as on a pivot. In order to apply this tourniquet, the limb is to be surrounded with a double strap, about four finger-breadths wide, and made of chamois leather, which is the softest material which can be used. To one end of the strap a double little cushion is fastened, ofthe same length and breadth as the lower piece of the tourniquet A narrow compress, or cy- lindrical pad, is also requisite, for the purpose of compressingthe track ofthe vessels.This compress consists of a very- firm roll of linen, covered with chamois leather. The ends of a piece of tape are sewed to the outer part ofthe pad, TOU TRE 327 and thus the tape leaves a passage for the leather strap. By this artifice, the pad can be moved to any situation on the strap, which is most convenient, according as the bulk of the limb may require. The middle of thej tape is to be fastened to the outside of the lea- ther strap. The cylindrical compress, or pad, is to be put over the course of the vessels. The double cushion is to be placed on the opposite side of the member, while the leather strap is to surround the limb in a circular manner. All the different pieces of the appara- tus are next to be retained by the tape, which is to be tied by the side of the cushion. The tourniquet is now to be put over the cushion, on that side of the limb, which is furthest from the track of the large vessels, and is to be fastened in this situation by a double band, with a hole in it for the reception ofthe upper part ofthe screw. In order to make the proper com- pression, the screw is to be half turned round, from the right to the left. The upper piece of the tourniquet, becom- ing now further from the lower one, the double band draws the pad, and presses it against the vessels, so as to make the due degree of compression. The following are the advantages, attending the use of Petit's tourniquet: 1. It compresses the lateral parts ofthe limb less, than the tourniquet previous- ly in use. 2. It requires the aid of no assistant, either to hold, tighten, or loosen it. 3. The operator is able of himself to stop the flow of blood in the artery, by means ofthe screw. 4. When there is any danger of hemorrhage af- ter an operation, this kind of tourni- quet may be left on the limb, and, in case ofthe bleeding coming on, the pa- tient, if no one be at hand, can tighten the instrument himself, as much as is necessary. 5. The constriction, which this tourniquet produces, does not cre- ate any danger of mortification, be- cause it does not altogether stop the flow of blood through the collateral ar- teries. The tourniquet just described, is certainly very complex, "when compar- ed with the one used by the best mo- dern practitioners; but, still it is the original ofthe latter, and both are con- structed on the same principles. All the pieces of modern tourniquets are kept connected together, and instead of two pieces of wood, used by Petit, there is contrived a brass bridge, which is capable of being elevated, or depress- ed, by means of a screw, made of the same metal. Over this bridge a very strong band proceeds, and by passing under two little rollers, at each end of the bridge, it always remains connect- ed with the instrument. A convex firm pad is sewed to the band, and put im- mediately over the artery, where the instrument is applied. There are no cushions for the opposite side of the limb under the screw; but a thick piece of leather, through which the band proceeds in two places, is always situated under the lower surface of the brass, and serves to prevent any bad effects of its pressure. It is usual also for the surgeon to fold some rag, and put it in this situation, at the time of applying the instrument. (See some other remarks on the tourniquet, in the article Hemorrhage.) TRACHEA, (from rgaxyc, rough.) The wind-pipe, so named from its as- perities. For an account of its wounds, see Throat. TRACHELO'PHYMA, (from rga- ^iiXof, the tliroat, and the hair.) The disease, called the plaited- hair, or plica polonica. TRICHOSIS. The same. TRIPSIS, (from rgiSu, to bruise.) A contusion. TRISMUS, (from rgi{a, to gnash the teeth). The locked jaw. See Te- tanus. TROCHAR, or TROCAR, (from the French, trois-quart, three fourths, from its point, being of a triangular form.) An instrument used for dis- charging aqueous fluids, and now and then, matter from different cavities in the body', particularly, those ofthe pe- ritoneum, and tunica vaginalis, in cases of ascites aud hydrocele. Trocars are also employed for tapping the bladder, dropsical ovaries, &e. A trocar consists of a perforator, or stilette, and of a cannula, which latter is so adapted to the first piece of the instrument, that, when the puncture is made, they both enter the wound to- gether, with perfect ease, after which the stilette being withdrawn, the cannula remains in the wound, and gives a ready passage for the fluid out- ward. Such are the use of a trocar, and the principle, on which it should be constructed. It would be unnecessary in this work to detail every little par- ticularity in the instrument. I shall just observe, that the triangular-point- ed trocars seem to retain the greatest share of approbation; for, although flat, lancet-pointed ones enter parts with most ease, their cannula: are not large enough for readily letting fluids pass out, which are at all thick, gela- tinous, or blended with hydatids, and flaky substances. The trocar, which is used for punc- turing the bladder from the rectum, should be eight, or nine inches long, and of a curved form. Surgeons ought always to have at least three trocars; one of full size; another of middling width; and i 340 TRU third, small one. The latter is often preferable to a larger one, in cases of hydrocele. "TRUSS, (trousse, French.) Brache- rium. A bandage, or apparatus, for keeping a hernia reduced. Trusses are either of an elastic or nonelastic kind: the latter cannot be much depended upon, and are now seldom employed. The spring, is a very essential part of every elastic truss, and it consists of a narrow piece of steel, which is adapted to the side of the body, on which the hernia is situa- ted. The front part of the steel spring has an expanded form, and, when the truss is properly applied, ought to be situated over the mouth of the hernial sac. Under the back surface ofthe an- terior end of the spring is placed the pad, which should be adapted in shape and size to the passage, wliich it is in- tended to shut up. The steel spring is usually covered with leather, is fined with soft materials, and, after being put on the patient, it is fastened in its situation by means of a strap, which extends from the two ends of the spring, round that side ofthe body, on which the hernia is not situated. When the pad of the truss cannot bp kept from rising too high, another strap, passing under the thigh from the back of the spring to its anterior end, becomes necessary. Sometimes, a band, extending over the shoulder, is requisite for keeping the pad from descending too low. The springs of trusses, intended for children, and persons, who do not un- dergo much labour and exertion, need not be made so strong, as those de- signed for hard-working, active peo- ple. The idea, that children cannot wear steel trusses, is as erroneous, as it is dangerous in practical consequences. Mr. Pott has strongly written against this ill-founded supposition. When great pressure, and a very strong spring, are found necessary for keeping a hernia securely reduced, and the spermatic cord swells and inflames in consequence of such pressure, it is better to have a little excavation in the pad, for the reception of this part. Some trusses are formed with pads, which are moveable on a rack, so that their position can be altered, and adapted to the parts, with the greatest ease. l'UM A compress of calico, placed under the pad, is said both to preserve the instrument from the effect of perspira- tion, and make the truss fulfil its object in a better manner. Mr. Lawrence has described a new kind of truss, invented by Mr. Whit- ford, surgeon's instrument maker, near St. Bartholomew's Hospital : " The spring passes on the ruptured side, just below the outer edge ofthe crista ofthe ilium, as far as the poste- rior superior spinous process of that bone. It then goes straight across to the same point of the opposite bone, and pursues its course, on the sound side ofthe pelvis, in the same relation to the crista ilii, as it held on the side ofthe rupture, as far as the anterior superior spinous process, where it terminates as usual in a leathern strap; In this mode of construction, the mo- tions ofthe trunk and thigh cannot de- range the instrument, which requires a still further stability from the exten- sion ofthe spring round the sound side of the pelvis." (Treatise on Hernia, p 41.) In the article Hernia, we have given an account of the truss for umbilical hernia, invented by Mr. Morrison, and described by Mr. Hey. In the same part of this Dictionary may also be found some observations, relative to the place, against which the pressure ofthe pads of trusses should be direct- ed in cases of inguinal hernia, in con- formity to Mr. A. Cooper's description of the situation, at which the parts first protrude from the abdomen. TUBERCLE, (dim. of tuber, a knob.) A little tumour. TUMEFACTION, (from tumefacio, to make swell.) Swelling. TUMOUR, (from tumco, to swell.) A swelling. In the present article, I merely intend to treat of, what are usually called, sarcomatous and encyst- ed tumours. Mr. Abernethy thinks, that the manner, in which tumours are formed, is best illustrated by those, which hang pendulous from the mem- braneous lining of different cavities. This gentleman adverts to an example noticed by Mr. Hunter, in which, on the cavity of the abdomen being open- ed, there appeared lying upon the pe- ritoneum, a small portion of red blood recently coagulated. This, on examina- tion, was found to be connected with the surface, upon which it had been TUMOURS. 341 deposited by means of an attachment, half an inch long, and this neck had been formed before the coagulum had lost its red colour. (See Trans,, of a Society for the Improvement of Med. and Chirurg. Knowledge, vol. 1. p. 231.) Mr. Abernethy observes, that if ves- sels had shot through the slender neck, and organized the clot of blood, this would then have become a living part: it might have grown to an inde- finite magnitude, and its nature and progress would probably have depend- ed on the organization, which it had assumed. He mentions his having in his own possession a pendulous fatty tumour, which was found growing from the surface of the peritoneum, and which was undoubtedly formed in the same manner as the tumour noticed by Mr. Hunter; viz. by vessels shoot- ing into a piece of extravasated blood, or lymph, and rendering it a living or- ganized substance. Tumours, in every situation, and of every description, are probably formed in the same way. The coagulating lymph being effused, either accidentally, or in consequence of dis- ease, is afterwards converted into a liv- ing part, by the growth of the adjacent vessels and nerves into it. Mr. Aber- nethy remarks, that when the deposit- ed substance has its attachment by a single thread, all its vascular supply must proceed through that part; but, in other cases, the vessels shoot into it irregularly at various parts of its sur- face. Thus an unorganized concrete becomes a living tumour, which has at first no perceptible peculiarity as to its nature. Although its supply of blood is furnished by the vessels of the sur- rounding parts, it seems to live and grow by its own independent powers, while its future structure seems to de- pend on the operation of its own ves- sels. Mr. Abernethy conceives, that the altered structure of an enlarged gland affords no contradiction to the above account, as, in this latter case, the substance of the gland is the ma- trix, in which the matter forming the tumour, or enlargement, is deposited. According to Mr. Abernethy, the structure of a tumour is, sometimes, like that of the parts, near which it grows. Such, as are pendulous in joints, are cartilaginous, or osseous. Fatty tumours, he observes, frequently form in the midst of the adipose sub- stance, and he has seen some tumours growing from the pala.te? which had a slender attachment, and resembled the palate in structure. However, this resemblance of the structure of a tumour, to that of the neighbouring parts, is not always ob- servable. I have in my own possession a completely cartilaginous tumour, which I found in the midst of the fat near the kidneys. The pendulous por- tion of fat, growing from the perito- neum, and mentioned by Mr. Aberne- thy, serves as another instance of the fact; and, one might add, that every polypus, which we meet with, bears no resemblance in structure to the neighbouring parts. Mr. Abernethy mentions his having seen bony tu- mours, which were unconnected with the bone, or periosteum, and, he ob- serves, that the structure of a tumour is, in general, unlike that of the part, in which it is produced. When the coagulable part of the blood is effused, and the absorbents do not take it away, the surrounding blood-vessels grow into it, and convert into a vascular tumour. The effusion ofthe coagulable part of the blood may be the effect of accident, or of a com- mon inflammatory process, or it may be the consequence of some diseased action ofthe surrounding vessels,which (diseased action) may influence the or- ganization, and growth of the tumour. In the former cases, the parts sur- rounding the tumour, may be consider- ed simply as the sources, from which it derives its nutriment, whilst it grows apparently by its own inherent powers, and its organization depends upon actions begun and existing in it- self. If such a tumour be removed, the surrounding parts being sound, soon heal, and a complete cure ensues. But, if a tumour be removed, whose exist- ence depended on the disease of the surrounding parts, which are still left, and this disease be not altered by the stimulus of the operation, no benefit is obtained. These parts again produce a diseased substance, which has gene; rally the appearance of fungus, and, in consequence of being irritated by the injury of the operation, the disease is in general increased, by the means which were designed for its cure. It appears, therefore, that in some cases of tumours, the newly formed part alone requires removal, whilst, in others, the surrounding substance must be taken away, or a radical cure can- not be effected. (Surgical Observations, 342 TUMOURS, SARCOMATOUS. by John Abernethy, F. R. S. &c. 1804.) This gentleman conceives, that the ir- ritation of the tumour itself, when once tbe swelling has been produced, keeps up an increased action in the surrounding vessels, so as to become a sufficient cause of the disease continu- ing to grow larger. As the tumour be- comes of greater magnitude, it con- denses the surrounding cellular sub- stance, and thus makes for itself a sort of capsule. The close, or loose manner in which tumours become connected with the surrounding parts, seems to depend very much on the degree of ir- ritation, and inflammation excited in the circumjacent parts. When a tu- mour has been at all tender, painful, and inflamed, it is generally found inti- mately adherent to all the neighbour- ing parts. Mr. Abernethy conceives, that the increased irritation, which a tumour creates, when it has exceeded a certain size, may explain, why some tumours, which are at first slow in their progress, afterwards begin to grow with great rapidity. The process, by which tumours are formed, is commonly thought to be at- tended with an increased action of the vessels, which supply the swellings with blood. It is supposed, in short, to be the same kind of process, which forms all the thickenings and indura- tions, which, under various circum- stances, occur in all the different parts of the human body. It has sometimes been named chronic inflammation, to distinguish it from that, which is more quick in the production of certain ef- fects, and is attended with a mani- fest throbbing in the part affected. It- seems generally to be admitted, that the growth of all tumours may be always retarded, and that sometimes, they may even be diminished by means of topical bleeding with leeches, and keeping the parts in a continually cool state, by the incessant application of cold sedative washes. Afterwards, when the increased action of the ves- sels seems checked, and the tumour ceases to enlarge, discutients are indi- cated, such as frictions with mercurial ointment, pressure, electricity, rubefa- cient plasters, solutions of salts, blis- ters, and issues. Veiy few sarcomatous or encysted tumours, however, are ever completely removed by these lo- cal means. The swelling, on the con- trary, generally increases, notwith- standing them, and the irritation of these diseases by the latter stimulants* is not altogether unattended with dan- ger ofthe affections becoming changed by them into very malignant, and dan- gerous ones, sometimes to all appear- ances, cancerous. The most advisable plan is to recommend the removal of all these tumours with the knife, while they are small, and in an incipient state. For, thus, they are got rid of by an ope- ration, which is, in comparison, trivial, compared with the one, wliich may af- terwards become requisite, when the disease has attained an enormous mag- nitude. TUMOURS, SARCOMATOUS — These have been so named, from their firm, fleshy feel They are of many kinds, some of which are simple, while others are complicated with a malig- nant tendency. Mr. Abernethy attempt- ed to form a classification of sarcoma- tous tumours, for the different species of which he has proposed names, de- duced from the structure, which they exhibit on dissection. This gentleman has named the kind of swellings, which he first considers, Common Vascular, or Organized Sarcoma. Under this title, Mr. Abernethy includes all those tu- mours, which appear to be composed of the gelatinous part of the blood, ren- dered more, or less vascular by the growth of vessels through it. The ves- sels, which pervade this substance are, in different instances, either larger, or smaller; and more or less numerous; being distributed in their usual arbore- scent manner, without any describable peculiarity of" arrangement. Perhaps, all the varieties of sarcomatous tu- mours are at first of this nature. The structure, under consideration, is met with not only in distinct tumours, but, also, in the testis, mamma, and absor- bent glands. When a common vascu- lar, or organized sarcoma has attained a certain magnitude, the veins of the skin seem remarkably large, and their winding under the integuments excites notice. This kind of sarcoma is not at all tender, so that it may be freely han- dled, and also electrified, without giv- ing pain. The tumour sometimes grows to such a size, that the skin bursts, the substance ofthe swelling sloughs out, and the disease is got rid of. However, this mode of cure is attended with such terrible local appearances, and so much fever, &c. that the removal of the dis- ease with the knife is preferred. The second kind of sarcomatous tu- TUMOURS, SARCOMATOUS. 343 mour, noticed in Mr. Abernethy's clas- sification, is the Adipose Sarcoma. Every one, at all in the habit of seeing surgi- cal diseases, must know, that ratty tu- mours are exceedingly common. There can be little doubt, that these swellings are formed in the same manner, as others: viz. in the first instance, they were coagulable lymph, rendered vascular by tbe growth of vessels into it, and that their future struc- ture depended on the particular power and action of the vessels.— Adipose sarcomatous tumours always have a thin capsule, formed by the sim- ple condensation of the surrounding cellular substance. It adheres very slightly to the swelling, and, chiefly by means of vessels, which pass through this membranous covering in order to enter the tumour. As Mr. Abernethy has accurately described, the vessels are so small, and the con- nexion so slight, that, in removing the tumour, no dissection is requisite, as the operator may easily put his fingers between the swelling and its capsule, so as to break the little vascular con- nexions, and entirely detach the disease Adipose tumours are never furnish- ed with any large blood-vessels, and the fear of hemorrhage, which fre- quently deters surgeons from operat- ing, is very unfounded. It is an un- doubted fact, that there is no species of tumour, that can be removed with s.o much celerity, with such apparent dex- terity, or with such complete security against future consequences, as those of an adipose nature. However, now and then, when the tumour has been at all in an inflammatory- state, the cap- sule becomes thickened, and intimate- ly adherent to the surface ofthe swel- fing, so that the separation of the dis- ease is more difficult, and requires the knife to be more employed. The tu- mour also sometimes becomes, after in- flammation, closely adherent to the contiguous parts. Adipose tumours of- ten acquire an enormous magnitude; Mr. Abernethy relates an example of ■ 'tie, which Mr. Cline removed, which weighed between fourteen and fifteen pounds. In this state, of course, the immense size of a wound, requisite for the removal ofthe tumour, is very dan- gerous, and it is a strong argument in favour of having recourse to the opera- tion at an earlier period. The next species of sarcoma, notic- ed in Mr. Abernethv's classification. :■ what this gentleman names pancreatic, from the resemblance of its structure to that of the pancreas. This kind of disease, according to Mr. Abernethy, is occasionally formed in the cellular substance; but, more frequently, in the female breast, on that side of the nip- ple, which is next to the arm. When a pancreatic sarcoma is indolent, and in- creases slowly, the surrounding parts.. and-the glands in the axilla, are not af- fected. But, some of these swellings deviate from the common character, and become of a very irritable nature, occasioning severe and lancinating pain, and producing an inflammatory- state ofthe skin covering them, so that it becomes adherent to their surface.— The absorbents leading to the axilla are also irritated, and the glands en- larged. Pancreatic sarcomas do not grow to a very large mzc; but, when their progress is unrestrained, the pain, attendant on the disease, becomes lan- cinating, and so severe, as to make the patients feverish, and lose their health and strength. Mr. Abernethy remarks, that, when the axilliary glands become affected, one generally swells at first, and is extremely tender and painful; but, afterwards the pain abates, and the part remains indurated. Another then becomes affected and runs through the same course. Another* species of sarcoma, Mr. Abernethy has characterized by the epithet mastoid or mammary, from the resemblance which this gentleman con- ceives its structure bears to that of the mammary gland. This kind of disease, Mr. Abernethy says he has not often seen. In the example, which he met with, the tumour was about as large as an orange, and situated on a woman's thigh. This swelling was removed by an operation; but, the wound after- wards degenerated into a malignant ul- cer, attended with considerable indura- tion of the surrounding parts, and the woman died of the disease in two months. Mr. Abernethy conceives, that the whole of the morbid part had been cut away, but, tli.it the contigu- ous parts had a disposition to disease, which was irritated by the operation, and, that if the nature of the case could have been known beforehand, it would have been right to have made a freer re- moval ofthe substance surrounding the tumour. Mr. Abernethy places the mastoid sarcoma, between such sarcomatous 344 TUMOURS, ENCYSTED. swellings as are attended with no ma- lignity, and the following ones, which have this quality in a very destructive degree. The tuberculated sarcoma is compos- ed of a great many small, firm, round- ish tumours, of different sizes and co- lours, connected together by cellular substance. Some ofthe tubercles are as large as a pea; others equal a horse- bean in size; most of them are of a brownish red colour; but some are yel- lowish. Mr. Abernethy mentions his having seen this species of sarcoma chiefly in the lymphatic glands of the neck. The disease proceeds to ulcera- tion; becomes a painful and incurable Sore; and ultimately occasions death. Another kind of sarcoma, mentioned in Mr. Abernethy's classification of tu- mours, is distinguished by the epithet medullary, from its having the appear- ance of the medullary matter of the brain. It appears to be an exceedingly malignant disease; communicates to the lymphatic glands a similar distemper; ulcerates and sloughs, and at last proves fatal. It is particularly apt to make its attack on the testis, and it is treated of in another part of this book. Sec Testicle, Diseases of. Mr. Abernethy includes also in his classification carcinomatous sarcoma.— See Cancer. For an account ofthe plan of operat- ing, in removing sarcomatous tumours, see Mamma, Removal of TUMOURS, ENCYSTED. These which are also commonly named wens, consist of a cyst, which is filled with different substances. When the con- tained matter is fatty, it is termed a steatoma; when somewhat like honey, meliceris; when like pap, atheroma. These are the three species, into which writers usually divide encysted tumours. However, some of these swellings do not conform to either of the above distinctions, as their contents are subjectto veiy great variety indeed, and are occasionally of an earthy, bony, er horny nature. It is said, that some encysted tumours ofthe latter descrip- tion have occasionally burst, and as- sumed the appearance of horns, by the gradual projection of the matter secret- ed in their cy^ts. I remember seeing an excrescence ofthe kind alluded to, removed some years ago from the scro- tum of a man in St. Bartholomew's Hospital. Sir James Earle performed ••he operation; and, if lam not mista- ken, the preparation ofthe disease is in Mr. Abernethy's Museum. Encysted tumours are generally of a roundish shape, and are more clastic, than fleshy ones. However, the latter circumstance depends very much on the consistence of the contents, and the thickness ofthe cyst. As far as my ob- servation extends, encysted tumours form more frequently on the head, than any other part; but, they are very fre» quently met with in all situations under the integuments, and sometimes in deeper places. Encysted tumours are also very often seen on the eye-lids. Some surgeons have tried to cure encysted tumours by pricking them with needles, and squeezing out their contents; or by applying stimulating, and discutient applications to them. This practice, however,"is by no means a prudent one; for, it seldom succeeds, and sometimes, in consequence of ma- king the cyst ulcerate, it induces a ter- rible disease, in which a frightful fun- gus shoots out from the inside of the cyst, attended with immense pain, and irritation, and often proving fatal. In order to confirm this statement, I shall quote the following case, recorded by Mr. Abernethy. A gentleman, of a stout make, and about forty years of age, had a tumour, supposed to be sarcomatous, which had formed beneath the integuments on the lower edge of the pectoral mus- cle. It was attended with severe pain occasionally, at which time it rapidly increased in size, and produced a great deal of fever and irritation, which made him look very sickly, and grow very thin, and caused some persons to deem the disease cancerous. When the tumour had acquired a magnitude of about four inches in length, and three in breadth and depth, he submitted to its removal; the inte- guments were divided and turned back, and the tumour dissected off the sur- face, and, in some degree, from under the edge ofthe pectoral muscle. When the tumour was examined, it was found to be composed of a steato- matous substance, contained in a thin capsule. The substance resembled that, which I have described as being some- times found in cells in the testis, or in- termixed with the diseased organiza- tion of that part. It was firm, and re- sembled cheese in its yellow colour and unctuous appearance; but, it was not unctuous to the touch. TUM TYP 345 The wound made in the operation soon healed, and the patient's health was restored to as good, or seemingly a better state, than before the forma- tion of this disease. He also regained his usual athletic form. But, in less than three months after his recovery, two new tumours formed, one above, and the other below the cicatrix ofthe wound The patient did not particular- ly attend to them till they had attained a size equal to that of a large walnut. To dissect out both these tumours, and make so free a removal of parts as to render it probable, that no new growth would ensue, seemed to be a very for- midable operation; and, as the nature of the former tumour was known, and it was supposed, that these were ofthe same nature, it was agreed to puncture the upper one, to express the contents, and await the event. This was done by a puncture of half an inch in length, made by an abscess lancet. The con- tents were exactly like those of the original tumour. Vehement erysipela- tous or irritative inflammation took place, and sloughing about the diseas- ed part: the inflammation rapidly ex- tended to the opposite side of the tho- rax, and then down the integuments of the abdomen to the groin. The derange- ment of the constitution was as violent as the local disease, and, in about a week, the patient died. (Surgical Ob- servations, 1804, p. 94.) Similar, alarming, fungous diseases are also apt to arise, whenever the surgeon, in cutting out encysted tu- mours, leaves any part of the cyst be- hind. The most advisable method is to U LA, A gum-boil. Also, a cicatrix. ULCERATION, is the process, by which sores, or ulcers are produced in animal bodies. In this operation, the lymphatics appear to be, at least, as ac- tive as'the blood-vessels. An ulcer is a chasm formed on the surface of the body by the removal of parts back into the system by the action of the absorb- ents. At first, it may be difficult to conceive how a part of the body can be removed by itself; but, there is not more difficulty in conceiving this, than how a body can form itself. Both facts have recourse to the knife, before an encysted tumour has attained any con- siderable size. When it is large, how- ever, before the operation is resorted to, a portion of the skin must be taken away with the swelling in the manner mentioned in the article Mamma, Re- moval of. The chief piece of dexterity in the operation consists in detaching all the outside ofthe cyst from its sur- rounding connexions, without wound- ing it. Thus, the operator takes the part out in an entire state, and is sure, that none of the cyst remains behind. When the cyst is unskilfully opened, some of the contents escape, it collap- ses more or less, and the dissection is rendered more tedious and difficult. Excepting Mr. Abernethy's Classifi- cation of Tumours, contained in his Surgical Observations, 1804, I am not acquainted with any particularly good work expressly on the subject. How- ever, every system of surgery treats of it, and Mr. John Bell, in his Principles of Surgery, vol. 3, has written a great deal concerning it TURU'NDA, (d terendo, from its being rolled up.) A tent for keeping open wounds. TYLO'MA, or TYLOSIS, (from Tuxof, callus.) A callous roughness on the inside ofthe eye-lids. Also, a wart, or a corn. TYLOTICA, (from tuxoo, to har- den.) Medicines, which promote the formation of callus. TYMPANUM, (ru^ravov, a drum.) The cavity of the drum of the ear. For an account of its diseases, see Ear. TYPHLOSIS, (from nptoc, blind) Blindness. are equally well confirmed. When it becomes necessary, that some whole living part should be removed, it is evident, says Mr. Hunter, that nature, in order to effect this object, must not only confer a new activity on the ab- sorbents; but, must throw the part to be absorbed into a state, which yields to this operation. The absorption of whole parts in disease arises from five causes: pressure; irritation of stimula- ting substances; weakness; inutility of parts; death of them. (Hunter on In- flammation, &c. p. 442—446.) Vol. II. 2 X u 346 ULCERATION. Ulceration, or, in other teims, ab- sorption, takes place much more readi- ly in the cellular, and adipose sub- stance, than in muscles, tendons, liga- ments, nerves, and blood-vessels. Hence, in the progress of pus to the surface of the body, ulceration often takes a circuitous course for the pur- pose of bringing the matter to the skin. The skin itself, also, being highly or- ganised, considerably retards the burst- ing of abscesses. It is on this same ac- count, that, when ulceration is spread- ing, the edges of the skin hang over the ulcerated surface. (Hunter, p. 447) New formed parts, such as cica- trices, callus, and all adventitious new matter, such as tumours, readily admit of being absorbed. The adventitious matter, indeed, is more prone to be ab- sorbed, than that, which is a substitute for the old. Mr Hunter explained this circumstance on the principle of weak- ness. When ulceration takes place, in con- sequence of the death of an external part, it occurs first on the outer edge, between the dead and living substance. Abscesses constantly make their way to the surface of the body by ul- ceration; but, as some textures more readily admit of being absorbed, than others, the matter often follows a cir- cuitous course, before it can arrive at the skin. (Hunter, p. 448, 449.) A tumour, when it makes equal pressure in every direction around, will only make its way in an external course, because what Mr. Hunter termed interstitial absorption, only happens in this direction. (P. 449.) The parts, which are situated be- tween an abscess, or any extraneous substance, and the nearest surface, are those, which are most susceptible of ulceration. This is one of the most cu- rious phenomena, connected with the process under consideration. It shows, that there is a principle in the human body, by which parts are always prone to free themselves of disease. Slight pressure from without will even pro- duce a thickening of parts, and hence, Mr. Hunter remarks, there even ap- pears to be a corresponding backward- ness to admit disease. (P. 449.) Both these facts, he observes, are shown in the case of fistula lachrymalis; for, though the matter is nearest the cavity ofthe nose, still it makes its way ex- ternally by means of ulceration, while the Schneiderian membrane even be- comes thickened, so as to become a barrier against the progress of the disease inward. (P. 451.) There is one difference, between the advancement of an encysted tumour to the surface of the body, and the pro- gress of an abscess in the same direc- tion: viz. that the former does not ex- cite ulceration of the cyst; but, an in- terstitial absorption ofthe sound parts, between the cyst and skin, till the cyst and external skin come into contact, at which period, inflammation takes place, and absorption becomes accele- rated into ulceration. In an abscess, the progressive ulceration begins in the cyst, at the same time, that the inter- stitial absorption in the sound part, co- vering the matter, is going on. (P. 452 —457.) The action of progressive absorption is to remove surfaces contiguous to ir- ritating causes, which Mr. Hunter re- ferred to pressure, irritation, and weak- ness. In cases of tumours, pressure be- comes a cause. The buttocks and hips of persons, who lie long on their backs, often ulcerate. The heels of many pati- ents, with fractures, who lie for a great while in the same position, are apt to ulcerate. In the latter instances, Mr. Hunter conceived, that ulceration is a substitute for mortification, and is, at the same time, a proof of a certain de« gree of strength; for, if the patient's constitution were very weak, the same parts would mortify. (P. 453) That pressure is a frequent cause of ulcera- tion, is also evinced by the occasional effects of chains on prisoners, and har- ness on horses. That irritating substances produce ulceration, needs no illustration. Progressive absorption may occur ei- ther with, or without suppuration. We have instances ofthe latter in cases of extraneous bodies, which travel about the body, without producing irritation enough to give rise to the secretion of pus. In the progress of aneurisms of the aorta, and of fungous tumours of the dura mater to the surface, the same fact is also illustrated. (P. 455.) Absorption with suppuration, in other words, ulceration, either happens in consequence of suppuration already be- gun, in which event the pus acts as pressure; or else absorption attacks ex- ternal surfaces from particular irrita- tions, or weakness, in which case, sup- puration must follow. (P. 456.) The production of ulceration requires much greater pressure from -without, than from within. The process is al- ULCERS. 347 ways disposed to take place more quickly, when near the surface of the body, and its progress becomes acce- lerated, in proportion as it arrives near the skin. The adhesive inflammation precedes the suppurative, and prevents the pus from becoming diffused, as soon as it is secreted, and when the cyst afterwards ulcerates, in order to let the matter ap- proach the skin, the adhesive inflam- mation still continues to go before the ulcerative process, and thus prevents the matter from insinuating itself into die interstices ofthe cellular substance. (P. 4.57.) The pain of ulceration is, in some degree proportioned to its quickness. When ulceration begins on a surface, or takes place for the purpose of bring- ing matter to the skin, the pain is al ways considerable. When ulceration takes place, in order to separate a dead part, as in sloughing, exfoliations, &c. there is seldom any particular pain.— (P. 459.) The ulcerating sore always exhibits little cavities, while the edge of the skin is scolloped, and thin, at the same time, turning a little out, and over- hanging, more, or less, the ulcerated surface. The face ofthe sore appears foul, and the discharge is very thin. When ulceration stops, the edges of the skin become regular, smooth, a lit- tle rounded, or turned in, and of a pur- ple colour, covered with a semi-trans- parent white. (Hunter on Inflamma- tion, Ore p. 460.) ULCERS. Surgeons usually define an ulcer to be a solution of continuity in any of the soft parts of the body, at- tended with a secretion of pus, or some kind of discharge. In the present part of this Dictiona- ry, there will not be occasion to speak of several sorts of sores, which have been treated of in other articles. See Cancer, Scrophula, and Venereal Disease. Some authors divide ulcers into local and constitutional ones. Other writers make distinctions, which are more par- ticular, and Mr. Home has treated of six kinds of ulcers, viz. 1. Ulcers in parts, which have suffi- cient strength to carry on the actions, necessary for their recovery. 2. Ulcers in parts, wliich are too weak for that purpose. 3. Ulcers in parts, whose actions are too violent to form healthy granula- tions, whether this arises from the state ofthe parts, or ofthe constitution. 4. Ulcers in parts, whose actions are too indolent, whi ther this arises from the state of the parts, or of the consti- tution. 5. Ulcers in parts, which have ac- quired some specific action, either from a diseased state of the parts, or of the constitution. 6. Ulcers in parts, which are prevent- ed from healing by a varicose state of the superficial veins of the upper part of the limb. OF ULCERS IN PARTS, WHICH HAVE SUFFICIENT^TRENGTH TO CARRY ON THE ACTIONS NECESSARY FOR THEIR RECOVERY. Mr. Home remarks, that, in this species of ucler.the pus is of a white co- lour, thick consistence, and readily se- parates from the surface ofthe sore, and when diluted, and examined in a microscope, is found to be made up of small globules, swimming in a trans- parent fluid. The granulations are small, florid, and pointed at the top.— As soon as they have risen to the level ofthe surrounding skin, those, next to the old skin, become smooth, and are covered with a thin, semi-transparent film which afterwards becomes opaque, , and forms cuticle. In the treatment of this kind of ul- cer, it is only necessary to keep the surface clean, and prevent the natural processes from being interrupted. Mr. Home observes, that this is in general best done, by the application of dry lint, for the purpose of absorbing and retaining the matter, which serves as a soft covering for the granulations, and by putting over the lint a pledget of any simple ointment, in order to hinder the matter from evaporating, by which means the dressings will not become adherent, and may be easily taken off, as often as requisite. Although healthy ulcers require no medicated application to be made to them, the dressings must be such as do not disagree with the granulations, or surrounding skin. With some patients, a roller, applied with moderate tightness, with a view of retaining the dressings, will cause uneasiness in the part, and make the ulcer lose its healthy appearance. Mr. Home states, that he has seen several such cases, in which the proper appear- ance ofthe sore returned as soon as the bandage was discontinued. In some patients, ointment irritates and inflames the neighbouring skin; '348 ULCERS. and certain superficial ulcers will not heal, while kept in a moist state, and unexposed to the air; but heal, when allowed to become dry and covered with a scab. Mr Home refers these particulari- ties to constitutional causes, and not disease; for, the ulcers heal as soon as the particular things, which disagree with them, are discontinued. These pe- culiarities in certain healthy sores may also attend others of a different de- scription, and should always be discri- minated from the effects of disease. Mr. Home very judiciously reqom- mends inquiring of patients, who have had sores before, what kind of applica- tions they derived most benefit from, and what ones were found to disagree. TREATMENT. 1. Applications in the form of va- pour, and fomentations, should never be employed, as they render the tex- ture of the granulations looser and di- minish the disposition to form skin. 2. With respect to fluid applications, Mr Home also very properly con- demns poultices, as well as fomenta- tions. He speaks of alcohol, as being an application, which promotes the forma- tion of a scab, when this mode of cure is chosen. 3. In regard to ointments, their only use, in cases of healthy ulcers, is to keep the matter from evaporating.— The most simple ointments are the best for the purpose; particularly, the one composed of white wax and olive oil. Mr. Home observes, that the great objections to the common simple oint- ments are, that they sometimes dis- agree with the skin, even when recent, and free from all rancidity. When they have acquired the latter quality, they still more frequently create a greater degree of irritation. 4. With respect to applications in the form of powder, Mr. Home remarks, that, when it is desirable to form a scab on the ulcer, any inert powder may be sprinkled on the sore; but, he prefers dry lint. Nothing should touch the pow- der, or lint, and, to prevent this cir- cumstance, Mr. Home recommends applying a little bolster on each side of the sore, and over them a roller, which will go from' one bolster to the other, in the manner of a bridge. For healthy ulcers, dry lint is to be regarded as being, upon the whole, the most eligible application. When the sore does not secrete pus enough in twenty-four hours to moisten the lint, the dressings are only to be chai.ged every other day. When a moderately tight bandage is not forbidden b\ constitutional pcculi- arities, it is useful, both in supporting the muscles and skin, which are often in a flabby state from the unexercised state ofthe fimb, and in defending the newly formed parts. (See Home on Ul- cers.) ULCERS IN PARTS, WHICH ARE TOO WEAK TO CARRY ON THE ACTIONS NECESSARY FOR THEIR RECOVERY. This is the second ofthe classes, in- to which Mr. Home has divided ulcers in general. The granulations of these sores are larger, more round on their external surface, and of a less compact texture, than those formed on ulcers in healthy parts. Mr. Home has also noticed their semi-transparent appearance. When they have filled up the cavity of an ul- cer to a level with the surface of the body, they do not readily form skin, but, rising up in a still higher manner, often lose altogether the power of pro- ducing new cutis. When the parts are still weaker, the granulations some- times continue gradually to fill up the hollow of the ulcer, and then, all on a sudden, are suddenly absorbed, so as to leave the sore, as deep as it was before. Ulcers may be weak from the first, or become so in the progress of the case. Even granulations of the most healthy kind, if they are not skinned over in a certain time, gradually lose their primitive strength. Sores on the legs are greatly under the influence of all natural peculiarities of the constitution, and every thing, which affects the health. When the constitution becomes in the least weaker or stronger, the appearance of the granulations becomes changed ac- cordingly, and this effect of constitu- tional weakness, or strength, on ulcers is greater, in proportion as the sores are further from the source of the cir- culation. While the constitution is undergoing any kind of disturbance, the healing of an ulcer is suspended. Mental anxiety is very apt to retard cicatrization. Such effects, of the constitutional kind, on ulcers are greater in weak, and delicate persons, than in the strong and robust. Change of weather has considerable influence over the healing ULCERS. 349 of sores.Mr. Home mentions, in proof of this fact, that, when there were several hundreds of ulcers in the Naval Hospi tal at Plv mouth in 1778, every time the weather changed, from a dry to a moist state, the ulcers universally assumed an unhealthy appearance; but, put on a better aspect, when the weather be- came dry again. In the treatment of this kind of ul- cer, tonics are to be exhibited, parti- cularly bark and steel; and eveiy thing, which disagrees with the constitution, is to be avoided. Wine and cordial medicines are also usually prescribed. Porter, however, is deemed better, than wine, for working people. Mr. Home observes, that the first object, in the local part of the treat- ment, is to keep the granulations from rising above the edge of the surround- ing skin. This gentleman (in my opi- nion) very judiciously represents the greater propriety of preventing the granulations from ever becoming too high by the employment of proper ap- plications, than following the common plan of destroying the high granula- tions with escharotics, after they have risen to an improper height. There cannot be the smallest doubt, that if the granulations could always be pre- vented from rising up too much, the pa- tient would suffer a great deal less pain. Instead of applying to the surface of the ulcers, now under consideration, lunar caustic, blue vitriol, red precipi- tate, &.c. Mr. Home prefers mixing these escharotics with other sub- stances, so as to render them only strong stimulants, and using them in this latter form. He conceives, that, when the high granulations are de- stroyed with escharotics, the disposi- tion of the surface underneath to re- produce them is increased, but, that this is not the case, when the luxuriant parts are only stimulated, so as to be- come absorbed. The same gentleman seems to think, that, when animal substances grow with great rapidity, they are, like ve- getable ones, weaker, than when pro- duced in a slower manner. Hence, Mr. Home is of opinion, that the growth of granulations ought to be checked in the early stage of their formation, by some resistance, which they are just able to overcome, under which cir- cumstances, they derive strength from the limited increase of action, which they are obliged to undergo. On the same principle, according to Mr. Home, the pressure of tight ban- dages is advantageous, and ulcers, wliich heal, while the patient is walk- ing about, are not so apt to break out again, wben healed, while the parts are in a state of perfect rest. In the treatment of these ulcers, when the granulations have come to a proper height, and do not form a thin, semi-transparent pellicle upon their surface, they are to be considered as ** weak parts, and treated accordingly. Mr. Home thinks, that, in this circum- stance, the best plan, when no particu- larity of constitution forbids, is pres- sure, made with a thin piece of lead over the dressings, and supported with a tight bandage. OF APPLICATIONS TO ULCERS AT- TENDED WITH WEAKNESS. Although, strictly, we have no topi- cal applications, which can directly communicate strength to granulations, there are certainly some, which pre- vent the granulations from exhausting themselves by luxuriant growth, and stimulate them to draw more blood from the arteries; which effects, as. Mr. Home remarks, render such gra- nulations stronger: 1. This gentleman very properly i condemns, as applications to weak ul- cers, all relaxing fomentations com- monly employed; and recommends,"in- stead of them, the use of spirits and wine and the decoction of poppies, in equal proportions, not, however, to be applied hot. 2. With regard to moist applications, the same gentleman expresses his dis- approbation of poultices, and mentions a weak solution of the argentum nitra- tum, as the most eligible application in an aqueous form. 3. On the subject of powdered sub- stances, as applications to weak ulcers, Mr. Home says, he has often tried bark, and the lapis calaminaris, without per- ceiving, that the former had any power of strengthening granulations, or the latter any virtue in disposing them to form new skin; properties commonly imputed to these applications. Mr. Home entertains no better opi- nion of plaster-of-paris, or powdered chalk, employed with a view of pro- moting the formation of skin. Powder- ed carbon, he speaks of, as being more adapted to irritable, than weak ulcers. He praises powdered rhubarb, as par- ticularly applicable to the latter kind of ulcer, because, it represses the lux- 350 ULCERS. uriant growth ofthe granulations, ren- ders them sm..U ami compact, and dis- poses them to form skin. When, how- ever, the granulations have risen above the level ofthe skin, it is not powerful enough to reduce them. When the rhubarb is too stimulating, it is to be mixed with a fourth part of crude opi- um in powder. A piece of lint, a little less, than the sore, is always to be put over the pow- der, and covered with a pledget of simple ointment. 4. Ointments, according to Mr. Home, are particularly apt to disagree with weak ulcers. When other appli- cations fail, however, greasy ones may be tried, and the above gentleman gives a preference to the ung. hydrarg. nitrat. mixed with hog's lard, in the proportion of one to five, or else to common cerate, blended with a small quantity of the hydrarg. nitrat. ruber. OF ULCERS IN PARTS, WHOSE AC- TIONS ARE TOO VIOLENT TO FORM HEALTHY GRANULATIONS; EITHER FROM THE STATE OF THE PARTS, OR THE CONSTITUTION. There are three states ofthe consti- tution influencing the nature of ulcers: an irritable state, in which all the ac- tions of the animal economy are more rapid, than in health; an indolent state, in "which they are unusually languid; and, lastly, a diseased state, by which they are affected. An irritable, and an indolent ulcer cannot in general be distinguished from each other by mere appearances, though they may be so in a few in- stances. Mr. Home informs us, that the disposition of an ulcer, like the disposition of a constitution, can only be accurately ascertained by deter- mining the actions, which arise from the different impressions made upon it The same gentleman notices, that the following appearances at once shew the ulcer to be of an irritable kind. The margin of the surrounding skin being jagged, and terminating in an edge, which is sharp and under- mined. The bottom of the ulcers being made up of concavities of different sizes. There being no distinct appear- ance of granulations, but, a whitish spongy substance, covered with a thin, ichorous discharge. Every thing, that touches the surface, gives pain, and very commonly makes it bleed. The discharge is altered from common pus to a thin fluid, in proportion to the de- gree of irritability communicated to tile sore by constitutional causes. The pain of an irritable sore in gene- ral gradually becomes less. When it is not constant, but comes on in pa- roxysms chiefly in the evening, or night-time, with great violence, con- vulsive motions of the limb are apt to occur, and extend to various other parts. Mr. Home refers this symptom to irritation communicated along the course of the nerves, and producing an action in them, attended with a violent contraction ofthe muscles, which they supply. When the above-mentioned signs of an irritable ulcer are not present, we must form a judgment ofthe nature of the sore from listening to the history ofthe case, the effects of various ap- plications, &c. When this kind of in- formation cannot be obtained, Mr. Home recommends the treatment to begin on the supposition of the ulcer being of an irritable nature. When an ulcer occurs just over the malleolus externus, it is generally of an irritable kind, in consequence of the nature of the part, on which it is situated, quite independently of any constitutional, or local disposition to irritability. Mr. Home conceives, that the periosteum, which here lies im- mediately under the skin, becomes the seat ofthe ulcer, is the cause of its be- ing very difficult to heal, and gives it the irritable appearance. The fact, that sores, situated on the ligament of the patella, and over the periosteum of the anterior surface of the tibia, as- sume a similar appearance, and are equally difficult to heal, made the above gentleman more confirmed in his sentiment. In treating ulcers in general, the surgeon will find it exceedingly ad- vantageous to be acquainted with the effects of a great many different exter- nal applications; for, a very few cases will continue to heal more, than for a certain time, under the same treat- ment The necessity of changing the applications, after they have been con- tinued for a certain time, is strikingly illustrated by the fact, that leaving off a powerful application, and employing one, which at first would have had no effect, often does a great deal of ser- vice. When the change is made to a medicine of powers, equal to those of the previous one, the benefit will be more lasting, titan in the preceding circumstance. ULCERS. 351 Mr. Home compares the principle of this occurrence, with that, by which change of air, even of a very salubrious air, for one that is less so, often pro- duces an infinite improvement of the health. OF APPLICATIONS TO IRRITABLE ULCERS. 1. Mr. Home recommends applica- tions, in the form of vapour, as being particularly useful, by their quality of allaying irritation, and soothing pain. The steam of warm water is pro- ductive of benefit in this way, though seldom used by itself. Its good effects are increased, when it is mixed with spirits. Mr. Home speaks also in favour of the benefit derived from fomentations containing opium; such as, the tinc- ture of opium, sprinkled on flannel, wrung out of hot water; or the appli- cation of flannels, wet with a warm solution of the extract of opium, or with a decoction of poppy-heads. A decoction of chamomile flowers, the tops of" wormwood, or hemlock leaves, may also be employed for the same purpose. Mr. Home points out particular irri- table ulcers, however, which are ren- dered more painful by warm applica- tions, and he states, that, the sores al- luded to, are generally attended with a mottled, purple discolouration ofthe limb, for some way from them, and a coldness ofthe lower part of the leg, and that they are often disposed to mortify, which event is promoted by warmth. 2. As for moist applications, the poultice made of linseed meal is the most simple and most easily made, and, as it does not necessarily require any addition of oil, is to be preferred, when this disagrees with the sore. Mr. Home does not say much in fa^ vourof the use of the extract of lead in poultices; for, though he allows, that it often answers very well, he adds, that it also frequently disagrees witb the ulcer, and, if long used, is apt to bring on the lead-colic. A decoction of poppy-heads is said to be a veiy good liquor for making poultices. The carrot-poultice is also found to agree with a great many irritable sores. The great objection to poultices, in these cases, being the weight of such applications, the limb should always, if possible, rest upon the poultice, and not the poultice upon the limb. When the weight cannot be avoided, and is hurtful, a lighter application should be chosen. If poultices be employed, their use is to be continued, as long as the gra- nulations are small, and the ulcer is ra- pidly diminishing in size, and this even till the cicatrization is complete. When the granulations become large, and loose in their texture, poultices should be left off. When the weight of poultices pro- hibits their use, Mr. Home advises the trial of lint, dipped in one of the fol- lowing lotions, and covered with a. pledget ofsome simple ointment: a so- lution ofthe extract of opium; a decoc- tion of poppies; the tincture of opium; a decoction of cicuta; the aqua lithar- gyri acetati composita; or a diluted so- lution of the argentum nitratum. 3. Powdered applications are gene- rally too stimulating for irritable ulcers. Carbon has been found useful; so has powdered extract of opium, mixed with an equal quantity of carbon, or linseed flour. However, opium occa- sionally affects the constitution, in con- sequence of absorption, and it has been known to excite violent inflammation, ending in mortification. 4. Ointments are not often proper applications for irritable ulcers; as they are always, more or less rancid, and generally disagree with the skin of persons, most subject to such diseases. Mr. Home mentions cream, as be- ing a very useful application, particu- larly in cases, in which warmth is found to do harm. The same gentle- man recommends, as a substitute for it, an ointment, composed of hog's lard, purified by being repeatedly washed in spring water, and then mixed with a small quantity of white wax, and rose water. The observations, made respecting solutions of lead, apply to the unguen- tum cerusss acetatx. 5. The pressure of bandages is generally hurtful to irritable sores, though a slight degree of it proves serviceable to certain ulcers, which are somewhat less irritable, and arise from weakness. OF ULCERS IN PARTS, WHOSE ACTIONS ARE TOO TNDOLENT TO FORM HEALTHY GRANULATIONS, WHE- THER THIS INDOLENCE ARISES FROM THE STATE OF THE PARTS, OR OF THE CONSTITUTION. Such is the next division of ulcers adopted by Mr. Home in his treatise 352 ULCERS. on the subject. The indolent ulcer forms in its appearance a complete contrast to the irritable one. The edges of the surrounding skin are thick, pro- minent, smooth, and rounded. The surface of the granulations is smooth and glossy. The pus, instead of being of a perfect kind, is thin and watery, being composed of a mixture of pus and coagulating lymph. The lymph consists of flakes, which cannot be easily separated from the surface ofthe sore. The bottom of the ulcer forms quite a level, or nearly so, and, as Mr. Home very accurately remarks, the general aspect conveys an idea, that a portion of Ijie skin and parts under- neath has been for some time removed, without the exposed surface having begun any new action to fill up the ca- vity. When, however, the indolence ofthe ulcer is not so strongly marked, the sore does not correspond to the pre- ceding description, but resembles in appearance the ulcer, which posses- ses an inferior degree of irritability, and can only be discriminated from it by receiving no benefit from soothing applications. The odd circumstance ofsome indo- lent sores not having the appearance of indolent ones is, in some degree, ex- plained by ulcers always being influen- ced by changes in the constitution, and accidental circumstances affecting the parts. Most of the ulcers, which are to be seen in the London hospitals, are of the indolent kind. An indolent disposi- tion in the ulcer may proceed altoge- ther from the long existence ofthe dis- ease, and, hence, Mr. Home very just- ly observes, it is immaterial, whether at first it was healthy, weak, or irrita- ble, for, if not cured within a certain time, it becomes indolent, with the exception of a few ofthe irritable kind, which never change their nature. Indolent sores do form granulations; but, these, every now and then, are all on a sudden absorbed, and, in the course of four and twenty hours, the sore becomes as much increased in size, as it had been diminished in as many days, or weeks. This absorption of the granulations arises principally from their not being of a healthy kind; but, the event is promoted by changes in the weather, anxiety, fatigue, &c. The object in the treatment of indo- lent ulcers is not simply to produce a cure, but to render such cure as per- manent as possible. This can only be accomplished by altering the disposi- tion ofthe granulations, and rendering them strong enough to stand their ground after the ulcer is filled up. When an ulcer, which has existed six months, is dressed with poultices for a week, the granulations, at the end of this time, will have in parte- filled up the hollow of the sore, but, they will be found, large, loose, and glossy. Should the poultice be now disconti- nued, and some proper stimulating ap- plication used for another week, the granulations will be found, at the ex- piration of this time, to have become smaller, more compact, redder, and free from the glossy appearance. The ulcer, when healed, by the latter appli- cation, will not be so likely to break out again, as when healed with large, loose, flabby, glossy granulations. Mr. Home states, that the number of indolent sores, which heal under the use of stimulating applications, and do not break out again, compared with si- milar cases, treated with mild dress- ings, are as four to one. APPLICATIONS TO INDOLENT ULCERS. 1. Medicines in the form of vapour, cannot heal indolent sores, so that the cure shall be lasting. Itis only when these ulcers assume a foul appearance, and are in a temporary state of irrita- tion, that such applications can be ad- vantageously employed. In general, patients on their first ad- mission into hospitals with sore legs, have their ulcers in a temporary state of irritation from neglect, exercise, ex- cesses, &e. Hence, it is generally found advantageous, for the first few days, or even a week, to have recourse to poultices and fomentations. I believe, that any common fomen- tation, whether of camomile, poppy- heads, or mere warm water, answers equally well. The time for using them, is while a fresh poultice is preparing, and this latter application should be changed twice a-day. 2. Moist applications, such as poul- tices, are to be employed, when fo- mentations are proper, and they may be made of bread, oatmeal, or linseed. Mr. Home describes a species of in- dolent ulcers, which occur in patients of debilitated constitutions, which put on a sphacelated appearance, without any apparent cause, even after they have made some progress towards a ULCERS. 35£ cure, and in this way spread to a very large size. Some of these ulcers, if judged of from their appearances, would be ranked as irritable ones; but, as soothing applications do not agree with them, they are not to be classed with the latter kindof sores. They are said to occur particularly in seamen, and soldiers,who have been long at sea, and have been termed scorbutic ulcers. Mr. Home represents them, however, as not being necessarily connected with the scurvy, and being often met with in patients, who have not been on the sea. This gentleman states, that these ulcers are not of necessity joined with any specific disease; but are com- mon to all kinds of patients, whose constitutions have been impaired, ei- ther by salt provisions, warm climates, or drinking. From some trials, first made by Dr. Harness,and afterwards by "Mr. Home, it appears, that these particular ulcers, when in a sphacelated state, are bene- fited by employing the gastric juice of ruminating animals, as an external ap- plication. It makes the sloughs fall off, and the sore assume a better appear- ance. Some pain follows on its being first applied, and it is to be regarded as a stimulating application. Mr. Home mentions, that in the West Indies, such ulcers are advan- tageously dressed with the fresh root of the cassada, grated into a pulp. Lime- juice has also been found a useful ap- plication, and solutions of vitriol and alum have been recommended. When indolent ulcers are not at- tended with certain peculiarities, a so- lution ofthe argentum nitratum is one ofthe best of the watery applications. It stimulates the granulations, and makes them put on a more healthy ap- pearance, and its strength may be in- creased according to circumstances. An ulcer, wliich at first cannot bear this solution above a certain strength, without pain, and without the granula- tions being absorbed, becomes able, af- ter the application has been used, about ten days, or a fortnight, to bear it twice as strong, without such effects being produced: a proof of the granu- lations having acquired strength. The tincture of myrrh is often em- ployed as an application to indolent ul- cers. Hunezowsky has praised a de- coction of the walnut-tree leaves, and soft covering of the walnut, for the same purpose. (Acta Acad. Med. Chir. Vindob. torn. 1.1788.) Mr. Home gives his testimony in favour of both the lat- ter dressings. The diluted vitriolic acid, and the expressed juice ofthe pod of different species of pepper in a recent state, are mentioned by Mr. Home as having been used as applications to indolent ulcers: the latter one in the West In- dies. This gentleman recommends also a scruple of nitrous acid, mixed with eight ounces of water, as a very useful medicine for external use.The strength must be increased, or diminished, ac- cording to circumstances. Mr. Home has found, that this application pro- motes, in a very uncommon manner, the progress of the cure. The first application of diluted ni- trous acid gives a good deal of pain, which lasts about half an hour, and then goes off. When an indolent ulcer heals with the diluted nitrous acid, the process of skinning is accomplished with more rapidity, than when other applications are employed; and the new skin is said to be more completely formed. The acid coagulates the pus as soon as it is secreted. Mr. Home says, that several patients, who had ulcers dressed with the dilut- ed nitrous acid, were allowed to walk about, without finding the progress of the cure retarded, although no bandage to support the limb was made use of. This gentleman informs us, also, that in ulcers ofthe leg, attended with an ex- posure of a piece of bone, which is nei- ther acted upon by the absorbents, nor deprived of life, so as to form an exfoli- ation, so that the ulcer is kept from healing, the application of diluted ni- trous acid to the bone, removes the ear- thy part, and excites the absorbents to act upon the remaining animal por- tion. 3. The only application, in the form of powder, adapted to indolent ulcers, is, accordingto Mr. Home, the hydrar- gyrus nitratus ruber. It is only to be oc- casionally used for ulcers of the most indolent kind. 4. Ointments are represented as be- ing particularly proper applications for the sores under consideration. The idea of the air having bad effects on ulcers exposed to it, is now disbe- liev ed. That air has no irritating pro- perty of this kind, is proved by the fact, that, when the abdomen of an animal is filled with it, no inflammation is excit- ed. When the cellular membrane is Vol. II. 2 Y 364 ULCERS. loaded with it, in cases of emphysema, the parts do not afterwards inflame.— Nor, do ulcers in the throat, ~s Mr. Home justly'remarks, heal less favour- ably than others, although they are of necessity always exposed to the air. Whatever ill effects arise, may pro- bably be explained by the consequences of evaporation, which converts the soft pus into a scab. The granulations are, m all probability, most favourably cir- cumstanced, when they are covered with their own matter, which should only be now and then removed, in or- der that such applications may be made, as will stimulate them to secrete a more perfect pus. From what has been just stated, it must be obvious, that indolent ulcers should not be fre- quently dressed, and, tljat if they are so, and the dressings are stimulating, the practice will do harm. Changing the dressings once in twenty-four hours is deemed quLte sufficient, unless the quantity of matter is very great, which very seldom happens in these cases. One part of the unguentum hydrar- gyri nitrati mixed wi'h three of hog's lard, is one ofthe best applications. Its strength, however, must be increased after being used, for some time, as a dressing for the same ulcer. The unguentum hydrargyri nitrati has the effect of quickly removing the thickening of the edges of indolent ul- cers, and the surrounding dark red co- lour ofthe skin. It seems also to have particularly great power in making the granulations become small and healthy, and, of course, the ulcer is less likely to break out again. With some ulcers, however, this ointment is found to disagree. The unguentum resinse flavae, and the unguentum elemi, mixed with the balsam of turpentine, or that of copaiba, are other common applications to indo- lent sores. Mr. Home states, that the resins and turpentines are not so pow- erful, as the acids and metallic salts, in giving the granulations a healthy ap- pearance, and a disposition to resist be- ing absorbed. Cases, attended with a degree of in- dolent thickening, are such as are most likely to be improved, by camphorated ointments. In numerous cases, the applications, whatever they are, soon lose their ef- fect, and others should then be substi- tuted for them. The past and present states ofthe sore are always to be con- sidered. AJ.tb.ough, the ulcer may be in its nature indolent, it is liable to tem- porary changes, from constitutional causes, and hence, a temporary altera- tion in the treatment becomes1 proper. S. Bandages are undoubtedly of the most essential service in healing many kinds of ulcers: but, their efficacy is so great in curing numerous indolent sores that they are considered by same as the principal means of cure. Among the advocates for the em- ployment ofthe roller, Mr. Whately is one of the most zealous. The following extracts will convey to the reader a tolerably good idea of this gentleman's opinions. " The efficacy of pressure in counter- acting the effects of the dependent posture, was indeed known to the fa- ther of English surgery; and the use of the laced stocking was recommended- by him for this purpose; nor can there be any doubt, that, the good effects of it in his hands, were very manifest. His ideas, however, seem not to have been mucb regarded by succeeding sur- geons. We find but little said by the writers on surgery, on the effects of pressure in the cure of ulcers on the lower extremities, previous to the ap- pearance of Dr., Underwood's treatise. Yet I am aware, that there always have been practitioners, who were acquaint- ed with the importance of this mode of treatment, and have adopted it in their practice. I had, myself, an opportunity of seeing the extraordinary success at- tending it, during my apprenticeship in the country. It is matter of fact, however, that the practice is very far from being general. Even in one ofthe latest publications on the subject, and this too by a surgeon of the first emi- nence, the effect of pressure is- not much relied upon for the cure of these complaints. It is, indeed, there stated, in seyeral passages, not only that no be- nefit is derived from compression in se- veral species of these ulcers, but that many ulcers are rendered worse, more painful, and more unhealthy in their appearance by its use (as observed in Mr. Home's Remarks on Ulcers ofthe Legs.) That there are certain condi- tions of an ulcer, which will not bear compression, I have allowed, and have endeavoured to point out the proper treatment, to bring on a fit state for the application of that pressure: but that an experienced surgeon should pass over so slightly this most essential part ofthe cure, and even speak of it as fre- quently injurious, is. a circumstance ULCERS. 355 hardly to be attributed to any other cause than that of a careless and inef- fectual application ofthe bandages. For my own part, having now been for twenty years constantly in the habit of treating a very large number of these cases, I can speak so confidently ofthe good effect of pressure, properly appli- ed, that I can venture to affirm, that he who doubts its efficacy, has never given it a fair trial. " In the cases, which are added to this essay, (says Mr. Whately) very little variety of dressing was used; the cure was almost always trusted princi- pally to the pressure made on the limb, under the exceptions particularly speci- fied in the work. My success has been so uniform,that I cannot but be anxious to see this practice become established and generally followed. Nothing but a conviction, that in promoting this end, I am really doing an important service t my fellow-creatures, could have in- duced me to appear before the tribu- nal of the public, conscious as 1 am of my incompetency as a writer. But may I not hope, that the plain tale of a prac- tical man will be heard, though not told with the graces of elegant lan- guage " " In whatever 'Tianner this attempt be received, I cannot doubt but that the practice here recommended must, in the end, prevail, notwithstanding it has this great obstacle to contend with, that surgeons must condescend, for the most part, to apply the bandages with their own hands. The clumsy and inef- fectual manner, in which this business is too frequently done, can never be ex- pected to produce the desired effect. I am certain, that if the necessary pains be taken, according to the directions here laid down, such effects will uni- formly follow, as must convince the un- prejudiced mind, that to have recourse to the operation of tying varicose veins, and the application of a great variety of remedies, can be very rarely, most pro- bably never necessary. I can safely de- clare, that all such cases, as are de- scribed by Mr. Home to be cured by this operation, have readily yielded, under the proper management of pres- sure alone. ' " Since these papers were preparing for the press, I have seen with pleasure Mr. Baynton's new method of treating these complaints. Every thing that is there said on the efficacy of his me- thod, may be considered as confirming the doctrine }aid down in the following pages. His mode, however, of making the pressure with adhesive plaster, ap- pears to me inconvenient, and on seve- ral accounts objectionable I have no doubt but that the proper application of compresses and flannel rollers, would, in every case recorded by him, have produced similar good effects. The in- stances of success by this method, after the supposed failure by the roller, I can only attribute to this, that the pres- sure made with the plasters was appli- ed by his own hands, whereas that with the roller, was probably, as is usu- al, so made, that the effect intended by it could not possibly have been obtain- ed. No surgeon, who will not be at the trouble of applying them himself, can be a judge of what may be effected by the proper management of the roller and compresses." The following is the calamine ce- rate, which Mr. Whately has usually employed: R. Axung. Porcin. depur. lib. iij. Empl. Lithargyr. lib. iss. Lap. Calam. prsep. ap. lib. j. M. " To this formula (says Mr. Whate- ly,) I shall add another for making a cerate which nearly resembles the un- guentum tripharmacum ofthe old Dis- pensatory, but being less oily, it makes a much more adhesive plaster. It should be spread on rag, or silk, as an exter- nal covering to the dressing on lint, where a tow plaster cannot be conve- niently used; as in wounds of the face or hands, a bubo, or any other sore, where an external plaster cannot be readily retained in its situation by a bandage. This plaster is likewise so mild, that it never irritates the skin. I have found it also a very useful plaster in fractures. The following is the for- mula: R. Empl. Litharg. lib. j. Axung. Porcin. depur. une. vj. Aceti une. iv. M. With respect to the proper method of applying the roller and compresses, Mr. Whately offers the following re- marks: " I have said, that the flannel rollers should be four inches wide, to allow for shrinking in washing; by which I would have it understood, that when they are made of that width, they are a little too wide: especially for those whose legs are small. The best width for a flannel roller, designed for those who have slender legs, is three inches; but for those, whose legs are of a large size, they should be always three inches 356 ULCERS. and a half in width. They must there- fore be at first torn a little wider, that they may be of their proper width when repeatedly washed. It will likewise be found, that rollers made of fine, soft, and open flannel, will answer mucb bet- ter, than those made of coarse or hard flannel. " For those who have full-sized legs, the length of six yards is but just sufficient to answer all the purposes in- tended by a roller; but in those who have very small legs, five yards is a suf- ficient length. Care should be taken that the rollers be not washed in very hot water, and they should be hung up to diy immediately on being washed. If these precautions be not attended to, repeated washing them will, in some kinds of flannel, make them as narrow as tape, by which they will be render- ed almost useless. They should be of- ten washed, as they are much softer, and of course sit easier, when quite clean, than when they are soiled. " In applying a roller, (says this gentleman,) the first circle should be made round the lowest part of the an- kles as near as possible to the heel; the second should be formed from thence round the foot; the third should be passed again round the foot quite to the toes. The roller should be passed from the foot round the ankle and in- step a second time to make the fourth circle. In doing this, it should be brought nearer (but not over) the point ofthe heel than it was at the^Jm time of going round this part. The fifth cir- cle should pass over the ankles again, and not more than half an inch higher up the leg than the fourth circle. The sixth, seventh, eighth, and ninth cir- cles should ascend spirally along the small ofthe leg, at the exact distance of three fourths of an inch from each other. Having proceeded thus far up the leg, we may begin to increase the distances of the circles from each other; they may succed each other up- ward to the knee at the distance of from one to two inches, according to the size and shape of the leg. At that part where the calf of the leg com- mences, it is generally necessary to let the upper edge of the roller be once, twice, or thrice, turned downwards for about half the circumference ofthe leg, in order to make the roller lay smooth between the middle ofthe calf, and the small of the leg. When the roller has been thus applied as far as the knee, there will be a portion of it to spare, of perhaps a yard in length: this remainder should be brought down by spiral windings, at greater distances from each other than those which were made on the ascent of the roller. The windings should in general be completed in the small of the leg, where the roller should be pinned. " In many cases, it is necessary to apply the roller over the heel. It should be brought as low as possible round the ankle; as in the former description. From thence, the second circle of the roller should pass from the instep over one side of the heel, and be brought over the other side of the heel to the instep again. The third circle should be passed round the ankle a second time, but still nearer to the heel than the first circle was. The roller should after this be brought back to the foot, and passed round it to make the fourth circle. A fifth circle should be again made (though it is not in all cases ab- solutely necessary) round the foot to the toes. To make the sixth circle, the roller should be brought back, and pass- ed round the ankle again. The seventh, eighth, ninth, tenth, and eleventh cir- cles should ascend spirally at the exact distance of three fourths of an inch from each other; these distances commen- cing at the sixth circle. The roller should then be carried to the knee, and be brought down again to the small of the leg, as described in the former in- struction. " In applying the compresses, it is necessary in every instance to put them on one by one, and not all in a mass, though they be of a proper size and number. They should be crossed in dif- ferent directions; the largest of them should in no case be longer than just to meet on the opposite side ofthe leg, to which they are applied. 1 have in many instances seen the compresses applied by the patients of such a length as to go round the leg like a roller, and be fastened together with pins. This method generally wrinkles and blisters the skin, and by no means answers the purpose of making a compression on the part where it is most wanted. I never suffer a pin to be used in com- presses. If the same compresses in any case be applied two days together, they should always be turned on the contraiy side at each re-application, in order to prevent wrinkles on the skin." Mr. Whately notices two objections made by Mr. Baynton to rollers. "The first is, that it is difficult to retain the; ULCERS. 35-r roller on the parts to which it is appli- ed; the second is, that, it gives pain to the patient" Mr. Whately's experi- ence, however, warrants him in saying, that a flannel roller will, in almost every instance, keep the exact position it was first placed in, for a much longer time than is necessary. " 1 have seen these rollers (says Mr. Whately) many hundred times keep their situations without any variation whatever for two days; and that too without the least re- straint upon exercise. This-has hap- pened in those cases, where from the distance of the patient, or from the cir- cumstance of his being nearly cured, I have wished to dress the leg only every forty-eight hours. I must go a step further, and observe, that I have seen repeated instances in which these rol- lers have remained in their situation for three or four days, and even nearly for a week without being applied afresh. In short, it is one of the best properties of a flannel roller, that it is easily ret.ined in its situation, when well applied. In every instance, in which it is necessary to use one, I could pledge myself to apply it in such a manner, as should prevent its alter- ing its position for two days. The me- thod I should use, I have already de- scribed; in addition to which, nothing more would be necessary, even in those cases where the shape ofthe leg is pe- culiarly unfavourable to the retention of a bandage, than the insertion of a few pins. " In answer to the second objection, I observe, that I have invariably found, that when aflannel roller has been appli- ed in the manner here described, and has not been drawn unnecessarily tight, it gives no pain. It sits nearly as easy as a common stocking, and allows a very free motion and exercise of the limb. It has been stated in this work, that the application ofthe compresses makes the necessary degree of pressure on the ulcer, and thereby prevents the neces- sity of drawing the roller so tight over the other parts of the leg, as would have been necessary were the compres- ses not used. " There is another circumstance which Mr. Baynton considers as giving his method a great advantage over the roller, which is, that by means of the plaster, the edges of the sore may be made to approximate in such a manner, that the cicatrix, or new formed skin, will be less after a cure performed by this method, than by any other. In al- most all these cases, before the cure is attempted, the leg is more or less en- larged by swelling; and as this swell- ing is entirely removed by compression, it readily allows the skin to approxi- mate on the healing of an ulcer. Add- ed to this, there is a process of nature always going on in healing an ulcer or wound in any part of the body, (whe- ther there be a loss of substance or not,) by which a cicatrix is always con- siderably less than the previous size of the sore. This effect occurs in all cases, whether the patient be cured by the horizontal position, a roller, or by strips of adhesive plaster. The size of this cicatrix will likewise vary in different cases where the ulcers have been of the same size, by whichever of these three methods they be cured. It will be larger in those ulcers which are ac- companied with strong adhesions of the adjoining parts, than in those where such adhesions have not been produ- ced; and \his effect will take place to the greatest degree where the ulcers are situated over the tibia, and by long continuance h.ve produced immovable adhesions of the cellular substance to the adjoining periosteum. The adhe- sive plaster, when applied as a ban- dage, will without doubt leave as small a cicatrix as any other method of cure; but, for the reasons already assigned, I do not believe that the cicatrix will in any case be smaller than that produced by a roller. In every case cured by the latter method, I have found the cica- trix very small, when compared with the previous size of the ulcer."—(See Practical Observations on the Cure of Wounds and Ulcers on the Legs, without Rest; by Thomas Whately, 1799.) 6. We shall next introduce an ac- count of Mr. BiVnton's plan of curing old ulcers of the leg, by means of ad- hesive plaster. Were I to say. that any particular method of dressing such sores is entitled to superior praise, I should certainly decide in favour of this gentleman's practice. I have seen it most successful myself, and I hear it highly spoken of by numerous profes- sional friends, in whose unprejudiced judgment I place much reliance. Mr. Baynton acquaints us, that the means proposed by him will, in most instances, be found sufficient to ac- complish cures in the worst cases, without pain or confinement. After having been repeatedly disappointed in the cure of old ulcers, Mr. Baynton determined on bringing the edges of old 358 ULCERS. ulcers nearer together by means of slips of adhesive plaster. To this he was chiefly led, from having frequently observed, that the probability of an ulcer continu- ing sound, depended much on the size of the cicatrix, which remained after the cure appeared to be accomplished; and from well knowing, that the true skin was a much more substantial sup- port and defence, as well as a better covering, than the frrdl one, which is obtained by the assistance of art. But, when he had recourse to the adhesive plaster, with a view to lessen the pro- bability of those ulcers breaking out again, he little expected, that an ap- plication so simple would prove the easiest, most, efficacious, and most agreeable means of treating ulcers. Although the first cases, in which Mr. Baynton tried this practice, were of an unfavourable nature, yet he had soon the satisfaction to perceive that it occasioned very little pain, and ma- terially accelerated the cure, while the size ofthe cicatrices were much less than they would have been, had the cures been obtained by any ofthe com- mon methods. At first, however, the Success was not quite perfect; as, in many in- stances, he was not able to remove the slips of plaster, without removing some portion of the adjacent skin, which, by occasioning a new wound, proved a disagreeable circumstance, in a part so disposed to inflame and ul- cerate, as in the vicinity of an old sore. He therefore endeavoured to obviate that inconvenience by keeping the plas- ters and bandages well moistened with spring-water, for some time, before they were removed from the limb. He had soon the satisfaction to observe, that the inconvenience was not only prevented, but that every succeeding case justified the confidence he pow began to place in the remedy. He also discovered, that moistening the ban- dages was attended with advantages he did not expect: while the parts were wet and celd, the patients were much more comfortable in their sensa- tions, and th^e surrounding inflamma- tion was sooner removed, than he had before observed it to be. By the mode of treatment here re- commended, Mr. Baynton found, that the discharge was lessened, the offen- sive smell removed, and the pain abat- ed in a very short time. But, besides these advantages, he also found, that the callous edges were in a few days level with the surface ofthe sore; that the growth of fungus was prevented, and the necessity of applying painful escharotics much lessened, if not en- tirely done away. Mr. Baynton gives the following description of his method. " The parts should be first cleared ofthe hair, sometimes found in consi- derable quantities upon the legs, by means of a razor, that none of the dis- charges, by being retained, may be- come acrid, and inflame the skin, and that the dressings may be removed with ease at each time of their renewal, which, in some cases, where the dis- charges are very profuse, and the ul- cers very irritable, may, perhaps, be necessary twice in the twenty-four hours, but which I have, in every in- stance, been only under the necessity of performing once in that space of time. " The plaster should be prepared by slowly melting, in an iron ladle, a suffi- cient quantity of litharge plaster, or diachylon, which, if too brittle, when cold, to adhere, may be rendered adhe- sive by melting half a drachm of resin with every ounce ofthe plaster: when melted, it should be stirred till it begins to cool, and then spread thinly upon slips of smooth porous calico, of a con- venient length and breadth, by sweep- ing it quickly from the end, held by the left hand ofthe person who spreads it, to the other, held firmly by another per- son, with the common elastic spatula used by apothecaries; the uneven edges must be taken off, and the pieces cut into slips, about two inches in breadth, and of a length that will, after being passed round the limb, leave an end of about four or five inches. The middle ofthe piece so prepared, is to be appli- ed to the sound part of the limb, oppo- site to the inferior part ofthe ulcer, so that the lower edge ofthe plaster may be placed about an inch below the low- er edge of the sore, and the ends drawn over the ulcer with as much gradual extension as the patient can well bear; other slips are to be secured in the same way, each above and in contact with the other, until the "whole surface of the sore and the limb are completely covered, at least one inch below and two or three above the dis- eased part. " The whole ofthe leg should then be equally defended with pieces of soft calico, three or four times doubled, and a bandage of the same, about three inches in breadth, and four or five yards ULCERS. 359 in length, or rather, as much as will be sufficient to support the limb from the toes to the knee, should be applied as smoothly as can be possibly performed by the surgeon, and with as much firm- ness as can be borne by the patient, be- ing first passed round the leg, at the ankle-joint, then as many times round the foot as will cover and support every part of it, except the toes, and after- wards up the limb till it reaches the knee, observing that each turn of the bandage should have its lower edge so placed as to be about an inch above the lower edge ofthe fold next below. " If the parts be much inflamed, or the discharge very profuse, they sliould be well moistened, and kept cool with cold spring-water poured upon them as often as the heat may indicate to be ne- cessary, or, perhaps, at least, once every hour. The patient may take what exercise he pleases, and it will be al- ways found, that an alleviation of his pain and the promotion of his cure will follow as its consequence, though, un- der other modes of treating the disease, it aggravates the pain and prevents the cure. '* These means, when it can be made convenient, should be applied soon af- ter rising in the morning, as the legs of persons affected with this disease are then found most free from tumefaction, and the advantages will be greater than when they are applied to limbs in a swollen state. But at whatever time the applications be made, or in what- ever condition the parts be found, I believe it will always happen, that cures may be obtained by these means alone, except in one species ofthe dis- ease, which seldom occurs, but that will hereafter be described. The first application will sometimes occasion pain, which however, subsides in a short time, and is felt less sensibly at every succeeding dressing. The force, with which the ends are drawn over the limb, must then be gradually in- creased, and when the parts are restor- ed to their natural, state of ease and sensibility, which will soon happen, as much may be applied as the calico will bear,-or the surgeons can exert; espe- cially if the limb be in that enlarged and incompressible state, which has been denominated the scorbutic, or if the edges ofthe wound be widely sepa- rated from each other." Mr. Baynton afterwards takes notice of the breaking of the skin, near the ul- cers; a circumstance, which sometimes proved troublesome, and arose partly from the mechanical effect ofthe adhe- sive plasters, and partly from the irri- tating qu.dity ofthe plaster. Mr. Bayn- ton, however, only considers such sores of serious consequence, when they are situated over the tendon of Achilles, in which situation they are sometimes se- veral weeks in getting well. This gen- tleman recommends, with a view of preventing these ulcers, a small shred of soft leather to be put under the ad- hesive plaster. Mr. Baynton next adds, " that cures will be generally obtained without dif- ficulty, by the mere application of the slips and bandage; but, when the parts are much inflamed, and the secretions great, or the season hot, the frequent application of cold water will be found a valuable auxiliary, and may be al- ways safely had recourse to, where the heat of the parts is greater, than is na- tural and the body free from perspira- tion." (See A Descriptive Account of a New Method of Treating Old Ulcers of the Legs, by Thomas Baynton, Surgeon at Bristol. Edit. 2. 1799.) OF ULCERS ATTENDED WITH SOME SPECIFIC DISEASED ACTION, EI- THER CONSTITUTIONAL, OR LO- CAL. 1. Ulcers which yield to Mercury. Here we shall exclude from conside- ration venereal ulcers, as this subject is treated of in the article Venereal Dk- ease. At present, we shall only notice such sores, as are produced by other diseases of the general system, or of the parts, and are capable of being cur- ed by mercury. Perhaps, there is no greater source of error in the whole practice of surge- ry, than the supposition, that a sore, when it yields to mercury, must be a syphilitic one. Surgeons, however, who run into this absurdity, can hardly be imagined to be unaware, that so potent a medicine must have effects on nume- rous diseases of very different descrip- tions. Mr. Home very truly remarks, that many ulcers, unconnected with the venereal disease, which receiv e uo be- nefit from other medicines, heal under a mercurial course, or yield to mercuri- al applications. In some cases, the ul- cer remains in the same state, while mercury is used, but, begins to look better, as soon as the medicine is dis- continued, in consequence ofthe bene- ficial change, produced in the system by the mercurial caurse, In these casesi 360 mercurial frictions are they occasion the least impairment of the constitution, in consequence of the stomach continuing undisturbed, and capable of digesting well. Another description of ulcers, notic- ed by Mr. Home, as deriving benefit from mercuiy, occur on the instep and foot, have a very thickened edge, and are attended with a diseased state of the surrounding skin, so as to bear some resemblance to elephantiasis.— They are frequently observed affecting servants, who live in opulent families, in an indolent and a luxurious way. Mr. Home states, that fumigations with the hydrargyrus sulphuratus ruber heals these ulcers, and resolves in a great degree the swelling of the sur- rounding parts. In some instances, an ointment of calomel and hogslard; in others, the camphorated weak mercu- rial ointment, is the best application. Many diseased ulcers, particularly, superficial ones, with a thickened edge, may be healed, when they are dressed with a solution of one grain ofthe hy- drargyrus muriatus, in an ounce of wa- ter, containing a little spirit. 2. Ulcers, which are curable by Hemlock. Mr. Home places more reliance on hemlock, as an external, than an inter- nal remedy, for ulcers. The ulcers, which usually receive benefit from hemlock applications, look like those of an irritable sort; but, the surrounding parts are thickened, in consequence of some diseased action. Such sores occur near the ankle; which joint is at the same time enlarged. Sometimes, but not so often, they take place over the li- gaments of the knee. On account of their situation, and the swelling of the joint, they may be suspected to be scro- fulous, though they are more sensible, than strumous ulcers usually are. The sores, just described, are rendered less painful, their diseased disposition is checked, and the swelling of the joint diminished, by hemlock. Several irri- table scrofulous ulcers are also particu. larly benefited by this medicine. Mr. Home gives the preference to hemlock poultices, unless their weight should be objectionable, in which cases, he advises lint to be dipped in a decoc- tion ofthe herb, and put on the sore. Of the ointment, made with the in- spissated juice, Mr. Home seems to say little, in regard to its efficacy. i.Ulcers whkh may be cured by salt water, Mr. Home takes notice of other spe- ULCERS. the best, for cific ulcers, wliich yield to this applica- tion, after resisting other remedies.— Poultices, made with sea-water, are of- ten employed; hut, this gentleman seems to prefer keeping the part im- mersed* in the water in a tepid state, about a quarter of an hour, twice aday. When sea-water poultices bring out pimples, in cases of scrofulous ulcers on the legs and feet, Mr. Home informs us, that this disagreeable circumstance may be obviated by diluting such water with an equal quantity of a decoction of poppies. After a time, the salt water may be tried by itself again. While each fresh poultice is preparing, the part should also be immersed in such water warmed. When there is a tendency to anasar- ca, or when there is an unusual coldness- in the limb, unattended with any pro- pensity to mortification, tepid salt wa- ter may be used with infinite advantage. 4. Ulcers, which may be cured by the Ar- gentum Nitratum. Mr. Home notices, under this head, an ulcer, which does not penetrate more deeply, than the cutis; but, spreads in all directions, producing ul- ceration on the surface ofthe skin, and often extending nearly through its whole thickness. The part, first affect- ed, heals, while the skin beyond is in a state of ulceration. Of this description are a leprous eruption, mostly seen in men impress- ed in Ireland; a disease ofthe skin in- duced by bubois, which have continu- ed a great while, after the venereal vi- rus h.s been destroyed; and the ring- worm. All these diseases are most easily cured by applying to them a solution of tbe argentum nitratum. The leprous eruption is communica- ted by contact, and makes its appear- ance in the form of a boil. This is con- verted into an ulcer, which discharges a fetid fluid, by which the surrounding skin is excoriated, and the ulceration is extended over a large surface. The pain is the most severe, and the dis- charge greatest, in hot weather. The parts first diseased heal, while others are becoming ulcerated, and the dis- ease is always rendered worse, by spi- rituous liquors, salt provisions, and catching cold. Mr. Home remarks, that the disease in the skin, produced by the effects of very irritable buboes, in constitutions broken down by mercury, is attended with ulceration of a more violent, ULCERS. 361 deep, and painful kind, than the fore- going distemper. The progress of this disorder is, in other respects, very similar to that of the leprous eruption. Although the ring-worm only oc- curs in the form of an ulcer in warm climates, a mild species of the affec- tion takes place in summer-time in this country. It seems to be infectious; though it often occurs without infec- tion. It commences with an efflores- cence, which is attended with very trivial swelling, and spreads from a central point. The circumference of the efflorescence becomes raised into a welt, while the rest assumes a scur- fy appearance. The welt becomes co- vered with a scab, which falls off, and leaves an ulcerated ring, in general, not more than a quarter of an inch wide. The outer margin of this ring continues to ulcerate, while the inner one heals, so that the circle gets lar- ger and larger. The discharge con- sists of a thin, acrid fluid, which seems to have a great share in making the disease spread. For all the three preceding diseases, a solution of the argentum nitratum is strongly recommended by Mr. Home. 5. Ulcers, which yield to Arsenic. The sores, which are named noli Trie tangere, derive great benefit from this powerful remedy. Mr. Home ob- serves, that they are nearly allied to cancer, differing from it in not conta- minating the neighbouring parts by absorption, and only spreading by im- mediate contact. From some cases, which fell under Mr. Home's observation, he discover- ed, that arsenic was not only effica- cious as an external, but, also as an in- ternal remedy. I shall not unnecessa- rily enlarge upon this subject in the present place, as the reader may refer to the articles Arsenic, Cancer, and Noli Me Tangere, for additional informa- tion, relative to the uses of this potent mineral in the practice of surgery. Mr. Home is an advocate for its em- ployment, both internally and exter- nally, for ulcers of untoward appear- ance on the legs. Thcfungated ulcer is particularly pointed out by this gentle- man as being benefited by arsenic. This ulcer occurs on the calf of the leg, and on the sole of the foot. From its surface, a fungus shoots out, which is entirely different from common gra- nulations. The new formed substance is radiated in its structure, the bottom of the ulcer being the central point, and the external surface, which is con- tinually increasing, the circumference. The substance of this fungus is very tender, and readily bleeds. The first stage of the disease sometimes has the appearance of a scrophulous af- fection ofthe metatarsal bones; but, the parts seem more enlarged, and, when the skin ulcerates, a fungus shoots out, and betrays the nature of the case. One species of the fungated ulcer is capable of contaminating the lympha- tic glands; the other is not so. The first is represented by Mr. Home as being incurable by arsenic, or any other known medicine. The second yields to this remedy. Mr. Home uses a saturated solution, made by boiling white arsenic in wa- ter, for several hours, in a sand heat. He gives from three to ten drops in- ternally; and, for outward use, dilutes a dram with two pints of water, mak- ing it afterwards gradually stronger and stronger, till it is of double strength. The application may either be made in the form of a poultice, or by dipping lint in the lotion. The best and safest preparation of arsenic, both for internal and external use, is the kali arsenicatum. The mode of employing it may be learnt by turn- ing to the articles Arsenic, Aqua Kali Arsenicati, Noli Me Tangere, &c. 6. Ulcers attended with Varicose Veins. A certain kind of ulcer is very apt to occur on the inside of the leg, and is equally difficult to cure, and liable to break out again. It has the look of a mild, indolent sore; but, the branches and trunk of the vena saphena are en- larged, and this varix of the veins keeps the ulcer from healing. The sore is seldom deep, usually spreads along the surface, and has an oval shape, the ends of which are vertically situa- ted. There is a pain affecting the limb rather deeply, extending up in the course ofthe veins, and exasperated by keeping the leg a long while in an erect posture. This is a kind of ulcer, wliich derives immense benefit from a tight roller, ap- plied from the toes to the knee, al- though the direct operation ofthe pres- sure ofthe bandage on the sore is itself productive of no particular good. Mr. Home found, however, that many patients could not bear to wear Voi. II. 2 7. 3.62 ULC laced stockings, or tight bandages, and that some received no relief from them. Hence, this gentleman was led to con- sider what else could be done for the cure of the varicose state of the veins. He represents, that, in consequence of the size of the vena saphena, and its numberless convolutions, the return of blood from the smaller branches is so impeded, as to retard the circulation in the smaller arteries, and to interfere with their action in forming healthy granulations. The coats, and valves of the veins also become thickened, so that the latter parts (the valves) do not do their office of supporting the weight ofthe column of blood. These reflections induced Mr. Home to think, that some benefit might be obtained by taking off a part of the pressure of this column of blood, by making a ligature round the vena sa- phena, where this vessel passes over the knee-joint. Thus the cavity ofthe vein at this part would be obliterated, and a kind of artificial valve would be formed. This gentleman recommends the fol- lowing way of performing the opera- tion: " As the veins are only turgid in the erect posture, the operation should be performed while the patient is stand- ing; and if placed upon a table, on which there is a chair, the back of the chair will serve him to rest upon, and he will have the knee-joint at a very convenient height for the surgeon.The leg to be operated upon must stand with the inner ankle facing the light, which will expose very advantageously the enlarged vena saphena passing over the side of the knee-joint. While the patient is in this posture, if a fold of the skin, which is veiy loose at this part, is pinched up transversely, and kept in that position by the finger and thumb ofthe surgeon, on one side, and of an assistant on the other, this fold may be divided by a pointed scalpel, pushed through with the back of the knife towards the limb to prevent the vein being wounded; much in the same way, as the skin is divided in making an issue. This will expose the vein suf- ficiently; but, there is commonly a thin membranous fascia confining it in its situation; and, when that is met with, the vein had better be laterally disen- gaged by the point of the knife. This is most expeditiously done by laying hold ofthe fascia with a pair of dissecting forceps, and dividing it; foritisdiffi- UNG cult to cut upon parts, which give lit- tle resistance; and there is a risk of wounding the vein. After this a silver crooked needle, with the point round- ed off, will readily force its way through the cellular membrane connected with the vein, without any danger of wound- ing the vessel, and carry a ligature round it. This part, or, indeed, what may be considered as the whole ofthe operation, being finished, the patient had better be put to bed, so as to allow the vein to be in its easiest state before the ligature is tied, and then a knot is to be made upon the vein: this gives some pain; but it is by no means se- vere. The edges of the wound in the skin are now to be brought together by sticking plaster, except where the li- gature passes out, and a compress and bandage applied, so as to keep up a mo- derate degree of pressure on the veins, both above and below the pail includ- ed in the ligature." (Home on Ulcers, p. 296. edit. 2.) It appears, that A. Pare proposed and performed an operation, similar to the one described by Mr. Home. See A. Fare's Works, translated by Johnson; folio edition, page 319. For information on the foregoing sub- ject, consult Underwood's Surgical 'Tracts on Ulcers, &c. 1799; B. Bell's System of Surgery; Baynton's Descriptive Account of a New Method of Treating Old Ulcers of the legs, 1799, edit. 2; Whately's Practical Observations on the Cure of Wounds and Ulcers on the Legs, without Rest, 1799; Practical Observa- tions on the Treatment of Ulcers on the Legs, to which are added, some Observa- tions on Varicose Veins and Piles, by Ever- ard Home, F. R. S. 1801, edit. 2; Princi- ples of Surgery, by John Bell.vol. 1.1801; Hunter on the Blood, Inflammation, Qrc. UNGUENTUM ACIDI VITRIO- LICI.—R. Acidi Vitriolici gj. Adipis Suilhe prxparatae ^j.—These are to be well mixed together in a glass mortar. This ointment is said to have been used by Dr. Duncan, of Edinburgh, for curing the itch. It has the character also of being able to reduce some chro- nic swellings ofthe joints. Mr. Naylor, of Gloucester, has employed frictions with this ointment, containing a good deal of camphor, for the purpose of re- ducing the swelling of the thyroid gland, in cases of bronchocele. As the vitriolic acid is particularly destructive of vegetable substances, UNGUENTUM. 363 the parts to which this ointment is ap- plied, should always be covered with flannel instead of linen. UNGUENTUM CALCIS HY- DRARGYRI ALBjE.—R. Calcis Hy-, drargyri Alba: 3J. Adipis Suillae prae- paratae giss. Misce.—Useful for seve- ral cutaneous diseases. UNGUENTUM CANTHARI- DIS.—R- Cantharid. Pulv. gij. Aquae Distillatse §viij. Unguent. Resins Fla- vae ^viij. Boil the water with the can- tharides, till one half of the fluid has evaporated. Then strain the rest, to which add the ointment of yellow re- sin. Evaporate the mixture in a water- bath, saturated with sea-salt, until it is ofthe consistence of an ointment. UNGUENTUM CER^E.—R. Cera: Alba: 3iv. Spermatis-Ceti giij. Olei Olivae mj- These are to be melted with a slow fire, and then briskly stirred till cold.—Tliis, spread on lint, serves as a simple dressing for wounds, ulcers, &c. UNGUENTUM CERjE CUM ACETO—R. Cera: Alba:giv. OleiOli- vx, lbj. Aceti Distillati gij. The vine- gar is to be gradually mixed with the two first ingredients, after these have been melted together. Dr. Cheston re- commends this ointment for superficial excoriations, cutaneous eruptions, &c. UNGUENTUM CERUSSA ACE- TATjE.—R. Cerussae Acetatae ^ij. Ce- ra: Albs ^ij. Olei Olivae ibss. Rub the acetated ceruse (previously powdered) with part ofthe olive oil. Then add it to the wax melted with the rest ofthe oil. Stir the mixture until cold. This is a very good saturnine application, in cases which require it to be made in the form of an ointment. UNGUENTUM CICUTA-—R. Fo- liorum Cicuta: recentium, Adipis Suil- lac praeparatae, sing. §iv. The cicuta is to be bruised in a marble mortar, after which the lard is to be added, and the two ingredients thoroughly incorporat- ed by beating. They are then to be gently melted over the fire, and after being strained through a cloth, and the fibrous part of the hemlock well pressed, the ointment is to be stirred till quite cold. To cancerous or scro- phulous sores, this ointment may be applied with a prospect of advantage. (Pharm. Chirurg.) The Pharmacopoeia of St. Bartholo- mew's Hospital directs the unguentum cicutx to be made as follows:—R- Fo- liorum Cicuta: lbj- Adipis Suilla: tbiss. Boil the leaves in the melted hogs- lard, until they become crisp. Then strain the ointment. An hemlock ointment might be more conveniently made, by mixing the suc- cus cicutae spissatus, with any common salve. UNGUENTUM DIGITALIS—R. Foliorum Digitalis Purpureae recen- tium, Adipis Suillae prxparatae, sing. §iv. This ointment may be made in the same manner as the unguentum cicutae, and tried in the same cases as the latter. UNGUENTUM ELEMI COMr'O- S1TUM.—R. Elemi ifej. Terebinthinae §x. Sevi Ovilli prxparati ibij. Olei Olivae ^ij. Melt the elemi with the su- et; remove them from the fire, and mix them immediately with the turpentine and oil. Then strain the mixture.— Sometimes employed for dressing ul- cers, which stand in need of stimulat- ing applications. UNGUENTUM GALLjE CAM- PHORATUM.—R. Gallarum Pulveris Subtilissimi :tij. Camphorae ^ss. Adipis Suillae praeparatae J j. Misce.—This is a Very good application to piles, after their inflammatory state has been di- minished by the lotio aq. litharg. acet. ■unci leeches. UNGUENTUM HELLEBORI AL- BI.—R. Hellebori Albi Pulv. 3J. Adi- pis Suillae praeparatae Jiv.Olei Limonis t")ss. Misce.—This ointment will cure the itch, and several other cutaneous diseases. Tinea capitis will sometimes yield to it. UNGUENTUM HYDRARGYRI FORTIUS.—R. Hydrargyri purificati Jbij. Adipis Suillae praeparatae Jxxiii. Sevi Ovilli praeparati 5J. First rub the quicksilver with the suet, and a little of the hogslard, until the globules dis- appear; then add. the remainder ofthe lard, and make an ointment.—This is the common, strong, mercurial oint- ment. Of its uses we need say nothing in this place. UNGUENTUM HYDRARGYRI CAMPHORATUM.--R. Unguenti Hydrargyri §j- Camphorx 5ss. Misce. __This is often recommended to be rubbed on thickened, indurated parts, with a view of exciting the action ofthe absorbents. Rubbed along the course ofthe urethra, it is very serviceable in diminishing and removing chordee. UNGUENTUM HYDRARGYRI MiriUS.—R. Unguenti Hydrargyri fort. ibj. Adipis Suillae praeparatae Ibij Misce.—The weaker mercurial ojnt- 364 UNG UNI ment is often rubbed on indurated, thickened parts and tumours, when the object is merely to promote their absorption; and, it is not advisable to employ the unguentum hydrargyri fort. lest a salivation should be induced. UNGUENTUM HYDRARGYRI NITRATI.—R- Hydrarg. Purificati §j. Acidi Nitrosi £ij. Adipis Su'iII.t: prxparatx lbj. Dissolve the quicksil- ver in the nitrous acid; and whilst the solution is yet hot, mix with it the hogslard, previously melted, but be- ginning to concrete, by being exposed to the air.—This ointment is a celebra- ted application to the inside ofthe eye- lids, in cases of chronic ophthalmy, and also to specks on the cornea. When blended with a little olive oil, it also forms a very eligible stimulating dress- ing for numerous kinds of sores. It is very efficacious in curing tinea capitis, and many other herpetic and cutaneous U1S6 £LS e S • UNGUENTUM HYDRARGYRI NITRATI RUBRL—R. Hydrargyri Nitrati Rubri 5iss. Cerae Albx ^iv. Olei Olivae 5V"J- Misce.—This is a most common application to indolent ulcers, and sores in general, which re- quire being stimulated. UNGUENTUM L1THARGYRI ACET ATI.—R. Aquae Lithargyri A- cetati %v. Adipis Suillae lbj- Cerae Al- bae 3'iv. Melt the ingredients together, and continue to stir them till cold.— This is an excellent saturnine ointment for ulcers with inflamed edges, and it may be employed with great advantage as a simple dressing in numerous in- stances. UNGUENTUM OPHTHALMI- CUM.—R. Adipis Suillx prxparatx ""fss. Tutix prxparatx, Bol. Armen. sing. 3'j- Calcis Hydrarg. Albx zj. Misce.—This is Janin's celebrated oph- thalmic ointment, which may be used for the same diseases ofthe eye and eye- lids, as the unguentum hydrargyri ni- trati. It must be at first weakened with about twice its quantity of hogslard. UNGUENTUM PIC IS—R. Picis, Sevi Ovilli prxparati, sing. Ibss. Melt, and then strain them. UNGUENTUM PICIS COMPO- SITUM.—R. Unguenti Picis, Unguen- ti Cerussx Acetatx, sing. Ibss. Misce. The two preceding ointments are applicable to cases of tinea capitis, and some eruptive complaints. Also to some kinds of irritable ulcers. UNGUENTUM PICIS CUM SUL- PIIL'RE.—R. Unguenti Picis, Ungu- enti Sulphuris, sing. 51V. Misce.—This is the most common, and, I believe, the most efficacious, application for curing tinea capitis. UNGUENTUM RESINjE FI.A- VjE.—R. Resinx Flavx, Cerx Flavx, sing. lbj. Olei Olivx lbj. Melt the resin and wax with a slow fire; then add the oil, and strain the mixture while hot.—This is a common applica- tion to ulcers, which stand in need of being gently stimulated. UNGUENTUM SAMBUCI.—R. Florum Sambuci, Adipis Suillx, singu- lorum lbj- The hogslard being melt- ed, boil the elder-flowers in it till they become crisp, then strain the mixture. UNGUENTUM SPERM ATIS-CE- TL—R. Spermatis-Ceti gvj. Cerx Al- bx 3'ij. Olei Olivx 5'iij. Melt them to- gether with a slow fire, and then stir them briskly till cold.—This is the common white dressing, so extensive- ly used by surgeons as a simple salve. UNGUENTUM SULPHURIS.— R. Adipis Suillx Ibss. Florum Sul- phuris ^iv. Misce. UNGUENTUM TUTIiE.—R. Tu- tix prxparatx, Unguenti Spermatis- Ceti, q. s. Misce.—Used for smearing the borders and inside of the eyelids, in cases of chronic ophthalmy, &c. UNGUENTUM TUTI.E COMPO- SITUM.—R. Tutix prxparatx, Lapi- dis Calaminaris prxparati, sing. Xv] Camphorx 3ij. Unguenti Sambuci fbj. Misce.—This formula is contained in the Pharmacopoeia of St. Bartholo- mew's Hospital. It may be applied, in some cases, to the inside of the eye- lids; also to piles; certain ulcerations, excoriations, Sec. UNGUENTUM ZINCI CALCI- NATL—R. Florum Zinci 5'j. Ungu- entum Spermatis-Ceti lbj. Misce.— Sometimes used in the same affections ofthe eye and eye-lids, in which the un- guentum hydrargyri nitrati, and the un- guentum ophthalmicum, are employed. UNGUIS. (A Nail.) Some surgical authors have applied this term to a col- lection of pus, or matter in the eye, when the abscess has appeared.through the cornea, to be shaped like a finger nail. UNGULA, (A Hoof.) A collection of matter in the eye, shaped like a hoof. UNION BY THE FIRST INTEN- TION.—When the opposite surfaces of a wound are brought into contact, and grow together at once, without URETHRA. 365 suppurating, union by the first inten- The first progress of the contraction tion is said to have taken place. When is, in general, very slow; but, when wounds heal by suppurating, granulat- once it has so far increased, that the ing, &c. they are sometimes surgically urethra is not wholly relaxed by the described as getting well by the se- force of the urine, its subsequent ad- cond intention. See Wounds. vances are more rapid, and new symp- URETHRA, STRICTURES OF. toms are perceived. The urine is void- Mr. Hunter informs us, that most ob- ed more frequently, does not pass with- structions to the passage of the urine, out a considerable effort, attended with if not all, are attended with nearly the pain, and a straining sensation conti- same symptoms. Few persons take nues, after the bladder is emptied. If notice ofthe first symptoms of a stric- the patient accidentally catches cold, ture, till they have either become vio- drinks a glass of spirituous liquor, acid lent, or other inconveniences have been beverage, or punch, commits an excess the consequences. A patient may have '" drinking wine, or removes quickly a considerable stricture, and yet be un- fr°m a warm to a cold climate, the conscious, that his urine does not free- urine will, perhaps, pass only in drops, ly come away; he may often have, in ?r be entirely obstructed. These causes consequence of a stricture, a tendency induce, in the contracted part, a spas- to inflammation and suppuration in the modic action, by which it is closed. perinxum, without feeling any obstruc- Cold« externally applied to the body, tion to the passage of his urine, or sus- has. so S1"63* an effect upon a spasmodic pecting that he has any other complaint, stricture, that a patient, who can make There are three kinds of strictures; water without the smallest difficulty in viz. the true permanent one, which a warm room> is often quite unable to arises from an alteration in the struc- V0ld a droP> on making the attempt in ture ofa part of the urethra; the mixed the °Pen air- However, on returning case, consisting of a permanent stric- {-? a wur'?ri room, and sitting down a ture and a spasm; and, thirdly, the true llttle while, he becomes able again to spasmodic stricture. exPel his urine. The symptoms of a In all these obstructions, Mr. Hun- stricture are more frequent in persons, ter remarks, that the stream of water who lead a sedentary life, than in becomes small in proportion to the others who lead an active one. (Home.) stoppage; but, though this symptom is Strictures m tbe urethra, being at- probably the first, it is not always ob- tended with a discharge and pain in served by the patient. In some in- making water, especially after any ex- stances, the water is voided only in cess, ai-e frequently regarded and treat- drops, and then it cannot escape notice. ed as a gonorrhoea. These two symp- In other cases, the stream of urine is toms often come on a few hours after forked, or scattered. Under such cir- connexions with women; tne degree cumstances, Mr. Hunter recommends of inflammation is very slight; the dis- the passage to be examined with a charge is the first symptom, and is bougie; and, if one of a common size more violent at the commencement, can be readily introduced, the difficul- than at any other period. The inflam- ty of voiding the urine is likelv to de- mation subsides in a lew days, leaving pend on a diseased enlargement of the only the discharge, which also fre- prostate gland, which should, there- quently disappears m five or six days, fore, be examined. See Prostate Gland, whether any means are employed or The spasmodic stricture may be not, for its removal. (Home.) known bv its being only of temporary What renders a stricture particular- duration.' This kind of case, and more ly apt to be mistaken for a gonorrhoea, particularly the permanent stricture, is the circumstance that, in both dis- are generally attended with a gleet, eases, the pain in making water is ex- The latter complaint is often for a long perienced about an inch and a half while suspected as being the only one, from the orifice of the glans penis. and the surgeon finds all his efforts to In a more advanced stage, the stric- effect a cure fruitless. tured part of the urethra is always In diseases of the urethra, and also much narrower, than the rest of the of the prostate gland and bladder, canal. However, it retains the power there is commonly an uneasiness about of becoming contracted and relaxed. the perinxum, anus, and lower part of In the contracted state, the passage is the abdomen. (Hunter.) closed up; in the relaxed, the urine 366 URETHRA. can pass through it in a small stream. The spasmodic contraction must act with considerable force, ^ince the urine cannot even pass in a small stream, and a small bougie, which, in a relaxed state of the urethra, met with no resistance, can now be scarce- ly introduced at all. Also, if the bougie be allowed to remain for a few min- utes in the stricture, it is not unfre- quently grasped so tightly by the spas- modic contraction, that, when an at- tempt is msde to withdraw it, some force is requisite to succeed. The bou- gie, when examined, seems as if it had liad an impression made round it by a piece of packthread. (Home.) In old cases of stricture, the mus- cular coat of the bladder becomes thickened and stronger, than natural, in consequence of more force being necessary to propel the urine through the obstructed part. The bladder, in this thickened state, does not admit of the usual dilatation, so that the patient is obliged to make water very fre- quently, and he is unable to pass the whole night, without making this eva- cuation once or twice. (Home.) A nocturnal emission of the semen is another very common symptom of a stricture; and some patients seem to have no other complaint attendant on the affection ofthe urethra. A periodical discharge is sometimes brought on by cold, or other occasional causes. The inflammation extends to the bladder; the frequency of making water is very much increased, and the urine very turbid. It is voided for twelve, or twenty-four hours, once, or even twice every hour; and, when al- lowed to stand, it deposits a substance in the form of powder, consisting of coagulable lymph. This is the slight- est kind of attack. Sometimes the bladder is inflamed in a greater degree, and secretes pus, which is discharged with the urine. In a still more violent attack, the dis- charge is similar to the white of an egg, and particularly adhesive. Mr. Home states, that it has been discover- ed by examinations after death, to be the vitiated secretion of the prostate gland. When the inflammation of the bladder becomes still worse, the affec- tion sometimes extends to the perito- neum, and the patient dies. Since strictures of long standing al- ways impede the passage ofthe urine. the bladder acts with augmented force to overcome the resistance. In this manner, the stricture is kept in a con- tinual state of irritation, and made to contract in a greater degree. " In a few cases, indeed, the diseased part of the urethra is rendered quite impervious; and the patient's life is preserved by the urethra ulcerating, at some point within the obstruction, and fistulous openings taking place in the perinxum. See Fistula in Perinao. Strictures are frequently attended with constitutional symptoms, one of the most common of which, in warm climates, is a complete paroxysm of fever. The cold fit is very severe; this is followed by a hot fit, and then a very profuse perspiration. During the ri- gour, nausea and vomiting generally occur, and at this period the patient has occasion to make water frequently, seldom experiencing at the same time any strangury. When the fit is tolera- bly complete, the patient suffers, in general, only one; in the opposite cir- cumstance, two; but, a greater number rarely happen. Such febrile paroxysms are not frequent in cold countries; but do every now and then take place, particularly in consequence of expo- sure to cold, excesses, and the "intro- duction both of common and armed bougies. With regard to the formation of strictures, Mr. Home has noticed, that the membrane ofthe urethra, like eve- ry other muscular structure, is liable to a spasmodic contraction, in which state the canal loses the power of re- laxing itself again, till the spasm is re- moved. This spasmodic stricture is only a wrong action of the urethra; and, if the parts could be examined in their relaxed state, there would be no appearance of disease. A part ofthe urethra, once disposed to become preternaturally contracted, generally becomes more and more af- fected in this manner, and, at last, be- comes permanently narrower. The case now becomes both a permanent stric- ture and a spasmodic one; being so far permanent, that it is always narrower than the rest of the canal, and so far spasmodic, that it may become con- tracted in a still greater degree. When the contraction is not consi- derable, it appears, on examination af- ter death, to be merely a narrowing of the urethra; but, a permanent stric- ture, in a more advanced state, usually URETHRA. 367 consists of a ridge, which forms a pro- jection in the passage. (Home.) Mr. Hunter informs us, that the dis- ease generally occupies no great length ofthe passage; at least, that this was the case in most of the instances, which he had seen. In these the contraction was not broader, than if it had been produced by surrounding the urethra with a piece of packthread; and in ma- ny, it had a good deal of the appear- ance, which one may fancy such a cause would produce. Mr. Hunter states, however, that he had seen the urethra Contracted for above an inch in length, owing to its coats, or internal membrane, being irregularly thicken- ed, and forming a winding canal. A stricture does not always arise from an equal contraction of the ure- thra all round; for, in some instances, the contraction is only on one side. This contraction of one side of the ca- nal only throws the passage to the op- posite side, which often renders the introduction of a bougie difficult The contracted part is whiter, than any other part ofthe urethra, and is harder in its consistence. In some few cases, there are more strictures than one\ Mr. Hunter mentions his having seen half a dozen in one urethra, and he ob- serves, that a stricture is frequently attended with small tightnesses in other parts of the urethra. Mr. Hunter remarks, that every part ofthe urethra is not equally subject to strictures, the bulbous portion being much the most subject to the disease. A stricture is sometimes situated on this side of the bulb, but very seldom beyond it, that is, nearer the bladder. Mr. Hunter never saw a stricture in that part of the urethra, which passes through the prostate gland; and the bulb, besides being the most frequent seat of this disease, is also subject to it in its worst forms. (Hunter.) Mr. Home has measured the length of the urethra in different subjects, and examined the diameters of the se- veral parts of the passage. Strictures, according to this gentleman, occur most commonly just behind the bulb of the urethra, the distance from the ex- ternal orifice being 6£, or 7 inches. The situation, next in the order of fre- quency, is about 4J inches from the orifice of the glans. The disease does also occur at Si inches, and, some- times, almost close to the external ori- fice. The two parts of the urethra, most frequently affected with stric- tures, are naturally the narrowest. Sometimes the very orifice of the ure- thra is contracted, and the circum- stance often leads to an erroneous sup- position, that the whole canal is natu- rally formed of* the same size. The prepuce also is observed to be parti- cularly often affected with a natural phymosis, in persons, who have stric- tures in the urethra. In almost all the cases, which Mr. Home has met with, there has been one stricture, about seven inches from the external orifice, whether there were any others, or not. With respect to the causes of stric- tures, some writers have imputed the disorder to the effects of the venereal disease,and often to the method of cure. Mr. Hunter, however, entertained ve- ry strong doubts, whether strictures commonly, or even ever, proceeded from these causes; though he acknow- ledges, that since most men have had venereal complaints, a refutation of the above opinion is very difficult Mr. Hunter was led to think, that stric- tures did not commonly arise from ve- nereal causes, from reflecting* that strictures are common to most passa- ges in the human body. They often take place in the oesophagus; the in- testines, particularly, the rectum; the anus; the prentice, so as to produce phymosis; and in the lachrymal duct, so as to occasion a fistula lachrymalis. Strictures sometimes take place, when there have been no previous venereal complaints. Mr. Hunter mentions his having seen an instance of this kind in a young man, nineteen years of age, who had had the complaint for eight years, and which therefore began, when he was only eleven years old. He was of a weak, scrophulous habit. Mr. Hunter had also seen a stricture in a boy only four years old, and a fis- tula in perinxo in consequence of it Strictures happen as frequently in per- sons, who have had the gonorrhoea in a slight degree, as in others, who have had it in a severe form. Many believe, that strictures arise from the use of injections in the treat- ment ofthe gonorrhoea; but, Mr. Hun- ter thought, that this opinion was founded on prejudice, and, he states, that he had seen as many strictures after gonorrhoeas, which had been 368 URETHRA cured without injections, as after those, which had been treated with these latter applications. Mr. Hunter also disbelieved the idea, that strictures are a consequence of" ul- cers in the urethra; for, ulcers hardly ever occur in this passage, except when there are strictures. It is now generally admitted, that, in gonorrhoea, no sores exist in the urethra. TREATMENT OF STRICTURES, WITH COMMON BOUGIES, ON THE PRIN- CIPLE OF DILATATION. Mr. Hunter remarks, that the cure of strictures may be accomplished, ei- ther by a dilatation of the contracted part, or a destruction of it by ulcera- tion, or escharotics. The dilatation is ac- complished by means of bougies; but, Mr. Hunter considered, that a cure, thus effected, was seldom or ever more than temporary. The removal of the stricture by ulceration, may also be done with bougies; its destruction with caustic used formerly to be done through a cannula, contrived for the purpose; but, is now performed by means of what are te rmed armed bougies. The cure by dilatation is principally mechanical, when affected by bougies, the'powers of which are generally those of a wedge. However, Mr. Hunter re- marks, that their ultimate effect is not always so simple as that of a wedge up- on inanimate matter: for, pressure makes living parts either adapt them- selves to their new position, or else re- cede by ulceration. Bougies, of course, either dilate strictures, or make them ulcerate. The disease has generally made con- siderable progress, before the patient seeks surgical assistance, and the stric- ture may be so advanced, that a small bougie cannot be made to pass, without a great deal of trouble. If the end of a small bougie, let it be ever so small, can be introduced through the stric- ture, the cure is then in our power. However, a small bougie frequently cannot be passed in the first instance, and even not after repeated trials. Often, when the stricture is very considerable, a great deal of trouble is given by occasional spasms, "which ei- ther resist the introduction of a bougie altogether, or only allow a very small one to pass. At other periods, however, a "targer one may De introduced. In these circumstances, Mr. Hunter men- tions, that he was sometimes able to get the point of a bougie to enter, by rubbing the outside of the perinxum with the finger of one hand, while he pushed the bougie on with the other. The same eminent practitioner also of- ten succeeded by letting the bougie re- main a little while close to the stric- ture, and then pushing it on. Some- times, the spasm may also be taken off by dipping the glans penis in cold wa- ter. Although, in cases of permanent strictures, the bougie may not pass at first, yet after repeated trials, it will every now and then find its way. In this manner, future attempts become more certain and easy. However, the success of the subse- quent trials to introduce a bougie does not always depend on the instrument having been once, or twice passed. Sometimes, it can be introduced to- day; but, not to-morrow; and, in thi9 state, the case shall continue for weeks, notwithstanding every trial we can make. Mr. Hunter observes, however, that, in general, the introduction ofthe bougie becomes gradually less difficult, and, therefore, that we ought not to de- spair of success in any case. When the passage is very small, it is not easy to know, whether the bougie has entered the stricture, or not; for bougies, so slender as those, which must be at first employed, bend so very easily, that the surgeon is apt to fancy, that they are passing along the urethra, while they are only bending. Mr. Hun- ter advises the surgeon to make him- self, at first, acquainted with the situa- tion of the stricture, by means of a com- mon-sized bougie. Then he is to take a smaller one, and, when itspoint arrives at the stricture, the instrument is to be gently pushed forward; but, only for a short time. If the bougie has passed further into the penis, the surgeon may know how far it has entered the stric- ture by taking the pressure off the bougie. For, if it recoil, he may he sure, that it has not passed; at least, has not passed far: but, only bent. On the con- trary, if it remain fixed, and do not recoil, it has certainly entered the stricture. Mr. Hunter informs us, however, that the preceding remarks are not so applicable, when a very small bougie is employed, which may become bent, without our being aware ofthe circum- stance. A bougie may frequently be intro- duced a very little way, for instance, URETHRA. 369 nnlyone tenth of an inch, and then it bends and cannot be pushed further. To determine whether this is the case, Mr. Hunter says, it is necessary to withdraw the bougie and examine its end. If the end be blunted, we may be sure that the bougie has not entered at all; but, if it be flattened, for an eighth, or tenth, of an inch, be grooved, or have its outer waxen coat pushed up to that extent; or, if there be a circular impres- sion made upon the bougie, or only a dent on one side, made by the stricture, we may be sure, that the instrument has passed as far as these appearances extend.lt then becomes necessary to in- troduce another exactly the same size, and in the same manner, and to let it remain as long as the patient can bear it, or convenience will allow. By repeti- tions of this plan, the stricture will be overcome. Mr. Hunter remarks, that the time, which each bougie ought to remain in the passage, must be determined by the feelings ofthe patient; for, if possible, no pain should ever be given. If the pa- tient should experience veiy acute pain when the bougie is passing, it ought not to be left in the urethra above five, or, at most, ten minutes; or, not so long, if the pain be exceedingly severe. Each time of application should afterwards be lengthened so gradually as to be im- perceptible to the feelings of the pati- ent, and the irritability ofthe parts. Mr. Hunter affirms, that, he has known many patients, wbo could not bear a bougie to remain in the passage ten, or even five minutes, till after several days, and even weeks, but, who in time were able to wear the instrument for hours, and this, at last, without any dif- ficulty. The best time for keeping a bougie in the urethra, is when the pati- ent has least to do; or, in the morning, while he is in bed, if he can introduce the instrument himself. Mr. Hunter next observes, that the bougie should be increased in size, ac- cording to the facility, with which the stricture becomes dilated, and the ease, with which the patient bears the dila- tation. If the parts are very firm, or very irritable, the increase ofthe size of the bougie should be very slow, so as to allow them to become gradually adapted to the augmented size of the instrument. But, if the sensibility ofthe parts will allow, the increase ofthe size ofthe bougie may be somewhat quicker but, never more sudden than the pati- ent can easily bear. The surgeon must continue to increase the size of the bougie, till one ofthe largest size can freely pass; nor should the use of this be discontinued till after three weeks, or a month, in order that the dilated part may have time to become habituat- ed to its new position, and lose its dis- position to contract again. However, Mr. Hunter believed, that the perma- nency of a cure, effected on the princi- ple of dilatation, could seldom be de- fended upon. CURE OF STRICTURES BY ULCERA- TION. This is also accomplished by means of a bougie, and the plan may be tried both when the instrument can, or can- not, be introduced through the stric- ture. In the first instance, the method is less proper; because the stricture ad- mits of being dilated. In order to cure a stricture by mak- ing it ulcerate, the bougie is to be in- troduced as far through the con- tracted part as possible, and the size of the instrument is to be aug- mented, as fast as the sensations of the patient can well bear. In this man- ner, ulceration will be produced in the part, which is pressed, and, Mr. Hun- ter remarks, that the cure will be more lasting, because more of the stricture is destroyed, than when the parts are simply dilated. This eminent surgeon notices, however, that few patients will submit to this practice, and that few, indeed, would be able to bear it, since it is apt to bring on violent spasms in the part, attended with a very trouble- some retention of urine. If the smallest bougie cannot be made to pass a stricture, by using some de- gree of force, dilatation becomes im- practicable; and, as the stricture must be destroyed, something else must be tried. In many cases, says Mr. Hun- ter, it may be proper to get rid of the stricture by making it ulcerate, or, in other words, be absorbed. Bougies, in- tended to excite ulceration, need not be so small, as in the foregoing cases, as they are not designed to be passed through the stricture; and, in conse- quence of being of the common size, they may be more surely applied to the parts, causing the obstruction. The force, applied to a bougie, in this case, should not be great; for, a stricture is the hardest part of the urethra; and if a bougie is forcibly pushed on, its end may slip off the stricture, before ulcer- ation has commenced, and make a false Vol. II. 3 A 370 URETHRA. passage for itself in the corpus spongi- osum urethrx. In trying to cure strictures by ulcera- tion, the utmost attention must be paid; and, if the patient does not make water better, notwithstanding the bougie passes further, the surgeon may be sure that he is forcing a false passage. When the stricture has so far yield- ed, as to allow a small bougie to be in- troduced, the treatment is then to be conducted on the princi pie of dilatation. Mr. Hunter observes, that whenevet a bougie, of a tolerable size, passes with ease, and the parts and the pati- ent have become accustomed to it, the surgeon need no longer attend for the purpose of introducing it. The patient may now be allowed to introduce bougies himself; and when he can do this with ease, the business may be trusted to him, as he can make use of the instruments at the most convenient times, so that they maybe, more fre- quently, and longer, applied. In the mean while, the surgeon should only pay occasional visits. Mr. Hunter adds, that, this practice ofthe p..tient, under the surgeon's eve, by which means, the former learns the art of introducing bougies, is the more necessary, since strictures are diseases, which common- ly recur; and, therefore, no man, who has ever had a stricture, and is cured of it, should rely on the cure as lasting; but, should always be prepared for a return, and always have some bougies by him. He should not go a journey, even of a week, without them; and the number should be according to the time, which lie is absent, and the place, to which he is going; for, in many parts of the world, he cannot be supplied with them. To prevent the inconvenience of a bougie slipping out, or the mischief of its gliding into the urethra, a soft cotton thread must be tied round that end of the bougie, which is out ofthe urethra, and then round the root of the glans. This last part of the thread should be very loose. The projecting portion of the bougie should also be bent down upon the penis, by which means, it is rendered less troublesome, and more secure. (Hunter on the Venereal Dis- ease.) When a considerable part of the bougie remains out ofthe urethra, sur- geons usually clip a piece of it off". CURE OF STRICTURES BY THE AR- GENTUM NITRATUM. Wiseman makes mention of the plan of curing strictures in the urethra by means of caustic. He observes, that, when the obstruction is a caruncle, and you cannot pass it, you may well con- clude it is callous: " in which case, you may pass a cannula into the urethra to that caruncle, and, whilst you hold it there stead)-, you may convey a grain of caustic into the cannula, and press the caustic to it; and, whilst you hold it there, you will perceive its operation, bv the pressing forward of the cannu- la"." About the year 1752, Mr. Hunter at- tended a chimney-sweeper who had a stricture. Not finding, that any benefit was derived from the use of common bougies, for a space of six months, Mr. Hunter, unaware ofthe above passage in Wiseman, conceived, that the stric- ture might be destroyed by escharotics, and the first attempt, which he made, was with red precipitate. He put some salve on the end of a bougie, and then dipped it in red precipitate. The bou- gie, in this state was passed down to the stricture; but, Mr. Hunter found, that it brought on considerable inflam- mation all aloi.g the inside ofthe pas- sage, as he thought, in consequence of the precipitate being rubbed off, while the bougie was passing to the stricture. Mr. Hunter then introduced a silver cannula down to the stricture, and passed the bougie with precipitate, as before, through the tube. As the pa- tient, however, did not make water any better, and the smallest bougie could not be introduced through the stricture, he suspected that the precipitate had not sufficient power to destroy the ob- struction. Mr. Hunter was, therefore, induced to fasten a small piece of the argentum nitratum on the end of a piece of wire with sealing-wax, and in- troduce the caustic through the cannu- la to the stricture. After having made the application three times, at intervals of two days, he found, that the man voided his urine much more freely, and, on applying the caustic a fourth time, the cannula went through the stricture. A bougie was introduced for a little while afterwards, till the man had completely recovered. URETHRA. 371 Having experienced such success in the foregoing example, Mr. Hunter was encouraged to apply his mind to the invention of some instrument, bet- ter suited to the purpose, than the above contrivance. He succeeded in devising an improved instrument, al- though he acknowledges, that it was not perfectly adapted to strictures in every situation in the urethra. He re- marks, that the caustic should be pre- vented from hurting the unaffected part ofthe urethra by introducing- the active substance, through k cannula, down to the stricture; and it should be capable of protruding a little beyond the end ofthe cannula, by which means it will only act upon the stricture. The caustic should be fixed in a small port- crayon, and it is necessary to have a piece of silver ofthe length ofthe can- nula, with a ring at one end, and a but- ton at the other, ofthe same diameter as the cannula. The button forms a kind of plug, which should project beyond the end of the cannula in the urethra, so as to make a rounded end; or, Mr. Hunter says, the portcrayon may be formed with this button at its other end. The cannula, with the button, is to be passed into the urethra, and when it reaches the stricture, the silver plug should be withdrawn, and the portcray- on with the caustic introduced in its place; or if the plug and portcrayon are on the same instrument, then it is only necessary to withdraw the plug, and introduce the portcrayon with the caus- tic. The plug, besides giving a smooth rounded end to the cannula, answers another good purpose, by preventing the tube from being filled with the mu- cus of the urethra, when the instru- ment is passing inward, which mucus would be collected in the end of the cannula, dissolve the caustic too soon, and hinder its application to the stric- ture. When the stricture was beyond the straight part of the urethra, Mr. Hun- ter owned, that it was difficult to ap- ply caustic to the disease through a cannula. A better mode of applying lunar caustic to strictures, was afterwards devised by Mr. Hunter, and has since been extensively introduced into prac- tice by Mr. Home. This gentleman di- rects us to take a bougie of a size, that can be readily passed down to the stric- ture, and to insert a small piece of lu- nar caustic into the end of it, letting the caustic be even with the surface, but surrounded every where laterally by the substance of the bougie. This should be done some little time before it is required to be used; for, the ma- terials, of which the bougie is compos- ed, become warm and soft by being handled in inserting the caustic; and, therefore, the hold, which the bou- gie has of the caustic, is rendered more secure after the wax has been al- lowed to cool and harden. The bougie, thus prepared, is to be oiled and made ready for use; but, before passing it, a common bougie of the same size is to be introduced down to the stricture, in order to clear the canal, and to measure the exact distance of the stricture from the orifice ofthe urethra. This distance being marked upon the armed bougie, it is to be passed down to the stricture, as soon as the other is withdrawn. The caustic, in its passage, is scarcely al- lowed to come into contact with any part of the membrane, because the point of the bougie, of which the ar- gentum nitratum forms the central part, always moves in the middle line ofthe canal; and, indeed, the quickness, with which it is conveyed to the stric- ture, prevents any injury of the mem- brane lining the passage, when the caustic accidentally touches it. In this mode, the caustic is passed down with little, or no irritation to the lining ofthe urethra, it is applied in the most advantageous manner to the stric- ture, and can be retained in that situa- tion sufficiently long to produce the de- sired effect. The reasons, urged in favour of the employment of bougies, armed with the lunar caustic, are: that a permanent cure is effected, which common bou- gies cannot accomplish; that the pain arising from the application of the ar- gentum nitratum to the stricture, is very inconsiderable; and that neither pain, nor inflammation are found to en- sue. The meaning of these remarks, however, is to be received as a general one, liable to exceptions. Indeed, Mr. Home himself has candidly acknow- ledged, that some inconveniences oc- casionally follow the use of armed bou- gies. But, what practice, however ju- dicious and eligible, is altogether free from occasional ill-consequences? Mr. Home remarks, that against treating strictures of the urethra with caustic ",7-1 I'RETHRA. bougies, numerous objections have been adduced, and many bad conse- quences have been attributed to the practice, without any real foundation; " for, whatever, d priori, might be supposed the effects of so violent an ap- plication, to a membrane so sensible and irritable, as the urethra, and I will admit, that it is very natural to conceive they would be very severe, the result of experience, the only thing to be re- lied on, evinces the contrary. The pain, that is brought on, is by no means vio- lent; and neither irritation, nor inflam- mation, is found to take place. " That cases do occur, in which strictures have produced so much mis- chief, and rendered so great an extent ofthe canal diseased, that the use of caustic has proved unsuccessful, is cer- tainly true; and several of these cases have fallen within my own knowledge. But, when it is stated, that none, even of these, were made worse by its use; that no bad consequences attended it; and that no other mode, at present known, is equally efficacious; any occa- sional want of success, cannot be con- sidered as an objection to this mode of practice. " But if the apprehension of violent effects from the caustic, however ill- founded, cannot be removed, let the al- ternative be considered; namely, the only operation previously in use, where a stricture cannot be dilated by the bougie. " In those cases, we are obliged to have recourse to means certainly more severe and violent, laying open with a "knifethe diseased urethra, and passing through the divided parts a flexible gum catheter into the bladder. This I have done myself, and have frequently $een it performed by Mr. Hunter, and it always succeeded; neither bringing on so much inflammation as was ex- pected, nor being attended with any symptoms of irritation. " This practice has by other surge- ons been carried still further; the por- tion of diseased urethra has been dis- sected out, and entirely removed; nor bas so severe an operation always brought on untoward symptoms; and patients have recovered. " If the membrane of the urethra when diseased, is capable of suffering so much injury, without any conse- quent symptoms of irritation, it cannot be doubted that it will bear with impu- -nity to be touched, in a very partial manner, several different times witju lunar caustic." Mr. Home afterwards informs us, that, " having met with a number of facts, from which a general principle appears to be established, that the irri- table state of a stricture is kept up, and even increased, by the use ofthe bou- gie, but lessened and entirely destroy- ed by the application of lunar caustic; I am desirous to communicate my ob- servations upon these facts, and to re- commend the use of the caustic, in many cases of irritable stricture, in pre- ference to the bougie. " As the use of tbe caustic, upon this principle is, I believe, entirely new, and is contrary to every notion, that has been formed upon the subject, it will require something more, than general assertion, to gain even the at- tention of many of my readers, still more their belief; I shall therefore de- tail the circumstances, as they occur- red, by which I conceive the propriety of this practice, to be established; and afterwards make some observations up- on the principle on which it depends. " My connexion in practice with Mr. Hunter, afforded me oportunities of attending to cases of stricture, in all their different stages; many of them brought on during a long residence in India, attended with great irritability, and exceedingly difficult of cure. " One case of this kind (which Mr. Home has related) admitted the pas- sing of a small bougie, but, in the course of three years, very little was gained by a steady perseverance in the use of that instrument, either in dilat- ing the canal, or palliating the symp- toms of stricture; this made me look up- on the bougie as less efficacious, than I had always been taught to believe it.— I was willing, however, to consider this as an uncommon case, depending more on the peculiarities of the pati- ent's constitution, than on the nature of the disease: but, I found, on a particu- lar inquiry, that several other gentle- men, from India, were under circum- , stances nearly similar; the bougie only preventing the increase ofthe stricture, but being unable to dialate it beyond a certain size; and when it was left off, the stricture in less than two months returned to its former state of contrac- tion. " What plan ought to be followed in such cases, I was then unable to deter- mine; but, that the bougie could not be URETHRA. S7S depended on was evident. During this suspense, the following case came un- der my care. " In August, 1794, a gentleman con- sulted me for some symptoms, which had been considered as indicating the presence of gonorrhoea; but, as they did not yield to the common treatment in the usual time, he was induced to take my advice respecting the nature of his complaint. In the necessary inqui- ry', to obtain a perfect history of the case, among other tilings it was stated, that, nineteen years before, there was a stricture, which became very trouble- some, and that Mr. Hunter, by the de- sire of the patient, had applied the caustic, by which the stricture was re- moved, and never afterwards returned. He said, that he was one of the first persons, on whom the caustic had been used. From this account, I was natu- rally led to believe, that the stricture had gradually returned, and was now increased so much as to produce the present symptoms; a discharge being almost always a symptom of stricture, when it is much contracted: but, upon examining the canal, a bougie of full size, passed on the bladder without the smallest impediment I therefore took up the case as au inflammation in the urethra; and large doses ofthe balsam copaiva, given internally, effected a cure. " The circumstance of a stricture having been removed nineteen years before, and not returning, made a strong impression on my mind; and made me desirous to ascertain, whe- ther this practice could be employed in cases of stricture in general, and the cure produced by it, equally perma- nent. A short time afterwards, I had an opportunity of trying it in the following case. " A captain in the East-India Com- pany's service, in September, 1794, ap- plied to me for assistance. His com- plaints were, great irritation in the ure- thra and bladder, constant desire to make water, and an inability to void it, except in very small quantities.— These symptoms had been at first sup- posed to arise from gonorrhoea, after- wards rendered more severe by catch- ing cold; but, not yielding to the usual remedies for gonorrhoea, they were in- vestigated more minutely, and a stric- ture was discovered in the urethra. The mode of treatment was now chang- ed, and the bougie employed; but, its use aggravated all the symptoms, and brought on so great a degree of irrita- bility on the bladder and urethra, that there was an alarm for the patient's life, which was the reason for applying for my assistance. " Besides the local symptoms, this patient had those of quick pulse, white tongue, hot and dry skin, loss of appe- tite, a total want of sleep, with frequent attacks of spasm on the bladder and urethra. A very small flexible gum ca- theter was passed, and the water drawn off, in quantity about a pint, which gave him great relief; this was repeated morning and evening, to keep the bladder in as easy a state as possible; but, in other respects, he con- tinued much the same. " As the present symptoms were brought on by the use of the bougie, little good was to be expected from that instrument; and where the urethra had been so easily irritated, and was dis* posed to continue in that state, there Was no prospect of the use of the bougie afterwards effecting a cure. These circumstances I explained to the patient; and mentioned, in proof of my opinion, the case, in which so little had been effected in three years. " I then proposed to him a trial of the caustic, with a view to deaden the edge ofthe stricture, as the only proba- ble means of effecting a cure. The de- gree of irritation was already great; I was, however, led to believe, that the application of the caustic was not likely to increase it; since, by destroying the irritable part, it might lessen, and even remove the spasmodic affection; but if, contrary to my expectation, the irrita- tion continued, we still should be able to draw oft' the water, as the slough formed by the caustic would prevent the edge of the stricture from acting, and obstructing the instrument. " The application of the caustic was, upon these grounds, determined on: and it was applied in the following manner. " I passed a common bougie, nearly the size ofthe canal, down to tbe stric- ture, to ascertain its exact situation, and to make the canal of the urethra as open as possible. The distance was then marked upon a bougie armed with caustic, of the same size, which was conveyed clown as quickly as the na- ture of the operation would admit. It was retained upon the stricture, with a slight degree ofprcssure; at first, there 374 URETHRA. was no pain from the caustic, but a soreness from pressure; in less than a minute, a change was felt in the sensa- tion ofthe part; it was at first a heat, succeeded by the burning pain peculiar to caustic; as soon as this was distinctly felt, the bougie and caustic were with- drawn, having remained in the urethra about a minute altogether. The sore- ness, he said, was entirely local, by no means severe, was unaccompanied by irritation along the canal, and he thought the uneasiness in the bladder diminished by it. He described the pain as resembling very, exactly the first symptoms of gonorrhoea. This sen- sation lasted half an hour after with- drawing the bougie. " The caustic was applied about one o'clock in the forenoon, and he passed the day more free from irritation than he had been since the beginning of the attack, which had lasted six days. In the evening, the water was drawn off, with more ease, than the night before. He passed a tolerable night, and, the next day, continued free from irritation. On the third day, the caustic was again applied in the forenoon; the painful sen- sation was less than on the former ap- plication, lasted a shorter time, and in an hour after the armed bougie was withdrawn, he made water freely for the first time since the commencement of his indisposition. He said the irrita- tion in the bladder was removed, and he felt very well. His appetite return- ed, he slept very well, and continued to void his urine with ease. " In this state, nothing was done till the fifth day, leaving always a day be- tween the application of the caustic. " On this day a common sized bougie went readily into the bladder; it was immediately withdrawn, and the cure was considered as complete; no bougie was afterwards passed, lest it might bring back an irritation upon the pas- sage. I met this gentleman twelve months after, and he assured me, he had continued perfectly well, and I have since learned, that in three years, there has been no return. " From the result of this case, I was encouraged to hope that the caustic might be applied to strictures in the urethra with more confidence, than I had hitherto believed, since it evident- ly did not bring on, or increase the ge- neral irritation, but, on the contrary, seemed to allay it." The foregoing case, together with another one, which Mr. Home has re- lated in his book on tbe present sub- ject, convinced this gentleman, that he had discovered an effectual mode of treating such strictures, as do not ad- mit of being relieved by the common bougie. Hence, he adopted the use of armed bougies, as a general prac- tice; but, he has not concealed the cir- cumstances, under which the method has not proved successful. Mr. Home informs us, that " In some constitu- tions, where the patients have resided long in warm climates, every time the caustic is applied to a stricture, a regu* lar paroxysm of fever, called by the pa- tient an ague, takes place; and this has been so violent as to render it impossi- ble to pursue this mode of practice. Of this I have met with two instances. I consider this disposition to fever, as the effect ofthe climate, and not of any na- tural peculiarity of constitution; for the brother of one of these patients labour- ed under the same disease, but as he had not been in warm climates, it was removed by the caustic without his ex. periencing such attacks. In gouty constitutions, attacks ofthe gout have in two instances brought on spasmodic constrictions, after the stric- ture had been removed by caustic. This, however, cannot be called a fai- lure of the caustic. It only shows, that gout can affect strictures, and re-pro- duce them. " In some patients, the strictures are so obdurate, that the use ofthe caustic is necessary to be continued for a longer time, than the parts can bear its appli- cation, or even that of the bougie pass- ing along the urethra; irritation there- fore comes on and stops the progress ofthe cure, and when the same means are resorted to again, the same thing takes place. The cases of failure of this kind that I have met with, some of which may yet ultimately be cured, if the patients will take the necessary steps for that purpose, amount in all to six. " In some patients, the stricture is readily removed by the caustic, but, in a few weeks, contracts again. The stricture being wholly spasmodic, the caustic, by taking off'the spasm, is al- lowed to pass through, and cannot com- pletely destroy the stricture. Of this kind, I have met with one instance, which I must consider as a failure, as I have hitherto been unable to get the better of it. URETHRA. 3f5 " In those cases, where the caustic gradually removes the stricture, and brings the urethra to a size, that al- lows the patient to make water per- fectly well, if there is any return, it is not to be attributed to the failure of the caustic, but to the want of proper management, either from the caustic being too small, or its use left off too soon; but, all such cases are, I believe, witlun the power of being cured by the caustic, if its use is recurred to wiien that is found necessary." For the generality of strictures in the urethra, which certainly do not » occupy more extent of the canal, than if caused by a piece of packthread be- ing tied round it, the bougies, armed with the lunar caustic, should be pre- ferred. But, there are instances, in which the urethra is diminished in diameter, for an inch or more: in these cases, I cannot help considering the employment of common bougies most advantageous, that is to say, when they can be introduced through the stricture, so as to cure it on the prin- ciple of dilatation. We shall conclude this part of the subject of strictures, with inserting some of the general directions given by Mr. Home how to arm the bougie, and apply the lunar caustic to stric- tures. In arming a bougie, it will be diffi- cult to get a piece of caustic of a pro- per shape and size for the purpose, un- less it be cast in a small cylindrical mould. " In this state (says Mr. Home) it is to be procured from Mr. Savigny, instrument-maker, in King- street, Covent-Garden; and, if these pieces are thicker, than the bougie can readily enclose, by putting them in water, the outside qiuckly dissolves, so as to diminish their size, as much as is required. The piece of caustic, so prepared, is to be cut into small por- tions, about a quarter of an inch in length, and an orifice being made in the end of a bougie, the caustic is to be inserted into it, and the bougie rolled, so as to be made perfectly smooth, taking care, that the sides of the caus- tic are every where covered, and only the end exposed. "This (continues Mr. Home) was the mode, in which I armed bougies, when I first took up this practice; but, h/ happened, that, in two or three in- stances, the caustic was left in the urethra; that canal, when in a very ir- ritable state, grasped the bougie, and pulled the caustic out; I was there- fore led to consider how such an acci- dent might be prevented, and appfied to the makers of* bougies for that pur- pose. Mr. Pass, the beadle ofthe Sur- geons' company, who deals in bougies, discovered a very ingenious and effec- tual mode of 'securing the caustic. In forming the bougie, a piece of wire, the size of the caustic, is rolled up along with it, passing into the sub- stance for half an inch; when the bou- gie is nearly finished,^the wire is with- drawn, and the caustic inserted in its place; after this, the bougie is rolled again, so that the sides of the caustic become firmly cemented to the linen, by means of the composition of the bougie, and when cold, cannot be se- parated by any force. In this way bou- gies are now generally armed. " After the bougie has been thus prepared, the distance of the stricture from the external orifice is to be mea- sured, and the canal cleared by pass- ing a common bougie, fully as large as that which is armed. The armed bou- gie, with the distance marked upon it, is then to be introduced, and applied to the stricture; when it is brought in contact with the obstruction, it is to be steadily retained there, with a mode- rate degree of pressure at first, and less as it is longer continued, since the bougie becomes soft by remaining in the urethra, and readily bends, if the pressure is too great. The time it is to remain depends a good deal upon the sensations of the patient, and the length of time the parts have bee.i dis- eased; but on the first trial, it should be less than a minute, as it then com- monly gives greater pain than on any subsequent application. The pain pro- duced by the caustic is not felt so im- mediately as it would be natural to ex- pect; the first sensation arises from the pressure ofthe bougie on the stric- ture; a little after, there is the feeling of heat in the parts; and lastly, that of pain. " As soon as the caustic begins to act, the surgeon, who makes the ap- plication, is made sensible of it by the smaller arteries of the parts beating with unusual violence, which is very distinctly felt by the finger and thumb, that grasp the penis. " The pain that is brought on by the caustic, lasts for some time after it is withdrawn; but this period differs in 3r6 URETHRA almost every patient, being sometimes extended to half an hour, and some- times only a few minutes. " The kind of pain is heat and sore- ness, which is not severe, not being accompanied by the peculiar irritation, upon so many occasions experienced by patients who have strictures; an ir- ritation that cannot be described, which is most insupportable, and is too often brought on by dilating strictures with the bougie. After the caustic has been withdrawn, it is desirable, that the patient should make water before be uses exercise, as the parts are com- monly more tranquil after having done so; but sometimes no water will flow at the first effort. When that is the case, it should not be urged, as it is not of any material consequence. It happens not unfrequently, that at the first time of making water, some blood passes along with it. This is rather fa- vourable; as, when the parts bleed, the stricture usually proves to be so far destroyed, that at the next trial the bougie passes through it. Every other day, appears in general to be as often as is prudent to apply the caustic. I have, however, done it every day, in very obstinate cases, where the parts are less sensible, without any detri- ment " The bougie, which is passed down to prepare the way for the caustic, and measure the distance for the armed bougie, must b.- made of soft materials, that it may readily receive an impres- sion from the part against which it is pressed, and its colour should be light, so as fo admit of those impressions be- ing more distinctly seen. With the as- sistance of such bougies, I am able to discover the size and shape of the ori- fice ofthe stricture; to ascertain witli accuracy the progress of the caustic upon it; to see whether it is on one side of the canal, or equally all round; and to apply the caustic accordingly. " When the soft bougie passes through the stricture, by leaving it in the canal a few minutes it can be known whether the stricture is com- pletely destroyed or only relaxed; in the last case, there is an impression on the side ofthe bougie. " So necessary is the information which is acquired in this way, to ena- ble the surgeon to prosecute the cure of stricture by means of the caustic, that without it I should have been una- ble to pursue this mode of practice. I should have wanted a sufficient degree of confidence to carry me on, which nothing but an accurate knowledge of what had been already done, could have given, and, in no other way, is that to be acquired." (Home on Stric- tures.) CURE OF STRICTURES BY THE KALI PURUM. Mr. Whately, in his publication on strictures, has endeavoured to show, that they are not merely contracted fibres ofthe urethra, but really diseas- ed portions of the membrane lining that canal, with a continued disposition to increased contraction. Hence, this gentleman seems to conceive, that the application of a remedy, calculated both to remove the diseased affection, and to dilate the contracted part, might perfectly cure the complaint, without putting the patient to the in- convenience of wearing a bougie. Mr. Whately affirms, that such a remedy is caustic, when judiciously used. Hith- erto the lunar caustic has been chiefly employed; but, this gentleman states, that it has been his good fortune to discover a more efficacious, and, at the same time, a less painful and hazard- ous remedy for the disease in ques- tion. The kali purum is the applica- tion alluded to, which Mr. Whately says, if used in the manner, and with the precautions about to be described, will be found to possess singular effi- cacy in curing the complaint. He avows, that he has already had so much experience of it, and that he is so perfectly convinced of its superiority over the lunar caustic, as well as over the common bougie, that he now uses it in a considerable number of the ca- ses, which come under his care. Of its safety he is also as well convinced as of its efficacy; for, if used with circum- spection, experience shows, that there is little danger of its producing any disagreeable effect. However, if the kali purum be ap- plied while the parts are in a highly inflamed, or irritable state, or (as Mr. Whately adds) tending to gangrene; if the habit be bad, and the patient very far advanced in years; we may ex- pect the most mischievous effects from the application; and this practitioner censures the use of any kind of caustic under such circumstances, for stric- tures in the urethra, as dangerous i.i the extreme. URETHRA. 377 Mr. Whately represents, that if the patient be affected with fever, or any other acute disease; if he be much in- disposed from any cause; if, in pailicu- lar, he have a gonorrhoea, attended with much inflammation and irritation in the urethra; if the prepuce, glans, or any other part of the penis, or the parts adjoining to it, be swelled and in- flamed; if the urethra, and especially, the strictured part of it, be so irritable, as not to bear the touch of a bougie; the use ofthe caustic is for the present forbidden. Mr. Whately also enjoins great caution in applying this remedy to persons advanced in years. Even when no objections of the above kind exist, tiie caustic should not be resort- ed to in the first instance. Mr. Whate- ly maintains, that in every case of stric- ture, before venturing to employ the caustic, we ought to be able to pass into the bladder a bougie, of at least a size larger, than one ofthe finest sort. This is necessary, both to enable us to apply the caustic to the whole surface ofthe stricture, and to relieve a reten- tion of urine, should it occur during the use ofthe caustic. When a bougie ofthe preceding de- scription can be introduced, without occasioning pain, faintness, or great dejection of spirits, the use of caustic may commence immediately, when none ofthe above-described objections exist. When the urethra is very irritable, Mr. Whately recommends a common bougie to be introduced every d^y, and kept in the urethra; at first, for a few minutes only; but, by degrees, for a longer time; till the irritability of the parts has been sufficiently lessened. When the urethra is rendered so impervious by a stricture, that a small bougie cannot be passed into the blad- der, which viscus is also in a painful inflamed state, Mr. Whately asserts, that caustic, in any form, or quantity, must not be immediately employed;' but, that the stricture should be first rendered capable of allowing a bougie a little larger, than one of the finest size, to be introduced into the bladder. When this is done, the urine is more freely evacuated, and the consequent irritttion and inflammation ofthe blad- der lessened, if not removed, together with the danger of a retention of" urine. Caustic may then be advantageously conveyed into the centre of the stric- ture. Mr. Whately considers the practice of at once thrusting down, in this sort of case, an armed bougie, considerably larger than the narrowest part of the contracted canal, as most dangerous, and horridly painful. For, says this gentleman, it frequently happens, that nearly the whole of the urethra ante- rior to the bulb, is so much contracted by numerous and uncommonly rigid strictures, that, it is impossible, by any art whatever, to dilate the pas- sage to its natural size. If, therefore, the canal, whilst in such a state, be rudely torn open by a large caustic bougie, hemorrhage, pain, dangerous suppressions of" urine, inflammation, mortification, and death itself, must sometimes inevitably ensue,—even be- fore the caustic can be applied to the principal seat of the disease. In cases, like the one just mentioned, the first step, preparatory to the use of the caus- tic, should be, according to Mr. Whate- ley, to dilate the strictured part ofthe urethra; for which purpose, he advises the slow and gentle introduction of a fine bougie, with its point inclined to the lower side ofthe canal, in order to avoid the large lacunx, situated on its upper part. When the surgeon, by stea- dy perseverance and dexterity, has suc- ceeded in getting a fine bougie through the worst stricture into the bladder, the instrument should be worn, for a few hours, every day, till the passag« is sufficiently dilated to admit a larger one. Mr. Whately, after explaining, that the kali purum ought not to be applied to strictures of the urethra, till a bou- gie of a proper size can be passed into the bladder; after having pointed out the methods to be taken, before apply- ing this caustic; and enumerated cer- tain cases and circumstances, in which its employment is interdicted; next proceeds to describe the mode of prac- tice fc which it is the particular object of his book to recommend. For the purpose of arming a bougie, Mr. Whately advises us to put a small quantity of kali purum upon a piece of strong paper, and to break the bit of caustic with a hammer into small pieces of about the size of large and small pins' heads. In doing this, cue should be taken not to reduce it to powder. Thus broken, it should be kept for use in a phial, closed with a ground «,'.;>;:per. The bougie should have a proper degree of curvature giv- Voi.. II. 3B 378 URETHRA. en to it, by drawing it several times be- tween the finger and thumb ofthe left hand. Mr. Whately next acquaints us, that before the caustic is inserted into the bougie, it is necessary to ascertain the exact distance of the stricture, (to which the caustic is to be applied) from the extremity of the penis. For this purpose, tiie bougie, which should be just large enough to enter the stricture with some degree of tighness, ought to be gently introduced into the ure- thra; and when its point stops at the stricture, which it almost always does, before it will enter it, a notch is to be made with the finger-nail, on the upper or curved portion of the bougie, on the outside of the urethra, ex ctly half an inch from the extremity of the penis. When the bougie is withdrawn, a small hole, about the sixteenth part of an inch deep, should be made at the extremity of its rounded end. A large blanket-pin two inches and a half in length, with the head*struck off, will answer the purpose; the hole being made with the point of the pin. The extremity ofthe bougie should then be made perfectly smooth with the finger and thumb, taking care, that, in doing this, the hole in its centre be not closed. Some of the broken caustic should then be put on a piece of writing-pa- per, and a piece less in size, than the smallest pin's head, should be selected; the particle, indeed, says Mr. Whate- ly, cannot be too smail for the first ap- plication. Let this be inserted into the hole ofthe bougie with a pocket-knife, spatula, or some such instrument; and pushed down into it with the blunt end ofthe pin, so as to m.ike the caustic sink a very little below the margin of the hole. To prevent the kali from com- ing out, the hole should then be con- tracted a little wiih the finger, and the remaining vacancy in it is to be filled •with hogslard. This last substance (continues Mr. Whately) will prevent the caustic from acting on the sound part ofthe urethra, as the bbugie pas- ses to the stricture. When the bougie is quite prepared, let it be first oiled, and immediately afterwards introdu- ced, by a very gentle motion, with the curvature upwards, as far as the ante- rior part of the stricture, upon which the caustic is to be applied. In doing this, the end ofthe bougie, that is held by the finger and thumb, should be a good deal inclined towards the abdo- men, on the first introduction ofthe in- strument, in order to preserve its cur- vature. After it has passed about five inches, this end should be gradually brought downwards, as the bougie passes on, till it forms a right angle with the body. The bougie is known to have arrived at the stricture by the resist- ance made to its progress. As soon as the bougie has reached the anterior part of the stricture, it sliould rest there for a few seconds, that the caustic may begin to dissolve. It should then be pushed very gently forward, about one eighth of an inch; after which, there should be another pause for a second, or two. The bougie should then be carried forward in the same gentle manner, till it has got through the stricture. The sense of feeling will generally inform the opera- tor when the point of the bougie has proceeded so far; but, the notch in the bougie is to be an additional guide, by becoming very near the orifice of the urethra, when the end of the instru- ment has just got through the stric- ture. The bougie should now be immedi- ately withdrawn by a very gentle mo- tion to the part, at which it was first made to rest awhile. Then it should be very slowly passed through the stric- ture a second time; but, without letting the bougie stop in its passage. If the patient complain of pain, or be faint, the bougie should be immediately with- drawn, but, if these effects are not pro- duced, we may repeat the operation of passing and withdrawing the bougie through the stricture once or twice more, before we finish the operation, which will take up, in the whole, about two minutes. The first application of the kali pu- rum, in this manner, gives, according to Mr. Whately's account, a very little pain. A slight scalding in making wa- ter, and a trifling discharge, duringthe first day or two, however, are common- ly produced. At the end of seven days, the appli- cation ofthe caustic is to be repeated in the same manner. When the first application has enlarged the aperture of the stricture, which may be known by passing a bougie through it, ofthe same size as that by which the caustic was conveyed, the bougie, used in the second operation, should be a size larger, than the one, used in the first; but it mus; not be too large to pas? URETHRA. through the stricture. If the patient had no pain on the first application, the bit of kali purum may also be trivially larger. At the end of seven da\s more, the armed bougie should be introduced a third time. At this, and all future ap- plications, the bougie should be in- creased in size, in proportion as the aperture in the stricture becomes di- lated. The quantity of caustic, how- ever, is never to be increased in a ra- tio to the size of the bougie In no eases whatever, does Mr. Whately ap- ply more of the kali purum at a time, than a piece about the size of a com- mon pin's head. Twelve bits of the largest size, which this gentleman ever uses, weigh one grain. When there are several strictures, the kali purum should be generally ap- plied to only one at a time. An interval of seven days is what Mr Whately generally allows to elapse between the application of the caustic. The rule, however, may now and then be deviated from; but, the kali purum ought never to be reapplied till the action of the last application has com, pletely ceased. In a few instances, the interval may only be five days; in some others, it may be eight, nine, or even a longer space. In the above method of using the kali purum, Mr. Whately represents, that this substance is equally diffused over every part of the strictured sur- face, and only abrades the membrane ofthe stricture, without producing a slough. The degree of this, abrasion, he says, may be increased, or lessened, as circumstances dictate, by paying atten- tion to the quantity of the caustic. The foregoing account will suffice for conveying an adequate idea of Mr. Whately's method. I am sorry I can- not add my favourable opinion of the practice. To abrade, without destroy- ing, is to me perfectly unintelligible. Nor can I conceive, that a liquid caus- tic (for so it is represented as becom- ing) can be applied with the accuracy to strictures, which Mr. Whately seems to suppose happens. The gene- rality of strictures are also like such mere contractions, which one may sup- pose would be produced by tying a piece of packthread round the urethra. For these, the lunar caustic bougies seem best; and, when the stricture oc- cupies some extent of the passage, common bougies are the most eligible. The works, which contain the chief 879 information on the subject, wliich we have just been treat'ng.f are: A Trea- tise on the Venereal Disease, by John Hunter; Practical Observations on the Treatment of Strictures in the Urethra and (Esophagus, by Everard Home, in 2 vols.; An improved Method of treating Strictures in the Urethra, by Thomas Whately, edit. 2- 1806. URETHRA, FALSE PASSAGE IN. One of the worst consequences of using catheters, and bdugies, in an improper manner, is the rupture ofthe urethra, or the formation of a false pas- sage by ulceration. With bougies, this accident is generally occasioned by trials to excite ulceration by the appli- cation ofthe ends ofthe bougie to the stricture, when this instrument cannot be passed through it. When once the new passage has formed, whenever the bougie is introduced, it cartnot be hin- dered from going into the false track, and its action on the stricture is alto- gether frustrated. Mr. Hunter has advised the follow- ing operation to be practised in this kind of case. Pass a staff, or any such instrument into the urethra, as far as it will go, which will probably be to the bottom of the new passage, and this, we may be certain, is beyond the stric- ture. Feel for the end of the instru- ment externally, and cut upon it, mak- ing the wound about an inch long, if the disease be before the scrotum; and an inch and a half, or more, if in the perineum. If the new passage be be- tween the urethra and body of the pe- nis, you will most probably get into the sound urethra, before you come to the instrument, or new passage. If so, in- troduce a probe into the urethra, through the wound, and pass .it to- wards the glans penis, or, in other wordi, towards the stricture. When it meets with an obstruction, this must be the stricture, which is now to be got through, and afterwards dilated. To complete the operation, withdraw the probe, and, instead of it, introduce a hollow cannula forwards to the stric- ture. Then introduce another cannula from the ghms downwards, till the two tubes are opposite each other, having the stricture between them. An assist- ant is now to take hold of the urethra on the outside, with his finger and thumb, just where the two cannulx meet, in order to keep them in their places. Through the upper cannula next introduce a piercing instrument, 380 URINE, INCONTINENCE OF. which is to perforate the stricture, and enter the lower cannula. The piercing instrument is now to be withdrawn, and a bougie introduced through the first cannula and stricture, into the se- cond cannula. The tubes are to be with- drawn, and the end of the bougie, in the wound, directed into the bladder, through the further portion ofthe ure- thra It may also be necessary to lay the whole ofthe false passage open, in order to make it heal; for otherwise, it might still obstruct the future passage of bougies into the proper canal. When the i^ew passage is between the skin and urethra, the surgeon must extend his incision more deeply, for the purpose of finding out the natural pas- sage. Then he is to proceed as above exph ined. The longer the first bougie is allow- ed to remain in the canal, the more readily will the second pass. The bougies must be gradually increased in size, and used till the wound is healed. The only improvement, which seems proper to be made in this plan, is to emplov hollow bougies, or flexible gum catheters, which might be worn longer than common bougies, as the patient could void his urine through them. (See Hunter on the Venereal Disease.) URINE, INCONTINENCE OF.— This complaint is quite the reverse of a retention of urine; for, as in tbe latter affection, the urine is continually flow- ing into the bladder, without the pati- ent having the power to expel this fluid, go in the former, the urine flows out, without the patient being able to pre- vent the occurrence. An incontinence of urine may origi- nate from several causes. 1. From the irritation ofthe neck ofthe bladder by stones. 2. From a paralysis of the sphincter vesicx, while the contractile power ofthe muscular coat ofthe blad- der remains in its natural state. 3. From laceration ofthe parts in the extraction of large stones, and a consequent para- lysis of the sphincter after the wound has healed. 4. From tiie injury, which the parts suffer from pressure in diffi- cult labours. When an incontinence of urine pro- ceeds from an irritation of the neck of the bladder by a stone, it can only be ra- dically cured by the operation of litho- tomy; though great relief maybe given by mifcilaginous and anodyne medi- cines; particularly, when given in the form of injections. In the other two cases, in which it is occasioned by a paralytic affection ofthe sphincter, we can only attempt the cure by such me- dicines as are proper in other paralytic cases, viz. the Peruvian bark, chaly- beates, the cold bath, and other tonics; but, of all topical remedies, cold appli- cations to the perinxum are found to be the most effectual. The most powerful remedy of this kind is to dash cold wa- ter upon the part; though it is some- times found useful to apply cloths dip- ped in vinegar and water, or a solution of saccharum saturni, in the acetous acid. When no relief can be obtained by the above proposed remedies, we must then have recourse to some mechanical method of compressing the urethra, and thus preventing the continual drib- bling ofthe urine, which must always be very disagreeable. A very proper in- strument for this purpose is called nju- gum, or yoke. It ought to be lined with silk or velvet; and, by means of the screw, the pressure may be made greater or lesser at pleasure. For wo- men, *Kve must make use of pessaries. These must be made of sponge, only of such a size as to be easily admitted, and, before it is introduced, it must be moistened with the finest olive oil, which, according to Mr. Latta, most effectually prevents it from becoming so soon troublesome by excoriating the vagina. Pessaries, made of wood, can never be used in cases of this kind with effect; for, in placing them in the va- gina, so as to compress the neck ofthe bladder, it is obvious they must at the same time press upon the rectum, and, on that account, prevent the natural passage of the feces. In some particu- lar cases, even these palliative reme- dies prove ineffectual; for, when the disorder proceeds from an irritation on the neck ofthe bladder, the patient has such a continual desire to make w^ter, that it is impossible to bear any con- finement of it. We can then only em- ploy proper receptacles for collecting it as it flows. In women these can only be by pieces of sponge, applied external- ly, and kept in that situation with a T bandage; but in men, other contrivances may be employed. In the Medical Observations, we have some surprising instances of the efficacy of blisters in removing this complaint. A girl of thirteen years of age, who, for four years, had been able to retain her water only a very short URINE, RETENTION OF, 381 time in the day time, and not at all dar- ing the night, was cured in twenty- four hours by the application of a blis- ter to the os sacrum A man, thirty- two years of age was attacked by this disease, accompanied with a palsy of the lower extremities, in consequence of having taken some vindent quack medicines, probably ofthe mercurial, or arsenical kind. In twenty-four hours after the application * of a blister to the os sacrum, he was able to retain his water for an hour, and in a week after, for two hours. In about a month, he was able to retain it for five hours, and at last, obtained a perfedt cure. He also recovered in some degree the use of his limbs, which were paralytic. The like good effects were produced on a wo- man of fifty, in whom the disease had been brought on by f: strain. In her it was likewise accompanied with a pal- sy ofthe lower extremities, and of this too she got the better. In a woman of forty-three, in whom the disease seems to have come on without any evident cause, the cure wras accomplished, al- most during the time that the blister was rising. In a young man, who had been attacked with the dise se, after lifting a heavy load, a cure was accom- plished in sixteen days A man of forty- four years of age, who had been at- tacked by the disease, without any evi- dent cause, was in the like manner cu- red on the first application of a blister. This man had likewise symptoms of a diabetes; but, the blister had no effect in removing them. A boy, ten years of age, had violent complaints in the uri- nary passage, whiflti were supposed to proceed from an ulcer. " When about to make water, he was obliged to put himself in a prone posture, and then his urine generally came away by drops, with exquisite torture. At length it began to come aw y insensibly dur- ing the night;" but, by application of a blister, this incontinence was removed in less than forty-eight hours, the other symptoms remaining as they were. In all these cases, the blisters were very large, covering not only the os sacrum, but, extending from side to side. (Lat- ta's System of Surgery, vol. 2-) URINE, RETENTION OF. Mr. Hey has very truly remarked, that a re- tention of urine in the bladder, when the natural efforts are incapable of af- fording relief, is, in male subjects, a disease of great urgency and danger. Persons, advanced in years, are more subject to this complaint, than those. who are young, or middle-aged. It is often brought on by an incautious re- sistance t. the calls of nature; and, if not speedily relieved, generally excites some degree of fever. It is sometimes attended with aeon. sider.ible degree of fever, and an in- flammatory affection of the bladder, which terminates in a discharge of pu- rulent matter, and a fotul hectic. The distinction, says Mr. Hey, which has sometimes been made, between a suppression and retention of urine, is practical and judicious. The former most p. operly points out a defect in the secretion of the kidneys; the latter, au inability of expelling the urine when se- creted. The retention of urine is, an inability, whether total or partial, of expelling, by the natural efforts, the urine contain- ed in the bladder. The characteristic symptom of this disease, previous to tiie introduction of the catheter, is a distention ofthe bladder (to be per- ceived by an examination ofthe hypo- gastrium), after thp patient has dis- charged all the urine, which he is ca- pable of expelling. As this complaint may subsist, when the flow of urine from the bladder is by no means totally suppressed, great caution is required to avoid mistakes on this subject. Violent efforts to make water are of- ten excited at intervals, and, during these strainings, small quantities of urine are expelled. Under these cir- ■ cumstances, the disorder may be mis- taken for the strangury. At other times, a morbid retention of urine subsists, when the patient can make water with a stream, and dis- charge a quantity equal to that, which is commonly discharged by a person in health. Under this circumstance, Mr. iky has known the pain in the hypo- gastrium, and distention ofthe bladder, continue, till the patient was relieved by the catheter. And lastly, it sometimes happens, that when the bladder has suffered its utmost distention, the urine runs off by tbe urethra, as fast as it is brought into the bladder by the ureters. Mr. Hey has repeatedly known this circum- stance cause a serious misapprehen- sion of the true nature ofthe disease. In every case of retention of urine, which this gentleman has seen, the dis- ease might be ascertained by an exami- nation of the hypogastrium, taken in connexion with the other symptoms. :>Si2 URINE, RETENTION OF. The distended bladder forms there a hard and circumscribed tumour, giving pain to the patient when pressed witi the hand. Some obscurity may arise up- on the examination of a very corpulent person; but, in all doubtful cases, the catheter should be introduced. Mr. Hey mentions, that he has seen but a few cases ofthe ischuria renalis, or complete suppression of" the secre- tion of urine by the kidneys. The dis- ease proved fatal in all his patients ex- cept one, in whom it was brought on by the effect of lead, taken into the body by working in a pottery. It subsisted three '-ys, during a violent attack of the coliea pictonum, and was then re- moved, together with the original dis- ease. Mr. Hey found no difficulty in distinguishing this disorder, in any of the oes, from the ischuria vesicolis, though, for the s-itisf.'ctiou of some of his p.:'it; ts, he introduced the cathe- ter. (Practical Observations in Surgery, p. 374, c.Vc.) Ischuria, or retention of urine, may be the effect of a great many different causes. We shall proceed to take no- tice ofthe causes, which age produced by a paralysis ofthe bladder; by inflam- mation of its neck; by foreign bodies in it; by pressure made on it by the gravid uterus; by enlargement of the prostate gland; and by strictures in tiie urethra. 1. Or THE RETENTION OF URINE CAUSED BY A PARALYSIS OF THE BLADDER. This complaint, to which persons. advanced in life are particularly sub- ject, may occur in subjects of any age, in consequence of a violent concussion ofthe spinal marrow, or (what is very common) if, after having taken a large quantity of drink at a time, a person should neglect to obey the calls of na- ture, and hold his urine too long. I; is also observed to be a symptom of cer- tain typhoid fevers, and, consequently, too great attention cannot be paid to the state ofthe bladder in such disorders. The retention of urine is easily ascer- tained to exist by the prominence, which it forms above the pubes; a pro- minence, which may be readily distin- guished by its elasticity and circum- scription from til* general tension of the abdomen, so common in this dis- ease. A retention of urine may either come on in a gradual or sudden man- ner. In the first sort of cace. it begins by a kind of debility, which hinders the patient from completely emptying his bladder, so that, after having made water, he still feels an inclination to repeat the evacuation, and is com- pelled to make frequent efforts to do so. This inconvenience gradually in- creases; at length, none of the urine can be discharged; and the biadder rises higher than the pubes, above which part it forms a round circum- scribed tumour, the size and elasti- city of which are more or less consi- derable. . In the second kind of case, or that which occurs suddenly, the retention ofthe urine is the first symptom which the patient experiences, and his blad- der becomes filled, and distended, in the same manner, as in the preceding case. iVIust frequently, the swelling, which this viscus forms, is at first not very painful, but, afterwards becomes very much so. Some patients make frequent efforts to expel their, urine; others are more tranquil. This state lasts two, or three days, after which the urine begins again to escape from the urethra, sometimes by drops, sometimes in a stream, but, almost al- ways, at the will of the patient. In some instances, as much urine is void- ed, as the fluid, which is drunk; yet, notwithstanding this, the bladder con- tinues to be distended with urine, and to form an elevation above the pubes. This circumstance has frequently led practitioners into error, and some of them have even mistaken the swelling of the hypogastric region for an ab- scess. Collot mentions, that, in his time, this mistake ruippened very fre- quently, and that such supposed ab- scesses would have been often opened, had not the patients warned their me- dical attendants of the erroneous opi- nion. M. Sabatier informs us, that he was consulted about a woman, who had been advised to resort to the min- eral waters, with a view of dispersing a tumour, which had occurred in con- sequence of a difficult labour, and which swelling was supposed to be si- tuated m the uterus. The tumour, however was nothing else, than the bladder, distended with an accumula- tion of urine, since it disappeared as soon as a catheter was introduced. No suspicion hr.d been entertained of the real na ure ofthe case, in consequence of the patient having voided her urine URINE, RETENTION OF. 383 in a voluntary manner, and reasonable quantity, for five or six weeks, during which time the swelling had existed. M. Sabatier makes mention of a case, inserted in a thesis by Dr. Mur- ray, from wliich it appears, that the swelling of the bladder may become so considerable as to lead to mistakes of a still more serious nature. A deli- cate woman found her abdomen swell without any apparent cause, and with- out experiencing any inconveniences. She imagined, that she was pregnant. However, she was soon undeceived by the rapidity, with which her abdomen continued to enlarge, and by the consi- rable degree of anarsaca affecting her lower extremities. The latter affection extended also to the arms, and face. The patient was considered to be drop- sical; and a surgeon was sent for to tap her. The fluctuation of a fluid in the abdomen was quite evident. Some diuretics were prescribed, before hav- ing recourse to the operation. While such remedies were put to a trial, the patient complained of having had a to- tal retention of urine for three days; a symptom, which she had not previous- ly suffered. The belly was elastic, and the veins on it were every where swol- len. It was judged prudent to intro- duce a catheter, before employing the trocar. The surprise was very great when eighteen pints of urine were drawn of, and the swelling of the ab- domen subsided. The next day, the catheter drew off"twelve more pints of urine. The anasarca, which was en- tirely symptomatic, disappeared. The application of cold water re-establish- ed the tone of" the bladder, so that, when three pints of urine had been drawn off by means of the catheter, the patient herself could spontaneous- ly expel three or four others, with the aid ofsome degree of pressure on the hypogastric region. Dr. Murray en- deavoured to ascertain, whether the woman got completely well; but, he could not trace this circumstance. The retention of urine, produced by a paralysis of the bladder, and the Swelling, which this viscus occasions above the pubes, may continue for a long while, without patients feeling any other inconvenience, than a sense of weight about the region of the pubes, and the frequent inclinations to make water, which accompany this State. M. Sabatier mentions his having seen patients, who had been attacked by the complaint for more than six months". The disorder may be relieved by in- troducing a catheter into the bladder, by which means the urine has an op- portunity of escaping. For an account of the manner of introducing this in- strument, see Catheter. It is not enough to empty the blad- der, care must be taken to prevent the urine from accumulating again, and, consequently, the catheter, according to some, must be left introduced. Others are of opinion, that it is better to pass the instrument whenever the patient has any occasion to make wa- ter. According to Desault and Mr. Hey, the bladder regains its contrac- tile power soonest, when the catheter is introduced as often as occasion re- quires, instead of being allowed to re- main continually in the urethra. When the retention of urine has lasted a considerable time, when the hypogastric region is painful, and the patient is feverish, venesection may be performed, and, in all cases, diluent beverages, of a slightly astringent na- ture, are to be prescribed. The intes- tines are to be emptied with glysters, and the regimen is to be regulated by the condition, in which the patient happens to be. For a certain length of time, things remain in this state. When the urine flows from the catheter in a rapid stream, which is projected to some distance, and when it also passes out between the catheter and the urethra, it is a sign, that the bladder has re- gained its power of contraction, and that it can empty itself, without the aid ofthe instrument. In this circum- stance, the catheter is to be taken away, and the patient may gradually resume his occupations and usual mode of life. When the urine only es- capes through the catheter, and in a slow stream, the employment of this instrument is always requisite, and its use cannot be discontinued, without hazard of the bladder becoming dis- tended again, and losing whatever de- gree of tone it may have recovered. However, a catheter cannot be suffer- ed to remain in the bladder, more than twelve days, or a fortnight. Some per- sons have in their urine so much mucus and earthy matter, that an incrustation would not i'ui to take place on fhe in- 384 URINE, RETENTION OF. strument, if care were not taken, every now and then, to withdraw it and clean it. In other persons, the pres- sure, which the catheter makes on the part of the urethra, corresponding to the root of the penis, in front of the scrotum, occasions in this situation an inflammation, which ends in mortifica- tion, so that a slough about as large as a crown, takes place, followed by an opening with loss of substance, wliich opening remains fistulous during the remainder of the patient's life. The latter inconveniences do not attend the employment of flexible gum-ca- theters. The time, which the bladder takes to regain the power of contracting, varies considerably in different cases. When the disease is accidental and sudden, it frequently goes off'in a few days. When it has come on in a slow manner, it usually lasts about six weeks. The cure, however, is not to be despaired of, if the paralytic affec- tion of the bladder should continue much longer. M. Sabatier says, that he has seen patients wear a catheter upwards of ninety days, and yet ulti- mately get completely well. When there is reason for believing, that the urine will come away of itself, the use ©f the catheter may be discontinued, grct attention being paid to the state of the patient. When he makes water very slowly; when he is obliged to make frequent attempts; and when he feels a sense of weight about the neck of the bladder; this viscus has not re - covered the whole of its tone, and the employment of the catheter is still ne- cessary. Sabatier states, that he has often successfully recommended the catneter to be worn only in the night- time, when the patient could make water tolerably well in the day, and experienced the above complaints in the night. When three or four months elapse, without the urine resuming its ordina- ry course, Sabatier informs us, that, we may be sure, that the tone of the bladder is lost for ever. In this unfor- tunate case, all that can be done is to advise the patient to make continual use of a flexible catheter, which he should be taught to introduce himself, whenever he has occasion. (See De la Medicine Operatoire par Sabatier, tom. Among the means deserving of trial, when the contractile power of the bladder does not return with the use of the catheter, I have to mention the tincture of cantharides; blisters ap- plied to the sacrum, and kept open with the savine ointment; and cold washes to the hypogastric region. 2. OF THE RETENTION OF URINE, OCCASIONED BY INFLAMMATION OF THE NECK OF THE BLADDER. This case makes its attack with the most urgent symptoms. Besides the inclination to make water, and the ef- forts, which such inclination causes, the patient is affected with a swelling of the Bladder above the pubes, a deep-seated pain in that viscus and all the neighbouring parts. Fever, nausea, vomiting, aurinaiysmell in the breath, and perspiration, great restlessness, a difficulty of breathing, convulsions, and death, are the train of evils, which may ensue. The present kind of retention of urine demands the employment of the antiphlogistic plan of treatment; par- ticularly, of bleeding, diluent emol- lient beverages, glysters, the warm bath, and anodynes. When these are unavailing, the catheter should be re- sorted to, and its use should never be deferred so long, as to afford any chance ofthe distention ofthe bladder occasioning a paralysis of this viscus. When the catheter cannot be intro- duced, the operation of puncturing the bladder is immediately indicated. See Bladder. 3. OF THE RETENTION OF URINE, OCCASIONED BY FOREIGN BODIES IN THE BLADDER. Several kinds of extraneous matter may be lodged in the bladder; for in- stance, stones, worms, pus, blood, &c. Here, we shall only treat ofthe reten- tion of urine, originating from the pre- sence of stones, or of blood, because these causes are the most frequent. One, or more stones in the bladder give rise to particular symptoms, ex- plained in the articles Calculus and Li- thotomy. They seldom occasion a total retention of urine. If such a case were to present itself, it might be easily un- derstood by preceding circumstan- ces. The compl tint might be relieved, and this, perh;.;)s, for a considerable time, by introducing a sound, which v, ould push the stone away from the URINE, RETENTION OF. 585, «ck of the bladder, towards the fun- dus of this viscus. Instances are not uncommon, in which the patients, after having been tormented by the lodgment of stones in the bladder, became af- terwards quite free from all kind of un- easiness. Sabatier makes mention of a clergyman, who was sounded by a very skilful surgeon, and who finding him- self afterwards free from the pains, which he before suffered, thought, that the surgeon had been mistaken, when he said, that there was a stone in the bladder, and that lithotomy ought to be performed. The patient also bequeath- ed his body for dissection to this surgi- cal practitioner, in order that the lat- ter might reap instruction from the ex- amination. The surgeon accepted this odd legacy; and, when the body was opened in the presence of numerous spectators, a large stone was found in the bladder. Blood may descend from the kidneys into the bladder; or it may accumulate in this latter receptacle, in consequence of some injury, or ulceration of its in- ner coat. When the blood remains in a fluid state, it may be voided almost as easily as the urine itself. But, when it coagulates, the clots, which are form- ed, may obstruct the neck ofthe blad- der, and occasion a retention of urine; a case, which is the more alarming, as the collection of blood generally cannot be drawn off by means of a catheter. However, one of a very large size should be introduced, in order to try whether the thing is practicable. When this method fails, authors advise a sy- ringe to be fastened on and adapted to the outer end ofthe catheter, by which means the blood and urine are to be sucked, as it were, out of the bladder. Sabatier states, that this plan has been practised with success, in cases, which seemed almost desperate. 4. OF THE RETENTION OF URINE, CAUSED BY THE PRESSURE OF THE GRAVID UTERUS ON THE BLAD- DER. Such pressure often occasions a diffi- culty of making water, and a retention of urine. Women relieve themselves by leaning down on their knees and el- bows, in which position, the uterus makes less pressure on the neck ofthe bladder. Some introduce one, or two fingers into the vagina, and push the uterus upward. Others must have the catheter introduced, particidarly, about the period of parturition. When there are no other impediments to the pas- sage ofthe catheter, than the cause of the disease, the instrument may easi- ly be introduced. When, however, the course of the meatus urinariu- is rendered crooked, either in consequence of an old prolap- sus uteri, or ofthe pressure occasioned during labour, the urine can only be drawn off" by means of a catheter, with a rounded end, which instrument should be first introduced with its han- dle as much towards the belly as possi- ble, after which, this part of the instru- ment is to be brought downward by a semicircular motion. (Sabatier Medir cine Operatoire, torn. 2, p. 137.) 5. OF THE RETENTION OF URINE, CAUSED BY THE ENLARGEMENT OF THE PROSTATE GLAND. When the swelling of the prostate gland is of an inflammatory kind, the retention of urine makes its appearance by symptoms, which always attend an inflammation of the neck of the blad- der. This affection sometimes ends in an abscess, which bursts of itself. Some writers have considered about the pro- priety of making an incision into tbe suppurated gland; but, such a proceed- ing, perhaps, can never be at all justifi- able, or prudent. The diseased enlargement of the prostate gland has been treated of in another part of this Dictionary. See Prostate Gland. The retention of urine, occasioned by this disease, begins with a difficulty of making water, just such a kind of difficulty, as occurs when the bladder has been deprived of some of its contractile power, and receives re- lief from the use of slightly diuretic be- verages. When the complaint becomes more urgent, and the urine cannot be any longer evacuated, the introduction of a catheter becomes indispensable. Although this operation is, in every respect, perfectly easy of accomplish- ment, it is not always attended with the desired success. The catheter pas- ses in as far as it can; but the urine is not discharged, because the end ofthe instrument, according to Sabatier, be- comes entangled in the prostate gland, or between a swollen portion of this gland and the neck ofthe bladder, and does not reach to the situation of tbe urine. Hence, Sabatier recommends Vol. II. 3 C 386 URINE, RETENTION OF. tbe employment of a catheter with a very long beak. From the account, how- ever, which we have delivered of the al- teration produced in the course of the urethra by the morbid enlargement of the prostate gland,(see Prostate Gland,) it appears, that the canal in question generally makes, in this case, a sudden turning upward, just before it ap- proaches the bladder, consequently, when a catheter has its end bent a little more upward, than usual, it is best adapted for passing into the bladder, in the affection under consideration. When the surgeon has succeeded in introdu- cing a catheter, it is to remain introdu- ced, till the bladder has recovered its tone, or contractile power, just as was recommended in the case of paralysis of this viscus. When, however, all efforts to pass a catheter are quite ineffectual, the only remaining resource is to punc- ture the bladder above the pubes. (See Bladder, Puncture of.) The operation should never, in this case, be done through the perinxum, or rectum, as the very great size, which the diseased prostate gland sometimes attains, would be an obstacle to making a punc- ture in either of these situations. Punc- turing the bladder, however, is only a temporary means of relief, unless this organ recovers its contractile power, or the surgeon succeeds in introducing a catheter through the urethra. When neither of these circumstances occurs, the cannula of the trocar must not be withdrawn. The objections, which immediately present themselves to leaving in the cannula, for any considerable time, are: the irritation of the extraneous body; the fear of calculous incrustations form- ing bqth on the outside, and inside of the cannula; and the hazard of* not be- ing able to find out again the track into the bladder, when the instrument is ever withdrawn. However, Sabatier confirms, that the cannula may some- times be successfully allowed to remain in the bladder. Collot adduces two in- stances, in which he found this method very serviceable. Sabatier also refers to another example of similar success, related in a thesis by Murray. An inci- sion had been made above the pubes, in order to be more easily able to in- troduce the trocar into the bladder. The wound inflamed, suppurated, and was in a healing state; but, as the urine could not be voided through the ure- thra, the cannula was left in the punc- ture. Things had gone on in this man- ner, more than a year, when Dr. Mur- ray saw the patient. The man was six- ty years of age, and enjoyed very good health. He was in the habit of taking a stopper out ofthe cannula, every four hours The wound had healed very well all around the tube, and was quite free from redness.^-(Sabatier, Medi- cine Operatoire, tom. 2. p. 140.) 6. OF THE RETENTION OF URINE PRODUCED BYSTRICTURES IN THE URETHRA. From the account, which is given of strictures in another part of this Dic- tionary, (see Urethra, Strictures of,) it appears, that almost every stricture, how bad soever it may be, is capable of being rendered still worse, and the morbid part of the urethra, more im- pervious, by a spasmodic affection. Go- ing out of a w;.rm into a cold situation, drinking, and other kinds of intempe- ranee, will often bring on an irritable state ofthe canal, attended with a spas- modic action of the strictured part, an increased difficulty of voiding the urine, and even a total retention of this fluid. The patient makes repeated efforts to relieve himself; but hardly a drop, of urine is discharged. In the mean while, the bladder becomes fill- ed, and ascends above the pubes; the abdomen grows tense and painful; fe- ver comes on; the countenance looks red; the brain becomes affected; and circumstances assume an extremely urgent appearance. In this case, antiphlogistic means should be adopted, without delay. The patient ought to be bled, if nothing in his constitution and age prohibits this evacuation, which it may even be pro- per to repeat He should also be' pat into the warm b.lh, and fomentations should be continually applied to the hypogastric region. Slightly diuretic beverages may be prescribed; and leeches put on the perinxum. The principal means, however, from which the greatest benefit may be expected, is a liberal dose of the tinctura opii, together with aiT anodyne glyster. When such measures fail in enabling the patient to em, ty his bladder, and this viscus is becoming more and more distended, an immediate attempt should be made to introduce a small flexible eLstic gum-catheter, through the stricture or strictures into the Mad- UTERUS, INVERSION OF 387 der, which object may be frequently accomplished, when due care, perse- verance, and gentleness are not ne- glected. Sometimes when a small flexible ca- theter cannot be introduced, a fine bougie admits of being passed into the bladder, and, on being withdrawn, the urine follows, and is discharged. When all the preceding plans prove unavailing, and the danger arising from the retention of urine continues to increase, the only remaining resource is to puncture the bladder.The cannula ofthe trocar should then be left in the wound, till the strictures are either cured, or at least till the urine seems to resume its natural course through the urethra. Useful information on the subject of retention of urine, may be found in De la Medicine OpSratoire, par Sabatier, tom 2. Hey's Practical observations in Surgery. Desault's Parisian Chirurgical Journal. Home's Practical Observations on the treatment of Strictures, t/c. vol. 3, 1804. UTERUS, INVERSION OF. This case may either be complete, or incom- plete. VVhen it is incomplete, only the fundus ofthe uterus passes through the os tincx. When the inversion is com- plete, the uterus becomes entirely turn- ed inside out, passing through the opening in its cervix, dragging along with it a part of the vagina, and de- scending more or less far down, some- times even between the patient's thighs. The inversion of the uterus mostly arises from the manner, in which the placenta is extracted after delivery. Just after parturition, the parietes of the uterus have not had time to become contracted, and the mouth of this viscus is as capacious as it can possibly be. It is easy of comprehension, how it may happen, that, when things are thus dis-. posed, the uterus may follow the after birth, which is attached to the parietes of this organ, and thus become invert- ed. This event is particularly liable to happen; 1st, When a premature at- tempt is made to extract the placenta. 2dly, When the funis is pulled out- ward, without any care being taken to support the uterus by the fingers ofthe left hand. 3dly, When the operator draws the after-birth outward in too rough and forcible a manner. It is true, that the placenta is sometimes so adhe- rent, that its extraction is veiy difficult and some risk must be encountered of dragging down the uterus with it. However, this unpleasant occurrence may generally be avoided by taking care to separate the placenta, by introducing one's fingers into the cavity of the ute- rus. The inversion ofthe uterus, follow- ing parturition, should not always be ascribed to unskilfulness on the part of the practitioner. The accident fre- quently happens, notwithstanding eve- ry precaution to prevent it, either be- cause the patients make too violent ef- forts to deliver themselves; or because the uterus is enlarged and heavy; or else in consequence of some natural disposition in the uterus, which dispo^ sition can neither be foreseen, nor pre- vented. Ruysch has seen an inversion of the uterus take place, after the expul- sion ofthe placenta, although the deli- very had occurred in the most favoura- ble way. This disposition is very com- mon in persons, who have once been af- flicted with an inversion of tiie uterus. Am and makes mention of a case, in which a woman, who had had an inver- sion of the uterus in her first delivery, and who had been cured of it by this practitioner. The same patient was at- tended by Amand again in her next ac- couchement, and another inversion of the uterus, quite as bad as the first, would certainly have happened, had not Amand, on perceiving the disposition to the accident, introduced his finger into the cavity of the uterus, in order to separate the placenta from its attach- ments, before making any attempt to extract it. Besides the causes of the inverted uterus, which are connected with par- turition, there are some others, wbich have no concern, with it whatsoever. Ruysch, Mauriceau, and Lamotte, were of opinion, that the inversion of the uterus could only happen at the time, when the placenta was extracted or a little while afterwards. The occur- rence seemed to them quite impossible at any other period, both because the substance of the uterus is very thick and solid, and its mouth is very con- tracted. However, Sabatier remarks, that there are many facts, wliich prove, that this disease may depend on in ternal causes, and that it may affect women, who have had no children, as well as others, who have had them. Polypi ofthe uterus are causes of this kind. As their pedicle is attached to 388 the fundus ofthe uterus, and is very firmly inserted into it, they may easily drag it downward, when its texture is lax and soft, particularly, as their action, arising from their weight, is continual and uniform. We may also reckon among the causes, the hemor- rhages, to which women are subject, both because they relax the texture of the uterus, and because they are usual- ly attended with an acute pain, which makes the diaphragm and abdominal muscles contract, and act upon the ute- rus with all t'.eirpower. When an inversion of the uterus takes place after delivery, there are symptoms, by which it may easily be known. The uterus, when in its natu- ral situation, presents itself in the hy- pogastric region in the form of a round circumscribed tumour; but, when it has fallen downward, and become in- verted, the above tumour cannot be found, and, a vacancy may be felt in the situation, which it ought to occupy. When the inversion is incomplete, an examination with the fingers detects in the vagina a tumour, shaped like the segment of a sphere, having a smooth surface, and being surrounded with the cervix uteri, with a kind of collar, round which the finger may easily be passed, either between the kind of cob lar and the uterus, or between the col- lar and the vagina. When the inversion of the uterus is complete, there is in the vagina, and sometimes quite pro- truded, a tumour, apt to bleed, of an ir- regularly round shape, with a smooth surface, and hanging by a neck, which is surrounded by the above circular, thick, fleshy, substance, consisting of the os uteri itself. In the incomplete inversion, patients feel acute pain in the groins, and kidneys, an oppressive sense of heaviness in the hypogastric region, and a tenesmus, which compet- ing them to make violent efforts, forces the uterus down more and more, and produces a total inversion of it To such symptoms are often added hemor- rhages, which are more or less copious. But, when the inversion is complete, the pain is more acute, the loss of the blood more considerable, and the pati- ent is often affected with peculiar weakness, which is frequently follow- ed by cold sweats, convulsions, and de- lirium. The reduction of the uterus is the only metiiod, by which the above de- scribed sufferings can be appeased, and UTERUS, INVERSION OF- it ought to be put in practice the more quickly, in proportion to the urgency of the symptoms. When these are pressing, the least delay may be fol- lowed by the worst consequences.— Some women, indeed, perish in a few hours, and when they live longer,the reduction becomes exceedingly diffi- cult, because the uterus and its cervix are continually becoming more and more contracted. Sabatier censures the advice to put some linen between the hands and the uterus, in making the reduction, as an unnecessary measure, and one, which bereaves the operator of the informa- tion to be derived from the organ of touch, relative to the progress ofthe operation. The manner of proceeding can hardly be determined by any pre- cepts. It must be regulated by existing circumstances; and the trial should not be abandoned, as long as the patient's strength will allow a perseverance. —Perhaps, however, if the tumour should be in an inflamed state, it might be prudent, before attempting to re- duce it, to take away blood, put the pa- tient in the warm bath, use emollient applications, exhibit anodyne medi- cines, &c. When the inversion of the uterus is complete, and the reduction has not been accomplished in due time, an en- deavour must be made to quiet the spasms and pain arising from the acci- dent, and the surgeon must await what nature will do for the patient. Many die; while others survive, subject to an oppressive sense of weight, and fre- quent hemorrhages, which bring on great emaciation. Sabatier informs us of his having seen two patients, who had had an inversion of the uterus, during six months, and who were still able to go about their family affairs* The same author says, he has heard of some other persons, who have had an inversion ofthe uterus several years. One of the most afflicting conse- quences, which may result from an in- version ofthe uterus, is so considerable an inflammation of the part, as to in- duce a danger of its mortifying. In this circumstance, some have proposed to extirpate the uterus; an operation however, that has not been attended with any degree of success, as the ma- jority of patients, on whom it has been practised, have died. However, there are instances recorded of women hav- ing recovered after such an operation. UTERUS, PROLAPSUS OF. 389 Vieussens has related a case of this kind, in which a ligature was applied round the neck of the swelling, and the part below amputated. The practice of extirpating the in- verted utems, through apprehension of the part mortifying, however, cannot be reprobated in terms too strong. The only alleged reason for having recourse to the operation is the very consider- able degree of inflammatory swelling, which affects the part. But, it is not al- together impracticable to bring the uterus into a state again, in which the inconveniences, arising from its inver- sion, would be very supportable, so that an operation might be avoided, which is always attended with extreme danger. Even supposing mortification were to take place, the indication would be to appease the bad symptoms, and promote the separation of the sloughs by suitable applications. Rousset has recorded an example, in which the lat- ter mode of practice was adopted with success. Some writers have not been content with advising the extirpation of the uterus, when it is entirely inverted, very painful, and irreducible, in conse- quence of the contracted state of the cervix of this organ; but, they have al- so thought such a proceeding proper in cases of a complete prolapsus, when the partis much swollen and inflamed. Instances have been adduced, illustra- tive of the success of this operation. However, it is now generally thought, that most of these examples are inva- lid, as polypi, growing from the uterus, frequently attain so considerable a size, that they protrude out of the vagina, so as to have occasionally been mistaken for the uterus itself. These have been extirpated with a ligature with most beneficial consequences to the patient. There is no doubt, however, that, in a few instances, the uterus has been amputated, and the patient has reco- vered. Although it is easy to distinguish the inversion ofthe uterus, which hap- pens soon after delivery, it is not so to make out the nature of such cases, as happen in other circumstances, not- withstanding the presence of the same kind of symptoms. As cases ofthe lat- ter kind are exceedingly uncommon, and, consequently, they are not at all expected, mistakes are the more liable to be made. A very little attention suf- fices for discriminating an inversion of the uterus from a polypus, with which it has sometimes been confounded. In short, the pedicle of a polypus is al- ways narrow; the tumour is not very sensible, and is irreducible; whereas the uterus forms a scmi-epherical swelling, sometimes a little ' oblong, but, always broader above, than below. It is very sensible, and may be easily reduced. The reduction of the inverted uterus is also the only step, which can be tak- en, whether the weight has arisen from the weight of a polypus, or from hemorrhages. However, this proceed- ing is generally useless, when the dis- ease originates from obesity. In the latter case, as the cause still continues in full force, it in general soon dis- places the uterus in the same way, as before, and a pessary is the only means, to which the patient can resort. This instrument is to be worn, rather with a view of supporting the weight ofthe abdominal viscera, which pushes the uterus down into the vagina, as well as the fundus, through the cervix of the womb, than with any design of pre- venting the inversion. (Sabatier, Me- dicine Operatoire, tom. 2.) UTERUS, POLYPI OF. See Poly- pus. UTERUS, PROLAPSUS OF. This may take place in three different de- grees. When the prolapsus occurs on- ly in its first or second degree, the uterus is situated in the vagina, where may be felt a pyriform tumour, round which it is easy to pass the end ofthe finger. At the lower part of this tu- mour, an opening, placed transversely, may also be distinguished. In the first, or slightest degree, the uterus is situ- ated higher up, than in the second. When the disease has proceeded to its third, or last degree, the uterus is completely protruded out of the vulva. In the latter circumstance, it always drags down the vagina, which becomes doubled on itself, and it also draws down a part of the bladder, wliich is connected with the upper part of the latter tube. It also sometimes happens, that some of the abdominal viscera in- sinuate themselves into the kind of cul-de-sac, formed by the vagina, and they then considerably increase the. size ofthe tumour. The swelling, oc- casioned by a complete prolapsus of the uterus, is of an oblong, nearly cy- lindrical form, and it terminates below in a narrow extremity, in which a Q90 UTERUS, PR( transverse opening, the os tincx, may be discerned, from which the menses are discharged at the periods pre- scribed by nature. The cylindrical shape ofthe tumour is the more apt to lead to mistakes, as the vagina, being doubled on itself, and exposed to the effects of the air, sometimes assumes an appearance, very similar to that of the skin. Hence, women, afflicted with a complete prolapsus uteri, have some- times been regarded as hermaphro- dites, in consequence of the tumour having been mistaken for a penis. Sa- viard has recorded an instance, in which this kind of error was made. The inconveniences, arising from the first and second degrees of prolapsus •uteri, arc a sense of heaviness in the pelvis, and a degree of uneasiness in the kidneys. These complaints are aggravated, when the patient sits up, or walks about. On the contrary, they diminish, and even entirely subside, wheh the patient has remained a cer- tain time in bed. The symptoms, attending a com- plete prolapsus uteri, are of a more se- vere nature. The patient experiences a greater sense of heaviness in the pel- vis, and pain and dragging in the loins. She is troubled with tenesmus, and sometimes feels acute pain in the tu- mour itself, which is subject to in- flame, and ulcerate, in consequence of its depending posture, the friction, to which it is exposed, and the irritation ofthe urine, as this fluid runs over it. The uterus, when only affected with the first, or second degree of prolap- sus, may be easily reduced. Indeed, it often resumes its natural situation, when the patient is put in a position, in which she lies on her buck, with her loins raised a little higher than her chest. When this method is insuf- ficient, the fingers may be introduced into the vagina, for the purpose of ac- complishing 'the reduction. The pa- tient suffers no pain, at the time when the reduction is performed, which, for the most part, takes place spontane- ously. By the latter circumstance, a prolapsus uteri may be discriminated from polypi, either of the uterus, or Vagina, which tumours do not admit of being reduced, which are in shape, bi-j-de.- below, than above, and which pres. ntno aperture, similar to the os tin. x When the uterus is affected with a complete prolapsus, the reduction is LAPSUS OF. not so easy of accomplishment. The great number of parts, which the dis- placed viscus drags downward with it, and the tumefaction, wliich sometimes follows, render it necessary to take some preparatory measures, before trying to replace the part in its natu- ral situation. For this purposet the pa- tient should be kept in bed, be put on a low regimen, be bled, take purgative medicines, use the warm bath, ani drink diluent beverages, while emol- lient applications are to be made to the part itself. This plan of treatment has often been attended with complete success, in cases of prolapsus uteri, of long standing and considerable size. Ruysch was against making any at- tempt to reduce the uterus, while this part was inflamed and swollen. He al- so thought, that the operation should be postponed when the uterus was in an ulcerated state. Hiwever, Sabatier observes, that, as this complication is only an accidental one, and merely ari- ses from the friction, to which the tu- mour is exposed, and the irritation of the urine, the plan of immediately re- placing the part cannot be attended with any danger. On the contrary, since the cause which produces and keeps up the ulceration, will cease, as soon as the reduction is accomplished, it follows, that, the sores will soon heal after the uterus is put into its na- tural situation again. When we reflect on the position of the uterus, on the strength ofthe liga- ments, destined to support it, and on the manner in which the vagina is con- nected with the surrounding parts, we cannot easily conceive, how the womb can become so much displaced, as it is in cases of complete prolapsus. It is still more difficult to comprehend, how the uterus can become displaced dur- ing pregnancy, even when this viscus has attained its utmost state of disten- tion. However, this sort of case has frequently happened Sabatier remarks, that he could adduce several examples, and quotes an instance from the Traite des Accouchemens de Portal. The prolapsus uteri, which occurs during pregnancy,demands the utmost care. The pail is capable of being re- duced, while the patient is in the early stage of pregnancy. When pregnancy has far advanced, or the disease is of long standing, the reduction is diffi- cult. Perhaps, says Sabatier, it may be more prudent in these circumstances, UTERUS, RETROVERSION OF. 891 to let tbe uterus continue protruded, than to disturb the mother and foetus with reiterated attempts to reduce the part. The uterus, however, should not be left to itself; but be well supported with a suitable bandage, and the pa- tient ought to be kept in her bed. When the prolapsus uteri occurs at the very period of delivery, every at- tempt at reduction is both useless and dangerous. In this case, every exertion should be made to promote the delive- ry of the foetus, by gradually dilating the os tincx, which should, at the same time, be carefully supported. The extraction ofthe placenta also re- quires a great deal of caution, and it should be accomplished by introducing a hand into the uterus, with the palm turned away from the cavity of this vis- cus, towards the Outside ofthe placen- ta, which is to be gradually separated by proceeding from one of its edges towards its centre. In cases of complete prolapsus uteri, Ruysch was an advocate for leaving the expulsion ofthe foetus, if alive, to be effected by nature; and the same wri- ter advises us to be content with sup- porting the os tincx. But, when the child is dead, he recommends extract- ing it with one hand, while the uterus is supported with the other. Sabatier, however, entertains different senti- ments. The expulsion of the child is not less the effect ofthe contraction of the diaphragm and abdominal muscles, than of the womb itself. Hence, it is easy to conclude, that when either of these agents fails in cooperating, the delivery becomes either very difficult, or impossible. This is exactly what happens in the present case; for, the uterus having fallen down, can no lon- ger be Compressed by the action ofthe diaphragm and abdominal muscles. Sa- batier sets down the practice, advised by Ruysch, as an exceedingly danger- ous one; because, the efforts, made by the mother to deliver herself, would have a tendency to render the prolap- sus uteri more complete, and thus in- crease the dragging of all those parts, with which this organ is connected. Sabatier, also, cannot discern the rea- son why Ruysch should recommend the line of conduct to differ, according to the different state ofthe child. This is, probably, quite passive in parturi- tion, and contributes not in the least to its own expulsion. Sabatier, therefore, contends, that the treatment should not be at all influenced by the conside- ration ofthe child being dead, or alive. In whatever degree a prolapsus ute- ri has taken place, it is not sufficient to have reduced the part. The prolapsus woidd soon recur, if it were not pre- vented by the employment of astrin- gent injections and pessaries. (See Pessary.) UTERUS, RETROVERSION OF. A retroversion of the uterus is snid to happen, when the fundus of this viscus, carried by its own weight, and forced downward by the action of the dia- phragm and abdominal muscles, be- comes situated between the sacrum and posterior part ofthe vagina, while the cervix uteri becomes inclined to- wards the symphysis pubis. This kind of case was not understood till about the middle of the preceding century. Sabatier states, that Gregoire, a mem- ber of the college of surgery at Paris, first mentioned it in his private instruc- tions in midwifery. Walter Wall, an English surgeon, who had attended Gregoire, suspected, that he had met with a retroversio uteri in a woman, some months advanced in pregnancy, and he called in D"<- Hunter, in order to have the advantage of his advice. The woman was attacked with an ob- stinate constipation, and retention of urine, and died in about a week. A large tumour was found occupying the whole of the pelvis, and pushing the vagina against the os pubis. It had been found impracticable to push the swelling back into the abdomen, al- though the patient had been put on her knees and elbows, while one hand had been introduced into the vagina, and two fingers of the other hand into the rectum. Some curiosity was enter- tained, concerning what state things would be found in. Opening the body showed, that the bladder, which was exceedingly full of urine, occupied al- most the whole anterior pari ofthe ab- domen, in the same manner as the ute-. rus does in the last month of pregnan- cy. When the bladder had been emp- tied, that part of it, in which the ure- ters terminate, and which is connected with the vagina and cervix uteri, was found raised up, as high as the upper aperture of the pelvis, by a large tu- mour, which filled the whole cavity of the pelvis, and was found to be the ute- rus. A catheter, when passed into the vagina, could be made to lift up the lat- ter viscus, and the upper part of the fu 392 UTERUS, RETROVERSION OF. wiour. This portion of the swelling, on which the bladder lay, consisted ofthe •ervix uteri,while the fundus of this or- gan was situated downwards towards the us coccygis and anus. The uterus had attained such a magnitude, that it could not be taken out of the pelvis, before the symphysis pubis was divid- ed, and the two ossa innominata were pulled asunder. It was found impossi- ble to assign any cause for the manner, in which the uterus had become dis- placed, as the patient had been making no exertion, had met with no fall, and had only been frightened at something just before the complaint commenced. Dr. Hunter, struck with the singu- lar nature of the case, thought it de- serving of attention among medical men, and he made it the subject of a lecture, which he delivered to his pu- pils in 1754. He was afterwards con- sulted by several persons, who were afflicted with the retroversio uteri; but, not in so acute a way, as in the above instance. All the patients were in the third month of pregnancy, and first suffered a difficulty of making wa- ter, succeeded by a retention of urine, and afterwards by constipation. Dr. Hunter always emptied the bladder by means of a catheter and glysters, which measures sometimes effected a cure, the uterus spontaneously resum- ing its natural position. In every in- stance, the accident disappeared, when pregnancy was more advanced, and the uterus had acquired larger dimen- sions. Success was not always obtain- ed: for, in some cases, in which Dr. Hunter was consulted too late, the tri- als to replace the uterus proved fruit- less, and the women died. Dr. Hunter was so firmly convinced of the impos- sibility of saving patients, circum- stanced in the above manner, unless extraordinary means were resorted to, that he thought one should endeavour to diminish the size of the uterus, by introducing a trocar into the body of this viscus, through the posterior pa- rietes ofthe vagina, so as to let out the water of the amnios, the relative quan- tity of which is known to be greater, in the early, than in the advanced, stage of pregnancy. Such a puncture might certainly be the means of the uterus resuming its natural position; but, there would be considerable danger of its exciting the contraction of the uterus, and causing abortion. No risk of this kind would be encountered by puncturing the blad- der above the pubes. In this manner, a free passage would be afforded for the escape of the urine, and the reduction ofthe -uterus might be effected. Mr. Lynn, a surgeon in Suffolk, has seen the bladder burst, and the urine become extravasated in the abdomen, in a case of a retroversion of the ute- rus, in consequence ofthe patient's re- fusal to submit to the preceding ope- ration.-The woman was forty years of age, of a relaxed habit, mother of se- veral children, and had been pregnant four months. She had been for some time before afflicted with a prolapsus ofthe vagina. The swelling had been a few days reduced, when, in conse- quence of tripping, she felt something become displaced in her abdomen, and fall towards the lower part of her back. She was immediately attacked with constipation, retention of urine, nausea, and pain in her belly. The means,which were employed, not proving effectual, Mr. Lynn suspected, that a retroversio uteri had happened, and introduced his fingers into the vagina, in order to ascertain the fact. His fingers were stopped by a tumour, as large as a child's head. The swelling occupied the back part of this passage, and de- scended as low as the perinxum. Be- ing certain, that the uterus was dis- placed, he attempted to reduce it. The patient was put into various positions, and the fingers of one hand were intro- duce d into the vagina, while those of the other were passed into the rectum. The use of the catheter was not for- gotten; but, it could not be introduced far enough to reach the urine. Glysters were stopped at the very beginning of the rectum. The abdomen was ex- tremely tense, especially, in the hypo- gastric region. A proposal was made to puncture the bladder; but, the patient refused to submit, and preferred being left to her fate. On the seventh day of her illness, she w:.s very much redu- ced; and became affected with nausea, and hiccough, the forerunners of the mortification, which was ;.bout to hap- pened. At length, she felt something give way in her abdomen, and the ease, which succeeded, revived her hopes. These, however, were not of long duration; for, after being deliver- ed of the foetus, she sunk and died the next morning. On opening lhe body, the bladder was found to h,ve sloughed and burst atsome points, and two p £» UVA IJVU 392 a of urine were consequently extravasa- ted m the abdomen. We may conclude, from what has been stated, that the retroversio uteri is an exceedingly dangerous affection. However, it is not invariably fatal, par- ticularly when the patient receives succour, before the disease has made much progress. It only occurs in the early months of pregnancy, and in wo- men, whose pelvis is very wide, while its brim is very contracted. If the ute- rus, which occupies a pelvis of this conformation, should be pushed back by a distended state of tb,e bladder, and pressed against the sacrum, while the soft parts yield, the viscus, in ques- tion, becomes, as it were, wedged, and is incapable of changing its posi- tion In this immoveable state, it pres- ses upon the surrounding parts, and these upon it, so that a very serious train of bad symptoms are the conse- quence. The first care of a practitioner, con- sulted in 0. case of retroversio uteri, should be to empty the bladder and large intestines, and to relax the parts by every possible means. Then, he should immediately proceed to replace the uterus, by placing the patient in a suitable posture, and making methodi- cal pressure in the rectum and vagina. Should he be so fortunate as to succeed, the patient is to be kept in bed, her bowels are to be kept open, and she is to be advised always to obey the calls of nature the first moment she feels any inclination to make water. She is also to be enjoined to avoid all kinds of exertion, and wait, till the gradual en- largement of the uterus removes the possibility of this viscus descending in- to the pelvis. (Sabatier, Medicine Ope- ratoire, tom. 2.) UVA URSI. The author of the Pharmacopoeia remarks, this plant, which was first brought into notice by De Haen, has generally been consider- ed as a powerful remedy in calculus; but that it has not been proved, in any instance, to possess the properties of a solvent. The late Dr. Austin, however, recommended it upon the principle of its lessening the irritability ofthe blad- der, and diminishing that secretion of diseased mucus, which, he supposed, greatly to contribute to the augmenta- tion ofthe stone. Mr. Bell, of Edinburgh, strongly re- commends it in that state of a gonor- rhoea where the irritability ofthe blad- der is excited in a high degree, and where the urine is loaded with viscid matter. In these cases, he directs the powder to be given in doses of a scru- ple or half a drachm, three times a-day. A remedy of this sort is certain- ly a great desideratum in surgery. Dr. Saunders directs three drachms of uva ursi to be macerated in a pint of hot water, and two or three ounces of the strained liquor to be given three times a-day. (Pharm. Chirur.) UVULA, AMPUTATION OF.— The uvula is subject to several kinds of enlargement, in which it becomes long- ger and more bulky, than natural, or in which it merely has its length increas- ed. Inconsequence of such changes, it acts as an impediment to swallowing, and speaking, or else causes a disagree- able tickling at the root of the tongue, with which it comes into contact, and thus it may excite frequent retchings, and an annoying cough. When things have attained this state, medicines are often ineffectual, and the only plan of relief consists in amputating a portion of the uvula, a very simple operation, which has been advised to be done in various ways. The ancients recommended taking hold ofthe uvula with a pair of forceps, and cutting off the piece below the blades of the instrument. Celsus re- mavks: Neque quidquam commodius est quam, vosella apprehendere, sub eaque, quod volumus, excindere. Fabricius ab Aquapentlente objects to this method of operating, on the ground, that it is necessary to employ both hands, so that there is a necessity for the aid of a third for holding the tongue and lower jaw. He prefers employing scissors, and thus to leave the left hand at liber- ty. When the uvula had been cut oft", he advised a heated spoon to be appli- ed to the cut end of the part, with a view of stopping the bleeding. Pare speaks in favour of the method,' advised by Celsus. When the size of the uvula is considerable, and there is reason to fear, that the vessels will bleed freely, he recommends it to be tied with a ligature, by means of an in- strument, invented by Castellan, a phy- sician distinguished in his time* both by his learning and judgment. The in- strument in question consists of a ring, with a groove on its convexity, which ring is mounted on a slender handle. A ligature is put round the ring with a slip-knot, which is to be tightened by means of another ring, of much smaller size, mounted, like the preceding one, Vol. II. * 3 C 392 & •UVULA. on a long slender handle. The ligature is to be left in the mouth, and, when it does not seem to make sufficient con- striction, it is to be tightened. Fabricius Hildanus has since de- scribed an instrument, constructed on the same principles, and applicable to the same purposes. Scultetus made use ofthe latter on a soldier, whose uvula was affected with the venereal disease. This author does not state-, however, whether the ligature, which was ap- plied in this way, was painful, produc tive of considerable inflammation, or whether the patient suffered much in- convenience from the presence of the ligature. Such effects were probably produced. Heister, in plate 01, has given the engravingof an instrument, which was invented by a Norwegian peasant, in whose country a relaxed state of the uvula is a very common affection. The contrivance was perfected by Raw. It is only necessary for me to state, that it is a kind of knife, concealed in a ■heath. At the end of this last part, when the blade is drawn back, a notch is left, in which the uvula is to be en- gaged, and then divided by pushing forward the knife. Sabatier's plan of cutting off a por- tion of the uvula, is performed in a way very similar to the one described by Celsus. After having placed the patient on a high chair, and in a good light, with his head properly supported, he takes hold of the uvula with a pair of forceps, with holes in the blades, like those used for the extraction of polypi from the nose. He then divides the uvula with a pair of scissors, made with concave cutting edges, like the scis- sors recommended by Levret for divi- ding the umbilical cord. As the uvula is rendered tense with the forceps, perhaps, any other kind of scissors would answer equally well; but, Saba- tier states, that those, which he uses, have the advantages of taking hold of a larger piece ofthe uvula, and of not letting it slip away. The perforated forceps also take better hold of the part, than common ones do, from which it is apt to slip. Sabatier observes, that he has never seen any bleeding of consequence fol- low the trivial operation just described. (See Medicine Operatoire, tom. 3.) In my First Lines of the Practice of Surgery may be found an engraving of a pair of scissors, which seem well cal- culated for cutting off portions of the uvula, as they have at the end of one of their blades a transverse piece, which prevents the part, about to be cut, from slipping away. VAGINA IMPERFORATE., 393- V V AGIN A IMPERFORATE. It is very common to meet with female infants, born with different kinds of imperfora- tions of the vagina. Sometimes, this passage is not completely shut up, so that the usual evacuations happen in an uninterrupted manner, and it is a con- siderable time before the malformation is discovered. Doubtless, there has of- ten been occasion to obviate the defect in question, in order to qualify young women for marriage. Some females have certainly become pregnant, not- withstanding the sort of obstruction al- luded to, and, in these cases, the mem- brane, which shuts up a part of the mouth of the vagina, has either been torn by the effects of labour, or been divided as much as was necessary for promoting this process of nature. What is more curious, is, that there should have been found two mem- branes, one placed beyond the other, and obstructing the vagina. That, which is commonly met with, is no- thing more than the hymen, which is thicker, and stronger, than natural. Ruysch relates, that a woman, who had been in labour three days, could not be delivered. The head presented itself; but was prevented from coming out by the hymen, which shut up the vagina, and was very tense. Ruysch made an incision into the membrane; but to no purpose, since there was another mem- brane, of a thicker texture, and situ- ated more deeply in the passage, hin- dering the delivery of the child. On an incision being made into this second membrane, the" child was expelled, and the case ended well. When the vagina is completely im- perforate, as soon as the time of the menses coaimences, a great many com- plaints occur, wliich afflict the patient with more severity, in proportion as the blood accumulates in the passage, and they may even lead to a fatal termina- tion, when the cause is not understood, or not detected till it is too late. The complaints alluded to, arc very similar to those of pregnancy; for instance, rumbling noises in the bowels, loss of appetite, nausea, vomiting, enlarge- ment of the mammx, spasms, convul- sions, swelling of the abdomen, &c. Hence, girls, in this situation, have of- ten been supposed to be pregnant, al- though they were not in a state even to become so; and some young women have been known to die, after suffering the most afflicting symptoms. When the only malformation consists in the orifice of the vagina being shut up by a membrane, the patient may be easily relieved by a crucial incision, or a single cut, the edges of which are kept apart by a tent of suitable shape and size. Instances of the success of such an operation are to be found in nu- merous writers. Fabricius ab Aquapen- dente informs us, that a female child was born with a membrane, which com- pletely shut up the vagina. The girl ex- perienced no inconvenience from it, till She was about thirteen years of age, when the period of her menses began. As the blood was retained, she became afflicted with more severe pains in the loins, the lower part of the abdomen, and about the upper part ofthe thighs. It was supposed, that she was attacked by the sciatic gout, and she was treat- ed accordingly. Notwithstanding the medicines, which were prescribed, she became hectic, and reduced to a com- plete state of marasmus, in which she passed restless nights, had lost her ap- petite, and was delirious. A painful ve- ry elastic tumour afterwards took place in that part of the abdomen correspond- ing to the uterus. The pains were ag- gravated every month, at the period, when the patient ought to have men- struated. She was in a dying condition, when Fabricius ab Aquapendente was consulted, who, after ascertaining the real nature of the case, performed the requisite operation. A prodigious quan- tity of black putrid blood was dischar- ged from the vagina; the bad symp- toms gradually subsided, arid the pa- tient recovered Vol. II 3D J94 VAG VA(. It is not always equally easy to cure the imperforate vagina, when the mal- formation is produced by an extensive accretion of the sides of this passage to each other. The success of the ope- ration is more doubtful, because, it is impossible to reach the situation of the blood without cutting through a consi- derable thickness of parts, in doing which there is some danger of wound- ing the rectum, or bladder. A lady, twenty-four years of age, after having tried, for eight years, such remedies, as seemed best calculated for exciting the menstrual discharge, became af- fected with a large hard swelling of the abdomen, and a kind of herpetic affec- tion round the body near the navel. At length, it was discovered, that the im- perforation of the vagina was the sole cause of all the bad symptoms, which the patient had long endured. An inci- sion was made, which enabled the ope- rator to introduce his finger into a large cavity, and which gave vent to a con- siderable quantity of blood. It was thought, that an opening had been made into the vagina; but, the patient having died three days afterwards, it was seen, that a mistake had been made, as the cavity, in which the finger had been introduced, was that of the bladder. The vagina was closed below by a substance an inch in diameter, and half an inch thick. The upper part of this passage, the uterus, and the Fallo- pian tubes, were exceedingly enlarged, and filled with a dark-brown, sanious fluid. A similar fluid was found extra- vasated in the abdomen, and, it was discovered to have got there through a rupture, which had taken place in the, Fallopian tube. The ovaries were in a natural state. De Haen, who has related this case in the sixth part of his work, entitled Ratio Medendi, was of opinion, that, in order to avoid opening the rec- tum, or bladder, only one oblique cut should be made in the membrane, which stops up the vagina, just as was advised, by Meeckren. (Sabatier de la Medicine Operatoire, tom. 1.) VAGINA, PROLAPSUS, OR IN- VERSION OF. This affection maytake place in various degrees. The prolaps- ed part does not consist of all the coats of the va fina, in the manner that the inverted uterus is formed of the whole substance of that viscus, which becomes turned inside out. The inner lining of the vagina is alone displaced, in consev quence of the swelling, and thickening, with which it is affected. The inversion of the vagina appears like a thick, cir- cular substance, irregularly plaited in the middle, and at the bottom of which the cervix uteri is situated, having de- scended further down, than natural. The prolapsed portion of the vagina increases, or diminishe*s, according as the patient sits up, or keeps in bed a certain time. The complaint is accom- panied by a sense of beaviness in the hypogastric region; tenesmus; and a difficulty of making water, in conse- quence of the alteration produced in the direction of the meatus urinarius. Such is the prolapsus of the vagina in an early state; but, when it has been of long standing, and the patients have remained, for a long while, without any assistance, the membranous lining of the passage becomes more and more thickened; the tumour, which it forms, becomes more considerable, elongated, and hardened. In this state, there still continues at the lower part of the swel- ling, an opening, out of which the usual evacuations are made. The grievances, which patients suffer, are similar to those arising from a prolapsus uteri, to which, indeed, the present case bears a great resemblance. The prolapsus va- ginx, however, differs, inasmuch as the tumour, formed by a descent of the ute- rus is very firm, and terminates in a narrow end, on which may be observed the longish transverse opening, named the os tincx, while the tumour, arising from a prolapsus of the vagina, is soft, thicker below, than elsewhere, and ends in an irregular aperture. When the prolapsus vaginx is recent, the part may be easily reduced, and kept up with a pessary; but, when the case has been of long standing, it is neither easy to effect the reduction, nor to prevent a recurrence of the dis- order. Softening, relaxing remedies, in this circumstance, are recommended, and the patient should, in particular, confine herself to her bed, and wear a T bandage, which should be made to press upon and support a piece of sponge in the orifice of the vagina. The swelling of the membranous lining of this passage, being folded back on itself, increases in such a de- gree, that the tumour, thus occasioned, falls into a state of mortification. In this VAR VAR 395 event, some writers have advised the extirpation of the swelling, justifying the practice, on the authority of some distinguished practitioners, and the lit- tle danger, attendant on the operation. Even Sabatier only objects to this pro- ceeding, on the ground of the danger of mistaking a prolapsus of the uterus, for one of the vagina. However, no modern surgeons in this country would hesi- tate about rejecting such an operation, and leaving the sloughs to separate of themselves. VARICOCELE, (from varix, a dis- tended vein, and k»\», a tumour.) Ma- ny writers mean by the term varicocele, a varicose enlargement of the sperma- tic veins, which latter affection, we have, with Celsus and Pott, treated of under the name of Cirsocele. Pott remarks, that the varicocele (which is an enlargement and disten- sion of the blood-vessels of the scro- tum) is very seldom an original dis- ease, independent of any other, and, when it is, is hardly an object of sur- gery. The blood-vessels ofthe scrotum are of different size in different people; and like the vessels in other parts of the body, are liable to become varicose; but, they are seldom so much enlarged, as to be troublesome, unless such en- largement is the consequence of a dis- ease, either of the testicle, or sperma- tic chord. When this is the case, the original disease is what engages our attention, and not this simple effect of it; and, therefore, considered abstract- edly, the varicocele is a disease of no importance. (Pott's Chirurgical Works, vol. 2.) - VARl'CULA, (dim. of varus, a di- lated vein.) A varicose enlargement of the blood-vessels ofthe tunica conjunc- tiva of the eye. VA'RIX, (from varius, unequal.) The term varices is applied to a kind of knot- ty, unequal, dark-coloured swellings, arising from a dilatation of different parts of the veins. Varices most fre- quently occur in the feet, near the an- kles, and, sometimes, higher up, in the legs, thighs, and other parts, as, for in- stance, the scrotum, and even the abdo- men, as Celsus has accurately remark- ed. Pregnancy is one of the most com- mon causes of varicose veins. The dis- ease, however, may be occasioned by the pressure of other swellings, besides that of the gravid uterus; it may also be produced by leading too sedentary a life, and, in short, by every kind of cause, capable of retarding the return ofthe blood, through the veins, towards the heart. The larger the diseased ves- sels become, the more painful and trou- blesome they are, in consequence ofthe great distension of their coats. Some- times, they even burst, and emit a con- siderable quantity of blood; while, in other instances, they give rise to very obstinate ulcers. When the affected veins are not of large size, they seldom cause any very serious inconveniences. Hence, patients commonly make no complaint, and the neglect of the case gives it an opportunity to acquire an aggravated form. When varicose veins are in a painful state, the patient (if other circumstan- ces do not forbid} should be bled, and be put on a cooling regimen. A roller should also be applied with due tight- ness, and its employment continued for a considerable time. Celsus informs us, that the ancients used to relieve patients, afflicted with varicose veins, by the actual cautery, or an incision. The first is a very ob- jectionable method; and the latter way is seldom necessary, except as formerly described by Pare, and latterly by Mr. Home, in particular cases of ulcers on the legs. (See Ulcers.) However, some writers are of opinion, that, when the varicose veins are exceedingly painful, and likely to burst, it is best to make a longitudinal opening into the largest of them with a lancet, in order to give vent to a certain quantity of blood, pro- portioned to the patient's strength, and, they advise a compress and bandage to be afterwards applied. Dionis assures us, that he did not know any better means of compressing varicose veins, than buskins, made of dog-leather, and so contrived as to be laced on the part, with the requisite de- gree of tightness. Thus the leg might be compressed in an equal, regular way, without any occasion for removing the pressure at night. Since the time of Di- onis, laced stockings have been very commonly and usefully employed for the cure of varices, situated in the leg. Some have spoken in favour of apply- ing astringent applications to varicose veins, as, for instance, compresses dip- ped in vinegar. But, though such reme- dies, perhaps, ought not to be altoge- 396 VENEREAL ther rejected as useless, little depen- dence can be put on them, unless they are employed in conjunction with compression, which, in tiie majority of cases, has of itself much greater ef- fect, than any other plan, provided it is methodically made, and duly main- tained. For this purpose, a laced-stock- ing is certainly better, than any kind of roller. For an account of the method of cur- ing a particular sore on the leg, de- pending on varicose veins, see Ulcer. For a description of the varicose affec- tion of the veins of the rectum, see Hemorrhoids. VENEREAL DISEASE. Lues Vene- rea. .Morbus Galliens. Svphilis, or Siphi- 'lis. About the year 1494, or 1495, the venereal disease is said to have made its first appearance in Europe. Some writers are of opinion, that the distem- per originally broke out at the siege of Naples; but, most of them have sup- posed, that, as Columbus returned from his first expedition to the West Indies, about the above period, his followers brought the disorder with them from the new to the old world. Other au- thors, among whom is Mr. B. Piell, maintain the opinion, that many argu- ments might be adduced to show, that the venereal disease was well known in the old continent, and that it prevailetl among the Jews, Greeks, and Romans, and their descendants, long before the discovery of America. Marcellus Cumanus, Johannes de Vi- go, and other early writers on the lues venerea have left an account of some of the symptoms, and their description, as far as it extends, is found to agree with the appearances, observed even at the present day. Marcellus remarks: " I observed many of the officers and foot-soldiers in Milan, while I was in the camp at Navarre, to have several scabs, or pustules, breaking out op the face, and spreading all over the rest of their bodies. The first of which ap- peared usually under the prxputium, or on the outside, like a grain of mil- let, sometimes behind the glans, with a small itching. At other times, a sin- gle pustule would arise, like a little bladder, without much pain, but, itch- ing also. If rubbed, or scratched, there arose an ulcer, corrosive and smarting, like the sting of an ant," &c. (Vide Js- DISEASE. true, vol. 2. p. 226. translated by Dr. Bum roivby.) Johannes de Vigo notices the way in which the disease is communicated by a chancre, in a still more particular and accurate manner: " ejus origo in parii- bvs q-enitalibus, viz. in vulva in mulieri- bus, et in virgd in hominibus, semper fere* fuit cum pustulis parvis, interdum lividi color is, aliquando nigri, nonnunquam sub- albidi cum callositate eas circumdante." De Morbo Gallico. These quotations show, that the venereal disease was propagated from the beginning, as it now is, by what the old writers called a pustule, and we name a chancre. The venereal disease arises from a morbid poison, which, when applied to the human body, has the power of pro- pagating, or multiplying itself, and is capable of acting both locally and con- stitutionally. It may also be communi- cated to other persons, in all the vari- ous ways, in which it is received, pro- ducing, as Mr. Hunter remarks, the same disease in some one of its forms. The same celebrated writer notices, that, in whatever manner the venereal poison arose, it certainly began in the human race, as no other animal seems capable of being affected by it. The parts of generation were, probably, al- so, the first affected; for, if the disease had taken place ip any other part of the body, in all probability, it would never have gone further, than the person, in whom it first arose. However, since it was situated in the parts of" generation, where the only natural connexion takes place, between one human being and a- nother, except that between the mother and child, it was in the most favorable situation for being propagated; and Mr. Hunter infers, also, that the first effects ofthe disease must have been local, in consequence of the fact, now well es- tablished, that none ofthe constitution- al effects are communicable to other persons. The particular properties of the ve- nereal poison are quite unknown, its effects on the human body being the only information, which we possess concerning it. Mr. Hunter says, that it is commonly in the form of pus, or mixed with pus, or some other secre- tion. The virus excites, in most cases, an inflammation in the parts contami- nated, which inflammation is attanded VEfEREAL DISEASE. 397 * i-ff specific mode of action, which is different from all other actions at- tending inflammation, and, according to Mr. Hunter, produces the specific quality in the matter. The formation of matter, though a very general, is not a very constant at- tendant on this disease; for, inflamma- tion, produced by the venereal poison, sometimes does not terminate in sup- puration. But, if Mr. Hunter's senti- ments are correct, it is the matter pro- duced, whether with, or without in- flammation, which alone contains the poison. Hence, a person, having the ve- nereal irritation in any form, not attend- ed with a discharge, cannot communi- cate the disease to another. In proof of this doctrine, the above-mentioned dis- tinguished writer states, that, though married men often contract the disease, and continue to cohabit with their wives, even for weeks, yet, in the whole of his practice, he never once found, that the complaint was communicated under such circumstances, except when connexion had been continued, after the discharge had appeared. It is possible to conceive, that the venereal poison may be in so diluted a state, that it would be incapable of ex- citing any degree of irritation, and, con- sequently, that no effects would be pro- duced. However, when the poison has the power of irritating the part, to which it is applied, the same consequences will follow, whether from a large, or small quantity; from, a strong, or weak solution. The same matter, however, may af- fect different persons very differently. Two men sometimes have connexion with the same woman; both catch the disease; but, one may have very severe symptoms; the other exceedingly mild ones. Mr. Hunter adds, that he has known one man give the disease to dif- ferent women, and some of the women have had it with great severity, while others have suffered very slightly. • It is a great contended question, in the subject of the venereal disease, whether this malady and gonorrhoea a- rise from the same poison ? Mr. Hunter acknowledges, that the opinion, that they originate from two distinct per- sons, seems to have some foundation, when we consider the difference in the symptoms, and method of cure. But, the same author contends, that, if we take up this question upon other grounds, and, also, have recourse to "experiments, the result of which we can also safely depend upon, we shall find this notion to be erroneous. I shall not repeat, in this place, the arguments adduced by Hunter in support of the doctrine, that both diseases are pro- duced by the same virus: the reader will find some notice taken of them in the article Gonorrhoea. Mr. B. Bell, and several other writers, have supported an opinion contrary to the one, set forth by John Hunter, rela- tive to the poison, from which lues ve- nerea, and gonorrhoea arise, and, in- deed, after impartially considering the evidence brought forward by the two' opposite parties, I feel much inclined to believe, that the two diseases do not originate from the same virus. Mr. Hunter, it is true, has brought forward. some observations tending to show, that, a chancre and other venereal symptoms, following absorption from such chancre, might be communicated by inoculating a person with the mat- ter of a gonorrhoea. However, in speak. ing of gonorrhoea, I have suggested some reasons for not placing implicit belief in the inferences, which Mr. Hun- ter has drawn. Mr. B. Bell adduces some facts, from which an almost decisive conclusion may be made, that the poisons of the venereal disease, and the gonorrhoea, are entirely different and distinct. Mr. Bell observes, that, on a subject such as this, the names of persons, by whom the following experiments were con- ducted, cannot be mentioned; but, he is personally acquainted with all of them, and he believes his friend, Dr. Duncan, saw the progress of some of the cases. Mr. Bell knows, that all, which they relate, may be with certain- ty relied on, and he explains, what was done, in nearly their own words. One gentleman states: " My experi- ments were made a good many years ago, and were meant to form the sub- ject of a paper for a medical society, of which I am a member. I had no theory to support, nor no other view in mak- ing them, than to support the opinion, at that time generally received among practitioners, namely, that lues venerea and gonorrhoea virulenta, are one and the same disease, arising from the same matter of contagion,-acting in a diffe- 398 VENEREAL DISEASE. 5-ent manner on different surfaces. I was soon, however, convinced,' by the very distressful and unexpected event of my experiments of the fallacy of this opi- nion. " Matter was taken upon the point of a probe, from a chancre on the glans penis, before any application was made to it, and completely introduced into the urethra, expecting thereby to pro- duce a gonorrhoea. For the first eight days, I felt no kind of uneasiness; but, about this period, 1 was attacked witb pain in passing my water. On dilating the urethra, as much as possible, nearly the whole of a large chancie was dis- covered, and, in a few days thereafter, a bubo formed in each groin. No dis- charge took place from the urethra, during the whole course of the disease; but another chancre was soon perceiv- ed in the opposite side of the urethra, and red precipitate was applied to it, as well as to the other, by means of a probe previously moistened for the purpose. Mercurial ointment was at the same time rubbed on the outside of each thigh, by which a profuse saliva- tion was excited. The buboes, which, till then, had continued to increase, be- came stationary, and, at last, disap- peared entirely; the chancres became clean, and, by a clue continuance of mercury, a complete cure was at last obtained." Mr. B. Bell informs us, that the next experiment was made with the matter of gonorrhoea; a portion of which was introduced between the prepuce and glans, and allowed to remain there without being disturbed. In the course of the second day, a slight degree of inflammation was produced, succeeded by a discharge of matter, which, in the course of two or three days, disappear- ed. The same experiment was, by the same gentleman, repeated once and again, after rendering the parts tender, to which the matter of gonorrhoea was applied; but, no chancre ever ensued from it. Mr. B. Bell also acquaints us, that two young gentlemen, while prosecut- ing the study of medicine, became anxious to ascertain the point in ques- tion; with which view, they resolved on making the following experiments, at a time, when neither of them had ever laboured under either gonorrhoea, or syphilis, and both in these and in the preceding experiments, the matter of" infection was taken from patients, who had never made use of mercury. A small dossil of lint, soaked in the matter of gonorrhoea, was, by each of them inserted between the prepuce and the glans, and allowed to remain on the same spot for the space of twenty-four hours. From this, they expected, that chancres would be produced; but, in the one, a very severe degree of inflam- mation ensued over the whole glans and prxputium, giving all the appearance of, what is usually termed, gonorrhaa spuria. A considerable quantity of fetid matter was discharged from the sur. face of the inflamed parts, and, for se- veral days, he had reason to fear, that an operation would be necessary for the removal of a paraphymosis. By the use of saturnine poultices, laxatives, and low diet, however, the inflamma- tion abated, the discharge ceased, no chancre took place, and he soon got en- tirely well. The other gentleman, says Mr. B. Bell, was not so fortunate. The exter- nal inflammation, indeed, was slight, but, by the matter finding access to the urethra, he was attacked, on the se- cond day with a severe degree of go- norrhoea, which continued for a consi- derable time to give him a great deal of distress, nor did he, for upwards of" a v ear, get entirely free of it. The latter gentleman, impressed with a sense of the imprudence and hazard of all such experiments, could not be prevailed upon to carry them further, although they were prosecuted by his friend. This young man, soon after the inflammation, arising from his first ex- periment, had been removed, inserted the matter of gonorrhoea on the point of a lancet, beneath the skin of the prxputium, and, likewise, into the sub- stance ofthe glans; but, although this was repeated three different times, no chancres ensued. A slight degree of inflammation was excited; but, it soon disappeared, without any thing being done for it. His last experiment was attended with more serious conse- quences. The matter of* a chancre was inserted on the point of a probe to the depth of a quarter of an inch, or more, in the urethra. No symptoms of go- norrhoea ensued; but, in the course of five, or six days, a painful inflammato- VENEREAL DISEASE 399 ry chancre was perceived on the spot, to which the matter was applied. To this succeeded a bubo, which ended in suppuration, notwithstanding the im- mediate application of mercury, and the sore, that was produced, proved both painful and tedious. L'lcers were at last perceived in the throat, nor was a cure obtained, till a very large quan- tity of mercury was given under a state of close confinement for thirteen weeks. (Treatise on Gonorrhoea Virulen- ta and Lues Venerea, vol. 1, edit. 2. p. 438, Vc.) Some have supposed, that the poison- ous quality of venereal matter arises from a fermentation taking place in it as soon as it is formed. However, Mr. Hunter conceives, that the animal body has a power of producing matter ac- cording to the irritation given, where- by tiie living powers, whenever irri- tated in a particular manner, produce such an action in the parts, as to gene- rate a matter, similar in quality to that which excited the action. It does not seem necessary to adduce the arguments, by which the idea of a fermentation being concerned in the production of the venereal virus might be refuted, as no modern practitioner now defends the doctrine. Mr. Hunter was of opinion, that the effects, pro- duced by the venereal poison, arise from its peculiar, or specific irritation, joined with the aptness of the living principle to be irritated by such a cause, and the parts, so irritated, act- ing accordingly. Hence, he consider- ed, that the venereal virus irritated the living parts in a manner peculiar to it- self, and produced an inflammation, pe- culiar to that irritation, from which a matter is produced, peculiar to the in- flammation. The venereal poison is capable of af- fecting the human body in two differ- ent ways; locally, that is, in those parts only, to which it is first applied; and, constitutionally, that is, in consequence of the absorption of the venereal pus, which affects parts, while it is diffused in the circulation. Though Mr. Hunter uses the term constitutional, he explains in a note, that the word is not altogether correct- ly applied, as every complaint of a ve- nereal nature is truly local, and pro- duced by tiie simple application of the poison to the parts. The latter circum- stance may happen, either by the im- mediate contract of the matter with the skin, before any absorption has taken place, or it may happen by the matter coming into contact with such pails, as are susceptible of the venereal disease, after absorption has taken place, and while the virus is circulating in the system. Mr. Hunter believed, as the reader al- ready understands, that gonorrhoea was only one form of the venereal disease. In gonorrhoea, he observes, there is a formation of matter without a breach in the solids, while, on the contrary, a chancre is attended with a breach of this kind; and, he imputed the two dif- ferent ways, in which the disorder ap- ears, not to any thing peculiar in the ind of poison applied, but, to the dif- ference in the parts contaminated. When the poison was applied to a se- creting surface, which had no cuticle, he believed, tbat, it never produced ulceration, but, only an alteration in the quality of the secretion. Thus in the urethra, instead of mucus, pus be- came secreted, and a gonorrhoea arose. On the other hand, Mr. Hunter thought, that, when the virus was applied to a surface, that is covered with a common cuticle, as the common skin of the bo- dy, ulceration would be the effect In this manner, he accounts for the same poison producing two such different consequences, as gonorrhoea, and chan- cre. OF CHANCRE^ From the account, already delivered, that the venereal disease can only be imparted from one person to another by the actual contact of the matter, it must be obvious, that the first effects of the disorder must in general make their appearance on the pails of gene- ration, in consequence of the virus be- ing applied to them during coition. Mr. Hunter reminds us, however, that the penis, which in men, is the common seat of a chancre, is, like eve- ry other part of the body, liable to dis- eases of tiie ulcerative kind, and that, on account of some circumstances, it is rather more so, than other parts. When attention is not paid to cleanliness, ex- coriations, or superficial ulcers often originate in consequence of such neg- lect. The genitals, also, like almos* 400 VENEREAL DISEASE. every other part that has been injured, when once they have suffered from the venereal disease, are very liable to ul- cerate again. *ince, therefore, the penis is not exempted from the common dis- eases of the bod}, Mr. Hunter very properly remarks, that an opinion, con- cerning" ulcers situated on it, must be formed with great attention, particu- larly, as every disease in this part is supposed to be venereal. " Venereal ulcers (says Mr. Hunter) commonly have one character, which, however, is not entirely peculiar to them; for, many sores, that have no disposition to heal, (which is the case with a chancre) have so far the same character. A chancre has commonly a thickened base, and, although, in some, the common inflammation spreads much further, yet the specific is con- fined to this base." (P. 215.) Mr. Hunter notices, that there are three ways, in which chancres may be produced; first, by the poison being in- serted into a wound; secondly, by be- ing applied to a non-secreting surface; and, thirdly, by being applied to a com- mon sore. To whichever of these three different surfaces it is applied, the pus produces its specific inflammation and ulceration, attended with a secretion of pus. The matter produced, in conse- quence of these different modes of ap- plication, partakes of the same nature, as the matter, which was applied, be- cause, as Mr. Hunter observes^ the ir- ritations are alike. Mr. Hunter takes notice, that the poison much more readily contami- nates, when it is applied to a fresh wound, than to an ulcer. Though chancres commonly occur on the parts of generation, this circum- stance is entirely owing to their being the only parts, with which the virus comes into contact, the application be- ing made during the connexion between the sexes. Every part of the body may be affected by the application of vene- real matter to it, particularly, when the cuticle is thin. Mr. Hunter mentions his having seen on the red part of the lip a chancre, which was as broad as a sixpence. The venereal virus had most probably been inadvertently applied to the part by the patient's own fingers. Mr. Hunter had not the least doubt of the sore being really a chancre; for be- sides it§,<-iset*3ed appearance, it was at- tended with a bubo iivone of the glands under the lower jaw. Chancres have occasionally occurred on the fingers, particularly, when there has been any previous cut, or scratch on tlrese parts, and they have been em- ployed in this state in dressing vene- real sores. Mr. Hunter computed, that claps oc- cur more frequently, than chancres, in the proportion of four, or five to one. As this celebrated writer conceived, that these diseases originated from the same virus, which only produced dif- ferent effects by its having to act on a secreting, or non-secreting surface, he • attempts to explain the less frequent occurrence of chancres by the opera- tion ofthe venereal poison, being often prevented by the intervention of the cuticle. The same author states, that, in men, chancres generally make their appear- ance on the frsnum, glans penis, pre- puce, or on the common skin of the body of the penis; and, sometimes, on the forepart of the scrotum; but, he thought, that such sores took place most frequently on the frxnum, and in the angle, between the penis and glans. He refers the cause of the venereal poi- son affecting these parts to the manner, in wliich the disease is caught, and not to any specific tendency in these parts to catch the complaint; and he imputes the circumstance of the frxnum being more frequently affected, than other parts of the penis, to the external form of that part being irregular, and allow- ing the venereal matter to lie undisturb- ed in its folds. Thus the virus has time to irritate, and inflame the parts, and to produce the suppurative and ulcera- tive inflammation in them. Mr. Hunter next observes, that the interval, between the application ofthe poison, and its effects upon the parts, is uncertain; but, that, on the whole, a chancre is longer in appearing, than a gonorrhoea. However, the nature of the parts affected makes some diffe- rence. When a chancre occurs on the frxnum, or at the termination of the prepuce, in the glans, the disease in general comes on earlier; these parts being more easily affected, than either the glans penis, common skin of this organ, or the scrotum. Mr Hunter adds, that, in some cases, in which both the glans and prepuce were con- VENEREAL DISEASE. 401 laminated from the same application of the poison, the chancre made its ap- pearance earlier on the latter part. Mr. Hunter states his having been acquainted with some instances, in v which chancres appeared twenty-four hours after the application of the mat- ter; and with others, in which an inter- val of seven weeks, and even two months elapsed, between the time of contamination and that, when the chan- cre commenced. A chancre first begins with an itch- ing in the part. When the inflammation is on the glans penis, a small pimple, full of matter, generally arises, with- out much hardness, or seeming inflam- mation, and with very little tumefac- tion: for, the glans penis is not so apt to swell, ,in consequence of inflamma- tion, as many other parts are, especial- ly, the prepuce. Mr. Hunter also ex- plains, that chancres, situated on the glans, are not attended with so much pain and inconvenience, as sores of this nature on the prepuce. When chancres occur on the frxnum, or, particularly, on the prepuce, a much more consi- derable degree of inflammation soon fol- lows, attended with effects, more ex- tensive and visible. These latter parts, being composed of very loose cellu- lar membrane, afford a ready pas- sage for the extravasated fluids. The itching is gradually converted into pain; in some cases, the surface of the prepuce is excoriated, and afterwards ulcerates;, while, in other examples, a small pimple or abscess appears, as on the glans, and then turns into an ulcer. The part becomes affected with a thick- ening, which, at first, while of the true venereal kind, is very circumscribed; not diffusing itself, as Mr. Hunter ob- serves, gradually and imperceptibly in- to the surrounding parts; but, termina- ting rather abruptly. Its base is hard, and tiie edges a little prominent. When it begins on the frxnum, or near it, that part is very commonly wholly destroy- ed, or a hole is often made through it by ulceration. Mr. Hunter thought it better, in general, under the latter cir- cumstance, to divide the pail at once. When the venereal matter is applied to the body of the penis, or front of the scrotum, where the cuticle is thick- er, than that on the glans penis and pre- puce, the chancre usually makes its ap- pearance in the form of a" pimple, which commonly forms a scab, in consequence of evaporation. The first scab is ge- nerally rubbed off: after which a se- cond, still larger, one is produced. When the disease is more advanced, it is often attended with such inflam- mation as is peculiar to the habit, be- coming in many instances more dif- fused, and often producing phymosis, and paraphymosis. However, says Mr. Hunter, there is yet a hardness around the sores, which is peculiar to such as are caused by the venereal virus, parti- cularly, those on the prepuce. The local, or immediate effects ofthe venereal disease are seldom wholly spe- cific; but, are usually attended both with the specific and constitutional in- flammation. Hence, Mr. Hunter advises particular attention to be paid to the manner, in which a chancre first ap- peal's, and to its progress. If the inflam- mation spreads in a quick and consi- derable way, the constitution must be more disposed to inflammation, than is natural. When the pain is severe, Mr. Hunter remarks, there is a *trong dis- position to irritation. Chancres also, sometimes, soon begin to slough, there being a strong tendency to mortifica- tion. It is also observed by Mr. Hunter, that when there is a considerable loss of substance, either from sloughing, or ulceration, a profuse bleeding is no uncommon circumstance, more espe- cially, when the ulcer is on the glans. The adhesive inflammation does not appear to take place sufficiently to unite the veins of this part of tiie pe* nis, so as to prevent their cavity from being exposed, and the blood escapes from the corpus spongiosum urethrx. The ulcers, or sloughs, often extend, as deeply as the corpus cavernosum penis, and similar bleedings are the conse- quence. With respect to chancres in women, the labia, and nymphx, like the glans penis in men, are subject to ulceration, and the ulcerations are generally more numerous in females, than males, in con- sequence of the surface, on which the sores are liable to form, being much larger. As Mr. Hunter observes, chan- cres are occasionally situated on the edge of the labia; sometimes on the outside of these parts; and even on the perinxum. When the sores are formed on the inside of the labia or nymphx, Vot.. H 3E 402 V ENEREAL DISEASE. they can never dry, or scab; but, when they are externally situated, the mat- ter may dry on them, and produce a scab, just as happens, with respect to chancres situated on the scrotum, or body of the penis. Mr. Hunter remarks, that the vene- real matter from these sores is very apt to run down the perinxum to the anus, and excoriate the parts, especial- ly, about the anus, where the skin is thin, and where chancres are liable to be thus occasioned. Chancres have been noticed in the vagina; but, Mr. Hunter suspected, that they were not original ones; but, that they had spread to that situation from the inside of the labia. Before any of the virus has been taken up by the absorbents, and con- veyed into the circulation, a cliancre is entirely a local affection. TREATMENT OF CHANCRES. It wa6 one of Mr. Hunter's opinions, that the ulceration, arising from vene- real inflammation, generally, if not always, continues, tdl cured by art, and his theoretical reason for this cir- cumstance was, that, as the inflamma- tion in the chancre spreads, it is always attacking new ground, so as to produce a succession of* irritations', and hinder the disease from curing itself. 'We have already noticed, that chan- cres are not wholly venereal, but are attended with effects, dependent on con- stitutional peculiarities, to which the va- riety in the treatment must be adapted. The venereal symptoms, abstractedly considered, may be cured by mercury; but, tiie treatment of the symptoms, which depend on peculiarity of consti- tution, have no specific remedy, and demand different means in different cases. Though the treatment of a chancre may be attempted both constitutionally and locally, it is commonly a consider- able time before the sore appears to be affected by mercuiy. Sometimes tiie cir- culation must be loaded with mercury for three, or four weeks, or even longer, before a chancre begins to separate its discharge from its surface, so as to look red, and exhibit a living surface; but, says Mr. Hunter, when once it does change, its progress towards healing is more rapid. This author describes ft chancre as being generally much Ion- ger in getting well, than the other lo- cal effects of the venereal disease, aris- ing from the absorption of the poison into the constitution. Mr. Hunter enjoins the practitioner to consider, also, whether weakening, strengthening, or quieting medicines, should be exhibited; sometimes, one kind; sometimes, another being proper. Chancres (observes the same cele- brated writer) admit of two modes of treatment. The object of one is to de- stroy or remove them by means of es- charotics, or by extirpation. That of the other is to overcome the venereal irritation by means of the specific re- medy for the syphilitic poison. That chancres are local complaints, is confirmed by the circumstance of their admitting of being destroyed, or cured merely by local treatment. It has been a question, whether mercury- should ever be locally applied to chan- cres, or not. On this subject Mr. Hunter considers, that, in the cure of such sores, there are two objects to be aimed at; one is the cure of the chancre itself; the other is the prevention of a conta- mination of the habit. The cure of the chancre is to be ef- fected by mercury, applied either in ex- ternal dressings, or, internally, through the circulation, or in both ways. The preservation of the constitution from contamination is to be accomplished, first by shortening the duration of the chancre, which shortens the opportu- nity for absorption; and also by inter- nal medicine, which must be in propor- tion to the time, that the absorption may have been going on. If, says Mr. Hunter, the power of a chancre to contaminate the constitu- tion, or, what is the same thing, if the quantity of the virus absorbed is pro- portioned to the size of the chancre, and the time of absorption, which most probably it is, then whatever shortens the time, must diminish the above pow- er, or tbe quantity of the poison ab- sorbed. Also, if the quantity of mercu- ry, necessary to preserve the constitu- tion, is proportioned to the quantity of the virus absorbed, then whatever les- sens the quantity absorbed, must pro- portionally preserve the constitution. For instance, says Mr. Hunter, if the power of a chancre to contaminate the VENEREAL DISEASE. 402 constitution in four weeks is equal to four, and the quantity of mercury ne- cessary to be given internally, both for the cure of the chancre and the preser- vation ofthe constitution, is also equal to four, then whatever shortens the du- ration of the chancre, must lessen in the same proportion the quantity of mercury necessary. Hence, if local ap- plications, together with the internal use of mercuiy, will cure a chancre in three weeks, then it will only be neces- sary to exhibit three-fourths of the quantity of mercuiy internally. Mr. Hunter observes, therefore, that local applications, inasmuch as they tend to shorten the duration of a chancre, shorten the duration of absorption, and, in this manner, shorten the neces- sity for the continuance of an internal course of mercuiy, all in the same pro- portion. For example, if four ounces of mercurial ointment will cure a chancre and preserve the constitution, in four weeks, three ounces will be sufficient to preserve the constitution, if the cure of the chancre can be, by any other means, forwarded, so as to be effected in three weeks. Mr. Hunter affirms, that this is not speculation; but the re- sult of experience, and confirmed by the destruction of chancres. DESTROYING CHANCRES. Mr. Hunter notices that the simplest method of treating a chancre is to de- stroy, or extirpate it, whereby it is re- duced to the state of a common sore, or wound, and heals up as such. This can only be done on the first appear- ance of the chancre, when the sur- rounding parts are not yet contamina- ted; for, it is absolutely necessary to remove the whole of the diseased part, and this object is exceedingly difficult of accomplishment, when the disease has spread considerably. The plan may be effected either with the knife, or caustic. Mr. Hunter states, that, when the chancre is situated on the glans pe- nis, touching the sore with the lunar caustic is preferable to cutting it away, because the hemorrhage from the cells of the glans would be considerable in the latter method. The caustic will not give a great deal of pain, as the glans is not an exceed- ingly sensible part The caustic em- ployed should be pointed at the end, like a pencil, in order that it may only touch such parts as are really diseased. This treatment should be continued, till the surface of the sore looks red and healthy, after the separation of the last sloughs. When it has attained this condition, it will heal like any other sore, made with caustic. . When the sore is on the prepuce, or the common skin of the penis, and, in an incipient state, the same practice may be adopted with success. When the chancre is large, however, it cannot be destroyed with the argentum nitra- tum, which does not extirpate the in- creasing sore deeply enough. In such cases, Mr. Hunter thought, that the lapis septicus would' answer very well. Wben the latter caustic cannot be con- veniently employed, this author recom- mended the chancre to be cut away. He mentions his having taken out such a sore by dissection, and that the part afterwards healed with common dress- ings. However, says he, as our know- ledge of the extent of the disease is not always certain; and as this uncer- tainty increases with the size of the chancre, the cure must be in some measure promoted by proper dress- ings, and, it will be prudent to dress the sore with mercurial ointment. When this plan is followed, Mr. Hunter be- heved, that there is but little danger of the constitution being infected, parti- cularly, when the chancre has been de- stroyed almost immediately on its first appearance; for, then, it is reasonable to conclude, that there has not been time for absorption to have taken place But, observes the same author, as it must be in most cases uncertain, whe- ther there has been absorption, or not, this practice should not always be trust- ed to, and, perhaps, never should be re- lied in. Hence, even when the chancre has been destroyed in its incipient state, some mercury should be given from mo- tives of prudence, the quantity of which medicine should be proportioned to the duration and progress ofthe sore. When the chancre is large, before it is extir- pated, mercury is absolutely necessary, and Mr. Hunter conceived, that very lit- tle good is done by the extirpation. LOCAL APPLICATIONS TO CHANCRES. The cure of a chancre (says Mr. Hun- ter) is a different th.ing from its extiiv 404 VENEREAL DISEASE nation, and consists in destroying its ve- nereal disposition, which object being effected, the parts heal of course, as far as they are venereal. The employment of mercury, both as a topical application, and a constitution- al remedy is necessary in order to cure a chancre. Mercurial ointments have been com- monly used as dressings to chancres; but, Mr. Hunter was of opinion, that if the mercury were7 joined with watery substances, instead of oily ones, the ap- plication, by mixing with the matter, would be continued longer to the sore, and would prove more effectual. This, he observes, is one advantage, which poultices have over common dressings. He has often used mercury rubbed down with some conserve, instead of oint- ment, and it answered extremely well. Calomel used in the same way, and al- so the other preparations of mercury, mixed with mucilage, or honey, answer the same purpose. Such dressings, ac- cording to Mr. Hunter, will effect a cure, in cases, which are truly vene- real, and free from other morbid ten- dencies. Some chancres are indolent, and re- quire a little warm balsam or red pre- cipitate to be joined with the mercu- rial dressing. Mr. Hunter says, that ca- lomel mixed with salve is more active, than common mercurial ointment, and is attended with better effects, when the case requires stimulants. Solutions of blue vitriol, verdigrease, calomel, &c. have been recommended. But, Mr. Hunter very judiciously ob- serves, that, as all these applications are only of service in remedying any peculiar disposition ofthe parts, as they have no specific power over the venere- al poison, and as such dispositions are innumerable, it is almost impossible to say, what applications will be effectual in every instance. Some kinds of dress- ings will answer in one state of the sore; some in another. The parts affected are often found extremely irritable, in which circumstance the mercuiy should be mixed with opium or preparations of lead. Mr. Hunter was an advocate for chan- ging the dressings very often, because the matter separates them from the sore, so as to diminish their effects. He states, that changing the applications, Mince a day, will not be found too of- ten, particularly, when they are in the form of an ointment. When the venereal nature of a chan- cre is removed, the sore frequently be- comes stationary, in which case, Mr Hunter observes, that new dispositions have been acquired, and the quantity of disease in the part has been increased. When chancres are only stationary, Mr. Hunter says, they may often be cured, by touching them slightly with the lu- nar caustic. No cicatrization, in this case, seems possible, till the contami- nated surface, or the new flesh, which grows on that surface, has either been destroyed or altered. It is often sur- prising, how quickly the sores heal up, after being touched with the applica- tion. (See Hunter on the Venereal Dis- ease.) INTERNAL EXHIBITION OF MER- CURY FOR CHANCRES. At the same time that topical appli- cations are made to chancres, mercury must be internally exhibited, both with a view of curing these ulcers, and pre- venting a lues venerea. Mr. Hunter be- lieved, that the venereal disposition of the chancre would hardly ever with- stand both local and internal mercu- rials. When local applications cannot easily be made to chancres, as in cases of phy- mosis, there is a still greater necessity for giving mercury internally, by which means, the cure may in the end be ef- fected. Mercuiy should always be given in- ternally in every case of chancre, let it be ever so slight, and even when the sore has been destroyed on its very first appearance. The remedy should always be exhibited the whole time ofthe cure, and continued for some time after the chancre has healed; for, says Mr. Hun- ter, as there are, perhaps, few chancres without absorption ofthe matter, it be- comes absolutely necessary to give mer- cury to act internally, in order to hin- der the venereal disposition from form- ing. How much mercury should be thrown into the constitution in the cure at a chancre, with a view of keeping the system from being affected, cannot la!lly bte d*e™lned> as there is no dis- ZJ'Tflf0™^' hy whi<* we can be guided. Mr. Hunter states, that the VENEREAL DISEASE. 405 quantity must in general be proportion- ed to the size, number, and duration, of the chancres; or, in other words, pro- portioned to the opportunity, which there has been given for absorption. The mercury, which is exhibited to act internally, may be conveyed into the system, either by the skin, or sto- mach, according to circumstances, and it should be so taken, as to produce a slight affection of the mouth. Mr. Hunter next remarks, that when the sore has put on an healthy look, when the hard basis has become soft, and the ulcer has skinned over in a fa- vourable manner, it may be regarded as cured. The same distinguished writer no- tices, however, that, in very large chan- cres, it may not always be necessary to continue the application of mercury, either for external, or internal action, till the sore is healed; for, the venereal action is just as soon destroyed in a large chancre, as it is in a small one, since every part of the sore is, equally affected by the medicine, and, of course, cured with equal expedition. But, in re- gard to cicatrization, circumstances are different, because a large sore is longer than a small one, in becoming covered with skin. Hence, Mr. Hunter very just- ly explains, that a large chancre may be deprived of its venereal action, long before it has healed; while, on the other hand, a small one may heal before the syphilitic affection has been destroyed. In the latter case, this gentleman repre- sents it as most prudent, both on ac- count of the chancre and constitution, to continue the employment of mercury a little while after the sore has healed. Mr. Hunter, in the valuable work, which he has left on the present sub- ject, takes notice of sloughs, which oc- cur in the tonsils, from the effect of mercury on the throat, and are apt to be mistaken for venereal complaints. He also mentions, that, sometimes when the original chancre has been doing well, and been nearly healed, he has seen new sores break out on the pre- puce, near the first, and assume all the appearance of chancres. When, in the treatment of chancres, a bubo arises, while the constitution is loaded with a sufficient quantity of mercury to cure such sores, which me- dicine has also been rubbed into the lower extremity, on the same side as the bubo, Mr. Hunter suspected, that the swelling in the groin is not vene- real, but is produced by the mercury. In these cases, he always preferred con- veying mercury into the system in some other manner. With respect to the treatment of chancres in women, since it is difficult to keep dressings on the parts, Mr Hunter advises the sores to be fre- quently washed with some mercurial solution, and, speaks of one, made with corrosive sublimate, as perhaps being the best, since it will act as a specific, and stimulant also, when this is requi- site. When the chancres, however, are irritable, they are to be treated in the same manner, as similar complaints in men. When the sores extend into the vagina, this passage must be kept from becoming constricted, or closed, by the introduction of lint. Sometimes, after a chancre and all venereal disease are cured, the pre- puce continues thickened and elon- gated, so that the glans cannot be un- covered. Perhaps, the case is often without remedy. Mr. Hunter however, very properly recommends trying every possible means, and he informs us, that the steam of warm water, hemlock fo- mentations, and cinabar fumigations, are frequently of singular service. When the thickening and enlarge- ment of the prepuce cannot be removed by applications, all the portion, anterior to the glans penis, may be cut away. (See Phymosis.) Mr. Hunter lias very ably explained, that chancres, both in men and women, often acquire, during the treatment, new dispositions, which are of various kinds, some retarding the cure, and leaving the parts in an indolent thick- ened state, after the cure is accom- plished. In other instances, a new dis- position arises, which utterly prevents the parts from healing, and often pro- duces a much worse disease, than that, from which it originated. Such new dispositions may lead to the growth of tumours. They are more frequent in men, than women, and generally occur only when the inflammation has been violent from some peculiarity of the parts, or constitution. They have some- times been considered as cancerous. Among the diseases in question, Mr. Hunter notices those continued, and often increased inflammations, suppura- 406 VENEREAL DISEASE. tions, and ulcerations, vviiich .become diffused through the whole prepuce, and, also, along the common skin of the penis, which become of a purple hue, attended with such a general thickening of the cellular membrane, as makes the whole organ appear con- siderably enlarged. The same writer observes, that the ulceration on the in- side of the prepuce will sometimes in- crease, and run between the skin and the body of the penis, and eat holes through in different places, till the whole is reduced to a number of ragged sores. The glans. often shares the same fate, till more, or less of it is gone. Frequently, the urethra in this situa- tion is wholly destroyed by ulceration, and the urine is discharged some way farther back. The ulceration, if un- checked, at length destroys all the parts. In this acute case, prompt re- lief is demanded; but, often the proper mode of treatment cannot be at once determined, owing to our ignorance, in respect to the exact nature of the pe- culiar cause of the disease. Mr. Hun- ter states, that the decoction of sarsa- parilla is often of service, when given in large quantities, and that he has known the German diet-drink effect a cure, after every other remedy had failed. The following diet-drinks, he says, have been much recommended. Take of crude antimony and pumice- stone, pulverized, and tied up in a bit of rag, of each one ounce; China root, sliced, sarsaparilla root, sliced and bruised, of each half an ounce; ten wal- nuts with their rinds bruised; spring- water, four pints; boiled to half that quantity; filter it, and let it be drunk daily in divided doses. Take of sarsaparilla, Saunders-wood, white and red, of each three ounces; li- quorice and mezereon, of each half an ounce; of lignum rhodium, guaiacum, sassafras, of each an ounce; crude anti- mony, two ounces; mix them and infuse them in boiling water, ten pints, for twenty-four hours; and, afterwards boil them to five pints, of which let the dose be from a pint and a half to four pints a day. Mr. Hunter also states, that the ex- tract of hemlock is sometimes of ser- vice, and that he has known sea-bath- ing effect a perfect cure. Sometimes, when such sores are healing, it becomes necessary to keep the orifice of the urethra from closing, by the introduction of a bougie. Sometimes, after a chancre has heal- ed, the cicatrix breaks out again, and puts on the appearances of the preced- ing sore. Occasionally, similar diseases break out in different places from that of the cicatrix. Mr. Hunter represents, that they differ from a chancre in ge- nerally not spreading so fast, nor so far; in not being so painful, nor so much inflamed; in not having such hard bases, as venereal sores have; and in not pro- ducing buboes. This writer was of opi- nion, that they were hot venereal. They are very apt to recur. Mr. Hunter does not specify any par- ticular mode of cure for all these cases; but, he meutions one instance, which seemed to be cured by giving forty drops oflhe lixivium saponarium, eve- ry evening and morning, in a basin of broth; and he adverts to another case, which was permanently cured by sea- bathing. In some instances, after a chancre has healed, the parts, as Mr. Hunter remarks, do not ulcerate; but, appear to become thickened, and indurated. Both the glans and prepuce seem to swell, so as to form on the end of the penis a tumor, or excrescence, shaped very much like a cauliflower, and, when cut into, showing radii, running from its base, or origin, towards the external surface. It is extremely indolent. It is not always a consequence of the vene- real disease; for, Mr. Hunter has seen it arise spontaneously. No medicine seems to be at all like- ly to cure the disease: the only success- ful means is to amputate a considerable part of the penis, and then to keep a proper catheter introduced into the urethra. WARTS. Another disposition, induced by the previous occurrence of chancres is a disposition to form excrescences, or cutaneous tumours, called warts. These are considered by many not simply- as a consequence of the venereal poison; but, as possessed of its specific dispo- sition, and, therefore, says Mr, Hunter, they have recourse to mercury for the cure of them; and, it is said, that such treatment often removes them. This eminent practitioner never saw mercu- VENEREAL DISEASE. 407 ry produce this effect, although the me- dicine was given in sufficient quantity to cure recent chancres, and a lues ve- nerea, in the same person. Mr. Hunter observes, that as these substances are excrescences from the body, they are not to be considered as truly a part of the animal, not being endowed with the common, or natural animal powers. Many trifling circum- stances make them decay. An inflam- mation of the sound parts round the wart, or stimuli applied to its surface, will often make it die. Electricity will also induce an action in such excres- cences, which they are not able to sup- port; an inflammation is excited round them, and they drop off. From this account, we must perceive, according to Mr. Hunter, that the knife and escharotics are not always necessa- ry, although, these modes will act more quickly than any other, especially, when the neck of the wart is small. When such is the form of the excrescence, perhaps, a pair of scissars is tiie best instrument; but, says the above distin- guished writer, when cutting instru- ments of any kind are horrible to the patient, a silk-thread, tied round the neck of the wart, will do very well. However, whichever plan is adopted, it is in general necessary to touch with caustic the base of the little tumour, after this has separated. Mr. Hunter remarks, that escharotics act upon warts in two different ways, namely, by deadening a part, and sti- mulating the remainder, so that, by the application of escharotic after escha- rotic, the whole excrescence decays moderately fast; and it is seldom ne- cessary to destroy them down to the very root, which is often thrown off*. This, however, is not always the case, and the wart grows agajn, in which circumstance, it is proper to let the caustic destroy even the root itself. The kali purum cum calce viva, lu- nar caustic, and blue vitriol, are all pro- per applications. But, one of the best stimulants is the xrugo xris and pow- der of savin-leaves, mixed together. (Hunter on tlte Venereal Disease.) BUBOES. The immediate consequence of a chan- cre, which is called a bubo, and also the remote effects, implied by the term lues venerea, arise from the absorption of re- cent venereal matter from some sur- face, where it has either been applied or formed. - We are already aware, that Mr. Hun- ter believed the matter of gonorrhoea capable of communicating the venereal disease. Hence, he explains, in the fol- lowing terms, the three ways, in which he thought a bubo might arise in con- sequence of absorption. He observes, that the first and most simple manner, is when the matter, either of a gonor- rhoea, or chancre, has only been applied to some sound surface, without having produced any local effect on the part; but, has been absorbed, immediately after its appbeation. Mr. Hunter af- firms, that lie has seen instances of this kind, though, he confesses they are very rare, and, that, in most cases apparent- ly of tins nature, a small chancre m.;v be found to have existed. I'he second mode of absorption, or that taking place in a gonorrhoea, Mr. Hunter represents as more frequent. The third mode is the absorption of matter from an ulcer, which may either be a chancre, or a bubo. This mode is by far the most common, and, it proves, with many other circumstances, that a sore, or ulcer, is the most favourable for absorption. Mr. Hunter believed, that absorption was more apt to take place from sores on the prepuce, than those on the glans, and he says, he bad seen more buboes from chancres in the first situation. A fourth mode of absorption from a wound is also an occasional occurrence. Mi. Hunter notices, that, what is now commonly understood by a bubo, is a swelling, taking place in the ab- sorbing system, especially, in the glands, arising from the absorption of some poison, or other irritating matter. When such swellings take place in tiie groin, they are called buboes, whether they proceed from absorption, or not. Mr. Hunter regards every abscess in the absorbing system as a bubo, whe- ther in the vessels, or the glands, when the complaint originates from the ab- sorption of venereal matter. The matter is taken up by the ab- sorbent vessels, and is conveyed by them into the circulation. In its pas- sage through these vessels, it often af- fects them with specific inflammation. 408 VENEREAL DISEASE. The consequence is the formation of buboes, which are venereal abscesses. These are exactly similar to a chancre in their nature and effects, the only difference being in regard to size. As the lymphatic vessels and glands are irritated by the specific matter, before it has undergone any change in its pas- sage, the inflammation produced, and the matter secreted, partake of the specific quality. Inflammation of the absorbent ves- sels themselves is not nearly so fre- quent, as that of the glands. In men, such inflammations, in consequence of chancres upon the glans, or prepuce, generally appear, like a cord, leading along the back of the penis from the sores. Sometimes, the absorbents in- flame, in consequence of the thicken- ing and excoriation of the prepuce in gonorrhoea. The indurated lymphatics often terminate insensibly near the root of the penis, or near the pubes; while, in other instances, they extend further to a lymphatic gland in the groin. Mr. Hunter believed, that this affection of the absorbent vessels is truly venereal. The formation of a hard cord, the same author conceived, arose from a thicken- ing of the coats of the absorbents, and from an extravasation of coagulable lymph on their inner surface. A cord, of the above kind, often sup- purates, sometimes in more places, than one, so as to form one, two, or three buboes, or small abscesses in the body of the penis. Inflammation much more frequently affects the absorbent glands, than the vessels. The structure of tiie former parts appears to consistof the ramificati- ons and reunion ofthe absorbent vessels. From this structure, observes Mr. Hun- ter, we may reasonably suppose, that the fluid absorbed is in some measure detained in these glands, and thus has a greater opportunity of communica- ting the disease to them, than to the distinct vessels. Swellings of the absorbent glands may originate from other diseases, and such should be carefully discriminated from those, which arise from the vene- real poison. With this view, Mr. Hunter advises us first to inquire into the cause, in order to ascertain, whether there is any venereal complaint at some greater distance from the heart, such as chan- cres on the penis, or any preceding disease in this situation. He recom- mends us to inquire, whether any mer- curial ointment has been at all applied to the leg and thigh on the diseased side; for, mercuiy applied to those parts for the cure of a chancre, will some- times cause glandular enlargements, which are occasionally mistaken for venereal ones. Mr. Hunter also reminds us to observe, whether there has been any preceding disease in the consti- tution, such as a cold, fever, &c. The quick, or slow, progress of the swell- ing, is likewise to be marked, and the tumour must be distinguished from fe- moral hernia, lumbar abscesses, and aneurisms of the crural artery. Sometimes, the venereal matter does not produce its effects on the absorbent glands, for some time after absorption has taken place. In certain instances, Mr. Hunter notices, that, at least, six days have elapsed; a circumstance, which could only be known by the chancres havng been healed six days before the bubo began to appear. How- ever, Mr. Hunter infers, that the mat- ter had been much longer absorbed, as the last matter of, a chancre is proba- bly not venereal. Mr. Hunter next remarks, that the glands, nearest to the seat of absorp- tion, are in general the only ones, which are attacked. Thus, when the matter has been taken up from the penis in men, the inguinal glands are affected; and, when from the vulva in women, those glands swell, which are situated between the labia and thigh, and the round ligaments. It was one of Mr. Hunter's opinions, that only one gland at a time is com- monly affected by the absorption of ve- nereal matter. If this sentiment be cor- rect, the circumstance may be consi- dered as a kind of criterion between venereal and other buboes. The second order of lymphatic vessels and glands are never affected; as, for instance, those along the iliac vessels, or back. Mr. Hunter informs us, that he has alsa observed, that, when the disease was contracted by a sore, or cut upon the finger, the bubo occurred a little above the bend ofthe arm, by the side ofthe biceps muscle, and no swelling of thi* sort formed in the armpit. However, he mentions his having heard of a few rare cases, in which a swelling in the axilla was also produced. VENEREAL DISEASE. 409 VV hen buboes arise from a venereal disease on the penis, they are situated in the glands of the groin. When a bu- bo arises from a gonorrhoea, either groin may be attacked. But, when the disease originates from a chancre, the bubo most frequently takes place in the near- est groin. The situation of the absorbent glands, however, is not always exactly the same, and the course of the lymphatics there- fore is subject to some variety. Hence, Mr. Hunter has seen a venereal bubo, produced by a chancre on the penis, situated a considerable way down the thigh; he has also often seen buboes as high as the lower part ofthe belly, be- fore Poupart's ligament; and sometimes near tiie pubes. BUBOES IN WOMEN. The seat of absorption is more ex- tensive in the female sex, and the course of some of the absorbents is also diffe- rent. Hence, buboes in women may oc- cur in three situations, two of which are totally different from those in men. When chancres are situated forwards, near the meatus urinarius, nymphx, cli- toris, labia, or mons veneris, the absorb- ed matter is generally conveyed along one, or both of the round ligaments, and the buboes are formed in those lig- aments, just before they enter the ab- domen. Mr. Hunter suspected such bu- boes not to be glandular ones; but, only inflamed absorbents. When chancres are situated far back, near, or on the perinxum, the absorbed matter is carried forward along the an- gle, between the labium and the thigh, to the glands in the groin, and often, in this course, there are formed small bu- boes in tiie absorbents, similar to those abscesses, which occur on the penis in men. When the effects of the poison do not rest here, a bubo in the groin may be occasioned, in the same manner as in men. It is more difficult to learn, whether a bubo is venereal in women, than men, owing to the frequent difficulty of as- certaining, that there is no infection present. In men, who have had no lo- cal complaint, the bubo can only be venereal, when direct absorption from tbe surface of the skin has taken place. MANNER IN WHICH BUBOES MAKE THEIRAPPEARANCE, &C A bubo, says Mr. Hunter, commonly begins with a sense of pain, which leads the patient to examine the part, where a small hard tumour is to be felt. This increases, like every other inflamma- tion, that has a tendency to suppura- tion, and, unless checked, pus forms, and ulceration follows, the matter mak- ing its way to the skin very fast. The above celebrated writer remarks, however, that there are some cases, which are slow in their progress. This circumstance he imputes either to the inflammatory process being kept back by mercury-, or other means, or by its being retarded by a scrophulous ten- dency. The inflammation, he says, is at first confined to the gland, which may be moved about in the cellular membrane; but, when the pail has become enlarg- ed, or when the inflammation, and sup- puration, are more advanced, the sur- rounding parts become more inflamed, and the tumour is more diffused. Some buboes, become complicated with an erysipelatous and oedematous affecti- on, by which means, they are rendered more diffuse, and less disposed to sup- purate. Mr. Hunter allows, that to distin- guish, with certainty, the true venereal bubo from swellings ofthe glands in the groin, may be very difficult. He repre- sents the true venereal bubo, in conse- quence of a chancre, as being most commonly confined to one gland. It preserves its specific distance till sup- puration has taken place, and then be- comes more diffused. It is rapid in its progress from inflammation to suppu- ration and ulceration. The suppuration is commonly large, considering the size of the gland, and there is only one ab- scess. The pain is very acute, and the inflamed part of the skin is of a florid red colour. Mr. Hunter describes such buboes, as arise without any visible cause, as being of two kinds. One sort inflame and suppurate briskly. These he always suspected to be venereal, although he allows, there was no proof of it, and only a presumption deduced from the quick progress of the disease. Vol. II. SP 4-10 VENEREAL DISK ASF.. The second kind are generally pre- ceded, and attended with slight texer, or the common symptoms of a cold, and they are generally indolent and slow in their progress. If they are quicker, than ordinary, they become more diffused, than venereal ones, and they may not be confined to one gland. Wlien very slow, they give but little sensation; but, when quicker, the sen- sation is more acute, though not so much so as in venereal cases. They usually do not suppurate, < and often become stationary. When they do sup- purate, it is in a slow manner, and, fre- quently, in more glands, than one, while the inflammation is more diffused, and not considerable, in relation to the swelling. The matter makes its way to the skin slowly, and the pail affected is of a more purple colour. Sometimes, the abscesses are very large, yet not painful. ' In considering whether the swellings of the inguinal glands are, or are not venereal, the first thing to be attended to is, whether, or not, there are any ve- nereal complaints. It* there are none, Mr. Hunter observes, that there is a strong presumptive proof, that the swellings are not venereal. When the swelling is only in one gland, very slow in its progress, and gives but little, or no pain, it is probably merely scrophu- lous. However, when the swelling is considerable, diffused, and attended with some inflammation and pain, the constitution is most probably affected with slight fever, the symptoms of which arc lassitude, loss of appetite, want of sleep, small quick pulse, and an appearance of approaching hectic. Such swellings are long in getting well, and do not seem to be affected by mer- cury, even when very early applied. Mr. Hunter mentions his having seen the above affection of the groin, together with the constitutional indis- position, take place when there were chancres; and he was puzzled todeter- mine, whether the disease in the groin was sympathetic, from derangement of the constitution, or from the absorption of matter. He had long suspected, that there was a mixed case, and was at last certain, that such a case may pre- vail. He says, he had seen instances, in which the venereal matter, like a cold, or fever, only irritated the glands to disease, producing in them scrophula, to which they were disposed. In such cases, says Mr. Hunter, the swellings commonly arise slowly, give but little pain, and seem to be rather hastened in their progress, if mercury is given to destroy the venereal disposi- tion. Some suppurate while under this resolving course; and others, which probably had a venereal taint at first, become so indolent, that mercuiy has no effect upon them, and, in the end, they either get well of themselves, or by other means. Mr. Hunter states, that buboes are undoubtedly local complaints. TREATMENT OF BUBOES. When a bubo is certainly a venereal one, and only in an inflamed state, an attempt is to be made to resolve the swelling. The propriety of the attempt, however, depends on the progress, which tbe disease has made. If the bubo be very large, and suppuration appears to be near at hand, resolution is not likely to be effected. When sup- puration has already taken place, Mr Hunter much doubted the probability of any success attending the endea- vour, which now might possibly only retard the suppuration, and protract the cure. The resolution of these inflamma- tions, says Mr Hunter, depends prin- cipally on mercury, and almost abso- lutely on the quantity, wliich can be made to pass through them. When sup- puration has taken place, the cure also depends on the same circumstances. The quantity of* mercuiy, which can be made to pass through a bubo, is represented by Mr. Hunter, as depend- ing principally on the quantity of" exter- nal surface of absorption beyond the bubo. However, Mr. Hunter accurately no- tices, that the situation of* many buboes is such, as not to have much surface for absorption beyond them; for in- stance, the buhoes on the body of the penis, arising from chancres on the glands, or prepuce. When the bubo is in the groin, Mr. Hunter recommends surgeons to pay attention whether the swelling is in the upper part of the thigh and groin, on the: lower part of the belly before Poupart's ligament, or near the pubes. When the buboes are situated on the body of the penis, the absorbents, lead- ing directly from Qie seat of absorp- VENEREAL DISEASE. 411 t'on are themselves diseased. When the bubo is in the groin, and, at the upper part of the thigh, we may conclude, that the lymphatics, both from the pe- nis and thigh, run to the affected gland. .When the bubo is high up, or .on the lower part of the belly, before Pou- part's ligament, probably, the absorb- ents, which arise from about the groin, lower part of the belly and pubes, pass through the bubo. When the bubo is far forward, the absorbents of the pe- nis and skin about the pubes, pass through the swelling. Mr. Hunter con- tends, that the knowledge of these cir- cumstances is very necessary, in order to apply mercury in the most advan- tageous situations. The utility of rubbing the mercury into surfaces, the absorbents of which lead through the bubo, must be obvi- ous, when it is considered, that the medicine cannot pass to the common circulation, without going through the diseased parts; that it must promote the cure, as it passes through them; and that it also prevents the matter, which has already passed, and is still continuing to pass into the constitution, from acting there. Thus the bubo is cured, and the constitution, at tiie same time, preserved. Mercury alone, however, is not al- ways capable of effecting the cure of buboes. When the inflammation rises very high, bleeding, purging, and foment- ing, are generally recommended. When the inflammation was erysipelatous, Mr. Hunter had a high opinion of bark; and, when it was scrophulous, he used to recommend hemlock, and poultices made with sea-water. The same eminent writer also takes notice of the fact of emetics sometimes occasioning the absorption of buboes, even after they contain matter. 1. Resolution ofthe Inflammation ofthe Absorbents on the Penis. Though there is not surface enough beyond the bubo, for rubbing-in a suf- ficient quantity of mercury, to prevent the effects of* absorption, Mr. Hunter still advises this surface to be kept con- stantly covered with mercurial oint- ment In consequence of the surface in question being so small, more mercury must also be conveyed into the system bv the mouth, or frictions on some other part Mr. Hunter observes, that this is necessary, both in order to pre- vent a lues -venerea, and to cure the parts themselves. The quantity of mer- cury must be regulated by the appear- ances of the original complaint, and the readiness, with which the disease gives way. The same method, he adds, is to be followed in women, and the oint- ment should be kept continually appli- ed to the inside and outside of the labia. 2. Resolution of Buboes in the Groin. The inflammation of the absorbent glands is to be treated on the same principle as that of the vessels. In the first case, however, we are able to make a larger quantity of mercury pass through the diseased parts. When the bubo is in the groin, the mercurial ointment is to be rubbed on the thigh. This surface, as Mr. Hunter remarks, will in general absorb as much mercu- ry as will be sufficient to resolve the bubo, and preserve the constitution from being contaminated; but, when resolution does not readily take place, the same author advises us to increase the surface of friction, by rubbing the ointment upon the leg. - When the bubo is on the lower part of the belly, the ointment should be rubbed also on the penis, scrotum, and belly. The same plan should be fol- lowed when the bubo is still more for- ward. Mr. Hunter states, that when the bu- bo gives way, the mercurial frictions must be continued, till it has entirely subsided, and, perhaps, longer, on ac- count of the chancre, which may not yield so soon as the bubo. After the bubo has suppurated, Mr. Hunter is doubtful, whether rubbing-in mercury is useful, or not. 3. Resolutiom of Buboes in Women. When the swellings are situated be- tween the labia and thigh, Mr. Hunter recommends the mercurial ointment to be rubbed-in all about the anus and buttock, from which parts the absorb- ents probably run through the seat of the diseases. When the buboes are in the round ligaments, the surface for absorption will not be large enough, and more mercury must be internally given, or rubbed into otiier surfaces. When the bubo is in one of tiie in- guinal glands, the same plan is to be adopted, as in the same case in men. 118 V ENEREAL DISEASE. 4 Buboes in unusual Situations. When buboes form in the arm, or arni-pit, in consequence of the absorp- tion ->f venereal matter from wounds on :he hands or fingers, mercurial oint- m.it should be rubbed on the arm and fore-.- in. Mr Hunter adds, however, that thib surface may not be sufficient, so that it may be proper to convey more mercury into the system in other ways. He states, that he has seen a true ve- neres 1 chancre on the middle of the lower lip, attended with a bubo, on each side of the neck, under the lower jaw, close to the maxillary gland. The swellings were resolved by applying mercurial ointment to them, and tiie chin, and lower lip. 5. Quantity of Mercury necessary for the Resolution of a Bubo. Mr. Hunter observes, that the quan- tity of mercury, necessary for the reso- lution of a bubo, must be proportioned to the obstinacy of" the complaint; but, that care must be taken not to extend the employment of the medicine so far as to produce certain effects on the con- stitution. When the bubo is in a situa- tion, which admits of a large quantity of mercury being rubbed in, so as to pass through the swelling, and when the complaint readily yields to the use of half a dram of mercurial ointment, every night, the mouth not becoming sore, or at most, only tender, the above author thinks it sufficient to pursue this course, till the gland is reduced to its natural size. In this manner, the con- stitution will probably be safe, provided the chancre, which may have caused the bubo, heals at the same time. When (he mouth is not affected in six, or eight days, and the gland does not readily re- solve, then two scruples, or a dram, may be applied every night; and, continues Mr. Hunter, if there should still be no amendment, even more must be rubbed >.n. In short (says he) if the reduction is obstinate, the mercury must be push- ed as far as can be done without a sali- vation. When there is a bubo on each side, so much mercury cannot be made to pass through each, as the constitution in general will not bear this method. However, Mr. Hunter sanctions the plan of minding the soreness of the mouih less in this kind of case; though, he adds, that it is better to let the bu- boes proceed to suppuration, than to load the system with too much mer- cury. When the situation of buboes will not allow an adequate quantity of ab- sorbed mercury to pass through them, the frictions must be continued in or- der to affect the constitution; but, ac- cording to Mr. Hunter, more mercury in this case will be requisite, than when the remedy can be made to pass direct- ly through the diseased gland. Many buboes remain swollen, with- out either coming to resolution, or sup- puration; and, notwithstanding every attempt to, promote these changes, the glands become hard and scirrhous. Mr. Hunter conceived, that cases of this sort are either scrophulous at first, or become so as soon as the venereal dis- position is removed. He advises the use of hemlock, sea-water poultices, and sea-bathing. 6. Treatment of Buboes which suppurate. The suppuration of buboes frequent- ly cannot be prevented by any known means. They are then to be treated, in some respects, like any other abscess. Before opening buboes, Mr. Hunter conceived it was advantageous to let the skin become as thin as possible, as a large opening would then become un- necessary, and no measures would be requisite for keeping the skin from closing, before the bottom of the sore had healed. Mr. Hunter thinks it doubtful, whe- ther the application of mercuiy should be continued through the whole suppu- ration. He was inclined to continue it; but, in a smaller quantity. There has been much dispute, whe- ther a bubo should be opened, or al- lowed to burst of itself, and whether the opening should be made with a cut- ting instrument, or caustic. On this sub- ject, Mr. Hunter remarks, that there is no peculiarity in a venereal abscess to make one practice, more eligible, than another. The surgeon, he says, should in some degree be guided by the patient. Some patients are afraid of caustics; others, of cutting instru- ments. But, when the surgeon has the choice, Mr. Hunter expresses a prefe- rence to opening the bubo with a lancet, in which method, no skin is lost. But, he observes, that when a bubo is very large, and there will be a great deal of loose skin, after the discharge of the VENEREAL DISEASE. 413 matter, he thinks, that caustic may, perhaps, be better, as it will destroy some of the redundant skin, and occa- sion less inflammation, than what is caused by an incision. The kali purum with the calx viva is the caustic com- monly employed. After the bubo has been opened, sur- geons usually poultice it, as long as the discharge and inflammation are considerable, and then they employ dressings, which must be of such a quality, as numerous undescribable cir- cumstances may indicate. The use of mercury, in the mean while, is to be continued, both to make the bubo heal, and prevent the bad effects, which might otherwise arise from the matter continually absorbed. The mercury should also be so rubbed in, as to pass, if possible, through the diseased groin. The mercurial course is to be pur- sued, till the sore is no longer venereal. But, in general, since this point is diffi- cult to ascertain, the mercury must be given till the part has healed, and even somewhat longer, when the bubo has healed very quickly; for, the constitu- tion is afterwards very apt to become contaminated. However, mercury is not to be con- tinued thus long in all cases; for, as Mr. Hunter explains, buboes often as- sume, besides the venereal, other dis- positions, which mercury cannot cure; but, will even exasperate. CONSEQUENCES OF BUBOES. Sometimes, the sores, when they are losing, or entirely deprived of the ve- nereal disposition, become changed in- to ulcers of another kind, and, most probably, of various kinds. How far it is a disease arising from a venereal taint, and the effects of a mercurial course jointly, says Mr. Hunter, is not certain. This writer suspected, howe- ver, that the nature of the part, or con- stitution, had a principal share in the malady. Mr. Hunter observes, that such dis- eases make the cure of the venereal af- fection much more uncertain, because, when the sore becomes stationary, or the mercuiy begins to disagree, we are ready to suspect, that the virus is gone; but, this is not always the case. Per- haps, the action of the venereal poison is only suspended, and will commence a- gain, as soon as the other disease ceases. In these case9, Mr. Hunter recom- mends attacking the predominant dis- ease; but, ne allows there is difficulty in ascertaining its nature, and finding out, whether it is venereal, or not. The same author also acquaints us, that he has seen some buboes exceed- ingly painful and tender to almost eve- ry thing, that touched them, and the more mild the dressings were, the more painful the parts became. In some instances, the skin only seems to become diseased. The ulcera- tion spreads to the surrounding integu- ments, while a new skin forms in the centre, and keeps pace with the ulcera- tion, so that an irregular sore, which Mr. Hunter compares with a worm-eat- en groove, is formed all round. It ap- pears only to have the power of con- taminating the parts, which have not yet been affected; and those, which have, readily heal. When buboes become stationary, and seem little inclined to spread, attended with a sinus, or two, hemlock, joined with bark, is, according to Mr. Hunter, the medicine most frequently servicea- ble. It is best to use it both externally and internally. The same author also speaks favourably of sarsaparilla, sea- bathing, and sea-water poultices. He states, that at the Lock Hospital, gold- refiners' water has been found a useful application; that, in some cases, drink- ing large quantities of orange-juice, and in others taking mezereon, have been found serviceable. LUES VENEREA. Surgeons imply, that a lues venerea has taken place, when the venereal virus ' has been absorbed into the circulation. Mr. Hunter does not think the epithet constitutional strictly proper in its appb- cation to this form of the venereal dis- ease. By constitutional disease, he ob- serves, he should understand that, in which every part of the body is acting in one way, as in fevers of all kinds; but, the venereal poison seems to be only diffused through the circulating fluids, and, as it were, to force certain parts of the body to assume the vene- real action, which action is perfectly local. To use Mr. Hunter's phrase, it takes place in different parts in a regu- lar succession of susceptibilities. Only a few parts are acting at the same time.; and a person may be constitutionally 414 VENEREAL DISEASE. affected in this way, and yet almost every function may he perfect The venereal poison is generally con- veyed into the system from a chancre. Tt "mav, also, accordingto Mr. Hunter's doctrine, be absorbed from a gonor- rhoea. There is likewise a possibility of its getting into the circulation from the surface ofthe body, without any previ- ous ulceration. It may be absorbed from common ulcers, without necessarily ren- dering these venereal; and it may be taken up from wounds, in which cases, it in general induces a previous ulcera- tion i!. ehe wound. venereal ulcers. In consequence of the blood being contaminated with real venereal pus, it might be expected, that the local ef- fects, thus produced, would be similar in their nature to those, producing them. Mr. Hunter believetl, that this is not the case. II. notices, that the local effects, from a constitutional contami- nation, are all of one kind, viz. ulcers, let the effects make their appearance on any surface whatever* either the throat, or common skin. But, Mr. Hun- ter conceived, that if the matter, when in the constitution, were to act upon the same specific principles, as th»t, which is externally applied, a gonor- rhoea would arise, when it affected a ca- nal, and, only sores, or chancres, when it attacked other surfaces. Mr. Hunter found, that even the sores, which are caused in the throat, arc very different from chancres. He sav-<-., that the true chancre produces considerable inflammation, often at- tended with a great deal of pain, and quickly followed by suppuration. But, the local effects, arising from the virus in the constitution, are slow in their progress, attended with little inflam- mation, and are seldom or ever painful, except in particular parts. However, Mr. Hunter allows, that this sluggish- ness in the effects of the poison depends on the nature ofthe parts diseased; and, he owns, that when the tonsils, uvula, or nose, are affected, the progress of the morbid mischief is rapid, and bears a greater resemblance to a chancre, than when it occurs on the skin. Even, in those parts, Mr. Hunter thought, the ulcers were attended with less inflam- mation, than chancres, which were spreading with equal celerity. The matter, secreted by such sores, as arise from a constitutional contami- nation, was alwav s considered, before the time of Mr. Hunter, as being of a poisonous quality, like the matter of a clu-.ncre. At first, one would certainly expect, that this was actually the case, because venereal matter is the cause, ami mercury cures chancres, and also ulcers proceeding from a lues venerea. Mi-. Hunter remarks, however, that the latter circumstance is not a decisive proof, since mercury is capable of cur- ing many diseases, besides the vene- real. He also takes notice, that, when pus is absorbed from a chancre, it ge- nerally produces a bubo; but, that a bu- bo is never occasioned by the absorp- tion of matter from a venereal sore., arising from the virus diffused in the circulation. Kor instance, when there is a venereal ulcer in die throat, no bu- boes occur in the glands of the neck; when there are syphilitic sores on the arms, or even suppurating nodes on the ulna, no swellings form in the glands of the arm-pit, although these com- plaints occur, when fresh venereal mat- ter is applied to a common sore on the arm, hand, or fingers. No swelling is produced in the groin, in consequence of nodes, or blotches on the legs and thighs. Some very important experiments are related in Mr. Hunter's Treatise on the Venereal Disease, in order to show, that the matter from a gonorrhoea, or chancre, is capable of affecting a man locally-, who has already got a lues ve- nerea, and that the matter from secon- dary syphilitic sores has not the same power. The particulars, however, are too long to be inserted in this book. PARTS MOST SUSCEPTIBLE OF THE LUES VENEREA, &C. Some parts of the body seem to be much less susceptible of the lues ve- nerea, than others; indeed, Mr. Hun- ter observes, that, as far as our know- ledge extends, certain parts cannot be affected at all. The brain, heart, sto- mach, liver, kidneys, and several other viscera, have never been known to be attacked by the lues venerea. The first order of parts, or those, which become affected in the early- stage of the lues venerea, are the skin, tonsils, nose.throat, inside ofthe mouth, and sometimes the tongue. The second order of parts, or those, which are affected at a later period, are the pei-,*u urn, fascia:, and bones. VENEREAL DISEASE. 415 Mr. Hunter conceived, that one great reason of the supeificial parts of the body suffering the effects of the lues venerea, sooner than the deep-seated ones, depended on the former being more exposed to external cold. Even the second order of parts do not all be- come diseased at the same time, nor eveiy where at once. But, on the con- trary, it is observed, that, those, which are nearest the external surface of" the body, are first diseased, as, for instance, the periosteum, or bones of the head, the tibia, ulna, bones of the nose, &c. Neither does the disease affect these bones on all sides equally; but, first on that side, which is next to the exter- nal surface. Mr. Hunter notices, howe- ver, that the susceptibility of particular bones does -not altogether depend on their nearness to the skin; but, on this circumstance, and their hardness toge- ther. After many ingenious observations, Mr. Hunter presents the reader of his treatise with the following-summary of his doctrines of the lues venerea. First; that most parts, if not all, that are affected in the lues venerea, are af- fected with the venereal irritation at die same time. Secondly; that the parts, exposed to , cold, are the first which admit the ve- nereal action; then the deeper-seated parts, according to their susceptibility for such action. Thirdly; the venereal disposition, when once formed in a part, must neces- sarily go on to form the venereal ac- tion. Fourthly; that all parts of the body, under such disposition, do not run into action equally fast, some requiring six or eight weeks; others, as many months. Fifthly; in the parts, which first come into action, the disease continues to in- crease, without wearing itself*out; while those, which are second in time, follow the same course. Sixthly; mercury hinders a disposi- tion from forming, or, in other words, prevents contamination. Seventhly; mercuiy does not destroy a disposition already formed. Eighthlv; mercuiy hinders the action from taking place, although the dispo- sition be formed. Ninthly; mercury cures the action. On these principles, Mr. Hunter as- serts that the cure of the disease may- be easily cxpla'uied. SYMPTOMS OF LUES VENEREA. Mr. Hunter remarks, that the time, necessary for the appearaflce, or pro- duction of the local effects, in parts most susceptible of the disease, after tiie virus has got into the constitution, is uncertain; but, he snys, in general, it is about six-weeks; in many cases, the period is much longer; in other instan- ces, it is shorter. Sometimes, the local effects make their appearance within a fortnight after the possibility of absorp- tion. The effects, on other parts ofthe bo- dy, which are less susceptible of the venereal irritation, or slower in their action, are of course much later in making their appearance. Mr. Hunter also notices, that when the first and se- cond orders of parts are both contami- nated, the effects, generally, do not be- gin to appear in the latter, till after a considerable time, and, sometimes, not till those affecting the former parts have been cured. Mr. Hunter, however, mentions his having seen instances, in which the pe- riosteum, or bone, has been affected be- fore any of the first order of parts; but, he was uncertain, whether the skin, or throat, would afterwards have become diseased, as the disorder was not allow- ed to go On. In the first order of parts, most sus- ceptible of the effects of lues venerea, the disease is much quicker in its pro- gress, than in the second order of parts. Mr. Hunter represents, that the symp- toms in each succeeding part, which becomes affected, are slower and slow- er in their progress, and of a more fix- ed kind. It was also an observation, made by the same ingenious writer, that similar parts come sooner into ac- tion, and appear to go on more rapidly with it, in proportion as they are nearer the source of the circulation. The dis- ease appears earlier on the face, head, shoulders, and breast, and the erup- tions suppurate sooner, than on the legs. SYMPTOMS OF THE FIRST STAGE Ol TIIE LUES VENEREA. According to Mr Hunter, the first symptoms of the disease, after absorp- tion, appear either on the skin, or in the tluioat. or mouth. 416 VENEREAL DISEASE VENEREAL ERUPTIONS. The appearances on the skin gene- rally occur all over the body. The dis- colorations make the skin appear mot- tied, and many of the eruptions disap- pear, while others continue, and in- crease with the disease. In other cases, the eruption comes on in distinct blotches, which are often not observed, till the scurfs have begun to form. At other times, the eruption as- sumes the appearance of small distinct inflammations, containing matter, and resembling pimples, not being, howe- ver, so pyi:.midal, nor so red at the base. Mr. Hunter also observes, that venereal blotches, on their first coming out, are often attended with inflamma- tion, which gives them a degree of transparency, which is generally great- er in the summer, than the winter, es- pecially, if the patient be kept warm. In a little time, ,this inflammation dis- appears, and the cuticle peels off in the form of a scurf. The latter occurrence often misleads the patient and the sur- geon, who look upon this dying away of the inflammation, as a decay of the disease, till a succession of scurfs un- deceives them. Mr. Hunter adds, that the discolorations of the cuticle arise from the venereal irritation, and are to be seldom regarded as a true inflam- mation, since they rarely have any of its characteristics, such as tumefaction and pain. However, he explains, that in parts which are well covered, or which are constantly in contact with other parts, there is more of the true inflammatory appearance, especially, about the anus. The parts affected next begin to alter their appearance, and form a copper- coloured, dry, inelastic cuticle, called a scurf. This is thrown off", and new ones are formed. Mr. Hunter relates, that these appearances spreael to the breadth of a sixpence, or shilling; but, seldom more extensively, at least, for a considerable time. In the mean while, every succeeding scurf becomes thicker and thicker, till at last it becomes a com- mon scab. Then the disposition for the formation of matter takes place in the cutis underneath, and a true ulcer is formed, which commonly spreads, al- though in a slow way. Mr. Hunter states, that these appear- ances arise first from the gradual loss ofthe true sound cuticle, which the dis- eased cutis cannot reproduce. As a kind of substitute for this want of cuticle, an exudation takes place, and forms a scale. The matter afterwards acquiring more consistence, at last forms a scab. How- ever, before the disease has attained this condition, the cutis has ulcerated, after which the discharge is more like true pus. When this form of the lues vene- rea attacks the palms ofthe hands and soles of the feet, where the cuticle is thick, this latter part first becomes se- parated, and peels off. A new one is immediately formed, which also sepa- rates. In this manner, a series of new cuticles takes place, in consequence of scurf's not being so readily formed as on the common skin. When the disease is confined to the palms of the hands, or soles of the feet, Mr. Hunter mentions, that there is difficulty in determining whether it is venereal, or not; because, most diseases of the cutis, in these si- tuations, produce a separation of the cuticle, attended with the same ap- pearances in all, and having nothing characteristic of the venereal disease. When the affected part of the skin is opposed by another portion of skin, which keeps it in some degree more moist, as between the nates, about the arms, between the scrotum and the thigh, in the angle between the two thighs, on the red part of the lip, or in the arm-pits, the eruptions, instead of being attended with scurfs and scabs, become accompanied by an elevation of the skin, which is swollen with extrava- satedlymph into a white, soft, moist, flat surface, which discharges a white mat- ter. A venereal eruption often attacks that part of the fingers, on which the nail is formed. Here, the disease ren- ders that surface red, which is seen shining through the nail; and, if allow- ed to continue, a separation of the nail takes place similar to that of the cuti- cle in the above cases. However, Mr. Hunter states, that there cannot be the same regular succession of nails, as of cuticles in other instances. Such surfaces of the body, as are covered with hair, may also be attack- ed, and the hair separates, and cannot be produced as long as the disease lasts. VENEREAL DISEASE OF THE THROAT, MOUTH, AND TONCUE. In the throat, tonsils, and inside of the mputh, the disease generally makes its appearanse at once in the form of VENEREAL DISEASE. 417 an ulcer, without much previous tume- faction. Consequently, the tonsils are not much enlarged, "it is observed by Mr. Hunter, that, the venereal inflam- mation attacks the surface of these parts, and very soon forms an ulcer. A venereal ulcer in the throat should be carefully distinguished from other kinds of sores in the same situation. The syphilitic one is in general tolera- bly well marked. However, Mr. Hunter confesses, that, it may not,in every in- stance be distinguishable from an ulcer of a diff'erent nature. Sores in the throat, which are really venereal, may resem- ble others, which are not so. The same celebrated author mentions, that there are several diseases of this part, which do not produce ulceration on the sur- face. One of these is common inflamma- tion of the tonsils. The inflamed place often suppurates in the centre, so as to form an abscess, which bursts by a small opening; but, never looks like an ulcer, that has begun upon the surface, like a true venereal one. The case, just al- luded to, is always attended with too much inflammation, pain, and tumefac- tion, of the parts, to be venereal. Also when it suppurates and bursts, it sub- sides directly, and it is generally at- tended with other inflammatory symp- toms in the constitution. Mr. Hunter next takes notice of ano- ther disease, consisting of an indolent tumefaction of the tonsils, and peculiar to many persons, whose constitutions are disposed to scrophula. The com- plaint produces a thickness in the speech. Sometimes, coagulable lymph is thrown out on the surface of the parts affected, and occasions appear- ances, which are by some called ul- cers; by some, sloughs; and occasion- ally, by others, putrid sore-throats. The case is attended with too much swelling to be venereal, and, with a little care, it may easily be distinguished from an ul- cer, or loss of substance. However, when this difference is not obvious at first sight, it is proper to endeavour to remove some of the lymph, and, if the surface of the tonsil underneath should appear to be free from ulceration, we may conclude with certainty, that the disease is not venereal. Mr. Hunter states, that he has seen a chink filled with coagulable lymph, so as to appear very much like an ulcer; but, on re- moving that substance, the tonsil un- derneath was found perfectly sound. He adds, that he has seen cases of a swelled tonsil, having a slough in its centre, which slough, before its detach- ment, looked very like a foul ulcer. The stage of the complaint, he says, is even more puzzling, when the slough has come out; for, then the disease has most of the characters of the venereal ulcer. Whenever he met with the dis- ease in its first stage, he always treat- ed it, as if it had been of the nature of erysipelas, or a carbuncle. When the complaint is in its second stage, with- out any preceding local symptoms, he recommends the practitioner to suspend his judgment, and to wait a little in or- der to see how far nature is able to re- lieve herself. If there should have been any preceding fever, the case is still less likely to be venereal. Mr. Hunter informs us, that he has seen a sore- throat of this kind mistaken for vene- real, and mercury given, till it affected the mouth, when the medicine brought on a mortification of all the parts con- cerned in the first disease. Another complaint of these parts, which Mr. Hunter represents as being often taken for a venereal one, is an ul- cerous excoriation, which runs along their surface, becoming very broad and sometimes foul, having a regular ter- mination, but, never going deeply into the substance ofthe parts, as the vene- real ulcer does. No part of the inside ofthe mouth is exempted from this ul- cerous excoriation; but, Mr. Hunter thought, that the disease most fre- quently occurred about the root of the uvula, and spread forwards along the palatum molle. He remarks, that the complaint is evidently not venereal, since it does not yield to mercury. He has seen these ulcerous excoriations continue for weeks, without undergo- ing any change, and a true venereal ul- cer make its appearance on the surface of the excoriated part. He says, that the excoriations in question have been cured by bark, after the end of the mer- curial course, which cured the syphili- tic sore. This author describes the true vene- real ulcer in the throat, as a fair loss of substance, part being dug out, as it were, from the body of the tonsil; it has a determined edge, and is com- monly very foul, having thick white matter, like a slough, adhering to it, and not admitting of being washed away. Ulcers in such situations are al ways kept in a moist state, and the matter cannot drv and form scabs, as Vol. II 3 V, 418 VENEREAL DISEASE. it does on sores upon the skin. The ul- cer is also much more rapid in its pro- gress, aiftl generally has tliickened edges. When lues venerea attacks the tongue, it sometimes produces a thick- ening and hardening of the part. How- ever, it also frequently gives rise to ul- ceration, as in other parts of the mouth. Venereal sores on the tongue, are ge- nerally more paiiiful, than those on the ■•kin; but, less so, than common sore- throats from inflamed tonsils. They ob- lige.the patient to speak thick, as if his tongue was too large for his mouth, with a small ilegree of snuffling. Mr. Hunter doubted the reality of a venereal ophthalmy, though he owns there are inflammations of the eyes, which yield to mercury. The ca^e, com- monly supposed to be venereal, is de- scribed in the article Ophthalmy. SYMPTOMS OF THE SECOND STAGE OF THE LUES VENEREA. The second order of parts, or those, which are commonly affected at a later period, may occasionally assume the ve- nereal action, before the disease has produced its local effects on the first order of" parts; and they may even go on with the action, in many cases, after these latter have taken on the action, and been cured. The periosteum, fasciae, tendons, lig- aments, and bones, are the parts, which are usually affected in the second stage of the lues venerea. Mr. Hunter re- marks, however, that we cannot always know with certainty what parts may be- come affected in this stage of the dis- ease. He says, he has known the dis- temper produce a total deafness, some- times followed by suppuration, and great pain in the ear, and side of the head. We have already explained, that it was one of this gentleman's doc- trines, that the second order of parts were generally deep-seated. When these become irritated by the poison, he ob- serves, that the progress of the disease is more gr. dual, than in the first order of parts. It assumes very much the cha- racter of scrophulous swellings, or chro- nic rheumatism; only it affects the joints, less frequently, than the latter affection does. A swelling sometimes makes its appearance on a bone, when there has been no possible means of catching the infection for many months; and, in consequence of the little pain experienced, the tumour may be of some considerable size, before it is no- ticed. Sometimes, a great deal of pain is felt; but, no swelling comes on, till after a long while. Mr. Hunter states, that these remarks are also applicable to swellings of the tendons, and fas- ciae. As tumours of this kind only in- crease by slow degrees, they are not at- tended with symptoms of much inflam- mation. When they attack the perioste- um, they seem like an enlargement of the bone itself, in consequence of being very firm, and closely connected with the latter part. Mr. Hunter also further observes, that, in these advanced stages of the disease, the inflammation can hardly get beyond the adhesive kind, in which state, it continues to become worse and worse, and when matter is formed, it is not true pus, but of a sli- my description. Some nodes, he says, both of the tendons and bones, last for years, before they form any matter at all. These eases, he mentions as not being certainly venereal, though com- monly considered as such. It is not easy to explain the reason, why, when lues venerea attacks the bones, or the periosteum, the pain should sometimes be very considera- ble, and, sometimes, very trivial. The pains are usually of a periodical kind, being, in general, most severe in the night-time. TREATMENT OF LUES VENEREA. The first order of parts, or those which are most susceptible of being af- fected in lues venerea, are also the ea- siest of cure, While the second order of parts take more time to be remedied. In the class of complaints, arising in the second stage of the lues venerea, Mr. Hunter believed, that it was unne- cessary to continue the employment of mercury, till all the swelling had dis- appeared. For, it is observed by this distinguished writer, that, since these local complaints cannot contaminate the constitution by reabsorption, and since the venereal disposition and ac- tion from the constitution can be cured, while the local effects still remain, and this even when the tumefaction, form- ing nodes on the bones, fasciae, &c. has proceeded to suppuration, there can be no occasion for continuing the course, after the venereal action has been de- stroyed. Mr. Hunter thought, that in this latter stage of tiie lues venerea, VENEREAL DISEASE. 419 the syphilitic irritation was more easy °ffCUr,Vh.an the swelling and other ettects of that irritation. Mercury, in the lues venerea, as well as in cases of chancres, is the great specific. In the present state of our knowledge, nothing else is to be de- pended upon. For an account of the various wavs of exhibiting this valuable medicine," I must refer the reader to the article Mercury, in this Dictionary. In curing the lues venerea, mercury can only have two modes of action; one on the poison; the other on the con- stitution. If, says Mr. Hunter, mereury acted on the poison only, one might conceive it did so, either by destroying its qualities, by decomposing it, or else by attracting it and carrying it out of the circulation. If mercury acted in the first of these ways, one would expect, that tiie cure would depend on the quantity of the medicine taken into the system. If it acted in the second man- ner, one would infer, that, the progress of the cure would be proportionate to the quantity of evacuation. But, ob- serves Mr. Hunter, if it act upon tbe principle of destroying the diseased action of the living parts, and of coun- teracting the venereal irritation, by producing one of a different kind, then neither quantity alone, nor evacuations, will avail much. He states, that the quickness of the cure depends on quan- tity, joined with visible effects. Howe- ver, it is added, that, although the ef- fects, which mercury has upon the ve- nereal disease, are in some degree pro- portioned to tiie local effects of the me- dicine on some of the glands, or parti- cular part of the body, as the mouth, skin, kidneys, and intestines, yet such effects are not altogether proportioned to these other circumstances. When mercuiy disagrees with the constitu- tion, so as to produce great irritability and hectic symptoms, this action, or ir- ritation, as Mr. Hunter explains, is not a counter-irritation to the venereal dis- ease. It was also noticed by the same au- thor, that the effects of mercury on lues v enerca, are always in proportion to the quantity of the remedy, exhibited in a given time, and the susceptibility ofthe constitution to the mercurial irritation. He says, that these circumstances re- quire the minutest attention, and, that, in order to obtain the greatest action of mercury with safety, and in the most effectual manner, the medicine must be given, tillit produces effects some- where. However, it must ndl be exhi- bited too quickly, in order that a suffi- cient quantity may be given, before we arc obliged to stop, in consequence of the effects. Mr. Hunter justly informs us, that when the local effects are pro- duced too quickly, they prevent a suf- ficient quantity of the remedy from be- ing taken into the system to counteract the venereal irritation at large. Mr. Hunter mentions his having seen some cases, in which mercury acted ve- ry readily locally, and, yet the consti- tution was hardly affected by it, for the disease would not give way. He states, that he has met with other cases, in which the mere quantity of mercury did not answer, till it was given so quickly as to affect the constitution in such a manner, as to produce local ir- ritation, and, consequently sensible eva- cuations. This, he observes, is a proof, that the local effects of mercury are often tiie sign of its specific effects on the constitution at large, and shows, that the susceptibility of the disease*! parts to be affected by the medicine, is in proportion to its effects on the mouth. Its effects, he contends, are not to be imputed to evacuation; but, to its irrita- tion. Hence, he inculcates, that mercu- ry should be given, if possible, in such a manner, as to produce sensible effects upon some parts of the body, and in the largest quantity, that can be given, to produce these effects within certain" bounds. Mr. Hunter also remarks, that these sensible effects should be the - means of determining, how far the me- dicine may be pushed, so as to have the greatest effect on the disease, without endangering the constitution. The prac- tice must vary according to circum- stances; and, if the disease is in a vio- lent degree, less regard must be had to the constitution, anei mercury must be thrown into the system in larger quantities. Mr. Hunter likewise acquaints us, that, when the disease is in the first order of parts, a smaller quantity of mercury is necessary, than when the second order of parts are affected, antl the disease has been of long standing. its first appearances alone being cured and the venereal disposition still re- maining in the secondary parts. For the purpose of curing the venereal dis- ease, whether in the form of chancre, bubo, or lue6 venerea, Mr. Hunter was 420 VENEREAL DISEASE. of opinion, that probably the same quantity of mercury is necessary. He represents*, that one sore requires as much mercury as fifty sores in the same person, and a small sore as much as a large one. He thought, that the only difference, if there is any, must depend upon the nature of the parts affected, that is, on their being natu- rally active, or indolent. He conceived, however, that, on the whole, recent venereal complaints are generally more difficult of cure, than the symptoms of lues venerea, and that this may make a difference, in regard to the quantity of mercury necessary. The principles above laid down, and other observations, contained in the ar- ticle Mercury, must suffice for the di- rection of the cure of lues venerea by this great specific remedy. Other infor- mation, connected with the subject, will be found by referring to Acidum JVitrosum, Guaiacum, Mezereon, Sarsa- parilla, &c. With respect to the local treatment of the symptoms of lues venerea, Mr. Hunter thought, that none would in general be necessary, since the consti- tutional treatment would commonly ef- fect a cure. The same writer notices, however, that sometimes the local effects will not give way, and the parts remain swollen in an indolent inactive state, even after there is every reason to be- lieve, that the constitution is perfectly cured. In such cases, he recommends assisting the constitutional treatment by local applications of mercury to the part, either in the form of a plaster, or ointment. The latter application, he says, is the best. When these are not sufficient, he advises an attempt to be made to excite inflammation of another kind. He says he has seen a venereal node, which gave excruciating pain, cured by merely making an incision down to the bone, the whole length of the node. The pain ceased, the swel- ling decreased, and the sore healed up kindly, without the assistance of a grain of mercuiy. He mentions, that blisters have been applied to nodes with suc- cess, removing the pain, and taking away the swelling. DISEASES RESEMBLING THE VENE- REAL PSEUDO-SYPHILIS. Sores on the glans penis, prepuce, 8ic. in the form of chancres, as Mr Hunter notices, may and do arise With- out any venereal infection, although in general they are a consequence of" for- mer venereal sores, which have been cured. The symptoms, produced by the vene- real poison in the constitution, are such as are common to many other diseases. For instance, Mr. Hunter remarks, that blotches on the skin are common to what is called scorbutic habit; pains are common to rheumatism; swellings of the bones, periosteum, fasciae, &.c. to many bad habits, perhaps, of the scrophulous and rheumatic kind, thus, says this va- luable writer, most of the symptoms of the venereal disease, in all its forms, are to be found in many other diseases. Hence the original cause, and many leading circumstances, such as dates, effects ofthe disorder upon others, from connexion, when only local, the previ- ous and present symptoms, &c. must be considered, before we can determine absolutely what the disease truly is. All the circumstances and symptoms, taken together, may be such, as will at- tend no other disease. However, Mr. Hunter confesses, that with all our knowledge, and with all the applica- tion of that knowledge to suspicious symptoms of this disease, we are often mistaken, calling distempers venereal, which are not so, and sometimes sup- posing really syphilitic affections to be of another nature Mr. Hunter takes notice, that, in some constitutions, rheumatism, in many of its symptoms, resembles the lues venerea. The nocturnal pains, swel- fing of the tendons, ligaments, and pe- riosteum, and pain in those swellings, are symptons both of the rheumatism, and also the venereal disease, when it attacks those parts. Mr. Hunter, how- ever, did not know, that he ever saw the lues venerea attack the joints, though many rheumatic complaints of such parts are cured by mercury, and therefore suppposed to be venereal. Mercury, given without caution, of- ten produces the same symptoms as rheumatism. Mr. Hunter has seen such complaints supposed to be venereal, and the medicine continued. This interesting author also explains, that some diseases not only resemble the venereal in appearance, but in the mode of contamination, proving them- selves to be poisons by affecting the part of contact; then producing imme-1 'Hate consequences similar to buboes. VENEREAL DISEASE. 421 and also remote consequences similar to the lues venerea. Mr. Hunter observes, that it is nearly as dangerous, in some constitutions, to give mercury, when the disease is not venereal, as to omit it in other cases, which are really syphiutic. Many of the constitutions, which put on some of the venereal symptoms, when the disease is not really present, are those, with which mercury seldom agrees, and com- monly does harm. Mr. Hunter has seen mercury, which was exhibited for a sup- posed venereal ulcer of the tonsils, pro- duce a mollification of those glands, and the patient was nearly destroyed. Mr. Abernethy, in his Surgical Ob- servations, 1804, has treated at some length of diseases resembling syphilis, and has adduced several very interest- ing cases, which I advise every surgi- cal practitioner to read with the great- est attention. The following case, re- corded by this gentleman, I shall take the liberty of quoting. "A gentleman (says Mr. Abernethy) thought, that he had infected a slight cut on his hand (which was situated in front of and just below the little finger) with the discharge from a bubo in the groin, that he had occasion to open. The wound fretted out into a sore about the size of a sixpence, which he showed me, and which I affirmed had not the thickened edge and base, and other characters of a venereal chancre. I therefore recommended him to try the effect of local means, and not to use mercury. " In about a month the sore, which had spread a little, became again con- tracted in its dimensions, and assumed an healing appearance. At this time pain was felt extending up the arm, and sud- denly a considerable tumour arose over the absorbing vessels, which proceed along the inner edge of the biceps mus- cle. This tumour became nearly as big as a small orange. As the original sore seemed now disposed to heal, and as there was no surrounding induration, I could not believe it venereal, and there- fore recommended him still to abstain from mercury, and apply leeches, and linen moistened in the aq. litharg. acet. comp. to the tumour formed over the inflamed absorbents. For it seemed to me, that if the venereal poison had been imbibed from the sore, it would have passed on to one ofthe axillary glands, and would have caused induration and inflammation to take place there, more slowly, than had occurred on the pre- sent occasion. " Under this treatment the tumour was discussed, and the sore at the same time healed. About three weeks after- wards the patient called on me, and said that there were venereal ulcers in his throat; and in each tonsil there was an ulcer deeply excavated, with irregular edges, and with a surface covered by adhering matter; ulcers, in short, which every surgeon who depends on his sight as his guide, would have pronounced to be venereal. Shortly after also, some copper-coloured eruptions appeared on his face and breast. He showed his dis- eases to several surgeons, on whose opi- nion he relied, who, without hesitation, affirmed that they were venereal, and that the mercurial course had been im- properly delayed. " Whilst the patient was looking out for lodgings, in order that he might go through the mercurial process, a cir- cumscribed thickening and elevation of the pericranium covering the frontal bone, appeared; it was of the circum- ference of an half-crown piece; and was, in short, what every surgeon, who is guided only by his sight and touch, would, without hesitation, have called a fair corona veneris. I now told the patient that I was more inclined to be- lieve his disease was not syphilitic, from the sudden and simultaneous oc- currence of this node with the sore throat, &c. Other surgeons thought differently; and I believe this very sen- sible and amiable young man imagined, that his health would become a sacri- fice, if he any longer attended to my opinion. He was preparing to submit to a mercurial course, when very impor- tant concerns called him instantly into the country. He went with great reluc- tance, taking with him mercurial oint- ment, &c: and after a fortnight I re- ceived a letter from him, saying that he found his complaints benefited by his journey, that business had prevent- ed him from beginning the use of mer- cury for a few days, that he now found it was unnecessary, for his symptoms had almost disappeared, and shortly afterwards he became perfectly well." Mr. Abernethy considers this case as the most unequivocal instance extant of a disease occurring, which could not from appearance be distinguished by surgeons of the greatest experience from syphilis, and which, however, was undoubtedly of a different nature. He 422 VENEREAL DISEASE. believes, that there is no one, who would not have decided on this case, as those'did who declared it to be vene- real, unless they had had an opportuni- ty of watching its progress very atten- tively. Mr. Abernethy, in the course of his remarks, makes it appear, that cases, which are venereal, and others, which are not, cannot in general be discrimi- nated by the mere aspect of the affec- tions. He believes, however, that there are some circumstances, in the pro- gress of such different distempers, from which a line of distinction might be drawn. A very simple fact has enabled this gentleman inmost cases to distinguish the two diseases: " yet, simple as it is, (says Mr. Abernethy,) if it be general- ly true, it is very important; and if it Were universally true, it would be of the highest consequence. The fact al- luded to is, that the constitutional symptoms of the venereal disease are generally progressive, and never disap- pear unless medicine be employed. It may be added too, they are as general- ly relieved under an adequate effect of mercuiy on the constitution, &c. " I have asked the opinion of several surgeons of great practice and abilities respecting this question; Whether con- stitutional symptoms of syphilis do ever spontaneously amend? and no one has decidedly replied in the affirmative, whilst all, without hesitation, agreed that they were generally progressive till checked by the effect of mercury. It seemed useless to seek further infor- mation; for what surgeon is there at present, if he sees diseases, that cannot be distinguished by the sight from sy- philis, and hears that they arose in con- sequence of a chancre, that would sus- pend his judgment, and forbear to ad- minister mercury? If I have lived in the habit of so frequently detecting the im- posing appearances ofthe secondary ef- fects of these diseases, it is because I have been upon the watch, and because they have occurred in patients, in whom I have seen the primary sores, the ap- pearance and progress of which have excited my suspicion as to their nature. I have stated the rule as general, but not universal; for I could myself relate cases of diseases, in wliich, from the great abatement, and even disappear- ance of symptoms, I have concluded the disease was not syphilitic; yet, from the duration of the disorder, or from the subsequent aggravation of its symp- toms, the patient has desired, and I have recommended the use of mercu- ry, and the disease has been treated as- venereal, without its real nature being ascertained. " The rule, which has been mention- ed, relates to the constitutional symp- toms of the venereal disease, for the primary ones, chancres, do sometimes heal spontaneously, generally however, though not constantly, Leaving a thick- ening or induration of the affected part. They may also be induced to heal by topical means, without mercury, with similar events. Some enlargements of glands in the groin will also in like man- ner subside. " It may be fairly supposed, that if some chancres heal spontaneously, that constitutional diseases arising from the same cause, may, in like manner, some- times get better without medicine. The administration of nitrous acid, opium, and other remedies have been said to have amended, if not entirely cured, these constitutional diseases. But the question is, will they get better sponta- neously? and the question can only be solved by experience. Delay will fre- quently enable a surgeon to decide; but, there are cases, in which no amend- ment takes place, and the surgeon is as it were forced, from the progress of the disease, to employ mercury. " In recommending prudent delay and attentive observation, I hope and believe, (continues Mr. Abernethy,) that I am not recommending any thing likely to be of dangerous consequence. The venereal disease is generally sobn checked by the use of mercuiy; and in constitutions, where much medicine is required to counteract its effects, that medicine may be given with freedom. By delay and observation, we perhaps may perceive, that eruptions and sore throats, which could not from appear- ance be distinguished from venereal, spontaneously amend: that some erup- tions scale, and become well, and the probability will of course be that the rest will do so likewise: or that an ul- cer mends in one part, though it may spread in another, when the natural in- ference is that the diseased actions in the sore will gradually cease, and health return spontaneously; and that what has occurred in one part of an ulcer, will successively take place in another. " In recommending delay it cannot, I suppose, be thought that I would advise VENEREAL DISEASE. 423 any one to wait till an ulcer destroyed the velum pendulum palati, or did ma- terial injury to any important part. There are cases where the progress of the disease obliges a surgeon to use mercury, even though he may be sus- picious that it is not syphilitic. The ef- fect of exciting a mercurial affection of the constitution in diseases resembling syphilis is, as far as my observation enables me to determine, very various. It sometimes cures them very suddenly and very differently from the gradual amendment, which it produces in truly venereal diseases. Sometimes, however, these diseases yield more slowly to its operation, and are cured permanently. Sometimes the diseases recur in the same parts after a severe course of mercury; sometimes mercury merely checks the disease, and can scarcely be said to cure it; in which case it seems important to support the strength of the constitution, and to keep up that mercurial effect which controls the disease, and can be borne without ma- terial derangement of the constitution for a great length of time. Sometimes also the use of mercury aggravates these diseases. " Again, in some constitutions, the venereal disease may assume unusual characters, and be very difficult of cure. It must then be scarcely possible to discriminate between these anomalous cases of syphilis and those of diseases resembling it, unless some new distinc- tions are discovered." (See Surgical Observations, by John Abernethy, F.R.S.) For information concerning the ve- nereal disease, the reader should par- ticularly consult Astruc de Morbis Ve- nereis. John Vigo's Whok Works in Chi- rurgerk, by Gak, 15&6; or the Latin edition, published at Leyden, in 1518. Fal- lopius de Morbo Gallico. Antonius Musa Brasavolus in the Aphrodisiacus. Ulricus de Hutten de Morbo Gallico. Boerhaavius de Lue Venerea, \2mo. 1751. Rondelettt Opera Omnia, Aito,- Genera, 1620. Mor- gagni de Sedibus et Causis Morborum. Francantianus de Morbo Gallico, 8vo. J'atav. 1563. Gataker on Venereal Com- plaints, 1754. Chapman on the Venereal Disease, 1770. Fordyce on the Venereal Disease, -with an Appendix, 1777. Plenck Doctrina de Morbis Venereis. B. Bell's Vr-eatise on Gonorrhoea Virulenta, and Lues Venerea, edit. 2. 1797. Lalonette's New Method of Curing Diseases by Fu- migation, 8vo. 1777. Hunter's Treatise on the Venereal Disease, edit. 2-; which is by far the most valuable tvork ever pub- lished on the subject. An Inquiry into some of the Effects of the Venereal Poi- son, £4c. by S. Surwrey, 1802. Observa- tions on the Effects of various Articles of the Materia Medico in the cure of Lues Venerea, edit. 2, 1807. Practical Obser- vations on the JVatural History and Cure ofthe Venereal Disease, 2 vol. 8vo. edit. 2. 1806. Practical Observations on Venereal Complaints, by F. S-wediaur, edit. 3. Aber- nethy on Diseases resembling Syphilis, in his Surgical Observations, 1804. Adams on Morbid Poisons, edit. 2. VENESECTION, (from vena, a vein, and sectio, a division.) The operation of opening a vein. Phlebotomy. This sub- ject has already been spoken of" in the article Bleeding. However, I wish to in- sert here a few directions, which were accidently omitted in that part of the Dictionary. In bleeding in the arm, the fillet is to be tied round the limb, a little above the elbow, with sufficient tightness to intercept the passage &f the Mood through all the superficial veins; but, never so as to stop the flow of blood through the arteries, which would tend to prevent the veins from rising at all. The veins being thus rendered turgid, the surgeon must choose the one which seems most conveniently situated for being opened, and large enough to fur- nish as much blood as it may be proper to take away. Before applying the fillet round the arm, however, tbe operator should al- ways feel where the pulsation of the artery is situated, and, if equally con- venient, he should not open the vein immediately over this part. It is also prudent to examine where a pulsation is situated, on account of the occasional varieties in the distribution of the arte- ries of the arm. The ulnar artery is sometimes given off from the brachial very high up, and, in this case, it fre- quently proceeds superficially over the muscles, arising from the internal con- dyle, instead of dividing under them, in the ordinary manner. In general, it is best to select a vein which rolls least under the skin. Such a vessel, though sometimes, not so su- perficial as another, may commonly be more easily opened. The operator, however, is always to fix the vein, as much as he can, by placing the thumb of his left hand a little below the place where he intends to introduce the lan- cet. 424 VERTEBR-iE, DISEASE OF. When the external jugular vein is to be opened, the surgeon generally makes the necessary pressure with his thumb. The orifice should be made in the di- rection of the fibres of the platysma myoides muscle; and the vein is not so apt to glide out of the way, when the surgeon makes the puncture just where it lies over a part of the sternocleido- mastoidens muscle. When blood is to be taken from the foot, tbe ligature is commonly applied a little above the ankle. The fillet having been put on the arm, the operator is to take the blade ofthe lancet, bent to a somewhat acute angle, between the thumb and fore-fin- ger, and, steadying his hand upon the other three fingers, he is to introduce the lancet, in an oblique direction, into the vessel, till the blood rises up at the point ofthe instrument. Then bringing up tiie front edge in as straight a line as possible, the wound in the skin will be made of just the same size as that in the vein. The operator next takes away the thumb of his left hand, with which he steadied the vessel, and al- lows the blood to escape freely, till the desired quantity is obtained. The arm ought to be kept in the same position while the blood is escaping, lest the skin should slip over tiie orifice of the vein, keep the blood from getting out, and make it insinuate itself into the cellular substance. When the blood does not issue freely, however, most surgeons direct the pa- tient to move his fingers, or turn some- thing round and round in his hand. This puts the muscles of the arm into action, and the pressure, they then make on the veins, makes the blood circulate more briskly through these vessels, The proper quantity of blood being discharged, the fillet is to be untied. The flow of blood now generally ceas- es; though sometimes, when the orifice is large, and the circulation very vigor- ous, it still continues. In this circum- stance, the operator may immediately stop the bleeding by placing the thumb of his left hand firmly on the vessel, a little below the puncture. VERRU'CA. A wart. (See Wart.) VE'RTEBRiE, DISEASE OF. In the present part of the Dictionary, I have little more to do, than insert some of the very excellent account, which Mr. Pott has left us of the affection, about to be considerc d The disorder, which w<- are going to consider, is a disease of the spine, attended with more, or less, complete loss of the power of using the legs. Mr. Pott mentions, that it has in ge- neral been called a palsy, and treated as a paralytic affection; to which it is in almost every respect perfectly unlike. This author observes, that the occa- sion of the mistake is palpable; the pa- tient is deprived of the use of his legs, and has a deformed incurvation of the spine; the incurvation is supposed to be caused by a dislocation of the vertebrae; the displaced bones are thoughtto make an unnatural pressure on the spinal marrow, and a pressure on that being very likely to produce a paralysis of some kind, the loss of the use of the legs is in this case determined to be such: the truth is, that there is no dis- location, no unnatural pressure made on the spinal marrow, nor are the limbs by any means paralytic, as will appear to whoever will examine the two com- plaints with any degree of attention. In the true paralysis, (says Mr. Pott,) from whatever cause, the muscles of the affected limb are soft, flabby, unre- sisting and incapable of being put into even a tonic state; the limb itself may be placed in almost any position, or posture; if it be lifted up, and then let go, it falls down, and it is not in the power of the patient to prevent, or even to retard its fall: the joints are perfect- ly and easily moveable in any direction; if the affection be of the lower limbs, neither hips, knees, nor ankles, have any degree of rigidity, or stiffness; but, permit the limb to be turned, or twist- ed, in almost any manner.. Mr. Pott next notices that in the present case, the muscles are indeed ex- tenuated, and lessened in size; but, they are rigid, and always at least in a tonic state, by which the knees and ankles acquire a stiffness not very easy to over- come; by means of this stiffness, mixed with a kind of spasm, the legs of the patient are either constantly kept stretched out straight, in which case considerable force is-required to bend the knees, or they are, by the action of the stronger muscles, drawn across each other, in such manner as to require as much to separate them: when the leg is in a straight position, the exten- sor muscles act so powerfully, as to re- quire a considerable degree of force to bend the joints of the knees; and, when they have been bent, the legs VERTEBRiE, DISEASE OF. 425 are immediately, and strongly, drawn up, with the heels toward the buttocks: by the rigidity of the ankle-joints, join- ed to the spasmodic action of the gas- trocnemii muscles, the patient's toes are pointed downward, in such manner as to render it impossible for him to put his foot flat to the ground: which makes one of the decisive characteris- tics of the distemper. These (says Pott) are strong marks of the distinction, which ought to be made between the two diseases; and, fully sufficient to show the impropriety of confounding them with each other. The majority of those, who labour under this disease, are infants, or young children: adults are by no means ex- empt from it; but Mr. Pott never saw it at an age beyond forty. Mr. Pott remarks, that, when it at- tacks a child, who is old enough to have walked properly, its awkward.and imperfect manner of using its legs, is the circumstance, which first excites attention, and the incapacity of using them at all, which very soon follows, fixes that attention, and alarms the friends. Mr. Pott tells us, that the account, most frequently given, is, that for some time previous to the incapacity, the child had been observed to be languid, listless, and very soon tired; that he was unwilling to move, much or brisk- ly; that he had been observed frequent- ly to trip and stumble, although no im- pediment lay in his way; that when he moved hastily, or unguardedly, his legs would cross each other involuntarily, by which he was often and suddenly thrown down; that if he endeavoured to stand still, and upright, unsupport- ed by another person, his knees would totter and bend under him; that he could not, with any degree of preci- sion or certainty, steadily direct either of his feet, to any particular point, but, that in attempting so to do, they would be suddenly, and involuntarily brought across each other; that soon after this, he complained of frequent pains and twitchings in his thighs, particularly when in bed, and of an uneasy sensa- tion at the pit of his stomach; that when he sat on a chair, or a stool, his legs were almost always found across each other, and drawn up under the seat; and that in a little time after these particulars had been observed, he to- tally lost the power of walking. These, continues Pott, are the gene- ral circumstances, which are found, at least, in some degree, and that pretty uniformly, in most infants and children; but, there are others, which are diffe- rent in different subjects. The same author observes, that if the incurvation be of the neck, and to a considerable degree, by affecting several vertebrae, the child finds it in- convenient and painful to support its own head, and is always desirous of lay- ing it on a table or pillow, or any thing to take off the weight. If the affection be of the dorsal vertebrae, the general marks of a distempered habit, such as loss of appetite, hard dry cough, labo- rious respiration, quick pulse, and dis- position to hectic, appear pretty early, and in such a manner as to demand at- tention: and as, in this state of the case, there is always, from the connexion be- tween the ribs, sternum, and spine, a great degree of crookedness of the trunk, these complaints are by every body set to the account of the deformi- ty merely. In an adult, the attack, and the progress of the disease, are much the same; but, there are some few cir- cumstances, which may be learned from a patient of such age, which either do not make an impression on a child, or do not happen to it. Mr. Pott states, that an adult, in a case, where no violence hath been com- mitted, or received, will tell you, that his first intimation was a sense of weak- ness in his back-bone, accompanied with what he will call a heavy dull kind of pain, attended with such a lassitude as rendered a small degree of exercise fatiguing: that this was soon followed by an unusual sense of coldness in his thighs, not accountable for from the weather, and a palpable diminution of their sensibility. That in a little time more, his limbs were frequently con- vulsed by involuntary twitchings, parti- cularly troublesome in the night: that soon after this, he not only became in- capable of walking, but that his power either of retaining or discharging his urine and feces, was considerably im- paired, and his penis became incapable of erection. The adult also finds all the offices of his digestive, and respiratory organs much affected, and complains constant- ly of pain and tightness at his stomach. Mr. Pott next continues; In infants^ the curve is seldom, noticed till it has got to such size and state, as to de- mand attention from the deformity: Vol. II. 3H 426 VERTEBRAE, DISEASE OF. previous to this, all the marks of dis- temper, which appear in the child, pass for tbe effects of general weakness, and are treated as such; differently by dif- ferent people, and under different cir- cumstances, but never with any perma- nent good effect; some of the adventi- tious symptoms, if I may so call them, are, in some degree, relieved, but the principal remain in full force, or, what is much more frequent, go on increas- ing. In an adult it passes for rheumatism, or gravel, or a strain, and the defect in the limbs is the first thing, that occa- sions in inquiry into the state ofthe back-bone. When a curvature, says Mr. Pott, is perceived in an infant, it is always sup- posed to have received a hurt by a blow, or fall, and an adult has always recourse to some exertion in pulling, drawing, lifting, cr carrying, by which the spine is thought to have been deranged, or injured; but which supposition is sel- dom, if ever true, in either case. The true cause of the disease, is a morbid state of the spine, and of some of the parts connected with it; which distempered state of parts will, upon careful inquiry, be always found to have preceded the deformity some length of time; in infants, this is the sole cause, and external violence has nothing to do with it. In the adult, (continues Mr. Pott,) I will not assert, that external mischief is always and totally out of the question; but, I will venture to af- firm, what is equal, as far as regards the true nature of the case, which is, that although accident and violence may in some few instances be allowed to have contributed to its more imme- diate appearance, yet the part, in which it shows itself, must have been previ- ously in a morbid state, and thereby predisposed for the production of it. I do not (says Pott) by this mean to say, that a violent exertion cannot injure the .spine, nor produce a paralytic com- plaint, that would be to say more than I know; but, I will venture to assert, that no degree of violence whatever is capable of producing such an appear- ance as I am now speaking of, unless the bodies ofthe vertebrae were by pre- vious distemper disposed to give way; and that no supposable dislocation, caused by mere violence done to the bones of the back, which bones were, before the receipt of the injury, in a sound state, can possibly be attended with the peculiar symptoms of a curved spine. In which distinction, according to my judgment, (observes Mr. Pott,) consists the very essence of the disease. Violence may easily be supposed to bring the two vertebrae nearer to each other than they ought to be, and by crushing an intermediate one to pro- duce a curvature; but, then the body of the vertebrae so crushed, must have been in a distempered state previous to such violence: great violence may also suddenly and immediately displace a perfectly sound vertebra, from its proper and natural situation, with re- gard to those annexed to it; but, the necessary consequences of these two kinds of injury, must be so veiy diffe- rent, that they never can be confound- ed together, or mistaken for each other even by the most inattentive observer. Mr. Pott nexi acquaints us, that the true curvature is invariably uniform, in being from within outwards; but, it va- ries in situation, in extent, and in de- gree; it affects the neck, the back, or the loins; it comprehends one vertebra only, or two, or more; and as few or more are affected, or, as these are more or less morbid, and, consequently give way more or less, the curve must be different; but, whatever variety these circumstances may admit, the lower limbs alone,* in general, feel the effect. Some are, very soon after the curva- ture, rendered totally and absolutely incapable, not only of walking, but of using their legs in any manner; others can make shift to move about with the help of crutches, or by grasping their thighs just above the knees with both hands; some can sit in an armed chair, * Since I began to put these papers together, (says Pott,) I have seen two cases, in one of which the arms only were affected, in the other both legs and arms. Mr. E. Ford, of Golden-square, has favoured me with the examination and case of a lad, who lost the use of both legs, and both arms, from a curvature Which Mr. Ford cured by means of the caustics.—Mr. Parke, of Liverpool has also obliged me with an account of two persons, both under his care, both with useless arms and legs, and both cured, by the same means. (Pott.) VERTEBRA, DISEASE OF. 42f without much trouble or fatigue; others cannot sit up with any help; «ome re- tain such a degree of power of using their legs, as to be able to shift their posture when in bed; others have no such power, and are obliged to be moved upon all occasions. Mr. Pott adds, that weak and deli- cate children are the most frequent sub- jects of this distemper; and when in these, it seizes on the dorsal vertebrae, great deformity of the trunk, both be- fore, and behind, is the almost inevita- ble and necessary consequence: this will be different in different persons; but, let tiie difference in this be what it may, it is an adjunct circumstance, and upon due inquiry it will always be found, that the curvature from within outward, preceded the other deformity, and was, at one time, the only one to be seen. Before the alteration of figure in the back-bone has been discovered, says Mr. Pott, all the attention is paid to the limbs, in which the whole disorder is supposed to reside; and all the applica- tions for refief are made to them: fric- tions, liniments, embrocations, blisters, &c. to which, is generally added cold bathing and electricity; when the cur- vature has been noticed, recourse is im- mediately had to back-boards, collars, steel boddice, swings, screw-cbairs, and other pieces of machinery, but all to no purpose; the patient becomes daily more and more helpless and unhealthy, languishes for more or less time, and at last dies, either in an emaciated state, from an hectic, or by a drain from an abscess, formed within the body. That this is the case, frequent and melancholy experience evinces; but, why it is so, is perhaps not generally so well understood, or attended to as it ought to be. Mr. Pott contends, that the primary and sole cause of all the mischief, is a distempered state of the parts compos- ing, or in immediate connexion with the spine, tending to, and most fre- quently ending in, a caries of the body, or bodies, of one or more of the verte- brae: from this proceed all the ills, whe- ther general, or local, apparent or con- cealed; this causes the ill health ofthe patient, and, in time, the curvature. The helpless state of tiie limbs, is only one consequence of several, proceeding from the same cause; but, though this effect is a very frequent one, and al- ways affects the limbs in nearly tbe same manner; yet, the disease not hav- ing its origin in them, no application made to them only, can ever be of any- possible use. The same failure of success (observes Mr. Pott) attends the use of the diffe- rent pieces of machinery, and, for rea- sons, which are equally obvious. They are all, (says this author,) from the most simple, to the most complex, but, particularly the swing and tbe screw, calculated to obviate and re- move what does not exist. They are founded upon the supposition of an ac- tual dislocation, which never is the case, and therefore they always have been, and ever must be, unsuccessful. To understand this in the clearest and most convincing manner, we need only reflect on the nature of the dis- ease, its seat, and the state, in which the parts concerned must necessarily be. Mr. Pott states, that the bones are either already carious, or tending to become so; the parts connected with them are diseased, and not infrequently ulcerated; there is no displacement of the vertebrae, with regard to each other, and the spine bends forward only be- cause the rotten bone, or bones, inter- vening between the sound ones, give way, being unable, in such state, to bear the weight of the parts above. The most superficial reflection on this, must point out to every one, why attempts of this kind can do no good, and a little more attention to the subject will show, why they may be productive of real, and great mischief. The bones are sup- posed to be sound, but displaced: these machines are designed to bring them back to their former situation, and thereby to restore to the spine its pro- per rectitude; if, therefore, they have any power, that power must be exer- cised on the parts in connexion with the curve; which parts, when the disease is at all advanced, are incapable of bear- ing such a degree of violence, without being much hurt thereby: this, if it were merely theoretical, being a conclusion drawn from the obvious and demon- strable state of the distempered parts, says Pott, could not be deemed unrea- sonable; but, unfortunately for the af- flicted, it is confirmed by practice. They who have had patience and fortitude to bear the use of them, to such a degree as to affect the parts concerned, have always found increase of pain and fever, 428 VERTEBRAE, DISEASE OF. and an exasperation of all their bad symptoms, and (observes Mr. Pott) I have known more than one instance, in which the attempt has proved fatal. The use of some or other of these pieces of machinery was so general, and the vulgar prejudice in their favour so great, that notwithstanding Mr. Pott was long convinced of their perfect in- utility, yet if he had had no other ob- jection to them, he says he would not have attempted to rob the afflicted of what they seemed to derive such com- fortable expectation from. However, as he was satisfied of their mischievous effects, not only in the case of the pre- sent subject, but in many others; he could not help bearing his testimony against the indiscriminate and very im- proper use, which was daily made of them. Mr. Pott says, they are used with de- sign to prevent growing children from becoming crooked or misshapen, and this they are supposed to do, by sup- porting the back-bone, and by forcing the shoulders unnaturally backward; the former they cannot do, and in all cases where the spine is weak, and thereby inclined to deviate from a right figure, the latter action of these instru- ments must contribute to, rather than prevent such deviation; as will appear to whoever will, with any attention, ex- amine the matter: if, instead of adding to the embarrassments of children's dress, by such iron restraints, parents would throw off all of every kind, and thereby give nature an opportunity of exerting her own powers; and if, in all cases of manifest debility, recourse was had to friction, bark, and cold bathing, with a due attention to air, diet, exer- cise, and rest, the children of the opu- lent would, perhaps, stand a chance of being as stout, as straight, and as well shapen, as those of the laborious poor. Mr. Pott observes: When a child ap- pears to be what the common people call naturally weakly, whatever com- plaints it may have, are supposed to be caused by its weak state, and it is ge- nerally believed, that time and common care will remove them; but, when a cur- vature has made its appearance, all these marks of ill health, such as labo- rious respiration, hard cough, quick pulse, hectical heat and flushing, pain and tightness of the stomach, i these abscesses. 18. That the true curvature of the spine from within outward, of wliich the paralytic, or useless state of the lower limbs, is a too frequent conse- quence, is itself but one effect of a dis- tempered spine: such case being always attended with a number of complaints, which arise from the same cause: the generally received opinion, therefore, that all the attending symptoms are de- rived from the curvature, considered abstractedly, is by no means founded in truth, and may be productive of very erroneous conduct. 19. That in the case of true curva- ture, attended with useless limbs, there never is a dislocation, properly to be so called; but that the alteration in the fi- gure of the back-bone, is caused solely by the erosion and destruction of a part of one or more of the corpora vertebra- rum; and, that as there can be no true curvature without caries, it must be de- monstrably clear, that there must have been a distempered state of parts pre- vious to such erosion; from all which it follows, that this distemper, call it by what name you please, ought to be re- garded as the original cause of the whole, that is, ofthe caries, ofthe cur- vature, and all the attendant mischiefs, be they what they may, general or par- ticular: a consideration, as it appears to me, of infinite importance to all such infants and young children, as show, either from their general complaints, or from their shape, a tendency to this kind of evil: and whose parents and friends generally content themselves with a * Mr Pott mentions his having seen two cases in which the bodies of the ver- tebrae were totally separated from all connexion with the other parts, leaving the; membrane, which included tiie spinal marrow, perfectly bare Vol. II. 3 1 434 VERTEBRJE, DISEASE OF. swing, or piece of iron machinery, and look no further. 20. That whoever will consider the real state of the parts, when a caries has taken place, and the parts sur- rounding it are in a state of ulceration, must see why none of the attempts, by means of swings, screws, &c. can pos- sibly do any good, but, on the contrary, if they act so as to produce any effect at all, it must be a bad one. 21. That the discharge, by means of the issues, produces in due time (more or less under different circumstances) a cessation ofthe erosion of the bones; that this is followed by an incarnation, by means of which the bodies of the vertebrae, which had been the seat of the disease, coalesce, and unite with each other, forming a kind of anchylo- sis. 22. That the different degrees and extent of the caries, in diff'erent sub- jects, must render all attempts to cure uncertain, both as to the time required, and as to the ultimate event: the least and smallest degree will (every thing else being equal) be soonest relieved and cured: the larger and more exten. sive will require more time, and where the rottenness is to a great degree, and all the surrounding parts in a state of distempered ulceration, it must foil all attempts, and destroy the patient. 23. That when two or more vertebrae are affected, forming a large curve, however perfect the success may be with regard to the restoration of health and limbs, yet the curvature will and must remain, in consequence of the union ofthe bones with each other. 24. That the useless state ofthe limbs is by no means a consequence of the altered figure ofthe spine, or oT the dis- position of the bones with regard to each other, but merely of the caries: of this truth there needs no other proof, than what may be drawn from the cure of a large and extensive curvature, in which three or more vertebrae were con- cerned: in this tiie deformity always re- mains unaltered and unalterable, not- withstanding the patient recovers both health and limbs. Upon the whole, after due considera- tion of what has been said concerning the nature of the complaint, its produ- cing cause, and the method by which it is capable of being cured, Mr. Pott says, be would ask, whether the dis- eased state ofthe spine, and of the parts connected with it, (which, if not pre- vented, must produce some of its very dreadful effects,) may not, by a timely use of proper means, be prevented? He contends, that a morbid state of the parts, previous to deformity, caries, or curve, must be allowed: every com- plaint of the living, and every appear- ance in the dead, he says, prove it be- yond contradiction or doubt. All the ge- neral complaints of persons, afflicted with this disorder, will always, upon careful inquiry, be found to have pre- cedetl any degree of deformity, to have increased as the curve became appa- rent, and to have decreased as the means used for relief took place: the pain and tightness about the stomach, the indigestion, the want of appetite, the disturbed sleep, &c. &c. gradually disappear, and the marks of returning health become observable, before the limbs recover the smallest degree of their power of moving. Mr. Pott remarks, that on the other hand, it is as true, that when from ex- tent, or degree, or inveteracy of the caries, the issues are found to be une- qual to the wished-for effect, the gene- ral complaints receive no amendment; but increase until the patient sinks un- der them. If all this be true, says Mr. Pott, which that it is, the manifold and re- peated experience of many, as well as myself, can amply testify;"and if it be found, that the issues are capable of ef- fecting a perfect cure, even after a ca- ries has taken place, and that to a con- siderable degree, which is also true to demonstration, is it not reasonable to conclude, that the same means, made use of in due time, might prove a pre- ventive? If this was a matter of mere specula- tion, or opinion, observes the celebrated surgeon, I would be very cautious how I spake on tiie subject; but it is really a matter of experiment; and as far as I have had it in my power to put it to that test, it has succeeded, by the re- storation of lost health, and the preven- tion of a deformity, which was advanc- ing rapidly. It may, perhaps, be said, continues Mr. .Pott, that 'if no such means had been used, the same space of time might have produced the same effect to this it is impossible to make an answer. I shall, therefore, content myself with having given my opinion, with the cir- cumstances and reasons on which it is founded. WART. 435 Mr. Pott concludes: I should be sorry to be misunderstood on this point, or to have it thought, that I meant to say, that every weak or ricketty child was necessarily liable to a curved spine; or that issues were to be deemed an in- fallible remedy for the ills arisingfrom a strumous habit: far be it from me to say either: what I would wish to be un- derstood to mean is, that such kind of habit appears to me to be most apt to produce some of the mischiefs men- tioned in this tract: that, as a purulent discharge, derived from the neighbour- hood of the spine, is found, from re- peated experience, to be a successful remedy, even after the disease is con- firmed by a caries, it seems to me to bid fairer than any thing else, if used in time, to become a preventive; and, that as some other kind of deformity are found to follow attacks of the same . »V ART. Mr. Hunter observes, that a wart appears to be an excrescence from the cutis, or a tumour forming upon it, by which means, it becomes covered with a cuticle, which is either strong and hard, or thin and soft, just as the cuticle is, which covers the parts, from which the excrescence arises. Warts are radiated from their basis to their circumference. The surface of the radii appears to be pointed, or granulated, like the surface of healthy granulations, with the exception bf being harder, and rising higher. The surface, on wliich a wart is formed, seems only to be Capa- ble of producing one; for, the surround- ing and connecting surface does not throw out a similar substance. Thus, when a wart has once begun to grow, it rises higher and higher, without be- coming larger at its basis. Such excres- cences seem to have within themselves the power of growing larger; for, as Hunter remarks, after they have risen above the surface of the skin, on which their basis cannot grow larger, they swell out into a round thick substance, which becomes rougher and rougher. In consequence of having this struc- ture, warts are very liable to be hurt by kind of constitutional disorder, seizing on these parts, and which, though not causing precisely the same effect, are nevertheless attended with the same general symptoms; I cannot help think- ing, that it may be well worth while to try whether benefit be not obtainable by the same means, in the one case as in the other; and if the old maxim, " anceps remedium quam nullum" be ad- missible, surely an experiment, which is in its nature perfectly incapable of harm, is worth making. (Pott on the Palsii ofthe Lower Limbs.) VERTIGO, (from verto, to turn, be- cause all things seem to turn round.) A giddiness ofthe head; a symptom of several diseases. VIPER, BITE OF. See Wounds. VOLVULUS, (from volvo, to roll up.) See Intussusception. bodies rubbing against them, and, from such a cause, they often bleed very pro- fusely, and are rendered very painful. (Treatise on the Venereal Disease, p. 25Q. edit. 2.) As warts are adventitious substances, and not any part of the original struc- ture of the body, their powers of life are weak. Hence, when stimulated by particular applications, these excres- cences generally become smaller and smaller, and, at length, altogether dis- appear, or drop off. On this principle, warts may fre- quently be cured by stimulating them with a powder, composed of aerugo aeris and savine leaves, in equal propor- tions. However, the employment of escha- rotics; the removal of such excrescences with a knife or pair of scissars; or tying their necks with a ligature; is a mode frequently preferred, because the cure is sooner accomplished. The two last methods are certainly particularly eligible, when the wart has a narrow neck; but, after the removal ofthe excrescence, it is still proper to touch the root with caustic; for, unless the whole be completely destroyed, the wart will inevitably grow again. w 436 WHITLOW. With respect to caustics, the practi- tioner may use the kali purum cum calce viva, tbe argentum nitratum, or the cuprum vitriolatiim. 1 tliink a strong solution of the argentum nitratum is as efficacious an application of the caustic kind, as any, which can be used in these cases. Wails on tiie pudenda, and about the anus, which are often supposed to be ve- nereal, scarcely ever withstand the ef- fect of the powder of savine, and aeru- go aeris. WHITLOW. (Punaris, Panaritium, Paronychia.) A whitlow is an inflamma- tion, which occurs about the end of the finger, and is exceedingly painful, and very much disposed to suppurate. The affection is commonly seen attacking the fingers, but the toes are undoubt- edly in a few instances the seat of the disease. Writers usually divide whitlows into four kinds or degrees. The first one is the mildest. In this case a vesicle, filled with matter, com- monly arises near the root, or side ofthe nail, after a preceding superficialinflam- mation of trivial extent. The matter is situated immediately under the cuticle. Sometimes, the abscess takes place under the nail, in which case, the pain is very severe, and not unfrequently shoots upward as far as the external condyle. The second kind of whitlow is chiefly situated in the cellular substance under the cutis, and, for the most part, occurs at the very end of the finger. In this sort of case, the inflammatory symp- toms, especially the pain, are far more violent, than they usually are in inflam- mations of such little extent. However, although the pain is thus severe, it does not in general extend far from {he part affected, unles the tendon par- takes in the inflammation. Writers usu- ally impute the violence of the pain, and the inconsiderable degree of in- flammation attending the complaint, to the hard and unyielded nature of the skin on the finger. To the same cause they also ascribe the difficulty of per- ceiving any fluctuation, after matter has formed; and the slowness, with which the pus makes its way outward. The third kind of whitlow is distin- guishable from the others by the fol- lowing circumstances. With the most excruciating pain, there is very little swelling in the affected finger, but, a vast deal in the hand, particularly, about the wrist, and over the whole fore-arm. The pain extends to the hand, wrist, elbow, and even the shoulder. When suppuration has taken place, a fluctuation can never be felt in tiie af- fected finger, though the undulation of matter may very often be distinctly per- ceived in the hand, at the wrist; or even somewhere in tiie fore-arm. The case is frequently accompanied by a considerable degree of fever. In this species of whitlow, the disease is seat- ed in the tendons and their sheaths, and the power of* moving the fingers, and even the whole hand, is lost. Authors describe the fourth kind of whitlow, as arising principally from an inflammation of the periosteum. The case is attended with one peculiarity, which is, that, however violent the pain may be, it never extends to the hand, and fore-arm, nor is there any exter- nal swelling of the affected finger. Sup- puration generally very soon follows, the usual consequence of which is a caries of the subjacent finger-bones. Whitlows commonly begin on the in- side of the fingers; but, they do occa- sionally commence on the back of these parts, and even on that of tiie hand. Though pain about the wrist is usually the effect of the inflammation in the finger, yet Acrel makes mention of a case, in which the disorder was alto- gether confined to the hand itself. ( Vor- fcilk, 2 B. p. 191.) Besides the above species of whit- lows, Richter takes notice of a very painful affection ofthe finger, that has been termed the dry whitlow. Acrel re- lates, that a man, without any particu- lar preceding cause, was siezed with a very violent darting pain, near the nail of the little finger. The pain some- times ceased for a few minutes, or hours, and then recurred and lasted for weeks, and months. At length, it became still more intolerable and unre- mitting, and extended all up the arm. Hence, the removal of the first pain- ful portion ofthe finger was determined on. Nothing unnatural was found in the appearance of the integuments and ten- dons; but, the texture of the bone was quite destroyed, and changed into a fatty substance. (Acrel, lorfalle. 2 B. p. 210.) The causes of whitlows are generally of a local nature. Writers enumerate the following as the most common ones: a contusion; suddenly warming the fin- ger when it is exceedingly cold; pricks WHITLOW. 43r with needles, or other sharp instru- ments; and the insinuation of irritating matter into scratches on the finger. A surgeon, in operating for a fistula in ano, has been known to cut his finger, and have in consequence of the acci- dent a very severe and dangerous kind of whitlow. Richter also mentions a person having had a most obstinate whitlow, in consequence of getting a slight wound on the finger, in examin- ing the head of a horse, that had the glanders. Sometimes, the cause of a whitlow depends on a splinter, which still continues lodged in the part. Very often, no particular cause whatever can be assigned for the complaint. The different kinds of whitlows are not all to be treated in the same manner. The first case, which occurs about the root of the nail, ought to be opened as soon as possible. When this plan is not adopted, tiie matter not only makes its way round the nail, but penetrates more deeply, so as to reach the root of the nail, and occasion a loss of the part. When an effectual opening is not made, the matter is apt to collect again. In general, a detachment of the cuticle takes place, as far as the abscess ex- tends. When the inflammation has been very violent, and the matter has made its way as far as the root of the nail, the nail itself is in general gradually detached, while the denuded portion of the root of the nail acts on the sore as a foreign body, and hinders it from healing. Hence, the surgeon should repeatedly cut away as much of the lower edge of the nail as he can, and insinuate a little soft lint between the margin of the nail and the sore in order to keep the latter from being irritated by the former. In proportion as the old nail gradually separates, a new one makes its appearance. VV'hen matter lies under the nail, an opening should be made through the part, as speedily as possible, for the discharge of the abscess. In order to perform this operation, Richter advises the surgeon to scrape, with a piece of glass, the part of the nail to be opened, till it is as thin as it can well be and then to cut through it with the point of a bistoury. In the second species of whitlow, suppuration may sometimes be prevent- ed, and the inflammation be resolved, by the timely employment of proper means. When the pain is exceedingly violent, and there is acute fever, it may be advisable to bleed the patient in the arm. In a few severe cases, the appli- cation of three, or four leeches to the affected finger, has been known to pro- cure prompt relief. (Schmucker.) The- den thinks, that applying a roller round the finger, hand, and arm, and frequent- ly wetting the two first parts with a lo- tion, the most certain means of resolv- ing the inflammation. Platner advises the finger to be for some time immers- ed in water, as warm as the patient can bear. Some recommend the external use of camphorated spirit, or the vola- tile alkali; while others advise the af- fected finger to be plunged in a very warm solution of soap, or kali. When the whitlow has been occasioned by a prick, particular care must be taken, that there is no extraneous substance remaining in the puncture. When the symptoms do not lessen by the fourth day, Richter recommends making an opening in the finger. Even when no fluctuation is discovered, the same surgeon approves of making a crucial incision in the seat of tiie pain, and, he states, that although no matter may be discharged, the patient always derives infinite relief from the opera- tion. The benefit, he says, may either be imputed to the bleeding, or to the di- vision of the hard tense skin, which com- presses the subjacent inflamed parts. Sometimes, the collection of matter can be plainly felt, and, in this case, there can be no hesitation about the place, where the opening should be made. However, it may be proper to re- mark, that the opening should always be made sufficiently large. When the sur- geon makes a small puncture, it very soon closes again, and a repetition of the operation becomes necessary. When opening the abscess is delayed, the the- ca of the flexor tendons easily becomes affected, or the matter may make its way to a considerable extent around un- der the skin. Sometimes the matter gets through the cutis by ulceration, and elevates the cuticle, in the form of a pustule. Tii this case, as soon as the cuticle has been opened, a director should be introduced into the aperture in the skin, and the latter opening be enlarged with a bistoury. The third species of whitlow seldom affects the last phalanx of the fingers; but, generally, the second, or third one. In this case, Richter enjoins us never to defer making an opening longer, than the third 4ay. If we wait till suppura- ' 438 WOUNDS tion happens, we shall wait till the ten- dons are destroyed, and the use of tiie finger lost. In the case under conside- ration, the matter is always of a bad quality, and very small in quantity. A fluctuation in the finger can very seldom be felt. However, in a very few in- stances, the matter becomes percepti- ble at the extremity of the finger, or about the finger-joints, but, more often, in the palm of the hand, or near the wrist. In these circumstances, the ten- dons are in general already destroyed, and a stiffness of the finger and hand is to be apprehended. When the com- plaint is the consequence of a puncture, the best plan, according to Richter, is at once to enlarge the wound; for, in this sort of case, all other methods are quite unavailing. It is not enough, how- ever, to cut through the skin; the ten- dinous theca itself* must be laid open. When the pain does not undergo any diminution, after tiie tendinous sheath has been opened, or, shoidd the pain, after'subsiding, recur again, the first opening should be dilated by means of a knife and director. Also, if the pa- tient should experience in any other part of the hand an acute pain, which does not diminish in consequence of this first opening; or if signs of the for- mation of matter should be observed elsewhere in the hand; an opening should be made there, of sufficient depth to reach tlu'ough the theca for the flexor tendons. When a collection of matter forms towards the wrist, or the patient feels violent pain in that situation, an opening must also be made there. If an opening should have been already made in the hand, a probe may be introduced into the wound, and ano- ther aperture made in an eligible situa- tion by cutting on the end of the instru- ment. In the same way, Richter advises making an opening in any part of the fore-arm, where great pain, or the symptoms of suppuration, indicate. In the fourth kind of whitlow, early incisions, made down to the bone, are the most certain means of obviating the danger. When such incisions are not made early enough suppuration takes place, and the bone becomes carioUs. The cut is to be made in the place, where the pairi is most severe. When the first phalanx is affected, the incision may be made in front of the finger; but, when the second, or third, is the seat of the complaint, the opening had bet- ter be made on one side. However, in order that the opening may be at all useful, it is absolutely necessary to make it down to the bone. When the incision has been delayed too long, a small quantity of unhealthy matter is usually detected, and the bone is found to be carious. As an exfoliation can hardly be expected in this situation, it is best to remove the diseased piece of bone at once, which can generally be effected without difficulty. When the last phalanx alone is affected, the finger retains its form, with the exception of its end being a little shorter and flat- ter. When the disease, however, is si- tuated in the third phalanx, Richter thinks it better to amputate the finger than remove the diseased bone, as the finger, if left, would always remain stiff and unserviceable. (See Anfangsgr. der ll'undarzneykunst, vol. 7.) WOUNDS. A great deal of the sub- ject of wounds is already treated of in several parts of this work; for instance, the articles Abdomen; Hydrophobia,- Gun- shot Wounds,- Head, Injuries of; Parotid Duct; Sutures; Thorax; Throat, &c. A wound may be defined to be a re- cent solution of continuity in the soft parts, suddenly occasioned by external causes. Wounds in general are subject to a great deal of variety, both in their na- ture and external appearance. The dif- ferences depend, in a very great mea- sure, on the nature of the injured parts, the manner in which the wound has happened, and its extent. Wounds of fleshy parts are exceed- ingly different from those of tendinous ones, both in regard to their appear- ance, and nature, and the degree of danger. There is also an essential dif- ference, between such as are made with a sharp cutting instrument, and others, in which the fibres, besides be- ing divided, have suffered considerable contusion and laceration. A wound, made with a narrow-pointed instru- ment, is also of a very different nature from one that has an ample orifice. Wounds are distinguished by surgi- cal writers into several kinds, viz. inci- sed, punctured, contused, lacerated, and poisoned ones, and gun-shot injuries. The latter cases have been treated of in the article Gun-shot H ounds; but-, of the other kinds of wounds, we shall presently treat. The degree of danger, attending every wound, depends veiy much on some of the following circumstances WOUNDS. 439 the extent ofthe injury; the additional violence which the fibres of the part have suffered, besides their division; the nature of the blood-vessels, or nerves, which happen to be cut; the nature of the wounded part in respect to its general power of healing favour- ably, or not; whether the operations of the system at large, and life itself, can be well supported, or not, while the functions of the wounded pail are dis- turbed, interrupted, or suspended, by the accident; the age of the patient; the goodness, or badness of his consti- tution; and the opportunities, which there may be, of receiving proper sur- gical aid, and assistance of every kind. INCISED WOUXDS. As a general observation, we may state, that, cateris paribus, a wound, which is made with a sharp cutting in- strument, which is, in short, a mere in- cision, is attended with less hazard of dangerous consequences, than any other kind of wound whatever. The fibres have only been simply divided; they have suffered no contusion, nor lacera- tion: they are consequently less likely to inflame much so as to suppurate, and slough; and they commonly admit of being united again in a very expe- ditious manner. Simple incised wounds commonly bleed more freely, than contused and lacerated ones, which at first frequently emit no blood at all although consider- able blood-vessels may be injured. But, this circumstance, apparently diminish- ing the danger of contused and lacerated wounds, is deceitful, and serves rather to render the case in reality more peril- ous, by inducing the inexperienced practioner to be off his guard against hemorrhage. Certainly, it often hap- pens, that, on the immediate occur- rence of such wounds, there is no bleeding of consequence. However, the side of some large artery having suffered great violence at the time of the accident, it may ulcerate, or slough, a week or ten days afterwards, and an alarming, and even fatal effusion of blood be the result. This unpleasant occurrence of sud- den hemorrhage is particularly apt to occur in cases of gun-shot wounds, which are injuries always attended with a considerable degree of contu- sion and laceration. In cases of simple incised wounds, the bleeding, which at once takes place from all the divided vessels, is a source of very useful information to the sur- geon, inasmuch as it enables him to judge, what danger is to be apprehend- ed from the hemorrhage, whether the cut vessels are large enough to demand the ligature, or, on the contrary, whe- ther they are such as will cease to bleed, either by slight pressure, or of their own accord. A surgeon, called to a recent simple incised wound has three objects which he should endeavour to accomplish, without the least delay. The first, and tin.*, which requires his immediate in- terference, is the bleeding, which must be checked. The second is the removal of all extraneous matter from the sur- face of the wound. The third object is to unite the opposite sid^s of the in- jury. When the divided vessels are not, above a certain size, the bleeding soon spontaneously ceases, and no surgical measures need be taken on this parti- cular account. When the wounded ves- sels are even somewhat larger, and their situation is favourable for com- pression with a bandage, it is often ad- visable to close the wound and apply compresses and a roller, rather than have recourse to ligatures, which al- ways create a certain degree of suppu- ration. However, though I have made this observation, I should be exceed- ingly sorry to appear at all against the general preference to ligatures, when- ever the wounded arteries are above a certain magnitude. In this circum- stance, tying tiie bleeding vessels is the only safe mode of proceeding. When the artery is of considerable size, and its mouth can be readily seen, the most proper instrument for taking hold of it, is a pair of forceps. In applying the lig- ature, the surgeon must take care to pull its ends in such a manner, that the noose will not rise above the mouth of the vessel, and for the purpose of altering the direction ofthe force em- ployed in tightening the ligature, the ends of the thumbs are generally made use of. The tenaculum is commonly employeel for taking up arteries, which are not exceedingly''large and distinct. However, I need not expatiate on the mode of tying arteries, as the subject is fully considered in another part of the Dictionary. See Hemorrhage. The bleeding having been suppress- ed, the next object is to remove any 440 WOUNDS. extraneous matter, such as dirt, bits of glass, clots of blood, &c. from the sur- face of tiie wound. Were this circum- stance neglected, the plan of uniting the opposite sides of the cut by the ad- hesive inflammation, or by, what is more frequently termed, union by the first intention, would in general be frus- trated. As soon as the foregoing indications have been attended to, the surgeon must approximate the lips ofthe wound, put them in contact, and take proper precautions for keeping them in this state, until they have firmly grown to- gether. The sides of wounds are k'pt in a state of apposition by the aid of adhesive plaster, a proper position, the pressure of a roller, and, in a few par- ticular instances, by the employment of sutures. Of this last means, nothing need be said in this place, as all the requisite information may be found in another place. See Sutures. The best and most common method of keeping the surfaces of divided parts in contact is by means of strips of ad- hesive plaster. At the imie, when they are to be applied, the surgeon should put the wounded parts in such a posi- tion, as shall render them capable of being brought into a state of apposition with most facility. With this view, a position should generally be chosen, which relaxes the skin and subjacent muscles. An assistant should then place the edges of the wound as evenly together as possible, and hold them i-.i tins' state, until the surgeon has secured them in this condition by strips of ad- hesive plaster, applied across the line ofthe wound. In general, it is deemed advisable to leave a small interspace of about a quarter of an inch between each two strips of plaster, by which means, the matter cannot be confined in case of suppuration. Over these first strips, lint is to be applied, and kept in its place with some more pieces of ad- hesive plaster. Then, if necessary, a pledget, and compresses are to be put on the part, and, lastly, the bandage, or roller, is to be applied. In this manner, tne fresh-cut surfaces are brought into contact, and to pre- serve them quietly Tn this state, is the next great aim, which the surgeon should have in view. The wounded part should be laid in the posture, which was found the most favourable for ap- proximating tiie sides of the cut, at the time of applying the dressings, and the patient should be directed to keep the part in a perfectly quiet state. When attention is paid to these cir- cumstances, it often happens, that the two opposite surfaces of the wound grow together again in the course of forty-eight hours, without the occur- rence of the least degree of suppura- tion. The process, by which this de- sirable event is accomplished, is well known among surgeons, by the name of union by the first intention. Besides the advantage ofthe cure being effected in this way with the greatest expedition possible, there is still another thing much in favour of always promoting this method of healing wounds, which is, that the scar is much less, than af- ter any other plan, and the part is co- vered with original skin, which is al- ways much stronger, than any which can be formed as a substitute for it. It is wonderful with what celerity union by the first intention takes place under favourable circumstances. In the course of three days, the large wound, made in the operation of amputation, is frequently all healed except just where the ligatures are situated. When the two sides of the wound have been brought together, before the oozing of blood has entirely ceased, it is probable, that blood itself becomes the first bond of union, and this con- nexion must happen indeed almost im- mediately. In other instances, what Mr. Hunter called the adhesive inflamma- tion occurs. In this process, coagulat- ing lymph either issues from the half- closed mouths of the vessels, or from the surface of the opened cells of the cellular substance. This becomes the first uniting medium, and, very soon afterwards, in some inexplicable man- ner, a vascular intercourse is establish- ed between the opposite sides of the wound. The power, which parts of the ani- mal body have, of growing together in the above manner is strikingly evinced by the possibility of removing a part of one body, anel then uniting it to some part of another. In this latter case, there can be no assistance given to the union on one side, since the de- tached part, as Mr. Hunter observes, can hardly do more, than just preserve its own living principle, and accept of union. In this way, says the same wri- ter, the spurs of the young cock can be made to grow on his comb, or on that of another cock; and its testicles, WOUNDS. after having been removed, mav be made to unite to the inside of any ca- vity of an animal. Mr. John Bell describes the process of adhesion to be this: either the arte- ries ofthe opposite surfaces inosculate mouth to mouth, or rather each cut- surface throws out a gluten; the gluten fills up the intermediate space; into that gluten, the lesser arteries of each cut- surface extend themselves, and it is thus, perhaps, by the generation of a new intermediate substance, that the conti- nuity and entireness of the part are so quickly restored. If any one point fail to adhere, there the wound must run into suppuration; because, says Mr. J. Bell, at that point there is a separation of parts, which is equivalent to a loss of substance. The same writer1' observes, that there are, -no doubt, accidents, both of tiie constitution and the wound, wliich will prevent adhesion. If the patient be of a bad habit of body; if he be lying in a foul hospital, in the midst of putrid sores, and breathing a contagious air; if he be ill of a fever, or flux, or any general disease; then the properties of the body being less perfect, the wound will not adhere. Mr. J. Bell also notices, that, if the wound be foul, made with a poisoned weapon, or left with foreign bodies lodged in it; or if a considera- ble quantity of blood be poured out into the eavity of the wound; or if there be a wounded lymphatic, pr a wounded salivary-duct, a wounded intestine, or a bleeding artery or vein, the immedi- ate adhesion of the whole of the wound may be prevented. However, 1 cannot help remarking, that,though Mr. J. Bell, in imitation of most surgical writers, sets down the wound of a lymphatic, as preventive of the union of wounds, I cannot say, that 1 ever saw such an ef- fect imputable to the cause just men- tioned. Also, when an artery, or vein is out, and requires being- tied, the adhe- sion of the wound would only be pie- vented just where the ligature lies. There is no wound,observes Mr. John Bell, in which we may not try with per- fect safety to procure this adhesion; for, nothing can agree better with one sur- face of the wound, than the opposite •ne, which has been just separated from it. They may immediately adhere together, and even if they should not do so, no harm is done, and the wound will yet suppurate as favourably, as if it had been roughly drewed with drv 4^1 caddis, or some vulnerary balsam, or acrid ointment. If one part should sup- purate, while one half adheres, then, says Mr. John Bell, one half of our bu- siness is done. In short, this simple duty of immediately closing a wound is both natural and safe. (Discourses on the JYat ture and Cure of Wounds, vol. 1.) Sometimes, the attempt to procure an union by the first intention fails, even in cases of incised wounds. The mo- ment, when we observe pain, inflamma- tion, and swelling of the wound, a sepa- ration or gaping of its lips, the stitch- es tense (when these have been used,) and the points, where tiie stitches pass, particularly inflamed, Mr. John Bell advises us to undo the bandages, draw out the sutures, and take away every thing, which acts like a stricture on the wound. These prudent measures, he observes, may abate the rising in- flammation, and prevent the total sepa- ration of the skin, while an endeavour may still be made to keep the edges of the wound tolerably near each other by the more gentle operation of sticking- plasters. However, when the inflammation rises still higher, and it is evident, that a total separation of the sides of the wound cannot be avoided, the above author recommends leaving tiie parts quite loose, and applying a large soft poultice; for, says Mr. John Bell, should you, in this critical juncture, persist in keeping the parts together with su- tures, the inflammation, in the form of erysipelas, would extend over the whole limb, attended with a fetid and bloody suppuration. After the wound has got into a favourable state, another attempt may now be made to bring the edges near each other, not with sutures, but, strips of adhesive plaster, or the gen- tle application of a bandage. Mr. John Bell concludes with re- marking, that the suppuration, produc- tion of granulations, and all that fol- lows, are the work of nature. The only thing, that the surgeon can usefully do is to take care of the health. When the wound does not suppurate favour- ably, the discharge generally becomes profuse, thin, and gleety. This state is to be amended by bark, wine, rich diet, and good air. I shall conclude this subject of union by the first intention with an extract from the writings of Mr. Hunter, who observes, that "It is with a view to fhis principle Yor<.lfc • 3K 44£ WOUNDS. of union, that it has been recommended to bring the sides (or lips) of wounds together; but as the natural elasticity of the parts makes them recede, it has been found necessaiy to employ art for that purpose. This necessity first sug- gested the practice of sewing wounds, and afterwards gave rise to various in- ventions in order to answer this end, such as bandages, stickingiplasters, and ligatures. Among these, the bandage commonly called the uniting bandage is preferable to all the rest, where it can be employed; but its application is very confined, from being only adapted to parts where a roller can be used. A piece of sticking-plaster, which has been called the dry suture, is more general in its application than the uni- ting bandage, and is therefore prefera- ble to it on many occasions. " I can hardly suppose (says Mr. Hunter) a wound, in any situation, where it may not be applied, excepting penetrating wounds, where we wish the inner portion of the wound to be closed equally with the outer, as in the case of hare-lip. But even in such wounds, if the parts are thick, and the wound not large, the sides will seldom recede so far as to make any other means ne- cessary. The dry suture has an advan- tage over stitches, by bringing a larger surface of 'the wound together, by not inflaming the parts to which it is ap- plied, and by neither producing in them suppuration nor ulceration, which stitches always do. When pails, there- fore, can be brought together, and es- pecially where some force is required for that purpose, from the skin not being in large quantity, the sticking-plaster is certainly the best application. This happens frequently to be the case after the removal of tumours, in amputation, or where the sides of the wound arc Only to be brought together at one end, as in the hare-lip; and I think the differ- ence between Mr. Sharp's cross-stitch, after amputation, as recommended in his Critical Inquiry, and Mr. Allanson's practice, shows strongly the superiority of the sticking-plaster (or dry suture.) In those parts of the body where the skin recedes more than in others, this treatment becomes most necessary; and as the scalp probably recedes as little as any, it is therefore seldom necessary to apply any thing in wounds of that part; the practice will certainly answer best in superficial wounds, because the bot- tom is in these more within its influence. " The sticking-plasters should be laid on in strips, and these should be at small distances from each other, viz. about a quarter of an inch at most, if the pail requires close confinement: but when it does not, they may be at greater distances. This precuation be- comes more necessary if the bleeding is not quite stopped: there should be passages left for the exit of blood, as its accumulation might prevent the union, although this does not always happen. If any extraneous body, such as a ligature, should have been left in the wound, suppuration will take place, and the matter should be allowed to vent at some of those openings, or spaces, between the slips of plaster. I have known a very considerable abscess formed in consequence of this precau- tion being neglected, by which the whole of the recently united parts has been separated. " The interrupted suture, which has generally been recommended in large wounds, is still in use, but seldom proves eqUal to the intention. This we may reckon to be the only one that de- serves the name of suture; it was for- merly used, but is now in a great mea- sure laid aside in practice, not from the impropriety of uniting parts by this pro- cess, but from the ineffectual mode of attempting it. In what manner better methods could be contrived, I have not been able to suggest. It is to be under- stood, that the above methods of bring- ing wounded parts together, in order to unite them, are only to be put in practice in such cases as will admit of it; for if there was a method known, wliich in all cases would bring the wounded surfaces into, contact, it would, in many instances, be improper, as some wounds are attended with con- tusion, by whicli the parts have been more or less deadened; in such cases, as was formerly observed, union can- not take place according to our first principle, and therefore it is improper to attempt it. " In many wounds, which are not at- tended with contusion, when we either know, or suspect, that extraneous bo- dies have been introduced into the wound, union by the first intention should not be attempted, but they should be allowed to suppurate, in or- der that the extraneous matter may be expelled. Wounds, which are attended with laceration, although free from contusion, cannot alv ays be united bv VVOUND.v 44^ the first intention, because it must fre- quently be impossible to bring the ex- ternal parts, or skin, so much in con- ta£t> as" to prevent that inflammation which is naturally produced by expo- sure. But even in cases of simple lace- ration, where the external influence is but slight, or can be prevented (as we observed in treating of the compound simple fracture,) we find that union by the first intention often takes place; the blood, which fills up the interstices of the lacerated parts, having prevented the stimulus of imperfection in them, and preventing suppuration, may after- wards be absorbed. "Many operations may be so per- formed as to admit of parts uniting by tiie first intention; but the practice should be adopted with great circum- spection : the mode of operating with that view, should in all cases be a se- condary, and not a first consideration, which it has unluckily been too often among surgeons. In cases of cancerj it is a most dangerous attempt at refine- ment in surgery. " In the union of wounded parts by the first intention, it is hardly or never possible to bring them so close together at the exposed edges, as to unite them perfectly by these means; such edges are therefore obliged to take another method of healing. If kept moist, they will inflame as deep between the cut- surfaces as the blood fails in the union, and there suppurate and granulate; but if the blood is allowed to dry and form a scab between, and along the cut edges, then inflammation and suppuration of those edges will be prevented, and this will complete the union, as will be de- scribed by-and-by. " As those effects of accidental inju- ry, which can be cured by the first in- tention, call up none of the powers of the constitution to assist in the repara- tion, it is not the least affected or dis- turbed by them; the parts are united by tiie extravasated blood alone, which was thrown out by the injury, either from the divided vessels, or in conse- quence of inflammation, without a sin- gle action taking place, even in the part itself, except the closing, or inoscula- tion of the vessels; for the flowing of the blood is to be considered as entire- ly mechanical. Even in cases where a small degree of inflammation comes on it is merely a local action, and so inconsiderable," that the constitution is not affected by it; because it is au ope- ration to which the powers belonging to the parts themselves are fully equal. The inflammation may produce a small degree of pain, but the operation of union gives no sensation of any kind whatever." (Hunter on the Blood, In* flammation, and Gun-shot Wounds. CONTUSED AND LACERATED WOUNDS. Lacerated wounds are those, in which the fibres instead of being divided by a cutting instrument, have been torn a- sunder by some violence, capable of overcoming their force of adhesion. The edges of such wounds, instead of being straight and regular, are jagged and unequal. The term contused is applied to those wounds, which are occasioned by some blunt instrument, or surface, which has violently struck a part of the body. These two species of wounds greatly resemble each other, and as they re- quire nearly tiie same kind of treat- ment, writers usually treat of them to- gether. Lacerated, and contused, wounds dif- fer from simple incised ones in appear- ing, at first view, much less alarming, than the latter, while, in reality, they are infinitely more dangerous. In sim- ple cut wounds, the retraction of the parts, and the hemorrhage, are gene. rally much more considerable, than in a lacerated wound of the same size. However, notwithstanding these cir- cumstances, they commonly admit of being healed with by far the greatest ease. It is even proper to remark, that lacerated and contused wounds are scarcely ever attended with any serious effusion of blood, even though some large blood-vessels may be injured. This circumstance often leads inexpe- rienced practitioners to commit great mistakes, by inducing them to promise too much in the prognosis, which they make. Surgeons, versed in practice, however, do not allow themselves to be deceived by the absence of hemor- rhage, and, in proportion as there is lit- tle bleeding, they apprehend that the violence, done to the fibres and vessels has been considerable. "Whole limbs have frequently been torn from the bo- dy, without any hemorrhage of conse- quence taking place. Cheselden has described, in the Phi- losophical Transactions, a very remark- able case, in wliich a man's arm was 444 WOUNDS. suddenly torn from his body. Samuel Wood, a miller, had round his arm a rope, which got entangled with the wheel of a mill. He w;>s lifted off* the ground, and then stopped by a beam, which prevented his trunk from pass- ing further. At this instant, the wheel, which was moving with immense force, completely tore, and carried away, his arm and scapula from his body. The appearance of a wound occasioned Hi this manner, must of course be horri- ble, and the first idea, thence arising, must naturally be, that the patient can- not possibly survive. Samuel Mood, however, escaped with his life. The limb had been torn off' with such velo- city, that he was unaware of the acci- dent, till he saw his arm moving round on the wheel. He immediately descend- ed by a narrow ladder from the rn.il, and even walked some paces, w';h a view of seeking assistance. He.now fell down from weakness. The persons, who first came to his assistance, covered the wound with powdered sugar. A. surge- on, who afterwards arrived, observing that there was no hemorrhage, was con- tent with bringing down the skin, which was very loose, so as to make it cover the surface ofthe wound. For this pur- pose, he used two cross-stitches. The patient was conveyed, the next day, to St. Thomas's Hospital, and put under the care of Mr. Fern, who was then the head-surgeon of that charity. This practitioner employed the means, usu- ally resorted to, with a view of prevent- ing the bad symptoms to be apprehend- ed in this sort of case. The first dress- ings came away without any bleeding; Bo alarming consequences ensued; and the patient got completely well in the Course of a couple of months. When the arm was examined, it was "found, that the muscles, inserted into the scapula, were torn in half near their insertions; while other muscles, arising from this bone, were carried •way with it. The skin, covering the scapula, had remained in its natural situation, and seemed as if it had been divided precisely at the insertion of the deltoid muscle. In La Motto's Traite des Accouche- imens, may be found an account of a lit- tle boy, who, while playing near the wheel of a mill, got his hand, fore-arm, and arm, successively entangled in the machinery, and the limb was violently torn away at the shoulder-joint, in con- "swpaemce of the lad's body not being able to pass in the direction, in whiclt »he arm was drawn. The bleeding was so trivial, that it was stopped with a little lint, and the boy very soon reco- vered. In the fifth volume of the Edinburgh Medical Commentaries, may also be perused the history of a child, three years and a half old, which had its arm torn off* by the wheel of a mill. Mr Carmichael, who saw the child about an hour after the accident, found it al- most in a dying state, \\ itb cold extre- mities, small faultering pulse, and .all the right side of the body convulsed. However, there had been hardly any bleeding. The arm had been broken about an inch and a half above the el- bow; the stump had a very dreadful ap- pearance; all the soft parts were in a contused and lacerated state, and the humerus was laid bare as high as the articulation, which was itself exposed. The skin and muscles were lacerated to a much greater extent, and in diffe- rent directions. The remainder of the humerus was removed fronv the shoul- der Joint by amputation, only as much skin and muscle being left, as was suf- ficient to cover the wound. The child got completely well in two months. In the second volume ofthe Memoires de PAcatiemie de Chirurgie, is an ac- count of a leg being torn away at the joint by a call-wheel. The patient was a boy, about nine, or ten years of age. This accident, like the foregoing ones, was accompanied by no hemorrhage. The lower portion of the os femoris, which was exposed, was amputated, together with such portion of the soft parts, as was in a contused and lace- rated state. The patient experienced a perfect recovery. The preceding cases strikingly con- firm the observation, which 1 have al- ready made, in regard to the little bleeding, which usually arises from contused and lacerated wounds. In these instances, the pain is also in an inverse ratio to the cause of the ac- cident: it is generally very severe, when the wound is only moderately contused; and, on the other hand, the patient scarcely suffers any pain at all, when there has been so violent a degree of contusion, as almost to destroy the or- ganization of the nerves of the pail. When the bruised fibres have not been exceedingly injured, the part suppurates; but, such portions of the wound, as have suffered greater vio- WOUND? 445 lence, inevitably die, and are cast off in the form of sloughs. Granulations arc afterwards formed, and the breach of continuity is repaired by the process of cicatrization. (See this word.) When a still greater degree of vio- lence has been done to the parts, and, especially, when arteries of a certain magnitude have been injured, a morti- fication is too frequently the conse- quence. However, if" the constitution is good, and the mischief is not too exten- sive, the case may still end well. But, in other instances, the event is always alarmingly dubious; for, the mischief is then not limited to the wounded parts, which have suffered the greatest degree of contusion; but, too frequent- ly, extends over such parts, as were not at all interested by the wound it- self. The mortification, arising directly from the impaired organization of parts, is not what is the most alarming circumstance. The most dangerous kind of mortification is that, which is apt to originate from the violent in- flammation, occasioned by the accident. This consequence demands the utmost attention on the part of the surgeon, who must let no useful means be neg- lected, with a view of diminishing the ' inflammation, before it has attained so high a pitch, as to induce fatal effects. He should not be afraid of letting the wound bleed a little, if it -should be disposed to do so in the first instance. The edges of the wound should then be approximated with a few strips of sticking-plaster, so as to lessen the ex- tent of the exposed surface: but, no su- tures are proper. Not much of the wound can be expected to unite by the first intention; the whole, or the greater part of it, will necessarily suppurate, after the detachment of the sloughs. The surface will then granulate, new skin will form, and the part heal just like a common wound. Perhaps, until the sloughs have separated, the best application over the adhesive plaster is a soft poultice, which should be put on cold, lest it sUkld bring on too great an oozing oPWood. When, however, there is much bleeding, lint, and a sim- ple pledget must be employed for the first few hours. The healing of a con- tused, or lacerated wound, is to be ac- complished on the same principles as the cure of sores in general. (See Ul- cers.) PUSCTTKED WOUNDS. A punctured wound signifies one, that is made with a narrow-pointed instru- ment, the external orifice of the injury being small and contracted, instead of being of a size proportionate to its depth. A wound, produced by the thrust of a sword, or bayonet, affords us an example of a punctured wound. Wounds of this description are in general infinitely more dangerous, than incised ones, notwithstanding the latter have the appearance of being by far the most extensive. The greatest degree of danger, in cases of punctured wounds; always depends on the additional inju- ry, and rough violence, which the fibres have suffered, besides being divided. Some ofthe disagreeable consequences, apt to follow, are also to be imputed to the frequent great depth, to which punctured wounds are liable to extend, in consequence of which circumstance, important parts and organs, are often injured. These cases are likewise less easy of cure, owing to the difficulty of extracting any extraneous substances, which may happen to be lodged in the wound. All punctured wounds, and stabs are at the same time dangerous, inasmuch as they are particularly apt to be followed by a great deal of inflam- mation, fever, deep-seated abscesses, sinuses, &c. A strange notion seems to pervade the writings of every systematic author, that all the danger and disagreeable consequences of punctured wounds are entirely owing to the narrowness of the orifice, which prevents suitable appli- cations to the bottom of such wounds. Hence, it is absurdly recommended to dilate the opening of every stab, with a view, as is generally added, of convert- ing the accielent into a simple incised wound. Some of these writers are ad- vocates for making the dilatation with a cutting instrument, while others, with equal absurdity, advise enlarging the opening with tents. Certain authors regard a punctured wound, as a recent sinus, and, in order to make the inner surfaces unite, they recommend exciting a degree of inflam- mation in them, either by means of se- tons, or injections. In the First Lines of the Practice of Sunrev;i, I have taken particidar pains to expose the folly and error, which 446 WOUNDS". prevail in most writings en this part of practice. In the above work, I have re- marked, that, certainly, if the notion were true, that an important punctured wound, such as the stab of a bayonet, is actually changed into a wound par- taking pf the mild nature of an incision, by the mere enlargement of its orifice, the corresponding practice would be highly commendable, however painful it might be. But the fact is otherwise; the rough violence done to the fibres of the body by the generality of stabs, is little likely to be suddenly removed by an enlargement of the wound. Nor can the distance, to which a punctured wound frequently penetrates, and the number and nature of the parts injured by it, be at all altered by such a pro- ceeding. These, which are the grand causes of the collections of matter that often take place in the cases under con- sideration, must exist, whether the mouth and canal of the wound be en- larged or not. The time when incisions are proper is, when there are foreign bodies to be removed, abscesses to be opened, or sinuses to be divided. To make painful incisions sooner than they can answer any end, is both injudicious and hurtful. They are sometimes ren- dered quite unnecessary by the union of the wound throughout its whole es- tent, without any suppuration at all. Making a free incision in the early Stage of these cases, undoubtedly seems a reasonable method of preventing the formation of sinuses, by preventing the Confinement of matter, and, were sinu- ses an inevitable consequence of all punctured wounds, for wliich no inci- sions had been practised at the moment of their occurrence, it would undoubt- edly be unpardonable to omit them. Fair, however, as this reason may ap- pear, it is only superficially plausible, and a small degree of reflection soon discovers its want of real solidity. Un- der what circumstances do sinusesform: Do they not form only where there is some cause existing to prevent the heal- ing of an abscess? This cause may ei- ther be the indirect way, in which the abscess communicates externally, so that the pus does not readily escape; or it may be the presence of" some fo- reign body, or carious bone; or, lastly, it may be an indisposition of the inner surface ofthe abscess to form granula- tions, arising from its long duration, but removable by laying the cyst complete- ly open to the influence of the air. Thus it becomes manifest, that the occur*. rence of suppuration in punctured wounds, is only followed by sinuses in cases, in which the surgeon neglects to procure a free issue for the matter, af- ter its accumulation; or in which he neglects to remove any extraneous bo- dies. But, as dilating the wound at first can only tend to augment the inflam- mation, and render the suppuration more extensive, it ought never to be practised in these cases, except for the direct objects, of giving free exit to matter already collected, and of being able to remove extraneous bodies pal- pably lodged. I shall once more repeat, that it is an erroneous idea, to suppose the narrowness of punctured wounds, so principal a cause ofthe bad symptoms, with which they are often attended, that the treatment ought invariably to aim at its removal. Recent punctured wounds have ab- surdly had the same plan of treatment applied to them, as old and callous fis- tulae. Setons and stimulating injections, which, in the latter cases, sometimes act beneficially by exciting such inflam- mation as is productive of the effusion of coagulating lymph, and of the gra- nulating process, never prove servicea- •ble when the indication is to moderate an inflammation, which is too apt to rise to an improper height. The counter- opening, that must be formed, in adopt- ing the use of a seton, is also an objec- tion. However, what good can possibly arise from a seton in these cases? Will it promote the discharge of foreign bo- dies, if any are present? By occupying the external openings of the wound, will it not be more likely to prevent it? In fact, will it not itself act with all the inconveniences and irritation of an ex- traneous substance in the wound? Is it a likely means of diminishing the im- moderate pain, swelling, and extensive suppuration, so often attending punc- tured wounds? It will undoubtedly pre- vent the external openings from heal- ing too soon; but cannot this subject be effected in a better wav' If the surgeon observes to insinuate a jufepe of lint into the sinus, and pass a piffoe through its track once a day, the danger of its clos- ing too soon will be removed. The practice of enlarging punctured wounds by incisions, and of introducing setons, is often forbidden by the parti- cular situation of these injuries. In the first stage of a punctured wound, the indication Is to guard WOUNDS! 44Jf against the attack of violent inflamma- tion. \\ hen no considerable quantity of blood has been lost, general and topi- cal bleeding should be practised. In short, the antiphlogistic plan is to be followed. As no man can pronounce, whether such wounds will unite, or not, and as no harm can result from the at- tempt, the orifice ought to be closed with strips of adhesive plaster, and gen- tle compression applied alongthe whole course of the puncture. Perfect quie- tude is to be observed. When the pain is very severe, opium is to be adminis- tered. Sometimes, under this treatment, the surgeon is agreeably surprised to find the consequent inflammation mild, and the wound speedily united by the first intention. More frequently, however, in cases of deep stabs, the pain is in- tolerable; and the inflammatory symp- toms run so high, as to leave no hope of avoiding suppuration. In this condi- tion, an emollient poultice is the best local application; and, when the matter is formed, the treatment is like that of abscesses in general. (See Suppuration.) POISONED WOUNDS. Wounds of this description are not \-ery common in this country. The stings and bites of certain insects; and the bites of vipers, mad dogs, cats, &c. are the only instances, which we meet with. In this article, I shall dismiss from consideration the symptoms and treat- ment of the alarming indisposition aris- ing from the bite of particular rabid animals, and content myself with refer- ring the reader to Hydrophobia. With respect to the stings of bees, wasps, hornets, &c. and the bites of gnats, and other" insects, these cases are seldom of sufficient consequence to require the assistance of a surgeon. However, were his advice requested, he should be prepared to give it. The hornet is, to appearance, the most formidable creature of the winged kind in Britain. Mr. Latta says, it is ■ot to be met with in Scotland; though there are nests of them in some of the woods in England. The fact, however, is, that its sting, though- more painful, than that of either the wasp or bee, is not attended with any material conse- quence. Wrasps seldom sting, unless irritated by tiie destruction of their nest, and then they attack in great num- bers every one who passe* by. It is an error to suppose that bees sting more frequently; and that the human breath is particularly offensive to them. It has even been represented, as part of the secret of those, who make them swarm at pleasure, without danger to them- selves, upon any part of their bodies, to keep their breath from them, as much as possible, lest they should thereby be provoked to sting them. Bees are, however, the most harmless of all creatures, if not touched or in-: terfered with, and use their weapons only in their defence. The stings of all these insects are attended with a sharp pain in the part, very quickly succeed- ed by an inflammatory swelling, which in no long time goes off of itself. It may, however, be relieved, by rubbing the part, immediately after the injury, with honey, oil, vinegar, or spirits of wine, or even by immersing it in cold water. There are several other insects, known to us, which do not fly, that. seem to have something poisonous in their bite. Were any material degree of inflam- mation to be induced by tiie irritation, occasioned by the bites and stings of insects the best plan would be to keep the part continually covered with linen, wet with the saturnine lotion, and to ex- hibit one or two doses of some saline purgative. With regard to the bites of serpents, those* inflicted by the rattle-snake of America, and the cobra de capello of the East-Indies, are said to be the most speedily mortal. Indeed, writers state, that this is so much the case, that there is scarcely time to apply any remedy, although it be at hand at the very mo- ment, when the bite is received. Mr. Latta takes notice, that Mr. Catesby, in the Preface to his Natural History of Carolina, informs us, that the Indians, who, by their constant wanderings in the woods, are liable to be bit by those venomous animals; know, as soon as they receive the injury, whether it will prove mortal or not. If it be on any part at a distance from large blood-ves- sels, or where the circulation is not vi- gorous, they apply their remedies; but, if any vein, of considerable magnitude, happens to be hurt, they quietly resign themselves to their fate, as knowing that they could then be of no benefit. It is not well known, what the remedies are, on which they chiefly depend. Se- neka root and volatile alkali, are among tbe number; but, we have so few his- 448 WOUNDS. tories, or rather none at all, ofthe dis- ease, that can be depended upon, that we can scarcely say any tiling about the matter. Mr. Latta observes, that the only per- son, who has particularly considered this subject, ofthe bites of serpents, is the Abb£ Fontana. This latter gentle- man agrees with Dr. Mead that the poison of the viper is neither acid nor alkaline; but, denies that he could per- ceive in it any thing like salts, by means of a microscope, which Dr. Mead says he saw. He even denies, that it has any determinate taste when put upon the tongue; though Dr. Mead assures- us, that both he and others, who had tasted it, felt it exceedingly sharp and burning to the taste; and he particularly takes notice, that one gentleman, who could not be satisfied without tasting a large drop undiluted with water, had an in- flammation of his tongue, and the inside of his lips, of some continuance. Mr. Latta remarks, that it is of no small consequence, towards the-cure of such bites, to consider attentively the symptoms, which take place in the pa- tient, whether they indicate any violent stimulus suddenly applied, in conse- quence of which the person dies of an universal inflammation; or whether it operates, by suddenly checking the vi- tal power, to such a degree, that it can- not be restored. From a vast number of experiments made by M. Fontana, he concludes, that the bite of an ordina- ry viper will not prove fatal to a full- grown person, nor even to a large dog-, though it certainly will do so to small- er animals. Five bites from three strong and healthy vipers were not able to kill a dog weighing sixty pounds; and, as this dog was little more than a third part of the weight of" an ordinary man, he concludes, that a single bite ran never be fatal to an adult In con- firmation of this, he says that he lias- seen a dozen of" cases himself, and that he has heard of fifty more, only two of whom died. Concerning one of these cases he could get no infor- mation; the other perished of a gan- grene, twenty days after tiie bite, and which began in three days after it, the bitten place having been deeply scari- fied almost immediately after tiie injury was received. Fontana believes that much of the faintness, &c. which en- !»ue upon the bite of a viper, are the mere effects of terror. " Upon a per sort's being bit, (says he,) fke fear vf its proving fatal, terrifies himself and^ the whole family. From the persuasion of the disease being mortal, and that not a moment is to be lost, they apply violent, or hurtful remedies. I'he fear increases the complaint. I have known a person, that was imperceptibly bit, in the hands or feet, and who, after see^ ing the blood, and observing a viper near him, has suddenly fainted away; one, in particular, continued in a swoon for upwards of an hour, until he was ac- cidentally observed, and recovered out of it, by being suddenly drenched in cold water. We know, that death itself may be brought on by very violent af- fections of the mind, without any inter- nal disease. Why may not people, that are bit, die from a disease, produced entirely from fear, and who would not otherwise have died from any com- plaint produced by the venom ?" Mr. Latta acknowledges, that M Fontana has bestowed a great deal of attention upon this subject; but, he rightly contends, that the above reason- ing is hypothetical and inconclusive. Mr. Latta owns, that some very timid, delicate, or nervous people might die from fear alone; but, he remarks, that it is by no means fail" to conclude from. thence, that the generality of people will do so. It is easy to see, that the bite of a viper must be more or less dangerous, according to circumstances. It depends on the creature itself, to throw out more or less of this poison; and the greater the rage is, into which it is thrown, the greater quantity it will throw out. If it has bitten any creature soon before it bites a man, the latter will be in less danger, because the quantity is but small. In like manner, when the person is bit through his clothes, they will absorb a quantity of it, and therefore the wound will also be tiie less dangerous: and the same thing must happen when only tiie .small vessels are wounded; for then only a small quantity is likely to be conveyed immediately into tbe system. It must be otherwise, however, when the bite ib inflicted upon a bare place of the bu- dy, and the poison is conveyed directlv into a large vein; in this case, says Mr Latta, it is quickly conveyed to the heart, and there can be little doubt, that it will veiy soon manifest its dele' terious effects. Nay, M. Fontana him- self" informs us of a woman in Tuscany, who, though bit only in tbe little finger by a viper, fell into an hemiplegia, WOUNDS. 449 which could not be removed; and, Mr. Latta argues, that if such a violent dis- ease could be induced by a wound in- flicted at such a distance from the heart, we can have no reason to sup- pose, that, had the viper been large, and the poison quickly conveyed to the heart, that death would not have ensued. Writers usually notice the following symptoms, as those wliich result from the bite of a viper:—1. A violent burn- ing pain, with tension in the injured part. 2. The whole ofthe affected limb, and sometimes the whole body, become tense and inflamed in like manner. 3. The patient becomes extremely faint, the pulse low and feeble; he has a giddi- ness in his head, nausea, and vomiting. 4. There is a fixed pain in the region of the heart. 5. The urine becomes tinged, of a deep yellow, the skin becomes yel- low, like one who has the jaundice, and .there is an evident diffusion of bile throughout the whole vascular system. 6. Cold sweats, with slight convulsive motions, ensue; and if relief be not soon obtained, death is the consequence. These symptoms come on within twelve, or fourteen, hours after the bite, sooner or later, according to the violence of the injury; and the sooner they make their appearance, the more dangerous they are. The cures recommended for the bites of vipers are, according to M. Fontana, not only of very different, but even op- posite qualities. " In no country, (says he) through which I passed, could I ever find any two people or persons, bit by the viper, either in the mountains or valleys, that used the same remedies. Some usedtheriaca alone, either exter- nally or internally applied; others com- mon oil: a third set used stimulants, such as the strongest sprirituous liquors; whilst others, on the contrary, tried eve- ry diff'erent kind of sedative. In short, there is hardly any active kind of me- dicine that has not been tried as a cure in this disease; while, at the same time, it is certain, that, under all the varieties of application, none of them died." Hence, our author concludes, that none of the remedies made use of had any ef- fect in curing the disease; which, indeed, is by no means improbable, consider- ing that many of them must have acted in a manner directly contrary. But this only proves that the bites of the vipers of Italy are not mortal. In a hotter cUmate, they certainly will be attended with more dangerous consequences. Hence, in the island of Malta, even in the winler-time, when the viper came out of the fire, no doubt enraged to the utmost degree, and fastened on the hand of the Apostle Paul, the people expected, that " he should have swoln, or fallen down dead suddenly," whence we may see, that in Malta, which is in- deed very hot, the symptoms attending the bite of these creatures, were then extremely violent; and it was thought miraculous to escape death in conse- quence of it. And we have the most undoubted authority for believing, that, in America, as well as the East Indies, the bite of some serpents is attended with very speedy death. With regard to the cure of the bite of vipers, in such animals as were liable to be killed by it, our author says from his own experi- ence, that neither scarifications, nor even the excision of the part, are bene- ficial, but, on the contrary, hurtful. We may indeed, readily conclude, that sca- rifications, can do no good, because they do not tend to take away the poison, but rather to allow it more free access to the blood; but, we cannot so well say this of excision, if properly performed. In- deed, there can be no doubt, that it is a most prudent plan, when care is taken to make a complete removal of the parts as deeply as the bite extends. Fon- tana also found oil, volatile alkali, the- riaca, &c. either useless, or absolutely hurtful, particularly the volatile alkali. The only thing, which he found of any avail, was the tying of a ligature round the bitten limb, to stop the progress of the blood towards the heart. This method, however, cannot prevent the poison from entering the mouths of the absorbents, nor from getting into the system, when the ligature is removed. The constriction of the limb might also bring on swelling, inflammation, and mortification, and it must evidently be inferior, in point of efficacy, to the care- ful excision of the bitten parts. The practice of sucking the wound has been recommended to be employed very early; and, indeed, if it could be done with safety to the person who sucks, it affords some chance of suc- cess. Dr. Mead endeavours to show, that it may be done with safety; but, Mr. Latta is altogether at a loss to ac- count for the difference between this author and M. Fontana, concerning the teste of the poison; the former affirm- ing, from his own experience, and that of several others, that it had a violent hot, and fiery taste, as if the tongue Vol. II. 3 b 450 WRY-NECR. was struck through with something burning, or scalding; while M. Fontana as confidently affirms, that it has no taste, nor raises any inflammation on the tongue. Dr. Mead relates, that, in a gen* h-inan already mentioned, an in- flammation was raised on the tongue, which did not go off" in two days. In treating this disease, Dr. Mead seems to lay considerable stress upon emetics; and, "nuked, in all cases where the poison seems to be diffused through the body, this remedy has a chance of being useful, by relieving the extreme sickness and nausea, with which the pa- tient is affected- In cases of this kind, external appli- cations can avail but little. Oil has been recommended; but the trials made by Dr. Mead proved to be insufficient. He seems to have some confidence in the fat of* the viper itself; but, it is evident, that the success of" this, or any other remedy of the kind, must depend en- tirely upon an accidental circumstance. It is not impossible, that, if any oily matter could get at the poison, it might so blunt or soften it, that its deadly ef- fects would be prevented; but, it is easy to see, that, by reason of the narrow- ness and depth of the woimd, we have but a small chance of* mixing it with the poison, after it has once been in- jected. Nevertheless, this has perhaps been sometimes done; and, thus, both oil olive, and viper's fat, have gained their reputation, though, in by far the greatest number ofinstances, they could be of no efficacy. To complete the cure, Dr. Mead re- commends the use of warm cordials, among which he mentions volatile sal- ammoniac, to produce a sweat, and seems, indeed, to insist upon these me- dicines as necessary for the recovery of the patient Indeed, Mr. Latta thinks it probable, that the cure can only be ac- complished by the exhibition of the very strongest cordials. He approves of applying a ligature; but, I would ad- vise excision of the parts. He also speaks in favour of trying wine, bark, and vegetable ;.cids. L>.. Temple directs the use of caustic volatile alkali and eau de luce, as speci- fi ■•- against the bite ofthe viper, in the following way: ft. Alkal. volatil. caust. gutt. XL. in quovis vehiculo sumend. R. Sp. ammoniae succinat. (vulgo eau de luce) gutt. xl. quovis vehi- culo sumend. This, he observes, should be given as soon as possible, after the accident, re- peating the dose in five minutes, and also embrocating the parts well with it. (See Catesby's History of Carolina; Mead on Poisons; Fontana on the Venom of the Viper; Latta's System of Surgery, vol. 3.) The best doctrines, relative to wounds in general, are those contained in vari- ous parts of A Treatise on the Blood, In- flammation, &c. by John Hunter. WRY-NECK, (Torticollis.) An affec- tion, in which the head becomes inclin- ed to one side. The ancient writers have taken no notice of the disorder. Some of the modern ones have termed it ca- put obstipum; a word, indeed, which has been employed by the best Latin au- thors, to denote the affliction about to be considered. The wry-neck should be discriminated from the tension and stiffness of the neck, occasioned by a rheumatic affection of this part, and al- so from the faulty position of the head, arising from deformity in the ccrvica"! vertebra:. Tulpius, who was a learned physi- cian at Amsterdam, about the middle of the seventeenth century, gives au account of the cure of a boy, twelve years old, who, from his earliest infan- cy, had had his head drawn down to- wards the left shoulder, by a contrac- tion of the scalenus muscle. Fomenta- tions had been applied in vain, with a view of relaxing the parts, the stiffness and corrugated state of which seemed to produce the disorder. Steel-collars also proved ineffectual in bringing the head into a right posture. Tulpius had a consultation with two other skilful physicians, about the case, and it was decided to put the boy under the care of an eminent surgeon, of the name of Minnius, who had performed several operations with success in similar in- stances. He first made a large eschar by applying caustic, and then with a^ knife divided the muscle, which drew the head to one side. Tulpius, who has left only a very confused account of the operation, observes, that it was per- formed with great slowness and cir- cumspection, for fear of wounding the carotid artery, and jugular vein. The author expresses his disappro- bation of this manner of proceeding, and advises such persons, as will run the risk of doing so dangerous an ope- ration, not to make any preliminary ap- plication of caustic. The latter mea- sure only caused useless pain, ami could not possibly be of any service. Tulpius also recommends the opera WRYNECK. 451 tion not to be done by little and little, at repeated times; but, to make a com- plete division of the" muscle at once, with the necessary degree of caution. Meckren, a surgeon at Amsterdam, who has published a valuable collec- tion of medico-chirurgical cases, also treats of the operation applicable to the wry-neck. He states, that he had seen it performed on a boy, fourteen years old. The tendon of the sterno- cleido-mastoideus muscle was divided with one stroke of a sharp pair of scis- sars, and in a very skilful manner, by a surgeon named Flurianus, and as soon as the incision was made, tiie head took * its right position. The author has also noticed the remarks made by Tulpius, relative to the plan of operating. On approaching nearer to modern days, we find, that the celebrated Mr. Samuel Sharp considered the wry-neck as mostly arising from a contraction of the sterno-cleido-mastoideus muscle. He has proposed dividing this muscle, whenever the disorder seems to pro- ceed from the kind of cause, which we have just now mentioned. However, he makes an exception, in regard to those cases, in which the affliction has exist- ed a considerable time, and, particu- larly, in instances, in wbich it has pre- vailed from infancy. He remarks, that it would be impossible to rectify the position of the head, if the cervical vertebra should have grown in a dis- torted direction. The following is the operation, which this author recom- mends to be done in proper cases. Af- ter placing the patient on a table, a transverse incision is to be made through the skin and fat, of a size somewhat more extensive, than the breadth of the muscle, and about one- third of its length from the clavicle. A probed-razor is then to be passed un- derneath the muscle, and to be drawn out, so as to make the requisite divi- sion of the part. After the incision was made, Mr. Sharp recommended the wound to be filled with dry lint, and to be always dressed in a way, that would keep the extremities ofthe muscle from growing together again. For this pur- pose, he advised the cut ends to be se- parated from each other as much as possible, by the assistance of a ban- dage to support tiie head, during the whole time of the cure, which, he suv s, will generally be about a month. (See Treatise on the Operations of Surgery, c/iap- 35. According to Mr. Sharp s accnur.t. the operation above described, ought to be a very common one. However if attention be paid to the nature and causes of the disease, and to the diffe- rences, resulting from whether the dis- order be recent, or of long standing! constant, or periodical; idiopathic, or sympathetic; dependent on spasm, or merely on paralysis of the antagonist muscles; and, lastly, if it be recollect- ed, that the affection may be produced by other muscles, besides the sterno- cleido-mastoideus; we shall find, that cases, in which the foregoing operation can be judiciously undertaken, are not so very frequent. With regard to the manner, in which Mr. Sharp operated, Mr. B. Bell con- ceived, that it was attended with haz- ard of wounding the large blood-ves- sels. But, though, it seems to me bet- ter to use a probe-pointed bistoury and a director, than the kind of razor, which Mr. Sharp employed, I do not coincide with Mr. B. Bell in thinking, that the latter surgeon's plan was at all objectionable on the score of dan- ger, in respect to wounding the vessels. Perhaps, some might think Mr. B. Bell's method most likely to injure the large vessels; for, he advises the o.perator to cut the muscle from without gradually inward, as deeply as seems necessary. The most prudent method of opera- ting, in my opinion, is first to divide the clavicular portion of" the contract- ed muscle, near the clavicle, and even to cut out a sufficient piece, to remove all chance of the two ends uniting again. This step would weaken the muscle considerably, and, perhaps, might answer every purpose. It could easily be accomplished, by means of a director, and curved bistoury, after making the requisite division of the skin with a common scalpel. Were this proceeding only to produce a partial amendment of the wry-neck, the ope- rator might then venture to divide the sternal portion of the muscle. A direc- tor should be passed under it, and the division made with a probe-pointed cur- ved knife. Although the wry-neck may occa- sionally depend on the contraction of the sterno-cleido-mastoideus muscle, this case is far from being very fre- quent. The deformity is much oftener owing to some affection of the integu- ments. M. Louis often divided with suc- cess contractions ofthe skin, which had kept the head drawn to one side for n «-\ years, and had been occasioned 452 WRY-NECK. by burns. He remarks, that he has met with contractions of this kind, which might have been mistaken for a pail of the sterno-cleido-mastoideus itself. Mr. Gooch has related a case of wry- neck, which was caused by a contrac- tion of the platysma myoides muscle. The patient was a young gentleman, fourteen years of age, who appeared to have always enjoyed very good health in every other respect. He had had his head, for several months, strongly drawn to one side by a constant con- traction of the platysma myoides mus- cle, which had become exceedingly ri- gid, especially just where it is inserted at the basis of the jaw, and it made the skin, from the angle ofthe os max- illare inferius to the chin, seem like the cicatrix of a burn. The same side of the face, quite from the point of the chin, was much shrunk, and distorted by the contraction ofthe muscle, and the cor- ner of the mouth, in particular, was so drawn to one side and downward, when the patient turned his head, that a vast deal of deformity was the consequence. From the inferior part of* the eyebrow at the internal angle of the eye, to near the top of" the head, there was a kind of furrow upon the skin, about half"an inch broad, having a shining, polished ap- pearance, like the cicatrix of a wound, and destitute of hair, which had fallen off". From the corner of" the eye down- wards, there was the same kind of ap- pearance in a less degree. The patient was subject to repeated attacks of spasms, which began at tiie insertion of the muscle, and terminated at the eye, attended with a great deal of pain. The ear, and, also, the temporal and frontal muscles, were sometimes affect- ed in a similar manner. 'I'he parts, in the course of the insertion Of* the mus- cle into the jaw-bone, were considera- bly thickened, without being in the least inflamed externally, and they were only a little painful, when touched, except they were at the same time stretched. The subjacent muscles did not seem to be at all affected. It appears from the account, given by Mr. Gooch, that, in the treatment of this affection, every known means had been tried, by the advice of the most eminent practitioners; but, without ef- fect. Mr. Gooch determined to try what benefit would be produced by dividing the muscle in the situation of the dis- order. He first divided the integuments a little below the jaw, and thus ex- nosed the whole breadth of the platys- ma myoides muscle, the fibres of which seemed to be in a state of" violent exten- sion, especially, when the patient's head was inclined towards the opposite side. Mr. Gooch then divided the muscle completely across, by a very careful dissection, until he had brought into view the fascia: of the muscles under- neath. The patient was then directed to turn his head towards the opposite side, and Mr. Gooch had the satisfac- tion of observing, that the patient could perform this motion, without his face, and corner of his mouth being affected, as they had been before. The wound was treated in the ordinary way, and no particular symptoms arose. As soon as the inflammation had subsided, the pa- tient was directed to move his head about very frequently, in order to pre- vent any kind of stiffness, which might ensue, in consequence of the contrac- tion of the muscular fibres, and inelas- ticity of the cicatrix. The patient found himself perfectly relieved by the foregoing operation, and had no return ofthe painful spasms, to which he had been previously sub- ject. The side of his face, however, never recovered the proper degree of plumpness. (Chirurgical Works of B. Gooch, Vol. 2. p. 81. Whenever an attempt has been made to cure a wry-neck, by dividing any of the muscles, or merely the integuments, it becomes necessary to take some measures for keeping tiie head in a proper position, during the treatment of the wound, lest, in consequence of the head inclining in the direction, in which it was before the operation, the divided parts should immediately grow together again, and bring the patient almost into the same condition, as he was before any thing had been done. Willi a view of preventing this unplea- sant circumstance, Mr. Sharp recom- mends filling the wound with lint, and making it suppurate. Mr. B. Bell, on the other hand, advises the employment of a proper machine for keeping the head in a due position. Some writers think the use of a bandage quite suffi- cient for the purpose. Perhaps, as pru- dent a plan as any, when the sterno- cleido-mastoideus is affected, is to cut out a certain portion of it. (See Sharp's Treatise on the Operations of Surgery, chap. 35. Chirurgical Works of B. Gooch Vol. 2. p. 81. B. Bell's System of Surgery. Encyclopedic Methodique,- Partie Chirur- gicak; tom. 2. Art. Torticollis.) THE END. r lYkcL.Hist. WZ / VfV * ©n "\. J