1 - A': <■ v--; •* - 'k>* Jt * .*■ ■$ *. P-A.:*" ^■!^.Q^g.g9gS.ff.^.Lrc^.^ V*.- '*- -*-*------.-^1 PRACTICAL SURGERY, CONTAINING A COMPLETE EXHIBITION OF THE PRESENT STATE OF THE PRINCIPLES AND PRACTICE 4 OF SURGERY, COLLECTED FROM THE BEST AND MOST ORIGINAL SOURCES OF INFORMATION, AND ILLUSTRATED BY CRITICAL REMARKS. BY SAMUELJDOOPER, MEMBER OF THE ROTAL COLLEGE OF SURGEONS, LONDON, AND AUTHOR OF THE " FIRST LINES OF THE PRACTICE OF SURGERY." WITH NOTES AND ADDITIONS, BY JOHN SYNG DORSEY, M. D. ADJUNCT PBOFESSOB OF SURGERY IN THE UNIVERSITY OF PENNSYLVANIA, &C IN TWO VOLUMES. VOL. I. SECOND AMERICAN, FROM AN ENLARGED LONDON EDITION. - <.rfl"l:]''->... PHILADELPHIA: PUBLISHED BY B. &T. KITE, JOHNSON & WARNER, M CAREY, I.PIERCE, S. W. CONRAD, B. C. BUZBY, E. PARKER, AND A. SMALL. 1816. ****»*»*****»• DISTRICT OF PENNSYLVANIA, TO WIT: BE IT REMEMBERED, That on the first day of January, in the fortieth year of the Independence of the United States of America, A. D. 1816. BENJAMIN AND THOMAS KITE, of the said district, have deposited in thit office the Title of a Book, the right whereof they claim as Proprietors, in the words following, to wit: " A Dictionary pf Pi-actical Surgery, containing a complete Exhibition of the present " State of the Principles and Practice ol Surgery, collected from the best and most original sources of * information, and illustrated by critical remarks. By Samuel Cooper, Member of the Royal College ot " Surgeon*, London, and author of the " First Lines of the Practice of Surgery." With notes and " additions, by John Syng Oorsey, M.D. Adjunct Professor of Surgery in >he University-of Pennsyl- *•* vauia, &c. In two volumes. Vol. I. Second American, from the London second edition." In conformity to the act of the Congress of the United States, entitled " An Act for the Encouragement of learning, by securingthe Copies of Maps, Charts, and Books, to the Authors and Proprietors of such Copies during the times therein mentioned." And also to the Act, entitled " An Act supplementary to an Act, entitled " An Act for the Encouragement of Learning, by securing the Copies of Maps, Charts, and Books, to the Authors and Proprietors of such Copies during-the time therein mentioned," and extending the Benefits thereof to the Arts of designing, engraving, and etching historical and other Prints." D CALDWELL, Clerk of the District of Pennsylvania ADVERTISEMENT. THE American Editor begs leave to prefix a few remarks to this edition. He was induced to republish the first edition, from a conviction, that he would render an important service to his fellow practitioners throughout the United States, by placing within their reach, a mass of Surgical knowledge, greater than had been ever be- fore, condensed into so small a compass. That he was not greatly mis- taken in his estimate of the work, has been rendered highly probable by the rapid sale of a large edition, and by the concurrent approba- tion of many distinguished Surgeons throughout the extensive territo- ries of the United Stat s. The second London edition, from which this edition is re- printed, has been g.-eatly enlarged by the Author, by copious extracts from most of the recent publications on Surgery. The American Editor has retained, in the present edition, the notes published in the first, and has added others, which he trusts will be found of sufficient interest to justify their insertion. He is conscious that he can hope to derive neither literary nor professional reputation from the task he has undertaken, but in ushering into the world a book, containing the united wisdom of the most eminent writers on Surgery, he has at least one satisfaction, that of promoting the best interests of his profession. January 1, 1816. » A DICTIONARY PRACTICAL SURGERY. >#»»< ABA i BANET. A bandage resembling a j\ girdle. ABAPTISTON, or Abaptista (from it priv.SiRdlZ(C7rTi£et,immergo,to sink under.) Galen, Fabricius ab Aquapendente, and especially Scultetus, in his Armamentarium Cldrurgicum, so denominate the crown of the trepan; or, in other words, the circu- lar saw which makes the perforation in the bone,whentheinstrumentisused. The term came into use, in consequence of this part of the trepan having had, at its first inven- tion, a conical form, which kept it from penetrating the cranium too rapidly, so as to plunge the. teeth of the saw in the dura mater and brain.—Encyclopedic Methodi- qite; Partie Chirurgicale, art. Abaptislon. Whatever suppositious advantages the ancient practitioners of surgery may have imputed to the conical shape of the crowns of their trepans, certain it is, that modern surgeons do not, in general, adopt their no- tions on this subject; but, almost univer- sally, make useof a circular saw, the figure of which is simply" cylindrical. Mr. Samuel Sharp notices the idea of there being the above danger in employing a cylindrical trepan, and remarks, that the great labour of working so slowly and diffi- cultly (with a conical one) is not only very inconvenient to an operator, but by no mean? serviceable to the operation; for, notwithstanding the saw be cylindrical, and work without any other impediment than what lies before the teeth, yet, even with this advantage, the operation goes on so gradually, that, in all the experience which Mr. Sharp has had, he never found the least danger of suddenly passing through to the brain, if care be taken not to lean too hard on the instrument when the bone is almost sawn through. With respect to the impracticableness of inclin- ing the cylindrical saw on any particular Vol. It ABD part of the circle, when sawn unevenly, (which was formerly alleged) whoever will try the experiment, will, in a moment, discover the falseness of the assertion. The very instance stated overthrows this rea- soning ; for, if the circle has already been made more deeply in one part than ano- ther, it must imply, that we have leaned with more ibrce on one part than another, and, consequently, may at pleasure do the same thing again. Mr. Sharp next takes notice of the supposed advantage, which the conical saw had in receiving and re- taining the piece of bone; a circumstance, which he, very properly, calls frivolous. Sharp on the Operations of Surgery. ABDOMEN. The Belly. The term is said to be derived from the Latin verb abdo, to hide, because many of the chief viscera of the body are concealed in the cavity, which it denotes. When a surgeon speaks of the cavity of the abdomen, lie confines his meaning to the space, which is included within the bag of the peritoneum. Hence, neither the kidneys, nor the pelvic viscera, are, strictly speaking, parts of the abdomen. Anatomists have distinguished this large cavity into different regions, and the terms, allotted to these, are so very frequent in the language of surgical books, that some ac- count of them in this Dictionary seems in- dispensable. The middle of the upper part of the ab- domen, from theensiform cartilage, as low down as a line drawn across from the great- est convexity of the cartilages of the ribs, is called the epigastric region. The spaces at the sides of the epigastric. region are termed, the right and left hypo- chondria, or hypochondriac regions. The umbilical region extends upward to the line, forming the lower boundary of the epigastric region, and downwanfl, to a B -) ABDOMEN. ^Kne drawn across from one anterior su- perior spinous process of the ilium to the other. All below the last line, down to the os pubis, is namett the hypogastric region. The abdomen is a part of the body claim- ing the particular attention of every practi- cal surgeon; for, it is the frequent situation of several of the most important surgical diseases. It is also very much exposed to wounds, and various operations are often requisite to be done in different parts of it. One of the most common afflictions, to which mankind are subject, is that in which some of the bowels are protruded, pushing out before them a portion of the peritoneum. This disease is called hernia, and ought to be well understood by every practitioner who, however, can never ac- quire the necessary knowledge,.without being well acquainted with the anatomy of the abdomen, la dropsical cases, it is frequently proper to tap the abdomen, and this operation, named paracentesis, simple as it may seem, requires more considera- tion, and attention to anatomy, than sur- geons often bestow on the subject. But the abdomen is, above all things, exceed- ingly liable to be wounded, to which case We shall confine our present remarks, re- ferring the reader to Hernia and Paracen- tesis for information on these particular subjects. wounds or the audomex. In these cases, we find that the chief cau-e of danger is the tendency ot the peiitoneum to inflame. Every wound of the belly is apt to excite this inflammation, and every inflammation, however slight, is prone ,to spread, to extend itself over all the viscera, and to terminate in gangrene and death. There are (says Mr. John Bell) a thou- sand occasions, on which this delicacy of the peritoneum may be observed; the wound of the (.mall sword, and the stab of the stiletto, explain to us, hi.w quickly the peritoneum, antl all its contained bow- els, inflame from the most minute wound, although it he almost too small to be visi- ble on the outside, and scarcely within j for, often, upon dissection, no intestines are seen to be wounded, arid no frees have escaped into the abdomen. In those, who die after lithotomy, we find the cavity of the peritoneum universally inflamed. The operation of Cesarean section ic fatal, not from any loss of blood, for there is lutle bleeding; nor, from the parts being ex- posed to the air, for, patients als-o die, in whom the womb bursts, and where the air has no possible opportunity of insinuating itself; but, the case proves fatal from the inflammation, which is always disposed to ongiuate from wounds of the peritoneum, small as well as great. (Discourses on the Nature and Cure of Wounds,p 310, edit. 3 ) But, although there can be no doubt, that the wound, abstractedly considered, is the most frequent occasion of this dread- ed inflammation; yet, it sometimes hap- pens, that the inflammatory consequences must be ascribed to another kind of cause. If an intestine be wounded, its contents may, under certain circumstances, be ef- fused in the abdomen ; if the liver, spleen, kidney, or any large vessel be injured, blood may be poured out among the vis- cera; if the gall bladder be wounded, bile may be effused; and, if the bladder be pierced," the urine may escape into the abdomen. Now all these extravasated fluids are extraneous substances, with re- spect to the surfaces, with which the) have come into contact, and usually give rise to inflammation of the peritoneum and vis- cera. I must not, however, prematurely allude to subjects, which will more properly fall under future consideration. Wounds of the abdomen are divided, by almost all-writers, into such as penetrate the cavity of the abdomen, and intoothers, which only interest the skin and muscles. The former differ very much in their na- ture, and degree of danger, according as they do, or do not, injure parts of import- ance, contained in the peritoneum. The latter are not very different from the ge- nerality of other superficial wounds. The chief indications are to lower.inflamma- tion, and to prevent collections of matter. A few particularities, however, in the treatment of superficial wounds of the ab- domen, seem to merit attention. SUPERFICIAL WOUNDS. The most ancient surgeons, and their successors, regularly up to the present day, have recorded, that wounds of tendinous parts are more perilous, than those of fleshy ones. Almost the whole front of the ab- domen is covered with tendinous expan- sions, and, on this account, it is'fiot un- usual to see wounds in this situation fol- lowed by great local inflammations, and the formation of abscesses. The patient is, at the same time, affected with a great deal of the sympathetic inflammatory fe- ver. (Hfte Fever.) When the tension and swelling of the abdomen abate, shivering* sometimes occur, and indicate the occur- rence of suppuration. The matter, which forms in these cases sometimes makes its way into the tendj! noussheath oftherectusmuscle,and, wheti ther^ollection of matter in this situation remains undiscovered until a pointing* ap- ABDOMEN. 3 pears, no sooner does the absces3 burst or is it opened, than an extraordinary quan- tity of matter is discharged. The surgeon should carefully remember the nature of this kind of case, as there is frequently no alteration in the appearance of the inte- guments to denote, either the existence, or the extent, of the suppuration. This kind of abscess tonus one remark- able exception to the excellent general rule of allowing acute phlegmonous abscesses to burst of their own accord. In the pre- sent instance, there is an aponeurotic ex- pansion, intervening between the abscess and the skin, and nothing retards the natu- ral progress of the matter to the surface of the body so powerfully, as the interpo- sition of a tendinous fascia. But, even in this circumstance, the propensity of pus to make its way outward is often seen to have immense influence. Though there is only a thin membrane, (viz. the perito- neum) between matter so situated, and the cavity of the abdomen, yet, in time, the abscess mostly points externally. The proper treatment of this case is to prevent the surprising accumulation of matter, and rapid increase of mischief, b\ • /taking a depending opening, sometimes at the very lowest part of the sheath of the rectus muscle, and thw, as soon as the lodgment of matter is clearly ascertained. The matter sometimes forms between the external and inter*at oblique muscles, and spreads most extensively. The pus may eveji insinuate itself into the abdo- men, and"the case end fatally. Such an example is recorded by Dr. Orowther, of Wakefield. In this instance, however, the disease proceeded from a contusion, not a wound. (See Edinb. Med. and Sur- gical Journal, vol. ii. p. 129.) Superficial wounds of the abdomen are to be treated on the same principles, as similar wounds in other situations. The indications are to prevent inflammation as much aspossiblc, and, if suppuration should be inevitable, to let out the matter by a depending opening, as soon as the abscess is known to exist. The inflammation is to be checked by general and topical bleeding, low diet, emollient clysters, di- luent beverages, quietude, and the mild- est, and most simple dressings. (See In- flammation.) Whenever the abdominal muscles are wounded, it is desirable to relax them; but, this object should not lead us to put the patient out of a horizontal position. A very important point, in the treatment of wounds, which interest the parietes of the abdomen, is to afford a certain degree of support to the wounded part, when there seems the smallest chance of their being too weak to resist the pressure of the *«- cera. The parietes of the abdomen are almost wholly com posed of soft parts, which easily yield. No p-*rt of the front, or sides, of the abdomen, is supported by the sta- bility of a bony structure, and, as the vis- cera are, for the most part, more or less moveable, and closely compressed by the abdom inal muscles, and diaphragm, they are extremely liable to be protruded, when- ever the resistance of the parietes of the abdomen is not sufficiently potent. Thus very perilous cases of hernix may origi- nate. For the above reasons, all wounds of the abdomen, especially those, in which both the integuments and muscles have been cut, demand strict attention to the -pre- caution of supporting the wounded part, and this, though the peritoneum itself should not happen to be divided. The patient ought to keep as much as possible in a horizontal position, while suitable compresses and bandages should be. applied to the situation of the wound. In order to guard against the occurrence of hernia, the part should be supported, in this way, a considerable time after the wound is healed. The peritoneum being connected by means of cellular substance, with the in- ner surface of the abdomiiialmuscles, there is always some risk of the inflammation of these murclesextending to the membranous lining of the abdomen. This occurrence must be averted by the rigorous employ- ment of the antiphlogistic treatment. What renders the event still more dan- gerous is, that when one point of the peritoneum is affected, the inflammation usually spreads with immense rapidity over its whole extent, and too often proves fatal. As superficial wounds of the abdomen are to be treated on.the general princi- ples, applicable to all other wounds of this sort in other situations, it is -hardly necessary to state, that union by the first intention is always, when possible, to be ' attempted. OP WOUNDS PENETRATING THE CAVITV OF THE ABDOMEN. In these cases, the first thing, which the surgeon is generally anxious to know, is, whether the wound penetrates the cavity of the abdomen, and whether any of the viscera are probably injured. When the wound is extensive, and any of the bowels protrude, the first part of the question is at once decided. But, when the wound is narrow, and allows none of the viscera to protrude, it is often exceed- ingly difficult to ascertain, whether the in- jury extends into the abdomen, or not. 4 ABDOMEN. An opinion, however, may usually be form- ed, by carefully examining the wound with one of the fingers, or a probe, after having put the patient, as exactly as pos- sible, in the posture in which he was at the time of receiving the accident; by observ- ing, if possible, the shape and dimensions of the instrument, with which the injury was done; how much of the weapon has entered the flesh; the direction in which it was pushed ; by attending to the quan- tity of blood, which the patient has lost, the state of "his pulse, &c. and, lastly, by observing, whether there is any discharge of bile, feces, or other fluids, known to be naturally contained in some of the abdo- minal viscera. When the wound is sufficiently large to admit the finger, we may always ascertain whether the injury extends into the cavity of the abdomen, because the viscera may then be easily felt. There is only one chance of deception, and that arises from a possibility of the practitioner's mistaking the inside of the sheath of the rectus muscle for the cavity of the peritoneum. When the examination is made with a probe, we should be particularly cautious in forming a judgment; for, the parts are so soft and yielding, that a very little force will make the instrument pass a consider- able way inward. Every examination of this kind should always be undertaken, if possible, when the patient is exactly in the same position, as he was at the time of re- ceiving the wound. Injections have been employed for ascer- taining, whether wounds penetrate the ca- vity of the abdomen. This absurd experi- ment, however, has now been most justly exploded from practice. It is well known to the moderns, that the space termed the cavity of the abdomen, is in fact, com- pletely filled with tlie various viscera, and that a fluid would, in general, not so easily find its way into the bag of the peritone- um, as an unreflecting person might sup- pose. If the injection were propelled with much force, it would be quite as likely to insinuate itself into the cellular substance of the parietes of the abdomen, or, per- haps, into the sheath of the rectus muscle. The feast tortuosity of the wound, or a piece of bowel, or omentum, lying against the internal orifice of the injury, would completely prevent an injection from pass- ing into the abdomen. When a considerable quantity of blood issues from a wound of the abdomen, we may pronounce, almost with certainty, that some large vessel, within its cavity, is in- jured. Excepting the epigastric artery, which runs on the forepart of the abdomen, along the inner surface of the rectus mus- cle, there is not one very considerable ves- sel, distributed to the muscles, and inte- guments. At the same time, it is deserv- ing of particular notice, that a very large artery may be opened in the abdomen, and, yet, not a drop of blood may be dis- charged from the external wound. A co- pious quantity may accumulate in this manner, even without there being any pal- pable swelling of the belly. In such cases, the subsequent symptoms very quickly lead us to suspect what has happened. The patient complains of ex- treme debility and faintness; his pulse faulters ; he has cold sweats; and, if the bleeding should not speedily cease, these symptoms are, in general, soon followed by death. Sometimes, the first glimpse is enough to shew, that the wound extends into the cavity of the abdomen. The event is in- dicated by the escape of chyle, bilious matter, feces, or other fluids,known to be contained in some of the viscera. The same information may also be obtained from seeing a considerable quantity of blood vomited up, or discharged by stool. The urine, however, may flow from a wound, which does not actually penetrate the abdomen, for the kidneys, ureter, mid bladder may be said to be out of the abdo- men, because they are really on the out- side of the cavity of the peritoneum. When no symptoms of the abovedescrip- tion occur, when neither the finger, nor probe, can be introduced; when none of the fluids, known to be contained in the various receptacles in the abdomen, arc emitted from the wound; when the pulse remains natural, and the pain is not exces- sive; there is teason to hope, that the wound has not injured parts of greater consequence than the integuments, and muscles. ( EncyclopedicMethodique,Partie Chirurgicale. Art. Abdomen ) We have now taken a survey of such criteria, as are commonly noticed by sur- gical writers, for the purpose of instruct- ing thereader how to discriminate a wound which has penetrated the abdomen, from one which has not. It is our next place to warn the practitioner, that too much solicitude to determine this point, is very frequently productive of serious harm. It may be set down, as an axiom in surgery, that, whenever the probing of a wound is not renderedabsolutely necessary by some particu- lar object in view, it may, in general, be judici- ously ondtted. A narrow, oblique wound may enter the cavity of the abdomen, with- out there being any particular methodof as- certaining, whether it has done so, or not. This, however, is of no practicul import- ance; for, when there are no urgent symp- toms, evincing the nature of the case, the treatment ought obviously to resemble that ABDOMEN. 5 of a simple wound; and whether the wound is deep, or superficial, the anti- phlogistic treatment is equally indicated. The edges of a wound penetrating the abdomen, but, unattended with any obvi- ous injury of the viscera, are to be brought together with a sticking-plaster, just in the same way as Common wounds. In this situation, sutures are more frequently proper, than in most others. Particular care is also to be taken to keep the bowels from protruding, by the application of a compress, and bandage. All the means of preventing inflammation are to be adopted, (see Inflammation) and quietude is, above all things, to be enjoined. Our good old surgeon Wiseman (ob- serves Mr. Jphn Bell) has said with great simplicity, as a great many have said after him, " Thus it frequently happeneth, that a sword passeth through the body, with- out wounding any considerable part." He means, that a rapier, or ball often passes quite across the belly, in at the navel, and out at the back, and that with- out one bad sign, the patient recovers, and as has very often happened, walks abroad in good health, in eight days; which speedy cure has been supposed to imply a sim- ple wound, in which all the bowels have escaped. But, we see now, how this is to be explained; for, we know, that in a thrust across the abdomen, six turns of in- testine may be wounded,—each wound may adhere ; adhesion, we know, is begun in a few hours, and is perfected in a few days; and, when it is perfect, all danger of inflammation is over; and, when the danger of inflammation is over, the patient may walk abroad; so that we may do, just as old Wiseman did in this case, here alluded to,* " Bleed him, and advise him to keep his bed, and be quiet." In short, a man, thus wounded, if he be kept low, has his chance of escaping bv an adhesion of the internal wounds." (Discourses on the Nature and Cure of Wounds, p. 329, 330, edit. 3.) AVhen a man is stabbed, or shot in the belly, the surgeon can seldom do any good by being very officious; and the wisest conduct, that he can in general adopt, is to keep his patient as quiet as possible, have recourse to bleeding, prescribe ano- dynes, and the lowest fluid diet, and con- tent himself with applying superficial dressings. In the event of severe pain awd swelling of the belly coming on, leeches, fomentations, and emollient poul- tices will be necessary, and nothing will * P. 98. T'ic en e of a man, who was wounded across the belly, an/a well and abroad, in seven days. now avail, except the most rigorous anti- phlogistic means. INFLAMMATORY CONSEQUENCES OF WOUNDS OF THE ABDOMEN. Sometimes, notwithstanding the best treatment, alarming symptoms cannot be prevented. At first, these are commonly of the inflammatory kind ; consequently* repeated bleeding, and redoubled attention to every part of the antiphlogistic treat- ment, are indicated. If the inflammation should not be subdued by such measures, internal mortification and death may fol- low, or abscesses form in the abdomen. SUPPUHATION IN THE ABDOMEN, LN CONSEQ.CENCE OF WOUNDS. Abscesses within the bag of the perito- neum are far from being common occur- rences. As a late writer well observes, " the containing and contained parts of the abdomen present to each other a uni- form and continuous surface of membrane. This membrane is of the serous class, and the species of inflammation, to which it is especially subject, is that, which has been denominated the adhesive. The mem- brane lining1 the intestinal canal,- is of the mucous class, and the ulcerative in- flammation is the species, to which this class is liable. This beneficent provision is an irresistible evidence of the operation of a salutary principle in disease. If the inflamed peritoneum had run directly into suppuration, ulceration of the surrounding parts would have been required for an out- let; and if the internal surface of the irri- tated bowel had tended to form adhesions, the canal would have been in constant danger of obliteration." (Travers on Inju- ries of the Intestines, &c. p. 10.) That collections of matter, however, do sometimes take place in the cavity of the abdomen, in consequence of wounds, is a fact of which there are too many proofs on record, for the possibility of the case to be doubted. At this moment, be it suffi- cient"*for our purpose to refer to two ex- amples of the occurrence, as related fy Mr. Benjamin Bell, in his System of Sur- gery, vol. v. p. 256. If the abscess were in any other part of the body, and did not readily point, the wisest practice would undoubtedly be to make an opening sufficient for the evacua- tion of the matter. But suppuration in the abdomen can seldom be ascertained with certainty, before the collection of matter has existed a- good while; for, the situation of the abscess is so deep^that no fluctuation, nor swelling, becomes perceptible, until a considerable quantity of pus has accumu- 6 ABDOMEN. lkted. Besides, it would not be judicious to expose the patient to the hazard, which might arise from making an opening, into the abdomen, merely for the sake of giv- ing vent to a small collection of matter. Many, indeed,almost all writers, impute a vast deal of th*e danger of wounds of the abdomen to the entrance of air into the cavity of the peritoneumrand they also ad- duce this as an argument against opening abscesses of the abdomen. In inculcating such opinions, however, they betray an in- accuracy of observation, which a very little reflection would have set right. Too much stress has long been laid on the introduc- tion of air into the abdomen, as being a cause of inflammation. The fact is, that the cavity of the belly is always so com- pletely occupied by the various viscera, that the whole inner surface of the perito- neum is constantly in close contact with tfl—ii, and, consequently air cannot so easily diffuse itself from the vicinity of the wound, throughout the abdomen, as has been conceived. After tapping, in drop- sical cases, we seldom see inflammation arise, though air has, in this instance, quite as good an opportunity of entering the abdomen, as in any case of a wound. The peritoneum in animals has been in- flated, without any inflammation being ex- cited. In cases of tympanitis, the perito- neum is distended with air, and yet both this membrane and the bowels are quite uninflamed. In the human subject, it seems probable, that, if a wound were made in a vacuum, the breach of conti- nuity itself would lead to inflammatory consequences. We have also to remark, that collections of matter in the abdomen are almost always completely circumscrib- ed, and separated from the general cavity of the peritoneum, by the adhesion of the viscera to each other, and to the inside of the peritoneum. I am of opinion, that no surgical writer has succeeded so well, as Mr. John Bell, in exposing the absurd apprehensions, not uncommonly entertained by practitioners, respecting the entrance of air into the ab- domen and other cavities of the bod*y\ He Squires: 1st, Whether air can really get into the cavity of the abdomen ? and 2dly, Whether, if it were there, it would pro- duce the dreadful effects ascribed to it i Upon the first question, his arguments "v.n thus: " Suppose a wound of an inch in length;—suppose the bowel to have sunk, in some strange way, into the pel- vis, for example, so as to have left a mere vacuum; what should happen with the flexible parietes of the abdomen? Should they stand rigid, while the air rushed into the cavity to fill it? No, surely. But, on the contrary, the walls of the abdomen would fall together, and the pressure of the outward air, far from making the air rush in by the outward wound, would, at once, lay the belly flat, and close the wound. But, since the walls of the abdo- men are not flaccid, nor the cavity empty, but the abdomen full, and the flat mus- cles, which cover it, acting strongly, the effect must be much more particular; for, the moment that the belly i9 wounded, the action of the muscles will force out part of the bowels: the continuance of that ac- tion is necessary to respiration; the re- spiration continues as regular after the wound, as before; and the continual pres- sure of the abdominal muscles and the diaphragm, against all the viscera of the abdomen, prevents the access of air so effectually, that, though we should hold such a wound open with our fingers, no air could pass into the abdomen, further than to that piece of gut which is first touched with the finger, when we thrust it into the abdomen. Nothing is absolutely exposed tovthe air, except that piece of intestine, which is without the abdome>, or that, which we.see, when we expose a small piece of the bowels, by holding aside the lips of the wound. The pressing forward 9f* that piece, and the protrusion of a por- tion of the gut, proportioned always to the size of the wound; the pressure from be- hind keeping that piece protruded, so that it is with difficulty, we can push it back with our finger ; this incessant pressure, in all directions, is an absolute security against the access of air. The intestine comes out, not like water out of a bottle, the place of which must be supplied bv air entering into the bottle, in proportion as the water comes out; but, the gut is pushed down by the action of the muscu. lar walls of the abdomen, and that action follows the intestine, and keeps it down, and prevents all access of the air whether the gut continue thus protruding, or whe- ther it be reduced; for, if it be reduced, the walls of the abdomen yield, allowing it to be thrust back, but admitting no air. Those, who want to know the effect of air, diffused within the cavity of the abdomen, must make other experiments, than merely cutting open pigs' bellies;—they must give us a fair case, without this unneces- sary wound. We will not allow them to say, when they cut open the belly of any creature, with a long incision, that the inflammation arises from the air: much less shall we allow them to say, when they open the belly with a smaller incision that, by that little incision, the air gets into the abdomen, and that all the bowels are exposed to the air." (Discourses on the Nature and Cure of Wounds, p. 333> 334 v In adverting to the question, whether ABDOMEN. 7 air is so irritating to the cavities of the body, as many have supposed, Mr. John Bell criticises, with much spirit and suc- cess, the opinions, published on this sub- ject, by Dr. A. Monro, in his account of the Bursx Mucosa:, as the annexed quo- tations will shew. " That the vulgar should believe, the first superficial im- pression that strikes them, of air hurting a wound or sore, is by no means surprising; but, it is not natural, that men, bred to philosophy, should allow so strange an assertion as this, without some kind of proof. That the air, which we breathe, and which we.feel upon the surface so bland and delightful, should have so op- posite a relation to the internal parts, that it shou'd there be a stimulus, m**ke acrid and more dangerous, than the urine, is not tb be believed upon slight grounds. I do affirm, (says Mr. John Bell) that it re- mains to be proved, that this fluid, which seems so bland and pleasant to all our senses, and to the outward surface, is yet a horrible stimulus, when admitted, as a celebrated author grandly expresses it, •' into the deep recesses of our body." (Munro's Bursx Mucosa.) With how much reason, Mr. John Bell objects, that this doctrine is founded, will be manifest to every man of any dis- cernment, or impartiality. " The air, for instance, escapes from the lungs, in a fractured rib, and first goes abroad into the thorax; then into the cel- lular substance; then the emphysematous tumour appears; but, often, without any scarifications, with very little care and as- sistance on our part, the air is absorbed, the tumour disappears, and, without in- flammation of the chest, or any particular danger, the man gets well. Here then is the air, within the cavity of a shut sac, filling the thorax, and oppressing the lungs, without any dangerous inflamma- tion ensuing. " That the air n.ay be pushed,under the cellular substance over all the body, without causing inflammation, is very plain from the more desperate cases of emphysema, where the patients, after liv- ing eight or ten days, have died, not from inflammation, but, from oppression mere- ly, the body being so crammed with air, that even the eye-balls have, upon dissec- tion, been found as tense as blown blad- ders. We have also many ludicrous cases of this kind, which prove this to our perfect satisfaction. Soldiers, and sailors, some- times touch the scrotum with a lancet, in- traduce a blow-pipe, and blow it up to an enormous size, imitating hernix, by which they hope to escape from the service. The old story of a man, who was so wicked as to make a hole in h;**- child's head, and blow it up", that he might shew the child in the streets of Paris for a monster, is well authenticated; and, I have little doubt, that a fellow, who knew how to do this, would blow it up every morning, and squeeze it out when he put the child to bed at night. Some viHainous butchers, having a grudge at a soldier, found him lying drunk, under a hedge; they made a little hole in his neck, and blew him up, till he was like a bladder, or, as Dr. Hun- ter describes the disease of emphysema, like a stuffed skin." (P. 338, 339.) After many other pertinent observations, blended with appropriate satyr, on the ex- travagant notions professed by Monro on the bad effects of the air, In lithotomy, operations for hernia, and hydrocele, the Cxsarean section, &c, Mr-John Bell most justly holds up to ridicule the propositions of Dr. Aitken to perform this last operation under the cover of a warm bath in order to exclude tfie air. " This, though it may seem to be a scurvy piece of wit, was really pro- posed in sober serious earnest. But (adds Mr. John Bell), the admission of atmo- spheric air, as a stimulus, when compared with the great incisions of lithotomy, of hernia, of hydrocele, of Cesarean sec- tion, of the trepan, is no more, than the drop of the bucket to the waters of the ocean. And it is just as poor logic to say, that, after such desperate operations, these cavities are inflamed hy the admis- sion of air, as it would be to say, (as Mon- ro did) that when a roan is run through the pericardium with a red hot poker, that the heart and pericardium are inflamed by the admission of the air." (P. 347, edit. 3.) Enough, I conceive, has been said, to dispel all the idle fear and prejudices which have prevailed concerning the bad effects of the air in wounds of the abdo- men, as well as several other cases. When so justly eminent a man as Dr. Alexander Monro, senior, wus disturbed with such apprehensions, it is not wonderful, that many a poor ordinary member of the pro- fession should have been terrified nearly out of his wits upon the subject; and for quieting this alarm, and exposing its absurdities, 1 really think Mr. John Beil deserving of particular praise. In general, it is an excellent rule, in all cases of wounds of the abdomen, never to be officious abcutabscesses, which may take place, nor concerning such viscera, as we may suspect to be injured. It is quite time enough to interfere, when the urgency of the symptoms has confirmed our con- jectures. A great deal of harm is fre- quently done, by handling and disturbing the wounded parts more than is necessary, and, it is well known, that wounds, whicU 8 ABDOMEN. are at first attended with most alarming symptoms, frequently terminate in a fa- vourable . manner. Persons have been known to have swords passed completely through their bodies, without suffering afterwards any threatening symptom, or, indeed, any effects which would authorise one to conclude, that the viscera had been at all injured. We are aware, that se- vere inflammations may not end in suppu- ration, and we also know, that when pus has been formed, the fluid has been often absorbed again. Nothing then indicates the necessity for givir-g vent to purulent matter lodged in the abdomen, except the fluctuation and situation of the abscess be very distinct, and the quantity and pressure of the matter productive of in- conveniences. . For making an opening, some writers recommend a trocar; others, a lancet. The matter must be very copious and dis- tinct, to justify the sudden introduction of such an instrument as a trocar. In other cases, the surgeon should make a Cautious puncture with a lancet. PROTRUSION OF THE VISCERA. Wounds, penetrating the abdomen, sometimes allow considerable portions of the bowels, or omentum, to protrude, and though these viscera may not have re- ceived any injury, yet, their being dis- placed in this way is sometimes productive of fatal consequences. The best mode of preventing such a catastrophe, is to return the viscera into the cavity of the abdomen, as speedily as possible. Almost all authors recommend fomenting the displaced parts, before at- tempting t» reduce them; but, in giving this advice, they seem to forget, that, while time is lost in this preparation, the protruded bowels suffer much more harm from exposure, and other circumstances, than they can possibly receive good from any applications made to them. No kind of fomentation can be half so beneficial, as the natural warmth and moisture of the cavity of the abdomen. In order to faci- litate the return of protruded piece of io- testine, or omentum, the abdominia mus- cle's should be relaxed by placing the pa- tient in a suitable posture, and the large intestines be emptied with a glyster. In mentioning the last measure, it is not meant, that a surgeon should delay the attempt to reduce the part, until the glyster has operated. No, this means is only enumerated as one that may become serviceable, io case the surgeon cannot immediately accomplish the object in view —The mesentery ought always to be reduced before the intestine; the intestine before the omentum; but, the last pro- truded portion of each of these part* ought to be the first one reduced. It is only when the intestine and omen- tum are free from gangrene and mortifica- tion, that they are invariably tu be re- turned into the cavity of the belly, with- out hesitation. Also, when the protruded parts are covered with sand, dust, or other extraneous matter, it is undoubted- ly proper to make them as clean as possi- ble, before putting them back into the abdomen. For this purpose, the parts should be tenderly washed with a little luke-warm milk and water. The two index fingers are the most con- venient for reducing the parts, and, it is a rule to keep the portion, first returned, from protruding again by one finger, until it has been followed by another portion, introduced by the other finger. The second piece is to be kept up, in the same way, by the finger used to retura it; and so on, till the whole of the displaced parts have been put into their natural situation. In attempting to reduce a piece of pro- truded intestine, \h6 patient should be placed in the most favourable posture; the head and chest should be elevated, and the pelvis raised with pillows. Nothing can be more absurd, than the advice to have the thorax rather lower than the pelvis, in order that the weight of the viscera may tend to draw inward the pro- truded parts. This is another erroneous idea, arising from the ridiculous supposi- tion, that a great part of the abdomen is actually an empty cavity. The relaxa- tion of the abdominal muscles is a much more rational and useful object.—When this is properly attended to, and the wound is not exceedingly small, in rela- tion to the bulk of the protruded viscera, the parts may generally be reduced by observing the above directions. But, in addition to what has been already stated, it is necessary to remark, that the pressure should be made in a straight direction into the abdomen; for, when made obliquely, towards the edges of the wound, the parts are liable to suffer contusion, without be- ing reduced, and even to glide between- the layers of the abdominal muscles, and become strangulated. When the wound is in the front of the abdomen, pressure made in this unskilful way, may easilv make the viscera slip into the sheath of the rectus muscle, and cause the same perilous symptoms, as arise from an incar- cerated hernia. (See hernia.) When the reduction seems complete, the surgeon should assure himself of it, by introducing his finger into the cavity of the abdomen, so as to feel, that the parts are all actually reduced, and suffer no con- ABDOMEN. 9 Rtriction between the edges of the wound and the viscera in the abdomen. A difficulty of reduction may arise from the protruded intestines being distended With feces, or air. In this circumstance, the contents of the gut may frequently be made to pass, by little and little, into that portion of the intestinal canal, which is within the abdomen. To accomplish this purpose, the surgeon must press the con- tents of the bowel towards the wound, and, if he succeeds in emptying the part, he will commonly experience equal suc- cess in his next attempt to r. place it in the abdomen. Sometimes, considerable pieces of in- testine are found protruded, through narrow wounds of the abdomen, and the reduction cannot be effected, without do- ing more violence to the bowel, than its delicate structure would bear. In this case, dilating the wound becomes in- dispensable. However, very frequently, when the reduction seems almost a matter of impossibility, on account of the small- ness of the wound, relaxing the abdomi- nal muscles, drawing a little more in- testine out of the wound, and gently press-' ing the contents of the bowels, through the constriction into the abdomen, will render the protruded part sufficiently reducible, without any operation to enlarge the wound. When such operation is unavoidable, the dilatation should be made in a direction, which will not endanger the epigastric ar- tery, and if possible, in the same line as the muscular fibres. It would be unpar- donable to make a more extensive incision than absolutely requisite, as hernix are very much disposed to occur, wher< ver the peritoneum has been divided. The opera- tion may be done with a curved bistoury and a director, much in the same way as is done in cases of strangulated ruptures. (See Hernia.) Instead of enlarging vVounds. of the ab- domen, it has been proposed to let out the air from the~intestines, by making small punctures with the point of a needle, and thus lessen the volume of the protruded part sufficiently to render it easily reduci- ble. This suggest ion first originated with Ambroise Pare, who declares, that he has several times practised the method with success. Rousset, his cotemporary, also in- forms us, that the plan was adopted by another surgeon,. in an instance, where the epigastric region was wounded, and a largi* portion of the intestines was pro- truded and strangulated. Peter Lowe, an English surgeon, likewise assures us, that he has frequently pursued such prac- tice, when other means failed. Garcn- jreot, Sharp, and Van Swieten, are all ad- b Vol. I. vocates for Pare's proposal; but they re- commend employing a round needle, which will merely separate the intestinal canal, without cutting them, as a flat, triangular, sharpedged needle would unavoidably do. These last celebrated writers, however, only sanction the practice, when the quan- tity of protruded intestine is exceedingly great, and when it is so enormously dis- tended with air, that it would be impossi- ble to reduce the part, though the wound were enlarged, and every thing else, •likely to promote the reduction, were put in practice. But, as the judicious Saba- tier has remarked, the punctures must be entirely useless, if made with a fine needle, since they will be immediately stopped up* with tne mucous secretion, with which the inside of the bowels is constantly co- vered; and if the punctures are made with a broad triangular needle, or a very large round one, as Desault and Chopart have advised, they must be highly dangerous, inasmuch as they must be extremely likely to give rise to inflammation, and even to extravasation within the abdomen. (See Mederine Operatoire, Tom. i,p. 10.) It was the circumstance of small punc- tures being unavailing, that led Desault and Chopart to recommend the use of a large round needle, " pour que Pouverture ne soitpointboucheeparies mucosites dont les intestines sont enduits." But, they were also aware of the danger ofemploying such an instrument, since they give us directions how to -proceed, in order to prevent ex- travasation ami inflammation: *" On pre viendra I'epanchement des matieres slercora- les en passant, avant tie reduire I'intestin, une anse tlefil duns la portion de mesentere qid repond d la piqure pour la fixer contre les bords de laplaie exterieure, et Von com- battrapar les remedes generaux Pinf anima- tion que cet piqure pent attirer." (Traite des Maladies Chirurg. 'Torn. 2. p. 135 ) Mr. Travels, one of the latest writers upon this subject, most properly joins in the condemnation of the plan of pricking the protruded bowels. " Blancard and others protested against this practice, on the very sufficient ground of its ineflicacy. La Faye very truly says, it is a useless as well as dangerous practice; for the open- ings, made by a round needle, cannot give issue to the containing air." Mr. Travels then cites two cases, shewing that even small stabs in'a bowel will not pre- vent its becoming distended with air. " A man was brought to St. Thomas's hospital, on Saturday, the 30th of June last (1811,) 'vho had been ■*>tabbed in the direction of the epigastric artery, on the left side of the abdomen, by a case knife. Fie died in eighteen hours, apparently from the sudden and copious hcmorrhagp, 10 ABDOMEN. which had taken place within the belly. About half a yard of'ileon was protruded. The gut was highly discoloured, and so much distended, notwithstanding it was pierced in three places, that the wound of the integuments required to be freely dilated, before it could be returned. The apertures were in fact obliterated by the mu- cous coat." " It appeared upon the trial of Captain Sutherland (Ann. Reg. June 1809) for the murder of his cabin boy, that the intes- tines had been extensively protruded through a wound near the left groin, and had lain exposed for four or five hours— that the dirk had pierced through one fold of intestine, and entered another—that the wound of the intestine was half an inch long, that the reduction could not be ac- complished until the parietal wound was dilated; and that the intestine was then returned, and the integuments sewed up." (Travers on injuries of the Intestines, p. 174, 176.) I must observe, however, with respect to this last case, that it does not satisfac- torily prove what the author intends it to shew, namely, that the bowel was distended with air, though there was a wound in, it half an inch long, for, the evidence does not inform us, that the difficulty of reduction was owing to this cause. I have seen a very small portion of omentum protruded through a wound, and baffle all endea- vours to reduce it for nearly an hour. The first case, adduced by Mr. Travers, however, is more explicit and interesting; and we are to infer from it, and the ob- servations of Hallcr, that tlie punctures, made in an intestine, are not closed by mucus, as Sabatier and Desault have as- serted, but by the mucous coat itself". As the above expedient had been re- commended by writers of some weight, I thought that the subject should not be passed over in silence and without a caution to the reader, never to put any confidence in the method. The plan does not facilitate the business of the operator; there is not even this solitary reason in favour of the practice; and though it may have answered when large needles were used, and some patients, so treated, may have recovered ; yet, every person, who hrs the least knowledge of the animal econo- my, will easily comprehend, hw even the smallest opening, rnude in parts, so irritable and prone to inflammation, as the bowels, must be attended with greater danger than would result from enlarging a wound of the skin and muscles. Besides tlie air may frequently be pressed out of the intestine in a safer way,* as I have al- ready described. A wound of the abdomen, attended with one of the most considerable protru - sions of the viscera, that I have ever read of, is recorded by Mr. Hague, surgeon at Ripon: " August 30th 1808 (says this gentleman,) I went to Norton Mills, about four miles from hence, to see John Brown xt. 12 years, who had received a wound in the abdomen by a wool shears. On my arrival, which was little more than an hour after the accident, I found the poor lad in a very distressing situa- tion ; the great arch of the stomach, and the whole of the intestinal canal, (duodenum excepted) contained within the abdomen, having protruded through the wound. The incision was on the left side of the body, commencing at about two inches below the scrobiculus cordis, and extend- ing in a straight line near four inches in length, distant from the navel two inches, and he was quite sensible, and had vo- mited so as to empty the stomach ; very little blood was lost. I immediately pro- ceeded very carefully to examine the pro- truded viscera, none of which were wounded, and reduced them as quickly as possible, beginning with the stomach, and following the regular course of the intes- tines, in the latter portion of which, I distinctly felt feces, of rather firm con- sistence. He complained of some pain, during the reduction, though not much, and expressed great relief, when the parts were completely returned. I now desired an assistant, to lay the palm of his hand over the wound, and make some pressure upon it; for, 1 found, that, without this, the> parts would soon have protruded again by the action of respiration, which was oppressed and laborious. I brought the sides of the wound together by five sutures, beginning from above down- wards, and passed the needle on each side, quite through the integuments with the peritoneum, &c. The wound was also dressed with adhesive plaster, and co- vered with a bandage." Vide Edinburgh Medical and Surgical Journal, Vol. 5, p. 129, &c. This case is really an interesting one; for, notwithstanding so unlimited a pro- trusion of tlie viscera, and tlie parts had been left unreduced for more than an hour, a recovery ensued, under the judi- cious employment of bleeding, purging, anodynes, &c. When the protruded intestine is wound- ed, the opening is to be closed with a par- ticular suture, before the part is returned into the abdomen. Of this subject, when we speak of the wounds of the intestines. Some of the exposed intestine may have mortified, before the arrival of sur- gical assistance. This event is exceed- ingly rare in cases of wounds, but, is not ABDOMEN. 11 uncommon in those of strangulated liemix. The treatment will be explained in the article Hernia. When the protruded intestine is in a stale of inflammation, its immediate re- duction is, beyond all dispute, the means most likely to set every thing right. Even when the inflammation has risen to a vehe- ment pitch, a timely reduction of the dis- placed part, and the employment of anti- phlogistic means will often prevent gangre- nous mischief. The dull, brown, dark red colour of the intestine may induce the practitioner to suppose, either that the part is already mortified, or must inevi- tably become so, and, consequently, he may delay returning it into its natural si- tuation. But, notwithstanding this sus- picious colour of the intestine, its firm- ness will evince, that it is not in a state of gangrene. The ultimate recovery of a portion of intestine, so circumstanced, is always a matter of uncertainty ; but, the propriety of speedily replacing the part in its natural situation is a thing most cer- tain. In case the bowel should mortify after being reduced, all hopes of the pre- servation of life are not to be abandoned,- as we shall notice again in the subject of hernia, where every thing necessary to be known, concerning the mode of reducing protruded omentum, will also be found. The protruded viscera having been re- duced, the next object is to retain them in the abdomen, until the wound is complete- ly healed. When the wound is small, this is a matter of no difficulty; in this instance, it is enough to put the patient in such a position, as shall relax the fibres of the wounded muscles, while the edges of the wound are maintained in contact with sticking plaster, and supported, in this way, by a compress and bandage. Costiveness is to be removed by the mild- est purgatives, such as the soda phos- phorata and oleum ricini, or by laxative glysters, which are still preferable. But, in cases of extensive wounds, even when the treatment is conducted with all possi- ble judgment, it is occasionally very diffi- cult, and impossible, to hinder the pro- trusion of the bowels by common dressings, and a bandage. In this circumstance the edges of the wound must be sewed to- gether by a particular suture, named Gas- troraphe. (See this article.) It is proper lo remark, however, that, in modern times, this suture is very rarely employed, in comparison with what it was formerly, and, in the description of gastroraphe, some remarks will be offered, for the pur- pose of proving, that even the generality of large wounds of" the abdomen do not require any suture whatsoever. EXTRAVASATION IN THE ABDOME? Wounds of'the abdomen maybeom- plicated with extravasations of bod, chyle, excrement, bile, or urine. lone of these complications, however, arthalf so frequent, as an unreflecting and nex- perienced practitioner might apprcsnd. The employment of the phrase cavity rthe abdomen has paved the way to much to- neous supposition upon this subject, md has induced many absurd notions, wlch even the sensible observations, long ^o published by Petit (le fils,) have scarcly yet dispelled. Asa modern writer has observed," thee is not truly any cavity in the hurnn body, but, all the hollow bowels are fille'. with their contents, all.the cavities fillet with their hollow bowels, and the whole is equally and fairly pressed. Thus, in the abdomen, all the viscera are moved by the diaphragm and the abdominal mus- cles upwards and downwards, with an equable continual pressure, which has no interval; and one would be apt to add, the nUestineshave no repose, being kept thus in continual motion; but, though the action of the diaphragm, and the re- action of tlie abdominal muscles are alter- nate, the pressure is continual; the mo- tion, which it produces, (they produce) is like that which the bowels have, when we move forwards in walking, having a motion, with respect to space, but none with regard to each other, or to the part of the belly, which covers them; the whole mass of the bowels is alternately pressed, to use a coarse illustration, as if betwixt two broad boards, which keep each turn of intestine in its right place, while the whole mass is regularly moved. When the bowels are forced down by the diaphragm, the abdominal muscles re- cede : when the bowels are pushed back again, it is the reaction of the abdominal muscles, that forces them back and fol- lows them; there is never an instant of interruption of this pressure, never a mo- ment, in which the bowels do not press against the peritoneum; nor is there the smallest reason to doubt, that the same points in each are continually opposed. We see, that the intestines do not move, or, at least, do not need to move in per- forming their functions; for, in hernia, where large turns of intestines are cut off'by gangrene, the remaining part of the same intestines is closely fixed to the groin, and yet the bowels are easy, and their functions regular. We find the bowels re- gular, when they lie out of the belly, in hernia, rs when a certain turn of, in- testine lies in the scrotum, or Ihigh, or, in a hernia of the navel; and where yet 12 ABDOMEN. theyre so absolutely fixed, that the piece of irestine is marked by the straitness of the ngs. We find a person, after a woun of the intestine, having free stools for any days ; and what is it that pre- ventthe feces from escaping, but merely this Jgular and universal pressure? We find person, on the fourth or fifth day, Tvitl feces coming from the wound'! a pro-', surely, that the wound of the in- tesne is still opposite, or nearly opposite, to ie external wound. We find the same patent recovering without one bad sign! v\iat better proof than this could we de- sie, that none of tlie feces have exuded iito the abdomen ? "If*, in a wound of the stomach, the pod could get easily out by that wound, die stomach would unload itself that way, there would be no vomiting, the patient must die ; but, so regular and continual is this pressure, that the instant a man is wounded in the stomach, he vomits, he continues vomiting for many days, while not one particle escapes into the cavity of the abdomen. The outward wound is commonly opposite to that of the stomach, and, by that passage, some part of the food comes out; but, when any accident removes the inward wound of the stomach from the outward wound, the abdominal muscles press upon the stomach, and follow it so closely, that if there be not a mere laceration extremely wide, this pres.sure closes the hole, keeps the food in, enables the patient to vomit, and not a particle, even of jellies, or soups, is ever lost, or goes out into the cavity of the belly. " How (proceeds Mr. J. Bell) without this universal and continual pressure, could the viscera be supported ? Could its liga- ments, as we call them, support the weight of the liver ? Or, what could support the weight of the stomach when filled ? Could the ntesentery, or omentum, support the intestines; or could its own ligaments, as we still name them, support the womb ? How, without this uniform pressure, could these viscera fail to give way and burst ? How could the circulation of the abdomen go on ? How could the liver and spleen, so turgid as they are with blood, fail to burst ? Or what possibly could support the loose veins and arteries of the abdomen, since many of them, e. g the splenic vein, is, (are) two feet in length, is (are) of the diameter of the thumb, and has (have) no other, than the common p- llucid and deli- cate coats of the ve.ns ? How could the viscera of the abdomen bear shocks and falls, if not supported by the universal pressure of surrounding parts ? In short, the accident of hernia being forced out by any blow upon the b.-ily, or by any sudden •itrain, explains .to us how perfectly full the abdomen is, and how ill it is able to bear any pressure, even from its own mus- cles, without some point yielding, and some one of its bowels being thrown out. And the sickness and faintness, which im- mediately follow the drawing off of the waters of a dropsy, explain to us, what are the consequences of such pressure being even for a moment relaxed. But, per- haps, one of the strongest proofs is this, that the principle must be acknowledged, in order to explain what happens daily in wounds; for, though in theory we should be inclined to make this distinction, that the hernia, or abscess of the intestines, will adhere and be safe, but, that wounded intestines, not having time to adhere, will become flaccid, as we see them do in dissec- tions, and so, falling away from the ex- ternal wound, will pour out their feces into the abdomen, and prove fatal; though we should settle this, as a fair and good distinction in theory, we find, that it will never answer in practice. Soldiers recover daily from the most desperate wounds ; and the most likely reasons, that we can assign for it, are, the fulness of the abdomen, the universal, equable, and gentle pressure; and the active disposition of the peritoneum, ready to inflame with the slightest touch. The wounded intes- tine is, by the universal pressure, kept close to the external wound, and the pe- ritoneum and the intestine, are equally inclined to adhere. In a few hours, that adhesion is begun, which is to save the patient's life, and the lips of the wounded intestine are glued to the lips of the ex- ternal wound. Thus, is the side of the intestine united to the inner surface of the abdomen; and, though the gut casts out its feces, while the wound is open; though it often casts them out more freely, while the first inflammation lasts; yet, the feces resume their regular course, whenever the wound is disposed to close." (John Bell's Discourses on Wounds, p. 323, 327, edit. 3.) The foregoing extract, though drawn up in a most careless style contains such observations, as are well calculated to make the reader understand, that the ab- domen is in reality not a cavity, but a compact mass of containing and contained parts; that the close manner in which the various surfaces are constantly in con- tact, must powerfully oppose extravasa- tions ; and that, in fact, it often entirely prevents them. The passage cited im- presses us with the utility of that quick propensity to the adhesive inflammation, which prevails throughout every peritoneal surface, and which not only often has the effect of permanently, hindering effusion of the contents of the viscera, by agglutinat- ABDOMEN. 13 ing the parts together, but which, even when an extravasation has happened, be- neficially confines the effused fluid in one mass, and surrounds it with such adhe- sions of the parts to each other, as are rapid in their formation, and effectual for the purposes of limiting the extent of the effusion, and preventing the irritation of the extravasated matter from affecting the rest of the abdomen. It is to M. Petit, that we are indebted for the introduction of more correct modes of thinking upon the foregoing subject, and, as his valuable observations in the Mem. de l'Acad. de Chirurgie, are highly interesting, it is my intention to intro- duce them into this Dictionary, in the article, Extravasation, to which, for the present, I shall be content with referring. But, notwithstanding the influence of the reciprocal pressure of the containing and contained parts against each other, and the useful effect of the quickly arising adhesive inflammation, in all penetrating wounds of the belly, complicated with the injuries of the. viscera, we are not to sup- pose, that extravasation never happens; but, only that it is much less frequent than has been commonly supposed. Mr. Tra- vers, with much laudable industry, has endeavoured to trace more minutely, than any preceding writer, the particular cir- cumstances, under which effusions in the abdomen are likely or unlikely to happen. " It being admitted (says he) that there are cases, in which effusion does take place, it is easy to conceive circumstances, which must considerably influence this event. If, for example, the stomach and bowels be in a state of emptiness, the nausea, which follows the injury, will maintain that state. If the extent of the wound be considerable, the matter will more readily pass through the wound, than along the canal. A wound of the same dimensions in the small and the large intestines, will more readily eva- cuate the former, than the latter, because it bears a larger proportion to the calibre. Incised and punctured wounds admit of the adhesion of the cut edges, or the ever- sion of the internal coat of the gut, so as to be in many instances actually obliterat- ed ; whereas, lacerated, or ulcerated open- ing, do not admit of these salutary pro- cesses. Again, in a transverse section of the bowel, contraction of the circular fibre closes the wound, whereas in a longitudi- nal section, the contraction of this fibre enlarges it. Such (says Mr. Travers) are the circumstances, which combined, in a greater or less degree, increase or diminish the tendency to effusion." (On Injuries of Intestines, SJfc. p. 13—14.) After the details of some experiments and cases, the precedi'ng author makes among other conclusions, the following: 1. That effusion is not an ordinary con- sequence of penetrating wounds. 2. That, if the gut be full and the wound extensive, the surrounding pressure is over- come, by the natural action of the bowel tending to the expulsion of its contents. 3. That, if food has not recently been taken, and the wound amounts to a divi- sion of the gut, or nearly so, the eversion and contraction of the orifice of the tube, prevent effusion. 4. That, if the canal be empty at the time of the wound, no subsequent state of tlie bowel will cause effusion, because •the supervening inflammation agglutinates the surrounding surfaces, and forms a cir- cumscribed sac; nor can effusion take place from a bowel at the moment full, provided it retains a certain portion of its cylinder entire, the wound not amounting nearly to a semidivision of the tube, for then the eversion and contraction are too partial to prevent an extravasation. 5. That, when however air has escaped from the bowel, or blood has been extra- vasated in quantity within the abdomen at the time of the injury, the resistance, op- posed to effusion, will be less effectual, al- though the parietal pressure is the same, as such fluids will yield more readily, than the solids naturally in contact. P. 25— 26, 100. 6. That, though extravasation is not common in penetrating wounds, it follows more generally in cases, where the bowel is ruptured by blows, or falls upon the belly, while the integuments continued un- wounded. P. 36. 7. That when the bowels are perforated by ulceration, there is more tendency to effusion, than in cases of wounds. P. 38, &c. Mr. Travers attempts to explain the reason of the greater tendency to effusion, in cases of intestine burst by violence, and in those^>f ulceration "by the dif- ference in the nature of the injury, which the bowel sustains, when perforated by a sword or bullet, as in the one case, or burst or ulcerated in the other. A rup- ture by concussion could only'take place under a distended state of the bowel, a condition most favourable to effusion, and from the texture of the part, a rupture, so produced would seldom be of limited ex- tent. The process of ulceration, by which an aperture is formed, commences in the internal coat of the bowel, which has al- ways incurred a more extensive lesion, than the peritoneal covering. The puncture, or cut is merely a solution of continuity in a point, or line ; the ulcerated wound is 14 ABDOMEN. an actual loss of substa-nce. The conse- quence of this difference is, that, while the former, if small, is glued up by the ef- fusion from the cut vessels, or, if large, is nearly obliterated, by the full eversion of the villous coat, the latter is a permanent orifice." P. 46. How much Mr. Travers and Mr. John Bell differ in opinion, upon these latter points, will appear from the following passage: after adverting to the adhesion, which takes place between the viscera and the peritoneum, under a variety of circum- stances attending disease, Mr. John Bell observes: " this it is, which makes the chief difference, in point of danger, be-- twixt an ulcerated and a wounded intes- tine; for, in a wound, there is, as we should suppose, no time for adhesion, no- thing to keep the parts in contact, no cause, bv which the adhesion might be produced. But, in an ulcer, there is a slow disease, tedious inflammation, adhe- sion first, and abscess, and bursting after- wards ; sometimes a fistula remains dis- charging feces, and sometimes there is a perfect cure. If a nutshell, a large coin, a bone, or any dangerous thing be swal- lowed, it stops in the stomach, causing swelling and dreadful pain; at last, a hard, firm tumour appears, and then it suppurates, bursts, the bowel opens, the food is discharged at every meal, till the fistula gradually lessens, and heals at last. But, where the stomach is cut with a broad wound of a sabre, the blood from the wounded epiploic vessels, or Uie food itself, too often pours out into the abdo- men, and the patient dies." &c. ( Discourses on Wounds, p. 321, edit. 3.) The author afterwards proceeds to explain how the compact state of the containing and con- tained parts, and the incessant and equa- ble pressure, which the viscera sustain, frequently hinders effusion in cases of pe- netrating wounds. Which of these gentlemen is most cor- rect on the subject, I cannot pretend to say. Mr. Travers has certainly adduced a few cases, in favour of his own state- ment. Whether they are deviations from what is most common, can only be decided by a comparative examination of a greater number of facts. When the intestines ul- cerate, and thus rid themselves of foreign bodies, the general tenor of the cases on record undoubtedly affords us little reason to be apprehensive of extravasation. Yet, with respect to ulceration of the intestines from other causes, circumstances may be very different. Blood is more frequently extravasated in the abdomen, than any other fluid. Extravasations of this kind, however, do not invariably happen, whenever vessels of nota very considerablesize are wounded. The compact state of the abdominal vis- cera, in regard to each other, and their action on each other, oppose this effect. The action, alluded to, which depends on the abdominal muscles and diaphragm, is rendered very manifest by what happens, in consequence of operations for hernix attended with alteration of the intestines, or omentum. If these viscera should burst, or suppurate, after being reduced, the mat- ter which escapes from them, or tlie pus, which they secrete, is not lost in the ab- domen ; but is propelled towards the wound of the skin, and there makes its exit. The intestinal matter, effused from a mortified bowel, has been known to re- main lodged the whole interval, between one time of dressing the wound and ano- ther, in consequence of the surgeon stop- ping up the external wound with a large tent. When the abovementioned action or pressure of the muscles, is not sufficient to keep the -blood from making its escape from the vessels, still it may hinder it from becoming diffused among the convo- lutions of the viscera, and thus the extra- vasation is confined in one mass- The blood, effused and accumulated in this way, is commonly lodged at the inferior and anterior part of the abdomen, above the lateral part of the pubes, and by the side of one of the recti muscles. The weight of the blood may propel it into this situation, or, perhaps, there may be less resistance in this direction than in ano- ther. In opening the bodies of persons, who have died with such extravasations, tilings may put on a different aspect, and the blood seem to be promiscuously extra- vasated over every part of the abdomen. But, when such bodies are examined with care, it will be found, that the blood does not insinuate itself among the viscera, till the moment when the abdomen is opened, and the mass previously lies in a kind of pouch. This pouch is frequently circum- scribed, and bounded by thick membranes, especially when the extravasation has been of some standing. (Sabatier Medecine Operatoire Tom. 1, p. 28—30.) It is of the highest consequence to a practical surgeon to remember well, that all the parts contained in the abdomen are closely in contact with each other, and with the inner surface of the peritoneum. This is one grand reason, why extravasa- tions are seldom so extensively diffused as one might imagine; but, commonly lie in one mass, as Petit, Sabatier and all the best moderns have noticed. The pressure of the elastic bowels, of the diaphragm; and abdominal muscles, not only fre- ABDOMEN. 15 quently presents an obstacle to the diffu- sion of extravasated matter, but often serves to propel it towards the mouth of the wound. The records of surgery make mention of numerous instances, in which persons have been stabbed through the body, without any fatal consequences, and sometimes without the symptoms being even severe. In Mr. Travers's publication many cases, exemplifying this observa- tion, are quoted from a variety of sources; Fab. Hildan Obs. Chirurg. Cent. 5. Obs. 74. CEuvres de Pare, liv. 10. Chap. 35. Wiseman's Surgery, p. 371. La Motte's Traite Complet de Chirurgie, &c. &c. In such cases the bowels have been supposed to have eluded the point of the weapon, and this may perhaps in a few instances, have been actually the fact; but, in almost all such examples, there can be no doubt, that the bowels have been punctured, and an extravasation of intestinal matter has been prevented by the opposite pressure of the adjacent viscera. Such resistance and pressure may, also, have occasionally obliged intestinal matter, or blood, actu- ally extravasated, to pass through the wound of the bowel into its cavity, and thus be speedily removed. Certain it is, such copious evacuations of blood per an- num have followed stabs of tlie abdomen, as could hardly proceed from the arteries of the intestines. This way of getting rid of an extravasation must be rare, how- ever, compared with that by absorption. The pouch, or cyst, including extrava- sated blood, or matter, as mentioned by Sabatier, is formed by the same process, which circumscribes tlie matter of absces- ses. (See Suppuration.) It is in short the adhesive inflammation. All the surfaces in contact with each other, and surrounding the extravasation, and track of the wound, generally soon become so intimately con- nected together by the adhesive inflamma- tion, that the place in which the extrava- sation is lodged, is a cavity entirely desti- tute of all communication with the cavity of the peritoneum. The track of the wound leads to the seat of the effused fluid, but, has no distinct opening into the general cavity of the abdomen. The rapidity with wliich the above adhesions form, is often very great, almost incredible. It should be known, however, that ex- travasations are occasionally diffused in various degrees among the viscera, owing to the patient being subjected to a great deal of motion, or his having violent spas- modic contractions of the intestines, aris- ing from tlie irritation of the extravasated matter. Urine and bile are more frequent- ly dispersed to a great extent among the abdominal viscera, than blood. The latter fluid, indeed, must often coagulate; a circumstance, that must both tend to stop further hemorrhage, and confine the ex- travasation in one mass. SIMPTOMS AND TREATMENT OF EXTRAVA- SATIONS IN THE ABDOMEN. 1. Blood. Wounds of the spleen, and of such veins and arteries, as are above a certain size, almost always prove fatal from internal hemorrhage. Tlie blood generally makes its way downwards,and accumulates at the inferior part of the abdomen, unless the existence «f adhesions happen to oppose tlie descent of the fluid to theniost depend- ing situation. The belly swells, and the fluctuation of afluidis perceptible through the anterior part of the abdominal parietes The patient grows pale, loses his strength, is affected with syncope, and his pulse becomes weaker and weaker. In short, the symptoms, annually attendant on hemor- rhage, are observable. The viscera and vessels in the abdomen being continually compressed on all sides, by the surround- ing parts, the blood cannot be effused, without overcoming a certain degree of resistance ; and unless a vessel of the first magnitude, like the aorta, the vena cava, or one of their principal branches, has been wounded, the blood escapes from the vessel slowly, and several days elapse, be- fore any considerable quantity has accu- mulated in the lesser cavity of the pelvis In these cases of extravasated blood, the symptoms which, perhaps, had disap- peared, under tlie employment of bleeding and anodyne medicines, now come on again. A soft, fluctuating tumour may be felt at the lower part of the abdomen; sometimes on the right side; sometimes on the left; occasionally, on both sides. The pressure, made by the effused blood on the urinary bladder, excites distressing inclinations to make water; while the pres- sure, which the sigmoid flexure of the colon suffers, is tlie cause of obstinate con- stipation. In the mean time, the quantity of extravasated blood increasing, irritation and inflammation of the peritoneum are induced. The pulse grows weaker; debili- ty ensues; the countenance is moistened with cold perspirations; and, unless insti- gated by all the antecedent circumstances, the surgeon practices an incision for the discharge of the fluid, the patient falls a victim to the accident. In the year 1733, Vacher, principal sur- geon of the military hospital at Besancon, successfully adopted this mode of treat- ment, as I shall more particularly notice in the article Extravasation. Petit (the son) afterwards tried the same plan, though it did not answer, (as is alleged) in conse- quenceoftheinflammationhavingadvanced ABDOMEN. too far, before the operation was perform- ed. Long before the time of Vacher and Petit, a successful nstance of similar prac- tice had been recorded by Cabrole, in a work, which this author published, under the title of AA-^*/3jjtov ccvxrofttKov, id est, Anatomes elenchus accuratissimus, omnes humani corporis partes ed quci solent secari methodo, delineans. Accessere osteologia, observationes que Medicis ac Chirurgis perutiles. Geneva 1604. Hence, as Saba- tier has remarked, the method pursued by Vacher, was not so new as Petit imagined. (Medecine Operatoire, Tom. 1, p. 32.) Indeed, when the symptoms leave no doubt of there being a large quantity of blood extravasated in the abdomen ; when the patient's complaints are of a very se- rious nature, and are evidently owing to the irritation and pressure of the blood on the surrounding viscera; and when a local swelling denotes the seat of the extravasa- tion, there cannot be two opinions about the propriety of making an incision for its evacuation. „ Surgeons, however, should recollect, that a small extravasation of the blood may exist, without producing any very consid- erable irritation, provided no opening be made into the cyst, with which it becomes surrounded. On the contrary, when such \ cyst is opened, the air then having free access to the blood contained there, that partofthe fluid, which cannot be discharg- ed, is very apt to putrify, and become so irritating, as to excite inflammation of the surrounding parts.—Even though there may be an evident extravasation of blood, the bad symptoms are also sometimes en- tirely owing to the injury done to the parts within the abdomen, and neithej to the pressure, nor the irritation of the effused blood. But, sometimes as we have already no- ticed,, the accumulated blood at first, nei- ther irritates the adjacent parts by its quantity nor quality. An inflammation, however, of the parts surrounding the ex- travasation at length takes place. The ten- sion, irritation, and pain, which, in the first instance arose from the wound itself, and subsided, seem now to be renewed. When the extravasation is at the lower and ante- rior part of the abdomen, the patient ex- periences pain about the hypogastric re- gion. He is also constipated, and, as he suffers great irritation of the bladder, he feels frequent propensities to make water, but cannot relieve himself. At last, a tu- mour makes its appearance, attended with i fluctuation more or less distinct. In this instance, it seems proper to give vent to the accumulated blood. If this fluid should be found coagulated, injec- tions of warm water would facilitate its discharge. (Sabatier Medecine Operatoire, Tom. 1) 2. Chyle and ftces. These are not so easily extravasated in the abdomen as blood, because they do not require so much resistance, on the outside of the stomach and intestines, to make them continue their natural rout through the ali- mentary canal, as blood requires to keep it in the vessels. Extravasations of this kind, however, sometimes happen, when the wound is large and the bowel distended at the moment of the injury, or when, as Mr. Travers has likewise explained, air is ex- travasated, or blood effused in the abdo- men; these fluids being incapable of making effectual resistance to the escape of the in- testinal matter. (See an Enquiry into tlie Process of Nature in repairing Injuries of the Intestines, &c. p 26.) Nothing is a bet- ter proof of the difficulty with which chyle and feces are extravasated, than the ope- ration of an emetic, when the stomach is wounded and hill of aliment. In this in- stance, if the resistance to the extravasa- tion of the contents of the stomach were not considerable, they would be effused in the abdomen, instead of being vomited up. A peculiarity in wounds of the stomach and intestines is, that the opening, which allows their contents to escape, may also allow them to return into the wounded viscus. Extravasation of intestinal matter in the abdomen is attended with a severe train of febrile symptoms; dryness of the mouth, tongue, and fauces; considerable pain and swelling of the belly; convulsive starlings ; and hiccough and vomiting, with which the patients are generally .a ucked on the day after that, on which tiie wound - as received. (Sabatier de la Medecine Opera- toire, Tom. 1, p. 34.) In these cases, general means are the only ones which can be employed ; vene- section, fomentations, low diet, perfect rest, anodynes, &c. All solid food must be most strictly prohibited. The close state of the viscera m. y also be increased by applying a bandage ound the body. If the symptoms are not speedily as- suaged, the abdominal viscera become affected with general inflammation, and gangrene, and the patients die in the course of a few days. 3. Bile. Bile, on account of its great fluidity, is more easily extravasated extensively in the abdomen, t ban either blood, or the contents of the stomach and intestines. Besides, the gall bladder has the power of contract- ing itself so completely, as to expel the whole of its contents. Notwithstanding ABDOMEN. 17 these circumstances, however, extravasa- tions of this kind are exceedingly uncom- mon, doubtless, on account of the small size of the gall bladder, and its deep guarded situation, between the concave surface of the liver, and upper part of the transverse arch of the colon. Sabatier informs us, that he has only been able to find one example on record. This case, after having been communicated to tlie Royal Society of London, by Dr. Steward, (No. 414, page 341. Abridgm. Tom. 7, page 571—572,) was inserted, as an extract, in the third volume of the Edinburgh Essays, and also in the third volume of Van Swieten's Commentaries on the Aphorisms of Boerhaave, (transl. p. 65, edit. 1754.) An officer received a wound, penetrating the cavity of the abdomen, and entering the fundus of the gall bladder, without doing any material injury to the adjacent parts. The abdomen was imme- diately distended, as if the patient had been afflicted with an ascites, or tympa- nitis; nor, did the swelling either increase, or diminish till the patient's death, which happened a week after the infliction of the wound. There was no rumbling noise in the abdo- men,thoughitwasexceedinglytense.There were no stools, and very little urine was dis- charged, notwithstanding purgatives, and glysters, and a good deal of liquid nourish- ment, were given. The patient never had one instant of sound sleep, but, was always restless, though anodynes were exhibited. There was no appearance of fever, and the pulse was always natural till the last day of the patient's life, when it became inter- mittent. The intestines were found after death, veiy much distended, the gall blad- der quite empty, and a large quantity of bile extravasated in tlie abdomen. Sabatier met with an opportunity of ob- serving the symptoms of an extravasation of bile, in consequence of a wound of the gall bladder. The patient's abdomen swelled very quickly ; his respiration be- came difficult, and he soon afterwards complained of tension and pain in the right hypochondrium. His pulse was small, fre- quent, and contracted; his extremities were cold, and his countenance very pale. The bleedings, which were practised the first day, gave him a little relief; but, the tension of the abdomen, and the difficulty of breathing, still continued. A third bleeding threw the patient into the lowest state of weakness, and he vomited up a greenish matter. On the third day, the lower part of the belly was observed to be more prominent, and there was no doubt of an extravasation. M. Sabatier intro- duced a trocar, and gave vent to a green blackish fluid, which had no smell, and Vol. I. was pure bile, that had escaped from the wound of the gall bladder. After the ope- ration, the patient grew weaker and weaker, and died in a few hours. On opening tlie body, a large quantity of yellow bile was found between the peritoneum and intes- tines ; but, it had not insinuated itself among the convolutions of the viscera. A thickgluten connected the bowelstogether, andthey were prodigiously distended. The gall bladder was shrivelled and almost empty. Towards its fundus, there was a wound, about a line and a half long, cor- responding to a similar wound in the peri- toneum. The wound, which had* occur- red at the middle and lower part of the right hypochondrium, between the third and fourth false ribs, had glided from behind forward, and from above downward,be- tween the cartilages of the ribs, until it reached the fundus of the gall bladder. Sabatier takes notice, that tlie symptoms of the two cases, which have just now been related, were very similar. Both the pa- tients were affected with an exceedingly tense swellingof thebellyunattended with pain, or borborygmus, and they were both obstinately constipated. Their pulse was extremely weak the lajter days of their in- disposition, and they were afflicted with hiccough, nausea, and vomiting. We must not positively infer, however,that such ex- actly would be the symptoms in every in- stance of a wound of the gall bladder, un- accompanied by injury of other viscera: this conclusion only admits of confirmation by attention to more numerous facts. M. Sabatier seems to think one thing certain, viz. that wounds of the gall blad- der attended with effusion of bile, are absolutely mortal, and that no operation can be of any avail. (Medecine Opera- toire, Tom. 1, p. 34—37. 4. Urine. Urine being of a very fluid nature may, like the bile, be easily extravasated in the abdomen, when the bladder is wound- ed at any part, \\ hicl\ is connected with the peritoneum. If the urine, in this kind of case, be not drawn off with a catheter, so as to prevent this fluid issuing by the wound of the bladder, the patient soon perishes. There are many instances re- corded of the bladder being injured even by gun shot wounds, which were not mor- tal. Such wounds, however, might only have injured the sides, or lower part of the bladder. But, in operating for the stone, above the pubes, the bladder has undoubt- edly been occasionally cut at the part of the fundus, which is covered with the pe- ritoneum. However, as the accident was known in the first instance, the right treat- ment was adopted, and such patients have D 18 ABDOMEN. recovered. (Sabatier, Medecine Operatoire, Tom. 1, p. 37.) W0UND6 OF THE INTESTINES. The vomiting of blood, or discharge of it by stool, the escape of fetid air, or of intestinal matter, from the mouth of the wound; an empty collapsed state of" a portion of bowel, protruded at the opening in the skin, are the common symptoms at- tending a wound of this kind. When the wound is situated in the protruded portion, it is obvious to the surgeon's eye; but when it affects a part of the intestinal canal within the abdomen, the nature of the case can only be known by a conside- ration of other symptoms. In addition to such as I have already described, there are some others, which ordinarily accom- pany wounds of the bowels; as, for in- stance, oppression about the prxcardia, accute or griping pain in the belly, cold sweats, syncope, &c. But unless the wounded intestine be protruded, there is no practical good in knowing, whether the bowel is injured or not, since, if it be in the abdomen, the treatment ought not to be materially different from that of a sim- ple penetrating wound of the belly, unat- tended with a wound of any of the viscera. A wounded intestine is said to present some particular appearances, to which the gene- rality of writers have paid no attention: " If a gut be punctured, the elasticity of the peritoneum, and the contraction of the muscular fibres, open the wound, and the villous, or mucous coat forms a sort of hernial protrusion, and obliterates the aperture. If an incised wound be made, the edges are drawn asunder and reverted, so that the mucous coat is elevated in the form of a fleshy lip. If 1he section be transverse, the lip is broad and bulbous, and acquires tumefaction and redness from the contraction of the circular fibres behind it, wh ich produces, relat ively to the everted portion, the appearance of a cervix. If the incision is according to the length of the cylinder, the lip is narrow, and the eontractidn of the adjacent longitudinal, resisting that of the circular fibres, gives the orifice an oval form. This eversion and contraction are produced by that se- ries of motions, which constitutes the pe- ristaltic action of the intestines." (Travers on Injuries of the Intestines, p. 85.) According to this gentleman, some of these appearances were described by II:. I - ler, in Element. Physiol lib. 24, sect. 2, and Opera Minora, torn. 1, sect. 15. Having witnessed the facility,with which considerable injuries of the intestinal tube were repaired, Mr. Travers was desirous of ascertaining more fully the powers of nature in the process of*spontaneous repa- ration, and of determining, under how great a degree of injury, it would com- mence, as well as the mode of its accom- plishment. For ihese purposes,he divided the small intestine of several dogs as far as the mesentery. All these animals died, in consequence of the intestinal matter being extravasated, if they had been lately fed, or if they had been fasting in consequence of inflammation, attended with a separa- tion of the ends of the divided bowel, eversion of the mucous coat, and oblitera- tion of the cavity, partly, by this eversion, and partly by a plug of coagulated chyle. In one particular instance in which Mr. Travers made a division of tlie bowel, half through its diameter, a sort of pouch was formed round the injured intestine. " A pouch, resembling somewhat the diverti- culum in these animals, was formed op- posite to the external wound, on the side of the parietes, by the lining peritoneum, on the other side, by the mesentery of the injured intestine, that intestine itself, and an adjacent fold, which had contracted with it a close adhesion. The pouch, thus formed andinsulated,includedth«.opposed sections of the gut, and had received its contents, &c. The tube, at the orifices, was narrowed by the half eversion, but, offered no impediment to the passage of fluids." (P. 96.) Whether, under these circumstances, the functions of thealimen- tary canal could have been continued, Mr. Travers professes himself incapable of de- ciding. Among the inferences, which this gentleman has drawn from the experiments, detailed in his publication, the tendency of the twp portions of a divided bowel to recede from each other, instead of coalesc- ing to repair the injury, merits notice, in as much as it tends to shew, that the only means of spontaneous reparation consists in the formation of an adventitious canal, by theencirclingbowelsandtheirappendages. Theevertedmucouscoat, which is the part opposed to the surrounding peritoneum, is also indisposed to the adhesive iijflam- mation. When, however, the wound of the in- testine is smaller, the obstacles to repara- tion are not absolutely insurmountable. Here, retraction is prevented, and the pro- cesses of eversion and contraction modi- fied by the limited extent of the injiuy. If, therefore,the adhesive inflammation unite the contiguous surfaces, effusion will be prevented, and the animal escape imme- diate destruction. But, union can only take place through the medium of die sur- rounding parts. According to Mr. Travers, it is the re- traction, immediately followingthe wound that is a chief obstacle to the reparation of* ABDOMEN. 19 "the injury; for, if the division be performed in such a way, as to prevent retraction, the canal will be restored in so short a time, as but slightly to interrupt the digestive function. In confirmation of this state, a ligature was tightly applied round the duo- denum of a dog, which became ill, but entirely recovered, and was killed. " A ligature, fastened around the intestine, divides the interior coats of the gut, in this effect resembling the operation of a liga- ture upon an artery. The peritoneal tunic alone maintains its integrity. The inflam- mation, which the ligature induces on either side of it, is terminated by the de- position of a coat of lymph, which is exte- rior to the ligature, and quickly becomes organized. When the ligature, thus enclos- ed, is liberated by the ulceraive process, it falls of necessity into die canal and pas- ses off with its contents." (P. 103, 104.) It appears also from Mr Travers's ex- periments and observations, that longitu- dinal wounds of the bowels are more easily- repaired, than such as are transverse. In a dog, a longitudinal wound, of the extent of an inch and a half, was repaired by the adhesive inflammation. Here the process of eversion is very limited; the aperture bears a smaller proportion to theiylinder of the bowel, and the entire longitudinal fibres resist the action of the circular.which are divided, and can now only slightly les- sen the area of the canal. (P. 108.) We come now to the consideration of the treatment, which may be proper in cases of wounds of the intestines ; a subject in which much difference of opinion has pre- vailed ; principally, however, concerning the circumsu-uices, in which sutures are necessary, and the most advantageous way of applying them. When the wounded bowel lies within the cavity of the abdomen, no surgeon of the present day would have the rashness to think of attempting to expose the injured intestine, for the purpose of sew ing up the breach of continuity in it. In fact, the surgeon seldom knows at first what has happened; and when the nature of the case is afterwards manifested, by the dis- charge of blood per anum, an extravasa- tion of intestinal matter, &c. it would be impossible to get at the injured part of the bowel, not only because its exact situation is unknown, but, more particularly, on ac- count of the adhesions, which are always formed with surprising rapidity. But, even if the surgeon knew, to a certainty, in the first instance, that one of the bowels was wounded, and the precise situation of the injury, no suture could be applied, without considerably enlarging the external wound, drawing the wounded intes-ine out of the cavity of the abdomen, and handling and , disturbing all the adjacent viscera. No- thing would be more likely, than such proceedings, to render the accident, which may originally be curable, unavoidably fatal. I entirely agree upon this point with Mr. John Bell, who says, " When there is a wounded intestine, which we are warned of only by the passing out of the feces, we must not pretend to search for it, nor put in our finger, nor expect to sew it to the wound; but we may trust, that the uni- versal pressure, which prevents great effu- sion of blood, and collects the blood into one place, that very pressure, which always causes the Wounded bowel and no other to protrude, will make the two wounds, the outward wound and the inward wound of the intestine oppose each other, point to point; and, if all be kept there quiet, though but for one day, so lively is the tendency to inflame, that the adhesion, will be begun, which is to save the patient's life." (Discourses on Wounds, 'p. 361, edit. 3.) When the extravasation.and other symp- toms, a few days after the accident, shew^ the nature of the case, a suture can be of no use whatever, as the adliesive inflam- mation has already fixed the part in its situation, and the space, in which the ex- travasation lies, is completely separated from the general cavity of the abdomen, by the surrounding adhesions. When the- bowel is not protruded, and the opening in it is situated closely behind the wound in the peritoneum, a suture is not requisite, for the contents of the gut not passing onward, will be discharged from the outer wound, and not be diffused among the viscera, if care be taken to keep the external wound open. There is no danger of the wounded bowel changing its situation, and becoming distant from the wound in the peritoneum, for the situation which it now occupies, is its natural one. Nothing, but violent motion, or exertions, could cause so unfavourable an occurrence, and, these should always be avoided. The adhesions, which take place in the course of a day or two, at length render it impos- sible for the bowel to shift its situation. Things, however, are far different when the wounded part of the bowel happens to be protruded. Here we have the authority of all writers, in sanction of the employ- ment of a suture. No enlargement of the outer wound is requisite to enable the? practioner to adopt such practice; there is no disturbance created by the adjacent parts; there is no doubt concerning the actual existence of the injury; no difficulty in immediately finding out its situation. But, though authors are so generally agreed about the propriety of using a su- -ture, in the case of a wounded and pr«« 20 ABDOMEN. truded bowel, they differ exceedingly, both as to the right object of the method, and the most advantageous mode of sewing the injured part of the intestine. Some have little apprehension of extravasation, advise only one stitch to be made, and use the ligature chiefly with a view of confin- ing the injured bowel near the external wound, so that, in the event of an extra- vasation, the effused matter may find its way outward. Other writers wish to re- move the possibility of e xtravasation, by ap- plying numerous stitches, and attach little importance to the plan of using the liga- ture principally for the purpose of keeping the intestine near the superficial wound. When the wound of a bowel is so small, that it is closed by the protrusion of the villous coat, the application of a suture must evidently be altogether needless, and since the ligature would not fail to cause irritation, as an extraneous substance, the employment of it ought unquestionably to be dispensed with. Supposing, however, the breach in the intestine to be small, but yet sufficient to let the feces escape,what method oughtto be adopted? The following practice seems rational. As Mr. Astley Cooper was per- forming the operation for a strangulated hernia, at Guy's hospital, an aperture, giving issue to the intestinal contents, was discovered in a portion of the sound bowel, just when the part was about to be reduced. The operator, including the aperture in his forceps, caused a fine silk ligature to be carried beneath the point of the instru- ment, firmly tied upon the gut, and the ends cut off close to the intestine. The part was then replaced, and the patient did well. Mr. Travers, who has related this fact, approves of the plan of cutting away the extremities of the ligature, instead of leaving them hanging out of the external wound. It appears, that, when the first practice is followed, the remnant always makes its way into the intestine, and is discharged with the stools, without any inconvenience. But, when the long ends are drawn through the outer wound, and left in it, they materially retard the pro- cess of healing. (Sec Travers on Injuries »f the Intestines, &c. p. 112, 113) Let us now enquire into what ought to be tlie conduct of a surgeon, should he be called to a patient, whose bowel is divided through its whole cylinder, and protruded out of the external wound. Various have been the schemes and pro- posals, for the treatment of this sort of ac- cident ; and since experience has furnish- ed few practitioners with an opportunity of seeing such a case in the human subject, a variety of experiments have been made on animals, in order to determine what treat- ment would be the most successful. Ramdohr, indeed, is stated by Moebius, to have had occasion to try, on tlie human subject, a plan, of which a vast deal has been said and written. He cut off a large part of a mortified intestine, and joined tlie two sound ends together, by inserting the upper within the lower one, and fixing them in this position with a suture, the ligature being also employed to keep them at the same tune near the external wound. The patient recovered, and the feces con- tinued to pass entirely by the rectum in the natural way- (See Halleri Disput. Anat. Vol. 6. Obs. Med. Miscellan. 18.) Moebius attempted to repeatRamdohr's operation upon a dog; but, he could not succeed in insinuating the upper part of the divided bowel into the lower one, on account of tlie contraction of the two ends of the intestinal tube, and the smallness of the canal. Moebius, therefore, was obliged to be contentwith merely bringing the ends of the bowel together with a su- ture : the animal died, however, of an ex- travasation of the feces. Dr. Smith, of the Philadelphia Medi- cal Society, also tried to repeat Ramdohr's • method, but could not succeed. He di- vided tltf intestine of a dog transversely, and having inserted a piece of candle into that portion of the bowel, which was sup- posed to be uppermost, he endeavoured to introduce the superior within the inferior; but, the ends became so inverted, that it was found utterly impossible to succeed. The scheme was therefore given up, and only one stitch made, the ligature being then attached to the external wound, in the manner advised by Mr. John Bell. The dog died, and, on examination, there was found a considerable quantity of feces and water in the abdominal cavity. Two other trials were made of Mr. John Bell's plan by Dr. Smith, on tlie intes- tines of dogs : in both instances the ani- mals died, the intestines being much in- flamed, and feces effused in the abdomen. (See Dr. Smith's Thesis.) Mr. Travers likewise tried the same ex- periment. " I divided the small intestine of a dog, which had been for some hours fasting, and carried a fine stitch through the everted edges, at the point opposite to their connexion with the mesentery. The gut was then allowed to slip back, and the wound was closed. The animal survived only a few hours. Examination. The pe- ritoneum appeared highly inflamed. Ad- hesions were formed among the neighbour- ing folds, and lymph was deposited in masses upon the sides of the wounded gut. This presented two large circular orifices. Among the viscera were found a quantity of bilious fluid, and some extraneous sub- ABDOMEN. 21 stances-, and a worm was depending from one of the apertures. By the artificial connexion of the edges in a single point of their circumference, and their natural con- nexion at the mesentery, they could recede only in the intervals, and here they had receded to the utmost." In another ex- periment, Mr. Travers increased the num- ber of points of contact, by placing three single stitches upon a divided intes- tine, cutting away the threads, and re- turning the gut. The animal died on the second day. Examination. Similar marks of inflammation presented themselves. The omentum was partially wrapped about thewound; but, one of the spaces, between the sutures was uncovered, and from this the intestinal fluids had escaped. On cautiously raising the adhering omentum, the remaining stitches came into view. Here again the retraction was considera- ble, and the intervening elliptical aperture proportionally large. On the side, next to the peritoneum, however, the edges were in contact and adhered, so as to unite the sections at an angle. From such experiments, the conclusion, drawn by Mr. Travers, is, that apposi- tion, at a point, or points, is, as respects effusion, more disadvantageous, than no apposition at all; for, it admits of re- traction, and prevents contraction, so that each stitch becomes the extremity of an aperture, the area of which is detfjrmined by the distance of the stitches. (P. 116, 119.) This gentleman, there- fore maintains, that the absolute con- tact of the everted surfaces of a divided intestine, in their entire circumference, is requisite to secure the animal from the danger of abdominal effusion. (P. 121.) The spe- cies of suture employed (says Mr. Travers) is of secondary importance, if it secures this contact. (P. 134.) And among other observations, 1 find "wounds amounting to a direct division of the canal are irrepara- ble,andthereforeinvariablyfatal."(P133.) Without entertaining the least desire to give offence, I confess, I do not know what could induce Mr. Travers to be so positive in these inferences. We are told, that apposition at a point, or powits, is, as respects efrusion,more disadvantageous than no apposition at all, and that the ab- solute contact of the divided surfaces, in their entire circumference, is requisite to secure the animal from the danger of ab- dominal effusion. The foundation of these unqualified conclusions is five expe- riments, made on dogs, in four of which ex- periments, the divided bowel was brought together with one stitch, on Mr. John Bell's plan, while, in another three stitches were made; and, yet, in all these instances, the animals died with tlie con- tents of the bowels effused. So far the inferences seem established. Unfortu- nately, for their stability, however, Mr. Travers immediately afterwards proceeds to relate other experiments, instituted by Mr. Astley Cooper, Dr. Thomson, and. Dr. Smith, which, though Mr. Travers seems unaware of the fact, tend most completely to overturn the conclusions which he had been previously making. " Mr. Cooper repeated the experiments of Duverger, who had succeeded, in uniting by suture, the divided intestine of a dog, including in it a portion of the trachea of a calf. In place of the unin- terrupted suture, .three distinct stitches were inserted. On the sixteenth tlay, the animal was killed, and the union was complete." (P. 123.) Here we have two facts, proving that a wounded intestine may be united, though the suture was not such, as to maintain the divided surfaces in contact, in the whole of their circumference. Mr. Astley Cooper then made the ex- periment, without including the foreign substance. The animal recovered, being a third fact, tending to shew, that the ab- solute contact of every point of the ends of the divided bowel is not essential to the cure. (See A. Cooper on Inguinal and Congenital Hernia. Chap. II) After dividing the small intestine of a dog, Dr. Thomson, Regius professor of Mi- litary Surgery at Edinburgh, applied five interrupted stitches, at equal intervals, the ends of the ligatures, were cut off, and tlie external wound was closed with a suture. This animal did not die of the operation, and, when he was afterwards killed, it appeared, that the threads had madotheir wayinto the interior of the intestinal canal. Dr. Thomson repeated this experiment, and did not kill the animal till six weeks afterwards, when the same tendency of ligatures to pas's into the bowels, and be thus discharged, was exemplified. These two last cases make five, in proof that the absolute contact of every part of the ends of a divided bowel is not essential to prevent effusion, or the consequences of the wound from proving fatal; and several other experiments were made by Dr. Smith, of Philadelphia, who employed four stitches, with similar suc- cess. As far then as the majority of such facts ought to have weight, we are bound to receive the conclusions of Mr. Travers as incorrect, and unestablisbed. I am only surprised, that Mr. Travers him- self, who has cited the particulars of all these last experiments, did not perceive, that they struck directly at his own in- ferences. They are not only irresistible ABDOMEN arguments against Mr. Travers's conclu- sion, that the union of a divided bowel requires tlie contact of the cut extremities in their entire circumference; but, they are a plain denial of another position, advanced by this author, viz. that wounds, amounting to a direct division of the ca- nal are irreparable, and, therefore, inva- riably fatal. With respect to the species of suture being of secondaiy importance, provided it secure the complete contact of every part of the everted ends of the divided bowel, I regret, that Mr. Travers has omitted to institute experiments, in order to shew, that any such suture can be prac- tised, and, if he has the ingenuity to apply it, whether the result would be for, or against, the conclusions, which he has formed. The fact of the sutures always making their way into the cavity of the bowel, and being thus got rid of, appears to me highly interesting, since it shews the safety of cutting away tlie ends, in- stead of leaving them hanging out of the external wound, so as to create the usual irritation and inconveniences of extrane- ous substances. It seems, that Mr. Ben- jamin Bell first recommended cutting the ends of the ligatures away, and reducing the bowel in this state into the abdomen, as he says, a considerable part of the re- mainder of the ligature will fall into the cavity of the gut. (System of Surgery, Vol. II.p. 128, Edit. 7) We have seen, that the experiments of Dr. Thomson confirm the observation, and those, in- stituted by Mr. Travers, tend to the same conclusion. According to the latter writer, the fol- lowing is the process by which a divided intestine is healed, when sutures are em- ployed. " It commences with the agglu- tination of the contiguous mucous sur- faces, probably, by the exudation of a fluid, similar to that, which glues toge- ther the sides of a recent flesh wound, when supported in contact. The adhesive inflammation supervenes, and binds down the everted edges of the peritoneal coat, from the whole circumference of which a layer of coagulable lymph is effused, so as to envelope the wounded bowel. The ac- tion of the longitudinal fibres, being op- posed to the artificial connexion, the sections mutually recede, as the sutures loosen by the process of ulcerative ab- sorption. During this time, the lymph deposited becomes organized, by which further retraction is prevented, and the original cylinder, with the threads attach- ed to it, is encompassed by the new tunic. " The gut ulcerates at the points of the ligatures, and these fall into its canal. The fissures, left by the ligatures, are gradually healed up; but, tlie opposed villous surfaces, so far as my observation foes, neither adhere, nor become conso- dated by granulation, so tliat the inter- stice, marking the division internally is probably never obliterated." ( Travers on Injuries of the Intestine, &c. p. 128.) Notwithstanding I have carefully read all the arguments adduced by Mr Tra- vers in favour of stitching a divided bowel at as many points as possible, I still re- main unconvinced of the advantage of such practice, for reasons already sug- gested. If a case were to present itself to me, in which a bowel was protruded and partly cut tlu-ough, I should apply only a single suture, made with a common sew- ing needle, and a piece of fine silk. If the bowel were completely cut across, I should have no objection to attach hs ends together by means of two or three stitches of the same kind. I coincide with Mr. Travers respecting the advan- tage of cutting off the ends of" tlie liga- ture, instead of leaving them in tlie wound, as I believe he is right, in regard to the little chance there is of the injured intestine receding far from the wound, and if the ends of the ligature are then of no use in keeping the bowel in this posi- tion they must be objectionable, as extra- neous substances. Sometimes, only one end of the divided gut protrudes at the wound, and, the other lies concealed in the cavity of the abdo- men. If the hidden continuation of the intestinal canal, cannot be found without enlargingThe wound, it may be questioned, whether tlie urgency of the case does not justify this practice. If the upper end should happen to be the one concealed in the abdomen, almost certain death must result from its continuance there ; if it be the lower one, and no attempt be made to find it, the patient can only sur- vive with the loathsome affliction of an ar- tificial anus. When the protruded intestine is morti- fied, which must be a very rare occurrence in cases of wounds, the surgeon's conduct should be the same as in a mortified en- terocele. (See Hernia.) With regard to the constitutional treat- ment, in wounds of the intestines, the principal indication is to prerent a dan- gerous degree of inflammation. Hence bleeding and the antiphlogistic treatment are highly indispensable. Let not the surgeon be deterred from putting such practice in execution by the apparent de- bility of the patient, liis small concentrated pulse, and tlie coldness of his extremities, symptoms, common in acute inflammation of the bowels, and, in fact, themselves in- dicating the propriety of repeated vene- ABD section. Wounds of the small intestines arc attended with more vehement inflam- mation, than those of the large ones. All flatulent, stimulating, and solid food, is to be prohibited. The bowels are to be daily emptied with glysters, by which means, no matter will be allowed to accu- mulate in the intestinal canal, so as to create irritation and distention. When excrementitious matter is dis- charged from the outer wound, it is highly necessary to clean and dress it very fre- quently. Gentle pressure should also be made, with the fingers, at the circumfer- ence of the wound, at each time of apply- ing the dressings, for the purpose of pro- moting the escape of any extravasated matter. For the same reason, the patient should always lie, if convenient, in a pos- tui e that wili render the external opening a depending one. After a day or two, the surgeon need not be afraid of letting the outer wound heal up; for the adhesive inflammation, all around the course of the wound, will now prevent any extravasated matter from becoming diffused among the viscera. If the case should end well, the intestine ge- nerally undergoes a diminution in its dia- meter at the place where the wound was situated. When tliis contraction is in- considerable, the patient occasionally ex- periences colic pains at the part, especially after eating such food, as tends to produce flatulence. As these pains usually go en- tirely off after a certain time, and no in- convenience whatsoever remains, the in- testine may possibly regain its wonted capacity again. A more considerable con- striction of the above sort has been known to have occasioned a fatal miserere. Even the intestine itself has been known to burst in this situation, after its contents had ac- cumulated behind the contracted part. Patients, who have recovered from wounds of the intestines, should ever afterwards be particularly careful not to swallow any hard substances, or indigestible, flatu- lent food. In some instances, intestinal matter continues to be discharged from the outer wound, either in part, or entirely, so that either a fistula, or an artificial anus is the consequence. A fistula is more apt to follow, when an intestine has been injured by a ball, has been quite cut through, or has mortified. But, numerous cases have evinced, that this is not invariably the consequence, and that a perfect cure has frequently followed each of these occur- rences. When an intestine is completely cut through, and the lower portion of the canal lies inaccessibly concealed in the ab- domen, there is a necessity for promoting A C C .23 the formation of an artificial anus. In this particular case, the extremity of the intestine is to be attached, with a fine su- ture, to the edges of the outei wound. In order to distinguish the upper end of the intestine from the lower one, some re- commend giving the patient some milk to drink, and to wait a little, to see whether the fluid issues from the mouth of the gut. In the mean while, they content themselves with applying fomentations. If the upper end of the intestine should be in the abdo- men, it certainly seems justifiable, when the accident is quite recent, to dilate the outer wound sufficiently to see, whether the part is near enough to be got at. If the surgeon should succeed in this object, / the two ends of the bowel ought to be sewed together, as above directed. In gun-shot wounds of the abdomen, the treatment is limited to the employ- ment of general means. For information, relative to wounds of the abdomen, see Richter's Anfangsgrunde tier Wundarzney- kunst, Band 5. Kap. 1. Discourses on the Nature and Cure of Wounds, by Jolin Bell, Edit. 3. Encyclopedic Methodique, Partie Chirurgicale, Art. Abdomen, and Intestins. Dr. Smith's Inaugural Thesis. An Enquiry into the Process of Nature in repairing Inju- ries oftlieintestines, &c. by B. 7 'ravers Hun- ter on Gun-shot Wounds. Mr. A. Cooper's , work on Inguinal and Congenital Herrua, Chap. II. Sabatier*s Medecine Operatoire, Tom. 1. Essai sur les Epanchemens, and Sidte de I' Essai sur les l.panchemens par M. Petit, le fils, in Mem. de V Acad, de Chirurgie, Tom. 2 and 4, Edit, in 12mo. ABSCESS. This term signifies a tu- mour containing pus, or a collection of purulent matter. Authors differ about the original derivation of the word. The most common opinion is, that it comes from tlie Latin abscedo, to depart, because parts, which were before contiguous, be- come separated, or depart from each other. Abscesses are divided into two principal kinds, viz. acute and chronic. For every thing, relative to the former, see Suppura- tion; and, for information, concerning the latter, refer to Lumbar Abscess. The Mammary Abscess is a distinct article. See also the articles,Antrum,Anns Abscesses of, Bubo, Empyema, Hypopium, Whitlow, &c. ACANTHA'BOLUS. (from evcou/fa, a thorn, and fictXXm, to cast out.) Art instru- ment for taking thorns out of the flesh, and described by Paulus iEgineta. It is said to be like an instrument called the volsella, used for extracting bones from the oesophagus, and foreign substances from wounds. A'CCIPITER, (a hawk.) The name of a bandage, which was formerly employ- 24 ACHILLES ed by surgeons for covering the nose: it derived its name from its supposed re- semblance to a hawk's claw. ACCRETION. A growing together of parts, as of the toes, or fingers to each other, in consequence of burns, &c. ACETUM. Vinegar. (From aceto, to be acid.) Called in the last Pharmaco- poeia of the London College, AcidumAce- ticum. Vinegar is an article of very con- siderable use in surgery. Mixed with farinaceous substances, it is frequently applied to sprained joints, and, in conjunc- tion with alcohol and water, it makes an eligible lotion for inflammations of the surface of the body. Vinegar has acquired reputation at the Gloucester Infirmary, for quickening the exfoliation of dead bone, which effect may be owing to its property of dissolving the phosphate of lime. The excellent effects of vinegar, when immediately applied to burns and scalds, have been taken particular notice of by Mr. Cleghorn, a brewer in Edin- burgh, who communicated his sentiments to Mr. Hunter. (See Med. Facts and Ob- servations, Vol. II) See the Article, Burns. In chronic inflammations ofthe eyes and eyelids, vinegar has lately been brought into considerable repute. It is also re- commended as an application, in certain instances, in which the eyes are weak and watery. It is said to be an efficacious re- medy even in cases of acute ophtlialmy, after topical and general bleeding. When- ever vinegar is applied to the eye, it is in a diluted state, as may be seen in another part of this work. (See Collyrium Acidi Acetici.) Very strong vinegar may be obtained by freezing and separating the water, which is mixed with the acid. When thus concentrated, it is said to be an excellent styptic for stopping hemorrhage from the nose. With this view, it may be used either as an injection, or a lotion, in which lint is to be dipped, and afterwards intro- duced up the nostril. ACHILLES, Tendon of. So called, be- cause as fable reports, Thetis, the mother of Achilles, held him by that part, when she dipped him in the river Styx, to make him invulnerable. It signifies that great and powerful tendon, which is formed by the junction of the gastrocnemius and so- leus muscles, and which extends along the posterior part of the tibia, from the calf to the heel. When this tendon is unfortu- nately cut, or ruptured, as it may be, in consequence of a violent exertion, or spasm of the muscles, of which it is a continuation, the use of the leg is imme- diately lost, and unless the part be after- wards successfully united, the patient must remain a cripple for life. The ancient surgeons seemjnot to have been well acquainted with tlie rupture of the tendo Achillis, which they probably might mistake for a sprain, or some other complaint. In cases, in which this part had been cut, they recommended approxi- mating the separated portions, and main- taining them in contact bymeans of a suture. When the ruptured tendo Achillis, was afterwards better understood, the plan, just mentioned, was even adopted in this case, the integuments having been previ- ously divided, for the purpose of bringing the tendon into view. But, there is no ne- cessity for having recourse to this painful proceeding. (Encyclopedic Methodique, Partie Chirurgicale, 'Tom. 1, p. 55.) The superficial situation of the tendo Achillis, always renders the diagnosis of its rupture exceedingly obvious, and the accident can only become at all difficult to detect, when there is a considerable degree of swelling, which is very rare. When the tendon has been cut, the division of the skin even allows the accident to be seen. When the tendon has been ruptured, the patient hears a sound, like that of the smack of a whip, at the moment of the occurrence. In whatever way the tendon has been divided, there is a sudden inca- pacity, or, at least, an extreme difficulty, either of standing or walking. Hence, the patient falls down, and cannot get up again. Besides these symptoms, there is a very palpable depression, between the ends of the tendon, which depression is increased when the foot is bent, and di- minished, or even quite removed, when the foot is extended. The patient can spontaneously bend his foot, none of the flexor muscles, being in. terested. The power of extending the foot is still possible, as the peronei mus- cles, the tibialis posticus, and long flexors, remain perfect, and may perform this mo- tion. (OEuvres Chirurgicales de Desault par Bichat, Tom. 1 ) The indications are to bring the ends ofthe divided part together, and to keep them so, until they have become firmly united. The first object is easily fulfilled by putting the foot in a state of complete extension; the second, namely, that of keeping the ends ofthe tendon in contact, is more difficult. In order to have a right comprehension ofthe indications.we should consider what keeps the ends of the tendon from being in contact. The flexion of the foot has this effect on the lower portion; the con- traction ofthe gastrocnemius, and a soleus on the upper one. The indications then are to put the foot in an unalterable state of extension, and to counteract the action of the above muscles. ACHILLES. 23 Tiie action of the muscles may be op- posed : 1. By keeping these powers in a continual state of relaxation. For this purpose, the leg must be kept half bent upon tlie thigh. 2. By applying metho- dical pressure to the muscles; methodical, because it is to operate on the fleshy por- tion ofthe muscles, and not on the tendon, the ends of which being depressed by it, would be separated from each other, and, instead of growing together, would unite to the adjacent parts. The pressure should also operate so as {p prevent the ends of the tendon from inclining either to the right or left. This kind of pressure, which the band- age ought to make, seems to have escaped the attention of all authors. Who cannot see, however, that the action ofthe mus- cles being by tins means resisted, the up- per end of the tendon will not have such a tendency to be drawn upward, and se- parated from the lower one? ((Euvres Chirurgicales de Desault par Bichut, Tom. 1.) The famous Fetit seems entitled to the honour of having first devised the plan of treating the ruptured, or divided tendo Achillis, by keeping the leg and foot in a particular posture, with the aid of an apparatus. Seeing that the extension of the foot brought the ends of the tendon into contact, it occurred to hun that such extension should be maintained during the whole ofthe treatment, in order to bring about a permanent union. This happy idea, the simplicity of which should have rendered it obvious to all practioners, once having originated, became the com- mon basis, on which have been founded all the numerous methods of cure, which have been^iince recommended. (Desault par Bichat.) The celebrated Dr. Alexander Monro, professor of anatomy at Edinburgh, hap- pened to rupture his tendo Achillis. When tlie accident took place, he heard a loud crack, as if he had suddenly broke a nut with his heel, and he experienced a sensa- tion, as if the heel of his shoe had made a hole in the floor. This sensation, he says, has also been observed, by others, though some have complained of a smart stroke, like what would be produced by a stone or cane. Immediately suspecting what had happened, the doctor extended his left foot, in which the occurrence had taken place, as strongly as he could with his right hand, while with his left, he pressed the muscles of the calf downward, so as to bring the ends of tlie broken tendon as near together as possible. In this position he sat, until two surgeons came to his resistance. They applied compresses, and a hent board to the upper part ofthe foot, and forepart of the leg, both which they Vol. I. kept, as nearly as possible, ih a straight line, by a tight bandage, made with a long roller. But, as this mode of dressing soon became very uneasy, it was changed for the following one. A footsock, or1 slipper, was made of double quilted tick- ing, from the heel of which a belt or strap projected, of sufficient length to come up over the calf of the leg. A strong piece, of the same materials, was prepared of sufficient breadth to surround the calf, and this was fastened with lacings. On the back part of this was a buckle, through which the strap of the footsock was pass- ed, so that the foot could be extended, and the calf brought down at pleasure. The leg and loot were wrapt up in soft flannel, fumigated with benzoin, and the bandage was kept on day and night, the belt being made tighter, when the doctor was about to go to sleep, and loosened when he was awake, and on his guard. For a fortnight, he did not move his foot and leg at all, but, was conveyed in a chair on castors from one part of the room to another. After this, he began to move the ankle-joint, but in such a gentle man- ner as not to give any pain. The degree of motion was gradually increased, as the tendon became capable of bearing it, care being taken to stop, when the motion be- gan to create uneasiness. The affected limb was moved in this way, for half an hour at a time. In a few days, the hollow, 1 between the separated ends ofthe tendon, became imperceptible, though the part continued soft much longer. It became, however, gradually thicker and harder until a knot was at last formed in it, appa- rently of a cartilaginous nature. Though this was at first as large as a middling plum, and gradually became softer and smaller, yet it did not disappear entirely. Having occasion to go out six weeks after the accident, the doctor put on a pair of shoes, with heels two inches high, and contrived a steel machine to keep his foot in the proper position. This machine, however, he afterwards changed for ano- ther, made of the same materials as tin*- former. It was not till five months after the accident, that he thought proper to lay aside all assistance, and to put tiie strength of the tendon to a trial. (See Monro's Works, p. 661.) It seems unnecessary to enumerate the various plaRs, devised since the time of Petit. Suffice it to state, that both in a wound and rupture of the tendo Achillis, the ancient method of using a suture, for keeping the ends of the tendon in contact, is at present quite exploded, and position of the limb is the grand agent, by which the cure is now universally accomplished. The following was Desault's method, which, though it was expressly designed 26 ACI ACN to fulfil all the above-mentioned indica- tions, may not after all be a more valua- ble practical plan, than the one adopted by Dr. Monro. Afier the ends of the ten- don had been brought into contact, by moderate flexion of the knee, and com- plete extension of the foot, Desault used to fill up the hollows, on each side of the tendon with soft lint and compresses. The roller, applied to the limb, made as much pressure on these compresses, as on the tendon, and hence this part could not be depi essed too much against the subja- cent parts. Desnult next took a compress, about two inches broad, and long enough to reach from the toes to the middle ofthe thigh,' and placed it under the foot, over the back of the leg, and lower part of the thigh. He then began to apply a few cir- cles of a roller round the end of the foot, so as to fix the lower extremity of the lon- gitudinal compress. After covering the whole foot with the roller, he used to make tlie bandage describe the figure of 8, pass- ing it under the foot, and across the place where the tendon was ruptured, and the method w^s finished by encircling the limb upward, with tlie roller, as far as the upper end of the longitudinal compress. (Desault par Bichnt.). Certainly this plan seems to answer every object, and may be worthy of being adopted in this country. The continued pressure on the muscles of the calf, by which their action is materially resisted, is too much disregarded by the generality of English surgeons. Consult Monro's Works ; Encyclopedic Metltodique, Article Acliille, tendon d', and Memoire sur la divi- sion du tendon d'Actrille, in (Euvre's Chirur- gicales de Desault parBichat, Tom. l,p.306. ACHORES, (from a^-aif £«, bran.) The scald head, so called from the branny scales thrown off* it. (See Tinea Capitis.) ACIDUM NITROSUM, now called by the London College, Acidum Nitiuccm. Dr. Rollo, Mr. Cruikshank, Dr. Beddocs, Mr. Blair, and many others have tried this acid, as a substitute for quicksilver in the cure of the lues venerea. The practice began with Mr. Scott, a surgeon in Bengal, who is said to have caught the idea from Dr. Girtanner, who suggested, that the efficacy of tlie various prepara- tions of quicksilver might arise from the oxygen, which they contained. A multitude of cases have been brought forward in favour of nitric acid, a$> an an- tisyphilitic, but, there are also some others adduced, which seem very decidedly to controvert its claims to that character. It should be carefully remembered, that it is the nitric acid, not the nitrous, wiiich seems to deserve a further trial in syphi- litic cases. Mr. Pearson is of opinion, that the power of this medicine has not yet been ascertained in so satisfactory a way as to preclude all difference of opinion on the subject. Another writer says, that the symptoms of confirmed lues venerea are not removed by nitrous acid; but, that the medicine has been used both liberally and success- fully for removing the debilitating effects of mercury, for giving tone to the sto- mach, improving the appetite, and im- parting a granulating and healthy aspect to certain ulcers remaining after a due course of mercury had been tried, and which were aggravated by persevering in the use of the hitter medicine. The ef- fects of this acid in syphilis, will be more particularly noticed, in the article Venereal Disease. Nitrous acid, given in doses of eight, ten, or fifteen drops, two, or three times a day, is said to have proved particularly efficacious in the cure of some eruptive complaints, especially of the lower extre- mities,and joined with disorder of tlie liver (II ilson's Pliarm. Chirurgica, p. 6.) The common way of giving the nitric*' acid, at first, is to mix gj with a pint of distilled water, the mixture being sweet- ened with simple syrup. This quantity is to be drank, at different times, in the course of 24 hours, through a small glass tube, which is used to keep the teeth from being injured. If no inconvenience is felt, the dose of the acid may be in- creased to ^iss, gij, and even, in certain cases, to ^iij. The acid is said to increase the appe- tite, and secretion of urine; to cause more or less thirst, a white tongue, sizy blood, and an increase in the actions of the whole system, but nothing like mercu- rial salivation is produced. It does not agree, however, equally well with all con- stitutions. The nitric acid is beneficial both in the primary and secondary symptoms of the ve- nereal disease ; more so, however, in the former. But, in the latter, even mercury itself frequently fails, and proves hurtful, so that the nitric acid suffers no dispar- agement from this fact. A change is said to be produced on the disease, by the acid, in six or eight days, and a cure very often m little more than a fortnight. The oxygenated muriate of pot-ash which contains an immense quantity of oxygen, is said by Mr. Cruikshank, to be more efficacious than the nitric acid in relieving venereal symptoms. A'CME. (from ccxf*.*), a point.) The highest pitch of a disease. A'CNA, or A'cxe. (from ecrcvr;, bran, or JEG AIR 27 chaff) A hard, purplish tubercle in the face, covered'with a scale. A'CORES. See Achors. ACOU'STICS. Medicines, or instru- ments to assist the hearing. The term is derived from etrcovu, to hear. ACROMION, (from ot^oi, the top, and 6>f*.«i, the shoulder.) The process of the scapula, articulated with the external end of the clavicle, and formed by the anterior and superior projecting part of the spine of the scapula. It is liable to be broken. (See Fracture.) ACTUAL CAUTERY. A heated iron formerly muth used in surgery for the ex- tirpation and cure of diseases. The in- strument was made in various shapes, adapted to different cases, and it was of- ten applied through a cannula, in order thai no injury might be done to the sur- rounding parts. Actual cauteries were so called in opposition to other applica- tions, which, though they were not really hot, produced the same effect as fire, and, consequently, were named virtual, or po- tential cauteries. ACUPUNCTURE, (from aens, a needle, and pungo, to prick.) The operation of making small punctures in certain parts ofthe body with a needle, for the purpose of relieving diseases, as is practised in Siam, Japan, and other oriental coun- tries, for the cure of headaches, lethargies, convulsions, colics, &c. (See Phil. Trans. No. 148 ) ACUTENACULUM, (from news, a nee- die, and teneo, to hold.) Heister so deno- minates the port aiguille. It is a handle for a needle, to make it penetrate tlie flesh more easily. ADAMITA. Lithiasis, or the stone in the bladder. (See Urinary Calculi and Lithotomy.) ADHESIVE INFLAMMATION. That kind of inflammation, which makes parts of the body adhere, or grow together. It is the process, by which recent incised wounds are often united, without any sup- puration, and it is frequently synonymous with union by the first intention. (Sec Union by the First Intention.) ADYNA'MIA. (from«,neg.andi,ut«ftte, strength.) Extreme debility. JEGIAS. (from «i|, a goat.) A white speck upon the cornea, opposite the pupil, and so named from the supposition, that goats were very subject to such a disorder. JEGI'DES.V (from «i|, a goat.) Small white scars, or opacities, on the cornea. JEGYLOPS. (from«n|, a goat, and wfy, an eye.) A disease, so named from the supposition that goats were very subject to it. The term means a sore just under the inner angle ofthe eye. ^ The best modern surgeons seem to con- sider the xgylops, only as a stage of the fistula lachrymalis. Mr. Pott remarks, when the skin covering the lachrymal sac has been for some time inflamed, or sub- ject to frequently returning inflamma- tions, it most commonly happens, that tlie puncta lachrymalia are affected by it, and the fluid, not having an opportunity of passing off by them, distends the inflamed skin, so that, at last, it becomes sloughy, and bursts externally. This is that state of the disease, which is called perfect aigylops, or xgylops. (Pott in Fistula Lachrymalis.) JEgylops was a very common term with the oid surgical writers, who certainly did not suspect, that obstruction in the ".ichrymal parts ofthe eye, is so frequently the cause of the sore, as it really is. The skin over the lachrymal sac must undoubt- edly be, like that in every other situation, not exempt from inflammation, and ab- scesses ; but, we do not find, that sores, unconnected with disease of the lachry- mal sac, are so frequent, as to merit a distinct appellation. The term, xgylops is therefore going more and more into dis- use, every day. iERUGO, (Subacetas Cupri Impura) pre- pared verdigrease is by some used as an application to incipient chancres. Its acting as a caustic, and completely de- stroying the diseased surface at once, seems to offer a chance of preventing the absorption of the venereal matter, and, consequently, of doing away tlie necessity of making the patient undergo a salivation. However, it is perhaps never safe to rely solely upon this mode of treatment, with- out exhibiting mercury, in some form, or another. Whenever the plan is tried, and it is certainly a very rational one, as long as the chancre is very small and recent, it is better to employ the argentum nitratum, which is a more active caustic, and for this reason, more sure to destroy the whole surface of the sore. AGARIC. A species of fungus, grow- ing. on the oak, and much celebrated for- merly- for its efficacy in stopping bleeding. (See Hemorrhage.) AGGLUTINATION. The union of parts ; the adhesion of parts together, by an effusion of coagulating lymph, follow- ed by a communication of vessels. AGGLUTINANTS. Applications em- ployed with a view of giving an opportu- nity for the opposite surfaces of a wound to adhere and grow together. AGO'MPHIASIS. (from a, neg. and yo^ot;, compact.) A painfull looseness of the teeth. ALR. For an account of the abiurd 28 AL V ALV opinions entertained, concerning its en- trance into several cavitiesof the body, ami its pernicious effects there, see Abdomen. ALBORA. A species of itch, or rather leprosy. ALBUGO, (from albus, white.) A white opacity of the cornea, not of a superficial kind, but affecting the very substance of this membrane. This disease is very simi- lar to the leucoma, with which it will be considered. (See Leucoma.) ALNUS, (tlie Alder Tree.) The leave*;, when cut in small pieces, and applied to the breast, as Warm as can be borne, are much praised by professor Murray, of Got- tingen, for their efficacy in discussing the milk of women, who do not suckle. ALPHONSIN is the name of an instru- ment for extracting balls. It is so called from the name of its inventor Alphonso Ferrier, a Neapolitan physician. It con- sists of three branches, which separate from each other by their elasticity, but are capable of being closed by means of a tube, in which they are included. ALUM, (an Arabic word.) Alum, ei- ther in its simple state, or deprived of its water of crystallization, by being burnt, has long been used in surgery. The inge- nious author ofthe Pharmacopoeia Chirur- gica remarks, that unless for external use, as a dry powder, the virtues of alum are not improved by exposure to fire. Ten grains of alum made into a bolus with con- serve of roses, are given thrice a day at Guy's Hospital, in such cases, as demand powerful tonic, or astringent remedies. In a relaxed state of the urinary passages, or want of power of the sphincter vesicx.small doses of alum have been found of service. It is also recommended by Dr. Percival, to counteract the poison of lead. Burnt alum is a mild caustic, and is a principal ingredient in most stvptic powders. ALVINE CONCRETIONS. Surgical writers have recorded many instances, in which concretions of various sizes, and pro- ducing a series of very bad and even fatal complaints have been formed round plum and cherry stones in the alimentary ca- nal. The knowledge ofthe dangerous con- sequences, which may ensue from swallow- ing such indigestible bodies, cannot be too extensively diffused; for, it is certain, that this pernicious habit of children and thoughtless persons is by no means un- common, and must be a more frequent occasion of ill-health, if not of dea.;h, than is generally supposed. The symptoms induced by thelodgment of concretions of the above kind in the bowels are of a formidable description : severe pains in the stomach and bowels, diarrhoea, violent vomitings of blood and mucus, a discharge of thin fetid matter from the rectum, a diflicu-'.y of voiding the excrement, an afflicting tenesmus, extreme emaciation, and debility. That the foregoing account is not at all exaggerated may be seen by a perusal ofthe cases, and remarks published on the subject by Mr. Charles White, of Man- chester, and Mr. Hey, of Leeds. I shall take the liberty of quoting a case from each of these gentlemen, the first example is one related by Mr. White, shewing the proper mode to be pursued, when practicable. "On March 2, 1762, Dr. Brown de- sired I would visit J. Parkinson, of Man- chester, an out-patient of the infirmary, who had been some time under his car£ for complaints much resembling nephrytic paroxysms, which the medicines, usual in such cases, had frequently relieved. The night before he had perceived a lump in the rectum, which had brought on a con- tinual tenesmus. 1 found him extremely emaciated; the sphincter ani very much dilated, with a continual discharge of thin, excrementitious, and very fetid matter. Upon introducing my finger into the anus, I very distinctly felt a large body moveable in the rectum, which I easily took hold of with a pair of for- ceps, such as are used in lithotomy, and immediately brought away without much difficulty. It was a ball nearly as big as my fist, and, breaking in the extraction, discovered a plum-stone in the centre, which was its nucleus. Upon further examination, I found there was another, which I extracted entire nearly as large as the first. The patient recovered very fast, and in a month's time, was a hearty strong man." (Cases in Surgerywith remarks, &c.) The concretions, which form round fruit stones in the intestinal canal, may become so large as to be incapable of passing onward to the rectum, and, of course, occasion fatal complaints. The annexed case, recorded by Mr. Hey, furnishes us with a proof of this remark. " I was permitted (says this practical writ- er) to examine the body of a boy, whose parents lived at Holbeck, near Leeds, and who had died in an emaciated state, hav- ing had long continued pain in the abdo- men, attended with frequent attacks of the ileus. " 1 found lying in the transverse arch of the colon a concretion which was become of so great bulk, that it could pass no farther along the course of the intestine. Tins seemed to have been the sole cause ofthe boy's death."—Practical Observations in Surgery, p. 492. Sometimes, patients ultimately get well A M A A M A bv voiding the concretions either by vomit- ing, or stool. Mr. Charles White gives us an account of some such instances ; in one fourteen concretions on plum-stones were discharged from the anus; in another, twenty-one similar bodies were ejected from the stomach. The latter gentleman concludes some interesting cases with warning practi- tioners, and mankind in general, of the great danger of swallowing fruit-stones, and he doubts not, that many persons have lost their lives from this cause, when the disorder has not been understood, but been mistaken for the cholic. • The reader may find the principal in- formation on this subject, in Cases in Sur- gery by Charles White, F. R. S. 1770. p. 17. Philos. Trans, abridged, Vol. V. p. 256. et seq. Edinburgh Med. Essays and Obsei^v. Vol. 1. p. 301. Ibid. Vol. 5. p. 431. Essays Phys. and Literary, Vol. II. p. 345. Dr. Leiglis Natural History of Lancashire, Plate I. fig. 4. Practical Observations in Surgery, by W. Hey, F. R. S. p. 490. AMAUROSIS, (from ctfixvpoar, to ob- scure.) Frequently called, Gutta Serena. This is a disease ofthe eye, attended with a diminution, or total loss of sight, and arising from a paralytic affection of the retina and optic nerve. The symptoms of amaurosis are noted for being extremely irregular, and the diag- nosis of the disease is often much more difficult, than is commonly supposed,when there is no visible defect in the eye, and we have nothing more than the patient's assurance, that he has lost the faculty of seeing things. In many cases the pupil is very much dilated, immoveable, and pos- sesses its .natural black colour, and usual transparency. It Aannot be denied, that this is the state of numerous cases; but it is equally true, that there are many excep- tions. Sometimes, in the most complete and incurable cases, the pupil is of its pro- per size, and even capable of very free mo- tion ; and, occasionally, it is actually smal- ler and more contracted, than natural. We have the authority of Richter for asserting, that in particular instances, the iris not only possesses a power of motion, but is capable of moving withuncommon activity, so that, in a very moderate light, it will contract in an unusual degree, and nearly close the pupil. (Anfangsgr-unde tier Wun- tlarzneykuitst, Band. 3. p. 424, Edit. 1795.) Two or three remarkable instances of the active state of the iris, in cases of amaurosis, were some time ago shewn to me by Mr. Albert, surgeon of the York Hospital, Chelsea, and 1 have seen some other similar cases in St. Bartholomew's Hospital Tbo patients alluded U\ had most of them not the least power of distin- guishing the difference, between total darkness, and the vivid light of the sun, or a candle placed just before their eyes. Janin and Richter have seen the pupil ca- pable of motion, in this disease, and Schmucker has twice seen the same fact. From the various conditions of the pu- pil, in different cases of gutta serena, no conclusions, entitled to much confidence, can even be drawn, with regard to the par- ticular nature and character of the com- plaint. For instance, the moveable or im- moveable state of the pupil can neither be considered, as a favourable, or unfavour- able circumstance. Sometimes an amau- rosis may be cured, which is attended with a pupil extraordinarily dilated, and en- tirely motionless. Sometimes, the disorder proves incurable, notwithstanding the pu- pil is of its proper size, and capable of mo- tion. There are likewise examples, in which the pupil recovers its moveableness, in the course of the treatment, although nothing will succeed in re-establishing the sight. (Richter, Op. cit. p. 425.) The pupil of an eye, affected with amau- rosis, (says this experienced surgeon) sel- dom exhibits the clear shining blackness, which is seen in a healthy eye. In gene- ral it is of a dull, glossy, hornlike black- ness, which symptom alone is frequently enough to apprise a well-informed practi- tioner of the nature ofthe disease. Some- times the colour ofthe pupil has an incli- nation to green ; while, in other examples, this aperture seems to be dense, white, and cloudy, so that the complaint might easily be mistaken for the begiiuiing of a cataract. This error, into which inexpe- rienced surgeons are liable to fall, may easily be avoided by attention to the follow- ing circumstances. The misty appear- ance is not situated close behind the pupil, in the place of the crystalline lens; but, frequently, is manifestly deeper in tlie eye. Nor is it in proportion to the impairment of sight, the patient being quite blind, while the misty appearance is so trivial, that, if it arose from the opacity of the crystalline lens, it could at most only oc- casion a slight weakness and obscurity in vision. It must be acknowledged, that it is more difficult to avoid mistake, when a beginning amaurosis is accompanied with this cloudiness in the eye, and consequent- ly, when the degree of blindness seems to bear some proportion to the degree of mis- tiness in the pupil. However, in this case, if we are to credit the observations of Rich- ter, the true nature ofthe disease may ge- nerally be known, by considering, that though the patient's sight is weak, it is not rendered faulty by an appearance of mist before the eyes, which latter circumstance 30 AMAUROSIS. is always complained of by persons, who are beginning to be afflicted with cataracts; not to mention that there are usually pre- sent several other symptoms, which exclu- sively belong to the gutta serena. Sometimes, the interior of the eye, a good way behind tlie pupil, seems quite white, and a concave light coloured surface may be observed, upon which the ramifi- cations of blood-vessels can be plainly seen. In particular instances, this white surface extends over the whole back part of the eye; while in other cases, it only occu- pies a half, or a small portion of it. This peculiar appearance has been ascribed to a loss of transparency in the retina itself, and a consequent reflection of the rays of light. (Holler, Element. Physiol. Tom. 5, p. 409.) There can now be no doubt, that such whitenessbehind the pupil must sometimes have originated from the diseased mass, which, in cases of fungus hxmatodes of the eye, grows from the deeper part of this organ, and gradually makes its way for- ward to the iris, being always attended with total loss of sight. If we put out of consideration the im- pairment of vision, a degree of squinting is, according to Richter, the only one symptom, which is inseparable from amau- rosis. An obliquity of sight, accompany- ing the imperfect state of the disease, has also been particularly adverted to by Mr. Hey, of Leeds. (Med. Observations and In- quiries, Vol. 5.) The patient, says Richter, not only does not turn either eye towards any object, in such a manner, that the ob- ject looked at is in the axis of vision ; but, he also does not turn both his eyes towards tiie same thing. This is alleged to be the only symptom, which we can trust, where implicit confidence should not be put in the mere assurance of the patient, that he cannot see, while all the coats and humours ofthe eye present their natural appearance. Provided this observation be correct, it must be highly interesting to the military surgeon, amaurosis being a common afflic- tion of soldiers, many of whom, however, endeavour to avoid service by pretending to labour under a disease, which they well know does not necessarily produce any very considerable alteration in the natural appearance of the part affected. The gutta serena originates with very various symptoms, and in exceedingly dif- ferent ways. Richter thinks it probable, that this variety, attendant on the begin- ning of the disease, depends upon some difference in the cause of the complaint, and indicates the propriety of having va- riety in the modes of treatment. Some- times, the patient loses his sight quite sud- denly ; while, in other instances, the power of seeing diminishes so slowly, that months*:, and even years elapse, before the disease attains the worst degree. Sometimes, the gutta serena commences with several sym- toms, which seem to betray an increase of sensibility in the eye, or some irritation affecting this organ. In moderately light places, the patient can discern things very well; but, in a great light, he is not able to see at all. The eye is sometimes so sen- sible, that a strong light will make it weep and become painful. Patients of this de- scription ought always to wear a shade, however bad their sight may be. Some- times the gutta serena originates with symptoms of weakness and diminished ir- ritability. The sight is cloudy, and the patient finds that he can see better in a light, than a dark situation. He feels as if some dirt, or dust, were upon his eyes, and is in the habit of frequently wiping them. His power of vision is greater after meals, than at the time of fasting. His sight is always, for a short time, plainer, after the external use of tonic remed'es, such as hartshorn, cold water, &c. Richter informs us of a person, who was nearly quite blind, but, was constantly able to see very well, for the space of an hour, after drinking champagne wine. He also mentions a wo- man, who had entirely lost her sight, who was in the habit of having it restored again, for half an hour, whenever she walked a quick pace up and down her garden. This author likewise acquaints us with the case of a lady, who had been blind for years; but, experienced a short re- covery of her sight, on having a tooth ex- tracted. Sometimes, as Richter observes, the symptoms appear to indicate a preterna- tural accumulation of the humours of the eye. The patients complain of a tension ofthe eye-ball, which is often particularly irksome and distressing. Whenever such sensation is experienced, the eyesight be- comes weak; and, on the subsidence of this feeling, the patient is again able to see better. The eye-hall feels hard, and occasionally is more or less enlarged, so that the state of the affected organ some- what resembles that, which takes place in hydrophthalmia. (Seethis Word) When a cataract is complicated with a gutta se- rena, the vitreous humour is sometimes found, in operating for the first disease, to be preternaturally thin, the eye being, as it were, in a dropsical state. Sometimes, the blood-vessels of the conjunctiva are varicose; the patient sees black specks, net-like appearances, streaks, snake-like figures, &c. It seems as if, in this case, the blood-vessels of the retina and choroide9 were in the same varicose state, as those ofthe conjunctiva, so as to make pressure AMAUROSIS. 31 upon the first of these membranes. That the vessels are in reality thus dilated, says Richter, is rendered probable by the bleed- ing, which is apt to occur in the eye in operating for cataracts, complicated with the gutta serena. In particular examples, the eye seems to be under the influence of some peculiar irritation. The patients see several ob- jects, which are in motion, and of different colours, more especially, shining, fiery spots, flames, and. rays of light. Some- times, amaurosis arises after violent inve- terate ophthalmies, and headachs. Cer- tain patients, before being attacked with the complaint,are repeatedly afflicted with catarrhs, which cease as soon as the gutta sereru is formed. According to Richter, the mucous membrane of the nose then becomes unusually dry and free f. om se- cretion. Some patients, of this kind, have been known to regain their sight, for a short time, on a copious '.scharge of mu- cus spontaneously taking place from the nose. Paying diligent attention to these various circumstances, attending the ori- gin of the disorder, says Richter, will of- ten be of great assistance to the practi- tioner, in enabling him to select a judi- cious method of treatment, when all other indications are absent. The disease commonly makes its attack upon both eyes at once, and even in those occasional instances, in which only one is deprived of sight, the other rarely con- tinues for a long time sound. The disor- der generally extends over the whole eye; but, sometimes only a half ofthe organ is affected, the case being then named amau- rosis dimidiata. In the first example, the patient is quite blind ; in the second, he can discern tlie half of objects. Some- times the malady seems to be confined to a single little spot in the eye, in which case, the patient is conscious of having before the retina an immoveable bluck speck. It is'to this particular instance, that some pathologists apply the term, scotomia. Also patients, who may he said to be entirely blind, sometimes have a small part of the retina, which is still susceptible ofthe im- pression! of light, and is usually situated towards cne side of the eye. (Hey, in Med. Observations and Inquiries, Vol. 5.) Richter mentions, that, in one man, who was in other respects, entirely bereft of vision, this sensible point of the retina was situated obliquely over the nose, and so small, that it was always a considerable time, before its situation could be dis- covered : he adds, that it was so sensible, as not only to discern the light, but even the spire of a distant steeple. Accoiding to this author, it is the centre of the eye, that seems to be the first and most serious- ly affected in the gutta serena. Hence, the generality of patients, who have a begin- ning imperfect amaurosis, can always see objects,laterally situated,better than those which are immediately before them. The gutta serena is sometimes an inter- mittent disorder, making its appearance at regular or irregular intervals. In cer- tain examples, as Richter remarks, the disease prevails at particular times, com- monly all day, till a certain hour; or from one day till the next; or at a stated time every month. The attacks of the complaint sometimes take place at indeterminate pe- riods. In particular cases, another mor- bid affection is associated with the im- pairment of sight. Richter mentions a man, who became blind at twelve o'clock in the day, when the upper eye-lid used also to hang down in consequence of be- ing affected with paralysis. The attack always lasted twenty-four hours. On the following day, at twelve o'clock, the sight used to return, and the patient then sud- denly regained the power of raising the upper eye-lid. He would continue thus able to see for the space ofthe next twen- ty-four hours. Whenever he took bark, the disease was regularly doubled; that is to say, the man then alternately remain- ed blind forty-eight hours, and recovered the power 9! seeing for only twenty-four. In another patient, cited by this experienc- ed surgical writer, t)pe aqueous humour, during the blindness, always became dis- coloured, whitish, and turbid; but, its transparency regularly returned on the ces- sation of the attack. According to Rich- ter, the periodical amaurosis commonly depends upon irritation affecting the di- gestive organs, the stimulus of worms, or irregularity in the menstrual discharge. Sometimes, it is plainly a symptom of a confirmed ague, the patient being attacked with an ordinary intermittent, and blind during each paroxysm; but, always re- gaining his sight as soon as each fit is over. (See Richter's Avfavgsgrunde der Wnndarzneykunst, Band 3, Kup. 14. Before treating of the different causes of the gutta serena, it seems proper to de- scribe the ordinary symptoms of the dis- ease. When the patient is first attacked, his sight gradually grows weaker; he feels, as if a gauze, or cob-web, were drawn over his eyes, and imagines he sees a white sur- face, studded with black specks, which he endeavours to wipe away. By degrees, the pupil of the eye loses its brilliancy, and distends itself much beyond the na- tural size ; and if the patient's eye be closed, the upper eye-lid gently rubbed, and then suddenly opened, in a light place, the pupil will contract very little, or not at all. The sight grows weaker and AMAUROSIS weaker; spectacles and convex glasses are of no service, and the patient, (gene- rally speaking) sees worse in the open day- light, than in a dark situation. While the patient is at all conscious of the im- pression of the rays of light, or while a certain power of seeing still continues, the disease is called the imperfect, or in- complete amaurosis; but, when the patient is wholly insensible of the stimulus of light, the disorder is termed perfect, or complete. Schmucker remarks, that, although the complete gutta serena is generally a gradual disease, there are cases, in wliich it comes on quite suddenly, without being pre- ceded by tiie above-mentioned circum- stances. These cases,, he says, have fre- quently fallen under his observation, and been more easy of cure, than when the af- fliction has taken place in a more gradual way. In such instances, the sight is to- tally lost, the patient can distinguish no object whatever, the pupil of the eye is uncommonly enlarged, and if the eyelid be shut, and then rubbed, and opened in a strong light, tlie aperture in the iris re- mains fixed, and incapable of contraction. A lighted candle may be held to the pa- tient's eyes, without exciting sensation. The pupil now loses its shining black gloss, and grows pale, so that a skilful practitioner can perceive the difference, without being closPto the patient. Per- sons, attacked irt this manner, usually have an unhealthy and timid look. (See Schmucker's Veiinischte Chirurgische Schriften, Band 2.) Acording to Richter, the remote causes of gutta serena may be properly divided into three principal classes.thedifferences of which indicate three general methods of treatment. It is alleged, that the first class of causes seem to depend upon an extraordi- nary plethora and turgidity of the blood- vessels of the brain, or of those of the optic nerves and retinx, upon which last parts a degree of pressure is thereby sup- posed to be occasioned. A considerable plethora, especially, when the patient heats himself, or lets his head hang down, will frequently excite the appearance of" black specks before the eyes, and some- times complete blindness. A plethoric person (says Richter,) who held his breath, and looked at a wlute wall, was conscious of discerning a kind of network, wliich alternately appeared and disap- peared with the diastole and systole ofthe arteries. This phenomenon, it is con- jectured, originated from the plethoric state of the vessels of tlie retina. Boer- haave mentions a man, who, always lost his sight on getting tipsy, and regained it on becoming sober. Richter thinks it likely, that it is m this manner, that the disease is produced, by the suppression of some habitual discharge of blood, by not being bled according to custom, by the stoppage of the menses, and by the cessation of hemorrhage from piles; circumstances, which, if we can give credit to all the accounts of Richter, Scarpa, Schmucker, and other experienced writers on the subject, frequently give rise to the gutta serena. In the same manner, the complaint may be brought on by great bodily exertions, which must de- termine a more rapid current of blood to the head. Richter informs us of a man, who became blind, all on a sudden, while carrying a heavy burden up stairs. He tells us of another man, who laboured ex- cessively hard, for three days in succes- sion, exerting .his strength very much, and who became blind at the end of the third day. Pregnant women, in like manner, are sometimes bereft of their sight during the time of labour. Schmuc- ker has recorded a remarkable instance of this in a strong young woman, thirty years old, and of a full habit. Whenever she was pregnant, she was troubled with violent sickness, till the time of delivery, so that nothing would stop in her sto- mach. She was bled, three or four times, without effect. Towards the ninth month, her sight grew weak, and for eight or ten days before parturition, she was quite blind. Tlie pupil of the eye was greatly enlarged, but, retained its shining black appearance. She recovered her sight im- mediately after delivery, and did not suf- fer any particular complaints. Schmucker assures us, that he has been three times a witness of this extraordinary circumstance. (Vermischte Chir. Schriften, Band 2, p. 6, edit. 1786.) Richter speaks of a person, who lost his sight, during a violent fit of vomiting. Schmucker acquaints us, that it is not uncommon for soldiers, who are performing forced marches in hot wea- ther, to become blind all on a sudden. All great exertions of sirengthjflriien the body is plethoric, or heated, orient for- wards with the head in a low posture, are usually attended with some dangers of bringing on amaurosis. The blindness, which follows external injuries ofthe head, is ranked by Richter among the preceding class of cases. A man, who received a smart box on the ear says this author, lost his sight on the spot. Richter conceives it probable that a concussion of the head may some! times produce an atony of the blood-ves- sels, giving rise to their dilatation, and consequent pressure «ti the adiacent AMAUROSIS. 33 nerves: perhaps, It is more likely, that the blow itself actually ruptures them, and produces an effusion of blood. Richter suspects, that the gutta serena, which originates during a violent ophthalims, or during a severe inflammatory fever, may be ot the same nature. He thinks it pro- bable, that persons, who become blind while exposing themselves to the burning sun with their heads uncovered, have their sight impaired in a similar way. The diagnosis of this first species of the gutta serena is founded on an acquaint- ance with the preceding remote causes, which are for the most part very evident, as the blindness, which is the consequence of them, follows with remarkable quick- ness. The second class of causes are supposed to operate, by weakening either the whole body, or the eye alone, and they indicate the general, or topical use of tonic reme- dies. In the first case, the gutta serena appears as a symptom of considerable uni- versal dehility of the whole system ; in the second case, the disease is altogether local. Every great general weakness of body, let it proceed from any cause what- soever, may be followed by a loss of sight. The gutta serena, if we can give credit to the statement of Richter, has sometimes been the' consequence of a tedious diar- rhxa, a violent cholera morbus, profuse hemorrhage, and immoderate salivations. He informs us of a dropsical woman, who became blind, on the water being let out of her abdomen. According to the same author, no general weakening causes ope- rate upon the eyes, and occasion total blindness, so powerfully and often, as premature and excessive indulgence in venereal pleasures. The causes are various, which operate locally in weakening the eyes. Nothing has a greater tendency to di bilitate these organs, than keeping them fixed very at- tentively, for a long while, upon minute objects. But, however long- and assidu- ously objects are viewed, if they are di- versified, the eye suffers much less, than when they are all of the same kind. A frequJBfchange, in the objects, which we look arenas a material effect in strength- ening and refreshing the eye. The sight is particularly injured by looking at ob- jects with only one eye at a time, as is done with telescopes and magnifying glasses; for when one eye remains shut, the pupil of that, which is open, always becomes dilated beyond its natural diameter, and lets an extraordinary quantity of light into the organ. The eye is generally very much hurt, by bein;? employed ,n the close inspection of bHliant, light-colour- ed, shining objects. They are greatly mis- Voju I. taken, says Richter, who think, that they save their eyes, when they illuminate the object, which they wish to see, in the evening, with more lights, or with a lamp, that intercepts and collects all the rays of light, and reflects them upon the body, which is to be looked at. Richter makes mention of a man, who, in the middle of winter, went a journey on horseback, through a snowy country, while the sun was shining quite bright, and who was at- tacked with amaurosis. He speaks of an- other person, who lost his sight, in con- sequence of the chamber, in which he lay, being suddenly illuminated by a vivid flash of lightning. A man was one night siezed with blindness, while he had his eyes fixed on the moon in a fit of contem- plation. Richter also expresses his belief, that a concussion of the head, from exter- nal violence, may sometimes operate di- rectly on the nerves, so as to weaken and render them completely paralytic. The third class of causes consist of irritations, which, in some inexplicable way, directly, or, probably, for tlie most part, directly, affect the optic nerves, and render them insensible of the impression of the light. Most of these irritations are asserted to lie in the abdominal viscera, whence they sympathetically operate upon the eyes. The observations of Richter, Scarpa, and Schmucker, all tend to con- firm, that amaurosis more frequently arises from irritation in the gastric or- gans, than any other cause whatever. It may often be ascertained that patients with amaurosis have suffered much trou-> ble, and long grief, or been agitated with repeated vexations, anger, and other pas- sions, which are supposed to have a great effect in disordering the bilious secretion, and the digestive functions in general. Richter tells us of a man, who lost his sight, a few hours after being in a violent passion, and recovered it again the next day, upon taking an emetic, by which a considerable quantity of bile was evacu ated. A woman is also cited, who be- came blind, whenever she was troubled with what are termed, acidities in the stomach. (See Anfangsgrunde der Wun- darzneykunst, Band 3, Kap. 14.) The continental surgeons are excessive- ly comprehensive in their ideas of the causes of the gutta serena, and, with many truths, they blend an evident quantity of unestablished conjectures, and palpable absurdities. I believe, it will generally be found, that,'when surgical writers as- sign a multitude of causes for any disease, they deal very much in mere supposition. It would be idle credulity, indeed, to put frith in the assertions concerning the amau- rosis being occasioned by the bad treat- 34 AMAUROSIS. ment of particular fevers, suppressed diar- rhoeas, the repulsion of eruptive com- plaints, &c. There is no reason, why a person should not become blind about the time, when another disorder gives way; but, we ought to have some other ground for the doctrines, to which allusion is made, before we can presume to offer them as entitled to confidence. Worms in the alimentary canal are al- leged to be sometimes the cause of amau- 1 rosis, and, since a disordered state of the gastric organs is universally acknowledged to be frequently concerned in the produc- tion of blindness, we can have no difficulty in conceiving, that worms may likewise have the same effect. Besides gastric irri- tations, there are some others, which class as causes of this disease. A violent fright, which is considered as being a frequent remote cause of the gutta serena, is sup- posed by Richter to operate chiefly by irritating the nerves. The blindness sometimes proceeds from a mechanical kind of irritation. A man received in his right orbit a small shot, which pierced the upper eye-lid,and lodged at the upper part of the socket, between the eye-lid and eye-ball, so that it could be felt externally. Richter adds, th.it this patient shortly afterwards became blind in the left eye; but recovered his signt in it again, upon the excision of the shot. (Anfansg. der Wundarzn. Band 3, p. 439.) Sometimes, says this experienced sur- geon, the irruption, exciting amaurosis, seems to have its seat in the mucous mem- brane of the nose and frontal sinuses. We have already adverted to the unusually dry state ofthe nostril, that has been sus- pected of being occasionally conducive to this species of blindness. The gutta serena is generally difficult of cure. However the degree of difficulty in relieving the disease varies in different cases, according to the way in which the malady originates, and the nature of the cause. Professor Scarpa, of Pavia, has given an excellent account of the prognosis in cases of" amaurosis. Some of"his doctrines, however, founded on the humoral patho- logy, are hypothetical, and, consequently, are purposely omitted in the following account. It also deserves notice that the case supposed to originate from injury of the supra-orbitary nerve, is not always in- curable, as the experience of Hey con- firms. (See Med. Obs. and Inq. Vol. 5.) Amaurosis is divided by Scarpa into the perfect, or imperfect; inveterate or recent ; and continued, or periodical. The perfect, inveterate amaurosis, attend- ed with organic injury of the substance, constituting the immediate organ of sight, says Scarpa, is a disease »absolutcly in- curable. The imperfect, recent amaurosis, particularly that which is periodical, is commonly curable; for, it is mostly sym- pathetic with the state ofthe stomach and primx vix, or dependent on causes, which though they affect the immediate organ of sight, are capable of being dispersed, without leaving any vestige of impaired organization in the optic nerve, or retina. When amaurosis has prevailed several years, in persons of advanced age, whose eyesight has been weak from their youth ; when it has come on slowly, at first with a morbid irritability of the retina, and then with a gradual diminution of sense in this part, till total blindness was Abe conse- quence; when the pupil is motionless, not circular, and not much dilated; when it is widened in such a degree, that the iris seems as if it were wanting, and the margin of\this opening is irregular and jagged ; and, when the bottom of the eye, independently of any opacity of the crys- talline lens, presents an unusual paleness, like that of horn, sometimes partaking of green, and reflected from the thickened retina, the disease may be generally set down as incurable. Cases may be deemed irremediable which are attended with pain all over the head, and a continual sensa- tion of tightness in the eye-ball, which are preceded by a violent, protracted excite- ment of the nervous system, and then by general debility, and languor of the con- stitution, as after masturbation, prema- ture venery, and hard drinking There is no rem -dy for cases, connected with , epileptic fits, or frequent spasmodic hemi- ennia; nor for such as are the conse- quence of violent, long-continued, internal ophthalmia. Cases are incurable, also, when produced by violent concussions of tlie liead, direct blows on the globe ofthe eye, or a violent contusion, or other injury ofthe supra-orbitary nerve, and this, whe- ther the disease take place immediately after the blow, or some weeks subsequent- ly to the healing ofthe wound ofthe eye- brow. Amaurosis is also incurable, when occasioned by foreign bodies inthe eye- ball, lues venerea, or exostosesjiout the orbit. Lastly, amaurosis is absol^e'.y irre- mediable, when conjoined with a manifest change in the figure and dimensions of the eye-ball. On the contrary, all cases of imperfect, recent amaurosis, whether the blindness be total or partial, are mostly curable, when not produced by causes, capable of contusing or destroying the organic struc- ture of the optic nerve, and retina. This is especially true, when the retina is in some degree sensible to the impression of light. Recent, sudden cases, in which the AMAUROSIS. 35 pupil is not excessively dilated, and its disk remains regular, while the bottom of the eye is of a deep black colour; cases, unaccompanied with any acute, continual pain in the head and eye-brow, or'any sense of constriction in the globe of the eye its-It"; cases, which originate from violent anger, deep sorrow, fright, exces- sive fulness of the stomach, a foul state of this viscus, general plethora, or the same part.-ii affection of the head, suppression of the menses, habitual bleedings from the nose, piles, &c. great loss of blood, nervous debility, not too inveterate, and in young subjects, are all, generally speak- ing, curable Amaurosis is also, for the most part, remediable, when produced by convulsions, or the efforts of difficult par- turition ; when it arises during the course, or towards the termination of acute, or intermittent fevers; and when periodical, coming on at intervals, such as every day, every three days, every month, &c. Before entering into the consideration of the treatment of the gutta serena, I shall take this opportunity of noticing a few remarkable circumstances, which are connected with the disease. It sometimes happens, that, when a patient shuts one eye, he can only half dis- tinguish objects; but, that if he opens both eyes, he sees every thing in its natu- ral form. In this case, according to Schmucker, one eye is sound, and only some fibres of the nerve of sight are in- jured in the other. In the gutta serena, which comes on gradually, the patient also sometimes sees double, with both eyes. Some years ago, Schmucker cured a major of hussars, who saw the three lines of his squadron double; and the same surgeon was ordered by the king of Prussia to attend a gentleman, who was afflicted in a similar way. In the opinion of -this eminent surgeon, such cases are brought on by a violent disten- tion of the vessels ofthe choroides, where he thinks, that varices may easily arise, in consequence of tlie weak resistance of that membrane. In iliis manner, the filaments ofthe rj^na suffrr pressure, and the rays of lighflre broken. Under these circum- stancesTu prompt assistance be not afford- ed, total and frequently incurable blind- ness may be the consequence. Schmucker met with an example of such an irreme- diable amaurosis, (the only instance in his practice), in a young man, twenty-six years of age. When the patient'made application for the advice ofthe foregoing surgeon, he had been blind a year. Before he lost his sight, he remarked, that, after any violent emotion, his s.ght at first grew weak, and that obje-sts afterwards appeared double. When his circulation was at all hurried, he saw black spots be- fore his eyes, and, at length, was quite blind. The vessels ofthe choroides were as large, as if they had been injected with wax, and every kind of surgical assistance proved ineffectual. I have already adverted to the occasion- al moveableness of the iris, notwithstand- ing the insensible staU ofthe retina. Let me next take notice of a case, which some- times presents itself, and is quite the reverse of this last. The nerves of the iris may be paralytic, while those of sight continue unimpaired. Schmucker tells us, he was acquainted with a woman, whose pupil was uncommonly distended, and totally incapable of motion. Her sight was very weak, and spectacles were of no use to her. She could scarcely discern any thing by day, or in a strong light; but, she could see rather better at night and in dark places. This infirmity of sight depended upon the dilated, paralytic state of the pupil, by which too many rays of light were admitted into the eye; and the reason, why the patient could see better at night, was, because the pupil, in its natural state, always becomes widened and dilated in a dark situation. (See Ver- mischte Ckirurgische Schriften, Von J. L. Schmucker, Band 2, p. 13, 14.) TREATMENT OF AMAUROSIS, OR THE GUTTA SEREA'A. Here the first endeavour of the practi- tioner should be to find out and remove the cause of the disease. This is the surest and best way of proceeding; but, it is worthy of notice, that sight does not inva- riably return, although the real cause of the blindness has been radically removed. In such cases, the continuation of the loss of sight is ascribed to the torpor of the nerves, wliich have been for a consider- able time without action, and have been impaired by the disease. The practitioner usually prescribes stimulants and tonics, with a view of bringing the nerves into their original state of activity. In other cases, sight returns as soon as the cause ofthe disease is removed. When it is found impossible to make out any thing, respect- ing the cause of the disorder; the surgeon should found the curative indications up- on the symptoms and appearances, which have taken place in the origin and course of the disease, and from wh.cft symptoms some conjectures may be drawn, in regard to the nature ofthe case. When no appear- ances of this kind occur, and nothing can be le«rnt about the cause of the maladv, the surgeon must have recourse to such empirical remedies, as extensive experi- ence has shewn to be sometimes truly ca- pable of removing the affection, although 36 AMAUROSIS. an explanation cannot always be given of the manner, in which they operate. We shall follow Richter, and first treat of that method of cure, wliich is directed against the causes ofthe disease,and which, wiienever circumstances will admit of its adoption, must be regarded as the most proper and scientific. In that species of amaurosis, which arises from the firstclass of causes, namely, from those, which seem to induce the dis- ease, by means of a preternatural fulness and dilation of the blood vessels of the brain, or eye, the indication is evidently to lessen the quantity of blood, and dimi- nish the determination of it to the head. For this purpose, the patient may be bled in the arm, temporal artery, or foot. This evacuation is to be repeated as often as seems necessary, and it will be better to begin with Liking away from twelve to six- teen ounces. We are also advised by Schmucker to apply ten or twelve leeches to the* tcck and temples. The efficacy of bleeding, m the cure of particular cases of the gutta serena, is strikingly exemplified by numerous well authenticated ob.sei\a- tions. Richter informs us of a woman, who, on leaving • if having children, lost her sight; but, recovered, it again by being only once bled it tlie foot. A spontaneous hemorrhage from the nose also cured a young woman, who had been blind for se- veral weeks. (Anfangsgrunde der Wundarz- neykunst. Band 3, p. 442 ) General bkeding sometimes proves inef- fectual, unless assisted by topical. Leeches may be applied to the temples, or cupping glasses to the back part of the neck. "\V hen the disorder seems to be connected with an interruption ofthe menses, or the cessation of bleeding from piles, leeches may be put on the pennxum, the inside of the thigh, or the sacrum. Local bleeding, however, seldom avails, except the whole mass of blood has been previously diminished by a prudent employment of the lancet. Be- sides bleeding, the surgeon may advan- tageously have recourse to other means at the same time, as, for instance, emollient glysters, purgatives, blisters, bathing the feec in warm water, &c. In some cases all the foregoing means fail in producing the desired benefit, even when they have been followed up, as far as the state of the pulse, and strength of the constitution will allow. Here the con- tinuance of the disease may depend, either upon the stoppage of some wopted evacu- ation of blood, or else upon some other cause of the first class. In the first of these cases, (says Richter) experience shews, that the i-sease will sometimes not give way, before the accustomed discharge is re-established, on which the malady de- pends, notwithstanding evacuants may be employed in any way whatsoever. A woman, who (as this author acquaints us) had lost her sight, in consequence of a sudden suppression ofthe menses, did not recover it again till three months after the return ofthe menstrual discharge, notwith- standing every sort of evacuation was tried. He also tells us of another woman, who had been blind half a year, and did not menstruate, and to whose external parts of generation leeches were several times ap- plied. As often as the leeches were put on, (says Richter) the menses in part recom- menced ; and, as long as they made their appearance, which was seldom above two hours, the woman always enjoyed a degree of vision. (Anfangsgruntle der Wundarz- neykunst, Band 3, p. 443.) For the amaurosis, arising from sup. pression of the menses, Scarpa recom- mends leeches to the labia pudendi, bath- ing the feet in warm water, and afterwards exhibiting an emetic, and tlie resolvent pills, of which I shall presently speak. If these means fail in establishing the men- strual discharge, he says, great confidence may be placed in a stream of electricity, conducted from the loins across the pelvis, in every direction, and thence repeatedly to the thighs and feet. He enjoins us not to despair at want of success at first, as the plan frequently succeeds, alter a trial of several weeks. For the amaurosis, proceeding from the" stoppage of an habitual copious bleeding from piles, Scarpa recommends the appli- cation of leeches and fomentations to the hemorrhoidal veins, then giving the patient an emetic, and, afterwards the resolvent pills. ( Saggio di Osservuzicni e d'esperienze sulle principali malattie degli occhi, cap. 19.) When the disease does not appear to originate from the stoppage of any natural or habitual discharge of blood, and does not y ield to the evacuating plan, Richter thinks, that the surgeon is justified in concluding, that the pi-eternaturally dilat- ed vessels have not regained their proper tone and diameter, and that he^oughl to employ topical corroborant remfpies, par- ticularly cold water. Richter, in this kind of ease, is an advocate for washing and bathing the whole head with cold wa- ter, especially, the part about the eyes; a method, he says, wliich may often be prac- tised, after evacuations, with singular and remarkable efficacy. When the return of sight cannot be brought about in this manner, Richter advises us to try such means, as seem calculated to stimulate the nerves, and re- move the torpid affection of the optic nerves in particular. Of these last reine- AMAUROSIS. 37 dies, says he, emetics are the principal and most effectual. Soldiers, who lose their sight in performing forced marshes, in hot weather, very commonly have it re-esta- blished again, by being immediately bled, and taking an emetic the next day. (See Schmucker's Chirurgisch Wahrnehmungen 1. Theil.) We come now to the consideration of that species of the gutta serena, which is regarded as the effect of some unnatural irritation. Here, according'to the pre- cepts delivered by Richter, we should en- deavour to discover what the particular ir- ritation is, and then endeavour to effect.its removal. When it cannot be exactly de- tected, we are recommended generally to employ such remedies, as will lessen the sensibility of the nerves, and render them less apt to be affected by the irritation, of whatever kind it may be. Sometimes the irritation is both dis- coverable and immoveable, and still the ef- fect, that is to say, the blindness continues. In this circumstance, Richter thinks, that tlie surgeon should endeavour to obviate the impression, which the irritation has left upon the nerves, by the use of ano- dynes, or, else, he is of opinion, that the practitioner should try to remove the tor- por of the nerves by the employment of stimulants. But, according to Schmucker, Richter, and Scarpa, the curable imperfect amauro- sis commonly depends on some disease, or irritation, existing in the gastric system, and, in some instances, complicated with general nervous debility, in which tlie eyes participate. Hence, the chief indication, in the majority of cases, is to free the sto- mach and primx vix from all irritating matter, to strengthen the gastric organs, promote digestion, and reanimate the ner- vous system in general, and the neives of the eye in particular. Emetics and internal resolvents answer the first purpose,*and tartar emetic should be preferred to every pharmaceutical pre- paration. When afterwards administered, in small repeated doses, it also acts as a resolvent remedy, which operation may be rendfc-ed stronger by joining it with gummy saponaceous substances. Dissolve three grains of the antimonium tartarizatum, for an adult, in six ounces of water, and give a spoonful of this solution, every half hour, until nausea and copious vomiting are produced. The next day- exhibit some resolvent powders, consisting of an ounce of cream of tartar, and one grain of tartar emetic, divided into six equal parts. The patient must take one of these in the morning, another four hours afterwards, and a third in the evening, for eight or ten days in succession. This remedy will create a little nausea, a few more alvine evacuations, than usual, and, perhaps, in the course of a few days, vo- miting. If the patient, during the use of these resolvent powders, should make vain efforts to vomit, complain of bitterness in his mouth, loss of appetite, and no reno- vation of sight, the emetic, as at first di- rected, is to be prescribed again. This is to be repeated a third, and fourth time, should the morbid state ofthe gastric sys- tem, the bitter taste in the mouth, the ten- sion of the hypochondria, the acid eructa- tions, and the inclination to vomit, make it necessary. The first emetic otten pro- * duces only an evacuation of an aqueous fluid, blended with a little mucus; but, if it be repeated, a few days after the resolv-, ent powders have been administered, it then occasions a discharge of a consider- able quantity of a yellow, greenish, mat- ter, to the infinite relief of the stomach, head, and eyes. The stomach having been thus emptied, Schmucker's, or Richter's, resolvent pills are to be ordered. These are composed as follows : S< Gum. Sagapen. "") Galban. \. an. gj Sap. Venet. j Rhei optim. giss Tart. Emet. gr. xvi. Sue. liquerit £j fiant pilulx gran. quinque. Three of these pills to be taken every morning and evening for a month, or six weeks. 9i Gum. Ammoniac.""! Ass. foetid. Sap. Venet. )-an. gij Rad. Valer. s. p. j Summit. Arnicx. J Tart. Emet. gr. xviij. fiant pilulx gran, quinque. Six to be taken thrice a day for several weeks. The pills are here directed to be made larger, than Schmucker and Richter order, that the number in one dose may be di- minished. To prescribe 15 pills three times a day would seem absurd to the generality of patients in this country. The following are the usual effects. The patient, after having vomited copiously, experiences a general calm, and an easi- ness not felt before. Sometimes, he be- gins to distinguish the outlines of objects the very day on wliich he takes the eme- tic ; at other times, he does not reap this benefit till the fifth, seventh, or tenth day; and, in some instances, not before some weeks have elapsed, after the exhibition 38 AMAUROSIS. ofthe emetic, and the uninterrupted use of the resolvent powders and pills. When the patient begins to recover his sight, the dilated state ofthe pupil diminishes; the iris contracts more on being exposed to the vivid light of a candle; and, in proportion as the power of seeing things increases, the contraction and moveableness of the pupil augments. On the whole, the cure is very seldom completed in less than a month, during which time the employment of such remedies, as are calculated to re- vive the languid action of the nerves of the eye, must not be neglected. When the above plan has rectified the state of the stomach, and partly effected the restoration of sight, such remedies must be employed, as strengthen the di- gestive organs, and excite the vigour of the nervous system in general, and of the nerves ofthe eye in particular. A powder is to be prescribed, composed of an ounce of bark, and half an ounce of valerian, divided into six equal parts, one of which is to be taken in the morning, and another in the evening, in any convenient vehicle, for, at least, five or six weeks. During this time, the patient's nourishment must consist of tender succulent meat, and wholesome broths, with a moderate quan- tity of wine, and proper exercise in a salu- brious air. To excite the action of the nerves of the eye, the vapour of the aqua ammnmx purx; properly directed against the eye, is of the greatest service. This remedy is applied by holding a small ves- sel, containing it, sufficiently near the eye to make this organ feel a smarting, occa- sioned by the very penetrating vapours, with which it is enveloped, and which cause a copious secretion of tears, and a redn ss, in less than half an hour after tlie beginning of the applications. It is now proper to stop, and repeat the ap- plication, three or four hours afterwards. Tiu plan must be thus followed up till the incomplete amaurosis is quite cured. The ammoniacal vapours should be used as soon as the stomach has been freed from all irritating matter, and they should not be discontinued, tilt long after the eye has been cured. The operation of these vapours may be aided by other external stimulants, applied to such other parts X)f the body, as have a great deal of sympathy with the eyes. Of this kind, are blisters to the nape of the neck; friction on the eye-brow with the anodyne liquor; the irritation of the nerves of the nostrils by sternutative powders, like that composed of two grains of tur- bith mineral, and a scruple of powdered betonv leaves; and, lastly, a stream of electricity. The latter has been proposed, as one of the principal means of curing amaurosis; but, experience has shewn, that electricity only merits confidence, as a secondary remedy, and Mr. Hey, one of its most zealous advocates, confesses, that it only succeeds in cases of recent amauro- sis, and, usually, not in these, unless it be combined with proper internal medi- cines, among which resolvents are the chief. (Med. Obs. and Inq. Vol. 5, p. 26.) Many might suppose bark to be a speci- fic for the imperfect periodical amaurosis. This, however, is not the case. Bark, which is efficacious in intermittent fevers, and other periodical diseases, far from curing the periodical amaurosis, seems to, exasperate it, rendering its return more frequent, and of longer duration, than be- fore. On the other hand, this disease is most commonly cured, in a very short time, by exhibiting first emetics, then internal resolvents, and lastly, corroborants, and even hark, which was before useless and , hurtful. The above plan of curing the recent imperfect amaurosis succeeds in the ma- jority of cases, when the disease is only sympathetic, or dependent on the morbid state of" the gastric system. But, there are cases, in the formation of which many other causes operate, besides the most frequent one already stated. These demand the employment of particular cu- rative means, in addition to those which have been already described. Such is, for example, thr imperfect amaurosis, which occurs suddenly, in consequence of the body being excessively heated, or ex- posure to the sun, or violent anger, in ple- thoric subjects. This case requires, in particular, general and topical evacuations of blood, and the application of cold washes to the eyes and whole head. An emetic should next be given, and after- wards a purge of the kali tartarisatum, or small repeated doses of the tartar emetic. Schmucker relates, that, by means of bleeding and an emetic, he has oftentimes restored the eye-sight of soldiers, who had lost it in making forced marches, with very heavy burdens. In amaurosis, suddenly occasioned by violent anger, an emetic is the more strongly indicated afWbleeding, as the blindness, thus arising, is always attended with a bitter taste in the mouth, tension of the hypochondria, and continual nausea. Richter gives an account of a clergyman, who became completely blind, after being in a furious passion, and whose eye-sight was restored the very next day, by means of an emetic, which was given with a view of relieving some obvious marks of bilious disorder in the stomach. The treatment of the imperfect amau- rosis, from fevers badly treated, deep sor- row, great loss of blood, intense study AMAUROSIS. 39 •and forced exertions of the eyes on very minute, or brilliant objects, consists also in removing all irritation from the sto- mach, and afterwards strengthening the nervous system in general, and the nerves of the eye in particular. In the case ori- ginating from fevers, the emetic and resol- vent piUs are to be given ; then bark, steel medicines, and bitters; while the vapours ofthe aqua ammonix purx are applied to the eye itself. When the disorder seems to proceed from grief, or fright, the stomach and in- testines are to be emptied by means of tartar emetic, and the resolvent pills; and the cure is to be completed by giving bark and valerian together ; by applying the vapour of the aqua ammonix purx to the eye; ordering nourishing easily digesti- ble food; diverting the patient's mind, and fixing it on agreeable objects, and recommending moderate exercise. The amaurosis from fright is said to require a longer perseverance in such a plan, than the case from sorrow. (Scarpa's Osservaz. Cap. 19.) The third species of gutta serena, or that which arises from debilitating causes, is of two kinds; in one, the disease is the consequence of a general weakness of the body ; in the other, it is the effect of a de- bility, which is confined to the eye itself", and does not extend to the whole consti- tution. According to Scarpa, the incomplete amaurosis from general nervous debility, copious hemorrhage, convulsions, ab inani- tione, and long continued intense study, especially, by candle light, is less a case of real amaurosis, than a weakness of sight from a fatigued state of the nerves, espe- cially of those constituting the immediate organ of sight. When this complaint is recent, in a young subject, it may be cured, or diminished by emptying the ali- mentary canal with small repeated doses of rhubarb, and then giving tonic cordial remedies. At the same time, the patient must abstain from every thing, that has a tendency to weaken the nervous system, and consequently, the eye-sight. After emptying the stomach, prescribe the de- coction of bark, with valerian, or the infu- sion of quassia, with the addition of a few drops of the xther vltriolicum to each dose, with nourishing, easily digestible food. The aromatic spirituous vapours (mentioned in the article Ophthalmy) may then be topically applied; or if these should prove ineffectual, the vapour of the aqua ammonix purx. The patient must take exercise on foot, horseback, or in a carriage, in a wholesome dry air, in warm weather, and take advantage of sea bath- ing. He must avoid all thoughts of care, and refrain from fixing bis eyes on minute shining objects. In proportion as the en- ergy of the nervous system returns, and the constitution is strengthened, the sight is restored. In order to preserve, and improve this useful sense, the patient must adopt, above all things, every mea- sure, calculated to maintain the tone of the stomach, and moderate the impression of light on the retina. This object can easily be obtained by always wearing flat green glasses before the eyes, in a vivid light. (Saggio di Osservaz. Cap. 19.) When the weakness is confined to the eye alone, Richter thinks the topical em- ployment of corroborant applications alone necessary. Bathing the eye with cold water, says he, is one of the most power- ful means of strengthening the eye. The patient should dip in cold water a com- press, doubled into eight folds, and suffi- ciently large to cover the whole face and forehead, and this he should keep applied, as long as it continues cold. Or, else, he should frequently apply cold water to his eyes and face with his hand, on a piece of rag. In these cases, Richter does not ap- prove of employing eye-glasses; he objects to their smallness, from which the eye soon makes the fluid warm, or presses the greater part of it out. The eye may also be remarkably strength- ened by repeatedly applying blisters of a semi-lunar shape above the eye-brows, only allowing the plaster, however, to re- main just long enough to excite redness. Richter likewise speaks favourably of rub- bing the upper eyelid, several times a day, with a mixture of the tinctura canthari- dum, and spiritus serpilli, great care being taken, that none of the application come into contact with the eye itself. All spi- rituous and aromatic remedies are also proper. The infusum valerianx et salvix, with a proportion of camphorated spirit, and the oleum c. jeput, are likewise enu- merated, as useful and efficacious lini- ments. (Anfangsgrunde der Wunderzney- kunst, Band 3, p. 452.) When no probable cause whatsoever can be assigned for the disease, the sur- geon is justified in employing such reme- dies, as have been proved by experience to be sometimes capable of relieving the affection, although upon what principle is utterly unknown. The chief means of this kind are emetics, given in small doses, so as to excite nausea, and occasionally in larger ones to occasion vomiting. A simple solution of two grains of the an- timonium tartarizatum in-a few ounces of water, taken by spoonfuls, frequently proves productive of remarkable benefit. Experience is also highly in favour of giving a trial to Schmucker's pills, the 40 AMAUROSIS. composition of which has been already described. The operation of these pills may be greatly assisted with the exhibi- tion of arnica and valerian, sixteen grains of which should be taken every morning and evening, and the dose be gradually increased. The leaves and flowers of ar- Hica, in an infusion, or else in powder, have been found efficacious. Of the last, at first ten grains, afterwards gradually increased to half a dram, may be pre- scribed every two, or every four hours. Mercury also deserves trial, and its ad- ministration may be pushed till the patient begins to be salivated. This mineral may be tried either alone, or in conjunc- tion with other medicines, as sarsapai'illa, cicuta, or sulphur auratum antimonii. Valerian alone, in the form of powder, and in the dose of half a dram, two or three times a day, may also be tried. Or this medicine may be joined with the de- coction of bark, containing either some of the ammonia prxparata, or a proper pro- portion of the spiritus xtheris vitriolici compositus. Stork has recommended Pul- satilla, in the form of an extract, of which from half a grain to two grains is to be taken with sugaJT or antimonial wine; or else an infusion of this plant may be given. The extractum hyoscyami albi is said to be often serviceable, either alone, in the dose of from two to eight grains, or to- gether with antimonial wine. A sort of tincture of millepedes is among the em- pirical remedies in repute on the conti- nent. Hemlock is another celebrated re- medy. So is the powder of belladonna, given in the dose of five grains a day. The ammonia prxparata, in the dose of a scruple, once a day, is likewise praised. Externally, the aqua ammonix acetatx, mixed with sage, or setwell tea, has been spoken favourably of, as a collyrium. A mixture of oleum castorei and hartshorn, in equal parts, may be taken inwardly, in the dose of forty drops, and also rubbed upon the upper eyelid and eyebrow. Warner exhibited the oleum animale and musk. The application of sternutative powders to the nostrils, is, perhaps, to be regard- ed as a mode of treatment, established on empirical principles, unless, indeed, we oan place confidence in the statement of Schmucker and Richter, that an unusual dryness of the mucous membrane of the nose, following tedious and severe ca- tarrhs, may have the effect of inducing amaurosis. The snuff, employed by Schmucker, is thus composed: * Mer- cur. viv. :;j. Sacchar. alb. 3*uj, Lill. Alb. Rad. Valerian, a a ,"5J. Misce. Mr. Ware has written in favour of the efficacy of electricity and a mercurial snuff in cases of gutta serena. The snuff is compounded of ten grains of turbith mineral (kydrargyrus mlphuratus) Well mixed, with about a dram of the pulvis sternutatorium, glycirrhiza, .or common . sugar. A small pinch of this snuff, taken up the nose, is found to stimulate it very considerably—sometimes exciting sneez- ing, but, in general producing a very large discharge of mucus. Mr. Ware has observed, that the pupil has been generally dilated, in the cases benefited by electricity. He notices, how- ever, that there are many instances in * which a contraction of the pupil is the only change, which takes place, in the appearance of the eye. In this sort of case, the impairment of sight is usually preceded by severe pain, and the original cause may be an internal ophthalmy of long continuance. The crystalline is sometimes visibly opaque. Here electri- city has been found useful; but, Mr. Ware states, that, in these instances, the sublimate has proved superiorly and more certainly efficacious, and, consequently, he prefers it to all external applications whatever. He recommends 1-fourth of a grain, as a quantity proper for a com- mon dose, and says, that it agrees best with the stomach when first dissolved, as Van Swieten directs, in half an ounce of brandy, and taken in a basin of sago or gruel. For young patients the dose must be diminished in proportion to their youth. The medicine is to be continued, as unin- terruptedly as the constitution will allow, for a month, six weeks, or even longer. Electricity is said to have proved more strikingly useful, in cases of amaurosis, ori- ginating from lightning, than when.the disease has arisen from any other cause. Mr. Ware relates a very interesting in- stance of the success of electricity, in a case, which came on very suddenly, after great pain in the teeth, and a swelling of the face had gone off. The disorder came on more suddenly; the temporary blindness was more entire; the eye-lids were more affected, and the cure more speedy, than in the instances related bv Mr. Hey in the 5th vol. of the Med. Oos. and Inq. (Chirurgical Observationsrelativ to the Eye, by James Ware, Vol. 1.) With the exception of one case related by Valsalva, Scarpa was unacquainted with any instance of amaurosis, arising from a wound of the eye-brow, that was relieved, and he has therefore, set down this species as incurable. The opinion, however, is not perhaps correct, for, the first case related by Mr. Hey arose from this cause, and was cured by giving every night the following dose: * Calomel. pp. Camphor a a iij. Conser-v. Cynosb. q. s. A MA A M B 41 probe misceant et f. Bolus, in conjunction with electricity. The lady, however, had been previously bled twice, had taken some nervous medicines, and had had a blister between the shoulders. The pa- tient was first set upon a stool with glass feet, and had sparks drawn from the eyes, and parts srrrounding the orbits, especi- ally, where the superciliary, and infra orbitary branches of the fifth pair of nerves spread themselves. After this ope- ration hi 1 been continued half .an hour, she was made to receive, for an equal time, slight shocks through the affected parts. In a few days sight began tore- turn, and in less than three months it was quite restored.—In another Case, one grain of calomel, and two of camphor^ given every night, and the employment of electricity, effected a cure. The disease had come on gradually, without any pre- vious accident, or pains in the head. The patient a boy nine years old. There are several other very interesting cases of amaurosis related by Mr. Hey, all of which make electricity appear a most efficacious remedy, though it is true, as Scarpa observes, that, in most of these in- stances, internal medicines, were also given, and bleeding occasionally practised. Mr. Hey attributes the benefit chiefly to the electricity, because, in two of his cases, no medicines were used, yet the progress of the amendment seemed to be as speedy in them, as in the rest, and in two instances, a degree of sight was obtained by the first application of electricity. Mr. Hey makes particular mention of an obliquity of sight, as invariably attendant on amaurosis. It was most remarkable in those, who had totally lost the sight of either eye, for, in them, the most oblique rays of light seemed to make the first sen- sible impression upon the retina ; and in proportion as that nervous coat regained its sensibility, the sight becamemore direct and natural. (Med. Obs. and Inq. Vol. 5.) Many of the causes of amaurosis are of such a nature, as to render the disease to- tally incurable. Bonetus, in his Sepul- chretum Anatomicum, lib. 1. sect. 18. has given us several such cases: after death, the blindness in one was found to be occa- sioned by an encysted tumour weighing fourteen drams, sitt-ltted in the substance ofthe cerebrum, and pressing on the optic nerves near their origin. In a second, the blindness was produced by a cyst, contain- ing water, and lodged on the optic nerves, where they unite. In a third, it arose from a caries of the os frontis, and a consequent alteration in the figure of the optic fora- mina. In a fourth, the cause of the dis- ease was, a malformation of the optic nerves themselves. In some of the in- Voi.. I. stances, in which no apparent alteration can be discovered in the optic nerve,' Mr. Ware conjectures, whether a dilat-oion of the anterior portion of the circulus arteri- osus may not be a cause of the affeck>n. Tlie circulus arteriosus is -an t.rterial orcle, surrounding the sella turcica, formed by the carotid arteries on each s.de, branches passing from t!nm to meet each oilier before, and other branches passing back- wards, to meet branches from the basilary artery behind. The anterior part of the circulus arteriosus lies directly over, crosses, and is in contact, with the optic nerves, just in the same way as the ante- rior branches lie over the optic nerves, the posterior ones lie over the nervi motores oculorum. Hence Mr. Ware attempts to refer the amaurosis itself, and the paralytic affection ofthe eye-lids, and muscles ofthe eye, sometimes attendant on the complaint, to a dilatation of the anterior and posterior branches of the circulus arteriosus. Dr. Baillie has noticed, in his Morbid Ana- tomy, the frequently diseased state of the trunk, or the small branches of the carotid arteries at the side of the sella turcica, and he says the same sort of diseased structure is also found in the basilary artery and its branches. [From an idea that the pressure of an inordinate secretion of the humours of the eye might occasion a paralysis of the retina, Dr. Physick has punctured the cornea, and evacuated the aqueous humour, in some cases of gutta serena, and with temporary advantage.—Mr. Ware has punctured the sclerotica in certain cases of amaurosis. (See "Gutta Serena.") Blisters applied to the eye- lids, have also been found beneficial.] The most valuable information, concern- ing amaurosis, is to be met with in Ver- mischte Chiri/rgische Schriften von J. L. Schmucker, Band 2. Berlin Edit. 2.1786. Remarks on Ophthalmy, &c by James Ware. Inquiry into the causes preventing success in the extraction of tlie Cataract, &c. by the same. Osservazioni sulle Mulattie degli Occhi di A. Scarpa, Venez. 1802. Hey's Practical Observations in Surgery. Medi- cal Observations and Inquiries, Vol. 5. Schmucker's Wahrnehmungen. Richter's Anfangsgrunde der Wuvdarzneykunst. Band 3. Warner's Description ofthe Human Eye, &c. Chandler's Treatise of the Dis- eases of the Eye, chap 24. Some scattered remarks in the posthumous work on the dis- eases of tlie eye ofthe late J. C. Saunders,&c. Some observations connected with the subject of Amaurosis, will be found in the articles Cataract, Hemeralopia, Hemiopia, and Nyctalopia. AM BE. (ttuSn, the edge of a rock: 42 A M M AMP from ctfj.Za.ivu, to ascend.) An old chirurgi- cal machine for reducing dislocations of the shoulder, and so called, because its extremity projects, like the prominence of a rock. Its invention is imputed to Hippocrates. Theambe is the most ancient mechanical contrivance for the ahove pur- pose; but, is not at present employed. Indeed, it is scarcely to be met with in the richest cabinets of surgical apparatus. It is composed of a piece of wood, rising vertically from a pedestal, which is fixed. With the vertical piece is articulated after the manner of a hinge, an horizontal piece, with a gutter formed in it, in which the luxated limb is laid, and secured with leather strings. The patient places himself on one side of the machine; his arm is extended in the gutter, and se- cured ; the angle, formed by the union of the ascending piece, and by the horizontal branch, is lodged in the armpit, and then the horizontal branch is depressed. In this way extension is made, whilst the vertical part makes counter extension, and its superior part tends to force the head ofthe humerus into its cavity. But, thene is nothing to fix the scapula, and the compression made by the superior portion of the vertical piece of the ma- chine, tends to force the head of the hu- merus into its cavity, before it is disen- gaged by the extension. (Boyer on Dis- eases of the Bones, Vol. II.) AMBLYO'GMOS, or Amblto'smos, (from ctfji£xvs, dull.) A dimness of sight. AMBLYOPIA, (from */k£Ai/«, dull, and an}/, the eye.) Hippocrates means by this word, in his Aph. 31. Sect. 3. the dim- ness of sight, to which old people are sub- ject. Paulus, Actuarius, and the best modern writers, seem to think, that am- blyopia means the sane thing as the in- complete amaurosis. ( Encyclopedic Metho. dique; Partie Chirurgicale; Art Amblyopic) A'MMA,(from«a-7*'» to bind.) A truss, or kind of bandage, or machine, for pre- venting a protrusion of the bowels in cases of b'-mia. AMMONL-E MURIAS, AMMONIA MURIATA, or Sal Ammoniac. Its chief U-ae in surgery is as an external discutieut application. See Lotio Amnion. Muriatx cum Aceto. Mr. Jnstamond recommends the follow- ing application for the cure of milk ab- scesses: rn Ammonix Muriatx £j. Spi- ritus Roris marini lbj. Misce. Linen rags are to be wet with the remedy, and kept continually applied to the part affected. AMPHISMI'LA. (from a/*.», I shall now present tlie rcadc: nith the whole of La l-'aye's observations on tliis subj*.ct. In perusing the account, it is to be recollected, that La Faye was a zeal- 60 AMPUTATION. ous advocate for the method, which, though at present thought well of by a few, is not t xtt nsively approved. La Faye's relation, however, is truly inte- resting, for it muk s us at once acquainted with all the principal arguments and rea- sons, which hive been adduced in favor ofthe operation, and it explains to us the different plans of performing it, which were followed by such surgeons, as made tlie earliest trials of it. The description of the new machine for compressing the stump is less interesting now, than for- merly, when a main argument in support of this operation was, that the flap, when applied and pressed upon the stump, stop- ped the bleeding, and rendered ligatures unnecessary*. I have chosen, however, not to omit the account of the instrument, in order that the reader may possess the whole of the memoir. MEMOIR BT M. DE LA FATE ON THE FLAP AMPUTATION. Though surgeons have diligently appli- ed themselves, for more than a century, says La Faye, to bring the ordinary me- thod of amputation to perfection, yet still there are such defects found in it, as the greatest masters have not been able to re- medy. According to this method, a liga- ture is put on the vessels, which produces great pain, and sometimes convulsive mo- tions in the patient: the bones remain bare, and must exfoliate, which requires a considerable time ; it has been some- times necessary to saw tliem .1 second time ; the wound is of a large extent; the suppuration, which is very copious, greatly debilitates the patients, and the cure be- comes exceeding tedious. The reflections, made by several sur- geons at the end of the 17th century, as well as by those of tiie present, on these inconveniences, have induced them to think, that, by preserving a fl *p of fiVsh and skin, for covering the s'ump, the operation would be rendered less painful, more certain, and the cure much quicker. From this portion of flesh, the new me- thod of taking off a limb, has been stiled the flap-amputation. I shall here ex- amine the different notions of those, who have invented or followed this method, and propose such as have occurred to me on this subject. The amputation, with the double inci- sion, is very recent; though it has been surmised l.y .some persons, tn*. ■ Celsus had pointed it out in the followi , and the other end was placed on tlie side with the threads ; after which 1 raised the flap, in order to adjust it to the stump, .and then laid on, not the apparatus used by M. Verduin, but the common sort, or pretty nearly tlie same that is generally employed in the amputation of the leg; by which means, the method of cure becomes more simple, as I make no use of the machines invented by this author and M. La Faye. . I did not take off this apparatus till the fourth day; when I found the flap adhe- rent, with a gentle heat. The longuette or small compress, which hindered the reunion of the flap, in that place alone wliich it possessed, was simply humid. I drew it out with facility, on the eighth day after the operation; and as I found such resistance from the ligature, as made me presume that it would not fall off so soon as I expected, I cut it in the loop with blunt scissars, which were directed into the space of the sinus formed by the presence of the compress. I afterwards joined it together again, by applying an apparatus like that which had been put on, at the instant of the operation. 1 did not remove it till three days after, and saw with pleasure the flap firmly reunited, though a portion of it had been applied on the linen for eight days. The patient was cured on the twentv- seventh day of the operation, and could easily bend and stretch out the extremity which remained of the leg. I am not insensible, that some surgeon- majors of this regiment have performed this operation; but by following Verduin's method too exactly, it has proved unsuc- cessful. I am persuaded that the alter- ations I have already made in it, are of some consequence, and I should still add more, did I see any occasion for making them. What I have experienced in mv third patient, would induce me to make the li&ature, in such a maimer, that it might exactly embrace, if I may use the term, no more than the vessel, in order to its falling oft* more speedily, and sooner re- uniting the flap. I am still of opinion, that if the ligature should not fall off, so soon as we appre- hend it has produced its effect, it would be necessary to cut it; because its too long continuance must naturally obstruct the advantages proposed from this operation, with regard to the speedy re-union. But as it is not vcrv easy to cut the ligature very close, I should make use, m preter- ence to other remedies, of the agaric of oak, whose success is well known. "Iwq pieces of this fungus, each fastened by a string, (to one of which there should be made a knot to distinguish them) being afterwards applied, the one on the other, to the orifice of the vessels, and the two strings covered by the long compress abovementioned, would certainly stop the hemorrhage: the whole being withdrawn in the space of three days, there would need no more than the same space for the whole flap's adhering to the stump, and the cure would be perfectly completed in a short time after. As to what remains to be said on this subject, although I am convinced, says Garengeot, that the method of amputation with a flap, has some advantages, which the others have not; it is not my present design to examine into the reasons of the preference, but only to deliver what has occurred to me on this head, and to pro. pose such alterations as I thought, might render the operation more perfect. (M. de Garengeot, in Memoires de I'Acad, de Chirurgie, Tom. 5, in 12?no.) SUBJECT OF AMPUTATION WITH A FLAP CONCLUDED. __ "We have already spoken of the flap. operation having been done by White and Bromfield above the ankle. In the year 1765, Sylvester O'Halloran, an eminent surgeon, of Limerick in Ireland, published a revival of the flap-amputation, upon a plan entirely new. However, his fruit con- si-.ted in not putting the flap in contact with the wound, till after the inflammation had subsided, about the twelfth day. Messrs. Alanson and Lucas conjectured that the cure might be rendered more safe, easy, and expeditious, by applying the fkp, with a view of uniting it by the first intention. Tlie following case explains Mr. Alan- son s flap-operation. The disease was in the left leg, the patient, therefore, lav on his right side, upon a table of convenient height, so as to turn the part to be first cut fully into view. The intended line, where the knife was to pass in forming the flap, had been previously marked out with ink. A longitudinal incision was made with a common scalpel, about the middle ofthe side of the leg ; first on the outside, then on the inside, and across the tendo Achillis- hence, the intended flap was formed, first by incisions through the skin and adipose membrane, and then completed, by push- ing a catling through the muscular parts in the upper incised point, and afterwards AMPUTATION. 67 carrying it out below, in the direction of the line already mentioned. Thus the whole flap was completed. The flap was thick, containing the whole substance of tlie tendo Achillis. The usual double in- cision was made; the retractor applied to defend the soft parts; and the bone divid- ed, as high as possible, with the saw. The flap was placed in contact with the naked stump, and retained there, at first by three superficial stitches, between which adhesive plasters were used. Not- withstanding the patient caught an infec- tious fever, a few days afterwards, the stump healed in three weeks, except half an inch at the inner angle, where the prin- cipal vent had been. In another week, the wound was reduced to a spongy substance, about the size of a split-pea. This being touched with caustic, healed in a few days. The man was soon able to use an artificial leg, with which he walked remarkably well. He went several voyages to sea, and did his business with great activity. He bore the pressure ofthe machine total- ly upon the end of the stump, and was not troubled with the least excoriation or soreness. In the next instance, in which Mr. Alan- son operated, he formed the flap by push- ing a double-edged knife through the leg, and, passing it downwards and then out- wards, in a line, first marked out for the direction of the knife. In this way, the flap was made more quickly. (Alanson on Amputation.) 1'he leg should be completely extended during the operation ; and kept in that posture, till the wound is perfectly healed. We shall next notice Mr. Hey's method. This gentleman is satisfied, that very near the ankle, is not the most proper place for this kind of amputation. Some cases occurring, in which, from a scrophulous habit, the wound at the stump would not heal completely, nor remain healed, Mr. Hey determined to try, whe- ther amputation in a more muscular part would not secure a complete healing, and give the patient an opportunity of resting his knee on tlie common wooden leg, or using a socket, as he might find most convenient. Mr. Hey now prefers this method, and has reduced it to certain measures. It had been customary, at the Leeds Infirmary, to make the length of the flap equal to one-third of the circumference of the leg. This was determined by the eye of the operator, who usually pushed the catling through the leg,near the posterior part of the fibula. Mr. Hey, finding the flap was not always ofthe proper breadth began to determine this by measure, and uotv operates as follows : to ascertain the place where the bones are to be sawn, to- gether with the length and breadth ofthe flap, he draws upon the limb five lines, three circular, and two longitudinal ones. He first measures the length of tiie leg from the highest part of the tibia to the middle of the inferior protuberance of the fibula. At the midpoint, between the knee and ankle, he makes the first or highest circular mark upon the leg. Here the bones are to be sawn. Here Mr. Hey also measures the circumference of the leg, and thence determines the length and breadth of the flap, each of which is to be equal to one-third of the circumference. In measuring the circumference of the limb, Mr. Hey employs a piece of marked tape, or ribbon, and places one end of it on the front edge ofthe tibia. Supposing the circumference to be twelve inches, he makes a dot in the circular mark on each side of the leg, four inches from the anterior edge of the tibia. These dots must, of course, be four inches apart be- hind. From each of these dots Mr. Hey draws a straight line downwards, four inches in length, and parallel to the front edge of the tibia. These lines shew the direction, which the catling is to take in making the flap. At the termination of these lines, Mr. Hey makes a second mark round the limb, to shew the place where the flap is to end. Lastly, a third circular tnark is to be made an inch below the up- per one, first made, for the purpose of di- recting the circular cut through the inte- guments, in front of the limb. The cat- ling, for making the flap, should be longer than those commonly "employed in ampu- tations. Mr. Hey uses one which is seven inches long in the blade, and blunt at the back, to avoid making any longitudinal wound of the arteries, which is very diffi- cult to close with a ligature, and, for the same reason, he pushes the catling through the leg a little below the place where such muscles are to be" divided, as are not in- cluded in the flap. The limb being nearly horizontal, and tlie fibula upw. rd, he pushes the catling through the leg, where the dot was made, and carries it down- ward along the longitudinal mark, till it approaches the lowest circular mark, a lit- tle below which the instrument is brought out. The flap being held back, Mr. Hey divides the integuments on the front ofthe limb along the course ofthe second circu- lar mark. The muscles not included in the flap, are dien divided a little below the place where the bones are to be sawn. No great quantity of these muscles can be saved, nor is it necessary, as the flap con- tains a sufficient portion of the gastrocne- mius and soleus muscles to make a cushion for tiie end of the bones. After sawing 68 AMPUTATION. the bones, Mr. Hey advises a little of the end ofthe tendon ofthe gastrocnemius to be cut off", as it is apt to project beyond the skin, when the flap is put down; and he recommends the large crural nerve, when found on the inner surface of the flap, to be dissected out, lest it should suffer compression. As strips of adhesive plaster cause great pressure on the end of the stump, Mr. Hey prefers using sutures for keeping the flap applied. Small strips of court plas- ter are to be put between the ligatures. The sutures may be cut out on the eighth or ninth day, and the flap supported by plasters. Mr. Charles Bell describes another sort of flap-amputation. The operation is not to be done so low, as there will not be a sufficiency of muscle to cover the end of the bones. An oblique cut is to be made with the large amputating knife, upward, tlirough the skin of the back part of the leg. The assistant is to draw up the skin, and the knife is to be again applied to the upper margin of the wound, and carried obliquely upward till it reaches the bones. The knife, without being withdrawn, is next to be carried, in a cir- cular direction, over the tibia and fascia, covering the tibialis anticus, until it meets the angle of the first incision on the out- side ofthe limb. The surgeon is then to pierce the interrosseous membrane, &c. The sawing being completed, and the ar- teries secured, the flap is to be laid down, and the integuments of the two sides of tiie wound will be found to meet. (See Bell*s Operative Surgery, Vol. 1.) The flap-amputation is certainly more painful than tlie common method, and, though it has had very able men for its patrons, it is questionable, whether it is productive of the smallest advantage. Nor is there any necessity for adopting this kind of operation, though you may choose Jo amputate near the ankle. Mr. Lucas (Med. Obs. and Inq. Vol. 5.) does indeed endeavour to prove, that the stump will not bear the pres.sure of a machine for walking unless a flap be preserved. However,-as the author ofthe article Am- putation, in the Encyclop. Method, remarks, if care be taken to save muscle, a machine for walking may be worn as conveniently as if a flap had been made. The flap-amputation of the tlngli is now quite abandoned by all the best surgeons in this country, and no description of it seems necessary. Foreign surgeons, how- ever, seem not to have entirely rejected this way of operating. We read in De- sault's works, by Bichat, that the former was in the habit of adopting this kind of amputation; but, it is a justice due to the eminent M. Sabatier, to state his disap probation ofthe practice. (Medecine Ope ratoire, Tom. 3, p- 257.) Some criticisms on the flap-amputation, by the intelligent M. Louis, will be found among the observations, which I have taken from the valuable writings of that eminent surgeon, and inserted at the end of the present article. AMPUTATION OF THE ARM. The structure of the arm is very ana- logous to that of the thigh ; like the lat- ter, it contains only one bone, round which the muscles are arranged. The interior ones are attached to the os brachii, while the more supeificial ones extend along the limb, without being at all adherent. The first consist of the brachialis inter- nus, and the two short heads of the tri- ceps ; the second, of the biceps, and long head of the triceps. Hence, amputation is here to be done in the same way as in the thigh, unless when we are necessitated to amputate very high up, above the in- sertion ofthe deltoid muscle. The patient being properly seated, the arm is to be raised from the side, and, if the disease will allow it, into a horizontal position. The surgeon is to stand on tlie outside of the limb, apply the tourniquet as high as possible, and to have the skin and muscles which he is about to di- vide, made tense, by the hands of an assist- ant. The soft parts are next to be di- vided, as much of the limb being pre- served as possible. The bone is to be sawn with tire usual precautions, and the bleeding stopped in the usual way. The stump is then to be dressed, and the pa- tient put to bed, with the wound a lit- tle elevated from the surface of the bed- ding. If the disease should require the arm to be taken off at its upper part, there would be no room for the application of the tourniquet. A compress might then be put in the axilla, and compressed by any strong bystander. With a straight bistoury, the surgeon is now to make a transverse incision down to the bone, a little above the lower extremity of the deltoid muscle. Two other longitudinal incisions, made along the front and back edge of this muscle, would form a flap, which must be detached and reflected. Lastly, the rest of the soft parts of the limb are to be divided by a circular cut, made on a level with the base of the flap. (Sabatier Medecine Operatoire, Tom. 3, p. With regard to placing a compress on the artery in the axilla, as advised by Sabatier, this is not so eligible, as mak- AMPUTATION. 69 ing pressure on the artery, as it passes over the first rib, and of which method we shall speak when we treat of amputa- tion at the shoulder. AMPUTATION OP THE FOREARM. The wisest maxim, with respect to the place for making the incision, is to cut off as little of the limb as possible. The forearm is to be held by two assistants, one of whom is to take hold ofthe elbow, the other of the wrist. The tourniquet is to be applied to the lower part of the arm, and the assistant,holding the elbow,should draw up the integuments, so as to make them tense. The circular incision is then to be made down to the fascia; from this as much skin js to be detached, reflected, and saved, as is necessary for covering the ends of the bones, and the muscles are to be cut on a level with the reflected skin, at the same time directing the knife obliquely upward, As many of them are deeply situated between the two bones of the forearm, too much attention cannot be paid to dividing all of them, with a double-edged knife introduced between the radius and ulna. The soft parts are to be protected from the saw by a linen retractor. It is gene- rally recommended to saw the two bones together, for which purpose the forearm should be placed in the utmost state of pronation. In any other position, the ulna is situated almost directly under the radius. The ulnar, radial, and two interosseous arteries, are those, which usually require a ligature. AMPUTATIOX AT TIIE HIP-JOINT. The French Academy of Surgery pro- posed the following question in 1756, as the grand prize subject: In the case, i?i which amputation of the hip-joint should ap- pear to be the only resourcefor saving the pa- tient's life, to determine whether this operation ought to be practised, and what would be the best way of performing it? No satisfactory memoirs having been presented, the same subject was proposed in 1759. The ap- probation of the academy was now con- ferred on a paper, in which the possibility' of amputation at the hip-joint was esta- blished The cases/demanding the opera- tion, are also determined by Baibet, the author. If, for instance, a cannon ball, or any other violently contusing cause, should have carried off or crushed the thigh, so as only to leave a few parts to be cut to make the separation complete, we ought not to hesitate about doing it. A sphacelus, extending to the circumfer- ence of the joint, and destroying the greatest part of the surrounding flesh, might render the operation equally ne- cessary and easy. (See Sabatier, Tom. 3, p. 271, &c.) Cases are adduced of the limb being taken off', by the surgeon com- pleting the separation of the dead parts with a knife. However, this cannot be considered as amputation at the hip-joint. Dividing a few dead fibres was a thing of bo importance, in regard to the likelihood of its creating any bad symptoms. The proceeding, in fact, seems to me to have no analogy at all to the bloody operation of taking the thigh bone out of the socket. 1 cannot conceive any case, in which th*! circumstances, however perilous, would be at all improved by this operation. The following are Mr. Pott's sentiments : " M. Bilguer, and M. Tissot, are the only peo- ple whom 1 have met with, or heard of, in the profession, who speak of an ampu- tation in the joint of the hip, as an ad- visable thing, or as being preferable to the same operation in the thigh." After a quotation or two, he continues ; " that amputation in the joint of the hip is not an impracticable operation (although it be a dreadful one) 1 very well know. I cannot say, that 1 have ever done it, but I have seen it done, and am now very sure I shall never do it, unless it-be on a dead body. The parallel, which is drawn be- tween this operation and that in the shoulder will not hold. In the latter it sometimes happens, that the caries is confined to the head of the os humeri, and that the scapula is perfectly sound aud. unaffected. In the case of* a carious hip-joint, this never is the fact; the ace- tabulum iscliii, and parts about, are al- ways, more or less in the same state, or at least in a distempered one, and so indeed most frequently are the parts within the pelvis, a circumstance this ofthe greatest consequence ; for the power of performing the operation beyond tlie seat of the dis- ease, and, consequently, of totally remov- ing all the distempered parts, is the very decisive circumstance in favour of ampu- tation every where, but, in the hip, where (to say nothing of the horridness of the operation itself") the hemorrhage, from a multiplicity of vessels, some of which are of considerable size, and the immense dis- charge which a sore of such dimensions must furnish, the distempered state ofthe parts, wliich cannot by the operation be removed, will render it ineffectual, bold and bloody as it must be." (Pott on Am- putation.) This dreadful operation was performed in this country, some year* ago, by Dr. Kerr, of Northampton. (See Duncan's Med. Commentaries, Vol. 6, p\ 337) M. Larrey informs us, that lie hrJ performed 70 AMPUTATION. it three times ; twice in Egypt, and once, while he was surgeon to the French army on the Rhine. One of his patients sur- vived tiie operation a week, at the end of which he was carried off* by the plague ; and the others died, after being conveyed, .n a very uneasy manner, during a preci- pitate march of the army. (See Relation de l' Expedition de I' Armee d' Orient en Egypte, &c.) For my own part, with all the respect, which I entertain for this ju- dicious surgeon, I cannot conceive any circumstances, in wliich a patient would be benefited by so severe an operation Were the upper portion of the thigh bone the only part diseased, or were it and the adjacent part of the pelvis splintered by a gun-shot injury, I should rather listen to the suggestion of Mr. Charles White, of Manchester, and endeavour to per- form the excision of the diseased, or splintered parts, than have recourse to amputation at the hip, an operation, how- ever, which, as we have seen, has the sanction of authority. [Military- surgery has undergone, with- in a few years, great alterations. Innova- tion has, in some instances, been followed by real and important improvements ; but whether in the full extent supposed by its advocates, admits of a doubt. Ampu- tation at the hip joint, is an operation on which a surgeon can never reflect with- out horror; but 1 am not prepared to say with Mr. Cooper, that " I cannot conceive any circumstances in which a patient would be benefited" by it. The following extracts from a new work on gun-shot wounds, by Mr. Guth- rie, will shew, that, the military surgeons continue, occasionally, to perform it. " I have not much to offer from ac- tual experience of the operation, having performed it but once unsuccessfully. I have however seen many cases in which it ought to have been attempted, and which died. I have seen many in which the operation would have been necessary, if the constitution of the patients could ever have recovered the shock it had re- ceived at the moment of injury. I know that many cases have died after long con- tinued disease of the thigh bone from gun-shot wounds, that would have had a chance of recovery, if the operation had been performed; and I have several times amputated so close to the trochanters, that I could with ease have removed the head of the bone without any increase of the external incisions. This amputation is cf course either pri- mary or secondary ; but the nature ofthe injury or disease differs very much in these two stages; for very few, or none of the cases t!uit render its performance necessary on the field of battle, ever live to the period when secondary amputation is usually recommended. Wounds demanding amputation of tne hip joint on the field of battle, arise from cannon or grape shot, or the explosion of shells. Few surgeons would think ot per- forming it for a wound by a musket ball; although cases may occur that require it, and the principal one that will render it necessary, will be a fracture of the head or neck of the bone, with a wound of the great vessels, or some other arterial trunk causing hemorrhage, and stuffing the thigh with blood. A grape or small cannon shot, may strike the fore part of the thigh, and without wounding the in- guinal artery itself, may, in its passage to the neck of the femur, wound some large arterial branches, causing considerable haemorrhage: the wound shall not be large, and yet the chance of saving the life of the patient will be but very small indeed. I recollect two cases of this kind in particular; one after the battle of Vimiera, by a cannon shot, which proved fatal on the second day after the injury, no one at that time thinking of the amputation at the hip joint. The other occurred at Salamanca, by a large ball, which shattered the neck of the femur and the body, of the bone below. I did not see this person for near forty-eight hours after the injury, but was informed that on his first presentation for assist- ance, an artery, supposed to be a large branch of the femoral, had thrown out its blood per saltum, and was stopped by pressing some lint on the wound. The limb soon swelled to nearly twice its na- tural size, with much external inflamma- tion. The patient himself thought his case desperate, as did every one about him, and declared his willingness to sub- mit to any operation that might be pro- posed ; but the time for operating was past, even if any operation could have been agreed upon. After two months of severe suffering, in which there were even some prospects of life being preserved, this man died. The latter period of the time was passed, however, without any hope of recoven, and surgical aid was given merely with the view of rendering his last moments as easy as possible. The great strength of constitution shewed by this man during the whole course of his illness, and his great endurance of suffering, have always inclined me to think the operation at the hip joint would have succeeded, if it had been performed shortly after the receipt of the injury. A shell bursting near a soldier mav drive a large piece of an inch in thick. AMPUTATION. 71 ness, and a pound or two in weight, into the inner part of the thigh, without wounding the femoral artery, yet frac- turing the head of the bone: here seve- ral large vessels, and perhaps the great sciatic nerve would be divided, and the only chance of life, in my mind, would be in the immediate removal of the whole. I saw a fatal case of this kind during the siege of Ciudad Kodrigo, where the pa- tient livecLlong enough to shew the neces- sity of performing this operation. A piece of a shell may strike between the trochanter and the ilium, go through the neck of the bone, and tear its way out below the tuberosity of the ischium, destroving all the parts in its course, without either killing the soldier by hae- morrhage, or by the shock of the blow to the constitution. This accident hap- pened to a man of the 40th Regiment, at the battle of Salamanca, about four o'clock in the afternoon. He was in a good state to undergo the operation when I saw him next morning, but none of the surgeons present with me would agree to it; all allowed nothing could save the man ; but the opinion entertained of the cruelty of the operation, and of its certain failure prevented its being done. I took this man into Salamanca with me, and his ap- pearance for six successive days before he died, made me reproach myself for my want of courage, in not contemning any remarks that might be made, on my having undertaken it in opposition to tlie opinion of my colleagues; and I declined it, not because the general opinion was against it, but in consequence of the bad success of one, and of the good success of the other, of the two next cases to be related. When a cannon-shot carries away the tlngh above its middle, so as to exclude the more common flap operation close to the trochanter, it is almost always fatal. These accidents generally destroy at once. On the field of battle, I have seen many, having searched particularly- for them, but have found them dead, or beyond the roach of surgical aid. I have seen a case of a cannon-shot striking the outside of the thigh, tearing i.way the trochanter and surrounding parts, without wounding the femoral artery, or any great vessel that would cause any serious haemorrhage, or so great a shock to the constitution as to render the operation impracticable ; yet this man died without any attempt being made for his relief, winch was neither good surgery or humanity.. When die femoral artery has been torn through by a cannon-shot there is, at the moment, a great loss of blood, but the patient does not bleed to death, neither does he appear to die ultimately from the effects of the hxmorrhage; for I have seen several men lose a greater quantity from the same vessel without any such effect, but from the shock to the constitu- tion ; and this observable in many cases of amputation of the thigh, where there has been Uttle loss of blood ; and yet the patient dies, during, or immediately after the operation. A considerable haemor- rhage, on the other hand, renders a pa- tient less able to bear an operation than he otherwise would do, and where there has been much and sudden bleeding, the powers of life are so exhausted as not to be able to bear any further disturbance. Tliis effect is most frequently caused by wounds of the femoral artery, and where it has occurred, the chance of success from the operation, will be very small; and the combination of injury arising from the loss of blood, and the shock of the blow, will have so much diminished the powers of life, that the operation in addi- tion, will destroy the remainder. If (as I have seen in many instances) the bones of the pelvis are injured, in any of the preceding kinds of accident, the result will be fatal, and the operation should not be performed; but some little destruction of the soft parts, should not prevent it, if the patient be otherwise in a favourable state. A very extensive injury of the soft parts of the thigh, if the bone be not , broken, and the femoral artery not divid- ed, does not authorize the operation, al- though the artery be laid bare for three or four inches of its course. An officer of the 88th Regiment, was wounded in the trenches', at the siege of Ciudad Kodrigo, by a twenty-four pound shot, which struck the outside of the an- terior part of the left thigh, and carried away the fore part of it from the groin to within a. hand's breadth of the knee ; the femoral artery lay bare at the bot- tom of tlie upper part of the wound, and was seen pulsating for near three inches ; tlie'sartorious and rectus muscles were carried away, and all the muscles on the outer and inner side of the thigh more or less mangled by the shot, or torn by the laceration ; it was altogether the most frightful looking wound I had seen, not even excepting where the limb has been completely torn oft*. Having the super- intendance of the 3d and 4th divisions of infantry, tlie greater part of the medical officers of both were with me at the time; and on this officer's being brought to our field hospital in the rear of the trenches, they all, without an exception, declared he must shortly die, if the limb was not 72 AMPUTATION. removed. In compliance with this opin- ion, I proposed to tie the artery below Poupart's ligament, and to endeavour to save flaps to cover the great trochan- ter, the bone being sawed off below, as I have since done in several instances; and if this was not practicable, the head of the femur was to be removed. On placing liim on the panniers for the purpose of operating, he was so exceedingly faint, the pulse at the wrist being scarcely per- ceptible, that I conceived the operation would be useless, as he would certainly die under our hands. He was removed to a corner of the hospital, and placed on a hay mat amongst other cases of wounded supposed in a dyintf state, a little lint being laid over this enormous surface. By the next morning he had much recovered, and as his thigh became very painful, he was desired bv the sur- gcon of the division arriving] in succes- sion, to wet it with warm water; this was done, but his countenance was so ghastly that he was considered by every one as dying; indeed his regiment actu- ally returned him dead, and his commis- sion was filled up in England. In this state he remained till the day after the storming of Ciudad Rodrigo, when, from the advance of Marshal Marmont, the wounded were sent across the Agueda. Desirous of knowing whether any strag- glers of the corps I belonged to might still be at the field hospital, I rode to it on leaving the town, and found every one' gone except this poor gentleman, who requested my assistance ; having convey- ance in the town, I offered to take him • to my divisional hospital, five leagues distant, where all the other wounded had been conveyed, wliich offer he gladly ac- cepted, and reached the village of Aldea del Obispo, with less inconvenience than I expected; I daily feared the femoral artery would give way, but nothing of the kind occurred, the slough from the whole surface of the wound soon sepa- rated, and there was much less of it than is usual on such occasions, but this may be attributed in some measure* to the attention paid him, and to the ex- treme coldness of the weather in a room without a fire-place. The discharge of pus was very great, and the artery lay in a channel completely covered by it;—I hourly expected it would ulcerate, but granulations soon began to shoot out, and by the end of three weeks the artery was covered in, although its pulsations were still visible at a dfstance ; the sore gradually contracted in a surprising de- gree, and in two months it was diminish- ed to half its original size, very little new skin having been formed. At this period he left me on his way to the rear, on the army moving down to the siege of Badajos. The attention paid to this officer in regard to diet, attendance, and surgical aid, was very great; more, in- deed, than he could have received under any other circumstances. His recovery was considered so unlikely, that no one looked at his wound after the first day ; all supposed him past relief, as was really the case with an officer of Engi. ncers, lying beside him, whose arm was shattered to pieces by a shell, and the os ilium bared on the outside of the glutaci muscles, and on the inside af the iliacus internus, as if it had been for some time in maceration. The insertions of the ex- ternal and internal oblique, and the trans. versalis muscles were torn out without the peritoneum being opened, which alone prevented the intestines from coming out at the wound. Although this gentleman's life was saved, still, I am of opinion, that very few would have recovered under the same injury. The secondary operation has seldom, I believe, been performed during the high suppurative stage succeeding to injury from gun-shot wounds ; and as I do not believe it can be successful, if done at this period, I would not perform it after the second day, until the third or fourth week. There are not many cases that will demand it at this period, as tha femur, in most compound fractures of the thigh,, can in general be sawed off, at, or immediately below the little tro- chanter." The operation has been twice perform- ed in England: in one case it was com- pletely successful; and in the other, the patient lived thirty days. " Mr. Brownrigg, Surgeon'to the Forces, has performed the operation four or five times : on one occasion the patient lived eight days, and died from fevei**, supposed to arise from causes foreign to the opera- tion. In the last case he was completely sue- cessful. The man received a gun-shot wound in the thjgh, which fractured the bone close to the trochanter, on the 29lh Dec. 1811, near Merida, in Spain. On the 12th of December, 1812, the opera- tion was performed, and the man is now living at Spalding, in Lincolnshire, in per- feet health. ' Mr Brownrigg intends, I believe, to publish the particulars of this case. I have also been informed, that the opera- tion has been performed in the West In- dies. . These cases prove, that the operation is not only necessary, but practicable, AMPUTATION. 73 and that it may be effected with success under certain circumstances. This being granted, it necessarily follows that the operation ought to be recommended and performed in every case in which it can alone bring relief, or offer a prospect of success. No man should, therefore, be allowed to die without its being proposed to him ; and if it be a case for primary operation, the sooner it is done on the field of battle, consistent with propriety, the greater will be the chance of success, for the patient cannot live to the period for secondary amputation. It is in this, and other operations high in the thigh, that the question of time is most import- ant, for haste is as injurious as delay, when improperly applied. If the patient has suffered much loss of blood, or is in a state qf syncope, or nearly approaching to it, unable to arti- culate, with a pulse scarcely perceptible, and the skin clammy and cold, an imme- diate operation would only hasten his death ; but if excited by stimulants and cordials, he will have some chance of re- covering himself in an hour or two, so as to undergo the operation with a bet- ter prospect of success, or he will in that period sink and die. If, on the contrary, he is brought to tiie surgeon, although , much alarmed and reduced by the sud- den shock and loss of blood, with strong sensations of pain, expressed by his cries for assistance, convulsive motions of the limb and body, and tlie powers of the sensorium not destroyed, the operation should be performed immediately; or, in-- stead of becoming more calm and col- lected, he will gradually sink into the state of tlie first described, and be una- ble to bear the operation. . On the other hand, the first mentioned, if he be ex- citable, will in time rather approach to the state of the latter, and from the pain, &.c. he suffers, will call for the fierformance of the operation. This vio- ent nervous commotion, however, is not common; it depends upon particular idi- osyncrasies, and will never in the first be so excessive as in the last. The operations being decided upon, it is, I confess, not like that at the shoul- der-joint, to be done by every one of moderate ability. No surgeon should at- tempt it, unless he is conscious of pos- sessing great coolness, a presence of mind equal to any emergency, and a correct knowledge ofthe parts to be divided. I consider the operation to be best per- formed in the following manner. The patient should be laid on a low table, or two field panniers placed together, co- vered with a folded blanket to prevent the edges giving pain, and properly sup- Vot. I. ported in a horizontal position. An as- sistant leaning over, and standing on the outside,should compress the artery against tlie brim of the pelvis, with a firm, hard compress of linen ; such as is usually used before the tourniquet; he should also be able to do it with his thumb, behind the compress, if it be found in- sufficient. The surgeon standing on the inside, with a strong pointed amputating knife of a middle size, with the back curved, makes his first incision through the skin, cellular membrane, and fascia, so as to mark out the flaps on each side, commencing about four finger's breadth, and in a direct line below the anterior superior spiuous process of tlie ileum in a well-sized man; and continuing it round in a slanting direction at an almost equal distance from the tuberosity of the ischium, nearly opposite to the place where the incision commenced. Bring- ing the knife to tlie outside of the tliigh, he connects the point of the incision where he left off with tlie place of com- mencement, by a gently curved line, by which means the outer incision is not in extent more than one third of the size of the internal one. The integirmients having retracted, the glutaeus maximug , is to be cut from its insertion in the linea aspera, and the tendons of the glu- teus medius and minimus from the top of the trochanter major. The surgeon now placing the flat edge of the knife on the line of the retracted muscles of the first incision, cuts steadily through the whole of the muscles, blood-vessels, &c. on the inside of the thigh. The ar- tery and vein, or two arteries and vein, if the profunda is given off high up, are to be taken between the fingers and thumb of the left hand, until the sur- geon can draw each vessel out with the tenaculum, and place a ligature upon it. Whilst this is doing, the assistants should press with their fingers on any small ves- sels that bleed. The surgeon thfcn cuts through the small muscles running to be inserted between the trochanters, and those on the under part ofthe thigh, not •yet divided; and with a large scalpel opens into the capsular ligament, the bone being strongly moved outwards, by Which its round head puts the liga- ment on the stretch. Having extensively divided it on the fore and inside, the liginientum teres comes into view, and may readily be cut through. The head of the bone is now easily dislocated, and two or three strokes of the knife sepa- rates any attachment the thigh may still have to the pelvis. The vessels are now carefully to be secured. The capsular ligament, and as much ofthe ligamentous I. r-i AMPUTATION. edge of the acetabulum may be removed as can readily be taken away. The nerves, if long, are to be cut short, the wound well sponged with cold water, and tlie integuments brought together in a line from the spinous process of the ilium, to the tuberosity of the ischium. Three sutures will in general be required, in addition to tlie straps of adhesive plas- ter, to keep the parts- together; the liga- tures are to be brought out in a direct line between the sutures, a little lint and compresses are to be placed over the wound, and on the under flap, to keep it in contact with the cotyloid cavity, and assist the union of the parts. A piece of fine linen is to be laid over them, and the whole retained by a calico bandage put round the waist, and brought over the stump. It is recommended to pare the bone, of its cartillage; and if this could be readily done, I would willingly agree to it, but the cartilaginous surface of the acetabu- lum is not to be cut away without much difficulty and some time, which cannot be spared ; for I consider the success of the operation to depend very much upon the quickness with which it is performed,not on account of haemorrhage, but to avoid the shock the constitution receives from J the continued exposure and irritation of so large a surface in the immediate vici- nity of the trunk of tiie body. It is proved by experience to be unnecessary at the shoulder joint; and will, I think, be found equally so at the hip joint. M'hen I wrote these observations, and shewed the method of performing tlie'v operation in the Peninsula, I thought F1 was tlie first to recommend that the artery should not be tied previous to commenc- ing the operation. M. Baffos, however, h.ts the priority in practising it, .which I readily grant to him, and am gratified in having his authority to'adduce in support of the measure. Uni-an by the first intention is to be wished for in a great degree, as lessening the surface of the wound; but as all the parts beneath the skin cannot unite, and especially- about the acetabulum and the inside of the glutxus muscle, it is not advisable to let the skin adhere on the middle and lower part of the stump ; for as the parts deep-seated must suppurate and granulate, a fair opening for the dis- charge should be preserved, and collec- tions of matter in any part should be care- fully guarded against by gentle pressure, compress, and bandage. The after treatment will be the same as in other cases of amputation : the shock, however, ofthe injury and the amputation v ill be so great, that the antiphlogistic regimen to the extent of blood-letting will not be necessary. If the patient be very low, cordials "in small quantities, with opiates, should be given, and a light nourishing diet. If inflammatory symp- toms come on, the appropriate remedies formerly recommended must be employed without delay. If there be heat or un- easiness in the wound, it must be kept wet with cold water. If the surgeon called upon to perform this operation, has not been in the habit of dealing with large arteries, he may feel an unconquerable repugnance to cut- ting through the femoral artery before it has been tied; and although I can most positively assure these gentlemen, there is nothing to fear in doing it, atill they may tie the artery first, if they cannot overcome this feeling ot danjft-r. It is to be done by cutting through the integu- ments in the usual manner, and then dis. secting for the artery and vein, previous to cutting through the muscles. AlUrUTATlOX AT THE SHOULDER JOIST. The first description of this is to be found in Le Dran's Observations. His fa- ther, "it seems, undertook the operation, in a case of caries conjoined with exos- tosis, which affection reached from the middle to the neck of the humerus. He began with rendering himself master of the bleeding, by introducing a straight needle, armed with a strong ligature, doubled several times. This was passed from the front to the back part of the aim, as closely to the axilla and bone as possible. The ligature, including the vessels, the flesh surrounding them, and the skin covering them, was tightened over a compress. Then Le Drun, with a straight narrow knife made a transverse incision through the skin and deltoid muscle down to the joint, and through the ligament surrounding the head of the , humerus. An assistant raised tlie arm, and dislocated the head of the bone from the cavity of the scapula. This allowed the knife to be passed with ease between the bone and the flesh. Le Dran then in- traduced the knife downward,, keeping its edge continually somewhat inclined towards the bone. In this manner, he gradually cut -through all the parts, as far as a little below Ihe ligature. As there *ns a Urge flap, Le Dran made a second , ligature with a curved needle, which li- gature included a great deal of flesh, the redundant portion of which was cut off together with the first ligature, which had become useless. The cure was completed in about ten weeks. Le Dran (the son) does not state, that the operation was a AMPUTATION. fS new one, and it appears, from the Re- divide that muscle and part of the deltoid, cherches Critiques sur Vorigine, &c. de la .all which may be done without danger of Chirurgie en France, and from Lu Faye's wounding the great vessels, wliich will notes on Dion s, that it had been previ- become exposed by these openings. If* ously practised by Morand the fhther. they be not, cut still more of the deltoid Garengeot thought a curved needle, muscle, and carry the arm backward. with sharp edges, would be better for Then with a strong .ligature, having tied making the first* Jigature, and that the the artery and vein, pursue the circular wound need not be so large, if the incision incision through the joint, and carefully were to begin two or three finger-breadths divide the-vessels at a considerable dis- from the acromion, and made so as to tance below the ligature; the other small form two flaps, tlie lower one of which vessels are to be stopped, as in other would correspond to the axilla, and cases. might be brought into contact with the "In doing this operation, regard should other, after the second .ligature was ap- be had to the saving as much skin as plied. possible^ and to tlie situation of the pro- La Faye extended the improvements cessus acmmion, which, projecting con- further. After placing the patient in a siderably beyond the joint, an unwary chair, and bringing»the arm into a hori- operator would be apt to cut upon." zontal position, he made, with a common (Operations of Surgery.) bistoury a transverse incision into the Bromfield's plan consisted in first ex- ♦deltoid muscle-down to the bone, four posing the axillary vessels, by dividing finger-breadths below the acromion. Two the integuments in the axilla. These other incisions, one in front, the other vessels he detached, and tied. Then hav- behind, descended perpendicularly to this ing cut the capsular ligament with scis- first, and made a large flap of the figure sars, he finished the operation on Mr. of a trapezium, which was detached and Sharp's plan. turned up towards the top of the shoulder. At length, P. H Dahl, in 1760, pub- The two heads of the biceps, the tendons lished at Goettingen, a Latin dissertation of the supra-spinatus, infra- spinatus, on amputation at the shoulder, in which teres minor and subscapular'^, and the publication he proposes making one's self capsular ligament, were next divided. The master of the blood, before the operation, head of the humerus could now be easily by a tourniquet, the "pad of which pressed dislocated, when the assistant, who held on the subclavian artery under the clavi- the lower part of the limb, made the bone cle. This enabled the operator to dis- describe the motion of a lever upward, pense with tying the vessels in the first La Faye next carried his incisions down- instance. Gamper had observed, that if ward, along the inner part of the arm, we push the scapula backward, and press until he was able to feel the vessels, which the axillary artery with the finger between he tied as near the axilla as possible., the clavicle, coracoid process, and great Then he completed the separation of the pe\>toral*-muscle, the pulse at the wrbt limb, one finger-breadth lower down. All instantly stops. remaining to be done, was to bring down Dahl's tourniquet was obviously eon- the flap over the glenoid cavity, and dre'ss structed, in conseque/ice of what Camper the wound. (See NouveUe Methode pour had observed, and it consists of a curved, faire I'Operation de I'Amputation dans I'ar- elastic plate of steel, the length of which ticidation du Bras avec I' Omoplate,par M. may be readily imagined. A pad is at- La Faye, in Mem. de PAcad. tie Chirurgie, tached to the shortest end of this plate, Tom. 5, p. 195, Edit, in 12mo. and is made capable of projecting further The advantages of this plan are ob- by means of a screw. The instrument is vious. As only one ligature is applied, applied by making* it embrace the shoulder the patient is saved a great deal of* pain; from behind forward, while the pad presses the flap, which is connected with the on the hollow under the clavicle, between acromion, is more easily applied and kept tlie margins of the deltoid and pectoral on the stump, than the one, which Ga- muscles. The long extremity of tlie steel rengeot recommended to be made, at the plate, wliich descends behind the shoulder, lower part of the axilla. Lastly, any dis- is to be fixed to the body by a sort of charge can readily find vent downward. belt. The pad is then to be depressed, Mr. Samuel Sharp recommended the until the pulsation of the axillary artery following plan. " The patient's arm be- is stopped. ing held horizontally, made an incision Further experiments have proved, how- through the membrana adiposa, from the ever, that this tourniquet may be dis- upper part ofthe shoulder across the pec- pensed with, and the flow of blood in the toral muscle, down to the arm-pit, then axillary artery commanded, by properly turning the knife with its edge upwards, compressing this vessel with a pad, at tlie 76 AMPUTATION. place where it emerges from between the scaleni muscles, above the middle part of the clavicle. Thus> the arteiy becomes pressed between the pad and the first rib, across which it runs. This method, which is as simple as possible, is preferable to that, which requires a tourniquet that is so seldom at hand. Amputation at the shoulder has been in some degree superseded by a preferable operation, even in cases in which it would formerly have been deemed quite indis- pensable, such as considerable gun-shot fractures of the head of the humerus ; a caries of the substance of this part, -Sec. Boucher, in Tom, 2, .Mem. tie I'Acad, de Chir. shews, that considerable wounds, extending into the shoulder joint, were capable of being successfully treated, by extracting the pieces of bone, which had been separated by violence. Instances are also recorded, in which, when the head and neck of the humerus had been totally disunited from the body of that bone, a cure was accomplished by making such incisions as allowed the portions of bone, now become extraneous bodies, to be taken away. Mr. White, of Manchester, proceeded further, and ventured to make a deep incision at the upper part of tlie arm, to dislocate the head ofthe humerus, which he knew was carious, and, pushing it through the wound, took it oft' with a saw. "Edmund Pollit, of Sterling, near Cockey-Moor, in this county, (Lancashire) aged fourteen, of a scrofulous habit' of body, was admitted into tlie Manchester Infirmary, April 6,1768. The account I received with him was, that he had bees suddenly seized, about a fortnight before, with a violent inflammation in his left shoulder, which threatened a mortifica- tion, but at last terminated in a large ab- scess, wliich was opened with a lancet a few days before his admission. The ori- fice was situated near the axilla, upon the lower edge of the pectoralis major, and through it I could distinctly feel the head of the os humeri, totally diverted of its bursal ligament The matter, which was very offensive, and in great quantity, had made its way down to the middle of the humerus, and had likewise burst out at another orifice, just below the processus acromion, through which the head of the os humeri might easily be seen. The whole arm and hand were swelled to twice their natural size, and were intirely useless to him. He suffered much pain, and the absorption of the matter bad brought on hectic symptoms, such as night sweats, diarrhoea, quick pulse, and loss of appetite, which had extremely ema- ciated him. " In these verv dangerous circumstances there seemed to be no resource but from an operation. The common one in these cases, that of taking off the arm at the articulation, with the scapula, appeared dreadful, both in tlie first instance, and m its consequences. I therefore proposed the following operation', from which I expected many advantages, and performed it on the fourteenth of the same month. I began ray incision at that orifice which was situated just below the processus acro- mion, and carried it down to the middle of the humerus, by which all the subja- cent bone was brought into view. I then took hold of the patient's elbow, and easily forced the upper head of the humerus out of its socket, and brought it so entirely out of the wound, that I readily grasped the whole head in my left hand, and held it there till I had sawn it off, with a com- mon amputation saw, having first applied a pasteboard card betwixt the bone and the skin. I had taken the precaution of plac- ing an assistant, on whom I could de- pend, with a compress just above the cla- vicle, to stop the circulation in the artery, if I should have tlie misfortune to cut or lacerate it, but no accident of any kind happened, and the patient did not lose more than two ounces of blood, only a small artery which partly surrounds the joint being wounded, which was easily secured. " He was remarkably easy after the operation, and rested well that night; the discharge diminished every day, the swell- ing gradually abated, his appetite re- turned, and all his hectic symptoms van- ished. h\ about five or six weeks I pav ceived the part from wliich the bone had •. been taken, had acquired a considerable degree of firmness, and he was able to lift a pretty 'arge weight in his hand. At the end of tvo months I found that a large piece of the whole substance of the bor.e that had been denuded by the matter, and afterwards exposed to the air, was now ready to separate from the sound, and with a pair of forceps I easily removed it. After this exfoliation the wound healed very fast, and on August 15, he was dis- charged perfectly cured. On comparing this arm with the other, it is not quite aft inch shorter; he has the perfect use of it, and can not only elevate his arm to any height, but can^,likewise perform the ro- tatory motion as well as ever. The figure of the arm is no ways altered, and from the use he has of it, and its appearance to the eye and to the touch, I think I may safely say the head, neck, and part of the body of the os humeri are actually regenerated. "I did not make use of any splints, machine, or bandage, during the cure, to AMPUTATION. „_ 77 confine the limb strictly in one certain situation, nor was his arm ever dressed in bed, but sitting in a chair, and as soon as he could bear it, standing up with his body leaning forwards, to give room for the application of the bandages, which were no more than what was j ust neces- sary to retain the dressings; and to this method I attribute the preservation of the motion of the joint, which could not have been so well effected any other way, as the joint would in all probability have remained stiff, and formed an anchylosis, if it had not been allowed to play about. " Though from this operation I hoped for many advantages preferable to the am- putation of tUt limb at the scapula, yet my most sanguine expectations fell greatly short of the success attending it. I did not flatter myself with the hopes of a moveable joint, or that the length of the limb would be so nearly preserved, where there was a loss of above four inches of the whole substance of the hone, without any other bone to support-^k as in the leg and forearm, and wher-e^me dreadful condition of the aim, at the time of the operation, prevented me from making use of any machine to keep it extended.* But I suppose the weight of the arm was in this case in some measure sufficient to counterbalance the contractile power of tlie muscles, as his arm was only sus- pended by a common sling, and the pa- tient not at all confined to his bed. I could not help being surprised to find so much strength and firmness, as evidently shewed a regeneration of the. bone, before the lower part had exfoliated, or even be- fore it had begun to loosen. The osseous matter could not proceed from the scapula, the glenoid cavity of that bone not being divested of its cartilage, could it then pos- sibly escape from the end of the sound bone, before the morbid part had begun to separate from it? Or are there any vessels that could convey the bony mat- ter, and deposit it in the place of what had been removed ?f * After the extraction of three inches and ten lines of the os humeri, M. Le Cat made use of a machine to keep the upper and lower pieces of the bone at their pro- per distances. He has given* description of the case, and a figure of the machine in vol. 56 of the Philos. Trans, p. 270. f Mr. Gooch, in his volume of cases and practical remarks, relating the case of a compound fracture of the leg, where a veiy considerable portion of the tibia was sawn off, says, " In about three weeks I was sensible, as were also several sur- geons, whom curiosity led to see so un- " These are points that I will not pretend to decide absolutely, but I am much in- clined to the latter opinion. Is it not pro- bable that there was a regeneration of the cartilage as well as of the bone ? It is well known to every body conversant in ana- tomy, that not only the ends of some bones, wliich are joined to no others, are covered with cartilages, but that they are never wanting on the ends, and in the jointed cavities of such bones as are designed for motion, and I cannot see in this case how the motion could be preserved so complete without a cartilage; and indeed without a bursal ligament, or something analogous to it, to contain the synovia, and keep the bone in its place. " As this is the first operation of the kind-that has been performed, or at least made public, 1 thought the relation of it might possibly conduce to the improve- ment of the art. That ingenious surgeon, Mr. Gooch, has indeed related three in- stances of the heads of bones being sawn off in compound luxations. In one of these cases the lower heads of the tibia and fibula were sawn off!, and in another that of the radius, and in the third that ofthe second bone of the thumb, but these were in many respects different from the present case. I believe it will seldom happen that this operation will not be greatly preferable to the amputation of the arm at the scapula, as this last is ge- nerally performed for a caries of the upper head of the os humeri, and as the preser- vation of a limb is always of the utmost consequence, and what eveiy surgeon of the least humanity would at all times wish for, but particularly where, as in this case, the whole limb, and its actions, are preserved entire, the cure no ways protracted, and the danger of the opera- tion most undoubtedly less. For though amputation is often indispensably neces- common a case, that the substance which grew in the space of five inches entirely void of bone, had acquired in the middle only a greater degree of solidity than flesh, which circumstance not agreeing with the generally received notion of the generation of callus, we proved, beyond dispute, with a sharp pointed instrument; and we ob- served that the ossification was gradually formed from that central point, which was considerably advanced before any exfolia- tion was cast off the ends of the divided bone. In less than four months the whole space was so well supplied with the callus, or rather new bone, that he was able to raise his leg, when the bandage was off', with- out its bending." (Cases and Remarks, new edit. p. 287.) 7B AMPUTATION. sary, and frequently attended with little danger or inconvenience when only part of a limb is removed, yet where the whole is lost, the danger is greatly increased, and the loss irreparable. " I had frequently performed this opera- tion upon dead subjects, and where the parts had not been diseased, and never found any difficulty; and from a dissec- tion of the parts bad no reason to doubt of suceess in a living subject, where the ligaments and muscles are more supple, and the matter, by insinuating itself be- twixt the bone and integuments, has made less dissection necessary. I have likewise, in a dead subject, made an incision on the external side ofthe hip joint, and con- tinued it down below the great trochanter, when, cutting through the bursal liga- ment, and bringing the knee inwards, the upper head of the os femoris hath been forced out of its socket, and easily sawn off; and I have no doubt but this opera- tion might be performed upon a living sub- ject with great prospect of success. " The Royal Academy of Surgery at Paris, proposed for a prize question, whe- ther amputation of the thigh, at its arti- culation with the os innominatum, was ever advisable; but, was I under a necessi- ty of performing this operation, or that which I have been describing, I should not hesitate a moment which to prefer. " I had the honour of shewing to the Royal Society the bones which were taken from the boy's arm, at the time this paper was read, and they are now deposited in their museum." (Cases in Surgery, with Remarks by Charles White, F. R. S. p. 57.) Bent, of Newcastle, has inserted a si- milar case in the 64th Vol. ofthe Philoso- phical Transactions. White made only one incision, from the vicinity of the acro- mion down to the middle of the arm. Bent, not being able to get at the head of the bone, through the wound, which he had made from the clavicle to the attach- ment of the pectoral muscle, detached a portion of the deltoid, where it is connect- ed with the clavicle, and another part, where it is adherent to the humerus. Sa- batier has proposed making two cuts at the upper part of tlie arm, which meet be- low like the letter V, extirpating the flap, dividing the inner head of the biceps, and capsular ligament; dislocating the head of the bone, and sawing it off' (Medecine Operatoire. Tom. 3.) I think the cases, recorded by White and Bent, are truly important, inasmuch as they appear to have been the earliest models of a practice, which promises in a great measure to supersede all occasion for one of the most formidable and muti- lating operations of surgery. To military and naval surgeons, these cases cannot fail to be highly interesting, as they must have frequent opportunities of availing themselves of the instruction, wliich they afford. M. Larrey, who was surgeon go- neral to the French army in Egypt, em- ployed the practice, with the greatest success, in cases of gunshot wounds. He thereby saved limbs, which, according to ordinary precepts and opinions, would have been a just ground for amputating at the shoulder; and, when we consider not only that a most dangerous operation is avoided, but that an upper extremity is saved, for which no substitute can be ap- plied, we must allow, that*he plan, first suggested and practised by Mr. White, cannot be too highly appreciated. When the arm is fractured near its upper ex- tremity by a musket ball, it is considered by most surgeons necessary to amputate the limb, and, in such cases, the opera- tion used .invariably to be performed; but, says ,J^Mtarrey, " I have had the good fortur^7 on ten different occasions, yto supersede the necessity for the opera- tion, by the complete and immediate ex- traction of the head of the humerus, and of the splinters. I perform the operation in the following manner: I make an in- cision in the centre of the deltoid muscle, and parallel to its fibres, carrying the in- cision as low down as possible. I get the edges of the wound drawn asunder, in order to lay bare the articulation, of which the capsule is generally opened by the first incision, and by means of a probe pointed bistoury, I detach with the great- est ease from their insertions the tendons of the^supra and infra spinati, of the teres minor, of the infra scapular, and of the long head of the biceps; then I disengage the head of the humerus, and remove it through the wound in the deltoid by means of my fingers, or of an elevator. I bring the humerus up to the shoulder, and fix it in a proper position by means of a sling and a bandage. Such is the operation which I performed on ten pa- tients, in extirpating the head of the hu- merus ; one of these died of the hospital fever, two of the scurvy, at Alexandria, and the fourth, after he was cured, died of the plague on our return to Syria. The rest returned to France in good health. The arm became anchylosed to the should- er in some, and an artificial joint allowing of motion was formed in others." [On the subject of amputation at the shoulder-joint, Mr. Guthrie has published some valuable remarks:—his diffuse style, however, precludes me from presenting them all to the American reader. The following are selected; AMPUTATION. 79 •"This operation has until lately been con- sidered ofthe utmost danger and import- ance, not only to the life of the person who is unfortunately the sufferer, but to the reputation of the surgeon who has the performance of it: many and various have therefore been the methods recom- mended for conducting it, all impressing on the mind of the operator the great ex- tent of danger, and tending to disturb the steadiness of his judgment. Anato- my, which has thrown so much light on operative surgery in general, has not fail- ed in the last few years to dispel the cloud that obscured this part of military surgery; and experience has proved it to be as simple, easy, and safe an operation, as any other of importance performed on the field of battle. The knowledge ac- quired from this source of its success, has given to military surgeons a confidence in performing it, that-divests it of half its former terrors, and by removing "from the mind of the patient the idea of his having suffered a hopeless operation, diminishes the subsequent danger, and most materi- ally aids his recovery. The dread former- ly entertained of this operation was very great, even by men of the best abilities ; and under certain circumstances in do- mestic surgery, it may still be tedious. It can never however again be considered formidable in military surgery, except un- der bad management, and from extreme ignorance. The distinction between the necessity of the operation, and the possibility of avoiding it, requires in many cases the exercise of the nicest judgment, and a due consideration of attending circum- stances ; for there is no part of military surgery, in which an operation can be per- formed with more advantage at the in- stant ; or, delayed for a few days with a view of gaining information, with more prejudice ; inasmuch as the necessary in- cisions are made in the first instance, in pirts disposed to take on healthy actions, and in the best possible state for undergo- ing sur Jpil operations. The constitution of the pftient being also at that moment generally good, and able to sustain the demands upon it, under untoward circum- stances ; or of supporting, without future injury, tlie restraint and controul requi- site for the successful accomplishment of the cure. The difference- between cutting in sound and diseased parts is justly appreciated by every surgeon, both as to his personal convenience and ease in operating, as well as to the future healing of the wound ; and the advantage here is particularly great, as from thecontiguity of the wound to the chest and the principal organs of life, it is advisable to avoid any excess of actios; and experience has demonstrated that the evil to be apprehended from the equilibrium of the circulation being de- stroyed, is infinitely less than it would be at a subsequent period of three or four weeks, after high suppurative action has been going on. In the latter, the opera- tion is delayed until the parts to be divid- ed have been long carrying on an increas- ed action, and may even be diseased. The health and strength of the patient have been so much reduced, that he may be unable to support the additional pain ahd shock of the operation, which increase with the delay, or of giving that assist- ance requisite for the consolidation ofthe wound. Another and great consideration, is the ease and safety with which a person can be moved after the operation, com- pared with the danger and pain resulting from the disturbance of broken bones, the increase of inflammation, and other atten- dant evils under the same circumstances. It cannot be therefore too strongly im- pressed on the mind, that the necessary examinations should take place; and the operation be performed in those cases de- manding it, as soon after the injury as pos- sible, consistent with the state of the pa- tient ; and the surgeon should not satisfy himself with the idea of being able to accomplish it as safely, or as successfully, when suppuration has been established, and when perhaps he may have better as- sistance at hand ; a kind of self deceit that is occasionally permitted, but which cannot be too much reprobated. The importance of the arm is so great, and even a limited use of it so valuable, that much should be hazarded to save it, when there is a tolerably fair prospect of success: the situation also and structure ofthe upper extremity, together with the command the surgeon lias over it, and the less proportionate inconvenience resulting from a severe wound in that part to any other of equal value, renders its preserva- tion after a serious injury, more practica- ble, and less dangerous than is frequently supposed. The operation should not therefore be performed, unless simple am- putation by the flap operation cannot be successfully accomplished; or, where the limb is evidently destroyed, or, the injury seriously affecting the articulation itself, while the general health ofthe patient, or the unfortunate circumstances of situation, raider the attempt at a farther persever- ance in saving the limb improper. Injuries from musket-balls penetrating the capsular ligament, attended with frac- ture and destruction ofthe head and adja- so AMPUTATION. cent parts of the humerus, and wounding the axillary artery, require immediate operation.* A simple penetrating* or in- cised wound of the joint, of small extent, does not call for any operation, as the pa- tient, with due care, will escape with a certain degree of loss of motion, and of debility in the joint; nor is it proper in a wound from a musket-ball, where there is even some partial injury of the bone, as these cases frequently do well, and the patient preserves the use of the fore-arm. Mr. Guthrie proceeds to state at great length, " accidents in the field," and " subsequent occurrences," which may demand the operation: for these the reader is referred to his work.— It is now time to correct another misap- prehension that the fear of haemorrhage has introduced into this operation; I allude to the idea prevalent amongst many surgeons, that it is to be performed in a different manner from any other of import- ance; that instead of the calm, steady determination that distinguishes a sur- geon of ability, who feels himself master of his subject, he is to forget or lay aside, what on all other occasions is considered most valuable, and endeavour to attain a peculiar precipitation and haste of man- ner, that is excluded from all other parts of surgery. There is still a practical point usually overlooked, that in military surgery there is little or no arm left to use as a lever in facilitating the operation, and that the separation of the head of the bone depends upon the surgeon, and not upon the assistants. The patient should be placed on a seat lower than the surgeon ; (in the field an hospital pannier is the best) and so sup- ported that he may not be able to slide off" during the operation, the assistant in charge of the tourniquet, or instrument described,-j- standing behind, and regulat- ing the support, in such manner that he may always be able to make steady com- pression when required. The shattered arm or stump is then to be raised from the body, sufficiently to enable the hand of the operator to examine the axilla, and as- certain that his assistant can compress the artery when he pleases; for this sim- ple motion of raising the arm to near a right angle with the body, to afford access to the axilla after the pressure is made, will frequently render some alteration of * General Scott of the United States army, happily recovered from such a wound and has a very useful arm. \ The handle of the common tourni- quet covered with a linen bolster, is to be pressed by an assistant on the subclavian artery where it crosses, the first rib. it necessary. The arm should be also raised, so as to point out more clearly the insertion of the pectoralis major, and the posterior fold of the arm-pit; and as being more convenient to tlie operator, who, placing his finger on the lower end of the acromion process in the centre of the shoulder, (the hair in the axilla hav- ing been previously removed) with th% smaller amputating knife commences his incision immediately below it, and with a gentle curve carries it downwards and in- wards throurh the integuments only, » little below the anterior fold of the arm- pit, andwhich the raising of the arm rea- dily points out. The second incision out- wards, is made after the same manner, but something lower down, and is continued underneath, so as to shew the long head of the triceps at the under edge of the deltoid, without dividing any of the mus- cular fibres; by which means the skin has time and freedom to retract, which is a great object, being the part in general most wanted, and when retracted allows of subsequent extension. The third in- cision commencing at the same spot as tlie first, but following the margin of the retracted skin, divides the deltoid on that side to the bone, and exposes the insertion of the pectoralis major, which must be perfectly cut through, to shew the short head of the biceps flexor etibiti, and the coraco brachialis, which are then-readily known by their longitudinal fibres, and the freedom the arm or stump receives from losing its attachment to the fore part of the chest: these two muscles however are not to be touched, although the flap thus formed is to he separated, and raised so as to expose the head of the bone, nearly as far as the coracoid process of the sca- pula. The fourth incision outwards, in the same manner divides the deltoid mus- cle down to the bone, and extending to the long head of the triceps, which it is not necessary to touch, as it would be af- terwards divided : this flap is to be well turned back, so as to shew the insertions of the teres minor and infr*«K>inatus, coming across horizontally fronr the sca- pula, to be inserted into the great tuberos- ity of the humerus; the posterior circum- flex artery will be divided close to the bone, the anterior circumflex, and the continuation of the thoracica humeriana on the integuments of the arm, and some other small vessels may bleed, if the com- pression be not correctly applied; they ought not however to be tied, but merely stopped with the finger, and particularly the posterior circumflex, as this must again be divided, and pressure on the sub- clavian readily commands it; both the outer and inner flap being now raised, the AMPUTATION. 8l head of the bone may be rolled a little outwards, and the teres minor and infra spinatus cut across upon it with a large scalpel, opening at the same time into the cavity of the joint; by which means the error of slitting up the bursa under the acromion, instead of the capsular liga- ment, will be avoided, and continuing the incision upwards, cutting through tlie capsular ligament, the tendon of the supra spinatus, and the long head of the biceps flexor cubiti as close as possible to the edge of the glenoid cavity. The surgeon placing his fingers on the head ofthe bone, cuts through the inner side of the capsu- lar ligament, and wi»h it the subscapulars muscle, going to be inserted into the les- ser tuberosity of the humerus The edge of the knife being constantly towards the bone, he divides the under part ofthe lig- ament, separating the head of the bone from the glenoid cavity: resuming jke small amputating knife, he cuts through the long head of the triceps, to prevent its hanging too much into the wound, and then with one sweep he connects the points of the two first incisions under- neath, separating the arm from the body, dividing again the circumflex arteries above* the first incision, the teres major, latissimus dorsi, coraco brachialis, long head of the triceps, axillary artery, veins, and nerves. This being the only danger- ous step of the operation, the surgeon should inform himself if the artery be sufficiently compressed, which he will know by the posterior circumflex artery not bleeding, and the want of pulsation in the axilla : he should caution the assist- ant to preserve the steady position of the patient, and have another ready to press his closed hand upon the artery, if it should bleed. Laying down the knife, he takes the artery if bleeding between the finger and thumb; or if compressed pulls it out with a tenaculum, and ties it firmly with a small ligature of two good threads. The vessel is found contracted amongst the nerves in the lower third of the wound; all pressure being removed, tlie anterior and posterior circumflex arteries will bleed, and must be secured; or, if the ar- tery subdivides high up, there may be a fourth large branoh. In recent cases of injury I have seldom had occasion to take up more than three arteries, and no cutaneous or other Vessels* besides those divided by the last incision. The nerves, if hinging in the wound must be shortened, which though painful, pre- vents a source of irritation hereafter from their adhering in tiie neighbourhood of the cicatrix. The axillary vein, if it con- tinue to bleed, should be secured with a single thread, as it allows some blood to Vet. I. pass into the wound after it has been brought together, and, what is of more material consequence, permits it to pass into the loose cellular membrane sur- roundingthe vessels down to the clavicfoj which may cause considerable mischief, as the position of the patient is favoura- ble to its gravitation. All compression having been taken off* the artery, the wound should be well cleansed, and here a little delay may be allowed If the tendon of the long head of the biceps flexor cubiti be left long, it ought to be cut off With the scissars, as well as any ragged portions of the capsu- lar ligament. The glenoid cavity need not be deprived of its cartilage. Tfr- pec- toralis major will be observed to have re* traded considerably, and to have doubled or folded in the skin covering it; through this (the p;>rts being brought together,) a suture should be put to the opposite side, and the whole properly supported ^nd compressed by strips of adhesive plasier and bandage, the ligatures being" brought out direct. The incision then forms but one line from the acromion downwards, curving at the bottom to the fore part of the chest, the skin at the axilla being always a little Wrinkled, and much inclined to retract. The flaps of the deltoid meet firmly, sink a little into the hollow under the acromion, lie close upon the glenoid cavity and the cdracoid process; and from the pressure of the adhesive plaster and compress, with the evenness of the wound, the skin of this part nearly unites by the first intention i the hollow round the glenoid cavity is comparatively small to what might be expected, and the Consolidation in healthy subjects, where every thing has done well, goes on steadily, so as not to leave any cause of future inconvenience. The! surgeon, in all his dressings, should take care that no collection forms any where by keeping up a regular and proper com- pression in the course of the artery, the coracotd process, the pectoralis major* and the muscles from the scapula and back. The pain and sensation principally complained of is from the hand and arm j there is seldom any haemorrhage, and the patient does not suffer more than in any other common amputation. I have insisted on the arm being raised from the first, because in all operations) that require the principal artery-to be1 compressed, it should not be done until the limb be placed in the situation in which the operation is intended to be per- formed, as tile mere alteration of postdre removes the pressure from its destined point, as must frequently have been ob- served, when the tourniquet te applied M S2 AMPUTATION. without this caution in the axilla, or thigh. This elevation also allows more freedom to the knife in every direction, and points out more clearly the situation of parts. I beg, however, to be under- stood as rot recommending the arm to be raised in secondary cases, when there is partial anchylosis, or thickening of the ligaments, or other fair obstacles to its being done with ease to the patient. It is not necessaiy to lay bare the acro- mion, on the contrary, the finger should be placed immediately upon it, to insure the first incision, being near half an inch below it, if the eye of the operator be not a sufficient guide; the flaps turn aside sufficiently without it, the head of the humerus is extricated with equal ease, and there is no subsequent danger if the stump should slough, or of the acromion coming through and being a future incon- venience to the patient. In making the last incision of separation, care should be taken to save as much of the integuments as the nature of the ope- ration will permit; and this is done by keeping the head of the bone as far from the glenoid cavity as the att chment of the teres major and latissimus dorsi will allow, and by then cutting ss close to the bone as possible. The long head of the triceps muscle is divided befo e tile last incision, to prevent its hang r.g. too long in the wound, and interfering with the ap- proximation of the integuments. The anterior and posterior circumflex arteries require only a single thread; the latter will be divided about three quarters of an inch from its origin, and the axillary ar- tery in general near an inch, from where it gives off the subscapularis. In giving an account of the success of some of my cotemporaries in the cam- paigns in the Peninsula, I must premise that the operation has become much more common among military surgeons than formerly; whether it be that its own utility has rendered it necessary, or that our surgeons are better operators, or that it has been occasionally performed with- out due discrimination,! cannot determine. Perhaps a combination of the whole of these circumstances may have been the cause of its multiplication; the latter, I I am desirous of believing, to have little increased the number. The following returns of the operation, as*performed in the army under the Duke of Wellington, during a period of six months, from the 21st June to the 24th December 1814, may not perhaps be unins'ructive. It includes the wound- ed at the battle of Vitoria, the destructive siege of St. Sebastian, and the battles of Pampeluna and the Pyrenees, and is ano- ther remarkable dlustration of the neces- sity of operating on the field of battle, in pr-ference to the delay of a secondary operat.on : the operations with the di- visions of" the army having been all p mary, at the general hospitals, se- condary. General Hospitals. Number of operations performed. Died. Cured, or out of danger. Vitoria, Bilboa, Passages, Total 13 5 1 10 5 0 3 0 1 19 15 4 iDivisions ofthe Army. Number of operations performed. Died. Cured. Transferred, but considered out of danger. 1st, 2d, 3d, 5th, 6th, ■Light, Total 3 1 1 12 1 1 0 0 0 0 1 0 2 1 1 12 0 0 1 0 0 0 0 1 19 1 16 2 The 5th division performed the duties of the siege of St. Sebastian, and tlie men were principally wounded in the upper part of the body. The loss with the divisions of the army was as one in nineteen in favour of the primary operation; a success truly asto- nishing. In the General Hospitals, under AMPUTATION. 83 surgeons equally able, the loss was fifteen in nineteen, a want of success as dis- heartening, as in the other encouraging; and arising from all the causes mentioned in the remarks on " Amputation," as con- curring in the ill-success of secondary operations. Bromfield • states, that before his time the operation had been performed in the British armies, but unsuccessfully, which I believe was frequently the case when formerly attempted. It is now, however, the reverse, is in general successful, and performed by military surgeons, without hesitation or fear; and I trust I have proved, that this once formidable opera- tion may now be considered as safe, as sim- ple, and as little hazardous, as any other of importance performed on the human body] AMPUTATION OF T«E HEADS OF BONF.S. In a letter, dated 1782, and addressed to Mr. Pott, Mr. Park, surgeon of the Liverpool Hospital, made the proposal of totally extirpating many diseased joints, by which the limbs might be preserved, with such a share of the motions which nature originally allotted, as to be consi- derably more useful than any invention which art has hitherto been able to sub- stitute. Mr. Park's scheme, in short, was to en- tirely remove the extremities of all the bones, which form the joints, with the whole, or as much as possible, ofthe cap- sular ligament; and to obtain a cure by means of callus, or by uniting the femur and tibia, when the operation was done on the knee; and the humerus, radius, and ulna, when done on the elbow; so as to have no moveable articulation in those situations. To determine whether the popliteal vessels could be avoided without much difficulty in the excision of the knee, Mr. Park made an experiment on the dead subject. An incision was made, begin- ning about two inches above the upper end of the patella, and extending about as far below its lower part. Another one was made across this at right angles, imme- diately above the patella down to the bone, and nearly half round the limb, the leg being in an extended state. The lower angles formed by these incisions were raised, so as to lay bare the capsular lig- ament ; the patella was then taken out; the upper angles were raised, so as fairly to denude the head of the femur, and to * Page 209 of his Chirurgical Observa- tions and Cases. allow a small catling to be passed across the posterior flat part of the bone, imme- diately above the condyles, care being taken to keep one of the' flat sides of the point ofthe instrument quite close to the bone, all the way. The catling being withdrawn, an elastic spatula was intro- duced in its place, to guard the soft parts, while the femur was sawn. The head of the bone thus separated, was carefully dis- sected out; the head of the tibia was then with ease turned out, and sawn off, and as much as possible of the capsular lig:v- ment dissected away, leaving only the posterior part covering the vessel, which on examination had been in very little danger of being wounded. The next attempt was on the elbow, a simple longitudinal incision was made from about two inches above, to the same distance below, the point of the olecra- non. The integuments having been raised, an attempt was made to divide the lateral ligaments, and dislocate the joint; but this being found difficult, the olecranon was sawn off, after wliich the joint could be easily'dislocated, without any trans- verse incision, tlie lower extremity of the os humeri sawn off, and afterwards the heads of the radius and ulna. This ap- peared an easy work; but, Mr. Park con- ceives the case will be difficult in a dis- eased state ofthe parts, and that a crucial incision would be requisite, as well as dividing the humerus, above the condyles, in the way done with respect to the thigh bone. Mr. Park first operated, July 2, 1781, on a strong, robust, sailor, aged 33, who had a diseased knee, of ten years stand- ing. The man's sufferings were daily in- creasing, and his health declining. Mr. I'ark, in the operation, wished to avoid making the transverse incision, thinking that after removing the patella, he could effect his object by the longitudinal one; but, it was found that the difference be- tween a healthy and diseased state of parts, deceived him in this expectation. Hence the idea was relinquished, and the transverse incision made. The operation was finished exactly as the one on the dead subject related above. The quan- tity of bone removed was very little more than two inches of the femur, and rather more than one inch of the tibia. The only artery divided was one on the front of the knee, and it ceased to bleed before the operation was concluded, but the ends of the bones bled very freely. To keep the redundant integuments from falling inwards, and to keep the edges of the wounds in tolerable contact, a few su- tures were used. The dressings were light and superficial, and the limb was 9* AMPUTATION. put in a tin case, sufficiently long to receive the whole of it, from the ankle to the in- sertion of the gluteus muscle. We shall not follow Mr. Park through- out the whole treatment. Suffice it to re- mark, that the case gave him a great deal of trouble, and that it was attended with many embarrassing circumstances, aris- ing chiefly from the difficulty of keeping the limb in a fixed position, the great depth of the wound, and the abscesses and sinuses, which formed in the part. On the other hand, however, the first symptoms were not at all dangerous. But, the patient was obliged to keep his bed nine or ten weeks, and it was many months more before the cure was com- plete. The man afterwards went to sea, and did his duty very well, so useful was his limb to him. Since the publication of the letter ad- dressed to Mr. Pott, another excision of the knee has been done by Mr. Park. This operation was performed on the 22d of June, but the event was unsuccessful, as the patient lingered till the 13th of October, and then died. About the same time that Mr. Park made his proposal, P. F. Moreau, a French surgeon, wrote in favour of a similar me- thod. It only seems necessary to notice here the difference in Moreau's plan of operating from that adopted by our coun- tryman. Moreau, the son, who has pub- lished the account, observes that the mul- tiplicity of flaps is unnecessary, as two an- swer every purpose; and he deems Mr. Park's direction to remove the olecranon, if this be free from caries, at least useless. Moreau, junior, operated on the elbow as follows: he plunged a dissecting scalpel in upon the sharp edge, or spine of the inner condyle of the os humeri, about two inches above its tuberosity; and, directed by the spine, he carried the incision down to the joint. He did the same on the other side, and then laid the two wounds into one, by a transverse incision, which divided the skin and the tendon of the tri- ceps, immediately above the olecranon. The flap was dissected from the bone, and held up out ofthe way, by an assistant. The flesh which adhered to the ti ont of the bone, above the condyles, was now separated, care being taken to guide the point of the instrument with the fore-finger of the left hand, and, when tlie handle of the scalpel could be passed through between the' flesh and the bone, M. Moreau allowed it to remain there, and sawed the bone through upon it. The removal of the piece of bone was next finished, by detaching it from all its adhe- sions. The removal of the heads of the radius and ulna, remaining to "he done, was more difficult, and the first flap beinjjp insufficient, it became necessary to make another. The lateral incision, at the out. er side of the arm, was extended down- wards, along the external border of the upper part ofthe radius. The head of the radius was separated from the surround* ing parts; its connexion with the ulna destroyed, and a strap of linen was intro- duced between the bones, to keep the flesh out of the way of the saw. The ra- dius was sawn through, near the insertion of the biceps, which was fortunately pre. served. Some remaining medullary cells, filled with pus, were removed with a gouge. The ulna was not exposed, by extending the lateral incision on the in. ner side of the arm. Thus another flap was made, and detached from the back part of the fore-arm, and that part ofthe bone which it was wished to remove. The bone, separated from every thing that adhered to it, and a strap of linen being put round it to protect the flesh, about an inch and a half of it was sawn off, measuring from the tip of the "olecra. non, downwards. A few diseased me- dullary cells were taken away with the gouge. Two or three vessels were tied, and the flaps were brought together with sutures. In a fortnight this man became so well, that he was allowed to go wher- ever he pleased, with his arm supported in a case. The arm was at first power. less, but it slowly regained its strength, and the man could ultimately thresh corn and hold the plough with it, &c. Seven months after another operation, performed in the same way as the preced- ing one, by Moreau the father, the patient was completely cured, and two years after this period, the-flexion ofthe fore-arm on the arm, was very distinct. In another case, only one longitudinal incision, and a transverse one, were made, the flap of course was triangular. The patient got well in six weeks, and in three months more joined his regiment. In all Moreau's cases, the flexion and extension of the fore-arm were preserved, which circumstance no doubt depended very much on the insertion of the biceps not being destroyed. After the excision of the knee, however, the bones grew to- gether. Moreau, junior's, method of operating differed from his father's, in having the patient in a recumbent, instead of a sit- ting, posture, and in sawing the os humeri before it was dislocated. In a knee case, Moreau the father ope- rated as follows:—He made a longitudi- nal incision on each side of the thigh be- tween the vasti and the flexors of the' le-ff down to the bone. These incisions began AMPUTATION. §5 about two inches above the condyles of the femur, and were carried down along the sides ofthe joint, till they reached the tibia. They were united by a transverse cut, which passed below the patella, down to the bone. The flap was raised; the patella was attached to it, but being diseased, was dissected out. The limb was then bent to bring the condyles of the femur into view. As it was desired to cut them from the body of tlie bone, before dislocating them, every thing adhering to them be- hind, where they joined the body of the bone, was separated, and, at that place the fore-finger of the left hand was passed through, in order to press back the flesh from the bone, and on that the saw was used. The knee having been bent, Mo- reau drew the cut piece towards him, and easily detached it from the flesh and liga- ments. The head of the tibia was laid bare by an incision, nearly eighteen lines long, made on the spine of that bone. The first lateral incision on the outer side of the knee, was extended nearly as far down on the head of the fibula. Thus were ob- tained one flap, which adhered to the flesh filling up the interosseous space, and an- other triangular flap, formed of the skin, covering the inner surface of the tibia, which bone was of necessity exposed, be- fore the saw could be applied. Upon raising the outer flap, the head of the fibula came into view, and, after being separated from its attachments, was cut off with a small saw. The inner flap was then raised, and the tibia, having been se- parated from the muscles behind, its head was sawn off. It does not appear necessary to insert in this work the account of cutting out the ankle joint; an operation which will never be extensively adopted; nor shall I add any thing more concerning the mode of removing, in a similar way, the shoul- der joint. In treating of amputation in this situation, I have already said enough, and whoever wishes for further informa- tion, respecting this practice, must refer to Dr. Jeffray's Work, entitled " Cases of the Excision of Carious Joints." This pub- lication contains all that is known on the subject. Dr. JefrVay has recommended a particular, and, indeed, a very ingenious, saw, for facilitating the above operation. The saw alluded to is constructed with joints, like the chain of a watch, so as to allow itself to be drawn through behind a bone, by a crooked needle, like a thread, and to cut the bone from behind forward, without inuring the soft parts. An in- strument of this kind was executed in London, by Mr Richards, who was as- sisted in making it by his nephew, the present Mr. Richards, of Brick-lane. In placing the saw under a bone, its cutting edge is to be turned away from the flesh. Handles are afterwards hooked on the in- strument. In my treatise on the diseases of the joints, which was honoured with the pre- mium for 1806, by the College of Surgeons in London, I have made the followintr remarks on the excision of the large joints. " My sentiment has been already stated, with regard to the time, when every hope of curing a diseased joint ought to be abandoned. I have stated, that the approach of dissolution, in other words, the sunk state of the system can be the only solid reason for amputation, and that, as long as the patient's strength is not subdued by the irritation of the lo- cal disease, humanity dictates the propri- ety of persevering in an attempt to save the affected limb, &c. Will a patient, greatly reduced by hectic symptoms, be able to recover from so bold and bloody an operation, as the dissection of the whole of tlie knee-joint out of the limb I If some few should escape, with life and limb preserved, would the bulk of persons, treated in this manner, have the same good fortune ? I cannot admit, that the extirpation of the whole of so large an ar- ticulation as the knee, can be compared with the operation of amputation, in point of simplicity and safety. Hi wever, it is not on the difficulty of practising the former, that I would found my objections; for, I believe, that any man possessing a tolerable knowledge ofthe anatomy ofthe leg, might contrive to achieve the busi- ness." " The grounds on which I shaft at present withhold my approbation from the attempt to cut out large joints, are the following:—1. The great length of time which the healing of the wound requires* Whoever peruses the case of Hector M'Caglian, will find that the operation was performed on the 2d of July, 1781, and that it was February i8th of the fol- lowing year, before all the subsequent abscesses and sores were perfectly healed. This space of time is very neatly eight months ! Mr. Park describes the patient as a strong, robust sailor, and gives no further particulars concerning the state of his constitution, than that his health was declining. I entertain little doubt, that if the excision of the knee had been per- formed in that state of the health, in which amputation becomes truly indis- pensable, this man would not have sur- vived the illness arising from the opera- tion. The only other case, in which Mr. Park extirpated the knee, ended fotally. In the instance related by Moreau, there 86 AMPUTATION. seemed, indeed, to be considerable debi- lity. This patient escaped the first dan- gers consequent to so severe an opera- tion; and, after three months confinement, the patient was in such a state, that Mo- reau expected he would be able to walk upon crutches in another month or six weeks ! The young man in the mean time was attacked by an ep.demic dysentery, and died. 2. Even supposing the excision of the knee to be followed with all possible success, is the advantage of having a mutilated, shortened, stiff limb, in lieu of a wooden leg, sufficiently great to induce any man to submit to an operation, beyond a doubt infinitely more dangerous than amputa- tion ? I think not" (See the author's Treatiseon the Diseasesof the Joints, p. 138 ) AMPUTATION OF THE FINGERS AND TOES, AND PAHT OF THE FOOT. Mr. Samuel Sharp observes, that the amputation of the fingers and toes is bet- tei performed in their articulation, than by any of the other methods. For this purpose a straight knife must be used, anil the incision of the skin be made not exactly upon the joint, but a little to- wards the extremity of the finger, that more of it may be preserved for the easier healing afterwards. It will also facili-, tate the separation in the joint, when you cut the finger from the metacarpal bone, to make two small longitudinal incisions on each side of it first. It may happen that the bones of the toes, and part only of the metatarsal bones, are carious, in wliich case the \eg need not be cut off, but only so much of the f iot as is disordered. A small spring saw is here better than a large one. When this operation is performed, the heel and remainder of the foot, will be of great service, and the wound heal up safely, as Mr. Sharp has once seen. (Operations of Surgery.) In amputating the fingers and toes, the operation is greatly facilitated by cutting into the joint when it is bent. Having made an opening into the back part of the capsule, one ofthe lateral ligaments may easily be cut, after which nothing keeps the head of the bone from being turned out, and the surgeon has only to cut through the rest of tlie exposed ligament- ous and tendinous parts. Some recommend making a small semi- circular flap of skin to cover the bone; but this is quite unnecessary-, if care be taken to draw the skin a li'tie up, and to cut where Mr. Sharp directs. Mr Hey describes a new mode of re- moving the metatarsal hones, which, on repeated trial has fully answered his ex. pectations. Mr. Hey makes a mark across the upper part of the foot, to denote where the metatarsal bones are joined to those of the tarsus. About half an inch from this mark, nearer the toes, he makes a transverse incision, through the intcgu. ments and muscles covering the metatar. sal bones. From each extremity of this cut, he makes an incision along the inner and outer side of the foot to tiie toes • he removes all the toes from the metatar- sal bones, and then separates the integu- ments and muscles, forming the sole of the foot, from the inferior part of the me- tatarsal bones, keeping the edge of the knife as near the bones as possible, in or. der to expedite the operation, and pre- serve as much muscular flesh in the flap as can be saved. He then separates the four smaller metatarsal bones, at their junction with the tarsus, and divides, with a saw, the projecting part ofthe first cuneiform bone, which supports the great toe. The arteries being tied, Mr. Hey ap. plies the flap, which had formed the sole of the foot to the integuments, which re- main at the upper part, and keeps them in contact with sutures. The cicatrix being situated at the top ofthe foot, is in no dan- ger of being hurt, while the place where the toes were situated, is covered with such strong skin, viz. what previously formed the sole of the foot, that it cannot be injured by any moderate violence. (See Practical Observations in Surgery, p. 535, &c) It is certainly veiy often quite unneces. sary to remove the whole foot, when the metatarsal bones are carious, and every other part of the leg is sound. The re- mainder ofthe foot is of immense service in walking, as the use of the ankle is not destroyed. Mr. Hey very judiciously re- commends dissecting out the metatarsal bone ofthe great toe, when diseased, from the cuneiform bone, instead of sawing it The latter plan cannot be easily accom- plished, without removing part of the in- teguments and muscles, and making a transverse, as well as a longitudinal, in- cision. These disagreeable things may be avoided by following Mr. Hev's me- thod. & ' The metatarsal bone of the little toe may be removed in a similar way. It is very awkward to saw the me- tatarsal, and metacarpal bones, and, when the middle ones are to be divided, is indeed hardly practicable, without in- juring the soft parts I am, therefore, of opinion with Mr. C. Bell, that, instead of a iormal amputation, it is better to ex- tract the diseased bones from the foot, er AMPUTATION. 97 hand, as, indeed, Mr. Hey is in the habit of doing. After the perusal of the foregoing ac- count of* the subject of amputation, I tliink a surgeon will derive many useful hints from the valuable observations of M. Louis, although his mode of operat- ing is not now imitated, and several of the things, which he recommends, are not at present attended to, I am of opinion, that the practitioner, who is acquainted with his remarks on this operation, will have a decided superiority over another surgeon that is entirely ignorant of them. Many of the observations are incontro- vertible ; the principles, inculcated, are generally founded on the most correct anatomical considerations; and, in the present indiscriminate fashion of dissect- ing up the skin, often very unnecessarily, and always to the severe suffering of the patient, I am convinced, that M. Louis's sentiments may be studied with advan- tage. It is not to be inferred, however, that I suppose the double incision a bad mode of operating; but, only that I think it the duty of every surgeon to know where the dissection and preservation of skin are necessaiy, and where not. ABSTRACT FROM THE MEMOIRE SUR LA SAILLIE DE l.'0S AFRE8 L*AMFUTATION, &.C. BY M. XOUIS. The contraction of the muscles has hi- therto appeared the most probable reason of the protrusion of the bones, after the amputation of the thigh. There is no complaint of the bones protruding, after the amputation of the arm or fore-arm ; and if we observe things carefully in the amputation of the thigh, we shall con- stantly see muscles protruding from the level of the other flesh, by a real elon- gation, whilst there are some muscles that are drawn back, even on dead bodies, where undoubtedly the contractile power ofthe muscles cannot be supposed to act. The solution of these difficiUties will re- move all the doubts which may arise on the subject here treated of. The protrusion of the bones will never take place, so long as they are immedi- ately encompassed with the fleshy sub- stance of the muscles : this proposition is incontestable. The state ofthe skin, whe- ther longer or shorter, conduces nothing to this protrusion, as we have proved. Thus the precaution of drawing it up- wards, and preserving as much of it as possible, will not prevent this inconve- nience. We do not find this to he the case, either in the leg or fore-arm, because the greater part of the muscles, which are there cut, adhere to the bones, and are contained by aponeuroses, which fix them in their situation. In the amputation of the arm, there is only the biceps-muscle, which can be drawn back towards the upper part. The extremity of the hume- rus always remains encompassed with the brachial and extensor muscles, which are retained and fixed by their adhesions to the bone itself From hence proceeds the facility of curing amputations of the arm, without exfoliation of the bone. But, this is not the case with the th.gh. Only the crural muscle is there fixed to the bone in its whole extent; but this muscle is very slender, its fibres short, and converging to its axis, which is pa- raUel to that of the bone. The vastus in- ternus, the vastus externus, and the tri- ceps muscles, have also adhesions to the femur; but they are not attached to it, except by their interior edge. The plane of these muscular substances is disem- barrassed and pretty large, and conse- quently capable of changing their direc- tion, and folding over each other, after their resection. All the other muscles are separated from each other, as well as the preceding, by the cellular texture, and there is none of them which, in its direc- tion, is parallel to the axis of the femur. Every one of them cut it, by more or less acute angles. From thence it happens, that when these muscles are divided, they change their direction; there is nothing to maintain them, in order to form an equal surface at the extremity of the stump. I have examined minutely into these matters, by the inspection of dead bodies, and recollected, on this occasion, the amputations I myself had made of the thigh, and the much greater number which I had seen performed by others. I do not think there can be any manner of doubt with regard to this fact. I am likewise fully persuaded, that there are no means of preventing this change of situation in the muscles ofthe thigh, after its amputation; but it seems to me, that there is a very simple method of prevent- ing the ill effects of this change, with re- gard to the protrusion ofthe bone. It is laid down as a rule, that, besides the tourniquet, which is fixed to prevent the hemorrhage, during the operation, there should be applied a tight ligature immediately .above the part, where the circular incision is to be made. All au- thors, except Le Dran, recommend the use of this ligature, in order to sustain the flesh in such a manner, that it might be cut with the instrument, smoothly and evenly, and with facility. Guy de Chau- liac would even have the incision made between two ligatures; Verduc and se- veral others have given the same advice. 8*8 AMPUTATION The modern practice is, not to remove the ligature that sustains the flesh, till after the bone is sawn ; and this even our books of surgery prescribe. But in the amputation of the thigh, in case we would prevent the protrusion ofthe bone, (which it has been impossible to avoid, notwith- standing all the precautions hitherto in- dicated) we must take care to remove the ligature that secured tiie flesh, as soon as the section ofthe soft parts shall be made. The muscles, being set at liberty, will be drawn back immediately, and change their situation ; we shall then be able to raise the flesh with tlie retractor, to direct the bistoury on the crural muscle.and to cut the point of adhesion of tlie vasti and tiie triceps at the posterior spine of the femur. By this method the bone may be very easily sawn, three fingers breadth higher, than it could have been, had it been sawn to the level of the flesh sustained by the ligature. This remark will appear very simple to many; but this simplicity does not dimi- nish, either the importance or solidity of it. This consideration induces me to re- fer to another memoir, a series of reflec- tions on the same subject, and to conclude the present with the same words, which Monro, a celebrated professor of Edin- burgh, makes use of, at the beginning of his remarks on amputation of the larger extremities. " There is," says he, "in the operations of surgery, an infinity of mi- nute circumstances, which do not appear, at first sight, very important, and wliich, notwithstanding, the observation or omis- sion of in practice, has considerable con- sequences, by rendering the cure more expeditious or more tedious; by bringing on or preventing dangerous symptoms ; by preserving the patient from violent pains, or increasing them, and putting hi* life in danger; circumstances, the good or ill effects of wliich ought conse- quently to be examined with attention, and concerning which, those who treat of these matters, with a view to the public utility, ought to give the necessary direc- tions." FROM THE SECOND MEMOIRE SUR I,'AMPU- TATION DES GRA3TDES EXTREMITe's, BT M. LOUIS. The frequent opportunities of amputat- ing limbs, and the simplicity of the ob- jects of this operation, one might suppose, ought long ago to have brought it to the highest pitch of perfection ; but, says M. Louis, it frequently happens, that the most familiar things are those, to which we pay the least attention. Modern wri- ters regard amputation, as an operation much more embarrassing, than difficult { and it is, perhaps, on account of its ob- je.ct being simple, and of the proceedings to be followed in its performance, not requiring great dexterity, that surgeon**. adhere to methods, to which they have been accustomed, without examining, whether the practice is as perfect as it is capable of being rendered. The force of custom has not imposed on me; I have made my remarks on this operation; and, I hope, that such readers, as will duly and impartially consider them, will find them not destitute of utility. I do not pretend to insinuate, that most of the rules, which have hitherto served as a guidance, are faulty; but, I am of opinion, that the best are too vague, and ought to be made more determinate. However solid they may appear in general, they will be found respectively erroneous when applied to particular cases, and great blunders may therefore be committed in their applica- tion. The design of amputation i^ to se> parate from the rest of the body, a part, the endeavour to preserve which might cau-e the patient's death. The ancient professors of surgery appear to have al. ways been more occupied about the end, proposed in the practice of this operation, than solicitous to improve the means, by which its pain and inconveniences might be lessened. The nature of the parts, divided in each kind of amputation; their attachments; the change, which naturally or accidentally, takes place in their dis- position after the operation; even tlie uses, which the parts must serve after the cure ; are all considerations, says M. Louis, which appear to me to demand different modes of proceeding, which may be usefully varied according to the diver- sity of circumstances. In this point of view, I imend to examine the received precepts, relative to the surgery of am- putations, and shall offer a series of re- flections, which seem to me to be appli- cable to the operation, in respect to each particular member. SECTION I. REMARKS ON THE AMPUTATION OF THE THIGH, BY M. LOUIS. Of all amputations, that ofthe thigh is the most liable to inconveniences, arising from the method of operating. I have elsewhere explained the reason of this fact (Vid. Mem. de PAcad. de Chir. Tom. 5, p. 273, Edit, in 12mo.) and I have pointed out a very simple mode of avoiding them. So important a subject deserves a more circumstantial detail, which I shall now offer with as much precision as is in my power. AMPUTATION. 85 The patient being put into a suitable situation, and the tourniquet applied,* an assistant is to draw the skin up towards the upper part of the thigh, where it is to be kept by means of a roller, which is to be applied, with sufficient tightness, round the limb, a little above the place, where the incision is to be made. This band makes the skin tense, steadies the flesh, and serves as a guide for the ope- rator, in the direction of his instrument. Guy de Chauliac applied a second liga- ture, below the place, where the ampu- tation was to be done. Experience proves the usefulness of this plan, and several practitioners adopt it,although our modern writers have not thought proper to make any mention of it. The skin and flesh, says M. Louis, cannot be too carefully fixed ; for the incision can then be made more easily, and with greater regularity. There is no occasion to repeat here whjt 1 have observed in my first memoir against what is called the double incision. It is for the thigh, that the preliminary division of the skin and fat is the most strongly recommended. Heister says, that he has often seen the bone project, like a stiok, two, or three finger-breadths, be- yond the flesh, in consequence ofthe dou- ble incision not having been practised. Si muscuH und cum cute und eddemquesec- tione discindantur, musculi hie dissecti for- tissimi tantope sursum retrahuntur, quernad- modum sxpius vidi, ut osfemoris post alteram tertiamve deligatiunem, ad duorum, imd tri- Um, transversorum digitorum longitudinem, super carnem, instar baculi atjusdam emi- nuerit. (Heister, Instit. Chirurg. deAmput. Femoris.) Notwithstanding this authority, con- tinues M. Louis, I am bold enough to assert, that on the thigh, this preli. minary incision of the skin is the least proper. The usefulness of this plan would consist in saving skin enough to cover the muscles; but, their retraction could not be at all lessened by having a greater length of integuments. The pre- caution that is taken to pull the skin up- ward, and keep it so with a band, is the more effectual in amputation of the thigh, inasmuch as the retraction of the musojes is here greater. The inconvenience is, that the end of tlie bone projects beyond the surface of the wound, unsurrounded by the soft parts, which naturally cover it. Besides M. Louis contends, that the preservation of a larger quantity of skin * Among tlie different authors, who may be consulted on the application of the tourniquet, it is essential not to forget Monro, in Edinb. Essays, vol. 4. M Vol. I. will not supply tlie deficiency of muscle, with which it is always desirable to cover the bone. Hence, he maintains, that this first incision, so much extolled, is abso- lutely useless, and that it unnecessarily lengthens ihe operation, and increases the suffering of the patient. He lays it down, as a precept, founded on reason and experience, that i»e should begin the operation by a deep incision, which is to di- vide the muscles and skin at the same stroke. The only thing to be observed, in order to make this first incision as well as possible, is to do ihe whole of the cut with one luru ,of the amputating knife ; an object, which may be accomphshed with ease. The surgeon, placed externally, with one knee on the ground, and his right arm under the thigh, which is about to be amputated, is to take hold of the handle of the knife, which is to be presented to him perpen- dicularly between the patient's thighs. In this position, the point of the instrument is turned towards the operator's chest. Now, if he raises his right hand consi- derably, and turns his wrist very prone, he will be able to commence the incision externally, carrying it from above down- wards. In this first direction of the in- strument, hew dl cut the muscles, covering the outer part of the thigh-bone. Then, carrying the knife in a contrary direction, from below upwards, and round the an- terior part of this bone, he will cut the extensor muscles. The instrument is after- wards to be directed from above down- wards, in order to divide the muscles si- tuated on the inside of the thigh; and the surgeon, now rising1 up, is to complete the circular incision, by cutting the parts on the posterior side of the limb. By fol- lowing this plan, says M. Louis, the flesh will be uniformly cut by one stroke ofthe knife; and the operator, not having oc- casion to reapply the instrument several times, he will run no risk of making an irregular section. As soon as the incision is made,a largish interspace- appears betwixt the divided parts. I have remarked, says M. Louis, that this separation was much more con- siderable in amputations, where only one ligature was applied round the limb. Hence, the gaping of the wound appears to depend principally upon the retraction of the muscles towards their inferior at- tachments. The ligature which fixes the skin, and presses the whole circumference of the member, above the incision, is an obstacle to the shortening of the muscles, and it should therefore be removed, a# soon as the cut has been made. The uti- lity of this method is obvious. The mus- cles, whose action will now be no more re- strained, (especially if M. Petit's tour. N 90 AMPUTATION. niquet be employed,) will contract, and change their situation, according to the difference of their direction. A small scalpel may then be used, for dividing the crurabs muscle, which is intimately at- tached to the femur, and may now be cut even higher than the level ofthe retracted parts. The other portions of muscles attached to the spine of the os femoris, are next to be divided on the same line, and, lastly, the periosteum. The slit bandage, named a retractor, will be an easy means of/enabling the sur- geon to cut such fleshy fibres, as are ad- herent to the bone. There are some wri- ters, who say, that it may be dispensed with; but, it deserves notice, that they have only proscribed its use, when em- ployed with a view of drawing the soft parts upward, in order to protect them from the action of the teeth of the saw; and, it is true, saysM. Louis, that in the received mode of operating, the retractor is not absolutely necessary, because the bone is^ sawn on a level with the flesh, which is steadied and fixed by the ligature. But, as I expressly recommend such ligature to be removed, in order to divide the peri- osteum, and to saw the bone, higher than the level of the soft parts, the retractor becomes extremely useful. We shall mere- ly observe, that the ends of this slit ban- dage ought not to be applied too closely to the bone, since its design is to push upwards the soft parts, which are loose and unfixed, in order to facilitate the di- vision of those fleshy fibres which lie close to the bone, and are firmly attached to it. I shall say nothing about the sawing of the bone, having nothing particular to urge on this point. The operation, says M. Louis, practised "in the way, which 1 have just now been describing, will be attended with all the advantages, which have been constantly- desired, and for the acquisition of which, methods have been practised, which are less simple, and liable to many inconve- niences. I here allude to the amputations with two flaps. It is only' necessary to read the description of such operations (Le Dran, Traitedes Operations,) to be con- vinced, how much this method of ampu- tating increases the patient's suffering; and the idea, thus collected, would not nearly equal that, which would arise from seeing the method tried on the dead sub- ject. We are directed, first tomakeacircu- lar incision, three or four finger breadths, lower down, than the place, where we in- tend to saw the bone. The assistant, who holds the upper part of the limb, is to draw the skin upward, and, on a level with it, the flesh is to be divided down to the bone. Ihe point of the knife is then to be pushed through the thickness of the flesh to the bone, exactly at the place where this is to be sawn; an-d. a longitu. dinal wound is to be made in the integu. ments and muscles, which is to terminate at the'circular incision. The same is to be done on the opposite side. These two incisions must be so managed, that the large vessels will be situated in the middle of one of the flaps. Both these flaps are to be dissected so as to expose the bone; they are then to be drawn up, and kept in this position by a linen re- tractor. The operator now has an opportu- nity of making a circular incision through the fibres attached to the bone, and at the same time through the perios- teum, on a level with the base of the flaps. Lastly, the bone is to be divided with a saw, that has a very narrow blade. This concise account of the manner of executing the flap amputation will enable the reader to judge, how painful such operation must be. Without saying any thing about the first cut through the in- teguments, which is made without any reasonable motive, and may be dispensed with, it is manifest, that the patient has to suffer, in addition to what he suffers in the other operation, two perpendicular wounds, and the dissection of the two flaps thus produced. There can be no doubt, that the swelling and inflammation of the stump, the pain, tever, and all the consequent symptoms, already so formi- dable, independently of any other cause, in the operation done in the most simple manner, must be much more considerable, in proportion to the number of parts di- vided, and the larger surface ofthe wound. And for what is all this train of symptoms and dangers encountered ? The sole ob- ject is to prevent the protrusion of the bone, to make the soft parts extend be- yond its extremity, and to avoid an ex- foliation, the tediousness of wliich some- times seriously protracts the cure. This last consideration, says M. Louis, is fu- tile enough, since the prolongation of the treatment from this cause does not put the patient's life in any danger. How- ever it may be, the operation, which I have described, has all these advantages; the end ofthe bone is covered with flesh, and all the intentions, proposed in the flap amputation, are fulfilled in a manner, that is at once easy, less painful, and as free from inconveniences as possible., The reasons for preferring the method of amputating the thigh, which I have been explaining, admit of intuitive de- monstration. I have performed the ope- ration in the presence of many, who are capable of appreciating its merit. The "^newal of this mode of practising ampu- AMPUTATION. 91 tation will be as advantageous for the af- flicted, as honourable to surgery. I say, the renewal; for the plan is very ancient, and the first description, which we have ofthe manual of amputating limbs, is ,on the principle, which we have been detail- ing more fully, in order that it may be better understood. Upon this subject, Celsus has thus expressed himself: Inter unnam vitiatamque partem incidentla scapello caro usque ad os - - - reducenda ab eo sana caro et circa os subsecanda est, ut ed quoque parte aliquid ossis nutletur ; detn id serrulA prxcidendum est, quam proxime sanx carni etiam tnhxrenti. - - • Cutis sub ejusmodi curatione laxa esse debet, ut quam maxime undique os contegat. (Corn. Celsus, lib. 7. cap. ultimo.) In an historical dissertation on the am- putation of limbs, which is inserted in tlie Memoires de 1'Academie Royal des Sciences, annee 1732, the late M. Petit (the physician) has quoted- this passage in Celsus tn which he finds much-obscurity. Operations, apparently the most easy, are attended with delicacies, of which . only those can be aware, who are in the habit of seeing and reflecting upon them. A surgeon, accustomed to the perform- ance of amputation, and to the consider- ation of tlie inconveniences, to which the operation is liable, must be struck with the flash of light, that issues from the words of Celsus. Mr. S. Sharp, a cele- brated surgeon in London, is in this case; but, prepossessed about the practice of the day, he has only perceived in Celsus a glimmer, that has astonished him; he knew its safety; but, he did not pursue it. A judgment may be formed of what I have been remarking, from the passage, that I am going to cite from Mr. Sharp's work. " The first inconvenience, which I have mentioned, as a consequence ofthe ancient method of amputating, was the protrusion of the bone; for, making the incision di- rectly down to the bone at onCe, the mus- cles and skin afterwards withdrew, leav- ing a large portion of it either naked, or so little covered, that it always perished, and made an exfoliation necessary. This exfoliation was often a tedious and pain- ful work, and frequently, by long pre- venting the cure, reduced the woupd at last to an habitual ulcer. Or, if the wound did heal, the cicatrix proved so large, and the stump so pointed, that it was liable to ulcerate again. " These mischiefs resulte-oVpurely from the want of a lax skin in the neighbour- hood of the wound; for, cicatrization is not effected by the mere generation of a new skin; but, chiefly, by the elongation af the fibre," of the circumjacent skin to- wards the centre; and it is only when tlie skin resists a farther extension, that the cicatrix begins to form; from whence, it must plainly appear, that the more lax the skin is, the more readily will the wound heal, and the smaller will be the cicatrix. " But, though the old surgeons could not apply this maxim to practice, so use- fully as the moderns now do, yet, they made some efforts towards it; 'Jfor, before they amputated, they drew back the skin with all their force, and, after the limb was taken off, they might bring a larger quantity of it over the extremity of the bone, and obviate, in some degree, the inconveniences I have stated. However, this seems to have been all the contrivance they -were provided with to answer so great an end; unless, it may be admitted, that Celsus had a faint idea of the double- incision; and, to speak my own mind, I question, whether it can be doubted. In his chapter on the gangrene, he unluckily happens to be more concise, than usual ;* but, I think, he expressly says, th*t, after we have cut down to the bone, we must draw back the muscles, and cutdeep round the bone, so that a portion of it may be laid bare; after wliich, it is to be sawn off, as close as possible to the flesh. He tells us, that, by this method of treatment, the skin will be so lax as almost to covec the bone. " Perhaps, I may have mistaken Cel- sus's meaning; if I have not, it has been a great misfortune to mankind, that so bene- ficial an instruction should have been either overlooked, or misunderstood. But, it is cer- tain, no writer has copied him, and tlie double incision, as now perfected, is the invent ion of another great man ( Cheseldenf) to whom posterity will be always indebted for the many signal services he has done? to surgery. " It must be confessed, however, that, notwithstanding we derive such benefits * This criticism, passed by Mr. Sharp on Celsus, M. Louis thinks, might be an- swered by citing what a great man in his time has said of the great men of anti- quity ... lis avoient I'esprit eleve, des connoissance varices, approfondies, et des vues generates; et s'il nous paroit au premier coup d'oeil qu'il leur manquat un, peu d'exactitude dans de certains derails, il est aise de reconnoitre en les lisant avec reflexion, qu'ils ne pensoient pas que les petites choses meritassent tine at- tention aussi grande, que celle qu'on leur a donnee dans ces df-rniers terns. (M de Buffon, Histoire Nuturellej Premier Dis- cours, Tov.e 1.) 9J AMPUTATION from the double incision, tlie contractile disposition of the muscles, and, perhaps, of the skin itself, is so great, that, in spite of any bandage, they will retire from the bone, especially in the thigh, and some- times render the cure tedious. ' "To remove this difficulty, I have lately, on some occasions, made use of the cross-stitch, &c. (Sharp's Critical Inquiry into the present state of Surgery, p. 282,284, Edit. 4.) The best way of remedying this inconvenience, says M. Louis, is to follow the method, which Celsus has de- scribed. It seems that Mr. Sharp was the more called upon to adopt it, inas- much as he rightly considered it as a great misfortune to mankind, that so beneficial an instruction should have been either overlooked, or misunderstood. Led away, however, by tlie general prejudice, he commends the pretended advantages of the double inci- sion in saving as much skin as possible; but, he immediately afterwards owns the insufficiency of this method, and con- cludes with proposing, as a very useful assistance, an ancient practice, that is ab- solutely useless and hurtful. This is the opinion, which Vanhorue entertained of it,* and, in my first memoir on amputa- tion, I have adduced facts, which confirm the, sentiment of this writer. Such per- sons, as will take the trouble of reading attentively the reasons, which Mr. Sharp urges in support of this method, will see, that his arguments are by no means strong; and, says M. Louis, there is every reason to hope, that, after he has consulted experience, he will alter his opinion, and be generous enough to condemn it. By such conduct, Mr. Sharp has already gained great honour on points of equal importance. Instances of this kind are never afforded, except by men truly great. General rules, how solid soever they may be, almost always admit of modifica- tions, according to the diversity of the cases, to which they are to be applied. The flap amputation furnishes us with a proof of this observation. I believe, that I have urged strong reasons against this operation: but, it is not to be inferred, that" it should be proscribed in all cases. There are even some instances, in which it appears * Cum Hildano rejicimus Paraci metho- dum descriptam cap. 21, cum qiu.tuor lo- cis cutis fimbriae acu et filo traducto, ad se invicem adducit, et denudatum os ob- tegere satagit, ne ab acre laedatur. Quor- sum euim opus est aegrum non prafuturis carnific'u.is excmciare? (Microtechne, p. 485. See also HUdanus, lib. de Gangrxna et Sphacelo) to me, that it ought to be preferred to tlie other method. In a comminuted fracture, with laceration of the soft parts, where amputation is indispensable, if the cir- cumstances of the accident are such, that there are fewer parts to be divided, and, consequently, the pain will be less, in forming the flaps, than in amputating higher up, according to the other method; in this case, says M. Louis, all other things being equal, I should not hesitate to perform the flap operation. The cases, in which this mode deserves the prefer- ence, cannot be precisely specified. Dis- cernment is necessary to rate the advan- tages and inconveniences of either me- thod, in respect to particular circum- stances, as well as a great deal of saga- city, to be able, with a knowledge of the cause, to select the most proper course in delicate occurrences, where nothing less, than the life of a man, is at stake. SECTION 2. REMARKS ON THE AMPUTATION OF THE ABM, BV M. LOUIS. Authors have made no difference, says M. Louis, between the method of amputating the arm, and that which they have ad- vised for cutting off the thigh. External appearances, indeed, would lead.to a sup- position, that these members are only dissimilar in shape; and that such differ- ence necessarily requires none in the mode of operating. But, when these limbs are viewed less superficially, and the relative disposition, and action.of the component parts of the arm are seriously studied, a source of useful reflections will be discovered, with respect to the oon- duct, which ought to be pursued, in order to perform the amputation of this member with success. The humerus, from its middle to its lower part, is covered by muscles, which are adherent to it, and whose action is direct and parallel to the axis of the bone. This is not the case with the thigh: most of the muscles, which form its bulk, are either not at all adherent to the bone, or are only attached to it by surfaces of small extent. Besides, their direction is not parallel to the axis of the femur. Hence, as soon as they are divided, they draw themselves a great way from it, less on account of their retraction, than their change of situation in regard'to the bone; for, in becoming merely retracted, they retain their parallelism. In the arm, there is only the biceps muscle, along the front of the limb, which retracts itself" under the skin, and how badly soever amputation may be performed, no appre- hensions are ever entertained of the de- AMPUTATION. 98 nudation of the bone.* The stump is only liable to be pointed, which renders the cure more tedious, than it ought to be. I have several times observed the cause of this inconvenience in the amputation ofthe •arm, and I have noticed it even in oper- ations done by men, who had the reputa- tion of operating well; that is to say, of operating quickly, and with all possible dexterity. The soft parts were properly supported ,with two ligatures, between which, an incision was made down to the bone. The periosteum having been cut, and scraped downwards, the humerus was sawn precisely on a level with the muscles, according to the received maxim, that we should endeavour to make the section of the bone, and that of the flesh uniform, so that they may appear like a smooth cut, made at one stroke. What I have always seen happen in such a case, then took place: as soon as the circular liga- ture was taken away, the biceps retracts itself; but, the brachialis internus, the long and short heads of the triceps, and the coracobrachialis, cannot abandon the -hone, because they are adherent to it by one of their surfaces. The rest of the fibres, forming the substance of these muscles, and which are not attached to the bone, however, are retracted, and ren- der the stump conical. The operator, engaged in stopping the hemorrhage, and applying the dressings, does not take no- tice of this retraction; he is entirely taken up with applying the first dressings; and he thinks, that the projection of the bone is caused by the subsequent retrac- tion of the parts, whereas the retraction happens before his face, and is the imme- diate effect of the method of operating. I have not perceived the reason of this effect, in the cases, in which I have oper- ated myself, because 1 carefully followed the precepts given on this subject; and my endeavours to be exact blinded me. I only became conscious of it, as a specta- tor, when 1 was sufficiently well informed to reap instruction from the errors of my masters. The pointed form of the stump, after the amputation of the arm, may easily be prevented. If, after the first incision, made deeply down to the bone, the ligature, wliich supports the soft parts, * The denudation of the bone is uncom- mon even in the thigh, says M. Louis, un- less abscesses have promoted the occur- rence. The change in the situation of tlie muscles causes the femur toform a consi- derable prominence; but, still this bone usually remains covered by the cruralis muscle, and some fibres of other muscles attached to its posterior crista^ is removed, they retract. The muscular fibres, adherent to the bone, and the pe- riosteum, may then be divided, on a level with those fibres, which the retraction has brought nearer to their superior attach- ment. Attention to these circumstances, simple as it may seem, will enable the surgeon to saw the bone an inch higher, than he would be able to do, without such precaution. In this way, says M. Louis, I have accomplished -speedy cures, and never had any exfoliations. The observations, which have just been offered, are only applicable to the ampu- tation of that portion of the arm, where the fibres of tlie muscles are parallel to the axis of the bone. Another mode of pro- ceeding must be followed in operating at the upper part of the member; for, the case is here altogether different. This is an important consideration, which has not hitherto been adverted to. The at- tachments and the direction of the differ- ent muscles, to be cut, and the alteration unavoidably made in their disposition, according to the attitude, in which the limb is placed, merit particular attention. The deltoid muscle, as is well known, covers the Shoulder joint, and reaches ex- ternally nearly as far as the middle of the humerus. Its fibres are convergent to^the axis of this bone, and its action is direct. In order to amputate the arm towards its upper part, the limb should form a right angle with tlie body. In this position, the deltoid is shortened by a strong contrac- tion. This shortening, which precedes the division, incapacitates the fibres of this muscle from becoming any further re- tracted, when they are out. The deltoid, also, not being adherent to the bone,. may be pushed upward with the retract- or, so that thie bone may be sawn above the level of the extremity of the divided fibres. Therefore, inasmuch as this muscle is concerned, no inconvenience will arise. They are to be ascribed to the ill-made section of tlie tendons of the pectoralis major and latissimus dorsi. The action of these is likewise oblique, in regard to the axis of the humerus; their fibres form an angle with this bone; and, it follows from this observation, on the struc- ture and action of the parts, that, after tlie circular incision, tiie fibres of these muscles will retract, and a gaping wound will be produced, because the shortening" of tiie fibres will happen obliquely, on each aide, in a contrary direction. The absorption of the fat, and the shrinking of the soft parts, which, in other amputa- tions, cause the approximation ofthe skin towards the centre of the division, and are the chief means, by wliich nature ac- complishes the re-union of wounds with 9-4 AMPUTATION. loss of substance, cunnot have this salu- tary effect in the wound, that we are con- sidering. It is liable to degenerate into an habitual ulcer. Such instances I have seen, and the reason of them is manifest. The cicatrix never begins to form, till the skin can be extended no further. This is a reflection made by Mr. Sharp. The nearer we approach the upper part of the arm, the more we perceive the cause of this inconvenience, that is to say, of the difficulty, with wliich the skin extends towards the centre of the wound. The long head of the triceps, and the coraco- brachialis, both run obliquely; the last from the coracoid process; the first, from the inferior part of the neck of the sca- pula; to be inserted into the humerus, one anteriorly, the other posteriorly. When they are cut above their attachments to this bone, there is nothing to hinder their retraction, which will take place oblique- ly, in contrary directions. Such disposi- tion must obviously be unfavourable to the approximation of the skin to the mid- dle of the wound. The knowledge of the causes of this inconvenience ought to teach us how to prevent it; and, I believe, the object is not difficult. A preference should here be given to the flap amputation, as would be practised, were' it the intention of the surgeon to perform the operation at the shoulder joint. I reserve, for another memoir, some observations on the manner of executing this amputation. Suffice it to mention the advantage of making a flap, when we have to amputate the arm high up near the shoulder. The least reflection on what has been stated, concerning the direction and action of the muscles, will shew, that they could be retained, so as to facilitate the cure, only by preserving them, with the skin, beyond the level of the bone. The making of a flap will even prevent the symptoms, which are liable to be caused by the imperfect division of the tendons of the latissimus dorsi and pectoralis major. Every thing concurs in favour ofthe adoption of this method. Experience proves the inconveniences of the ordinary operation, as applied to the upper part of the arm. Reason demon- strates the utility ofthe practice proposed, and its success has been proved by seve- ral cases. M. Trecour, surgeon-major of the regiment of Piedmont infantry, and correspondent of the Academy, h .-com- municated to us an interesting fact on this point. During the siege of Maestricht, three days before the suspension of arms, M. de Moyon, a lieutenant in the Piedmont vrginjent. was struck by a cannon ball on the left arm. The humerus was smashed from the elbow to the upper middle por- tion, as high as within a finger breadth of its neck. A piece of the posterior part of- the bone was left, an inch long, and shaped like the mouth of a clarionet. .M. Trecour, on being sent for, went to the hospital ofthe trenches, and begged such of his colleagues, as he found there, to as- sist him with their advice. On viewing the considerable splintering, with wliich the wound was attended, they were of opinion, that the arm should be taken off at the shoulder joint. There were, in- deed, motives in justifica ion of their ad- vice. When we are obliged to amputate a limb, that is broken to pieces by any kind of external violence, it is a rule to perform the operation higher up than the wound. But, if the contusing body has been propelled by the force of gunpow. der, more extent is given to this precept. We are then directed to amputate above the nearest joint. The reasons, assigned for this doctrine, are principally founded on the in .-qualities of the bone, wliich is never smoothly broken, and the splinters of which are apt to extend far above the place, where the violence, has operated. Even, when the bone is neither splin- tered, nor smashed, as far up as the joint above the injury, it is customary to per- form amputation above such articulation, if the wound should be near it, under the apprehension, that the shock, which the member has received, may have injured, contused, or even lacerated the capsular ligament. This would give rise to swell. ing, inflammation, and abscesses of the joint; consequences, of which the patients ordinarily perish. M. Trecour felt all the validity of these reasons : the natural inference was, that the wound, being situated near the supe- rior articulation of the limb, the amputa- tion must be done in that joint. This case, however, gave rise to some doubts. the patient, aged eighteen years, was of the most delicate constitution imaginable; and he seemed little able to bear so tedious an operation, the consequences of which are sometimes grievous. Such are the sinuses, wliich are formed along the ten- dons, and reach even into the substance of the muscles. The advice of M. Tre- cour, was, therefore, followed, which was to make two lateral incisions, to turn up the flap of the deltoid, and, if the head and neck ofthe humerus should be found to be unbroken, not to amputate at the joint. Things proved to be so, and the bone was sawn through at its cervix, just at the base of the fragment shaped like the mouth of a clarionet. The flapsA AMPUTATION. 95 which were saved, extended more than two finger-breadths beyond the end of the bone. Although the operation took up little time, the patient fell into a debilitated state, so that his life appeared to be in danger. It was necessaiy to support him with cordials for two days ; the plan succeeded ; no future bad symptoms oc- curred ; and the patient got perfectly well. M. Trecour assures us, that, the same day, on which this operation was per- formed, his colleagues had occasion to do two amputations in a similar way, for nearly the same sort of injuries, and that the cases did exceedingly well. From these facts, he makes thetollowing infer- ence : *' Among the motives, assigned for the practice of amputating limbs higher than the articulations, above the wound, we should not so generally adopt that, which is deduced from the commotion of the ligaments, holding the heads of the bones in their cavities. It even appears, that the more the bone is broken, the less the shock and concussion must be; as may be observed in injuries of the head, where the commotion is greater, or less, on account of the resistance made by the bones of the cranium." There are few cases, which do not offer some circumstance or another, that has not been the object of particular consider- ation, and that would constantly escape our notice, were we not engaged in eluci- dating some particular doctrine, with which it is connected. M. Trecour men- tions, that he sawed the bone at the base of the end of the fracture. A cursory perusal of this circumstance does not ap- pear to present any prospect of material improvement in practice; yet, says M. Louis, it has been of use, inasmuch as it has led us to investigate the difficulties, which occur in this operation. There is no surgeon, at all versed in practice, that has not experienced the trouble there is in fixing the part during the action of the saw, even in operations, where the limb is entire, and, consequently, where there is the best opportunity of holding it with firmness. The reason of this is self-evi- dent. The assistants only afford move- able points of support ; and whatever pains they may take to fix the extremity operated upon, they cannot prevent the motion, which takes place involuntarily in the articulation of the limb with the trunk. But, wiien we have to saw the end of a bone, which can hardly be laid hold of, the difficulty in fixing it must.be far greater. M. Bertrandi informed me, that he has been a witness of this incon- venience. A Piedmontese officer did not get well after amputation of his thigh, because the bone protruded. It was therefore determined to saw the project- ing part off. Endeavours were made in vain to effect this operation; the limb could not be kept steady enough. M. Bertrandi then proposed a very simple means, which answered the purpose, and wh.ch he has since employed with suc- cess. It is a machine, composed of a per- pendicular piece of wood, firmly fixed on a foot and notched at its upper part, so as to form a kind of fork. This notch affords the end of the bone an invariable fixed point, which renders an assistant unne- cessary for this object, who may now be employed in pressing upon the limb, till the bone is half sawn through. The part must afterwards only be held laterally. With this machine, the bone cannot slip about, and it may be sawn, with as much ease, as a stick on a trestle. Tins means appears to me commendable on account of Us simplicity, and, I believe, there are numerous occasions, on which it may be employed with advantage. In common amputations, a machine, constructed on the principle ofthe Ambi of Hippocrates, in order to support the limb, together with a contrivance, that would answer tlie views of Bertrandi, might be used, in cases, where assistants are not at hand, or instead of careless stupid assistants, by whom the bone is frequently splin- tered. SECTION 3. REMARKS OK THE AMPUTATION OF THE LEG, BT M. LOUIS. Such authors, as have treated the most correctly of the amputation of the leg, have paid some attention to the particular disposition of the parts, which compose the limb. They have recommended the operation to be done below the tuberosity of the tibia, in order to avoid cutting the tendons of the muscles. They have de- termined, that the operator should place himself between the patient's legs, for the sake of sawing the bone with most ease; and they have given directions, how to employ tlie saw most advantageously. Such are nearly tlie particular objects, on which they have dwelt. A considerate reflection on the relative disposition of the. parts, which enter into the formation of the leg, cannot fail to furnish, room for more extensive remarks on this ope- ration. The absorption of tiie fat, the subsi- dence ofthe soft parts, and the diminution of the cellular substance, cause the skin to advance considerably over the stump in amputations of tlie arm and thigh; and 96 AMPUTATION. we have shewn, says M. Louis, that the integuments can never contribute to the inconveniences following those operations. But, thi-. is not the case, with regard to the leg; h-re the skin is the immediate covering of a large surface ofthe principal bo*e. There are no soft parts interposed, the primitive retraction and subsidence of which can occasion the skin to project on the stump. The precept, therefore, to preserve as much of the integuments as possible essentially claims the surgeon's case in the amputation of this part. The precautions directed, on this account, consist in pulling the skin firmly towards the knee, and in adopting the double in- cision. The ancients observed the first of these rules; they were ignorant of the second, but, they obtained all its advan- tages by the position of the patient, and the attitude, in which the limb was put during the operation. We are in the ha- bit of having the thigh and leg held hori- zontally. This posture is attended with obvious objections; for, after the opera- tion, the thigh and stump are placed in a state of flexion, by which means, the skin is drawn up, and tiie end of the tibia is necessarily denuded. Ambroise Pare" wished, that "lajambe fut unpen ploy ee pendant I''operation, et qu'on I'etendit ensuite, afin que les vaisseaux fus- sentplus saillans." This precaution appear- ed to him necessary, because he used to take up the vessels with forceps in order that they might be tied. Guillemeau car- ried his views further; he knew the ad van- tage of bedding the leg, during amputa- tion, in promoting the extension of* the skin over the end ofthe bone after the operation. He directs, .that the surgeon " se mettra entre les jambes du rnalade, et commandera d un serviteur de rehausser gontremont le plus qrlil pourra le cuir et les muscles situes en la partie qu'il eonviendra extirper, ayant auparavantfait plier et Hi- chir letht membre, tant ifin de fau-e prolong- er la pe^u, que les veines et les arteres." The reasons, why this usetul position has been aba idoned, are naturally ob- vious. The limb in amputating must be firmly held, and, when the thigh and leg are bent, it is extremely difficult for the assistants to fix the lower extremity. M. Louis says, it is surprising, that, among the successors of Pare* and Guillemeau, not one should have paid attention to the advantages of the posture, which these celebrated men recommended, with a view of obviating inconveniences, which they had experienced. M. Louis next speaks of an apparatus, by which the leg mi$rht be rendered suffi- ciently steady in the bent position to ad- mit of the saw being used; but, the ob- servations on this subject I have omitted. M Louis, indeed, acknowledges, his con- clusion, that the horizontal position will be always continued by practitioners. In this circumstance, says he, the precau. tion of drawing the skin up towards the knee will not suffice for the preservation of an adequate quantity. Hence, the double incision has been resorted'to; i.e. the skin is first divided by a circular in- cision, an inch below the place, where it is intended to saw the bone, in order to be able to draw the integuments upward, and keep them there with a band, while the muscles are cut on a level with them. I have examined this mode of proceeding attentively, and, I am of opinion, that it admits of being shortened, so as to lessen the pain of the operation. The gastroc- nemius and solxus muscles, which form the major part ofthe bulk ofthe leg, and are the only ones not adherent to the bone, retract as soon as divided. The skin, which is insusceptible of such retraction and is more extensible, will always pro. ject more than those muscles, even were the latter cut on the same line with the wound of the integuments. It follows from this consideration, that the operation by the double mcis.on can only be com- mendable, on the ground of having a suf- ficient quantity of -skin to cover that par. tion of the tibia, vhich is directly under the integuments; and thus, says M. Louis, the benefit, expected from the double in- cision, is limited to a part of the circum- ference of the member. But, this advan- tage may be obtained, by merely making, through the skin of the anterior part of the leg, a semicircular incision, reaching from the internal edge of the tibia to the outside of the fibula. In this method, the patient will be saved from the pain, that would arise from dividing the skin, so as to make the cut completely circu- lar. This first cut may be made more or less advantageously. It has appeared to me, observes M. Louis, that the most proper plan is to draw the skin up, from a point sufficiently low down, and to fix it with a band, in such a way, that the incision, which is to be made above this band, will be an inch lower, than the place where the bone is to be sawn. The band, when applied with due tightness, will keep the skin from descending, and will aid in fixing the soft parts, above the part, where they are to be divided. The semicircular incision of the integuments having been made with a common scalpel, the skin must be drawn-up ward: there.it is to be kept by means of another band; and then the section ofthe soft parts is* to be completed, on a level with tlie skin» "ttttis raised on the front of the limb. AMPUTATION. 97 In performing' this second incision, it will be very useful to incline the edge of the knife obliquely upwards. By this means, the skin will be longer than the muscles, and the cure will be considerably accelerated, &c. After this incision, the flesh, betwixt the two bones, it to be divided, and, then, the periosteum, as usual. It remains to saw the bones. Authors have given different advice on this sub- ject. Some say, we should begin with the fibula, and end with the tibia; be- cause, if we were to saw through the tibia first, the fibula, remaining alone, would hardly be able to bear the action of the saw, without great disturbance ofthe soft parts. Others, whose counsel is most list- ened to, recommend us to apply the saw to both bones, in such a -manner, however, that we are to begin with dividing a part of the tibia, until the instrument has reached the fibula, when the two bones are to be sawn together. Thus, the tibia serves, as a support, while the fibula is divided, and the sawing ends with com- pleting the section of the tibia. This practice seems very rational; but, it does not entirely prevent the moveableness of the fibula, which, unless care be taken, will move about under the saw, and even cause laceration of the muscles. In order to avoid this inconvenience, says M. Louis, I have always taken care to direct the assistants, who hold the limb, to press tlie fibula strongly against the tibia. This precaution, however, cannot be follow- ed, when the bones are much broken, nor in cases of worm-eaten caries, and it is always less safe and commodious, than a plan, which, in these cases, is adopted by Bertrandi. As soon as this surgeon has divided the flesh, which is between the bones, before sawing them, he applies round them a strong narrow ligature. This cotd brings the fibula nearer tlie tibia, and fixes it in a way, that materially facilitates the action ofthe saw. It is on- ly by combining several little practices of decided utility, that we can expect to bring the operative part of surgery to per- fection. On the subject of Verduin's mode of amputating the leg so as to form a flap, M. Louis observes, that the operation is tar more painful, than that which is ordi- narily performed, and Verduin is candid enough to believe this, rather than the modern panegyrists of his method. Ver- duin states positively, that it is cruel and embarrassing; but, carried away, as he was, with the ambition of being praised, as the inventor of a new practice (of which, by the by, not he, but Loudham was,) his seduced imagination made him see unreal Vol. I. advantages in this method, and blinded him, in respect to its defects. In speaking of a young man, on whom this opera- tion was successfully performed, Verduin states, that he walks and bends his knee so freely, that it is hard to say, which leg is of the most use to him. Such an exag- geration, observes M. Louis, is not unusu- al with an author, whose foible is to insist on the merit of his own invention. But, it is very singular, that a modern writer, the only one, who has bestowed, unquali- fied praise on this method, should have alleged, in the most extravagant strain of prejudice, that officers, on whom thi9 operation have been done, have been seen dancing and jumping, just as if they had real legs. Such gratuitous assertions, says M. Louis, are not to be believed; they are the effect of immoderate admiration, and can deceive nobody. I shall pass over what M. Louis urges against Verduin's pretension to effect a cure by apposition ofthe parts, without suppuration. It was alleged, that they, on whom the flap amputation of tlie leg had been performed, suffered no sympathetic pain in the limb. Verduin thought, that this was proved by an example, in which a man had had his leg cut off at sea. He felt severe and grievous pains, seeming as if they were in the amputated foot. As the stump was too long, part was amputated by the new method, and the shootings and pains, formerly experienced, were no longer felt. Celsus, observes M. Louis, would not have approved this second ope. ration; but, would have considered it as superfluous: Stultum est decoris causa rur- sum et dolorem et medicinam sustinere, lib. 5, cap. 26. Had Verduin been offering his opinion on the invention of another, he would have perceived reasons in expla<* nation of the pains being relieved; and, no doubt, he would not, for want of such reasons, have argued, that a solitary fact was sufficient to establish a general con- sequence. Indeed, about five years after Verduin's dissertation was published, the famous Ruysch ^assisted at an operation, performed according to this new method; it succeeded; but, the patient was not exempt from the sympathetic pains. Be- sides, there is no reason authorising the supposition, that such an advantage would result from this manner of operating. Another point, adverted to by M. Louis, is the moveableness of the stump. The panegyrists of this method have regarded the preservation ofthe motion of the knee, as an advantage exclusively belonging to this operation. But, Verduin positively states, that the motion of tlie knee con- tinues free, if care be taken to move it, O 98 AMPUTATION. from time to time, during the treatment. Would not the same thing happen, after the common operation, with the same pre- caution ? Tlie saving of a flap cannot at all promote tlie motion ofthe stump, since the use of the muscles, which compose such flap, is to move the foot. The mo- tion ofthe stump depends upon the action of muscles, wliich are situated in the thigh, and which are inserted into the leg, above the place, where the amputa- tion is performed. The motion of the knee may, therefore, be preserved after the ordinary operation; and it is not an advantage particularly arising from the flap amputation, as has been asserted^ through inattention to the mechanical ar- rangement, and the use of the parts. With regard to the utility, alleged to proceed from the flap serving as a cushion to the bone, so that the patient bear on the end of tiie stump, without any incon- venience, or pain, M. Louis remarks, that he knows not, whether the portion of flesh, that grows in its new situation, is of a nature to sustain, without any ill effects, the weight ofthe body, under narrow sur- faces, and a substance, as hard as the ends of the bones; but, that, to facilitate pro- gression with an artificial leg, which imi- tates the natural one, there is no occasion for the weight of the body to bear on the end ofthe stump. Ttraize of the upper part of the tibia allows a machine to be adapted, that will afford, under the head of this bone, a circular point of sup- port, on which the weight of the body may be sustained. M. Louis argues, that nearly all the partisans of the flap operation, before the time, when he wrote, had only extolled it speculatively. Garengeot was the only one that had practised it. It is a reflec- tion against the real superiority of this method, that it has been relinquished in the very country, where it was first re- ceived as an important discovery, and where it had been originally practised with success, by surgeons of skill and re- putation. Good things, adopted by seve- ral persons at once, in different parts, do not usually fall into disrepute, especially, if pains be taken to cultivate the art, and keep it from declining. Had the flap amputation possessed all the advantages, that were ascribed to it, it would not so soon have been abandoned. Objections to the plan must also have conduced to its declensioM. M. Louis then adverts to the probability, that abscesses frequently formed in the stump, when any part of the flap did not unite; and he concludes with observing, that if the retraction of the muscles, composing the flap, prevented the bone being covered, all the alleged benefit of theplan was lost. This might the more easily happen in the leg, inas- much as the bones were at the circumfer- ence of the wound, and the largest sur- face, which they presented, was exactly at that point of the circumference, which was opposite the base ofthe flap, towards which the retraction must have taken place. In relating the inconveniences and objections, which present themselves to me (says M. Louis,) I do not mean to deny the facts in testimony of the success of the operation; the object of the discus- sion is to ascertain, if this plan is prefer- able to the other. SECTION 4. REMARKS OIT THE AMPUTATION OF THE FOM- ARM, BY M. LOUIS. Of all the amputations which I have seen, that ofthe forearm most frequently proves unsuccessful. From the middle to the lower end of this part ofthe limb, the member is composed of numerous ten- dons ; and amputation, done at any point of this extent, leaves the bone denuded, and the cure is tedious and painfi/i. Towards the upper part ofthe forearm, the radius and ulna are sufficiently co- , vered with muscles, which never leave the bone denuded, because they are adhe- rent to it, and are bound down by strong aponeuroses. These tendinous expan- sions even pass into the interstices ofthe muscles, and furnish these organs with particular sheaths, serving to confine them in their proper direction. The knowledge of this structure of the parts will indicate to us certain rules of conduct, which will contribute to the perfection and success of our operations. The preliminary division of the skin, which we have rejected as useless in some cases of amputation, is essentially proper in that of the forearm. The adhesion of the muscles, and tlie way, in which they are fixed in their direction, make it ne- cessary to save as much skin as possible, in order that this may extend to the edge of the divided muscles. In order to make this first cut advantageously, continues M. Louis, the inferior ligature should first be put round the limb, with the precau- tions, which have been explained in speak- ing of the amputation of the leg. While an assistant draws the skin upward, as much as possible, in embracing the whole circumference of the limb with both his hands, the operator is to apply the liga- ture at least an inch lower than the place, where he designs to saw the bones, He is then to make a circular incision, above this ligature, the assistant observing at AMP ANA 99 the same time to pull the skin towards the elbow joint. The upper ligature is next to be applied with a view of fixing the soft parts, and tlie skin that is drawn up, and the muscles are to be divided on a level with it, in the ordinary way. For making these incisions, says M. Louis, the curved knife does not appear to me so convenient, as a bistouiy with a slightly convex edge; for, the forearm is not round, its figure being that of an oval, flattened on the inside. When the mus- cles and periosteum have been completely divided, the bones are to be sawn. The limb is usually put in a state of pronation, the surgeon standing on the inner side. The saw is to be applied horizontally, in such a manner, that the bones may be cut at once, beginning, however, with the ulna. The radius, every body knows, is exceed- ingly moveable, and is much more diffi- cult to fix, than the fibula. M. Louis, therefore, conceived, that it might be an useful precaution, to tie the two bones of the forearm together with a ligature, as Bertrandi used to do, with respect to those ofthe leg. (See Memoires de I'Acad. de Chirurgie, Tom. 5. Edit, in 12mo.) The following sources of instruction, on the subject of amputation, are parti- cularly entitled to notice : Celsus de Re Medicd. CEuvres tie Pare, livre 12, chap. 30 and 33. Sharp's Operations of Surgery, chap. 37. Sharp's Critical Enquiry into the present State of Surgery, chap. 8. Ravaton's Traite des Plaies d'Armes d Feu. Bertran- dps Traite des Operations de C/ururgie, thap. 23. Le Dran's Traite des Operations de Chirurgie. Heister's Instil. Chirurg. Pars 2. Sect. 1. Young's Currus Trium- phalis e'Terebinthind, Londini 1679. Nou- velle Met/wde pour faire Poperation de PAmputation dans PArticulation du Bras avec I' Omoplatepar M. la Faye. Histoire de PAmputation, suivant la Methode de Verduin et Sabourin, avec la Description d'un nouvel instrument pour cette Operation, par M. la Faye. Moyens de rendre plus simple et plus stire PAmputationd Lambeau,parM. de Ga- rengeot. Observation sur la Resection tie P Os, apres PAmputation de la Cmsse, by M. Vey- ret. Memoire sur la Saillie de P Os apres PAmputation des Membres; ou P on examine les causes de cet inconvenient, les moyens d'y remedier,et ceux tlelaprevenir,parM. Louis. Second Memoire sur PAmputation des Gran- ties Ettre mites, par M. Louis. The forego- ing Essays are in Mem. de PAcad. de Chi- rurgie, 'Tom. 5. Edit. 12mo. Essai sur les Amputations dans les Articles, par M. Bras- dor, in Tom. 15. ofthe same work. Bilguer on the Inutility of Amputation. White's Cases in Surgery. Bromfield's Cldrurgical Obser- vations und Cases, Vol. 1. chap. 2. O'HaHo- run's 'Treatise on Gangrene, &c. with a new method of Amputation. Alanson's Practical Observations on Amputation. Pott's Re- marks on Amputation. Sabatier's Medecine Operatoire, Tom. 3. Hey's Practical Obser- vations in Surgery, Edit. 2. Remarques et Observations sur I'Amputation des Mem- bres, in CEuvres, Chir. de Desault par Bichat, Tom. 2. Encyclopedic Methodique, Partie Chirurgicale, Tom. 1. art. Ampu- tation. Rees' Cyclopxdia, art. Amputa- tion. Vermischte Cliirurgische Schriften, von J. L. Schmucker, Band. 1. John Bell's Principles of Surgery. Cases ofthe Exci- sion of carious Joints, by Park and Moreau, published by Dr. Jeffray. Operative Sur- gery, by C. Bell, Vol. 1. Richter's Anfangs- gr-undeder Wundarzneykunst,Band7 ■ Riche- rand's Nosographie Chirurgicale, Tom. 4, Edit. 2. B. Bell's Surgery, Vol. 5. Me- moire sur PAmputation des Membres, in Pelletan's Clinique Chirurgicale, Tom. 3. Gooch's Chirurgical Works—various parts of the three volumes. Larrey'a Relation Chirurgicale de PArmee iT Orient en Egypte et Sgrie. Petit's Traite des Maladies Chirurgicales, Guthrie on Gunshot wounds, &c. AMYGDALA. The tonsils, so termed from their resemblance to almonds. (See Tonsils.) AMYLUM. Starch. The word is de. rived from «neg. and (t,vX>i, a mill, because starch was formerly made of corn, with- out being ground in a mill. Powdered starch is sometimes used as an external application to erysipelas; but, chiefly, in glysters, when the neck of the bladder is affected with spasm. The following is the formula used at St. Bartholomew's Hospital. $t Mucilaginis Amyli, Aquae distillats, sing. §ij Tinct Opii guttas quadraginta: Misce. ANASARCA, (from xvx, through, and tr»t\, flesh.) A dropsical disease, in which an aqueous fluid is extensively diffused in the general cellular texture of the body. When less extensive, the complaint is termed, xdema, which then becomes a surgical case, unless entirely dependent on constitutional causes. ANASTOMOSIS, (from «y«, through, and oTo/*tt a mouth.) Inoscxuatio. Ana- tomists and surgeons imply, by this term, the communications of the blood vessels with each other, or their running and opening into each other, by which the continuance of a free circulation of the blood is greatly insured. The immense importance of this part of our structure, in all cases in which the main artery, or, vein of a limb, is rendered impervious* is particularly conspicuous in aneurisms. (See Aneurism.) ANATKE3IS,(from«v«, and urftt»,to 100 A N C ANC perforate.) Galen signifies, by this term, the operation of trepanning. ANCHYLOBLE'PHAKON. A concre- tion ofthe eyelids; a closure of them. ANCHYLOGLO'SSUM. . An accretion of the tongue to the adjacent parts 5 also being tongue-tied. (See Frxnum Lingux.) ANOHYLOMtfKl'SMA. A growing together of tlie soft parts. ANCHYLOl'S, (from tvy%i, near, and trjs, the eye.) Same as JEgylops. ANCHYLOSIS, (from ayKvXot, crOok- ed.) This denotes intimate union of two bones, w hich were naturally connected by a moveable kind of joint. All joints ori- ginally designed for motion, may become anchylosed, that is, the heads ofthe bones, forming them, may become so consolidat- ed together, that no degree of motion whatever can take place. Bernard Conner (De stupendo ossium coalitu) describes an instance of a general anchylosis of all the bones of the human body. ' A still more curious fact is mentioned in the Hist, of tlie Acad, of Sciences, 1716, of a child 23. months old, affected with an universal an- chylosis. In the advanced periods of life, anchylosis more readily occurs, than in the earlier parte of it. The author ofthe article anchylosis hi the Encyclopedic Me- thodique, mentions his having preserved a specimen, in which the femur is so anchy- losed with the tibia and patella, that both the compact and spongy substance of these bones appears to be common to them all, without the least perceptible line of separation between them. In old subjects, the same kind of union is com- monly observable between the vertebrs, and between these and the heads of the ribs. The greater, or lesser degree of immo- bility, has caused anchylosis to be distin- guished into the true and false. In the true anchylosis, the bones have grown to- gether so completely, that not the smallest degree of motion can take place, and the case is positively incurable. The position, in which the joint has become thus inalterably anchylosed, makes a material difference in the inconvenience resulting from the occurrence. The false anchy- losis is that, in .iich the bones have not completely growa together, so that their niotiori is only diminished, not destroyed. The true anchylosis is sometimes termed complete; the false, incomplete. Li young subjects in particular, anchy- losis is seldom an original affection, but genially the consequence of some other disease- It very often occurs after frac- tures, 11' the vicinity of joints; after sprlins, and dislocations attended with a great deal of contusion; and after white swell- ing* and abscesses in joints. An?£™™* and swellings and abscesses on the out. tide of a joint, may also induce anchylo- sis. In short, every thing which keepi a joint long motionless, may give rise to the affection, which is generally the more complete the longer such causes have operated. When a bone is fractured near a joint, the limb is kept motionless by the appa- ratus, during the whole time requisite for uniting the bones. The subsequent in- flammation also extends to the articula- tion, and attacks the ligaments and sur. rounding parts. Sometimes, these only become more thickened and rigid; on other occasions the inflammation produces a mutual adhesion of the articular sur- faces. Hence fractures so situated, arc more serious than when they occur at the middle part of a bone. But, it is to be noticed, that all fractures leave, after their cure, a certain degree of stiffness in the adjacent joints; but, this arises from the inactivity, in which the muscles and arti- cular surfaces have been", "and may gene- rally be cured by gradually exercising, and increasing the motion ofthe limb. The position of an anchylosed limb is 1 thing of great importance. When ab- scesses form near the joint of the fingers, and the tendons mortify, the fingers should be bent, that they may anchylose in that position, which renders the hand much more useful, than if the fingers, were per- manently extended. The knee, on the contrary, should always be kept as straight as possible, when there is danger of an- chylosis. The same plan is to be pur- sued, when the head of" tlie thigh bone ii dislocated in consequence of a diseased hip. When the elbow cannot be prevented frambecominganchylosed,thejointshould always be kept bent. No attempt should ever be made to cure, though every pos- sible exertion should often be made to prevent, a true anchylosis. The attempt to prevent, however, is not always propeis for many diseases ofjoints may be said to terminate, when anchylosis occurs. When the false, or incomplete anchylo- sis is apprehended, measures should be taken to avert it. The limb is to be moved as much as the slate of the soft parts will allow. Boyer remarks, that this precaution, is much more neclssary in affections of the ginglhnoid articula- tions, than of the orbicular ones, on ac- count ofthe tendency ofthe former to be- come anchylosed, by' reason of the great extent of their surfaces, the number of their ligaments, and tlie naturally limited degree of then- motion. The exercise of the joint promotes the ANC secretion of the synovia, and the grating first perceived in consequence ofthe defi- ciency of this fluid, soon causes. A cer- tain caution is necessary in moving the limb: too violent motion might create pain, swelling, and inflammation, and even ca- ries of the heads of the bones. It is by proportioning it to the state of the limb, and increasing its extent daily, as the soft parts yield and grow 6upple, that good effects may be derived from it. (See Jioyer Mai. des Os. Tom. 2.) The use of embrocations, and pumping cold water on the joint, every morning, have great power in removing the stiffness of a limb remaining after the cure of fractures, dis- locations, &c. Unreduced dislocations are not always followed by anchylosis. Nature often forms a new joint, especially in persons of the lower order, who are obliged to move their limbr a great deal, in order to obtain a livelihood. The surrounding cellular substance becomes condensed, so as to form, around the head ofthe luxated bone, a membrane serving the purpose of a cap- sular ligament. The muscles, at first im- - peded in their action, become so habitu- ated to their new state, that they resume their functions. This is particularly the case with bones which move in every di- rection, and have round heads; but, in ginglimoid joints, the heads of the bones are only imperfectly dislocated, and the motion is greatly restrained by the ex- tent of surface ; while some of the nu- merous ligaments are only sprained, not ruptured. These causes promote the oc- currence of anchylosis. ' Anchylosis may follow contusions of the joints, and such shocks, as the articular surfaces experience in leaping, or falling * on the feet, from great heights. This is more likely to happen, when the inflam- matory symptoms, resulting from such violence, have not been properly counter- acted by bleeding, and other general re- medies. Sprains, which violently twist the joints, very often, on this account, cause an anchylosis, especially, when the Inflammation has long hindered such joints from being at all moved. When diseases of joints end in a com- plete anchylosis, the occurrence is to- be looked upon, as a very favourable one. In fact, it is as much a means of cure, as the formation of callus is for the union of broken bones. The disease of the verte- brae, described by Pott, is cured, at soon as tlie bones anchylose, nor can the pa- tient be considered well, before this event has taken place. Sec on this subject P Encyclopedic Methodiquc,Partie Chirurgi- cale, Tom. 1. art. Anchylose. Beyer sur les Mai. des Os. Tom. 2. RiokerantPs Noso- graphic C/i-iirgicale, Tom.3,p. 238,edit. 2. A N E 1Q1 ANEURISM, or Aneurism, (from *uv(via, to dilate.) The tumours which are formed by a preternatural dila- tation of a part of an artery, as well as those swellings, which are occasioned by a col- lection of arterial blood, effused in the cellular membrane, in consequence of the rupture, or opening ofthe coats ofthe ar- tery, receive the name of aneurisms. Ac- cording to the common opinion, then, aneurisms are of two kinds; the first be- ing termed true ; the second, spurious, or false. Some writers admit a third species, which is said to happen, when, in conse- quence ofthe external coata ofthe artery having been divided, the internal tunics are protruded, much in the same manner as the peritoneum is by the intestines, or omentum, in cases of hernia. This ima- ginary case has been denominated the mixed aneurism. Aneurisma. herniam arte- rix sistens. It was no less celebrated a man, than Dr. William Hunter, who first supposed, that a disease, like the last, might proceed from the outer coats of an artery being cut, and the inner ones be- coming consequently dilated. But, the experiments of Hunter and Home, as I shall have occasion to mention again, fully prove, that an aneurism will not arise from the kind of weakness, which cutting, or even stripping off, the external coat of an artery must produce; and Scarpa, as I shall presently notice, satisfactorily shews, that, in all common aneurisms, the internal coats of the affected artery are invariably ruptured or wounded. It deserves attention, however, that, by the term mixed aneurism, Dr. Alexander Monro implied the state of a true aneu- rism, when its cyst has burst, and the blood has become diffused in the adjacent cellular substance. This event is cer- tainly a real one ; but, Dr. Hunter's case may be deemed altogether suppositious. Besides these common divisions of aneu- rism, there are two other kinds, one named the aneurismal varix, or venous aneurism ; the other called by Mr. John Bell, the aneurism from anastomosis ; the particulars of both which cases will be offered in due time. Before the time of Galen, the diseases, now known by the name of aneurisms, do not appear to have been noticed. It was the doctrine of this physician, that such swellings were produced either by anas- tomosis, or by rupture, and he has de- scribed their symptoms, without inform- ing us, however, of the characters by which each of these cases was distinguish- able, one from the other. Paulus iEgineta endeavoured to give a more particular ac« count of tlie diagnpsis, and he has de- ' tailed different modes of operating, appli- cable to the various cases of the disc**'' 102 ANEURISM. The sentiments of these writers was adopt- ed by all their successors down to Ferne- lius, who declared, that every aneuris- Hial tumour was occasioned by a dilata- tion of tlie coats of the arteries. This opinion has been almost universally adopt- ed by the moderns, and, until tne late publication of Scarpa, few surgeons en- tertained a suspicion, that a doctrine, so positively taught in the schools, could pos- sibly be erroneous. Even the learned Sabatier say s, there can be no doubt, that many aneurisms depend upon the dilata- tion of the arterial coats; but, continues he, when this happens, the cases present remarkable differences. Sometimes the three arterial tunics are dilated all toge- ther. In other instances, only the two in- ternal coats-are affected with dilatation. While, in more numerous examples, the in- ternal tunics are ruptured, and it is the cel- Udar coat alone, which separates from them, and enlarges, so as to form the aiieurismal sac; de sorte que les arteres, qui sont dans ce cas, sont diloriquees, suivant P expression de Lancisi. Jt is difficult to conceive, observes Sa- batier, how all the coats of an artery can dilate and yield sufficiently to form the investment of such immense tumours as some aneurisms are. Indeed, that very tunic, which composes the greater part of the thickness of the vessel, and wliich is termed the muscular coat, is known to con- sist of fibres, whose texture is firm, and little capable of bearing extension. How- ever, Sabatier states, that there are some observations, which prove, that the mus- cular tunic may become dilated as well as the others. Haller, in describing a very large aneurism, situated in the aorta near the heart, relates, that the innermost coat of this vessel, was ruptured and torn, the loose jagged edges of the laceration being visible in the aiieurismal sac. These were squamous, bony, and of little thick- ness; while the muscular and cellular coats were quite sound. Donald Monro noticed the same tiling in five different aneurisms, which occurred in the course ofthe femoral and popliteal arteries of a man, who had been confined a long while to. his bed, after submitting to the opera- tion for the bubonocele. Monro succeeded in tracing the fibres ofthe muscular coat over these swellings, so that he had no doubt of this tunic being dilated. Saba- tier thinks, that it is not to be inferred, that all such writers, as have related the histories of time aneurisms, proceeding from a dilatation of all the arterial coats, ran have been mistaken, although they have not minutely described .the tex- ture of the sac, in which the blood was contained. Yet, possibly, adds the 5..me judicious writer, most of these aneu- risms may have been of a similar kind to those, which result from the rupture of the internal tunics of the arteries, and the dilatation of the cellular coat; for, in such tumour, the fragments of the lace- rated coats are often blended with osseous, steatornatous, or purulent matter, and confounded with the cellular coat, that forms the exterior investment. (See Me- decine Operatoire, Tom. 3. p. 160—162.) We find then from the foregoing observa- tions, that Sabatier was much disposed to consider the true aneurism, or that sup- posed to be formed by a dilatation of all the arterial tunics, as, by no means a case, that is of usual occurrence, or that has been satisfactorily demonstrated. This eminent surgeon, I think, is the first mo- dern author, who has shewn a propensity to doubt the notion, so generally enter- tained at the present day, concerning the actual dilatation of all the coats of the artery in cases of true aneurism ; and this remark is the more deserving of notice, in consequence ofthe opinions lately pro- fessed by Scarpa, on the point in question. The latter writer, we shall presently see, sides entirely with the ancients on this subject, and, as he is unsurpassed in mi. nute anatomical investigations, and in ac- curacy of observation, his sentiment can- not fail to have great weight in the mat- ter. Previously, however, to offering an account of his opinions, concerning the formation of aneurisms, it seems proper to make the reader acquainted with the various species of the disease, their or- dinary symptoms, and a few other circum- stances, as usually explained by surgical writers. When any part of an artery has the ap- pearance of being dilated, the swelling is commonly named a true, or genuine aneu- rism. In such cases, the artery either seems only enlarged at a small part of its track, and the tumour has a determinate border, or, the vessel seems dilated, for a considerable length, in which circum- stance, the swelling is oblong, and loses itself so gradually in the surrounding parts, that its margin cannot be exactly ascertained. The first case, which is the most common, is termed the circumscribed true aneurism; the last, the diffused true aneurism. When blood escapes from a wound, or rupture, .of an artery, into the adjoining cellular suBstance, the swelling occasioned is denominated the spurious, or false aneurism. In this instance, the blood either collects in one mass, distends the cellular substance, and condenses it into a cyst, so as to form a distinctly cir- cumscribed tumour; or it is injected into all tlie cavities of the surrounding cellu- lar substance, and extends along the ANEURISM. 103 uourse of the great vessels, from one end of the limb to the other, thus producing an irregular, oblong swelling. The first case is named, the circurtucribedfalse an- eurism ; the second, the diffused false an- eurism. (Richter's Atifangsgr. Band. 1.) Mixed aneurism was the name given by Dr. W. Hunter to one which he supposed might proceed from the outer coats of an artery being cut, and the inner ones be- coming consequently dilated. But, the experiments of Hunter and Home, as we shall have occasion to mention again, fully prove, that an aneurism will riot arise from the kind of weakness which cutting, or even stripping off, the exter- nal coat of an artery, must produce ; and Scarpa, as we shall presently notice, sa- tisfactorily shews that the internal coats are always ruptured. By the mixed aneu- rism, Dr. Monro implied, the state of a 'true aneurism, when its cyst has burst, and the blood has become diffused in the adjacent cellular substance. This event is certainly a real one, but, Dr. Hunter's case may be deemed altogether supposi- tious. The symptoms of the circumscribed true aneurism take place as follows : the first thing the patient perceives is an ex- traordinary throbbing in some particular situation, and, on paying a little more at- tention, he discovers there a small pulsat- ing tumour, which entirely disappears, when compressed, but, returns again as soon as the pressure is removed. It is commonly unattended with pain, or change in tlie colour ofthe skin. When once the tumour has originated, it continually grows larger, and, at length, attains a very considerable size. In proportion as it becomes larger, its pulsation becomes weaker, and, indeed, it is almost quite lost, when the disease has acquired much magnitude. The diminution of the pul- sation has been ascribed to the coats of the artery losing their dilatable and elastic quality, in proportion as they are distended and indurated, and, conse- quently, the sneutismal sac being no longer capable of an alternate diastole and systole from the action of the heart. The fact is also imputed to the coagulated blood, deposited on the inner surface of the sac, particularly, in large aneurisms, in which some of the blood is always in- terrupted in its motion. In true aneu- risms, however, the blood does not coa- gulate so soon, nor so often, as in frlse ones. Immediately, such coagulated blood lodges in the sac, pressure can only produce a partial disappearance of the swelling. In proportion as the aneuris- mal sac grows larger, the communication of blood into the artery beyond the tu- mour is lessened. Hence, in this state, the pulse, below the swelling, becomes weak and small, and the limb frequently cold, and ocdomatous. On dissection, the lower continuation of the artery is found preternaturally small and con- tracted. The pressure of the tumour on the adjacent parts also produces a variety of symptoms, ulceration, caries,' ike. Sometimes, an accidental contusion, or concussion, may detach a piece of coagu- lum from the inner surface of the cyst, and the circulation through the sac be obstructed by it. The coagulum may pos- sibly be impelled quite into the artery be- low, so as to induce important changes. The danger of an aneurism arrives when it is on the point.of bursting, by which occurrence the patient usually bleeds to death, and this sometimes in a few se- conds. The fatal event may generally be foreseen, as the part about to give way becomes particularly tense, elevated, thin, soft, and of a dark purple colour. (Rich- ter's Atifangsgr. Bund. 1.) A large axillary aneurism, which burst in St. Bartholomew's Hospital, a few years ago, did not burst by ulceration, but by the detachment of a small slough from a conical, discoloured part of the tumour. Since this case fell under my observation, I have had an opportunity of seeing the process, by which an in- guinal aneurism burst: at a certain point, the tumour became more conical, thin, and inflamed, and here a slough, about an inch in width was formed. On the dead part becoming loose, a profuse bleeding began. We are then to con- chide, that external aneurisms do not burst by ulceration, but, by the forma- tion and detachment of a slough. The false aneurism is alway s owing to an aperture in the artery, from which the blood gushes into the cellular substance. The case may arise from an artery being lacerated in violent exertions ; but, the most common occasional cause is a wound. This is particularly apt to occur at the bend of tiie arm, where the artery is ex- posed to be injured in attempting to bleed. (For this case see Hemorrhage.) In this circumstance, as soon as the punc- ture has been made, the blood gushes out with unusual force, and in a bright scar- let, irregular, interrupted current. It flows out, however, in an even, and less rapid stream, when pressure is applied higher up than the wound. These last are the most decisive marks ofthe artery being opened; for blood often flows from a vein with great rapidity, and in a broken cur- rent, when the vessel is very turgid, and situated immediately over the artery, which imparts its motion to it. Tlie sur- 104 ANEURISM. geon endeavours precipitately to stop the hemorrhage by pressure, and he common- ly occasions a' diffused false aneurism. The external wound in the skin is closed, so that the blood cannot escape from it; but, hence, it insinuates itself into the cellular substance. The swelling, thus produced, is uneven, often knotty, and extends up- ward and downward along the track of the vessel. Tlie skin is also usually of a dark purple colour. Its size increases, as long as the internal hemorrhage con- tinues, and, if this should proceed above a certain pitch, mortification of the limb ensues. The circumscribed false aneurism arises in the following manner. ^ When proper pressure has been made in the first in- -stance, so as to suppress the hemorrhage; but, the bandage has afterwards been re- moved too soon, or before the artery has healed, the blood passes through the tin- cldsed wound, or that which it has burst open again, into the cellular substance. As this has now become agglutinated by the preceding pressure, the blood cannot diffuse itself into its cells, and, conse- quently, a mass of it collects in the vici- nity of tlie aperture of the artery, and distends the cellular substance into a sac. Sometimes, though not often, this cir- cumscribed false aneurism, originates im- mediately after the opening is made in the artery. This chiefly happens when the aperture in the vessel is exceedingly small, and, consequently, the hemorrhage takes place so slowly, that the blood, which is first effused, coagulates, and prevents the entrance of that which fol- lows into the cavities of the cellular sub- stance, and, of course, its diffusion. A membrane, aponeurosis, &c. may also be just over the orifice, so as to prevent the aneurism from being diffused. -The circumscribed false aneurism con- sists of a sac, composed of cellular sub- stance, filled with blood, and situated close to the artery, with which it has a communication. At every pulsation, fresh blood gushes from the opening of the ar- tery into the sac, and distends it; but, its elasticity then makes it contract a little, and urge a portion of the blood back into the vessel. Hence, in false aneurisms, a throbbing is always percep- tible, and is more manifest, the smaller such tumours are. The larger the sac becomes, the less elastic it is, and the greater is the quantity of coagulated blood in it; so that in very large aneu- risms of this kind, the pulsation is some- times wholly lost. The tumour is at first small, and on compression entirely disappears; but, re- turns as soon as this is removed. It also diminishes, when the artery above it is compressed; but^esumes its wonted mag. nitude, immediately such pressure is dis. continued. When there is coagulated blood in the sac, pressure is no longer capable of producing a total disappear- ance of the tumour, which is now hard. The swelling is not painful, and the in- teguments are not changed in colour. It continually increases in size, and, at length, attains a prodigious magnitude. The following are generally enume- rated, as the discriminating differences between circumscribed true and false aneurisms i the true aneurism readily yields to pressure, and as readily recurs on its removal; the false one yields very gradually, and returns in the same way, as the blood in the sac can only pass and repass slowly through the aperture in the artery. Frequently, a hissing sound is very audible, when the blood gushes into the sac. The pulsation of the false aneu. rism is always more feeble, and, as the tumour enlarges, is sooner lost, than that of the true one, which even throbs after it has acquired a very considerable vo- lume. The sac of the true aneurism is the artery itself; that of the false one is cellular substance. (See Richter's An- fangsgr. Band. 1.) Besides these common divisions of aneurism, there are two other kinds, one named the aneurismal vari.r, or venous aneurism, the other called by Mr. J. Bell, the aneurism from anastomosis; the particulars of both of which will be pre- sently explained. If the doctrines, however, of Professor Scarpa, of Pavia, which were published in 1804, are correct, the grand distinc- tion of aneurism into true and false must be rejected, as erroneous: " for," says he, " after a very considerable number of investigations, instituted on the bodies of those, who have died of internal, or ex- ternal aneurisms, I have ascertained, in the most certain and unequivocal man- ner, that there is only one kind, or form of this disease ; viz. that caused by a solu- tion of continuity, or rupture of the pro- per coats of the artery, with effusion of blood into the surrounding cellular sub- stance ; which solution of continuity is occasioned sometimes by a wound, a stea- tomatosis, earthy degeneration, a corrod- ing ulcer, a rupture of the proper coats of the artery, I mean the internal and muscular, without the concurrence of a preternatural dilatation of these coats being essential to the formation of this disease; and, therefore, that every aneu- rism, whether it be internal, or external, circumscribed, or diffused, is always formed by effusion.'' Treatise on Alneu- ritm by A. Scarpa, Trans, by IVisharl ANEURISM. 105 Preface. If this opinion be true, the differ- ence in the symptoms of aneurisms above related, is to be imputed to the difference in the degree of rupture, diffusion, Skc. [In the first volume of the Philadel- phia Medical Museum, a case of vari- cose aneurism is described, different from all those which have been men- tioned. Dr. Physick has illustrated his account of the case, with an engraving from which it appears, that the aneu- rismal sac was formed of cellular mem- brane, ,and situated between the vein and artery, communicating freey with both. A case somewhat similar is described by Mr. Park in the 4th vol. of Medical Facts and Observations, both these cases are also recorded in Wishart's translation of Scarpa on aneurism.] Scarpa observes, that it is an error to suppose, that the aneurism at the curva- ture, or in the trunk,'of the aorta, pro- duced by a violent and sudden exertion of the whole body, or of the heart in par- ticular, and preceded by a congenital re- laxation of a certain portion of this artery, or a morbid weakness of its coats, ought always to be considered, as a tumour formed by the distention, or dilatation of the proper coats of the artery itself, that is, of its internal and fibrous coats. Scarpa considers it quite demonstrable, that such aneurisms are produced by a corrosion and rupture of these tunics, and, conse- quently, by the effusion of arterial blood under the cellular sheath, or other mem- brane, covering the vessel. If ever there be a certain degree of preceding dilata- tion, it is not essential to constitute the disease; for it is not a constant occur- rence, most aneurisms are unpreceded by it, and, in those rare cases, in which the aneurism is preceded and accompanied by a certain degree of dilatation of the whole diameter of the curvature of the aorta, there is an evident difference be- tween an artery simply enlarged in diame- ter, and the capsule, which forms tiie aneurismal Sac. Dissections, carefully conducted, will shew, that the aorta contributes nothing to the formation of the aneurismal sac, anil that this is merely the cellular mem- brane, which, in the sound state, covered the artery, or that soft cellular sheath, which the artery received in common with the neighbouring parts. This is raised by the blood into the form of a tumour, and is covered, in common with the artery, by a smooth membrane. The Italian professor does not deny, that, from congenital relaxation, tiie pro- per coats or the aorta may not occasion- ally yield and become disposed to rup- Voi. I. turo; but he will not admit, that dilata- tion of this artery precedes and -accompa- nies all its aneurisms, or that its proper coats ever yield so much to distention, as to form the aneurismal sac. The root of an aneurism of the aorta never includes the whole circumference of the artery ; but, the aneurismal sac arises from one side in the form of an appendix, or tube- rosity. On the contrary, the dilatation of the artery always occurs «in its whole circumference, and, therefore, differs es- sentially from aneurism. Thus, there is really a remarkable difference between a dilated and an aneurismatic artery, al- though these two affections are some- times found combined together, especial- ly, at the origin of the aorta. If we also consider, that the dilatation of an artery may exist, without any organic affection, the blood being always in the cavity of the vessel; that in an artery so affected, there is never collected any grutnous blood, or polypous layers ; that the dila- tation never" forms a tumour of consider- able bulk, and, that, while the continu- ity of the proper coats remain uninter- rupted, the circulation ofthe blood is not at all, or not so sensibly changed, we "shall be obliged to allow that aneurism differs essentially from the dilatation of an artery. Galen, CEtius, Paulus, Actuarius, Ha- ly, Albucasis, Oribasius, and Avicenna, who only treat of external aneurisms, speak of no other cases, than those by ef- fusion ; and, although some of these writ- ers introduce the distinction, that external aneurisms are produced in three ways, viz. by anastomosis, by diapxdesis, and by dix- resis, they all affirm, that external aneu- risms are invariably formed by the extra- vasation of blood under the skin. By dilatation, the Greek and Arabian physi- cians did not mean the expansion of the proper coats of the diseased artery ; but, that tumour which the effused and coagu- lated arterial blood forms ,in the cellular membrane under the skin. Thus QStius : oritur dilatatio, aut dum sanguis, et sfiiritus ex arteriis firosultarit; aut dum oscula ifi&orum afidriuntur, aut dum rumfiuntur. Sanguis autem et sfiiritus fiaullatim excreti sub cute colliguntur. See also additional quotations in Scarpa from Actuarius, Silvaticus, &c. Fernelius first published the theory of the dilatation of the coats ofthe arteries, as the proximate cause of aneurisms, par- ticularly, internal ones, arising from no evident causes. The theory of Fernelius, however, instead of being c'ed iced from observations on the dead iunject, was only tlie result of his own imagination, and false conjectures, that effused arterial P 106 ANEURISM. blood would immediately putrify, and could never form, out of tlie vessels, a pulsating tumour, sennertus, Hildanus, Barbette, and several others, rejected this theory, and were all convinced, that both internal and external aneurisms were form- ed by the rupture, and not by the dilata- tion ofthe internal coats ofthe artery. Scarpa endeavours to demonstrate, by accurate dissections of arteries both in the sound amd morbid state, what share tlie proper and constituent coats of the artery have in the formation of the aneu- rismal sac, and what belongs to the cellu- lar covering, and other adventitious mem- branes surrounding the artery. The covering of an artery is merely an adventitious sheath, which the vessel re- ceives in common with the parts in the vicinity of which it runs. On cutting an artery across in its natural situation, the segment of the cut vessel retires and con- ceals itself in this sheath. This cellular covering is most evident round the cui-\ature and trunk of the aorta, the carotid, mesenteric, and renal arteries ; it is less dense round the trunk of the brachial, femoral, and popliteal arteries. The pleura lies over the cellular sheath of the arch of the aorta, and over that of the thoracic aorta; and that ofthe abdominal aorta is covered by the perito- neum. Both these smooth membranes adhere to, and surround, two-thirds of the circumference of the vessel. The great arteries of the extremities are not covered, in addition to the cellular substance, by any s.n >oth membrane of this sort, but by a cellular sheath, which is demonstrably distinct from the adipose membrane, and serves to inclose the vessels, and connect them with the contiguous parts. Wli n air, or any other fluid, is injected by a small hole made artificially, between the cellular covering, and the subjacent muscular coat of the artery, the injected matter elevates into a tumour the cellular membrane, which closely embraces the artery, without properly destroying its cells, which it distends in a remarkable manner. When melted wax is injected, and pu-hed with much force, the cellular sheath of the artery is not only raised over the vessel, like a tumour, but, the internal cells of that covering; are also lacerated, and, on examining afterwards the capsule of the artificial tumour, it appears as if it were formed of several layers, rough and i.regular internally, smooth and polished externally. The same tiling happens, when any injection is push- ed with such force into an artery, as to rupture the internal and muscular coats at some point of their circumference. N-cholls performed this experiment seve- ral times before the Royal Society. (Phuot. Trans, an. 1728.) As soon as the internal coat is ruptured, the muscular one also gives way; but, the external cellular sheath, being of an interlaced texture, and tlie thin lamina:, of which it is com- posed, being not simply applied to one another, bui, reciprocaliy intermixed, is capable of supporting great distention, by yielding gradually to the impulse of the blood, without bemg torn, or ruptured This celebrated professor is of opinion, that the same phenomena may be observ- ed, when the internal coat of the aorta becomes so diseased, as' to be ruptured by the repeated jets of blood from the heart. In this circumstance, the blood, impelled by the heart, begins immediate- ly to ooze through the connexions of the fibres, of the muscular coat, and gradu- ally to be effused into the interstices of the cellular covering, forming, for a cer- tain extent, a kind of ecchymosis, or ex- travasation of blood, slightly elevated upon the artery. Afterwards, the points of contact, between the edges of the fibres of the muscular coat being .insensibly separated, the arterial blood, penetrating between them, fills and elevates, in a re- markable manner, the cellular covering of the artery, and raises it after the man- ner of" an incipient tumour. Thus**the fibres and layers of the muscular cW, being wasted, or lacerated, or simply separated from each other, the arterial blood is carried with great force, and in greater quantity, than before, into the cel- lular sheath of* the arluri^ which it forces more outwards ; and, finally, the divisions, between the interstices of the cellular coat being ruptured, converts it into a sac, which is filled with poly potts concre- tions, and fluid blood, and at last forms, strictly speaking, the aneurismal sac. The internal texture, although apparently com- posed of membranes placed one over the other, is, in fact, very different from that of the proper coats of the artery, not- withstanding the injured vessel and aneu- rismal sac are both covered externally, in tne thorax and abdomen, with a smooth membrane. Scarpa has examined a considerable number of aneurisms, of the arch, and of the thoracic, and abdominal trunk, of the aorta, without finding a single one, in which tlie rupture of the proper coats of the artery was not evident, and in which, consequently, the sac was produced by a substance completely different from the internal and muscular coats. The aneurismal sac never comprehends the whole circumference of the ve.-seL At the place where the tumour joins the side of the tube, the aneurismal sac pre- ANEURISM. 107 scnts a kind of constriction, beyond which it becomes more or less expanded. This would never happen, or rather the con- trary circumstance would occur, if the sac were formed by an equable distention ofthe tube and proper coats ofthe affect- ed artery. In incipient aneurisms, at least, the greatest size of the tumour would then be in the artery itself, or root of the swelling, while its fundus would be the least But, whether aneurisms be recent and small, or of long standing and large, the passage from the artery is al- ways nareow, and the fundus ofthe swell- ing greater in proportion to its distance from tlie vessel. The sac is always co- vered by the same soft dilatable cellular substance, w-hich united the artery in a ' sound state to the circumjacent parts. Such cellular substance, in aneurisms of the thoracic aorta, is covered by the pleu- ra, and, in those of the abdominal aorta, by the peritoneum, which membranes in- clude the sac and ruptured artery, pre- sent ing outwardly a continued smooth surface, just as if the artery itself were dilated. But, if the aorta be opened lengthwise on the side opposite the con- striction, or neck ofthe tumour, the place of the ulceration, or rupture, of the pro- per coats of the artery, immediately ap- pears within the vessel, on the side oppo- site to that of the incision. The edge of the fissure, which has taken place, is sometimes fringed, often callous*, and hard, and through it it was, that thfe blood formed itself a passage into the cellular sheath, wliich is converted into the aneu- rismal sac. if, as sometimes happens, in the arch of the aorta near the heart, the artery, before being ruptured, has been somewhat dilated, it seems, at first, as if there were two aneurisms; but, the con- striction, which the sac next to the ar- tery, presents externally, points out ex- actly the limits, beyond which the inter- nal and muscular coats of the aorta had not been able to resist tlie distention, and where of course they have been ruptured. The partition, which n.ay always be seen dividing the tube of the artery from the aneurismal sac, and which is lacerated in its middle, consists of nothing else than the remains of the internal and muscular coats ofthe ruptured artery. By carefully dissecting the proper coats of the ruptured aorta in its situation, and comparing them with the cellular sub- stance forming the sac, the truth ofthe pre- ceding statement may be indisputably de- monstrated. When an incision is made lengthwise in*he side of the'vessel opposite the rup- ture, its proper coats are found either per- fectly sound, or a little weakened and studded with earthy points, but, still ca- pable of being separated into distinct layers. On the contrary, in tlie opposite side of the aorta, where the rupture is, the proper coats are unusually thin, and are •-only separable from each other with dif- ficulty, or even not at all; they are fre- quently brittle, like an egg-shell, and are disorganised and torn at the place where they form the partition between the rup- tured artery and the mouth of the aneu- rismal sac. Continuing to separate these coats, from within outwards, we arrive at the cellular sheath surrounding the aorta.. This sheath being much thickened in large aneurisms, and very adherent to the subjacent muscular coat of the artery at the place of the constriction ofthe sac, is very apt to be mistaken for a dilated por- tion of-the vessel itself. But, even in such cases, we may at last separate it, without laceration, from the tube of the artery, above and below the injury, and, successively, from the muscular coat, as far as the neck of the aneurism. Then it is clear, the muscular coat docs not pass beyond the partition, separating the ca- vity of the artery from that of the aneu- ' rismal sac, over which it is not prolonged, but terminates at the edge of the rupture like a fringe, or in obtuse points. Errors are rendered more apt to occur, in con- sequence of the aorta and sac being both covered by the pleura, or peritoneum. The portion ofthe aorta, within the pe- ricardium, being only covered by a thin reflected layer of this membrane, such layer may also be lacerated, when the proper coats give way, and blood be effused into the cavity of the pericardium. Examples of this kind are related by Walter, Morgagni, &c. and Scarpa him- self. In the latter instance, on making an incision into the concave part of the aorta, opposite the tumour which had formed under the layer of the pericar- dium, which had also burst by a small ' aperture, its internal coat, corresponding to the base of the swelling, was quite rough, interspersed with, yellow hard spots, andactually ulcerated for the space of an inch in circumference. The pre- paration is preserved in the museum at Pavia. But all other parts of the aorta having, between them and the pleura and perito- neum, a cellular sheath of a stronger and more yielding nature, which allows itself to be distended into a sac, and being strengthened internally, by polypous lay- ers, and, externally, by the "pleura or peritoneum, oppose for a long while the fatal effusion of blood. Scarpa believes, that what he calls the slow, morbid, steatomatous-, fungous, 103 ANEURISM. squamous, degeneration of the internal coat of the artery is more frequently the cause of its bursting, than violent exer- tions ofthe whole body, blows, or an in- creased impulse of the heart. This kind of diseased change is very common in the curvature, and thoracic and abdominal trunks, of the aorta. In the incipient state of such disease, the internal coat of the artery loses, for a certain space, its beautiful smoothness, and becomes irre- gular and wrinkl*d. It afterwards ap- pears interspersed with yellow spots, which are converted into grains, or earthy scales, or into steatomatous, and cheese- like concretions, which render the inter- nal coat of the artery brittle and so slight- ly united to ti>e adjoining muscular coat, that, upon being merely scratched with the knife, or point of the nail, pieces are readily detached from it, and, on being cut, it gives a crackling sound, similar to tlie breaking of an egg-shell. This ossi- fication cannot be said to be propftr to old age, since it is sometimes met with in subjects not much advanced in life. The whole of the side of the artery, in that part which is occupied by the morbid af- fection, is, for the most part hard and rigid, sometimes soft and fungous, and, in most cases, the canal of the artery is preternaturally constricted. In the high- est degree of this morbid disorganization, true ulcerations are found on the inside of the artery, with hard and fringed edges, fissures, and lacerations of the in- ternal and fibrous coats of the artery. Whenever an aneurismal sac of an im- moderate size beats violently, and, for a long while against a bone, as the sternum, ribs, clavicle, and vertebrae, the bones are in the end invaris-bly corroded, so that the aneurismal sac elevates the integu- ments of the thorax, or back, and pul- sates immediately under the skin. Scar- pa, with the best modern writers, attri- butes the effect to absorption, in conse- quence of the pressure. Having presented the reader with an abridged account of the most important remarks, made by Scarpa, in support of the doctrine he defends, we now annex his conclusions. 1. That this disease is invariably formed by the rupture of the proper coats of the artery. 2. That the aneurismal sac, is never formed by a dila- tation of the proper coats of the artery, but, undoubtedly, by the cellular sheath, which the artery receives in common with the parts contiguous to it; over which cellular sheath the pleura is placed in the thorax, and the peritoneum in the abdo- men. 3. That if the aorta, immediately above tlie heart, appears sometimes in- creased beyond its natural diameter, this is not common to all the rest of the arte- ry, and when the aorta, in the vicinity ot the heart, yields to a dilatation greater than natural, this dilatation does not con- stitute, properly speaking, the essence of the aneurism. 4. That there are none of those marks regarded by medical men as characteristic of aneurism from dilatation, which may not be met with in aneurism from rupture, including even the circum- scribed figure of the tumour. 5. That the distinction of aneurism into true and spurious, adopted in the schools, is only the production of a false theory; sinc'f observation shews, that there is only one form of this disease, or that caused by a rupture of the proper coats of the artery, and an effusion of arterial blood into the cellular sheath, which surrounds the rup- tured artery. (See Treatise on Aneurism, by A. Scarpa, translated by J. H. Wishart. Edinb. 1808 ) Even the believers in the doctrine of dilatation, will, 1 think, now agree with Sabatier, that, in what they call true aneurisms, the internal coats of* the ar- tery, that is to say, the cuticular and muscular coats, are mostly ruptured, while that which is called cellular, or elastic, is dilated, so as to form the pouch, in wliich tiie blood is contained. This, he says, is particularly apt to be the case, when these swellings are the consequence of some exertion or violent shock. The fenerality of modern surgical authors, y whom the true aneurhm, attended with a real dilatation of all the coats of the artery, is implicitly believed, univer- sally admit, that, when such a tumour has acquired a large size, the inner coats of the vessel, which are imagined to be dilated, may give way and be ruptured. The blood, forcibly impelled into the vessel, or tumour, is described as pro- ducing a laceration of the resisting coatsj becoming effused within the cellular coat, which is very elastic, occasioning a se. paration of this tunic from the others, and collecting within it in a more or less considerable quantity. " I have found this proved," says Sabatier, "in nearly all the aneurisms which I have seen dis- sected, as well as in those, which I have examined myself, but, particularly in a subject, whose carotids I was about to inject. In endeavouring to expose these vessels, I found a large quantity of blood extravasated in the adjoining cellular substance. As they appeared to me to be larger than ordinary, my curiosity was excited, and I traced them to the aorta, which was extremely dilated, as was likewise the pericardium. The dc*p livid colour of this latter membrane shewed, that there was an accumulation ANEURISM. 109 of blood in its cavity. In fact, a large quantity was found there, and the por- tion of the aorta, included within this membrane, was much enlarged. I soon perceived a considerable rent, which led into the cavity of the vessel, and, on this opening being made larger, I found, that the aorta began to be dilated at its ori- gin from the heart, and that the increased size, which it had acquired, extended to the curvature, and the vessels arising there ; that these arteries were contained in a kind of continuous sac, which had borrowed their form, though its width was greater ; that they appeared to be stripped of their cellular covering, just as if they had been dissected for anato- mical purposes ; and, lastly, that it was the aorta itself, which was rent, a little way from the opening, that had taken place in its membranous covering within the pericardium. Similar cases are re- corded by Morgagni, and others." (Sa- batier, op.cit. p. 165, 166.) Iticherand does not altogether reject the doctrine of a dilatation of all the ar- terial coats; but, he asserts that this is only the case when the tumour is small and incipient, while, in aneurisms of a certain size and standing, two out of the three coats, which compose the parietes of the artery, namely, the internal and middle tunics, are constantly lacerated. (Nosografihie Chirurgicale, Tom. 4. p. 81. Edit. 2.) According to Sabatier, true aneurisms most frequently occur in the abdomen and thorax. Here, there are no pathog- nomonic signs, by which the existence of such swellings can be known with cer- tainty, before the disease is sufficiently targe to be felt externally; for, the symp- toms produced differ according to the si- tuation of the tumour, and are very like those of numerous other diseases, so that it is impossible to ascribe the complaints to this or that particular affection. Some- times, the train or circumstances, wliich accompany aneurisms, joined with the patient's complaining of* a strong throb- bing- in the situation of the disease, may lead to a suspicion of the nature of the case, even before tlie turnout can either be felt, or seen. When, however, true aneurisms are situated in the neck, or the extremities, they may easily be known by the ease, with which they yield to pres- sure, and by their pulsations ; but the last symptoms may disappear, when the tumour has become exceedingly large. The greater number of aneurisms in- creases gradually, and sooner or later in- cline to the side, on which the least re- sistance is experienced. De Haen men- tions an aneurism, of the aorta, which first made its appearance between the se- cond and third ribs of the left side, and, which instead of growing larger, as is usual, subsided, and could neither be seen, nor felt, for more than a month be- fore tlie patient's decease, although, on opening the body, a tumour of the arch of thfe aorta was found, three times as large as the first. De Haen imputes the sudden disappearance of the swelling to its weight, the yielding of the parts with which it was connected, and to its gravi- tating into the chest, when the patient lay on his right side; for, the difficulty of breathing, and other complaints, pro- duced by the pressure on the lungs, un- derwent a material increase, as soon as the tumour ceased to protrude. The pulsations, which accompany true aneurisms, continue to be strong, until the inner coats of the vessel give way, or the layers of coagulated blood, lodged in the sac, are numerous. Hence, when soft swellings, situated near any large arteries, lose their pulsatory motion, their course, precise situation, and other circumstances, ought to be most carefully investigated, before the surgeon ventures to make an opening. In many instances, the most fatal accidents have happened, in consequence of" incisions having been made into aneurisms, which were mis- taken for abscesses, because there was no pulsation. Vesalius was consulted about a tumour of the back, which he pro- nounced to be an, aneurism. Soon after- wards, an imprudent practitioner made an opening in the swelling, and the pa- tient bled to death in a very short time*. Ruysch relates, that a friend of his, hav- ing opened a tumour near the heel, which was not supposed to be an aneurism, the greatest difficulty was experience-! in suppressing tiie hemorrhage. De I ken speaks of a patient, who died in con liac and superior mesenteric arteries. Opposite to this aperture, the bodies of the two last dorsal, and of tiie two first lumbar vertebrae, were destroyed; an or- dinary effect of aneurisms on such bones as happen to he near them, but, which effect Pelletan had never previously seen take place in so considerable a degree. The two cavities of the chest contained a large quantity of bloody serum, which had no connexion with the aneurism, and tiie lungs were sound. Pelletan says, he never met with so large an aneurism; he tliinks it probable, that it was brought on by the fall, which the patient met with in 1803, and that it had been increasing for six years. He states, that the man died from nearly the whole mass of the blood having passed I into the aneurismal sac, most of the ves. sels, and the heart itself, being in fact quite empty. However, the most interesting circum- stance in this case, with regard to prac- tice, was the resemblance, which the ap- parent symptoms of this aneurism bore to those of a lumbar abscess, with, or, without a caries of the vertebrae. (See Pelletan's Ctiiuque Chirurgicale, Tom. I, p. 97—100.) Aneurisms often seem to originate spontaneously, it being in many instances exceedingly difficult to assign any cause for the commencement of tlie disease. Among the circumstances, which predis- pose to aneurisms, however, the large size of the vessels may undoubtedly be reckoned. Those trunks, which are near the heart, are said to have much thinner parietes, in relation to the magnitude of the column of blood, with which they are filled, than the arteries of smaller dia- meter ; and since tiie lateral pressure of this fluid against the sides of the arteries, is in a ratio to the magnitude of these vessels, it follows, that aneurisms must be much more frequent in the trunks near the heart, than in such as are re- mote from the source of the circulation. (Richerand,NosographieCkirurgicale,Tom. 4, p. 72, Edit. 2.) The whole arterial system is liable to aneurisms ; but, aays Pelletan, experience proves, that the in- ternal arteries are much more frequently affected, than those which are external. (Clinique Cliirurgicale, Tom. 1, p. 54.) The curvatures of the arteries are an- other predisposing cause of the disease, and, according to Richerand, such cause has manifest effect in determining- the formation of the great sinus of the aorta, the dilatation, which exists between the ANEURISM 113 cposs and the origin of" this large artery, and is the more considerable, the older the person is. Monro rightly observes on this subject, that one half of old persons have an aneurism at the beginning of the aorta. There is one artery of moderate size, without any curvature, which is never- theless more subject to aneurism, than other vessels of much larger diameter: the popliteal artery is that, which is here alluded to. The crural, of which this last is only the continuation, is much less commonly affected. This frequency of anenrisms of the popliteal artery does not depend upon the vessel being situated in the middle of a very extensible cellular substance; for, the crural, at its upper third, is not better supported by the surrounding parts. The cause is imputed by Richerand to the situation of the artery in the ham, at the back of the knee joint, an articulation, of which the extension is only limited by tlie resistance of such tendons, ligaments, and soft parts, as are placed behind it. In the stretching, to which all the parts behind the joint are subjected, when the leg is forcibly extended on the thigh, the artery, whose texture is the slightest, is particularly apt to be lacerated. Riche- rand affirms, that, out of twelve popli- teal aneurisms, which he has seen, either in hospital, or private practice, ten have been caused by a violent extension of the leg. This statement, he says, will derive confirmation from the following experi- ments : Place the knee of a dead subject on the edge of a firm table, and press on the heel, so as forcibly to extend the leg far enough to make the ligaments of the ham snap. Now dissect the part, cut out the artery, and examine its parietes in a good light, when the lacerations of the middle coat will be observable, and ren- dered manifest by the circumstance of those places appearing semitransparent, where the fibres are separated, the parietes at such points merely consisting of the internal and external tunics. (Nosogra- phie Chir. Tom. 4, p. 73, 74, Edit. 2.) The implicit belief, however, which Richerand seems to place in the idea, that the laceration of the middle coat of* an artery will bring on an aneurism, while the inner coat is perfect, will appear to be unfounded, when it is remembered, that Hunter and Home even dissected off the external and middle coats of arteries, with- out being able in this manner to cause an aneurism. Pelletan accounts for the frequency of popliteal aneurisms somewhat differently from It icherand: speaking of the two Vol. I principal motions of the knee, viz. ex- tension! and flexion, he remarks, that the first of these is so limited, that it is actu- ally an incipient flexion, necessarily pro- duced by the curvature backward both of the condyles of the femur, and those of the tibia. This curvature, which would seem to protect the popliteal artery against any dangerous elongation, that might otherwise be caused by a forcible extension of the joint, becomes the very source of such an elongation in persons, who are accustomed to keep their limbs bent, or, who, from this state, proceed hastily and violently to extend the leg. The arterial tubes are really shortened, when the limbs are in the state of flexion, and lengthened, when the extension of the members renders it necessary. Hence, says Pelletan, it is manifest, that an ha- bitual shortened state of these vessels, and their, sudden elongation, must be at- tended with hazard of rupturing their pari- etes. (Clinique Chirurgicale, Tom. Lp. 112.) Aneurisms are exceedingly common in the aorta, and they are particularly often met with in the popliteal artery. Tlie vessels, which are next to these the most usually affected, are the crural, common carotid, subclavian, and brachial arteries. The temporal and occipital arteries, and those of the leg, foot, forearm, and hand, are far less frequently the situations of the present disease. But, although it is true, that the larger arteries are the most subject to the ordinary species of aneu- risms, the smaller arteries seem to be more immediately concerned in the form- ation of one peculiar aneurismal disease, now well known by the name of the aneurism by anastomosis, of which 1 shall hereafter speak. According to surgical writers, the causes of aneurisms operate either by weaken- ing the arterial parietes, or by increasing the lateral impulse of the blood against the sides of* these vessels. It is said to be in both these ways, that the disease is occasioned by violent contusions of the arteries, the abuse of spirituous drinks, mercurial courses too often repeated, fits of anger, rough exercises, exertions in lifting, heavy burdens, &c In certain persons, aneurisms appear to depend upon a particular organic disposition. Of this description was the subject, whose arteries,, on examination after death, were found by Lancisi affected with several aneurisms of various sizes. I have known a person, who had an aneu- rism of one axillary artery, wliich disease got spontaneously well, but, was soon afterwards followed by a similar swell- ing of the opposite axillary artery, which last affliction proved fatal. I have Q 114 ANEURISM •seen another* instance, in which an aneu- rism of the popliteal artery was accom- panied with one of the femoral in the other limb. The most remarkable case, however, proving the existence of a dis- position to aneurisms in the whole arte- rial system, is mentioned by Pelletan. " J'ai pourtant vu plusieurs fois ces nom- breux aneurismes occupant indistincte- ment les grosses ou les petites arteres, mais sur-tout celles des capache> ; fen ai compte soixatite trois sur un seul homme, depuis le volume d'une aveline jusqu' d celui de la moitie d'un xuf tie poule. (Clinique Chirurgicale, 'Tom. 2, p. 1.) In this country it has been noticed, that popliteal aneurisms occur with particular frequency in postilions and coachmen, whose employments oblige them to sit a good deal with the knees bent. It has been observed in France, by Richerand, that the men, who clean out the dissect- ing rooms, and procure dead bodies for anatomists, almost all die of aneurismal diseases. Tins author remarks, that he never knew any of these persons, who were not addicted to drinking, and he comments on the debility, which their in- temperance and disgusting business to- gether must tend to produce. (Nosogra- phie Chirurgicale, Tom. 4, p 74, Edit. 2.) Aneurisms of the axillary artery ap- pear, in some instances, to have arisen from violent extension of the limb. (See the cases recorded by Pelletan in Clinique Chirurgicale, Tom. 2, p. 49, and 83.) In other examples, related by the same interesting practical writer, aneu- risms arose from reiterated contusions and rough pressure on parts. (06. cit. p. 10, p. 14.) •■ The extremity of a fractured bone may injure an artery, and give rise to an aneu- rism, an instance of which is recorded by Pelletan. (Op. cit. Tom. 1.p. 178.) The disease followed a fracture of the lower third of the leg. An aneurism of the an- terior tibial artery, from such a cause, is also described in Mr. Charles White's Cases in Surgery, p 141. The following case of an aneurism of the humeral artery, after amputation, is recorded by Warner: C. D. was afflicted with a caries of the joint of the elbow, which- was attended with such circum- stances, as rendered the amputation of the limb necessary. The operation was performed at a proper distance above the diseased part, and the vessels were taken up by the needle and ligatures. In a few days, after the operation, the humeral artery became so dilated above the ligature as to endanger its bursting. Upon this account, it was judged neces- sary to perform the operation for the aneurism, which was done, and the vessel was secured by ligature, above the upper extremity of its distended coats. After this operation, every thing went on, for some time, exceedingly well, when sud- denly the artery appeared again dilated, and was in danger of bursting above the second ligature. These circumstances made it necessary to repeat the operation for the aneurism. From this time, every thing went on successfully, till the stump was at the point of being healed; when, quite unexpectedly, the artery appeared a third time diseased in the same manner as before ; for which reason, a third ope- ration for aneurism was determined on, and performed. The last operation was near the axilla. The patient continued well, from this time, without any relapse. Query. Could the several aneurisms of the humeral artery, (says Mr. Warner) be attributed to the sudden check alone, which the blood met with from the extre- mity of the vessel being secured by liga- ture ; or is it not more reasonable to sup- pose, that tlie coats of the artery, nearly as high up as the axilla, were originally diseased and weakened? The latter, in the opinion of this judicious writer, seems the most probable way of accounting for the successive returns of the disease of the vessel: since it is found from expe- rience, -that such accidents have been very rarely known to occur after ampu- tations, either of the arm, or thigh, where nearly the same resistance must be. made to the circulation in every subject of an equal age and vigour, who has undergone the like operation. If it should be supposed, that the several dilatations ofthe coats of the vessels, con- tinues Mr. Warner, arose merely from the check in the circulation, it will not be easy to account for the final success of this operation; and, especially, when we reflect, that the force of the blood is in- creased in proportion to its nearness to the heart. (See Cases in Surgery, by J. Warner, F. R. S. p. 139, 140, Edit. 4.) Aneurisms sometimes follow the injury, which a large artery suffers in gunshot wounds. The passage of a bullet through the thigh, in one example, gave rise to a femoral aneurism. (See the Parisian Chi- rurgical Journal, Voi.2,p.l09.) TREATMENT of ANEURISMS IX GENERAL A complete cure of an aneurism cannot be effected, in whatever part of the body the tumour is situated, unless the artery, from which the aneurism is derived, be, by nature or art, obliterated and convert- ed into a perfectly solid, ligamentous sub- ANEURISM. HI stance, for a certain extent above and below the place of the ulceration, lacera- tion, or wound. When aneurisms are cured by compression, the cure is never accomplished, as some have supposed, by tlie pressure strengthening and dilated proper coats of the artery, and restoring, especially to the muscular coat, the power of propelling the blood along the tube of the artery, as it did p^viously to its sup- posed dilatation. M. Petit and Foubert thought, that the natural curative process sometimes consisted in a species of clot, which closed the laceration, ulceration, or wound of the artery, and resisted the impulse ofthe blood, so as still to preserve the continuity of the coats of the artery, and the pervious state ofthe vessel. Hal- ler imbibed a similar sentiment, from ex- periments made on frogs. That a punctured artery may occasion- ally be healed in this manner, Scarpa proves by a case which he examined, in which an aneurism took place from the wound of a lancet in bleeding. In the article Hemorrhage we shall see, that Jones's experiments shew the same thing, and the particular circumstances in which it may happen. But, the occurrence is excessively rare, and can hardly be called a radical cure, as the cicatrix is always found in a state ready to burst and break, if the arm is, by any accident, violently stretched or struck, where the wound was situated. Whenever the ulcerated, lacerated, or wounded artery, is accurately compressed against a hard body, like the bones, it ceases to pour blood into the surround- ing cellular sheath, because its sides, being kept in firm contact, for a certain extent, above and below the breach of continuity, become united by the adhe- sive inflammation, and converted into a solid, ligamentous, cylinder. Molinelli, Guattani, and White, have given exam- ples and plates, illustrative of this fact. When aneurisms get well spontaneously, the same fact is observed after death, as Valsalva, Ford, &c. have demonstrated. lhave myself seen in St. Bartholomew's Hospital, an instance, in which a man had had a spontaneous cure of an aneu- rism in the left axilla, but afterwards .died of hemorrhage from another one under the right clavicle; the artery on the left side was found completely im- pervious. My friend, Mr. Albert, had under bis care, in the' York Hospital, .Chelsea, a dragoon, who recovered spon- .taneously of a -/ery large aneurism of the external iliac artery: the tumour slough- ed, discharged about two quarts of coa- gulated blood, and then granulated and jiealed *»p. Paoli relates a similar ter- . initiation of a popliteal aneurism. Moini- chen and Guattani, relate other exam- ole*. Hunter found the femoral artery quite impervious, and obliterated, at the place where a ligature had been applied fifteen months before. Boyer noticed the same fact in a subject, eight years after the operation. Petit relates a spon- taneous cure of an aneurism at the bifur- cation of the right carotid, and the sub- ject having afterwards died of apoplexy, tlie vessel on dissection, was found closed up and obliterated from the bifurcation, as far as the right subclavian artery. Desault had an opportunity of opening a patient, in whom a spontaneous cure of a popliteal aneurism was just beginning; he found a very hand, bloody thrombus, which extended for three finger-breadths, within the tube of the artery, above the sac, and was so firm, as to resist injec- tion, and make it pass into the collateral branches. Both the spontaneous and surgical curea of aneurisms, have two stages ; in the first, the entrance of the blood into the aneurismal sac is interrupted ; in the se- cond, the parietes of the artery approach each other, and, becoming agglutinated, the vessel is converted into a solid cylin- der. This doctrine is corroborated by the tumour first losing its pulsation, and then gradually diminishing and disappearing. Dr. Thomson, as well as Scarpa, has long expressed his opinion, that the spontane- ous radical cure of aneurisms, may some- times arise from the pressure of the aneu- rismal sac on the trunk of the injured artery, just above the communication between the vessel and the cavity of the aneurism. Morand proved that a vio- lent blow may lead to the obliteration of an artery, and Dr. Jones has demonstrat- ed, that arteries always become imper- vious, after having a tight ligature put round them, even though such ligature be removed the moment after its appli- cation. When an aneurism is affected deeply by gangrene, a dense, compact, bloody, coagulum is formed within the vessel, shutting up its canal, and interrupting completely the course of the blood. Hence the sphacelation which follows, and the bursting of the integuments, and of the aneurismal sac, are never accom- panied by a fatal hemorrhage, and the patient is cured of the gangrene and the aneurism, if he has strength sufficient to resist the destructive action of the sphace- lus on the constitution. When a patient dies of'hemorrhage, after the mortificatioa of an aneurism, it is because only a por- tion of the integuments and sac has sloughed, without the root of the aneu. 116 ANEURISM. rism, and, especially, the arterial trunk, being in this way affected. In order that compression may make the* opposite side of an artery unite, and thus produce a radical cure of an aneu- rism, Scarpa says, the degree of pressure must be such as to place these opposite sides in firm and complete contact, and such as to excite tlie adhesive inflamma- tion in the coats of the artery, which must also possess a state of vitality, presently to be noticed. The point of compression must also fall above the laceration, or wound of the artery; for, when it operates below, it hastens the enlargement of the tumour; and Scarpa adds, that, in prac- tice, bandages, which are expulsive and compressive, are more useful for making pressure, than any tourniquets or instru- ments*, many of which are contrived to operate, without retarding the return of blood through the veins. For pressure to succeed, the coats of the vessel must possess, at the place where it is made, such a degree of vitali- ty, as to be capable of feeling the stimu- lus, and of inflaming. When the arterial coats, round the root of the aneurism, are diseased, as above described, they are insusceptible of the adhesive inflamma- tion, although compressed together in the most scientific manner, and, even when tied with a ligature, which only acts by making circular pressure on the vessel. Some advise trying compression in every case of aneurism, whether small, circumscribed, soft, flexible, indolent, or elevated, diffused, hard, and painful. In the latter case, however, compression is hurtful. Every bandage, which compres- ses the aneurism, and also constricts cir- cularly the affected part, is always in- jtu-ious. The bandage, likewise, which, compressing only the aneurism, directs the point of pressure below the rupture in the vessel; that which, on account of the great size, exquisite sensibility, depth of the root, of the aneurism, and fleshiness of the surrounding parts, can- not effectually compress the artery against the bones, so as to bring the opposite sides ofthe vessel into contact; and, last- ly, the compression applied to a spontane- ous aneurism, attended with a steatoma- tous, ulcerated, earthy, disease of the arterial coats ; ought to be considered as an useless, or rather hurtful plan. In cases of a completely opposite description, ban- dages have produced, and may produce, radical cures of aneurism, and should not be entirely disused. Guattani first employed compression systematically for the cure of aneurisms, and he has related many cases, in which he succeeded. Freer details other ones j- but, in general, pressure has hitherto been applied to the tumour itselt, a me- thod less likely to answer, than that of making pressure on a sound part of the artery. Mr. Freer recommends the em. pfoyment of Sennfio's instrument, or the following method: first place a bandage moderately tight, from one extremity of" the limb to the otfcer ; then place a pad upon the artery, a few inches above the tumour; next, surrounding the limb with a tourniquet, let the screw be fixed upon the pad, having previously secured the whole limb from the action of the instru- ment, by a piece of board wider than the limb itself, by which means the artery only will be compressed, when the screw is tightened. The tourniquet should now be twisted till the pulsation in the tu- mour ceases. In a few hours the limb will become cedematous and swelled, when the tourniquet may be removed, and the pressure of a pad and roller will afterwards be enough. By experiments which this gentleman made on the radial arteries of horses, these vessels were found to become inflamed, and to be rendered impervious by such a process. (Freer, p. 112.) Mr. A. Cooper mentions an excellent machine for compressing the femoral ar- tery, in cases of popliteal aneurism. It was used by Sir W. Blizard. " The points of support for this instru. ment were the outer part of the knee, and the great trochanter, a piece of steel pass- ing from one to the other; and to the middle of this a semicircular piece of iron was fixed, which projected over thefemo- ral artery, having a pad at its end, moved by a screw, by turning which, the artery was readily compressed, and the pulsation in the aneurism stopped, without any in-- terruption to the circulation in the smaller vessels." But, although the patient on whom it was tried possessed unusual forti- tude of mind, and indifference to pain, he was incapable of supporting the pressure of the instrument longer than nine hours. Indeed, the agony arising from long con- tinued pressure is insupportable to almost all men. (Med. and Phys. Journal, Vol. 8.) The grand means most to be depended upon, however, for curing aneurisms, is tying the artery above the tumour. This more certainly prevents the usual ingress of blood into the sac, and, what is more important, more certainly excites the ad. hesive inflammation, by dividing the in- ternal coats of the vessel. The blood in the sac is afterwards gradually absorbed, and the tumour dwindles away in pro- portion. The natural course of the blood ANEURISM. 'H-* bting now peirmanently interrupted in the arterial trunk, it passes more copi- ously into the collateral branches, and these enlarging and anastomosing with others, which originate from the large arteries beyond the obstruction, the ne- cessary circulation is carried on. The ligature of the superficial femoral artery, may be performed with the same confidence of success, as the ligature of the brachial artery, that is, without any fear of destroying the circulation, or de- priving the subjacent limb of its vitality. indeed, the numerous and conspicuous anastomoses, which are met with all" round the knee, correspond exactly with those which are observed round the el- bow, and at the bend of the arm. This is not a peculiarity of the arteries of the extremities, but it is a general rule which nature has followed in the distribution of all the arteries, that the superior trunks communicate with the inferior, by means of the lateral vessels. After the prin- cipal trunk of an artery is tied, its lateral branches not only carry on the circula- tion in the parts below the ligature, but do so with greater quickness and activity than they did before, when the course of the blood was unimpeded through the principal trunk. This evidently arises from the increase of pressure which the blood, that takes the rout of the lateral vessels, receives, as well as from the en- largement in the diameter of these ves- sels. After the amputation ofthe thigh, wliile the blood fjows in a full stream from the superficial femoral artery, very little or no blood is poured out of the lateral vessels ; but as soon as that ar- tery is tied, the blood issues with impe- tuosity from the small arteries which run along, within the vasti and crurseus mus- cles ; and, on these smaller arteries being also tied, the blood immediately oozes out, from the minute arterial vessels of the muscles and cellular membrane. When tlie principal trunk of an artery is tied, its lateral branches gradually ac- quire a much larger diameter. After am- putation of the thigh, on account of a popliteal aneurism, the size and situa- tion of which could not fail materially to impede the course of the blood through the trunk of the femoral artery, it has been often remarked, that, although both the trunk and the greater and smaller branches, had been tied with the greatest accuracy, the patients have been in danger of losing their lives, on account of the repeated copious hemorrhages from the innumerable small lateral vessels, that had become unusually enlarged. In se- veral cases, during the treatment, and especially ajter the radical cure of pop. liteal aneurism, by tying the superficial femoral artery, in the upper third of the thigh, all the ramifications of the recur- rent popliteal arteries have been felt beating strongly round the knee. Boyer found, in a man, who some years before had been operated on for a popliteal aneu- rism, but had afterwards died from a caries of the tibia, that the arterial branch, which runs through the substance ofthe sciatic nerve, was dilated so much, as to be equal in diameter to the radial artery. White, in dissecting the arm of a lady, who, fifteen years before had been operated on for an aneurism in the bend of the arm, found the brachial ar- tery obliterated, and converted into a solid cylinder, for three inches below the place of the ligature, and as far as the division into the radial and ulna arte- ries ; but, the recurrent radial and ulnar branches had become so much enlarged that, taken together, they exceeded the size of the brachial artery, above the situ- ation of the ligature. In the dead body it is found, that an anatomical injection will pass more freely from one extremity to the other of an ani^reumatic, than of a sound limb, and this, even when no vessels are visibly enlarged. Although it be self-evident, that the circulation. through the collateral vessels ought to be much more easy and quick the lower down the ligature is applied to the prin- cipal trunk; yet, experience shews, that this difference is not to be estimated very high; for in cases of popliteal aneurism, cxteris paribus, the success is the same, whether the femoral artery be tied very low down, or very high up in the thigh. (Scarpa.) This facility of the passage of the bloofl through the lateral vessels, is not the same in subjects of all ages ; and, in the same subject; it is not the same in the inferior, as in the superior extremity. An age under forty-five, and the operation being done on the arm, which is nearer the source of the circulation, than the lower extremity, increases the chance of success. The circumstances chiefly preventive of success, especially in the popliteal and femoral aneurisms, are the following: Rigidity, atony, or disorganization of the principal anastomoses, between the supe- rior and inferior arteries of the ham and leg; sometimes depending on advanced age, or'on it, together with the large size ofthe aneurism, which, by long continued pressure, has caused a great change in the neighbouring parts: or sometimes on steatomatous, ulcerated, earthy, cartila- ' ginous, disorganization of the proper coats of the artery, not c-pnfinei to the n8 ANEURISM. seat of the rupture, but extending a great way above and below the aneurism, and also to the principal popliteal recurrent arteries, tibial arteries, artd occasionally, to portions of the whole track of the su- perficial femoral artery. Sometimes, the pressure of large aneurisms, renders the thigh bone carious. In such circum- stances the ligature is apt to fail in clos- ing the trunk of the artery; and, if it should succeed, the state of the anasto- mosing vessels will not admit of a suffi- cient quantity of blood being conveyed into the lower part of the limb. Hence, when the patient is much advanced in hfe, languid and sickly, when the in- ternal coat of the artery is rigid, and in- capable of being united by a ligature; when the aneurism is of long standing, and considerable size, with caries of the os femoris, or tibia; when the leg is weak and cold, much swelled, heavy, and cede- matous; Scarpa considers the operation contra-indicated. I must, however, de- clare in this place, that I have seen very large aneurisms, as well as aneurisms in persons of advanced age, cured by the Hunterian plan, in St. Bartholomew's Hospital. It appears, then, that the obliteration of the artery, for a certain extent, above and below the place of rupture, forms the primary indication in the radical cure of aneurism, whether compression or the ligature, be employed. All other means are only auxiliary. Internal remedies may be useful in so far as they tend to moderate the determination of the blood towards the place, where the artery has been tied or compressed. Bleeding in young, very robust, plethoric patients, low diet, diluent drinks, gentle laxatives and glysters, mental and bodily rest, and cool air, have such effect. When there is weakness, not from age, but from pain, long want of rest, or loss of blood, tonics, cordials, and a moderate diet, may be given. Scarpa also advises the outward use of corroborants and stimulants; but, I think, few English surgeons will ap- prove the practice. Notwithstanding, however, aneurisms cannot in general be cured, as Scarpa has explained, unless the artery be rendered impervious for some extent above and below the tumour, I believe, we must make an exception to this observation, with respect to the few aneurisms of the aorta, (especially those of its arch,) which, according to the records of surgery, have been diminished and cured by Valsalva's treatment. In such examples, we are not to suppose, that the aorta becomes obliterated at its very beginning; but, that th* diminution of the quantity of circulating blood, the reduced impetus of this fluid, the lessened distention of the aneurismal sac, the general weakness in- duced in the constitution, and the in- creased activity of the lymphatic system, all necessary effects of Valsalva's method, have combined to bring about a partial subsidence of the tumour. In internal aneurisms, and other cases, out of the reach of operative surgery, practitioners have usually been content with prescribing occasional bleedings, debilitating remedies, abstinence, a milk diet, and quietude, &c. As bleeding-, however, cannot always be frequently re- peated, instead of it, Scarpa says, the hands and feet may be immersed in tepid water, the limb rubbed, and water given internally, with a small quantity of Hoft'- man's liquor anodynus mineralis. (Spir. AEtheris. Comp.) The great difficulty of breathing, adds the same writer, may receive a temporary relief, by applying sinapisms. All pressure on the tumour, when it protrudes externally, should be avoided, as it might increase the com. pression on the viscera, and would cer« tainly accelerate the fatal bursting of the aneurism. Digitalis has been given with advan- tage ; but, occasional bleedings, and opi- um, have been found to produce most re- lief. In the latter stage, opium can alone be relied on. (Freer!) It must be acknowledged, that practi- tioners have too commonly abandoned, such aneurisms as do not admit of an operation, as inevitably fetal, and, what- ever measures have been taken, in cases, of this kind, have rather been pursued with a view of palliating the patient's sufferings, than with any hope of effecting a cure. Yet, we shall find, in the ensuing section of this article, that some exceed- ingly large aneurisms of the aorta itself, have been cured by copious and repeated, venesections, and the rigorous adoptiou of Valsalva's practice. Were the same treatment more generally followed, no doubt, internal aneurisms might seem much more curable than they have usu- ally been regarded. The celebrated Desault conceived, that, when an aneurism was so situated, that a ligature could not be applied to tlie ar- tery leading to the swelling, a cure might possibly arise from tying the ves- sel, on that side of the tumour, which was most remote from the heart. De- sault conjectured, that, by this means, the circulation through the sac would be stopped, the blood in it would coagulate, that the circulation would go on by the collateral arteries, and that the tumour would be finally aJaorbed. These spe< ANEURISM. W fulations, however, were not found to answer in practice. Dechamps tied the femoral artery below an inguinal aneu- rism ; but the progress of the disease, instead of being checked, seemed to be accelerated by this novel experiment. The operator was obliged, as a last re- source to open the tumour, and try to take up the vessel. In this attempt, the patient lost a large quantity of blood, and died eight hours afterwards. (See QZuvres Chir. de Desault par Bichat, Tom. 2, p. 568.) OP ANEURISMS OF THE AOnTA, AND VAL- saxva's TREATMENT. This afflicting and fatal disease is by no means unfrequent, and the arch of the aorta is the most common situation of the tumour. Dr. Hunter was of opinion, that the latter circumstance depended on the forcible manner, in which the blood, K repelled from the left ventricle of the eart, must be driven against the angle ofthe curvature ofthe vessel. The same distinguished physician also thought, that the aneurismal sac was composed of the dilated coats of the artery, which parts nature thickened and studded with ossi- fications, after the origin of the disease, for the purpose of resisting its increase. The writings of Scarpa, however, make it appear highly probable, that, the gene- rality of aneurisms of the aorta are the consequence of a rupture of the proper coats of this large vessel; and that the cellular sheath of the artery is what be- comes distended into the thickened and ossified aneurismal sac. It seems also a fact, that, when tlie coats of the aorta jrive way in a certain situation (viz. with- in the pericardium) where they only re- ceive a very slight external membranous "covering, this last part is also apt to be ruptured at the same time, so as to bring on a copious effusion of blood in the chest, and sudden death. If these things be true, (and, they ap- pear to be confirmed by^nost careful and accurate dissections) the common distinc- tion of aneurisms into true and false, or into aneurisms by dilatation and rupture, can no longer be regarded as accurate, as we have already explained. Therefore, the idea of Dr. Hunter, that aneurisms of the aorta were swellings of this vessel itself was a mere supposition, and the aneurismal sac, in these, as in all other cases, is composed of the sheath of cel- lular substance, which surrounds the ar- tery. We have stated, that Dr. Hunter con- sidered the ossifications of the sac as con- sequences of the disease; but the cele- brated Haller looked upon such scales of bone in the aorta as the very cause of the affection, by rendering the artery inelas- tic, and incapable of yielding to each pul- sation of the heart. It is very certain, that aneurisms of the aorta are most commonly met with in per- sons, who are advanced in life, and, it is equally well known, that the aorta of every old subject, whether affected with aneu- rism, or not, is almost always marked in some place, or another, with ossifications, or, rather, with calcareous concretions. Such productions appear to occasion a decay, or absorption, of the muscular and inner coats of the vessel, so that, at length, the force of the blood makes the artery give way, and this fluid, collecting on tiie outside of the laceration, or rup- ture, gradually distends the external sheath of the artery into the aneurismal sac, which itself becomes at least of consi- derable thickness and studded with ossi- fied specks. " If any person, who is not prejudiced in favour of the common doctrine, with regard to the nature and proximate cause of this disease (says Scarpa), will examine, not hastily and superficially, but, with care and by dissection, the intimate struc- ture and texture of the aneurism of the aorta, unfolding with particular attention the proper and common coats of this ar- tery, and, in succession, those, which constitute the aneurismal sac, in order to ascertain distinctly the texture and limits of both, he will clearly see, that the aorta, properly speaking, contributes nothing to tiie formation of the aneurismal sac, and, that, consequently, the sac is merely the cellular membrane, which, in the sound state, covered the artery, or that soft cel- lular sheath, which the artery received in common with the neighbouring parts. This cellular substance, being raised and compressed by the blood, effused from the corroded or lacerated artery, assumes the form of a circumscribed tumour, covered externally, in common with the artery, by a smooth membrane, such as the pleura in the thorax, and the peritoneum in the abdomen. " I do not pretend to deny, (continues this accurate anatomist,) that, sometimes, in consequence of congenital relaxation of the proper coats ofthe aorta, at its exit from the heart, a certain degree of yield- ing of these coats may contribute to the rupture of the aorta at this place, and, by that means, to the formation of an aneu- rism, which, in this case, is likewise con- joined with a certain degree of preterna- tural dilatation of the whole tube ot the artery. I only deny, that dilatation of this arteryprecedesand accompanies every aneurism of the aorta, and am unwilling C21 ANEUUlsM. to admit, that, in the formation of this formidable disease, the proper coats of the aorta ever yield so much to disten- tion, as to form the aneurismal sac. With regard to this point, it is a fact worthy of the attention of medical men, and of all those, who wish to investigate this sub- ject, that the root of an aneurism of the aorta, in whatever point of this artery it appears, never includes the whole circum- ference of the tube of the artery; but, that the root constantly occupies and in- volves only the one, or the other side of the artery, from which side, the aneuris- mal sac rises and enlarges, in the form of an appendix, or tuberosity, more or less large and extended, according to the cir- cumstances of the place, or of the period of the disease; while, on the contrary, the dilatation of tlie artery occurs con- stantly in the whole circumference ofthe tube, and therefore differs essentially from aneurism." (Scarpa on the Anatomy, Pa- thology, and Surgical Treatment of Aneurism, Transl. by Wisliart,p. 55, 56.) In whatever manner aneurisms of the aorta are formed, there are no diseases, which are more justly dreaded, or which more completely fill the surgeon, as well as the patient,' with despair. No afflic- tion, indeed, can be more truly deplor- able ; for, tbe sufferings, which are occa- sioned, hardly ever admit even of pallia- tion, and the instances of recovery are" so very few, that no consolitary expectation can be indulged of avoiding the fatal end, to which the disease naturally brings the miserable sufferer. The existence of aneurisms of the aor- ta, is scarcely ever known with certainty, before they have advanced so far, as to be attended with an external pulsation, and a tumor, that admits of being felt, or even seen. In very thin subjects, the throbbing of the abdominal aorta is some- times unusually plain through the integu- ments and viscera, and this has occasion- ally given rise to the suspicion of an aneu- rism; a circumstance, which deserves to be remembered by eveiy surgeon, desirous of not pronouncing a wrong opinion. While thoracic aneurisms of the aorta are accompanied with no degree of external swelling, the symptoms are all equivocal, and might depend on a disease of the heart, angina pectoris, and several other affections. Violent and irregular throb- bings frequently occur between the fourth and fifth true ribs of the left side; the same irregularity of the pulse prevails as often proceeds from organic affections of the heart; the respiration is exceedingly obstructed; the voice altered; and, in a more advanced period of the malady, the patient is at times almost •Buffocated. The pressure of the internal swelling on tf* trachea, bronchia, and lungs is sufficient to account for this difficulty of breathing. In many instances, the irritation and com. pression, produced by tiie tumor, occa- sion an absorption of the greater part of the lungs, and abscesses and tubercles throughout the portion, which remains. Even the function of deglutition suffers interruption, in consequence of* the pres- sure made on the oesophagus, which may even be in a state of ulceration. Tha% in an example recently published, we read, that "the cavity of the windpipe was nearly obliterated from the pressure of the aneurism; and the extremities of four of its cartilages lay in the oesopha- gus, having entered that canal, through an ulcer in its coats." (Transactions of a Society for the Improvement of Med. and Chirurgical Knowledge, Vol, 3, p. 83.) The way, in which aneurisms of the thoracic aorta prove fatal, is subject to consider- able variety. These swellings do not al- ways destroy the patient by hemorrhage; in numerous instances, the magnitude of the disease so impedes respiration, that death seems induced by suffocation, and not a drop of blood is found internally effused. Frequently, (to use the descrip- tion of Mr. John Bell) before the awful and fatal hemorrhage has had time to oc- cur, the patient perishes of sufferings too great for nature to bear. The aneurismal tumour so fills the chest, so oppresses the lungs, compresses the trachea, and curbs the course of the descending blood, that the system, with a poor circulation of ill- oxydated blood, is quite exhausted. And, thus, though the patient is saved from the most terrible scene of all, he suffers great miseries; he experiences in hit chest severe pains, which he compares with the stabbing of knives ; terrible pal- pitations ; an awful sense of sinking within him; a sound within his breast, as if of the rushing of waters; a continual sense of his condition; sudden startings during the nighj; fearful dreams and dangers of suffocation, until, with sleep- less nights, miserable thoughts by day, and the gradual decline of an ill-supported system, he grows weak, dropsical, and expires. (See Anatomy ofthe Human Body, by John Bell, Vol. 2, Edit. 3, p. 234, 235.) The situations, in which aneurisms of the curvature of the aorta buret, are dif- ferent in different cases. Sometimes the swelling bursts into the cavity of the chest, or that of the pericardium, and the patient drops suddenly down. In other examples, the blood is effused into the trachea, or bronchia, and the patient, af- ter violent coughings and ejections of blood from the mouth, expires. In cer- ANEURISM. 121 t.tin cases, the swelling beats it* way through the .ribs, destroys the vertebra, and injures the spinal marrow, so that the patient suffers a species of death, some- what less violent and sudden. But, al- though aneurisms in the chest do some- times present at the back, a circumstance, that depends on the particular situation ofthe disease, (see Pelletan's Clinique Chi- rurgicale, Tom. 1, Obs. 7, p. 84.), they more commonly rise towards the upper part of the breast, where a throbbing tu- mour occurs, which has caused an absorp- tion of the opposing parts of the ribs and sternum; and sometimes dislocated the clavicles. The swelling now pulsates in an alarming way. The blood is only re- tained by a thin covering of livid skin, which is becoming thinner and thinner. At length, a point of the tumour puts on a more conical, thin, and inflamed appear- ance than the rest; a slough is formed, and, on this becoming loose, the patient is instantaneously carried off by a sudden gush of blood. A singular case of aneurism of the aorta is related by Dr. C. W. Wells. The dis- ease, being unattended with any exter- nal swelling, it seems, was not known with certainty during tiie patient's life- time. The following is an abstract of the symptoms, and particulars of the case. Mr. A. B. a gentleman, thirty-five years of age, and temperate in his habits, be- came affected in 1789 with symptoms, which were thought to denote the ap- proach of pulmonary consumption. These, however, after some time, entirely disap- peared. In 1798, he was attacked with a slight hemiplegia, from which he also recovered, with the exception of an in- considerable sense of coldness in the foot, which had been paralytic. In March 1804, he complained of being frequently troubled with a noise in his ears, flatu- lence in his bowels, and pains in his hands and feet, sometimes attended with slight swellings in the same parts. From one, or more of these symptoms, he was never afterwards quite free; but, he did not complain of any unusual feelings in his chest. August 11, 1807, he fatigued himself considerably with walking; ate rather a hearty dinner; and, liaving re- freshed himself with some sleep after- wards, he played about with his children. While thus amusing himself, he was sud- denly seized, between eight and nine o'clock, with great oppression in his chest. He soon afterwards became sick, and, in the matter thrown up, some streaks of blood were observed. He now went to bed; but, though the weather was v arm, and he was covered with bed- Voi. I clothes, his skin felt cold to the attend- ants. At midnight he laboured under a constant cough, and expectorated mucus tinged with bloou. His body was moist- ened with a cold sweat, and his pulse was extremely feeble; sometimes, it was scarcely perceptible. About five in the morning, his pulse was feeble and irregu- lar ; his breathing difficult, his skin pale, cold, and covered with a clammy sweat. He frequently tossed, and writhed liis body, as if he was suffering great pain or uneasiness. The mental faculties, how- ever, seemed unimpaired. Shortly, after- wards, he expired, having complained, just before his death, of much heat in his chest, and thrown off* the bed-clothes. The most remarkable circumstance found on opening the body, is thus re- corded : " The ascending aorta was dis- tended to about the size of a large orange. The tumour adhered to the pulmonary artery, just before its division into the right and left branches. Within the-cir- cumference of this adhesion, there was a ' narrow hole, by means of which a com- munication was formed between the two arteries." j£ Dr. Wells concludes with observing, that, though such a disease might easily have been imagined, he has found no in- stance of it in books, and that it has not been observed by any of the surgeons, or anatomists in London. He supposes, that the communication, between tlie aorta and pulmonary artery, took place on the even- ing before the patient's death, when the oppression in the chest was first felt; and that, in consequence of M^ superior strength of the left side «|Pne heart, a part of the blood, which was thrown into the aorta, must have been forced into the pulmonary artery, from which circum- stance, he conjectures most of the symp- toms originated. (Trans, of a Society for the Improvement of Med. and Clururgical Knowledge, Vol. 3, p. 85.) The bursting of an aneurism of the. aorta into the pulmonary artery is then another possible mode, in which the dis- ease may prove fatal. It is well worthy of notice, that aneu- risms of the arch of the aorta may occa- sion a tumour, so much like that of a sub- clavian aneurism, as to be in danger of being mistaken for the latter disease. An example of this kind is related by Mr. Allan Burns, " a case," says he, " on which several of the most distinguished practitioners in Edinburgh, and almost every surgeon in Glasgow were consulted. The nature of the disease appeared to be so decided, and its situation in the sub- clavian artery so clear, that, on that sub- ject, there was no difference of opinion It 122 ANEURISM. Some were, however, of opinion, that an operation might be performed, while others were fully convinced, that the case was hopeless. For myself, I must confess, that I was firmly persuaded, that, in the early stage of the disease, an operation might have been beneficial," &c. (Sur- gical Anatomy of the Head and Neck, p. 30.) After death, the vessel, which was supposed to have been most materially affected, Was found perfectly healthy.— (P. 39.) After detailing all the particulars of this interesting case, Mr. A. Burns observes, that, " it corroborates Mr. Astley Cooper's remark, that aneurism of the aorta may assume the appearance of being seated in one of the arteries of the neck; an infer- ence, drawn from the examination of a case, wliich came under his own observa- tion, and of which he had the goodness to transmit a short history to me, along with a sketch, illustrative ofthe position ofthe tumour.. In one case, the aneurism was attached to the right side of the aortic arch, and involved a part of the arteria Snominata; in Mr. Cooper's, the tumour ose from the left side of the arch, from between the roots of the left subclavian, and carotid arteries. It formed a florence- flask-like cyst, the bulbous end of which projected at the root of the neck, fi-om behind the sternum, and so nearly resem- bled aneurism of the root of the carotid artery, that the practitioner, who consult- ed Mr. Cooper, actually mistook the dis- ease for carotid aneurism." (Allan Burns, Op. cit. p. 41^ As we ha^fllready noticed, aneurisms of the aortalre-most frequent at its cur- vature r but,*Jlhey are also met with on the other portion of this vessel in the thorax, and likewise on that part of it, which is below the diaphragm. In subjects, pre- disposed to aneurisms, such swellings are frequently seen affecting various parts of the aorta at the same time. When the disease occurs in the abdo- minal aorta, a preternatural pulsation generally becomes perceptible at some point of the parietes of this part of the body. The pressure of the tumour inter- feres with the functions of the viscera; tlie breathing is rendered difficult by the swelling resisting ihe descent of the dia- phragm ; the patient suffers at times ex- cruciating internal pains; sometimes he is affected with costiveness; sometimesj with diarrhoea; and, not unfrequently, with incontinence of the urine and feces. At length, an immense external swelling is formed, which pulsates alarmingly, and, if the patient survives long enough, destroys him by a sudden external, or internal effusion of blood. Aneurisms, within the thorax and ab- domen, being entirely out of the reach of operative surgery, have been too com- monly abandoned as unavoidably fata), and when any thing has been done in such cases, it has generally been only with a. view of palliation. Moderating the force of the circulation by bleedings and-low diet, avoiding every thing that has the least tendency to heat the body, or quieken the motion ofthe blood, keeping the bow- els well open with laxa'.ve medicines, and lessening pain with opiates, have been the means usually employed. Of late years, also, the digitalis, which has a peculiar power of diminishing the action of sanguiferous system and impetus ofthe blood, has been prescribed, with every appearance of benefit. It was tlie opinion of the celebrated Valsalva, that the utility of a lowering plan of treatment might do more, than merely retard the death of aneurismal patients. It was his belief, that the me- thod might entirely cure such aneurisms as had not already made too much pro- gress, and he put it into practice with such rigour and perseverance, that the treat- ment became considered as particularly his own. The plan, alluded to, is not de. scribed in his writings; but, was published in the first volume of the Commentaries of the Academy of Bologna, by Albertini, one of his fellow students; and several persons, who had learnt this method of Valsalva, afterwards imparted it to others. Thus, as Morgagni was passing through Bologna, in 1728, Stancazi, a physician of that place, is said to have informed him of Valsalva's practice. After taking away a good deal of blood by venesection, Valsalva used next to di- minish the quantity of food gradually, till the patient at length was allowed only half a pint of soup in the morning, a quar- ter of a pint in the evening, and a very small quantity of water, medicated with mucilage of quinces, or with the lapis osteocolla. Whef*, the patient had been so reduced, as to be incapable of getting out of his bed, Valsalva used to give him more nourishment till this extreme debility was removed. Valsalva was sure, that some aneurisms, thus treated, had got well, be- cause every symptom disappeared, and liis conviction was verified by an oppor- tunity, which he had of dissecting the body of a person that had been cured of this disease, and afterwards died of an- other affection -, for, the artery, which had been dilated, was found contracted and in some degree callous. Morgagni relates, that this method of treating aneurisms, is somewhat Hke the plan, which Bernard Gengha tried with ANEURISM. 123 success, as well as Lancisi, and he refers us to the 24th chapter of the 2nd. vol. of the Anatomy of the one, and to lib. 2, cap. 4, of the Treatise on the Heart and Aneurisms, of the other. But, Sabatier tells us, that, in consequence of this in- struction, he examined both these works, without finding any thing on the subject. However this may be, we are informed by the latter, that he has seen the good ef- fects ofthe practice in an officer, who had an alarming aneurysm in front of the hu- meral extremity of the clavicle, in conse- quence of a sword wound in the axilla. The patient, after having been bled se- veral times, was confined to his bed, and kept to an extremely low diet. He was allowed, as drink, only a very acid kind of lemonade. He took pills containing alum, and the swelling was covered with a bag, full of tan mill dust, which was every now and then well wet with port wine. By a perseverance in this treat- ment, the swelling was reduced to a small- ish hard tubercle, having no pulsation, and a perfect cure ensued. (See Sabatier's Medecine Operatoire, Tom.3,p. 170—172.) A French surgeon, named Guerin, has written in favour ofthe efficacy of apply- ing ice water, or pounded ice to aneuris- mal swellings; a plan, which he repre- sents, as being often of itself sufficient to effect a cure. This topical employment of cold applications may be rationally and conveniently adopted in conjunction with Valsalva's practice. The most interesting and convincing facts, hi proof of the efficacy of this mode of treatment, have been lately published at Paris by M. Pelletan. Indeed, upon the whole, I have no hesitation in saying, that I have never read any modern collec- tion of surgical cases, which have appeared tome more valuable, than those which com- pose the Clinique Chirurgicale of this ex- perienced writer. The following extract from a well written critique on this work will serve to convey to tlie reader some idea of the important information con- tained in the memoir on internal aneu- risms. " The intent in the treatment is to reduce the patient gradually to as ex- treme a degree of weakness, as is possi- ble, without imminently endangering life. It is done by absolute rest, a rigorous diet, and bleeding; to these means, M. Pelletan adds the external application of ice, or cold and astringent washes, &c. He has here detailed many cases from his own practice, of partial, or complete success, which cannot be too generally known, as they may be the means of cre- ating in some, and of confirming in others, a good opinion of the only method of treatment, which has been found at all efficacious in a dreadful and not unfix* quent organic disease. " Of the cases here recorded, some ap- pear to have been cured; in others, the treatment had marked good effects. In extreme cases, at best, it afforded but par- tial and temporary relief. We can notice but a few of these cases, which are, in every respect, highly interesting. In one, a robust man, an aneurism at the root of the aorta, with a pulsating tumour of the size of an egg, projecting between the ribs, (the edges of which were already partly absorbed) was reduced, so as to recede within the ribs in the course of eight days. At the end of this time, the patient re- fused to submit any longer. The tumour did not appear again for nearly a year, although he returned to very drunken and irregular habits. He died in about two years and a half, with the tumour again appearing, and much increased in volume. The aneurismal sac communicated with the aorta by a smooth and round opening, opposite to one of the sigmoid valves. There can be no doubt of the efficacy of the treatment in this case ; and it is high- ly probable, that,his health and his life might have been long preserved, but for his own indiscretion. In a case somewhat similar, but not so far advanced, the pa- tient appears to have been cured. There was a swelling on the right side of the breast, about six inches in circumference, with a very strong beating. The pulsa- tion was accompanied by a pain, which stretched towards the scapula and the oc- ciput. It was evident, that the disease was, an aneurism of the great arch of the aorta. The patient was a trier, of a strong frame, who was accustomed to drink free- ly. In the four first days, he was bled eight times, drawing three dishes, " pa- lettes" in the morning, and two in the evening. On the fifth, the pains and the beating were much lessened, but the pulse was still full. He was agjiin bled once. The pulse was in a favourable state, as to strength till the seventh day, when it. again rose, and the man was twice bled. During this time, the man was kept to a most rigorous diet. A cold poultice of Unseed and vinegar was placed on the tumour, and renewed when it became warm. At. the end of eight days, the good effects of this plan were very evident, the pain and the pulsation were gone. The patient, though weak, was in health and tranquil. He was now allowed more food by degrees. At the end of four weeks from the commencement ofthe treatment, he left the Hotel Dieu well. He after- wards led a sober life, became fatter than before, without any vestige of disease^ except a slight and deep pulsation at the 124 ANEURISM. part, in which the aorta may always be felt beating in its natural state. He died, two or three years after, of another com- plaint. His death was not known, and the body was not examined." (See Lon- don Med. Review, Vol. 5, p. 123.) M. Pelletan also cured by similar treat- ment a large axillary aneurism, which was regarded as beyond the reach* of operative surgery. On the thirteenth day, the pa- tient Was reduced to a degree of weakness, which alarmed many of the observers. From that time, all pulsation in the tu- mour ceased. The contents were gradu- ally absorbed ; and the patient returned to his former laborious life with his arm as strong as ever. The pulse at the wrist was lost, in consequence ofthe obliteration of the axillary artery, and the limb only receiving blood through the branches of the subclavian artery. By a beaucoup cTex- emples cPaneurismes gueris spontenemant et sans le secours de Part; (says Pelletan) mais on ne peut leur comparer le cas que nous venons de dec.rire; Vetat extreme de la maladie, Tenergie des moyens employes, et Teffet immediat et successif qrd en est r£- sulte, prouvent assez que le succes a ete dft tout entier d I'art." (Clinique Chirurgicale, Tom. 1, p. 80.) In this work, we find not less than three cases, in which aneurism of "the aorta is stated to have been effectually cured. One instance was greatly relieved; but, the disease returned, the next year, in consequence of the patient's intemperate mode of life. In another example, an aneurism at tiie origin of the aorta was cured; but, the disease recurred in an- other part of that vessel further from tlie hei-rt. Even such cases, as proved incura- ble, to the number of fourteen, all receiv- ed various degrees of palliation from the treatment adopted. I shall now proceed more particularly to the consideration of aneurisms, Which may be cured by a surgical operation, and, here, we shall be fully satisfied, that " Part de gicerir ne triomplie jamais plus lieureuse- ment que lorsqu'il peut employer la mede- cine efficace, e'est d dire, les moyens chirur- gicaux ou operatoires." (Clinique Chirur- • gicale, Tom. 1, j&.'HO.) OF THE POPLITEAL AXEURiaM, AITD OPERATION FOB ITS CURE. The practice of tying arteries, wounded either by accident or in the performance of surgical operations, and even the plan ■st" tying the humeral artery for the cure of the aneurism at the bend of the arm, were known long before the operation for ""fihe relief of the popliteal aneurism was attempted. The considerable size of the femoral artery; its deep situation, the urgent symptoms ofthe disease, and igno- rance of the resources of nature for trans- mitting blood into the limb, after the li- gature of the vessel, are the circum- stances, which appear to Pelletan to have deterred former surgeons from this opera- tion. Valsalva, indeed, had treated pop- liteal aneurisms on the debilitating me- thod, and has adduced one or two equi- vocal proofs of its success. In Pelletan's first memoir on aneurism, and in the third vol. of Sabatier's Mede- cine Operatoire, as I have already stated, are two cases of axillary aneurisms, which were cured by Valsalva's treatment. But, encouraging as such examples may be, experience is not yet sufficiently favoura- ble to this practice to allow it to bear a comparison, in point of efficacy, with the surgical operation, or to justify the gene- ral rejection of this last more certain means of cure. As Pelletan admits, Valsalva's treatment is extremely severe -, the event of it is doubtful; and, should it not be found to answer, it is questionable, whe- ther the patient would be left in a condi- tion to bear the operation, for the success of which, it seems necessary, that, a cer- tain strength of vascular action should ex- ist in order that the blood may be freely transmitted through such arterial branch- es, as are to supply the place of the main trunk, after this last has been tied. The time, therefore, has not yet arriv- ed, when surgical operations for the relief of aneurism should be relinquished. (Pel- letan, Climque Chirurgicale, Tom. 1, p. 114, 115.) The cure of popliteal aneurisms by means of compression is occasionally ef- fected; but, it happens too seldom to claim a great deal of confidence, or to less- en in any material degree the utility and importance of operative surgeiy in this part of practice. Pelletan records the cure of one popliteal aneurism by compression and absolute repose, during eleven months (Tom. 1, p. 115,) *nd other examples might be cited, were it necessary. Aneurisms in general, and, among them, the popliteal case, are all attended with some little chance of a spontaneous cure; yet, this desirable event is too uncommon to be a judicious reason for postponing the operation, especially, as it is the usual course of the disease to continue to in- crease, the cure in the early stage may be more speedily accomplished, and the expe- rience of modern operators leaves no room for apprehending that the anastomoses will not suffice for the due nourishment of the leg, and, consequently, proves, that waiting for the enlargement of the collateral vessels to take place, js alto- ANEURISM. 125 oether an unnecessary and ineligible me- thod. Popliteal aneurisms, as well as •other external tumours of the same na- ture, stand the best chance of a spontane- ous cure, when any cause induces a gene- ral, violent, and deep inflammation all over the swelling; for, then, the commu- nication, between the sac and arteiy, may possibly become closed with coagulating lymph, and the pulsation of the tumour be suddenly and permanently stopped. If, in this state, the disease sloughs, and the patient's constitution holds out, the coa- gulated blood in the sac and the sloughs, are gradually detached, leaving a deep ulcer, wliich ultimately heals. An exam- ple, in which a popliteal aneurism seems to have been cured by such a process, is related in the Trans, of a Society for the Improvement of. Med. and Chirurgical Knowledge, Vol. 2, p. 268. After what has been stated, it is almost unnecessary to say, that, in former times, when all hopes of curing a popliteal aneu- rism by Valsalva's method,, by compres- sion, or a natural process, were at an end, amputation ofthe limb was considered as the sole and necessary means of saving the patienf s life. In modern times, a great and beneficial change of opinion has taken place upon this subject, and not only may the patient's life be in general saved, but his limb also, and this without any opera- tion, that can be compared with amputa- tion, in regard to severity. It is alleged, that Teislere, Molinelli, Guattani, Mazotti, and some other cele- brated Italian surgeons, were the first, who ventured to tie the popliteal artery for the cure of aneurism. The path, as Pelletan remarks, had been pointed out to them by Winslow and Haller, whose va- luable descriptions and plates of the ar- terial anastomoses about the knee joint, shewed by what means the lower part of the limb would be nourished, after a liga- ture was made on the principal arterial * trunk. For almost thirty years, however, the practice of tying tb/ popliteal artery was confined to the Italian surgeons. Pel- letan believes, that he was the first, who attempted such an operation at Paris nearly thirty years ago, (alluding to about the year 1780, the Clinique Chirurgicale being dated 1810.) However, this operation of opening the tumour and tying the popliteal artery it- self, was a severe and often a fatal pro- ceeding, and does not admit of being com- pared with the Hunterian operation, in point either of simplicity, safety, or suc- cess, as I shall explain, after a few parti- culars relating to the popliteal aneurism have been detailed. On whatever side of the artery the tu- mour is produced, -it can be plainly felt in the hollow between the hamstrings, and its nature is as easily ascertained by the pulsation in every part of the tumour. Though the disease may, perhaps, not occur in the popliteal artery so often as in the aorta itself, yet, it certainly is seen more frequently in the former vessel, than any other branch, which the aorta sends oft". As Mr. Home has observed, this cir- cumstance has never been satisfactorily explained, and, what is rather curious, in many recent instances of this disease, the patients have been coachmen and posti- lions. Morgagni found aneurisms of the aorta most frequent in guides, post-boys, and other persons, who sit almost conti- nually on horseback. This he imputes to the concussion and agitation, to which they arc exposed. When we contemplate the effects of va- rious postures of the leg and thigh on the popliteal artery, and the obstruction, which the circulation in it must expe- rience, when the knee is in a state of flexion, we perceive an assignable cause, why this artery should be so often diseas- ed. This account is, in some degree, strengthened by aneurisms of the aorta itself, occurring more frequently at its cur- vature, than any other part. (Home in Trans, of a Society for the Improvement of Med. and Chirurgical Knowledge, Vol. 1.) The popliteal aneurism is generally supposed to arise from a weakness -in the coats of the artery, independently of dis- ease. If this were true, we might reasona- bly conclude, that, except at tlie.dilated part, the vessel would be sound. Then the old practice of opening the sac, tying tlie arteiy above and below it, and leaving the bag to suppurate sand heal up, would naturally present itself. Mr. Hunter finding, that the arterial coats were al- tered in structure higher up, than the tumour, and that the artery, immediately above the sac, seldom united when tied; but, Jhati when the ligature came away, the bleeding destroyed the patient; con- cluded, that some disease affected the coats ofthe vessel, before the actual oc- currence of the aneurism. Dissatisfied with Haller's experiments on frogs, shew- ing that weakness alone could give rise to aneurism, he tried what would happen in a quadruped, whose vessels were very similar in structure to the human. Hav- ing denuded above an inch of the carotid arteiy of a dog, and removed its external coat, he dissected off the other coats, layer after layer, till what remained was so thin, that the blood could be seen through it. In about three weeks, the dog was killed, when the wound was found closed over the artery, which w as 126 ANEURISM. neither increased, nor diminished in size. It being conjectured, that aneurism was perhaps, prevented, by the parts being immediately laid down on the weakened portion of the arteiy, Mr. Home stripped off the outer layers of the femoral arteiy of a dog, placed lint over the exposed part of the vessel to keep it from uniting to the sides of the wound, and, in six weeks, killed the animal, and injected the artery, which was neither en- larged, nor diminished, and its coats had regained their natural thickness and ap- pearance. These experiments strengthened Mr. Hunter's belief, that aneurismal arteries are diseased; that the morbid affection frequently extends a good way from the sac along the vessels ; and that the cause of failure in the old operation, arose from tying a diseased arteiy, wliich was inca- pable of uniting, before the separation of the ligature. Mr. Hunter's reflections led him to propose taking up the artery in the ante- rior part of the thigh, at some distance from the diseased portion, so as to dimi- nish tlie risk of hemorrhage, and be en- abled to get at the vessel again, in case it should bleed. The flux of blood into the sac being stopped, he concluded, the sac and its contents would be absorbed, and the tu- mour gradually disappear, so as to render any opening of the sac unnecessary. The first operation of this kind, ever done, was performed on a coachman, by Mr. Hunter, in St. George's Hospital, December, 1785. An incision was made on the anterior and inner part of the thigh, rather below its middle, which wound was continued obliquely across the inner edge of the sartorine muscle, and made large, in order to facilitate doing whatever might be necessary. The fascia, covering the artery, was then laid bare, for about three inches, after which the vessel itself could be plainly felt. A cut, about an inch long, was then made through this fascia, along the side of the arteiy, and the fascia dissected off. Thus the vessel was exposed. Having disengaged it from its connexions with the knife and a thin spatula, a double ligature was put under it, by means of an eye probe. The doubled ligature was then cut, so as to% make two separate ones. The artery was now tied with both these ligatures, but, so slightly as only to compress the sides together. Two additional ligatures were similarly applied a little lower, with a view of compressing some length of ar- teiy, so as to make amends for the want of tightness, as it was wished to avoid great pressure on any one part of the vesseL The ligatures were left hanging out of the wound, which was closed with sticking plaster. On the second day, the aneurism had lost one-third of its size, and, on the fourth, the wound was every where healed, except where the ligatures were situated. On the ninth, there was a considerable discharge of blood from the apertures ofthe ligatures, but it ceas- sed on applying a tourniquet and did not recur. On the fifteenth day, after the operation, some of the ligatures came away, followed by a small quantity of matter, and about the latter end of Janu- ary, 1786, tiie man went out of the hos- pital, the tumour having become still less. In the course ofthe spring, some abscesses in tiie vicinity of the cicatrix followed, and some pieces of ligature were dis- charged, from time to time. In the be- ginning of July, a piece of ligature, about one inch long came away, after which the swelling went off' entirely, and the man left the hospital again on the 8th, per- fectly well, tiiere being no appearance of swelling in the ham. This subject,died of a fever in March, 1787, and, on dissection, the femoral ar- tery was found impervious from the giv- ing off of the arteria profunda down to the place of the ligature, and an ossifica- tion had taken place for an inch and a half along the course of this part of the vessel. Below this portion, the vessel was pervious, till just before it came to the aneurismal sac, where it was again closed What remained of the sac was somewhat larger than a hen's egg, and it had no remains of the lower opening into the popliteal artery. The rest of the particulars of this dissection are very in- teresting. (See Med. and Chir. Trans. Vol. 1. p. 153.) This celebrated case led to the know- ledge, that simply taking off the force of the circulation is sufficient to cure an aneurism, the tumour being then taken away by absorption. To confirm the fact, Mr. Home relates a case of femoral aneurism, which got well without an operation, but, on the same principle. A trial of pressure had been made, without avail. The tumour became very large, and such inflamma- tion took place in the sac and integu- ments, that mortification seemed im- pending. In this state, no pulsation could be felt in the tumour, or the arteiy above it. A coagulum, which we know always occurs in an artery previously to mortification, seemingly to prevent bleed- ing, probably formed in this instance, and kept the blood from entering the sac. (Home.) Mr. Hunter's second operation was on ANEURISM. 127 a trooper. Instead of using several liga- tures, which were found hurtful, he tied the artery and vein with a single strong one ; but, unluckily, made the experiment . of dressing the wound from the bottom, instead of uniting it at oftce: the event was, tlie man lost a good deal of blood, and died. After this, Mr. Hunter's practice was to tie the artery alone with one strong ligature, and unite the wound as speedily as possible. ■Since the time of Hunter, several in- novations, and some considerable im- provements in the mode of operating have been proposed. The peculiarity in Mr. Abernethy's first operation consisted in applying two ligatures round the artery, close to where it was surrounded with its natural con- nexions. For this purpose, he passed two common sized ligatures beneath the fe- moral vessels, and having sliifted one upwards, the other downwards, as far as these vessels were detached, he tied both the ligatures firmly. The event of this case was successful. An uneasy sensation of tightness, how- ever, extending from the wound down to the knee, and continuing for many days after the operation, made Mr. Abernethy determine, in any future case, to divide the artery between the two ligatures, so as to leave it quite lax. Mr. Abernethy next relates a case of popliteal aneurism, for which Sir Charles Blicke operated, with the innovation of dividing the artery between the ligatures. The man did not experience the above kind- of uneasiness; and no hemorrhage ensued when the ligatures came away, although there was reason to think, that the whole arterial system had a tendency to aneurism, as there was also another tumour of this kind in .the opposite thigh. Mr. Abernethy has referred bleeding, after operations for aneurisms, to two causes; viz. 1st', the inflammation and ulceration of the arteiy; 2dly. the want of union between the sides of the vessel. "When an artery is laid bare, and detached from its natural connexions, and the middle of such detached portion tied with a single ligature, as was Mr. Hunter's practice, it is observed by Mr. Abernethy, that the vessel, so circumstanced, must necessarily inflame, and be very likely to ulcerate. The occurrence of bleeding led to a practice, which this gentleman justly censures, viz. applying a second ligature above the first, and leaving it loosefi but ready to be tightened, in case of hemorr- hage. As the second ligature, however, must keep a certain portion of the artery separated from the surrounding parts, and must, as an extraneous substance, "jrritate the inflamed vessels, it must make \ts ulceration more apt to follow. For the same reason, Mr. Abernethy thinks pieces of wood, cork, &c. hurtful, and when employed with a view of hindering the ligature from cutting completely through the arteiy, their interposition is not necessary, as such an accident scarce- ly ever occurs, and, as they would prevent the ligature from dividing the inner and muscular coat, (See Hemorrhage) they would tend to prevent the adhesion of the opposite sides of the vessel to each other. When the artery is tied in Mr. Aberne- thy's manner, and is divided in the space between the ligatures, it becomes quite lax, possesses its natural attachments, and is, as nearly as possible, in tlie same circumstances as the femoral artery is, when tied on the surface of a stump. (See Surg, and Physiol. Essays by J. Aber- nethy.) Notwithstanding Scarpa has excelled other writers so muph, in his description of the anatomy and formation of aneu- risms, his practice in regard to the opera- tion, is certainly far inferior to Mr. Aber- nethy's, and that of practitioners in gene- ral in this country. His interposing a cylindrical roll of linen, between the arte- ry and knot of the ligature, and his not bringing the sides of the wound toge- ther immediately after the operation, are particularly objectionable parts of his method. There is one excellence, however, in Scarpa's mode of operating, which I think will soon obtain the universal approba- tion of the surgical profession; he pre- fers making the incision in the upper third of the thigh, or* a little higher than the place where Mr. Hunter used to make the wound. His reason for this, is to avoid the necessity of removing the sartorus muscle too much from its posi- tion, or of turning it back, to bring the artery into view, so as to be tied. 1 have seen the best operators embarrassed, by having the sartorius muscle immediately in their way after the first incision, anil as the vessel is more superficial a little higher up, the place is further from the diseased part of the artery, and there is no hazard of the anastomoses failing to keep up the circulation; this part of Scarpa's practice is highly deserving of imitation. It will in no manner diminish the merit of those men, who have success. fully laboured to improve the present part of the practice of surgery, to state, that the most ancient surgeons seem to 128 AXEUttIS"M have known and practised some of the chief things, upon which the superiority of the plan now adopted appears princi- pally to depend. Such methods having quite sunk into oblivion, and John Hunter not being one who pried into old works, his innovations claim all the ho- nour due to the strictest originality. It is a fact, worthy of notice, that the Greeks were acquainted with the prac- tice, lately recommended, of tying and dividing the trunk of the artery high above the tumour, as will appear from the following extract: (.Etii. 4 Serm. Tetr. 4. cap. 10.) At vero quod in cubiti co- mitate fit aneurisma, hoc modo per chirurgiam aggredimur : primurn arteria superne ab ula ad cubitum per internum brachii parte sim- plicem sectionem, tribus, aut quatuor digitis infra alam, per longitudinem facimus, ubi maxime ad factum arteria occunit.- atque ea paulatim denudatu, deinceps incumuentia cor- puscula sensim excoriamus ac separamus, et ipsamarteriam cxcouncino attractum duobus fili vinculis probe adstringimus, mediamque inter duo vinculo dissecamus; et sectionem pol- linethurisexplemus, ac linamentis inditis con- gruas deligationes adlubemus. Afterwards we are directed to open the aneurismal tumour at the bend of the elbow, and when the blood has been evacuated, to tie the artery twice, and divide it again. If the ancients had only omitted the latter part of their operation, they would ab- solutely have left nothing to be disco- vered by the moderns. What a striking example of the bold manner in which our forefathers have acted, without being guided by the lights of anatomy and phy- siology ! But there are two or three pas- sages in Galen, Celsus, and Hippocrates, from which we may suspect, that even ./Etius himself was not the inventor of this operation, &c. See also Paul. AEgin. lib.6. cap. 37. (Rees'Cyclopedia, Art. Aneu- rism.) The French surgeons of the present day are exceedingly jealous about the improvements, which British practi- tioners have been the means of introduc- ing into this branch of surgery. Pelletan declares, that, with regard to dividing the artery between the ligatures, his countryman M. Tenon, used to advise this practice forty years ago. (Clinique Chirurgicale, Tom. 1, p. 192.) Yet we find that M. Tenon himself must give up the claim of priority to -"Etuis, and other an- cients. The merit of the thing appears to me to consist in the revival of the practice, and in insisting on its advan- tages, with sufficient stress to make it extensively approved. M. Richerand seems also offended, that Hunter's name should be affixed to an operation, wliich he conceives wax in reality the invention of Guillemeau. Here we observe, A-:tius again puts in a prior claim, and, with much more effect, be- cause his operation truly resembled Mr. Hunter's, inasiiiuch as it was done at some distance above the swelling, while Guillemeau only tied the artery close above the disease, and opened the swell- ing, a serious deviation from the Hunterian practice. Guillemeau (says Richerand) a con- temporary, and disciple of Ambrose Pare, having to treat a tumour of blood, at the bend ofthe arm, in consequence of bleed- ing, exposed the artery above the tu- mour, tied this vessel, then opened the sac, took out the coagulated blood con- tained in it, and dressed the wound, which healed by suppuration. After more than a century, Anel, on being con- sulted about a similar case, tied the ar- tery above the swelling, but left this to itself. The pulsations ceased, the tu- mour became smaller, and hard, and after some months, no traces of the dis- ease were perceptible. In 1785, Desault operated in the same manner for a popliteal aneurism: the swelling diminished by one half, and the throbbings ceased; on the 20th day, it burst, coagulated blood and pus were discharged in large quantities, and the wound, after continuing a long time fis- tulous, at length healed. Towards the ' end of the same year, says Richerand, Hunter applied the ligature somewhat differently; instead of placing it close to the swelling, or directly above it, he put it on the inferior part of the femoral ar- tery. (See Riclierand's Nosographie Chi- rurgicale, Tom. 4, p. 98, 99, edit. 2.) Unquestionably, M. Anel did in one solitary instance, tie the humeral artery immediately above an aneurism at the bend ofthe arm, and effected a cure with- out opening the swelling; but he did not think of applying the plan to the femoral artery, or draw the attention of the French surgeons sufficiently to the mat- ter, to make the latter imitate his opera- tion: on the contrary, the method fell into oblivion, and was never practised. With regard to Desault's operation, said to have been done in an earlier part of 1785, than-Mr. Hunter's first operation, it is only necessary to say, that Desault tied the popliteal arteiy itself, while the grand object in Mr. Hunter's method was to take up the femoral artery, at a dis- tance from the disease, and that it is this last mode alone, which has gained such approbation, and been attended wjth un- paralleled success. Mr. Astley Cooper lias published a cast ANEURISM. 129 ui popliteal aneurism, in which a parti- cular occurrence happened, that led this gentlemrn to make a little innovation in the method of tying arteries for the cure of aneurisms. The femoral artery had been tied with two ligatures, as firmly as could be done without risk of cutting it through. " But, (says Mr. A. Cooper) as I was proceed- ing to dress tlie wound, I saw a stream of blood issuing from the artery, and when the blood was sponged away, one of the ligatures was found detached from the vessel. Soon after the other was also forced off, and thus the divided femoral artery was left without a ligature, and unless immediate assistance had been afforded him, the patient must have pe- rished under hemorrhage." The same kind of accident has occurred in Mr. Cline's practice. These events naturally induced Mr. A. Cooper to reflect on the means, wliich were to be employed to obviate them, and the first which suggested itself was to in- clude a larger portion of the artery be- tween the two ligatures. But this plan was given up, when it was recollected, that many branches of arteries must be divided, and that it was a mode of secu- rity (if it was so) which could only apply to particular cases of aneurism, since in some situations of that disease, there is scarcely any length of vessel between the tumour and a principal anastomosing branch of the artery. Mr. A. Cooper thinks, that a plan of greater security, and more general appli- cation, consists in conveying the ligatures, by means of two blunt needles under the artery, an inch asunder, and close to the coats ofthe vessel, excluding the vein and nerve, but passing the threads through the cellular membrane surrounding the artery. When these are tied, and the artery is divided between them, the liga- tures will be prevented from slipping from the artery by the cellular membrane through which they are passed. Mr. A. Cooper next relates a case of aneurism after bleeding, which he cured by this way of operating. "But although this plan, as to the event, answered my expectations, yet a different mode of securing the ligature, suggested to me by my young friend Mr. H. Cline, struck me so forcibly for its simplicity and security, that I felt imme- diately disposed to adopt it." Mr. A. Cooper put the new plan to the test of experiment in operating for a popliteal aneurism on Henry Figg, aged 29. " An incision being made on the middle of the inner part of the tliigh, and the femoral arterv exposed, the arterv Vol. I. was separated from 'he vein and nerve, and all the surrounding parts, to tiie ex- tent of an inch, and an eye-probe, arm;. J with a double ligature, having a curved needle at each end, was conveyed under the artery, and the probe cut away. The ligature nearest the groin was first tied ; the other was separated an inch from the first, and tied also. Then the needles were passed through the coats of the ar- tery, close to each ligature and between them. The thread they carried, was tied into the knot of the ligature, which had been already secured around the vessel; and thus a barrier was formed in the ar- tery, beyond which the ligature could not pass." The event of this operation was successful. (Med. and Pliys. Journ. Vol.8.) Upon the foregoing proposal a few ob- servations are necessary, and these I shall offer with due deference to the eminent character, whose fame alone has attached undue importance to the innovation. In the first place I shall prove that Mr. H. Cline's proposal is not an original one. It appears to have been mentioned by Dionis, and to have been noticed by some subsequent writers. In the 13th chapter, on hemorrhage, in Richter's An- fangsgrundetier Wundarzneykunst,we read the following passage. Die hervorgezog- ne Schlagader umwickelt man mit dem gewo"hnlichen Faden zweymal, befestigt den- selben miteiiwm Knoten, ziehet daruufwenn die Schlagatler gross ist, vermittelsteinerNa- del ein ende des Fadens vor tier Unterbm- dilng durch dieselbe, knuft beyde Enden zu- sammen,und la'sstsie wie gewo" hnlich her ab- ha'ngen. Dritte Aufiage. 1799. " The ar. tery, when drawn out, is to be twice sur- rounded with the common ligature. This is to be tied in a knot, and when the ar- tery is large, one end of the ligature is to be passed, by means of a needle, through the vessel before the knot, then both ends are to be tied together, and left hanging out of the wound, as in the ordinary way." Edition 3. 1799. In making this quotation, my object is to remove the supposition, that the world is indebted to Mr. H. Cline for the suggestion, if we may use the term indebted, when the plan has certainly very little merits and would undoubtedly never have acquired much celebr*tv, had not Mr. A. Cooper's name een coupled with it. What power can possibly force the liga- ture, when tied with due tightness, off the extremity of the vessel ? If Mr. A. Cooper had reflected a little, he would have seen, that no action of the heart, or artery itself, no turgid state of this vessel, could do so. If a piece of string were tied round any tube for the purpose of 130 ANEURISM preventing a fluid from escaping from its mouth, provided the string is applied with due tightness, no fluid can possibly escape, however great the propelling pow- er may be, supposing that the string, and structure of the tube, do not break. If the ligature be applied so slackly as to slip, who can doubt, that a hemorrhage will stdl follow, even though the ligature is carried through the end of the vessel, and tied in the way mentioned above. In the case, in which tlie ligature slip- ped off, as mentioned by Mr. A. Cooper, we must, therefore, conclude that the ar- teries were not tied with a sufficient tight- ness, perhaps through an unfounded fear that a ligature, might cut its way com- pletely through all the coats of an arteiy. The inner coats of the artery we know, from the experiments of Dr. Jones, are invariably cut through when the vessel is properly tied, and the circumstance is al- ways useful in promoting its closure. OF ANEURISMS HIGH UP Til's FEMORAL ARTERY. Mr. Aberoetliy has been called upon in at least four cases to take up the exter- nal iliac artery. The events of all these have shewn, that the anastomosing vessels were fully capable of conveying blood enough into the limb below, and that a vessel even of this size could become per- manently closed after being tied. Messrs. Freer and Tomlinson, of Birmingham, have both also done tlie same operation with success. Our limits, however, will only allow us to describe the operation, and the particulars must be consulted in Abernethy's Surg, and Physiol. Essays; his Surgical Observations, 1804; Edinb Sled. and Surg. Journal for January, 1807; and Freer's Observations on Aneurism, 1807. J.n Mr Abernethy's first operation of tins kind, an incision, about tlu-ee inches in length, was made through the integu- ments of the abdomen, in the direction of the artery, ,and thus the aponeurosis of the external oblique muscle was laid bare. This w:is next divided, from its connexion with Poupart's ligament, in the direction of the external wound, for the extent of about two inches. The margins of the internal oblique and transverse muscles being thus exposed, Mr. Abernethy ia- troduced his fingers beneath them to protect the peritoneum, and then divided them. Next he pushed this membrane with its contents upwards and inwards, and took hold of the external iliac artery with his finger and thumb. It now only remained to pass a ligature round the artery,and tie it;Tmt, this required cau- tion, on account of the contiguity of tlie vein to tlie artery. These Mr. A, sepa- rated with his fingers, and introducing a ligature under the artery with a common surgical needle, tied it about an inch and a half above Poupart's ligament. {Sur. Essays) The following was the method Mr. Abernethy adopted the second time of tying the external iliac artery. An incision of three inches in length was made through the integuments ofthe abdomen, beginning a little above Pou- part's ligament, and being continued up- wards ; it was more than half an inch on the outside of the upper part of the abdo- minal ring, to avoid the epigastric artery. The aponeurosis of the external oblique muscle being thus exposed, was next di- vided, in the direction of the external wound. The lower part of the internal oblique muscle was thus uncovered, and the finger being introduced below the in- ferior margin of it and ofthe transversalis muscle, they were divided with the crook- ed bistoury for about one inch and a half. Mr. Abernethy now introduced his finger beneath the bag of the peritoneum, and carried it upwards by the side of the psoas muscle, so as to touch the artery about two inches above Poupart's liga- ment. He took care to disturb the peri- toneum as little as possible, detaching it to no greater extent than would serve to admit his two fingers to touch the vessel. The pulsations ofthe artery made it clear- ly distinguishable, but Mr. Abernethy could not get his finger round it with fa- cility. He was obliged to make a slight incision on either side of it, in the same manner as is necessary when it is taken up in the thigh, where the fascia which binds it down in its situation is strong. After this the forefinger could be put be- neath the arterv, which Mr. A. drew gently down, so as to see it behind the perito- neum. By means of an eye-probe, two ligatures were conveyed round the vessel; one of these was carried upwards as far as the artery had been detached, and'the other downwards: they were firmly tied, and the vessel was divided in the inter- space between them. (Sur. Observ. 1804 ) Mr. Abernethy, in his third instance of tying this vessel, operated exactly as in the foregoing case, and with complete success. (See Edinb. Sur?. Jour. January 1807.) Mr. Freer, in his operation, made an incision about one inch and a half from the spine ofthe ilium, beginning about an inch above it, and extending it down- wards about three inches and a half no ANEURISM. 131 as to form altogether an incision four inches uid a half long, extending to the base of the tumour Tiie tendon of the external oblique being exposed, was care- fully opened, and also the internal ob- lique, when the finger was introduced be- tween the peritoneum and transversalis, and served as a director for the crooked bistoury, which divided the muscle. Avoiding all unnecessary disturbance, Mr. Freer separated tlie peritoneum with his finger, till he could feel the artery beating, which was so firmly bound down, that he could not get his finger under it without dividing its fascia. The vessel being separated from the surrounding parts, a curved blunt needle, armed with a strong ligature was put under it, and tied very tight, with the intention of di- viding the internal coats of the vessel. The operation led to a perfect cure. (Freer on Aneurism, p. 83.) Mr. Tomlinson applied only one liga- ture, and, of course, left the artery undi- vided ; the event was attended with per- fect success. Since the first edition of this publica- tion, tiie operation of tying the external iliac artery has been performed in nume- rous examples, and, I am happy to say, that most of the events of these cases have been highly favourable to a conti- nuance ofthe practice. Mr. Astley Cooper has taken up this vessel in several in- stances, and saved his patients from im- minent death. Even on the other side of the Atlantic, the operation has now been practised with the most successful con- sequences. Such facts must be highly gratifying to Mr. Abernethy, through whose'•judgment and boldness, the me- thod was first suggested and practised. In my opinion, had this gentleman made no other improvement in his profession, this alone ought to crown him with un- fading honours. The practice seems to astonish our neighbours, who appear al- most to withhold their belief: " Lorsqu un aneurisme a commence vers la partie la plus ehee de la crurale, au moment meme ou elle vient tic sortir de V abdomen, peut-on se permettre iTinciser la partie iiiferieure de eette cavite", de couper I arcade crurale, et tie chercher Partere iliaqne cxterne, pour Pern- brasserpur la ligature? S'il enfullait croire des observations inserees dans la B/b/i- otheque britanmque, cette operation hardie aurttit ete fuite avec succes a Londres, pur le docteur Abernethy, dans un cas iPiineii- risme du commencement tie la crurale; ce. partickn n'hesita pas, tlit on, de penetrer dans le bassin, en incisant le ligament tie Fallope; mais, en mettant de cote la difftculte d' Poperation dans laquelle on estoblige de travailler en sous-auvre, et suns que la vue puisse guiderP aiguille,que Pon passe aut our du vaisseau, la ligature simultanee, de la veine iliaque, et desnerfs places sur les cotes du detroit superieur du bassin, occasionnera la grangrene. Quels vaisseaux continueront d nourrir le membre dans le defaut presque absolu tPanastomoses ? Enfin, dans la sup- position peu probable, qu'il ne tombdt pas en gangrene, ties hernies enormes seraient Pin- "evitable resultat de Paffaiblissement des parois abdominales." (Richerand, Nosogra- phie Chirurgicale, Tom. 4, p. 106—107, edit. 2.) In this passage, M. Richerand is full of error; he supposes an easy operation difficult; he forgets all the amastomosing arteries, which are branches of the in- ternal iliac, and emerge from apertures ofthe pelvis; and he is impressed with a thorough expectation of gangrene, her- ni-x, &c. which, in fact, have never arisen, in consequence of this operation. But, it is enough to say in reply to this gentleman, that he is arguing against cases, many of which were in public hospitals, and seen by hundreds of spec- tators. Some of the cases, on which Mr. Aber- nethy operated, I was an eyewitness of, and can therefore bear testimony to the ease and simplicity of the necessary ope- ration. The external iliac artery was most readily tied the beginning of the present vear, 1812, by Mr. llumsden, when the aneurismal swelling rose much higher than Poupart's ligament. The patient, it is true, died; but, his age was not less than 70; and, yet, notwithstanding this circumstance, the limb had a full supply of blood, and not the least tendency to gangrene shewed itself [The operation was first performed in America, in August 1811, by the editor of the present work. The result was com- pletely successful.—The use of a curved forceps, for the purpose of conveying the needle round the artery, was found to facilitate the operation very greatly.—For a particular account of the case, the reader is referred to Dorsey's Elements of Surgery.] The many operations, which have now been done'on the external iliac artery, have impressed me with a conviction, that, in subjects under a certain age, 1 here is no reason to fear, that the anastomoses, will not suffice for the supply of the lower extremity. 1 h.ve heard of no instance to the contn.ry, and, should such an event ever happen, it cannot be common, nor ought it, as, being only an unusual occurrence, to be admitted as a just rea- son for deluy, until the collateral vessels hive hud time to enlarge. 1 believe, that, in all aneurismal diseases, early 132 ANEURISM. operating is tlie best, and most judicious practice. I say this, not without recol- lecting, that all aneurisms "are attended with a chance of getting spontaneously well in time. 1 saw the inguinal aneu- rism, which did so, under Mr. Albert, in the York Hospital, but as this also is a rare incident, I da not .believe that it ought to influence us against having speedy recourse to an operation. Besides, the cure by inflammation and sloughing, ap- pears to me to be attended in reality with more peril, than a well executed opera- tion, and, consequently, has less recom- mendations, than many may imagine. Had not Mr. Albert's patient been a very strong man, he would certainly have fallen a victim to the extensive disease, which the burs-ting and sloughing of tlie tumour created. ANEURISMS OF THE BRAC»iHr. AIITKKT, AND THE OPEHATJON FOR THEM. Surgical wTitings contain many histo- ries of aneurisms in the bend of the arm, produced by the puncture of the brachial artery in venesection, or caused by a deep wound inflicted ut the bend of the arm, along the inner side of the humerus, or in the axilla. Such cases must indisputably be formed by effusion. Although Morand, &c. have found, lhat along with aneu- risms, caused by a wound of the brachial artery, the diameter of the vessel is some- times unusually enlarged through its whole length, above (he seat of tl:*£ tu- mour, this e<*lurgemeiit, which is very rare, might have existed naturally, before the puncture occurred. Even were it frequent, such an equable longitudinal expansion of the tube of the artery could not explain the formation of the aneu- rismal sac in the bend of the arm, along the inner side of the humerus, or in the axilla, after wounds. (Scarpa,p. 160.) The proximate cause of these cases may invariably be traced to the solution of continuity in the two proper coats of the artery, and the consequent effusion of blood into the cellular substance. The effect is the same, whether from an inter- nal morbid affection, capable of ulcerat- ing the internal and fibrous coats of the artery, the bhxd be effused into the neighbouring cellular sheath surrounding the artery, which it raises after the man- ner of an aneurismal sac ; or, tlte wound of the integuments having closed, the blood issue from the artery, and be dif- fused in the surrounding p-irts. The cellular substance, on the outside of the wounded vessel is first injected, as in ecchymosis; the blood then distends it, and elevates it in the form of a tumour, and, the cellular divisions being destroyed, converts it at last into a firm capsule, or aneurismal sac. (Scarpa p. 167.) The circumscribed or the diffused na- tufe of tlie aneurism, and the rapidity or slowness of its formation, depend on the greater or less resistance to the impetus of the blood, during the time of its effu- sion, by the interstices of the cellular sub- stance surrounding the artery, and by the ligamentous fasciae and aponeuroses, ly- ing over the sac The aponeurosis of the biceps muscle, being only half an inch broad, and situated lower than the com- mon place for bleeding, cannot, at least, in most cases, materially strengthen the cellular substance surrounding the artery, as is commonly supposed. (Scarpa, p. 168—170.) This author refers the greatest resistance to the intermuscular ligament, wliich after having covered the body of the biceps muscle extends over the whole course of the humeral artery, and is im- planted into the internal condyle. This ligamentous expansion has a triangular shape, the base of which extends from the tendon of the biceps, to the internal con- dyle, while the apex reaches upward along the inner side of the humerus to- wards the os bracliii. The humeral ar- tery and median nerve, kept in their situ- ation by the cellular sheath, and this ligamentous expansion run in the furrow, formed between it and the internal mar- gin of the biceps. (Scarpa, 171.) This author anatomically explains many cir- cumstances relative to the diffusion, cir- cumscription, shape, &c. of brachial aneu- risms, from this intermuscular ligament. While aneurisms, from an internal cause, are not unfrequent in the aorta, thigh, and ham, they are very rare in the brachial artery; but, such instances, however, arc recorded. (Scarpa, 174.) The mode of distinguishing a wound of the brachial artery, in attempting to bleed, and the method of trying to effect a cure by pressure, are described in the article Hemorrhage. Anel is said to have been the first who tied tlie brachi:-! artery, for the cure of aneurisms in the s-rm, in the same way that Hunter did the femoral, for the cure of those in the ham, viz. within one ligature above the tumour, without mak- ing any incision upon, or into, the sic itself. The operation is performed as fol- lows :—the surgeon having traced the course of the brachial artery, and felt its pulsations above the aneurism, he may either cut down to the vessel immediately above the tumour, or much higher in the long space between the origins ofthe supe- rior and inferior collateral arteries. The ANEURISM. 133 integuments are to be divided in the course ofthe artery, and also the cellular sheath, for the space of about two inches and a half. The surgeon now introducing his left fore-finger to the bottom of the wound, will feel the denuded vessel, and, if it is not sufficiently bare, he must di- vide the parts which still cover it, op- serving to introduce the edge ofthe knife, on the side next to the internal margin of the biceps, to avoid dividing any of the numerous muscular branches, which go off from the opposite side of the arteiy. He is then to insulate, with the point of his finger, the trunk of the vessel, alone if he can, or together with the median nerve and vein, and raise it a little from the bottom of the wound. He is to se- parate the median nerve and vein, for a small space from the artery, and with an eyed needle is to pass a ligature under the latter, and then tie it with a simple knot. Whoever, after these directions, says Scarpa, shall have the treatment of a cir- cumscribed aneurism in tlie bend of the arm, -will no longer, it is to be hoped, fol- low the method of those, who, supposing the tumour to be formed by the dilatation of the artery, used first to divide the in- teguments over the tumour, insulated the sac, and sought for the vessel above and below the aneurism, in order to tie it in two places; and then endeavoured to make the sac slough away. The opera- tion is now reduced to the greatest sim- plicity, viz. tying the artery merely above the tumour. (See Scarpa, p. 358, 359.) When the aneurism is diffused, and ac- companied with violent inflammation and swelling of the whole arm, from the ex- cessive distention of the clots of effused blood, Scarpa recommends the old ope- ration of opening the tumour, and tying the artery at the bottom of the sac, above and below the wound made by the lancet. In this method it will be proper to apply a tourniquet to the upper part of the arm, near the axilla; or, if the limb should be very painful and swelled, it is better to let an assistant compress tlie artery from above the clavicle, against tlie first rib. The incision having been made into the tumour, and the biood discharged, a probe is to be introduced into the puncture in the vessel, from below upwards, so as to raise the arteiy. This, being separated from the parts beneath, and the median nerve, for a small extent, is to have two ligatures put under it, one of which is to be tied above, the other below, the wound in the vessel. Then tlie tourniquet," or pressure is to be taken off', and if there be no bleeding, the wound is to be brought together. (See Scarpa, p. 359.) MH. £A-UB1RT's FltOPOSAt. Having observed, after an operation performed in the common way, by a liga- ture above and below the aperture in the artery, such violent pain, swelling and inflammation, as threatened gangrene bf the limb, and which symptoms, when mi- tigated, left the arm weak, and with a much more feeble pulse, than in the other arm, this gentleman Wished to see the operation done, so as to make less disturb- ance of the chculation. " I recollected," he remarks, ••* all that I had seen or read ofthe effects of styptics, of pressure, and of ligatures, in the cure of hemorrhages. I considered the coats and motions of ar- teries, and compared their wounds with the wounds of veins and other parts. I reflected upon the process of nature in the cure of vVounds in general, and con- sidered, in particular, how the union of divided parts was brought about in the operation of the harelip, and in horses necks, that are bled by farriers. Upon the whole, I was in hopes, that a suture of the wound in the artery might be suc- cessful ; and, if so, it would certainly be preferable to tying up the trunk of the vessel. 1 communicated my thoughts to Mr. Hallowell, Mr. Keenlyside, and some other friends of the profession. A case of art aneurism from bleeding occurred, and fell to Mr. Hallowell's lot. I re- commended the method ? have hinted. He put it in execution June 15, 1759. Every thing w is done in the usual me- thod, till'the artery was laid bare, and its wound discovered; and the tourniquet being now slackened, the gush of blood per saltum shewed there was no deception. Next, two ligatures, one above the ori- fice, and one below, were passed under the artery, that they m'ght be ready to be tied at any>time, in c:*s< the method pro- posed should fail. Then a small steel pin, rather more than a quarter of an inch long, was passed through the two lips of the wound in the artery, and secured by twisting a thread round it, as in the hare- lip. This whs found to stop the bleed- ing, upon "Which the arm was bound up, the patient put to bed, and ordered to be kept quiet, &c. The pin came away with the dres.*-i-..gs, June 29, and July 19th, tlie patient was discharged from tiie hos- pital perfectly well, and with a pulse in that arm nearly as strong as in the other.. Indeed, the pulse was very little altered immediately after the operation ; it was weakened in a small degree, as might be expected from the diameter of the vessel being straitened , but it was so strong and equal, that we had not the least doubt of the blood's continuing to circu- 134 ANEURISM. late freely through it." (Medical Obser-- vations and Inquiries, Vol. 2.) We need hardly inform the reader, that the idea of healing the wound in the ves- sel, so as to preserve the pervious state of it, is a mere hypothesis, certainly never realized by adopting Mr. Lambert's me- thod. If ever a small puncture of an ar- tery heals, so as to leave the tube pervi- ous, it is under the circumstances pointed out by Dr. Jones. (See Hemorrhage.) Had Lambert had an opportunity of examin- ing the state of the vessel, sometime after the above operation, he would have found its canal obliterated; and the preserva- tion of the perviousness of the artery be- ing the only foundation for Lambert's method, the practice must of course fall to the ground. AXILLABT ANEURISMS. Aneurisms occasionally take place in the axilla, and rather than that the pa- tient should perish of hemorrhage, it is the duty of the surgeon to tie the subcla- vian artery, if it be necessary, even as far inward, as where it proceeds over the first rib. A question, which here natu- rally presents itself is, whether the sur- geon should attempt the operation in an early period of the disease, or wait till circumstances are urgent; the aneurism large and far advanced; tlie arm cede- tnatous and insupportably painful; and the tumour in danger of bursting? It cannot be denied, that, in all cases of aneurism, there is a certain chance of the disease getting spontaneously well; and one axillary aneurism in a man in St. Bartholomew's Hospital a few years ago, had certainly disappeared of itself, as was proved by the account which the man gave of the case while living, and by the obliteration of the artery, found on in- spection after death. I believe, however, we ought not to suffer our conduct to be too much influ- enced by the hope of so unfrequent an event, and, from the observations, which I have made on this subject, I am now decidedly- of opinion, that the operation should never be delayed, so as to allow the tumour to acquire an immoderate size. The operation is always difficult; but, the difficulty is seriously increased, when the swelling has extended far to- wards the breast, and has become so large as to push considerably upwards the ciavicle. The memorable and inter- esting examples, in which Mr. Keate and Mr. R.imsden tied the subclavian artery, have shewn, that the anastomoses are fidly competent for the supply ofthe limb with blood, and, I think, that delaying the operation, with a view of allowing the inosculating arteries to enlarge, is not necessary, and, as giving time for the swelling to increase, ought to be con- demned. At all events, the tumour should never be suffered to acquire an enormous size. A wound of the axillary artery, might render it necessary to do this operation. This vessel was tied by a Mr. Hall, in Cheshire, when it had been wounded with a scythe, so as to bring the ends of the artery into view; and the arm was pre- served, though it remained afterwards i little weak, which, indeed, might be ow- ing to some large nerve being divided. (See Scarpa,p. 372.) Mr. White, of Man- Chester, relates another instance of this vessel being tied, in the case of a wound; but, mortification of the limb, and death followed. Three of the nerves were found included in the ligature- London Medical Journal, Vol. 4.) There are two modes of operating for axillary aneurisms; one by cutting below the clavicle; the other by making the wound above this bone. The first of these methods has been at- tempted in France by Desault and Pelle- tan. The former undertook the opera- tion in a case, where the axillary artery had been wounded. An incision, six inches long, was made below the external third of the clavicle; two thoracic ar- teries cut were immediately tied; the two lower thirds of the great pectoral muscle were next divided with a bistoury guided on a director; a large quantity of co»- gulated blood was now discharged; and the artery was directly taken hold of, and tied, together with tiie brachial plexus of the nerves. The arm mortified, and the patient died. This case, we must agree with Scarpa, was not a fair trial of the operation, inasmuch as the inclusion of the plexus of nerves in the ligature was an improper measure, and must have promoted the occurrence of sphacelus. It seems also probable from the account, that the vein was likewise tied; another serious and objectionable proceeding. Besides, it is worthy of notice, that the case was a wound of the axillary artery, attended with a copious effusion of blood in the cellular membrane, hi all exam- ples of this kind, gangrene is more readily induced, than when the case is a mere circumscribed aneurismal tumour. (See GCuvres Chir. tie Desault par Bichat, Tom. 2, p. 553.) As for Pelletan's example, it hardly deserves recital, because the ope- ration in fact was not achieved. His col- leagues objected to dividing the pectoral muscle ; a random thrust was made with a needle and ligature; but, the artery ANEURISM. 1-35 was not included, and the experiment was not repeated. (See Clinique Chirurgicale, Tom. 2, Obs. 7, p. 49.) In a case of axillary aneurism, which had actually burst, and the hemorrhage from whicli could only be stopped by pressing the artery against the first rib, Mr Keate, the surgeon-general, practised the following operation, which was- at- tended with completely successful conse- quences. This gentleman determined on taking up the artery, above the diseased and ruptured part, in its passage over the first rib. Accordingly, he made an inci- sion obliquely downwards, divided the fibres of the pectoral muscle, that were in his way, and, when he came to the artery, passed a curved, blunt-pointed, silver needle, armed double, as he conceived, under the artery, and tied two of the ends. After a careful examination, finding that the artery pulsated below the ligature, he determined on passing another liga- ture higher up, and nearer to the clavicle: lie, therefore, passed the needle more deeply, so as evidently to include the ar- tery. In a few days the swelling of the arm began to subside, the wbund suppu- rated, and the ligatures came away with the dressings. The arm afterwards re- covered its feeling, and the patient re- gained, in a great measure, .the.entire motion of the .shoulder, &c. (See Med. Review and Magazine for 1801.) Mr. Keate's operation is objectionable, inasmuch as it was a dive made with a needle, and attended with great danger of wounding and. tying parts, which should be left undisturbed. The subclavian artery might be got at below the clavicle, as follows : the sur- geon is to make an incision, through the integuments, about an inch from the sternal end of this bone. The cut is to run in the direction towards the acro- mion, deviating a little downward from a line parallel to that of the clavicle. This wound will bring into view some fibres of the great pectoral muscle originating from the last mentioned bone. These are next to be divided. Some cellular substance will be found underneath, which is to be carefully raised with a pair of dissecting forceps, and cut. The operator will thus arrive at the great subclavian vein, and cephalic vein uniting with it. Under the subclavian vein, and a little further backward, more under the clavicle, the subclavian artery may be felt and tied. (See Charles Bell's Operative Sur- gery, Vol. 2. p. 370.) The axillary artery may be got at by making an incision above the clavicle, and it is undoubtedly not a very difficult plan to accomplish in the dead subject, without any tumour under the clavicle*. But it is more difficult in a living subject, having a large axillary aneurism ; for, then the clavicle becomes so much ele- vated, and the artery lies so deeply be- low it, that the vessel can hardly have a ligature carried under it, without a par- ticular needle for the purpose. This was the case in an attempt which I once saw made to tie the artery, and in which one of the cervical nerves, affected by the pulsation of the artery, was mistaken for it, and tied, so that the aneurism soon afterwards burst, and a fatal hemorrhage arose. Were a surgeon to operate above the clavicle, he should adopt the follow- ing plan:—-An incision should be made just over the sternal end of the clavicle, and the clavicular portion of the sterno- cleido-mastoideus muscle be detached with a blunt pointed curved bistoury. No further use should be made of a cat- ting instrument. The chief difficulty would now be, to get a ligature under the arteiy; but, it may be done with the aid of an ingenious needle, which Mr. Ramsden has described, and which is ex- actly similar in principle to one employed by Desault, called by the French, aiguille d ressort. As the artery communicates its pulsations to the cervical nerves in the vicinity, the operator should be particu- larly careful not to mistake one of them for the vessel itself. In order to avoid the inconveniences of the needles ordinarily used for conveying ligatures under deep arteries, Desault (says Bichat) inventea " une aiguille 4 ressort," composed of a silver tube, or sheath, which was straight at one end, and bent at the other in a semicircular form. This sheath enclosed an elastic wire, the projecting extremity of which ; was accurately fitted to the end of the sheath, and perforated with a transverse eye. The instrument was passed under the arteiy, and, as soon as it had reached the other side of the vessel, the sheath was kept fixed, while an assistant pushed the elastic wire, which, rising from the bottom ofthe wound, presented the aper- ture or eye to the surgeon, who now pass- ed the ligature through this opening. The wire was next drawn back into its sheath again, and the whole instrument brought from beneath the artery, by which means, the ligature was conveyed under the vessel. (See OZuvres Chirur- gicale de Desault, par Bichat, Tom. 2, p. 560.) The invention of this needle makes a material diminution in tlie difficulty of taking up the subclavian artery from above the clavicle; nor, can it be won- dered, that, without such an instrument; Io* ANEURISM. the operation should have baffled even so skilful a surgeon as Mr. A. Cooper. The following example is the first in which the attempt to *e tiie subclavian artery, by cutting above the clavicle, was ever accomplished. I conceive, that it reflects great honor on Mr. Ramsden, vrtio undertook it, and who preferred ex- posing himself to a failure, rather than omit the only possible means of saving his patient from an imminent death. John Townly, a tailor, aged thirty-two years, addicted to excessive intoxication, of an unhealthy and peculiarly anxious countenance, was admitted into St. Bar- tholomew's Hospital, on Tuesday, the 2d of November, 1809, on account of an aneurism in the axilla of his right arm, which had been coming on about four months. The prominent part of the tu- mour in the axilla was about half as big as a large orange, and there was also much enlargement and distention under- neath the pectoral muscle, so that the elbow could not be brought near tiie side ofthe body. " The temperature of both arms," says Mr. Ramsiten, "was alike, and the pulse in the radial artery of each of them was correspondent. After the patient had been put to bed, some blood taken from the left arm, and his bowels emptied, his pulse, which, on his admission had been at ISO, became less frequent; his coun- tenance appeared more tranquil; and he experienced some remission of the dis- tressing sensations in the affected arm: this rehef, however, was of short dura- tion ; the weight and incumbrance of his arm soon became more and more oppres- sive, and, in resistance to eveiy medical assistance, his nights were again passed without sleep, and his countenance re- assumed the anxiety, which had charac- terized it,-when he first presented him- self for advice. " On the sixth day, after his admission, his decline of health became so very evi- dent, and the progressive elevation ofthe clavicle, from the increasing bulk of the tumour, was so decidedly creating addi- tional difficulties to any future operation, that I considered it necessary to convene my colleagues, and avail myself of their opinions, as to the propriety of perform- ing the operation; when it was agreed in consultation, that as the tumour, (al- though increasing) did not appear im- mediately to endanger the life of* the pa- tient, from any probability of its burst- ing suddenly, it would be adviseable yet to postpone the operation, for the purpose of allowing the greatest possible time for the anastomosing vessels to become en- larged ; and, in the meanwhile, that the case should be most vigilantly watchei!. "About this period of the case, tlie pulsation of the radial artery of the af. fected arm gradually became more ob- scure, and soon after either ceased entire- ly, or, what is more probable, was lost in the succeeding oedema ofthe forearm and hand, both of which became loaded to a great extent. "Notwithstanding the aneurismal tu. mour had continued to increase, and the patient's health had proportionately de. clined, yet no particular alteration was observed on the integuments, until I vi. sited him in the evening of the twelfth day after his admission, when I found him complaining of more than usual we«. riness and weight in the affected limb, and painfully impatient for the impos- sibility, as he described it, of finding a posture for the arm. " On examining the tumour, a dark spot appeared on its centre, surrounded by in. flammation, which threatened a more ex. tensive destruction of the skin. Under these symptoms and appearances, no far- ther postponement of the operation being admissible, I performed it the next day in the following manner. " The patient being placed upon an operating table, with his head obliquely towards the light, and the affected arm supported by an assistant at an easy (lis- tance from the side, I made a transverse incision through the skin and platysma myoides along and upon the upper edge of the clavicle, of about two inches and a half in length, beginning it nearest to the shoulder, and terminating its inner extremity at about half an inch within the outward edge of the sterno-cleido- mastoideus muscle. This incision di- vided a small superficial artery, which was directly secured. The skin, above the clavicle, being then pinched up, be- tween my own thumb and finger, and those of an assistant, I divided it, from within, outwards and upwards, in the line of the outward edge of the sterno- cleido-mastoideus muscle, to the extent of two inches. " My object, in pinching up the skin for the second incision, was to expose at once the superficial veins, and by dissect ing them carefully from the cellular mem- brane, to place them out of my way, with- out wounding them. This provision proved to be very useful, for it rendered the flow of blood during the operation very trifling comparatively with what might otherwise have been expected; and, thereby, enabled me with the greatest facility to bring into view those parts, which were to direct me to the arterv. ANEURISM. I.i7 *♦ My assistant liaving now lowered the shoulder, for the purpose of placing the first incision above the clavicle, (wliich I had designedly made along and upon that bone) I continued the dissection with my scalpel, until I had distinctly brought into sight the edge of the anterior sca- lenus muscle, immediately below the angle, which is formed by the traversing belly of the omo-hyoideus aid the edge of the stcrno-cleido-mastoideus, and hav- ing placed my finger on the artery, at the point where it presents itself between the scaleni, I found no difficulty in tracing it without touching any of the nerves to the lower edge of the upper rib, at which part, I detached it with my finger nail for the purpose of applying the ligature. " Here, however, arose an embarrass- ment, which (although I was not unpre- pared for it) greatly exceeded my expect- ation. I had learned from repeatedly performing this operation, many years since, on the dead subject, that to pass the ligature under the subclavian artery, with the needle commonly used in aneu- risms, would be impracticable; 1 had therefore, provided myself with instru- ments of various forms and curvatures to meet the difficulty, each of which most readily conveyed the ligature underneath the arteiy ; but, would serve me no far- ther ; for, being made of solid materials, and fixed into handles, they would not allow of their points being brought up again at the very short curvature, which the narrowness of the space, between the rib and the clavicle afforded, and which, in this particular case, was rendered of unusual depth, by the previous elevation of the shoulder by the tumour. " After trying various means to over- come this difficulty, a probe of ductile metal was at length handed me, which I passed under the artery, and bringing up its point with a pair of small forceps, I succeeded in passing on the ligature, and then tied the subclavian artery at the part, where I had previously detached it for that purpose. The drawing of the knot was unattended with pain, the wound was closed by tlie dry suture, and the patient was then returned to his bed." (See Practical Observations on the Sclerocele &c. to which are adiladfour cases of opera- tionsfor Aneurism, by Thomas Ramsdnn, sur- geon to Christ's Hospital, &c.p. 276, &c.) It only seems necessary for me to add, that immediately, the artery was tied, the pulsation of the swelling ceased; that the arm of the same side continued to be freely supplied with blood, and was even rather warmer than the opposite arm; that the operation, which was severe from Vol. I. the length of time it took up, was after a time followed by considerable indispo- sition; that the patient died about five days after its performance; that, after the artery had been tied, the oedema of the arm, and the aneurismal tumour part- ly subsided; and, that, on examinat.on after death, nothing, but the vessel, was found included in the ligature. The case, in my opinion, does Mr. Ramsden great honor; for, the difficulty he had to encounter in conveying the li- gature under-the artery was such as would have haffled all men of ordinary manual dexterity. In this-gentleman's publica- tion are descriptions of instruments, which will be of great service to any fu- ture performer of this operation. The chief one is a needle, resembling that, which was invented and used by Desault, and of which I have already endeavoured to give an idea. By means of this in- strument, I conceive, that the main dif- ficulty of the operation will for die future be no longer experienced, llud Mr. Ramsden had its assistance, his patient would have been detained a very little time in the operating theatre, and the event of the case might have been com- pletely successful. Having witnessed all the circumstances of the case, the infer- ence, that 1 drew from tliem was, that, if the operation could have been done in a moderate time, which now seems prac- ticable with the aid of the aiguille a res- sort, the case in all probability would have ended well. The preceding case is particularly memorable, as being the first instance, in which tiie subcla- vian artery has been scientifically tied, without any random thrust of a needl*, and without the inclusion of any part be- sides the arteiy in tlie ligature. It is a fact, that furnishes an encouragement to repeat the experiment, holds out the hope, that axillary aneurisms may hereafter be cured as well as inguinal ones; and con- firms the competency of the anastomosing arteries to nourish the whole upper ex- tremity, when the subclavian is tied where it emerges from behind the ante- rior scalenus muscle CAn-OTID ANEURISMS. Tlie possibility of tying the carotid ar- tery, in cases of wounds and aneurisms, without any injurious effect on the func- tions of the brain, now seems completely proved. Petit mentions, that the advo- cate Viellard, had an aneurism at the bifurcation of the right carotid, for the cure of which he was ordered a very spare diet, and directed to avoid all violent exer- T US ANEURISM. else. Three months after this prescription, the tumour had evidently diminished; and, at last, it was converted into a small, hard, oblong, knot, without any pulsa- tion. The patient having died of apo- plexy, the right carotid was found closed up and obliterated, from its bifurcation, as low down as the right subclavian ar- teiy.—(Acad, des Sciences de Paris, an. 1765.) Hebenstreit, vol. 5, of his Trans- latiou of B. Bell's Surgery, mentions a case, in which the carotid artery was wounded, in extirpating a scirrhous tu- mour. The hemorrhage would have been fatal, had not the surgeon immediately tied the trunk of* the vessel. The patient lived many years afterwards. Dr. Baillie knew an instance, in which one carotid was entirely obstructed, and the dimeter of the other considerably lessened, without any apparent ill effects on the brain. (See Trans of a Society for the Improvement of Med. and Chirurgical Knowledge, Vol. 1. p, 121.) Mr. Astley Cooper has also recorded an example, in which the left carotid was obstructed by the pressure of an aneurism of the aorta. (See Metlico-Chirurgical Transactions, Vol. l.p.223.) Mr. Abernethy was under the necessity of tying the trunk of the carotid, in the case of a large, lacerated wound of the neck, in which accident the internal ca- rotid, and all the branches in front of the external one, were wounded. The pa- tient seemed to be going on very well at first, but in the night he became deli- rious and convulsed, and died about thirty hours after the ligature was ap- plied. Mr. A. considers tlie delirium and the inflammatory appearance found on the brain, on opening the body, as effects of stopping the supply of blood to the brain. I was fortunate enough to be a spectator of this interesting case, and, with due deference to Mr. Abernethy, cannot help thinking, especially when the above facts press on mv mind, that the delirium might more properly be regard- ed as the consequence of so terrible a la- cerated wound as this poor man received. Stopping the flow of blood to a part, has always been considered a chief means of averting inflammation of it, not bringing it on. That the carotid may be tied without injuring the functions'of the brain, and that aneurisms of this artery admit of being cured by the operation, is now fully proved. On Friday, Nov. 1, 1805, Mr. Astley Cooper operated on Mary Edwards, aged 44, who had an aneurism of the right carotid artery. At this time, the tumour reached from near the chin to beyond the angle of the jaw, and downward to with- in two inches and a half from tiie cla- vicle. The swelling had a strong pulsatory motion. The woman also complained of a particular tenderness of the scalp on the same side of tiie head, and of such a throbbing in the brain as prevented her from sleeping. An incision, two inches long, was made on the Inner edge of the stemo-cleido- mastoideus muscle, from the lower part ofthe tumour to tiie clavicle. This wound exposed the omo-hyoideus, and sterno- hyoidetis muscles, which being drawn aside towards the trachea, the jugular vein presented itself to view. The mo- tion of this vein produced the only dif- ficulty in the operation, as, under the dif- ferent states of breathing, the vessel sometimes became tense and distended before the knife, and then suddenly col- lapsed. Mr. Astley Cooper introduced his finger into the wound to keep the vein out of the way of the knife, and, having exposed the carotid artery by another cut, he passed two ligatures under this vessel by means 6f a curved aneurism- needle. ' Care was taken to exclude the recurrent nerve on the one hand, and the par vagum on the other. The ligatures were then tied about half an inch asun- der; but, the intervening portion of the artery was left undivided. The pulsation of the swelling ceased immediately, the vessel was tied, and, on the day after the operation, the throbbing in the brain had subsided, while no di- minution of nervous energy in any part of the body could be observed. The patient was occasionally afflicted with bad fits of coughing; but, upon the whole went on at first pretty well. On the eighth day, however, a paralysis ofthe left leg and arm was noticed, attended with a great deal of constitutional irrita- tion. Nov. 8th, the putient could move her arm rather better; but, became un- able to swallow solids. Nov. 12th, the palsy of her arm had now almost disap- peared. The ligatures came away. Nov. 14th, the woman was in every respect better; she swallowed with less difficul- ty; the tumour was smaller, and quite free from pain. On the 17th, she became very ill; the tumour increased in size, and was sore when pressed. The wound was as large as immediately after the ope- ration, and discharged a sanious serum. Great difficulty of swallowing, and a most distressing cough, were also expe- rienced. The pulse was ninety -six, and the left arm again very weak. On the 21st, the patient died, the difficulty of swallowing having previously become still ANEURISM. 139 greater, attended with a further increase of the tumour, the skin over which had acquired a brownish red colour. On opening the swelling after death, the aneurismal sac was found inflamed, and the clot of blood in it was surfbund- ed with a considerable quantity of pus. The inflammation extended on the out- side of the sac, along the par vagum, nearly to the basis of the skull. The glottis was almost closed, and tlie lining of the trachea was inflamed and covered with coagulating lymph. The pharynx was so compressed by the" tumour, which had suddenly become much enlarged by the inflammation, that a bougie, of the size of a goose-quill, could hardly be in- troduced into the oesophagus. Mr. Ast- ley Cooper concludes with expressing his opinion, that these causes of the fatal event might in future be avoided by ope- rating before the tumour is of such size as to make pressure on important parts ; or, if the swelling should be large, by opening it, and letting out its contents, as soon as inrlammation comes on. (See Medico- C/drurgical Transactions, Vol. 1.) Mr. Cline operated for a carotid aneu- rism, Dec. 16,1808, in St. Thomas's Hos- pital. Tlie tumour was veiy large, and had increased with great rapidity. The pres- sure of the swelling was such as to inter- rupt both respiration and deglutition; and to put the larynx out of its natural position. The patient had besides a fre- quent and troubleso-ne cough. The pain was confined to the tumour and same side ofthe face. These symptoms seemed relieved dur- ing the first twelve hours after the ope- ration. They tin n became worse, parti- cularly the cough and difficulty of* breath- ing, and a violent irritative fever took place. The man died on the 19th ofthe same month. (See London Medical Re- view, No. 3.) In the month of June 1308, Mr. Astley Cooper operated, in Guy's Hospital, on a man, aged 50, who had a carotid aneu- rism, attended with pain on one side of tiie head, throbbing in the brain, hoarse- ness, cough, slight difficulty of breathing, nausea, giddiness, &c. The patient got quite well, and resumed his occupation as a porter. The facial and temporal arteries ofthe aneurismal side of the face afterwards had no perceptible pulsation. On the opposite side the temp-oral arteiy became unusually large The tu- mour was at last quite absorbed, though a pulsation existed in it till the beginning of September. The man's intellects re- mained perfect; his nervous system was un-ift'-cted ; and *t.he severe pain, which, :,*»*fore the operation used to affect the aneurismal side of the head, never're- turned. The swelling, at the time of the opera- tion, was about as large as a pullet's egg, and situated on the left side about the acute angle, made by the bifurcation of the common carotid, just under the angle of the jaw. Mr. Astley Cooper began the incision opposite the middle of the thyroid carti- lage, at the base of the tumour, and ex- tended the wound to within an inch of the clavicle, on the inner side of the sterno- cleido-mastoideus muscle. On raising the margin of this muscle, the omo-hyoideus could.be distinctly seen crossing the sheath of the vessels, and the nervus descendens noni was also brought into view. The sterno-cleido-mastoideus was now sepa- rated from the omo-hyoideus, wh.en the jugular vein was seen. This vessel be- came so distended at every expiration as to cover the artery. When the vein was drawn to one side, the par vagum was manifest, lying between this latter vessel and the carotid artery, but a little to the outer side of the arteiy. The nerve was easily avoided. A double ligature was then conveyed under the arteiy with a blunt iron-probe. The lower ligature was immediately tied, and tlie upper one was also drawn tight, as soon as about an inch of" the artery had been separated from the surroundingparts above the first ligature, so as to allow the second to be tied at this height. A needle and thread were passed through the ves- sel below one ligature, and above the other. The artery was then divided. (See Medico. Chirnrg. Transact. Vol. 1.) Mr. Travers, anatomical demonstrator at Guy's Hospital, tied the carotid artery in a woman, who had an aneurism by anastomosis in the left orbit. The dis- ease had pushed the eye out of its socket. Two small ligatures were applied, which came away on the twenty-first and twenty- second day. No hemorrhage, nor im- pairment of the functions of the brain took place, and the disease in the orbit was effectually cured. (See Medico-Chi- rurgical 'Transactions, Vol. 2, part 1. and tlie Ijondon Medical Review, No. 7.) In order to get at the carotid artery in the safest manner, Mr. Abernethy has re- commended making an incision on diat side of it next the trachea, where no im- portant parts are exposed to injury, and then to pass a finger -underneath the ves- sel. The par vagum must be carefully excluded from the ligature ; for, to tie it would be fatal.—(Surgical Observations, 1804.) [Dr. Port, of New York,-successfully performed the operation of tying up 140 ANEURISM. the carotid artery, in January 1813. An account of this interesting case of carotid aneurism, has been published in s.mie of the periodical works, and also in the " Elements of Surgery."] ANXURISJIAL VAIUX, OR VENOUS ANEURISM. The scat of this tumour is, in general, in the basilic vein, which is enlarged, so as to form an oblong swelling, in the mid- dle of which is the scar, made by the lan- cet in bleeding. The tumour seldom ex- tends more than two inches above ami be- low the injury; beyond this distance the vein regains its natural size. Dr. W. Hunter is undoubtedly the first who gave an accurate description of this disease, although Professor Scarpa is dis- posed to claim a share, ofthe merit for his own country man Guattani, who, about the tame time when Dr. Hunter wrote in the Medical Observations and Inquiries, pub- lished the history of two cases of aneuris- mal varix. " Dies it ever happen in surgery," says Dr. Hunter, " that when an arteiy is opened- through a vein, a communication, or anastomosis, is afterwards kept up be- tween these two vessels ?■ It is easy to conceive this case, and it is not long, since I was consulted about one, that had all the symptoms that might be expected, supposing such a thing to have actually happened, and such symptoms, as other- wise must be allowed to be very unac- countable. It arose from bleeding; and was of some years standing, when I saw it about two years ago, and I understand very little alteration has happened to it s.ncc-that time. The veins, at the bend- ing of the arm, and especially the basilic, which was the vein that had been opened, were there prodigiously enlarged, and came gradually to their natural size, at about two inches above, and as much below the elbow. When emptied by pressure, they filled again almost instan- taneously, and this happened, even when a ligature was applied tight round the forearm, immediately below the affect- ed part. Both when the ligature was made tight, and when it was removed, they shrunk, and remained of a small size, while the finger was kept tight upon the artery, at .the part where the vein had been opened in bleeding. There was a general swelling in the place, and in tlie direction of the artery, which seemed larger, and beat stronger, than what is natural, and there was a tremu- lous jarring motion in the vein, which was strongest at the part, which had been punctured, and became insensible at some distance both upwards and down- wards," (Medical Observations and Inqui- ries, Vol. \.) In the second volume of this work, Dr. Hunter adds some further remarks on the aneurismal varix. " In the operation of bleeding, the lan- cet is plunged into the arteiy through both sides ofthe vein, and there will be thrce:wounds made in these, vessels, viz. two hi the vein, and one in the arteiy, and these will be nearly opposite to one another, and to the wound in the skin. This is what all surgeons know has often happened in bleeding, and the injury done the arteiy is commonly known by the jerk- ing impetuosity of the stream, whilst it flows from the vein, and by the difficulty of stopping it, when a sufficient quantity is drawn." " In the next place, we must suppose that the wound,of the skin, and ofthe ad- jacent, or upper side ofthe vein, heal up as usual; but, that the wound of the ar- tery, and ofthe adjacent, or under side of the vein, remain open, (as the wound of the artery does in the spurious aneurism) and, hf that means, the blood is thrown from the trunk ofthe arteiy, directly into the trunk of the vein. Extraordinary as this supposition may appear, in reality it differs from the common spurious aneu- rism in one circumstance only, viz. the wound remaining open in the side of the vein, as well as in the side of the arterv But this one circumstance will occasion a great deal of difference in the symptoms,. in the tendency of the complaint, and ;n tie proper method of treating it: uporP" which account the knowledge of such a case will be of importance in surgery." "It will differ in its symptoms from the common spurious aneurism principally thus. The vein will be dilated, or become varicose, and it will have a pulsating jar- ring motion on account ofthe stream from the artery. It will make a hissing noise, which will be found to correspond with the pulse for the same reason. The blo»d ofthe tumour will be altogether, or almost entirely fluid, because kept in constant motion. The arteiy, 1 apprehend, will become larger in the arm, and smaller at tlie wrist, than it was in the natural state; which will be found out by comparing the size, and the pulse, ofthe artery in both arms, at these different places. "The rea- son of which, I shall speak of hereafter. And the effects of ligatures, and of pres- sure upon the vessels above tiie elbow and below it, will be what every person may readily conceive, who understands any thing of the nature of arteries and veins in the living body." " The natural tendency of such a com- plaint will be very different from that of ANEURISM. 1«' the spurious aneurism. The one is grow- ing worse every hour, because of the re- sistance to the arterial blood, and if not remedied by surgery must at last burst. The other, in a short time, comes to a nearly permanent state; and, if not dis- turbed, produces no mischief, because there is no considerable resistance to the blood, that is forced out ofthe artery." " The proper treatment must, therefore, be very different in these two cases, the spurious aneurism requiring chirurgical assistance, as much, perhaps, as any dis- ease whatever; whereas, in the other case, I presume it will be best to do nothing." " If such cases do happen, they will no doubt be found todiffer among themselves, in many little circumstances, and parti- cularly in the shape, &c: of the tumefied parts. Thus the dilatatiofl of the veins may be in one only, or in several, and may extend lower, or higher, in one case, than in another, &c. according to the manner of branching, and to the state ofthe valves in different arms. And the dilatation of the veins may, also, vary, on account of the size of the artery, that is wounded, and ofthe size ofthe orifice in the artery and in tlie vein." " Another difference in such cases will arise from the different manner, in which the orifice ofthe arteiy may be united or continued with the orifice of the vein. In one case, the trunk of the vein may keep close to the trunk of" the artery, and the very thin stratum of cellular membrane be ween them, may, by means of a little inflammation and coagulation ofthe blood among its filaments, as it were solder the two orifices of these vessels together, so that there shall be nothing like a canal going from one to the other; and then the whole tumefaction will he more regular, and more evidently a dilatation of the veins only. In other instances the blood, that rushes from the wounded artery, meeting with some difficulty of"admission and passage through the vein, may dilate the cellular membrane, between the arteiy and vein, into a bag, as in a common spu- rious aneurism, and so make a sort of canal between these two vessels. The trunk of the vein will then be removed to some distance from the trunk of the arteiy, and the bag will be situated chiefly upon the under side of the vein. The bag may take on an irregular form, from the cellu- lar membrane being more loose, and y ield- ing, at one place, than at another, and from being unequally bound down by the fascia of the biceps muscle. And if the bag be very large, especially, if it be of an lingular figure, no doubt, coagulations of blood may be formed, as in the common spurious aneurism." After relating two cases, very illustrative of the nature ofthe aneurismal varix, Dr. W. Hunter proceeds to enquire: " Wby is the pulse at the wrist, so much weaker in the diseased arm, than in the other; surely, the reason is obvious and clear. If the blood can easily escape from the trunk of the arteiy directly into the trunk of the vein, it is natural to think, that it will be driven along the extreme branches with less force, and in less quantity." 2. " Whence is it, that the artery is en- larged all the way down the arm ? I am of opinion, that it is the consequence of the blood passing so readily from the artery into the vein, and is such an extension, as happens to all arteries, in growing bodies, and to the arteries of particular parts, when the parts themselves increase in their bulk, and, at the same time, retain a vascular structure. It is well known, that the arte- ries of the uterus gro^f much larger in the time of utero-gcstation. I once saw a fleshy tumour uponT the top of a man's head, as large nearly"as his-head; and his temporal and occipital arteries, which fed the tumour, were enlarged in proportion. I have observed the same change in the ar- teries of enlarged spleens, testes, &c. so that I should suppose it will be found to be universally true in fact, and the reason of it in theory seems evident." (See Me- dical Observations and Inquiries, vol. 2.) Professor Scarpa, Dr. Hunter, Mr. B. Bell, Pott, and Garneri, mention cases of the aneurismal varix, which remained stationary for fourteen, twenty, and thirty. five years. Several cases are related by Brambilla, Guattani, and Monteggia, of a cure having been obtained by means of compression. But, as this method of cure, if it does not succeed, exposes the. patient to the danger of a complication ofthe dis- ease with an aneurism, it ought not to be employed, except in recent cases, where the tumour is small, and in slender pa- tients, at an early period of life, and where both of the vessels can be compressed ac- curately against the bone. If the dis- ease is complicated with an aneurism, which threatens to become diffused, we are under the necessity of having recourse to an operation. (Scarpa on Anatomy, &<:. of Aneurism.) ANKOniSM VTtOM AX4.ST03IOSIS. This is*the term which Mr. John Bell, of Edinburgh, has* given to a species of aneurism, which resembles such bloody tumours, (nxvi materni) as appear in new- born children, grow to a large'size, and, « 143 ANEURISM. ultimately bursting, emit A considerable quantity of blood. We find clear descriptions of this dis- ease in writers, though before the publi- cation of Mr. John Bell's Principles of Surgery, it was not classed with aneu- risms. Thus, Desault has recorded a cas2 of this affection, for the express purpose of proving, that pulsation is an uncertain sign of tiie existence of an aneu- rism. (See Parisian Chirurgical Journal, Vol. II. p. 73.) The aneurism from anastomosis often affects adults, increasing from an appear- ance like that of a mere speck, or pimple, to a formidable disease, and being com- posed of a mutual enlargement of the smaller arteries and veins. The disease originates from some accidental cause; is marked by a perpetual throbbing; grows slowly, but incontrollably ; and is rather irritated, than checked, by compression. The throbbing is at first indistinct, but when the tumoihiis perfectly formed, the pulsation is veiy manifest. Every exer- tion makes the thjobbing more evident. The occasional tui'gid states ofthe tumor produce sacs of blood in the cellular sub- stance, or dilated veins, and these sacs form little, tender, livid, very thin, points, which burst, from time to time, and then, like other aneurisms, this one bleeds so profusely, as to induce extreme weakness. The tumour is a congeries of active ves- sels, and the cellular substance, through which these vessels are expanded, resem- bles, as Mr. John Bell describes, the gills of a turkey cock, or the substance of the placenta, spleen, or womb. The irritated and incessant action of the arteries fills the cells with blood, and from these cells, it is reabsorbed bytheteins. The size of the swelling is increased by exercise, drinking, emotions of the mind, and by all causes w hich accelerate the circulation. The hemorrhage from the aneurism by anastomosis sometimes usurps, in the fe- male subject, the place of menstruation, as the following example illustrates. Ann Vachot, of St. Maury, in Bresse, was born with .a tumour on her chin, of the size and shape.of a small strawberry, without pain, heat, or discolouration of tlie skin. As it produced no uneasiness, nor inconvenience whatever, it excited little attention, particularly as it did not seem to increase with the growth of the child. For the first fifteen years, there was but little alteration; but, about the menstrual period, it increased • suddenly to double the size, and became more elongated in its form. A quantity of" red blood was observed to oose from its ex- tremity. This flux became, in some mea- sure, periodical, and sometimes was suf- ficiently abundant to produce an alarming degree of weakness. Each period of iljt return was preceded by a violent pain in tiie head and numbness. Before and after the appearance of these symptoms, there was no alteration in"the size of the tumour; the only difference was a small enlargement of the cutaneous veins, with an increase of heat in the part, occasioning some degree of tenderness. The menses at length took place, but, in small quantity, and, at irregular pe- riods, without influencing the blood dis- charged fi-om the tumour, or the frequency of the evacuation. The breasts- were not enlarged till a late period, nor did the approach of pu- berty seem to have its accustomed influ- ence on those glands, &c. (See Parisian Chirurgical Jourmal, Vol. II. p. 73, 74.) " This aneurism, (observes Mr. John Bell,) is a mere congeries of active vessels, which will not be cured by opening it; all attempts to obliterate the disease with caustics, after a simple incision, have proved unsuccessful, nor does the Inter- rupting- of particular vessels, which lead to it, affect the tumour; the whole group of vessels must be extirpated. In varicose veins, or in aneurisms of individual arte- ries, or in extravasations of blood, such as that produced under the scalp from blows upon the temporal artery, or in those aneurisms, produced in schoolboys by pulling the hair, and, also, in those bloody effusions from blows on the head, which have a distinct pulsation, the pro- cess of cutting up the varix, aneurism, or extravasation, enables you to obliterate the vessel and perform an easy cure. But, in this enlargement of innumerable small vessels, in this aneurism by anastomosis, the rule is ' not to cut into, but to cut it out.' These purple and ill-looking tu- mours, because they are large, beating, painful, covered with scabs, and bleeding, like a cancer in the last stage of ulcera- tion, have been but too often pronounced cancers! incurable breeding cancers! and the remarks, which 1 have made, while they tend, in some measure, to explain the nature and consequences ofthe disease, will remind you of various unhappy cast s, where either partial incisions oulv had been practised, or the patient left entirely to his fote." (See John Bell's Principles of Surgery, Vol. I.) In the section on carotid aneurisms, I have mentioned the case, in which Mr. Travers cured an aneur.sm by anastomo- sis in the orbit, by tying the common ca- rotid artery. For information on aneurism, consult Louth's Scriptores Latini de AneurismaH- bus, which-work contains .Inman's Disser- tatio Medico limit rp traits tie Annmsmtite; Guattani,de Extemis An<'.i/Hsmatibu*:LaL ANT cisf de Aneurysmatibus. Opus Posthumum; Mtitani de Aneurysmaticis Prxcordiorum Morbis Animadversiones; Verbrugge, Dis- sertatio Anatomico Chirurgica de Aneuris- mate; Wetinus Dissertatio Inauguralis Me- dico tie Aneurysmate Vero Pectoris Externa Hemiplegix Sobole; Murray, Observations in Aneurismata Femoris; Trew, Aneurys- matis Spurii Post Venx Basilicx Sectionem Orti, Historia et Curatio. See also an ac- count of Mr. Hunter's Method of perform- ing the Operation for the Cure ofthe Popli- teal Aneurism, by E. Home, in the Trans, of a Society for the Improvement of Med. and Chirurgical Kiwwledge, Vol. I. p. 138, and Vol. II. p. 235. Sabatier's Medecine Ope- ratoire, Tom. 3. Medico-Chirurgical Tran- sactions, Vol. I. and II. Cases in Surgery by J. Warner, p. 141, &c. Edit. 4. Richer- and's Nosographie Chirurgicale, Tom. 4. Pelletan's Clinique Chirurgicale, Tom. 1 and 2. A Burn's Surgical A/uitomy ofthe Head and Neck. Ramsden's Practical Observa- tions on the Sclerocele, with four cases of operations for aneurism. CEuvres Cliirur- gicales de Desault par Bichat, Tom. 2, p. 553. Wells in Transact, of a Society for the Improvement of Med. and Chiricrg. Knowledge, Vol. 3, p. 81—85, SJc. Corvi- sart, Essai sur les Maladies et les Lesions Organiques du Ceeur et des Gros Vaisseaux. Edit. 2. _ C. Bell's Operative Surgery, Vol. I. Jolm BelPs Principles of Surgery, Vol. I. Richter's Anfangsgrunde der Wundarz- neykunst, Band 1. Abernethy's Surgical Works. Monro's Observ. in the Edinb. Med. Essays. Various productions in the Med. Observ. and Inquiries. TAe article Aneu- rism in Rees's Cyclopedia. Freer'.i Observa- tions on Aneurism, 1807; and a Treatise on the Anatomy, Pathology, and Surgical Treatment of Aneurism by A. Scarpa, trans- lated by J. H. Wishart, 1808. The original Italian was published 1804. ANODYNES, (from «neg. and o^vvsj, pain.) Medicines are so termed, wliich diminish, or remove, pain, and they are in- dicated in. surgery in all cases, in which it is desirable to relieve any intense pain. Opium is the principal one deserving con- fidence. ANTHRACOSIS,(from «v0*»«f, a burn- ing coal.) A red, livid, burning, sloughy, very painful tumour, occurring on the eye- lids. At fir*t, antiphlogistic means, are proper; but the grand thing is to make a free and early opening for the discharge of the matter contained in the swelling. The eye-lids and eye should be bathed with a collyrium, and kept cool with the satur- nine lotion. ANTHRAX, («t,'?«^, a burning coal.) See Carbuncle. ANTIMONIUM CALCINATUM,—or puivis axtixohialis. (Supposed to be ANT 143 very similar to James's Powder.) Is now called the antimonial powder. In all cases of surgery, in which it is desi- rable to promote the secretions in ge- neral, and those of urine, perspiration, and of the alimentary canal, in particular, it is proper to have recourse to this im- portant preparation. In all inflamma- tions ofthe brain and its membrane, and, in every instance, in which there exists an inflammation of aviscusof high importance in the system, antim ;ny should be exhi- bited, and, in general, the antimonial powder is as eligible a prescription as any. For an adult, four or five grains may be ordered, and tlie dose, if requisite, may be repeated, two or three times a day. ANTIMONHJM MURIATUM. This has often been named, butter of antimony, and is employed in surgery as a caustic. ANTIMONIUM TARTARIZATUM, (Emetic Tartar.) This medicine is well known as the most common emetic. For this purpose, it may be given in either of the following ways, as the indications of the case may demand. 5*. Antimonii Tart. gr. ij. Aq. distil. !|iv. Misce et cola. Dosis %"$ij.pro emetico; vel ^ss quadrante quoque hora:, donee supervenerit vomitus. If tartarised antimony be exhibited merely to excite a diaphoroesis, half an ounce, or one table spoonful, of the above mixture is to be given once every six hours. This preparation is very much employed by the best continental surgeons, for in- creasing the gastric secretions, and main- taining, for a length of time, a lax state of the bowels. We shall have occasion to notice its efficacy in the cure of numerous surgical diseases, particularly Amaurosis, Erysipelas, Injuries ofthe Head, &c. ANTIPHLOGISTICS, (from «Vr/, against, and tpxeya, to burn.) All means are so termed, which have a tendency to subdue inflammation. (See Inflammation.^ The first of these, to which the surgeon should direct his attention, when he wishes to cure an inflammatory affection, is to re- move as far as it is in his power, the oc- casional cause. Extraneous bodies, lodged in parts, susceptible of this kind of ir- ritation, and which substances produce inflammation by their mechanical opera- tion, should be extracted as soon as pos- sible, if their particular situation, shape, &c. will admit of it. The removal of substances, which irritate by their che- mical properties, is difficult, and some- times impracticable. On account of their great activity, how- ever, it is necessary to oppose their effects, without loss of time. This is accomplished, in a certain degree, by diluting such sub- stances with aqueous fluids, defending the parts from their action by oily and sedative* HI v ANT applications; and, by correcting the spe- cific irritation of the substances applied, by means of other substances, which have a particular affinity with them. Antiphlogistic remedies, properly so called, are divided into general ones, by which are meant such as affect the whole system ; and into topical ones, the opera- tion of which is, at least, for a certain time, entirely local and circumscribed. Generalanliphlogistics are: 1. Bleeding. (See this word.) 2. Glysters, and gentle laxative medi- cines. The most active cathartics may sometimes be considered in the same light; but, there are many inflammations, in which the effect of strong purgatives is hurtful and dangerous. Such are, in par- ticular, all instances, in which there is inflammation ofthe thoracic, and abdomi- nal viscera. 3. Aqueous diluting beverages, taken in large quantities. 4. The warm bath. 5. Cooling medicines, such as acid drinks, saline draughts, and some of the neutral salts, such as nitre, the ammonia muriate, aq. amnion, acet. &c. 6. Anodynes, especially opium, only to be given, however, under the circumstan- ces, and in the way, to be noticed in the article, Inflammation. W ith these direct means of diminishing the action of the sanguiferous system, we must combine a more or less complete ab- stinence from all solid animal food. Too warm an atmosphere should also be avoid- ed, as well as aiL stimulants whatever, every kind of noise, every thing likely to alarm, or disturb the mind, &c. Topical antiphlogistics are: 1. Local bleeding practised by means of leeches, scarifications, or cupping. 2. Emollient poultices, which are pro- per, when the inflammation is accompanied with an extraordinary degree of pain and hardness, and, especially, when it is dis- posed to suppurate. The best emollient poultice is that of linseed, described in the article Inflammation. Some use the one made of bread and milk; some dis- liking milk, in consequence of its inutility, and its tendency to turn sour, only use water: while others make the bread into a poultice by softening it, and beating it up, with Goulard's lotion. 3. Discutients are particularly used in all cases, in which the inflammation is less acute, and seems to have no tendency to suppurate. Cold water, various prepara- tions containing lead, a solution of sal ammoniac in vinegar and water, spirit of wine, vinegar, aether, the various infu- sions of bitter aromatic plants, and the decoction of bark, are very good discutient remedies. ANT 4. The maintenance of a continual eva- poration from the surface of the inflamed part, by applying folded linen, wet with the lotio aq. litharg. acet. cold water, % solution of zincum vitriolatum, &c. Spi- rits, atlier, snow, or powdered ice, pro- duce more cold, and, are sometimes, though not very commonly, made use of. This is the ordinary principle, on which surgeons conduct the local treatment of phlegmonous inflammation, when there is the prospect of avoiding the formation of an abscess. 5. Fomentations. These are prepared by dipping flannels in some warm liquor, squeezing a certain quantity of fluid out of them, and then placing them quite warm on the inflamed part. They are mostly used in cases, in which emollient poultices are the permanent local applica- tions, and when the patient suffers extra- ordinary pain. A decoction of while pop. py heads, or camomile flowers, is the liquor commonly employed. Fomentations are very temporary means, being only ap- plied in general, about half an hour, two, or three times a day. The best opportu- nity of doing this, is when the poultice is to be changed. 6. Among the means, essential to an antiphlogistic regimen, perfect quietude, both of body and mind*, is not the least important. (See Inflammation.) Encydt- pedie Methodique ; Partie Chirurgicale. ANTISEPTICS, (from . *m, against, and e-ijiru, to purify.) This name is given to such remedies, as are supposed to have the virtue of resisting the tendency to putrefaction in the human body, or to arrest its progress, after it has commen- ced. According to these ideas, they are, indicated in cases of mortification, and sloughing ulcers. " The greatest part of antiphlogistic re- medies are also antiseptic, as we shall see the reason of in the article Mortification. The most renowned antiseptic remedies of tiie internal kind, are vegetable, and mineral acids, fluids impregnated with carj i bonic acid gas, wine, aromatics, camphor, bitters in general, and, particularly, bark. The chief external antiseptic applications are prepartions of lead, cold water, snow, ice, spirits, turpentine, or aromatics, suck as camomile flowers, rue, &c.Mt has als6 been recommended to apply the carbonic acid gas itself. This may be done, either by directing the air against the parts affected through a funnel, as soon as the gas is extricated from the substances, which contain it; or by applying to the parts affected poultices, composed of such ingredients, as will ferment, and form a large quantity of the gas. (See I'Encyclo- pedie Methodiqtuf; Partie Cltirttrgicale.) ANTRUM. 145 ANTRUM MAX1LLARE. This is a considerable cavity, situated in the upper jaw bone. It is also named the Sinus Max- illaris, or Antrum Highmorianum, from the name of an anatomist, who gave the first accurate description of it. The antra are liable to several morbid affections. Sometimes, their membranous lining inflames, and secretes pus. At other times, in consequence of inflammation, or Other causes, various excrescences and fungi are produced in them. Their bony parietes are occasionally affected with ex- ostosis, or caries. Extraneous bodies may be lodged in them, and, it is even asserted, that insects may be generated in them, and cause, for many years, very afflicting pains. ABSCESSES IN THE ANTRUM. Of all the above cases, this is far the most common. Violent blows on the cheeks, inflammatory affections ofthe ad- jacent parts, and, especially, of the pitui- tary membrane lining the nostrils, expo- sure to cold and damp, and, above all things, bad teeth, may induce inflamma- tion and suppuration in the antrum. The first symptom is a pain, at first imagined to be a tooth-ach, particularly if there should be a carious tooth, at this part of the jaw. This pain, however, extends more into the nose, than that usually does, which arises from a decayed tooth; it also affects, more or less, the eye, the orbit, and the situation of the frontal sinuses. But, even such symptoms are insufficient to charac- terize the disease, the nature of which is not unequivocally evinced, till a much later period. The complaint is, in general, of much longer duration, than one entirely dependent on a caries of a tooth, and its violence increases more and more, until, at last, a hard tumour becomes percepti- ble below the cheek bone. The swelling, by degrees, extends over the whole cheek: but, it afterwards rises to a point, and forms a very circumscribed hardness, which may be felt aboye the back grin- ders. This symptom is accompanied by redness, and sometimes by1 inflammation and suppuration of the external parts. It is not uncommon, also, for the outward abscess to communicate with that within the antrum. The circumscribed elevation of the tu- mour, however, does not occur in all cases. There are instances in which the matter makes its way towards the palate, causing the bones of this part to swell, and, at length, rendering them carious, unless. timely assistance be given. There are other cases, in which the matter escapes between the fangs and sockets ofthe teeth. Lastly, there are other examples, in which Vox. T matter, formed in tiie antrum, makes its exit at the nostril of the same side, when the patient is lying with his head on the opposite one, in a low position. If this mode of evacuation should be frequently repeated, it prevents the tumour, both from pointing externally, and bursting, as it would do if the purulent matter could find no other vent. But this evacua- tion of pus from the nostril is not very common ; for, according to Mr. Hunter, the opening between the antrum and cav- ity of the nose, is generally stopped up. This celebrated anatomist even seems in- clined to think, that the disease may sometimes be occasioned by the impervious state of this opening, in consequence of which obstruction, the natural mucus of the antrum may collect therein such quan- tity, as to irritate and inflame the mem- brane, with which it is in contact. This may happen in the same way as an obstruc- tion in the ductus nasalis hinders the pas- sage ofthe tears into the nose, and causes an abscess in the lachrymal sac. (See Natural Hist, of tlie Human Teeth, &c. by John Hunter, p. 174.) However, in the ma- jority of cases, we may conclude, that the impervious state of the opening is rather an effect, than the cause, of the disease, since inflammation in the antrum is often manifestly produced by causes of a dif- ferent kind, and since the opening in question is not invariably closed. Abscesses in the antrum require a free exit for their contents, and, if the surgeon neglects to procure such opening, the bones become more and more distended and pushed out, and, finally,carious. When this happens, the pus nukes its appear- ance, either towards the orbit, the alveoli) the palate, or, as is mostly the case, to- wards the cheek. The matter having thus made a way for Its escape, the disease now becomes fistulous. In all cases the principal indication is to discharge the matter, whether the pus is simply confined in the antrum, or whe- ther the case, be conjoined with a carious affection of the bones. The ancients seem to have known very little of the treatment of diseases of the antrum. Drake, an English anatomist, is reputed to be the first proposer of a plan for curing abscesses of this cavity. Meibo- mius, however, had, a long while before him, proposed, with the same intention, to extract one or more of the teeth, in order that the matter might find an open- ing for its escape, through the sockets. This plan may be employed with success. The pus frequently has a tendency to make its way outward towards the teeth ; it often affects their frogs; and, after their extraction, the whole of the abscess is seen U U6 ANTRUM. to escape through the sockets. But this very simple plan will not suffice for all cases, as there are numerous instances, in which there is no communication between the alveoli and the antrum. Drake, and, perhaps, before him, Cow- per, rtook notice of the insufficiency of Meibomius's method, and, hence, they proposed making a perforation through the socket into the antrum with an awl, for the purpose of letting out the matter, and injecting into the cavity such fluids as were judged proper. The extraction of one or more teeth, and the perforation of the alveoli, being essential steps in treating diseases of the antrum, we must consider what tooth ought to be taken out in preference to others. A caries, or even a mere continual ach- ing, of any particular tooth, in general ought to decide the choice. But, if all the teeth should be sound, which is not often the case, writers direct us to tap each of them gently, and to extract the one, which gives most pain on this being done. When no information can be thus obtained, other circumstances ought to guide us. All the grinding teeth, except the first, correspond with the antrum. They even sometimes extend into this cavity, and the fangs are only covered by tiie pituitary membrane. The bony lamella, which se- parates the antrum from the alveoii, is at- tenuated, towards the back part of the upper jaw. Hence, it is best, when the choice is in our power, to extract tlie third or fourth grinder, as, in this situation, the alveoli can be more easily perforated. Though, in general, the first grinder and canine tooth dohot communicate with the antrum, yet, their fangs occasionally ap- proach the side of this cavity. When one or more teeth are carious, they should be removed, because they are both useless and hurtful. The matter fre- quently makes its escape, as soon as a tooth is extracted, in consequence of the fang liaving extended into the antrum, or rather in consequence of its bringing away with it a piece ofthe thin partition between it and the sinus. Perhaps a discharge may follow from the partition itself being ca- rious. If the opening thus produced, be sufficiently large to allow the matter to escape, the operation is already completed. But, as it can easily be enlarged, it ought always to be so when there is the least sus- picion of its being too small. However, when no pus makes its .appearance, after a tooth is extracted, the antrum must be opened by introducing a pointed instru- ment in the direction ofthe alveoli. Some use a small trocar, or awl; others a gim- blet for this purpose. The patient should sit on the ground, in a strong light, resting his head on the surgeon's knee, who is to sit behind him. Immediately the instrument has reached the cavity, it is to be withdrawn. Its en- trance into the antrum is easily known by the cessation of resistance. After the matter is discharged, surgeons advise the opening to be stopped up with a wooden stopper, to keep victuals from getting into the antrum. The stopper is to be taken out, several times a day, to allow the pus to escape. This plan soon disposes the parts affected to discontinue the suppuration, and resume their natural state. Sometimes, however, the pus continues to be discharged, for a long time after the operation, without any change occurring, in regard to its quality or quantity. In such instances the cure may often be accelerated by employing injections of brandy and water, lime-wa- ter, or a solution of zincum vitriolatum. Some surgeons prefer a silver cannula instead of the stopper, as it can always be left pervious except at meals. If no opening were made in the antrum, the matter would make its way, some- times towards the front of this cavity, which is very thin; sometimes, towards the mouth, and fistulous openings, and caries would inevitably follow. When the bones are carious, the above plan will not accomplish a cure, until the affected pieces of bone exfoliate. A probe will generally enable us to detect any ca> ries in the antrum. The fetid smell, and ichorous appearance of the discharge, also, leave little doubt that the bones are diseased; and, in proportion as the bones free themselves of any dead portions, the discharge has less smell, and its consist- ence becomes thicker. There are cases, in which there are loose pieces of dead bone to be extracted, and, in which it is requisite to make a larger opening into the antrum, than can be ob- tained, at its lower part. Instances also occur, in which patients have lost all the grinding teeth, and the sockets are quite obliterated, so that a perforation from below could hardly be effected. Some practitioners have also objected to ever sacrificing a sound tooth. In these cir- cumstances, it lias been advised to make a perforation in the antrum, above the al- veolary processes, M. Lamorier is the first who proposed this method. It con- sists in making a transverse incision, be- low the malar process, and above the root ofthe third grinder. Thus the gum and peri isteurn are divided, and the bone ex- ANTRUM. H7 posed. A perforating instrument is to be conveyed into tlie middle of this incision, and the opening in the antrum made as large as requisite. There are cases of very extensive exfoliations of the antrum, in which it is absolutely necessary to ex- pose a great part of the surface of the bone, and to cut away the dead pieces which are wedged, as it were, in the liv- ing ones. A small trephine may some- times be advantageously applied to the malar process of the superior maxillary bone. Surgeons formerly treated carious af- fections of the antrum in the most absurd and unscientific way, introducing setons through its cavity, and even having re- course to the actual cautery. The mo- derns, however, are not much inclined to adopt this sort of practice. It is now known, that the detachment of a dead portion of bone, in other terms, the pro- cess of exfoliation, is nearly, if not en- tirely, the work of nature, in which the surgeon can at most only act a very infe- rior part. Indeed, he should limit his in- terference to preventing the lodgment of matter, maintaining strict cleanliness, and removing the dead pieces of bone, as soon as they become loose. But, it is to be understood, that there are occasional ex- amples, in which the dead portions of bone are so tedious of separation, and so wedged in the substance of* the surrounding living bone, that an attempt may be properly made to cut them away. TUMOURS OF THE ANTRUM. Ruysch, Bordenave, Desault, Aber- nethy, and many others, have recorded cases of polypous, fungous, and cancer- ous diseases of the antrum, and of the parietes of tliis cavity being affected with exostosis. The indolence of a*ny ordinary fleshy tumour in the antrum, while in an inci- pient state, certainly tends to conceal its existence; but, such a disease rarely oc- curs without being accompanied by some affection of the neighbouring parts, and, hence its presence may generally be as- certained before it has attained such a size as to have altered the conformation of the antrum. This information may be ac- quired by examining, whether any of the teeth have become loose, or have sponta- neously fallen out; whether the aveolary processes are sound, and whether there are any fungous excrescencess making their appearance at the sockets; whether there is any habitual bleeding from one side of the nose; any sarcomatous tumour at the side of the nostril, or towards the great angle of the eye. When the swelling kae attained a certain size, the bony pariete* ( of the antrum are always protruded out- wards, unless the body of the tumour should be situated in the nostril, and only its root in the antrum. This case, how- ever, is very uncommon. As soon as a tumour is certainly known to exist in the antrum, the front part of this cavity should be opened, without waiting till the disease makes further pro- gress, In a few instances, indeed, we may avail ourselves of the opening, which is sometimes found in the alveolary pro- cess, and enlarge it sufficiently to allow the tumour to be extirpated. If the front of the antrum were freely opened, it would in general be better to cut away the disease in its interior. A swelling of the parietes of the an- trum, in consequence of an abscess, or a sarcomatous tumour in its cavity, may lead us to suppose the case an enlarge- ment of the bones, or an exostosis. The symptoms of the two first affections have been already detailed. A sign of an exos- tosis is, when besides the absence of the symptoms characterizing an abscess or a sarcoma, the thickened parietes of the an- trum form a solid resistance; whereas, in cases of mere expansion, the dimensions of the surface of the bone being increas- ed, while its substance is proportionally attenuated, the resistance is not so consi- derable. When such an exostosis depends upon a particular constitutional cause, and, es- pecially, upon one of a venereal nature, it must be attacked by remedies suited to tliis affection. But, when the disease re- sists internal remedies, and its magnitude is likely to produce an aggravation of the case, a portion of the bone may be re- moved with a trephine, or a cutting in- strument; Such operations, however, require a*great deal of delicacy and pru- dence. Mr. B. Bell, vol. 4, describes a kind of exostosis of the upper jaw, very different from what we have mentioned, since in- steadofitsbeingdistinguishable from other diseases ofthe antrum by the greater firm- ness of the tumour, the substance of the bone gradually acquires such suppleness and elasticity, that it yields to the pres- sure of the fingers, and immediately re- sumes its former plumpness, when the pressure is discontinued. If the bone be cut, it is found to be as soft as cartilage, and, in an advanced stage of the disease, its consistence is almost gelatinous. The swelling increases gradually, and extends equally over the whole cheek, without be- coming prominent at any particular point, or only so in the latter periods of the ma- lady, when the soft parts inflame and le- 148 ANTRUM. come affected. The complaint is describ- ed as totally incurable. Cutting and tre- phining the tumour, as recommended in other cases of exostosis, only exasperate the patient's unhappy condition. Mr. Abernethy has related an account of a very singular disease of the antrum. The patient, who was 34 years of age when the account was written, perceived, when about ten years old, a small tumour on his left cheek, which gradually attained the size of a walnut, and then remained, for some time, stationary. About a yea* afterwards, the tumour having again en- larged, a caustic was applied to the inte- guments, so as to expose the bone. The actual cautery was next applied, and an opening thus made into the antrum. After the exfoliation the antrum became filled with a fungus, which rose out upon the cheek, and could not be restrained by any applications. Part of the fungus also made its way into the mouth, through the •socket of the second tricuspid tooth, the other teeth remaining natural. The dis- ease continued in this state nine years, occasionally bleeding in an alarming way. When the patient was in his 20th year, the whole fungus sloughed away during a fever, and has not returned. Aft er this the sides of the aperture in the bone be- gan to grow outwards-, forming an exos- tosis, winch has grown to a great magni- tude. A small exostosis took place in the mouth, but became no larger than a horse bean. The exostosis of the maxillary bone is of an irregular figure, and pro- jects from the whole circumference ofthe aperture a great way directly forward. Mr. Abernethy compares its appearance, when) he was writing, with that of a large tea-cup fastened upon the face, the bot- torn of which may be supposed to commu- nicate with the antrum. The diameter of the cup, formed by the circular edge of the bone was three inches and a half; the depth two inches and seven-eighths. The general height ofthe sides ofthe exostosis, from the basis of the face was two inches ; its walls were not thick, and terminated in a thin circular edge. The integuments, as they approach this edge, become at- tenuated, and they extend over the edge into the cavity. The exostosis now reaches' to the nose in front, and to the masseter muscle behind; above It includes the very ridge of the orbit, and below it grows from the edge of the,alveolary process. A line that would have separated the diseas- ed from the sound bone, would have in- cluded the orbit and nose, and indeed, one half of the face. Mr. Abernethy saw no means of affording the man relief. (Trans* of a Society for the Improvement of Med. and Chirurgical Knowledge, Vol. 2.) In a case of fungus growing in the an- trum, and which had distended the an- trum, hindered the tears from passing down into the nose, raised the lower part of the orbit, caused a protrusion of the eye, made two of the grinding teeth fall out, and occasioned a carious opening in the front of the antrum, through which opening a piece of the fungus projected, Desault operated as follows : the cheek was first detached from the os maxillare, by dividing the internal membrane ofthe mouth, at the place where it is reflected over this bone. Thus, the outer surface of the bone was denuded of all the soft parts. A sharp, perforating instrument was applied to the middle of this surface, and an opening made more forward than the one already existing. The plate of bone, situated between the two apertures, was removed with a little falciform knife, which, being directed from behind for- ward, made the division without difficulty. The opening, thus obtained, being insuf- ficient, Desault endeavoured to enlarge it below, by sacrificing the alveolary process. This he endeavoured to accomplish with the same instrument, but, finding the resistance too great, he had recourse to a gouge and mallet. A considerable piece of the alveolary arch was thus detached, without any previous extraction of the corresponding teeth, three of wliich were removed by the same stroke. In this man- ner an opening was procured in the exter- nal and inferior part of the antrum, large enough to admit a walnut. Through this aperture a considerable part ofthe tumour was cut away with a knife, curved side- ways, and fixed in its handle. A most pro- fuse hemorrhage took place; but, Desault, unalarmed, held a compress in the antrum for a short time; this being removed, the actual cautery was applied repeatedly to the rest of the fungus. The cavity was dressed with lint, dipped in powdered colophony. On the eighteenth day the swelling was evidently diminished, the eye less promi- nent, and the epiphora less visible. But, at this period a portion of fungus made its appearance again. This was almost entirely destroyed by applying the actual cautery twice. It appeared again, how- ever, on the 25th day, and required a third and last recourse to the cautery. From this time the progress ofthe cure went on rapidly. Instead of fungous excrescences, healthy-granulations were now formed in the bottom of the sinus. The parietes of the antrum, gradually approaching each other, the large opening made in the ope- ration was obliterated, and reduced to a small aperture, hardly large enough to admit a probe. Even this little opening ANTRUM. 149 was closed in the fourth month, at which time no vestiges of the disease remained, except the loss of teeth, and a very ob- vious depression just where they were situated.! In all fungous diseases of the antrum, making a free exposure of them is an es- sential part of the treatment: if you ne- glect this method, how can you inform yourself of the size, form, and extent, of the tumour .*" How could you remove the whole of the fungus, through a small open- ing, which would only allow you to see a very little portion of the excrescence ? How could you be certain that the disease were extirpated, to its very root ? Even when the antrum is freely opened, this circumstance can only be learnt with dif- ficulty ; and how could it be ascertained, when only a point of the cavity is opened -? A portion, left behind, very soon gives origin to a fresh fungus, the progress of which is more rapid, and the character more fatal, in consequence of being irri- tated by the surgical measures adopted. (CEuvres Cldrurgicales de Desault par Bichat, Tom. 2.) I imagine that English surgeons* unac- customed to use tiie actual cautery, will peruse with a degree of aversion, tliis means so commonly employed in France by Desault, and other celebrated sur- geons. Nor can I expect that they will altogether approve the use of the mallet and gouge, for making a free opening into the antrum. Perhaps, it might be better to trephine this cavity with a small instrument for the purpose, and then cut the fungus away. After removing as much of it as possible in tliis manner, some instrument of suitable shape might be used to scrape the part, where the tu- mour has its root. However, if there be any case in which potent and violent mea- sures, like those of Desault, are allow- able, it is the one, of which we have just been treating. Inveterate diseases de- mand powerful means, and tampering with them is generally more hurtful than useful. [To this preference of the trephine over any other method of exposing the cavity, the American editor begs leave to give his decided approbation: having perform- ed that operation, he can testify its facility and safety.] There is an interesting case of a fungus in the maxillary sinus, related in the first volume of the Parisian Chirurgical Jour- nal. It was at last cured by opening the antrum, applying the cautery, and tying the portion of the tumour, which had made its way into the nose. In the se- cond volume of the same work, is an ex- cellent case, exhibiting the dreadful ra- vages,, which the disease may produce when left to itself. IWSECTS IN THE AKTRUM. It is said, that insects in this cavity may sometimes make it necessary to open the part. This case, however, must be ex- ceedingly rare, and even what we find in authors (Pallas de insectis viventibus intra vivcntia), appears so little authentic, that we should hardly have thought it neces- sary to make mention ofthe circumstance, if there were not, in a modern work (Med. Comrn. Vol. 1.) a fact which appears enti- tled to implicit belief. Mr. Hey sham, a medical practitioner at Carlisle, relates, that a strong woman, aged sixty, in the habit of taking a great deal of snuff, was subject, for several years, to acute pains in the antrum, extending over one side of the head. These pains never entirely ceased, but were more severe in winter than summer, and were always subject to frequent periodical exasperations. The patient had taken several anodyne medi- cines, and others, without benefit, and had twice undergone a course of mercury, by which her complaints had been in- creased. All her teeth on the affected side had been drawn. At length it was deter- mined to open the antrum with a large trocar, though there were no symptoms of an abscess, nor of any other disease in this cavity. For four days no benefit resulted from tHis operation. During this space, bark injections, and the elixir of aloes, were introduced into the sinus. On the fifth day a dead insect was extracted, by means of a pair of forceps, from the mouth of the cavity. It was more than an inch long, and thicker than a common quill. The patient now experienced relief for several hours: but, the pains afterwards recurred with as much severity as before; oil was next injected into the antrum, and two other insects, similar to the former, were extracted. No others appeared, and the wound closed. The pains were not completely removed, but they were con- siderably diminished for several months, at the end of which time they became worse than ever, particularly affecting the situation ofthe frontal sinus. M. Bordenave has published, in the twelfth and thirteenth volumes of the Mem. de I'Acad. de Chir. Edit. 12mo. two excellent papers on the diseases of tite antrum. In the thirteenth volume, he re- lates the history of a casv, in whch sefe- ral small whitish worms, together with a piece of fetid fungus, were discharged from the antrum, after an opening had been made on account of an abscess ofthe antrum, attended with caries. (P. 381.) 150 A N U ANU But, in this instance, the worms had pro- bably been generated after the opening had been made in the cavity; for, when they made their appearance, tiie opening had existed nine months.—(See on this subject Precis d' Observations sur les Mala- dies du Sinus Maxillaire ParM. Bordenave, in Mem. de PAcad. Royale de Chirurgie, Tom. 12, Edit, in 12mo. Also Suite cP Ob- servations on tlie same Subject, byM. Borde- nave, Tom. 13, ofthe said Work. L'Ency- clopedic Methodique, Partie Chirurgicale, art. Autre Maxillaire. Remarques et Obser- vations sur les Maladies du Sinus Maxil- laire, in GZuvres ChirurgicAles de Desault par Bichat, Tom. 2, p. 156.' Desault's Pa- risian Chirurgical Journal, Vol. 1 and 2. Medical Communications, Vol. 1. Trans. of a Society for the Improvement of Med. and Chirurgical Knowledge, Vol. 2. Natural History ofthe Human Teeth, by John Hunter, p. 174,175, Edit. 3. Gooch's Chirurgical Works, Vol. 2,p.61,and Vol. 3,p. 161,Edit. 1792.) ANUS. The lower termination of the great intestine, named the rectum, is so called, and its office is to form an outlet for the feces. The anus is furnished with muscles, which are peculiar to it, viz. the sphinc- ter, which keeps it habitually closed, and the levatores ani, which serve to draw it up into its natural situation, after the ex- pulsion of the feces. It is also surround- ed, as well as the whole of the neighbour- ing intestine, with muscular fibres, and a very loose sort of cellular substance. The anus is subject to various diseases, in which the aid of surgery is requisite : of these we shall next treat. IMPERFORATE ANUS. This complaint is sometimes met with, though not very often. As it is of the ut- most consequence that such mal-forma- tions should not remain long unknown, one of *he earliest duties of an accoucheur, after delivery, should be the examination of all the natural outlets of the new-born infant. 1 Such an inspection sometimes evinces, that the place in which the extremity of tiie rectum, or the anus, ought to be, is entirely, or partly shut up by a mem- brane, or fleshy adhesion. In other in- stances, no vestige of the intestine can be found, as the skin retains its natural co- lour over the whole space, between the parts of generation and the os coccygis, without being more elevated in one place than another. In such cases the intestine sometimes terminates in one or two culs- de-sac, about an inch upward from the ordinary situation of the anus. Some- times it does not descend lower than the upper part of the sacrum; sometimes it opens into the bladder, or vagina. When a surgeon is consulted for such cases, he must not lose much time in de- liberation; for, if a speedy opening be not made for the feces, the infant will certainly very soon perish, with symptoms similar to those of a strangulated hernia. After ascertaining the complaint, which is an easy matter, we should endeavour to learn, whether the anus is merely shut by a membrane, or fleshy adhesion: or whether tiie anus is altogether wanting, i« consequence of the lower portion of tlie cavity ofthe gut being obliterated, or the rectum not extending sufficiently far down. When a membrane, or a production of the skin closes the opening of the rectum, the part producing the obstruction, is somewhat different in colour from the neighbouring integuments. It is usually of a purple or livid hue, in consequence of the accumulations of the meconium on its inner surface. The meconium, pro- pelled downward by the viscera above, forms a small, roundish prominence, which yields like dough to the pressure of the fingers; but, immediately projects as be. fore, when the pressure is removed. When a fleshy adhesion closes the intestine, the circumstance is obvious to the eye, if the part protrude, which is generally the case. The finger feels greater hardness and resistance, than when there is a mere membrane, and the livid colour of the meconium cannot be seen through the ob- structing substance. These last signs alone are enough to convince the surgeon of the necessity of the operation; but, they do not clearly shew, whether the intestine descends, as far as it ought, in order to form a proper kind of anus. Complete information on this point can only be acquired, after the membrane, or adhesion, has been divid- ed ; or else after the child's death, when the operation has proved ineffectual. Though there be no mark to denote, where the anus ought to be situated, and no degree of prominence, yielding, like soft dough, to the pressure ofthe fingers, and rising again, when such pressure is removed; yet, it may happen, especially on our being consulted immediately alter the child is born, that, notwithstanding the absence of such symptoms, denoting the presence of the meconium, and the natural extent of the intestine, as far as where tlie anus ought to be, the gut may exist, and have a cavity, as far as the mem- brane, or adhesion, closing it. When the anus is only covered with skin, and its place pointed out by a pro- minence, arising from the contents of the ANUS. 151 rectum, we have only to make an opening with a knife, sufficient to let out the me- conium. Levret recommends making a circular incision in the membrane; but, a transverse cut is sufficient. A small tent of lint is afterwards to be introduced, in order to keep the opening from closing. If the anus should only be partly closed by a membrane, the opening may be di- lated with a tent; but, if the aperture should be very small, it is preferable to use the bistoury for its enlargement. When no external appearance denotes where the situation of the anus ought to be, the case is much more serious and em- barrassing; and this, whether the intes- tine is stopped up by a fleshy adhesion, or the coalescence of its sides, or whether a part of the gut is wanting. However, it is the surgeon's duty to do every thing in his power to afford relief. For this purpose, an incision, an inch long, is to be made in the situation where the anus ought to be, and tlie wound is to be carried more and more deeply in the natural direction ofthe rectum. The cuts are not to be made directly upwards, nor in the axis of the pelvis, for the vagina, or bladder, might thus be wounded. On the contrary, the operator should cut back- ward, along the concavity of the os coccy- gis, where there is no danger of wounding any part of importance. In all cases of this kind, the surgeon's finger is the best director. The operator, guided by the index finger of his left hand, introduced within the os coccygis, is to dissect in the direction above recommended, until he reaches the feces, or has cut as far as he can reach with his finger. If he should fail in finding the meconium, as death must unavoidably follow, one more at- tempt ought to be made, by introducing, upon the finger, a long trocar, in such a direction as seems best calculated for find- ing the rectum. By the prudent adoption of such pro- ceedings, many infants have been pre- served, wliich otherwise would have been devoted to certain death. Hildanus, La Motte, Roonhuysen, and many others, have successfully adopted the above prac- tice. Mr. B. Bell informs us, he has seen two of these cases, in which the intestine was very distant from the integuments, and in which he was so successful, as to form an anus, which fulfilled its office tolerably well for several years; but, he found it exceeding difficult to keep the passage sufficiently large and pervious. A* soon as he removed the dossils of lint, and other kinds of tents, used for main- taming the necessary dilatation, such a degree of contraction speedily followed, that the evacuation of the intestinal mat- ter became very difficult, for a long while afterwards. He employed, at different times, tents made of sponge, gentian root, and other substances, which swell on be- ing moistened. But these always pro- duced so much pain and irritation, that it was impossible to persevere in their use. After remarking such inconveniences, he recommends, in opposition to the advice of other authors, not to make use of such tents in these cases. He is of opinion, that whoever makes trial of them upon parts, as sensible as the reClum, will soon find, that the advice ofthe writers alluded to is ill-founded. Tents, made of very soft lint, dipped in oil, or rolls of bougie plaster, cause less irritation, than those composed of any other materials. Though keeping the opening dilated may seem simple and easy, to sUch men as have had no opportunities of seeing cases of this description,%it is far otherwise in ' practice. Mr. Bell assures us, that he * never met with any disease, which gave him so much "trouble and embarrassment, as he experienced in the two cases of this sort, which occurred in his practice. Al- though in both instances he at first made the openings sufficiently large, it was only by very assiduous attention, for eight or ten months, that the necessity for another operation, and even repeated ones, was prevented. When only the skin has been divided, the rest of the treatment is doubt- less more simple; for, then, nothing more is requisite, than keeping a piece of lint, for a few days, in the opening made with the knife. But, when the extremity of the rectum is at a certain distance, though we may generally hope to effect a cure, after having succeeded in giving vent to the intestinal matter; yet, the treatment, after the operation, will always demand a great deal of attention and care on the part ofthe surgeon, for a long while. The difficulty of success may be considered as, in some measure, proportioned to the depth of the necessary incision. Sometimes, while the anus appears per- vious and well-formed, infants suffer the same symptoms, as if there were no-, anus at all. Tlie reason of this depends upon the intestine being occasionally closed by a membranous partition, situated more or less upward, above the aperture of the anus, and, sometimes the symptoms are/ owing to the termination of the gut in a cul-de-sac. This erroneous formation may always be suspected, whenever an infant, whose anus is externally open, does not void any excrement, Tor two or three days after its birth, and, especially, when ur- gent symptoms arise, such as swelling of tlie belly, vomiting, &c We are now 152 ANUS. to endeavour to ascertain, whether the rectum is impervious above the anus, by attempting to inject glysters, or to intro- duce a probe. If the gut be shut up, there is nothing to be done, but having recourse to the method described above, and form- ing a communication by means of a bis- toury guided on the finger, or else with a pharyngotomus. If the obstacle should only consist of a transverse membrane, the operation will be easy, and its success almost certain. But, if there should be a strangulation, or obstruction of the intes- tine, the case is infinitely more serious. However, as the operation is the only re- source for saving the child's life, we ought not to hesitate about performing it. When the anus is imperforate, the in- testine sometimes opens into the vagina, or bladder. The first of these cases is the least dangerous of all the malformations of this sort. The intestine may also open, and terminate at two places, at the same time, viz. at the usual place, so as to form a proper anus, more or less perfect; and also in the vagina. If these two openings should be ample enough for the easy evacuation of the ex- crement, nothing can be done at so tender an age; for, though voiding the feces through the vagina, is a most unpleasant inconvenience, yet, there is no effectual means of closing the opening of the intes- tine in this situation, nor could one be de- vised, which would not seriously incom- mode the infant. But, when the two openings are ex- ceedingly small, and the alvine evacua- tions cannot readily pass out, even with the aid of glysters, the opening of the anus ought to be dilated by cannula of different sizes. If this method should not avail, the knife must be employed, and the wound dressed, as already ex- plained. For the most part, the intestine has only one opening in the vagina. In tliis circum- stance, as in the instance in which the feces have no vent at all, we must make an incision in that place, which the anus ought to occupy. The natural course of the feces being opened by this operation, which in such a case is not at all perilous, much less excrement will pass out of the vagina, and, of course, the infirmity will be diminished. By the introduction of a tube into the new anus, the communica- tion between the rectum and vagina, might possibly be obliterated, and a per- fect cure accomplished. The opening between the intestine and vagina, may, also, be too small Tor the easy evacua- tion ofthe feces, and this might even ex- nose the infant to the same sort of dan- gerous symptoms, as it would be subject to, if the* rectum had positively no opening at all. In male infants, the rectum sometimes opens into ihe bladder, and, in this cir. cumstance, there is generally no anus. The case is easily known by the meconium being blended with the urine, wliich -ac- quires a thick greenish appearance, and is voided almost continually, though in small quantities. The most fluid part of the meconium, is the only one voided in this manner. The thicker part not get- ting from the rectum into the bladder, nor from the bladder into the urethra, greatly distends the intestines and bladder, and produces the same symptoms, as take place, in cases of total imperforation. Hence, without the speedy interference of art to form an anus, capable of giving vent to the feces, with which the urinary organs cannot remain obstructed, the in- fant will inevitably die. This case must, therefore, be treated like the foregoing ones. Though we can hardly hope to completely prevent the inconveniences, re- suiting from the rectum opening into the bladder, since even a new passage will not completely hinder the feces from fol- lowing the other course; yet, we shall thus afford the child a very good chance of preservation, and tiie only one which its situation will allow. In cases, in which we cannot procure an outlet for the feces, by any of the me- thods pointed out above, it has been pro- posed to make an opening into the abdo- men above the pubes, or on the right side, in order to get at the colon, and form an artificial anus, in one of these situations. But the prospect of" success would be so small, that the plan is not likely to be much adopted. (See De la Medecine Ope- ratoire par Sabatier, Tom. 1. Also Re- marques sur Differ ens Vices de Conforms tion, que les Enfians apportent en naissant Par M. Petit, in Mem. de PAcad. Royak de Chirurgie, Tom. 2,p. 236, Edit.inl2mo, Richerand's Nosographie Chirurgicale, Tom. 3, p. 415, &c. Edit. 2.) ABSCESSES OF THE A^US.—FISTULA IN AS0. The custom of giving the appellation of fistula to every collection of matter formed near to the anus, has, by conveying a false notion of them, been productive of such methods of treating them, as are di- ametrically opposite to those which ought to be pursued. A small orifice or outlet from a large or deep cavity, discharging a tliin gleet, or sanies, made a considerable part of the idea, which our ancestors had of a fistu- lous sore, wherever seated. With th< ANUS. 153 term fistulous, they always connected a notion of callosity: and, therefore, when- ever they found such a kind of opening yielding such sort of discharge, and at- tended with any degree of induration, they called the complaint nfistula. Imagining this callosity to be a diseased alteration made in the very structure of the parts, they had no conception that it could be cured by any means, but by removal with a cutting instrument, or by destruction with escharotics: and, therefore, they immediately attacked it with knife or caustic, in order to accomplish one of these ends: and very terrible work they often made. That abscesses, formed neap the funda- ment, do sometimes, from bad habits, from extreme neglect, or from gross mistreat- ment, become fistulous, is certain; but the majority of them have not, at first, any one character or mark of a true fis- Jule; nor cah, without the most supine neglect on the side of the patient, or the most ignorant mismanagement on the part of the surgeon, degenerate, or be con- verted into one. Collections of matter from inflamma- tion (wherever**' formed) if they be not opened in time, and in a proper manner, do often burst. The hole, through which tlie matter finds vent, is generally small, and not often situated in the most conve- nient, or most dependent part of the tu- mour: it therefore is unfit for the dis- charge of all the contents of the abscess ; and, instead of closing, contracts itself to a smaller size, and becoming hard at its edges, continues te drain off what is furnished by the undigested sides of the cavity. When an abscess about the anus bursts, the smallness of the accidental orifice; the hardness of its edges ; its being found to be the outlet from a deep cavity ; the daily discharge of a thin, gleety, disco- loured kind of matter; and the indura- lion of the parts round about, have all contributed to raise, and confirm the idea of a true fistula. Upon this idea was built the old per- nicious doctrine of free excision, or as free destruction. Abscesses about the anus present them- selves in different forms. Sometimes the attack is made with symptoms of high inflammation; with pain, fever, rigor, &c. and the fever ends as soon as the abscess is formed. In this case, a part of the buttock near to the anus is considerably swollen, and has a large circumscribed hardness. In a •short time, the middle of this hardness Vol. I. becomes red, and inflamed; and in the center of it matter is formed. This (in the language of our ances- tors) is called in general a phlegmon,- but when ie appears in this particular part, a phvma. The pain is sometimes great, the fever high, the tumour large, and exquisitely tender; but however disagreeable the ap- pearances may have been, or however high the symptoms may have risen, be- fore suppuration, yet, when that end is fairly and fully accomplished, the patient generally becomes easy and cool; and the mutter formed under such circum- stances, though it may be plentiful, yet is good. On the other hand, the external parts, after much pain, attended witil fever, sickness, 8tc. are sometimes attacked with considerable inflammation, but without any of that circumscribed hardness, which characterised the preceding tumour; in- stead of which, the inflammation is ex- tended largely and the skin wears an ery- sipelatous kind of an appearance. In this, the disease is more superficial; the quantity of matter small, and the cellu- lar membrane sloughy to a considerable extent, Sometimes, instead of either of the pre- ceding appearances, there is formed in this part, what the French call une sup- puration gangreneuse; in which the cellu- lar and adipose membrane is affected in the same manner, as it is in the disease called a carbuncle. In this case the skin is of a dusky red, or purple kind of colour; and although harder than when in a natural state, yet it has, by no means, that degree of tension or resistance, which it has either in the phlegmon, or in the erysi- pelas. The patient has generally, at first, a hard, full, jarring pulse, with great thirst, and very fatiguing restlessness. If the progress of the disease be not stopped, or the patient relieved by medicine, the pulse soon changes into an unequal, low, faul- tering one ; and the strength and the spi- rits sink in such manner, as to imply great and immediately-Stipending mis- chief. The matter formed under the skin, so altered, is small in quantity, and bad in quality; and the adipose membrane is gangrenous and sloughy throughout the extent of the discolouration. This gene- rally happens to persons whose habit is either naturally bad, or rendered so by intemperance. In each of these different affections, the whole maladv is often confined to the skin X 154 ANUS. and cellular membrane underneath it; and no other symptoms attend, than the usual general ones, or such as arise from lh* formation of matter or sloughs in the part immediately affected. But it also often happens, that, added to these, the patient is made unhappy by complaints arising from an influence, which such mischief has on parts in the neighbourhood of the disease ; such as the urinary bladder, the vagina, the urethra, the haemorrhoidal vessels, and the rectum; producing re- tention of urine, stranguiy, dysury, bear- ing dov/n, tenesmus, piles, diarrhoea, or obstinate costiveness : which complaints are sometimes so pressing, as to claim all our attention. On the other hand, large quantities of matter, and deep sloughs are sometimes formed, and great devastation committed on the parts about the rectum, with little or no previous pain, tumour, or inflammation. Sometimes the disease makes its first appearance in an induration of the skin, near the verge of the anus, but without pain or alteration of colour; which hard- ness gradually softens and suppurates. The matter, when let out, in this case, is small in quantity, good in quality; and the sore is superficial, clean, and well- conditioned. On the contrary, it now and then happens, that although the pain is but little, and the inflammation appar- ently slight, yet the matter is large in quantity, bad in quality, extremely of- fensive, and proceeds from a deep crude hollow, wliich bears an ill-natured as- pect. The place also where the abscess points, and where the matter, if let alone, would burst its way out, is various and uncer- tain. Sometimes it is in the buttock, at a distance from the anus -, at other times near its verge, or in the perineum: and this discharge is made sometimes from one orifice only, sometimes from several. In some cases, there is not only an open- ing through the skin externally, but an- other through the intestine into its cavity : in others, there is only one orifice, and that either external, or internal. Sometimes the matter is formed at a considerable distance from the rectum, which is not even laid bare by it; at others, it is laid bare also, and not per- forated ; it is also sometimes not only de- nuded, but pierced; and that in more places than one. All consideration of preventing sup- puration, is generally out of the ques- tion : and our business, if called at the beginning, must be to moderate the symp- toms ; to forward the suppuration; when the matter is formed, to let it out; and to treat the sore in such manner, as shall be most likely to produce a speedy and lasting cure. When there are no symptoms which re. quire particular attention, and all that w AQU ARN a day in cases of cancer. Mr. Barnes once shewed me a case of herpes of the nose, or noli me tangere, which was greatly benefited by this remedy externally ap- plied. The patient was under Mr. Har- vev, in St. Bartholomew's Hospital, and, at "the time when I saw her, Mr. Barnes was using the lotion with double the pro- portion of arsenic. There are many ulcer- ations round the roots of the nails of the fingers and toes, to which many apply Plun- ket's caustic; hut, the aquae kali arseni- cati would, in all probability, be quire as efficacious an application, and, certainly, it is a nearer one. AQUA KALI PURI. (lio.cor totassae, L. P.) This has been given with a view of dissolving urinary calculi, in consider- able doses, for a length of time. The trials, however, have not proved so suc- cessful as could have been wished, nor is the exhibition of so active a remedy un- attended with disadvantageous conse- quences to the system; for which reason, under the name "of mephitic alkaline water, vegetable alkali supersaturated with fixed air, has of late been much substituted. The proper dose, at first, is from ten to twenty drops, twice a day, in some lin- seed tea. At Saint Thomas's Hospital, the following is the w.y, in which the aqua kali puri is prescribed: . £ Aquae Kali puri Ji. Aquae Distillatae gij. Misce. Dosis Drachma una bis die ex unciis quatuor infusi lini. AQUA LITHARGYRI ACETATI. (liq.uor plumbi acetatis, L. P.) Is ex- tensively used largely diluted with water, as an application to inflamed parts. One dram to a quart of water is quite •strong enough for common purposes. .Mr. .Tustamond and Dr. Cheston used to ap- ply it mixed with an equal proportion of a spirit resembling the tinctura ferri muri- ati, to the edges of cancerous sores. The fear of the absorption of lead, has induced many practitioners to give up the use of this remedy, and have recourse to solutions of vitriolated zinc, which, it is said, answer equally well; but it is now rendered probable, from the experiments of Mr. Baynton, of Bristol, that cold water alone is of as much service as either in removing inflammation. (See Pharmaco- pxio ChirurgUta,) AQUA PICIS. May be applied to tinea capitis. There are ulcers on the legs, surrounded with a scorbutic redness, and pimples, covering a large extent of the skin. In such instances, the aqua picis, used as an application round the limb, over the dressings, is of great service. AQUEOUS HUMOUR OF THE EYE. The proposal of letting out this fluid, and the circumstances, in winch such an operation may be proper, will be considered in the article Opthalmy. ARDOR UlilNiE. Difficulty and pain in making water, attended with a sense of heat in the urethra, a symptom of go- norrhea, and some other affections. ARGEMA.or ARC EM ON. (from cc?y0( white.) A small white ulcer ofthe globe of the eve. (See Cornea, ulcers of) ARGENTI "NITR AS. (Nitrate of silver, lunar caustic.) Is the best of the mildest caustics. Its utility for stimula- ting indolent ulcers, and keeping granu- lations from rising too high, is known to every one. Mr. Hunter recommends the use of the argentum nitratum, on the first appear- ance of a chancre, before absorption can be supposed to have taken place. He di- rects the caustic to be scraped to a point, like a blacklead pencil; so that, when it is applied, every part of the surface ofthe chancre may come into contact with it; and he advises the repetition of", this pro- cess, till the last slough, which is thrown off, leaves the sore florid and healthy, (Hunter on the Venereal.) From this treatment, there is a chance, that the constitution will not be infected; but it is generally prudent, notwithstand- ing, to give the pil. hydrargyri. The important use of the argentum ni- . tratum, in the cure of numerous diseases, we shall have occasion to remark in vari- ous places of this work; particularly when we come to the article Urethra, strictures of, in the removal of which disease it is pe- culiarly useful. The argentum nitratum is often used in the form of a solution, in the proportion of a dram of the caustic to an ounce of dis- tilled water. In general this application ought to be at first more or less weakened, by the addition of a quantity of distilled water. Cancerous ulcers, and sores about the nose and neighbouring parts of the face, commonly going under the denomi- nation' of noli me tangere are often consi- derably benefited by the argentum nitra- tum, both in the solid and fluid state. The solution agrees very well with cer- tain sores, which occur round the roots of the nails of the fingers and toes. The lotion is sometimes applied with a camel- hair-pencil ; in general, however, by dip- ping little soft bits of lint in the fluid, laying them on the part, and covering them with a pledget. ' ARNICA. (xfiiKti, from ctgs, a lamb.) Leopardsbane. Amaurosis is the principal case in which surgeons now ever employ this medicine. From a dram to half an ounce ofthe flowers may be infused in a pint of water, and ARSENIC. 171 this may be taken in the course of four and twenty hours. Arnica, thus exhibited, sometimes produces vomiting, profuse per- spiration, and an increased secretion from the kidneys. At other times, no evident effects of tliis sort arise. The virtues of this medicine have undoubtedly been ex- aggerated, though no one can question that, as it is a powerful one, the trial of" it should still be continued. ARSENIC, (from the Arabic Arsenek, orapo'w, masculus, from the strength of its qualities.) Every one is acquainted with the deleterious effects of this mineral, wliich, in the dose of a few grains, acts as the most violent poison. Notwithstand- ing such effects which are generally dread- ed, practitioners have ventured to employ arsenic as a remedy for diseases, and this has sometimes been done with success, not only as an external topical applica- tion, but, even as an internal medicine. Arsenic is the principal ingredient of a secret remedy, which, in Ireland, has long possessed very great celebrity for the cure of. cancer, and which is known by the name of Plunket's caustic. This ap- plication is said to consist of the ranuncu- lus acris, the greater crow-foot, the flatn- mula vulgaris, and the lesser crow-foot: an ounce of each is to be bruised, and added to a dram of arsenic, and five scru- ples of sulphur. The whole is to be beaten into a paste, formed into balls, and dried in the sun. When used, they are to be beaten up with the yolk of an egg, and applied on a piece of pig's bladder. The use of the ranunculus is to destroy the cu- ticle, on which the arsenic does not act. The application is to remain on twenty- four hours, and the slough is to be after^ wards dressed with any simple, unirritat- ing ointment. Arsenic seems to have been first recommended as an external appli- cation to cancers, and it was generally combined with opium. It certainly some- times produces a salutary change in the appearance of the sore. We have reason to regret, that this change is usually not of permanent continuance. Besides Plun- ket's remedy, various other preparations of arsenic have been externally employed. Mr. Justamond's applications to cancer, originally suggested by a receipt, said to be preserved in the Earl of Arundel's fa- mily, were somewhat varied. They were generally combinations of arsenic and sul- phur. The above receipt directs an ounce of yellow arsenic, with half that quantity of armenian bole, and sometimes as much red precipitate. Mr. Justamond also em- ployed a sulphuret of arsenic, and a com- bination of this siilj.'iurel with crude an- timony. The at-iciiicul prestation, pre- frrred, was scraped-and laid on the mid- dle ofthe sore, while its edges were mois- tened with a combination of niuriated iron, and sal ammoniac. The effects were, the correction of the fetid smell, melioration of the appearance of the sore, and sepa- ration of the cancerous part. In the Pharmacopoeia Chirurgica, Mr. Justamond's arsenical caustic is directed to be made in the following manner: * an- timonii pulverizati ^ij. arsenici pulveri- .zati J j. These are to be melted together in a crucible. The application may be reduced to any degree of mildness by the addition of powdered opium. The latter ingredient may also act specifically in di- minishing the pain. M. Febure's remedy consisted of ten grains of arsenic, dis- solved in a pint of water, with an ounce of the extract of cicuta, three ounces of Goulard's extract, and a dram of lauda- num. With this fluid the cancer was washed every morning. He gave also arsenic internally, and directs two grains to be dissolved in a pint of water, to which must be added syrrup of chicory, with half an ounce of rhubarb. A table- spoonful is to be given night and morn- ing, with half a dram of the syrup of poppies. It may be remarked, that the dose of the arsenic, in this preparation, is one twelfth of a grain. The kali arsenicatum is an excellent preparation for internal exhibition, and is thus made: 5t Arsenici Albi, Nitri Punficati, singu- lorum unciam: Crucibulo amplo igne candenti injice nitrum, et liquefacto adde gradatim arse- nicum in frustulis, donee vapores nitrosi oriri cessaverint. Solve niateriam, in aquae distillatae libris quatuor et post idoneam evaporationem sepone, ut fiant crystalli. Dosis, Grani pars decima ter quotidie. It may be given in the following way. 5< Kali arsenicati gr. ij. . Aq. Mentha; Sativae ^;iv. Spirit. Vinosi tenuionsjjij. M. et. cola. Dosis drachmae duae ter quotidie. The following-is Dr. Fowler's method of preparing arsenic for internal use. Take of powdered arsenic, and prepared kali, each sixty-four grains; boil them gently in a Florentine flask, or other glass vessel, with half a pound of distilled water, un- til the arsenic is dissolved. To this so- lution, when cold, add half an ounce of the compound spirit of lavender, and as much water as will make the whole equal to a pint, or fifteen ounces and a half in weigh. The dose of this solution is as follows: From two years old to four, gutt ij or iij tQ v; from five to seven, guttv -J72 ARSE to vij ; from eight to twelve, gutt. vij to x; from thirteen to eighteen, gutt. x to xii; from eighteen upwards, gutt. xij. . These doses may be repeated once in eight or twelve hours, diluted with thick ^gruel or barley-water. It will only be in my power to specify here"" a few of the numerous surgical cases, hi which the internal employment of arsenic has been proposed. The follow- ing are particularly worthy of attention : tetanic affections ; cancer: noli me tan- gere ; elephantiasis; numerous unnamed malignant ulcers ; several obstinate cuta- neous diseases; pseudo-syphilis, and those sequelae of the venereal disease, which cannot be subdued by mercury, &c. Arsenic has also been recommended for the prevention of hydrophobia by Dr. J. Hunter. (See Transactions of a Society for the Improvement of Medical and Chirurgical Knowledge, Vol. J) Subsequent trials of this medicine, however, in such cases, do not seem to en tide it to much confidence. After the sympu-ms have begun, arsenic decidedly has no power in arresting the disease. It was lately tried by Dr. Mar- cet. Three drops of Fowler's solution were ordered to be taken, every other hour, in two drams of peppermint or water, w ith half a dram of syrup. How- ever, no relief whatever seemed to be de- rived from the medicine. (See Medico- Chirurgical Transactions, Vol. I. p. 141— 156.) But, although arsenic has hitherto fail- ed in producing benefit in cases of hydro- phobia, some facts have been recently pub- lished by Mr. Ireland, surgeon to the 4th Battulion of the 60th Regiment, which make it appear a truly valuable and effi- cacious remedy for counteracting the poi- son of serpents. (See Medico-Chirurgical Transactions, Vol.11, p. 393, and tlie article, Wounds—Bite of the Viper, in this Dic- tionary.) > Surgeons are frequently desired to ex- amine the bodies of persons, suspected of having been poisoned with arsenic, and every practitioner should qualify himself to judge whether the suspicion is rightly formed, or not. Often,* indeed, the life of the person, supposed to have adminis- tered the poison, will entirely depend upon the nature of the medical evidence. Be- sides, in certain cases, the symptoms, which precede a natural death, are of- such a description, as to create strong sus- picions that the patient has died of poi- son, when the fact is otherwise. Hence, it must be plain, that, both with respect to tlie question of murder, and of suicide, the evidence ofthe surgeon will frequently be of the utmost importance. * » The symptoms and effects of arsenic, when taken into the stomach, ought to be well remembered. A pricking and burn- ing sensation will soon be experienced in this organ. Sudden and excruciating pains will be felt in the bowelsr A severe vomit- ing will arise. The tongue, mouth, and throat, will become rough, and parched, and an unquenchable thirst will prevail, with much anxiety and restlessness. When the dose of arsenic has been considerable, and proper antidotes have not been em- ployed in time, an inflammation of the stomach and intestines will be the conse- quence, and it sometimes terminates in gangrene. Distention of the abdomen, coldness of the extremities, slow feeble pulse, fetid vomiting and stools, hiccough, and, lastly, death, ensue. In one instance of death from arsenic, related by Dr. Yel- loly, not the least mark of pain, or ten- derness, in the abdomen, was perceptible while the patient lived. (See Edinb. Med. and Surgical Journal, Vol 5. p. 391.) When the body of a person, who has . been poisoned with arsenic, is opened, the small intestines will generally be found to be inflamed and thickened, their external surface being in some places of a florid red colour, and in others, of a purple hue; while here and there effusions of coagulating lymph may be observed. The large intestines in general seem to suffer less, though, in some cases, they are found more or less inflamed as far as tlie extremity ofthe rectum. Sometimes, the bowels are even quite mortified in various places. The villous coat ofthe stomach is con. siderably inflamed, and points of extra- vasated blood may commonly be noticed upon it. In one case, examined by Dr. Yelloly, there were observed two, or three circular spots, of tiie size of a shilling, which were abrasions of the membrane. In some places, the villous coat seemed to be thickened by an effusion of lymph. The convolutions of the intestines will often be found connected together by ad- hesions. The lining of the oesophagus will also sometimes partake of the in- flammation. Very violent and even fatal effects may also arise from the absorption of arsenic from the skin into the circulation. (See Med. and Physical Journal, Vol 5. p 543.) There are five methods of detecting the • presence of arsenic. First, by precipi- tating this mineral from ajiy fluid, in which it is dissolved, by an alkaline hy- dro-sulphuret. Secondly, by precipitating any solution of arsenic by the sulphate of copper. Thirdly, by reducing the oxide into the metallic state, by heating it with extraneous substances in a glass-tube. Fourthly, by observing the effect, which ARSENIC. 173 arsenic has, in whitening copper, when heated in contact with it. Fifthly, by perceiving the peculiar odour, which is exhaled, when arsenic is evaporated from a heated surface. When some of the solution of sulphuret of potash (kali sulphuratum) is added to A solution of the white oxide of arsenic, a precipitate is instantly formed of a bright orange colour. ' All surgeons, however, should be aware, that a very similar effect is produced by adding the solution of kali sulphuratum to a solution of tartarised antimony; but, the puecipitate is not formed so readily as when arsenic is concerned. The .second means of ascertaining the presence of arsenic is by precipitating a mixed solution of the white oxide of this metal and potash, by adding some of the solution of the sulphate of copper, (Cu- prum vitriolatum.) The precipitate, formed by this process, is of a beautiful green colour, and is well known by the name of Scheele's green paint. In order to produce such precipitate in the best way, Dr. Bostock recommends, that the proportions of the* oxide of arsenic, pot- ash, and sulphate of copper, be to each other, as one, three, and five. (Edinb. Med. and Surgical Journal, Vol 5, p. 169.) The third method of detecting arsenic consists in reducing the oxide into the metallic state, by mixing the suspected powder with a little charcoal, putting these substances into a glass tube, and exposing them for a full quarter of an hour to a. red heat. One end of the tube should be hermetically closed, the other stopped with a plug of clay. The glass must also be every where well coated with clay and sand, be about a quarter of an inch in diameter, and "eight incbes in length. On the application of caloric, the oxygen of tlie arsenic unites with the car- bon, and forms carbonic acid gas, leaving the arsenic on the inside ofthe glass tube reduced to the metallic state. This is reckoned the most decisive test of. the presence of arsenic; but, it will not an- Bwer when the quantity of the latter mi- neral is less than a grain. The quality, wliich arsenic has, of uniting with copper and forming a white compound, is the fourth means of detect- ing the presence of the first of these me- tals. For tliis purpose, put one gram of suspected powder, with half a grain of powdered charcoal, and two drops of oil, between two plates of polished copper, wliich are to be bound together with some wire, and exposed, for some time, to a red heat. Dr. BQstockhas explained, that, when a paste of charcoal and oil alone is put between plates of copper, and exposed to heat, a somewhat similar white appear- ance is produced on them, so that the communication of a white colour to cop- per by arsenic is not' the most eligible cri- terion, particularly, when the quantity of the suspected substance is small. The fifth'mode of judging of the pre- sence of arsenic is by the. low, bluish, white, flame, alliaceous smell, and white smoke, which arise when that mineral is thrown on a red hot body. This experi- ment will only afford information, to be depended upon, when the quantity of arse- nic is considerable, and it is unmixed with other substances. Of all the foregoing modes, Dr. Bos- tock deems that, in which the green pre- cipitate is produced with the sulphate of copper, the most convenient, delicate, and decisive. Of late, a new test of arsenic has been suggested. The following is the account given of it by Dr. P. M. Roget: " Let the fluid, suspected to contain arsenic, be fil- tered : let the end of a glass rod, wetted with a solution of pure ammonia, be brought into contact with this fluid; and let a clean rod, similarly wetted with a solution of nitrate of silver, be brought into contact with the mixture. If the minutest quantity of arsenic be present, a precipitate of a bright yellow colour, inclining to orange, will appear at" the point of contact, and will readily subside to the bottom of the vessel.— (Note. As this precipitate is soluble in ammonia, particular care should be taken to avoid adding it in excess; indeed, the quantity of eiiher ammonia or nitrate of silver employed, can scarcely be too small for the purpose of detecting the presence of arsenic.) •' In examining the circumstance.0, at- tending the agency of this test, the fol- lowing particulars were observed. On adding successively ammonia and nitrate ol" silver to distilled water, no precipitation takes place. Fowler's arsenical solution affords a precipitate of a yellow colour, si- milar in appearance to that produced by a solution of the white oxyd; but, a solution of arsenic acid gives a precipitate of a red brick colour. The fixed alkalies, when substituted for ammonia, likewise produce a yellow precipitate; but, the results are less distinct, since, in the circum- stances, in which the experiment is made, they decompose the nitrate of silver, an effect, which ammonia does not produce. We found, by comparative experiments, that the precipitates, thrown down by the same reagents, (namely, ammonia andlii- trate of silver,) when either zinc, iron, copper, mercury, or lead was contained 174 ARb ART in the fluid, had an appearance totally different from that produced by arsenic ; and that the latter could readily be de- tected by the same means, notwithstand- ing the presence of these metals. The salts of copper, or lead, when previously mixed with a solution containing arsenic, occasioned no difference in the results. With a solution of oxymuriate of mer- cury, ammonia alone will occasion a white precipitate ; but, if arsenic be also pre- sent, on addition of nitrate of silver the precipitate immediately acquires a yel- low colour. The efficacy of this com- pound test is not weakened, but, on the contrary, seems to be rather increased by the presence of sulphate of iron. Sul- phate of zinc was not found to interfere with its operation, any otherwise than re- quiring a larger quantity of ammonia, in order to saturate tlie sulphuric acid; but, when this has been effected, and the whole of tlie zinc precipitated, the addition of nitrate of silver produces the same yellow tint as in tlie other experiments. There is, therefore, reason to presume, that no admixture of metallic, or other salts, will occasion ambiguity, or enable the arsenic to escape detection, when the above test is properly applied. (Dr. Roget observes, in a note, that in the Philosophical Ma- gazine, for 1809, Mr. Hume has proposed boiling the suspected matter with a solu- tion of carbonate of potash, and bringing into contact with it a stick of dry nitrate of silver: a method, somewhat analogous to that above described, but, much less convenient in its practical application.) " Being curious to determine the limit of minuteness in the quantity of arsenic, discoverable by this test, we dissolved a grain of white arsenic in a known quan- tity of distilled water, and, by successive additions of water to determinate portions of this solution, prepared other solutions, containing respectively one 2C00tli, one 20,000th, and one 200,000th of their weight of arsenic. By applying the test to a small quantity in a watch-glass, we found, that, when it contained only jpne 25,000th of a grain of arsenic, the preci- pitate was of a bright yellow colour. It was still distinctly yellow, when the quan- tity of arsenic was reduced by dilution to one 50,000th of a gram. When further diluted, the yellowness was gradually less and less discernible, and the precipitate appeared of a light blue. It retained this colour, until its quantity became too minute for observation. A bluish cloud, however, was very distinctly visible, when the fluid examined contained only the 250,000th part of a grain of arsenic. " If, (says Dr. Roget) along with the extraordinary -degree, of delicacy of this test, we take into consideration the ex- treme facility of applying it, and the reater convenience of operating upon uids, than upon solid bodies, as we are obliged to do, when we have recourse to the usual methods, it appears decidedly entitled to preference. (See Medico Chirurgical Transactions, Vol. 2, p. 156— 160.1 The following plan should be pursued, when arsenic has been swallowed in such a quantity as to endanger life. An eme- tic of white m* blue vitriol should be ex- hibited immediately, and large quantities of water swallowed, in which the liver of sulphur (k di sulphuratum) is dissolved. The stomach having been thus emptied, a mixture containing the kali sulphura- tum, about a scruple to a dose, should be frequently exhibited, milk, butter, or caster oil, being freely given in the in- tervals. The employment of .copious blood-let- ting, in cases of poison from arsenic, was suggested by Dr. Yi Holy, on the prin- ciple of removing inflammation. " Ana- logy (says he) seems to indicate its em- ployment; but, its particular fitness can only be determined by experience." (Edin- burgh Medical and Surgical Journal, Vol 5, p. 393.) Dr. Roget has put this proposal to the test of experhnent, and the reco- very, which was effected by that gentle- man, after a large quantity of arsenic had been swallowed, and most alarming symp- toms had come on, seems to be much in confirmation of the utility of the practice. (See Medico-Chirurgical Transactions, Vol. 2, p. 136.) This article would admit of being con- siderably lengthened; but, as some ofthe subject is as much medical as surgical, I think it will be sufficient in this work to re- fer the reader to sources, from which more extensive information may he obtained. (See Observations on the different Methods recommended for detecting minute Portions of Arsenic, by John Bostock, M. D. Edinb. Med and Surgical Journal, Vol. 5, p 166, also p. 14. Dissertatio Inauguralis de Effec- tibus Arsenici in varios organismos necnon de indiciis quibusdam veneficii ab Arsenica Ulati ; quamprxside C. F. Kiclmayerpublice defendet, Jan. 1808. Auctor Georg. Fried. Jaeger, Stuttgardianus, 8vo. Tubrisgx. in Nouvelles Experiences sur les Contre-poisons de PArsenic, par Casimir Renault, Paris an 1Xc Murray,s System of Chemistry, Vol. 3, p. 356, Edit. 2. Observations on tlie Use of Arsenic, by G. N Hill, in Edinburgh Med. and Surgical Journal, Vol. 5, p. 19—312. Pharmacopceia Chirurgica. Medico-Chirur- gical Transactions, Vol. 1, p. 141 y0l 2, p. 136, 156, and 393, &c. ARTERIOTOMY. (from «£rvpi*t an BAN BAN 175 artery, and "rtfuu, to cut.) The operation of opening an arteiy, for the purpose of taking away blood for the relief of dis- eases. (See Bleeding.) ARTERIES, Wounded. (See Hemor- rhage.) ARTICULATIONS, Diseases of. (See Joints.) ASTRINGENTS, (from astringo, to bind.) In medicine, are those substances which possess a power of making the liv- ing fibres become contracted, condensed, and corrugated. They are employed in the practice of surgery chiefly as exter- nal applications, either for restoring di- minished tonic power, or checking various discharges. They are also deemed very eligible local remedies for phlegmonous inflammation. ATHEROMA, (from «6npct, pap.) An encysted tumour, so named from its pap- like contents. (See Tumours Encysted.) AXILLARY ARTERY, Wounded.— When, in a case of this description, it is necessary to tie the injured vessel, Scarpa believes, that nothing tends more to em- barrass the surgeon, than an injudicious smallness ofthe first incision through the skin and such other parts as conceal the wound in the artery. An assistant must compress the vessel, from above the cla- vicle, as it passes over the first rib.' When the weapon has penetrated, fi-om below upward, directly into the axilla, the sur- geon is to make a free dilatation ofthe wound upon a director, or his finger. This must be done to a sufficient height to expose a considerable portion of the arterv, and the precise situation of the wound in it. When the weapon has pierced oblique- ly, or from above downwards, through a portion ofthe great pectoral muscle, into the axilla, Scarpa advises the surgeon to cut through the lower edge of this muscle, and enlarge the wound, on a director, or his finger, so as to bring f-.irly into view the injured part of the artery. The tho- racic arteries, divided in this operation, must be immediately tied. The clots of blood are then to be removed, and the bottom of the wound cleaned with a sponge, by which means the opening in the axillary artery will be more clearly seen. As this vessel lies imbedded in the brachial plexus of nerves, the surgeon must take care to raise it from these lat- ter parts with a pair of forceps, before he ties it. Two ligatures will be required ; one, above, the other below the wound of the arteiy. *>e$o< B. BALSAMUM COPAIViE. Exhibited by surgeons principally in cases of gonorrhea, gleet, and piles. A dram may be Riven thrice a day. „,,«» BALSAMUM PERUVIANUM CUM FELLE BOVINO. * Fellis Bovim guj B:dsami Peruv. 3 j M. Dr. H. Smith has advised this application to be occasionally dropped into the ear, when there is a fetid discharge from it. The meatus audito- rius externus is also to be washed out every dav, by syringing the passage with water, to which some recommend soap to be added. . BANDAGE. (Deligatio. Fascia.) An apparatus, consisting of one or several pieces of linen, or flannel, and intended for covering, or surrounding parts of the body for surgical purposes. The use of bandages is to keep such compresses, remedies, &c. in their proper situation, as are applied to any particular part; to compress blood-v-esse.s, so as to restrain hemorrhage; to rectify certain deformities by holding the deranged parts in a natural position; and to unite parts, in which there is a solution of continuity. As the application of bandages is a very important branch ol surgery, authors have not neglected it. Much has been written on the subject, and almost every writer has devised new bandages, perhaps with- out much benefit to surgery. Unfortu- nately, it is next to impossible to give very, clear ideas of the numerous sorts of bandages by description. The surgeon can only acquire all the necessary instruc- tion and information from the experience and habit resulting from practice. Hence, we shall confine ourselves to a general account of the subject. Bandages should be made of such ma- terials as possess sufficient strength to fulfil the end proposed in applying them, and they should, at the same time, be supple enough to become accommodated to the parts to which they are applied. Bandages are made of linen, cotton, or flannel. If possible, they should be with- out a scam, and Unen is woven for this *76 BANDAGE. purpose ; but the selvage is always harsh, and, as 'he edges are necessarily covered by the i ext round, they are sometimes inconvenient. Most surgeons prefer, there- fore, old linen, and more readily submit to the inconvenience ofthe edges unravel- ling, than to the irregularity which any stitching would produce. There are cases, in which the bandage should have a degree of firmness, that does not belong to the materials usually made use of. This circumstance is ob- vious in cases of hernia, and in all those in which there is occasion for elastic band- ages. As we have already observed, linen, , "flannel, and cotton (calico), are the com- mon materials. The first employment of flannel bandages is imputed to the Scotch surgeons, who preferred them to linen ones, in consequence of their being better calculated for absorbing moisture, while, being more elastic, they yield in a greater degree in cases requiring this property ; as in the swelling subsequent to disloca- tions, fractures, &c. It has been asserted, that Unen is better than flannel, because*' more cleanly; but neither one nor the other will continue clean, unless care be taken to change it very often. The employment of cotton or calico bandages is a more recent method, and many advantages are attributed to the softness and elasticity of this material. In applying a bandage, care must be taken, that it be put on tight enough to fulfil the object in view, without running any risk of stopping the circulation, or doing harm in any other way. If it be not sufficiently tight to support the parts in a proper manner, it is useless; if it be too tense, it will produce swelling, in- flammation, and even mortification. To apply a roller skilfully, the part which it is to cover, must be put in its proper situation; the head of the roller held in the surgeon's hand, and only so much unrolled as is requisite for covering the part. In general the bandage should, if possi- ble, be applied in such a manner as will admit of its beir>g removed with the most ease, and allow the state of the parts be- neath to be examined, as often as occa- sion requires. For this reason, in fractures of the leg and thigh, the eighteen-tailed bandage is generally preferred to a simple roller. The former may be loosened and tight- ened, at pleasiue, without occasioning the smallest disturbance ofthe affected limb; a thing which could not be done, were a • common roller to be employed. As soon as a bandage has fulfilled the object for which it is applied, and it has become useless, its employment should be discontinued; for, by remaining too long on parts, it may obstruct the circulation, diminish "the tone of the compressed fibres, and vessels, and thus do harm. Bandages are either simple or compound. They are also sometimes divided into general and • particular. The latter often derive their names from the parts, to which they are usually applied. A simple bandage is a long piece of linen or cotton, of an indefinite length, and from three to six inches in breadth. When about to be applied, it is commonly rolled up, and the rolled part is termed its head. When rolled up from each end, it is called a double-headed roller or bandage. The chief of the simple bandages are the circular, the spiral, the uniting, tlie retaining, the expellent, and the creeping. The circular bandage is the simplest; the rolls cover each. other, and it is sel- dom long, as two or three turns are ge- nerally enough. The spiral bandage is the most fre- quently used of all; for, it is this which we see in such common employment on the limbs, in cases of ulcers, &c. In apply- ing a common roller to the whole of a limb, the bandage must be carried round the part spirally, or else it is obvious that the whole member could never be covered. When the leg is the part, the surgeon is to begin by surrounding the foot with a few turns. Then carrying the head ofthe bandage over the instep, he is to convey it backward, so as to make the bandage unroll, and apply itself just above the heel. The roller may next be brought over the inner ankle ; thence again over the' instep, and under the sole; and the surgeon then brings the bandage spirally upward once more to the outer part of the leg. After this, every circle of the roller is to be applied, so as to ascend up the limb in a gradual, spiral form, and so as to cover about one third of the turn of the roller immediately below. The increasing and diminishing diameter of the Umb, is one great cause, which brings into view the unskilfulness of a surgeon in this common operation; for, it prevents the- roller from lying smoothly, although spirally applied, un- less a particular artifice be dexterously adopted. The plan alluded to, is to dou- ble back the part ofthe roller that would not be even, were the application to be continued in the common spiral way, without this manoeuvre. When the bulk of the Umb increases very suddenly, it is sometimes necessary to fold, or, as it is termed, reverse, every circle of the ban- dage in the above manner, in order to make it lie evenly on the limb. It is mani- BANDAGE. 177 fest, that the pressure ofthe roller will be greatest where the duplicatures are situat- ed, and hence, when it is an object to' compress any particular part, the surgeon should contrive to reverse the turns of the bandage just over the situation where most pressure is desirable. When a roller is to be applied to the forearm, it is best to make the few first turns ofthe bandage round the hand. Care must be taken not to make the bandage very tight, if it be intended to wet it afterwards with any lotion; for, it is always rendered still more tense by moisture. Mr. John Bell describes the principal purposes for which a roller is employed, as follows.- " Although in recent wounds, it is with plasters and sutures that we unite the parts point to point, yet it is with the bandage that we support the limb, preserve the parts in continual and perfect contact with each other, and pre- vent any strain upon the sutures, with which the parts are immediately joined, and we often unite parts by the bandage alone. (This is called the Uniting Band- age, and will be presently described) But it is particularly to be observed, that in gun-shot wounds, and other bruised wounds, though it would be imprudent to sew the parts, since it is impossible that they should altogether unite, yet the gen- tle and general support which we give by a compress and bandage, prevents them from separating far from each other, unites the deep parts early-, and lessens the extent of that surface, which must na- turally fall into suppuration. "In the hemorrhagy of wounds, we cannot always find the artery; we dare not always cut parts for fear of greater dangers; we are often alarmed with bleedings from uncertain vessels, &c. or from veins as well as arteries : these he- morrhages are to be suppressed by the compress; which compress, or even the sponge itself, is but an instrument of compression, serving to give the bandage its perfect effect. Frequently, in bleed- ings near the groin, or the arm-pit, or the angle ofthe jaw, wherever the bleeding is rapid, the vessels uncertain, the cavity deep, and the blood not to be commanded by a tourniquet, and where the circum- stances forbid a deliberate and sure ope- ration, we trust to compress and bandage alone. "Bandage is very powerful in sup- pressing bleeding. At one period of sur- gery, it took place of every other method, &c. If a compress be neatly put upon the bleeding arteries, if there be a bone" to resist the compress, or even if the soft parts be firm below, and the bandage be Voi. I. well rolled, the patient is almost secure. But such a roller must be rolled smoothly from the very extremity of the fingers or toes; the member must be thoroughly supported in all its lower parts, that it may bear the pressure above. It is par- tial stricture alone that does harm, creates intolerable pain and anxiety, or brings on gangrene. Hemorrhagy requires a very powerful compression, which must there- fore be very general, Sic. It must not be made only over the bleeding arteries, which is all that the surgeon thinks of in general, Sec. "In abscesses, where matter is work- ing downwards along the Umb, seeking out, as it were, the weak parts, under- mining the skin, and wasting it, insulat- ing and surrounding the muscles, and penetrating to tiie bones, the bandage does every thing. The expelling bandage, the propelling bandage, the defensive bandage, were among the names, which the older surgeons gave to the roiler, when it was applied for these particular purposes; and these are properties of the roUer, which should not be forgotten." (Principles of Surgery, Vol. 1.) Soon after this description of some of the chief surgical uses of the roller, Mr. John Bell proceeds to explain, in what manner this most simple of all bandages may be put on a limb. " Practice will convince you, that the firnfftpss.and neatness of a bandage de- pend altogether upon these two points; first, upon tlie turns succeeding each other in a regular proportion; and, secondly, upon making reverses, wherever you find any slackness likely to arise from the va- rying form of the limb. Thus, in rolling from the foot to the ankle, leg, and knee, you must take care, first, that the turns, or, as the French call them, doloircs, of the roller lie over one another by just one third ofthe breadth of the bandage ; and, secondly, that at every difficult part, as over a joint, you turn the roller in your hand, make an angle, and lay the roller upon the limb, with the opposite flat side towards it; you must turn the bandage *so as to reverse it, making, what the French call, a renversee of the roller at the ankle, at the calf of the leg, and at the knee. You must be careful to roll your bandage from below upwards, and sup- port the whole limb by a general pressure. That you may be able to support the dis- eased part with a particular pressure, you must lay compresses upon the hol- lows and upon the bed of each particular abscess, and change the place of these com- presses from time to time, so as now to prevent matter sinking into a particular hoUow, now. to press it out from a place A a 173 BANDAGE. where it is already lodged, and again to reunite the surface of an abscess already completely funned, iromwl.irh thcmaiier has been discharged." (Principles of Sur- gery, Vol. 1.) Id the article Joints, we have taken notice of the good effects of the pressure of a roller m tlie cure of white-swellings. Here we shall just introduce Mr. John Bell's sentiments upon the subject: "In a diseased bursa, as in a relaxation of tlie knee-joint, that disease, which, with but a little indulgence, a very little encourage- ment of fomentations, poultices, bleeding, and low diet, would end in white-swelling of the knee; may be stopper! even by so simple a matter as a well-rolled bandage. (Vol. I,p.l27.) The uniting bandage, or spica descendens, used in rectilinear wounds, consists of a double-headed roller, with a longitudinal slit in the middle, of three Or four inches long. The roller having one head passed through the slit-, enables the surgeon to draw the lips of the wound together. The whole must be managed, so that the band- age may act equally. When the wounds are stitched, this bandage supports the stitches, and prevents their tearing through the skin. When the wound is deep, wri- ters advise a compress to be applied on each side, in order to press the deeper part of its sides together. When the wound is very long, two or three bandages should be employed, and great care must be taken, that the pressure is perfectly equable. Henkel and Richter recommend a unit- ing bandage, which allows the surgeon to see the wound, over which only narrow tapes cross. The reader, if he should ever wish to employ this contrivance, may read a description of it in Rees' Cyclo- pa:dia, or Motherby's Medical Dictionary, though I confess I could not understand it from the description in those works, until I looked at the plate in'Richter's Anfangsgr. der Wundarzn. Band 1. When we make use of a single-headed roller, as a retentive bandage only, we should always remember to begin the ap- plication of it on the side opposite the wound. The obvious reason fin- so doing is to prevent a farther separation of the lips of the wound, as the contrary man- ner of applying the roller would tend ciirectlv to divide them. (Gooch, Vol 1, p. 143.) The intention of the expel lent bandage is to keep the discharge sufficiently near the orifice of the wound to prevent the formation of sinuses In general, a com- press of unequal thickness is necessary; the thinner part of t*,e compress being placed next, and immediately contiguous to, tiie orifice of the wound the thicket part below. Before the bandage is ap- plied, the pus must be completely pressed out, and the rolling begin with two, or three, circular turns on the lower part of the compress. The bandage must then be earned spirally upw arils, but not quite so tightly, as below, li is afterwards to be rolled downward to the place, where it began. The creeping is a simple bandage, every succeeding turn of which only just covers the edge of the preceding one. It is em- ployed in cases, in which the object it merely to secure the dressings, and not to make any considerable, or equable pressure. A bandage is termed compound, when several pieces of linen, cotton, or flannel, are sewed together in different directions, or when the bandage is torn or cut, so as to have several tails. Such are the T bandage, the suspensory one, the capi- strum, 8ic. The eightecn-tailed bandage is one of the "^ost compound. It is now in general use for all fractures of the leg and thigh, some- times for those of the forearm, and, fre- quently, for particular wounds. Its great recommendations are the facility with which it can be undone, so as to aUow the parts to be examined, and its not creating, on such an occasion, the small- est disturbance of tlie disease, or acci- dent. The eighteen-tailed bandage is made by a longitudinal portion of a common roller, and by a sufficient number of trans verse pieces, or tails, to cover as much of tiie part as is requisite. Each of the cross pieces is to be pro- portioned in length to the circumference of the part of the limb, to wliich it is to be applied; so that in making this sort of bandage for the leg, or thigh, the up- per tails will be twice as long as the lower ones. After laying the long part ofthe bandage on a table, fix the upper end of it in some way, or another. Then begin laying the upper tails across it, and pro- ceed with placing the rest. Each tail must be long enough to extend about two inches beyond the opposite one, when they are both applied. The tails, being all arranged across the longitudinal band, they are to be stitched in this position with a needle and thread. When the bandage is intended tor the leg, a piece of the longitudinal part of the roller be- ' low, is to extend beyond the tails. Tliis is usually brought under the sole of the foot, and then applied over the inner an- kle in the first instance, aftf-r the bandage has been put under the limb. Then the surgeon lays down tiie first of tlie lowef BANDA8E. X7Q tails, and covers it with the next one above. In this way, he proceeds upwards, till all the cross pieces are applied, the uppermost one of which he fastens with a pin. This bandage has a very neat ap- pearance. The tails are said to lie bet- ter, when placed across the longitudinal piece a little obliquely. (Pott.) The T bandage is, for the most part, used for covering parts of the abdomen and back, and, especially, the scrotum, perinseum, and parts about the anus. Its name is derived from its resemblance to the letter T, and it is, as Mr. John Bell remarks, the peculiar bandage ofthe body. If the breast, or belly, be wounded, we make the transverse piece, which encir- cles the body, very broad, and having split the tail-part into two portions, one of these is to be conveyed over each side of the neck, and pinned to the opposite part of the circular bandage, so as to form a suspensory for the latter, and prevent its slipping down. But, says Mr. JohniBell, if we have a wound, or disease, or opera- tion, near the groin, or private parts, the tail-part then becomes the most important part of the bandage; then the transverse piece, which is to encircle the pelvis, is smaller, while the tail-part is made very broad- When the disease is in the pri- vate parts, perinxum, or anus, we often split the tail according to circumstances • but, when the disease is in one groin, we generally leave the tail-part of the band- age entire and broad. The linteum scissum, or split-cloth, is a bandage applied occasionally to the head, and consists of a central part, and six, or eight tails, or heads, which are applied, as follows : When the cloth has six heads, the mid- dle, or unsplit part of the cloth is applied to the top of the head. The two front tails go round the temples, and are pinned at the occiput; the two back tails go also round the temples, and are pinned over the forehead, the two middle tails are usually directed to be tied under the chin ; but, as Mr. John Bell observes, this suf- focates and heats the patient, and it is better to tie them over the top of the head, or obliquely, so as to make pressure upon any particular point. (Principles of Sur- gery, Vol. I, p. 131.) The old surgeons usually split this middle tail into two parts, a broad, and narrow one. In the broad one, they made a hole to let the ear pass through. This broad portion was tied under the chin, while the narrow ends were tied obliquely over the head. As Mr. John Bell has observed, though this gave the split-cloth the effect of eight tails, yet, the ancient surgeons did not name il the split-cloth with eight tails. When they split the cloth into eight tails, and, especially, when they tied the eight tails in the fol- lowing particular manner, they called the bandage cancer, as resembling a crab in the number of its legs. The cancer; or Split-cloth of eight tails, was laid over the head, in such a manner, that four tails hung over the forehead and eyes, while the other four hung over the back of the head. They were tied, as follows; first, the two outermost tails, on each side in front, were tied over the forehead, while the two middle tails in front were left hanging over the knot. Then the two outermost, or lateral tails behind were tied round the occiput. Next the middle tails were tied, the two anterior ones be- ing made to cross oyer each other, and pass round the temples to be pinned at the occiput; while the two middle tails be- hind, were made to cross each other, and pass round the temples, so as to be pin- ned over the ears, or near the forehead* (See John Bell's Principles, Vol. 1, p. 132.) The triangular bandage is generally a handkerchief doubled in that form. It is commonly used on the head, and, now and then, as a support to the testicles, when swelled. The French term it couvre-chef en triangle The nodose bandage called also seapha, is a double-headed roller, made of a fillet four yards long, and about an inch and a half broad. It must be reversed two, or three times, so as to form a knot upon the part, which is to be compressed. It is employed, when a hemorrhage from a wound is to be stopped, or, for securing the compress, after bleeding in the tem- poral arteiy. The most convenient bandage in gene- ral for the forehead, face, and jaws is the four-tailed one, or single split-cloth. It is composed of a strip of cloth, about four inches wide, which is to be torn at each end, so as to leave only a convenient portion of the middle part entire. This unsplit middle portion is to be applied to the forehead, if the wound be there, and the two upper tails are carried backward, and tied over the back part of the head, while the two lower ones are to be tied either over the top of the head, or under the chin? as may seem most convenient. When the wound is on the top of the head, the middle of the undivided part is to be applied to the dressings. The two posterior tails are to be tied forward, and the two anterior ones are to be carried backward, so as to be tied behind the head. This is sometimes called Galen's bandage. < It is curious, that writers on bandages should use the terms head, and 180 BAN BEL tail, synonymously, and hence this four- tailed bandage is often caUed the sling with four heads. Such confusion of language is highly reprehensible, as it contributes, in a very great degree, to obstruct the comprehension of any, the most simple subject. If the upper lip be cut, and a bandage needed, which is seldom the case, it is almost superfluous to say, that this band- age will serve tiie purpose. It serves also in cuts of the lower lip, though there, also, we trust rather to the twisted su- ture, than a bandage. The single spUt-cloth is particularly useful in supporting a fractured lower jaw, and, in such cases, is the only one employed in modern surgery. This band- age, when used for this particular pur- pose, namely, supporting the lower jaw, is named capistrum, or bridle, because it goes round the part somewhat like a horse's halter. " In some cases, (says Mr. John Bell) the circumstances require us to support the chin particularly, and then the unslit part of the bandage is applied upon the chin with a small hole to receive the point; but, where the jaw is broken, we pad up the jaw-bone into its right shape, with compresses pressed in under the jaw, and secured by this baiidage. When we are in fear of hemorrhagy after any woiiHd, or operation, near the angle of the jaw, we can give the sling a very remarkable degree of firmness. For this purpose, we tear the band into three tails on each side, and we stitch the bandage at the bottom of each split, lest it should give way, when drawn firm, Sic." (Principles of Sur- gery, Vol. 1.) We have already described one way of applying a handkerchief, as a bandage to the head, when we noticed the triangular one, or couvre-chef en triangle. The other manner of applying the handkerchief, called the grand couvre-chef, is as fol- lows : You take a large handkerchief, and fold it, not in a triangular, but a square form. ,You let one edge project about three finger-breadths beyond the other, in order to form a general border for the bandage. YoU lay trie handkerchief upon the head, so as to make tlie lower fold, to which the projecting border belongs, lie next the head; while the projecting bor- der itself is left hanging over the eyes, tiU the bandage is adjusted. Tiie two coiners of the outermost fold are first to be tied under the chin; the projecting border is then to be turned back, and pinned in a circular form round the face, while tlie corners of the fold next the head are to be carried backward, au-d tied. After the outer corners of this bandage have been tied under the chin ; after the inner corners have been drawn out and carried round the occiput; and after the border has been turned back and pinned; the doubling of the handkerchief over each side of the neck hangs in a loose awkward manner. It remains, therefore, to pin this part of the handkerchief up above the eaF, as neatly as can be con- trived. (See J. Bell's Principles.) The grand couvre-chef has certainly no- thing to recommend it, either in point of utility, or elegance. A common night-cap must always be infinitely preferable to it. In the event, however, of a cap not being at hand, it is proper that the sur- geon should know, what contrivances may be substituted to fulfil the objects in view. Having, in the numerous articles of this Dictionary, noticed the mode of applying bandages in particular cases, and allotted a few separate descriptions for such band- ages, as are not here mentioned, but, which are often spoken of in books, we shall conclude for the present, with re- ferring the reader for further information' to Motherby's Medical Dictionary; Rees' Cyclopxdiu; and John Bell's Principles of Surgery, Vol. 1. Galen and Vidus Vidius are reckoned tlie best of the old writers on the subject; M. Sue, Thillaye, Heister, Lombard, and Bernstein ; of the modern ones. The latter are said, however, to be all loo prolix. (See Rees' Cyclopxdia, art. Bandage.) BARK, Peruvian. (See Cinchona.) BA'THRON. A Greek word, denot- ing, in a surgical sense, a machine for ex- tending broken limbs, sometimes called the Scamnum Hippocratis. It is described by Oribasius and Scultetus. BA'TRACHOS, or Ba'tracirts. The tumour, which occasionally takes place under tlie tongue, and is more commonly called Ranula. BDE'LLA. In a surgical sense, a va- rix, or dilated vein. BELLADONNA. Deadly Nightshade. Is violently narcotic. The leaves were first used externally for discussing scir- rhous swellings, and they have been sub- sequently given internally, in scirrhous and cancerous diseases, amaurosis, &c. Five -grains are reckoned a powerful dose: one is accounted enough to begin with. At present, the extract, as directed by the London College, is more commonly prescribed. From the power, which belladonna is known to possess, of lowering the action of the whole arterial system, it seems to BLA B L A 181 be a fit medicine in many surgical cases, where that object is desirable, particu- larly in examples of aneurism. A very peculiar virtue, which bella- donna has, is that of causing a dilatation of the pupil, when used as an external application to the eye-brow and eye-lids. The late Mr. Saunders was in the habit of employing belladonna a good deal for tliis express purpose. A little while be- fore undertaking the operation for the congenital cataract, he was accustomed to introduce some dissolved extract of belladonna between the eye-lids, or rub the eye-brow and skin about the eye freely with the same application. The conse- quence was, that, if there were no adhe- sions of the iris to other parts, a full di- latation of the pupil was produced in less than an hour, and the whole of the cata- ract was distinctly brought into view. This was unquestionably a considerable hnprovement in practice, as the iris was kept out of danger, and the operation materially facilitated. I allude here more particularly to Mr. Saunders's own method, in which he introduced the nee- dle through the cornea, in front of the iris, and then conveyed it to the cataract through the enlarged pupil. Belladonna was also externally applied by Mr. Saun- ders, after the operation, with a view of preventing the edge of the iris from be- coming adherent to the edges of the torn capsule. BINOCULUS. (from binus, double, and oculus, the eye.) A bandage for keep- ing dressings on both eyes. Its applica- tion will easily be understood by referring to Monoculus. BISTOURY. (Bistoire, French.) any small knife for surgical purposes. BLADDER, Puncture of. This is an operation, to wliich we are obliged to have recourse, after having in vam em- ployed all the other means indicated for preventing the bad, and even fatal conse- quences of a stoppage of the evacuation of the urine, and distention of the bladder. Various accidents, and diseases, both acute and chronic, may occasion tliis dangerous state, as we shall more parti- cularly notice in the article, Urine, Reten- tion of. The bladder, which can conveniently hold about a pint and a half of urine, is no sooner dilated, so as to contain two pints, than uneasy sensations are experi- enced. The desire of discharging the water now becomes very urgent, and if the inclination be not gratified, and the bidder be suffered to be cUlated beyond its natural state, it loses all power of contraction, and becomes paralytic. The desire, indeed, continues, and the efforts are renewed in painful paroxysms; but, the power is lost, and tiie bladder becomes more and more distended. When this viscus is dilated in the utmost degree, and neither its own structure, nor the space in the abdomen can allow a further distention; either the bladder must be lacerated, which it never is, so equally is it supported by the pressure of the sur- rounding parts; or its orifice must ex- pand and the urine begin to flow. After the third day of the retention, the urine often really begins to flow, and, whatever descends from the kidnies is evacuated in small quantities from time to time, and at this period, the bladder is distend- ed in as great a degree, as it ever can be, however long .the patient may survive. This dribbling of the urine, which be- gins, when the bladder is dilated to the utmost, and continues till the eighth, or tenth day, or till the bladder sloughs, has long been understood, and is named by the French, " urine par regorgement" To practitioners, who do not understand it, the occurrence is a most deceitful one. The friends felicitate themselves, that the urine begins to flow ; the surgeon believes it, basins and cloths, wet with urine, are easily produced; but, the patient lies un- relieved. The continued distention of the bladder is followed by universal in- flammation of the abdomen. The insen- sibility, and low delirium of incipient gangrene, are mistaken for that reUef, which was expected from the flow of urine, till either hiccough comes on, and the patient dies of fever, and inflamma- tion, or the urine gets through an aper- ture, formed by mortification, into the abdomen. Let no surgeon, therefore, trust to the reports of nurses and friends, but, lay his hand upon the hypogastric region, and tap with his finger, that he may distinguish the distended bladder, and the fluctuation of urine. As the bladder suffers no further distention, af- ter the third day, why should it burst .*" Not from laceration ; for, it is supported by the uniform pressure of the surround- ing viscera; not by yielding suddenly, for it is distended to its utmost on the third day of the retention, and y-et seldom gives way before the tenth; not by at- tenuation, for it becomes thickened. The term laceration was never more wrongly applied, than in this instance,- for, when there is a breach in the bladder, it is found, on dissection, to be a small round hole, such as might be covered with the point of the finger. The rest of the vis- cus, and the adjacent bowels, are red and inflamed, while this single point is black, and mortified. Delay is more dangerous, BLADDER. than even the worst mode? of making an opening into the bladder, and, while life exists, the patient should have his chance. —(See John Bell's Principles of Surgery, , Vol 2, Part 1, p. 262, &c.) That many patients die after the para- centesis of the bladder is an undoubted truth, and this circumstance has rather intimidated practitioners against the ope- ration. It appears to me, however, that death may in general be more fairly as- cribed io the effects of the disease, than to the puncture of the bladder, and that, if this last measure were not deferred so long, as it often is, the recoveries would be more numerous. Hence, when relief cannot be obtained by the treatment described in the article, Urine, Retention of; when no urine has come away, before the end of the third day ; when it only does so in a dribbling manner after this period, while the blad- der continues distended, and no catheter can be introduced; the operation should not be delayed. In urgent cases, one should rather operate, as soon as forty- eight hours have elapsed. j No doubt, a man, who is exceedingly skilful in the use of the catheter, and knows how to practise with science and judgment all the other means for reliev- ing the retention of urine, will not fre- quently find it necessary to have recourse to the operation of puncturing the blad- der. This is said to have been so much the case wjth the eminent Desault, that, in the course of ten years, he had occasion pnly once to perform such an operation in the Hotel Dieu, where diseases of the urethra are always extremely numerous. (See CEuvres Chir. de Desault par Bichat, 'Tom. 2, p. 316.) When, however, this superior manual dexterity with the cathe- ter is not the acquirement of the practi- tioner, the timely performance ofthe para- centesis ofthe bladder should ever be ob- served. I shall next treat of the three modes of doing the operation. 1. Puncture through the Perinxum. The first surgeon that ever performed thi-. operation is said to have been M. Tolet, a French surgeon, well known for a valuable treatise, entitled, " Traite de Iithutomie, ou de l'extraction de la pierre hors de la vessie, Troisieme edition, Paris 1681." According to Sabai r, it was cus- tomary, at the tune of Dioi.is, to make the opening with a nam \v pointed scal- pel, about tour or five inc'ies long, which w.is> plunged into the bl idder, at the place where the incision in the apparatus major terminated. (See Lithotomy.) The escape of the urine indicated when the surgeon iad reached the bladder. A straight probe was then conducted along the knl\ and, then a cannula was passed along thr probe into the bladder, where it was allowed to remain as long as necessary, care being taken to fix it by means of* tapes, passed through the rings at the broad part of the instrument; and to stop up the opening with a linen tent. Some practitioners, hrwever, began with cut- ting the perineum, afier introducing a staff as far into the urethra as possible. Having made an opening into this canal, they conveyed a gorget along the staff into the bladder, and a cannula was next passed into the same viscus along the gor- get, and allowed to continue there. This mode of proceeding, which Sabatier terms more methodical, than that which has been first mentioned, could only answer in cases, where the obstruction about the neck of the bladder was inconsiderable, and where in fact the introduction of tin catheter was not yet impracticable. At least, therefore, the method was unne- cessary. The other plan of piercing the urethra in several places, and making a passage for the urine through the prostate, says Sabatier, increased the inflammation, with which this gland was affected, and rendered the disease, if not mortal, at least much more difficult of cure Sabatier represents Dionis, as the first who suggested the method of opening the bladder on one side of the perineum, at the part, where Frere Jacques used to perform lithotomy. Dionis conceived, that, by operating in this way, the patient would suffer less pain, because neither the urethra, nor the neck of the bladder, would be injured ; but at the same time, he has recommended a process to be fol- lowed, which was similar to that pursued in making the puncture in tlie middle of the perineum, viz. that a narrow scal- pel should first he introduced, so as to make a passage for the probe, along which the cannula is to pass into the bladder. The idea of substituting for these unsuitable instruments a "trocar of convenient length was exceedingly sim- ple, and, for this improvement, which took place in 1721, surgery is indebted to Juncker, (See Conspectus Chirurgix, Tab. 97, p. 674,) unless the follow ing passage be correct: " In the year 1717, or 1718, M. Peyronie shewed in the Kind's garden a long trocar, which he had successfully employed i» ;i similar puncture." (De- sault's Parisian Chirurgical Journal, Vol 2, p. 267.) The patient having been placed in the same position as for li'hoomy, an ..ssist- ant is to press with his left hand on the region ofthe bladder, above the pubes, in order to propel that viscus as far down- BLADDER. 1-S3 "ward into the lesser pelvis as possible, while, with his right hand, he supports the scrotum. The surgeon is then to in- troduce the trocar at the middle of a line, drawn from the tuberosity of the ischium to the raphe of the perineum, two lines more forward than tlie verge of tlie anus. The instrument is first to be pushed in a direction parallel to the axis ofthe body ; and its point is afterwards to be turned a little inwards. Here, according to Bichat, there is no occasion to convey the cannula so for into the bladder, as is done, when the operation is performed above the pubes. The portion of this Viscus, that is pierced, being incapable of changing its position, with regard to other parts in the perineum, if the cannula only project a tew lines into its cavity, it will not be liable to slip out. It would be wrong, indeed, to carry it in furtner; for, the pressure of its end against tlie posterior parietes of the bladder would do harm. Lastly, the cannula is to be fixed in its place, by means of the T bandage. (See (Euvres Chirurgicales de Desuidt, Tom. 3, p. 320.) Sonr£ writers recommend the introduc- tion of the left index finger into the rec- tum, in order to draw this intestine out of the way ; but Sabatier thinks it better to use this finger for pressing on the part of the perineum, where tiie puncture is about to be made, so as to make the skin tense, and assist in the guidance of the trocar. (Medecine Operatoire, Tom. 2, p. 126.) The parts, divided in this puncture, are the skin, a good deal of fat, and cellu- lar substance, the levator ani muscle, and that portion ofthe lower part ofthe blad- der, which is situated on one side of its neck. The following is the judgment which Bichat has passed upon this method: There is in the track, which the trocar describes, no part, of which the puncture must of necessity give rise to bad symp- toms. A surgeon, moderately exercised in the practice of tliis operation, is almost always sure of piercing the bladder. This viscus is opened in the most de- pending sr nation, at a part, which con- stantly bears the same delation to the perinxum. But, tiie position, in which the patient is placed for the operation, is a great deal more disagreeable, than that for the puncture above tlie pubes. Seve- ral assistant s are required to fix him, and one is necessary for compressing the blad- der in the hypogastric region. There is a possibility of wounding the 'vessels of the perineum, and of prickiti, the nerves, wlur.h accompany them. It the point of ihe trocar is carried too much outwards, it may gUde on the external side of the bladder. If it is inclined forwards, it may slip between this viscus and the pubes. If it is turned too miich inwards, it may pierce the prostate gland. If directed too much backwards, it may wound the vasa deferentia, the rectum, the extremity of the ureter, and the vesiculae seminales. While the cannula is kept introduced, also, the patient can neither walk about, nor sit down ; but, must continually keep himself in bed. Listiy, this mode of operating is frequently counter-indicated, by tumours, or other common diseases, at this part of the body, in consequence of retentions of urine. (OSuvres Clarur- gicales de Desault par Bichat, Tom. 3, p. 321.) The puncture of the bladder from the perineum is now almost universally aban- doned by British surgeons. " We may esteem it fortunate," says Desault, " if the trocar penetrates directly into the bladder, after piercing tlie tat and the muscles, situated between the tuberosity of the ischium and the anus; and, as this viscus is subject to much variation in its form, the surgeon will be often defeated, unless he is perfectly clear in his ideas, respecting its situation and figure. This disappointment is not without example, and there is sufficient to deter a practi- tioner from performing this operation, in- dependently Of the danger of wounding with the trocar the vasa deferentia, vesi- culx seminales ureter," &c. (Parisian Chirurgical Journal, Vol. 2, p. 267.) If there are now any practitioners, who may be averse to the total relinquishment of this method, I think tlie following caution, given by Sabatier, may be of service to them: perhaps, the operation would be more safe, if the surgeon were to begin with making a deep incision in the perineum, as is practised in the la. teral Way of cutting for the stone, and if he were to desist from plunging the tro- car into the bladder, until he had assured himself of the situation of this viscus, and felt the fluctuation of the urine. Garengeot has given this advice to Fou- bert, in regard to the mode of cutting for the stone practised by the latter, and it seems equally applicable in the present place. (Medecine Operatoire, Tom. 2. p. 127.) \2. Puncture above the Pubes. The invention of the method of tap. ping the bladder from above the pubes was suggested by the practicableness of extracting calculi from that viscus, by what is usuaUy denominated the high operation. The first periormers of the puncture above tiie pubes are said to have 184 BLADDER. employed a straight trocar, the very same instrument as was used for tapping the abdomen in cases of dropsy. The con- sequence was, that when such a trocar was too long, its cannula was apt to hurt the opposite parietes ofthe bladdej^, so as to occasion inflammation and a slough, on the separation of which the urine was liable to insinuate itself either into the abdomen, or rectum, as happened in a case mentioned by Mr. Sharp, where no more urine was discharged through the cannula, and the patient died of a sort of diarrhaea. When the trocar is short, the bladder, on subsiding and contracting it- self, gradually quits the cannula, which becomes useless, and a necessity for mak- ing another puncture is produced. What- ever pains may be taken to direct the trocar obliquely downwards and back- wards, so that the cannula may be, in some degree, parallel to the axis of the bladder, one, or the other of these acci- dents, cannot always be prevented. Their prevention, however, may be effected by merely employing, instead of a straight trocar, a curved one, which Vill naturally take a suitable direction. This improvement was embraced by Frere Come, the inventor of the litho- tome cache, who also devised a curved trocar, for the paracentesis of the blad- der, veiy superior to the instrument of the same shape previously in use. To this way of operating, Mr. Sharp was partial, and Mr. Abernethy has more recently recommended it, under certain circumstances. The former celebrated surgeon remarks, that it is an operation of no difficulty to the surgeon, and of little pain to the patient, the violence done to the bladder being at a distance from the parts affected. It is equally appUcable, whether the disorder be in the urethra, or prostate gland, and when there are strictures, the use of bougies may be continued, while the cannula re- mains in the bladder. (Critical Enquiry, p. 125, edit. 4.) Some writers recommend making an incision, about two inches long, through the linea alba, a little way above the pubes, and then introducing a trocar into the bladder. Others deem this pre- liminary incision quite useless, asserting, that the operation may be performed with equal safety, and less pain to the patient, by puncturing at once the skin, the Unea alba, and the bladder. When the trocar has been introduced, the stilette must be withdrawn, and the cannula kep in its position by a ribbon, passed through two little rings, with which ft should be con- structed, and fastened round the body. The orifice of the cannula should be stopped up with a Uttle plug, so as to keep the urine from dribbling away In- voluntarily, and taken out as often as oc- casion requires. (EncyclopedicMethodique; Part. Chirurg.Art.Paracentesedela Vessie.} The trocar should be introduced in a direction obliquely downward and back- Ward; for as this corresponds with the axis of the bladder, the instrument is less likely to injure the oj-Tiosite side of that organ. Nearly all writers advise the puncture to be made an inch, or an inch and a half, above the pubes. The reasons for so doing are the following: " If the punc- ture be made close to-the os pubis, the bladder in that part, often rising with an almost perpendicular slope, leaves a chasm between it and the abdominal muscles, or, to speak more strictly, a certain depth of membrana cellularis only, so that, if the trocar penetrate but a little way, it possibly may not enter into the bladder. If it penetrates considerably, it may pass through the bladder into the rectum, or, if not in the operation itself, some days afterwards, when by the course of the ill- ness and confinement the patient is more wasted. For, the abdominal muscles, shrinking and falling in, occasion the extremity ofthe cannula to press against the lower part of the bladder, and, in a small time, to make a passage into the rectum." (Sharp in Critical Enquiry, p. 127.) Though the reasons here adduced seem at first as formidable, as they are numerous, does not the danger of injuring tiie peritoneum, form an objection to plunging in a trocar at the above distance from the pubis ? Certain it is, peritonitis would be more apt to be induced by such practice, than by introducing the instru- ment immediately above the pubes. Rich- erand decidedly condemns the plan, prin- cipally because the higher the puncture is made, the more apt will the bladder be to quit the cannula, on the urine being discharged. (SeeNosographie Chirurgicale, Tom. 3, p. 472, edit. 2.) In Desault's works, by Bichat, the puncture is also advised to be made immediately abov« the pubes. Tom. 3, /». 318. Some of Mr. Sharp's objections are done away, by taking care to pass the trocar into the bladder in the axis of this viscus, and employing one which is somewhat curv- ed, as Hunter, Frere Come, Sabatier, &c. have advised. Mr. Sharp confirms the danger of using too long a cannula, by mentioning an accident, which occur- red in his owti practice. Though he in- troduced the instrument-'" more than an inch and a half above the 03 pubis, yet having pushed it full two inches and a half, below the surface of the skin, its BLADDER. 1& extremity in six, or seven days insinuated itself into ihe rectum. (Critical Enqttiry, p. 127) The instrument, says an excellent writer, should be more or less long, ac- cording to the embonpoint of the pa- tient; but, the ordinary length should be about four inches and a half. The curvature should be ftjiform, and form the segment of a circle about eight inches in diameter. (Qluvres Chir. de Desault par Bichat, Tom. 3. p. 317.) A catheter left in the bladder, longer, than ten days, may possibly gather such an incrustation from the urine, as not only to render the extraction of it pain- ful, but even impracticable. This should caution us, therefore, never to leave the cannula in the bladder quite a fortnight. If necessary to leave one so long, Mr. Sharp advises a second one to be intro- duced, made with an end, like that of a catheter. (Critical Enquiery, p. 129.) Mr. Abernethy first made an incision, between the pyramidales muscles, passed his fingers along the upper part of" tiie symphysis pubis, so as to touch the dis- tended bladder, and introduced a com- mon trocar, of the middle size, in a di- rection obliquely downwards. On with- drawing the stiiette, he passed a middle- sized hollow elastic catheter, through the cannula, into the bladder. The can- nula was withdrawn, and the catheter left in, till the urine passed through the urethra. After a week, as the instrument was stopped up with mucus, it was taken out, and a new one introduced. (Surgical Observations, 1804.) It might be objected to this plan of employing a hollow bougie, that, as it is smaller, than the wound, the urine is not kept from passing between the instrument, and parts, into which it is introduced, as well as through the tube it- self. This happened in Mr. Abernethy's case, and, though no urine in this in- stance, got into the cellular membrane; yet, it would probably do so sometimes, because, it is not till after inflammation has tiken place, that the cavities of the cellular substance are closed by coagulat- ing lymph. After a time, however, the cannula of the trocar might be with- drawn, and the hollow bougie employed, if preferred, though it seems difficult to discover a reason for chusing it. The following is one of Mr. Home's conclusions: (Med.andChir.Trans. Vol.2.) " When the puncture is made above the pubis, tlie cannula, which incloses the trocar is not to be removed, till the sur- rounding parts have been consolidated by inflammation, so as to prevent the urine in its passage out from insinuating itself into the neighbouring parte; for where- tvcr the urine lodges, mortification takes Vol. I. place. Any advantage, therefore, which may arise from a more flexible instrument remaining hi the bladder, is more than counterbalanced by its not filling com- pletely the aperture through the coats of the bladder, and allowing the urine to escape into the cellular membrane." There is much truth in the following passage: The abdomen is inflamed; the preliminary incisions, which prepare for the introduction of the trocar, sometimes pass through several inches, of fat, and cellular substance ; the incisions must be wide in proportion to their depth; the cannula is no sooner lodged here, than it is displaced, in some degree, by the con- traction ofthe bladder, which, when emp- tied, subsides under the pubis. The can- nula stands so obliquely, that the urine never flows with ease, but, by running out upon the wound,and by being injected among the cellular substance, it causes the wound to inflame; the wound by its proximity to the inflamed peritonaeum soon mortifies, and thus, notwithstanding the temporary relief, produced by the emptying of the bladder, the patient dies on the third or fourth day. (John Bell's Principles ofSurgeiy, Vol. 2, p. 271.) That this operation is infinitely better, than that of making the puncture in the perineum is indisputable. There are even now some good surgeons, who seem to prefer it to the method of tapping the bladder from the rectum. In the CEuvres Chirurgicales de Desault, Tom. 3, p. 324, it has received the preference, and at p. 319 ofthe same book, a high encomium is bestowed on it, in the following terms. " This operation is easy. The little thickness of the parts, which are to be wounded, renders it quick and triflingly painful. The surgeon has occasion for no assistance. The patient is neither in- timidated, nor fatigued with the posture in wliich he is put. It is almost impos- sible to miss the bladder, except it were exceedingly contracted. There is no risk of piercing the cavity of the abdomen. Anatomy proves, that here the bladder is in immediate contact with the recti mus- cles, and that when tliis viscus is distend- ed with urine, it pushes the peritoneum upwards and backwards, under which membrane it enlarges, and thus makes the point of the trocar become more and more distant from the cavity of th * abdo- men. The patient may easily lie on lis side, or abdomen, so as to discharge all the urine contained in the bladder. There are here no nerves, nor vessels, of which the injury can be dangerous. No difficulty is experienced in fixing the cannula, and the presence of this instrument does not hinder the patient from sitting, standing B B 186 BLADDER. up, or even walking about in his chamber. When the cannula, also, is introduced to the lower part of the bladder, this viscus cannot possibly quit it. Lastly, the wound heals with more facility, than that made in any o'her method.'' Respecting this advice to push the can- nula so far into the bladder, it is highly ob- jectionable, for the reason already explain- ed. The writer of the preceding commen- dation seems to me rather too partial. He has toid us of the little thickness of the wounded parts, and, yet a little before bestowing these praises, he has acknow- ledged, " ilest rare, que dans cetteponction, on traverse directement la ligne blanche : on passe presque toujours sur ses elites, et I'on divise lapeau,Paponeurose des muscles larges du bas-ventre, les muscles droits, quclquefois Pun ties pyramidales, et la parol anterieure de la vessie." ('Tom. 3, p. 318.) According to my own judgment, the plan, v Inch is about to be described, is the safest and best, when the circum- stances of the case afford a choice, and that it would be for the benefit of the afflicted, if the puncture above the pubes were only performed in cases in which the enormous enlargement of the prostate gland prevents a puncture from being b&fLly made from the rectum. 3. Puncture from the Rectum. This method is nitre generally appli- cable, than either ofthe two plans above related. It is not, like the puncture in the perinacum, liable to the objection, that the wound is made on diseased or inflamed parts, which afterwards become gangrenous. Nor is it, like the puncture above the pubes, attended with a chance of the urine diffusing itself in the cellular membrane It has also the advantage of emptying the bladder completely. The puncture is made sufficiently far from the neck of the bladder not to increase any inflammation existing in that situation; and the operation is really attended with Utile pain, since there is no skin, nor muscles to be wounded, merely the coats of the bladder and rectum, at a point where these viscera lie in contact with each other. The enlargement of the prostate gland, is, perhaps, the only solid reason against its being uniformly preferred. When the bladder is to be tapped from the rectum, two fingers should be intro- duced into the intestine, instead of one, as has been directed. In this manner, the cannula can be more conveniently guided, and held in a proper position, while the trocar is introduced with the other hand. The stilette, however, must never be introduced into the cannula. except when this is properly placed, with its extremity against the part, where it ii intended to "make the puncture. We read in the Philosophical Transac- tions for 1776, of a case of" total retention of urine, from strictures, where the blad- der was successfully punctured from the rectum. Mr. Ihrtnilton, who did the operation, thought of the plan, in con.se. quence of feeling the bladder exceedingly prominent in the rectum, on introducing his finger into the anus. The patient was placed in the same position as that in lithotomy; a trocar was passed along the finger into the anutj and pushed into the lowest, and most projecting part of the swelling, in the direction of the axis of the bladder. A straight catheter was immediately in'ro- duced through the cannula, lest the blad- der by contracting -tiiould quit the latter, which was taken away, and, as soon as the water was discharged, the catheter wa's also removed. Notwithstanding the puncture, the bladder retained > he urine as usual, until a desire to make water occurred. Then the opening made by the instrument seemed to expand, and the water flowed in a full stream from the anus; The urine came away, in this manner, two days, after wh ch it passed the natural way, with the aid of a bougie, winch had been passed through the urethra, into the bladder, and which was used, till all the disease in tliis canal was cured. , The method is said to have been ori- ginally proposed in 1750, by M. Fleurant, surgeon of the hospital La Charite, at Lyons, and Pouteau, in 1760, published an account of it, and three cases in which Fleurant had operated. It was also the feel of the bladder, on the intro- duction of a finger intra anum, which kd the latter surgeon to choose making a puncture in this situation. The unre was immediately discharged, and the cannula supported in its place with the T bandage, until the natural passage was reduced previous again. But the cannula, being allowed to remain in the rectum, became incommodious to the pa- tient, when he went to stool, and, the in- convenience was vastly increased by the continual dribbling ofthe urine from the mouth of the instrument. Hamilton avoided both these inconveniences, by withdrawing the cannula at first. In another instance, however, Fleurant left the cannula in the anus and bladder, thirty-nine days, without the least incon- venience. In order to lessen the inconvenience, at- tending the presence ofthe cannula, Fleu- rant suggested that it would be better to BLADDER. 187 have the tube made of a flexible sub- stance; a proposal, that seems to merit attention, though, I believe, the inconve- niences of wearing the cannula are not in general very serious, and, were a case of this kind to present itself, I should have no hesitation in withdrawing the tube al- together. In the first volume of tlie Mem. of the Medical Society of London, two cases are , related, in wliich, after tapping the blad- der from tiie rectum, the cannula was im- mediately withdrawn, without any bad effect. Another similar -fact is recorded in the Medical Communications, Vol. 1. A long, curved, cylindrical trocar, is the best for performing the operation, and was the one recommended by Pouteau. It should be introduced a little beyond the prostate gland, exactly in the centre ofthe front ofthe rectum, and sufficient- ly far up this intestine. In this way the vesiculae seminales, which diverge from each other above, cannot be injured; and, even were they so, perhaps no serious Consequences would follow. It is not necessary to retain the can- nula in the puncture, after the inflamma- tion has consolidated the sides of the wound, and there is no danger of the aperture closing up, till there is another passage made for the urine. Mr. Home thinks, that after about thirty-seven hours, the cannula may be properly taken out. (Med. and Chir. Trans. Vol. 2.) Indeed, I am not acquainted with any fact, shew- ing tiie ill effect of removing the cannula at once; for, here the urine has only to pass through a mere opening, without any longitudinal extent, as after puncturing above the pubes. The safety and sim- plicity of tapping the bladder from the rectum, will always recommend this me- thod with impartial practitioners. The wound is made at a distance from the peritoneum, paSses through no thickness of parts, and is quite unattended with any chance of the urine becoming ex- travasated in the cellular substance. Whe- • ther the bladder be morbidly contracted and thickened; whether the neck of the ■bladder be inflamed; it is equally appli- cable : the diseased enlargement of the prostate gland, can alone warrant the puncture above the pubes being ever pre- ferred. I am happy trtjoin the experienced and judicious Mr. Hey with the advocates for this mode of performing the operation, and as his opinion on this subject must have considerable influence, I shall quote the foUowing passage from his valuable work, particularly as the observations confirm some other points adverted to in the present article. " It is sometimes impossible, fi-om various causes, to make a catheter pass through the urethra. The puncture of the bladder then becomes , necessary, if the retention of urine con- tinues. This operation may be perform- ed, either above the pubes, or through the rectum. I have seen it performed in both these methods ; but, give the preference to the latter. It is more ea-v to the sur- geon; and less painful to the patient. Pouteau's carved trocar is a very conve- nient instrument; and may be used with safety for puncturing the bladder through tlie rectum; but, the operator should cautiously avoid -wounding an artery, which may be felt running towards the anus, where the bladder is most protu- berant. The finger, which is introduced into the rectum to guide the trocar, may be conveniently placed a little on either, side of this vessel. It is not always ne- cessary to leave the cannula in the blad- der, as the urine sometimes begins to flow through the penis, within a few hours after the bladder is emptied. Perhaps, this event may be the most frequent, when the introduction of the catheter has been prevented by a stricture in the ure- thra. If the wound becomes closed, be- fore the power of expelling the urine is regained, recourse must be had to a repe- tition of the operation, which gives very little trouble to the patient; neither is he much incommoded by suffering the can- nula to reman two or three days in the bladder. This is sometimes necessary, and seldom improper." (Hey's Practical Observations in Surgery,p.430—43 l,edit.2.) Women seldom stand in need of the paracentesis of the bladder; but, when tlie operation is necessary in them, it is more safely and easily performed from » the vagina, than in any other way. If it should be proper to leave in the cannula, this must be long enough to allow its ori- fice to be situated on the outside of the labia, where it must be fixed with a T bandage. Consult particularly Sharp on the Ope- rations, Chap. 15, and his Critical Enquiry, L'Encyclopedic Methodique, Partie Chirur- gicale; art. Puracentese de la Vessie. Saba- tier's Medecine Operatoire, Tom. 2. Med. and Chir. 'Transactions, Vol. 2. Abemethy's Surgical Observations, 1804. John Bell's Principles of Surgery, Vol. 2. QHuvres Cld- rurgicales de Desault par Bichat, Tom. 3, p. 315, &c. Richeruna*s Nosographie Chirur- gicale, Tom. 3, p. 471, &c. edit. 2. Hey's Practical Observations in Surgery, p. 430, edit. 2. Metunges de Chirurgie,par Pouteau, Lyon, 1760, p. 500. Parisian Chirutgifal Journnl, Vol. 2,/>. 156, and p. 265. 188 BLA BLE Bladdeii, Tumour extirpated from. Mr. Joseph Warner, surgeon of Guy's Hos- pital, has recorded a case, in which an excrescence, growing from the inside of a young woman's bladder, was success-^ fully removed. The patient, on the 24th' of June, 1747, strained herself in endea- vouring to lift a great weight, and she was immediately seized with a pain in the small of her back, and a total reten- tion of urine. In April, 1750, she applied to Mr. Warner, who found, upon enquiry, that she had never been able, from the moment of the accident, to void a drop of urine, without the assistance of the ca- theter; that she was in continual pain, and had lately been much weakened, by having several times lost considerable quantities of blood, occasioned by the force made use of in introducing the in- strument into the bladder. Mr. Warner, upon examining the parts, with his forefinger, which he had great difficulty in introducing into the meatus urinarius, discovered a considerable tu- mour, which seemed to be a fl-eshy sub- stance, and took its rise from the lower part of the bladder near its neck. When the patient strained to make water, and the bladder was full, the excrescence pro- truded a little way out of the meatus urinarius ; but upon ceasing to strain, it presently returned. A purgative having been given the day before the operation, and tiie rectum emptied by means of an emollient clyster, Mr. Warner directed the patient to strain, so as to make the swelUng project. He then hindered it from returning into the bladder by passing a ligature through it, and endeavoured to draw it forther out.— The latter object was found impracti- cable, on account of the size of the tu- mour. Seeing this, Mr. Warner dilated the meatus urinarius on the right side, by cutting it upwards, about half way to- wards the neck of the bladder, when, by pulling the swelling forwards, he was enabled to tie its base, which was very large, with a ligature. For three days after the operation, a good deal of pain was felt in the abdo- men. On the sixth day, the tumour dropped off". From the first day, the urine came away without assistance, and tlie patient got quite well. The tumour resembled a turkey's egg in shape and size. (See Warner's Cases in Surgery, edit. 4, p. 303.) Perhaps, in this example, tying the tumour was preferable to cutting it away, even though its base was large ; for, had .the knife been used, there would have been some danger of the bladder becom- ing fi led with blood. Blaudf.*, Herrtia of. See Hernia. Blauurk, Insects discharged from. Tjfce instances in which worms are stated to have been discharged from the bladder, are very numerous. Many cases of this kind are referred to in Voigtel's Hand- buch der pathologischen Anatomie, b. 3, p. 337—342. A most interesting* example has also been lately recorded by Mr. Wil. liam Lawrence. (See Medico-Chirurgical Transactions, Vol. 2, p. 382, &c.) Bladder, Deficiency of. Numerous ex- amples, in which this deviation from the natural structure has occurred, are re- corded by medical writers. The publica- tions, however, which, as far as I know, contain the most ample information, on the subject, are, a Gottingen inaugural dissertation, entitled, " De Vesicx Uri- narix Prolapsu Nativo," by Dr. Roose, late professor in Brunswick, and a paper, called, " An attempt towards a systematic account of the appearances, connected with tlie malconformation of the Urinary Organs, in which the ureters, instead of terminating in a perfect bladder, open externally on the sur- face of the Abdomen," by A. Duncan, jun. in Edinb. Med. and Surgical Journal, Vol. 1. In this last production may be seen references to all the most noted cases on record, both male and female. Bladdkh, Wounds of. See Gunshot Wounds. BLEEDING. By this operation is understood the taking away of blood for the relief of diseases. Bleeding is called general, when practised with a view ofiles- sening the whole mass of circulating" blood ; topical, when performed in the vi- cinity of the disease, for the express pur- p se of lessening the quantity of blood in a particular part. General Blood-letting is performed with a lancet, and is subdivided into two kinds ; viz. the opening of a vein, termed phlebotomy, or venesecliuti ; and the open- ing of the temporal artery, or one of its branches, termed arteriotomy. Topical Blocd-lettingisperformed, either by means of a cupping-glass and sca- rificator, by leeches, or by dividing the visibly distended vessels with a lancet. The latter is frequently done in cases of opthalmy. PnLEBOTOMT, OR VBKESECTIOW. The mode of bleeding most frequently practised is that of opening a vein ; and it has been done in the arm, ankle, ju- gular vein, frontal vein, veins under the tongue, on the back of the hand, &c. In whatever part, however, venesection is performed, it is always necessary to com- press tlie vein, between the place where BLEEDING. 189 tlie puncture is made, and the heart. Thus the return of blood through the vein is stopped, the vessel swells, becomes con- spicuous, and when opened, bleeds much more freely than.it would otherwise do. Hence, according to the situation of* the part of the body where the vein is to be opened, with regard to the heart, the fil- let for making the necessary pressure must be applied, either above, or below the puncture. All the apparatus essential for blood- letting, on the part of the patient, is a bandage, or fillet, two or more small pieces of folded linen for compresses, a basin to receive the blood, and a little clean water and a towel. The bandage ought to be about a yard in length, and near two inches broad, a common ribbon or garter, being frequently employed. The com- presses are made by doubling a bit of linen rag, about two inches square. On the part of the surgeon, it is necessary to have a good lancet, of proper shape. He should never bleed with lancets with which he has been in the habit of opening any kind of abscesses, as very troublesome complaints have been the consequence of doing so. The shape of the instrument is also a matter of some importance. If its shoulders are too broad, it will not readily enter the vein, and when it does enter, it invariably makes a large open- ing, which is not always desirable. If the lancet be too spear-pointed, an in- cautious operator would often run a risk of transfixing the vein, and wounding the artery beneath it. More, however, cer- tainly depends on the mode of introduc- ing the lancet, than on its shape. In blood-letting, tiie patient may lie down, sit down, or stand up, each of wliich positions may be chosen according to cir- cumstances. If the patient be apt to faint from the loss of a small quantity of blood, and such fainting can answer no surgical purpose, it is best to bleed him in a re- cumbent posture. But, when the person is stro-ig and vigorous, there is little oc- casion tor this precaution, and a sitting posture is to be preferred, as the most convenient, both for the surgeon and pa- tient. This, indeed, is the common posi- tion. In some cases, however, particu- larly those of strangulated hernia, it is frequently an object to produce fainting, in order that the bowels may be more easily reduced. In this circumstance the patient may be bled in an erect pos- tnre, and the wound made large, as a sudden evacuation of blood is particularly apt to bring on the wished for swoon. For the same reason, if we wish to avoid making the patient faint, we should then make only a small puncture. Every operator should be able to use the lancet with either hand, which will enable him to bleed the patient in the right or left arm, as circumstances may render most eligible. At the bend of the arm, there are se- veral veins in which a puncture may be made; viz. the basilic, cephalic, median basilic, and median cephalic." The me- dian basilic vein, being usually the largest and most conspicuous, is that, in which the operation is mostly performed: but, surgeons should never forget, that it is under this vessel that the brachial artery runs, with the mere intervention of the aponeurosis sent off from the tendon of tiie biceps muscle. In very thin persons, indeed, the median basilic vein lies almost close to the artery, and nothing is then more easy than to transfix the first of these vessels and wound the last. Hence^ Richerand advises all beginners to prefer opening the median cephalic, or even the trunk of the cephalic itself, to puncturing either the basilic, or the median basilic, which last are internally situated, and nearer the brachial artery. Nosographie Chirurgicale, Tom. 3, p. 383, Edit. 2.) In exceedingly fat subjects, the large veins at the bend of the arm are sometimes totally imperceptible, notwithstanding the fillet is tightly applied, the limb is put in warm water, and every thing done to make those vessels as turgid as possible. In this circumstance, if the surgeon has not had much experience in the practice of venesection, he will do well to be content with opening one of the veins ofthe back of the hand, after putting the member for some time in warm water, and applying a ligature round the wrist. In children, a sufficient quantity of blood cannot always be obtained by venesection, and, in this event, the free application of leeches, and occasionally, the puncture ofthe temporal artery, are the only effectual methods. With respect to the choice of a vein in the arm, the most experienced operators give a preference to one, which rolls least under tlie skin. Such a vessel, though sometimes less superficial, than another, may commonly be opened with greater facility. The surgeon, however, is always to fix the vein, as much as he can, by pi .cing the thumb of his left hand a little below the place, where he intends to introduce the lancet. In bleeding in the arm, the fillet is to be tied round the limb, a little above the elbow, with sufficient tightness to inter- cept the passage of the blood through all the superficial veins ; but, never so as to stop the flow of blood through the arteries, which would tend to prevent the veins fi-om rising at all. The veins being thus render- 190 BLEEDING. ed turgid, the surgeon must choose the one which seems most conveniently situ- ated for being opened, and large enough to furnish as much blood as it may be proper to take away. Before applying the fillet round the arm, however, the operator should always feel where the pulsation of the artery is situated, and, if equally convenient, he should not open the vein immediately over this part. It is also prudent to ex- amine where a pulsation is situated, on account of the occasional varieties in the distribution of the arteries of the arm. The ulnar artery is sometimes given off from the brachial very high up, and, in this case, it frequently proceeds superfi- cially over the muscles, arising from the internal condyle, instead of dividing un- der them, in the ordinary manner. When the external jugular vein is to be opened, the surgeon generally makes the necessary pressure with his thumb. The orifice should be made in the direction of the fibres of the platysma myoi'des mus- cle ; and the vein is not so apt to glide out •f the way, when the surgeon makes the puncture just where it lies over a part of the sterno-cleido-mastoideus muscle. When blood is to be taken from the foot, the Ugature is commonly applied a little above the ankle. The fillet liaving been put on the arm, the operator is to take the blade of the lancet, bent to a somewhat acute angle, between the thumb and fore-finger, and, steadying his hand upon the other three fingers, he is to introduce the lancet, in an oblique direction, into the vessel, till the blood rises up at the point of the instru- ment. Then bringing up the front edge in as straight a line as possible, the wound in the skin will be made of just the same size as .that in the vein. The operator next takes away the thumb of his left hand, with which he steadied the vessel, and allows the blood to escape freely, till the desired quantity is obtained. The arm ought to be kept in the same position while the blood is escaping, lest the skin should slip over the orifice of the vein, keep tiie blood from getting out, and make it insinuate itself into the cellular sub- stance. When the blood does not issue freely, however, most surgeons direct the patient to move his fingers or turn something round and round in his hand. This puts tlie muscles of the arm into action, and the pressure, they then make on the veins, makes the blood circulate more briskly through these vessels. The proper quantity of blood being dis- v charged, the fillet is to be untied. The flow of blood now generally ceases; though sometimes, when the orifice is large, and the circulation very vigorous, it still con- tinues. In this circumstance, the opera- tor may immediately stop the bleeding, by placing the thumb of his left hand firmly on the vessel, a little below the puncture. The blood is next to be all washed off the arm, tlve sides of the wound placed in contact, and the compressrv applied, and secured with the fillet, put round the elbow in the form of a figure of 8, and regularly crossing just over the com- presses. The patient should be advised not to move his arm much, till the fillet is remov. ed, which may be done after twenty-four hours. In order to open the external jugular vein, the patient's head is to be laid on one side, and properly supported. Then the operator is to press upon the lower part of the vein with his thumb, so as to make the part above swell, and then the lancet is to be pushed at once into the vessel, with tiie cautions already stated. There is commonly no difficulty in stop- ping the bleeding, after the pressure is removed. Some practitioners have di- rected a scalpel to be used for dividing the integuments, before opening the vein it- self; but, tins is quite unnecessary. Blood-let,ing in the feet is executed on the same principle as in other parts; but, the blood from the veins in this situation, in general not flowing with much cele- rity, it is customary to immerse the feet in warm water, in order to promote the bleeding. [The use of the German fleame, or, as it is oftener called, the spring lancet, has in some parts of the United States, almost entirely superseded that of the lancet; it certainly possesses some ad- vantages over the latter, although I am not disposed to deny that it is in some respects inferior. In a country situated like the United States, where every sur- geon, except those residing in our largest cities, is compelled to be his own cutler, at least so far as to keep his instruments in order, the spring lancet has a decided preference over the lancet; the blade of this can with great ease be sharpened by any man of common dexterity, and if not very keen it does no mischief, whereas a dull lancet is a most dangerous instru- ment, and no one can calculate with cer- tainty the depth to which it will enter: to sharpen a lancet, is regarded by the cut- ler, as one of his nicest and most difficult jobs; it is one to wliich few surgeons are competent. The 'safety of using the fleame is de- monstrated by daily experience ; there ia BLEEDING. 191 no country in which venesection is more frequently performed tlinn in the United States, and perhaps no one .where fewer uccitlent*from the operation have occurred, of these few, I beg leave to state, that all the aneurisms produced by bleeding, which I have seen, have been in cases where the lancet was used. The manner of using the spring lancet differs in nothing from the operation de- scribed by Mr. Cooper, excepting that the surgeon must place the instrument in such a situation over the vein, that when the spring is touched, the orifice into the vein will have a proper size and direction. Dexterity in this is very readily and speed- ily acquired. In point of facility in its use it has a great advantage over the lancet. Among the advantages of the spring lancet economy is not the least. A country practitioner, who is constantly employing the English lancets, and who is particular in using none but the best, must neces- sarily consume half the emolument deriv- ed from the operation, in the purchase of his instruments. One spring lancet, with an occasional new blade, will serve him all bis life.] AKTEniOTOMY. The only arteries from which blood is ever taken in practice, are the trunk and branches ofthe temporal artery, which lie in such a situation, that they may easily be compressed against the subjacent bones, and the bleeding stopped. When the vessel which the surgeon chooses to open, lies very near the surface, or may be as- certained by feeling, or even seeing, its pulsation, it may be opened at once with a lancet. But, in many instances, it is so deeply situated, that it becomes necessary, in the first place, to make a cut in the skin, and then puncture the vessel. Tlie bleeding generally stops without any trouble; and may always be suppress- ed by'a compress and bandage. In a very few cases, the blood bursts forth from time to time, and more is lost than is necessary. When this happens, notwithstanding pres- sure,it is recommended to divide the vessel completely across, which facilitates the process of nature in closing the end of the vessel. TOPICAL BLEEDING.—CCPPINB. This is done by means of a scarificator, and a glass, shaped somewhat like a beU. The sacrificator is an instrument contain- ing a number of lancets, sometimes as many as twenty, which are so contrived, that when the instrument is. applied to M*y part of the surrace of tiie body, and a spring is pressed, they suddenly start out, and make the necessary punctures. The instrument is also so constructed, that the depth to which the lancets penetrate, may be made greater, or less, at the option of the practitioner. As only small vessels can be thus opened, a very inconsiderable quantity of* blood would be discharged, were not some method taken to promote the evacuation. This is commonly done with a cupping-glass, the air within the cavity of which is rarified by the flame of a little lamp, containing spirit of wine, or as some choose, by setting on fire a piece of tow, dipped in this fluid, and put in the cavily ofthe glass. When the mouth of the glass is placed over the scarifica- tions, and the rarified air in it becomes condensed, as it cools, the glass is forced down on the skin, and a considerable suc- tion takes place. Trials have been made of syringes, cal- culated for exhausting the air from cup- ping-glasses ; but the plan is not found so convenient as the one we have de- scribed. When the glass becomes moderately full, and it is desirable to take away more blood, it is best to remove it and put on another one. A common pledget is usually applied as a dressing for the punctures made with the scarificator. LEECHES. Leeches are often preferable to cup- ping, which is attended with more irri- tation than many surfaces, in particular circumstances, can bear, especially when the topical bleeding is to be frequently repeated. Leeches occasionally cannot easily be made to fix on the particular part we wish; but, they will do so, if the place be first cooled with a cloth dipped in cold water, or if it be moistened with cream or milk, and they are confined in the situation with a small glass. When they fall oft, the bleeding may be pro- moted, if necessary, by fomenting the part. SCARIFICATION WITH A LAXCET. is mostly done in cases of inflamed eyes. An assistant is to raise the upper eye-lid, while the surgeon himself depresses the lower one, and makes a number of slight scarifications, where the vessels seem most turgid, trying particularly to cut the largest completely across. 192 BLEEDING. DRT-CUPMSG. We may here mention this simple ope- ration, performed by rarify ing the air in a cupping-glass, as above directed, and then applying tlie vessel to the part af- fected. A cupping-glass, furnished with a syringe, might answer for this purpose. I think this operation is now not much used in this country: a proof that it is not a very efficacious measure. ILX COXSEftUENCES SOMETIMES FOLLOWING BLEEDING IN THE ABM. 1. Eccliymosis. The most common is a thrombus, or ecchymosis, a smail tumour around the orifice, and occasioned by the blood insin- uating itself into the adjoining cellular substance, at the time when this fluid is flowing out of the vessel. Changing the posture of the arm will frequently hinder the thrombus from increasing in size, so as to obstruct the evacuation of blood. But, in some instances, the tumour sud- denly becomes so large, that it entirely interrupts the operation, and prevents it from being finished. In these cases, how- ever, the most effectual method of pre- venting the tumour from becoming still larger, is to remove the bandage. By" allowing the bandage to remain, a very considerable swelling may be induced, and such as might be attended with great trouble. If more blood be required to be taken away, it ought to be drawn from" another vein, and, what is still belter, from a vein in the other arm. The best applications for promoting the absorption of these tumours, are those containing spirit, vinegar, or sal ammo- niac. Compresses, wetted with any lotion of this sort, may be advantageously put on the swelling, and confined there with a slack bandage. 2. Inflammation ofthe Integuments and sub- jacent cellular Substance. Mr. Abernethy says, that the inflamma- tion and suppuration of the cellular sub- stance, in which the vein Ues, is the most frequent occurrence. On the subsidence of this inflammation, the tube ofthe vein is free from induration. Sometimes the inflammation is somewhat indolent, pro- ducing a circumscribed, and slowly sup- purating tumour. Sometimes it is more diffused, and partakes ofthe erysipelatous nature. On other occasions, the affection is of the phlegmonous kind. When the lancet has been bad, so as rather to have lacerated, than cut the parts; when tiie constitution is irritable, and especially, when care is not taken to unite the edges of the puncture, and the arm is allowed to move about, so as to make the two sides of the wound rub against each other; inflammation will most probably ensue. The treatment of this case consists in keeping the arm perfectly at rest in a sling, applying the saturnine lotion, and giving one or two mild saline purges. When suppuration takes place, a small poultice is the best local applica- tion. 3. Absorbents inflamed. Sometimes, particularly when the arm is not kept properly quiet after bleeding, swellings make their appearance about the middle ofthe arm, over the large ves- sels, and on the fore-arm, about the mid- space, between the elbow and the wrist, in the integuments covering the flexor muscles. The swelling at the inner edge of the biceps is sometimes as large as an egg. Before such swellings take place, the wound in the vein often inflames, be- comes painful and suppurates, but without any perceptible induration of the venal tube, either at this time, or after the sub- sidence of the inflammation. Pains are felt shooting from the orifice in the lines, up and down the arm, and upon pressing in the course of this pain, its degree is in- creased. On examining the arm attentive. ly, indurated absorbents may be plainly felt leading to the tumour at the side of the biceps muscle. The pain and swelling often extend to the axilla, where the glands also some- times enlarge. Chord-like substances, evi- dently absorbents, may sometimes be fek, not only leading from the puncture to the swelling in the middle ofthe arm, but also from this latter situation up to the axil- lary glands, and from the wound in the vein down to the enlarged glands of tlie mid-space between the elbow and wrist, over the flexor muscles ofthe hand. The enlarged glands very often pro- ceed to suppuration, and the patient suf- fers febrile symptoms. Some may suspect that the foregoing consequences may arise from the lancet being envenomed, and from the absorption of the virulent mat- ter ; but the. frequent descent of the dis- ease to the inferior absorbents militates against this supposition. When the absorben's become inflamed, they quickly communicate the affection io the surrounding cellular substance. These vessels, when indurated, appear like small chords, perhaps of one eighth of an inch in diameter: this substance cannot be the slender sides of the vessels, suddenly in- creased in bulk, but an induration of the surrounding cellular substance. BLEEDINft. 193 The inflammation of the absorbents, in consequence of local injury, is deducible from two causes; one, the absorption of irritating matter; and the other, the ef- fect of the mere irritation of the divided tube. When virulent matter is taken up by the absorbents, it is generally con- veyed to the next absorbent gland, where its progress being retarded, its stimulat- ing qualities give rise to inflammation, and, frequently, no evident disease of the vessel, through which it has passed, can be distinguished. When inflammation of the absorbents happens in consequence of irritation, the part of the vessel nearest the irritating cause, generally suffers most, while the glands, being remotely situated, are not so much inflamed. The treatment of the preceding case consists in keeping the arm perfectly quiet in a sling, dressing the puncture of the vein with any mild simple salve, covering the situation of the inflamed lymphatics with linen wet with the satur- nine lotion, and giving some gentle purg- ing medicine. When the glandular swellings suppu- rate, poultices should be applied, and if the matter does not soon spontaneously make its way outward, the surgeon may open the abscess. (See Mr. Abernethy s Essay on this subject.) 4. Inflammation ofthe Vein. The vein itself is veiy likely to inflame, when the wound does not unite. This affection will vary in its degree, extent, and progress. One degree of inflamma- tion may only cause a slight thickening of the venal tube, and an adhesion of its sides. Abscesses, more or less extensive, may result from an inflammation of greater violence, and the matter may sometimes become blended with the circulating fluids, and produce dangerous consequen- ces, or the matter may be quite circum- scribed, and make its way to the surface. When the vein is extensively inflamed, a good deal of sympathetic fever is likely to ensue, not merely from the excitement, which inflammation usually produces, but also in consequence of the irritation con- tinued along the membranous lining of the vein to the heart. If, however, the excited inflammation should fortunately produce an adhesion of the sides of the vein to each other, at some little distance from the wounded part, this adhesion will form a boundary to the inflammation, and pre- vent it spreading further. The effect of the adhesive inflammation in preventing the extension of inflammation along mem- branous surfaces has been ably explained Vol. 1. by Mr. Hunter. In one case, Mr. Hilnter applied a compress to the inflamed vein, above tlie wounded part, and he thought that he thus succeeded in producing an adhesion, as the inflammation was pre- vented from spreading further. When the inflammation does not continue equally in both directions, but descends along the course of the vein, its extension in the other direction is probably prevented by the adhesion of the sides of the vein to each other. (See Mr. Hunter's Paper in the Medical and Chirurgical Transac- tions, Vol. 1.) Mr. Abernethy mentions his only having seen three cases, in which an inflammation of the vein succeeded venesection. In neither of these did die vein suppurate. In one, about three inches of the venal tube inflamed both above and below the puncture. The integuments over the ves- sel were very much swollen, red, and painful, and there was a good deal of fever, with a rapid pulse, and furred tongue. The vein did not swell, when compressed above the diseased part. In another in- stance, the inflammation of the vein did not extend towards the heart, but only downwards, in which direction it extended as far as the wrist. The treatment is to lessen the inflam- mation of the vein, by the same means, which other inflammations require, and to keep the affection from spreading along the membranous lining of the vessel, to- wards the heart, by placing a compress over the vein, a little way above the punc- ture, so as to make the opposite sides of the vessel adhere together. Mr. Abernethy can conceive a case, in which the vein may even suppurate, and a total division of the vessel might be proper, not merely to obviate the exten- sion of the local disease, but to prevent the pus from becoming mixed with the circulation. Might it not be better to put a ligature under the suppurating vein, above the affected part of the vessel? This plan would be quite effectual, without the ob- jection of hemorrhage. [We beg leave to recommend in this place, the application of a blister over the puncture as the most valuable remedy for this complaint; it*should be applied as early as possible after the discovery of the disease; a blister as large as the palm of the hand will be sufficient, and in a number of instances it has succeeded in removing immediately all the unplea- sant symptoms. If the orifice in the vein be not closed, a dossil of lint may be applied over it to defend it from the flies, but commonly this caution is un- necessary.] Cc 194 BLEE 5. Inflammation of tlie Fascia of the Fore- arm. Sometimes, in consequence of the in- flammation arising from the wound ofthe lancet in bleeding, the arm becomes very painful, and can hardly be moved. The puncture often remains unhealed, but, without much inflammation of* the sur- rounding integuments. The fore-arm and fingers cannot be extended without great pain. The integuments are sometimes affected with a kind of erysipeUs ; being not very painful, when slightly touched, Jbut when forcibly compressed, so as to affect the inferior parts, the patient suf- fers a good deal. The pain frequently extends ti wards the axilla and acromion; no swelling, however, being perceptible in either direction. These symptoms are attended with considerable fever. After about a week, a small superficial collec- tion of matter sometimes takes place, a little below the internal condyle : this being opened, a very little pus is dis- charged, and there is scarcely any dimi- nution of the swelling or pain. Perhaps, after a few days more, a fluctuation of matter is distinguished below the exter- nal condyle, and this abscess being open- ed, a great deal of matter gushes from the wound, the swelling greatly subsides, and the patient's future sufferings are comparatively trivial. The last opening, however, is often in- adequate to the complete discharge of the matter, which is sometimes originally formed beneath the fascia, in tlie course of the ulna, and its pointing at the upper part of the arm depends on the thinness ofthe fttscL in this situation. The col- lection of pus descends to the lower part of the detached fascia, and a depending opening for its discharge becomes neces- sary. This being made, the patient soon gets wrell. In these cases, neither the vein, nor the absorbents, appear inflamed. The integu- ments are not much affected, and the patient complains of a tightness of the fore-arm. Matter does not always form, and the pliability ofthe arm, after a good while, gradually returns again. Mr. Watson relates a case, which was followed by a permanent contraction of the fore-arm. Mr. Abernethy is of opinion, that a similar contraction ofthe fore-arm, from a tense state of the fascia, may be relieved by detaching the fascia from tiie tendon ,f the biceps, to which it is natu- raUy connected. Mr. Watson seems to have obtained success in his first case, by having cut 'h.s connexion. The treatment of an*inflamed fascia, in consequence of venesection, has in it DING. no peculiarity. General means for tlie cure of inflammation should be employed. The limb should be kept quiet, and the inflamed part relaxed. As soon as the inflammation abates, the extension of the forearm and fingers ought to be attempt- . ed, and daily performed, to obviate the contraction, which might otherwise en- sue. (Abernethy.) Mr. Charles Hell objects to calling the affection an inflammation of the fascia, because he sees no proof of this part being inflamed, and he conceives that the symp- toms proceed from the inflammation spreading in the cellular membrane, and passing down among the muscles, and under the fascia. The fascia acts as a bandage, and, from the swelling of the parts beneath, it binds the arm, but is not itself inflamed, and contracted. When necessary to divide the fascia, Mr. Charles Bell thinks it would be better to begin an incision near the inner condyle of the humerus, and to continue it some inches down the aim, rather than perform the nice, if not dangerous operation, of cut- ting the fascia, at the point, where the expansion goes oft'from the found tendon of tiie biceps. When the elbow-joint and fore-arm con- tinue stiff* after all inflammation is over, Mr. C. Bell recommends frictions with camphorated mercurial ointment, &c. and the arm to be gradually brought into an extended state by placing a splint on the fore-part ofthe limb. ( Operative Surgery, Vol. 1, p. 65.) 6. Ill Consequences of a wounded Nerve. Mr. Abernethy informs us, that Mr. Pott used to mention two cases, in wliich the patients had stiff red distracting pains, followed by convulsions and other symp- toms, which could only be ascribed to nervous irritation, arising from a partial division ofthe nerve, and he recommend- ed its total division, as a probable remedy. Dr. Monro is said to relate similar cases, in which such treatment has proved suc- cessful. Hence, it is highly necessary to know the characteristic symptoms of the case, particularly, as all the foregoing ones- would be exasperated by the treatm-pnt just now alluded to. It is to Mr. Aber- nethy that we are indebted for several valuable remarks elucidating this subject. He informs us, that the two cutaneous nerves are those, which are exposed to injury. \Iost frequently all their branches pass beneath the veins, at the bend of the arm ; but, sometimes, although the chief rami go beneath these vessels, many small filaments are detached over them, which ' B L E B L E 195 it is impossible to avoid wounding in phle- botomy. Mr. Abernethy thinks the situation of the median nerve, renders any in- jury of it very unlikely. If, however, a uouLt,should be entertained on this subject, an attention to symptoms will soon dispel it. When a nerve is irritated at any part, between its origin and teiim- nation, a sensation is felt, as if some in- jury were done to tlie parts, which it sup- plies. If, therefore, tiie cutaneous nerves were injured, tlie integuments ofthe fore- arm woufd seem to suffer pain; if the median nerve, the thumb, and two next fingers, would be painfully affected.— (Abernethy.) What are the ills likely to arise from a wounded nerve ? If it were partially cut, would it not, like a tendon, or any other aubstance, unite ? It seems probable that it would do so, as nerves, as large as the cutaneous ones of the arm, are very nu- merous in various situations of" the body, and are partially wounded in operations, without any peculiar consequences usu- ally ensuing. The extraordinary pain sometimes experienced in bleeding, may denote that a cutaneous nerve is injured. Tne situation of the nervous branches is such, that they must often be partially wounded in the operation, though they probably unite again, in almost all cases, without any ill consequences. Yet, says Mr. Abernethy, it is possible, that an in- flammation of the nerve may accidentally ensue, which would be aggravated, if the nerve were kept tense, in consequence of its impartial division. Mr. Abernethy thinks the disorder arises from inflamma- tion of the nerve, in common with the other wounded parts. Every one will admit that an inflamed nerve would be very likely to communicate dreadful irri- tation to the sensorium, and that a cure would be likely to arise from intercept- ing its communication with that organ. The general opinion is, that the nerve is only partially divided, and that a com- plete division would bring relief. Mr. Pott proposed enlarging the original ori- fice. It is possible, however, that the in- jured nerve may be under the vein, and, if the nerve be inflamed, even a total di- vision of it, at the affected part, would, perhaps, fail in relieving the general ner- vous irritation, which the disease has occasioned. To intercept the communi- cation of the inflamed nerve with the sen- sorium, does, however, promise perfect relief. Tliis object can only be accom- plished by making a transverse incision above the orifice of the vein. The inci- sion need not be large, for the injured nerve must lie within the limits of the o.riginal orifice, and it need only descend as low as the fascia of the fore-arm, above which all the filaments of the cutaneous nerves are situated. As the extent ofthe inflammation of the nerve is uncertain, Mr. Abernethy suggests even making a division of the cutaneous nerve still fur- ther from the wound made in bleeding. Examples are recorded, in which not only extraordinary pain was occasioned by the prick of the lancet; but, erysipe- las of the skin seemed to be induced by the operation, ending in gangrene of the whole limb, and the death of the patient. (See Richerand's Nosographie Chirurgi- cale, Tom. 2, p. 390. Edit. 2.) In former times, it was customary to refer many of the bad symptoms occa- sionally following venesection, to a punc- ture of the tendon of the biceps ; but, this doctrine is now in a great measure re- nounced, the experiments of Haller liaving completely proved, that tendons and apo- neuroses are, comparatively speaking, parts endued with little or no sensibility. In the foregoing account, the various ill consequences occasionally arising, af- ter venesection, are represented separate- ly; no doubt, in some cases, they may occur together. (See Essay on the ill Consequences some- times following Venesection, by J. Abernethy, F.R. S. Medical and CldrurgicalTransuc- tions, Vol I. Medical Communications, Vol. II. Richerand's Nosographie Chirurgicale, Tom. 2, p. 381. Etht.2.) BLEEPING. Effusion of blood from accidental wounds. (See Hemorrhage.) BLE'NORRHAGIA., or Bienorrhxa. (from /3Amo«, mucus, and geal, to flow.") A discharge of mucus. Swediaur, who maintains, that the gonorrhoea is attend- ed with a mucous, and not a purulent discharge, prefers the name of Menorrha- gia for the disease. However, in treat- ing of gonorrhaea, we shall find that this last appellation is itself not altogether free from objections. BLEPHAROPTOSIS. (from jSAf^ov, ktlie eyelid, and Krutris, a falling down.) Called also ptosis. An inability to raise the upper eyelid. (See Ptosis.) BLEPHARO'TIS. An inflammation of the eyelids. BLEPHARO'XYSIS. (from ptoQxpot, the eyelid, and |e«> to scrape.) CaUed also Ophthalmexystrum. A brush for the eye, employed by the ancient surgeons, and made of the beards of barley or rye. It was drawn across the inside of the eyelids, with the same design as scarifi- cations are now made. BLEPHARO'XYSTON. An ancient instrument for examining the eye. A 196 B L I B LI speculum oculi. Also, according to Pau- lus .Sigineta, tiie specillum asperatum, or rasp-like probe. BLINDNESS. This is an effect of many diseases of the eye. See, particu- larly, Amaurosis ; Cataract ; Cornea, opa- cities of; Hydrophthalmia; Leucoma; Oph- ilialmy; Pterygium ; Pupil, closure of; Sta- phyloma, &c. BLISTERS. Topical applications.which, when p-ut on the skin, raise the cuticle in the form of a vesicle, filled with a serous fluid. Various substances produce this effect on the skin; but, the powder of cantharides is what operates with most certainty and expedition, and, is now invariably made use of for tiie purpose. The blister plaster is thus composed : & Cantharidum lbj, Emplastri cerx Ibij. Adipis suillx prxp. lbss. The wax plaster and lard being melted, and allowed to become nearly cold, the powdered cantha- rides are afterwards to be added W'hen it is not wished to maintain a discliarge from the blistered part, it is sufficient to make a puncture in the cu- ticle to let out the fluid; but, when the case requires keeping up a secretion of pus, the surgeon must remove the whole of the detached cuticle with a pair of scissars, and dress the excoriated surface in a particular manner. Practitioners used formerly to mix powder »f cantharides with an ointment, and dress the part with this composition. But, such a dressing not unfrequently occasioned very painful affections of ihe bladder, a scalding sen- sation in making water, and very afflict- ing stranguries. An inflammation of the bladder, ending fatally, has been thus excited. The treatment of such com- plaints consists in removing every particle of cantharides from the blistered part, making the patient drink abundantly of mucilaginous drinks, giving emuIsions,and some doses of camphor. , These objections to the employment of salves, containing cantharides, for dree- ing blistered surfaces, led to the use of mezereon, cuphorbium, and other irritat- ing subsume* s, which, when incorporated with o ntment, form very proper compo- sitions for keeping blisters open, without the inconvenience of Irritating the blad- der, like cantharides. The favourite application, however, for keeping open blisters, is the powder of savme, which was brought into notice by Mr. Crowther, in the first edition of his book on the White Swelling. In the late edition, tliis gentleman remarks, that he was led to the trial of different escha- rotic applications, in the form of oint- ment, in consequence of the minute at- tention, which caustic issues demand; and among other things, he was induced to try powdered savine, from observing its effects in the removal of warts. Some ofthe powder was first mixed with white cerate, and applied as a dressing to the part, that had been blistered; but, the ointment ran off", leaving the powder dry upon the sore, and no effect was pro- duced. Mr. Crowther next inspissated a decoction of savine, and mixed the ex- tract with the ointment, which succeeded better, for it produced a great and per- manent discharge. At l*st, after various trials, he was led to prefer a preparation analogous to the unguentum sambuci V. L. and he now offers the following for- mula, as answering every desirable pur- pose: r< Sabinx recent is contusx lb ij. Cera flavi&lbj, Adipis suillx lbiv. Adipe et cera liquefactis, incoque sabinam et cola. Tits difference of this formula from the one, which Mr. Crowther published in 1797, only consists in using a double pro- portion of the savine leaves. The cera- tum sabinje of Apothecary's Hall, he says, is admirably made : the fresh sa- vine is bruised with half the quantity of lard, wliich is submitted to the force of an iron press, and the whole is added to the remainder ofthe lard, which is boiled until the herb begins to crisp; the oint- ment is then strained off, and the pro- portion of wax, ordered, being previously melted, is added. On the use of the sa- vine cerate, immediately after the cuticle, raised by the blister, is removed, it should be observed,, says Mr. Crowther, that ex- perience has proved the advantage of using the application lowered by a half, or two-thirds, of the unguentum cerx. An attention to this direction will pro- duce less irritation, and more discharge, than if the savine cerate were used in its full strength. Mr. Crowther says also, that he has found fomenting the part with flannel wrung out of warm water, a more easy, and preferable way of keep- ing the blistered surface clean, and fit for the impression of the ointment, than scraping the part, as has been directed by others. An occasional dressing of the unguentum res-nx flavx, he has found, a very useful application for rendering the sore free from an appearance of slough, or rather dense lymph, wliich has sometimes been so firm in its texture, as to be separated by the pTobe, with as much readiness, as the cuticle is detached after blistering. As the discharge di» minishes, the strength ofthe savine dress- ing should be proportionally increased. The ceratum sabinx must be used, in a stronger, or weaker degree, in proportion to the excitement produced on the pa- tient's skin. Some require a gTeater sti- BOU EOU 197 mulus, than others, for the promotion of tlie discharge, and this can only be ma- naged by the sensations, which tiie irri- tation of the cerate occasions. Mr. Crowther has used ointments, con- taining the flowers of the elematis recta, the capsicum, and the leaves of the digi- talis purpurea. The two first produced no effect; the last was very stimulating ; and Mr. Crowther mentions his intention to take the first convenient opportunity to determine its qualities more accurate- ly. He has also used kaU purum, rubbed down with spermaceti cerate, in the pro- portion of" one dram to an ounce: it proved very stimulating, but produced no discharge. He has tried one dram of the hydrargyrus muriatus mixed with two ounces of the above cerate; but the ap- plication was so intolerably painful, that Mr. Crowther was sent for at the end of two hours, and found it necessary immediately to remove the dressing. The patient was attacked with the most severe ptyalism Mr. Crowther ever witnessed. (Practical Observations on the White Sviell- irur, Uc. a nexv edition, by B. Crowther, 1808.) Instead of keeping a blister open, it is frequently a judicious plan to renew the application of the emplastrum lyttae (the new name now adopted for bUstering plaster) after healing up the vesication first produced, and to continue, in this manner, a succession of blisters, at short intervals, as long as the circumstances of the case may demand. BOl L. See Furuncuhus. BORBORY'GMUS. A r-rnbling sound, occasioned by air in the intestines. BO'THRION, or BStrion. A very small superficial ulcer of the cornea. BO"riA. The disease called Scro- fula. BO'TIUM. A swelling of the thyroid gland. See Bronchocele. BOUGIE. (French for Wax Candle.) This signifies an instrument somewhat resembUng a straight piece of wax-taper, and the chief use of which is to remove obstructions in the urethra, by being in- troduced into this canal. The composi- tion, of which they are made, ought, in particular, to possess a certain degree of suppleness, combined with a good deal of firmness. Scultetus, a practitioner and writer of great note, at Ulm, in Germany, about the middle of the seventeenth century, was not ignorant of" the manner of mak- ing and using bougies, in diseases of the urethra, as appears in his Armamenta- rium Chirurg. tab. 13, fig. 9, 10. And from his invention, as Mr. Gooch has observed, it is not at all improbable, that Daran may have taken the hint, and im- proved upon it. The making of bougies has now be- come so distinct a trade, that some sur- geons may consider it superfluous to treat of the subject in this dictionary. How- ever, though a surgeon may not actually choose to take the trouble of making bougies himself, he ought certainly to un- derstand how they ought to be made: Swediaur recommends the following com- position : g< Cerae flavx lbj. Spermatis ceti giij. Cerussx ace tat *x gv. These articles are to be slowly boiled together, till the mass is of proper consistence. Mr. B. Bell's bougie plaster is thus made : * Emplastri lythargyri 3'iv. Cerae flavx §iss. Olei Olivac Jiij. The two last ingredients are to be melted in one vessel, and the litharge plaster in ano- ther, before they are mixed. In Wilson's Pharmacopoeia Ohirurgica, I observe this formula : £ Olei Olivac lbiiss, Cerae flavae lbj, Minii lbiss. Boil the ingre- dients together over a slow fire, till the minium is dissolved, which will be in about four or six hours. The compo- sition for bougies, is now very simple, as modern surgeons place no confidence in the medicated substances, formerly ex- tolled so much by the famous Daran. The linen, which may be considered as the basis of the bougie, is impregnated with the composition alluded to, and which we see is generally made of wax and oil, rendered somewfcat firmer by a proportion of resin. Some saturnine preparation is commonly added, as the urethra is in an irritable state, and the mechanical irritation might otherwise in- crease it. Of whatever composition bou- gies are made, they must be of different sizes, from that of a knitting needle to that of a large quill, and even larger. The common ones are made in the following manner. Having spread any composi- tion, chosen for the purpose, on linen rag, cut this into slips, from six to ten inches long, and from half an inch, to an inch, or more in breadth. Then dex- terously roll them on- a glazed tile into the proper cylindrical form. As the end of tiie bougie, which is first introduced into the urethra, should be somewhat smaller than the rest, the slips must be cut rather narrower in this situation, and, when the bougies are rolled up, that side must be outwaid, on which the plaster is spread. Mons. Daran, and some others, attri- buted the action of" their bougies to the composition used in forming them. Mr Sharp apprehended that their efficacy- was chiefly owing to the pressure, which they made on tiie affected part; and Mr. 198 BOUGIE. Aikin adds, that as bougies of very dif. ferent compositions succeed equally well in curing the same diseases in the ure- thra, it is plain, that they do not act from any peculiar qualities in their composi- tion, but by means of some common pro- perty, probably, their mechanical form. There certainly is a great objection to making bougies of very active materials ; because the healthy, as well as the dis- eased, parts are exposed to their action. Hence, surgeons now prefer the common bougies, made of a simple unirritating composition. Plenck recommended bougies of catgut, which may be easUy introduced even in- to a urethra, greatly contracted, as their size is small, their substance firm, and they dilate with moisture. It is objected to catgut, however, that it dilates very much beyond the stricture, and gives great pain on being withdrawn. The elastic resin has been employed for this purpose with great success, as it unites firmness and flexibility. The resin is moulded on catgut by some se- cret method. Mr. Wilson, in this Phar- macopoeia Chirurgica, seems to suggest, with much appearance of probability, that the secret consists in finding a suitable solvent for the Indian gum. As this sub- stance, if dissolved in aether, completely recovers its former elasticity, upon the evaporation of this fluid, it is supposed that aether would' answer the purpose, though rather too expensive. The cat- gut is coated with the elastic matter by being repeatedly dipped in it. Elastic gum bougies are in many cases highly serviceable, though their surface soon be- comes rough, and they are expensive. Mr. Smith, apothecary, of Tavistock- street, has discovered a metallic compo- sition, of which he forms bougies, to which some practitioners impute very su- perior qualities. These bougies are flex- • ible, have a highly polished surface, of a silver hue, and possess a sufficient de- gree of firmness for any force, necessary in introducing them for the cure of stric- tures in the urethra. The advocates for the metallic bougies assert, that the short time they have been employed has con- vinced them, that such instruments ex- ceed any bougies, which have yet been invented, and are capable -of succeeding in all cases, in which the use of a bougie is proper. They are made either solid, or hollow, and answer extremely well as catheters; for, they not only pass into the bladder with ease, but may also be continued there for any convenient space of time, and hence produce the most essential benefit. The bougies certainly do not swell with moisture. The greatest objection, which has been urgetl against them, is, that they are attended with a risk of breaking. I have heard of an eminent surgeon being called upon to cut into the bladder, in consequence of a me- tal lie bougie having broken, and a piece of it got into that organ, where it became a cause of the severe symptoms, which are commonly the effect of a stone in the bladder. It has also been objected to metallic bougies, that, although they are sufficiently flexible, they are quite de- stitute of elasticity. See Sharp's Critical Enquiry, ch. 4. Aikin on the external use of Lead. Bell's Surgery, Vol. 2. 20, &c. White's Surgery, 371. The bougie, with its application, says Mr. Hunter, is perhaps one of the great- est improvements in surgery, which these last thirty, or forty years have produced. When I compare the practice of tlie pre- sent day, with what it was in the year 1750,1 can scarcely be persuaded, that I am treating the same disease. 1 remem- ber, when, about that time, I was attend- ing the first hospitals in the city, the com- mon bougies were, either a piece of lead, or a small wax candle, and, although the present bougie was known then, the due preference was not given to it, nor its particular merit imderstood, as we may see from the publications of that time. Daran was the first, who improved the bougie, and brought it into general use. He wrote professedly on the disease s for which it is a cure, and also ofthe manner of preparing it; but, he has- introduced so much absurdity in his descriptions of the diseases, the modes of treatment, and of the powers and composition of his dou- gies, as to create disgust. When Daran published his observa- tions on the bougie, every surgeon set to work to discover the composition, and each conceived, that he had found it out, from the bougies, which he had made, producing the effects described by Daran. It never occurred to them, that any extra- neous body, of the same shape and con- sistence, would do the same thing. [The following description of the mode of preparing bougies, is taken from the Elements of Surgery. " In this country it is essential for the surgeon to be acquainted with the man- ner of preparing bougies, because those which are imported and manufactured for sale are very unsafe, and are totally unfit for the purpose for wiiich they are designed. They are unsafe because be- ing formed generally of old linen they are apt to break, and in this manner may lodge in the bladder or urethra, and occa- sion great inconvenience, and they are BRO BRO 199 unfit for use, from their bad form, and from the improper substances of which they are composed. The best^materials for the construction of bougies are fine new linen and pure yellow bees wax. The linen should be cut into pieces about twelve or fourteen inches square, and dipped into melted wax; it should be taken out in such a manner that the wax may drip off at one end, and not more by one corner than another ; in this manner the linen will receive a coat of wax of a uniform degree of thickness, excepting that the depending portion will be more thickly coated than the superior part; the linen is to be cut into strips of a proper width, care being taken always to cut in the transverse direction, because as there is more wax upon the lower than the upper part, tiiere would be an irregu- larity in the form of tlie instrument if this caution were neglected. The strip of waxed linen or bougie plaster is next to be cut of a proper shape, so that when rolled up it may taper to a point. The form which I prefer, is to have the bougie slightly conical, through its whole length, but to taper at the end, very quickly to a point. The smaUness of the point ena- bles the surgeon to insinuate it into the stricture, and the conical form gives it a degree of firmness gradually increasing from the point to the opposite extremity. The art of rolling up the bougie and of giving it a proper point is to be acquired by habit, and need not be particularly de- scribed. I will only remark, that a mar- ble slab, or a polished mahogany table, and a broad spatula, or knife, are all the tools necessary for this purpose, and 1 conclude this part of the subject by re- commending to the practitioners of this cuuntry the preparation of their own bou- gies.] (Treatise on the Venereal Disease,p. 116, by John Hunter, 1788.) Of armed bougies, and of the manner of using bougies in general, we shall speak in the article Urethra, Strictures of. BRACHERIUM. A truss or bandage for hernia. A word used by the barba- rous Latin writers, and said to be derived from brachiale, a bracelet. BltAIN. (For concussion, compres- sion of, 8cc. see Head, Injuries ofj for the hernia of, see Hernia Cerebri.) BREAST. ' (See Mammary Abscess; Mamma, Removal of; Cancer, &c.) BRONCHOCELE. (from jipoyXof, the windpipe, and %v,Xri, a tumour.) Also called botium, or bocium. The Swiss call the disease gotre. Some have called it, herniagutturis,guttur tumidum, and troche- lophyma, gossum, exechebronchos; gongrona, hernia broncldalis. Heister thought it should be named tracheocele. Prosser, in his late publication on this disorder, from its frequency on the hilly parts of Derby- shire, caJfe-itj'with others, the Derbyshire neck; and, not satisfied respecting the similitude of this tumour to that observed on the necks of women on the Alps, the English Bronchocele. Modern surgeons constantly mean by bronchocele, an enlargement of the thyroid gland. This sometimes attains such a magnitude, that it not only occupies all the space from one angle of the jaw to the other, but also, forms a considerable pro- jection on each side of the neck, advanc- ing forward a good way beyond the chin, and forming an enormous mass, which hangs down over the chest. The swell- ing, which is more or less unequal, is commonly not particularly hard, especi- ally when the disease is not in a very ad- vanced state ; however, no fluctuation is perceptible, and the patients suffer no pain. The skin retains nearly its ordi- nary colour; but, when the tumour is of very long standing, and great size, the veins of the neck become more or less varicose. According to Prosser, the tumour gen- erally begins between the eighth and twelfth year. It enlarges slowly during a few years, till, at last, it augments ra- ther rapidly, and forms a bulky pendu- lous tumour. Women are far more sub- ject to the disease, than men, and the tu- mour is observed to be particularly apt to increase rapidly during their confine- ment in childbed. When only one lobe ofthe thyroid gland is affected, it may extend in front of the carotid artery, and be lifted up by each diastole of this vessel, so as to appear to have the pulsatory mo- tion of an aneurism. (A. Burns' Surgi- col Anatomy of the Head and Neck, p. 195, and Parisian Chirurgical Journal, Vol. 2, p. 292, 293) It is this disease, to which the term gotre, or goitre, has been particularly ap- plied, and which is so common in some ofthe vallics of the Alps. Indeed, there are certain places, where tiie disease is so frequent, that hardly an individual is" totally exempt from it. Larrey, in travel- ling through the valley of Maurienne, no- ticed, that almost all the inhabitants were affected with goitres, of different sizes, by which tumours, the countenance was deformed, and the features rendered hi- deous. (.Memoir es de Chirurgie MUitaire, Tom. 1. p. 123.) In many, the swelling is so enormous, that it is impossible to conceal it by any sort of cloathing. A state of idiotism is another affliction, which is sometimes combined with the 200 BRONCHOCELE. goitre, in countries, where the latter affec- tion is endemic. However, all, who have the disease, are not idiots, or cretins as they have been called, and in Switzer- land, and elsewhere, it is met with in persons who possess the most perfect in- tellectual faculties. Where bronchocele and cretinism exist together, Fodere, and several other writers ascribe the affec- tion ofthe mind to the state of the thy- roid gland (See Essai sur le Goitre et Cretinisme, par M. Fodere.) Thisjopinion, however, appears to want foundation, since the mental faculties are from birth weak, and, in many, the idiotism is com- plete, where there is no enlargement of the thyroid gland, or where the tumour is not bigger than a walnut, so that no impediment can exist to the circulation to, or from the brain. (Burns on the Sur- gical Anatomy of the Head and Neck, p. 192.) The direct testimony of Dr. Reeve also proves, that, in the countries, where cretins are numerous, many people of sound and vigorous minds have broncho- cele. (See Dr. Reeves' Paper on Cretinism, Edinb. Med. and Surgical Journal, Vol. 5. p. 31.) Hence, as Mr. A. Burns has re- marked, the combination of bronchocele and cretinism must be considered as acci- dental ; a truth, that seems to derive con- firmation from the fact, that, in some parts of this country, bronchocele is fre- quent, where cretinism is seldom or never seen. The bronchocele seems to be en- demic in several mountainous countries, particular Switzerland, Savoy, Tyrol, Derbyshire, &c. and it occurs remark- ably often in young subjects, and much more frequently in the female, than the male sex. In women, it usually makes its appearance at an early age, generally between the eighth andjtwelfth year, and it continues to increase gradually for three, four, or five years, and is said sometimes to enlarge more, during the last half year, than for a year, or two, before. It does not generally rise so high as the ears, as in the cases mentioned by Wiseman, and it is rather in a pendulous form, not unlike, as Albucasis says, the flap, or dewlap of a turkey-cock, the bot- tom being the largest part of the tumour. It is soft, or rather flabby to the touch, and somewhat moveable, but, after a few years* when it has ceased enlarging, it becomes firmer, and more fixed. When tlie disease is very large, it generally oc- casions a difficulty- of breathing, which is increased on the patient's catching cold, or attempting to run. In some subjects, the tumour is so large, and affects the breathing so much, that a loud wheezing is occasioned; but, there are many ex- ceptions to this remark. Sometimes, when the swelling is of great size, n.i- tients suffer very little inconvenience ■ while others are greatly incommoded, though the tumour is small. In general, the inconvenience is trivial. The voice is occasionally rendered hoarse. In some instances, only one lobe of the thyroid gland is affected. The causes of the bronchocele are little known. To the opinion, that broncho- cele is caused by the earthy impregnation of water used for drink, the following ob- jections offer themselves. 1. The water of Derbyshire, in districts, where this dis- ease is considered endemic, contains much supercarbonate of lime; but that in common use about Nottingham, where the disease is also prevalent, is impreg. nated with sulphate of lime. 2. Absti- nence from water unboiled does not di- minish, nor interrupt the gradual pro- gress of the disease. 3. Patients are cured of the disease, who still continue to drink water from the same source as before, without taking any precaution, as boiling, &c. 4. The disease is seldom found , among men. 5. Many instances may be related of a swelling in the neck, sometimes very painful, and generally termed bronchocele, being produced very suddenly, by difficult parturition, violent Ci-ughing, or any oilier unusually power- ful effort. (See'Edinb. Med. and Surgi- cal Jouriial, Vol 4, p. 279.) The disease is sometimes seen in scrofulous subjects; but, it may be quite independent of the other disorder. On the mountainous part / of Derbyshire, Genoa, and Piedmont, they attribute the bronchocele to drink- ing water cooled with ice. To this theory, many of the objections, concern- ing the earthy impregnation of water, stand in full force; with this additional reflection, that, " In Greenland, where snow water is commonly used, these un- sightly protuberances are never met with, nor, (says Watson) did I ever see one of them in Westmoreland, where we have higher mountains, and more snow, than they have in Derbyshire, in which cotin- ty, they are very common. But what puts the matter beyond a doubt, is, that these wens are common in Sumatra, where there is no snow, during any part of the year " ( Watson's Chemical Essays, Vol 2, p. 157.) Respecting the influence of particular water in bringing on the disease, Dr. Odier, the well informed professor of medicine, at Geneva, seems to give cre- dit to the opinion, because, it has ap- peared to him, that distilled water pre- vented the increase of the tumour, and even tended to lessen its bulk. (See Ma- nuel de Medecine Pratique.) However, BRONCHOCELE. 201 without denying this power of distilled water, I think the foregoing considera- tion satisfactorily proves, that the disease neither proceeds from snow water nor wa- ter impregnated with particular suits. An observation lately made by an in- telligent writer, would lead one to con- clude, that cretinism depends upon mal- formation of the head. Speaking of goi- tre, as it appears among the inhabitants of the v.dl-y of Mauriennc, M. Larry informs us, that, in many of these peo- ple, with this frightful deformity is j. lined th it ofthe cranium, of which the smallnc-is a.id excessive thickness are especially re- markable. (Memoires de C/urwgie .ifiti- taire, 'Tom. 1, /> 123.) Dr. I.^akc thinks, that tumours of this sort, may be owing to the severity of the cold damp air, as they generally appear in winter, and hardly ever in the warm dry climates of Italy and Portugal. Mr. Prosser is in- criivjd to consider the bronchocele, as a kind of dropsy of the thyroid gland, si- milar to tiie dropsy of the ovary, and he mentions, that Dr." Hunter dissected one thyroid gland, which hs.d been considera- bly enlarged, anel contained many cysts filled with wati--!-. These, he erroneously , concludes, must have been hydatids. Or. Ba.llie remarks, that when a section is made of the thyroid gland, affected with this disease, the part is found to con-i-.t of a number of cells, containing a trans- parent viscid fluid. The ordinary bronchocele is, in all .pro- bability, er.tirely a local discFC, patients usually find.ng'themselves, in other re- ,spect*-', perfectly well. The tumour itself frequently occasions no particular incon- venience, only deformity. There is no ma- lignancy in the disease, and the swelling is not prone to inflame, or suppurate, though, as I);-. Hunter remarks, abscesses (Wqccasiontiiy form in it. Bronchoceles never become cancerous. Mr. Gooch never knew life to be endangered by this sort of tumour, however large; but, he saw great inconvenience arise from it, when combined with q-ainay. Dr. Hunter says, that the bronchocele appears two, or three years before, or after the com- mencement of menstruation, and that it sometimes spontaneously disappears, when this evacuation goes on in a regu- lar manner. Mr. Prosser thinks, that this change in the constitution hardly ever affects the tumour. It is a curious fact, that the inhabit- ants of thu vallies of the Alps are parti- cularly liable to bronchocele, while those, who Uve in higher situations on the moun- tains, escape the disease* TREATMENT OF BnONCBOCELE. A bli-ter, kept open, has put a stop to the growth of the tumour; but, this me- thod is not much followed at present, as a better plan of treatment has been dis- covered. The most famous mode of cur- ing the bronchocele is by giving internal- ly burnt sponge, and occasionally, a ca- lomel purge, at the same time, employing frictions to the tumour itself. The efficacy of burnt sponge is said to be most conspicuous, when this medicine is exhibited in the form of a lozenge, composed of ten grains of this substance, ten of burnt cork, and the same quantity of pumice-stone. These powders are to b'j made into the proper form with a little svrup, and the lozenge is then to be put under the tongue and allowed to dis- solve there. To the latter circumstance, much importance is attached. Other practitioners give a scruple of the burnt sponge alone, thrirc every day, while some add a grain of calomel to each dose. A purge of calomel should be ordered about once a week, or fortnight, as long as the patient peiseveres in the use of ihe cab cined sponge; but, if mercury be com- bined with each dose of this medicine, no occasional purgative will be requisite. External means may very materially assist the above internal remedies. Fre- quently rubbing the swelling with a dry towel; bathing' the part with cold water; nibbing the tumour two, or three times a dav, with the aq. amnion, acet. or "the camphor liniment; are the best steps of this kind which the surgeon can take. '• In the treatment of bronchocele," says Mr. A. Bums, " repeated topical detraction of blood from the tumour is highly beneficial. Electricity also has sometimes a marked effect; but, there is no remedy, which I would more strongly advise, than regular and long continued friction over the tumour. By perseve- rance in this plan, a bronchocele, treated in London, was materially reduced in the course of six weeks. Its good effects I have likewise witnessed myself; and it is a remedy highly recommended by Girard in his cf Traite des Loupes." It has also been much used in scrofulous tumours by Mr. Grosveoor of Oxford, and by Mr. Russel of Edinburgh." (Surgical Anato- my ofthe Head and Neck, p. 204.) Mr. A Burns recommends the friction to be made with flannel, covered with hair powder, and the part to be rubbed, at least, three times a day, for twenty minutes. In two cases of bronchocele, related by Vol. I D D 202 BRONCHOCELE. Dr. Clarke, the patients were cured, by *■' the steady use of the compound plaster of ammoniac and mercury, conjoined with the internal exhibition of the burnt sponge, and occasional purgative*." (See Edinb. Med and Surgical Journal, Vol.4, p. 280.) We learn from Professor Odier, that, in Geneva, the bronchocele is cured by burnt sponge, exhibited in powder, or in- fused in wine, and combined with purga- tives to prevent the cramps ofthe stomach, winch sometimes accompany the disap- pearance of the swelling. Muriate of barytes has likewise been recommended. (See Manuel de Medecine Protique.) A whole volume might be written on the various remedies and plans of treat- ment, of" the bronchocele. The limits of this work, however, demand more con- ciseness, and, having detailed the most •approved practice, we shall be very brief on other proposals. Mr. Wilmer, credulously imputing great influence to the changes of the moon, used to begin with an emetic, the day after the full moOn, -«nd to give a purge the day i.fter that. The night following, and teven nights successively, he directed the above-mentioned lozenge to be put under the tongue at bed-time, and administered i»very noon a bitter stomachic powder. On the eighth day, the purge was to be re- peated, and, in tlie wane of the succeed- ing noon, the whole proce-.s, except tiie emetic, was renewed. ( Cases in Surgery, Appendix.) This famous Coventry plan of treatment is said tj be greatly assisted, by rubbing the tumour, with an ointment, containing tartar emetic, Mr. Prosser succeeded with his medi- cines, though the patient was nearly twenty-five years old, and the swelling had existed more than twelve years. It fs said, that no instance of cure has been known, after the patient was twenty-five. Mr. Prosser orders one of the following powders to be taken early in the morning, an hour, or two after breakfast, and at five, or six o'clock in the evening, every day, for a fortnight, or three weeks. The powder may be taken in a little syrup, or sugar and water, of any thing else, so that none may be lost. $i Cinnab. ant. op. levigat. milleped. ppt. et pulv. a a gr. xv. Spong. calcin. These powders should betaken for two, or three weeks, and left off" for a week or nine days, before a repetition. At bed- lime, every night, duringthe second course ofthe powders, s-ime purgative pills, com- posed of mercuiy, the extractum colocyn- thid. comp. and rhubarb, are to be ad- ministered. In general it will be proper to purge the patient with manna, or salt*, betore beginning with the powders. Mr. Prosser puts no faith in external applica- tions. Some have recommended giving two scruplesof calcined egg-shells, every morn- ing, in a glass of red \\ ine ; half a dram of the kali sulphuratum, every day, dissolv- ed in water; or ten, or fifteen drops of the tinct. digit pur pur. twice a day, the dose to be gradually increased. Muriated barytes; cicuta; and belladonna, have also been exhibited. Attempts have been made to extirpate the enlarged thyroid gland ; but, tlie numer- ous large arteries distributed to tliis part, the dilated state of these vessels, when the gland is much enlarged, and the vicii-ity of the carotid arteries, render Uns opera- tion exceedingly dangerous*, especially when the swelling is very large, the only instance, in which a patient would submit to this mode of cure. In doing it, one would be obliged to cut arteries large enough to pour forth a vast quan ity of blood in a very short time, and so situat- ed, that it would be difficult io tie, or effctually compress them. Mr. Gooch relates two cases, which do not encourage practitioners to have recourse to the ex- cision of enlarged thyroid glands. In one of these instances, so cop ous an hemor- rhage took place, that the surgeon, though equally bold and experienced, was obliged to stop in the middle of the operation. No means availed in entirely suppressing the bleeding, and the patient in a few days died. In the other example, the same event nearly took place, the patient's life only bemg saved by cqmpressing the wounded vessels with the hand, day and night for a whole week, by persons who relieved each other in turn. The surgeon found this the only way of stopping the hemorrhage, after many fruitless attempts to tie the vessels. Certainly these cases are well calculated to deter prudent men from undertaking the hazardous operation of cutting out an en- larged thyroid gland. The practice is the less proper for imitation, for, inconveni- ent as a bronchocele may be, it scarcely ever endangers life. It must be noticed, however, that there are a very few cases of enormous bron- choceles, every now and then occurring, which obstruct respiration, deglutition, and the return of the blood from the head, in so serious a degree, that every enterpiizng surgeon would feel greatly inclined to make any rational attempt to relieve his patient, even though it might be one of a bold description. In such pressing circumstances, a good operator, well acquainted with the anatomy of the BRO BRO SQ3 neck, would be warranted in attempting the extirpation of the swelling, and he would be most likely to succeed by imi'ating the plan, which was followed by Desault, and which I shall hereafter panictnarly relate. (See Thyroid Gland, Extirpation of) Were a surgeon to be afraid of this attempt, and, were the symptoms urgent, he might adopt another line of conduct, winch is, m every respect, rational and warrantable ; namely, he might expose, and tie, the superior thyroideal arteries, just as is done in cases of aneurisms. When the quantity of blood, flowing into a tumour, is, suddenly and greatly, les- sened, the size of the swelling commonly very soon undergoes a considerable dimi- nution. Th.s operation has been actu- ally practised by Sir William Blizard, who tied the arteries of an enlarged thy- roid gland, and, in a week, the tumour was reduced one-third in its size. The ligatures then sloughed off; repeated bleeding took place from the arteries, and by the extension of the hospital gan- grene, the carotid itself was exposed. The patient died ; yet, as Mr. A. Burns maintains, this does nnt militate against a repetition of the experiment; the same thing might have happened from merely opening a vein, and, in the confined air of an hospital, has actually happened. {Surgical Anatomy of tlie Head andNeck,p. 202.) For my own part, I am decidedly of opinion, that the great decrease in tlie size of the gland before death, is a suffi- cient encouragement to repeat the trial, particularly, as the mode of tying arte- ries is now brought to the greatest per- fection. If the femoral, and even the ex- ternal iliac, arteries will heal, when tied in Mr. Abemethy's method, there can be no doubt, that the superior thyroideal is capable of doing so. Recent bronchoceles may oft en be cured by proper medicines and applications ; inveterate ones may generally be dimi- nished, but they hardly ever can be en- tirely removed. It is somewhat extraordinary, that, not- withstanding there are so many recorded instances of the bronchocele being cured, Richerand, in his late work, should have set down the disease as totally incurable, either by external applications, or inter- nal medicines. (See his Nosographie Chi- rurgicale, Tom 4, p. 149, Edit. 2.) Albucasis gave the first good account of the bronchocele. His remarks are translated in Friend's Hist, of Physic, and James's Med. Die. (See also Tur- ner's Surgery, Vol. 1, p. 164, Wilmer's Cases and Remarks in Surgery. Prosser on Bron- chocele, Edit. 3. BelPs Surgery, Vol. 5. White's Surgery. Memoirs of the Med Society of Londoi»,217'. Gooch's Chirurgical Works, Vol-2, p. 96—Vol. 3, p. 157. De- sault's Parisian Chirurgical Journal, Vol. 2, p 292- CEuvres Chirurgicales de Desault, par Bichat. Tom. 2, p. -98. Edinb. Mrtl. and Surgical Journal, Vol 4, p. 279. Odi- er's Manuel de Medeane Pratique. Dr. Reeves's Paper on Cretinism, in Edinb. Med. and Surgical Journal, Vol. 5. Essai sur le Goitre et Cretinisme, par M. Fodere.— Richter's Anfangsgrunde der IVundarzney- kunst, Band. 4. Zweyter Aufiage, Kap. 13, Vom Kropfe. Surgical Anatomy ofthe Head and Neck, by A. Bums, p. 191, &c. Lar- rey, Memoires de Chirurgie Militaire, Tom. 1, p 123, Tom. 3, p. 199, &c.) BRONCHOTOMY. (from Ppe>y%°<;y the windpipe, and rc/^vu, to cut.) This is an operation, by which an opening is made into the larynx, or trachea, either for the purpose of making a passage for the air into, and out of, the lungs, when any dis- ease prevents the patent from breathing through the mouth and nostrils ; or 6f extracting foreign bodies, which have ac- cidentally fallen into the trachea; or, lastly, in order to be able to inflate the lungs in cases of sudden suffocation, drowning, &c. The operation is also named tracheoto- my, or laryagotomy. Its practicableness, and little danger, are founded on the fa- cility, with which certain wounds ofthe windpipe, even of the most complicated kind, have been healed, without leaving any ill effects whatever, and on the na- ture of the parts cut, which are net fur- nished with any vessel of consequence. This operation is proper in several cases, and requires beini? differently prac- tised, according to a variety of circum- stances. It is not at all a dangerous proceeding, dummodo (says Fabricius ab Aquapendente) qui secat sit ana tomes peri- tus, quia sub hoc medico et artifice, omnia tutissime et felicissime peraguntur. 1. Broncholomy, we have said, is oc- casionally performed, to enable the pa- tient to breathe, when respiration through the mouth and nostrils, is impeded by dis- ease. Quinsy is an affection sometimes creat- ing a necessity for the operation ; but, of all those cases whxh Boerhaave has de- scribed, and of which his learned com- mentator has said so much, there is only that, which is named strangulans, for which bronchotomy is indispensable. This species of quinsy presents no visible symp> torn, neither in the throat nor the pha- rynx. The examination of the dead sub- ject proves, that the disease is situated in the edges of the rima glottidis, which 204 BllONCHOTOMV. opening becomes so contracted as scarce- ly to leave the smallest space. For til s reason, and on account of the tension of the ligaments of the glottis, the voice is rendered excessively acute, and hissing as it were. The suffocation is imminent ; the lungs not being expanded, the blood accumulates in these organs, and there is an impediment to the return of the blood from the head through the jugular veins. Hence, a plethoric-state ofthe brain is occasioned. Considering all these cir- cumstances, some have inferred that many of the patients, who have thus perished, might have been saved by making a timely opening into the trachea. All writers, who have treated of bronchotomy in cases of quinsy, have invariably regarded this operation as the ultimate resource. Both the Greeks and Arabians were of this sen- timent. In such ca-,es, Avicenna only re- commends bronchotomy in violent quin- sies, when, medicines have failed, and the fatient must evidently die from the unre- ieved state of the affection. Rhases also advised the operation only when the pa- tient was threatened with death. Thus we see, that bronchotomy, which might be Eroper in regard to the object intended, ecame hurtful fi-om the way, in which it was executed. It was doubtless in consequence of the ill-success of the operation, that Paulus iEgineta observed : In synanchicis quitlem chirurgiam improhamus, cum inutilis sitprx- cisio. Bronchoiomy, says M. Louis, will always be done too late, when only allow- ed as an extreme measure. The danger of perishing by suffocation, in cases of quinsy, M. Louis remarks, has been kuown from the very dawn of medicine. The advice of Hippocrates, to remedy this ufgent symptom, is a proof of it, and, he observes, that the danger is evinced when the eyes are aff" cted and prominent, as in persons who have been strangled, when the face, the thro t, and neck burn, with- out any thing appearing tube wrong on inspection. He rccojnniends fistulx in fauces ad maxillas iniriitlendx, qua spiritus in pulmonem trahatur. No d< ubt, he would have advised more, had it not been for the doctrine of his time, that the wounds of cartilages were incurable. This method, detective as it was, con- tinued till Asclepiades, to whom we owe the invention of broncholomv, if we may believe Galen. Since Asclepiades, this operation has always been recommended, and practised in cases of quinsy, threat- ening suffocation, notwithstanding the in- culcation of Cilius Aurelianus, who treat- ed it as fabulous. The mode of doing it, however, has not been well detailed by any who put it in practice, except by Paulus iE-tincta, who is very I 'tcwe nr*d clear. " We must (say.-, he) make the in- ci. ion in the trachea, under the lurvnx, abnut the third or fourth ring. This si. tnation is the most eligible, because it is not covered with any muscle, and^lo ve:>- sels are near it. The patient's head must be kept backward, in order that the tra- chea may project more forward. A trans- verse cut is to be made between two of the rings, so as not to wound the cartilage, only the membrane." The knowledge of this method, and its advantages in cases of the angina strnnguluiis, when practised in time, ought, according to M. Louis, to have rendered its performance a general practice. The convulsive angina of Bcerlisiave, which particularly aH'tcts*those, who can only breathe well in an upright posture, hud also been adduced as a ca-e demand- ing the prompt performance of broncho- tomy. Mead, in his Pracepta et Monita Medico, relates a case The patient, had been bled very copiously twice in the space of s x hours, but he died notwith- standing th.s large evacuation. The same author toi.k notice in Wales, especially, on the sea coast, of an epidi-mic catarrhal quinsy, wliich carried the pati< nts off in tv. o or three days. In these instances, bleeding was not of much use, and bron- chotomy, wheli was not performed, was the only means of saving the patients. The practitioners of the present day are generally less sanguine in (heir tx- pectation of benefit, in cases of angina and croup, than M. Louis was. l-'rom the observations of Dr. Cheyne, it would appear, that, in croup, the operation cannot be necessary for the purpose of admitting air into the tvachea*; for, in those, who have died of the disease, he has found a pervious canal, of two-eighths of an inch in diameter, and through a tube of such diameter, even an adult can support re- spiration for a considerable time.' Ac- cording to the same writer, bronchotomy is equally unfitted for the removal of tlie membrane formed by the effusion of lymph; for, from its extent, variable tenacity, and adhesions, this is, in almost every case, totally impracticable; and even could the whole membrane be removed, still the function of respiration would be but litile improved, the ra- mifications of the trachea and bronchial cells remaining obstructed (See Chey- ne's Pathology ofthe Larynx and Bronchia.) M. Pelletan joins the best modern wri- ters, in representing the bronchotomy as generally useless in cases of croup: the only example, in which he thinks the ope- ration might be serviceable, is where the disease is confined to the larynx, a case, . BllONCIIOTOMV. JOo which seems to be very uncommon, and difficult to distinguish. " En suppoaant enfin P angine avec concretion bien caructer- i*ee, on se trouvera encore enlre la cruinte de prutiquer une operation inutie, si les con- cretions se prolongent jusque dans les bran- ches, et Pimpossibilite dejuger si ces concre- tions sont bornees au larynx. C'esl en effet dans ce seal cas que Poperation peut etre fructueuse ; ellefacilitera la respirution pen- dant que la nature, aidee de Part-, travaille- ra a dissoudre, detacher, el faire expectorer leifausses membranes qui obliterent laglotte etlelwytuc. (Cliitique Chirurgicale, Tom. l.p. 28 y Dr. liaillie has recently published three cases, in which death was produced in ■vie adult subject, and, in a very few days, by a violent inflammation of the larynx and trachea. The disease had a strong resemblance to croup -, but, yet was dif- ferent from it. Tiiere was not the same kind of ringing sound of the voice as in croup, and no layer of coagulable lymph was formed upon the biirface of the inner membrane of the l*..:*y;*.x and trachea, which, according to Dr. Baillie, uni- formly attends the latter disease. In one of these cases, the cavity of the glottis was found to be almost obliterated, by the thickening of the inner membrane of the larynx at that part. The inner membrane of the trachea was likewise inflamed; but, in a less degree. The lungs were sound. If, in thirty hours, no relief should be de- rived from bleeding ad deliquium, and the exhibition of" opiates, Dr. Baillie con- ceives, that, m this sort of case, it might be advisable to perform the operation of -bronchotomy at the upper part ofthe tra- chea, just under tiie thyroid gland. This operation, he thinks, would probably en- able the patient to breathe, till the inflam- mation in the larynx, more especially, at tlie aperture of the glottis, had time to subside. (See Transactions of a Society for the Improvement of Med. and Chirurgi- 'cai Knowledge, Vol 3, p. 275—289.) The compression of the trachea by fo- reign bodies, lodged in the pharynx, or by tumours, formed outwardly, and of suffi- cient size to compress the wind-pipe, is an equal reason for operating, more or less expeditiously, according to the symptoms. Mr. 15. Bell mentions two instances of suffocation from bodies falling into the pharynx. Respiration was only stopped for a few minutes; but, the cases were equally fatal, notwithstanding the em- ployment of all the usual means. This author thinks, there was every reason to believe, that bronchotomy would have been attended with the greatest success, if it had*been performed in time, before tlie effects of the suffocation had become mortal. The operation should also be done, when ihe trachea is compressed by tumours. The. author, of tiie article Bron- chotomie, in I* Encyclopedic Methodique, says, thatabou. tweniy years ago, he open- ed a man, who had died of an emphysema, winch came on instantaneously. He had had, for a long while, a bronchocele wh.ch was of an enormous magnitude towards the end of his life. The cavity of the tra- chea was so obliterated, that there was scarcely room enough to admit the ifiick- ness of a small piece of money. Doubt- less, bronchotomy, performed before tlie emphysema made its appearance, would have prolonged this man's days. In ca.-*es of this last description, Desault would have advised the introduction of an elastic gum catheter into the trachea from the nose, in order to facilitate re- spiration. This practice, I believe, has nothithertobeen attempted by English sur- geons, though it has been repeatedly tried in France. (See (Euvres Chirurgicales de Desault, par Bichat, Tom. 2, p. 236, &c.) M. Habicot, in a treatise, in titled, Question Chirurgicale sur la Possibilite et la Necessite de la Bronchotomie, mentions his having successfully performed this opera- tion on a lad fourteen years old, who, having heard it said, that gold, when swal- lowed, did no harm, attempted to swallow nine pistoles, wrapped up in a piece of cloth to hide them from thieves. The packet, which was very large, could not pass tiie narrow part ofthe pharynx ; and here it lodged, so that it could neither bt; extracted, nor forced down into the sto- mach. The boy was on 1he point of be- ing suffocated by the pressure, wliich the foreign body made on the trache;<; and his neck and face were so swollen and black, that he could not have been known. M. Hubicot, to whose house the patient was brought, attempted in vain, by differ- ent means, to dislodge the foreign body. At length, perceiving the patient in evi- dent danger of being suffocated, he resolv- ed to perform bronchotomy. This opera- tion was no sooner done, than the swelling and lividity of the face and neck disap. peared. M. Habicot pushed the pieces of gold down into the stomach with a leaden probe, and the pistoles were, at different times, discharged from the anus, eight or ten days afterwards. The wound of the trachea very soon became quite well. (See Mem. de I'Acad. de Chirurgie, Tom. 12, p. 243. Edit, in 12mo.) In such a case, Desault would have in. troduced an elastic gum catheter into the larynx, instead of performing bronchoto- my, which would not answer, were the foreign body low down. (See QSuvret Chirurg. de Desault, Torn. 2, p. 247.) 206 BRONCHOTOMY. 2. We have said, that foreign bodies in the trachea, may render it necessary to practise bronchotomy. M. Louis, in an excellent memoir, on extraneous sub- stances in the trachea, has proved, more convincingly than all other preceding writ- ers, the necessity of the operation in cir- cumstances of .this kind. The proofs are adduced in a case, which fell under his own observation, and which we shall quote. On Monday, tlie 19th of March, 1759, a little girl, seven years old, playing with some dried kidney-beans, threw one into her mouth, and thought she had swal- lowed it. She was immediately attacked with a difficulty of breathing, and with a convulsive cough, which was very afflict- ing. The little girl said, she had swal- lowed a bean, and such assistance as was thought proper, was given her. Want of success was the cause of several surgeons being successively sent for, who vainly employed the different means, prescribed by art, for extracting foreign bodies from the oesophagus, or forcing them into the stomach. A fine sponge, cautiously fas- tened to the end of a whalebone probang, was repeatedly introduced through the whole extent of the ccsophagus. The lit'le girl-, who made a sign with her fin- ger, that the foreign body was situated in the middle of the neck, thought that she felt some reUef, when the sponge was con- veyed below the place which she pointed out. She had, every now and then, a violent cough, tlie efforts attending which produced convulsions in all her limbs. Deglutition was unobstructed; and warm water and oil of sweet almonds had been swallowed without difficulty. Two whole days had passed in sufferings, when the relations called M. Louis to render his assistance. The little girl, with all pos- sible fortitude and sense, was several times held in her friend's arms, ready to die of suffocation. M. Louis, well aware of what had happened, came into the room, where the patient was. She was sitting up in her bed, suffering no other symptom, than a very great difficulty of breathing. M. Louis enquired where she felt pain, and she made such a sign in re- ply, as left no doubt concerning the nature of the accident. She put the index finger of her left hand on the trachea, between the larynx and sternum. The fruitless attempts which hid been made in the oesophagus, with a view of dislodging the foreign body; the nature and the small- ness of this body, which was not such as would be stopped in the passage for the food; and the ficility of swallowing, were negative proofs that the bean was not in the oesophagus. Respiration was the only function disturbed; it was at-, tended with difficulty, and a rattling in the throat. The tftTle""g'irl expectorated a frothy fluid, and she pointed out so ac- curately the painful point where the ob- ject producing all her sufferings was si- tuated, that M. Louis did not hesitate to declare to the relations, from this single inspection, that the bean was in the w ind- pipe, and that there was only one way of saving the child's life, which was to make an incision, for the purpose of extracting the foreign body. He apprised them that the operation was neither difficult nor dangerous, that it had succeeded as often as it had been practised, and that the very pressing danger of the case only just allowed time to take the opinion of some other well-informed surgeons, re- specting the indispensable necessity for such an operation. M. Louis thought this precaution necessary, in order to ac- quire the confidence of the parents, and to shelter himself from all reproach, in case the event ofthe case should not cor- respond with his hopes. M. Louis went home to prepare all the requisites for bronchotomy, and, in two i-ours, he was informed the surgeons, who were con- sulted, waited for him. Since M. Louis went away, the child had become quiet, and was lying on its side asleep. The opinion he had delivered, had been ill- explained by the friends and attendants, and had been discussed, before his return. They, who had been rendering their as- sistance, on the supposition, that the fo- reign body was in the oesophagus, evinced surprise at the proposal of extracting, by an operation, a substance, the presence of which, in any part of this tube was not obvious. M. Louis explained his advice, in regard to bronchotomy, and he did not expect a doubt to be set up against so posi- tive a fact. The investigation of truth may authorize objections, to which those who make them, only give the value which is due ; but M. Louis was asked concern- ing the possibility of the case. It was objected, that a substance as large as a bean could not insinuate itself into the trachea. He brought every one into his sentiment, by a short explanation of cases of this sort, with wliich he was himself acquainted. The little girl was examin- ed, she was better, than when M. Louis saw her before, and a very palpable em- physema was seen above the clavicle, on each side of the neck, a symptom which did not exist two hours previously. This swelling made M. Louis conclude, that the urgency for the operation was still greater. The friends, whose confidence had been shaken by the opposition he had experienced in .bringing about unanimity, BRONCHOTOMY. 207 were in the greatest embarrassment, when out much inconvenience, the passage be- they were told, that the child might die ing only somewhat obstructed, according of an operation, which he had represented to the position of the substance. It may as only a simple incision, free from all even remain several days, months, or years, danger. M. Lotus was repeatedly asked, without producing any symptom of its if he would be responsible for the child's presence, except a trivial sensation of ob- life during the operation, and he in vain struction, and this is what happens, when replied, that if there were any thing to the body lodges in one of the ventricle's fear during tiie operation, it would be of the larynx. Facts of this kind are to from the accident itself, and not from the be found in Pulpitis, Bartlioline, and many assistance rendered. This distinction other observers. But, when the extra- was not perceived, and M. Louis with- neons substance quits its situation, and drew, at the same time refusing his con- is carried into the trachea, the irritation, sent to the exhibition of two grains of which it produces there, and, particular- emetic tartar, the effect of wliich would ly, about the larynx, occasions coughing, be useless, and might be dangerous. The and if, in tiie fits, the foreign body should medicine was given in the night: the become fixed between the lips of the child was fatigued with its operation, and glottis, it may cause instantaneous death, quite unbenefited. On Tuesday morning, as probably has happened in many of the M. Louis found the little girl very quiet, cases of suffocation from extraneous sub- and they who had paid their visits before stances. him, found her wonderfully well. The Another remarkable circumstance which respiration, however, continued to be still deserves more attention, as it confirms attended with a rattling noise, wiiich the presence of a foreign body in the tra- M. Louis had observed in the evening, chea, is the emphysema, which appeared when the breathing was much more labo- about the clavicle, towards the termina- tions. The child was nearly suffocated tion ofthe case. M. Louis did not beUeve, several times in the course of the day, that any of the persons, who saw the and died in the evening, three days after patient, could entertain a just idea ofthe the accident. origin of this symptom. It might be M. Bordenave, who had seen the pa- imagined, that the obstruction, which the tient, informed M. Louis of the ciiild's foreign body caused, for two days, to the death on Friday. The body was opened, free passage ofthe air, might have occa- before a numerous assembly of persons, sioned a forcible distention of the trachea, After making a longitudinal incision and a rupture of the membranes, which through the skin and fat, along the tra- connect together the cartilaginous rings chea, between the sterno-hyoidei muscles, of this tube ; but this error was dispelled M. Hordenave slit open the trachea, cut- by the examination after death The windy ting three of its cartilages. This very tumour had not originated in the cir- instant, every one could see the bean, and cumference ofthe trachea; here its limits M. Louis took it out with a small pair of were only seen. The very substance of forceps. It was manifest, from the ease, tiie lungs, and the mediastinum, were with which this foreign body was extract- emphysematous. The air, which was con- ed, that the operation would have had, on fined by the foreign body, must have the Uving subject, the most salutary ef- ruptured the air-cells, during the violent feet. The relations had to regret having fits of coughing, and thus insinuated itself sacrificed a child, which was dear to them, into the interlobular cellular substance to an irresolution and a timidity, wliich of the lungs. Thence the air must have the most persuasive arguments could not passed into the cellular substance of the remove. (Mem. de PAcad. Royale de Chi- lungs. Thence it must have passed into rurgie, Torn. 12, p. 293,&c.Edit.inl2mo.) the cellular substance connecting the This case evinces, in the most decided pleura pulmonaUs with the outer surface manner, the symptoms, wliich result from of these organs, and by the communica- the presence of foreign bodies in the tra- tion of the cells with each other, it pro- chea, and shews the only one surgical duced a prodigious swelling of the cellu- proceeding, which can be of use But, lar substance, separating the two layers among the phenomena, apparently difficult of the mediastinum. The emphysema, in of explanation, is the calm, which, at dif- its progress, at length made its appear- ferent intervals, followed the afflicting ance above the clavicles. The swelling cough. Anatomy, however, has dispelled of the lungs, and the circumjacent parts, much of the doubt on this matter. It is in consequence of the insinuation of air known, that the whole canal ofthe trachea into the cellular substance, is a manifest is much less sensible, than the rima glot- cause of suffocation. The tumefaction tidis. A foreign body, like a bean, may appears to be so natural an effect of the remain a certain time in *hat canal with- presence of a foreign body in the teachea^ 20*8 BRONCHOTOMY. that one can hardly believe it is not an essential symptom,, though before M. Louis, no author made mention of it. Foreign bodies in the trachea, however, do not always cause death so suddenly, which may be owing to their smallness, their .smoothness, or the situation in which they are fixed. An example is related in les Ephemeriiles des Curieux de la Nature, Decad. 2. Ann. 10. As a monk was swal- lowing a cherry, precipitately, the stone of the fruit passed into the trachea. A violent cough, and excessive efforts, as it were, to vomit, were the first symptoms of the accident, and of these the patient thought he should have died. A sleep of some hours followed this terrible agita- tion, and the patient afterwards did not feel the least inconvenience during a whole year. At the end of this time, he ' was attacked by a cough, attended with fever. These symptoms became worse and worse, every day. At length the pa- tient evacuated a stone as large as a nut- meg. It was externally composed of tar- tareous matter, to which the cherry-stone had served ?s a nucleus. A copious puru- lent expectoration followed the discharge of the foreign body, and the patient died consumptive some time afterwards. No mention is made of the body being open- ed; but, from the symptoms, there is every reason to believe, that an abscess must hav*» arisen in the substance of the lungs, from the presence of the foreign body. That foreign bodies in the trachea, even when they do not induce pressing symp- toms of suffocation, may ultimately kill the patient by inducing disease of the lungs, is proved by several cases on re- cord, and, particularly by one, which occurred to Desault; a cherry-stone was lodged in one of the ventricles of the larynx; the patient would not consent to an operation, and died after two years d'une phthisie laryngee. (See GSuvres Chir. de Desault, Tom. 2, p. 258.) Some valuable observations, confirming the necessity of an early recourse to bron- chotomy, in cases, where foreign bodies are lodged in the trachea, have been pub- lished by M. Pelletan, now one of the surgeons ofthe H6tel-Dieu, and a practi- tioner of vast experience. In one case, in which a bean had fallen into a child's trachea, and in which the most urgent symptoms of suffocation had prevailed for four days, and convulsions during the last thirty-six hours of this space of time, M. PeUetan performed the operation, which a timid practitioner, under whose manage- ment the young patient was first placed, had neglected to do at an earlier period. Upon the incision being made into the rachea, -the beaa was immediately thrown out to the distance of two feet, and tns child for a time was relieved. The little boy was so extremely weak, that it was at one time supposed he was dead. How. ever, with the assistance rendered to him, he gradually revived, even regained his senses, called his parents, and asked for such things as he wanted. This hopeful state lasted eight or ten hours, after wliich, convulsions came on again, and the child died fourteen hours after the operation. Notwithstanding the turgid appearance of alf the blood-vessels of tlie brain, as detected after death, the little* boy had yet received a degree of relief at the in. statu of the foreign body being extracted. M Pelletan deems it unnecessary to insist on the great probability of success, that would have attended the operation, had it been performed at an earlier period. . Of such success, M. Pelletan gives ns the f< dlowing example. In the month of May, 1798, a child, about three years old, was brought to the Hotel-Dieu, who, in playing with some French beans, and putting them into its mouth, let one of them .slip into the tra- chea. For three days, the child was af- flicted with a continual cough, and some- times the symptoms of suffocation were most pressing. This time had bee**h spent in administering emetics, introducing in- struments into the oesophagus with the design of forcing the foreign body into the stomach, and in inspiring the relations with a pernicious confidence, arising from the very long intervals of repose, which the child experienced, during which, how- ever, a rattling in the throat continued, a characteristic mark of the accident Pelletan immediately decided to perform the operation. The child was very fat, and this circumstance, together with the small diameter of the trachea at this age, rendered the exposure of the anterior portion of this tube difficult. Pelletan was at this moment struck with the reflec- tion, that •bronchotomy should never be attempted except by men of science, cool- ness, and experience in operations. Th-**- rings of the trachea, however, were at length cut, and there was no Sensible In- terval, between the incision and the ex- pulsion of the foreign body. The bean had swelled considerably with the mois- ture. The child seemed restored to life; it spoke freely; it was only troubled with coughing, the effect of a small quanthy of blood insinuating itself into the trachea, which fluid was instantly rejected again. This event has the appearance of convul- sions, and may alarm those, who do not understand it; but, according to Pelletan, it is the guarantee ofthe patient's life by BRONCHOTOMY. 209 rxpelling, incessantly, and without diffi- culty, whatever happens to get into the trachea. The wound was healed in twen- ty days, and the child's voice was not per- ceptibly altered. In another interesting case, recorded by the same writer, a pebble was lodged in the windpipe, and the case, not being understood, was treated, for about three weeks, as a simple inflammation of the lungs. At last, bronchotomy was per- formed, and, by placing the child in a horizontal position, the stone was soon discharged through the incision. The patient was immediately reUeved; but, the effects of the inflammation of the lungs, and injury which these organs had sustained, could never be entirely cured, and the child died phthisical eight months afterwards. M. PeUetan details other cases, in which the foreign body, being fixed in the trachea, could not be forced out by the breath, as soon as tiie incision was made, but, required further means to disengage it. In one instance, Pelletan made a long cut in the windpipe of a child; but, no- thing" made its appearance. A probe, wrapped round with some oiled linen, was then introduced several times up and down the larynx, without creating a great deal of uneasiness, and the child con- tinued to respire very well through the opening in the trachea. The foreign sub- stance was presently brought to the wound and extracted: it proved to be part of the jaw of a mackarel, with many sharp teeth in it. This child soon experienced a per- fect recovery. In another instance, a young man came to the Hotel-Dieu, in consequence of be- ing afflicted, for six weeks, with a severe cough, frequently accompanied with a sense of suffocation. These complaints, on enquiry, were ascertained to arise from a button mould having fallen into the tra- chea. An opening was, therefore, made in this tube; but, though the button could be felt, it could not be extracted with the finger. The cricoid cartilage was now divided, and the foreign body was then taken out of the left ventricle ofthe la- rynx. The man recovered. In one case, related by Pelletan, a piece of tendon of veal, got down the glottis, and gave rise to most dangerous symp- toms. The foreign body was described as being so large, that this surgeon could not but suppose, that the complaints were owing to its lodgment in the oesophagus, as it ,seemed to be incapable of entering the glottis. The introduction of instru- ments down the pharynx, however, pro- duced no relief; but, on dividing the thy- roid cartilage, PeUetan passed his finger Vol. I. within the larynx, and, without knowing it, pushed the piece of tendon towards the glottis, when, w ith the aid of a pro- bang, it was forced into the pharynx and swallowed. The patient experienced im- mediate relief, and got quite well. (See Pelletmi's Clinique Chirurgicale, Tom. 1.) With respect to bronchotomy, or cases, in which extraneous substances are sup- posed to be lodged in the trachea, one im- portant caution seems necessary, viz; whenever the foreign body is above a cer- tain size, a probang should always be passed down the oesophagus before cut- ting into the windpipe; for, very similar symptoms to those, wliich proceed from extraneous substances in the trachea, may be caused by the lodgment of foreign bodies in the oesophagus. In fact, bron- chotomy has actually been performed, while the extraneous substance was in the oesophagus, from which last situation no attempt was made to displace it, and the patient lost his life. (See QZuvres Chirurgicales de Desault, Tom. 2, p. 261.) Bronchotomy has been proposed in cases, in which the tongue is so enlarged, as totally to shut up the passage through the fauces. Richter mentions an inflam- mation of the tongue, in which this part became four times larger than in the na- tural state. Valescus had made the same observation .- Ego eliquundo vidita magnifi- catan, linguam propter humores, ad ejus subslantiam venientes, et ipsarn imbibentes quod quasi totum os replebat, et aliquando ex ore exibat. Lib 2, cap. 66. Such prodi- gious swellings of the tongue ,are said sometimes to occur in malignant fevers, and the small-pox. They are also some- times quite accidental, as, for instance, the cases which happen from the stings of insects, or the unskilful employment of mercury. Mr. B. Bell gives an ex- ample of the latter sort. He says, that the patient had taken, in a very short time, so large a quantity of mercury, that the part became alarmingly swollen in a few hours, and, though all the usual re- medies were tried, none had the least ef- fect. Bronchotomy was delayed till the patient was nearly suffocated ; but he was restored as soon as an opening was made in the trachea. Some have objected to this practice, alleging, that scarifying the tongue will bring relief in time. (Encyclo- pedic Methodique; Partie Cldrurgicale, Art. Bronchotomie.) M. Malle's observa- tions on the swelling of the tongue, and the most effectual means of relieving it, seem to confirm the latter sentiment.— (Mem. de PAcad. de Chirurgie, 'Torn. 14, p. 408, &c. Edit, in 12mo.) In cases of the preceding description, Desault would have advised the introduc- E E 210 BRONCHOTOMY. tion of an elastic gum catheter, from the nose into the trachea, in order to enabtc - the patient to breathe, until the swelling ofthe tongue had subsided. (See (Euvres Chirurgicales de Desault par Bic/uit, Tom. 2, p. 246.) Bronchotomy has been proposed, when both the tonsils are so enlarged that they quite impede respiration. Here, the in- flammatory swelling is not meant; tliis commonly soon suppurates, and the spon- taneous bursting of the tumour, or the opening of it With a pharyngotomus, al- ways does away tiie necessity for so ex- treme a measure. It is the chronic en- largement now alluded to, that case men- tioned in the article Tonsils, and wl ich sometimes acquires an immense size. From our remarks on the disease, it will be seen, that more is to be expected from the excision of the tonsils, than from the operation now in question. Besides, be- fore the glands are so large as to threaten suffocation, they should be cut away, in preference to performing bronchotomy, which would reUeve the urgency, but not the cause. In general, thet e is here only a fear of suffocation, when the swelling is such as not only to shut up the posterior aperture ofthe mouth, but also the poste- rior openings of the nostrils, which is ex- ceedingly rare. In cases of obstructed respiration from enlargement of the ton- sils, Desault preferred the introduction of the elastic catheter, from the nose into the larynx, to the operation of broncho- tomy. It is not common for a polypus to make this operation necessary. Boerhaave, however, mentions a case, in which the patient was suffocated, as the surgeon was going to extirpate a tumour of this kind : no doubt, this patient might have been saved, if bronchotomy had been previously performed. Polypi, growing in the larynx itself, are very rare; but, examples are recorded; and, if such tumours happen "* to obstruct the glottis, the patients are instantly suffocated. Some instances of this kind are related by Bichat. The only mode of getting at such swellings so as to extirpate them, is by performing bronchotomy. (See QZuvres Cldrurg. de Desault par Bichat, Tom. 2, p. 254,255.) Lastly, bronchotomy has been recom- mended to be done on persons recently suffocated or drowned. Detharding is the first author, who has treated of the necessity of this operation, in the latter case, in a letter addressed to Schroeck, intitled, De Methodo subveniendi submersis per laryngotomiam. Hactenus recte, says Haller, si spuma qua pidmo in submersis of- fercitur ed administratione repelli quiret. This writer maintains, that drowned per- sons have no water in. their chests, or air-vessels of the lungs, and that thfy perish suffocated, for want of air and re- spuation, and that, while the person is under water, the epiglottis applies itself so closely over the glottis, that not one drop of water can pass. But, these as- sertions are quite contrary to the nume- rous experiments made by M. Louis, who drowned animals in coloured fluids, and proved that they who are drowned, in- spire water, with which the air-vessels and cells are quite filled. M. Louis has alsu opened men, who have perished under water, but, in them, he never found the epiglottis applied to the glottis, as Dethar- ding says it is; indeed, anatomy proves the impossibility of its being so. Dethar- ding's theories were wrong, and, as he did not use any power to distend the lungs with air, his mere practice of bron- choiomy must have been useless. iVhen there is a free communication between the cells of tiie lungs and the atmosphere, the air will not expand these organs, if the inspiratory muscles can no longer act. Hence, after opening the trachea, and letting as much water run out of this tube as possible, the pipe of a pair of bel- lows should be introduced, and the air forcibly introduced into the lungs. Dethaiding's opinion, that drowning is a species of suffocation, was right, and that the privation of oxygen gas is the cause of death. Hence, we ?ee the pro- priety of introducing this air in.o tie lungs, as speedily as possible, whenever we think, that animation has not been so long suspended, that every hope of re- storation is over. Indeed, it is proper to distend the lungs with air, in all cases in which animation has been recently sus- pended by suffocation, immersion under water, or by noxious vapours and gases. This measure is highly proper, in conjunc- tion with electricity, the communication of warmth to the body, the application of strong volatiles to the nostrils, rubbing the body with warm flannels, and the in- jection of any^fluid, like warm wine and water, into the stomach, through a hol- low bougie. Tobacco clysters, which even have had the sanction of the Koyal Humane Society, should, however, be re- probated, as the qualities of this plant are peculiarly destructive of the vital principle, and not simply stimulating. I am sorry to find this last means com- mended by so respectable a surgeon as M. Larrey, who joins the rest of the French surgeons in condemning electricity and bronchotomy. He speaks iw favour of opening the jugular vein, exposing the body to the fire, friction, Jkc. On dis- secting the bodies of some drowned per- sons, M. Larrey found, as M. Louis had BRONCHOTOMY. 211 done long since, that the air-tubes of the lungs were filled with water, instead of air, and, that the epiglottis was raised and applied to the os hyoides. (See Me- moires tie Chirurgie Militaire, Tom.'l, p 83—85.) There are many modern practitioners, who consider bronchotomy, as needless in cases of suspended animation, because, it is contended, that, as the patient is al- ways destitute of sensation, a tube may easily be passed into the trachea from tlie nose or mouth, for the purpose of in- flating the lungs. Either the curved pipe of a pair of bellows may be introduced into the glottis through the mouth, or an elastic gum catheter may be passed into the trachea from the nose. " On peut mettre ce moyen d execution (says Pelletan) chez les aspluxies, ou lesenfansnouveaux nes, qui ne respirent pas ; parsque, dans ces de- ferens cas, non settlement il n'y a pas d'in- fiammation, mais mime tpute sensibilite est suspendue, et la canule est commode pour souffier de Pair dans les poumons, en meme temps qu'elle peut causer une irritation salu- taire. M. Baudelocque, mon ceiebre con- frere m'a temoigne se servir habituellemcnt, et avec succes de ce moyen pour appelerd la vie les nouveaux nes dont la respiration ne s'etablitpas. (Clinique ChirurgicaleT Torn. l.p.29.) Desault likewise conceived, that the lungs might be easily inflated, without „ performing bronchotomy. (CEuvres Chir. Tom. 2, p. 239.) Mr. A. Burns adopts the same senti- ment. (Surgical Anatomy ofthe Head and Neck, p. 384.) My own individual opinion upon this •subject is, that, if a surgeon knows, that he can inflate the lungs as completely and expeditiously, without performing bron- chotomy, as he could, by making an in- cision in the trachea, he is right in dis- pensing with the latter operation. But, in the generality 0f cases of suspended animation, (that of new-born infants ex- cepted) where bronchotomy would be an objectionable undertaking, I much doubt, whether in actual practice bronchotomy will not be found the best and most speedy means of enabUng the surgeon to distend the lungs with air. If you follow De- sault's suggestion, I contend, that you are likely to be some minutes longer in getting the elastic catheter from the right nostril into the larynx, than you would be in cutting into the trachea, and intro- ducing into the incision the muzzle of a pair of'bellows. Supposing the elastic catheter introduced, will you now be able to distend the lungs with air, in an ade- quate degree, an object of the highest moment? A pair ot bellows seems to me almost essential to this purpose. I shall say nothing on the probability of many practitioners coining to the patient un- provided with the requisite sort of tube. If a pair of bellows, with a curved pipe, be employed, many surgeons would be a considerable time in getting the muzzle into the glottis, and, in the mean while every spark of life might be extin- guished. On the other hand, broncho- tomy (performed by a man of ordinaiy care and skill) is an operation free from danger. It may be executed with a pen- knife, if no better instrument be at hand; and, when the incision has been made, a pair of common belloWs will suffice for the inflation of the lungs. Did I con- ceive, that bronchotomy were a perilous operation ; that the lungs could be effec- tually distended without the employ- ment of bellows ; that the object could generally be accomplished as expedi- tiously without cutting into the trachea; I should be as ready to join in the con- demnation of this last proceeding as any cotemporary writer. Greatly, however, as I respect most of the authors, who differ from me on this point, the reasons I have assigned, prevents me from subscribing to their sentiment. Desault, who may be regarded as the founder of the doctrine, concerning the inutility of bronchotomy, it is also to be observed, spoke only from theory, and not actual practice, in these cases. / DESCRIPTION OF THE OPERATION. No preparation is necessary, as delay only increases the danger. The patient being seated in an arm-chair, or, what is better, laid on a bed with his head hang- ing backward, an incision is to be made, which is to begin below the cricoid carti- lage, and to be continued downward, about two inches, along the space be- tween the sterno-thyroidei muscles. Care should be taken not to cut the lobes of the thyroid gland, lest a troublesome and dangerous bleeding should be occasioned, and, as the left subclavian vein lies a little below the upper part of the first bone of the sternum, the incision should on no account ever extend in the least below the top of this bone. The knife must not be carried either to the right or left, in order to avoid all risk of injuring the large blood vessels situated at the sides of the trachea. The incision in the inte- guments being made, the sterno-thyroidei muscles are to be pushed a little towards the side of the neck, so <*as to bring the trachea fairly into view. M country has had the good fortune to sur- vive the Caesarean operation, though it is said, that there are eighteen examples recorded, in which it has been performed in Great Britain. Ten of the children, however, are stated to have been saved. On tlie continent, the practice has proved infinitely more successful; for, of 231 cases of this operation, to be found in the records of medicine, 139 are said to have terminated successfully. (Kellie, in Edinb. Med. and Surgical Journal, Vol, 8, p. 17.) When the foetus is contained in the womb, and cannot be expelled, by rea- son of the invincible obstacles already mentioned, the Caesarean operation should be practised, before the mother, and foetus, both perish from the violence of the nains, hemorrhage, convulsions, &c. For this purpose, it is necessary to make an extensive incision in the inte- guments of the abdomen, and in the uterus. Some have thought, that cutting the parietes of the belly was mortal, while others have believed a wound of the uterus to be so. Hence, such persons have condemned tbe operation on the principle, that religious reasons do not authorize taking one life to save another. All the opponents of the Caesarean opera- tion fear the hemorrhage, which, they say, must foUow. Indeed, if the uterus were not to contract sufficiently, when the foetus and after-birth have come away, the bleeding would really be pe- rilous. But when, by means ofthe Caesa- rean operation, the fectus is extracted, together with the placenta and mem- branes, the uterus will then contract, just Go 226 CESAREAN OPERATION as it does after a natural labour. Be- sides, even when the mother is alive, the operation is not commonly done, till the uterus evinces a propensity to deliver it- self, and begins to contract. The womb being delivered of its contents, the inci- sion becomes closed, the vessels oblite- rated, and there is no fear of hemorrhage. The wound must also make so irritable an organ more disposed to contract; but, whatever arguments may be adduced, it is enough to say in tM-s case: Artem ex- pcrientia fecit, exemplo monstrante viam. Rousset, in 1581, published a work, in French, intitled, Hysterotomie, nu I'Ac- cmchement Cesarien. This book, in 1601, was translated into Latin, and enlarged with an appendix by the celebrated Bau- hin. Even then, the practice ofthe Caesa- rean operation on the living mother had its defenders. Bauhin relates that, in tiie year 1500, a sow-gelder performed the Caesarean operation on his wife, tarn feli- citer, ut ea posted gemellos et quatuor adl uc infantes enixa fuerit. This is said to be the first instance, in which the operation was ever done on the living mother with success. -Many other cases were after- wards collected, and published. The possibility of operating successfully on the living mother has been demonstrat- ed, with so much perspicuity and accu- racy, by M. Simon, in Tom. 1, de I'Acad. de Chiriirgie, in 4to. that there cannot be a doubt of the thing having been fre- quently practised with success. Here we are presented with a collection of sixty- four Caesarean operations, more than a half of which had been done on thirteen women. Some of these had undergone the operation once, or twice ; others five or six times. There was one woman in particular, who had undergone it seven times, and always with success. This seems to prove, notwithstanding all asser- tions to the contrary, that the operation, for-the most part, succeeds. But, if the life of the mother should not invariably be preserved, the Caesarean operation ought not to be rejected on. this account; it ought always to be done, when relief cannot be obtained by other means; just as amputation and lithotomy are prac- tised, though they are not constantly followed by success. Would any thing be more cruel, than to abandon a mother and her child, and leave them to perish, while there is any hope of saving them both ? It is true, that when a pregnant •woman dies of any inward disorder, and not from the pains, and efforts of labour, the foetus is sometimes still alive in the uterus j but, in cases of death, after diffi- cult labours, and the great efforts, made by the uterus to overcome the obstacles to parturitibn, the foetus is generally dead; and the operation therefore is hss likely to be availing. (Sec Bertrandi Triu'te des Operations de Chirurgie, Chap. 5.) It is the opinion of the best writers upon this subject, that whenever a wo- man dies, at all advanced in pregnancy, the performance of the Caesarean opera- tion is highly proper. Experience has proved, that when the foetus has not attained the period, at which parturition •commonly happens, it will sometimes survive tiie operation a considerable time, and that, when it is full grown, hs life mayybe most happily preserved. Al- though instances are cited, in which the foetus in utero has been found alive up. wards of four and twenty hours after the death of the mother, little stress sluJuhl be laid on such prodigies. The operation ought to be done without any delay.^ Even •then, we are not certain of saving the infant's life. Tiie greater number of foetuses perish at the same time as tlie mother, and from the same causes. If the mother should happen to die in la- bour, and the neck of the uterus were sufficiently dilated, or disposed to be so, an attempt should be made to accomplish delivery in the ordinary way; for, ex- amples have occurred, in which, women, supposed to be dead in this circumstance, were in reality alive. Hence, we find, that the senate of Venice formerly enact- ed a law, by wliich practitioners were liable to punishment, in case they neg- lected to operate with as much caution on a pregnant woman, supposed to be dead, as on the living subject. (Riche- rand, Nosographie Chirurgicale, Tom. 4, p. 395, Edit. 2.) In the Journal de Savans de Janvier, 1749, the following case, con- firming the propriety of such caution, was inserted by M. Rigaudeaux, surgeon to the Military Hospital at Douay. This practitioner, having been sent for to a woman, to whose residence he was un- able to proceed, till two hours after her apparent death, he had the sheet, with which she was covered, removed, and perceiving that the body retained its sup- pleness and warmth, he tried whether the foetus could not be extracted in the ordinary way, which was easily effected as soon as the feet were got hold of, The first endeavours to save the child,' were very unpromising ; but, after a few hours, they had the desired effect. As the woman continued in the same state, five hours afterwards, Rigaudeaux recom- mended, that she might not be buried, before her Umbs were quite cold and stiff. He afterwards had the satisfaction to learn that she was also restored to CXSAREAN OPERATION. y22"/ hfe. This remarkable case happened on the 8th of June, 1745, and both the mo- ther and child were living, at the period, when Rigaudeaux published the observa- tion. Supposing, however, delivery in tlie ordinary manner to be impracticable, at all events, the Caesarean operation ought to be performed, with the same cautions, as if the mother were alive, only one inci- sion being made for the purpose of open- ing the uteni9. Almost all the insurmountable obsta- cles to delivery originate from the bad conformation ofthe pelvis, which depends upon rachitis ; though it is not an inva- riable consequence of it, since there are women, extremely deformed, in whom no ' imperfection of tiie pelvis exists, while it prevails in others, whose shape is but trivially disfigured. An examination of the dimensions of the pelvis is the right mode of ascertaining, whether there is really such an impediment to parturition. In order that the dimensions may not be an obstacle to delivery, the distance, be- tween the upper edge of the sacrum and the os pubis, ought to be three inches and a half; and the distances, between the tuberosities of the ischium, and be- tween each of these protuberances and the point ofthe os coccygis, three inches. Women have indeed beenvknown to be delivered, without assistance, although the first of the above distances, was only two inches and a half; but, then the heads of the children were so elongated, that tlie great diameter was nearly eight inches, whUe that, which extends from one parietal protuberance to the other, was reduced to two inches five or six lines, and the infants were lifeless. If they are to be born alive, they must be taken out of the womb by the Caesarean operation; but, the latter proceeding should never be adopted, without a cer- tainty, that they are actually living; for, when dead, they may be extracted in a way, that is attended with much less risk to the mother. It is not always an easy matter to as- certain with certainty, whether a foetus in utero, be living, or dead. If it has entirely ceased to move, after being af- f-cted with a violent motion, the proba- bility is, that it is no longer alive. But, to be certain, manual examination is ne- cessary, which may be practised in two ways. One, consists in pressing Upon the uterus, through the parietes of tiie ab- domen. If tiie child lives, such pressure makes it move, and the motion can be plainly felt,"" and distinguished. In the other method, one hand is employed in pressing upon the uterus externally, whKe, with the fingers ofthe other hand, passed up the vagina, corresponding pressure is also to be made. The uterus is Ukewise to be allowed to descend as far as possi- ble, in order to induce the foetus to move. When no decisive indications can be thus obtained, it becomes necessary to rup- ture the membranes, if they have not already given way, introduce the hand into the uterus, and put a finger into the child's mouth, for the purpose of mak- ing it move its tongue. The finger may also be applied to the region ofthe heart, so as to examine, whether this organ is beating; and the umbilical cord maybe touched, in order to ascertain, whether there is still a pulsation in it. When none of these proceedings furnish un- equivocal information, tiie conclusion is, that the child is dead, and its extraction is indicated, unless the narrowness of the parts be such, that tlie hand cannot be passed into the uterusj in which case, the Caesarean operation is indispensable. But, how are we to form a judgment respecting the dimensions of the pelvis I And how can we know, whether that dia- meter, which extends from the upper edg-e of the sacrum to tiie os pubis, is long enough to allow the passage of the child ? The proper conformation of this part is known, by the roundness and equality ofthe hips, both in the transverse and perpendicular direction;' by the pro- jection of the' pubes ; by the moderate depression of the sacrum; by an extent of four or five inches from the middle of this depression to the bottom, of the os coccygis; by an extent of seven or eight inches from the spinous process of the last lumbar vertebra to the highest part ofthe mons veneris, in a woman moderate- ly fat; and by there being an interspace of eight or nine inches, between the two anterior superior spinous processes ofthe ossa ilium. * These general calculations, however, are insufficient. In order to acquire more correct opinions, double compasses must be used. The branches of the first being applied to the top of the sacrum, and middle of the mons veneris, three inches are to be deducted from the dimensions, indicated by the instrument; viz. two inches and a half for the thickness of the upper part of the sacrum, (which is said to be constant in subjects of every size,) and half an inch for that of the os pubis. In women, who are exceedingly fat, some lines must also be deducted on this ac- count. , Hence, when the total thickness of the pelvis, measured in this direction, is seven inches, there wiU remain four for the distance from the upper part of the 228 CESAREAN OPERATION. sacrum to the os coccygis, or for the ex- tent of tlie lesser diameter of the upper aperture of the pelvis. For taking the measurement internally, a kind of sector was invented by M. Coutouly. It bears a considerable re- semblance to the instruments, employed by shoemakers for measuring the feet. It is passed into the vagina, with its two branches approximated, until one arrives opposite the anterior and upper part of the sacrum, when the other is to be drawn outward, so as to be applied to the pubes. The distance, between the branches, is judged of by the graduations on the in- strument. This was named by its invent- or a pelvimeter. According to M. Saba- tier^ it is not always easy to place it with accuracy; its employment is attended with some pain; and there are particular cases, in which it cannot be used. . Instead of this contrivance, the cele- brated Baudeloque has recommended a means, which seems to be very safe and simple. The index finger of one hand is to be introduced into the vagina to the upper part of the projection of the sa- crum. The finger, having the radial edge turned forwards, is then to be in- clined anteriorly till it touches the arch of the pubes. The point of contact being then marked with the opposite hand, the length from the point in question to the end ofthe finger is to be measured. This length, wliich indicates the distance be- tween the sacrum and the bottom of the symphysis pubis, usually exceeds that of the lesser diameter of the pelvis by about six lines. Baudeloque acknowledges, that this measurement is not exactly accu- rate; but, he believes, it will do very well, because, unless the narrowness of the pelvis be extreme, two, or three lines hardly make any difference in the facility of parturition. The pelvis may be everywhere well formed, and y§l present an insurmount- able obstacle to delivery, in case an ex- ostosis, lessening its dimensions, should exist on one of the bones, wliich compose this part of the skeleton. Pineau- met with a case of this description in a wo- man, who died undeUvered. The tumour originated from one of the ossa pubis. A steatomatosis swelling, situated with the head of the child in the upper aper- ture of the pelvis, might produce the same effect, unless it were detected, and could be pushed out of the way, so as to make room for the foetus to pass. Bau- deloque mentions a swelling of this kind. It was six or seven inches long, and an inch and a half in width. The extre- mity of it, which was as large as half an hen's egg, had a bony feei, and contain- ed nine weU-formed teeth, the rest of tile mass being steatomatous. It had de- scended into the lesser pelvis, below the projection of the sacrum, and a little to one side. It might have been taken for an exostosis of this last bone. The la- bour pains continued sixty hours, and the propriety of performing the Cxsa- rean operation was under consideration. Baudeloque was averse to this proceed- ing. He recommended turning the child, and extracting it by the feet, because he thought that the pelvis was sufficiently capacious to admit of delivery. The event proved, that it was three inches nine lines, from before backwaid, and four inches nine Unes transversely. The foetus was soon easily extracted. The assistance of the forceps was neces- sary to get out the head. The child was still-born. The mother, exhausted with numerous unavailing efforts, only sur- vived between fifty and sixty hours. Bau- m deloque was of opinion, that a defective _'_■_ regimen also tended to occasion her ; death. Among the insurmountable obstacle* to delivery may be reckoned such a dis- placement of the uterus, that this viscus protrudes from the abdomen, and forms a ... hernia. The records of surgery have + preserved some examples of this extraor- dinary occurrence. Twice has the Caesa- rean operation been performed, and, in one of the cases, the woman survived so long, that hopes were entertained of her ■•■ recovery. Indeed, as Sabatier observes, why should not the operation succeed in such a case, where the uterus is only co-i vered by the integuments, and there is no occasion to cut into the abdomen, just as well as other instances, in wliich it is indispensable to divide the muscles, and - open the cavity of the belly ? In the other case on record, delivery was effect- • ed in the ordinary way, either by raising the abdomen, and keeping it in this posi- tion with towels skilfully placed, or by <■ making pressure on the uterus, which had the beneficial effect of making this organ resume its proper situation. Having shewn the absolute necessity for the Caesarean operation, under certain circumstances, it remains to consider the proper time for performing it, the requi- site preparatory means, and the method of operating. Writh regard to the time of operating, practitioners do not agree upon this point; some advising the operation to be done, before,the membranes have burst, and the waters been discharged; others, not till afterwards. The arguments, in fiivor of the first plan, are, the facility with which the uterus may be opened CESAREAN OPERATION. .229 without any risk of injuring the foetus, and the hope that the viscus will con- tract with sufficient force to prevent he- morrhage. The advocates for the second mode beUeve, that, in operating after the discharge of the waters, there is less danger of the uterus falling into a state of relaxation, in consequence of becoming suddenly empty after being fully distend- ed, and that this method does not demand so extensive an incision Hence, they recommend, as a preliminary step, to open the membranes. Whatever conduct is adopted, it is essential, that the labour should be urgent and unequivocal, that the cervix uteri should be effaced, and that the os tincae should be sufficiently dilated to allow the lochia to be dis- charged ; but, at the same time, says M. Sabatier, if the operation is not to be done till after the escape of the waters, there ought not to be too much delay, lest the patient's strength should be ex- hausted, and the violent efforts of labour should bring on an inflammatory state of the parietes of the uterus. The propriety of emptying the rectum and bladder is so evident, that it is unne- cessary to insist upon it. This precau- tion is more particularly requisite in re- gard to the latter of these viscera, which has been known to rise so much over the uterus, as to conceal the greater part of it Baudeloque had occasion to remark this circumstance, in a woman, upon whom he was operating. The bladder ascended above the navel, and presented itself through the whole extent of the epening made in the parietes of the ab- domen. The instruments, dressings, &c. which may be wanted, are two bistouries, one with a convex edge, the" other having a probe-point; sponges; basins of cold water acidulated with a Utile vinegar; long strips of adhesive plaster; needles and ligatures; lint; long and square com- presses ; a bandage to be applied round the body, with a scapulary, &c. For the purpose of'undergoing the operation, the patient should be placed at the edge of her bed, well supported; her chest and head should be moderately raised; her knees should be somewhat bent, and held by assistants, one of whom ought to be expressly appointed to fix the uterus by making pressure laterally, and from above downward, so as to circum- scribe, in some degree, the swelling- of the uterus, and prevent the protrusion of the bowels. These things being attend- ed to, the integuments are to be divided with theconvex edged bistoury to the ex- tent of at least six inches. The i^lace, and direction of this incision, differ with different operators. In the most ancient method, it was cus- tomary to make the incision between the outer edge of the rectus muscle, and a fine, drawn from tiie anterior superior spinous processof the iUum, to the junc- tion ofthe bone of the first rib with its car- tilage. This cut was begun a little below the umbilicus, and was continued down- ward as far as an inch above the pubes. After the integuments had been divided, the muscles, aponeuroses, and peritone- um were cut, and the uterus cautiously opened. The left index finger was then introduced into this viscus, the wound of which was dilited by means of the probe- pointed bistoury. This manner of operating is subject to great inconveniences. The place, where the incision is made, is the situation of muscles, the fibres of which have a dif- ferent direction, and, on contracting, se- parate the edges of the wound, and make it gape. The considerable blood vessels, which ramify there, may be the source of perilous bleeding. The bowels can pro- trude in that situation more readily, than any where else. When the position ofthe uterus is oblique, and when, consequent. ly, the edges of this viscus are turned for- ward and backward, and its surfaces to the right and left, the incision will be made in one of the lateral portions of the uterus, where the trunks of *- its blood vessels are known to be situated, and sometimes even the Fallopian tube and ovary may be cut. The fibres of the ute- rus are cut transversely, so that the edges of the incision are,apt to gape, instead of being in contact. This last circumstance may the more readily permit the lochia to escape into the abdomen, inasmuch as the uterus is cut nearly through its whole length, and there is no cavity, in which they can accumulate, in order-to be dis- charged through the cervix of that organ. The Unea alba has been frequently considered the most eligible place for making the incision. As Sabatier informs us, it was the method adopted by Soley- res, andDeleurye, and it has the recom- mendation of Baudeloque, because there are fewer parts to be cut, and, when the uterus is exposed, an incision, parallel to its principal fibres, may be made in its middle part. Soleyres thought that this plan of operating originated with Platner and Guerin, a surgeon at Crepi en Va- lois. Platner says ; Iucidantur juxta U- neam album, plagd majore qux ab umbilico ' ad ossa pubis jere descendit, turn abdominis musculi, ttirn peritoneum, ubi tandem vitan- }dum ne violetur arteria epigastricu. M. ^0 CESAREAN OPERATION. Guerin, in his case, made an incision, six inches long, which began a little above the umbilicus, and extended to within an inch and a half of the pubes. He after- wards divided the fat, muscles, and peri- toneum, in order to get at the uterus, the anterior part of which Was opened, the wound being made rather in the body, than the fundus of that viscus. Deleu- rye will not admit, that these writers ac- tually divided the Unea alba, because they speak of having cut muscles, which in reality do not exist in that situation ; and he "attributes the honour of the in- vention to Varoquier, a surgeon of Lisle, in Flanders ; but, the method was known to Mauriceau, as we may be* onvinced of by the following passage, extracted from the chapter, in which he treats of the Caesarean operation, " La plupart venlent qu'on incise au cote gauche du ventre; mais Poumerture sera mieux au milieu entre les muscles droits, car il n'y a en ce lieu, que les tegumens et les muscles d couper." Lau- verjat, who has made this remark, and cited the Latin edition of Mauriceau, page 247, also observes, that the incision in the Unea alba was practised by a cotemporary of La Motte, a circum- stance which Sabatier has not been able to ascertain--. (Medecine Operatoire, Tom. 1.) The following would be the proper manner of operating in the Unea alba. The operator should first divide the inte- guments perpendicularly, so as to expose the linea alba, making the wound about six inches long. An opening should then be carefully made through the aponeu- rosis, into the abdomen, either at the upper, or lower part, of the linea alba in view. A curved bistoury is then to be in- troduced into the opening, and the ten- don and peritoneum cut from within out- ward, as far as the extent of the wound in the inteaaiments. The latter cut should be cautio-ifcly made, with the crooked bistoury, guided by the forefinger of the left hand, lest any ofthe intestines should be accidentally injured. The uterus must next be carefully opened, making an in- cision in it, of the same length, as the preceding wound. The fcetus is to be taken out through tiie wound, and then the placenta and membranes. In this way, M. Artiste lately operated, so as to save both mother and child. (See Edin- burgh Surgical Journal, Vol 4, p. 178 ) This mode of operating, as Sabatier ob- serves, gives more hopes of success, than the plan first described; but he argues, that such hopes have not been realised by ex- perience. Though the operation may- have been more easy, he contends, that the edges of the wound in the skin, and 'hose of the incision in the uterus, have had no tendency to remain in a state of proximity to each other, because the Unea alba is the point, on which all the large muscles of the abdomen principally act, and because the contraction of the uterus invariably takes place from above down- wards. Sabatier alleges, the wound in this viscus has been found to incline to one of its sides, for the same reasons, as occur, in operating at one of the sides of the abdomen. He also states, that the incision has been concealed under the integuments of the upper part of tlie ' pubes, and that the presence of the Wad- der hinders the wound from being carried sufficiently far down. Perhaps, says he, a part of these inconveniences, which de- pend upon the contraction of the uterus, and the return of this organ to its natural state, might be avoided, by extending "the incision to its highest part. Baude- loque has advised this plan, with a view ' of preventing the fatal exteavasations $) the abdomen, which frequently follow this operation. Sabatier, however, has doubts, whether, in operating in the Unea alba, the wound can be carried high enough. Be6ide9, he maintains, that this precaution would not prevent the wound from gaping, nor the greater tendency of the lochia to be extravasated in the ab- domen, than to accumulate in tlie uterus, and be discharged through the os tincae. (Medecine Operatoire, Tom. 1, p. 274— 275.) In this country, (where, indeed, the Cesarean operation, has proved most un- successful) the linea alba is preferred, I believe, by the majority of practitioners. That the method is not always attended with the formidable objections, urged against it by Sabatier, is quite certain: the case, lately published by Dr. Chis- holm, is a decisive proof of this assertion. (See Edinbl Med. and Surgical Journal, Vol. 4, p. 178, 179.) There is a third method of performing the abdominal Caesarean operation. It consists in making a transverse incision, five inches in length, through the parie- tes of the abdomen, between the rectus muscle and the spine, and in a situation more or less high, according to the more or less elevated position of the uterus. This plan was recommended by Lauver- jat, in a publication entitled, " Nouvelle Methotle de Pratiquer P Operation Cesarien- ne,Par. 1,1788." Lauverjat acknowledges, that the method has been successfully practised by different persons before him- self, and, especially, in one instance, wliich was particularly remarkable, as, in consequence of the first incision hav- ing been made too high up, it became ne- cessary to make a second one, which ex- CESAREAN OPERATIC**/. 231 tended obliquely from the other* How- ever, according to Sabatier, Lauverjat has as much merit, as if he had invented the plan, since he has jriven a better ex- planation of its advantages, titan any of his predecessors. The side, on which the operation is to be done, is in itself a matter of indifference. But, if the liver or spleen were to pro- ject, one ought to avoid it. Also, if the uterus were to incline more towards one side, than the other, it would be proper to operate on that side, where the uterus could be most conveniently got at. The patient being put in a proper position, and held by assistants, and her abdomen kept steady by an attendant, who must apply the palms of his hands to tiie sides of the uterus, the integuments, muscles, and peritoneum are to be divided, with the usual precautions. The uterus is then to be opened, and the wound in it enlarged in the requisite degree, by means of a probe-pointed bistoury. Should the placenta present itself, care must be taken not to injure it, for fear of opening one of the arteries of this mass, which commu- nicate with the umbilical arteries of the child, or of leaving a portion of it in the uterus; but, it"should be separated, in order to facilitate breaking the mem- branes at its circumference. The child is next to be extracted. This part of the operation is subject to no general rule. Delivery being accomplished, we are re- commended to introduce through the va- gina anodyne injections, in order to lessen spasm, and wash out the coagula. This method Is preferable to that of clearing out the uterus with the hand. Sabatier most' properly condemns the plan, for- merly advised by Rousset and Ruleau, of passing up the neck of this viscus a bougie for the purpose of washing out the lochia, as well as the absurd proposal of employing a seton to promote their escape. Should the lochia not pass rea- dily outward, we are recommended to in- troduce the finger occasionally' into the cervix uteri, so as to-free it from the coa- gula, which may obstruct it. W Sabatier observes, that nearly all au- thors, who have spoken of the Caesarean operation, whether performed at the sides of the abdomen, or in the linea alba, have advised keeping the edges of the wound in the skin, muscles, and peritoneum to- gether, by means of the interrupted, or twisted suture, care being taken to place at the lower part ofthe incision, a tent, in order to prevent adhesion, and bjave a free issue for whatever discharge may take place from the abdomen. Others have'been content with recommending the use of adhesive plasters and the uniting bandage. Sabatier condemns sutures as painful and irritating, and he states, that the other means only act upon the skin, with- out fulfilling the object in view, because the integuments have no fixed point, and the divided muscles tend to contract. Sabatier assures us, that, in the last mode of operating, the edges ofthe wound may be brought into contact by merely lay ing the patient upon her side. Besides, he remarks, that there are not many mus- cular fibres cut, those of the transversal is being only separated from each other. He affirms, that this manner of operating also favours the approximation of the edges ofthe wound in the uterus, in con- sequence of this organ, contracting most extensively in the perpendicular direc- tion. It is likewise asserted, that, as the uterus has only been opened at its upper part, it affords in its middle and lower portions a large cavity, which does not communicate with the abdomen, and in which the lochia may easily accumulate, and afterwards be discharged by the natu- ral way. The only dressings, advised by Sabatier, are a large pledget, com- presses, and a moderately tight bandage round the body. These are to be changed, when soiled with the matter or discharge. In this country, practitioners would not neglect to bring the edges of the wound, as much as possible together, by means of strips of adhesive plaster; for, though they may not act w ith so much effect in this situation as many others, they un- doubtedly assist in promoting the main aim of the surgeon, which :s to heal at least all the upper part of the incision, if possible, by the first intention. I have no doubt, there are many, who would be advocates for sutures. In this country, the last method of operating has also been tried. Mr. Wood, of Manchester, j|erformed the Caesarean operation, in Ta case, in which parturition was prevented by de- formity of the pelvis. Tfie incision was made nearly in a transverse direction, on the left side of the abdomen, about five inches in length, beginning at the um- bilicus. This part was fixed upon, be- cause the nates of the child could be felt there, and it was evident, that no intes- tine was interposed betwixt the abdomi- nal parietes and the uterus. There was scarcely any effusion of blood, either from the external wound, or from that of the uterus, though the latter was made di- rectly upon the placenta. Instead of di- viding the placenta, Mr. Wood introduced his hand betwixt it and the uterus, and, 232 CESAREAN OPERATION laying hold of one of the child's knees, extracted the foetus with ease. Kis hand passed with ease, betwixt the placenta and uterus ; this produced a hemorrhage, but, not in any considerable degree; for, the whole quantity of blood lost did not exceed seven, or eight ounces. After the uterus was emptied, the intestines and omentum protruded at the wound. These having been reduced, the integuments were brought into contact with sutures and adhesive plaster. This operation, how- ever, did not save the woman's life; she died on the fourth day from the time of its being done. (See Medical and Physical Journal, Vol. 6.) OF OrERATISG-, WHEN TBT FffiTUS IS EX- TRA UTERINE. Delivery cannot possibly happen in the ordinary way, when the foetus is si- tuated in the ovaries, or Fallopian tube, or in the cavity of the peritoneum. How- ever, there are many instances recorded of ventral pregnancies, which the mo- thers have survived, the dead putrified foetus having been discharged, either out of an abscess, or through the rectum. Practitioners are occasionally called upon to do a very similar operation to tiie Cxsarean, when the child has passed into the cavity of the peritoneum, in conse- quence of the rupture of the uterus. Un- fortunately, such an accident is not un- common, and though the causes of it may not be obvious, nothing is more certain, than that the foetus itself is entirely pas- sive, and has no share in producing the misfortune. The symptoms, by which the event cannot be known, are not always easy of comprehension. When, however, the pains have been violent; when the last, after being excessively severe, has been followed by a kind of calm; when the countenance loses its colour, the pulse grows weak, and the extremities become cold and covered with a cold sweat; when the abdomen is generally flattened, and is only partially affected with a swelling, which is known to be occasioned by the foetus, which either continues to move, or is dead and motionless ; when the patient complains of a moderate degree of heat about the belly ; and lastly, when the child shrinks from the touch of the ac- coucheur; it is manifest that the uterus is lacerated. If the child has passed rompletely into the abdomen, gastrotomy is the only resource. Should a part of it, however, yet remain in the uterus, it may be extracted, with the aid of the forceps, if the head presents, or by the feet, pro- vided only the upper part of the body be in the abdomen. Baudeloque quotes three instances of gastrotomy, performed on account of the rupture of the uterus. The first is that inserted by Thibaud Dubois in the Jour. nal de Medicine for May, 1760. Every preparation was made for a natural la. bour, when, after excessively violent paias about the upper and left part ofthe uterus, tlie child disappeared. Thibaud opened the abdomen, though not until some hours after the accident. The infant was dead; but, the mother experienced no ill effects after the operation, except such as are usual after ordinary labours. The second and'third cases were com- municated to the French Academy of Sur- Sery in 1775, by Lambron, a surgeon of rieans. He practised tlie operation twice, on the same wqman, with success. In the first instance, he operated eighteen hours after the rupture of the uterus. The child was dead. An iU-conditioned abscess formed near the wound ; but, the patient got quite well in the course of six weeks. She was pregnant again the fol- lowing year, and the uterus was once more ruptured. Lambron now had recourse to the operation without delay. The child betrayed some signs of life ; bnt, soon died. The mother not T>nly survived ; but, afterwards became pregnant again, and had a favourable delivery. A laceration in the uterus, or the wound, made in this viscus in the Cxsarean ope- ration, may give rise to dangerous and even fatal symptoms of strangulation, if any of the intestines insinuate themselves into the preternatural opening. When such an occurrence happens in the per- formance of the preceding operation, the intestine must be directly withdrawn and replaced. If the accident were to hap- pen, when the child is extracted the na- tural way, the bowel is to be pushed back into the abdomen from the uterus. Were the occurrence to take place several days after the operation, Sabatier enquires, what ought to be done ? A surgeon is said to have *pushed back the intestine from the uterus as hde as the third day. Sabatier thinks, tiiaf later it could not be done. In this circumstance, Baudeloque advises the operation, suggested by Pigrai, name- ly, that of opening the abdomen and with- drawing the bowel from the place, in which it is incarcerated. But, there are serious objections to this proceeding. There is no certainty that the intestine is strangulated, and if it were so, the ad- hesions, which are* soon formed, would fruste^te the operator in his design. Gastrotomy has not only been recom- mended for cases, where the child has passed into the abdomen through a rup- ture of the uterus; it has likewise been CESAREAN OPERATION. 233 advised for instances, in which the foetus has grown in the Fallopian tube, ovary or cavity of the abdomen. Here, indeed, the operation deserves to be called Caesa- rean ; for, in addition to the incision of the skin and muscles of the abdomen, it is necessary to open the pouch, in which the child is contained. The instances of conceptions in the Fallopian tube are not uncommon. Those in the ovary, and cavity of the peritoneum, are more rare. Sabatier conjectures, that most of the cases, reported to be of the latter kind, if attenth ely examined, would have been found to be in reaUty conceptions in the Fallopian tube. Extra-uterine conceptions hardly ever arrive at maturity. However, the fcutus, formed in the Fallopian tube, has some- times been known to attain the term of nine months, and then die, either from the impossibility of its expulsion, or from the insufficiency of the nourishment af- forded it. The pouch, in which it was contained, and the neighbouring parts, have then inflamed, and, after becoming connected together by numerous adhe- sions, have suppurated. The abscess has burst, partly at some point ofthe circum- ference of the belly, and partly, into the rectum ; and the dead foetus has been dis- charged piece-meal with the matter. In other examples, the foetus, instead of giving rise to abscesses, has become os- sified, with the envelloping membranes, and continued in this state many years, without any other inconvenience to the patient, than what depended on the size and weight of the tumour within the ab- domen. Most frequently, however, the pouch, containing the fictus, bursts, about the middle of the ordinary period of gesta- tion, and the child passes into the cavity of the peritoneum. At the same moment, the blood vessels, ramifying on the pa- rietes ofthe containing parts, usually pour • forth into the abdomen so much blood, that the patients generally die in the space of a few hours. Sabatier acquaints us, that two facts of this kind have fallen under his observa- tion. The women were in the end of the fourth month of pregnancy. Excepting a swelling, which affected only one side of the abdomen, and frequent dragging pains in this cavity, tiiere was no indica- tion of any thing extraordinary. In other respects, the patients were well. They were both, all on a sudden, attacked with extremely acute pains, which lasted two or three hours. A more violent suff'ei ing, than the rest, was followed by entire ease. The abdomen subsided, and became as it were flat. An equal moderate warmth Vol. 1. diffused itself over this.part of the body. The skin lost its colour. Almost con- tinual syncopes occurred. The pulse was feeble and concentrated. The whole body was covered with a cold sweat, and the women died. The rapid course of these symptoms rendered it impossible for Sa- batier to be of any assistance. The pa- tients were actually dying, when he was called to them. The examination of their bodies evinced, that the abdomen con- tained a large quantity of blood ; that the children lay on the intestines, con- nected with ther lacerated Fallopian tube By means of the umbilical cord; and that the tube itseflf, wliich was strongly con- tracted, presented no other tumour, ex- cept that which depended on the after- birth. There is nothing, that announces an extra-uterine pregnancy, with sufficient certainty, to justify any positive conclu- sion, respecting the nature of the case, be- fore the ordinary time of parturition. In many women, the gravid uterus inclines to one side, and numerous pregnant fe- males have dragging pains, which may depend upon other causes. Things, how- ever, are different, when the foetus has lived to the ordinary period of parturition, and the woman .is attacked with labour pains ; because, besides the unequivocal signs of the presence of a child in the ab- domen, the womb is empty, and is little changed from its common state. Should we now, asks M. Sabatier, have recourse to the Caesarean operation, just as if the foetus were in the womb ? Can we be sure, that the pouch, which contains the child, will contract itself, like the uterus, and that the incision, which is in contem- plation, will not give rise to a fatal he- morrhage ? Would it be easy to separate, and remove the whole pf the placenta? How could the discharge, analagous to the lochia, find an outlet, and Would not, its extravasation in the abdomen, be likely to prove fatal ? Sabatier thinks, that the risk, wliich is to be encountered, is much less, when things are left to na- ture. The child, indeed, must inevitably perish. It will either give rise to ab- scesses, with which it will be discharged in fragments, or it will remain for a length of time in the abdomen, without any ur- gent symptoms. Sabatier also .calls our attention to the great precariousness of an infant's life, and expresses his opinion, that, there can be no difficulty in deciding what conduct ought to be adopted. Hap- pily, practitioners are not often placed in circumstances so delicate, and extra-ute- rine conceptions mostly perish, before the end of the common period of gestation We have then only to second the efforts li h 2J4 C A S of nature; either by promoting suppura- tion, if it should seem likely to occur; by making a suitable opening, or enlarging one that may have formed spontaneously; by extracting such fragments of the foetus as present themselves; by breaking the bones, when their large size confines them in the abscess, as M. Littre did in an in- stance, where the abscess burst into the rectum ; and, lastly, by employing suita- ble injections. (See Sabatier's Medecine Operatoire, Tom.l.) Govei, p. 401, relates a case of ventral conception, in which instance the Caesa- rean operation was done, and the child preserved. A lady, aged 21, had a tu- mour in the groin, which, was at first supposed to be an epiplocele, but an ar- terial pulsation was perceptible in it. In tebout ten weeks, the swelling had become as large as a pound of bread. Govei, so- licited by the lady, opened the tumour. He first discovered a sort of membranous sac, whence issued a gallon of a limpid fluid. The sac was dilated, and a male foetus found, about half a foot long, and large in proportion. It was perfectly alive, and was baptized. After tying the umbilical cord, the placenta was found to be attached to the parts just behind, and near the abdominal ring; but it was easily separated. Govei does not men- tion whether the mother survived ; but the thing would not be very astonishing, con- sidering the situation of* the foetus. Ber- trandi says, he was unacquainted with any other example of the Caesarean opera- tion being done, in cases of extra-uterine foetuses, so as to save both the mother and infant.- This eminent man con- demned operating, in ventral cases, on the ground that the placenta could not be se- parated from the viscera, to which it might adhere, or, if left behind, it could not be detached, without such inflammation and suppuration, as would be mortal. But if, in addition to such objections, says Bertrandi, the operation has been pro- posed by many, and practised by none, we may conclude that this depends on the difficulty of judging of such pregnancies, and ofthe time when the operation should be attempted. He puts out of the ques- tion the dilatations, which have been in- dicated for extracting dead portions ofthe foetus, and also Govei's case, who ope- rated without expecting to meet with a foetus at all. (Bertrandi Traite des Ope- rations de Chirurgie, Chap. 5.) Whenever the Caesarean operation, or gastrotomy, has been performed, the prac- titioner is not merely to endeavour to pre- vent inflammation, heal the wound, and appease any untoward symptoms, which may arise; he should also prevail upon C AL the mother to suckle the child, in order that the lochia may not be too copious, and, after the wound is healed, she should be advised to wear a bandage, for the pur- pose of hindering the formation of a ven- tral hernia, of which, according to sur- gical writers, there is a considerable risk. The best sources of information are, Sabatier'sMetlecine Operatoire,Tom. l.Re- cherches sur P Operation Cesarienne par M. Simon, in Mem. de PAcad. Royale de Chi- rurgie, Tom. 3, p. 210, &c. and Tom. 5, p, 317, &c. Edit, in l2mo. Bertrandi Trait* des Operations tie Chirurgie, Chap. 5. Bau- delocque's Traite des Accouchemens. Den. man's Introduction to Midwifery. HuWs~ Defence of tlie Cxsarean Operation. Brigh- ton's Enquiry concerning the true and spu- rious Cxsarean Operation. Edinb. Med. and Surgical Journal, Vol. 4, p. 178, Vol 8, p. 11. Richerand's Nosographie Cldrurgi- cale, Tom. 4, p. 381, &c. Edit. 2. Richter's Anfangsgrunde der Wundurzneykunst, Band 7, Kap. 5; Gb'ttingen, 18U4. CALCULUS, (from calx, a limestone.) Any stony, or earthy concretion, formed in various parts of the body, is usually so called, as, for instance, calculi in tbe ducts of the salivary glands, in cases of ranula; calculi in the kidnies, bladder, urethra, gall-bladder, &c. Many of these last con- cretions, if we were to judge by their che- mical composition, seem to ill deserve the name of calculi, or stones. For an ac- count of, whatare commonly called, stones in the bladder, refer to Urinary Calculi. CALCULUS IN THE INTERIOR OF THE EYE. See Eye, &c. CALIGO CORNER. See Albugo, Cor- nea, Opacities of, Leucoma, Staphyloma, &c. CALLOSITY, (from callus, q. v.) Pre- ternatural hardness. CALLUS, (from calx, the heel, or calco, to tread.) This term used to be applied to the thick skin, at the bottom of the heel, hardened by pressure. In surgery,, the meaning of the word callus is new bone, or the solid substance, which serves lo join together the ends of a fractured bone. The old surgeons believed callus to be a mere inorganic concrete, a fluid poured out from the extremities of the ruptured vessels, wliich was soon hardened into bone. They always described it, as an " exudation of the bony juice," and ima- ined that it oozed from tiie ends of broken ones, as gum from trees, sometimes too profusely, sometimes too sparingly. The reunion of broken bones, and the hardening of callus, tliey compared with the glueing together of two pieces of wood, or the soldering of abroken pot. (AL Pare.) The old surgeons also conceived, that cal- CAL C A L 335 Ius sometimes flowed into tiie joints, so as to form a clumsy, prominent protube- rance. They imagined, that callus was a juice, which congealed at a particular period of time, and they therefore had fixed days for undoing the bandages of each particular fracture. They supposed, that its exuberance might be suppressed by a firm and well rolled bandage, and its knobby deformities corrected by pillows and compresses; that it might be softened by frictions and oils, so as to allow the bone to be set anew. All their notions were mechanical; and their absurd doc- trines have been the apology for all the contrivers of machines, from Hildanus down to Dr. Aitken and Mr. Gooch— (John Bell's Principles of Surgery, Vol. 1.) A bone is a well organized part of the living body; that matter, wliich keeps its earthy parts together, is of a gelatinous nature. The earthy matter, t > which a bone owes its firmness, is deposited in the interstices of the gluten, undergoing a continual change and renovation. It is incessantly taken up by the absorbents, and secreted again by the arteries. It is this continual absorption and deposition of earthy matter, which forms the bone at first, and enables it to grow with the growth ofthe body. It is this unceasing activity of the vessels of a bone, which enables it to renew itself, when it is broken or diseased. In short, it is by- various forms of one secreting process, that bone is formed at first, is supported during health, and is renewed on all ne- cessary occasions. Bone is a secretion, eriginally deposited by the arteries of the bone, which arteries are continually'em- ployed in renewing it. Callus is not a concrete juice, deposited merely for filling up the interstices betwixt fractured bones, but it is a regeneration of new and per- fect bone, furnished with arteries, veins, and absorbents, by which its earthy mat- ter is continually changed, like that of the contiguous bone. Indeed, there could be no connexion, between the original bone and callus, were the latter only the inor- ganic concrete, which it was formerly sup- posed to be. Notwithstanding the more accurate opi- nions now entertained, concerning callus, the supposition is still very common, that the slightest motion will destroy a callus, which is about to form". But, continues Mr. John Bell, it is an ignorant fear, pro- ceeding merely from the state ofthe parts not having been observed; for, when callus forms, the perfect constitution of the bone is restored; the arteries pour out from each end of a broken bone a ge- latinous matter; the vessels, by which that gluten is secreted, expand and multi- ply in it, till they form, betwixt the broken ends, a well organized, and animated mass, ready to begin anew the secretion of bone. Thus, the ends of the bone, when the bony secretion commences, are nearly in the same condition, as soft parts which have recently adhered; and it is only when there is a want of continuity in the vessels, or when a want of energe- tic action incapacitates them from renew- ing their secretion, that callus is imper- fectly formed. This is the reason, why in scorbutic constitutions, in patients in. fected with syphilis, in pregnancy, in fever, or in any great disorder of the sys- tem, or while the wound of a compound fracture is open, no callus is generated. (John BelPs Principles of Surgery, Vol. 1, p. 500, 501.) • For some time, the secretion of earthy matter is imperfect; the young bone ia soft, flexible, and of an organization suited for all the purposes of bone; but, as yet, delicate and unconfirmed ;l not a mere concrete, like a crystallization of a salt, which, if interrupted in the moment of forming, will never form ; not liable to be discomposed by a sUght accident, nor to be entirely destroyed by being even roughly moved, or shaken. Incipient callus is soft, fleshy, and yielding ; it 9 ligamentous in its consistence, so that it is not very easily injured; and, in^ts or- ganization, it is so perfect, that when it is hiu-t, or the bony secretion interrupted, the breach soon heals, just as soft parts adhere, and thus the callus becomes again entire, and tiie process is immediately re- newed. In consequence of the above circum- stances, if a limb is broken a second time, when the first fracture is nearly cured, the bone unites more easily, than after the first accident; and when broken a tliird, and a fourth time, the union is still quicker. In these cases, the limb yields, it bends under the weight of the body, which it cannot support; but, with- out any snapping or splintering of tiie bone, and, generally, without any over- shooting of the ends of the bone, and without any crepitation. Callus is found to be more vascular, than the old bone. Mr. John Bell men- tions an instance of a bone, wliich had been broken twelve years, before he in- jected it, yet the callus was rendered very singularly red. When a recently form- ed callus is broken, many of its vessels are ruptured, but some are only elon- gated, and it rarely happens, that its whole substance is torn. It is easy to conceive, how readily the continuity of the vessels will be renewed in a broken callus, when we reflect on its great vascu- 236 (J A L larity; and the vigorous circulation, ex- cited by the accident in vessels already accustomed to the secretion of bone. These reasons shew, why a broken, or bent callus, is more speedily united, than si fractured bone. (Observations, con- nected with the subject of Callus, will be found in the article Fracture.) CALOMEL. (Submuriate of mercury ; bydrargyri submurias, L. P.) Its exten- sive utility, in numerous surgical diseases, will be conspicuous in an immense pro- portion of the articles in this work. When prescribed, as an alterative, it is commonly directed in the dose of a grain or two a day; when ordered as a purga- tive, from three to ten grains are given ; and when directed, with a view ol excit- ing a salivation, from two to four or five grains a day may be exhibited conjoined with opium. Calomel, generally speak- ing, is not an eligible preparation for cur- ing venereal complaints; because, when the doses exceed a certain quantity, they generally affect the bowels. CALYA'TA Blunt, smooth, surgical instruments, such as a probe with a but- ton at the end of it. CALX CUM KALI PURO. This is th« strong kind of caustic, most com- monly employed in surgery. It is chiefly used for making the eschars, when issues are to "tFe formed. Tins is often neces- sary in cases of diseased vertebrae, white swellings, morbid hip-joints, -Sec. (See Vtrtebrx.) This caustic is also sometimes used, though not so often as it was for- merly, for opening buboes and other ab- scesses. Some are in the habit of making it into a paste with soft soap ; they cover the part affected with adhesive plaster, in which there is a hole of the size of the eschar intended to be made; and into this aperture they press the paste till it touches the skin. A bandage is then applied to secure the caustic substance in its situa- tion, till the intended effect is produced. The action of the calx cum kali puro, in this way^however, is more inert and tedious, and, perhaps, on this account, more painful upon the whole. Hence, many of the best modern surgeons never adopt this method; but, after covering the surrounding parts with sticking plas- ter, rub the caustic on the situation, where it is desirable to produce an eschar, till the skin turns brown. The end of the caustic must first be a little moistened. The calx cum kali puro, is commonly employed also for destroying large fun- guses. Before the port-wine injection was found to be the best radical cure for tbe hydrocele, this caustic was mostly used in this instance. (See Hydrocele.) Mr. CAN Else, in the case-alluded to, used to mix the caustic with powdered opium, by which, it is said, though not with much appearance of truth, that the sloughs were made with little or no pain to the patient. Some assert that the kali purum alone, acts more quickly, than when mixed with quicklime. 1 have not found this to be the fact, and, after trying both, give the preference to the calx cum kali pur*. CALYPTER. A fleshy excrescence in the situation of the hemorrhoidal veins. A pile. CAMARO'MA, CAMAno'sis, or Came- ha'tio. A fracture, resembling an arch, particularly, in the skull. CAMBU'CA. A bubo. An abscess about the pudenda. Also, a boil. CA.MOMILE. Chumameluni. The flow. ers are bitter and aromatic, and are em- ployed in surgery in fomentations. CAMPHOR, is used externally, chiefly as a means of exciting the action of the absorbents, and thus dispersing many kinds of swellings, extravasations, indu- rations, Sic. Hence, it is a very common ingredient in liniments. It has also the property of rousing the action of the nerves, and quickening the circulation in parts, on which it is rubbed. For this reason, in paralytic affections, it is some- times employed. Perhaps, there is no composition, that has greater power in exciting the absorp- tion of any tumour, or hardness, than camphorated mercurial ointment. Camphor is often given internally, in delirium, depending on the irritation of local surgical diseases, as we shall have occasion to explain in several parts of this work. It is also a remedy frequently administered in cases of" mortification. Some have recommended it, as singularly useful for the relief of stranguries, even those depending on the operation of can- tharides. But, although it may occasion- ally have'succeeded, when given with tins view, it not only does not always do so, but, it has been known to cause, an op- posite effect, sometimes producing great scalding in voiding the urine, and some- times pains like those of labour. (Medi- cal Transactions, Vol. 1, p. 470.) CA'MPULUM. A distortion of the eyelid. CAMPYLO'TIS". A distortion of the eyelid. CANCER, (derived from the Latin canter, a crab, to which, a part, affected with cancer, and surrounded with varicose veins, was anciently thought to have some resemblance.) Also called' Carcinoma. Practitioners distinguish cancer into two kinds, viz. occult and ulcerated, or open. CANCER. 237 No definition can be offered, which is ap- plicable to both, though each of these terms implies the same disease, only in a different stage. By occult cancer is meant a hard, scir- rhous tumour, for the most part accom- panied with pains, which are lancinating, excessively acute, and recur with more or less frequency. At length, the tumour breaking, is converted into cancer, strictly so called, or the disease in a state of ul- ceration. The occult cancer is also sometimes termed scirrhus, on account of its peculiar hardness. The female breast, and the uterus, are particularly subject to the disease. The breasts of men are but rarely affected' The testes, lips, (especially the lower one of male subjects,) the penis, the lachrymal gland and eye, the tongoe, the "sk Ti, (particularly that of the face,) the tonsils, the pylorus, the bladder, rectum, prostate, and a variety of other parts, are recorded by surgical writers as having frequently been tlie seat of scirrhus and cancer. They seem, however, to have compre- hended an immense number of different malignant diseases under one common name, and, in many of the cases called cancerous, there are no vestiges of the U-ue scirrhous structure. of scmnucs, on cato-eh, not in the ulce- rated STATE. , Mr. Abernethy has given a matchless history of this affection, as it appears in the female breast, where it most frequently occurs, and can be best investigated. Sometimes, says this valuable writer, it condenses the surrounding substance, so as to acquire a capsule; and then it ap- pears, like many sarcomatous tumours, to be a part of new formation. In other cases, the mammary gland seems to be the nidus for the diseased action. The boun- daries ofthe disease cannot be accurately ascertained in the latter case, as the car- cinomatous structure, having no distin- guishable investment, is confined with the rest ofthe gland. In either instance, car- cinoma begins at a small spot, and ex- tends from thence in all directions, like rays from a centre. This is one feature distinguishing this disease from many others, which, at their first attack, involve a considerable portion, if* not the whole, of the part, in which they occur. The progress of carcinoma is more or less quick in different instances. When slow, it is in general unremitting. Mr. Aber- nethy thinks, that though the disease may be checked, it cannot be made to recede by the treatment, which lessens other swellings. He is not, however, positive on this point; for, surgeons have inform- ed him, that diseases which eventually proved to be carcinomatous, have been considerably diminished by local treat- ment. With great deference to Mr. Aber- nethy, we may be allowed to remark in this place, that every tumour, which ends in cancer, is not from the first of this na- ture, though it has in the end become so ; consequently, it may at first yield to local applications, but will not do so, after the cancerous action has commenced. Hence, Mr. Abemethy's opinion, that a true car- cinomatous tumour cannot be partially dispersed, at least, remains unweakened by the fact, that some tumours have at first been lessened by remedies, though they have at last ended in cancer. Mr. Home's observations fully prove, what in- deed every surgeon has long known, that any sort of tumour may ultimately become cancerous. Without risk of inaccuracy, we may set down the backwardness of a scirrhous swelling to be dispersed, or diminished, as one of its most confirmed features. This obdurate and destructive disease ex- cites the contiguous parts, whatever their nature may be, to enter into the same dis- eased action. The skin, the cellular sub- stance, tfhe muscles, and the periosteum, all become affected, if they are in the vi- cinity of cancer. This very striking cir- cumstance distinguishes carcinoma, says "Mr. Abernethy, from several other dis- eases. In what this author calls medul- lary sarcoma, the disease is propagated along the absorbing system ; but the parts immediately in contact with the enlarged glands do not assume the same diseased actions. Neither in the tuberculated spe- cies does the ulceration spread along the skiii, but destroys that part only covering the diseased glands. Mr. Aberncihy ac- quaints us, that Mr. Hunter took notice, that a disposition to cancer exists in the surrounding parts, before the actual oc- currence of the diseased action. Hence arose the following rule in practice : That a surgeon ought not to be contented with removing merely the indurated, or actually diseased part, but that he should also take away some portion of the sutTounding sub- stance, in which a diseased disposition may. probably have been excited. In consequence of this communication of disease to the contiguous parts, the skin soon becomes indurated, and attached to aenreinomatous tumour, wliich, in like manner, is fixed to the muscles, or other part, over which it was formed. As a carcinomatous tumour increases, it generaUy, though not constantly, becomes unequal upon its surface, so that this in- 2oS CANC equality has been considered as charac- teristic of the disease. A lancinating pain is common ; but it is not experienced in every case, without exception. It is also a symptom, attending other tumours, which are unlike carcinoma in structure, and it cannot, therefore, be deemed an infallible criterion of the nature of the disease. (Abernethy.) A hard and painful glandular swelling, having a disposition to become cancer, says Richter, is the common, but, inade- quate and erroneous definition of scir- rhus. The disease is not regularly at- tended with swelling; sometimes scir- rhous parts diminish in size, and shrink. Hardness is not a characteristic property; for, many tumours, which are not scir- rhous, are exceedingly indurated. The disease is not always situated in a gland: it oftentimes attacks structures, which cannot be ctiled glandular; and hard glandular swellings are often seen, which do not partake of scirrhus. The dispo- sition to cancer cannot be enumerated among the marks of scirrhus, since it is not discoverable, till carcinoma has ac- tually commenced. Its termination in open cancer, is not an invariable occur- rence; and other tumours become can- cerous, to which no one would apply the term scirrhus, (Atifangsgr. der Wundarzn. Band 1.) Scientific surgeons ought undoubtedly to have a definite meaning, when they employ the word scirrhus; superficial practitioners do unquestionably use the word most vaguely; and, perhaps, in- fluenced by its etymology, they call an immense number of various morbid indu- rations scirrhous. I have always considered scirrhus, as a • diseased hardness, in which tiiere is a pro- pensity to cancerous ulceration, and a greater backwardness to recede, than ex- i->is in any other kind of d;seased hard- ness, although the skin may occasionally not break during life, and a few scirrhous indurations may have been lessened. Though Richter states, that this dis- position cannot be discovered, till carci- noma has actually taken place; though Messrs. Burns and Home confirm, that other indurations and tumours may ter- minate in cancer; though.Mr. Abernethy shews, that sarcomatous, and encysted tu- mours may end in most malignant dis- eases, and such as merit the name of can- cer; y et, it is now well ascertained, that in all these instances, the changes, which precede cancerous ulceration, bear no si- militude to the genuine scirrhus. The puckering of the skin, the dull leaden colour of the integuments, tlie knotted and uneven feel of the disease, the occasional darting pains in the pari, its fixed attachment to the skin above, and muscles beneath, form so striking an assemblage of symptoms, that, when they are all present, there cannot be the small- est doubt, that the tumour is a scirrhus, and that the disease is about to acquire, if it have not already acquired, the power of contaminating the surrounding parts, and the lymphatic glands, to which the absorbents of the diseased part tend. The truly scirrhous tumour, which is known to be capable of changing into the true open cancer, when allowed to increase in size is known to be hard, heavy, con- nected with the gland of the breast: and, when moved, the whole gland moves along with it. The structure of a scirrhous tumour in the breast, is different in the various stages of the disease; and a de- scription of the appearances, exhibited in the three principal ones, may give a to- lerable idea of what the changes are, which it goes through previous to its breaking, or becoming, what is termed, an open cancer. When a section is made of such a tu- mour, in an early stage, provided the structure can be seen to advantage, it puts on the following appearance: the centre is more compact, harder to the feel, and has a more uniform texture, than the rest of the tumour; and is nearly of the consistence of cartilage. This middle part does not exceed the size of a silver penny ; and, from this, in every direction, like rays, are seen ligamentous bands of a white colour, and very narrow; look- ing, in the section, like so many extremely irregular.lines passing to the circumfer- ence of the tumour, which is blended with the substance of the surrounding gland. In the interstices, between these bands, the substance is different, and be- comes less compact towards the outer edge. On a more minute examination, transverse ligamentous bands, of a fainter appearance, form a kind of net-work, in the meshes of whicli the new-formed sub- stance is inclosed. This structure accords with what Dr. Baillie describes to be the case, in cancerous diseases ofthe stomach and uterus. (Home.) In a further advanced stage of the tu- mour, the whole of the diseased part has a more uniform structure; no central point can be distinguished; the external edge is more defined, and distinct from the surrounding gland ; and the ligament- ous bands, in different directions, are very apparent, but do not follow any course, that can be traced. (Home.) When the tumour has advanced to what may be called cancerous suppuration, which, however, does not always happen CANCER. 239 in the centre, before it has approached the skin, and formed an external sore; it then exhibits an appearance totally different from what has been described. In the centre is a small irregular cavity, filled with a bloody fluid, the edges of which are ulcerated, jagged, and spongy. Beyond these, there is a radiated appear- ance of ligamentous bands, diverging to- wards the circumference; but, the tu- mour, near the circumference, is more compact, and is made up of distinct por- tions, each of which has a centre, sur- rounded by ligamentous bands, in con- centric circles. In some instances, the scirrhus has no appearance of suppuration, or ulceration, in the centre, but consists of a cyst, filled with a transparent fluid, and a fungous excrescence, projecting into this cavity, the lining of which is smooth and po- lished. When a large hydatid of tiiis kind occurs, a number of very small ones have been found, in different parts of the same tumour; and, in other cases, there are many very small ones, of the size of pins' heads, without a large one. These hydatids are certainly, by no means, suf- ficiently frequent in their occurrence to admit of their forming any part of the character of a cancerous tumour. (Home's Observations on Cancer.) In tlie fourth chapter of this work, the author relates two cases of hydatids found in the breast. In the first, the contents of the cyst were bloody serum ; in the se- cond, a clear fluid. These two cases of simple hydatids in the breast, unconnect- ed with any other diseased alteration of structure, led Mr. Home to consider the hydatids sometimes found in cancerous breasts; and, he believes, that such hy- datids are no part of the poisonous dis- ease, but accidental complaints super- added to it; and, since such hydatids do occur in the natural state of the glands, they are much more likely to do so in dis- ease. (Home.) Mr. Home endeavours to define his con- ception of a cancer, as follows : As cancer is a term, too indiscriminately applied to many local diseases for which we have no remedy, though they differ very much among themselves, it becomes necessary to state what the complaints are, which I include under this denomination. The present observations, respecting cancer, apply only to those diseased appearances, which are capable of contaminating other parts, either by direct communication, or through the medium of the absorbents; and when they approach the skin, produce in it small tumours of their O'.vn nature, by a mode of contamination, with which we are at present unacquainted. There is a disease, by which parts of a glandular structure are very frequently at- tacked, particularly the os tincat, the alae of the nose, the lips, and the glans penis. Tfiis has been called cancer, but differs from the species, of which we are now treating, in not contaminating the neigh- bouring parts, with which it is in con- tact ; and neither affecting the absorbent glands, nor the skin at a.distance from it. It is, properly speaking, an eating sore, which is uniformly progressive ; whereas, in cancer, after the sore has made some progress, a ridge is formed upon the mar- gin, and the ulceration no longer takes that direction. It also differs from a cancer, in admitting of a cure, in many instances, and under different modes of treatment. From the facts, which have been stated, (in Mr. Home's case) it appears, that can- cer is a disease, which is local in its ori- gin. In this respect, the cases (alluded to) only confirm an opinion very generally received. Mr. Home endeavours to establish a se- cond point, that cancer is not a disease, which immediately takes place in a healthy part of the body; but one, for the production of which it is necessary, that the part should have undergone some previous change, connected with the dis- ease. In proof of this, Mr. Home ad- duces the two first cases in his work, and the innumerable instances, in which a pimple, small tumour, or wart upon the nose, cheek, or prepuce, after remaining for ten, fifteen, or thirty years, without producing the smallest inconvenience; but, at the age of sixty or seventy, upon being cut in shaving, bruised by any ac- cidental violence, or otherwise injured, assumes a cancerous disposition. All the cases of induration of the gland of the breast, or of indolent tumours in it, wliich have continued for years, without producing any symptom, and, after being irritated by accidental violence, have as- sumed a new disposition, and become cancerous, admit ofthe same explanation ; and are adduced as so many proofs of the truth of this latter position. (Home.) DISTINGUISHING CHARACTERS OF SCIll- RHUS. A scirrhous induration seldom acquires the magnitude, to which almost all other tumours are liable to grow, when no steps are taken to retard their growth. Many scirrhi are certainly attended even with a diminution, or shrunk state, of the part affected. Scirrhi are generally more fixed, and less moveable, than other sorts of tumours; i40 CANCER. especially, when the latter have never been in a state of inflammation. With the exception of the fungus haema- toides, other diseases do not involve in their ravages indiscriminately every kind of structure, skin, muscle, cellular sub- stance, &c and the integuments seldom . become affected, before the distention, produced by the size of such swellings, becomes very considerable. In scirrhous cases, the skin soon becomes contaminat- ed, discoloured, and puckered. Some few tumours may be harder, and heavier, than a few scirrhous ones ; but, the reverse, is commonly the case. As other indurations, and tumours, may assume the cancerous action, and even. end in cancerous ulceration; and, as some true scirrhi, when not irritated by improper treatment, may continue sta- tionary for «years; the occurrence of ac- tual carcinoma cannot prove, that the preceding state was that of scirrhus. The only criterion of the latter disease is de- duced from the assemblage of characters already specified; for, except the peculiar puckering, and speedy leaden discolour- ation of the skin, no other appearances, considered separately, form any line of discrimination. The white ligamentous bands, around a scirrhus, is a very characteristic symp- tom; but, these cannot be detected, till the disease has been removed. Hence, how manifestly prudent it must be to take away a considerable portion of the sub- stance surrounding a scirrhous tumour! Were any of these white bands left, the disease would inevitably recur. OF CANCER IN THE STATE OF ULCERA- TION. The diseased skin, covering a carcino- matous tumour, generally ulcerates, be- fore the tumour has attained any great magnitude; a large chasm is then produc- ed in its substance, partly by a sloughing, and partly by an ulcerating process. Sometimes, when cells, contained in the tumour, are by this means laid open, their contents, which are a pulpy matter of dif- ferent degrees of consistence, and various colours, fall out, and an excoriating ichor issues from their sides. This dis- charge takes place with a celerity, which would almost induce belief, that it can hardly result from the process of se- cretion. When the diseased actions have, as it were, exhausted themselves, an at- tempt at reparation appears to take place, similar to that wliich occurs in healthy parts. New flesh is formed, constituting a fungus of peculiar hardness, as it par- takes of the diseased actions, by which it was produced. This diseased fungus oc- casionally even cicatrizes. But, though the actions of the disease are thus miti- gated ; though they may be for some time indolent and stationary ; they never cease, nor does the part ever become healthy. In the mean while, the disease extends through the medium ofthe absorbing veg- sels. Their glands become affected, at a considerable distance from the original tumour. They progress of carcinoma, in an absorbent gland, is the same as that, which has been already described. The disease is communicated from one gland to another, so that after all the axillary glands are affected, those, which lie under the collar bone, at the lower part of the neck, and upper part ofthe chest, become disordered. Occasionally, a gland, ortwo, become diseased higher up in the nick, and apparently out of the course which the absorbed fluids would take. As the disease continues, the absorbent glands, in the course of the internal mammary vessels, become affected. In the advanc- ed stage of carcinoma, a number of small tumours, of similar structure to the ori- ginal disease, form at some distance, so as to make a kind of irregular circle round it. The strongest constitutions now sink under the pain and irritation, which the disease creates, aggravated by the ob- struction, which it occasions to the func- tion of absorption, in those parts, to which the vessels leading to the diseased glands belong. Towards the conclusion of the disease,the patient is generally af- fected with difficulty of breathing, and a cough. (Abernethy.) The edges of a cancerous ulcer are hard, ragged, and unequal, very painful, and re- versed in different ways, being sometimes turned upwards and backwards, and, on other occasions, inwards. The whole sur- face ofthe sore is commonly unequal: in some parts, tiiere are considerable risings, whilst, in others, there are deep excava- tions. The discharge, for the most part, is a thin, dark coloured, fetid ichor ; and is often possessed of such a degree of acri- mony, as to excoriate, and even destroy, the neighbouring parts. In the more ad- vanced stages of the disease, a good deal of blood is often lost from the ulcerated vessels. A burning heat is universally felt over the ulcerated surface ; and, this is the most tormenting symptom, that attends the disorder. Those shooting, lancinating pains, which are generally very distressing in the occult state of the complaint, become now a great deal more so. Notwithstanding thatcancerous diseases are not always situated in glan- dular parts, yet the situation of such sores affords some assistant in the diagnosis; CANCER 241 for, six times as many cancerous affections occur in the lips, and female breasts, as in all the rest of the body together. (B. Bell.) Concerning the peculiar state of the parts in cancer, or the proximate cause, many opinions have prevailed. Until lately, the melancholic humour was sup- posed to be the fluid, which was obstruct- ed, and accumulated, in consequence of which it fermented, and produced a burn- ing ulcer; and whatever promdted the generation of this humour, was currently admitted as a remote cause of cancer. " Women," says Pare, " are more sub- 1'ect to scirrhus, than men ; because their iver is warmer, and their spleen, being weaker, is less able to purge the blood of choler." Grief and chagrin, by promot- ing the formation of tliis fiery fluid, were accordingly considered by Heister as very apt to induce the " cancerous diathesis ;" and he adds by way of corollary, " old maids, and women, who do not breed, are very subject to cancer in the breast." Some thought that the obstructed humour became charged with an acid, (Dionis) and that this produced ulceration. Others conjectured, that by an adustion, or over- concoction, it grew sharp and burning. Wiseman thought it more probable, that it might become arsenical. These changes were almost universally believed to depend upon the previous stagnation, in conse- quence of obstruction; and this leading point has uniformly been insisted upon by every preceding author, whatever may be his particular notion, with regard to the nature of the obstructed fluid, whe- ther bile, blood, or lyinph. Even Mr. B. Bell insists fully on the cause of cancer being a mechanical obstruction^ Some have asserted, that they have detected Uttle worms in the parts, which, eating them up, produced all the mischief attendant on cancer; and that to their introduction the disease was owing. Others have ri- diculously assigned a Uttle wolf in the part, as the cause ofthe disease! Strange as this doctrine, of hying- creatures pro- ducing cancer, may appear, it is never- theless adopted by Dr. Adams. (Obser- vations on Morbid Poisons.) When hyda- tids find their way into a solid substance, the consequence, in his opinion, will be cancer; and the success of an operation will, he conjectures, depend, in a great measure, upon these animals being con- fined in a common cyst, for then they may be all removed; whereas, if they be un- connected, some of the smaller ones may be allowed to remain. From the surface of the cyst, which contains the animal, a fungus shoots out, and thus acts, as a barrier, between it and the skin; or, if the, animal have been in the'stomach, it Vol I separates it from the coats of that viscus, " preventing suppuration in the one in- stance, and absorption in the other" This suppuration, and " disposition to fungate, before tlie skin is broken," is, (continues Mr. Burns) if I understand him, produc- ed by the death of the animal; for, says Dr. Adams, " if" hydatids possess the principle of vitality, during their trans- parent state, and their opacity is the ef- fect of the loss of that principle, would they not, in the latter stage, stimulate the part, in which they are situated, to sup- puration, as we find the case with the guinea-worm, when dead ?" Concerning the manner, in which these animals produce the symptoms of cancer, we are told, that "this enlargement of a foreign body in a solid substance, and so extremely sensible, as the breast, cannot but be attended with intense pain, and frequent inflammation." A doctrine not far removed, says Mr. Burns, from that taught in the humoral schools, which maintained, that the coagulation, and in- spissation ofthe fluids, distended tlie fol- licles of the glands, producing many ca- vities, and much pain. (See Burns on In- flammation, Vol. II.) We have already stated, that, though hydatids are occasionally found in cancer- ous tumours, they are not found often enough to make any part of the character of tiie disease, and they are met with, in cases, in which there is not the least ves- tige of such disorder. After cancer had continued some time, it was believed, that the matter was ab- sorbed into the blood, and that all the hu- mours were speedily assimilated. Hence, was explained the fatal and rapid progress of relapses, after an apparent cure. The only effect of absorption, however, is on the lymphatic glands, which intervene betwixt the sore and the heart; for, be- yond these, the absorbed matter is changed in its nature and properties. ( Burns.) In many instances, cancer is evidently produced by the same causes, which are capable of producing simple inflammation. It is, however, a general opinion, that cancer arises frequently from some un- known and mysterious cause, which we cannot detect, and which, therefore, has been resolved into some constitutional taint, or cancerous ferment. But, so far as we know, tile constitution is perfectly healthy, in the commencement of this dis- ease ; nor is there the smallest proof, that it resembles scrophula, in depending on any peculiarity of constitution, before the' causes operate. Blows, bruises, &c. may*. give rise to cancer; but, in many instan-' ces, there* is no evident local cause act- Ii 242 CANCER. ing directly on the part. In the breast, cancer frequently commences, without the interference of any topical agent. There is always, however, in these cases, an irre- gularity, or disappearance ofthe menses; and the affection of the mamma seems to depend on sympathy between it and the uterus. Certain it is, that cancer is very frequent about the time of Ufe, when the menstrual discharge ceases. Cancerous diseases are undoubtedly ■most common in elderly persons; but, no age is exempted from this disease. Air. Burns mentions his having seen it dis- tinctly marked, and attended wkh a fatal event, in children of five years old: he mentions two instances of the eye being affected in such subjects, though from the late observations of Mr. Wardrop, we may now reasonably suspect, that these exam- ples were really cases of the fungus hse- matodes. ' TBEATMINT OP CANCER. Some have supposed cancers to be a general disbrder of the system; while others have regarded them merely as a local affection. This is a point of much importance in practice; for, if cancers are originally only local affections, no objec- tion can be made to extirpating them. They who think, that cancer is aconstitu- tional disease, regard the operation as useless, perhaps hurtful, inasmuch as it may convert a scirrhus into an open can- cer, or make the affection occur in some other part. The best practitioners of the present day, however, have rejected the doctrine of cancer depending on constitutional causes ; and, we have"stated Mr. Home's sentiments, in opposition to tiie opinion. When cancer breaks out again, in the same part, after the performance of an operation, it is often owing to some por- tion of -the disease having been blameably left behind, or to the operation having been put off too long. How likely it is, that some of the cancerous mischief may be left unremoved by the operator, is obvi- ous, on considering the manner, in which the white bands, resembl.ng ligament, shoot into the surrounding fit; and that, even the fibres of the muscles, beneath a cancerous disease, are frequently affected. At the same time, it must be allowed, that the disease is sometimes, to all appear- ances, so freely and completely removed, that its recurrence must perhaps be im- puted to the continued operat ion of the same unknown cause, which originaUy jiroduced the first cancerous mischief. Unt'u very lately, the accounts given of tlie results of operations for cancers, were so unpromising, that they must have de. terred many patients from undergoing a timely operation ; which, for cancerous complaints, is the only remedy to be de- pended "on, with which we are as yet ac quainted. As Mr. B. Bell remarks, tbe great authority of Dr. Alexander Monro must have had no inconsiderable influence even with practitioners, in making them much more backward in undertaking the extirpation of cancers, than they other- wise would probably have been. "Of near sixty cancers," says he, " which I have been present at the extirpation of, only four patients remained free of the disease, at the ehd of two years : three of these lucky people had occult cancers in the breast, and the fourth had an ul- cerated cancer on the lip." (Edinb. Med. Essays, Vol 5.) Dr. Monro also observes, that, in those, in whom he saw the dis- ease relapse, it was always more violent, and made a quicker progress, than it com- monly did in others, on whom no opera- tion had been performed. Hence, he questions, " whether ought cancerous tu- moufs to be extirpated, or ought the pal- liative method only to be followed ?" and, upon the whole, he concludes against their extirpation, except in such as are of the occult kind, in young healthy pec pie, and that have been occasioned by bruises, or some other external causes. More modern experience, however, has afforded a very different result, and given ample encouragement to the early per- formance of an operation, and even to mak- ing an attempt to cut away the disease, in every instance, both of the occult, and ulcerated kmd, when such a measure can be so executed, as not to leave a particle of the cancerous mischief behind. Mr. Hill, in 1772, published some va- luable remarks on the present subject. At this period, he had extirpated from dif- ferent parts of the body eighty-eight ge- nuine cancers, which were all ulcerated, except four : and all the patients, except two, recovered ofthe operation. Ofthe first forty-five cases, only one proved unsuc- cessful ; in three more, the cancer broke out again in different parts; and, in a fifth, there were threatenings of some" tu- mours, at a distance from the original dis- ease. These tumours, however, did not appear, till three years after the opera- tion ; and the woman was carried off' by a fever, before they had made any pro- gress. All the rest of the forty-five con- tinued well, as long as they lived ; or are so, says Mr. Hill, at this day. One of them survived the operation above thirty years ; and fifteen were then alive, although the last of them Was cured in March 1761. Of the next thirty three, one Uved only CANCER. 243 tour months ; and, in five more, the can- cer broke out afresh, after having been once healed. THt reason, why, out of forty-five cases,,only four or five proved unsuccessful, and six, out of thirty-three, was as follows : " The extraordinary suc- cess, I met with, (says Mr. Hill) made cancerous patients resort to me from all corners of the country,, several of whom, after delaying till there was' Uttle proba- biUty of a cure by extirpation, or any other means, forced me to perform the operation, contrary both to my judgment and inclination." Upon a survey in April 1764, made with a view to publication, the numbers stood thus : Total cured, of different ages from eighty downwards, sixty tliree j of whom tiiere were then living, thirty-nine. In twenty eight of that number, the ope- ration had been performed more than two years before; and, in eleven, it had been done in the course of the last two years. So that, upon the whole, after thirty years' practice, thirty-nine, "-of sixty three pa- ( tients were alive and sound; which gives Mr. Hill occasion to observe, that the different patients Uved as long after the extirpation of the cancers, as according to the bills of mortaUty, they would have done, had they never had any cancers, or undergone any operation. The remaining twenty-five, which com- . plete the eighty-eight, were cured since the year 1764. Twenty-two of these had been cured, at least, two years ; and some of them, it may be remarked, were seven- ty, and one ninety years old. In the year 1770, the sum of the whole stood thus: Of eighty-eight cancers, ex- tirpated at least two years before ; not cured, two; broke out afresh, nine; threatened with a relapse, oner in all, twelve, which is less than a seventh part of the whole number. At'that time, there were about forty patients alive and sound, whose cancers had been extirpated above two years before. Mr. B. Bell, who was present at many of these cases, bears witness to Mr. Hill's accuracy; and, the former very judici- ously states, that, " from these and many other authenticated facts, which, if ne- cessary, might be adduced ofthe success, attending the extirpation of cancers, there is, it is presumed, very great reason, for considering the disease, m general, as a local complaint, not originally connected with any disorder of tlie system ; and that a general cancerous taint seldom, or per- haps never, occurs, but, in consequence of the cancerous virus being absorbed into the constitution from some local affection. This, in every case of real cancer, or ra- ther in auch scirrhositie9, as, from their nature, are known generally to terminate in cancer, should certainly determine us to have recourse to extirpation as early as possible ; and, if this were done soon after the appearance of such affections, or before the formation of matter takes place, their return would probably be a very rare occurrence." (System of Surgery, Vol 7.) MEDICINES AND PLANTS, WIIICH HAVE BEEN TRIED, FOR THE CORK OF SCIRRHUS AND CANCEn. It is a contested point, whether a truly cancerous disease is susceptible of any process, by which a spontaneous cure can be effected. It appears certain, however, that a violent inflammation, ending in sloughing, may" sometimes accomplish an entire separation of a cancerous affection, and>that the sore, left behind, may then heal. Facts, confirming this observa- tion, are occasionally exemplified in cases, where caustic is used, and accidental in- flammations have led to the same fortu- nate result, as we may be convinced of by examples recorded by Home, Richerand, ike. The latter writer, adverting to the effort, which nature sometimes makes to rid herself of the disease, on the inflam- mation and bursting of the tumour, takes the opportunity to relate the following case. A woman,' aged forty-eight, of a strong constitution, was admitted into the hospital of St. Louis, with a cancerous tumour of the right breast. The swelling, after becoming softer, and affected with lancinating pains, was attacked with an inflammation, which extended to the skin of the part, and all the adjacent ceUular membrane. The whole of the swelUng mortified, and was detached. A large sore, of healthy appearance, remained after this loss of substance, and healed in two months. (Nosagraplue Chirurgi- cale, Tom. 1, p. 381, Edit. 2.) In general, however, it must be con- fessed, that inflammation, attacking a can- cerous disease, renders things worse in- stead of better, and by converting occult cancers into ulcerated ones, hastens the patient's death, or, at all events, renders fiis cure more difficult, and forbids any attempts, which, on such a principle, might be made for his relief. Of the general remedies, narcotics, such as cicuta, opium, nightshade, &c. have been employed with most confidence. Cicuta owed its reputation to the ex-' perimenting talent of Storck, who has written several libclli on this plant. Ac- cording to him, cicuta possesses very evi- dent powers over cancer, and has cured a great many cases ; but, in less prejudiced hands, it has been found much less sue- 244 CANCER. cessful -, and even m many of the in- stances, adduced by Baron Storck, of its utility, it is by no means proved, that the disease was really cancer. The public have now with great reason, very little reliance on this medicine. In cancerous ulceration, Mr. Bums declares, that he never knew cicuta produce even the temporary melio- ration, which many talk of. The common way of exhibiting the hemlock is to begin with small doses, and increase them gradually, until they pro- duce vertigo. We may begin with two grains of the extract, or four of the pow- der, recently prepared, twice, or thrice a day, and tiie quantity is to be gradually increased. In this way, some patients have at last been able to take an ounce ofthe extract daily; but, says Mr. Burns, if a much less quantity, than this, pro- duce no good effect, we may consider it as useless to continue a remedy, which, in this dose, must injure the constitution every day that it is continued. On the continent, hemlock has been used in the form of a bath; but, it is so disagreeable, that few will submit to this method. The belladonna has been much recom- mended by Lambergen. During its use, he kept the bowels open with clysters, ad- ministered every second day. The dose should be, at first, a grain of the dried leaves, made into a pill. This, in the beginning, is to be given in the morning and evening, and afterwards more fre- quently. The reputation of belladonna has not been supported by much success. The hyocyamus has otten been tried in cancerous cases, and was held in great estimation by the ancients. Mr. Burns says, he has employed it occasionally, but with little effect. The dose, with wliich you may begin, is two grains of the extract. The aconitum has also been given; and, as it is a very powerful and dangerous narcotic, a quarter of a grain of the ex- tract is generally the dose, at first. The solanum dulcamara, Paris quadrifolia, Phytolacca, fee. have been recommended;, •but, they are now hardly ever employed ; which is a sufficient proof of their ineffi. Cacy. Mr. Burns mentions his having tried the hepatized ammonia, without any benefit. Richter has given the laurus ce- rasus, but with little success. The dose of the .distilled water, being uncertain, four, or five grains of the fresh leaves may be infused in a little water, as a dose. The digitalis diminishes vascular ac- tion, and may act on scirrhi, Uke absti- nence, bleeding, &c. It has, however, no specific virtue in curing cancerous dis- eases. Opium is seldom employed, with an in- tention of curing cancer, although it pro- bably has just as much piBwer of this kind, as other narcotics, wliich have been more frequently used. For the purpose of les- sening the pain of cancerous diseases, however, opium is very freely employ- ed. Tonics may sometimes improve the ge- neral health ; but, as they never produce any effect on the local disease, they are now seldom exhibited. Mr. Justamond thought arsenic a spe- cific for cancers. Future experience has not, however, altogether confirmed the truth.of this opinion,though there are many practitioners, who continue to think highly of the efficacy of this mineral in carcinoma- tous diseases. Indeed, 1 am of opinion, that arsenic has, greater claims to further trials in these cases, than perhaps any other medicine, that has hitherto been employ. ed. It unquestionably cures numerous ill- look ing sores, on the face, lips, and tongue, and is one of the best remedies for noli me tangere. Mr. Hill observes : " Ex- perience has furnished me with some sub- stantial reasons for considering arsenic as a medicine of considerable merit, both with regard to actual cancer and scirrhus, which may one day terminate in that hor- rible species of ulcer; and although I can- not as yet say it will remove the one, or cure the other, as certainly and safely as mercuiy commonly does a syphihtic swell- ing, or open sore, yet, it wiU, in a great majority of cases, retard the progress of the true scirrhous tumour, and often pre- vent its becoming cancer. In some, it has appeared to dissipate such swellings com- pletely." (See Edinb. Med. and Surgical Journal, Vol 6, p. 58.) Mercuiy, in conjunction with decoc- tions of guaiacum, sarsaparilla, &c. has been recommended; but, as Mr. Burns very justly remarks, no fact is more cer- tainly ascertained, than that mercury al- ways exasperates the disease, especially, when in the ulcerated state. Tlie cuprum vitriolatum has been tried*; but, it has at this day no fame whatever. The same may be said of muriated ba- rytes. The carbonate (rust) of iron has been extolled, by Mr. Carraichael, for its effi- cacy in curing cancer. Besides the car- bonate of iron, he has prescribed the tar« trate of iron and potash, and the phos- phate, oxyphosphate, and suboxyphos- pbate of the metal. Some constitutions can bear these preparations only in small quantities ; they affect most patients with constipation, and many with headach and dyspnea. These circumstances*; there- fore, must be attended to in regulating CANCER. 245 the dose. The above gentleman has sel- dom given less than thirty grains, in di- vided doses, in a day, or exceeded sixty. He prefers the suboxyphosphate for in- ternal use, and states, that it answers best in small doses, frequently repeated. It should be blended with white of egg. have a little pure fixed alkali added, and then be made into pills with powdered liquorice. Aloes is recommended for the removal of costiveness. When half a grain is combined with a pill, containing four grains of carbonate of iron, and taken thrice a day, the constipation will be ob- viated. When the internal use of iron brings on headach, difficult respiration, a quick, sometimes full pulse, which i3 also ,i generally, hard and wiry, excessive lan- guor, lassitude, &c. and such symptoms become alarming, the iron is to be left off, and four grains of camphor given, every fifth hour. At the same time, that preparations of iron were internally administered, Mr. Carmichael has employed externally, for ulcerated cancers, the carbonate, phos- phate, oxyphosphate, and arseniate of iron, blended with water, to the consist- ence of a thin paste, wliich was appUed once every twenty-four hours. To occult cancers, the same gentleman has applied a solution of the sulphate of iron, Sj to lbj of water. The acetite of iron, dilut- ed with eight or ten times its weight of water, was also used. These lotions were put on tlie part affected by means of fold- ed Unen, wet in them, and covered with a piece of oiled silk to prevent injury of the clothes. (See An Essay on the effects of the carbonate and other preparations of iron upon Cancer, &c. by Richard Carmi- chael.) > Many remedies have acquired celebrity in cases of cancer, because very bad and malignant diseases, only supposed to be cancers, have got well, under -their use. Such is probably the case with tlie car- bonate of iron. In some instances, Mr. Justamond used to join the corrosive sublimate with ar- senic. Opium, added to both applica- tions, mitigates the pain, without injur- ing the efficacy ofthe remedy. The only mode of treatment, which Mr. Pearson has ever seen do any particular benefit to cancer, is that of keeping the patient on a diet, barely sufficient for the support of life, such as barley-water, alone, tea, &c. Patients, with cancers, receive considerable benefit from being kept strictly on a milk diet. The old" surgeons commonly dressed cancerous sores, with narcotic applica- tions. Vesalius used cloths, dipped in the juice of the solanum ; whilst others em- ployed It mixed with oil of roses, and pre- parations of lead, and antimony. Others had recourse to the hyocyamus; but, of late, the cicuta poultices seem to have su« perseded most other narcotic applications. These have undoubtedly, in many cases, as Mr. Burns observes, abated the pain, and diminished the fetor; but, this is all ""which can reasonably be expected; and even this expectation will not always be realized. Carrot poultices are better, than those > of hemlock, as they produce as much ease, and diminish the fetor more powerfully. . The fetor of cancers having been thought to resemble that of the kali sulphuratum 0 (liver of sulphur) and tiie oxygenated mu- riatic acid being the best agent for de- composing, and destroying vsuch smell, it has been recommended, as an application to cancerous sores. It may correct the fetor; but, it will never accompUsh a cure. Carbonic acid has been said not only to correct the fetor, but, in some instances, completely to cure the disease. It was long-ago, proposed, says Mr. Burns, by M. Peyrille, and, of late, it has again been brought forward by Dr. Ewart. Ex- perience, however, has not shewn, that the efficacy of carbonic acid, in cases of cancer, is very great. Fourcroy remarks: " After the first applications, the cancer- ous sore appears to assume a more favour- able aspect; the sanies, which flowed fi-om it, becomes whiter, thicker, ano*. purer,and the flesh has a redder and fresher colour; but,these flattering appearances are deceit* f ul, nor do they continue long, for the sore speedily returns to its former state, and its progress goes on, as before the appli- cation." The best method of applying carbonic acid is, by means of a bladder, tlie mouth of which is fastened round the sore, with adhesive plaster. The air is introduced by a pipe, inserted at the other end. Sometimes, the fermenting poultice is employed. Digitalis, as a local application, is en- titled to about as much confidence as ci- cuta. Tar ointment, gastric juice, absorbent powders, &c. have been tried; but, with- out any evident good. (See Burns on In- flammation, Vol. 2.) Mr. Fearon rejects, probably with much reason, all internal remedies, as in- efficient in the treatment of cancer; and, he recommends, in the early stages of the complaint, a method of practice founded on his idea of the inflammatory nature of tiie disease. " In tiie beginning of scir- rhous affections of the breast and testis, the mode I have adopted of taking away 246 CANCER. blood, is by leeches repeatedly appUed to the parts. In this course, howi-ver, I have often been interrupted by the to- pical inflammation, produced by these animals, around the parts where they fastened. In delicate female habits, I have often lost a week, before'I could proceed to the re-application of them. When the symptoms lead me to suspect tlie stomach, uterus, or any of tlie viscera, to be so affected, that the complaint ei- ther is, or, most probably, soon will be- come cancerous, I then have recourse to general bleedings. But, whether topical, or general, perseverance for a sufficient length of time, is necessary. Though the pulse never indicated such practice, yet the patients have not suffered by re- peated bleedings ; on the contrary, when they passed a certain time without los- ing blood, they felt a return of their symptoms, and, of their own accord, de- sired to be bled again. To this plan of repeated bleedings, I joined a milk and vegetable diet, avoiding wine, spirits, and fermented liquors." Mr. Fearon used also to keep the belly open, and em-« ploy saturnine applications. From the preceding accounts, we may infer, that scarcely arty reliance is to be placed on any known remedy, or plan, in cases of real scirrhi, and ulcerated can- cers. The operation is the only rational means of getting rid of the disease; and, to waste time, so as to allow the disorder to increase in a serious degree, merely for the sake of trying a train of unpromis- ing medicines, is a conduct, which is un- worthy of a wise surgeon's imitation. Perhaps, in early cases, it may be right to make trial of arsenic, cicuta, or preparations of iron. But, the practitioner should beware or' devoting too much time to medicines, which will in all probability prove inadequate to the object, for which they are exhibited. Mr. Fearon's me- thod seems also warrantable, together with diet merely enough to support life; but the punishment, attending a resigna- tion to this last regimen, would be greater, than that of having the disease cut away, while the chance of efficacy would be much less. Upon the whole, therefore, the operation is what we should generally resort to, as the surest, and the safest means of getting rid of cancerous diseases. As I have before remarked, the operation is always admissible, when every particle of the disease can be re- moved by it. Even large open cancers, if they can be entirely cut away, are oft- en capable of being effectuaUy cured. The removal of cancerous disorders even in the slightest and most trivial cases, should be always effected with the scalpel, in preference to caustic; the use of which, though formerly recommended by some authors, and still adhered to by some, (Young) ought, for very obvious reasons, to be entirely laid aside. The irritation generally occasioned by every application of the caustic kind, together with the pain and inflammation, which commonly ensued are strong objections in cancerous cases. Plunket's remedy, which is chiefly arsenic, is equally objec- tionable. Nor can you, at once, so cer- tainly extirpate every atom of cancerous mischief with any caustic, as you can with the knife: for, with this, you imme- diately gain an ocular inspection of the surface surrounding the disease, so as to see and feel whether the disordered parts are completely removed, or whetiier any portion of the disorder requires a further employment of the instrument. With re- spect to the pain, that of caustics is infi- nitely greater, more intolerable, and more tedious, than that occasioned by die knife. When caustic also fails in destroy. ing every particle of the disease at once, it almost always tends to enlarge, in a very rapid way, the original boundaries of the mischief. For an account of the me- thod of removing scirrhi and ulcerated cancers, scs Mamma, Removal of. For information on cancer, the reader is particularly referred' to Le Dran't Operations in Surgery, p. 287, &c. Edit. 2. B. Bell's Surgery, Vol 2. Justamondon Cancers. Hill's Cases in Surgery. Pear- son on Cancerous Complaints. Abemethy's Surgical Observations, 1804. Fearon on Cancers. B. Bell on Ulcers. Home on Cancer Adams on Cancerous Breasts, and on Morbid Poisons. Medical Museum, Vol. 1. London Medical Transactions, Vol. 1. Gooch's Med Observations, Vol 3. V- Encyclopedic Methodique, Partie Clururgi- cale. Article Cancer, in London Medical Dictionary, and Rees's Cyclopxdia. Prac- tical Observations on Cancer, by the late John Howard Memoire Renforment quel. ques Vues Generates sur le Cancer, in (Eu- vres Chirurgicale de Desault par Bichat, Tom. 3. p. 4u6, &c Richerand's Nosogra- phie Clururgicale, Tom. l,p. 377, &c. Edit. 2. Lambe's Reports of the Effects of a pe- culiar Regimen in Cancerous Complaint*. Baillie's Morbid Anatomy of some of ihe most important Parts of the Human Body. The Queries ofthe Society for Investigating the Nature and Cure of Cancer may be seen in the Edinb. Med. and Surgical Journal, Vol. 2, p. 382, &c. Consult also Wardrop on Fungus Hxmatodes, in which may be seen an interesting comparative view of this last affection and cancer. Denman's Observa- tions on the Cure of Cancer, and on Carmi- ehael's Essay on €ancer, Edit. 2. CAP CANCER SCROTI. CHIMNEY- SWEEPER'S CANCER. (See Scro- tum.) CANCRENA. (See Gangrene.) CA'NCRUM ORIS. A deep, foul, ir- regular, fetid ulcer, with jagged edges, which appears upon the inside of the lips and cheeks, and is attended with a co- pious flow of offensive saliva. According to Mr. Pearson, this disease is seldom seen in adults; but, most commonly, in children from the age of eighteen months to that of six, or seven years. The gums, as well as the lips and cheeks, are some- times affected, in which circumstance, the teeth are generally carious and loose. The ulceration is occasionally attended with abscesses, which burst either -through the cheek, lip, or just be- low the jaw. Exfoliations* are not un- frequent, and, when the disease is neg- lected, extensive sloughing sometimes happen. Living in a marshy situation; unwhole- BOme food; and inattention to cleanli- ness; are suspected of being conducive to this disorder. The causes of the affliction seem not to be much understood; but, it is remarked, that the disease prevails most in houses, where children are crowd- ed together. It is uncertain, whether the complaint is contagious. Though children are the usual subjects of this disease, grown-up persons some- times do not escape its attacks. The treatment recommended consists, in extracting diseased teeth and loose pieces of bone; directing a milk vegetable diet, with a prudent quantity of ferment- ed liquors ; and prescribing bark, sarsapa- rifla, and elm bark, with mineral acid. The best external applications are said lobe such as diluted mineral acids; burnt alum; the 'decoctum cinchonae, with the zincum vitriolatum ; tincture of myrrh ; lime water, with spirit of wine, &c. (See Pearson's Principles of Surgery, Edit. 2. p. 287.) We cannot conceive it a safe and pru- dent method to use any preparation of copper, as an application to the ulcer. Jlowever, such practice has an advocate in the preceding author. CANKER OF THE MOUTH. (See Cancrum Oris.) CANNULA. Any kind of small tube, employed for surgical purposes. CANTHARIDES. (Lytta.) Spanish, or French flies, with which the common blistering plaster is made. In surgery, they are also prescribed in incontinence of urine, gleets, &c. The tincture is sometimes used as a liniment for stimu- lating parts. CAPEUNA. (from capeline, a woman's CAR ^47 hat, or bandage, French.) A reflex band- age. It is a double-headed roUer, about twenty-four feet long, and four inches broad; sometimes narrower. The mid- dle is applied to the occiput, and, after two or three circular rounds, the rollers intersect each other upoa the forehead and occiput; then one roller being re- flected over the vertex to the forehead, the other is continued in a circular track. They next cross each other upon the forehead, after which the first head is car- ried back obliquely towards the occiput, and reflected by the side of the other. The last is continued in a circular di- rection ; but the first is brought again over the sagittal suture, backward and forward, and so continued, tiU the whole head is covered. This bandage used to be ap'plied in cases of hydrocephalus; it has no ad- vantage, however, and is now hardly ever used. CAPILLARY FISSURE. A very mi- nute crack in the skull. The term came into, use from the resemblance of such a fracture to a hair. CAPILLA'TIO. A capillary fissure. CAPILLITIUM. The disorder of the eyelids, or eyelashes, better known by the appellations of distichiasis, and trichi- asis. CAPISTRATIO. A phimosis, or such a contraction of the orifice ofthe prepuce, as prevents the patient from uncovering the glans penis. CAPISTRUM.* (x,ccirtcpov, from caput, the head; as being made to guide and govern the head.) A surgical bandage, somewhat resembling a bridle or head- stall. (See Bandage.) CAPULUM. A distortion of the eve- lid. CARBO. See Carbuncle. CARBUNCLE, (from carbo, a burn- ing coal.) Anthrax. This is a very com- mon symptom in the plague; but comes on also sometimes as a primary disease. The first symptoms are great heat and violent pain in some part of the body, on which arises a kind of pimple, attended w ith great itching; below which a cir- cumscribed, but very deep-seated, and extremely hard tumour may be felt with the fingers. This tumour soon assumes a dark red, or purple colour, about the centre, but is considerably paler about the edges. A little blister frequently ap- pears on tiie apex, which, as it occasions an intolerable itching, is often scratched by the patient. The blister being thus broken, a brown sanies is discharged, and an eschar makes its appearance. Many such pimples are sometimes pro- duced upon one tumour, in consequence 248 CARBUNCLE. of the patient's scratching the part.— (BromfielePs Observ. Vol. 1.) Carbuncles have been distinguished into the benign and malignant kinds; but, these distinctions appear to be scarcely warrantable, or, at best, they are only founded upon the different degrees of violence, with which the disease makes its attacks. Some carbuncles are said to be pestilential, while others are not so. Fortunately, all the cases, which are met with in this country, are of the last sort; for, no opportunities of remarking the pestilential anthrax have occurred in England since the deplorable periods of 1665, and 1666. The carbuncle sometimes appears in persons affected with putrid fevers, in which case, it is attended with great weight 'and stiffness of the adjacent parts; the patient is restless and pale, the tongue white, or of a deep red, and moist; the pulse low, urine sometimes pale, sometimes very turbid, with all the other symptoms; in an exaggerated de- gree, which attend typhoid fevers. The patient often complains much of his head, either from pain, or giddiness. Some- times, he is drowsy; at other times, he cannot get tiie least sleep. OccasionaUy, he is deUrious. The case is also apt to be attended with chilliness, or rigors, and profuse perspirations. The patient is sometimes costive, sometimes afflicted with a profusion of stools; he generally complains of loss of appetite, nausea, and vomiting, takes but little nourishment, complains of difficulty of breathing, and is extremely low, with palpitations of the heart, and sometimes faintings. (See Bromfield's Observations, Vol. 1, p. 122.) Sometimes a little slough, of a black colour, appears in the middle of the tu- mour. This was supposed by the ancients to be a part of the body burnt to a cinder, or hard crust, by the violence of the dis- ease. The carbuncle is considered by some as a sort of gajjgrenous affection of the cellular substance. (Latta.) The progress of carbuncles to the gangrenous state is generally quick. Their size is very various; they have been known to be as large as a plate. Considerable local pain and induration always attend the disease. The skin, indeed, has a peculiar feel, like that of brawn. As the complaint advances, several apertures generally form in the tumour. Through these openings, there is discharged a greenish,' bloody, fetid, irritating matter. Thev in- ternal sloughing is often very extensive, even when no sign of mortification can be outwardly discovered. If attention is paid to the skin in this case, we shall frequently find some mili- ary eruptions about the clavicles, tli* breasts, or other parts of the body; and, towards the latter end of the disorder, a different collection of large pimples will sometimes be thrown out, like the small- pox, and suppurate. Some of these, in- deed, are occasionally converted into actual carbuncles. It was this species of anthrax, which was called malignant, and, certainly, if any cases, seen in this coun- try, demand this epithet more strongly, than others, it is the instance, the descrip- tion of which we have just quitted. The constitution is often so low and exhausted, that death follows. The car- buncle, indeed, is most frequent in old persons, whose constitutions have been injured by voluptuous living, ®M, hence, we cannot be surprised, that^ie local disease, influenced by the general dis- order ofthe system, should assume a dan- gerous aspect. The degree of peril may generally be estimated by the magnitude and situation of the tumour, the number of such swell. ings at the same time, the age of the pa- tient, and the state of his constitution. The duty of a surgeon, in cases of an- thrax, may be described in a very few words. With regard to the local treat- ment of a carbuncle, the grand thing is to make an early and free incision into the tumour, so as to allow the sloughs and matter to escape readily. As much of the contents as possible is to be at once pressed out, and then the part is to be covered with an emollient poultice. In- deed, until the tumour is opened, no ap- plications are more proper than emollient poultices, and, when an incision has been made, they are far preferable to any de- tersive antiseptic injections, made with bark, tincture of myrrh, &c. or to any lotions made with the sulphates of copper, and zinc, nitrate of silver, &c. fomentations will also be found to affojrd considerable relief, both before and after an opening has been made. As the discharge is ex- ceedingly fetid and irritating, it will be necessary to put on a fresh poultice two or three times a-day. The use of the poultice is to be continued, till all tlie sloughs have separated, and the surface of the cavity appears red, and in a gra- nulating state, when soft lint and a pledget of some unirritating ointment should be applied, together with a tow compress and a bandage. The dreadful manner, in which the disease is protract- ed, by not making a proper opening in due time, cannot be too strongly impress- ed upon the mind of every pracition- er, and it may justly be regarded as a frequent reason of the fatal termina- tions of numerous cases. Mr. Bromfield CAR CAR 249 forcibly inculcates this necessity of mak- ing, at a proper time, an opening suffi- cient to draw out the sloughs; for, says he, in case you cely on that opening, which is generally made by nature, the thin ** matter only will be discharged, and the slougliy membranes will remain, and the orifice close up. {See Vol. I, p. 128.) It was formerly not an uncommon cus- tom to extirpate carbuncles with the knife, or to destroy them with the actual and potential cauteries. The French were very fond of burning the swelling with a hot iron, the employment of which is sanctioned by Pouteau. (See his (Euvres Posthumes.) These methods, hav- ing been found cruelly paiuful, and, in no respect advantageous^ have long been brand^Lwith the reproaches of all Eng- lish surgeons. With respect to the con- stitutional treatment, we should remem- ber, that the disease is for the most part met with in bad constitutions, and in persons who are weak and irritable. Hence, it is only when there is a full strong pulse, and the complaint is just beginning, that bleeding is aUowable. Bark and camphor are the internal medi- cines most commonly needed. The vitri- olic acid is also very proper, «s well as wine and aromatics. As the pain is very severe, opium is generally an essential remedy. The constitutional treatment is very analagous to that of mortifications, and, for this reason, I do not deem it ne- cessary to enlarge the present article, by expatiating on this part of the subject. [From repeated experience the applica- tion of a blister over the affected part is confidently recommended as the best local remedy for carbuncle. See Mortification.'] In many of the southern parts of Eu- rope, a malignant species of carbuncle, appears to be endemic, contagious, and very often fatal. For an aceodtit of this form of the disease, I would particularly advise the reader to consult Richerand's Nosographie Chirurgicale, Torn. 1, p. 125, iic.Edit.2, and Larrey'sMemoires de Chirur- gieMdittdre, Tom. l,p. 104,&c. BromfieltTs Chirurgical Cases and Observations. L'En- eyclop/die Methodique, Partie Chirurg. art. Anthrax, Pearson's Principles. Richter's Anfangr. der Wundarzn. Band 1.) CARCINOMA.-(from xxpxtvas, a crab.) See Cancer. CARIES, (from *£'•?«) to abrade.) The clearest way, in which we can convey an idea of caries, is, by comparing it with ulceration of the soft parts, in which we know a breach is produced by the action ofthe absorbents. All the bones are liable to caries ; but the spongy ones are more frequently attacked, ti»an such as are Vol.. I. compact. Hence, the vertebrae, astranga- lus, and other bones of the tarsus, those of the carpus, the sternum, and the extre- mities of long bones, are the most com- mon situation of this affection. The bones of young persons are said to be more frequently carious, than those of old subjects. Many authors have confounded caries with necrosis, which they have called dry caries. Others have considered it to be the same as exostosis. The carious part of a bone becomes so soft, that the end of a blunt probe may be easily forced into its substance. The openings, with which the bone is perforated, are filled with fungous flesh, which bleeds from the sUghtest cause. A dark-coloured serum is discharged, which always has a dis- agreeable smell, but becomes particularly fetid when exposed to the air. In necrosis, the bone is entirely de- prived of the vital principle ; in caries, this principle exists, and there is a mor- bid action going on, which destroys the texture of the bone. Some of the causes of caries are in- ternal, others external. The former are the most frequent; a contusion, or ex- ternal violence, being more-apt to pro- duce necrosis than caries. Abscesses are said to produce, occa- sionally, a caries of the bones, over which they take place. For this reason, it has been laid down, as a rule, to open such abscesses at* an early period, in order to prevent the disorder of the bone. If some abscesses, however, as for instance, those which form over the anterior surface of the tibia, and mastoid process ofthe tem- poral bone, be frequently attended with caries, the latter is the cause and not the consequence of the suppuration. Pus, which is a bland, unctuous, inodorous fluid, never attacks the soft parts,"with which it is in contact, until its qualities are changed by exposure to the air. When an abscess forms in the anterior part of the parretes of the abdomen, the peritoneum of that part, naturally a thin membrane, instead of being corroded, be- comes thick, and strong enough to resist the effusion of pus into the cavity of the abdomen. The periosteum becomes thick- ened in similar circumstances, when the abscess is a consequence of an external injury. .,.. •-■» Scrophula invades'the spongy structure of the bones and the lymphatic system. A caries from this cause is very common in the tarsus, carpus, elbow, and knee; but it is always preceded by a white- swelling. The venereal disease is sometimes a cause of caries, though its action on the 250 CARIES. bones generally occasions necrosis, or ex- ostosis. However, when it attacks the bones of the nose it renders them carious, by which they are consumed, and the face sadly disfigured. The bones of the pa- late are sometimes destroyed in the same manner, and by the same cause. In cancers of the mammae, the sides of the sternum are sometimes found carious. A superficial caries is easily detected. When the affected bone is deeply situat- ed, the disease may be ascertained by in- troducing a probe, wliich will readily pass into the substance of the bone. But, bones not easy of access, may become ca- rious, in which cases, the diagnosis is not so obvious. However, if a fistula, from which a fetid blackish matter flows, run forwards to a bone, and the adjacent soft parts be swollen, and indurated, there is reason to suspect the existence of caries. Caries, occasioned by syphilis, affects most commonly the tibia, os frontis, ossa nasi, ossa palati, and sternum. A caries of ihe vertebrae is known by peculiar symptoms, among which a para- lysis of the inferior extremities, and lum- bar abscesses, are the most remarkable. A caries of tlie spongy parts of bones is much more difficult to cure, than a si- milar affection of their compact parts. Caries of the carpal and tarsal bones is par icularly obstinate. These bones being in close contact, the affection cannot easily be prevented from spreading from one to the other. Amputation is often the only means of cure. The same is frequently the case, when the spongy heads of the long bones become carious. Even this mode of relief is not practi- cable when the head of the bone Ues very deeply, like that of the os femoris. Caries, resulting from scrophulous, or cancerous mischief, is more difficult of cure, than when it arises from venereal or scorbutic causes'; for, some efficacious remedies against the l^ter are known ; but cancer and scrophiSa resist all the remedies hitherto discovered. The prog- nosis is less favourable in old, than young ■subjects, and much depends on the extent of the disease, the patient's strength, and the state of the soft parts. To form a just idea of the treatment of caries, we should consider, that a bone, thus affected, is, a prey to a morbid ac- tion of its own parts, and that this action creeps from one part to another,*and per- vades the whole with greater or less ra- pidity, if art should not interfere, and assist nature in arresting its progress. When the caries arises from constitu- tional disease, this should be resisted with suitable remedies. Thus mercurial and sudorific medi- cines put a stop to caries arising from the venereal disease. Spirituous drinks, vege- table diet, and acids, cure both the scur- vy, and the caries dependent on it. ' But, when caries is altogether a local affection, the separation of the diseased parts may be promoted by absorbent powders, and stimulant applications. Lint, dipped in the tincture of aloes or myrrh, has often been put on such, dis- eased bones. If these remedies be found ineffectual, a pledget of lint, dipped in a solution of the argentum nitratum, may be employed. On tiie continent, and particularly in France, they still adhere to the plan of touching carious parts of bones with the actual cautery,'after bringing them fairly into view by a previous use of the knife. It is thought, that the burning iron acts by changing the caries into a necrosis, irritating the subjacent sound parts, and exciting that action of the vessels, by which the dead or diseased part of the bones must be thrown off. (See Bayer on Diseases ofthe Bones, Vol. 1.) Issues seem to be most effectual in checking the caries attendant on white- swellings and diseased vertebrae. (See Joints and Verlebrx.) Mr. Hey has succeeded in cutting away a carious part of the tibia. He began the operation by dissecting off the granula- tions of flesh, which had arisen from the bone, and then sawed out, by means of a circular headed saw, a wedge of the tibia, two inches in length. The removal of this portion brought into view a caries of the cancelli, almost as extensive as the piece already removed. With different trephines, suited to the breadth of the caries, Mr. Hey removed the diseased cancelU of the bone, quite through to the opposite lamella. As the caries extended in various directions, it was not possible to remove the whole of it with a trephine, without removing also a large portion of the sound part ofthe bone, which Mr. Hey wished to avoid. By the assistance, therefore, of a strong sharp-pointed knife, he pursued the caries in every direction, until every part was taken away, which had an unsound appearance. The wound was simply dressed with dry lint; the whole surface was speedily covered with good granulations, and a complete cure was obtained, without any exfolia- tion. Mr. Hey concludes this subject, as fol- lows : " I have treated some other cases of caries of the tibia in the same manner, and with equal success. Where the ex- tent of the caries is. not so great as to prevent a complete removal ofthe morbid CAS part, tliis method is extremely useful, and far superior to the use of the potential or actual cautery. " The trephine is not wanted, where the cancelli of the bone are not affected with the caries. The diseased parts of the lamella may be removed with gouges or small chissels. Granulations of flesh will then arise from the sound parts of the bone, and become united with the inte- guments, which ought to be preserved as far as is possible." ^ The two cases, which Mr. Hey has re- .lated, are exactly of that kind, to which several writers apply the term spina ven- tosa. (See Practical Observations in Sur- CARp ADNATA. An old appellation for the sarcocele. CAROTID ARTERY, ANEURISM OF. (See Aneurism) CARTILAGES IN JOINTS. (See Joints.) CARUNCLE, (dim. of caro, flesh.) Caruncula. A small excrescence, which has the appearance of flesh. CASTRATION. Castratio. (from cas- tro, to castrate.) The operation of re- moving a testicle. For an account of the cases rendering this necessary, see Tes- ticle, Diseases of. The manner of operating is as follows: The patient being laid on a table of convenient height, the integu- ments covering the spermatic vessels in the groin, are to be divided. This inci- sion should begin as nearly as can be, opposite to the opening in the abdominal muscle, and should be continued a goofl way down the scrotum. -The manner of beginning this incision is differently described by writers ; some of them advising that the skin be held up by an assistant; others that the knife be used perpendicularly in this as in other parts. The latter mode is preferred by English surgeons in general. The length of the division is a more important* consi- deration. A small wound will incked serve to lay bare the spermatic chord; but it will not permit the operator to do what is necessary afterwards with dex- terity, or facility; and as the scrotum must, first or last, be divided nearly to the bottom, it had better be done at first. The spermatic chord, thus laid bare, is to be freed from its surrounding membranous connexions ; and then the operator, with his finger and thumb, separating the blood vessels from the vas deferens, must pass a ligature between them, and having tied the former only, must cut through the whole chord, at a quarter or half an inch distance from the said ligature, ac- cording as the state of the process and testicle will admit. This done; he is CAS 251 then, with the same knife, with which he has performed the former part ofthe ope- ration, to dissect the testicle out from its connexion with the scrotum ; the loose texture of the connecting cellular sub- stance, the previous separation of the testicle from the spermatic chord, and the help of an assistant to hold up the lips of the wound, will enable him to do this with very little pain to the patient, and great facility to himself. If any conside- rable arteiy bleeds in the scrotum, it is to be tied. (Pott.) Mr. S. Sharp once castrated a mart, whose testicle weighed above three pounds, and some of the vessels were so exceedingly varicous and dilated, as nearly to equal the size of the humeral artery. (Operations of Surgery, chap. 10.) Desault first divides the chord, and, holding its upper end between the index finger and thumb of his left hand, he then takes up the arteries with a pair of for- ceps, which are immediately tied by an assistant. (Desault par Bichat, Tom. 2) Pott used to fill the cavity ofthe, wound with lint; but, Desault, and all the mo- dern surgeons of this country, bring the edges of the wound together, and endea- vour to heal as much of it as possible by the first intention. Some, with this view, use sutures and sticking-plaster; others, only the latter, aided with compresses and a T bandage ; which means, in my humble opinion, are quite enough. The operation of the compresses and bandages cannot be too carefully attend- ed to, as it is the surest means of prevent- ing hemorrhage from any small arteries in the scrotum, while it conduces to the union of the parts. Care must be taken, however, not to let the pressure hurt the sound testicle. It is somewhat extraordinary^, that M. Larrey should condemn the plan of unit- ing the wound, though, indeed, we can- not be surprisedftat his delivering this advice, when we recollect, that he disap- proves of healing the stump, after ampu- tation, by the first intention. The pas- sage, relative to dressing the wound after castration, seems to be a contrast to the sensible observations which generally pre- vail in this author's publication : " II ne faut pas, reunir les bords de la plate, com&i Pont conseiliequelquespraticiens,parcequ'ils doivent suppurer, et que la suppuration est necessaire! (Mem. de Cliirurgie, Militaire, Tom. 3. p, 426.) Sometimes, one or more vessels begin to bleed soon after the patient is in bed, al- though they effused no blood just after the removal of the testicle. Keeping the dressings ^and scrotum continually wet 252 CASTRATION. with the cold saturnine lotion very often, suffices for the suppression of such he- morrhage : if not, the wound must be opened again, and the vessels tied. M J. L. Petit has made some useful remarks on ihis operation. The vessels of the scrotum, says he, are not the only oms, which may be the source of hemor- rhage. Anatomists know, that the sep- tum, which divides this part into two cavities, is furnished with an artery, that is not considerable, but, which becomes materially enlarged, in the case of a sar- cocele, or other tumour. It is sometimes so considerable, that it causes a bleeding, which makes a surgeon, who has had no previous opportunity of seeing the occur- rence, exceedingly uneasy. Such he- morrhage, adds M. Petit, may be easily suppressed with a ligature; and, he as- sures us, that he has seen a surgeon dress the patient tiiree times, without ever suspecting, that the bleeding, for which tiie applications were a third time re- moved, proceeded from this artery. (Petit Traite des Maladies Clururgicales, Tom.. 2, p. 524—525.) The same experienced and able sur- geon also acquaints us, that he has more than once extricated from trouble per- sons, who knew not how to stop the bleeding after the operation. He has seen some of them take off" the dressings several times, without discovering the wounded vessel. As they imagined, that the only hemorrhage, that could follow castration, must be from the -spermatic artery, they contented themselves with examining the ligat-ure on the cord, and increasing the compression, in order to stop the bleeding; but, finding their at- tempts fail, they were compelled to seek assistance: On being sent for, M. Petit found, that the blood did not issue from the cord, but from a small artery, under the skin, at the inferior angle of the wound. He easily stopped the hemor- rhage, and explained, »ot only, that the cord had no share in the accident, but, that it is generally suspected without foundation. Indeed, says he, the least constriction will stop the bleeding from the spermatic artery; it is not essential to tie it;—" 1 myself am content with cutting the cord, so as to leave it rather longer than usual, and apply no ligature; I press it against the os pubis, near the ring of the external oblique; I lay over it a linen compress, half as thick as the finger, two inches in length, sufficiently broad to cover the part, and yet narrow enough to be placed entirely within the wound. Over this compress, I put dossils of lint; I fill the scrotum with,plain lint, and then cover the whole with compresses, observing to put one, which is thicker than the rest, above the pubes, immedi- ately over that, which I have laid upon the cord, so that the bandage may make moderate pressure on this last part, yet sufficient to prevent bleeding." ( Op. cit. p. 526—527.) This quotation is not made with a view of inducing any modern operator to imitate tiie preceding practice, which, in- deed, the advantages of the present mode of dressing the wound entirely forbid, as well as the greater security of the liga- tore ; but, the passage is cited, for the express purpose of impressing on the mind ofthe youngsurgeon,that, in general there is more risk of bleeding from the vessels of the scrotum, than those of the cord, after the removal of a diseased rtesti9. I have never seen hemorrhage from the spermatic artery give trouble after the operation, but have often known sur- geons obliged to take off the dressings on account of bleeding in the scrotum. In every operation, in which a consi- derable portion of skin is to be divided, and particularly in this, and in the am- putation of womeii's breasts, it should al- ways be remembered, that, as the divi- sion ofthe skin (the general organ of sen- sation) is the most acute and painful part of what is done by the knife, it cannot be done too quickly, and should always be done at once; the scrotum should always be divided to the bottom, and the circu- lar incision in the skin of a breast always made quite round, before any thing else be thought of. If this be not executed properly, and perfectly, the operation will be attended with a great deal of pain which might be avoided, and the opera- tor will be justly blameable. (Pott.) When the diseased testicle is exceed- ingly large, or a part of the scrotum is diseased, the surgeon should take care to remove the redundant, or morbid portion ofthe skin, by including the piece, which he designs to take away, within two long elliptical incisions, which are to meet at the upper and lower part of the swelling. In this manner, as Mr. Samuel Sharp has observed, the hemorrhage will be much less, the operation greatly short- ened, the sloughing ofthe distended skin prevented, and tiie recurrence of cancer- ous disease rendered less likely. (See Treatise of tlie Operations, chap. 10.) If the tumour be of a pyriform figure, perfectly smooth, and equal in its sur- face, and free fi-om pain, notwithstanding the degree of hardness may be great, and the surgeon may, in his own opinion, be clear that the tumour is not produced by water, but is a true scirrhus, let him, immediately previous to the operation, CASTRATION. 253 pierce tlie anterior part with a trocar, in order to be certain. " My reason for giving this advice is, that I was once so' deceived by every apparent circumstance of a true, equal, indolent scirrhus, that I removed a testicle, which proved upon examination to be so little diseased, that, had I pierced it with a trocar previous to the operation, 1 could and certainly should have preserved it. (Pott.) It is well known, that the agony of ty- ing the chord is immensely increased by including the vas deferens, and, as no good results from so doing, the practice deserves the severest reprobation, not- withstanding the opposite opinion of Pearson, and the writer of the article Castration in Rees' Cyclopaedia. Cases *»re even recorded, in which the inclusion of the whole of" the spermatic cord appears to have occasioned severe and perilous consequences, and these in so great a degree, that it has been found necessary to cut and remove the ligature. Sometimes, says M. J. L. Petit, patients, on whom castration has been performed, suf- fer more or less acute pain in the kidnies. The suffering often becomes insupport- able and highly dangerous, the belly being swelled, tense, and painful; the patient being affected with syncopes, and affections of the heart, sometimes with vomiting, and a retention of urine, last- ly, an universal inflammation of the belly, and a violent fever, accompanied with delirium, are occasionally the fatal con- sequences of this operation. Petit was required to visit a patient, who had been in this deplorable state for twenty-four hours, after having suffered castration, and this distinguished surgeon could im- pute the sudden and violent symptoms to nothing, except the' ligature on the sper- i matic cord; consequently, he advised, the ligature to be removed. The patient received some slight relief from this step, and, after having been bled twice within a short space of time, he found himself a great deal better ;■ but, as tiie dressings became wet with blood, apprehension of bleeding began to be entertained. Petit, therefore, had recourse to moderate com- pression of the cord, in the manner above related. No hemorrhage ensued; the case afterwards went on well; and the patient recovered sooner than was ex- pected. (Traite ties Maladies Chirurgi- cales, Tom. 2, p. 527, 528.) In the operation of removing a testicle, one caution seems particularly necessary, viz. if the cord should be at all enlarged, tlie surgeon ought carefully to examine, whether the augmentation of its size may not be owing to a portion of intestine, or omentum, that is contained within it. (See Sabatier's Medecine Operatoire, Tom. 1, p. 332, Edit. 1.) In one case of extir- pation of the testicle, " after the ope- ration was completed, and the wound dressed, the patient being seized with a fit of coughing, to the astonishment and dismay of the surgeon, the dressings were forced oft" by a protrusion of several con- volutions of small intestines ; from this, it was proved, that the patient had had a hernia; but, the diseased enlargement of tlie testicle had acted as a truss, and pre- vented the rupture from coming down." (See Operative Surgery, by C. Bell, Vol. 1, p. 226, also p. 224.) There is another circumstance, which merits attention in the performance of this operation : when there are reasons, which oblige us to divide the cord high up, and this part has not been tied before such division is made, it may be drawn up by the cremaster within the abdominal ring, and some difficulty may be experi- enced in securing the spermatic arteries . Mr. B. Bell saw this happen twice, and the patients lost their lives from hemorr- hage. Hence, when it is necessary to cut through the cord near the ring, the best plan is always to apply the ligature first, observing not to include the vas deferens. Were the cord, however, before being tied, to happen in any instance to be drawn up within the ring, a surgeon would be guil- ty of most supine neglect to let the patient die of bleeding;, for, as Mr. C. Bell has remarked, we may follow the, cord, with perfect safety, even to the origin of the cremaster, which pulls it up, if atten- tion be paid to the course ofthe cord, ob- liquely upward and outward, within the inguinal canal. It sometimes happens, that abscesses form in the remains ofthe spermatic cord, after the operation of castration. Such suppuration may frequently be prevented by the employment of bleeding directly after the operation, and repeating the eva- cuation on the first access of the ,nflam- mation of the part concerned. Besides venesection, low diet, neutral salts, dilu- ents, &c. are indicated, and the part should be covered w ith an emollient poul- tice. When ihe pus is completely formed, the abscess should be opened. When the symptoms subside, observes M. Petit, they, who are little versed in practice, are apt to fancy the abscess cured ; but, they are sometimes mistaken. The matter is not always sufficiently near the surface to be felt, and, in this cir- cumstance, the aponeurosis of the exter- nal oblique muscle is so tense, that it hinders the fluctuation from being dis- tinctly felt. Indeed, as the matter finds a lodgment under this aponeurosis, fol- 254 CAT CAT lowing the course of the sheath of the vessels, there is reason to fear, that it may lead to additional inflammation and suppuration, and extend up the duplica- ture of the peritoneum to the loins. In these cases, the abscess occasionally makes its way outward, and the dress- ings are inundated with matter; but, if this should not happen quickly, the sooner the tumour is opened tiie better. The opening ought unquestionably to be made wherever the fluctuation is plainly dis- tinguishable ; but, as Petit lias remarked, the tension of the aponeurosis of the ex- ternal oblique muscle makes the undula- tion ofthe matter less readily and plainly perceptible, than if the abscess were only in the fat. Therefore, in order to avoid mistake, this surgeon advises us to feel at the abdominal ring, as, in general, the pus can be more readily felt here, than in other situations. If matter is felt, and no resistance is experienced, Petit advises the finger to be passed into this opening, and, in case the seat of the ab- scess should be found to be under the apo- neurosis, we are recommended to divide, with a probe pointed bistoury, the skin and fat immediately covering the ring, then to separate the fibres of this aper- ture, as it were, without cutting them. (See Traite ties Mahulirr, Chirurgicales, Tom. 2, p. 529—530.) No doubt, this sur- geon meant, that the division of the ten- don ought to be made in the direction of its fibres. Consult Le Dran's Operations. Sharp's Operations of Surgery, chap. 10. Pott on the Jtydrocele, Uc. Sabatier, tie la .Med. Oper. Tom. 1. Bertrandi Traite ties Oper. de Chi- rurgie, chap 11. (Euvres Chirurgicales de Desault par Bichat, Tom. 2t p. 449. l.ar- rey Memoires de Chirurgie Militaire, Tom 3, p. 423, &c. Pearson on Cancerous Com- plaints. J. L Petit, Traite des Maladies Chirurgicales, Tom. 2, p. 519, &c. C. Bell's Operative Surgery, Vol. I Richer- and's Nosographie Cliirurgicale, Tom. 4, p. 281, &c. Edit. 2, &c. A long account of the particular sentiments, of several eminent surgeons is to be found in Rees' Cyclopxtlia. art. Castration. CATAPLASM, (from KU.TXTrXec, to spread.) Cataplasma. A poultice. The following ones are eminently-useful. CATAPLASMA ACETI. Made by mixing a sufficient quantity of vinegar with either oatmeal, linseed meal, or bread crumb. When linseed is employed, it is best to add a little oatmeal, or bread crumb, to keep the poultice from soon becoming hard. The vinegar poul- tice is generally applied cold, and is prin- cipally used in cases of bruises and sprains. CATAPLASMA ACETOSJE. Sorrel Poultice, * Acetosx lbj. To be beaten in a mortar into a pulp. CATAPLASMA JERATUM. Fer- meriting Poultice, jy Farinx Tritici. Ce- revisix Spumx, Vest dictx; singulorum, Ibss. These are to be mixed together and exposed to a moderate heat,' till the effervescence begins. This is a celebrated application in cases of sloughing and mortification. CATAPLASMA ALUMINIS. Made by stirring the whites of two eggs with a bit of alum, till they are coagulated. It has been applied to the eye, between two bits of rag, in some cases of chronic and purulent ophthalmy, and is said to do good to clulblains, which are not broken. CATAPLASMA BYNES. (Malt.) r^ Farinae Bynes, Spumze Cerevisiae, q. s. This is applied to cases of gan- grene and ill-conditioned extending sores. It is used in instances similar to those in which the cataplasma aeratum is em- ployed, and, by giving out carbonic acid gas, is supposed to operate as a gentle stimulus, and as a corrector of the fetid effluvia. CATAPLASMA CARBONIS. Made by mixing powdered charcoal with lin- seed meal and warm water, and is applied to improve the condition of several kinds of unhealthy sores. CATAPLASMA CEREVISIAE. Made by stirring some oatmeal, or Unseed meal, in strong beer grounds. It is used in the same cases, as the Cataplasma JEratum, and Cataplasma Bynes. CATAPLASMA CICUTA. Hemlock Poultice. £ Herbx cicutx exfoliatx ^ij. Aqux fontanx Ibij. To be boiled, till only a pint remains, when as much Un- seed meal as necessary is to be added. This is an excellent application to many cancerous and scrophulous ulcers, and other malignant ones; frequently producing a great diminution of the pain of such diseases, and improving their ap- pearance. Justamond preferred the fresh herb, bruised. CATAPLASMA DAUCl. Carrot Poul- tice. 5< Radicis Dauci recentis, ifcj. Bruise it in a mortar into a pulp. Some, perhaps, with reason recommend the car- rots to he first boiled. The carrot poul« tice is employed, as an application to ul- cerated cancers, scrofulous sores of an irritable kind, and various inveterate ma- lignant ulcers. CATAPLASMA DIGITALIS. Made by mixing Unseed meal with a decoction of the leaves of the plant. It is said to have great sedative virtues, to be adapt- ed to the same cases, as the cicuta poul- tice, and even to be more beneficial. CAT -CAT 255 CATAPLASMA FARINACEUM. The bread and milk poultice, made by putting some sUces of bread crumb in milk, and letting them gently simmer over the fire in a saucepan, till they are properly sof- tened. The mass is then to be mixed and stirred about with a spoon, and spread on linen, in order to be applied. This poultice, which is of the emollient kind, is with many persons the common one for all ordinary purposes. Most surgeons, however, employ, instead of it, the Un- seed poultice, which is cheaper, more readily made, not apt to turn sour, and in all common cases", quite as advantageous in every respect. CATAPLASMA LINI. Linseed Poul- tice, it Farinx Lini, Ibss. Aq. ferventis Ibiss. The powder is to be gradually sprinkled into the hot water, while they are quickly blended together with a spoon. This is the best, and most convenient of all the emoUient. poultices for common cases, and has, in a great measure, super- seded the bread and milk one, so much in use formerly. Mr. Hunter speaks, in the follow- ing terms, of the linseed poultice, and its uses : "Poultices are commonly made too thin; by which means, the least pressure, or their own gravity, removes them from the part; they should be thick enough to Support a certain form when applied. "They are generally made of stale bread, and milk. This composition, in general, makes too brittle an application ; it breaks easily into different portions, from the least motion, and often leaves some part of the wound uncovered, which is frustrating the first intention. " The poultice which makes the best application, and continues most nearly the same between -each dressing, is that formed of the meal of linseed : it is made at once, and when applied, it keeps al- ways in one mass." " The kind of wound, to which the above application is best adapted, is a wound made in a sound part, which we intend shall heal by granulation. The same application is equally proper when parts are deprived of life, and conse- quently will slough. It is therefore the very best dressing for a gunshot wound, and probably for most lacerated wounds; ibr lint, applied to a part that is to throw off a slough, will often be retained till that slough is separated, which will be for eight, ten, or more days." CATAPLASMA LYTHARGYRI ACET ATI. * Aquae lythargyri acetati drach. j. Aqus distillantx lib. j. Mica panig q. s.—Mis.ce. Practitioners, who place much confi- dence in the virtues of lead, externally appUed, often use this poultice in cases of inflammation. CATAPLASMA MALI MATURI — This is made by roasting a ripe apple, removing the peel and core, and beating the pulp into a soft mass. It is some- times applied to inflamed eyes, by means of a little muslin bag. CATAPLASMA MURIATIS SO- DiE. 5j Pulveris Lini, Mxcx Panis a a partes xquales, Aq. Sodx Muriatx q. s. This is used for diminishing scrofulous tumours and glands. When it excites too much irritation in the skin, a linseed poultice may be put on for a little while. CATAPLASMA QUERCUS MARf- NI. This is prepared by bruising a quan- tity of the marine plant, commonly called sea tang, which is afterwards to be ap- plied by way of a poultice. Its chief use is in cases of scrophula ; white swellings and glandular tumours more especially. When this vegetable cannot be obtain- ed in its recent state, a common poultice of sea-water and oatmeal has been sub- stituted by the late Mr. Hunter and other , surgeons of eminence. CATARACT, (from xctrccgxa-Tu to con- found, or disturb; because the disease confounds, or destroys vision.) This is a species of blindness, arising almost al- ways from an opacity of the crystalline lens, or its capsule : the cataract depend- ing on an opaque state of the liquor of Morgagni being very rare. Hippocrates called it, yXotv%u[AM. Ga- len, ovoxvfMC. The Arabians, gutta opa- ca, Celsus, suffusio. Hippocrates, and tiie ancient Greeks described the cataract, as a disease of the crystalline lens under the name above mentioned; but, no sooner had Galen promulgated the doctrine of the lens being the immediate organs of sight, than the correct opinion of the ancient foun- der of medicine began to decline, and, for many ages afterwards, had no influence in practice. In fact, the seat of the catar- act seems to have been entirely forgotten, till about 1656, when first Lasnier, and, afterwards, Borel, Bonnetus, Bleg- ny, Geoffroi, &c. revived the truth, which appears to have been so long extinct, and they, and a few others, believed that tiie disease was situated in the crys- talline lens. The bulk of practitioners, however, remained ignorant of this fact even as late as 1713, or, in other words, until the several publications of 256 CATARACT Mery, Maltre-Jan, Brisseau, and Hei- ster, combined to render the truth univer- sally known. (Critical Refections on the Cataract. SYMPTOMS OF A CATARACT. The cataract shews itself, as a speck, or spot in the pupil of the eye, occupy- ing sometimes the whole, and sometimes only a part of this aperture. It is most "* commonly of a grey, or whitish colour ; but, sometimes, of a deep white, and, it may, in all cases, be easily distinguished from the naturally dark appearance of the pupil. In the commencement of the disorder, it occasions a weakness, or im- perfection of the sight; and it terminates, sooner or later, in the almost total ex- tinction of this sense. During its pro- gress the persons, who are affected by it, perceive objects more distinctly in a moderate, than a strong light; the rea- son of which is, that the pupil being more dilated in a weak light still admits some rays, through the yet transparent circumference of the crystalline. (Wea- sel on the Cataract.) A settled mist seems to cover objects, and confuse those, which are minute. In this disorder, especially, when it arises without any assignable external cause,, this mist is almost always perceptible by the patient, before any opacity has be- come visible in the pupil. (Ware.) D1FFF.HF.NT KINDS OF CATARACT, AND PARTICULAR SYMPTOMS OF EACH. When the opaque lens is either more indurated, than in the natural state, or retains a tolerable degree of firmness, the case is termed, %firm, or hard cataract. When the substance of the lens seems to be converted into a whitish, or other kind of fluid, lodged in the capsuie, the case is denominated a milky, or fluid cataract. When the opaque lens is of a middling consistence, neither hard, nor fluid, but, about as consistent, as a thick jelly, or curds, the case is named a soft or caseous cataract. When the anterior, or poste- rior, layer of the crystalline capsule be- comes opaque, after the lens itself has been removed, from this Uttle membra- nous sac, by a previous operation, the affection is named a secondary membra- nous cataract. There are no certain criteria, by which it can be ascertained previously to an operation, whether a cataract is soft or hard ; of a caseous or fluid consistence ; or whether, together with an opacity of the crystalline lens, the membranous cap- sule, in wliich it is contained, may not have lost its natural transparency j those formerly mentioned by Richter, and other similar ones proposed for consideration by Mr. Pott, cannot be sufficiently con- fided in, to form a guide in practice. I think it right, however, to state, in as concise a manner as possible, the symp- toms and appearances, wliich Richter has more recently explained, and, for a long series of years, found generally to portend the truth ; and I shall confine myself to the hard, the fluid, and the caseous or soft cataracts. The harder the cataract is, the thinner and smaller it becomes. In this case, the disease presents either an ash-coloured, a yellow, or a brownish appearance. Ihe interspace, betwixt the cataract and pu- pil, is very considerable. The patient very distinctly discerns light from dark. ness, and can even plainly perceive large bright objects. In the dilated state of the pupil, a black circle surrounding the lens is very perceptible. The motions of the pupil are free and prompt. The an- terior surface of the cataract appears flat without any degree of convexity. (Rich- ter's Anfancsgrunde der Wundarzneykuntt, p. 177. 3 Band.) The fluid, or milky cataract, has usu- ally a white appearance; and irregular spots and streaks, different in colour from the rest of the cataract, are often observ- able on it. These are apt to change their figure and situation, when frequent and sudden motions of the eyes occur, or when the eyes are rubbed and pressed ; sometimes, also, these spots and streaks vanish, and then re-appear. The lower portion of the pupil seems more opaque than the upper, probably, because the un- transparent and heavy parts of the milky fluid, sink downward to the bottom of the capsule. The crystalline lens, as it loses its firmness, commonly acquires an aug- mented size. Hence, the fluid cataract is thick, and the opacity close behind the pupil. Sometimes one can perceive no space between the cataract and margin of the pupil. In advanced cases, this aper- ture is usually very much dilated, and the iris moves very slowly and inertly. This happens because the cataract touches the iris, and impedes its action. The fluid cataract is sometimes of such a thickness, that it protrudes into the pupil, and presses the iris so much forward, as to make it assume a convex appearance. Patients, who have milky cataracts, ge- nerally distinguish light from darkness very indistinctly, and sometimes not at all; partly, because the cataract, when it is thick, lies so close to the iris, that few or no rays of light can enter between them into the eye j partly, because the fluid CATARACT. 25? cataract always assumes, more or less, a globu**.* form, and therefore has no thin edge, through which tlie rays of light can penetrate. (Richter's Anfangsgruntle der Wundarzneykunst. 3 Bund. 174,175.) Sometimes the,opaque lens is of a mid- dling consistence, neither hard, nor fluid, but about as consistent as thick jelly, curds, or new cheese. Cases of this de- scription are .termed soft or caseous ca- taracts. As the lens softens in this man- ner, it commonly grows thicker and larger, even acquiring a much greater size than the fluil. It is not unfrequent t*> meet with caseous cataracts of twice the ordinary size of a healthy crystalline lens. It impedes the motion of the pupil more considerably than the fluid cataract, because it lies closer to the irh. It is ac- companied with all the symptoms of fluid cataracts, except that the spots and streaks, sometimes also observable on this kind of cataract, do not vary their situation and figure. (Richter's Anfangs- gruntle der Wundarzneykunst. p. 178. 3 Band.) CAUSES OF THE CATARACT. Persons, who are much exposed to strong fires, as blacksmiths, locksmiths, glass-men, and th(jjj£, who are engaged in similar employments, seem to be more subject to the cataract, than others. Per- sons, above the age of forty, are reckoned more liable to cataracts, than younger ones. (Wenzel.) The disease, however, is, by no means, unfrequent in the latter; even children are often seen effected with this kind of blindness, and some are born with it. hi the majority of instances, a cataract seems to arise spontaneously, without any assignable cause. Some- times the opacity ofthe lens is the conse- quence of external violence: a case, which, more frequently, than any other, gets well without an operation. HIOGNOSIS, AND MODE OF JUDGING OF CASES FIT FOR AN OPERATION. Some little attention is necessary to dis- tinguish those cases of cataract, which afford a reasonable prospect of benefit from an operation, and to discriminate them from others, either less promising, or absolutely prohibitory of relief. When, in the incipient state of the dis- ease, the patient discerned objects, as it were, through a mist, which increasing in density, at length became a complete impediment to vision; when the opacity of the crystalline bus has supervened gra- dually, and has not been preceded, and is not accompanied by a chronic ophthal- Vol. I. my peculiarly affecting the interior of the eye; when no particular head-ach, nor pains in the eye and eye-brow have been experienced; when the pupil, notwith- standing the cataract, preserves its circu- lar figure, and the f.iculty of varying its dimensions in the different degrees of light; when the patient can distinguish abrilliant light from total darkness ; and, especially, if in a moderate light, where, usually-, the-pupil is not too much con- tracted, he should be able to distinguish bright colours, and the shadows of objects before him : there is every reason for per- forming, and expecting success from, an operation. (Scarpa sulle Malattie degli Occ/ii.) The power of distinguishing light from darkness, is much more satisfactory, than motion of the iris. 1 have seen in St. Bartholomew's Hospital, and in the York Hospital under Mr. Albert, several cases of complete gutta serena in both eyes, in which there was the freest contraction and dilatation of the pupils. It is obvi-, ous, that, had such patients been, at the same time, afflicted with cataract (a com- plication by no means unfrequent,) and a surgeon, induced by tiie moveable state of the iris, had undertaken an operation, how unavailing it must have proved, since the rays of light could only have been transmitted to an insensible retina. Rich- ter, and Wenzel, make mention of these peculiarities, and the latter refers the phenomenon to the iris deriving its nerves wholly from the lenticular ganglion, while the immediate organ of sight, is consti- tuted entirely by another distinct nerve, Hence we can no longer consider motion of the iris as an infallible criterion, ac - cording to several authors, ( Wathen) that the retina is endued with sensibility. Re- lating to this subject, is a curious remark by Mr. Lucas in tiie Medical Observa- tions and Inquiries : he attended, in con- junction with Messrs. Hey and Jones, his colleagues ofthe Leeds Infirmary, five children of a clergyman at Leaven, near Beverly, who were all born blind. He writes, " None of them can distinguish light from darkness, and, although the pupil is, in common, neither too much dilated nor contracted, and has motions, yet these do not seem to* depend upon the usual causes, but are irregular."— (Vol.6.) The reciprocal sympathy between the two organs of sight, is so active, that no one, solicitous to acquire either physiolo- gical, or pathological knowledge respect- ing them, ought, for a moment, to forget it. Hence, in the examination of cata- racts, it is of the highest importance to keep one eve entirely secluded from the Li. 258 CATARACT. light, while the surgeon is investigating the state of the iris in the other ; for, the very impression of the rays of light upon one eye, sensible to this stimulus, is known to be often sufficient to produce corre- sponding motions of" the iris in the oppo- site one, although in the state of perfect amaurosis. In other examples of cata- ract, the pupil may be quite motionless, and yet sight shall be restored after the performance of an operation. (Wenzel) T.ere are, however, two circumstances, which may prevent us from ascertaining, whether the retina is sensible to light or not: the first is, a circular adhesion of the ciystalline capsule to the ins. It must be a difficult thing to discriminate the nature of this case, by merely observ- ing, as R chter directs, the distance be- tween the cataract and pupil: inferring, that when the space, between the pupil and opaque lens, is inconsiderable, such an adhesion has happened; and, that when the cataract does not seem particu- larly close to the pupil, and yet the pa- tient cannot discern light from darkness, it is complicated with amaurosis. The second circumstance sometimes utterly preventing tbe ingress of any light to the healthy retina, is the round bulky form of the cataract. But although I have remarked, that the power of" distinguishing light from dark- ness is' more satisfactory, than motion of the iris; it is not an unequivocal test of the retina being perfectly free from dis- ease. While the gutta serena is incom- plete, the patient can yet distinguish light, atid the shadows of objects. Dilatation of the pupil is, also, a deceitful criterion to ascertain the complication of gutta se- rena with the cataract. When the cata- ract is large, or adherent to the ins, the pupil is frequently much dilated, however natural and sound the state of the optic nerve may be: the pupil often continues quite undiluted in the most perfect gutta serena. (Richter) From all this it must be manifest, 1st, that the irregularity, and inconstancy of the symptoms of gutta serena, together with the possibility of particular states of the cataract rendering the patient utterly unconscious of the stimulus of light, make it necessary for the surgeon to be particularly attentive to tiie appearance, and to tiie history of the origin and pro- gress of the disease, in order to under- stand the real condition of certain cases. 2d, That, when the patient can distin- guish light from darkness, though the iris may be motionless, there is good round for trying an operation. Possi- ly, in this circumstance, an incipient ■ amaurosis may exist, but, the chance of the defect of the iris arising from other causes; the certainty, that the opaque bo- dy must be removed from the axis ofsight, (even were the disease of tlie retina cured,) ere sight could be restored; and the improbability, that an operation to cure the cataract, would render the other com- plaint at all less remediable: fully justi- fy the attempt. 3dly, That, should the patient have been free from particular pain in the head and eye ; should be, in a previous stage of the cataract, have been able to distinguish light from dark- ness, and then suddenly have lost that power, in consequence of inflammation affecting the eye, and depriving the iris of motion; in which case there is ample reason to conclude, that adhesions be- tween the iris and cataract have taken place ; and should there be ground to suspect, from the appearances which I have already noticed, that the cataract is of exceedingly large dimensions; not- withstanding the incapacity to feel the stimulus of light, there is yet sufficient foundation to entertain a little hope, and to vindicate the practice of the only effort that can be availing, and, excepting a trivial and a temporary pain, one that cannot be materially injurious to the pa- tient. The concurrent testimony of al- most all writers upon the subject con- firms, that the restoration of sight has sometimes been effected in the most hope- less cases, and I am, therefore, of opi- nion with Mr. Lucas, that it is projier, in all doubtful cases, to try couching, as a remedy by no means violent, or hazard- ous. (Med. Observations and Enquiries, Vol 6, p. 257.) As it not unfrequently happens, that cataracts, produced by external violence, spontaneously disappear, (Pott, Hey, Uc.) the operation should never be too hastily recommended for such instances. One reason, assigned for not operating, when only one eye is affected, viz. that one eye is sufficient for tiie necessities of life, is but. of a frivolous description ; and, an- other, that the patient would never be able to see distinctly after the operation, by reason of the difference of the focus in the eyes, is (I have grounds for believ- ing) only a gratuitous supposition, blind- ly transmitted from one writer to another. In support of what I have here advanced, and to prove, that success does sometimes, probably in general (if no other causes of failure exist,) attend the practice of couching and extraction, when only one eye is affected with a cataract, 1 shall first adduce a fact from Mattre Jan. (Traite des Maladies de P Oeil Edit. Paris, 1741, 12mo. Obs. sur une Cataract elaitense,p. 1%.) "Le 17 Octobre de l'annee 1685. CATARACT. 259 .I'allui a Saviere pour abaiser une Cata- racte dans I'oiel gauche d'un jeune gar- con appelle Nicolas Very valet de Sebas- tien Coutan, laboureur." Cette cataracte me paroissoit d'une bonne couleur, la pu- pille se dilatoit lenteni.-nt, et beaucoup, et se resserroit de mime, quand je passois la main enlre l'oeil et le grand jour, le sain etant ferine," itc. After describing the operation, he continues : " Quelques jours apres je retournai le voir, et je trouvai que i'humeur nqueuse etoit fort eclairoie et qu'il distinguoit toutes sories d'objets; je le vis encore sept ou huit jours apres en passant par son village, et je le rencontrai faisant son ouvrage, et entierement gtieri, sans qu'il parut qu'il eut jamais €t€ incommode de cataracte. Baron Wenzel was in the habit of ex- tracting cataracts with the most success- ful result, when only one eye was affected with the disease, as may be learnt by re- ferring to the cases here specified. ( Cases 6, 13, 16, 19, 22, 25, 29, 30, 31, 34, &c. Treatise on the Cataract) It will only be necessary to quote here two cases, related by this eminent oculist. " Madame Har- vey, a tobacconist, at Chalons sur Marne, presented a complicated case similar to the preceding. She had a cataract in the right eye, combined with an opacity in the anterior portion of the capsule as ap- peared by the white spots and inequali- ties, of which I have spoken above, in the surface of the crystalline. Her left eye was sound. I operated on the right eye in the year 1782, &c. The patient suf- fered some*' pain in consequence of the operation, but it was soon removed by bleeding her in the foot; and, notwith. standing this obstacle, the sight was soon recovered to as great a degree of perfect- tion as wAs possible after such an opera- tion" (Wenzel on the Cataract, p. 138, Case 16.) The following case is as explicit as pos- sible on the point under consideration. " A poor woman, de la Ferte sous Jou- arre, who had a cataract in the right eye upwards of ten years, came to consult me in the year 1780. I found all the symp- toms of the case favourable to an opera- tion," &c. (after describing the maimer of doing it, he continues;) "I imme- diately bound up, not only the eye that had undergone the operation, but the sound one also; a precaution, which it is necessary to use after all operations on the eye, even the most simple; it being al- most impossible, that one eye should not follow the motions of the other, &c. In a fortnight she was perfectly cured; and, though the pupil remained larger than it was before the operation, or than that in the left eye, and had much less motion, yet this eye, as well as the other, per- ceived objects very distinctly." (Case 22, p. 166. In the Medical and Physical Journal for May 1808, there is a paper in support of tlie foregoing observations.) I next proceed to notice what Richter has remarked upon this head. He was formerly convinced, that tlie advice not to operate, when only one eye is affected with a cataract, ought, for several reasons, to be disregarded; he reminds us of the wonderful consent between the. eyes, so that one is seldom diseased without the dther, sooner or later, falling into the same state ; and hence he questions, whe- ther it may not be possible to prevent the loss ofthe sound eye by a timely opera- tion? An nou caveri possit jactura mte- gri oculi tempesttve extrahendo catarac- tam pnoris ? Obs. Chir. Fascic. I.) He adverts to tiie remarkable case related by St. Ives, where a man was wounded in the right eye by a small shot, and, shortly afterwards, had a cataract in it; he then gradually became blind in the left, but soon recovered his sight in it, after the cataract had been extracted from the right one. Here let us notice, that St. Ives (Maladiesties Yeux,Chap. 15,Art.3.)n\nk.cs no mention of any confusion in vision, in consequence of tiie different refracting powers of the two eyes in question. An- other reason judiciously assigned by Rich- ter, ( Obs. Chirurg. Fascic. I.) for disregard- ing the above precept, is, that in waiting until a cataract forms in the other eye, the existing one, which is at this moment, perhaps, in the most favourable state for , tlie operation, may soon change so much for the worse (for instance it may con- tract such adhesions to the iris,) as eithef to destroy all prospect of relief, or, at most, afford but a very precarious and discou- raging one. The length of time necessary to wart is also very uncertain and tedious. I once saw a man in St. Bartholomew's Hospital, who had had a cataract in one eye fifteen years, during all which time the other continued quite sound. I am surprised that Richter should latterly have inculcated a contrary opinion, and, not given the particular facts, that have induced him to revoke, as it were, his former sentiments. The principal reason stated by him is, that the patient, not only does not see much more acutely with the two eyes after the operation, than with one before it, but, he frequently sees more confusedly ; because the eye, that has been operated on, qamiot see well without the aid' of a glass, which, perhaps, the sound one does not require. " Er sieht nicht allein nach der Operation mit zwey Augen nicht viel scharfer, als vor der ope- ration mit einem Auge, sondern er sieht 260 CATARACT. auch oft undeutlichcr, da das operirte Auge nicht ohne Br-ile, das gesundc aber vielleicht ohne ttrille scharf sielu-t." (An- fangsgrunde dsr IVundarzn. Dritter Band p. 199.) When 1 remember, that no cases are adduced by this author to-contradict the rationality of his former sentiments; when T also reflect upnn the facts recorded by Maiire-Jan, St Ives, and Wenzel ; when I contemplate, that Callisen men- tions, as the feeble ground of his adopt- ing the common opinion, that, in one sin- gle instance of this description, he was unsuccessful, without particularizing from what immediate cause the failure aiose ; there appears to my mind strong cause to believe, that the advice, not to operate, when there is only one cataract, and tiie other eye is perfect, rests upon the false basis of prejudice and plagiarism. War- ner's object ion is similar to that specified by Richter: he writes, "-the eye, from which the crystalline lens is removed, cannot be restored to a de^rea of perfection at all equ.-ti to that of the sound eye, without the assistance of a convex glass.-" ( Descrip- tion ofthe Human Eye audits ftiscases, p.85 ) but, is not the power of using both eyes at the same time, even with the inconveni- ence of being necessitated to employ a glass for the purpose, preferable to being blind of one ? The cases, which I have quoted, at least prove, that confusion in vision, is not always the result of the prac- tice, which I contend for : whe.her the fact is concordant with the modern theory of vision, is entirely another considera- tion ; if it should be found inconsistent' with it, we must infer, that our know- ledge of optics still continues imperfect; not, that such well-attested examples, as some alluded to, are unworthy of be- lief. Whea, there are cataracts in both eyes, most authors are of opinion, that there is no reason, why one should not be couched immediately after the other; and, it must be confessed, that, in general, the simpli- city and mildness of the operation, will admit of this method without the least evil resulting from it. But it must also be confessed, that the ophthalmy after •couching sometimes attains a greater height than is agreeable, either* to the feelings of the patient, or the wishes of the surgeon. The excitement of violent inflammation, is what we ought to endea- vour to avoid in performing all operations. Will it not inevitably happen, by reason of the mutual sympathy between the two organs of sight, that tlie ophthalmy after couching wiU, cxterisparibus, be more se- vere when it is done at the same time on both, than when performed on each at separate periods ? Inflammation in one eye almost constantly kindles the same process m the otht r. Scarpa's experience establishes the truth of the^e reflections, and, what reason might anticipate, an ap. peal to pract-ct- confirms. " Ne' malati di cateratta in amheduegli occhi, lasperien- zami hainsegnato die non e puntovantag- gioso 1' operarli immediatamente unodopb l'altro; ma che gfova aspettare la guari- gione d' uno prima d' intraprendere l'ope- razione dell' altro." (Saggio di Osserva- zioni, &c. p. 255.) The majority of surgeons imbibe an, opinion, that no operation should be un- dertaken for the cataract, before the pa- tient has attained the age of docility and reason, and, in a point of view, abstract- edly surgical, there can be no doubt ofthe rectitude of such advice ; but, when it is further considered, how essential sight is to the acquirement of education; that youth is the condition best adapted for this indispensable pursuit; that couching is a very easy operation; that, to perform it conveniently, nothing more is required, than to have the child's head steadily fixed; that, with the aid of nn assistant, this object c:.n more effectually be accom- plished; that, in delaying the operation, the cataract may acquire adhesions; that persons have,-not only had cataracts suc- cessfully depressed at a very early figr, but, have, with the assistance of a sjiecu- lum oculi, even had them exti-acefe Mr. Ware's note,'p. 90, oj WenzePs Tr.-a- tise.) which is universally acknowledged to be a far mor>_- difficult process; and that the pupil of the eye, in a young sub- jecJ, is nearly as large as in an adult; ( Warner's Description ofthe Human Eye and its Diseases, p 34 ) Icuu.ot help thinking with Mr. Lucas, that, after a child is old enough to bear -an operation, couching may be proper at any age. This gentleman (we may infer from his observations) Vas m the habit of couching children; for he states, that the reason for h.s not operat- ing on the five children born blind (men- tioned above,) was the insensible state of the retina : not their youth. Here couching seems to be more appli- cable than extraction ; for, although it is veiy practicable to fix a child's head very securely, it is not so to prevent (without ihe use of a speculum, by which extrac- tion is rendered doubly dangerous) that rolling motion of the eyes from taking place, peculiar, almost without exception, to cliildren, and which would, undoubt- edly, make it loo arduous to cut the cornea with the due precision, necessary for the success ofthe more modern operation. Sur- geons do not refuse to operate for the hare Up, as early as two years of age ; they do CATARACT. 261 not Wait for docility and reason in the pati *nt, to make him manageable, and sensible of the propriety of submitting quU-.lv to the performance ofthe opera- tion ; they render him tractable by force, and thus they wisely succeed in making, perhaps, with more certainty, than re- liance upon the fortitude of any human being would afford, a very precise inci- sion, such as the nature of the operation demands; and, why should they refuse to couch children, when the motives are more urgent, and it is equally in tlie power of art to substitute means, quite as effect- ual as docility and reason in surgical patients? What experienced operator would trust to the*-»e qualities, when he undertakes any grand operation, even on the most rational and firm adult r (Critic- al Reflections on tlie Cataract, 1805.) During the last four or five years, the attention of surgeons has keen much drawn to the subject of operating on the cataracts of children, and the propriety I of the practice seems to be now firmly fixed on the basis of experience. It is even ascertained, that the couching needle may be successfully employed on children of the most tender age. The late Mr. Saunders, surgeon to the London Infirma- ry for curing diseases of the eye, may- be said to have had the principal share iu.pronioting the adoption of this import- ant improvement. His practice confirm- ed, what reason had long ago made pro- bable, and the judgment, tenderness, and skill, with which he operated, on the eyes ot'int'ui'8, as well as those of adults, were followed by a degree of success, which had never been previously witnessed, and which infused quite a new spirit into this most interesting branch of surgery. Sub- jects, from eighteen months to four years old, received most benefit from Mr. Saun- ders's operations ; and, if any intermedi- ate time be selected, Dr. Fane (the edi- tor of tins gentleman's publication) is in- clined to recommend i he age of two years. '*■ The parts have then attained a degree of resistance, which enables the surgeon to operate with greater precision, than at an earlier period; yet, the capsule has not become so tough and flexible, as it does at a later period, after the lens has been more completely absorbed. " Hut, this is not the greatest, although a considerable advantage of an early ope- ration, for, in cases, in which the patient has no perception of external objects, the muscles acquire such an inveterate habit of rolling the eye, that, for a very long time after the pupil has been cleared by an operation, no voluntary effort can con- trol this irregular motion, nor direct the eye to objects with sufficient precision for the purpose of distinct and useful vision. The retina too by a law, common to all the structures of an animal body, for want of being exercised, fades in power. Its sensibility, in many ofthe cases, cured at the age of four years and under, could not be surpassed in children, who hud enjoyed vision from birth: but, at eight years, or even earlier, the sense Was evi- dently less active; at twelve, it was still more dull; and from the age of fifteen and upwards, it was generally very imper- fect, and sometimes the mere perception of light remained. But, these observa- tions do not apply to those congenital ca- taracts, in which only the centre of the lens and capsule is opaque, the circumfer- ence being transparent, for, in those, the retira is exercised by a perception, al- thoigh an imperfect one, of" external ob- jects, the motions of the muscles, which direct the globe, are associated, and an absorption of the lens does not take place : therefore, in this variety of the disease, the argument in favour of an early opera- tion, is not so much a medical, as a moral one—it is preferable for the purposes of education and enjoyment." (Saunders on Diseases of the Eye, p. 153—155.) Besides Mr. Saunders, several other surgeons of the present day have become zealous advocates for operating upon the cataracts of children. Even Mr. Ware, one of the ablest partisans of* extraction, now strongly recommends the use of the needle in the congenital cataract of in- fants and children. His mode of operat- ing, I shall hereafter notice. Mr. Gib- son, of Manchester, has likewise urged the propriety of couching young subjects, and fixes on the age of six months, as pre- ferable to that of two years. " \\ hat ever objections (says he) have been uri^t-d against the s.ife and effectual use of" the couching needle in infants, have always appeared to me so blight, and so easily surmountable,that, without iuquiring'par- ticularly into the real state of tlie ques- tion, 1 have 1 ng concluded in my own mind, that the same motives, which would induce an operator to couch a cataract at any period of adult life, would equally lead him to perform that operation at any earlier period, when a cataract might ex- ist. Acting upon this presumption, f hav? operated upon children of all ages, for ten years past" (See Edinb. Med. and Sur- gical Journal, Vol 7, p 394.) Mr. Gibson's paper being dated June, 1811, we are of* course given to under- stand, that he has pursued this practice from the year 1801, and he asserts that his experience has embraced a considera- ble number of cases. " In performing the operation of couch- 262 CATARACT. ing infants, it has always appeared to me, (says this gentleman,) that ihe advantages to be gained by restoring vision at so early a period, are so important, as to bear down any obstacles which may occa- sionally be opposed to the safe use of the needle. Even the risk of deranging the figure ofthe pupil forms no solid objec- tion to its use ; and may always be avoid- ed by steadiness and good management. Should even a slight change in its figure be produced, it is seldom in the least de- trimental to distinct vision, and can scarcely- be considered a blemish in the eye of any one; except, perhaps, in that of a geometrician; who may not easily recon- cile to himself tlie presence of an oval opening, where one of a circular form should exist. It may fartoer be observed, that, if an operator cannot depend upon his management of the eye, so as to ren- der it steady by the introduction of the couching needle, he can avail himself of the assistance of a speculum to re- strain its motions. " The following observations will ap- ply principally to infants under twenty months old. The advantages, which an operator possesses, in operating upon a child of this age, as compared with a child of three years old, or upwards, are import- ant. An infant is not conscious of the operation intended: it is free from the fears created by imagination, and can op- pose very feeble resistance to the means employed to secure it with steadiness. At an early age, it has not acquired the power of" retractig the eye deep in the socket, so that the operator has always a good prospect of introducing the couching needle with ease, by watching a proper opportunity. The eye has not, at this time, acquired the unsteady rolling mo- tion, which, after a few years, is so com- mon and remarkable in children born blind, or reduced to that state soon after birth. So that this impediment to the easy introduction of the needle does not exist in infants a few months old. The operator also has it in his power to ad- minister a dose of opium, sufficient to ren- der the steps necessary to expose the eye, almost entirely disregarded by his pa- tient. With respect to the state of the eye itself, but, particularly, that ofthe ca- taract, this is more favourable for the operation, than at any future period of life. In infants, the cataract is generally fluid, and merely requires the freerupmre of its containing capsule, which is in that case generally opaque. The capsule, however, is tender, and easily removed by tiie needle, so as to leave an aperture sufficiently large for the admission of fight. The milky fluid, which escapes from the capsule, is soon removed by ah. sorption. If", on the other hand, (saya Mr. Gibson) the cataract should be soft, it is generally of so pulpy a softness, that the free laceration of the anterior part of its capsule, and the consequent admission ofthe aqueous humour, ensures its speedy dissolution, and disappearance, without the necessity of a second operation. Should the cataract happen to be hard, there will be no more difficulty in depressing it, than in an adult. So uniformly favourable is the state of the cataract to the success of the operation, that I may venture to pro- nounce, that an operator of common ex. pc rience and expertness, will selddm fail of success, if he can, in an adult, depress a hard cataract, or rupture the containing capsule, and break down the substance of a soft, or fluid cataract when it occurs. " Such (continues Mr. Gibson) are the advantages, derived from the age of the patient, and state of" the eye, which would induce an operator to use the couching needle a few months after birth. It, how. ever, a surgeon had even difficulties to en- counter, which do not occur in adults, surely the invaluable benefit, conferred by enabling an infant to become an intelli- gent being, like other children, instead of remaining in a state approaching to idiotism, would incline him to run some risk of failure, and to make more than common exertion, especially as there is little chance of injuring the eye, when proper cautions are used. Yet, so import- ant a consideration appears to have had little influence upon oculists, and hence, many children have been doomed to years of darkness, happy in the estimation of their parents and friends, if they could distinguish black from white; or discern any perceptible difference between the brightness ofthe sun, and the glimmering of a tallow candle. " These advantages, which an opera- tor will possess, when he attempts the re- moval of a cataract in a child of a few months old, are peculiar to that period. In proportion as the age of the patient advances, until he arrives at the age of dis- cretion, and can estimate, in some mea- sure, the value of sight, by feeling his loss, the difficulties, opposed to the use of the couching needle, increase. His fears of the operation, the unsteadiness ofthe eye, and his power of retracting it within the orbit, present considerable, but not in- superable obstacles: such, however, as every surgeon would willingly dispense with, if he had it in his power. " Before an operation, at an early age is recommended, the practitioner ought (as at any other age) to ascertain, that the cataract is not complicated with a defec- CATARACT. 263 five state of the retina, or with a complete amaurosis. Such cases are by no means uncommon. Some years ago, I recollect to have seen five or six children, the fami- lies of two sisters, who were all totally blind, and in an idiotic state, with cata- racts accompanied by amaurosis.", (Gi6- son Op et loco cit ) I find in this gentleman's paper, also, some arguments, wliich have been repeat- ed in Mr. Saunders's work. "Few prac- titioners, at all conversant with cases of blindness from birth, will deny, that it is highly probable, that the eye may lose a considerable part of its original powers, from the mere circumstances of its having ao long remained a passive organ. Hence, probably it happens, that, in some cases of congenital cataract, the only benefit conferred on the patient, by an operation, is that of enabling him to find his way in an awkward manner, and to discriminate the more vivid colours Such patients have never been able to discern small objects, or to judge, in any useful degree, of figure, or magnitude; 1 am well aware, however, says Mr. Gibson, that, in some rare instances, such a defective state of the eye exists from birth. " Another circumstance, which, must have attracted the attention of oculists, is, that, in a few years, the eye of a patient bom blind, acquires a restless and roll- ing motion, which is at length so firmly established by habit, that he has little controul over it. This motion unfortu- nately continues, for a considerable time, after sight has been restored to such a person, and is a very material obstacle to the early attainment of a knowledge ofthe objects of vision. He cannot fix his eye steadily upon one point for a moment, and the inconvenience, which arises from this unsteadiness, is, to such a person, occasionally as great a bar to the distinct view of an object, as the unsteady motion ofthe same object would be to one, whose vision is perfect. This inconvenience any one can appreciate, and, as far as I know, it is completely avoided by restor- ing sight at an early age." As a motive for operating on infants, Mr. Gibson also comments on the loss of those years, which ought to be spent in education (See Edinb. Med and Surgical Journal, Vol. 7, p. 394—400.) TREATMENT OF THE CATARACT. The principal external remedies, that have been employed in the cure of the cataract, are, bleeding, cupping, scarify. ing, setons, issues, blisters, and fumiga- tions; and the principal internal reme- dies are, aperients, uicisives, emetics, ca- thartics, ftudorifics, cephalics, and ster- nutatories. Preparations of eye-bright, millepedes, wild poppy, henbane, and hemlock, have also been much commend- ed, as specifics for the disorder. Scultetus asserts, that he checked,the progress of a cataract, by applying to the eye the gall of a pike, mixed with sugar ; and Spigelius, as we are informed by the same author, boasted of liaving success- fully used, for this purpose, the oil ofthe eel-pout (mustelafiuviatilis ) Cataracts are said to have been cured in venereal patients, while under a course of mercury. It is probable, however, that many such cases have been mere opa- cities of the cornea, which have been mis- taken for cataracts. Baron Wenzel placed no reliance whatever in the power of any remedies to dissipate a cataract, and, as he had remarked their inefficacy in nu- merous instances, he felt authorized in declaring, that internal remedies, either of the mercurial, or any other kind, are inadequate to the cure of tliis disorder; and equally so, whether the opacity be in the crystalline, or in the capsule, whether incipient, or advanced. Although Mr. Ware coincides with Wenzel, in regard to the uncertainty of all known medicines to dissipate an opa- city, either in the crystalline, or its cap- sule, or even to prevent the progress of such opacity, when once begun, yet, many- cases have proved; that the powers of na- ture are often sufficient to accomplish these purposes. The opacities, in parti- cular, which are produced by external violence, Mr. Ware has repeatedly seen dissipated in a short space of time, when no other parts of the eye have been hurt. In such cases, the crystalline lens has ge- nerally been absorbed, as is proved by tiie benefit, which has afterwards been deriv- ed from deeply convex glasses. In some of these cases, though the crystalline has been dissolved, the greater part of the capsule has remained opaque, and the light has been transmitted to the retina only through a small aperture, which has become transparent in its centre. In- stances are also not wanting, in which cataracts, formed without any violence, have been suddenly dissipated in conse- quence of an accidental blow on the eye. The remedies, which Mr. Ware has found more effectual, than others, have been the application to the eye itself of one, or two drops of xther, once, or twice, in the course of the day, and the occasional rub- bing of the eye, over the lid, with the point of the finger, first moistened with a weak volatile, or mercurial liniment. Cataracts are usually cured, either by removing the opaque len*, from tile axis 264 CATARACT. of vision by means of a needle ; or by ex- tracting the lens from the eye, through a semicircular incision, made at the lower part of the cornea. The first operation is termed couching, or depression of the ca- taract; the second is named extraction. Some account of the congenital cataract, and method of operating upon children, will be found in the future part of the present article. EXTRACTION OF THE CATARACT. As soon as it was fully proved, that the true cataract was an opacity, of the crys- talline humour, that the loss of sight would not be occasioned by tiie removal of this humour, that tiie cornea may be divided without danger, and that, if the aqueous humour be discharged, it will be quickly regenerated, the mode of cure, by extracting the cataract out of the eye, would naturally present itself to the mind. (Wenzel.) ■Freytag was the first operator, who made an attempt to extract the cataract, about the close of the 17th century. Af- ter him Lotterius of Turin, performed this operation. Daviel first communi- cated this method to the public. And the ingenuity and industry of Wenzel brought this mode of operating to a state of perfection never before attained. (Bram- billa Instrumentarium Chirurgicum Austria- cum, 1782, p. 71.) Wenzel's knife resembles the common lancet employed in bleeding, excepting that its blade is a little longer, and not quite so broad. Its edges are straight, and the blade is an inch and a half (eighteen lines) long, and a quarter of an inch (three lines) broad, in the widest part of it, which is at the base. From hence it gradually becomes narrower to- wards the point; so that this breadth of a quarter of an inch extends only to the space of about one-third of an inch from the base ; and, for the space of half an inch fi-om the point, it is no more than one-eighth of an inch broad. The lower edge of the knife, by which is meant, that wiiich is lowest durin-jf the operation, is sharp through the whole length ofthe blade. At the distance of a quarter of an inch from the base, this lower edge has a slight projection, which is of use in making the section through the cornea. The upper edge Wenzel di- vides into three portions. For the spzee of five-sixths of an inch from the basis, this edge is blunt, and very slightly flat- tened. For the space of half an inch, or rather six lines and a half, further to- wards the point, it is blunt and rounded ; although to the naked eye this part ap- pears sharp, on account of its being very thin. And the extremity of this edge, to the extent of one-eighth of an inch fr*m the point, is keen, like the lower edge, in order to facilitate the conveyance ofthe instrument through the cornea. The swelling in the middle of the blade is merely intended to prevent the instru- ment from breaking. The handle, in which the blade is fixed, has eight sides, which are alternately large and small. This form enables the operator to hold the instrument more firmly, which is not so apt to turn round in the hand. It is generally three inches and two-thirds in length, and, from two lines, to two and a half, in thickness. The blade is so fixed in the handle, that the two sides of the former lie parallel with the broadest side of the latter. On -the upper side of the handle, which answers to the upper, or blunt edge, ofthe knife, a small mark is placed, which directs the proper manner, in which the instrument should be held in performing the operation. The shape of this knife is well calcu- lated to effect the division of the cornea, with the utmost ease and safety, as ij cuts this membrane, in proportion as it enters the eye. (Wenzel.) Tbe knife employed by Mr. Ware, is, in regard to its dimensions, not unlike the instrument employed by the Baron. The principal difference between them is, that Mr. Ware's knife is less spear-pointed; in consequence of which, when this latter instrument has pierced through the cor- nea, its lower, or cutting edge will sooner pass below the inferior margin of the pu- pil, than tite knife used by Wenzel. On this account, Mr. Ware is of opinion, that the iris will be less Ukely to be entangled under the knife, which he recommends, than under Wenzel's when the instru^ ment begins to cut its way downwards, and the aqueous humour is discharged Mr. Ware particularly advises great care to be taken to have the knife* increase gradu dly in thickness from the point to the handle; by which means, if it be con- ducted steadily through the cornea, it will be next to an impossibility,' that any part ofthe aqueous humour should escape, be- fore the section is begun downwards; and, consequently, during this time, the cor- nea will preserve its due convexity. But, if the blade should not increase in thick- ness from the point; or if it be incurvated much in its back, or edge, the aqueous humour will unavoidably escape, before the puncture is completed ; and the iris, being brought under the edge of the knife, will be in a great danger of being wound- ed by it. (Ware.) Baron Wenzel considers all instru- CATARACT. 265 ments, invented for fixing the eye, quite unnecessary; they render the operation more complicated, more dreadful to the patient, more embarrassing to the opera- tor, and they are very liable to irritate and wound the eye. If the above oculist would approve of any kind of speculum, he should give the preference to Rum- pelt's instrument, which is nothing more than a thimble, at the end of which is a sharp pointed instrument, like the pique of Pamard. The thimble is to be placed on the middle finger of the operator, and it has the advantage of not obstructing the use of the forefinger, but leaves it at liberty to keep down the lower eye- lid. The pressure, occasioned by all con- trivances for fixing the eye, is a serious objection to their employment, as such pressure is apt to cause a sudden protru- sion and loss of great part of the vitreous humour. (Wenzel.") Mr. Ware coincides very much with Wenzel on the subject of specula. At the same time, he remarks, that, in some in- stances of children born with cataracts, he has been obliged to fix the eye with a speculum ; without the aid of which, he has found it totally impracticable to make the incision through the cornea, with any degree of precision, or safety. His specu- lum is an oval ring, the longest diameter of wliich is about twice as, long as the diameter of the cornea, and the shortest about half as long again as this tunic. Annexed to the upper rim ofthe speculum is a rest, or shoulder, to support the up- per eyeUd; and, by its lower rim, it is fixed to a handle of such a length, and bent in such a way, as may render it con- venient to be held. (Ware.) When tlie patient is to undergo the operation, he should be seated in a low chair, before a light, which is not too bright, and, which, consequently, does not occasion too great a contraction ofthe pupil. The sound eye being covered with a compress, an assistant, placed behind, must hold tiie patient's head, and support it on his breast. With the forefinger of the hand that is at liberty, he is tlien to raise the upper Ud of the eye to be opera- ted upon, and gently press the tarsus, with the extremity of the finger, against the upper edge of the orbit, avoiding all undue pressure on the eye. The operator is to be seated in a chair, a little, higher, than that of the patient. The eyes naturally turning towards the light, he is to place the patient's head obliquely at a window, so that the eye to be operated upon may be inclined towards the outer angle of the orbit. This posi- tion will enable the operator to bring out Vol. I. the knife, on the inner side ofthe cornea, opposite to the part, where it pierces this tunic, more exactly than he would other- wise be able to do. The operator is to rest his right foot on a stool, placed near the patient, that his knee may be raised high enough to support the right elbow, and to bring the hand, with which he holds the knife to a level with the eye, on which he is to operate. He is then to take the cornea knife in his right hand, if it be the left eye, on which he is to ope- rate, and, vice versa, in the left hand, if it be the right eye. The knife is to be held like a pen in writing, and the hand is to rest steadily on the outer side of the eye, with tiie little finger, separated a lit- tle from the rest, on the edge of the orbit. In this position, the operator should de- liberately wait, till the eye becomes quite still. (Wenzel) _ When tiie eye is perfectly quiet, and so turned towards the outer angle, that the inner and.inferior part of the cornea can be distinctly seen, through which Wenzel recommends the point of the knife to be conveyed, the operator is to plunge the knife into the upper and outer part of this tunic, a quarter of a Une distant from the sclerotica, in such a direction, that it may pass obliquely from above, down- wards, parallel to the plane of the iris. At the same time, the operator must de- press the lower lid with his fore and mid- dle fingers, taking care to avoid all pres- sure on the eyeball. ( Wenzel.) Mr, Ware does not approve of this plan of leaving the eye unfixed, while the in^ cision is made through the cornea. The! danger likely to arise from undue pres- sure, can only take place, after the instru- ment has made an opening into the eye ; but, the pressure, wliich Mr. Ware ad- vises, in order to fix the eye, is to be re- moved the instant the knife is carried through the cornea, and before any at- tempt is made to divide this tunic down- wards. To understand this subject bet- ter, however, the reader should know, that Mr. Ware divides the incision of the cornea into two distinct processes; the first of which may be called punctuation, and the second section. So long, says Mr. Ware, as the knife fills up the aper- ture, in which it is inserted, that is, until it has passed through both sides of the cornea, and its extremity has advanced some way beyond this tunic, the aqueous humour cannot be discharged, and pres- sure may be continued with safety. The punctuation of the cornea being complet- ed, the purpose of pressure is fully an- swered ; and if such pressure be con- tinued, when the section of the cornea begins, instead of being useful, it wdl be Mat 266 CATARACT. hurtful. To avoid all-bad effects-, Mr. Ware recommends the cornea to be cu6 in the following way. The operator is to place the fore and middle finger of the left hand, upon tiie tunica conjunctiva, just below, and a little on the inside of the cornea. At the same time, the assistant, who supports the head, is to apply one, or, if the eye projects sufficiently, two of his fingers, upon the conjunctiva, a little on the in- side and above the cornea. The fingers of the operator and assistant, thus oppos- ed to each other, will fix the eye, and prevent the lids from closing. The point of tiie knife i*-. to enter the outside of the cornea, a little above its transverse dia- meter, and just before its connexion with the sclerotica. Thus introduced, it is to bepushed on slowly, but steadily, wi'h- out the least intermission, and in a straight direction, with its blade parallel to the iris, so as to pierce the cornea towards the inner angle of the eye, on the side, opposite to that, which it first entered, and till about one-third part of it is seen to emerge beyond the inner margin of the cornea. When the knife has reached so far, continues Mr. Ware, the punctuation is completed. The broad part of the blade is now between the cornea and the his, and its cutting edge below the pupil, which of course is out of all danger of being wounded. As every degree of pres- sure must now be taken off' the eyeball, the fingers, both of the operator and his assistant, are instantly to be removed from this part, and shifted to the eyelids.— These are to be kept asunder by gently pressing them against the edges of the orbit; and the eye is to be left entirely to the guidance of the knife, by which, says Mr. Ware, it may be raised, depressed, or drawn to either side,- as may be found necessary. The aqueous humour being now partly, if not entirely evacuated, and the cornea of course rendered flaccid, the edge of the blade is to be pressed slowly downward, till it has cut its way out, and separated a little more, than half the cor- nea from the sclerotica, following ihe se- micircular direction, marked out by the attachment of the one to the other.— (Wum) As soon as the point ofthe knife had arrived opposite the pupil, Wenzel used to incline it gently backward, and thus puncture the capsule of the crystalline. Biit, Mr. Ware very properly objects to this method of opening the capsule with the instrument used for cutting the cor- nea, and at the same time. The plan may exhibit dexterity; but it is of no use, and is often attended with considerable danger of wounding the iris. In the eyes of some persons, the iris is convex, and it is almost impossible to complete the section of tlie cornea, with- out entangling the iris under the edge of the knife, unless a particular artifice be adopted. Wenzel, in this.circumstance, recommends gently rubbing the cornea downward with the finger: one of the most important directions, according to Mr. Ware, in the Baron's whole book. Wenzel imputed several advantages to the oblique manner, in which he used to divide the cornea. The best modern octi- lists, however, do not attribute any supe- rior uses to this method, and consequent- ly do not imitate it. If the edge of the knife should incline too much forward, and its direction be not altered, the incision in the cornea will be too small, and terminate almost opposite the pupil. In this case, tiiere will be great difficulty in extracting the cataract, and tbe cicatrix afterwards will often obstruct sight. If, on the contrary, tiie edge ofthe instrument be inclined too much backward, and. its direction be not changed, the incision will approach too near the part, where the iris and sclero-,. tica unite, and tiiere will be great danger of wounding one, or the other of teese coats of the eye. Both these accidents may be prevented by gently rolling tjie instrument between the fingers, until the blade takes tiie proper direction. (Wen- zel.) Mr. Ware has seen operators, through a fear of wo und. ng the iris, introduce and bring out the instrument at a consi- derable distance before the union of the cornea and sclerotica; in consequence of which, the incision from one side of the cornea to the other has been made too small to allow the easy extraction of the cataract, although from above downward, it was t'uUy large enough for this purpose. Mr. Ware has also sometimes observed, that though tiie punctuation of the cor- nea, from side to side, has been properly conducted, and its section, afterwardsyto all appearance, effectually completed, yet, on account of the frictions, employed to disengage the iris from the edge ofthe instrument, the knife, in cutting down- ward, has been carried between the layers of the cornea, and, consequently, though the incision has appeared externally, to be of its proper size; internally, it has been much too small for allowing the cataract to be easily extracted. In tins case, the incision must be enlarged, by means of a pair of curved biunt-[x>inted scissars, which should be introduced at the part, where the knife first entered the cornea. r Vare.) After t ; knife has pierced through tbe. CATARACT. 267 cornea, and while it is cutting its way downward, the assistant, to wiiose care the upper eyelid is entrusted, is gradually to let it drop, in order to prevent the ca- taract from escaping too hastily. Then the whole charge ofthe eye devolves solely on the operator, who is to solicit the ex- traction of the cataract by gentle pressure on the upper part of the globe, the cap- sule of the crystalline having been pre- viously opened. Wenzel himself does not recommend opening the capsule of the crystalline, in every instance, at the same time, that tlie cornea is cut. In cases, where the pupil is much contracted, as well as in those, where the muscles of the eye and ey-tiids are easily thrown into convulsions, it is improper, says he, to puncture the cap- sule when the section is made through the cornea. This is also improper when the space, between the crystalline, and the iris, termed the posterior chamber, is large. In all such cases, Wenzel ac- knowledges, that it is better simply to di- vide the cornea in the first instance, and then to puncture the capsule with a dif- ferent instrument. Wenzel and his father used to employ, for this purpose, a flat needle, one line, that is, one twelfth part of an inch, in diameter, having its cutting extremity a Uttle incurvated. This needle, which should be made of nealed gold, that its pliability may allow the operator to bend it in different directions, as occasion re- quires, is fixed i n a handle, two inches and* half in length, and similar to that of the cornea knife. At the other extre- mity of the same handle a small curette, or scoop, is fixed, made also of nealed gold, which is of use to extract the cata- ract. When the crystalline, dislodged from its capsule, protrudes through tlie wound in the cornea, its removal from the eye may -sometimes be assisted by the use of the above needle; and afterwards the opaque and glutinous matter, remaining, must be removed by means ofthe curette. It is always advisable, after the opera- tion, gently to rub the anterior part of the r.orneaover the lids, either with the thumb, or the curette. This process usually col- lects in the centre ofthe pupil some small fragments of opaque matter, which the crystalline leaves behind it, and which, if not taken away with the curette, might give rise to a particular kind of secondary cataract. The curette is also of use for replacing the iris, a portion of which mem- brane occasionally comes through the in- cision in the cornea. (Wenzel.) Sometimes the cataract is hindered from comiugout,on gentle pred^ircbeing made, in consequence of adhesions. Wenzel re- commends these to be broken by means of the golden needle, introduced under the cornea, and applied in different directions, according as the case requires, and more especially round the pircumference ofthe crystalline. Sometimes, when the capsule of the crystalline is destroyed, and the crystalline itself is perfectly free, this humour plunges to the inferior part of the vitreous hu- mour, leaving only its upper edge visible through the pupil. The hyaloid mem- brane is also most commonly destroyed, and the vitreous humour in a state of fluidity. All pressure, therefore, on the eyeball, must be avoided, since this would produce a large evacuation of the vitreous humour. The only method is to introduce through the pupil, a small steel hook to take hold ofthe crystalline, which, in this case, is often very small, and with this instrument to extract it from the eye. (Wenzel.) Wifen the capsule used to become opaque after the operation, so as to form, what is termed, the secondary membra- nous cataract, Wenzel, after dividing the cornea, used to remove the opaque sub- stance, by means of a small pair of for- ceps. After the operation, no fluid applica- tion, according to Wenzel, should be made to the eye. It should be simply covered with a dossil of lint; over which a dry compress should be applied. The dress- ings should in general be removed every day. Mr. Ware, however, approves of fluid applications. He has found, that a dos- sil of lint, steeped in plain water, or brandy and water, and covered with the spermaceti, or saturnine cerate, and re- moved once every day, is the most easy and convenient dressing, that can be ap- plied after the operation. The cerate over the lint prevents the latter, when im- pregnated with the discharge, from be- coming stiff and irritating the lids. Mr. Ware thinks the mode of applying the compress and bandage over the eye, a cir- cumstance of no small importance, because, if too loose, the dressings are very apt to slip off", and, consequently, to press un- equally and injuriously on the eye ; and, if too tight, the undue pressure will ex- cite pain and inflammation, and even force out some of the vitreous humour. Mr. Ware's compress is made of soft linen, folded, two or three times, wide enough to cover both eyes, and sufficiently long to extend from the upper part of the fore. head to the lower part of the nose. Tliis he pins at the top of the patient's night- cap ; and its lower part, which is divided 268 CATARACT. in the middle, to allow the nose to come through it, he lays loosely over the eyes. The bandage, also made of old linen, and as broad as six fingers, he carries round the head over the compress, and pins to the side ofthe night cap moderately tight. A slip of linen is afterwards curried under the chin and pinned, at each end, to the side of the bandage, to prevent it from slipping upwards. (Ware.) The patient should lie continually on his back, after the operation, as this pos- ture has a tendency to prevent the escape of the humours. Mr. Ware has published a very able en- quiry into the causes preventing the suc- cessof extraction of the cataract. The first, which he considers, is mak- ing the incision through the cornea too small. In this circumstance a degree of violence will be required to bring the ca- taract through the wound; and, if the ca- taract be not altered in its figure, the wound will be forcibly dilated, and the edge of the iris compressed between the cornea and the cataract. In this way, either some of its fibres may be ruptured, or it may be otherwise so much injured, as to excite a considerable degree of in- flammation, and even induce, in the end, a closure of the pupil. This accident may arise from the ope- rator's cutting the cornea, without being able to see exactly the position of this membrane, in consequence of the eye hav- ing turned inward, owing to its not being properly fixed. The fault may also pro- ceed from the incision having been begun below the transverse diameter of the cor- nea. In this manner, nine-sixteenths, or rather more than half of the circumference of this membranv, will, not be divided ; which extent the incision ought always to occupy, in order to allow the cataract to be extracted with facility. When the cornea is remarkably flat, and the iris projects unusually forward in the anterior chamber, however, Mr. Ware recommends including only one-third of the cornea in the first incision, and after- wards enlarging the aperture, on the outer side, by means of curved scissars. Whenever the wound in the cornea is made too small, it should always be en- larged before proceeding further in the operation; and this can be best accom- plished with a pair of curved blunt-pointed scissars, on the outer side of the cornea, where the knife first made its entrance. Taking care to fix the eye in Mr. Ware's way, is certainly of great consequence in hindering the wound in the cornea fi-om being made too small. Wounding the iris with the cornea knife, is the second accident, which Mr. Ware considers. The principal cause seems to him to be a discharge of the aqueous hu- mour, before the knife has passed through the cornea low enough to hinder the lower part of the iris, which forms the inferior rim ofthe pupil, from getting beneath the edge of the instrument. The escape of the aqueous humour may be owing to some inaccuracy in the shape of the knife, or unsteadiness in introducing it. The falling of the lower part of the iris under the edge of the knife, Mr. Ware believes, cannot always be prevented by the utmost skill, or precaution ofthe operator. Hup. pity, however, says he, we have been taught, that the iris may be reinstated, after it has been thus displaced, and with- out suffering any injury, by applying gen- tle friction on the cornea, over the en- tangled part, with the point of the finger. By unsteadiness in passing the knife, Mr. Ware means, that the knife may not only be suffered to make a punctuation through this tunic, but, that its edge may, at the same time, be unintentionally press- ed downward, so as to make an incision likewise ; in consequence of wliich down- ward motion of the knife, an aperture must unavoidably be left in the cornea, through which the aqueous humour will escape. If the cornea-knife increase through its whole length, both in width and thickness, and if it be merely pushed through tile cornea, no space will be left, through which any fluid can escape. The third accident, noticed by Mr. Ware, is the escape of the vitreous hu- mour. The common occasion of this oc- currence is the undue application of pres- sure. It may take place, either when the incision is made through the cornea, or at the time of extracting the cataract out of the eye. Some eyes are subject to spasm ; which renders them much more liable to this accident. To prevent it, Mr. Ware recommends every kind and degree of pressure to be taken from tiie eye, before the knife has completely cut its way through the cornea. And, as soon as the knife has proceeded sufficiently low to secure the iris from being wounded, the operator should not only take heed, that his own fingers do not touch the eye, but should also direct the assistant, who sup- ports the upper lid, to remove his fingers entirely from this part. The assistant seldom need make any pressure on the globe of the eye: however, when there is room for one of his fingers to be placed on the inner and upper part of the globe, without interfering with those ofthe ope- rator, the method may be followed, in order to make the eye still more fixed. But immediately the punctuation of the cornea is completed, the assistant's finger CATARACT. 269 should always be entirely removed, both from tbe eyelids and eye itself. Notwithstanding the upper lid is left thus free, there will be sufficient space betweep it and the lower Ud, to allow the progress of the knife to be seen; and, in finishing tlie wound, the operator should depress the lower lid with great gentleness. The vitreous humour may also be lost, in consequence of opening the capsule of the lens nearer the circumference, than the centre ofthe pupil. As the crystalline is both thinner and softer at that part, the instrument wUl be liable to pass through both sides ofthe capsule, and enter the vitreous humour. This humour having no longer any barrier to its escape, is liable .to be forced out by the action of the eyelids alone; and, when pressure is afterwards made, to bring the cataract through, a much greater quantity will be i lost, and the cataract, instead of coming forward, will recede from the pupil. The only way to extract it now, is, by having -tbe upper lid gently raised by an assistant, (a rare instance, in which this is neces- sary after cutting the cornea) while the operator, either with the fore-finger of the left hand, or with tiie blunt end of the curette, applied beneath the incision in the cornea, prevents the cataract from sinking further. Then, with his right hand, let him introduce a hook under the flap of tiie cornea, and with its point carefuUy entangle the cataract, and bring it away. f < To prevent, however, such difficulties, Mr. Ware very judiciously advises never attempting to puncture the capsule, until the whole pupil is in view. This gentle- man is in the habit of opening the cap- sule with a gold-pointed needle, arched towards its extremity. Wenzel's needle, for this purpose, is flat at its extremity : Mr. Ware's is pointed: and this is their only difference. The latter introduces his instrument under the flap of the cornea, with its arched part uppermost, until its point is on a level with the centre of the pupil. The end of tlie instrument should then be turned inward, and gently rub- bed on the capsule of the crystalline, until it pierces it. In a few instances, Mr. Ware has found the capsule so tough, that the point of the gold needle would not enter it, and he has been obliged to use a sharp steel instrument, of tiie same shape as the gold-pointed one. The vitreous humour may also be lost, at the time of extracting the cataract, and the usual cause is an undue application of pressure. All violent pressure is quite unnecessary for forcing out the cataract, when the wound in the cornea is suffici- ently large. Wheu the wound is too small, it should be enlarged as above directed. If pressure be continued at aU after the cataract is extracted, the capsule of the vitreous humour will certainly be rup- tured, and some of this part of the eye protruded. Pressure may even rupture the capsule ofthe vitreous'humour, before the cataract is brought through the inci- sion in the cornea; and the same conse- quences will ensue, and the same prac- tice be necessary, as in the case, in which the operator has unskilfully opened the capsule of the vitreous humour with the needle, in attempting to open that of the lens. In taking away fragments of opaque matter, remaining behind, by means of the curette, great care is requisite to avoid wounding tlie posterior part of the cap- sule of the crystalline with the end of the instrument, so as to open a way for the escape of the vitreous humour. The vitreous humour may, indeed, be forced out, after the extraction of the ca- taract, merely by a spasmodic action of the eyelids*. On this subject, Mr. Ware, after hinting his suspicion, that, in a case of this kind, which he saw, the assistant's keeping up the lid contributed to the event, repeats his advice, " that the upper eye>- lid should be raised solely by the fingers of the left hand of the operator," after cutting the cornea. Mr. Ware seems to think, that more evil has resulted from the operator's be- ing deterred, by the readiness, with which the vitreous humour continues to start out, from ascertaining, that aU the fragments of the cataract are removed, and that the whole of the iris has resumed its position, than from the mere loss of tiie vitreous humour, which is quickly regenerated. Mr. Ware afterwards takes notice of the accident of extracting only a part of the cataract, and leaving the remainder behind. He is an advocate for removing all opaque substances from the pupil, ex- cept an extreme degree of irritability, to Which some eyes are subject, should ren- der the introduction of every sort of in- strument, after the cataract is extracted, difficult and dangerous. Mr. Ware usually removes opaque portions of the cataract by means of a curette; and, occasionally, when the opaque substance has been large, and has adhered to the capsule, he has been obliged to extract it with small for- ceps. Before finishing the operation, Mr. Ware approves of always rubbing the end of the finger gently on the fore part of the eye, over the eyelids ; which proceeding tends to bring in view any opaque matter, wliich may previously lie behind the iris: Mr. Ware' relates a case, proving, that such opacities as cannot be removed in 270 CATARACT. the operation, are capable of being ab- sorbed. This gentleman says, that an opacity of tiie capsule can be the only reason for removing it. The anterior part, also, can alone become the object ofthe opera- tor's attention: its posterior part is neces- sarily hidden, while the cataract, remains in the eye, and afterwards, if discovered to be opaque, it is so closely connected with the capsule of the vitreous humour, that Mr. Ware believes it cannot be re- moved by any instrument, without hazard- ing a destructive effusion of this humour. When, however, the opaque lens, is ac- companied with an opacity in the front part of the capsule, Mr. Ware recom- mends the following plan. After cutting the cornea, as usual, a fine-pointed in- strument, somewhat smaller in size than a round couching needle, and a little bent towards the point, should be intro- duced under the flap of the cornea, with its bent part upward, until its point is parallel with the aperture of the pupil. The point should then be turned toward the opaque capsule, which is to be punc- tured by it, in a circular direction, as near to the rim of the pupil as the instrument can be applied, without hurting the iris. Sometimes, the part included within the punctures, may be^extracted on the point of the instrument; and, if this cannot be done, it should be removed with a small pair of forceps. The lens, whether opaque, or transparent, should next be extracted, by making a slight pressure with the cu- rette, either above, or below, the circum. ference of the cornea. Mr. Ware afterwards considers the bad consequences of allowing foreign bodies of any kind, after the operation, to press unequally on the globe of the eye; com- prehending, under this head, the inter- vention of the edge of the lower eyelid be- tween the sides of the divided cornea; the inversion of the edge of the lower eyeUd; and the lodgment of one, or more, loose eyelashes on the globe of the eye. To prevent the first accident, every ope- rator, before applying the dressings, should carefully depress the lower eye-lid; and*', before he suffers the lid to rise, should take care, that the flap of the cornea be accurately adjusted in its proper position; and, that the upper lid be dropped, so as Completely to cover it. After this, the eyelids should not be opened again, for three, or four days, that is, imtil there is Jood reason to suppose the wound in the ornea closed. (Ware.) The inversion of the lower eyelid is hurtful, in consequence of its making the eyelashes rub against the eye. These ihould be extracted the day before the operation. For the mode of effecting a permanent cure, see Trichiasis. Besides the danger, to which the eye is exposed, from the inversion of the edge of the lid, the eye may receive injury from the improper position of the eyelashes alone ; one, or more of which, during the operation, may happen to bend inwards; or, becoming loose, may afterwards insi- nuate themselves between the inside of the lid and the eye. An eyelash bent in- ward, should be rectified; if broken off and loose, it should be removed, before dressing the part. Mr. Ware lastly considers prematurely exposing the eye to a strong light. He censures the plan of opening the eyelids, within the first two or three days after the operation, because the stimulus of the light increases the ophthalmy, and the method is apt to disturb the wound in the cornea, before it is closed. Mr. Ware, however, wishes it not to be inferred, that* he' is an advocate for long confinement after the operation. His mode is to keep - the patient wholly in bed, and to direct - him to move his head, as little as possible, for the first three days after the operation. During this time, a dossil of wet lint is kept on his eyes, covered with a saturnine plaster, compress, and bandage, as already- described. The dressing is renewed once every day, and the outsides of the eyelids > washed with warm water in winter, and cold in summer. At each time of dress- * ing, the skin of the lower lid is drawn gently down to prevent any tendency to • an inversion. Animal food is prohibited, and the patient enjoined not to talk much. On the fourth day, he is permitted to sit up, for two, or three hours, and, if he has had no stool since the operation, a mild opening medicine is now administered. On the fifth, the time of his sitting up is lengthened, and, presuming that the wound in the cornea is now closed, Mr. Ware usually examines the state of the eye. After this, no dressings need be ap- plied in the day-time, care being taken to defend it from a strong light, by a paste- • board hood, or shade, and by darkening the room, so that no inconvenience is felt. The patient may now also look, for a short time, at large objects. The follow- ing part of the treatment need interfere very little with the wishes of the patient, unless unexpected- accidents should oc- cur. ( Ware.) OF COCCHING, OR DEPRESSION OF THE CATARACT. This operation consists in removing the opaque lens out of the axis of vision, by means of a needle, constructed for the purpose. CATARACT. vn There are two couching needles, which now seem to be preferred to all others : and these are the only ones requiring a description here. I allude to the one used by Mr. Hey ■> and to ttiat employed by Professor Scarpa. The length of Mr. Hey's needle is some- what less than an inch. It Would be suffi- cientlv long if it did not exceed seven- eighths of an inch. It is round, ex- cept near tlie point, where it is made flat by. grinding two opposite sides. The flat part is ground gradually thinner to the extremity of the needle, which is semi- circular, and, ought to be made as sharp as a lancet. The flat part extends in leugth, about an eighth of an inch, and its sides are parallel. From the part where the needle ceases to be flat, its di- ameter gradually increases towards the handle. The flat part is one-fortieth of an inch in diameter. The part which is nearest the handle, is one-twentieth of an inch. The handle, which is three inches and a half in length, is made of light wood, stained black. It is octagonal,* and has a little ivory inlaid in the two sides, wliich correspond with the edge of the needle. Mr. Hey describes the recommendations ' of tliis instrument in the following terms : 1. " It is only half the length of the common needle ; and this gives the ope- rator a greater command over the motions -> of its point, in removing the crystalline from its bed, and tearing its capsule, It is also of some consequence, that tiie ope- rator should know how far the point of his needle has penetrated the globe of the eye, before he has an opportunity of seeing it through the pupil; as it ought to be brought forwards when it has reached the axis of the pupil. Now he may undoubte edly form a better judgment respecting "\ tliis circumstance, when the lengtii of h.s I needle does not much exceed the diameter I of the eye, than when he uses one of ti\ tlie ordinary length, which is nearly 1 two inches. The-shortness of the needle 4S peculiarly useful, when the capsule is so opaque that the point cannot be seen ' (trough the pupil. ,-.'!' 2. " As this*needle becomes gradually L thicker towards the handle, it will remain j. fixed in that part ofthe sclerotis, to which Tl tlie operator has pushed it, while he em- ,lff' ploys its point in depressing and remov- ing the cataract. But the spear-shaped needle, by making a wound larger in di- ;: ameter, than that part of the instrument, which remains in the sclerotis, becomes unsteady, and is with difficulty prevented * from sliding forwards against the ciliary Z processes, while the operator is giving it those motions which are necessary for de- pressing tlie cataract. " On the same account the common spear-shaped needle may suffer some of the vitreous humour to escape during the operation, whereby the iris and ciliary processes would be somewhat displaced, and rendered flaccid; whereas the needle which 1 use, making but a small aperture in tiie sclerotis, and filling up that aper- ture completely during the operation, no portion of the vitreous humour can flow out so as to render the iris and ciliary processes flaccid. , 3. "This needle has no projecting edges: but the spear-shaped needle, liaving two sharp edges,which grow gradually broader to a certain distance from its point, will be liable to wound the iris, if it be intro- duced too near the ciliary ligament, with its edges in a horizontal position. I have been informed, that, in an operation per- formed by one of the most eminent sur- geons in the metropolis, now deceased, the iris was divided as far as the pupil. If the operator, in OTder to avoid this danger, introduces his needle with its edges in a vertical position, he will divide the fibres ofthe sclerotis transversely, and, by thus enlarging the wound, will increase the unsteadiness ofthe instrument. Be- sides, however the needle be introduced, one of its sharp edges must be turned to- wards the iris in the act of depressing the cataract; and, in the various motions wliich are often necessary in this operation, the ciliary processes are certainly exposed to more danger, than when a needle is used wliich has no projecting edge. 4. " It has no projecting point In the use of the spear-shaped needle, the ope- rator's intention is to bring its broadest part o er the centre of the crystal- line. In attempting to do this, there is great danger of carrying the point beyond the circumference of the crystalline, and catching hold of the ciliary processes, or .their investing membrane, the membrana nigra. This accident is the more proba- ble, as the point of the needle must un- avoidably be directed obliquely forwards, aufa this motion, if carru-d too far, bring tiie point into c-Sntact with the ciliary pro- cesses, as they surround the capsule of " the crystalline. " A needle, made according to the fi- gure given in the annexed plate, will pass through the sclerotis with ease. It will depress a firm cataract readily, and break down the texture of one that is soft. If the operator finds it of use to bring the point ofthe needle into the anterior cham- ber of the eye (which is often the case,) he may.do this with the greatest safety, 272 CATARACT. for the edges of the needle will not wound the iris. In short, if the operator, in the use of tliis needle, docs but attend pro-' perly to the motion of its point, he will do no unavoidable injury to the eye, and this caution becomes the less embarrassing, as the point does not project beyond that part of the needle by which the depression is made, the extreme part of the needle being used for this purpose." (Hey.) Scarpa employs a very slender need'e, possessing sufficient firmness to enter the eye without hazard of breaking, and hav- ing a point, which is slightly curved. The curved extremity of the needle is flat upon its dorsum, or convexity, sharp at its edges, and has a concavity con- structed with two oblique surfaces, form- ing in the middle a gentle eminence, that is continued along to the very point ofthe instrument; there is a mark on the side of the handle, which corresponds to^the convexity of the point. The surgeons of the Leeds Infirmary have had one ad- vantage in the needle, which they have used in imitation or Baron Hilmer; I mean, having it made of no greater length than the purposes of the operation de- mand. A couching needle is sufficiently long when it does not exceed, at most, an inch in length : this affords the operator a greater command over the motions of tlie point, and enables him to judge more accurately, how far it has penetrated the globe of the eye, before he has an oppor-' tunity of seeing it through the pupil. To the needle, therefore, so much recbm- mended by Scarpa, and so successfully used by him, and Doctor Morigi, prin- cipal surgeon of the hospital at Piacenza, and one of the most expert operators of the present day in Italy, it seems proper to unite the improvement of having it made no longer than is necessary. The needle here described, will penetrate the sclerotic coat as readily as any straight one, of tlie same diameter,'and, by reason of its slenderness, will impair the internal structure of the eye less in its movements than common couching needles. When cautiously pushed in a transverse direc- tion, till its point has reached the upper part of the opaque lens, it becomes situ- ated with its convexity towards the iris, and its point in an opposite direction; and, upon the least pressure being made by its convex surface, it removes the ca- taract a little downward, by which a space is afforded at the upper part of the pupil, between the cataract and ciliary processes, through which tlie instrument may be safely conveyed in front of the opaque body and its capsule, which it is prudent to lacerate in the operation. In cases of caseous, milky, and membranous cata. racts, the soft pulp of the crystalline may be most readily divided, and broken piece- meal by the edges of its curved extremi. ty; and the front layer of the capsule la- cerated into numerous membranous flakes, which, by turning the point of the in. strument towards tbe pupil, may be as easily pushed through this aperture into the anterior chamber, where Scarpa finds absorption takes place more quickly, than behind the pupil. In ordinary cases, there is not the least occasion for any preparatory treatment previous to the operation ; all that pru- dence requires is, that the patient should abstain from animal food and fermented liquors, for a few days before submitting to it, and should take one dose of a gentle purgative. But this, like every other ge- neral observation, is liable to particular exceptions. Hypochondriacal men, hy. sterical women, and patients subject to affections of the stomach and nervous system, should take, for two or three weeks before the operation, tonic bitter medicines, particularly the infusion of quassia, either with, or without a few drops of the aether vitriolicum to each dose; or, in other cases, 3j of Peruvian bark, with *9j of valerian, may be admi- nistered two or three times a day with particular benefit. It is observed by the most accurate writers upon this subject, that in such persons the symptoms con- sequent to operations upon tlie eyes, are often much more violent than in common cases ; and it therefore seems proper to endeavour, previously, to meliorate their constitutions. When the patient is timid; it is very advisable to give him, half an hour before the time of operating, about fifteen drops of the tihctura opii, with a little wine. V Some patients, besides being afflicted with cataracts, have the edges ofthe eye- lids swollen and gummy, with relaxation, and chronic redness of the conjunctiva. In this case, before undertaking to couch, it is advisable to apply* a blister to the nape of the neck, and to keep it open for two or three weeks, by means ofthe Savin cerate, and to insinuate every morning and evening, between the* palpebrac and globe of the eye, a small quantity of the unguentum hydrarg. nitrat. mitius, pre- pared according to the pharmacopoeia of St. Bartholomew's Hospital, increasing its strength gradually. (•%. Unguenti hv- drargyri nitrati, "§iv. Adipis Suillx ^viij. Olei Olivac, SJij.) In obstinate cases, when this ointment does not produce the desired effect, an ointment recommended by Janin, (Memoires sur 1'OeiL) should be substituted: it consists of^ai of hogs- lard, gij of prepared tutty, Jjij of arme. CATARACT. 2?3 niah bole, and %'\ of the white calx of quicksilver. At first, care should be taken to use it lowered, with twice or thrice its quantity of lard. In the day- time, a collyrium, composed of ^iv of rosewater, 5SS of the mucilage of quince seeds, and gr. v of the sulphate of zinc, may also be frequently used with consi- derable advantage. By such means the morbid secretion fi-om the Mi ibomian glands, and membranous lining of the eve-lids, will be checked, and the due action of the vessels, and natural flexi- bility of the eye-lids, will be restored. {Saggio di Osservazioni, &C. sulleprincipal! malattie tlegli occhi. Venet. 1802.) riRM CATARACT. In the operation, the patient should be seated rather low, opposite a window where the light is not vivid, and in such a manner that the rays may fall laterally upon the eye about to be couched. The other eye, "whether in a healthy or dis- eased state, ought always to be closed, and covered with a handkerchief, or any tiling convenient for the purpose; for, so strong is the sympathy between the two organs, that the motions of the one con- stantly produce a disturbance of the other. The surgeon should sit upon a seat rather higher than that upon which the patient is placed; and, to give his hand a greater degree of steadiness in the various manoeuvres of couching, he will find it useful to place his elbow upon his knee, which must be sufficiently raised for this purpose, by a stool placed under tlie foot. The chair, on which the pa- tient sits, ought to have a high back, against which his head may be so firmly supported, that he cannot draw it back- ward during the operation. The back of the chair must not slope backward; as that of a common one, but be quite per- pendicular, in order that the patient's head may not be too distant from the surgeon's breast. (Richter's Anfangsgrunde der Wundarzneykunst, P. 207. 3 Band.) The propriety of supporting the pa- tient's head rather upon the back of the chair, on which he sits, than upon an assistant's breast, must immediately strike every impartial mind; for, as Bischoff has observed, the least motion of the as- sistant, even that necessarily occasioned by respiration, causes, also, a synchro- nous motion of the part, supported on his breast, which cannot fail to be disadvan- tageous, both in the operation of extrac- tion, and of couching. Hence C-allisen and Richter have recommended the same method of supporting the patient's head, Vol. 1. as I have here submitted to public consi- deration. In certain cases, where the muscles of the eve, and eyelids, are incessantly af- fected with spasm ; 01', where the eye is peculiarly diminutive, and sunk, as it Were, in the orbit,- the elevator for the upper eyelid, invented by I'ellier, and approved by Scarpa, may possibly prove servicable; in operating upon young subjects, I think it might contribute much to facilitate the operation. The couching needle (if the curved one) is to be held with the convexity of its curvature forward; its point back- ward ; and its handle parallel to the- pa-' tient's temple. The surgeon having di- rected the patient to turn the eye towards the nose, is to introduce the instrument boldly through the sclerotic coat, at the distance of not less than two lines from the margin of the cornea, for fear of in- juring the ciliary processes. Most au- thors advise the puncture to be made at about one line, and some even at the mi- nute distance of l-16th of* an inch Hey) from the union of the cornea with the sclerotica; but, as the ciliary processes ought invariably to be avoided, and there is no real cause to dread wounding the aponeurosis of the abductor muscle, as some have conceived, the propriety of puncturing the globe of the eye, at the distance of two lines, or two and a half, from the margin of the cornea, as ad- vised by Petit, Platner, Bertrandi, &c. must, in all cases, be sufficiently mani- fest. Nor is it a matter of indifference, at what height the needle is introduced, if it be desirable to avoid, as much as possi- ble, effusion of blood in the operation. Anatomy reveals to us, that the long cili- ary artery pursues its course to the iris, along the middle of the external convexity of the eyeball, between the sclerotic and choroid coats; and hence, in order to avoid this vessel, it is prudent to intro- duce the instrument about one line below the transverse diameter of the pupil,-as Dudell, Guntz, Bertrandi, Scarpa, &c. have directed. If the couching needle were introduced higher than the track of the long ciliary artery, it would be incon- venient for the depression ofthe cataract. The exact place, where the point of the needle should next be guided, is, no doubt, between the cataract and ciliary processes, in front ofthe opaque lens, and its capsule : but, as I conceive, the at- tempt to hit this delicate invisible mark, borders upon impossibility, and, with a ^straight pointed netdle, might even en- danger the iris, 1 cannot refrain from ex- 2M CATARACT. pressing my dissent to the common me- thod of passing a couching needle at once in front of the cataract. On the contrary, it seems safer to direct the extremity of the instrument immediately over the opaque lens, and, in the first instance, to depress it a little downward, by means of the convex flat surface of the end of the needle, in order to make room for the safe conveyance of the instrument, be- tween the cataract and corpus ciliare, in front of the diseased crystalline and its capsule; taking care, in this latter step ofthe operation, to keep the marked side of the handle forward, by which means the point of the needle will be in an opposite direction to the iris, and will come into contact with the diseased body, and the membrane binding it down in the fossula of the vitreous humour. Having done this' (supposing it to be a firm cataract,) the instrument will be visible through the pupil; and now we are to push its point transversely, as near as possible the mar- gin of the lens, on the side next the in- ternal angle of the eye, taking strict care to keep it continually turned backward. The operator is then to incline the handle of the instrument towards himself, by which its point will be directed through the capsule, into the substance of the opaque lens; and, on making a move- ment bf the needle, describing the seg- ment of a circle, at the same instant in- clining it downward and backward, he will lacerate the former, and convey it, in the generality of cases, with the latter, deeply into the vitreous humour. It happened, unfortunately for the cre- dit of the operation of depression, that M. Petit admonished surgeons to beware of" wounding the anterior layer of the crystalline capsule .- he had an idea, that, in pbserving this caution, the vitreous humour would afterwards fill up the space, previously occupied by the lens, and that thus the refracting powers of the eye might become as strong as in the na- tural state, and the necessity for using spectacles might thereby be considerably obviated. But, we are now apprized, that leaving this very membrane, from which M. Petit anticipated such great utility, even were it practicable to leave it constantly uninjured in its natural situation, would be one of the worst in- culcations that could possibly be promul- gated ; for, in many cases, where extrac- tion proves fruitless, in some, where depression fails, the want of success is owing to a subsequent opacity of the crystalline capsule; in short, blindness is reproduced by'the secondary membra- nous cataract It seems more than pro- bable, that in some of the instances, where the opaque lens has been said to have risen again, nothing more has hap. pened, than the disease in question Therefore, notwithstanding the whole capsule may be, in the majority of cases, depressed with the lens out of the axis of vision, as it is not a constant occur rence, 1 cannot too strongly enforce the propriety of extirpating, as it were, every source and seat ofthe cataract in the same operation, and, in imitation of the cele- brated Scarpa, the only one who, as fax as my information reaches, has put suffi- cient stress upon this practice, I shall presume to recommend, as a general rule in couching, always to lacerate the front layer ofthe capsule, whether in an opaque or transparent state. The capsule of the crystalline lens may- retain its usual transparency, while the lens itself is in an opaque state. In this case, an inexperienced operator might, from the blackness of the pupil, suppose, not only that he had removed the lens, but also the capsule from the axis of sight; and, having depressed the cata- ract, he might unintentionally leave tliis membrane entire in its natural situation. Therefore, if there should be any reason for suspecting, that the anterior layer of the capsule has escaped laceration; if, in other words, the resistance made to mov- ing the convexity of the instrument for- ward, towards the pupil, should give rise to such a suspicion ; for the sake of re- moving all doubt, it is proper to commu- nicate to the needle a gentle rotatory motion, by wliich its point will be turned forward, and disengaged, .through the transparent capsule, opposite the pupil: then, by repeating a few movements downward and backward, it will be so freely rent with the needle, as to occasion no future trouble. FtCID, OB MILKV CATABACT. When the case is of this description, the operator frequently finds, that, on passing the point of the couching needle through the anterior layer ofthe capsule, its white milky contents instantly flow out, and, spreading like a cloud over the two chambers of the aqueous humour, completely conceal the pupil, the iris, and the instrument, from his view; who, however, ought never to be discouraged at this event. In the Critical Reflections on the Cataract, I have dissented from continuing the operation, when, in its commencement, blood is effused into the aqueous humour; I have there adverted to the effusion ofthe milky matter of ca- taracts, into the same situation; and, I have said, that the two cases are not to CATABACT. 275 be considered in a different light; but, I only alluded to the consequences of these occurrences. I shall now take the op- portunity to observe, that, although it seems to me most prudent, to postpone the completion of the operation, in the example of blood concealing the pupil, in the first step of couching, and not to renew it, before the aqueous humour has recovered its transparency ; yet, I am in- clined to adopt this sentiment, cliiefly be- cause the species of cataract is, in this circumstance, quite unknown to the ope- rator, consequently he must be abso- lutely incapable of employing that me- thod of couching, which the peculiarities of the case may demand. It is very dif- ferent, when a milky fluid blends itself with the aqueous humour, and prevents the surgeon from seeing- the iris and pu- pil ; this event is itself a source of infor- mation to him, inasmuch as it gives him a perfect insight into the nature of the cataract, which he is treating; and in- structs him what method of operating it is his duty to adopt. The surgeon, guided by his anatomical knowledge of the eye, should make the curved point of the needle describe the segment of a circle, from the inner, toward the outer canthus, and in a direction backward, as ifhe had to depress a firm cataract. (Scar- pa.) Thus he will succeed in lacerating, as much as is necessary, the anterior layer of the capsule, upon which, in a great measure, the perfect success of the operation depends ; and, not only in the milky, but almost every other species of cataract. In regard to the extravasation of the milky fluid, into the two chambers of the aqueous humour, numerous observations, from the most creditable authorities, prove, that it spontaneously disappears, very soon after the operation, and leaves the pupil of its accustomed transparency. " In twelve cases of a dissolved lens, on which I have operated," says Latta, " the dissolution was so Complete, that, on en- tering the needle into the capsule ofthe lens, the whole was mixed with the aqueous humour, and all that could be done, was to destroy the capsule as com- pletely as possible, that all the milky matter might be evacuated. In ten of these cases, vision was almost completely restored in four weeks from the opera- tion." Mr. Pott, in treating of this cir- cumstance, viz the effusion ofthe fluid contents of tiie capsule into the aqueous humour, observes, that so far from being an unlucky one, and preventive of suc- cess, it proves on the contrary, produc- tive of all the benefit which can be de- rived from the most successful depression or extraction, as he has often and often seen. But as this point is, I believe, no longer made an objection to couching, it would be superfluous to enlarge, in confir- mation of what has been stated concern- ing it. SOFT, OR CASEOUS CATARACT. When the cataract is of a soft, or ca- seous description, the paf-ticles of which it is composed, will frequently elude all efforts made with the needle to depress them, and will continue behind the pupil in the axis of vision. This has been ad- duced as one instance that baffles the efficacy of couching, and may really seem, to the inexperienced, an unfortunate cir- cumstance. It often happens that, in the operation of extraction, fragments of opaque matter are unavoidably overlook- ed and left behind; yet Richter, who once so strenuously signalised himself in favour of the new operation, confesses, that such matter is removed by the ab- sorbents. Supposing a caseous cataract should not bave been sufficiently broken, and disturbed in the first operation, and that, consequently, the absorbents do not completely remove it, such a state may possibly require a re-application of the instrument; but this does not generally occur, and is tlie worst that can happen. It is quite impossible to determine a priori, what effect will result from tlie most trivial disturbance of a cataract; its entire absorption may, in some in- stances, follow, while in others, a repe- tition of an operation becomes necessary for the restoration of sight. Even where the whole firm lens has re-ascended be- hind the pupil, as Latta and Hey con- firm, the absorbents have superceded the necessity for couching again. The dis- appearance of the opaque particles of ca- taracts was, in all times, and in all ages, a fact of such conspicuity, that, as ap- pears from the authorities already quot- ed, it was recorded, even previous to the discovery of the system of lymphatic ves- sels in the body. Indeed the modern observations of Scarpa, and others, so strongly corroborate the account which I have given, of the vigorous action of the absorbents, in the two chambers of the aqueous humour; and, particularly, in the anterior one, that, from the moment the case is discovered to. be a soft, or caseous cataract, it seems quite unneces- sary to make any further attempt to de- press it into the vitreous humour. Mr. Pott sometimes, in this circumstance, made no attempt of this kind, but con- tented himself with a free laceration of the capsule, and after turning the needle 276 CATARACT. round and round, between the finger and thumb, within the body ofthe crystalline, left all the parts in their natural situa- tion, where he hardly ever knew them fail of dissolving so entirely, as not to leave the smallest vestige of a cataract. This eminent surgeon even practised oc- casionally what Scarpa so strongly incul- cates at this day; lie even pushed the firm part of such cataracts through the pupil into the anterior chamber, where it always disappeared, without producing the least inconvenience : we must, at the same time add, that he thought this me- thod wrong, not on account of its ineffi- cacy, but an apprehension that it would be apt to produce an irregularity of the pupil, one of the worst inconveniences attending the operation of extraction. But the deformity of the pupil, after ex- traction, seems to proceed either from an actual laceration of the iris, or a forcible distention of the pupil, by the passage of large cataracts through it, a kind of cause that would not be present in pushing the broken portions of a caseous lens into the anterior chamber; therefore, it does not seem warrantable to reject this very effi- cacious plan of treatment, for which the curved pointed needle is, undoubtedly, the best calculated. Ii is very deserving of notice, that Mr. Hey, who has several times seen the whole opaque nucleus and very frequently small opaque pnr- tions fall into the anterior chamber, makes this remark: " Indeed, if the ca- taract could, in all cases, be brought into the anterior chamber of the eye, without injury to theins, it would be the best method of performing the operation." What the same author also observes in the subse- quent part of his work, is strikingly' cor- roborative ofthe efficacy of Scarpa's prac- tice. The practice of the Italian pro- fessor consists in lacerating the anterior portion of the crystalline capsule, to the extent of the diameter of" the pupil, in a moderately dilated state ; in breaking the pappy substance of the diseased lens piecemeal; and in pushing the fragments through the pupil, into the anterior chamber, where they are gradually ab- sorbed. MEMBRANOUS CATARACT. One great advantage in favour of couch- ing, depends upon its generally removing the capsule, at the same time with the lens, from the passage of the rays of light to the retina. Sometimes, however, this desirable event, by which the patient is extricated from the danger of a secondary membranous cataract, does not take place even in the operation of depression; and, when the lens included in its capsule is extracted from ihe eye, by the other me- thod, it may always be considered as ra- ther an uncmnnioii circumstance. What most frequently constitutes the secondary membranous cataract, is the anterior half of the capsule, which not having been removed, or sufficiently broken, in r previous operation, continues more or less entire in its natural situation, after- wards becomes opaque, and thus impedes the free transmission of the rays of light in the seat of vision. Sometimes the secondary membranous cataract presents itself beyond the pupil, in the form of membranous flakes, apparently floating in the aqueous humour, and shutting up the pupil: at other times it appears in the. firm of triangular membranes, with thtir bases affixed to the Membrana Ilya- loidea, and their points directed towards the centre of the pupil. When there is only a minute membranous flake suspend. ed in the posterior chamber, it is on no account necessary for the patient to sub- mit to another operation; vision is to- lerably perfect, and the small particle of opaque matter will, in time, sponta- neously disappear. But when the se- condary membranous cataract consists of a collection of opaque fragments of the capsule, accumulated so as either in a great degree or entirely to close the pupil ; or when the disease consists of the whole anterior half of the opaque capsule, neglected in a prior operation, and continuing adherent in its natural situation, it is indispensable to repeat an operation ; for, although in the first case, there may be good reason to hope that the collection of membranous fragments might, in time, disappear, yet it would be unjustifiable to detain the patient for weeks and months in a state of anx- iety and blindness, when a safe and simple operation would restore him, in a very short space of time, to the enjoyment of this most useful of the senses. In the second case, it is absolutely indispensa- ble: for while the capsule remains ad- herent to its natural connections, the opacity seldom disappears, and may even expand itself over a larger portion of the pupil. The operation should be performed as follows : when the aperture in the iris is obstructed by a connection of membranous flakes, detached from the membrana hyaloidea, the curved needle should be introduced, with the usual pre- caution of keeping its convexity forward, its point backward, until arrived behind the mass of opaque matter; the surgeon is then to turn the point ofthe needle towards the pupil, and is to push through this open- ing, regularly one after another, aU th« CATARACT. 277 tpaque particles into tlie anterior cham- ber, where, as we have before noticed, absorption seems to be carried- on more rigorously than behind the pupil. All endeavours to depress them into the vi- treous humopr, Scarpa has found to be vain ; for scarcely is the couching needle withdrawn when they all re-appear at the pupil, as if, (to use his own phrase) carried thithtr by a current: but when forced into the anterior chamber, besides being incapable of blocking up the pupil, they lie, without inconvenience, at the bottom of that cavity, and in a few weeks are entirely absorbed. When the secondary membranous cata- ract consis'.i of the whole anterior layer of the crystalline capsule, or of several portions of it connected with the mem- brana hvaloidea, tire surgeon, after cau- tiously turning the point of the needle towards the pupil, is to pierce the opaque capsule; or, should there be any inter- space, he is to pass the point of the in- strument through it; then, having turned it again backward, he is to convey it, as near as possible, to the attachment of the membranous cataract, and after piercing the capsule, or each portion of it succes- sively, and sometimes carefully rolling the handle of the instrument between his finger and thumb, sb as to twist the cap- sule round its extremity, he will thus break the cataract, as far as it is practi- cable, at every point of its circumference. The portions of membrane, by this means separated from their adhesions, are next to be cautiously pushed, with the point of the.couching needle turned forward, through the pupil, into the anterior chamber. In these manoeuvres the ope- rator must use the utmost caution not to i -jure the iris, and ciliary processes, for, upon this circumstance depends having no bad symptoms after the operation, not- wit hstanding its duration may have been long, and the necessary movements of the needle numerously reiterated. If a part of the membranous cataract should be found adherent to the iris, (a complica- tion, that will be indicated when, upon moving it backward or downward with the needle, the pupil alters its shape, and, from being circular becomes of an oval, or irregular figure,) even more cau- tion is required than in the foregoing c.ise| so as to make repeated, but delicate movements of the needle, to separate the membranous opacity, without injuring the iris. Nor will it be necessary to vary the plan of operating already explained, if occasionally the cataract should be formed ofthe posterior layer ofthe capsule. The same plan also succeeds in those rare instances where the substance itself of the crystalline wastes, and is almost completely absorbed, leaving the capsule opaque, and including, at most, only a small nucleus, not larger than a pin's head. Scarpa terms it the Primary Mem- br'anous Cataract; he describes it as being met with in children, or young people under the age of" twenty; as being cha- racterized by a certain transparency, and similitude to a cobweb; by a whitish opaque point, either at its centre or cir- cumference ; and, by a streaked and rati- culated appearance: he adds, that whoso- ever attempts to depress such a cataract is baffled, as it re-appears behind the pupil soon after the operation; he recom- mends breaking it frfely with the curved extremity of the couching needle, and pushing its fragments into the anterior chamber, where they are gradually ab- sorbed in" tlie course of about three weeks. No other topical application is gene- rally requisite, after the operation, than a small compress of fine linen; the pa- tient ought to be kept in a quiet, dark room, and in bed. A dose of some mild fiurgative salt, such as the natron vitrio- atum; magnesia vitriolata; soda phos- phorata, &c. may usually b? administered, •with advantage, on the following morn- ing. I shall not enlarge upon the method of treatment, when the inflammation, subsequent to couching, exceeds tiie or- dinary bounds; in hypochondriacal, hy- sterical, and irritable constitutions, this is more frequently met with, and I have already touched upon the propriety of some preparatory measures, b-fore couch- ing these unfavourable subjects. I cannot help remarking fiow judicious it is never to attempt too much at one time of couching. It happens in this, as in most other branches of operative sur- gery, that celerity is too often mistaken for skill: the operator should not only be slow and deliberate in achieving his purpose; he should be taught to consider, that a repetition of couching may, like tiie puncture of a vein, be safely and ad- vantageously put into practice again and again; and with far greater security than if, for the sake of appearing expeditious, or avoiding the temporary semblance of failure, a bolder use of the couching needle shoidd be made, than the delicate structure of the eye warrants. We read, in Mr. Hey's Practical Observations on Sur- gery, that he couched one eye seven times. before perfect success was obtained ; had he been less heedful, and endeavoured to effect by one or two rough applications of the instrument, what he achieved by seven efforts of a gentler description, it is highly 278 CATARACT. probable that the structure of the eye would have been so impaired, as well as the consequent ophthalmy so violent, as to have utterly prevented the restoration of sight. OF THE CONOENITlt CATARACT, AND OPE- RATING UPON CHILDREN. So much has been already said in a pre- ceding section of this article, concerning the propriety and striking advantages of operating for the cataracts of children, that, to expatiate farther upon this point, would be a mere waste of time. We have noticed the case, which Scar- pa terms the primary membranous cataract, and which is mentioned by that distin- guished professor, a? being met with in children, or young people, under the age of twenty, the substance of tlie crystalline itself being almost entirely absorbed, while the capsule is left in an opaque state, including, at most, only a small nucleus, not larger than a pin's head. This disease is described by Scarpa as being exceedingly rare, and characterised by a certain transparency, and similitude to a cobweb ; by a whitish opaque point, either at its centre, or circumference; and by a streaked and reticulated ap- pearance. Now, this example, which is represented by Scarpa, as being rare, appears, from the experience of Mr, Saunders, to be by no means uncommon, since, at the London Infirmary for curing diseases of the eye, it has been found that the majority of congenital cataracts were capsular, or membranous. This last statement is also at variance with that of the late Mr. Gibson, who has assert- ed, that, in infants, the cataract is gene- rally fluid. (Edinburgh Medical and Sur- gical Journal, Vol. 7, p. 397.) Mr. Ware also asserts, that, in children, born with cataracts, the crystalline humour has ge- nerally, if not always, been found either in a soft, or fluid state. (Observ. on tbe Cataract and Gutta Serena, Vol. 2, p. 380) However, as Mr. Saunder"# must have had the most experience in these parti. cular cases, I believe, we must consider his account as the most accurate. "We learn from this last gentleman's publica- tion, that, in the congenital cataract, after the crystalline lens is converted into an opaque substance, it is gradually absorb- ed ; and, in proportion to the progress of absorption, the anterior lamella of the capsule approaches the posterior, until they form one membrane, whieh is white, opaque, and very elastic. This process is commonly completed long before the eighth year, and the operator will now find a substance, wliich he will in vain endeavour either to extract, or depress. But, there is one form of the congenital cataract, in which the absorption of the lens does not proceed, viz. when the cen- tre of the crystalline is opaque, and its circumference is perfectly transparent. Should -the capsule and lens be penetrat- ed, however, with any instrument, the opacity soon becomes complete, and from this moment, the substance of the lens begins to be absorbed. The experience of Mr. Saunders proves, that, in the congenital cataract, the lens may be either solid, soft, or fluid, but, that more frequently it is partially, or completely absorbed, and the cataract is capsular. The following table of forty-four cases is given in Mr. Saunders' work, for the purpose of shewing in what proportion, each species of cataract has been found to prevail in congenital cases. Solid opaque lens, with or without opacity of the capsule. single, two double cataracts Three") . Solid lens, opaque in the centre, transparent in the circumference, / ^ with capsule m the same state. Five double 5 Soft opaque lens, with, or without opacity of the capsule. Two") . single, two double C 4 Soft opaque lens, with solid nucleus. One single, two double 3 Soft opaque lens, with dotted capsule, the spots white, the spaces "> transparent. Two double 5 ^ Fluid cataract, with opacity of the capsule. Two single 2 Fluid cataract, with opacity ofthe capsule, and closed pupil. Two / „ double C ^ Opaque and thickened capsule, the lens being completely absorbed,") or the remains of it being thin and squamose. Six single, twelve C18 double \ CATARACT. 279 Opaque and thickened capsule, with only a very smaU nucleus of the3 „ lens unabsorbed in the centre. Two single 5 Opaque and thickened capsule in the centre, remains of the lens in the circumference. One double H*%re the corresponding character of congenital cataracts in the eyes of each individual is exhibited by the" number of double cases, and, we are" informed, that the same character was preserved in the cataracts of several children of the same family. (Saunders on Diseases of the Eye, Edit, by Dr. Farre, p. 135,136.) The congenital cataract appears fre- quently to afflict several children of the same parents. In the course of the pre- sent article, I have already had occasion to advert to two striking examples of this fact. The first is related by Mr. Lucas, who attended five children of a clergyman at Leaven, near Beverly, all born with ca- taracts. (See Med. Obs. and Inquiries, Vol. 6.) The second is mentioned by Mr. Gibson, who, some years ago, saw five, or six children, the families of* two sisters, who were all totally blind, and in an idiotic state, having cataracts accom- panied with amaurosis. (Edinb. Med. and Surgical Journal, Vol 8, p. 398.) Se- veral instances occurred to the late Mr. Saunders. In one family, two brothers were thus afflicted. In a second family, two brothers, twins, became blind with cataracts at the age of twenty-one months, each within a few days of the other It is remarkable, that tiV four cataracts had precisely the same character. In a third family, a brother and two sisters were born with this disease. The eldest sister was affected with it only in one eye, the brother and youngest sister in both eyes. In a fourth family, three brothers and a sister had all congenital cataracts. (Saun- ders on the Diseases ofthe Eye,p. 134,135.) Children with congenital cataracts pos- sess various degrees of vision; but, when they are totally blind, their eyes not being attracted by external objects, volition is not exercised over the muscles of these organs, which roll about with an irregu- lar, rapid, and trembling motion. 1 shall now proceed to speak of the manner of operating upon children. Until the time of Mr. Pott, the intention of sur- , gecus, in couching, or depressing the ca- ' taract, (as- indeed the expression itself implies) was to push the opaque crys- talline downward, away from the pu- pil. Mr. Pott, conscious that the ca- taract often existed in a fluid, or soft state, was aware that it could^ not then be depressed; and, therefore, in such cases, he recommended using the couching needle for the express purpose of break- ing down the cataract, and of making a large aperture in the capsule, so that the aqueous humour, which he believed to be a solvent for the opaque crystalline, might come into immediate contact with this body. This operation, since the time of Mr. Pott, has been strongly and ably recommended by Mr. Hey, of Leeds, and Professor Scarpa, of Pavia. In the cases of children, it has even received the ap- probation of Mr. Ware, who informs us that he and his son have performed a similar operation on a considerable num- ber of infants and young persons with uniform success. (On the Operation of Puncturing the Capsule of the Crystalline Humour, p. 9.) But, notwithstanding the utility and efficacy of lacerating the front layer of the crystalline capsule had been so much insisted upon by Scarpa and others, their observations were confined to ihe cataract in the adult subject, and, before the ex- ample set by the late Mr. Saunders, no one, (excepting, perhaps, Mr. Gibson of Manchester) ventured to apply, as a re- gular and successful practice, such an •.ipei-Ation to the eyes of infants and chil- li: p Indeed, it seems highly probable, t;iat even Mr. Gibson himself would have remained sihnt upon the subject, had not his attention been roused by tiie reports of the London Institution for curing dis- eases of the eye, which reports, he says, were dispersed and exhibited in the pub- lic newsrooms of Manchester. For the creation and perfection of* this beneficial practice, therefore, I am disposed to give the memory of Mr. Saunders great ho- nour. The propriety of operating for the cataracts of children had long ago been insisted upon by a few writers, and the attempt even now and then made; but, the method never gained any ground, un- til Mr. Saunders led the way. It only remains for me to describe the plans of operating, executed by Mr. Saunders, Mr Gibson, aid Mr. Ware. The principle, on which Mr. Saun- ders proceeded in his operations on the congenital cataract, is founded on the opinion, that the only obstacle to the ab- sorption of the opaque lens is the cap- sule ; and that as the Utter also is most generally opaque, " the business cf art is to effect a permanent aperture in the cen- tre of this membrane. This applies to every case of congenital cataract, which can occur." Mr. Saunders used to over- 280 CATARACT. come the difficulty of operating upon children, by fixing the eye ball with Pel- tier's elevator, having the patient held by four or five assistants, dilating the pupil with the belladonna, and employing a very slender needle, armed with a cutting edge from its shoulders to its point, and furnished with a very sharp point, calcu- lated to penetrate with tiie utmost faci- lity. Before the operation, the extract of belladonna, diluted with water, to the consistence of cream, was dropped intothe eye, or, to avoid irritation, the extract it- self was smeared in considerable quan- tity, over the eyelid and brow. In less than an hour, if there be no adhesions, it produces a full dilatation of the pupil, exposing to view nearly the whole ante- rior surface of the cataract. The appli- cation should then be washed from the appendages of the eye. In using the needle, Mr. Saunders, most carefully abstained from doing any injury to the vitreous humour, or its cap- sule, and it Was an essential point with him to avoid displacing the lens. In di- recting the, extremity of the instrument to the centre of the capsule, he passed it either through the cornea, near the edge of this membrane, or through the sclerotica, a little way behind the iris. By the first, which is called the anterior operation, Mr. Saunders conceived, that less inj ury would be inflicted, and less ir- ritation excited, than by introducing the needle behind the iris, through all the tunics of the eye. In every case, the first thing aimed at was the permanent de- struction of the central portion of the capsule to an extent equal to that of the natural size of the pupil. If the capsule contained an opaque lens, Mr. Saunders used next to sink the needle gently into the body of the crystalline, and mode- rately open its texture ; cautiously ob- serving not to move the lens at all out of its natural situation. When the case was a fluid cataract, Mr. Saunders was content in the first operation with simply lacerating the cen- tre of the capsule, being desirous of avoid- ing to increase the irritation following the diffusion of the matter of cataract in the aqueous humour. When the cataract was entirely cap- sular, Mr. Saunders acted with rather more freedom, as he entertained in this case less fear of inflammation; but, in other respects, he proceeded with the srmne objects in view, which have been already related, and of which the princi- pal consisted in effecting a permanent aperture in the centre of the capsule, without detaching this membrane at its circumference; for then the pupil would have been more or less covered by it, and the operation imperfect, " becayse this thickened capsule is never absorbed, and the pendulous flap is incapable of pre- senting a sufficient resistance to the needle to admit of being removed by » second operation." (P. 145.) I have already explained, that Mr. Saunders found, that the greatest success attended the operation between the ages of" eighteen months and four years. One operation frequently accomplished a cure; as many as five were seldom requisite. The only particularity, in Mr. Saun- ders' treatment ofthe eye after the opera- tion, was that of applying the belladonna externally, for the purpose of making the pupil remain dilated, till the inflamma- tion had ceased, so as to keep the edge of the iris from contracting adhesions with the margin of the torn capsule. In hav- ing this part of the subject, I must advise every surgeon to read the interesting ac- count of Mr. Saunders' practice, pub- fished by his friend and colleague, Dr. Farre. Many minute particulars will be found in this work, highly worthy of the practitioner's attention and imitation. Mr. Gibson appears to have been un- acquainted with the usefulness of the ex- tract of belladonna in preparing the eye for the operation. A few hours before operating, he was in the habit of order- ing an opiate, sufficient to produce a con- siderable degree of drowsiness, so that the infant generally allowed its eyelids to be opened, and properly secured without resistance, and was little inclined to offer any impediment to the introduction of the couching needle; but, on the contrary, presented the sclerotica to view, natu- rally turning up the white of its eye. If the infant was more than a year old, and whenever it was necessary, Mr. Gibson used to introduce its body and arms into a kind of sack, open at both ends, and furnished with strings to draw round the neck, and tie sufficiently tight round the legs, so that its hands are effectually se- cured, and the assistants have only to steady its-body, and fix its head, whilst the child is laid on a table, upon a pil- low. Mr. Gibson never found it neces- sary to use a speculum, having uniformly experienced, that, after the coucnW*- needle was introduced, he had no diffi- culty in commanding the eye, aided by a' slight degree of pressure upon the eyeball with the index and middle fingers of his left hand, which were employed in de- pressing t\ig lower eyelid. He admits, however, thr.t the speculum can easily be applied, if an operator prefer it. He ge- nerally used Scarpa's needle, because, in CATARACT. SfU infants, the free rupture ofthe capsule of the lens ought commonly to be aimed at, in order that the milky cataract may es- cape, and mix with the aqueous humour; or, if the cataract be soft, that the aque- ous humour may be freely admitted to its pulpy substance, wh.ch has been pre- viously broken down with ihe needle. He thinks, that no peculiarity is neces- sary in depressing the hard cataract of infants. Before Scarpa's needle was known in this country, Mr. Gibson used Mr. Hey's, which was generally effectual, and, as he conceives, possesses the recom- mendation of being less liable to have its point entangled in the iris. He says, that, when a milky cataract has been thus evacuated, it renders the aqueous humour turbid; but, that, within the space of two days, the eye generally acquires its natu- ral transparency, and vision commences. When the capsule and substance of the soft cataract have been broken down, and the aqueous humour has come into contact with the lens, the solution and disappear- ance of the cataract, in all the cases, up- on which Mr. Gibson has operated, hive uniformly taken place, in a short time. The experience of Mr. Gibson curiously differs from that of Mr. Saunders in one respect: he assures us, that although he has met with cataracts in infants hard enough to bear depression, yet, that he has never met with a simple membranous cataract; though this is no uncommon oc- currence in patients at the age of eight, or ten, as well as in adults, who have been blind from birth. (See Edinburgh Med. and Surgical Journal, Vol. 8, p. 398, 399.) For the purpose of fixing the eye, Mr. Ware thinks Pellier's elevator requisite in operating upon infants. When the patient, however, has advanced beyond the age of infancy, Mr. Ware sometimes fites the eye by means of the fingers alone. For the purpose of putcturing the capsule, and breaking down the cata- ract, this gentleman gives the preference to an instrument, which resemoles one, that was recommended by Cheselden for the purpose of making an artificial pupil; but, it is somewhat narrower. lis blade indeed is so narrow, that it nearly re- sembles a needle. Its extremity is point- ed, and it cuts on one side for the space of about the eighth of an inch, the other Bide being blunt It is perfectly straight; is an inch long in the blade ; and forms a complete wedge through its wholelength. Upon one side of the handle is a coloured spot, by attending to which, the operator may always ascertain the position of tlie instrument in the eye. Mr. Ware dilates the pupil with the ex- Vox.. I. tractum belladonna, softened with a little water, and applied about half" an hour before the time of operating. This gentlemari thinks, that, in operating upon infants, tne surgeon will perform the operation with more composure, if the patient be laid upon a table, with the head properly raised on a pillow. The bent end of Pellier's elevator should be introduced under the upper eyelid, and the instrument committed to the care of an assistant. If the right eye is to under- go the operation, and the surgeon operate with his right hand, he must of course sit or stand behind the patient; and, in this case, he will himself manage the spe- culum with his left hand. The eye being thus fixed, Mr. Ware passes the point of the narrow bladed knife above mention- ed through the sclerotica, on the side next to the temple, about the eighth of an inch from the union of that membrane to the cornea, the blunt edge being turned down- wards. The instrument is pushed for- wards in the same direction, until its point nearly reaches the centre of the crystal- line. The point should then be brought forwards, until it has passed through the opaque crystalline and its capsule, and is plainly visible in the anterior chamber of the aqueous humour. If the cataract be fl uid, and the anterior chamber become im- mediately filled with the opaque matter, Mr. Ware thinks it advisable to withdraw the instrument, and defer further mea- sures until the matter is absorbed, which ab-sorption usually takes place in the course of a few days, and sometimes of a few hours. If no visible change be pro- duced in the pupil, the point and cutting edge of the instrument should be applied in different "directions, so as to divide both the opaque crystalline and its capsule into small portions, and, if" possible, to bring them forwards into the anterior chamber This may require the instru- ment to be kept in the eye for a minute or two ; but, if the operator preserve his steadiness, he may continue it there a , much longer time without doing the least injury to the iris or to any other part. If the cataract be found of a firm consistence, (though this rarely happens in young persons,) it may be advisable to depress it below the pupil; and in such a case particular care should be taken to perfo- rate largely the posterior part of the cap- sule, and to withdraw the instrument im- mediately after the cataract has been de- pressed, in order to hinder it from rising again. If the opacity be in tiie capsule, the instrument will not act so easily upon it as it does on the opaque crystalline ; but, notwithstanding this, the capsule as well as the crystaUine, may be divided by Oo 282 CATARACT. it into larger or smaller portions, which, when thus divided, will be softened by the action of the aqueous humour; and though in the first operation oiy uch case, says Mr. Ware, it may notjpe possible to remove the opacity, yet, on the second or third attempt, the divided portions may be brought forwards into the anterior chamber of the aqueous humour, in which place, they will then be gradually ab- sorbed, and will soon disappear. After the operation, Mr. Ware has seldom found it necessary to take away blood from chil- dren, or persons under the age of twenty. He continues a cooling antiphlogistic treatment a few days. After this, if any opaque matter remain, he expedites its absorption by dropping a small portion of powdered sugar into the eye once or twice a day. When, at the end" of a week Or ten days, the inflammation is over, and the pupil is' obstructed with opaque mat- ter, Mr. Ware advises a repetition of the operation. Afur a similar interval, the operation may be requisite again. Mr. Ware has, in most ca^es, been obliged to operate twice; in a few instances, once has been sufficient; and only in three, out of the last twenty, has he found it neces- sary to operate a fourth time. (O71 the Operation of Pw.cturing the Capsule of tlie Crystalline Humour.) 1 think any impartial man, who consi- ders the practice of the three preceding operators, will find great cause to admire the superior gentleness and skill, which predominate in the operations of the late Mr. Saunders. For my own part, I am so fully convinced of the mischief, which has been done to the eyes, by the rash boldness, awkwardness, and unsteadiness of numerous operators, that, it appears to me, the inculcation of gentleness and forbearance in all operations for the ca- taract, is the bounden duty of every man, who has occasion to write upon the sub- ject. Great manual skill, and invariable gentleness, indeed, seem to me to have bad more share in rendering Mr. Saun- ders' operations successful, than any particularity either in his method, or his instrument. I have no hesitation in de- claring my own partiality to the princi- ples, on which his practice was founded, and my belief, that they are well calcu- lated to improve most materially -this in- teresting branch of surgery. BOMB OBJECTIONS TO COUCHING CONSI- DERED. As it appears to me, that couching is a fitter operation for general practice, than the extraction of the cataract, and that several unfounded prejudices have been set up against it, I shall conclude this article with a few reflections on this part of the subject. Conceiving that baron Wenzel, who may be regarded as the chief modern champion of extinction, has had recourse to misrepresentation in the statement of his objections to couching, I shall beg the indulgence of a few minutes, to exa- mine how for his observations coincide with those of other experienced men. This author writes, (On the Cataruct, p. 34.) that " the pain is severe during the operation :" Scarpa, on the contrary, remarks, that the little pain experienced from it, and the consequent tranquillity of the patient's mind, may be one reason, why ihe ophthalmy is always milder after a repetition, than after the first time of couching. (Saggio di Osservazioni, &c. Sulle Mulattie degli Occhi, p. 255, Venez, 1802) How Uttle foundation there is for this objection, must also appear from the patient's spontaneous acknowledg- ment. (Hey's Pract. Obs. in Surgery,p. 63 ) and from the voluntary promptitude, with which he generally submits to a repe- tition ofthe operation. Mr. James Lucas remarks, " that a cataract would very frequently be cured by one operation (alluding to depression,) but the pain from a repetition of it is so tolerable, that many wish it to expedite their cure." {Med. Obs. and Inquiries. Vol. 6, p. 256 ) Mr. Warner, in making mention of a case, observes, " I was in hopes, from this appearance, that the cataract might in time have subsided, &c. but, on account of the little pain the patient had suffered from these operations, he insisted upon a third;" and it was even repeated a fourth time, at tiie same person's instigation, before the cure was complete. (Description of the human Eye, and its Diseases, p. 88.) From the comparative experiments made by Poyet, Morand, and De la Faye, it would yetn, that ihe pain of extraction and depression is about equal. (Mem. de P Acad, de Chirurgie, Tom. 2, p. 572, 4to.) Wenzel next objects, that *• the vomit- ing, which frequently comes on at the distance of some hours after the opera- tion, and the pain produced by the punc- ture of the retina and ciliary nerves, are apt to produce a collection of matter in the eye." ( On the Cataract, p. 34,35.) Mr. Hey has practised couching rather fre« quently for thirty-three years; he has also seen it frequently performed by his colleagues at the Leeds Infirmary, but has never yet seen an instance of sup- puration in the eye after the operation. (Pract. Obs. in Surgery, p. 101, 102.) If suppuration should sometimes, in parti- cular constitutions, follow the wound CATARACT. 283 inflicted in couching, and no doubt, it may occasionally ensue from this injury, it can furnish no argument against the operation, since it appears to be an un- ■common circumstance, and extraction is not exempt from the same consequence. (Mem. de P Acad, de Chirurgie, Tom. 2, jb. 581, 582, Wc. 4to. Wenzel on tlie Cata- ract, p. 232, &c.) The baron also remarks, that " those, who have been couched, sometimes feel violent pains in the eye as long as they live ;" (p. 35.) on the contrary, the expe- rienced gentleman last cited, never knew this effect happen after the operation; besides, we cannot but notice, that Wen- zel offers no authority for such an asser- tion but his own naked opinion. I am -still not unaware, that Heister speaks of the torment formerly experienced by many after couching. (Reflections annexed to his 5th Obs.) and, if Wenzel should chance to make allusion to what this writer has stated, as a foundation for the objection in question, I believe, it cannot be fairly made to answer that purpose. Every novice in the subject •* before us, must often have read and heard, that a cataract which presents a good prospect of relief from any kind of operation, ought neither to have been preceded by, nor to be accompanied with pains in the eye and its vicinity: what particulars are detailed in Heister, by which it can satisfactorily be made out, that, in the examples alluded to, such pains did not precede the operation ? and, as shooting pains in the eye do sometimes take place before, and independently of any operation, why may they not, in a few rare and solitary cases, happen after it from other distinct causes ? Wenzel also objects, that, " in intro- ducing the couching needle, the blood- vessels of the choroides and retina are liable to be wounded, and the extrava- sated blood not only confuses the sight of the operator, but, unless speedily ab- sorbed, is apt to produce a suppuration ofthe whole eye." (Treatise on the Cataract, p. 35, 36.) How little reason there is to apprehend tlie latter part of the objec- tion, must be evident from what has been already delivered; that blood may possibly be effused into the aqueous humour, and obscure the iris and pupil, no one will deny ; but, it is a well-known truth, that it is neither a frequent, nor, on account of the mere extravasation, a serious event. Wenzel is entu-ely mis- taken in the source bf the hemorrhage under consideration; it is impossible to conceive how blood, effused from the vessels of the choroides and retina, should rather find its way into the aqueous hu- mour than out of the wound externa'Jy; at least during the operation, the period when it is alleged to happen; for the only track, through which it could then possibly insinuate itself" into this fluid, is absolutely occupied and filled by tiie couching needle. As Richter more ac- curately represents, (Anfangsgrunde der Wundarzneykunst. 3. Band. p. 247. G6t- tingen, 1~'J5,) the blood extravasated from the choroides and retina is either voided externally, or, if that be impossible on account of the smallness of the wound, it probably finds its way into the vitreous humour; he confirms, that this sort of hemorrhage is seldom considerable; the blood is usually absorbed without further accident; and, when a round needle is employed, the extravasation rarely occurs at all. The fountain of that hemorrhage, to which Wenzel draws our regard, is totally different from what he would lead us to suppose; it is not in the vessels of the choroides or retina, but, undoubtedly, in those of the ciliary processes and iris. In this case, the inflammation and suppuration of the eye, were they to occur, would not be so much the effect of the extravasation, as of the unskilful and unnecessary injury of those important parts. Eveiy one is aware, that, in couching milky cataracts, the white con- tents of the crystalline capsule are often suddenly blended with the aqueous hu- mour, so as entirely to conceal the pupil: yet, so simple of accomplishment in this operation, that several modern surgeons (Latta, Scarpa, Wc.) do not even postpone its completion on account of this event; they continue to lacerate the capsule, and the opaque fluid, extravasated into the two chambers of the aqueous humour, is very soon absorbed. Neither can the case be considered in a different light, in regard to consequences, when blood is effused into the same situation. By what is here stated, I would by no means have it interpreted, that my opinion coincides with those, who may judge proper to continue the operation in this last circumstance; far from it,—-I am too strongly convinced of the propriety of the advice, inculcated by Messrs. Lucas and Hey, that a repetition of so mild an operation is always preferable to attempting too much at one time. " The principal cautions required in couching are, not to wound the iris and ciliary processes, and not to attempt too much at one operation." (Med. Observations and Inquiries, Vol. 6, p. 256. Also Practical Observations in Surgery, p. 71,72.) I have myself seen a rapid effusion of blood take place beneath the cornea, on making the incision of this membrane to extract 284 CATARACT. thr cataract; and it evidently proceeded dans la capsule Autre, et Postre. du Orys. from an injury of the iris. tallin." Tom. 3. p. 2. Sabatier.) Another futile objection is, "that the The total closure of tiie pupil, alleged ciliary processes, which surround the to happen rarely after extraction, more ciystalline, are liable to be wounded in frequently after depression, suffice it tot the different movements of the needle." state, Mr. Hey has never seen, as a con- (Wenzel on the Cataract, p 39.) In the sequence of couching, in the course of performance of the operation, the needle his long and extensive experience. (Pratr may, undoubtedly, be used, so as to do tical Observations in Surgery, p. 109.) considerable mischief; but then it must Here I shall introduce a short extract be from unskilfulness; ignorance of the from Richter's Elements of Surgery, to anatomy of the eye ; or from the bad con- shew how much this eminent surgeon has struction of the instrument employed; changed in favour of the old operation, and, as it is easy to achieve couching in in its present improved state. the best style, it cannot justly be charge- " With respect to the defects and in- able with ills deducible merely from its conveniences, with which the operation having been ill executed. of couching has been upbraided, it has Wenzel asserts, " that an opacity of been said; that the same only effects a the posterior layer of the capsule of the paUiative cure, as the cataract is merely crystalline lerts takes place much ofterter depressed, and is always liable to re- after depression than extraction. (P. 24.) ascend, and occasion a fresh blindness; Why he should fix upon the posterior that it can only be advantageously put part of" the capsule 1 know not. In Mr. into practice when the cataract is hard ; Ware's opinion, an opacity of the front not well when it is soft; and not at all portion is much more common. (See note, when it is fluid; that it is difficult to p. 25. if Wenzel's Treatise, translated,) and ascertain with certainty, before the opera- may now and then happen after the tion the consistence of a cataract; that usual manner of couching ; but, in the the result of this operation is also very method (which I have explained) in imi- uncertain ; that, in doing it, all the coats tation of the celebrated Scarpa, this of the eye are constantly pierced; that, kind of secondary membranous cataract the body of the vitreous humour is always will hardly ever follow the operation of lacerated by the depressed lens ; that depression. Callisen, who has enjoyed the aponeurosis of the abductor muscle, ample opportunities of estimating in his the. ligamentum ciliare, and nervi ciliares own experience the advantages and dis- are frequently injured; and lastly, that advantages, both of extracting and de- the lens, at the time when it is depressed, pressing the cataract, states, in his com- may easily be forced (without the con- parative conclusion in favour of tiie latter, sciousness or least fault of the operator) " A Depressione rarius surgit Cataracta against the choroidea and retina, so as to Secundaria, visus perfectior." Vid. System, contuse, or even lacerate them. CHrurgix HotUernx. Partem. Poster. p.637. " These various defects and inconveni- Hafnix, 1800. The reason, why the se- ences are (says Richter) partly, or en- condary membranous cataract so seldom tirely without foundation. Experience happens after couching, depends on tlie evinces, that the laceration of the vitreous circumstance of the capsule being com- humour by the cataract is unattended monly depressed into the vitreous humour with any bad consequences ; it appears at the same time with the opnque lens; from the preceding account, that every a fact to which I shall have occasion to sort of cataract, both the soft and fluid, advert again It is very certain, that, as may easily and successfully be operated the advocates of extraction acknowledge on w ith the needle; and that the kns.when their process to be inadequate to remove it has been properly depressed, seldom or with safety the species of cataract situated never re-ascends ; that it often dissipates, in the posterior layer of the crystalline and is quite absorbed in the vitreous capsule. (Y.athen on the Cataract,p 138. humour, by which the patient is com- Ware, in a note,p 264 of WenzePs 'Treatise, pletely secured fro^i any secondary blind- and Ids Enquiry into the Causes preventing ness ; and that, if the lens should happen the Success of 'Extraction, &c. p. 40.) and to rise again, it may always be again which, undeniably, does sometimes teke easily depressed. Besides, it is much in place, it must be a principal object with /avow of couching, that the capsule is, theru to impute the evil, whenever it probably, in most cases, depressed with. does happen, to the effect of couching, the lens, so that the patient continues ("\La Peyronie et Morand firent voir a in no danger of a secondary membranous I'Academiedes Sciences ties Cataractes vrai- cataract; that the eyesight afterwards is, msnt membraneuses qui avoicvt leur siege as experience declares, commonly more CATARACT. 285 tcute than after extraction; that the inflammation is less vehement, than in consequence of the other operation; that, upon the whole, itris much easier than it; and, lastly, that the two parts of the eye, upon the integrity of wliich sight afterwards principally depends, namely, the cornea and pupil, commonly suffer no injury." (Anfansgrunde der Wundarz- neykunst. Drifter Band. p. 359, 360.) Having thus been as brief* as possible in attempting to shew the invalidity of some objections urged against couching, I might, perhaps usefully, devote a small portion of these pages to consider parti- cularly the inconveniences of extraction; especially as the great exigency for this disquisition would fully acquit me of any spirit of retaliation. And, although it is, also, very certain, that the smooth side of this method has been solicitously held up to public view, while aU its roughnesses and inequalities have been as industriously concealed ; yet, since no- thing but comparative experiments, in- stituted upon an extensive and impartial scale, can extricate various questionable points from their present mysterious state, and since men of my own age never command sufficient opportunities for this decisive undertaking, all that I can do is, to reflect a little on what others have made out; to exhort surgeons of large hospitals to put both operations to the test of comparison; and earnestly to invite them to give a faithful detail of the particulars and result to the public. To contrast two rival methods of practice is the only fair and infallible way of ascertaining the best. On the continent, it appears, CalUsen and Scarpa have, like our eminent Pott, built their reflections in favour of couch- ing, not merely upon the firm ground of having themselves successfully and re- peatedly practised it, but they have drawn their conclusions, after having with their own hands both extracted and depressed cataracts to that immense ex- tent, which the office of surgeon to a large hospital permits ; after having been eye-witnesses of the advantages and dis- advantages of each method; and, after exemplifying in the theatres of surgery the comparative practice, upon which their observations and opinions were founded. Omnibus tarnen rite perpensis, tentandnumque ab idoneis chirurgis insti- tutorum eventibus invicem comparatis,facile apparebit, depressionem in universum pal- mam prxripere extractions, quod quoque propria nostra ac centenorum xgrorum ex- perientia, in quibus operationem cataractx instituisse nobis contigit, confirmat. (Syst. Chirurg. Hodiernx. Pars. Posterior, p. 637.) Such is the declaration of Callisen. The Italian professor, after mention- ing the advantages of couching; the facility of accomplishing it; its applica- bleness to every species of cataract; its producing subsequent symptoms far less severe and dangerous, than those which frequently happen after extraction ; and, the power of successfully repeating it, when any incidental circumstance has rendered the primary attempts fruitless; observes, " Mosso da queste veritd difatto, egli e da molto tempo che, posto a parte il metodo di curare la cateratta per estrazione, io mi sono appigliato onninarnente alia prac- tica di quello per depressione, ed ho continui e grandi motivi d' esser contento dellapresa risoluzione." (Saggio di osservazioni. &c. snlle principali Malattie degli occhi, p. 231. Venezia, 1802.) A fair comparison is the grand, and, indeed, the only standard of superior merit in any mode of practice; if it will not bear this test, then its exclusive adoption can only be attributed to the arbitrary influence of prejudice, a passion for novelty, or interested motives. Have they, who so deservedly have acquired fame and honour, for tlie inimitable skill, with which they surmount the diffi- culties of an arduous operation, have they, in their own experience, contrasted the two operations of extraction and de- pression ? Have they proved to the world, that there is a case of cataract, re- mediable by the former, that is not so by the latter process ? Have they satis- factorily demonstrated, that their method, backed, as it may be, with considerable adroitness, is more frequently efficacious and successful, than couching properly performed ? Have they, in short, proved any thing more, than that they are men of surpassing dexterity, to which are assignable their evasion of the dangers of extraction, and their successful career in practice ? Careful, as Baron Wenzel has been, to depict to the public only a series of prosperous cases, yet, the veil is not so dense, but that we may still dis- cern through it many disastrous casual- ties, to which extraction is exposed: division of the iris; protrusion of the vitreous humour; separation of tlie iris at its outer margin from tiie choroid coats ; prolapsus of the iris; irregularity of the pupil; irremediable opacity of the lower half of the cornea, &c. That to couch is an easier thing, than to extract the cataract, all men of great experience in both ways universally agree, and, from tlie frequent failures in the very attempt to go through the latter 286 CATARACT. operation, no slight argument might be deduced against it; for if it be true, that want of skill ought to throw no dis- credit upon any operation whatsoever, it roust, at least, be granted, that one so difficult as to baffle the ordinary dexterity of surgeons at large, and that is seldom well performed, except by a few pro- fessed oculists, has little to recommend it, even supposing it were, what it in fact is not, productive of superior efficacy and advantages. " Depressio hand atleo difficilis est quam extractio, qux consum- matam dexteritatem, vix a multis chirurgis expectandam poscit, si nitide et omnimode ad regulasartisinstituetur." (Systerna Chirur- gix Hodiernx. Pars posterior, p. 637.) It is not a little remarkable, that Mr. Sharp should, at so early a period of the practice, as when he published his Critical En- quiry, have made the following obser- vation :—" Now, after some trials, it seems rather to have fallen into disrepute, and 'I apprehend will be entirely dis- carded in favour of couching. To be candid, (he continues,) I perceive that tlie difficulty of performing the operation is too great to be universally practised." Neither is extraction, in any respect, more applicable to the various kinds of cataract, than depression, which is now found by men of the greatest experience. (Cusson, Pott, Callisen,Lucas, Scarpa,Hey, Latta, &c. &c.) by men, whose profes- sional emolument, and reputation, have not depended upon the adoption of this, or any other individual operation; by practitioners of the most unbiassed opi- nions, and worthy of implicit confidence, to be adequate to the removal of every species of the cataract, whether in the substance, or the capsule of the crys- talline lens; whether of a solid, or fluid consistence. But, besides being more easy of accomplishment, freer from ac- cidental inconveniences, and, at least, equally efficacious, it possesses an un- rivalled advantage over the opposite me- thod in the practicability of its being successfully applied to infants and chil- dren, and repeated, when the first at- tempts prove inadequate to the perfect restoration of sight, a circumstance al- most completely inadmissible after the first failure of extraction. It is true, Baron Wenzel relates two or three cases, where the operation was repeated with advantage, but, who will contend, that such reiterated sections of the cornea woidd not, in a great number of ex- amples, destroy its transparent texture ? But, why need I specify any particular cause of failure ? It is enough to mention the result of experience. " Depressio, si ex voto non successerit absque damno iterum iterumquerepetipotest, inutilibus hisce tenta- minibus hand impedientibus, quo minus ad Extractionem demum cum successu recitrri queat; quod ipsipluries comperimus ; quum e contrario Extractio, si visum non reddat, omnemfere eum recuperanili spem excludat." (System. Chirurg. Hodiernx. Pars posterior. p. 637, 638.) 1 o CalUsen's I shall add the authority of Scarpa upon this head. " Perche a motivo di qualche incidente ritis- cendo alcuna volt a infrutluosaladepr-essione, si puo, senza correre alcun rischio, ripeterr due e tre volte la stessa operazionc sopru il medesimo octddo: la qual cosa non ha luogo ogni qual volta P estrazione non ha avuto il desiato successo." (Saggio di Osservaxiont, &c. p. 231.) Difficult as extraction is upon a fa- vourable eye, it becomes exceedingly more so when it is to be done on the right one; when the cornea is at all defective in point of convexity; when the anterior chamber of the aqueous humour is diminutive; when the muscles of the eye and eyebds are affected with spasms; when the cataract is large, and the pupil smaU and contracted; and, when the surface of the eye is more than ordinarily- sunk in the orbit. When tlie cornea is flat, the blade of the knife may easily pass between its layers, and not at all into tbe anterior chamber; if it should have passed deeply in this manner, an opacity of the cornea is to be apprehended. (Richter's Anfangs- grunde der Wundarzneykunst. 3 Band p. 277.) A gentleman, professedly in favour of extraction, has affirmed that, because the couching needle is always en- tered into the sclerotica, that is, farther back in the eye than the knife in extrac- tion, it must be evident, that the elevated margin of the orbit is a greater impedi- ment to couching than it can possibly be to extraction. (Wathen on the Cataract, p. -111.) This statement is, for the fob lowing reasons, inaccurate; the knife, in extraction, must absolutely be di- rected transversely through the anterior chamber; the safety of the iris prescribes this as an invariable rule; but, in couching, the surgeon may, if he chooses, (and Callisen directs this plan in every case) (Systerna Chirurg. Hodiernx. Par's posterior, p. 616. Per omnia bulbi involucra in medium humor em vitreutn, &c.) intro- duce tlie needle in a direction towards the centre of the vitreous humour, by which the inconvenience, that would otherwise arise from the prominent mar- gin of tbe orbit, may be completely eluded. In extraction, the difficulty would only be augmented by attempting to cut the cornea in any other direction than the common one; for, it is evident, CATARACT. 287 that the projection of the superciliary ridge of tlie os frontis above; of the nose internally; and the os malae below; would create an additional source of em- barrassment to any such attempt. Wenzel proposed to pass the knife into the cornea, so that it should take a direc- tion fi-om above, downward and a little inward, and make its exit from the aque- ous humour below, rather toward the inner angle of the eye, and cut, not tlie lower, but the external segment of the cornea; he proposed this with an idea of diminishing the hazard of an escape of tlie vitreous humour. Richter, in taking notice of the inutility of this plan, on ac- count of the vitreous humour not being protruded merely by its gravity, but some other cause, observes, that it is attended with many difficulties; the prominent os frontis above absolutely hinders the knife from passing through the cornea in such a direction, as possibly to come out again below ; should it even be conducted out, its point would certainly injure the lower evelid, or cheek. In persons, whose eye- lids are but little asunder, the knife can hardly be passed from above downward, without cutting both the upper and lower one; and how, continues this author, can the knife be directed from above down- ward, without being impeded by tiie fing- ers of the assistant who holds the upper eyelid? (Anfangsgrundeder Wundarzney- kunst, p. 266, 3 Band.) In fact, the com- mon manner of cutting the cornea is the most practicable, and no variation in doing it will obviate the great inconve- nience, arising from the prominent margin ofthe orbit in particular subjects. The great difficulty in cutting the cor- nea with that accuracy, which the circum- stances of extraction require, will ever form a great obstacle to the universal practice of this operation : when the edge of the knife is turned too much forward, the wound is made too small, and, in a situation, where the cicatrix may impede vision; when it is turned perpendicularly downward, or a little inward, the iris will inevitably be cut. In altering the edge of the knife either a little inward or out- ward, when it has once been introduced inaccurately into the anterior chamber, it is evident, that the form of the instru- ment can no longer correspond to the wound which it has previously made, and, consequently, the aqueous humour must be very liable to a premature escape. (Richter's Anfangsgrunde der Wundarzney- kunst, 3 Band. p. 279, 28U.) In making the incision of the cornea, it sometimes happens, that the pressure of the knife causes the eye to turn towards the inner angle, and, of course, the wound in the cornea cannot, as lpng as the eye continues in this posture, be properly per- fected. I have no hesitation in asserting, that no means of remedying tliis incon- venience have hitherto been, or are likely to be devised : to endeavour to bring in the aid of an instrument to fix the eye, when once the knife has pierced into the anterior chamber, must be particularly dangerous and unavailing. They, who have had most experience in ,the practice of' this operation, ackuowledge, that all contrivances to fix the eye are, by reason of the pressure which they oc- casion, extremely pernicious and danger- ous ; and how can the eye be turned out- waid agrin without withdrawing the knife ? how can the knife be withdrawn without the aqueous humour escaping ? how can the instrument be again intro- duced without injuring the iris ? and, if the incision should be enlarged with scis- sars, what occasion will there be for any contrivance to prevent the eye from rolling toward the inner canthus, an effect that results from the transverse pressure of the knife ? Richter confesses, that to make the eye revolve outwaid, by means of the knife itself, when introduced, re- quires a circumspect hand; indeed, it must be too hazardous to attempt, because should the knife be in the least retracted, the aqueous humour would instantly es- cape, and the ins would fall forward be- neath its edge, so as almost inevitably to be cut; and, the moment the knife ceases to fill completely the wound that it has made, it must manifestly lose all power of moving the part, in which it is intro- duced. In this dilemma the preferable, though objectionable resource, is what Richter advises; to carry the knife per- pendicularly downward, so as to cut about one-fourth ofthe circle ofthe cornea, and afterwards to enlarge the incision by scis- sars. The knife, when it has entered far into the anterior chamber, cannot be with- drawn without great hazard of injuring the iris, before it is completely out of the eye, and as soon as the aqueous humour begins to escape. But even to cariy*'the knife directly downward, when you are in the dark with respect to tiie precise position of the cornea, cannot be free from risk ; either ofthe aqueous humour escaping too prematurely over the back of the knife; or of the wound being made too high in the cornea, so that its cicatrix may after- wards obstruct vision, and its size be too diminutive for the easy passage ofthe ca- taract ; or, lastly, of the wound being car- ried too much inward toward the iris, so as to injure it. The pressure necessary to extract large cataracts, when the inci- sion in the cornea is not sufficiently ex- 288 CATARACT. tensive, is c'ommonlv the source of much mischief: violent inflammation, says Rich- ter, and perpetual blindness are tiie in- evitable consequences of forcible and long- continued pressure on tlie eyeball. The eye endures nothing so badly as strong pressure of this kind: he observes, when the wound is much too small, and one ven- tures to extract the lens through it by making considerable pressure, the vitre- ous humour starts forward, tlie pupil closes, and the patient remains for ever blind." (Richter's Anfangsgrunde der Wundarzneykunst, p 262, 263. 3 Band.) When we consider, that these observations come from one, who has had unlimited op- portunities of observation; who once wrote so decidedly in favour of extraction; they claim the sincerest confidence. In regard to the loss of the vitreous hu- mour, unattended, as it undoubtedly has been, in certain instances, with any seri- ous impairment of sight, it is justly con- sidered as a cause very frequently pre- venting the success of extraction; nor can this objection be got rid of by referring the accident to want of skill in the ope- rator. How human invention shall pre- vent its escape is difficult of conception, when we consider the nature of those causes, by which it is produced, and the variety of periods, at which it may happen; when we reflect, that it may take place even before the cataract itself is expelled, or immediately afterwards; that it may occur some hours, or some days after the operation; that unforeseen and uncon- trollable spasm ofthe muscles of the eye; coughing, vomiting, sneezing, inadvertent friction, or pressure of the eye during sleep, fright, and other emotions of the mind, &c. may occasion it. If the evi- dence of experience unequivocally proves, and there is now no reason to doubt it, that a considerable, and even the greatest portion of the vitreous humour, has been protruded without the restoration of-sight being prevented, we must refer the com- mon fatality of the occurrence, not sim- ply to the s-^isequent state of this humour, but to the miect, which its deficiency a-nd sudden exit must have, in changing the condition of other more essential parts of the eye. Did the derangement of the vi- treous humour itself, abstractedly consi- dered, create the cause of failure, the ef- fect would then follow as invariably as the accident takes place, which experience contradicts; and couching would, for the same reason, always prove an unsuccess- ful operation. I shall refer the ill effect, arising from the exit of the vitreous hu- mour, to two other effects, wliich this event produces, and which operate as the immediate causes of failure. 1st. The unnatural condition, into which the retina must fall when deprived ofthe support of the vitreous humour. This change must always take place to a considerable de- gree, when much of this humour is lost. In tiie singular case, related by Wenzel, (On tlie Cataract, p. 169) where three- fburtlis of the whole quantity ofthe vitre- ous humour was lost, and yet the success of tile operation was not prevented, to what must we ascribe the good fortune ? Was it that some accidental circumstances prevented the flow of the aqueous humour (which we know to be secreted very rapid- ly) through the incision of the cornea, and consequently, that it occupied the place of the vitreous humour very speed- ily, and thus afforded a timely degree of support to the retina ? At all events, no inference can be drawn from so solitary an example, and the success must be at- tributed to some extraordinary circum- stance. 2dly. The considerable injury, perhaps laceration, which the soft and de- licate structure of the retina must fre- quently suffer, when the vitreous humour is suddenly protruded, offers one very rational explanation of the manner, in which the accident so often, and so seri- ously mutilates the eye. I shall not dwell here upon wounds of the iris ; no skill can regularly prevent their occurrence. No sooner does any in- strument penetrate the eye, than the mus- cles of this organ usually contract in a spasmodic manner, so as to make great pressure upon 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 injured by the edge ofthe instrument. Who can credit that, in the case of the iris being entangled against the edge of the knife, it can be so invariably disengaged without injury, as Wenzel describes, by gently touching the cornea with the finger? Richter justly observes, that this ma- noeuvre is, also, not without risk of press- ing out the aqueous humour; especially, if the irritation of touching the eye with the finger,, should cause it to move; or, if the operator should, in the least, disturb the knife. (Atifangs- grdnde der Wundarzneykunst, 3 Band. p. 334, 335.) It is unnecessary to enter into an argu- ment against the slight importance, which Richter attaches to the escape of the vi- treous humour, and wounds of the iris. They must ever be considered as the two chief dangers, to which extraction is ex- posed. Much as they, who espouse the side of extraction, have dwelt on the eradicative nature of that operation, it is an undent*-* CATARACT. 233 / able fact, that large fragments of soft ca- taking it entirely out of the eye. But i t.u-acts frequently remain unobserved, at may, With reason, be objected; that tin the time of operating, about the circuin- cuieofthe cataract by extraction, ought ference ofthe capsule ; a few days after- on no account, to be called radical, whih wards glide into the centre ofthe pupil, the capsule, the seat of the possible, anci and continue to impede vision, until the not unfrequent secondary membranous ca- same proce s takes place to remove them, taract, remains behind in the eye ; Jhat wliich takes place in consequence of couch- far more important accidents are to be ing, and renders this latter operation, in dreaded after^extt-action, than couching; reality, quae as productive of a radical opacity of tile cornea; closure of the pu« cure as the former. It is also a well-known pil; prolapsus ofthe vitreous humour and thing, that in extracting a cataract, the iris; and that extraction is much more principal and almost sole aim of the ope- difficult, and more subject to consequent rator, consists in endeavouring to extract inflammation, tfcan depression." (Anfangs. an opaque lens from its capsule; no at- gr der Wundarzn.p.360, 361.-3 Band) tempt is, or can safely be made to avert This author, except at one place, (P. the occurrence of the secondary membra- 316, 317) where he would induce one to nous> cataract. This is the practice of believe, that the loss of part of the vitre- Wenzel, Ware, and 1 believe of almost all ous humour is rather advantageous, in- the eminent patrons of extraction. Rich- asmuch as it renders the sight more acute ter was well convinced, how uncertain afterwards, and the disposition to oph- tliis leaving of the capsule always ren- thalmy less, th^n when no such accident dered the result of the operation; he, has lmppened, constantly enumerates it therefore, directs its anterior layer to be in the train of dangers, and takes great broken, and pierced very freely with the pains to inculcate how it is to be avoided. instrument employed to make an opening The inference to be drawn from this am- into it; he also saw the advantage, that biguity is too conspicuous to require men- would proceed from extracting the cap- turning. (Critical Reflections on the Cata- srile together with the lens ; but, he like- ract, 1805.) wise perceived the impediments to the ac- [Within a few years, many innovations complishment of so desirable an object, have been attempted in the treatment of (Anfangsgrunde der Wundarzneykunst, p~ cataract; and from the success of several 33u, &c. 3 Band.) modern oculists, there is reason to anti- I am bold enough to presume, that the cipate much improvement, as the result most fertile genius will never be able to of their experiments : at present, however, suggest any means, that will serve to ob- an exclusive preference of any one me- viate the accumulated danger, when tiie thod, may be properly considered pre- cataract is large, the iris very irritable mature. and contracted, consequently the pupil After Mr. Saunders' book appeared, small: and how much real cause there is (which, unfortunately for science, was a to fear, in this case, a sudden, but imper- posthumous publication,) the operation of feet exit of the cataract, with protrusion lacerating the capsule of the lens, which ofthe vitreous humour, and such disten- seldom failed in curing congenital cata- sion of the iris, as to create future irre- ract, was tried by surgeons in the cataracts gularity of the pupil, it is superfluous to of adults under various circumstances. dwell upon. It is a more important re- Mr. Adams, in 1812, published an es- flection, inasmuch as soft cataracts, of" say containing many remarks on the sub- various descriptions, are as frequently met ject; and in a more recent publication, with as firm ones, generally of large size, in 1814, has enlarged these-Ibservations. and the caseous kind, to which I parti- Having noticed the rapidity*with which cularly allude, not unfrequently even of the solution of the opaque lens takes place twice the ordinary dimensions of a in the aqueous humour, Mr. Adams di- healthy lens. " Es ist nichts ungewohn- vides it with a small knife into several por- Uches, dass der weiche Staar noch ein- tions, and pushes these through the dila- mal so gross ist, als die gesunde Krystal- ted pupil into the anterior chambet ofthe linse." (Richter's Anfungsgr. der Wund- eye. The operations of Mr. Adams hav- arzn. p. 178, 3 Band.) ing been tried on an extensive scale at I shall conclude this part of my ob>erva- Greenwich hospital, the medical officers tions with a passage from Richter's Ele- of that institution have published there- ments of Surgery. " The principal ad- suit, and have compared it with that of vantages of extraction consist in its in- their former practice. From their state- junng none of the more sensible parts of nlent it appears that of twenty four cases the eye, only tiie insensible cornea, and in in which extraction had been pe.-formed, its radically curing the cataract, that is, one only had been completely successful i Vol I V P » 290 CATHETER. ofthe remaining twenty-three, twelve eyes were entirely destroyed ; four, had obli- terated pupils; three, gutta serena, and secondary cataract; and four, opaque cor- nea, and other diseased changes. Mr. Adams operated on thirty-one cases, of which twenty -nine were perfectly cured, and one only failed; one patient having been dismissed for irregular conduct. The cases were nearly similar, in which the two operations were performed This is, indeed, a wonderful disparity of success. How much of it to ascribe to the superior professional skill of the operator, and how much exclusively to the neW mode of operating, it is not for the editor to decide. He cannot, however, avoid re- marking, that the twenty-four cases treat- ed by extraction, afford the most disas- trous specimen of surgery ever recorded, in regard to any operation. Were this a fair criterion of the general success of extraction, that operation h;-d been long since laid aside. That it has beea vastly more successful in other hands, the expe- rience of Wenzel alone, is a sufficient proof. The writer of the present article has witnessed its performance in a great number of cases and in a large majority it has succeeded. After the statement made by the medical officers of Greenwich hospital, sanctioned by Mr. Adams, it is truly surprising to find this gentleman an advocate for extraction, in all cases of hard cataract. His words are, " where the cataract is too hard and solid to admit this immediate division, I do not attempt, (as was my former practice,) to effect its absorption by a frequent repetition of the operation; but I at once extract it."!! Mr. Adams, (now Sir William) has in- vented a new mode of extraction, which he refuses to publish at present; but of which he says, he is " warranted in assert- ing, that it possesses the utmost degree of exceUence which it is possible for ex- traction to arrive at; and that its general iuccess will prove nearly as great as the operation fpr the removal of the soft cataract." It behoves the editor to withhold there- fore his opinion of the proper treatment of cataract, until a Uttle more experience shaft have enabled the medical world to judge of the new operations, some of which are as yet involved in secrecy. He will, however, take the liberty to state the result of his own experience in the treatment of cataract in the manner con- trived by Mr. Saunders, and improved by Mr. Adams. Between the 25th of April 1814, and the 25th of October 1815, he has performed Mr. Saunders' operation improved by Adams, in eighteen cases: eight ofthe patients are completely cured: in two of the eight, both eyes are well; ia the others, only one has been operated on: two of the patients having become impa- tient, have been cured by extraction. It has failed in two cases, having been follow- ed by violent inflammation, and an obli- terated pupil. In the rest, (which are still under treatment,) there is every prospect of success. The mode of operating which the editor has pursued, consists in dilating with the stramonium,* the pupil, and then in- troducing the needle of Saunders through the cornea; by the free use of which the capsule and lens are to be torn in pieces.: fragments of the lens can often be push- ed forward into the anterior chamber of the eye, where they speedily dissolve. An absolute division of the lens into two equal parts, as accomplished by Mr. Adams, the editor has never effected; nor does he believe it important to the success of the operation. In addition to these remarks it may not be uninteresting to state, that Dr. Physick has successfully- performed the ancient operation of sucking out a. cataract by a small tube introduced through a punc- ture in the cornea. The operation is, however, attended with difficulties which will necessarily prevent its general adop- tion, and a description of it is therefore omitted.] On the subject of the cataract, consult particularly Celsus De Re Medicd. Pott's Remarks on tlie Cataract, Vol. 3, of his Chi- rurgiccd Works. David sur une Nouvelle Methode de Guerir la Cataracte par PEx- traction du Crystallin, in Mem. de PAcad. de Chirurgie, Tom. 5, p. 369, Edit 12mo Wen- zel's Treatise on the Cataract, by Ware. Richter's Treatise on the same subject, and his Anfangsgrunde der Wundarzneykunst, Band 3. Ware's Chirurgical Observations on the Eye, 2 Vol. Edit. 3. Scarpa's Ob- servations on the Principal Diseases of the Eyes. Hey's Practical Observations in Surgery. Saunders on Diseases ofthe Eye, by Farre. Beer's Practische Beobachtung- en uber dengrauen Staar, &c. Vienna, 1791. Lassus, Pathologie Chirurgicale, Tom. 2, p. 504, &c. Edit 1809. Leveille, Nouvelle Doctrine Chirurgicale, Tom. 3, p. 308, &c Richerand's Nosographie Chirurgicale, Tom. 2, p. 84, Edit. 2. Adams on the Eye. CATHETER, (from **6n>fU, to thrust into.) A tube wliich is introduced through the urethra into the bladder, for the purpose of drawing off" the urine. (See Urine, Retention of) Of course tiiere are two kinds of catheters, one intended for * Either the extract, or tincture, may be used. CATHETER. 291 the male, the other for the female urethra. The common catheter is a silver tube, of such a diameter as will allow it to be in- troduced with ease into the urethra, and •f various figures and lengths, according as it is intended for the young or adult, the male or female, subject. A common male catheter is ten or eleven inches long. In general, a large instrument of this kind, like a large bougie, will enter the bladder with more ease than a small one, because less likely to be entangled in the lacuna: of the urethra. One-third of the male catheter, towards its point, should be moderately curved; the other two- thirds, towards its handle, should be •straight. The instrument, when gently curved, is found to be more easy of intro- duction than when it is very much bent. The female catheter is straight, except- ing a sUght curvature towards its point, and it is about six inches long. The catheter, as it need not enter far into the neck of the bladder, though it should always be as big as the urethra will easily admit, should not, says John Bell, be long, and should have a very gen- tle and simple curve. (Principles of Sur- gery, Vol. 2, p. 193.) The common flexible catheter is only a hollow bougie, and the elastic one con- tains in its composition elastic gum. The two last descriptions of catheters have the advantage of being less irritating to the urethra, and less apt to become covered with calculous incrustations, than silver tubes They can also be frequently in- troduced when an inflexible metallic one will not pass. Flexible catheters are now generally made of woven silk cylinders, covered with a coat of elastic gum. The best have hitherto been fabricated by M. Bernard, of Paris ; but they are at present well manufactured by Mr. Walsh, of London. Their size and form vary, according to the age or sex of the patient. Bernstein, in hfs Dictionary of Surgery, gives the fol- lowing account of this instrument, as it is fabricated in Germany: " One of the most useful inventions which have been made, with respect to these instruments, is to construct them of elastic gum, and the merit of this invention is to be ascrib- ed, without doubt, to Theden. Neue Be- merkungen u. Erfahrungen,hc Th. 2. Ber- lin, 1782, p 143. They* were afterwards improved by a silversmith at Paris, of the name of Bernard, who directed not to ap- ply the dissolved elastic gum to a wire cylinder, as Theden had done, but to one made of knitted silk ; and these catheters certainly deserve to be recommended in preference to all others. But with respect to their price, the clastic catheters, that are prepared by Pickel, of Wirzburg, (Richter's Chir. Bibaothek, B. 6, p. 512,) deserve particular recommendation.— These consist of silk cylinders, plaited, or worked upon a probe, and afterwards co- vered with the following varnish -. three parts of white-lead, minium, or sugar of lead, with boiled linseed oil, which is the common varnish used by cabinet-makers, mixed with one part of melted amber, and the same quantity of oil of turpen- tine. With tliis varni«h he spreads the silk cylinders, and repeats this three times, as soon as the former coating has dried in t the open air; after which he puts the ca- / theters into a baker's oven 24 hours, when bread has been baked in it the last time, and when it retains the temp, of 60. 70. R^aum. Here he lets them remain 10 or 12 hours. When he has taken the cathe- ter out of the oven, he rubs the inequali- ties off with a little pumice-stone, sews up the end, cuts into it the oblong lateral aperture, and then spreads it 12 or IS times more with the varnish. Every time, however, the catheter must be well dried in the open air, before the varnish is spread upon it again, and after every third coating which it has received, it must be put into the oven again, so that it must in all have received from 15 to 18 coatings with varnish, and have been laid five or six times in the oven. The end is smoothed off with oil. Each of these ca- theters costs a doUar." (Cyclopxdia by Rees, Art. Catheter.) Sometimes it is difficult to introduce the inflexible catheter, in consequence of the urethra and neck of the bladder being affected with spasm. In this case a dose of opium should be administered, before a second attempt is made. When inflam- mation prevails in the passage, the intro- duction may often be facilitated by a pre- vious bleeding. The operation of introducing the cathe- ter may be performed, either when the patient is standing up, sitting, or lying down. *f In doing it, one of the most important maxims k;, never to force forward the in- strument, when it is stopped by any ob- stacle. If there are no strictures, the stoppage of tbe catheter is always owing to one of the following circumstances. Its beak may be pushed against the os pubis. This chiefly occurs when the han- dle of the instrument is prematurely de- pressed. Here the employment of force can obviously do no good, and may be productive of serious mischief. The beak of the catheter may take a wrong direc- tion, and push against the side of the ure- thra, especially at its membranous part, which it may dilate into a kind of pouch. 292 CATHETER. In this circumstance, if force were ex- erted, it would certainly lacerate the ure- thra, and occasion a faise passage. The end of the catheter may get entangled in a fold of the lining of the urethra, and here force would be equally wrong. Last- ly, the point of the instrument may be stopped by the prostate gland, in which case force can be of no service, and may do great harm. Hence it is always pro- per to withdraw the instrument a little, and then push it gently onward in a dif- ferent position. The operation may be divided into three stages. In the first, the caiheter passes, m the male subject, that portion of the urethra which is surrounded by the corpus spongiosum t in tiie second, it passes the membranous part of the canal, situated between the bulb and tlie prostate gland: and in the third, it enters this gland, and the neck of the bladder. In the first stage, little trouble is usually experienced : for the canal is here so sup- ported by the surrounding corpus spon- giosum, that it cannot easily be pushed into the form of a pouch, in which the end of, the instrument can be entangled. The operator need only observe the fol- lowing circumsiance : the penis should be held, by placing the crona glandis be- tween the thumb and the index finger of the left hand ; in this way the entrance of the urethra w ill not be at all compressed. The penis is then to be drawn upward: the catheter being well oiled, is now to be introduced, with tiie concavity towards the abdomen, into the urethra, directly downward, until its point reaches the bulb. As soon as this is accomplished, and the beak of the instrument has passed under the arch of the pubes, the surgeon must very slowly bring the handle of the catheter forwards, between the patient's thighs, and, as he is doing this, the beak of tiie instrument bedomes elevated, and glides into the bladder. In this stage of the operation the penis must be allowed to sink down, and not be kept tense, as this would only drag the membranous part of the urethra against the os pubis, and render the passage of the instrument more difficult. The operation, however, is not always successfully accomplished in this manner. The beak of the catheter may be stopped by the os pubis; it may teke a wrong di- rection, so as to push the membranous part ofthe urethra to or.e side or the other ; or it may be stopped by a fold of the lining of the passage. The first kind of impediment is best avoided, by not depressing the handle of the catheter too soon ; that is, before the point has passed beyond the arch of the pubes. When the membranous part of the urethra is pushed to one side or the other, the instrument ought to be with- drawn a little, and then pushed gently on in a different direction. When this expe- dient is unavailing, the index finger ofthe left hand may be introduced into the rec- turn, for tiie purpose of supporting the membranous p irt of the urethra, and find- ing the extremity ofthe catheter. When the prostate gland is enlarged, the diameter of the urethra does not un- dergo any diminution as it passes through the diseased body ; but it turns up very 'suddenly, just as it approaches the blad- der. In such cases, the end of the cathe- ter should be more bent upward, than the rest of its curvature. In the third stage of the operation, the beak of the instrument has to pass the prostate gland and neck of the bladder. The principal obstacles to its passage, in this situation, arise from .-.pasm of the neck of the bladder, and from the instru- ment be'mg pushed against the prostate gland. The first impediment may gene- rally be obviated by waiting a few mo- ments, and gently rubbing the perineum, before pushing onward the catheter. The hindrance, a.used by the prostate, is best eluded by using an instrument the point of which is more curved than its other part. Sometimes the surgeon himself presses the prostate towards the os pubis, by means of* his finger in the rectum, and thus prevent s' he passage of the catheter, by increasing the sudden curvature at this part of the urethra. Hence, as Richter observes, t is a very important maxim, never to introduce the finger so far into the rectum, as to press on the prostate gland itself. When the catheter has turned round the pubes, and is just about to enter the neck ofthe bladder, is the critical moment, in which may be seen, whether a surgeon can, or cannot pass a catheter ; for, if he knows how to pass it, he suddenly, but not violently, changes its direction. He depresses the handle with a particular kind of address, and raises the point, which, as if it had suddenly surmounted some obstacle, starts into the neck of the bladder, and the ur.ne bursts out in a jet from the mouth of the catheter. They, who are unskilful, press the tube forward, and persist, as they had be- gun, in drawing up the penis, on the sup- position that by stretching ihis part they lengthen the urethra, and make it straight, whereas they elongate only that part of the canal, along which the catheter has already passed. (John BelPs Principles of Surgery, Vol. 2, p. 213) Mr. Ware passes the catheter in (he CATHETER. 293 following manner: the instrument being first thoroughly oiled, he introduces it into tiie urethra, with its convex part up- permost, and carries it as far as it will pass without using force. He then turns it slowly round, so as to bring its concave side uppermost; and in doing this he makes a large sweep with the handle of the instrument, and at the same time keeps his attention steadily fixed on its apex, which he takes particular care not to retract, nor to move from its-first line of direction. When the catheter is turn- ed, it must still be pressed onward, and its handle at the same time gently depressed. By this method, says Mr. Ware, it will be made to enter the bladder. The catheter, made use of by Mr.Ware, is twelve inches long, wliich is more than an inch above the ordinary length ; and the curvature is larger than common. With this instrument he has often suc- ceeded, when with others of a different size and curvature it was not possible to succeed. A great number of excellent modern surgeons prefer introducing the catheter as far as the perineum, as Mr. Ware does, with its convexi y towards the abdomen. They then keep the point stationary while they make the handle describe a semicir- cular movement -upward, sd as to bring the concavity of the in>trument towards the pubes. The catheter then becomes situated just as it is in the other method. Mr. Hey has offered some good prac- tical remarks on the introduction of the catheter. If, says he, the point of the ca- theter be less turned than the urethra, the point will be pushed against the pos- terior part of the passage, instead of fol- lowing the course ofthe canal. The pos- terior part of the urethra has nothing con- tiguous to it which can support it; and no considerable degree of force will push the point of the catheter through that part between the bladder and the rectum. If this accident is avoided, stiU the point will be pushed against the prostate, and cannot enter the bladder. Mr. Hey tells us, that the truth of this is illustrated, by the assistance which is derived, whenever tiie catheter stops at the prostate, from elevating the point ofthe instrument with a finger introduced in the rectum. Mr.'Hey takes notice of the impro- priety of pushing forwards the point of the catheter, before its handle is sufficiently depressed, as the point would move in a horizontal direction, and be likely to rup- ture the posterior side of the urethra. The difficulty, arising from the inflamed and dry state of the passage, Mr. Hey aays, is greatly obviated by the previous introduction of a bougie well covered with lard. In order to pass the catheter, Mr. Hey places his patient on a bed, in a recum- bent posture, his breech advancing to, or projecting a little beyond, the edge of the bed. If the patient's feet cannot rest upon the floor, Mr. Hey supports the right leg by a stool, or by the hand of an assist- ant. The patient's head and shoulders are elevated by pillows; but the lower part of the abdomen is left in a horizon- tal position. Mr Hey commonly intro- duces the catheter with its convexity to- wards the abdomen, and having gently pushed down the point ofthe instrument, till it becomes stopped by the curvature of tiie urethra, under the symphysis pu- bis, he turns the handle towards the navel, pressing at the same time its point. In making the turn he sometimes keeps the handle at the same distance from the pa- tient's abdomen, and sometimes makes it gradually recede ; but, in either method, he avoids pusliing forwards the point of the catheter any farther than is necessary to carry it just beyond the angle of the symphysis pubes. When he feels that tiie point is beyond that part, he pulls the catheter gently towards him, hooking, as it were, the point of the instrument upon the pubes. He then depresses the han- / die making it describe a portion of a cir- cle the centre of which is the angle of the pubis. When the handle of the ca- theter is brought into a horizontal posi- tion, with the concave side of the instru- ment upwards, he pushes forwards the point, keeping it close to the interior sur- face of the symphysis pubis; for when passing in this direction, it will not hitch upon the prostate gland, nor injure tlie membranous part of the urethra. If the surgeon uses a flexible catheter, covered with elastic gum, it is of great consequence to have the stilet made of some firm metallic substance, and of a proper thickness Mr. Hey always makes use of brass-wire for the purpose. If the stilet is too slender, the catheter will not preserve the same curvature during the operation; and it will be difficult to make the point puss upwards behind the sym- physis pubis in a proper direction. If the stilet is too thick, it is withdrawn with difficulty. When the stilet is of a proper thick- ness, this instrument has one advantage over the silver catheter, which is, that its curvature may be increased while it is in the urethra, which is often of great use, when the point approaches the pros- tate gland. When the proper manoeuvres with an 2U CATHETER. inflexible catheter do not succeed, the surgeon must change it, taking a bigger or more slender one, with a greater or less curve, according to such observations as he may have made in his first attempt. But if" the cadieter has been of a good form or commodious size, yet has not passed easily, he should, instead of choosing a rigid catheter of another size or form, take a flexible one for his second attempt. The flexible catheter is generally slender, and of sufficient length, and its shape may be accommodated to all occasions, and to all forms of tiie urethra; for, having a stiff wire, we can give that wire, either before or after it has passed into tiie ca- theter, whatever shape we please; and what is of still greater importance, we can introduce the instrument without, or with the wire, as circumstances may re- quire ; or what is more advantageous, we can introduce the wire particularly so as not quite to reach the point of the cathe- ter, but to within two inches or a little more of this part, by which contrivance the point, if previously warmed, and wrought in the hand, has so much elasti- city, that it follows the precise curve of the urethra, and yet has sufficient rigidity to surmount any slight resistance. It this too fail, and especiaUy, if there be tlie slightest reason to suspect, that the re- sistance is not merely spasmodic, but arises from stricture near the neck of the bladder in a young man, or sweUing of the prostate in an old one, we may take a small bougie, turn up the extremity of it with the finger and thumb, so as to make it incline towards the pubes, and allowing no time for the w.»x to be softened, pass k quickly down to the obstruction, turn it with a vertical or twisting motion, and make it enter the constricted part. On wi-hdrawing it in about ten minutes or a quarter of an hour, the urine generally escapes, or the catheter may now be in- troduced. (John Bell's Principles of Sur- gery, Vol. 2, p. 215.) Mr. Hey has found, that in withdraw- ing the stilet of an elastic gum catheter, the instrument becomes more curved; and he has availed himself of this information, by withdrawing the stilet, as he is intro- ducing the catheter beyond the arch of the pubes, by which artifice tbe point is raised into the due direction. Mr. Hey says, you may sometimes, though not always, succeed in introduc- ing an elastic gum catheter, by using one which has acquired a considerable degree of curvature and firmness, by having had a curved stilet kept in it a long while. Introduce this without the stilet, with its concavity towards the abdomen, taking care not to push on the point of the in- strument, after it has reached the sym- physis pubis, until its handle is depressed into a horizontal position. When it is necessary to draw off the urine frequently, and the surgeon cannot attend often enough for this purpose, a catheter must be left in the urethra, till an attendant, or the patient himself, has learnt the mode of introducing the instru- ment. (Hey.) Mr. Hey imputes the formation of a false passage, or the rupture of the mem- branous part of the urethra, generally ta the method of pusliing forwards the ca. theter, before its handle has been de* pressed. In this manner the course ofthe instrument crosses that of the urethra, and the point of the catheter, pressing against the posterior side of the membra- nous part of the urethra, is easily forced through the coats of that canal. The want of due curvature in the catheter, and of sufficient bluntness in its point, greatly contribute to facilitate this injury. In this case the point of the instrument passes more readily into the wound, than onward along the urethra against the symphysis pubis. Without this pressure, the point is apt to recede, and not readily enter the membranous part of the ure- thra. Mr. Hey surmounted a difficulty of this kind, by bending upwards the point of a silver catheter, so as to keep it more close- ly in contact with the anterior part ofthe urethra, and thereby pass over the wound made in the posterior side of the canaL In the instance alluded to, as it was ne- cessary to leave an elastic gum catheter in the urethra, Mr. Hey procured some brass wire of a ' proper thickness, with which he made a stilet, and, having given it the same curvature as that of the silver ca- theter, he introduced it about four hours after the preceding operation, and fixed it by tying it to a bag truss. Mr. Hey sometimes succeeded by partly withdrawing the stilet, at the moment when he wished to increase the curvature of the catheter. In an instance in which the urethra had suffered a violent contusion, Mr. Hey drew off the urine with a silver catheter of unusual thickness, after he had failed with instruments of a smaller bore. He suspected that the urethra was ruptured, and was obliged to raise the point of the catheter by a finger introduced into the rectum, and to use bleeding, purgatives, the warm bath and opium, before it could be made to pass. The elastic gum cathe- ter was afterwards employed. It is an unsettled point, whether it is best to leave the catiieter in the urethra, until th^ power of expelling the urine is regained, or CAt to draw off the urine twice a day, and withdraw the catheter after each opera- tion. Mr. Hey thinks that no general rule can be laid down-, some patients can- not bear the catheter to remain intro- duced ; others seem to suffer no incon- venience from it. On tiie whole, however, Mr. Hey commgnly prefers removing the catheter. In this manner, he is of opi- nion, that the power of expeUing the urine again is soonest acquired. To one acquainted with anatomy, the introduction of tlie female catheter is ex- ceedingly simple. From motives of de- Ucacy to the sex, the instrument should always be passed without any exposure. The surgeon should hold the catheter in his right hand, while he introduces the forefinger of his left hand between the nymphx so as to feel upon the upper sur- face ofthe passage the little papilla, which surrounds, and denotes to the touch, the precise situation of the orifice of the mea- tus urinarius. Holding the concavity of the catheter forward, the surgeon, guided ty tlie forefinger of his left hand, is then to introduce the instrument upward into the bladder. (See Urine, Retention of.) (Sec Hey's Practical Observations in Sur- gery. John BelPs Principles, Vol. 2. Ware on the Catheter. Richter*s Anfangsgr. der Wundarzneykunst. Rees' Cyclopxdia, Art. Catlieter.) CATHETER1SMUS. (from kxOcth^ the instrument.) A technical word, em- ployed by P. .Egineta, to denote the ope- ration of introducing the catheter. CATLING, often spelt, in surgical books, catlin, is a long, narrow, double- edged, sharp-pointed, straight knife, which is chiefly used, in amputations of the leg and forearm, for dividing the interrosse- ous ligaments and tiie muscles, &c. situ- ated between the two bones. The catling is frequently made too wide and large, so that it cannot execute its office with the right degree of ease. CATOMISMOS. Paulus ."Egineta sig- nifies by this word the method of reducing a dislocated humerus, by placing the patient's arm over a strong man's shoul- der, and making the latter raise him in this position off tlie ground, by which means, the limb becomes reduced by the weight of the body. CATULOTICA. (from xxraXou, to ci- catrize.) Medicines for healing wounds. CAUSTICS. • (from *«<«> to burn.) Caustica. Medicines, which destroy parts by burning, or chemically decomposing them. The potassa fusa (kali purum,) the po- tassa cum calce (calx cum kali puro,) the antimonium muriatum, the argenti nitras, the hydrargyri nitrico-oxydum, the act- CER 295- dum sulphuricum, and the cupri sulphas, are the caustics in most frequent use among surgeons. CAUTERIZATION, (from**^'*^ to cauterize.) Cauterisatio. The burning any part with a cautery. CAUTERY, (from *-*"** to bum.) Cauterium. Cauteries are of two kinds, viz. actual and potential. By the first term is implied a heated iron; by tlie se- cond, surgeons understand any caustic application. CELE. (from *sjAe», to swell out.) A tumour. CELOTOMIA. (from *»»** a tumour or hernia, and rtfam. to cut.) This has two meanings, viz. the operation for a hernia, and castration. CERATMALGAMA. (from**■?««> wax, and xfMt\yx\*M, a mixture.) A cerate. CERATOTOME. (from **•£*«> a horn, and rtfvm, to cut.) This is the name which Wenzel has given to the knife, which he was in the habit of using to di- vide the cornea, or horny coat of the eye. CERATE, (from *>»•?««> wax, the usual basis of its composition.) Ceratum. A composition rather harder than ointment, and softer than plaster. In this work we need only mention a few particular ones. CERATUM CALAMINE. (L) A good simple dressing. CERATUM CALOMELANOS. *. Ca- lorn. 3L Cerali Lapid. Calamin. ^ss. M. Some practitioners are partial to this as a dressing for chancres. CERATUM CETACEI. (L.) The spermaceti cerate. A mild unirritating salve for common purposes. CERATUM CIOUTJE. *. Unguenti Cicutx lbj. (See Unguentum.) Spermatis Cefcgij. Cer«Albx, giij. M. One of the formula at St. Bartholomew's Hospital, occasionally applied to cancerous, scro- fulous, phagedenic, herpetic, and other inveterate sores. CERATUM LYTTJE. (L.) This, which was lately called the cerate of can- tharides, was once much used for stimu- lating blistered surfaces, in order to main- tain a discharge.» The ceratum sabinse, however, has almost rendered this appti- cation useless, as it answers much better, and is not attended with the danger of bringing on strangury, inflammation ofthe bladder, &c. CERATUM PLUMBI SUPERACE- TATIS. (L. Acetite of lead.) A very eli- gible, mildly astringent, unirritating salve. CERATUM PLUMBI COMPOSI- TUM. (L.) Lately the ceratum lithar- gyri acetati. This is an exceUent, unir- 296 C E R CHE ritating, cooling salve for common pur- poses. CERATUM SABIN JE. *. Sabine Recentis Contnsx Cerx Flavx, sing. lbj. Atlipis Suillx, lbiv. Mix the savin with the melted wax and hog's lard, and strain the composition. This is the famous application for keep- ing open blisters, on the plan recom- mended by Mr. Crowther. We have no- ticed in t..e article Blisters^ what he says on the subject in the last edition of his work. CERATUM SAPONIS. (L.) *. Li- ^ thargyri Ixvigati lib. j. Aceti cong. j. Sd- ponis unc viij. Olei olivx. Cerx flavx sing. lib. j. This is the soap cerate of St. Bartholo- mew's Hospital, and adopted by" the Col- lege. In preparing it, the utmost caution must be used. The three first ingredients are to be mixed together and boiled gently till all the moisture is evaporated; after wliich, the wax and oil, previously melt- ed together, must be added. The whole composition, from first to last, must be incessantly and effectually stirred, without which the whole will be spoiled. This formula was introduced into practice by Mr. Pott, and is found to be a very con- venient application for fractures, and also as an external dressing for ulcers; being of a very convenient degree of adhesive- ness, and at the same time possessing the usual properties of a saturnine remedy. In applying this cerate, spread on linen, in fractures ofthe leg or arm, one caution is necessary to be observed, namely, that it be in two distinct pieces; for if, in one piece, the Umb be encircled by it, and the ends overlap each other, it will form a very inconvenient and partial constriction of the fractured part, in consequence of the subsequent tumefaction. (Pharm. Chirurg) CERCOS1S. (from **•» *««, a tail.) An enlargement of the clitoris, which hangs from the vagina like a tail. CEREBRUM. The brain; for con- cussion of; compression of, &c. see Head, Injuries of. For inflammation of, see Phrenitis. For hernia of, see Hernia Cerebri, CERION. (from »*•»<>{, wax.) A honey- comb. A small sore, with an orifice like the cell of a honey-comb. CERU'MEN AURIS. A degree of deafness is frequently produced by the lodgment of dry pieces of this substance in the meatus auditorius. The best plan, in such cases, is to syringe the ear with warm water, which should be injected with moderate force. In some instances, deafness seems to depend on a defective secretion of the cerumen, and a consequent dryness ofthe meatus. Here, it is advisable to intro- duce a drop or two of sweet oil every now and then into the ear, and to apply fo- mentatioi s. CERUSSA ACETATA. Sugar of lead. Acetite of lead. This preparation, which is now named by the*college plum- bi superacetas, is well known as an ingre- dient in a variety of lotions and collyria. It has the qualities of saturnine applica- tions in general, being highly useful for diminishing inflammation. CHALAZIUVI (from y.xXx^x. a hail. stone.) Tliis signifies a little tubercle on the eyelid, which has been whimsically supposed to resemble a hail-stone. It is the same as the hordeolum or stye. (See Hordeslutn.) CHAMOMILE. The flowers, which are bitter and aromatic, are used in sur- gery, for making fomentations. CHANCRE, (from Kttgxivof, cancer ve- nereum) A sore which arises from the di- rect application of the venereal poison to any part ofthe body. Of course it almost always occurs on the genitals. Such ve- nereal sores, as break out from a general contamination of the system, in conse- quence of absorption, never hi.ve the term chancre applied to them. (For an account of the nature and treatment Of chancres, see Venereal Disease) CHARP1E. (French.) Scraped linen, or lint. CHEILOCA'CE. (from &t\o<;t the lip, and xxr,ovt an evil.) A swelling, or ul- ceration of the lip. The same disease as the Cancrum Oris, which see. CHEMOSIS. (from %*">», to gape.) When ophthalmy or inflammation of the eye, is very violent, it frequently happens, that one or more vessels become ruptured on the side next the eyeball, and a quan- tity of blood is effused into the cellular membrane, which connects the conjunc- tiva with the anterior hemisphere of the eye. Hence, the conjunctiva becomea gradually elevated upon the eyeball, and projects towards the eyelids, so as to con- ceal within it tbe cornea, which appears, as if il were depressed. (Scarpa.) In this way the middle of the eye assumes the appearance of a gap, or aperture. When blood is extravasated under the tunica conjunctiva, there cannot be an easier or more effectual remedy than st her. A few drops are to be poured ifito 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 Clll CHI 297 evaporates, may insinuate itself into the part affected, and act on the blood, so as to disperse it. (Wareon Ophthalmy.) In a few instances of chemosis, in which the swelling and inflammation ofthe con- junctiva have been great, the following application has been found particularly beneficial, after free evacuation-? : it. In- terior um foliortim recentium J.actucx S'ssi- lis, ^iij. Coque cum . lq Pur. £ss. In bal- nea marix pro semihora; tunc exprimatur succus,et applicetur puultilum ad oculos et adpalpebras, sxdfie in the. ( Ware.) Ophthalmy, attended with chemosis, demands tlie most rig< -rous employment, of the antiphlogistic treatment. Both gene- ral and topical bleeding should be speedi- ly and copiously put in practice, with due regard, however, to the age and strength of the patient. Leeches should be applied to the vicinity of the eyel.ds, or, what is preferable, the temporal arteiy should be opened. When the chemosis is very con- siderable, the distention of the conjunc- tiva may be relieved by making an inci- sion imo this membrane, near its junction with the cornea. (See Ofihthalmy.) CHEVASTER or C'hbva'stre. A double headed roller, the middle of wliich was applied to the chin. The bandage then crossed at the top of the head, and passed on each -bide to the nape of the neck, where it crossed again. Then it was carried up to the top of the head, and so on, till all the roller was exhausted. CHIA'STOS. A bandage described by Oribasius, and so called from being si- milar in shape to the Greek letter %, CHIA'STRE. A bandage for stop. ping hemorrhage from the temporal ar- tery. The roller employed is double headed, about an inch and a half wide, and four ells long. The middle of the roller is applied to the unwounded side of the head; the bandage is carried round to the bleeding temple, and there made to cross over a compress on the wound. The roller is then continued over the coronal suture, and under the chin, care being taken to make the bandage cross upon the compress. In this way the roll- er is applied round the head, till the whole is spent. CHILBLAIN'S are the effect of in- fiammation, arising from cold. A chil- blain, in its mildest form, is attended with a moderate redness of the skin, and a sen- sation of heat and itching, all which symptoms, after a time, spontaneously disappear. In a more violent degree, the swelling is larger, redder, and sometimes of a dark blue colour; and the heat, itch- ing, and pain, are so excessive, that the patient cannot use the part. In the third degree small vesicles arise upon the tu- Vol. I. mrur, which burst and leave excoriations. These are soon converted into ill-condi- tioned sores, which sometimes penetrate even as deeply ?s the bone, discharge a thin ichorous matter, and generally prove very obstinate. The worst stage of chil- blains is attended with sloughing. Chilblains aie particularly apt to occur in persons, who arc in the habit of going immediately to the fire, when they come home in winier with their fingers and toes very cold ; they are also particularly fre- quent in persons, who often go suddenly into the cold, while very warm. Hence, the disease most commonly affects parts of- the body, which are peculiarly exposed to these sudden transitions; for instance, flic nose, ears, lips, hands, and feet. Rich- ter remarks th:-t they are still more fre- quently occasioned, when the part, sud- denly exposed to cold, is in a moist per- spiring state, as well ;-s a warm one. Young subjects are much more liable to this troublesome complaint than adults; and females brought up in a very delicate manner, are generally more afflicted, than the other sex. The most likely plan of preventing chil- blains is to accustom the skin to moderate friction ; to avoid hot rooms and making the parts too warm ; adapt the quantity and k.nd of clothing to the state of the constitution, so as to avoid extremes, both in summer and winter; to wash the parts frequently with cold water; to take regular exercise in the open air in all wea- thers ; and to take particular care not to go suddenly into a warm room or very near the fire, out of the cold air. Although ch'lblains of the milder kinds are only local inflammations, yet they have some peculiarity in them, for they are not most benefited by the same anti- phlogistic applications, wliich are most effectual in the relief of inflammation in general. One of the best modes of curing chil- blains of the milder kind is to rub them with snow, or ice-cold water, or to bathe them in the latter, several times a day, keeping them immersed each time, till the pain and itching abate. After the parts have been rubbed or bathed in this way, they should be well dried with a towel, anil covered with flannel or leather socks. This plan is perhaps as good a one as any; but it is not that which is always congenial to the fjelings and caprice of patients; with ihe constitutions of some it may even disagree. In such cases, the parts affected may be rubbed with spirit of wine, linimentum saponis, tinctura niyrrhse, or a sirong solution of alum, or vinegar. A mixture of oleum terebin- thinx and balsamum copaivs, in equal 298 CHI CIC parts, is a celebrated application. A mix- ture of two parts of camphorated spirit of wine, and one of the aqua lithargyri ace tat i, has also been praised. When chilblains have suppurated and ulcerated, the sores require stimulating dressings, such as lint dipped in a mix- ture of the aqua lithargyri acetati, and aqua calcis ; in tinctura myrrhx, or warm vinegar. If a .salve be employed, one wliich contains tlie hydrargyrus nitratus ruber, is best. Ulcers of this kind fre- quently require being touched w.tli the argentum nitratum, or dressed with a so- lution of it. Chilblains, attended with sloughing, should be poulticed, till the dead parts are detached. The sores should" then be first dressed with some mildly stimulating ointment, such as the unguentum resinae 'flavx. With this, in a day or two, a little ofthe hydrargyrus nitratus ruber may be mixed ; but the surgeon should not ven- ture on the employment of very irritating applications, till he sees what the parts will bear, and whether such will be re- Suisite at all. Were he too bold, imme- iately he leaves off the poultices, he might even bring on sloughing again. Thereader may find a long list of applica- tions for chilblains in Rees' Cyclopvtdia, ar- ticle Chilblains, See also Richter's Anfa7igs- gr. der Wundarzn. Band. 1. CHIMNEY-SWEEPER'S CANCER. See Scrotum. CHORDEE. (French, from #«•»<$% a cord.) When inflammation is not Con- fined merely to the surface of the urethra, but affects the corpus spongiosum, it pro- duces in it an extravasation of coagula- ble lymph, as in the adhesive inflamma- tion, which uniting the cells together, destroys tbe power of distention of the corpus spongiosum urethras, and makes it unequal in this respect to the corpora cavernosa penis, and therefore a curva- ture takes place at the time of an erection, Which is called a chordee. The curvature is generally in the lower part of the penis. When the chordee is violent, the inner membrane of the urethra is so much upon the stretch, that it may be torn, and cause a profuse bleeding from the urethra, that often reUeves the patient, and even some- times proves a cure. (Hunter on the Ve- nereal) This is the inflammatory chordee; there is another kind, which has been named spasmodic. In the beginning of the inflammatory chordee, ble.eding from the arm is often of service; but it is more immediately useful to take away blood from the part itself by leeches; "for we often find, that When a vessel gives way, and bleeds a good deal, the patient is greatly relieved^ ReUef may often be obtained by exposing the penis to the steam of hot water. Pirnl- tices have also beneficial effects; and both fomentations and poultices will often do more good when they contain cam- phor. Opium, given internaUy, is of sin- gular service; and if it be joined with camphor, the effect will be still greater. When the chordee continues after all inflammation is at an end, no evacua- tions are required. The consequence of the inflammation will cease gradually by the absorption ofthe extravasated coagu- lating lymph. Mercurial ointment rub- bed on the part will considerably pro- mote this event. Cicuta has seemed to do considerable good, after the common methods of cure have not availed. Elec tt-icity may be of service. A chordee is often longer in going off, than any other consequence of a gonorrhaea, but it dis- appears at last. Camphorated mercurial ointment is better than the simple unguentum hydrar- gyri, to bring about the removal of the extravasated lymph. The spasmodic chordee is very much be- nefited by bark. (Hunter on the Venereal.) CHRONIC, (from ^--javo?, time.) Chro- nicus. Of long continuance; opposed to CHYLOPOIETIC ORGANS, or vis. ceha. The parts of the body concerned in the preparation of the chyle, as the liver, gall bladder, pancreas, small intes- tines, &c. These viscera, with the sto- mach, compose what some surgical au- thors name the gastric system, and a dis- ordered state of their functions is sup- posed to be the cause of many medical and surgical diseases. The continental surgeons, perhaps, extend this doctrine beyond the bounds of truth. In our own country, Mr. Abernethy has lately drawn the attention of practitioners to the sub- ject by a publication, which has excit- ed considerable interest and discussion throughout the profession. CHYMOSIS. See Chemosis. CICA'l RISANTIA. (from cicatric; to skin over.) Epulotic medicines, or such as dispose wounds and ulcers to heal, and become covered with skin. CICATRIX. The scar remaining on • the skin, after the healing of a wound or ulcer. CICATRIZATION. The process by which wounds and sores heal. Granula- tions having been formed, the next ob- ject of nature is to cover them with skin. The parts which had receded by their na- tural elasticity, in consequence of the breach made in them, now begin to be brought together by the contraction of CICATRIZATION. 299 the granulations. The contraction takes place in every point, but principally from edge to edge, which brings the circum- ference ofthe sore towards the centre, so that tbe sore becomes smaller and smaller, even although Uttle, or no new skin is formed. The contracting tendency is in some degree proportioned to the'general heal- ing disposition of the sore, and looseness of the parts. When granulations are formed upon a fixed surface, their con- traction is mechanically impeded; as, for instance, on the skull, the shin, &c. Hence, in all operations on such parts, as much skin should be saved as possi- ble. When there has been a loss of sub- stance, making a hollow sore, and the contraction of the granulations has begun, and made a good deal of progress, before they have had time to rise as high as the skin, then the edges of the skin are gene- rally drawn down, and tucked in by it, in the hoUow direction of the surface of the sore. The contraction of the granulations continues, till the healing is complete ; but it is greatest at first. That there is a mechanical resistance to such contrac- tion, is proved by the assistance, which may be given to the process by the appli- cation of a bandage. Besides the contractile power of the granulations, there is also a similar power in the surrounding edge of the cicatriz- ing skin, which assists the contraction of the granulations, and is generally more considerable than that ofthe granulations themselves, drawing tiie mouth of the vyound together, like a purse. The con- tractile power ofthe skin is confined prin- eipally to the very edge, where it is cica- trizing, and, as Mr. Hunter believed, to those very granulations, which have al- ready cicatrized ; for, the natural or ori- ginal sknjsurrounding this edge does not contract, or at least not nearly so much, as appears by its having been thrown into folds and plaits, while the new skin is smooth and shining. Tlie uses ofthe contraction of granula- tions are various. It facilitates the heal- ing of a sore, as there are two operations going on at the same time, viz. contrac- tion and skinning. It avoids the formation of much new skin, the advantage of which is evident; for it is with the skin as with all other parts of the body, viz. that such as are originally formed are much fitter for the fturposes of life, than those that are new- y formed, and not nearly so liable to ul- ceration. When the whole surface of a sore has skinned over, the substance, the remains of the granulations, on which the new skin is firmed, 'still continues to con- tract, till hardly any thing more is left than what the new skin stands upon. This is a very small part, in comparison with the first formed granulations, and it in time loses most of its apparent vessels, becoming white and ligamentous. All new healed sores are at first redder than the common skin, but in time they be- come much whiter. As the granulations contract, the sur- rounding old skin is stretched to cover the part, which had been deprived of skin. When a sore begins to heal, the sur- rounding old skin, close to the granula- tions, becomes smooth, and rounded with a whitish cast, as if covered with some- thing white. This, Mr. Hunter supposed to be a beginning cuticle, and it is as early and sure a symptom of healing as any. While the sore retains its red edge all round, for perhaps a quarter, or half an inch in breadth, we may be certain it is not a heaUng one. Skin is a very different substance, with respect to texture, from the granulations upon which it is formed; but it is not known, whether it is a neUr substance formed by the granulations, or a change in the surface of the granulations them- selves. The new skin most commonly takes its rise from the^surrounding old skin, as if elongated from it; but not always. In very large sores, but principally old ul- cers, in which the edges of the surround- ing skin have but little tendency to con- tract, and the cellular membrane under- neath to yield, or the old skin to become drawn over tlie ulcerated surface, the nearest granulations do not acquire a ci- catrizing disposition. In such cases, new skin forms in different parts of the ulcer, standing on the surface of the granula- tions, like little islands. Whatever change the granulations un- dergo to form new skin, they are generally guided to it by the surrounding skin, which gives this disposition to the sur- face of the adjoining granulations. The new-formed skin is never so large as tlie sore was, on which it is formed, owing to the contraction of tlie granula- tions, and the yielding of the surround- ing old skin. If the sore is situated where the adjoining skin is loose, as in the scrotum, then the contractile power of the granulations being quite free from obstruction, a very little new skin is fcrmed; but if the sere is situated where 300 CICUTA. the skin is fixed or tense, the new skin is nearly as large as the sore. The new skin is at first commonly- on the same level with the old. This how* ever is not the case with scalds and burns, which frequently heal with a cicatrix, higher than the skin, although the granu- lations have been kept from rising higher than this part. The new-formed cutis is neither ..so yielding nor so elastic as the original is; it is also less moveable. It gradually be- comes, however, more flexible and loose. At first it is very thin and tender, but it afterwards becomes firmer and thicker. It is a smooth continued skin, not formed with those insensible indentations, which are observed in the natural or original skin, and by which the latter admits of any distention, which the cellular mem- brane itself will allow of This new cutis, and indeed all the sub- stance which hid formerly been granula- tions, is not nearly so strong, nor endow- ed with such lasting and proper actions, as the originally formed parts. The liv- ing principle itself is less active; for when an'old sore breaks out, it continues to yield, till almost the whole ofthe new- formed matter has been absorbed, or has mortified. The young cutis is extremely full of vessels; but these afterwards disappear, and the part becomes white. The surrounding old skin, being drawn toward the centre by the contraction of the granulations, is thrown into loose folds, while the new skin itself seems to be upon the stretch, having a smooth shining appearance. The new cuticle is more easily formed from the cutis, than the cutis itself from granulations. Every point of the surface of the cutis is concerned in firming cuti- cle, so that this is forming equally every where at once ; but the formation of the cutis is principally progressive from the adjoining skin. The new cuticle is at first very thin, and rather pulpy than horny. As it be- comes stronger, it looks smooth and sliin- ing, and is more transparent than the old cuticle. The rete mucosum is later in forming than the cuticle, and in some cases rifever forms at all. In blacks who have been wounded, or blistered, the cicatrix is a considerable time before it becomes dark; and in one black, whom Mr. Hunter saw, the scar ofasore, which had been upon his leg when young, rem.ti-td white when he was old. Many cicatrices of blacks, how- ever, are even darker than any other parts of the skin. (Hunter on tlie Blood, lifhim. mutton, &r.) CICUTA. (Conium Maculatum. Hem- lock) This is a medicine, to wliich my observations in practice incline me to im- pute considerable efficacy in several sur- gical diseases. However, there is no doubt, that when it is represented as a Certain cure for cancer, and scrofula, ex- aggeration is employed. It is an excel- lent remedy for irritable painful sores of the scrofulous kind, and it will complete the cure of many ulcers, in which the ve- nereal action has been destrdyed by mer- cury, though the healing does not pro- ceed in a favourable way. Cicuta is like- wise beneficial to several inveterate ma- lignant sores, particularly, some which are every now and then met with upon the tongue. It is an eligible alterative in cases of noli me tangere, tinea capitis, and various herpetic affections. 1 have seen some enlargements of the female breast give way to hemlock conjoined with calomel. Some swellings of the testes also yield to the same medicines. Cicuta cert-.inly has not the power of curing cancer;' but, its narcotic anodyne qualities tend to lessen the pain of that dis'.emper, so as to render it by no means a contemptible remedy in that intractable kind of case. Respecting hemlock, Mr. Pearson ob- serves, that the extract and powder may be sometimes given with evidently gooj effect in spreading irritable sores; whe- ther they are connected with the active state of the venereal virus, or Whether they remain aft r the completion of the mercurial course; and it would seem, that the benefit, conferred by this dru£, ought not to be ascribed solely to its ano- dyne qualities, since the same advan- tages cannot always be obtained by the %\ liberal exhibition of opium, even where ',*■ it does not disagree with the stomach. He states, that cicuta is almost a specific for the venereal ulcers, which attacks the toes at their line of junction with the foot, and wliich frequently become gan- grenous. Also, in spread-ng sores, which are accompanied with great pain, and no appearance of remarkable debility, hem- lock will often do more than bark, vitriol, or cordials. (Pearson on Lues Venera.) The common mode of exhibiting hem- lock is in the form of pills, made of the extractum conii, five grains to each. However, I have always thought three grains sufficient to begin with, the dose being afterwards gradually augmented. It is curious how large a quantity may at last be taken in this manner. Mr. J- Wilson, in his Pharmacopoeia Chirur- CIN C I N 301 gica, informs us of a remarkable case of a cancerous ulcer, for which the patient took a hundred and twenty pills, each consisting of five grains of the extractum conii, in twenty-four hours, and tins with- out any benefit being produced, or any in- convenience to the patient. The stomach being a little disordered, and the head somewhat giddy, is a sign Of the dose being sufficiently "strong. " According to some writers, but more particularly Dr. Withering, there are se- veral ways in which the views of a me- dical practitioner, in prescr.bing this re- medy, may be frustrated. Tlie plant chosen for preparing tlie extract, may not be the true conium maculatum, which is distinguished by red spots along the stalk. It may not be gathered when in perfec- tion, namely, when beginning to flower. The inspissation of the juice may not have been performed in a water-bath, but, for the sake of dispatch, over a com- mon fire. The leaves, of wliich the pow- der is made, may not have been cautiously dried and preserved in a well stopped bottle ; or if so, may still not have been guarded from tiie ill effects of exposure to light. Or, lastly, the whole medicine may liave suffered from the mere effects of foi-% keeping. From any of these causes, it is evident, the powers of cicuta may have suffered ; and it happens, no doubt, very frequently, that the failure of it ought, in fact, to be attributed to one orotherofthpm " (Pharmacopttia Chirur- gica, publislied 1802, p. 174 ) I have sometimes prescribed as an al- terative, with manifest benefit in seve- ral surgical diseases, a pill, containing three grains of extractum conii, one of hydr.irgyri submurias (calomel,) and one. of antimonii sulphuretum prxcipitatum. CILLOSIS. (fi-om cilium, the eye-lid.) A spasmodic trembling ofthe eye-lids. CINCHONA. As one of the designs of this dictionary is to embrace the sub- jects of a surgical pharmacopoeia, peruvi- anbark, which is administered in a multi- plicity of surgical cases, cannot be passed over in silence. Its great repute for its virtues in stop- ping mortifications, and accelerating the separation of the sloughs, every person, whether of the medical profession or not, has frequently heard of. Indeed, so high is tlie character of the medicine, that many practitioners order it in some stage, or another, ol almost every distemper, often . prescribe it when it is totally useless, give it when it actually does harm, and make their patients swallow such quantities as operate perniciously, when smaller doses would effect striking benefits Some men are credulous enough to think, that from the peruvian bark vigor and strength are directly extricated, and infused into tiie constitution, in exact proportion to the quantity of the medicine, which the sto- mach will keep down and digest. While a doctrine of this sort prevails, we must expect to see indiscriminate and erroneous practice. The generality of diseases will always be attended with an appearance of languor and weakness, and, certainly, while there exists a supposi- tion, that a drug is at hand, possessing the quality of evolving and communicat- ing strength, it would be absurd to fancy, that so important an article will not be largely exhibited in a multiplicity of sur- gical cases. 1 shall not presume to ha- zard an idea Of the powers of the peru- vian bark in the practice of physic; but, I have not the least doubt, that they have been unwarrantably exaggerated in sur- gery, so as to blind and prejudice many a practitioner of- good abilities, and lead him to adopt injudicious and hurtful me- thods of treatment. Under particular circumstances, bark has undoubtedly the quality of increasing the tone of the digestive organs ; ^nd, of course, whenever the indication is to strengthen the system by nourishing food, and the appetite fails, this medicine may prove of the highest utility, provided it is given in moderate doses, and it appears to agree with the stomach and bowels. But, the plan of making the patient swal- low as much of the medicine as can be got into his stomach, must, in my opi- nion, be invariably followed by bad, in- stead of good effects. How can it be rea- sonably expected, that the stomach, which is already out of order, can be set right by liaving an immoderate quantity of any drug whatever forced into it ? In fact, if the alimentary canal were in a healthy state, must not such practice be likely to throw it into a disordered condition ? Bark is an excellent medicine, when judiciously administered; but, like every other good medicine, in bad hands, it may be the means of producing the worst consequences. How much go:>d does mer- cury effect in an infinite number of surgi- cal diseases, when prescribed by a sur- geon of understanding ; what a poison it becomes under the direction of an igno- rant practitioner ! With respect to cases of mortification, bark is often most strong- ly indicated, when the sloughing is not surrounded with active inflammation, when the patient is debilitated, and his stomach cannot take nutritious food. I have always regarded the notion of giving bark, as a specific for gangrene, as totally unfounded and absurd. 1 have watched its effects in these cases, and could never 302 CI N CIN discern, that it had the least pecuhar power of operatingdirectly upon the parts, which are distempered. Whatever good it does, is by its improving the tone of the digestive organs, and making them more capable of conveying nourishment, and, of course, strength into the constitution. I should feel myself guilty of a degree of presumption in speaking thus freely upon this subject, were not my sentiments in some measure supported by those of certain surgical writers, the remem- brance of whom will always be hailed with unfeigned veneration and esteem. Mr. Samuel Sharp was not bigotted to bark, and, while he allowed it to possess a share of efficacy, he would not admit, that it was capable of" miraculously ac- complishing every thing, which the igno- rant or prejudiced alleged. "I know," says he, " It will be looked upon by many, as a kind of scepticism, to doubt the effi- cacy of a remedy, so well attested by such an infinity of cases ; and, yet, I shall frankly own, I have never clearly to my satisfaction, met with any evident proofs ofits preference to the cordial medicines usually prescribed ; though I have a long time made experiment of it with a view to search into the truth. " Perhaps, it may seem strange, thus to dispute a doctrine established on what is caUed matter of fact; but, I shall here observe, that in the practice of physic and surgery, it is often exceedingly difficult to ascertain a fact. Prejudice, or want of abilities, sometimes misleads us in our judgment, where there is evidently a right and a wrong ; but, in certain cases, to distinguish how far the remedy, and how far nature operate, is probably above our discernment. In grangrenes, particu- larly, there is frequently such a compli- cation of unknown circumstances, as can- not but tend to deceive an unwary ob- server. Mortifications aris-ng from mere cold, compression, or stricture, generally cease upon removing the cause, and are, therefore seldom proper cases for proving the power of the bark. However, tiiere are two kinds of gangrene, where inter- nals have a fairer trial ; these are a spreading gangrene from an internal cause, and a spreading gangrene from violent external accidents, such as gun- shot wounds, compound fractures, &c. Yet, even here we cannot judge of their effect with absolute certainty; for, some- times, a cyytification from internal causes is a kind of critical disorder. There seems to be a certain portion of the body destined to perish, and no more; of this we have an infinity of examples brought into our hospitals, where the gangrene stops at a particular point, without the least assistance from art. The same thing happens in the other species ot gangrene from violent accidents, where the injury appears to be communicated to a certain distance, and no farther; though, by the way, I shall remark in this place, con- trary to the received opinion, that gan- grenes from these accidents, (where there has been no previous straitness of band- age,) are as often fatal, as those from in- ternal causes. " As 1 have here stated the fact, we see how difficult it is to ascertain the real efficacy of this medicine; but, had bark in any degree, those wonderful effects in gangrenes, which it has in periodical complaints, its pre-eminence would no more be doubted in the one case, than in the other. What, in my judgment, seems to have raised its character so high, are the great numbers of single observations published on this subject, the authors of which not having' frequent opportunities of seeing the issue of this disorder, under the use of cordials, &c. and some of them, perhaps, prejudiced with the common supposition, that every gangrene is of it- self mortal, have therefore ascribed a marvellous influence to the bark, when the event has proved successful."--(*S*Aar-/r*j Crit. Enq chap. 8, on Amputation ) ' Some further remarks on this subject will be reserved for the article Mortifica- tion. According to Mr. Bromfield, bark is a specific for old ulcers, where the inflam- mation seems circumi-scribed at the dis- tance of an inch round the sore, the sur- face of the ulcers looks glossy, and the discharge is extremely thm and very of- fensive, with little or mo sleep, from the violence of the pain. He further ob- serves, that the addition of opium, as cir- cumstances may require, will often be found netfessary. ( CldrurgicalObservutions and Cases, Vol. I,p. 132) Hark is given so extensively in the practice of surgery, that there are few important cases, in which in certain cir- cumstances, and at some period or an- other, it is not indicated. When per- sons have been weakened by a course of mercuiy, or by the effects of any disease whatsoever, moderate doses of bark will frequently be found of great service. But, it"only becomes so on the principles above suggested, and, as far as my judgment extends, this medicine should never be prescribed in any surgical cases in exces- sive and unreasonable quantities. The yellow bark, or the Cortex cincho- na: co/difoliae of the new pharmacopoeia, is said to possess more efficacy, than the other kinds. ^ * ClNCLE'fUS^^INCU'SIS, or cw- CIR cu'smos. An involuntary winking, or trembjing motion of the eyelids. CINNABAR, ARTIFICIAL. (Ily- drargyri Sulphuretumjubrum.) Is chiefly employed by surgeons for fumigating ve- nereal ulcers. An apparatus is sold in the shops fbr this pui pose. The pOwder is thrown upon a heated iron, and the smoke is conducted by means of a tube to the part affected. CINZILLA. (Zona.) A kind of herpes surrounding the body like a girdle. CI'ON. Hippocrates uses the word *'*■», to denote a fleshy excrescence in the pudendum muliebre. CIOMS. (from x'«v, the uvula) A diseased and painful enlargement of the uvula. CIRCUMCISION, (from circumcido, to cut round) The operation of cutting off a circular piece ofthe prepuce, sometimes practised in cases of phymosis. (See Phymosis) CIRSOCELE. (from *«£«-•»«, a varix, and jtijAaj, a tumour.) The cirsocele is a varicose distention and enlargement of the spermatic vein ; and whether considered on account of the pain, which it some- times occasions, or on account of a wast- ing of the testicle, which, now and then follows it, may truly be called a disease. It is frequently mistaken for a descent of a small portion of omentum. The unea- siness which it occasions, is a dull kind of pain in the back, generally relieved by suspension of the scrotum. It has been resembled to a collection of earthworms ; but whoever has an idea of a varicose vessel, will not stand in need of an illus- tration by comparison. It is most fre- quently confined to that part of the sper- matic process, which is below tbe opening in the abdominal tendon; and the vessels generally become rather larger, as they approach the testis. Mr. Pott never knew any good effect from external appli- cations of any kind. - In general the testicle is perfectly un- concerned in, and unaffected by, this dis- ease ; but it sometimes happens, that it makes its appearance very suddenly, and with acute pain, requiring rest and ease ; and sometimes after such symptoms have been removed, Mr. Pott has seen the tes- tide sd wasted as hardly to be discern- ible. He has also observed the same ef- fect from the injudicious application of a truss to a true cirsocele; the vessels, by means of the pressure, became enlarged to a prodigious size, but the testicle shrunk lo almost nothing. (Pott's Works, Vol. 2) The cirsocele is more frequently than anv other disoider, mistaken for an omen- tal hernia. As Mr. Astley Cooper re- C 0 A 3Q3 marks, when large, it dilates upon cough- ing; and it appears in an erect, and re- tires in a recumbent, posture of the body. There is only one sure method of distin- guishing the two complaints: place the patient in a horizontal posture, and emp- ty the swelling by pressure upon the scrotum; then put the finger firm upon the upper part of the abdominal ring, and desire the patient to rise ; if it is a hernia, the tumour cannot re-appear, as long as the pressure is continued at the ring; but if a cirsocele, the swelling returns with increased size, on account of* the re- turn of blood into the abdomen being pre- vent ed by the pressure. (A. Cooper on Inguinal Hernia!) The cirsocele can generally only be pal- liated, and seldom radically cured. When the complaint is attended with pain, cold saturnine, and alum, lotions may be ap- plied to the testicle and spermatic cord. At the same time, blood should be re- peatedly taken away by means of leeches ; the bowels should be kept gently open; the patient should be placed in a hori- zontal posture; and the testicle should be supported in a bag-truss. In general, the patient only finds it necessary to keep up the testicle by this kind of suspensory bandage. Gooch, and other writers, have related cases of cirsocele, in which the pain was so intolerable and incurable, that nothing but castration could afford the patient any relief. CIRSOS. (from x{ <$, a little round cake.) A bump caused by a blow. COLLYRIUM. (from xaXvu, to re- strain, because it stops the inflammation.) An application to the eyes, and generally an eye-water. The following are some of the most useful collyria. COLLYRIUM ACIDI ACETICl.— * Aceti Distillati Jj. Spiritus Vini Ten- nioris 3SS. Aq. Rosas ^viij. Misce. The strength to be diminished, or increased, as circumstances may require. This col- ly rium is recommended for weak watery eyes, and for relieving pain in the or- gans, after exerting them on any objects. It is also said to be useful for the scrofu- lous ophthalmy. (See Wilson's Pharm. Chir. p. 66.) COLLYRIUM ALUMINIS. * Alu- minis purif ^j. Aq. rosae ^j. This is a good astringent collyrium, employed at Guy's Hospital. COLLYRIUM AMMONIiE ACE- TATiE. *. Aq. ammon. acet. Aq. rosae sing- 3.i- M COLLYRIUM AMMONLE ACE- TATE CAMPHORATUM. *. CoUyrii ammon. acet. Misturae camphoratae sing. COLLYRIUM AMMONIA ACE- TATE OPIATUM. *. CoUyrii ammon. acet. §iv. Tinct. opii. gutt. xl. M. COLLYRIUM CERUSS,£ ACETA- T.E. g,. Aqua rosae gvj. Cerussae Aceta- tae 383. Misce. This is a good applica- tion to the eyes, when one of a gently as- tringent, cooling quality is indicated. COLLYRIUM GUPRI VITRIOLATI CAMPHORATUM. *. Aq. Cupri vitri- olati camphoratae ^ij. Aq. distillatae ^iv. M. Recommended by Mr. W.*re, for the purulent ophthalmy of children. COLLYRIUM HYDRARGYKI Ml- R1ATI. iv. Hydrarg. muriati grsa. Aq. distillat. 3'v. M. This collyrium is fit to be employed, after the acute stage of the ophthalmy has for some time subsided, and it will disperse many superficial opa- cities of the cornea. COLLYRIUM LITHARGYRI ACE. TATI. 9<. Aq. distillatae 31V. Aq. li- tharg. acet. gUtt. x. M. COLLYRIUM OPIATUM. *. Opii. Extracti gr. x. Camphorae gr. vj. Aqui distillatae frrventis 3" xii. Beat the two first ingredients together in a mortar, and mix the hot water gradually, and strain the fluid. This collyrium is recommended in some ophthalmie&j, attended with great pain and swelling. (See Wilson's Pliarm. Chir. p. 70.) COLLYRIUM ZINCI VITRIOLATI. Zmci vitriol, gr. v. Aq. distillatae 31V. M. This is the most common colly- rium of all: it may be gradually made stronger. COLLYRIUM ZINCI VITRIOLATI CUM MUCILAGINE SEMINIS CY- DONII MALT. &. Aq. plahtaginis |iv. zinci vitriol, gr. v. et mucil. sem. cydon. mal. 3SS. M. In order to check the morbid secretion from the eye-lids, in cases of the fistula • lachrymalis, or what Scarpa calls ilflustt palpebrah puriforme, this celebrated Pro- fessor recommends a few drops of the above collyrium to be insinuated between the eye-lids and eye. COLON, Fruit stones lodged in. (See Alvine Concretions.) COLPOCELE. (from xoXvec, the vagi- na, and tcnXrit a tumour.) A tumour, or hernia, situated in the vagina. COLPOPTOSIS. (from *«**•«?, the va- gina, and 3nw7«, to fall down.) A bear- ing or falling down of the vagina. (See Vagina, Prolapsus of) »' COMA, (from *« or «•*", to lie down.) Anciently any total suppression of the powers of sense ; but now it means a .le- thargic drowsiness. It is a symptom of several surgical disorders. . COMATOSE. Comutosus. Lethargic. COMMINUTED, (from comminuo, to CON break in pieces.) A fracture is termed comminuted, when the bone is broken into several pieces. COMPRESS, (from comprimo, to press upon.) Compressa. A compress. Folded linen, lint, or other materials, making a sort of pad, which surgeons place over those parts of the body on which they wish to make particular pressure, and, for this purpose, a bandage is usually applied over the compress. Compressc s are also frequently applied to prevent the ill effects, which the pressure of hard bo- dies, or tight bandages, would otherwise occasion. COMPRESSION OP THE BRAIN. (See Head, Injuries of) CONCUSSION. (from concutio, to shake together.) Concussio. A concussion, or shock. CONCUSSION OF THE BRAIN — (See Head, Injuries of.) CONDUCTOR, (from conduco, to ' guide.) A surgical instrument for di- recting the knife in certain operations. It is more commonly called a director. CONDYLOMA, (from xovhxof, a tu- bercle, or knot.) A small very hard tu- mour. The term is generally appUed to excrescences of this description about the anus. The practitioner may either de- stroy them with the lapis infernalis, tie their base with a ligature, so as to kill them, or remove them at once, with a knife: the first is generally the worst; the last the best and most speedy method. CONGESTION, (from congero, to amass.) Congestio. A collection of pus, particularly one of the chronic kind. CONGLUTTNANTIA. (from conglu- tino, to glue together.) Such medicines as heal and unite parts. CONIUM MACULATUM. Hemlock. (See Cicuta) CONSTIPATION, (from constipo, to crowd together.) Constipalio. Costiveness. CONTRA-APERTURA.-(from contra, against, and aperio, to open.) A counter- opening. An opening made opposite to one that already exists. CONTRA-F13SURA. (from contra, again-.t, and findb, to cleave.) A crack in the skull opposite to the part on which the blow was given. CONTUSED WOUNDS. See Wounds. CONTUSION. (from contundo, to bruise.) Contusio. A bruise. SUght bruises seldom meet with much attention ; but when they are severe, very bad consequences may ensue, and these are the more likely to occur, when such cases are not taken proper care of. In all severe bruises, besides the in- flammation which the violence necessarily Vox. I. CON 305 occasions, there is an instantaneous ex- travasation, in ^consequence of the rup- ture of many of the smaU vessels of tlie part. In no other way can we1 account for those very considerable tumours, wliich often rise immediately after injuries of this nature. The black and blue appear- ance, instantly following many bruises, can only be explained by their being an actual effusion of blood from the small vessels, wliich have been ruptured. Even largish vessels are frequently burst in this manner, and very considerable col- lections of blood are the consequence. Blows on the head very often cause a large effusion of blood under the scalp. I have seen four or five ounces thus extra- vasated. Besides the rupture of ar. infinite num- ber of small vessels and extravasation, which attend all bruises, in a greater or less degree, the tone of the fibres and ves- sels which have suffered contusion, is considerably disordered. Nay, the vio- lence may have been so great, that the parts are from the first deprived of vita- lity, and must slough. Parts at some distance from such as are actually struck, may suffer greatly from the violence of tiie contusion. This effect is what the French have named a contrer coup. The bad consequences of bruises are not invariably proportioned to the force which has operated; much depends on the nature and situation of the part. When a contusion takes place on a bone, which is thinly covered with soft parts, the latter always suffer very severely, in consequence of being pressed, at the time of the accident, between two hard bodies. Hence, bruises of the shin so frequently cause sloughing and troublesome sores. Contusions affecting the large joints are always serious cases; the inflammation occasioned is generaUy obstinate, and abscesses and other diseases, wliich may follow, are consequences truly enough to excite alarm. In the treatment of bruises, the practi- tioner has three indications, which ought successively to claim his attention, in the progress of such cases. The first is to prevent and diminish the inflammation, which, from the vio- lence done, must be expected to arise. The bruised parts should be kept per- fectly at rest, and be covered with linen, constantly wet with tlie lotio aq. litharg. acet. When there are muscles bruised,* they are to be kept in a relaxed position, and never used. - If the bruise should have been very violent, it will be proper to apply leeches, and this repeatedly, and even, in some Rn 306 COR COR cases, particularly, when joints are con- tused, to take blood from the arm. In every instance, the bowels should be kept well open with saUne purgatives. A second object in the cure of contu- sions, is to promote the absorption of the extravasated fluid by discutient applica- tions. These may at once be employed in all ordinary contusions, not attended with too much violence ; for then nothing. is so beneficial as maintaining a continual evaporation from the bruised part, by means of the cold saturnine lotion, and, «t the same time, repeatedly applying leeches. In common bruises, how ever, the lotio ammonix muriatx (see this article) is an exceUent discutient application; but most surgeons are in the habit of ordering liniments for all ordinary con- tusions, and certainly they do so much good in accelerating the absorption of the extravasated blood, that the practice is highly praiseworthy. The linimentum saponis, or the linimentum camphoree, are as good as any that can be employed. (See Linimentum.) In many cases, unattended with any threatening appearances of inflammation, but in wliich there is a good deal of blood and fluid extravasated, bandages act very beneficially, by the remarkable power which they have of exciting the action of the lymphatics, by means of the pressure which they produce. A third object in the treatment of con- tusions, is to restore tiie parts to their proper tone. Rubbing the parts With Uniments has a good deal of effect in this way. But, notwithstanding such appli- cations, it is often observed, that bruised parts continue for a long w hue weak, and even swell, and become adematous, when the patient takes exercise, or al-r lows them to hang down, as their func- tions in life may require. Pumping cold water two or three times a day, on a part thus circumstanced, is the very best mea- sure which can be adopted. A bandage should also be worn, if the situation of tlie part will permit. These steps, to- gether with perseverance in the use of liniments, and in exercise gradually in- creased, wUl soon bring every thing into its natural state again. CORACOID PROCESS OF THE SCA- PULA, FRACTURED. (See Fracture. Fractures^,''ihe Scapula) CORNEA. TUMCA. (from cornu, a horn.) The anterior transparent convex part ofthe eye, which in texture is tough, like horn. It has a structure peculiar to itself, being composed of a number of concentric cellulw lamellae, in the cells of which is deposited a particular sort of fluid. It is covered externally by a con- tinuation of the conjunctiva, which be- longs to the class of mucous membranes; and it is lined by a membrane, the tunica humoris acquei, which seems to belong to the serous class. FLESUT EXCRESCENCES OF THE COHSXA. Mr. James Wardrop, in his Essays on the Morbid Anatomy of the Human Eye, has published an excellent chapter on thia subject. Besides pterygia, which are treated of in another part of this Dic- tionary, Mr. Wardrop states, that the cornea is subject to two kinds of ca- runcles, or fleshy excrescences One ap- pears at birth, or soon after it, and re- sembles the naevi materni so frequent on the skin of various parts of the body. The second is described, as having a greater analogy to the fungi, which grow from mucous surfaces, and being in gene- ral preceded by ulceration. Of the congenital excrescence of the cornea, Mr. Wardrop has seen two remark- able instances. The first was in a girl, eight, or ten years of age, on whose left eye, there was a conical mass, the base of which grew from about two-thirds of the cornea, and a small portion of the adjoining sclerotic coat. The second example occurred in a pa» tient upwards of fifty years old. The tumour had been observed from birth, was about as large as a horse-bean, and only a small portion of it seemed to gi ow from the cornea. The other part was situated on the white of the eye, next the temporal angle of the orbit. From ihe middle of the excrescence, upwards of twelve long firm hairs grew, and hung over the cheek. Mr. Wardrop acquaints us, that a si- milar, tumour, w.th two hairs growing out of it, was seen at Lisbon by Dr. Bar- ron, of St. Andrews. Mr. Crampton also mentions, that he once saw a " tuft of very strong hair-, proceeding from the sclerotica." (Essay on the Eutropeon,p. 7) And De Gazelles met with an instance, in which a single hair grew from the cornea. (Jour, de Medecine. 'Tom. 24.) According to Mr. Wardrop, thi-* species of excres- cence of the cornea greatly resembles the spots, covered with hair, which are fre- quent on various parts of the surface of the body With regard to the second kind of tu- mour growing from the cornea, a fungus; proceeding from an ulcer of this p rt of the eye, is stated to be very uncommon. ,However, it is said, that, when a portion of the iris protrudes through an ulcer of the cornea, the growth of a large excres- cence from the projecting part is not ao CORNEA. 307 unusual. Of euch a disease, Mr. War- drop has cited an example from Maitre Jan's Traite des Maladies des yeux. Voigtel, Beer, and Plaichner. Excres- cences, growing from the cornea, are also quoted from the following works ; Hand- buch der Pathologischen Anatomie, Von F. G. Voigtel, Halle, 1804. Pratische Beobachtungen Uber den grauen Staar und die Krankhieten der Hornhaut, von Joseph Beer, Vienna, 1791. Plaichner's Dissertatio, de Fungo Oculi. (See War- drop's Essays on the Morbid Anatomy ofthe Human Eye, chap. 4.) The only treatment, which excrescences ofthe cornea admit of, is to remove them with a scalpel and pair of forceps, or to destroy them with caustic* ABSCESSES OF THE CORXEA. The following description of abscesses ofthe cornea is taken from Mr. Wardrop's valuable work on the morbid anatomy of the eye. When the matter is collected between the lamellae of the cornea, it first appears like a small spot; and, instead of resem- bling a speck in colour, it is of the yel- low hue of common pus. As the quantity ofthe matter increases, this spot becomes broader, and it does not alter its situa- tion from the position of the head. If it is situated among the external layers of the cornea, or immediately below the cor- neal conjunctiva, a tumour is formed an- teriorly, and, if touched with the point of a probe, the contained fluid can be felt fluctuating within, or if the eye is looked at sideways, an alteration in the form of the cornea may be readily perceived. When the matter collects, between the interior lamellae, it does not produce any evident alteration, in the external form of the cornea; but, if it is touched with the point of a probe, a fluctuation can be more or less distinctly perceived, and the spot alters its form, and becomes some- what broader. Such collections of matter appear on eveiy part of the cornea. Sometimes they alter their situation by degrees, and sink downwards ; and sometimes they change both their situation and form. They very seldom cover more than one-fourth, or one-third of the cornea. If the quantity of matter is small, it is often completely absorbed during the abatement ofthe inflammatory symptoms, and it generally leaves no vestige behind it. In other eases, the cornea is eroded externally, producing an ulcer, and sub- sequent opacity. In some few instances, the internal lamellar of the cornea give way, and the matter escapes into the an- terior chamber. If an artificial opening is made, in order to discharge the matter, it often does not readily flow out; and it is sometimes so tenacious, and contain- ed in a cavity so irregular, that it neither escapes spontaneously, nor can it be eva- cuated by art. It is particularly to the cases, in which matter collects between the layers of the cornea, that the terms unguis, and onyx, are applied. (See Wardrop's Essays on the Morbid Anatomy ofthe Human Eye, chap.6) OPACITIES OF THE CORNEA. Opacity of the cornea is one ofthe worst consequences of obstinate chronic oph- thalmy. Scarpa distinguishes the super- ficial and recent species of opacity from the albugo and leucoma, (see these words,) which are not in general attended with inflammation, assume a clear pearl co- lour, affect the very substance of the cor- nea, and form a dense speck upon this coat of the eye. The nebula, or slight opacity, here to be treated of, is preceded and accompanied by chronic ophthalmy ; it allows the iris and pupil to- be discern- ed through a kind of cloudiness, and con- sequently does not entirely bereave the patient of vision, but permits him to dis- tinguish objects, as it were, through a mist. The nebula is an effect of protract- ed or ill-treated chronic ophthalmy. The veins ofthe conjunctiva, much relaxed by tfie long continuance of the inflammation, become preteraaturally turgid and pro- minent ; afterwards they begin to appear irregular and knotty, first in their trunks, then in their ramifications, near the union of the cornea with the sclerotica, and lastly, in their most minute ramifications, returning from the delicate layer of the conjunctiva, spread over the cornea. It is only, however, in extreme relaxation of the veins of the conjunctiva, that these very small branches of the cornea be- come enlarged. When .this happens, some reddish streaks begin to be perceptible, in the interspaces of which, very soon after- wards, a thin milky albuminous fluid is effused, which dims the diaphanous state of the cornea. The whitish, deficate, superficial speck, thence resulting, forms precisely what is termed, nebula, or that kind of opacity here to be considered. And since this extravasation may happen only at one point of the cornea, or in more places, the opacity may be in one speck, or in several distinct ones, but which all together diminish, more or less, the transparency of this membrane. The cloudiness of the cornea, which sometimes takes place in the inflammatory 308 CORNEA. stage of *4he violent acute ophthalmy, es- sentially differs from the species of opacity expressed by the term nebula. ' The first is a deep extravasation of coagulating lymph into tlie internal cellular texture of the cornea, or else the opacity proceeds from an abscess between the layers of tliis membrane about to end in ulceration. On the other hand, the nebula forms slowly upon the superficies of the cornea, in the long protracted chronic ophthalmy ; is preceded first by a varicose enlarge. ment of the veins in the conjunctiva, next of those in the delicate lamina of this tunic, continued over the front of the cornea; and finally it is followed by an effusion of albuminous lymph into the texture of this thin layer, expanded over the transparent part of the eye. This effusion never elevates itself in the shape of a pustule. Wherever the cornea is affected with this species of opacity, term- ed nebula, the part ofthe conjunctiva, cor- responding to it, is constantly occupied by a network of varicose veins, more knotted and prominent than other vessels of the same descr ption, and though the cornea.be clouded at more points than one, there are distinct corresponding fas- ciculi of varicose veins in the white ofthe eye. Scarpa injected an eye affected with chronic ophthalmy, and nebula, and he found that the wax easily passed, both into the enlarged veins of the conjunctiva, and of that part of the surface of the cor- nea where the opacity existed; the inos- culations all round the margin of tiie cor- nea were beautifully variegated, without trespassing that line, which bounds the sclerotica, except on that side, where the cornea was affected with this species of opacity. This kind of opacity of the cornea, from its very origin, requires an efficaci- ous plan of treatment; for though at first it may only occupy a small portion of the cornea, when left to itself it ad- vances towards the centre of this mem- brane, and the ramifications of the dilat- ed veins upon this coat growing still larger, at length convert the delicate con- tinuation of the conjunctiva upon the sur- face of the cornea, into a dense opaque membrane, obstructing vision, either par- tially dr totally. The curative indication in this disease is to make the varicose vessels resume their natural diameters, Or if that be imprac- ticable, to cut off all communication be- tween the trunk of the most- prominent varicose veins ofthe conjunctiva, and the rarnificitions coming from the surface of the cornea, the seat of the opacity. The first mode of treatment is executed by means of topical astringents and corrobo- rants, especially Janin's ophthalmic oint- ment, and success attends it, when tin opacity is in an early state, and not ex- tensive. But when advanced to tbe cen- tre of the cornea, the most infallible treat- ment is the excision of the fasciculus of varicose veins near their ramifications, that is, near the seat of the opacity. By means of this excision, the blood retarded in the dilated veins of tiie cornea is void- ed ; the varicose veins of the conjunctiva have an opportunity to contract and re- gain their tone, no longer having blood impelled into them; and the turbid secre- tion effused in the texture of the layer of the conjunctiva continued over the cornea, or in the cellular substance, connecting these two membranes, becomes absorbed. The celerity, with which tiie nebula dis- appears, after this operation, is surprising, commonly in twenty-four hours. The ex- tent to which the excision of the varicose veins ofthe conjunctiva must be perform- ed, depends upon the extent of the opacity of the cornea. Thus, should there be only one set of varicose vessels, corre- sponding to an opacity of moderate extent, it is sufficient to cut a portion of them away. Should there appear several dim specks upon the cornea, with as many distinct sets of varicose vessels, arranged round upon the white of the eye, the sur- geon must make a circular incision into the conjunctiva, near the margin of the cornea, by wliich he will certainly divide every plexus of varicose vessels. But let it be observed, that a simple incision through the varicose vessels is not perma- nently effectual in destroying all direct communication between the trunks and ramifications of these vessels upon the cor- nea, after such an incision made, for in- stance, with a lancet; though it be true that a separation ofthe mouths of the di- vided vessels follows in opposite direc- tions, it is no less true, that in the course of a few days after the incision, the mouths of the same vessels approximate each other, and inosculate, so as to resume their former continuity. Hence, to de- rive from this operation all possible ad- vantage, it is essential to extirpate with the knife a small portion of the varicose plexus, togelher with the adherent par- ticle ofthe tunica conjunctiva. To do this op.-ration properly, the plan of passing a needle threaded with silk through the varicose pleptus is to be dis- pensed with. The eye-lids are to be se- parated iiom the affected eye by a skilful assistant, who is, at the same moment, to support the patient's head upon his breast. The surgeon is then to take hold of tiie varicose vessels, with a pair of small forceps, near the edge ofthe cornea, CORNEA. 309 and to Uft them a little up, which the lax •jtate of the conjunctiva renders easy; then, with a pair of small curved scissars, be is to cut away the plexus of varicose vessels, together with a small piece of the conjunctiva, making the wound of a semi- lunar form, and, as near as possible to the cornea. If it should be necessary to operate upon more than one plexus of varicose vessels, situated at some distance apart, the surgeon must elevate them one after the other with the forceps, and re- move them. But when they are very close together, and occupy every side of the eye, he must make an uninterrupted circular incision into the conjunctiva, guiding it closely to the margin of the cornea A\ round, thus dividing v/ith the conjunctiva, all the varicose vessels. This being done, he may allow the cut vessels to bleed freely; even promoting the hemorrhage by fomenting the eyelids, until the blood discontinues to flow. Then tlie eye is to be covered with an oval piece of the emplastrum saponis, and a reten- tive bandage. The eye ought not to be opened till twenty-four hours after the operation, when, usually, the opacity of the cornea will be found completely dis- persed ; and, during the ensuing days, the patient is to be enjoined to keep the eye shut, and covered with a bit of fine rag. A colly rium of milk and rose-water warm, may be applied two or three times a day. It is worthy of observation, when the in- flammation of the conjunctiva happens, about the second or third day after ihe operation, particularly in c»ses in which the incision is made all round, that while the greater part of the sphere of the eye reddens, a whitish circle, in the place of the incision, forms a line of boundary to the redness which does not extend further upon the cornea. This inflammation of the conjunctiva, with the aid of internal antiphlogistic remedies, and topical emol- lients, abates in a few days, and then pus is secreted along the track of the incision in the conjunctiva. The wound con- tracts, and growing smaUer and smaller, soon cicatrizes. Bathing the eye will'. warm milk and rose-water is the only lo- cal treatment necessary in this state of the complaint. Thus not only the tranparency of the cornea is revived, but also the preterna- tural laxity of the conjunctiva is dimi- nished, or even removed. When after- wards the conjunctiva appears yellowish and wrinkled, the use of topical astrin- gents and corroborants, and of Janni s ophthalmic ointment, will yet prove highly beneficial, in preventing tlie recurrence of the varicose state of the vessels. ( Scarpa suite malaitie degli occhi.) For other opacities of the cornea re- fer particularly to Albugo Leucoma and Staphyloma, CLCEB OF THE CORXEA. Thi-3 is a very common consequence of the bursting of a small abscess, which not unfrequently forms beneath the delicate layer of the conjunctiva ^continued over the cornea, or in tbe very substance of the cornea itself, after violent ophthalmy. At other times, the ulcer of the cornea is produced by the contact of corroding matter, or sharp-pointed bodies insinu- ated into the eyes, such as quick lime, pieces of glass, or iron, "thorns, &c. The little abscess of the cornea is attended with the same symptoms, as the severe acute ophthalmy; especially with a troublesome sensation of tension in the eye, eyebrow, and nape of the neckj with ardent heat; copious secretion of tears; aversion to light; intense redness of the conjunctiva, particularly near the point of suppuration. The inflammatory pustule, compared with similar ones in any other part of the body, is slow in bursting after matter is formed. Ex- perience has nevertheless evinced, that it is improper to puncture the small abscess; for, though it assumes the appearance of being perfectly maturated, the matter contained in it, is so tenacious, and adherent to the^substance of the cornea, that not a particle issues out of the artificial aperture, and the wound exasperates the disease, increases the opacity of the cornea, and often occasions another small abscess to form in the vicinity of the first. The safest plan, in this case, is to temporize, until the pustule spontaneously bursts, promoting it by means of frequent fomentations, bathing the eye with warm milk and water, and applying emollient poultices. The spontaneous bursting of the little abscess is usually denoted by a sudden increase of all the symptoms of oph- thalmy; particularly by an intolerable burning pain at the point of the cornea, where tlie abscess first began, greatly in- creased by motion of the eye, or eyelid. The event is confirmed by ocular in- spection, and at tlie spot where the white pustule existed, a cavity appears, as may best be seen, when the eye is viewed in the profile. Extraneous bodies in the eye, which have simply divided a part of the cornea, or lodged in it, when soon extracted, do not in general cause ulcera- tion, as the injured part heals by tiie first intention. Those which destroy, or burn the surface of this membrane, or 310 CORNEA. which, when lodged, are not soon ex- tracted, excite acute ophthalmy, suppu- ration at the injured part, and at length ulceration. The ulcer of the cornea has this, in common with all solutions of continuity in the skin, where it is delicate, tense, and endowed with exquisite sensibility, that, at its first appearance, it is of a pale ash-colour; has its edges high, and irregular; creates sharp pain; dis- charges, instead of pus, an acrid serum, and tends to spread widely and deeply. Such is the precise character of ulcers upon the cornea, and such is that of those upon the nipples, of the mammae ; the glans penis; lips; apex of the tongue; the tarsi; the entrance of the meatus auditorius externus; nostrils; &c. Ulcers of this description, neglected, or ill-treated, speedily enlarge, make their way deeply, and destroy the parts in which they are situated. If they spread superficially upon the cornea, the trans- parency or this membrane is destroyed; if they proceed deeply, and penetrate the anterior chamber of the aqueous humour, this fluid escapes, and a fistula of the cornea may ensue; and if it should form a larger opening in it, besides the exit of the aqueous humour, it occasions another more grievous malady ihan the ulcer itself, namely, a prolapsus of a portion of the iris; an escape of the crystalline lens and vitreous humour, in short, a total destruction of the whole organ of sight. • This afflicting accident is not unfrequent, in consequence of acute ophthalmy from gonorrhea, when neither internal nor ex- ternal means avail, to arrest the progress of ulceration. It is therefore of the highest importance, as soon as an ulcer appears upon the cornea, to impede its growing larger, as much as the nature of it will permit; the morbid process should be converted into a healing one, and the surgeon must exert his skill with more attention, the more extensive and deep the ulceration has proceeded. The cica- trix of a large ulcer impairs the texture of the cornea so much, that the injury is irreparable. They, who inculcate, that no external application can be adopted with benefit, for the cure of this disease, before the acute ophthalmy has been subdued, or, at least, diminished, are, in Scarpa's opinion, deceived Experience teaches, that local remedies ought, in the very firsi instance, to he applied to the ulcer, such as are ■•ppropriate to lessen the in- creased morbid irritability, and stop the destructive process going on ; afterwards such means should be taken, as will cure the ophthalmy, if it does not subside gradually, as the ulcer heals. It is a fact, confirmed by repeated observation, that it is the ulcer which keeps up the ophthal- my, not the ophthalmy the ulcer. The case, however, is to be excepted, in which the ulcer makes its appearance in the height of a severe ophthalmy. Here the first indication is to abate inflammation, before attempting to heal the sore. On opening the little abscess of the cor- nea, it is true, the symptoms of acute oph- thalmy become aggravated; the redness of the conjunctiva is increased, as well as the turgid state ofits vessels; but it is equally certain, that it happens from no other cause, than an increased inflammation in the part, in consequence of the aug- mented sensibility in the ulcerated spot of the cornea. As soon as this increase of sensibility in the ulcer of the cornea ceases, or abates, in violence, the oph- thalmy retreats with equal speed, and, finally, when the ulcer heals, the inflam- mation vanishes gradually, or, at most, requires only the use of an astringent, and corroborant c«Wlyrium, for a few - days. Analogous examples every day oc- cur in practice, in ulcers of other parts, besides the cornea; particularly in little foul ulcers on the inside of the lips, on the apex of the tongue, on the nipples, on the glans penis, which, as was de- scribed above, at their first appearance, assume an ash-coloured surface, excite inflammation of the part in which they are seated, 'and cause a very trouble- some itching and ardent heat in the part affected. To subdue this inflammation, we do nothing more, and the vulgar do the same, than repel the excessive irrita- bility in these ulcers, and convert the ulcerative process into cicatrization. This done, the surrounding inflammation im- mediately disappears of itself. The resource of art, productive of such speedy and such good effects, in these cases, is the caustic. It immedi- ately destroys the naked extremities of the nerves in the ulcerated part, and soon removes that diseased irritability prevalent in the part affected; it converts the ash-coloured surface of the ulcer, and the serous discharge upon it, into an ' eschar and scab, which, as a kind of epidermis, moderates the contact of the neighbouring, parts upon the ulcer, and, at length, converts the process of ulcera- tion into that of granulation and cicatriza- tion. For cauterizing the ulcer ofthe cornea, the caustic to which Scarpa gives the preference, is the argentum nitratum. It must be scraped to a point, like a crayon pencil, and the eyeUds being opened perfectly, and the- upper eye-lid CORNEA. 311 suspended, by means of Pellier's ele- vator, the ulcer of the cornea is to be touched with the apex sufficiently to form an eschar. Should any. of tbe cau tic dissolve in the tears, the eye must be copiously bathed with warm milk. At the instant the caustic is applied, the patient complains of a most acute pain; but tliis aggravation is amply compensated, by the ease experi- diced a few minutes after the operation: the burning heat in tiie eye ceases, as it were by a charm; the eye and eye- lids become capable of motion without pain ; tbe flux of tears and the turgidity of the vessels of the conjunctiva de- crease ; the patient can bear a moderate light, and enjoys repose. These advan- tages hist while the eschar adheres to tiie cornea. On the separation of the eschar some- times at the end of two, three, or four days after the application of the caustic, the primary symptoms of the disease recur, especially the smarting and burn- ing pain at the ulcerated part of the cor- nea ; the effusion of tears; the restraint in moving the eye and eyelids ; and the aversion to light; but all these inconve- niences are less in degree than before. At their recurrence, the surgeon, without delay, must renew the application of the argentum nitratum, making a good es- char, as at first, upon the whole .surface of the ulcer, which will, as before, be followed by perfect ease in the eye. The application of the caustic is, if required, to be repeated a third time, that is, if upon the separation of the eschar, the extreme irritability in the ulcer is not exhausted, and its progressive mischief checked. When the case goes on favour- ably, it is a constant phenomenon in the cure of this disease, that, at every sepa- ration of the eschar, the diseased sensi- bility of the eye is decreased, the ulcer also, abandoning its pale ash-colour, assumes a delicate fleshy tint, a certain Sign that the destructive process wliich prevailed, is turning into a healing one. The turgid state of the vessels of the conjunctiva, and the degree of ophthalmy, disappears, in proportion ,as the uicer draws near to a cure. At this epoch, when the formation of granulations has begun, the surgeon would act very wrongly, did he continue longer tlie use of the argentum nitratum; it would now reproduce pain, effusion of tears, and inflammation in the eye; and the ulcer would take on that foul ash-coloured aspect, with swelled and irregular edges, which it had in the beginning. Platner has noticed tliis fact. Necesse est, ut hoc temperutd numu, nee crebrius fiat, ne nova inflammatio, novaque lachryma hie acrioribus concitetur. Inst. Clui~urg. *§ 314. As soon as ea^e is felt in the eye, and granulations begin to rise, whether after the first, second, or third application of the caustic, the surgeon must refrain from the use of every strong caustic, and use no other application than the vitriolic collyrium. fy Zinci Vitriolgr. iv. in Aq. Rosx ^iv cum j§ss mucil. Sem. Cydon, mali M. To be used every two hours, defending the eye, in the intervals, from the contact of the air and light, by means of a slight com- press, and retentive bandage. In cases in w hich, besides the ulcer of the cornea, a slight relaxation of the conjunctiva remains, Janin's ointment, towards the end of the treatment, introduced be- tween the eye and eyelids, morning and evening, proves extremely serviceable. It must be qualified in strength and quantity to the particular sensibility of the patient. To cure those superficial excoriations ofthe cornea, which make no incavation in the substance of this membrane, and which, in reaUty, are only a detachment of the cuticle, covering the layer of the conjunctiva continued over the cornea, the use of caustic is not requisite. The above vitriolic collyrium, combined with the mucilage, is sufficient. The symp- toms which accompany such slight excori- ations, or detachments ofthe cuticle, are unimportant, and when the patient takes care to bathe his eye, every two or three hours, with the solution of vitriol, and to avoid too much light, and the impres- sion of thp atmosphere, they soon get well. Thus far of the ulcer of the cornea, and the best mode of curing it in ordinary cases. However, sometimes, in conse- quence of ill-treatment, the ulcer, al- ready very extensive, assumes the form of a fungous excrescence upon the cornea, appearing to derive its nourishment from a band of blood-vessels of the conjunc- tiva ; and, on this account, it occasions, not unfrequently, a serious mistake in being taken for a real pterygium. Left to itself, or treated with slight astrin- gents, it produces, in general, a loss ofthe whole eye. It requires the speedy adoption of some active and efficacious plan, to de- stroy all the fungus upon the cornea, to annihilate the vessels of the conjunctiva tending to it, and to impede the progress of ulcerati-.n. This consists first in cut- ting away the fungus, with a pair of small scissars, to a level with the cornea, con- tinuing the incision fur enough upon the conjunctiva, to remove, with the ex- crescence, that string of blood-vessels, from which it seems to derive its supply. 312 CORNEA. Having effected this, and allowed the blood to flow freely, it is proper to apply the argentum nitratum to all the space of the cornea, which appeal's to have been the seat of tiie fungus, so as to make a complete eschar; and if, upon its sepa- ration, the whole morbid surface should not be destroyed, the caustic must be repeated, until the ulcerative process changes into a healing one. To execute commodiously such a full appUcationof the caustic, it is not in general enough to have the upper eye-lid raised by an assistant, and the lower one depressed ; it is also further requisite, that the ope- rator, by means of a spatula, introduced between the upper eye-lid and ,the eye- ball, should hold the same elevated with his own left hand, while, with the right, he appUes the caustic, so as to form a strong deep eschar. It must be acknowledged, the action of the caustic cannot always be calculated with precision, and therefore a portion of the whole thickness of the cornea may be destroyed with the fungus, which never fails- to be followed by a prolapsus of part of the iris, through the aperture made in the cornea. This accident may seem to some very grievous ; it is, how- ever, not irreparable, as shall be shewn in the article Iris, prolapsus of; and when the surgeon can produce a firm cicatrix at the point, where the excrescence was situated, which resists a reproduction of the fungus, and a total destruction of the eye, he has fulfilled the indications required. (Scarpa, sulle Mulattie degli Occhi.) OSSIFICATION OF THE CORNEA. j Mr. Wardrop has seen only one instance of ossification of" the cornea; and, in that case, the whole eye was changed in its form, and the cornea had become opaque. On macerating the latter part, a piece of bone, weighing two grains, oval shaped, hard, and with a smooth surface, was found between its lamellje. A piece of bone was also found between the choroid coat and retina ofthe same eye. The same gentleman informs us, that Walter had, in his museum, a piece of cornea, taken from a man sixty years of age, and containing a bony mass, which was three lines long,. two broad, and Weighed two grains. In Mr. Wardrop's publication, there is also recorded a curious case, in which a portion of bone was formed, either in the substance of the cornea, or immediately behind it, and which was extracted from the eye by Mr. Anderson, surgeon at Inverary. The patient was a woman thirty-one years of age, and the forma- tion of the bony substance, which was about half as large as a sixpence, is said to have been occasioned by' a fall against the root of a tree, fifteen years be- fore the operation, by which accident the eye was struck, though not cut. (See Wardrop's Essays, on tlie Morbid Anatomy*, of the Human Eye, Chap. 10.) ALTERATION IN THE FORM OF THE CORNEA. Tliis is the last subject which I shall take notice of in tlie present article. It is well known, thai the convexity of the cornea varies in different persons, and in the same individual at different periods of life, this part of the eye being naturally most convex in young subjects. It ap. pears, also, from the experiments of the late Mr. Ramsden, and those of Mr. Home, that the sphericity of the cornea is altered according to the distance, at which objects are viewed. Sometimes the cornea projects, or col- lapses, so considerably, without its trans. parency being affected, that sight is much impaired, or quite destroyed. The first case has been called by some authors, the Staphyloma pellucidum ; the second Rhyti- dosis. Leveille, the French translator of Scar- pa's book on the diseases of the eye, has described a case, in which the cornea of both eyes became of a conical form. Mr. Wardijop has met with two examples of a similar disease; but only one eye was af- fected in each of them. In both cases, the conical figure of the cornea was very remarkable, and the apex of the cone was in the centre of the cornea. When the eye was viewed laterally, the apex re- sembled a, piece of solid crystal, and when looked at directly opposite, it had a trans- parent sparkling appearance, which pi-e- vented the pupil and iris from being dis- tinctly seen. One of these cases occurred in a lady upwards of thirty years of age, and the changes, produced in her vision, were- very remarkable. At the distance of an. inch, or an inch and a half, she could plainly distinguish small objects, when held towards the temporal angle ofthe eye, although it required considerable ex- ertion ; but, the sphere of vision was very limited. On looking through a small hole in a card^she could distinguish objects held very close to the eye, and could even read a book. At any distance greater, than two in- ches, vision was very indistinct, and, at a few feet, she could neither judge of the distance, nor the form of the object. CORNS. 313 When she looked at a distant luminous Body, such as a candle, it was multiplied five or six times, and all the images were more or less indistinct. She could never find any glass sufficiently concave to as- sist her vision. She did not remark this complaint in her eye, until she was about sixteen years of age, and she does not think, it has undergone any change since that time. In Mr. Wardrop's publication may be read a letter from Dr. Brewster, giving an explanation of the phenomena of the fore- going case. It appears, that Mr. Phipps has had opportunities of watching the progress of several cases, in which the cornea had become conical, and that he never saw the disease in persons under the age of four- teen, or sixteen. The same gentleman also observes, that when the cone is once complete, the disease seldom makes any further progress, except that the apex sometimes becomes opaque. Burgman saw a remarkable case, where the cornea of both the eyes of a person, who was hanged were so prodigiously ex- tended, that they reached down to the mouth, like two horns. (Haller, Disputa- tiones Chirurg. Tom. 2) The chapter by Mr. Wardrop on the preceding subject will be found highly interesting to such as are desirous of further information concerning this curious disease of the eye. (See Wardrop's Essays on the Morbid Ana- tomy of the Eye, Chap. 13.) CORNS, (Clavi, Spina Pedum, Colli, Condylomata,hc.) A corn, technically called clavus, from its fancied resemblance to the head of a nail, is a brawn-like hardness of the skin, with a kind of root sometimes extending deeply into the subjacent cellu- lar substance. When this is the case, the indurated part is fixed; but while the hardness is more superficial, it is quite moveable. Some corns rise up above the level of the skin, in the manner of a flat wart. They are hard, dry, and insensi- ble, just like the thickened cuticle, which forms on the soles of the feet, or on the hands of labouring people. Corns are entirely owing to repeated and long-continued pressure. Hence, they are most frequent in such situations as are most exposed to pressure, and where the skin is near bones, as on the toes, soles of the feet, &c. However, corns have oc- casionally been seen over the crista of the ilium, from the pressure of stays, and even on the ears, from the pressure of heavy ear-rings. Corns of the feet are usually owing to wearing tight shoes, and, consequently, they are more common in the higher clas- ses, and in women, than other subjects. Vol.. 1 In females, indeed, the ridiculous fashion of wearing high-heeled shoes, was very conducive to this affliction; for, certainly, it merits the appellation. In shoes thus made, the whole weight of the body falls principally on the toes, which become quite wedged, and dreadfully compressed in the end of the shoes. Though some persons, who have corns, suffer very little, others occasionally en- dure such torture from them, that they are quite incapable of standing or walk- ing. Doubtless the great pain proceeds from the irritation of the hard corn on the tender cutis beneath, which is frequently very much inflamed, in consequence ofthe pressure. It is observed, that every thing which accelerates the motion of the blood, which heats the feet, which increases the pressure of the corn on the subjacent parts, or the determination of blood to tbe feet, or wliich promotes its accumulation in them, exasperates the pain. Hence, the bad effects of warm stockings, tight shoes, exercise, long standing, drinking, &c. The pain in warm weather is always much more annoying than in winter. If a person merely seeks temporary re- lief, it may be obtained by pulling off his tight shoes, sitting down, placing his feet in a horizontal posture, and becoming a little cool, the prominent portion of the corn should be cut off, as far as it can be done, without exciting pain, or bleeding, and the feet should be bathed in warm water. The radical cure essentially requires the avoidance of all the above causes, and, particularly, of much walking, or stand- ing. Wide, soft shoes, should be worn. Such means are not only requisite for a radical cure, but they alone very often ef- fect it. How many women become spon- taneously free from corns in child-bed, and other confinements? Though the radical cure is so easy, few obtain it, be- cause their perseverance ceases as soon as they experience the wished-for relief. When business, or other circumstances, prevent the patient from adopting this plan, and oblige him to walk or stand a good deal, still, it is possible to remove all pressure from the corn. For this purpose from 8 to 12 pieces of linen, smeared with an emollient ointment, and having an aperture cut in the middle, exactly adapt- ed to the size of the corn, are to be laid over each other, and so applied to the foot, that the corn is to lie in the opening, in such a manner, that it cannot be touched by the shoe, or stocking. When the plaster has been appUed some weeks, the corn commonly disappears, without any other means. Should the corn be in the sole of the foot, it is only necessary S s ^14 COR CUT to put in the shoe a felt sole wherein a hole has been cut corresponding to the situation, size, and figure, ofthe indura- tion. A corn may also be certainly, perma- nently, and speedily eradicated, by the following method, especially when the plaster, and felt-sole with a hole in it, are employed at the same time. The corn is to be rubbed twice a day with an emollient ointment, such as that of marshmallows; or with the volatile liniment, which is still better; and in the interim, is to be covered with a softening plaster. Every morning and everting, the foot is to be put for half an hour in warm water, and whilst there, the corn is to be well rubbed with soap. Afterwards, all the soft, white, pulpy outside of the corn, is to be scraped off with a blunt knife; but, the SBT-wping is to be left off, the moment thr patient be- gins to complain of pain from it. The same treatment is to be persisted in, with- out interruption, until the corn is totally extirpated, which is generally effected in eight or twelve days. If left off sooner, the corn grows again. A multitude of other remedies for cur- ing corns are recommended. They all possess, more or less, an emolUent and discutient property. The principal are green wax, soap, mercurial, and hemlock plasters, a piece of green oil-skin, &c. They are to be applied to the corn, and renewed as often as necessary. An infal- Uble composition consists of two ounces of gum ammoniacum, the same quantity of yellow wax, and six drams of verdi- grease. In a fortnight, if the corn yet remain, a fresh plaster is to be applied. It is frequently difficult, and hazardous to cut out a corn. The whole must be completely taken away, or else it grows again; -..nd tiie more frequently it is par- tially cut away, the quicker is its growth rendered. When the skin is moveable, and, consequently, the corn not adherent to the subjacent, parts, its excision may be performed with facility and safety, but, not without pain. But, in the opposite case, either leaving a piece of the corn behind, or wounding the parts beneath, can seldom be avoided. The latter cir- cumstance may excite serious mischief. A person, entirely cured of corns, is sure to be affected with them again, unless the above mentioned causes be carefully avoided. Some subjects are, indeed, more or less, disposed to have the complaint. There are persons, who for life wear tight shoes, and take no care of their feet, and, yet, are never incommoded with corns. On the contrary, others are constantly troubled with them, though they pay at- tention to themselves. Many are for a time vexed with corns, and then become quite free from them, though they conti- nue to wear tiie same kind of shoes and stockings. The above account is chiefly taken from Richter's Anfansgr&nde der Wundarzney- kunst. Band. 1 CORONOID PROCESS OF THE JAW; CORONOID PROCESS OF THE ULNA. For fractures of these parts, turn to Frac- ture—Fractures of the Lower Jaw—Frac- tures ofthe Ulna. CORROBORANTS Strengthening me*- dicines, or applications. CORTEX PERUVIANUS. (See Ci*. chona.) . COUCHING. The depression of the cataract, or the introducing of an instru- ment into the ey^, for the purpose of pressing the opaque crystalline lens down- Ward, out of the axis of sight. (See Ca- taract.) f COUVRE-CHEF. The name of some bandages. See Bandage. COXARIUS MORBUS. The ischias, or disease ofthe hip. See Joints. COXENDIX. (from coxa, the hip.) The ischium; the hip-joint. For an ac- count of the disease of the hip-joint, see Joints. CRANIUM, (quasi x*%xitoi, from **f«, the head.) The skull. For an account of its fractures, see Head, Injuries of. CREMOR LITHARGYRI ACE TATI. 9t Cremoris lactis 3j. Aq. litharg. acet. 3;j. M. Employed by Kirkland in ophthalmies, and other inflammations. CREPITATION. This term is often applied to the crackling noise, made in cases of emphysema, when the air is pass- ing from one part ofthe cellular membrane into another. CREPITUS, (from crepo, to make a noise.) This term is appUed by surgeons to the grating sensation, occasioned by the ends of a fracture, when they are moved, and rubbed against each other. A crepitus is one of the most positive symptoms of the existence of such an ac- cident. CRYPSOR'CHIS. A concealment of the testis within the abdominal ring. CRYSTALLINE LENS, (from *?f«*A- Xoe, crystal.) See Cataract. CUPRUM VITRIOLATUM. (Sulphate of Copper) is an escharotic, and an in- gredient in several astringent fluid appli- cations, lotions for ulcers, coUyria for the eyes, and injections for the urethra. CURVATURE OF THE SPINE. See Vertebrx, Disease of. CUTANEOUS NERVES OF THE DEC D E#C 315 ARM. The effects supposed to arise oc- casionally from these nerves being wound- ed in venesection, are spoken of in the article, Bleeding. CYSTIDES. (from *wone on the other, tend to produce this efle*t. Such was the action of the ladder, door, Ike. described in Hippocrstes's Trertwe on Fractures, and repotted in moilern works. Sometimes, the trunk is fixed in •an unchangeable manner, while the arm is powerfully extended, as is practised in employing the machine of Oribasius, and was one of the method's formerly adopted in the public places, where the wrestlers comba'ed. Sometimes, no extension is sensibly-ex- ecu'ed and while the end of the humerus is pushed'outward by a body placed un. der the axilla, the surgeon pushes it up- ward into the glenoid cavity. ,m We shall not here inquire into the in- conveniences peculiar to each of these methods. Petit and B. Bell have already don**- so. \\ e shall only point out the ob- jections, common to all of them. The exit of the head of the bone, DISLOCATION 339 through the lacerated capsule is not ne- cessarily attendant on tlie dislocation. Nor is it even possible to know with pre- cision the situation of this opening. Why then should we make use of an artificial force to direct the head of the bone to- wards tliis opening ?- However covered the body, placed un- der the axilla, may be, to serve as a ful- crum, there is always a more or less in- convenient chafing, frequently dreadful stretching and laceration of parts, in con- sequence of its application, when the trunk is suspended upon it, as in the in- stance of the door, &c. In this way, Pe- tit has seen a fracture of the neck of the humerus produced, and even a laceration and aneurism of the axillary artery. Few surgeons have ready at hand the different kinds of apparatus. Hence, trouble and loss of time in getting them ; time, which is of so much moment in the reduction; this being always the more easy, the sooner it is accomplished. When the luxation is consecutive, how can mechanical means bring back the head of the bone, through the track it has taken ? For instance, if to a dislocation downward one inward has succeeded, the head of tbe bone must necessarily be brought down, before it can be replaced in its cavity. The above artificial means often act repugnantly to the action of the muscles, which is a chief and essential agent in the reduction. If the dislocation should be upward, they would obviously be ineffectual. Perhaps, however, they might be ad- vantageously employed, when a primitive luxation downward is quite recent, and when the head ofthe bone is very near its cavity. Then the inferior costa of the scapula presents an inclined plane, along which the end of the bone can easily glide, when propelled by any kind of external force. No doubt, it is to this tendency of the head of the bone to be replaced, that we must attribute the success, certainly exaggerated, but in part real, on which .the inventor of such machines endeavours to establish the superiority of his plan. - But/ in this case, it is useless to multi- ply artificial powers, when natural means suffice, and when we can accomplish the reduction with tlie hands more effectually, because we can vary the motions with more precision. Thus Desault very often employed the following method with great success. The patient being seated upon a chair of mo- derate height, he took hold of the hand on the affected side, placed it between hrs knees, which he moved downward and backward, in order to make the extension, and disengage the head of the bjne, while an assistant held back the trunk to effect the counter-extension. This was some- times executed by the weight of the body, and effort of the patient. At the same time, the surgeon's hands applied to the arm, in such a way, that the four fingers of each were put on the hollow of the axilla, and the thumbs on the outer part of the arm, pushed upward, and a little outward, the head of the humerus, which usually returned with ease into its natural cavity. Petit explains this plan, though not as here described^ but complicated with the use of a napkin, passed under the patient's axilla, and over the surgeon's neck, who contributes to raise the dislocated end of the bone, by lifting up his head. This accessory method is always useless, and little methodical, preventing, also, such variation ofthe motions, as one may wish. The hands alone are always sufficient, and a multitude of instances attest the efficacy of this method, employed in De- sault's way. When the luxation downward has been very recent, Desault has, two or three times, succeeded in reducing it, by a still more simple process. Maria-Louise Fa- vert fell in going down stairs, dislocated her arm downward, and was conveyed, immediately after tiie accident, to tbe Hotel Dieu.,, Desault having recognized the disorder, placed his left hand under the axilla, to serve as a fulcrum, while with the right, applied to the lower and outer part of the arm, he depressed the humerus towards the trunk, and at the same time raised the upper part of the bone. The head ofthe humerus directed upward and outward by this, double mo- tion, returned into the glenoid cavity, without the least resistance. The arm was placed in a sling for two days, and, on the fourth, the patient resumed her wonted labour. Dislocation downward are not the only ones, to which the first of the above sim- ple plans is applicable. Primitive luxa- tions inward sometimes yield to its adop- tion. Two examples of such success are to be found in the Journal de C/iirurgie. REDUCTION BV EXTENSION ALONE. For the most part, however, such means are inadequate, and extension must be made. This employed alone, forms a se- cond sort of means for reducing disloca- tions of the shoulder, and a few practi- tioners have deviated from the beaten path, and tried this latter plan. Celsus had recourse to nothing but extension in the ordinary cases of dislocation down- ward and forward. Albucasis was ac- 340 DISLOCATION. quainted with no other mode. Deuey, Douglas, and Heister, among the mo- derns, have absolutely rejected the use of machines, as always useless, and frequent- ly dangerous/ Lastly, Dapoui and Fabre examined with more exactness the pro- cess of extension, pointed out the manner of rendering it most advantageous in all cases, by the proper application of the extending force ; and, in the dislocation of the humerus in particuL.r, they obviated the inconvenience of pulleys, placed un- der the arm-pit 0:1 the affected side, shew- ing that the motion, vulgarly termed, co- aptation, was of no utility. In these re- spects, the art is indebted to them for real improvement, and their doctrine, now uni- versally diffused, was principally put into practice by Desault, who made it the base of his method of reducing aU fractures, and dislocations in general. To reduce a dislocation ofthe humerus, it is necessary to have a sufficient number of assistants, in order to increase the pow- er according to the resistance which is to be overcome. But, two are usually suffi- cient for making the extension : in doing which, one should employ a linen pad, of sufficient thickness to project above the level of the pectoralis major, and latissi- mus dorsi. There must also be two ban- dages ; one made of linen, several times doubled, four inches wide, and eight or nine feet long; the other being a towel, folded in the same way, and which is often unnecessary. The patient is to sit on a chair of mo- derate height, or else he may lie down upon a table, which is firmly fixed, and covered with a mattress. Desault, for a long while, used to put the patient in the first of these positions, which, though generally employed in practice, is not the best. In it the arm may be advantageously drawn in a trans- verse direction ; but if, as is ofteri the case, there be occasion to make extension upward or downward, the assistant is then obliged to rise up, and depress him- self, has not sufficient power, finds himself obstructed, and cannot vary, at the plea- sure ofthe surgeon, the direction in which the arm is to be extended. This position is also much more fatiguing to the patient, than one in which the trunk is equally supported upon a horizontal plane.— Hence, Desault, in the latter ye^rs of his practice, abandoned the first position, and invariably adopted the last. The patient being put in the proper position, the linen compress is to be put under the axilla, on the side affected, and upon this compress the middle of the first extending bandage is to he put, while its two heads ascending obliquely before and behind the chest, meet'each other at the. top of the sound shoulder, and are held there by an assistant, so as to fix the trunk, and make the counter-extension. The action ot this bandage does not affect the margin ot the pectoralis major and latis- simus. dorsi, in consequence of the pad projecting higher than them. If this were not attended to, these muscles being drawn upward, would pull in this direc- tion the humerus, to which they are at- tached, and would thus destroy the effect of the extension, whch is to be made in the following manner :— Two assistants take hold of the fore- arm above the wrist, or else the towel, doubled several t.mes, is to be applied to this part. The two ends are to be twivei together, and held by one or two assist- ants, who are to begin pulling in tiie same direction in which the humerus is thrown. After this first proceeding, which is de- signed to dist ngage the head of the bone from its ace.dental situation, another mo- tion is to be employed, which differs ac- cording to the kind of luxation. If tlui should be downward, the arm is to be gra- dually brought near the trunk, at the same time that it is gently pushed upward, Thus, the head of the bone being sepa. rated from the trunk, and brought near the glenoid cavity, it usually glides inta this situation with very little resistance. When the luxation is inward, after the extension has been made in the direc tion of the humerus, the end of this bone should be incUned upward and forward, in order that its head may be guided backward -j vice versa, when the luxation is outward..; ■ When the head of the bone has heea disengaged by the first extension, the mo- tion imparted to it by the rest of the ex- tension, should in general be exactly con- trary to the course which the head of the bone has taken, after quitting the glenoid cavity. When there is difficulty experi- enced in replacing the head ol the bore, we should, after making the extension, move the bone about in various manners, according to the different direction of the dislocation, and the principle just noticed. This plan often accomplishes what exten- sion aione cannot; and the head of the bone, brought by such movementstowards its cavity, returns into it, while they are being executed. x When the dislocation is a consecutive one, it is the first exten-ion, made in tlje direction of the displaced bone, which brings back its head to where it was pri- mitively lodged, in order to act upon the bonev afterwards, just as if the luxation were one of the primitive sort. Often it is only at the moment of the reduction, DISLOCATION. 341 that it is possible to distinguish, whether a luxation is of one or the other kind. Infleed, as the reduction mostly takes place of it-self, when tiie extension is pro- perly made, if tiie head be situated conse- cutively inward, it is seen to descend along the internal part of the scapula, then to proceed to the lower part, and, lastly, to ascend towards the opening of the cap- sule, into which opening it returns. When the extension is properly made, the reduction is almost spontaneously ef- fected. Indeed, whatever may be the kind of primitive dislocation, it is clear, that tlie muscles on one side of the articula- jBoa must be put upon tlie stretch, while those on the other must be relaxed. Hence, a change must necessarily follow both in their directions and contractions, and also in the direction of these contractions. From this change the muscles,-when they act, instead of drawing back the head of the bone towards the ruptured capsule, pull it in another direction, and thus pro- duce a consecutive dislocation. But, if by rectifying things, the exten- sion should chance to restore to the mus- cles their former direction, then obey ing their natural irritability, increased by the stretching of the extending power, they will bring back tbe head of tiie bone to the opening in the capsule, and oblige it to enter with much more certainty, than the efforts of the surgeon could do*, who is-always ignorant ofthe precise situation of this opening. On the contrary, if the extension, in consequence of not having been properly made, should not have re- stored to the muscles their natural direc- tion, then the head of the bone will be drawn to some other point of the capsule, away from that which has been lacerated: and hence arise tlie very frequent diffi- culties attendant on the-reduction of dis-' located shoulders. It follows from what has been said :-- 1. That all the art of treating disloca- tions, consists in giving a proper direc- tion to tiie extending force. 2. That in general the coaptation ia useless. 3. That reducing a dislocation does not consist in putting back the head of the bone into its cavity ; but, in putting the muscles in a proper state for accomplishing this reduc- tion,, and that here, as every where else, art is only the handmaid of nature. There are cases, however, in which the action ofthe muscles, being perverted by (he oldness of tlie dislocation, and by the adhesions contracted- with the surround- ing parts, it becomes necessary to employ such means, as will serve to force, as it were, tlie head ofthe bone into its cavity, whither the musctes cannot bring it. With reasoning is combined experi- ence, which is always the most effectual proof" of this doctrine, both respecting re- ductions of the dislocated humerus, and of such accidents in general. Desault only employed extension, variously diver- sified, till he had put the muscles in a state, favourable for accomplishing reduc- tion. The most prompt success constantly crowned this part of his practice, and, doubtless, much of this success must be imputed to his wisely refusing to interfere in too great a degree. When the reduction has been accom- plished, if the arm should be very move- able, and seem to have a tendency to be dislocated again, it must be fixed, for a few days, in such a way as will prevent all motion. A sling, well applied', suffices for this purpose; and, indeed, the arm should always be kept quietly supported in one, after a dislocation. The French apply the bandage, which Desault has recom- mended for the fractured clavicle. i OF SOME CIRCUMSTANCES, RENBERINO THE REDUCTION MORE DIFFICULT. 1. Narrowness of the opening ofthe Capsule. The opening of the capsule, being too narrow to allow the head of the bone to return into the glenoid cavity, is one ofthe chief impediment* to reduction. The ob- vious indication is to enlarge such an opening, bv lacerating its edges. This is fulfilled by moving the bone about freely, in every direction, particularly in that in which the dislocation has taken place. Now, by pushing the head of the bone against the capsule already torn, the lat- ter becomes lacerated still more, in con- sequence of being pressed between two hard bodies. The reduction, which is frequently impracticable before this pro- ceeding,- often spontaneously follows, im- , mediately ^ftei it has been adopted. In the Journal de Chirurgie are two cases, by Anthaume, and Faucheron, establishing this doctrine. Mr. White, Of Manchester, believed, that the reduction was sometimes pre- vented by the head of the bone not being able to get through the laceration in the capsule again. He succeeded in reducing some such cases in the following manner: having screwed an iron ring into a beam at the top ofthe patient's room, he fixed one end of the pulleys to it, and fastened the other to the dislocated arm by liga- tures about the wrist, placing the arm in an erect position. In this way, he drew up the patient, till his whole body was suspended; but, that too much force might not be sustained by the wrist, Mr. 342 DISLOCATION. White at the same time directed two other persons to support tiie arm above the el- bow. He now u-ed to try with his hands to conduct the arm into its place, if the reduction had not already happened, as was sometimes the case. Occasionally, a snap would be heard, as soon as the pa- tient was drawn up; but, '.he reduction could not be completed, till he was let down again, and a trial made with the heel in the arm-pit. When no iron ring was at hand to suspend the patient from, Mr. White used to have the patient raised from the ground by three or four men, who stood upon a table. (Cases in Surge- ry, by Charles White, F. R. S.p. 95) 2. Oldness ofthe Dislocation. This is a second impediment to reduc- tion, still more difficult to surmount than the foregoing one. The head ofthe bone, which has lodged a long while in its ac- cidental situation, contracts adhesions to, it. The surrounding cellular substance becomes condensed, and forms, as it were, a new capsule, which resists reduction, and which, when such reduction cannot be accomplished, supplies, in a certain degree, the office of the original joint, by the motion which it allows. The majority of writers, and Bell in particular, advise, in this case, that no attempt at reduction should be made, as it would be useless in regard to the dislo- cation, and might be injurious to the pa- tient, from the excessive stretching of parts. This was for some time the doc- trine of Desault; but, in his latter years, experience led him to adopt a bolder prac- tice. Complete success, obtained in disloca- tions, which had existed from fifteen to twenty days, encouraged him to attempt reduction at the end of thirty, and thirty- five days, and, in the two years preceding his death, he succeeded, three or four times in reducing dislocations which had existed two months and a half, and even three months, both when the head of the bone w:.s situated at the lower, and at the internal part ofthe scapula. However violent or protracted the ex- tension may have been, none of the terri- ble consequences with which, authors threaten us, ever occurred. One pheno- menon, which it was difficult to foresee, and of which we shall speak presently only took place in two instances. In these cases it is necessary, before making the extension, to move the bone about extensively in all directions, for the purpose of first breaking its adhesions, lacerating the condensed cellular sub- stance, serving as an accidental capsule, and of producing, as it were, a second dis- location, in order to remove the first Extension is then to be made in the \i. dinary way, but with an additional num- ber of assistants. The first attempts frequently fail, and the. dislocated head of the bone continues unmoved, notwithstanding the most vio- lent efforts. In this case, after leaving off the extension, the arm is to be again moved about most extensively. The liu- merus is to be carried upward, down- ward, forward, and backward. Force the resistances. -. Let the arm describe a large segment of a circle, in the place where it is situated. Let it be once more rotated>m its axis; then let the extension be repeated, and directed in every way. Thus, the head of the bone will be first disengaged by the free motion, and will afterwanls be reduced. In these cases, when the dislocation, in consequence of being veiy old, presents great obstacles in tiie way of reduction, even though the attempts made for this purpose should fail, they are not entirely useless. By forcing tbe head of the bone to approach the glenoid cavity, and even placing it before the cavity, and making it form new adhesions, after ihe destruc- tion of the old ones, the motions of the arm are rendered freer. Indeed, they are always the less obstructed, the nearer the head of the bone is to its natural si- tuation. 3. Contractions ofthe Muscles. A third impediment to the reduction of every kind of dislocation, is tiie power of the muscles, which is augmented beyond the natural degree, in consequence of their being on the stretch. Sometimes, this power is so considerable, that it ren- ders the head of the bone immoveable, though the most violent efforts are made. Here the means to be adopted are such as weaken the patient, bleeding, the warm bath, &c. Extension unremittingly, • but not violently, continued for a length of time, will ultimately fatigue the resisting muscles, and overcome them with more safety and efficacy, than could be accom- plished by any sudden exertion'of force. The swelling about the joint, brought on by the accident, usually disappears without trouble. Another consequence, which seldom oc- curs in practice, concerning which, authors have scarcely said any thing, and which Desault several times had occasion to ob- serve, is a considerable emphysema, sud- denly originating at the time of rediiction. In the middle of such violent extension, as the loug standing of the dislocation re- DISLOCATION. 341 quires, a tumour suddenly makes its ap- pearance under the great pectoral muscle. Kapidly increasing, ft spreads towards the arm-pit, the whole extent of which it soon occupies. It spreads backward, and, jn a few minutes, sometimes becomes as large as a child's head. A practitioner, unacquainted with this accident, might tike it for an aneurism, occasioned by the sudden rupture of the axillary artery, from the violent extension. Hut, if at- tention be paid to the"* elasticity of the tumour, to its fluctuation, to the situation where it first appears, commonly under tlie great pectoral muscle, and not in the axiUa ; to the continuance of the pulse; and to the unchanged cofoucpf the skin; Hhe event may easily be discriminated from any rupture o* the artery. (CEuvres Chirurg. de Desault, par Bichat, Tom. 1) The saturnine lotion, and gentle com- pression with a bandage, are the most ad- vantageous means for dispersing the above kind of swelling. I shall conclude the subject of luxations ofthe shoulder with the following singu- lar observation recorded by M. Larrey. -" Among the curious anatomical pre- parations, (says he) which I »awvin the cabinet ofthe University of Vienna, there was a dissected thorax, shewn to me by Professor Prokaska, in which the whole orbicular mass of the head of the right humerus, engaged between the second and third true ribs, projected into the cavity ofthe chest. This singulir displacement was the result of an accidental luxation occasioned by a fall on the elbow, while the arm was extended and lifted from the Side. The head of the humerus, after tearing the capsidar ligament, had been violently driven into the hollow of the axilla, under the pectoral muscles, so as to separate tlie two corresponding ribs, and pass between them. The diameter ofthe head of the bone surmoun'ed this obstacle, and penetrated entirely into the cavity ofthe thorax, pushing before it the adjacent portion of the pleura. Erery possible effort was made in vain to reduce this extraordinary dislocation. The ur- gent symptoms, which arose were dissi- pated by'bleeding, w.um bathing, and an- tiphlogistic remedies. The arm, how- ever, rem:*ined at a distance from the Side, to which condition, the patient became gradually habituated, and, after several ve.irs of suffering and oppression, he at length experienced no inconvenience. The patient was about sixteen or seventeen, when be met with the accident; and he lived to the age of thirty-one, when he died of some disease, which had no con- cern with the dislocation. His physicians were anxious to ascertain the nature of this curious case, of which they had beei» able to form only an imperfect judgment. They were much surprised to find, upon opening the budy, the head of the hume- rus lof'./cd in the chest, surrounded by the pleura, and its neck closely embraced by the two ribs above specified They were still more astonished to find, instead of a hard spherical body covered with carti- lage/ only a vt-ry soft membranous ball, which yielded to the slightest pressure of the finger. The cartil. ge and osseous texti-re of the whole portion ofthe hume- rus, contained within the cavity of the chest, had entirely disu-peaved. Les ab- sorbans s'en elaient emparifs, (says M. Lar- l-iy) et comme autant tie gardiens fideles, ils avaient cherche d detruire par portions, n' ayant pu Pexpulser en masse, un ennemi qui .s'etaitfurtivement introduit dans un domicile on sapresence devait etreimpottune et nuisiblc Of the humerus, there only remained some membranous rudiments of its head, and a great part of these seemed to belongto the pleuracostalis." (See Larrey''sMemoiresde Chirurgie MilitOire, Tom. 2, p. 40S—407.) DISLOCATION OF THE FORE-ARM FROM TBI HUMERUS. Notwithstanding the extent ofthe arti- cular surfaces ofthe radius and ulna wiih the o*, humeri, the strength of the muscles and ligaments surrounding the joint, and the mutual reception of the eminences, which m ikes it a perfect angular gingly- mus, a dislocation of these two bones off the humerus, may take place at the same time. They are most frequently luxated backward; sometimes laterally, but very rarely forward: the latter luxation can- not occur without a fracture of ; he olecra- non. Indeed, it is so uncommon, that neither Petit nor Desault ever met with it. The luxation backwards is facilitated by the small size of the coronoid process, which may slide behind the humerus, when this is forcibly pushed downwards and forwards, and ascend as high as the cavity, which receives the olecranon dur- ing the extension of the fore-arm. Luxations laterally are much less fie quent, and are always incomplete. The great extent of the articular surfaces in the transverse direction, the reciprocal union of their inequalities, and especially the slrength ofthe ligaments and muscles, which, arising from the internal and ex- ternal condyles of the inferior extremity of the humerus, go to the fore-arm and hand, give great strength to the articula- tion, and render it impossible to effect by any violence, a complete luxation la- terally. In the luxation backwards, the radius 344 DISLOCATION. and ulna may ascend more or less behind the humerus; but the coronoid process of tlie ulna is always carried above the arti- ticular puUey, und is found lodged in the cavity destined to receive the olecranon. The head of the radius is placed behind and above the external condyle of the hu- merus. The annular ligament, which confines the superior extremity of the ra- dius to the ulna, may be lacerated: in which case, even when the bones are re- duced, it is difficult to keep them in their proper places, as the radius tends con- stantly to separate from the ulna. This luxation always takes place from a fall on the hand; for, when we are foil- ing, we are led by a mechanical instinct to bring our hands forwards to protect the body. If in this case the superior extremity, instead of resting vertically on the ground, be placed obliquely with the hand nearly in a state of supination, the repulsion which it receives from the ground will cause the two bones^of the "fore-arm to ascend behind the humerus, whilst the weight of the body press- ing on the humerus, directed oifiquely downwards, forces its extremity to pass down before the coronoid process of the ulna. The fore-arm, in this luxation, is in a state of half-flexion, and every attempt to extend it occasions acute pain. The si- tuation of the olecranon, with respect to the condyles of the humerus, is changed. The olecranon, which, in the natural state, is placed on a level with the external condyle, which is itself situated lower than the internal, is even higher than the latter. This luxation may be mistaken for a fracture of the olecranon, of the head of the radius, or even of the inferior extre- mity of tiie humerus. Such a mistake is attended with very bad consequences ; for, if the reduction be not effected before the end of fifteen or twenty days, it is of- ten impossible to accomplish it afterwards. The swelling which supervenes in twenty. four hours after the accident, renders a diagnosis more difficult; but the olecranon and internal condyle, are never so ob- scured, that the distance between them cannot be found to be increased, though Boyer makes a contrary assertion. It is true, that the rubbing of the coronoid process and olecranon against the hume- rus, may cause a grating noise, similar to that of a fracture; and some attention is certainly requisite to establish a diagnosis between a fracture of the head of the ra- dius, and a dislocation of the fore-arm backwards. The following method of reducing the case is advised by Boyer:—The patient being firmly seated, an assistant is to take hold of the midlife part of the humerus, and make the counter-extension, while another assistant makes extension at the inferior part of the fore-arm. The sur. geon, seated on the outside, grasps tlie elbow with his two hands, by applying the fore-fingers of each to the anterior part of the humerus, and the thumbs to the posterior, with which he presses on the olecranon, in^i direction downwards and forwards. This method will be in general successful. If the strength ofthe patient, or the long continuance of the luxation, render it necessary to employ a greater force, a fillet is to be applied on the wrist, »io make extension, and a cushion is to be placed in the axilla, and the arm and trunk fixed, as is done in cases of luxation of the humerus. A bandage may afterwards be applied, in the form of a figure of 8, and the arm is to be kept in a sUng. The laceration which always takes place, is invariably fol- lowed by more or less swelling, which is to be combated by antiphlogistic means. At the end of seven or eight days, when the inflammatory symptoms are nearly gone, the articulation is to be gently mov- ed, and the motion is to be increased every day, in order to prevent an anchy- losis, to which there is a great tendency. In this luxation, the annular ligament which confines the head of the radius to the extremity of the ulna, is sometimes torn, and the radius passes before the ulna. In such cases, pronation and su. pination are difficult and painful, though the principal luxation has been reduced. The head of the radius may be easily re- placed, by pressing it from before back- wards, and it is to be kept in its place by a compress, applied to the superior and external part of the fore-arm. The ban- dage and compresses, are to be taken off every two or three days, and re-applied. This is necessary, on account of the ne- cessity of moving the articulation to pre- vent an anchylosis. If the luxation be not soon reduced, it becomes irreducible; the heads of the ra- dius and ulna grow to the back part of the humerus, and the patient can neither bendnor extend his arm. However, in certain cases, especially in young persons, some motion is acquired in time ; the heads of the radius and ulna making in the humerus cavities, in which they per- form some motions, but always imper- fectly. The luxation forwards should be treated as a fracture ofthe olecranon, with which it would be inevitably accompanied. It may be necessary, on account of the great injury done to the soft parts, to bleed the DISLOCATION. 345 patient copiously, and put him on an an- tiphlogistic regimen. As to the lateral luxations, either in. wards or outwards, they are always in- complete, and easily discovered. They are reduced by drawing the humerus and fore-arm in contrary directions, and at the same time pushing the extremity of the humerus, and the >wo bones ot the fore-arm in opposite directions. These luxations cannot be produced without considerable violence; but when the bones are reduced, they are easily kept in their place. It will be sufficient to pass a roller round the part, to put the fore-arm in a middle state, neither much bent nor extended, and to support it in a sling. But much inflammation is to be expected from the injury done to the soft parts. In order to prevent it, or at least mitigate it, the patient is to be bled two or three times, and put on a low diet, and the articulation is to be covered with the lotio aq. litharg. acet. Boyer, however, has recommended emollient cataplasms. It is scarcely necessary to repeat, that the arm is to be moved as soon as the state of the soft parts will admit of it. ( Boyer's Legons sur les Maladies Des Os, Tom 2.) The dislocation of the fore-arm back- ward, is said to occur ten times as fre- quently as lateral luxations; and those forward are so rare, that no comparison whatever can be drawn. (GSuvres Chi- rurgicales de Desault par Bichat, Tom. I.) Lateral luxations have been divided into complete, that is, when the articular surfaces have entirely lost their state of reciprocal contact; and into incomplete, that is, when only one bone, or a part of it, is thrown off the hurnenis. But, what cause can operate with sufficient force to produce the first occurrence ? The mis- chief would also be so great, were such a case to happen, that amputation would most likely be requisite. The incomplete lateral luxation may be produced by a blow, which drives the up- per part of the fore-arm violently out- ward, or inward. A footman, says Petit, in falling from a coach, had his arm en- tangled in the spokes of a wheel, and a dislocation outward was the consequence. Another man luxated his fore-arm inward, by falling from his horse and driving his arm against an uneven place. When tiie ulna is pushed into the situa- tion of the ndius, the space, between the olecranon and internd condyle, is much greater, than is natural. These points of bone are always very distinguishable, let the joint be ever so much swollen; and hence, the information to be derived from mt examination of them, may be obtained Voi. I. in every case, without exception. Also, when the ulna is pushed into the place of the radius, the latter bone cannot be easily rotated, nor can the fore-arm be bent, and extended, in a perfect manner. The dislocation inward must be very uncommon, as the form of the bones is al- most an insurmountable obstacle to such an accident. It may happen, however, as the authority of Petit confirms. All recent dislocations of the elbow are very easily reduced, and as easily main- tained so; for the reciprocal manner in which the articular surfaces receive each other, and their mutual eminences and cavities, will not readily allow the bones to become displaced again. The application of a bandage in the form of a figure of 8, and supporting the arm in a sling, are proper in all these cases. DISLOCATION OF THE RADIUS FROM THE ULNA. * The majority of authors, who have written on dislocations of the fore-arm, have not separately considered those of the radius. Some detached observations, on luxations of its superior extremity, are to be found here and there; a subject, which Duverney alone has fully treated of. The dislocations of its lower end, which are more frequent, and easy of oc- currence, have almost escaped the notice of French, and, also, English writers. At present, cases of this sort have been so numerously collected, that a particular account of them may be offered. DIFFERENCE OF STRUCTURE, IIETWEEN THE TWO JOINTS OF THE RADIUS WITH THE ULNA. The radius, the moveable agents of pro- nation and supination, rolls round the ulna, wliich forms its immoveable sup- port, by means of two articular surfaces; ons above, slightly convex, broad inter- nally, narrow outwardly, and correspond- ing to the little sigmoid cavity of the ulna, in which it is lodged; the other below, concave, semicircular, and adapt- ed to receive the convex edge of the ulna. Hence, there are two joints, differing in their motions, articular surfaces, and U- gaments. By ascertaining such differ- ences, we shall be enabled to find out those, which exist between the luxations ofthe upper and lower head of the radius Above, the radius, in pronation and supination, only moves on its own axis; below, it rolls round the axis of the ulna. Here, being more distant from the centre. its motions must be both more exten*?'.\e Yt 346 DISLOCATION aud powerful, than they are above. The head of the radius, turning on its own axis in the annular Ugament, cannot dis- tend it in any direction. On the contrary, below, the radius, in performing prona- tion, stretches the posterior part of the capsule, and presses it against the im- moveable head of the ulna, which is apt to be pushed through, if the motion be forced. A similar event, in a contrary sense, takes place in supination. The front part of the capsule, being rendered tense, may now be lacerated. Add to this disposition, the difference of strength between the ligaments of the two joints. Delicate, and yielding be- low ; thick, and firm, above; their dif- ference is very great. The upper head of the radius, supported on the smaller immoveable articular surface of the ulna, it is protected from dislocation in most of its motions. On the contrary, its lower end, carrying along with it, in its mo- tions, the bones of the carpus, which it supports, cannot itself derive any soUd stability from them. DIFFEREKCES OF DISLOCATIONS OF THE RADII'S. From what has been said, the follow- ing conclusions may be drawn: 1. That with more causes of luxation, the lower articulation of the radius has less means of resistance ; and, that under the triple considelation of motions, ligaments ty- ing the articular surfaces together, and the relations of these surfaces to each other, this joint must be very subject to dislocation. 2. That, for opposite reasons, tiie upper joint cannot be very subject to such an accident. Indeed, what could be tlie cause pro- ducing it in this situation ? Can it arise from a violent pronation, or supination ? The lower joint being the weakest, would give way the first, and, however forcible any motion of this kind might be, the upper head of the radius would only be rotated on its own axis. How then can this part be dislocated, without being pushed forward, or backw ard ? All the muscular and ligamentous support of the joint must be broken; and the muscles and ligaments are too strong to admit of ibis, and the motion itself too feeble. Can the accident originate from any im- pulse on the radius, from below upward. The immoveable resisting end of the hu- merus would then prevent the radius from quitting the capsular ligament. Can the accident arise from a violent extension, or flexion of the forearm. Here the whole force operating on the ulna, the radius scarcely feels the impulse. Hence, accidental dislocations of the radius, suddenly produced by an external cause, must, if they ever happen, be ex- ceedingly uncommon at its upper end. This is not the case, with respect to such dislocations, as occur slowly at this joint, especially in children, in whom the ligaments become lax in consequence of repeated efforts. With this kind of case; we have here nothing to do. Experience sometimes seems to mili- tate against the above reflections. Du- verney quotes some instances of disloca- tions of the radius, suddenly produced by external causes. Some other practi- tioners mention similar examples. But, in their examinations, have these men paid all due attention ? An analogous case has been transmitted to the French Academy of Surgery, by one of" its fel- lows ; but, doubts have arisen concern- ing its reality, and there are too few facts for, and too much presumptive evidence against, the truth of such cases, for their existence to be believed. Desault himself rejected their reality. DISLOCATION OF THE LOWER END OF TUB RADIUS. The causes are the same, as those of all analogous cases. 1. Violent action of the pronator and supinator muscles This is, doubtless, a very unusual cause, for Desault never knew an instance of it. 2. External force, moving the radius vio- lently into a state of pronation, and rup- turing the back part of the capsule; or into a state of supination, and breaking the front part of the capsular ligament. Hence, there are two kinds of disloca- tion ; one forwasd, the other backward. The first is very frequent; the second is much less so. The latter case never pre. sented itself to Desault, but once, in the dead body of a man, who had both his arms dislocated, and no particulars could be learnt. The other case occur- red very often in the practice of this emi- nent surgeon. Five examples have been published. Doubtless, this difference is owing to all the principal motions of the radius being in the prone direction. This observation is confirmed by tlie feet, that the lower joint of the radius, in the dead subject, may be dislocated as easily by a supine, as a prone motion of this bone. The symptoms of the luxation forward are : 1. Constant pronation of the fore- arm:2. An inabiUty to perform supina- tion, and great pain on this being at- tempted : 3. An unusual projection at the back of the joint, in consequence of the protrusion of the little hvud of the DISLOCATION. 5V ulna through the capsule: 4. The posi- tion of the radius is more forward, than natural: 5. Constant adduction of the thumb, which also is almost always ex- tended : 6. A balf-bent state of the fore- arm, and very often of the fingers. This, indeed, is the position, which the fore- arm usually assumes in all affections of its bones, and, in the present instance, the posture cannot be changed, without considerable pain : 7. More or less sweU- ing around the joint. This sometimes comes on-immediately after the accident, bu^lways afterwards, if the reduction srould remain unaccomplished. The condition of the joint may thus be ob- scured, and the accident mistaken for a sprain; as Desault often observed to have occurred with surgeons, who had been called to these accidents before him. The serious consequence of this mistake is, that no attempt at reduction is made, and the articular surfaces having time to contract adhesions, the disorder is fre- quently rendered irremediable. A luxation of the radius backward is characterised by symptoms, the reverse of those above mentioned. They are, a violent supination of the limb ; inability to put it prone ; pain on making the at- tempt ; a tumour in front of the fore-arm formed by the head of the ulna; a pro- jection backward of the large head of the ' radius ; and abduction of the thumb. REDUCTION. When the dislocation is forward, an assistant is to take hold of the elbow, raising the arm a little from the body; another is to take hold of the hand and fingers. The surgeon is to take hold of the end of the fore-arm with both his hands ; one applied to the inside, the other to the outside, in such a manner, that the two thumbs meet each other before, between the ulna and radius, while the fingers are applied behind. He is then to endeavour to separate the two bones from each other, pushing tiie radius backward and outward, while the ulna is held in its proper place. At the same time, the as- sistant, holding the hand, should try to bring it into a state of supination, and consequently the radius, which is its sup- port. Thus pushed, in tiie direction op- posite that of the dislocation, by two powers, the radius is moved outward, and the ulna returns into the opening of the capsule, and into the sigmoid cavity. If chance should present a dislocation of the radius backward, the same kind of proceeding, executed in the opposite di- rection, would serve to accomplish the reduction. (See CEuvres Chirurgicales de Desault, par Bichat, Tom. 1) DISLOCATIONS OF THE WRIST. The carpal bones may be luxated from the lower ends of the radius and ulna forwards, backwards, inwards, or out- wards. The two first cases, especially the one backwards, are the most frequent. The dislocation backwards is rendered easy by the direction of the convex arti- cular surfaces of the scaphoid, semilunar, and pyramidal bones, which sloping more backwards than forwards, must make them more disposed to slip in this direc- tion, than any other. The accident may be caused by a fall on the back of the hand, while much bent; in which event the first row of the carpal bones slide backwards into the oblong cavity of the radius, lacerate the posterior ligament, and form an eminence behind the lower ends of the bones of the fore-arm. This prominence, the depression in front of the wrist, and the extraordinary flexion of the hand, which cannot be extended, are the characteristic signs of this kind of dislocation. The dislocation forwards generally arises from a fell on the palm, the fingers being extended, and more force operating on the lower, than upper part of the palm. The luxation is seldom complete; and the hand re- mains painfully extended. The great many tendon, which runs before the wrist, and the annular ligament, being pushed forward, the prominence formed by tbe carpal bones, in front of the ends of* the radius and ulna, is not easily de- tected, and the case may be mistaken for a sprain. Dislocations inwards, or outwards, are never complete. The projection of the carpal bones at the inner, or outer side of the joint, and the distortion of the hand, make such cases sufficiently evident. All dislocations of the wrist are very- easy of reduction. For this purpose, gentle extension must be made, while the two surfaces of the joint are made to slide on each other in a direction con- trary to what they took when the accident occurred. Dislocations of the wrist are always attended with a great deal of spraining of numerous tendons, and laceration of ligaments, and consequently considerable swelling generally follows, and the pa- tient is a long time in regaining the per- fect use of the joint. To relieve the symptoms as much as possible, the best plan is to keep the h.nd and wrist conti- Dually covered with linen wet with the 348 DISLOCATION saturine lotion, and to put the fore-arm and hand in splints, as in the case of a fracture. See Fractures of the Fore-arm. The arm must also be kept perfectly at rest in a sUng. When the ruptured l.gaments have united, the use of Uniments wiU tend to remove the remaining stiffness and weak- ness of the joint. DISLOCATIONS OF THE BONES OF THE CARPUS AND METACARPUS. A dislocation of the carpal bones from each other seems almost impossible. The os magnum, however, has been known to be luxated from the deep cavity formed for it by the scaphoides and semilunare, in consequence of too great a flexion of the bones of the first phalanx on those of the second, and it formed a tumour on the back of the hand. (Chopart; Boyer; Ri- cherand.) The metacarpal bones are never lux- ated from each other. The first one is sometimes, though very rarely, pushed off the trapezium. DISLOCATIONS OF THE FINGERS. The first phalanges, may be dislocated backwards off the heads of the metacar- pal bones. A luxation forwards would be very difficult, if not impossible, because the articular surfaces of the metacarpal bones extend a good way forwards, and the palm of the hand makes resistance to such an accident. The first phalanges of the thumb and little finger can alone be dislocated inwards; and the first phalanx of the thumb is alone subject to be luxated outwards This phalanx is also most liable to dislocations backwards, behind the head of the first metacarpal bone, in which case it remains extended, while the second is bent. These dislocations should be speedily reduced; for, after eight or ten days, they become irreducible. In a luxation of the first bone of the thumb, which was too old to be reduced, Desault proposed cutting down to the head ofthe bone, and pushing it into its place with a spatula. Dislocations ofthe thumb and little finger inwards, that of the thumb outwards, and luxations of the first phalanges of the other fingers backwards, are all reduced by making extension on the lower end of the affected thumb, or finger. The first and second phalanges may also be dislocated backwards. After the reduction, the thumb, or finger, affected, should be rolled with tape, and incased, and supported in pasteboard, till the lacerated ligaments have united; care being taken to keep the hand and fore-arm quietly in a sUng. DISLOCATIONS OF THE BONES OF THE PELVIS. M. Louis, in Tom. 4, of the Mem. de VAcad. de Chirurgie, 4to. relates a case, in wluch the os ilium of the right side was found separated from the sacrum, so as to pass nearly three inches behind it. This accident was caused by a very heavy sack of wheat falling on a labourer.juid the truth of it was ascertained by disSw. tion. Such a case must be exceedingly uncommon. The os coccygis is not so easy dislo- cated, as fractured. Boyer, however, has seen it displaced in a man, who was great- ly emaciated by disease. This subject had considerable ulcerations about the coccyx, and the bone itself was bare. There was an interspace of nearly, two inches, between the sacrum and base of the os coccygis. In proportion as the man regained his strength the bone recovered its right position; and at length united to the os sacrum, notwithstanding the ac- tion of the levatores ani, which are in- serted into it. (Boyer.) This case, how- ever, was not an accidental luxation; and it clearly arose from the destruction of the ligaments by disease. Authors mention two kinds of disloca- tion, to which the os coccygis is liable, one inward, the other outward. The first is always occasioned by external violence; the second, by the pressure of the child's head in difficult labours. The nature of these accidents is easily discovered by the preceding cause, and by an examina- tion with the fingers, externally, and within the rectum. Pain, difficulty of voiding the foeces and urine, tenesmus, and inflammation, sometimes ending in abscesses, which interest the rectum, are symptoms, said to attend and follow dis- locations ofthe os ccccy gis. These luxations are ea»ily reduced, by means of a finger in the rectum, assisted by the other fingers externally. No more can be done than in the case of a fracture. (See Fracture.) DISLOCATION OF THE RIBS. J. L. Petit w-s»s silent on this subject, as he thought such c:*ses never occurred. S.nce his death, a French surgeon, But- tet, has related an instance, which he supposed to be a dislocation of the poste- rior extremity of the rib f om the verte- brae ; but, Boyer clearly shews he had no true rcaspns for this opinion, and that DISLOCATION. 349 the case was only a fracture of the neck, or end of the bone, near the spine. Ambrose Pare, Barbette, Junker, Plat- ner, and Heister, not only admit the oc- currence of luxations of the ribs; but, describe different species of them. Lieu- taud also termed cases, in which the head of the rib was separated by disease, luxations. On the whole, we may con- clude, that the ribs are so rarely dislocat- ed, that the subject is not deserving of much attention in this work. DISLOCATIONS OF THE THIOH-BONE. The head of the thigh-bone may be dislocated upwards and outwards on the dorsum of the ilium; upwards and for- wards on the body of the os pubis ; down- wards and inwards on the foramen ovale; and downwards and outwards on the os ischium. The dislocation upwards and out- wards, and the one downwards and in- wards, are the most frequent. First, of luxations on the ilium. The common kind of dislocation of the thigh-bone, upward and outward, is at- tended with tlie following symptoms. The affected thigh is shorter, than its fellow, is a little bent, and carried inwards. The knee inclines more forwards and inwards, than the opposite one; the leg and thigh are turned inwards, and the foot points in this direction. The trochanter major is brought nearer the anterior superior spinous process of the os ilium, and is at the same time elevated and carried a little forwards. The natural length of the limb cannot be restored, without re-' ducing the luxation ; the foot cannot be turned outwards, and any attempt to do so causes pain; but, the inclination of the foot inwards may be increased. (Boyer) This luxation has nothing in common with a fracture of the neck of the thigh- bone, except tbe shortness of the limb. The cases are at once discriminated by this difference, that, in tliis kind of luxa- tion, the limb and toes are turned inwards, while in all fractures of tlie thigh-bone, they are invariably turned outwards. Many writers have been puzzled how to account for the toes being inclined in- wards. We have only to reflect, how- ever, that the trochanter major is situated forwards, and that the hejid of the bone lies backwards, when we shall immedi- ately perceive, that the limb is mechan- ically prevented from being rotated out- wards. To reduce this dislocation, the patient should be placed on his opposite side upon a table firmly fixed, or a large four- posted bedstead. A sheet, folded longi- tudinally, is first to be placed under the perineum, and one end being carried be- hind the patient, the other, before him, they are to be fastened to one of the legs, or posts of the bed. Thus the pelvis will be fixed, so as to allow the necessary extension of the thigh-bone to be made. Great care must be taken during the ex- tension to keep the scrotum and testicles from being hurt, or the pudenda in wo- men, by the sheet passed under the peri- neum. The patient must be further fixed by being held by assistants. The best practitioners of the present day in France, advise the extending force to be applied to the inferior part of the leg, in order to have it as far as possible from the parts, which resist the return of the head of the bone into its natural situa- ' ation. In this country, surgeons gene- rally prefer making the extension by means of a sheet, fastened round the limb just above the condyles ofthe os femoris. As soon as the head of the bone has been brought on a level with the aceta- bulum by the assistants, who are making the extension, the surgeon is. to force it into this cavity by pressing on the great trochanter. The extension should always be made in a gradual and unremitting manner: at first, gently ; but afterwards more strong- ly ; yet never violently. The difficulty of reduction arises from the great power and resistance of the muscles, and these must at length be fatigued, so as to yield to the extending force, if care be taken, that it be maintained the necessary time, without the least intermission. In very strong, athletic subjects, it may be proper to bleed them, in order to pro- duce a temporary weakness, for the pm> pose of facilitating the reduction. The disappearance of all the symptoms, and the noise made by the head ofthe bone, when it slips into the acetabulum, denote, that the reduction is effected. The bone is afterwards to be kept from slipping out again, by tying the patient's thighs together with a bandage placed a little above the knees. The patient shouldbekept in bed at least three weeks; live low, and rub the joint with the linimentum camph. et sapords. Due time must be given for the lacerated liga- ments to unite, and the sprained parts to re- cover ; and premature exercse may bring on irremediable d.sease in the joint. Mr. Hey gives the following directions, and description of the way, in which he reduced a case of this kind. " The extension of the limb must be made in a right line with the trunk of the body; and, during the extension, the head of the bone must be directed Out- 350 DISLOCATION. wards as well as downwards. A rotatory motion of the os femoris on its own axis, towards the spine,(the patient lying prone) seems likely to elevate the great trochan- ter, bring it nearer to its natural position, and direct the head of the bone towards the acetabulum. These circumstances led to the following method. A folded blanket was wrapped round one of the bed-posts, so that the patient, lying in a prone position, and astride of the bed- post, might have the affected limb on the outside of the bed. The bed was ren- dered immoveable, by placing it against a small iron pillar, which had been fixed for the purpose of supporting the curtain rods. The leg was bent to a right angle with the thigh, and was supported in that position by Mr. Lucas, who, when the ex- tension should be brought to a proper de- gree, was to give the thigh its'rotatory motion, by pushing the leg inwards, that is, towards the other inferior extremity. Mr. Jones sat before the patient's knee, and was to assist in giving the rotatory- motion, by pushing the knee outwards at the same moment. I sat by the side of the patient, to press the head of the bone downwards and outwards during the extension. Two long towels were wrap- ped round the thigh just above the con- dyles, one towel passing on the inside of the knee, the other on the outside. Three persons made the extension; but when we attempted to give the thigh its rota- tory motion, we found it confined by the towel which passed on the inside of the knee and leg. We therefore placed both the towels on the outside; and in this po- sition the extending force concurred in giving the rotatory motion. The first ef- fort that was made, after the towels were thus placed, had the desired effect, and the head of the bone moved downwards and outwards into the acetabulum." (Hey's Practical Observations, p. 313.) There is another kind of dislocation up- ward and outward, so rare, that many ex- perienced men have never seen it, and few have mentioned it. I allude to the case, in which the head of the thigh-bone is so situated on the dorsum of the ilium, that it lies forward, the trochanter major backward, and an instance of which I have myself seen in St. Bartholomew's hospital. This case deserves very parti- cular attention, because being attended with a considerable turning of the toes outwards, as well as a shortening of the Umb, it is the only example, which is at all likely to be mistaken for a fracture of the neck of the thigh-bone. The case, however, is not difficult of detection ; for, you can even feel the head of the bone projecting forward on the ilium, and you cannot rotate the limb inwards, which can be done in cases of fracture, though doing so is productive of immense suffer- ing. This rare kind of luxation is to be re- duced by the same means, and in the same manner, as the common dislocation up- wards and outwards, already treated of. Another of the most frequent luxations of the thigh-bone, is downwards and in- wards, upon the obturator foramen. The occurrence of this accident is facilitated by the great extent of the motion of ab- duction of the thigh; by the notch at the inferior and internal part of the acetabu- lum; by the weakness of the orbicular ligament on this side; and by the liga. mentum teres not opposing, nor being ne- cessarily ruptured by it. The head of the bone is thrown between the obturator ligament, and obturator externus muscle. The symptoms are as follow: the af- fected thigh is longer, than the sound onej the bead ofthe femur being situated lower than the acetabulum, the trochanter ma- jor is removed to a greater distance from the anterior superior spinous process of the ilium, and the thigh is flattened, in consequence of the elongation of the mus- cles. A hard, round tumour is felt at the inner and superior part of the thigh, formed by the head of the femur. The leg is slightly bent; and the knee and foot, are turned outwards, and cannot be brought back into their proper direction. This case, like a fracture, is attended with a turning ofthe toes outwards; but, besides being easy of discrimination on every account, the elongation of the limb at once denotes, that there is no fracture, which always causes a shortening of the member. Dislocations on the obturator foramen, are very easy of reduction. The exten- sion is to be made downwards and out- wards, so as just to dislodge the head of the bone, and then the muscles generally draw it into the acetabulum, on the ex- tending force being gradually relaxed, and the surgeon pushing the upper part of the bone outward. The thigh-bone is sometimes, though very seldom, luxated upwards and for- wards, into the groin. The whole limb is turned outwards and shortened; the trochanter major is approximated to the anterior superior spinous process of the ilium ; the head of the bone forms a tu- mour in the groin, and, pressing on the , anterior crural nerves, causes great pain, numbness,'and even paralysis; and the knee is carried backwards. The head of the bone felt in the groin; the inclination of the knee backwards; and the impossibility of rotating the limb DISLOCATION". inward; distinguish it from a fracture of the neck of the bone. It is reduced in the same way, as the luxation downwards and forwards. Mr. Hey says, that " In this species of dislocation, "(downwards and forwards,) as the head of the bone is situated lower than the acetabulum, it is evident, that an extension made in a right line with the trunk of the body, must remove the head of the bone farther from its pro- per place, and thereby prevent, instead of assisting, reduction. The extension ought to be made with the thigh at a right an- gle, or inclined somewhat less than a right angle, to the trunk of the body. When the extension has removed the head of the bone from the external obturator muscle, which covers the great foramen of the os innominatum, the upper part of the os femoris must then be pushed or drawn outwards ; which motion will be greatly assisted by moving the lower part of tiie os femoris, at the same moment, in a con- trary direction; and, by a rotatoiy mo- tion of the bone upon its own axis, turn- ing the head of the bone towards the ace- tabulum." (Hey, 316.) The ensuing case illustrates Mr. Hey's practice. " The lower bed-post, on the right side ofthe bed on which the patient lay, was placed in contact with a small immoveable iron piUar (about an inch square in thick- ness,) such as in our wards are used for supporting the curtain rods of the beds. A folded blanket being wrapped round the bed-post and pillar, the patient was placed astride of them, with his left thigh close to the post, and his right thigh on the outside of the bed. A large piece of flannel was put between the blanket and the scsotum, that the latter might not be hurt during the extension. " The patient sat Upright, with his ab- domen in contact with the folded blanket wliich covered the bed-post. He support- ed himself by putting his arms round the post, and an assistant sat behind him to prevent him from receding backwards. He was also supported on each side. " Two long towels were put round the lower part ofthe thigh, after the part was well defended from excoriation by the ap- plication of a flannel roller. The knot, which the towels form, was made upon the anterior part of the thigh, that the motion intended to be given to the leg might not be impeded by tiie towels. " The thigh being placed in a horizon- tal position, or rather a little elevated, with ihe leg hanging down at right angles to the thigh, I sat down upon a chair, di- rectly fronting the patient, and directed a gentle extension to be made by the assist- ants standing at my left side. This was done with the view of drawing the*bead of the bone a little nearer to the middle of the thigh, and the extension had this ef- fect. I then placed the two assistants, who held the towels, at my right side, by which means the extension would be made in a direction a little inclined to the sound limb. Mr. Logan stood on the- right side of the patient, with his hands placed on the upper and inner side of the thigh for the purpose of drawing the head of the bone towards tiie acetabulum, when the extension should have removed it suffi- ciently from the place in winch it now lay. " I desired the assistants to make the extension slowly and gradually; and to give a signal when it arrived atits greatest degree. At that momen , Mr. Logan drew the upper part of the bone outwards, while 1 pushed the knee inwards, and also gave tiie 03 femoris a considerable rotatory motion, by pushing the right leg towards the left. By these combined mo- tions, the head of the os femoris was di- rected upwards and outwards, or in other words, directly towards the acetabulum, into which it entered at our first attempt made in this manner. " The scrotum, as the patient assured me, was not hurt in the least by the ex- tension." (Hey, p. 318.) The last dislocation of the thigh re- maining to be spoken of, is that down- wards and backwards. The head of the bone rests against that part of the ossa innonimata where the ilium and ischium join. The limb is turned outwards. When the luxation is primary, the extremity is lengthened. A hard tumour is felt at the posterior and inferior pai t of the buttock, and the great trochanter is removed fur- ther from the spine of the ilium. When secondary (which is far more frequent,) the primary luxation having been upwards and outwards, the foot is turned inwards. The primaiy luxation downwards and backwards, with the toes turned out- wards, is as unusual, as the case upwards and backwards, with the foot in the same position. The lengthening of the limb, liowever, at once shews the case not to be a fracture. The pelvis being fixed, as already de-j scribed, the extension is to be made down- wards and forwards, to dislodge the head of the bone, while the surgedn, with u napkin, placed just below the trochanter minor, pulls the upper part of the femur towards the acetabulum. DISLOCATION OF THS PATELLA. This bone may be luxated either in- wards or outwards, when violently push- 352 DISLOCATION. ed in this direction. The luxation out- ward is the most frequent, because the bone more easily sfips in this direction off the outer condyle of the femur, than in- wardly. All these cases are easily reduc- ed, on relaxing the extensors of the leg, and bending the thigh ; but, owing to a relaxed state of the ligament of the pa- tella, or other predisposing causes, the bone is sometimes difficultly kept in its proper situation, without applying a roller to the part. The inflammatory affection of the joint is to be opposed by bleeding, purging, and using the saturnine lotion. The joint must be kept quiet a few days, and then gently moved in order to prevent stiffness. DISLOCATION OF THE KNEE. The tibia may be luxated forward, back- ward, or to either side. The dislocation backward is always in- complete, and sometimes is secondary, being a consequence of white swellings. The luxation forward is even more rare, than the one backward. Disloca- tions inward, or outward, are the most frequent, and are always incomplete. The nature of all these cnses is so conspicuous at first view, that there is no need of any detail of particular symptoms. The bones of the' leg are sometimes twisted outward, and the internal lateral Ugament ruptured; but, this may happen without the crucial ligamentbeing broken. On the other hand, when the bones of the leg are violently twisted inward, both the crucial Ugaments, and external lateral ligament, must inevitably be ruptured These accidents are all most easily re- duced, on making gentle extension, and pushing the head of the tibia in the pro- per direction. The grand object, after tlie reduction, is to avert inflammation of the knee, and promote the union of the torn ligaments. The first demands the rigorous observance of the antiphlogistic plan; both require the limb to remain perfectly motionless, supported by one, or two splints. As soon as the Ugaments bnve grown together, and the danger of inflammation is over, which will be in about three weeks, the joint should be gently bent and extended a certain time every day in order to prevent stiffness. Liniments will now also be of service. DISLOCATION OF THE FOOT. The foot may be dislocated inwards, or outwards; forwards, or backwards ; and either of these luxations may be complete, or incomplete. Dislocations inwards, and outwards, are the most c-jmmon ; the for- mer occurring, however, more frequently, than the latter, which are greatly resisted by the fewness of the malleolus exter- nus. Many of these accidents are compound; that is, attended with a wound communi- eating with the joint; a circumstance that greatly increases the danger, and is fre- quently the occasion of the patient's los- ing his limb, and even his life. It is only, however, when the soft parts are very much contused, and extensively lacerated, that amputation should be had recourse to in the first instance. When the bones are reduced, and the edges of the wound brought into contact, the unpromising as- pect of the case is very much diminished, and many, who might think amputation advisable at first view of the accident, would change their mind, as soon as the bones have been replaced. Dislocations inwards, or outwards, are very easily reduced, and require very lit- tie extension. In accomplishing the re- duction, it is best to relax the strong mus. cles of the calf by bending the leg on the thigh. The case is afterwards to be treated in the same way as a fracture of the leg. Mr. Pott has called the attention of surgeons to a particular kind of disloca- tion, in which the utility of relaxing the muscles, is strikingly illustrated. 1 mean the instance, in which, " by leaping, or jumping, the fibula breaks in the weak part already mentioned, that is, within two or three inches of its lower extremity. When this happens, the inferior fractured end ofthe fibula falls inwards towards the tibia, that extremity of the bone which forms the outer ankle, is turned somewhat outward and upward, and the tibia having lost its proper support, and not hring of itself capable of steadily preserving its true perpendicular bearing, is forced off from the astragalus inwards; by which means the weak bursal, or common liga- ment of the joint, is violently stretched, if not torn, and the strong ones, which fasten the tibia to the astragalus and os calcis, are always lacerated ; thus pro- ducing at the same time a perfect fracture and a partial cUslocation, to which is sometimes added, a wound in the integur ments, made by the bone at the inner ankle. By this means, and indeed as a necessary consequence, all the tendons which pass behind or under, or are at- tached to the extremities of the tibia and fibula, or os calcis, have their natural di- rection and disposition so altered, that, instead of performing their appointed ac- tions, they all contribute to the distortion of the foot, and that by turning it out. ward and upward. DI s DIS 353 f* When this accident is accompanied, us it sometimes is, with a wound of the integuments of the inner ankle, and that made by the protrusion of the bone, it not unfrequently ends in a fatal gangrene, un- less prevented by timely amputation.; though I have several times seen it do very well without. But in its most sim- ple state, unaccompanied wtith any wound, it is extremely troublesome to put to rights, still more so to keep it in order, and, un- less managed with address and skill, is very frequently productive both of" lame- ness and deformity ever after. " After what has been said, a farther explanation why this is so, is unnecessary. Whoever will take even a cursory view of the disposition of the parts, will see that it must be so. By the fracture of the fi- bula, the dilatation of tiie bursal ligament of the joint, and the rupture of those which should tie the end ofthe tibia firm- ly to the astragalus and os calcis, the per- pendicular bearing of the tibia on the as- tragalus is lost, and the foot becomes dis- torted; by this distortion the direction and action of all the muscles already re- cited are so altered, that it becomes (in the usual way of treating this case) a difficult matter to reduce the joint; and the support of the fibula being gone, a more difficult one to keep it in its place after reduction. If it be attempted with compress and strict bandage, the conse- quence often is a very troublesome, as well as" painful ulceration of the inner ankle, which very ulceration becomes it- self a reason why such kind of pressure and bandage can be no longer continued; and if the bone be not kept in its place, tlie lameness and deformity are such, as to be very fatiguing to the patient, and to oblige him to wear a shoe with an iron, or a laced buskin, or something of that sort, for a great while, or perhaps for life. " All this trouble, pain, difficulty, and inconvenience, are occasioned by putting and keeping ti\e limb in such position as necessarily puts the muscles into action, or into a state of resistance, which in this case is the same. This occasions the diffi- culty in reduction, and the difficulty in keeping it reduced ; this distorts the foot, and by pulling it outward and upward makes that deformity which always ac- companies such accident; but it the po- sition of the limb be changed, if by laying it on its outside, with the knee moderately bent, tlie muscles forming the calf of the leg, and those which pass behind the fi- bula, and under the os calcis, are all put into a state of relaxation and non-resist- ance, all this difficulty and trouble do in general vanish immediately ; the foot may easily be placed right, the joint reduced, Vol. I. and by maintaining the same disposition of the limb, every thing will in general succeed very happily, as I have many times experienced." (Pott.) It occasionally happens in compound luxations ofthe ankle, that the astragalus only remains attached by a few fibres, in which circumstance, if it be judged pru- dent to attempt the preservation of the limb, it is best to imitate Ferrand and Desault, by extirpating this bone entirely, so as to allow the tibia to become anchy- losed to the upper surface of the os calcis. Dislocations forwards and backwards are not very common. The first case is the most difficult to produce. The facijity, with which all dislocations ofthe ankle are recognized by surgeons, ac- quainted with anatoiny,renders a particular account of thc.symptoms quite superfluous. Both the latter cases are easy of reduc- tion, when care is taken to relax the mus- cles of the calf, which attention is most particularly essential to prevent the bones from becoming displaced again. The limb must be put in splints, just as if tlie case were a fracture. The os calcis and astragalus are so in- timately connected, that they are never completely luxated from each other. But, one, or both of these bones may be dislo- cated from the scaphoides and cuboides by violent force, when the forepart of the foot is fixed. (J. L Petit.) The astragalus and os calcis, particularly the former, may then be luxated upwards into the cavity on the back ofthe ?caphoides, so as to form a tumour on the buck of the foot. The reduction is difficult; Hoyer in one case could not succeed: but no lameness remained with the deformity. The first phalanx of the great toe is sometimes dislocated from the first meta- tarsal bone. The reduction is too simple to need explanation. On the subject of Dislocations, consult Duverney's 'Traite deS Maladies ties Os. Le- g.ons sur les Maladies des Os redigees en un Traite complet de res Jlfuladics par Riche- rund, 'Tom. 2. Richerand's Nosographie Chirurgicale, Tom. 3. p. 193, &c. Edit. 2. Petit, Traite des Maladies ties Os. Qiuvres Chirurgicales de Desault, par Bichat, Tom 1. Pott's Remarks on Fractures and Disloca- tions. Hey's Practical Observations in Sur- gery. Kirkland's Observations upon Mr. Pott's General Remarks on Fractures, &c. Wliile's Cases in Surgery. Medical Obser- vations and Inqtdries. Vol. 2. BromfieltPs Chirurgical Cases and Observations. Lf- veilie, Nouvelle Doctrine Cliirurgicale, Tom. 2. Callisen, Svstrina Chirurgix Hodiernx, Tom- 2. Desault's Journal tie Chu-urgie. DISTICIIIA, or distichiasis. (from fa, twice, and «/^e«, a row.) Oorrhzeus, '/. z 354 D I S ' Heister, and St. Ives, agree in applying this term to an affection ofthe eyelids, in which each tarsus has a double row of eye-lashes, which, inclining inward, irri- tate the eye, and keep up an ophthalmy. Such authors speak of this, as a very fre- quent complaint; but, the author of the present article in the Encyclopedic .Metho- dique, Partie Chirurgicale, remarks, that he has never met with it at all, though in ulcerations of the eyelids, he has often seen a certain number of the eye-lashes incline inward, and cause a good deal of disturbance to the eye, already in a state of inflammation. This disorder cannot be called the true distichiasis. However it may be, all.writers recommend plucking out such eyelashes, as assume an unna- tural direction. A few of the hairs are to be taken out at a time/one after the other, And a few days are to be allowed to elapse, before this trivial operation is to be repeat- ed. In order that the eye-lashes may bc,with more certainty, extirpated to their roots, end that others may not grow in the same situation, it is advised to touch the places, from which they grow with the argentum nitratum. (See Tric/uasis.) Encyclopedic Methodique, Partie Chirurgicale. DISTORTION, (from distorqueo, to wrest aside.) Distortio. The bones of the limbs frequently become distorted, in consequence of an unhealthy, ricketty, or scrofulous constitution. Sometimes, they are deformed merely by the contraction of tlie muscles; and, very frequently, they are naturally distorted by the feet being either turned too much outward, or inward. Mere weakness will some- times occasion a distortion ; for when a child is too soon put to walk, its legs will become crooked from the bones not being strong enough to bear the weight of the body. Distortions of the limbs are much more easily cured, than those ofthe spine. As they appear in infancy, when tiie bones are flexible, they can easily be brought into their proper shape by using machines, sometimes of a very simple kind; but it must always be remembered, that, as the disease, in cases, in which the limbs are not naturally distorted from birth, pro- ceeds from weakness, we must not omit to strengthen the system by tonics. Some- times, a gentle and long continued pres- sure wiU be sufficient to make a bone straight; but, generally, some kind of machines, or shoes, or boots, of a parti- cular construction, are necessary. When the Umbs are distorted, by rea-. son of a contraction ofthe muscles, emol- lient oils are highly recommended. The muscles and tendons, which are supposed DU R to cause the deformity, are to be rubbed throughout then- course, for half an hour, or more, three times a day, during which frequent endeavours must be made to ex- tend the limb; but, gradually, and with- out violence. Land's System of Surgery, Vol. 2, 467, 468. See Mollifies Ossium ; Rachitis .* Yer- tebrx, Diseased; Vim and Valgi. DOLO'IRES. The spiral turns of a roller. DURA MATER, FUNGOUS TC- MOURS OF. The dura mater, the outer membrane of the brain, was so named by thfe ancients, on account of its hardness, and its being formerly sup- posed to be the source of all the other membranes of the body. Fungous tumours of the dura mater, which have only had their nature under- stood about half a century, have not, however, escaped the notice of the an- cient writers; but, the disease is very imperfectly described by them, and under an erroneous denomination. They sup- posed, that the swelling was of the en- cysted kind, or what they termed natta, talpa, testudo, and that it gradually alter- ed and destroyed the cranium. They sometimes mistook the fungous, or sarco- matous tumour of the dura mater for co- agulated blood, or for ill-conditioned excrescences, like those which make their appearance on ulcers attended with ca- ries. Such are the ideas, which seem to be conveyed by some imperfectly detailed cases in the writings of Lanfranc, Guido di Cauliaco, Theodorictts, and other au- thors of the thirteenth and fourteenth centuries. Amatus Lu sit an us has given the appellation of lupus with caries to a fungous tumour of the dura mater. The swelling occurred in a child eight years old, who died in convulsions, two days after an opening had been made in it.— (Ceutur. 5, obs. 8) Another similar case, which happened in a child, and was no- ticed by Camerarius at Paris, is styled a singular bony excrescence. (Ephemer. curios, natur. decur. 2, arm. 6, 1687, obs. 99.) Lastly, Cattier, a physician of Montpellier, lias recorded the histoiy of a lady, who died from the consequences of a fungous tumour of the dura mater. The disease was so acutely painful, as to compel the patient to cry out. The swell- ing was opened with caustic. Pimpre- nelle, a Parisian surgeon, recommended the trepan to be employed; but, his ad- vice was over-ruled. After death, a fun- gous ofthe dura mater, with a perforation in the skull, was detected, and it is de- scribed by the author as a hard, stony, substance, accompanied with points and DURA MATER. 355 asperities. (Obs. Med. obs. 15, p. 48 — See Lassus, Pathologie Chirurgicale, Tom. I, p. 498. Edit. 18J9.) The old surgeons, being ignorant of the real character of fungous tumours of the dura mater, and often to commit the most serious and fatal mistakes in the treatment. These diseases are of a chro- nic nature, and make their appearance gradually, in the form of a tumour, which makes its way through the bones of the cranium, rises up, and insensibly blends itself with the integuments, Which seem, as it were, to make a part of it. Such fungous tumours of the dura mater may originate spontaneously at any part of this membrane ; but, they are particular- ly apt to grow on the surface, which is adherent to the upper part of the skull, or to its basis. They are firm, indolent, and chronic, seeming as if they were the con- sequence of slow inflammation, affecting the vessels which supply the dura mater, and inosculate with those of the diploe. It is very difficult, one might say, impos- sible, to determine, whether in an affec- tion of this kind, the disease begins in the dura mater, or the^lubstance of the bone itself. The general belief, however, is, that the bone is affected secondarily, and tlie disorder originates in the dura mater. The patient, who is tlie subject of the first case, related in a memoir by M. Louis, had received no blow upon the head, and, could only impute his com- plaint to a fall, which he had met with four, or five months before, and in which the head had not struck against any thing; but, from this time, he experi- enced a stunning sensation, which con- tinued till he died. The cranium and dura mater were found both equally dis- eased. Though this case may tend to shew, that fungous tumours of the dura mater may form spontaneously, yet it is not the less confirmed by the examination of a vast number of cases, that this affec- tion more frequently follows blows on the head, than any other cause. Hence, a slow kind of thickening of the dura mater is produced, which ends in a sarcomatous excrescence, the formation of Which al- ways precedes the destruction of* the bone. In the memoir, published by M. Louis, "m the fifth volume, 4to. of those of the Royal Academy of Surgery, there is a very interesting case, illustrating the nature of the present disease. The subject was a young man, aged twenty-one, who had a considerable tu- mour on the left side of the head, which was taken for a hernia cerebri. (See this Article.) The swelhng had begUn in the region of the temple, and had gradually acquired the magnitude of a second head. The external ear was displaced by it, and pushed down as low as the angle of tlie lower jaw. At the upper part of th« cir- cumference of the base ofthe tumour, the inequalities of the perforated bone, and the pulsations of the brain, could be di- stinctly felt. Some parts of the mass were elastic and hard, others were soft and fluctuating. A plaster, which had been applied, brought on a suppuration at some points, from which an ichorous matter was discharged. Shiverings and febrile symptoms ensued, and the man died in less than four months, in tiie year 1764. On dissection, a sarcomatous tu- mour ofthe dura mater was detected, to- gether with a destruction of the whole portion of the skull, corresponding to the extent of the disease. t When a tumour of this nature has de- cidedly formed, it makes its way outward through all the parts, sdft or bard, which are opposed to it. The swelling, in be- coming circumscribed, is partly blended with the dura mater, and its pressure produces an absorption of such parts of the skull, as oppose its enlargement. It unexpectedly elevates itself externally, confounding itself with the scalp, and pre- sents itself outwardly in the form of a preternatural, soft, yielding swelling, which even sometimes betrays an appear- ance of a decided fluctuation, or a pulsa- tion, which leads some to suppose it to be an aneurismal tumour. When once the swelling has made its exit from the cavity of the cranium, it expands on every side under the integuments, which readily make way for its growth. The scalp becomes distended, smooth, and codema- tous over the extent of the tumour, and lastly it ulcerates. The matter, which is discharged from the ulcerations, is thin and sanious ; the outer part of the tumour is confounded with the integuments and edges of the skull, on which it rests, so that, in this state, it easy to mistake the tumour for one, whose base is alto- gether external. While the swelling thus increases in .size externally, it also en- larges internally. The latter change takes place in particular, while the open- ing in the cranium is not large enough to admit tiie whole mass of the tumour, which then depresses the brain, and lodges in the excavation, which it form.s for itself. But, this cavity quickly di- minishes, and becomes reduced almost to nothing, as soon as the tumour projects outwardly. The tables ofthe skull are ab- sorbed to make way for the swelling to arrive externally ; but, it is remarked, that the internal, or vitreous table, is always found much more extensively de- stroyed, than the external one. Sonic- 356 DURA MATER. times, new bony matter is found deposited aiound the opening in the cranium. lf'is asserted, that, whatever may be the situation of a fungous tumour of the dura mater, the outer layer of* this mem- brane, upon which the disease* forms, is alone altered, the inner layer and the pia mater being always unchanged. (Lassus, Pathologie Chirurgicale, Tom. 1, p. 501. Edit. 1809.) According to surgical writers, fungous tumours of the dura mater have been caus- ed by contusions of the skull, falls on the buttocks, concussions ofthe head or whole body, lues venerea, scrofula, inveterate rheumatism, &c. The three last of the alledged causes, however, seem to be little better than mere conjecture. Children of the most tender years are even liable to the disease. M. Louis had related, that a child, two years of age, died of a fungus ofthe dura mater, which had produced a swelling above the right ear, attended with a destruction of a portion of the parietal and temporal bones. (Mem de PAcad. de Chirurgie, Tom. 5, 4to. p. 31.) The existence of a fungous tumour of the dura mater cannot be ascertained, as long as there is no external change. The effects produced, may originate from so many causes, that there would be great risk of a gro*-;s mistake in referring them to any particular ones. This is not the case, when there is an opening i*i tiie skull. Then a hardness, felt from the very first at the circumference of the tu- mour, denotes that it comes from within. When the swelling is "carefully handled, such a crackling sensation is perceived, as would arise from touching dry parch- ment stretched over the skin. On mak- ing much pressure, pain is occasioned, and sometimes a numbness in all the limbs, stupefaction, and other more or less afflicting symptoms. The tumour, in some measure, returns inwards, espe- cially, when not very large, and gradu- ally rises up outward again, when the pressure is discontinued. " Sometimes, tiiere is pain ; at other times, there is none; which may be owing to the man- ner, in which the tumour is affected by the edges of the bone, through which it passes,. The pain is often made to go off •by compression, but returns as soon as this is taken off. The tumour has an al- ternate motion, derived from the pulsa- tion of the brain, or of the large arteries at its base. This throbbing motion has led many into error, by making them mistake the disease for an aneurism, as happened in the second case, related in the memoir of M. Louis. When the tu- mbur is pushed sideways, and the finger carried between it and the edge of the bone, through which the disease pro- trudes, the bony edge may be felt, touch- ing the base of the swelling, and more or less constricting it. This symptom, when distinguishable, added to a certain hard- ness and elasticity, and sometimes a faci- lity of reduction, forms a pathognomonic mark, which cannot deceive. By uniting all the preceding symptoms, and exer- cising, in the investigation, the spirit of combination, so necessary in these diffi- cult, cases, fungous tumours of the dura mater may be discriminated from hernix of the brain, external fleshy tumours, ab- scesses, exostoses, and other affections, which at first sight resemble them. Generally speaking, fungous tumours of Ike dura mater are very dangerous, as well on account of their nature, as of the difficulty of curing them in any certain manner, and of the internal and external disorder, which they may occasion. Such as have a pedicle, the base of which is not extensive; which are firm in their tex- ture, without much disease in the sur- rounding bone^MU-e moveable, not very painful, and in persons, who are, in other respects quite well, are in geveral re- puted to be the least perilous. These are the cases, in which a cure may be at- tempted, with a hope of success, though the event is always exceedingly doubt- ful. When the contrary of what has been j ust related occurs, when the disease is of long continuance, and the brain already affected, nothing favourable can be ex- pected. Compression is the most simple means of cure, and that which has naturally oc- curred to such practitioners, as have mis- taken the disease for an aneurism, or a hernia cerebri. The effiency of this me- thod has been further misconceived, be- cause the tumour, when not very large, has sometimes been partly, or even wholly reduced, without any bad consequences. This had no little share in leading to errors, concerning the true character of the disease. But, as might be conceived, this reduction, only being attended with temporary success, and liaving no effect whatever on the original cause of the af- fection, the symptoms returned, and the tumour rose up again, the moment the compression was discontinued. There' is a fact in the memoir by M. I/>uis, which seems to' evince, that good effects may sometimes be produced by compression judiciously employed. A woman, brought to the brink- of the grave by the symp- toms, occasioned by a tumour of the above kind, having rested with her head, for some time, on the same side as the DUR tinpour, found the -swelling so suddenly reduced, without any ill effects, that she thought herself cured by some miracle. A compression artfully kept up, by means of a piece of tin, fastened to her cap, pre- vented the protrusion of the tumour again. The pressure, however, not having been always very exact, the symptoms every now and then recurred, while the tumour was in the act of being depressed again, and they afterwards ceased, on the swell- ing having assumed a suitable position. The symptoms were doubtless, occasion- ed by the irritation, which the tumour suffered, in passing the inequaUties around the opening, through which it protruded. The patient lived in this State nine years, having every now and then trances, in one of which, attended with hiccough and vomiting, she pe- rished. As compression cannot be depended upon, the following safer method may be tried. It consists in exposing the tumour with a knife, which is certainly prefer- able to caustics, the action of which can never be limited, nor extended, exactly as one wishes. A crucial incision may be made through the scalp covering tiie tu- mour, and the flaps dissected up, and reflected, so as to bring all the bony circumference into view. Then with trephines repeatedly applied, or with what would be better, Mr. Hey's saws, all the margin of the bone should be care- fully removed. The tumour, thus disengaged on all sides, may be cut off*with a scalpel. After this, some recommend applying to the cut surface an ointment containing the hy- drarg. nitrat. rub. an application, wliich I would not recommend, On the contrary, it seems to me preferable, in order to avoid all occasion for the use of caustic, to remove every part of both layers of the dura mater immediately under the ex- crescence. By this means, all chance of the regeneration of the tumour will be prevented. "When the tumour is sarcomatous, and its pedicle small and narrow, as some- times happens, one should not hesitate to cut it off. This method is preferable to tying the base of such tumours with a ligature, as the latter plan cannot be executed, with- out dragging, and seriously injuring the dura mater, so as to excite dangerous con- sequences. The excision is also prefer- able to caustics, which cause great pain, D Y S S5r and very often convulsions. In perform- ing the extirpation, we should remove the whole extent ofthe tumour, and, if possi- ble, its root, even though it may extend as deeply as the internal layer of the dura mater. Tliis step must not be delayed, for the disease will continue to increase, so as to affect the brain, become incur- able, and even mortal. It is to such de- cision, that we must impute tiie success, which attended the treatment of the Spa- niard Avalos, of whom Marcus Aurelius Severinus makes mention. The above nobleman was afflicted with intolerable head-achs, which no remedy could ap- pease. It was proposed to him to trepan the cranium, an operation, to which he consented. This proceeding brought into view, under the bone, a fungous ex- crescence, tiie destruction of which proved a permanent cure of the violent pains, which the disease had occasioned. It. is not mentioned in this case, whether the in- ternal layer ofthe dura mater was healthy, or not; but, there is foundation for be- lieving, that if the extirpation of these tumours be undertaken in time, and bold measures be pursued, as in the instance just cited, success would often be obtain- ed. Indeed, reason would support this opinion; for, when the disease is not ex- tensive, it is necessary to expose a much smaller surface of the dura mater. M. Louis has described other tumours, which grow from the surface of the dura mater, after this membrane has been de- nuded, as after the application of tlie trephine. They only seem to differ from the preceding ones in not existing, before the opening was made in the skull. These cases are not to be confounded with the ' hernia cerebri. (See this Article ) See on the preceding subject, Memoire sur les Tumeurs fongueuses de la Dure-Mere, par M. Louis, in Mem. de I'Academie de Chi- rurgie, Tom. 5, 4to. or Tom. 13, 12mo. Encyclopedic Methodique, Partie Chirurgi- cale, art. Dure-Mere. Richerand's Noso- graphie C/tirurgicale, Tom. 2, p. 284. Edit. 2. Lassus, Pathologid Chirurgicale, Tom. 1, p. 497 Edit. 1809. An account of the inflammation of the dura mater will be found in the article, Head, Injuries of. DYSTiECHIASIS. (from hct bad, and ratx<>S> order.) An irregular arrangement of the eye-lashes. DYSURIA, (from ^5, difficulty, and »f«», the urine.) A difficulty of discharg- ing the urine. ( 358 ) EAR, DISEASES OF. AN organ, so valuable and necessary to the perfection of our existence, as the ear is, should have all the resources of surgery exerted for the preservation of its integrity, and the removal of the dis- eases, with which it may be affected. What, indeed, would have been our lot, if nature had been less liberal, and not endued us with the sense of hearing ? As M. Leschevin has observed, we should then have been ill qualified for the re- ceipt of instruction; a principal inlet of divine and human knowledge would have been closed; and there being no recipro- cal communication of ideas, our feeble reason could never have approached per- fection. Even our life itself being as it were dependent upon all such bodies as surround us, would have been incessantly exposed to dangers. The eyesight serves to render us conscious of objects, which present themselves before us, and, when we judge them to be hurtful, we endea- vour to avoid them. But, to say nothing of our inability of looking on all sides at once, our eyes become of no service to us, whenever we happen to be enveloped in darkness. The hearing is then the only sense, that watches over our safety. It warns us, not only of every thing, which is moving about us, but likewise of noises, which are more or less distant. Such are the inestimable advantages which we de- rive from this organ. Its importance, when healthy, makes it worthy of the ut- most efforts of surgery, when diseased. (SeeJIii Leschevin's Dissert, in Memoires sur les Sujets proposes pour le Prix de PAcad. Royale de Cliirurgie, Tom. 9. p. Ill, 112. Edit. 12mo.. 1. Wounds of tlie External Ear. The external ear, which is a sort of in- strument calculated for concentrating the rays of sound, may be totally cut off, without deafness being the consequence. For a few days after the loss, the hearing is rather hard ; but, the infirmity gradu- ally diminishes, the increased sensibility of the auditory nerve compensates for the imperfections of the organic apparatus, and the acuteness of the sense is entirely restored. (Richerand, Nosographie Chi- rurgicale, Tom. 2, p. 122. Edit. 2.) How- ever, if we are to credit the statement of other writers, the recovery is far less com- plete, than M. Richerand represents it to be. Thus Leschevin notices, that they, who have lost tiie external ear, or have it naturally too flat, or ill shaped, have the hearing less subtile. The defect can only be remedied by an artificial ear, or an ear-trumpet, which receiving a large quantity of the sonorous rays, are direct- ing them towards the meatus auditorius, thus does tiie office of the external part ofthe ear. (Prix de PAcad. Royale de Chi. rurgie, Tom. 9, p. 120. Edit.l2mo) Wounds are not the only causes, by which the external ear may be lost: its separation is sometimes the consequence of ulceration, and sometimes the effect of the bites of horses and other animals. In some countries, it is a part, that is fre- quently attacked with inflammation and sloughing, in consequence of having been frozen. Except the external ear be to- tally separated from the head, the surgeon should not despair of being able to accom- plish the reunion of it. This attempt should always be made, however small a connexion the detached part may have with the skin ; for, in wounds of this kind, the efforts of surgery have occasion- ally succeeded beyond all expectation. Wounds of the external ear, whatever may be their size and shape, do not re- quire a different treatment from that of the generaUty of other wounds. The reunion of the divided part is the only in- dication, and it may be in most instances easily fulfilled by means of methodical dressings. Such writers, as have recom- mended sutures for wounds of tiie ear, (says Leschevin,) have founded this ad- vice upon the difficulty of applying to the part a bandage, that will keep the edges of tiie wound exactly together. The cra- nium, however, affords a firm and equal surface, against which the external ear may be conveniently fixed. Certainly, it is not more easy to secure dressings on the nose than the ear ; and, yet, cases are, recorded, in which the cartillaginous part of the nose was wounded, and almost entirely separated, and the union was effected without the aid ot sutures. (See Mem. tie M. Pibrac sur PAbus des Su- tures, in Mem. de PAcad. tie Clur. Tom. 3.) In wounds of the ear, then, we may conclude, that sutures are generally use- less and unnecessary. As examples may occur, however, in which the wound may EAR. 359 he so irregular and considerable as not to admit of being accurately united, except by this means, it should not be absolutely rejected. An enlightened surgeon will not abandon altogether any curative plans ; he only points out their proper utility, and keeps them within the right limits. When sticking plaster, sim- ple dressings, and a bandage, that makes moderate pressure, appear insufficient for keeping the edges of a wound of the ear in due contact, the judicious practitioner will not hesitate to employ sutures. When a bandage is applied to the ex- ternal ear, it should only be put on with moderate tightness, since much pressure gives considerable uneasiness, and may induce sloughing of the part. In order to prevent these disagreeable effects, M. Leschevin advises us to fill the space be- hind the ear with soft wool or cotton, against which the part may be compressed without risk. ( Op. cit. p. 119.) In the application of sutures, the an- cients have cautioned us to avoid care- fully the cartilage, and to sew separately, one after the other, the skin of both sides of the ear. They were fearful, that prick- ing the cartilage would make it mortify, " ce qui est sonvente-fois arrive" says Pare". But, notwithstanding so respectable an authority, as M. Leschevin has remarked, the moderns make no scruple about sew- ing cartilages. In wounds of the nose, Verdue expressly directs the skin and cartilage to be pierced at once in apply- ing sutures, and the success ofthe plan is put out of all doubt by a multitude of facts. The same treatment may also be safely extended to the ear. Celsus, lib. 8, c. 6, has mentioned frac- tures of the cartilage of the ear ; but, such an accident seems hardly possible, unless the part be previously ossified. Hence, M. Leschevin could never meet with such a case, either in practice, or in tlie works of surgical writers. 2. Of the Meatus Auditorius, and its Im- perfections. This is the passage, which leads from the cavity of the external ear, called the concha, down to the membrane of tlie tympanum. This tube, wliich is partly cartilaginous, and partly bony, has an ob- lique winding direction, so that its whole extent cannot be easily seen. There are circumstances, however, in which it is proper to look as far as possible into tiie passage. Such is the case, when the sur- geon is to extract any foreign body, to remove any excrescence, or to detect any other occasion of deafness. Fabricius Hil- danus gives a piece of advice upon this subject, not to be despised; namely, to ex- pose the ear to the rays of the sun, in order to be enabled to see the very bot- tom of the meatus auditorius externus. The surgical operations, practised on the meatus auditorius, are confined to opening it, when preternaturally closed, extracting foreign bodies, washing the passage out with injections, and remov- ing excrescences, which may form there. The case, which we shall next treat of, is the imperforation of the meatus audi- torius externus,a defect with which some children are born. When the malform- ation exists in both ears, it generally ren- ders the subject dumb as well as deaf, for, as he is incapable of imitating sounds, which lie does not hear, he cannot of course learn to speak, although the or- gans of speech may be perfect, and in every respect rightly disposed. In this case, the surgeon has to rectify the error of nature, and, (to use the language of M. Leschevin,) he has to give by a double miracle, hearing and speech to an ani- mated being, who, deprived of these two faculties, can scarcely be regarded in so- ciety as one of the human race. How highly must such an operation raise the utility and excellence of surgery in the estimation of the world! About twelve years ago, I remember a child being shewn to several medical gentlemen in London, as a curiosity; it was entirely destitute of all appearance of external ears, and no vestiges of the meatus auditorii could be seen. The na- tural situations of these openings were completely covered with the common in- teguments. Yet, it deserves attention, that the child could hear a great deal, though the sense was certainly dull and imperfect. I remember, that the circum- stance of the patient hearing so well as he did, was what excited considerable sur- prise. 1 am sorry I do not more parti- cularly recollect, at the present time, the degree, in which this sense was enjoyed, and several other circumstance*", such as the child's age, power of speech, &c. The example, however, is interesting, in- asmuch as it proves, contrary to the assertions of authors, that even an im- perforate condition of" both ears may be unattended with complete deafness, pro- vided the internal and more essential parts of these organs are sound and per- fectly formed. When the meatus auditorius externus is merely closed by an external mem- brane, the nature of the case is evident, and the mode of relief equally easy. But, when the membrane is more deeply situ- ated in the passage, near the tympanum, the diagnosis is attended with more dif- 360 EAR. «■" ficulty, and tlie treatment with greater trouble. If the preternatural membrane is ex- ternal, or only a little way within the pas- sage, it is to be divided with a bistoury ; the small flaps are to be cut away ; a tent, of a suitable size, is to be introduced into the opening; and the wound is to be healed secundum artem, care being taken to keep it constantly dilated, untU the cicatrization is completed. When the obstruction is deeply situat- ed, we must first be sure of its existence, which is never ascertained, or even sus- pected, till after a long while. It is not till after children are past the age, at1 which they usually begin to talk, that any defect is suspected in the organ of hear- ing, because until this period, little no- tice is taken, whether they hear or not. As soon as it is clear, that this sense is deficient, tiie ears should always be exa- mined with great attention, in order to discover, if possible, the cause of the deafness. Sometimes, the infirmity de- pends upon a malformation of the internal ear, and the cause does not then admit of detection. The most convenient method of making the examination is to expose the ear, which is about to be examined, to the light of the sun. In this situation, the surgeon will be able to see beyond the middle of the bony part of the meatus, if he places his eye opposite the orifice of the passage, and takes care to efface the curvature of the cartilaginous portion of the canal, by drawing upward the external ear. If the passage has been carefully cleansed, before the examination, the skin, forming the obstruction may now be seen, unless it be immediately adherent to the tympanum. When the preternatural septum is not closely united to the tympanum, its de- struction should be attempted, and hopes of effecting the object, either suddenly, or gradually, may reasonably be enter- tained. According to .VI. Leschevin, the particular situation of the obstruction is the circumstance, by which the surgeon ought to be guided in making a choice of the means for this operation. If the membranous partition is so far from the tympanum, that it can be pierced without danger of wounding the latter part, there can be no hesitation in choosing the plan to be adopted. In the contrary state of things, M. Leschevin is an advocate for the employment of caustic, not only on account of the. risk of injuring the tympa- num with a cutting instrument, but, also, because, if the puncture were ever so well executed.atentcouldnot be introduced in- to it, so as to prevent it from closing again. hi the first case, a very narrow sharp- pointed bistoury should be used: after its blade has been Wrapped round with a bit of tape to within a line of the point, it is to be passed perpendicularly down to the preternatural membrane, which is' to be cut through its whole diameter. The instrument being then directed first towards one side, then the other, the cm- cial incision is to be completed. As the flaps, which are small and deeply situat- ed, cannot be removed, the surgeon must be content with keeping them separated by means of a blunt tent. The wound will heal just as favourably as that occa- sioned in removing the imperforation of the concha, or outer part of the meatus auditorius. (Prix, de P Acad, de Chir. p. 124—126, Tom. 9) In the second case, that is to say, when the risk of wounding tlie tympanum leads us to prefer the em- ployment of caustic, the safest and most commodious way of putting the plan in execution would be that of touching the obstruction, as often as circumstances may require, with the extremity of a bon- gie armed with the argentum nitratum. In the intervals of the application, no dressings need be introduced, except a bit of clean soft cotton, for the purpose of absorbing any discharge, which may- take place within the passage. It is manifest, that if the whole, or a considerable part of the meatus audito- rius externus were wanting, the forego- ing measures would be insufficient. The following observations of M. Leschevin seem to merit att-Ation : " I do not here allude to cases, in which a malformation of the bone exists. I know not, whether there are any examples of such an imper- foration ; but, it is clear, that it would be absolutely incurable. I speak of a temporal bone perfectly formed in all its parts, and the meatus auditorius of which, instead of being merely lined by a mem- brane, as in the natural state, is blocked up by the cohesion of the parietes of this membrane throughout a certain extent of the canal; just as the urethra, rectum,or vagina, is sometimes observed to be not simply closed by a membrane, but by a true obliteration of its cavity. " Such a defect in the ear may be con- genital, and it may also arise from a wound, or ulceration, of tlie whole cir- cumference of the meatus auditorius ex- ternus, this canal having become closed by the adhesion of its parietes, on cica- trization taking place. " Such an imperforation, whether con- genital, or accidental, must certainly be more difficult to cure, than the examples treated of above ; but, (says M. Lesche- vin) I do not for this reason believe, that tlie case ought to be entirely abandoned. EAR. 361 Yet, I would not have the cure attempt- ed in aU sorts of circumstances. For in- stance, if the defect only existed in one par, and the other were sound, 1 would not undertake the operation,' because, as the patient can hear tolerably well on one side, the advantages wliich he might de- rive from having the enjoyment of the pther ear, would not be adequate to coun- terbalance the pain and bad symptoms occasioned by such an experiment, the success of which is extremely uncertain. I would not then run the risk of making a perforation, except in a case of com- plete deafness; and I propose this means only as a dubious one upon the funda- mental maxim, so often laid down, that it is preferable to employ a doubtful re- medy, than none at all. «• With respect to the mode of execut- ing this operation," says M. Leschevin, *' the trocar seems the most eligible in- strument. I would employ one, that is very short, and the point of which is bluntish, and only projects out of a can- nukas little as possible. This.construc- tion would indeed make the instrument less adapted to pierce any thing; but, still, as the parts to be perforated are firm, their division might be accomplish- ed sufficiently well; and the inconveni- ence of a trivial difficulty in the intro- duction of the trocar is comparatively much less, than that, whioh would attend the danger of wounding with a sharper point the membi-ane of the tympanum. I would plunge the point of the instru- ment into the place, where the opening of the meatus auditorius externally ought naturally to be, and which would be de- noted, either by a slight depression, or at all events, by attending to the different parts of the ear, especially, the tragus, which is situated directly over this pas- sage. I would push in tiie trocar gently, in the direction of the canal formed in the bon.e, until the point of the instru- ment felt as if it had reached a vacant space. Then, withdrawing the trocar, and leaving the cannula, I would try, whether the patient could hear. I would then introduce into the cavity of the can- nula itself a small, rather firm tent, of the length of the passage, or rather a small bougie. By means of a probe, I would push it to the end of the cannula, which I wpuld now take out, observing to press upon the tent, which is to be left in. The rest of the treatment consists in keeping the canal pervious, making it suppurate, and healing it with common applications. One essential caution, however, would be that of keeping tlie part dilated long after it had healed: Otherwise, it might close again, and are- Voi. I. petition of the operation become neces- sary. This happened to Heister, as he himself apprises us, and it occurred to Roonhuysen in treating imperforations of tlie vagina. . " If the cohesion of the parietes of the meatus auditorius externus were to ex- tend to the tympanum inclusively, the - operation would be fruitless; but, as it is impossible to ascertain this circum- stance, before the attempt is made, the surgeon would incur no disgrace, by re- linquishing the operation, and giving up the treatment of an incurable disease. If, then, after the trocar were introduced to about the depth of the tympanum, the situation of wliich must be judged of by our anatomical knowledge, no cavity were met with, the operation should be aban- doned; and, if in these circumstances, any one were to impute the want of suc- cess to the inefficacy of surgery, or the unskilfulness of the surgeon, he would act very unfairly. "It is also plain, that such an opera- tion could only cure a congenital deaf- ness, inasmuch as the infirmity might de- pend solely upon the imperforation; for, if there should exist, at the same time, in tiie internal ear, any malformation, which might destroy the power of the or- gan, the remedying of the external defect would be quite useless." (Leschevin, in Prix del'Acad, de Chirurgie, Tom. 9,p. 127—132.) We find, that this author entertains a great dread of wounding the tympanum, and, certainly he is right in generally in- sisting upon the prudence of avoiding such an accident. It will appear, how- ever, in the sequel of this article, that puncturing the tympanum has, under certain circumstances, been successfully practised, as a mode of remedying deaf- ness : so far is it from being particularly dangerous, or destructive of the functions ofthe ear. 3. Unusual smallness of the Meatus Audt- tortus Externus. Imperforation is not the only Affection of the meatus auditorius, with which na- ture sometimes afflicts us, brfore our birth. This passage is occasionally too narrow, and, hence, the* « not room enough, for the entrant of a due quan- tity of the sonorous n-ys and *■*« sense >s of course unavoidably feeble. Leschevin mentions, that M. de la Metric had seen this canal so nai^w in a young person, that it could hardly admit a probe. What has been observed concerning the imper- foration is also applicable to this case. If it depends upon malformation of the 3A 362 E A R bone, it is manifestly incurable ; but, if it is owing to a thickening of the soft parts, \vithin the meatus, hopes may be indulged of doing good by gradually dilating the passage by tents, which should be increased in size from time to time, and, lastly, making the patient wear for a considerable time, a tube, adapted to tbe part in shape. (Leschevin, in Prix de PAcad. de Chirurgie, Tom. 9, p. 132.) 4r. Faulty shape of the Meatus Auditorius Externus. Anatomy informs us, that this passage is naturally oblique, and somewhat wind- ing; and natural philosophy teaches us the necessity of such obliquity, in demon- strating, that it multiplies the reflections of the sonorous rays, and thereby strength- ens the sense. This theory, says M. Les- chevin, is confirmed by experience; for, there are persons, in whom the meatus auditorius is almost straight, and they are found to be hard of hearing. If there is any means of correcting this defect, it must be that of substituting, for the natu- ral curvature of the passage, a curved and conical tube, which must be placed at the outside of the organ, just like a hearing trumpet. The acoustic instrument, in- vented by Deckers, which is much more convenient, might also prove useful.— (Op. cit.p. 133.) 5. Extraneous Substances, Insects, &c. in tlie Meatus Auditorius Externus. Foreign bodies met with in this situa- tion are inert substances, which have been introduced by some external force; in- sects, which have insinuated themselves into the passage ; or the cerumen itself, hardened in such a degree, as to obstruct the transmission of the sonorous undula- tions. Worms, which make their ap- pearance in the meatus auditorius, are always produced subsequently to some ulcerations in the passage, or in the inte- rior if the tympanum, and, very often, such insects are quite unsuspected causes pf particular symptoms. In the cases of surgery, published in 1778 at Stockliolm, by Olaus Aciih there is an instance con- firming the statement just offered. It is the case of a w-»man, who having been long afflicted with % hardness of hearing, was suddenly seizei with very violent convulsions, without a*y apparent cause, and soon afterwards complained of an acute pain in the ear. TlAs affection was followed by a recurrence of convulsions, which were more vehement, than before. A small tent of fine Unen, moistened with a mixture of oil and laudanum, wa3 in- troduced into the meatus auditorius, and, on removing it the next day, several small round worms were observed upon it, and, from that period, all the symptoms dis- appeared. To this case, we shall add another from Morgagni. A young wo- man consulted Valsalva, and tola him, that when she was a girl, a worm had been discharged from her left ear; that another one, about six months ago, had also been discharged, very much like a small silk-worm in shape. This event took place after some very acute pain in the same ear, the forehead, and temples. She added, that since this, she had been tormented with the same pains, at dif- ferent intervals, and, so severely, that she often swooned away for two hours to- gether. On recovering from this state, a small worm was discharged, of the same shape as, but much smaller than, the pre- ceding one, and that she was now afflict- ed with deafness and insensibility on the sahie side. After hearing this relation, Valsalva no longer entertained any doubt of the membrane of the tympanum being ulcerated. He proposed the employment of an injection, in order to destroy the nest of wosms, which he presumed to exist. For this purpose, distilled water of St. John's wort, in which mercury had been agitated, was used. Morgagni adds; that nothing appears to him more proper, in such cases, to prevent a recurrence of such worms, than to avoid going to sleep, particularly in autumn and summer, without taking care to stop up the affect- ed ear. If this be not done,' flies attract- ed by the suppuration, enter the meatus auditorius, and, while the patient is in- conscious, deposit their eggs in the ear. Acrel, in speaking of worms, generated in the meatus auditorius, observes, that there is no better remedy for them, than the decoction of ledum palustre, injected into the ear, several times a day. How- ever, as it is not always possible to pro- cure this plant, we shall recommend in such cases, in preference to all other re- medies, a slight infusion of tobacco in oil of almonds, a few drops of which are to be introduced into tbe ear, and to be re- tained there by means of a Uttle bit of cotton. This application, which is not injurious to the lining of the passage, is fatal to insects, and, especially, to worms, as various experiments have convinced naturalists. This method may also suc- ceed in cases, in which caterpillars, ants, and other insects, have insinuated them- selves into the meatus auditorius; but, it is always better, first to endeavour to extract them. A piece of lint, smeared with honey, often suffices for this pur- EAR. 363 pose, and when they cannot be extracted by tliis simple means, they may be taken out with a very small pair of forceps, however little of them may be visible. The latter method serves also for the extraction of cherry-stones, peas, or other Heeds, which have been introduced into the meatus auditorius. If such sub- stances should make too much resistance, forceps with stronger blades for breaking the extraneous bodies must be employed, and then the fragments are to be extract- ed piecemeal. But, in these cases, it is always proper to inject into the ear some oil of almonds, before attempting to ex- tract the extraneous bodies. The pre- sence of these substances often occasions the most extraordinary symptoms, as we may see in the fourth observation of Fa- bricius Hildanus. Cent. 13. After four surgeons, who had been successively consulted, had in vain ex- erted all their industry to extract a bit of glass from the left ear of a young girl, the patient found herself abandoned to the most excruciating pain, which soon extended to all the side of the head, and which, after a considerable time, was fol- lowed by a paralysis of the left side, a dry cough, suppression of the menses, epileptic convulsions, and at length an atrophy of the left arm.^ Hildanus cured her by extracting the piece of glass, which had remained eight years in her ear, and had been tbe cause of all this disorder. Although the extraction must have been very difficult, it does not ap- pear that Hildanus found it necessary to practise an incision behind the ear, as some authors have advised, and amongst them, Duverney, who has quoted the foregoing case. We must agree with Leschevin, that such an incision does not seem likely to facilitate the object very materially; for, it must be on the outside of the extraneous substance, which is the bony part of the canal. It is true, in- deed, that the incision enables us, in some measure, to avoid the obliquity of the passage, as Duverney has observed; but, it is not such obliquity of the carti- laginous portion ofthe canal, that Can be a great impediment; for, as it is flexible, it may easily be made straight, by draw- ing upward the external ear. Hence, Fabricius ab Aquapendente rejected this operation, wliich was first proposed by Paulus iEjjineta; and it is justly disap- proved of by Leschevin. (Prix de I' Acad. tie Chir. Tom. 9, p. 147, edit, 12/uo.) C*. Meatus Auditorius obstructed with thick- ened, or hardened Cerumen. The cerumen, which is secreted into the meatus auditorius by the sebaceous glands of the part, frequently accumu- lates there in very large quantities, and becoming harder and harder, at length acquires so great a degree of solidity, as entirely to deprive the patient of the power of hearing. Galen has remarked ; e numero eorum qux meatum obstruunt, sor- des esse qux in auribus colligi sohmt. This species of deafness is one of those kinds, which are the most easy of cure, as is confirmed by observers, especially Du- verney. Frequent injections, either with simple olive oil, or oil of almonds, have always been recommended in such canes. The injection is to be retained by a piece of cotton, and, when there is rea- son to believe that the matter is suffi- ciently softened, an attempt may be made to extract it by means of a small scoop- Uke instrument. Whatever success this plan may have obtained, various experi- ments were made at Chester, in 1769, by Haygarth, from which it appears, that warm water is still preferable. This dissolves the mucous matter, which con- nects together the truly ceruminous par- ticles, and which is the cause of their tenacity; other applications only suc- ceeding by reason of the water which they contain. " The symptoms (says Mr. Saunders) which are attached to the inspissation of the cerumen are pretty weU known. The patient,, besides his inability to hear complains of noises, particularly a clash' or confused sound in mastication, and of heavy sounds, Uke the ponderous strokes of a hammer. " The practitioner is led by the rela- tion of such symptoms to suspect the ex- istence of wax ; but he may reduce it to a certainty by examination. " Any means capable of removing the inspissated wax may be adopted; but syringing the meatus with warm water is the most speedy and effectual, and the only means necessary. As the organ is sound, the patient is instantaneously re- stored." (Anatomy ofthe human Ear, with a Treatise on its Diseases, by J. C. Saun- ders, 1806. p. 27, 28.) T. Discharges from tlie Meatus Auditoriut. Purulent discharges from the ear, eitfier come from the meatus auditorius externus itself, or they originate from suppuration in the tympanum, in conse- quence of blows on the head, abscesses after malignant fevers, the small-pox, or the venereal disease. In such cases, the little bones of the ear are detached, and escape externally, and complete deafness is most frequently the consequence. 364 EAR. However, in a few instances, total deaf- meatus auditorius, is very delicate, it is ness does not always follow even this not the less liable to become thickened, kind of mischief, as I myself have wit- and to form polypous excrescences. This nessed in one or two instances. There case, however, is not common. " As such is greater hope, when the disorder is tumours are ordinarily firmer in their confined to the meatus; as judicious texture, than polypi of the nose, they ate treatment may now avert the most serious sometimes not so easily extracted with consequences. In Acrel's surgical cases, forceps. When they are situated near the there is a case, relative to the circum- external orifice, and admit of being taken stance, of which we are speaking. Sup- hold of with a small pair of forceps, or a puration took place in the meatus audi- hook, they may easily be cut away, when torius externus, in consequence of acute drawn outward, and this without any rheumatism, which was followed by ver- reason for fearing hemorrhage. This, tigo, restlessness, and a violent head-ach. indeed, is usually very trivial. When the Tlie matter discharged was yellowish, of tumours are more deeply situated, Mr. an aqueous consistence, and acid smell. B. Bell recommends giving tlie prefer- The meatus auditorius was filled with a ence to the use of a ligature. Here the spongy ftebh. On introducing a probe, same plan may be pursued as will be ex- our author felt a piece of loose rough plained in the article Polypus. But it bone, which he immediately took hold of sometimes happens, that the excrescences with a pair of forceps, and extracted, cannot be removed in this manner; as, From the time, when this was accom- instead of being adherent by a narrow plished, the discharge diminished; with neck, they have a broad base, which oc- the aid of proper treatment, the patient copies a considerable extent of the pai- became perfectly well. sage. Jh such cases, some have been sn from the retention tus, and not only obstructs the entrance" of the discharge. When the parts have of sound, but is accompanied With a great fallen into this state, it will be expedient degree of fcetor. This disease is not un- to hasten the cure by making an incision frequent. I have never seen it resist the into the sinus, between the auricle and effect of alterative medicines," the use mastoid process. of injections containing the hydrargyrus " It occasionally happens, that #the muriatus, and the application of the un- bone itself dies, in consequence of the guentum hydrargyri nitrati.' Mr. Sautt- sinus being neglected, or the original ex- ders exhibited calomel as tb* alterative, tent of the suppuration. The exfoliating and, in one instance, employed a solution parts are the meatus externus of the os of the argentum nitratum, as an injec- tempofis or the external lamina of the tion. (Page 25, 26.) mastoid process." (Page 24, 25 ) 8. Excrescences in the Meatus Auditorius. 10, ^fections °fthe Tympanum. Though the membrane, lining the This is sometimes effected with a pu- EAR. S6» rifbrm ichorous discharge, attended with a_ loss of hearing, proportionate to the degree of disorganization which tliis part of the ear has sustained. In general, on blowing tiie noSe, air is expelled at the meatus auditorius externus; and, when this is the case, it is evident, that the discharge is connected with an injury, or destruction of the membrana tympani. However, when the Eustachian tube is obstructed with mucus, or matter, or when it is rendered impervious, and per- manently closed by inflammation, the membrana tympani may not be perfect, and, yet, it is clear, no air can in this state be forced out of the external ear in the above manner. An examination with a blunt probe, or with the eye, while the rays of the sun fall into the passage, should therefore not be omitted. If the membrane have any aperture in it, the probe will pass into the cavity of the tympanum, and the surgeon feel that his instrument is in contact with the ossi- cula. In this manner the affection may be discriminated from an heapetic ulceration of the meatus auditorius externus. The causes are various: In scarlatina malig- na, the membrana tympani occasionally inflames, and sloughs; all the ossicula are discharged, and if the patient live, he continues quite deaf. An ear-ach, in other words, acute inflammation of the tympanum, is the most common occasion of suppuration in this cavity, in wliich, and the cells of the mastoid process, a good deal of pus collects. At length, the membrana tympani ulcerates, and a large quantity of matter is discharged ; but, as the secretion of pus still goes on, the discharge, continues to ooze out of the external ear. Instead of stimulating applications, in- flammation of the tympanum demands tiie rigorous employment of antiphlogis- tic means. Unfortunately, it is a too common practice, in this case, to have recourse to acrid spirituous remedies. Above all things the repeated application of leeches to the skin behind the external ear, and over the mastoid process, should never be neglected. As soon as the in- flammation ceases, the degree of deaf- ness, occasioned by it, will also disap- pear. This, however, does not always happen. When an abscess is situated in the ca- vity of the tympanum, Mr. Saunders seems to think, that the membrana tym- pani should not be allowed to burst by ulceration, but be ripened by a small puncture. (Pasfe 31.) Sometimes the disease, of which we aJ-e treating, is more insidious in its at- tack ; slight paroxysms of pain occur, and are relieved by sUght discharges. The case goes on in this way, until, at last, a continual discharge of matter from the ear takes place. The disorder is de- structive in its tendency to the faculty of healing, and it rarely stops, until it has so much disorganized the tympanum and its contents, as to occasion total deafness. Hence, Mr. Saunders very properly de- fends the propriety of making attempts to arrest its progress,—attempts which are free from danger ; and he censures the foolish fear of interfering with the com- plaint, founded on the apprehension, that bad constitutional effects may ori- ginate from stopping the discharge. If the case be neglected, the tympanum is very likely to become carious ; before which change, the disease, says Mr. Saun- ders, is most commonly curable. Mr. Saunders divides the complaint into three stages; 1. A simple puriform discharge. 2. A puriform discharge com- pticated with funguses and polypi. 3. A puriform discharge with caries ofthe tym- panum. As the disease is a local one, direct applications to the parts affected are chiefly entitled to confidence. Blis- ters and setons may be advantageously employed in aid of topical applications. Mr. Saunders' practice, hi these cases, consists in administering laxative medi- cines and fomenting the ear, while in- flammatory symptoms last, and after- wards injecting a solution of zincura vi- triolatum, or cerussa acetata. In the second stage, when there are funguses, he removes or destroys them with forceps, afterwards touches their roots with the argentum nitratum, or in- jects a solution of alum, zincum vitriola- tum, or argentum nitratum. 11. Obstructions of tlie Eustachian Tube. This is often a cause of a considerable degree of deafness, because it is neces- sary for perfect hearing, that air should be conveyed from the mouth through this passage into the cavity of the tympa- num, which now can no longer happen. A degree of deafness generally attends a severe cold, which is accounted for by the Eustachian tube being obstructed with thickened mucus. Mr. Saunders tells us, that the obstruction most fre- quently arises from syphilitic ulcers in the throat, or sloughing in the cynanche maligna. The deafness comes on when such sores are healed, that is, when the obstruction is complete. The descent of a nasal polypus into the pharynx, and enlarged tonsils have also been known to close the tube. (Page 42.) 366 EAR. When the Eustachian tube is obstruct- ed, the patient cannot feel the membrana tympani crackle, as it were, in his ear, on blowing forcibly with his nose and mouth stopped. Previous ulceration, or disease, of the throat, will sometimes aid in faci- litating the diagnosis. When the Eustachian tube is obstructed with mucus, it has been proposed to em- ploy injections, which are to be thrown by means of a syringe and catheter, into the guttural orifice of that canal. This operation, however, is alleged to be al- ways attended with trouble, and, when the os spongiosum inferius happens to be situated near the floor of the orbit, the introduction of any instrument like a female catheter, would be impracticable. (RicherandNosographie Cldrurgicale, Tom. 2, p. 131, edit. 2.) Mr. A. Cooper had noticed, that hear- ing was only impaired, not lost, when suppurations in the tympanum, had in- jured, and even destroyed the membrana tympani, and that the degree of deafness by no means equaUed what resulted from an obstruction of the Eustachian tube. Hence, when the tube was permanently obliterated, he conceived, that a small puncture of the membrana tympani might be the means of enabling the patient to hear. Mr. A. Cooper practised the plan with success, and others have imitated him with the same result. The operation consists in introducing an instrument, resembling a hydrocele trocar, but curved, into the meatus audi- torius externus, and pushing it through the anterior and inferior part of tlie mem- brana tympani; a place rendered most eligible on account of the situation of the chorda tympani and manubrium of the malleus, parts, which should be left unin- jured. The instrument must not be in- troduced far, lest it should wound the vas- cular lining of the tympanum, and cause a temporary continuance of the deaf- ness, by an effusion of blood. When the puncture is made, in proper cases, and in a judicious manner, hearing is imme- mediately restored. A small hole in the membrana tympani now conveys the air into the cavity of the tympanum, an- swering the same purpose as the Eusta- chian tube. The surgeon will be able to operate with more ease, if he take care to lessen the curvature of the meatus auditorius by drawing upward the external ear. There is some chance of a relapse in consequence of the opening closing up. This consideration has led Richerand to propose making the aperture with a caus- tic, so as to destroy a part of the mem- brane. (Nosographie Chirurgicale, Tom. 2. p. 132, edit. 2.) The suggestion is nof, however, likely to be adopted, on account of the inconveniences of applying caustic within the ear. Mr. Saunders is an ad- vocate for making the opening large.— This gentleman relates, that he instanta- neously restored hearing in one case, in which the patient had been deaf thirty years, in consequence of a loss of part of his palate by syphilis. (Page 45.) Mr. A. Cooper's cases are in the Philosophical Transactions for 1802.) Puncturing the membrana tympani has been attended with some degree of suc- cess in France, as well as this country. It is not to be dissembled, however, that there are numerous failures. We are in- formed, that Professor Dubois has done the operation in four instances, without success. (Richerand Nosographie Chirur- gicale, Tom. 2, p. 132.) In most cases, the patients, who have been benefited, are said to have experi- enced pain just after the trocar was with- drawn. The organ, in consequence of not being accustomed to sound, had be- come so extremely sensible, that it could not bear the gentlest impression of the sonorous vibrations, and the patient's first request, after the perforation was made, was that they, who were near him, might speak softly. This excessive ten- derness of the sense gradually subsides. 12. Diseases of the Labyrinth. No doubt deafness (and that kind of it which frequently foils tlie most skilful men) arises from an insensible state of the portio mollis of the auditory nerTe, or of the surfaces, on which its filaments are spread. This affection is analogous to the amaurosis, or gutta serena, in which, though, every part of the eye may seem to possess its natural structure, sight is lost, because the rays of light only strike against a paralytic, or insen- sible retina. Mr. Saunders dissected the ears of two deaf patients, with the great- est care, but could not discover the least deviation from the natural structure. Mr. Cline, however, found the labyrinth of a person born deaf filled with a caseous substance, in lieu of the natural limpid fluid, found in this situation, and the supposed use of which is to transmit the vibration of sound. Mr. Saunders remarks, that all the dis- eases of the internal ear may be denomi- nated nervous deafness : the term, in this sense, embracing every disease, the seat of which is in the nerve, or parts contain- ing the nerve. Nervous deafness is at- tended with various complaints in dif ferent cases, noises in the head of sundry ECC ECR 367 kinds, the murmuring of water, the hiss- ing of a boiling kettle, rustling of leaves, blowing of wind, &c. Other patients speak of a beating noise, corresponding with the pulse, and increased by bodily exertion, in tlie same degree as the action of the heart. Saunders, p. 47. According to tins author, there is a syphilitic species of nervous deafness, at- tended with a sensation of some of the above peculiar noises ; he relates a case, in which the hearing was completely re- stored, in five weeks, by a mercurial course. Mr. Saunders has relieved several cases of nervous deafness by confining patients to low diet, giving them calomel freely, repeated doses of natron vitriolatum, or magnesia vitriolata, sometimes twice, sometimes thrice, a week, or according to circumstances, and applying blisters be- hind the ears at intervals of a week. This plan is to be persevered in. Were I to offer an opinion on this sub- ject, I should certainly say, that the ana- logy, between the deafness, arising from paralysis of the nerve, and amaurosis, is so great, that the very same treatment, which has been found efficacious in the latter cases, promises to be of most avail in the former. (See Amaurosis.) The reader may consult Duverney surl'Organe de POuie; Memoire sur la Theorie ties Ma- ladies de P Oreille, et sur les moyens que la Chirurgie peut employer pour leur curatton, in prix de PAcad. de Chirurgie, Tom. 9, p, 111, &c. edit.l2mo. Richerand's Nosogra- phie C/ururgicale, Tom. 2,p. 122, &c. Edit. 2. A. Cooper, in the Philosophical Trans- actions for 1802 .' Saunders on the Anato- my and Diseases if the Ear, 1806. ECBRA'SMATA, Painful, inflammato- ry pustules on the surface of the body. ECBYRSO'MATA. Protuberances of the bones at the joints. ECCHY'MAIA. See Ecbrasmata. ECCHYMO'MA. ECCHYMOSIS.— (from tx^vu, to pour out.) This is a su- perficial, soft swelling, which makes the skin livid or blue, and is produced by blood extravasated in the cellular sub- stance. The causes of an ecchymosis are falls, blows, sprains, &c. which occasion a rup- ture of tlie small vessels on the surface of the body, and a consequent effusion of blood, even without an external breach of continuity. Ecchymosis is one of the symptoms of a contusion. (See Contu- sion) A considerable ecchymosis may originate from a very slight bruise, when one of the ruptured vessels is capable of pouring out a large quantity of blood into the interstices ofthe cellular substance. Ecchymosis does not, in general, make its appearance till several hours after the operation of its cause ; at least, it is not tiU after this time that the black, blue, and livid colour of the skin is most con- spicuous. A black eye, which is only an ecchymosis, is always most disfigured six or eight hours after its occurrence. In the article Bleeding, we have noticed bow an ecchymosis may arise from the blood getting out of the vein into the ad- jacent cellular substance. Common cases of ecchymosis are gene- rally easily cured, by applying discutient lotions, and administering one or two doses of any mild purgative salt. The best topical applications, are vinegar, the lotio salis ammoniaci, spirit, vin. camph. and aq. ammon. acet. The object is to avert inflaritmation, and to promote the absorption of the ex- travasated fluid. I have seen such success attend the practice of dispersing collections of ex- travasated blood, by means of absorption, that the plan of evacuating it by an inci- sion, seems to me to be hardly ever pro- per in cases of ecchymosis. When an open- ing is made into such tumours, and air is admitted, the portion of blood which can- not be pressed out, soon putrefies, and extensive inflammation and suppuration, are the too frequent consequences. ECCHYMO'MA ARTERIOSUM. The false aneurism. See Aneurism. ECCLY'SIS. A dislocation. E'CCOPE. The cutting away of any part. ECCOPE'US. The ancient raspatory used in trepanning. EC'DORA. An excoriation of the ure- tlira. ECIHNOPHTHA'LMIA. (from ,x,vei, a hedge-hog, and o@6aXft.ix, an inflamma- tion ofthe eye.) An inflammation ofthe eye lids, attended with a projection ofthe eyelashes, which stand out, like the quills of a hedge-hog. ECPEPIESvMENOS. Ulcers with high protuberant edges. A depressed fracture of the skull. ECPIESMA, ECPIESMOS. A mor* bid protrusion of the eye. ECPLEROMA. Hippocrates applies this term to hard balls, or substances, which were put in the arm-pit, when a dislocated shoulder was about to be redu- ced by the heel. ECPYE'MA. (from ex and t««v, pus.) . Suppuration ; an abscess. EC'PYSIS. An excrescence. ECRE'XIS. A rupture, or laceration of the uterus. ECROUELLES. The French name of tlie king's evil, or scropuula. 368 ECT ECT ECSARCO'UA. (from i* and who M. Louis conceived, that it wo with a great improvement of Petit's e\ making a sort of pivot were substitute, during hinge. The lever would thei>e died on being readily moved in every and put under any point of bone had the any occasion to alter the positiiken by a bridge or fulcrum. ;s respira- I have only to add, respectingthe first, for fractures of the skull; tha>ult, till best modern surgeons content thei h day with the common one, which is mo pie, and in the hands of a surgeon, had knows how to use it, is found to ansvle every desirable purpose. ELUXATIO. (from eluxo, to put out of joint.) A dislocation. ELYTROCELE. (from tyv(\oif the va- gina, and xjjAij, a tumour.) A hernia in the vagina. EMBREGMA. (from t^tXu, to make wet.) An embrocation. EMBROCATION, (from ef*£?eX», to make wet.) Embrocatio. Strictly a fluid application made to any part of the body. Many use the term, however, synony- mously with liniment. The following embrocations are noticed in the Pharma- copeia Chirurgica. EMBROCATIO ALUMINIS. j,. Alu" minis §ij. Aceti spiritus vinosi tenuio" ris, sing. ibss. For childblains, and dis- eased joints. EMBROCATIO A>L\IONL"E. 5,. Em- 376 E M P E M P brocat. ammon. Acet. cum sapone 31J. Aq. ammon. pur. 31J. M. For sprains and bruises. EMBROCATIO AMMONIA ACETA- TiE CAMPHORATJE. *. Solut. saponis cum camphora, Aq. ammon. acet. sing. 3j. Aq. ammon. pur. 3*jss. M. For sprains and bruises. It is also frequently applied to disperse chilblains, which have not suppurated. Said to be the same as Steers' opodeldoc. EMBROCATIO AMMONIJE ACETA- TM. &. Aq. ammon. acet. Solut. sapon. „-ing. §j. M. For bruises with inflamma- tion. EMBROCATIO CANTHARIDIS CUM CAMPHORA. *. Tinct. cantharidis. Spirit, camph. sing. gj. M. This may be used in any case, in which the object n-s to stimulate the skin. The absorption V cantharides, however, may bring on a onc-angupy. sitiniMBRYOTOMIA. (from e^vUv, a .e» is, and rtfjvtat, to cut.) The operation Dlovtuttm£ mt0 t^ie womb» 'm or&ev to ex- Jj J t the foetus. (See Cxsarean Operation.) ^lOLLIENTS. (from emollio, to svstem ?. Suck appUcations, as have the advantag' of softening and relaxing parts. that it m/YSEMA. (from eftQvTxa, to in- remote fn swelling produced by air being cation in 11 the cellular substance. times able mmon cause of this affection is nerves, wLd rib, by which the vesicles of ed the ser being wounded, the air escapes of friction, them into the cavity of the plants of But, as the rib on being frac- removed.nd pushed inwards, wounds the Accor, which lines the ribs and inter- cations muscles, part of the air most com- of they gets through the pleura, and those und'erated muscles into the cellular mem- ra .-ane, which is on the outside of the ''chest, and thence it is diffused through the same membrane over the whole body, so as to inflate it sometimes to an extra- ordinary degree. This inflation of the ceUular membrane has been commonly looked upon as the most dangerous part of the disease; how justly, will appear in the sequel. (Hewson, Med. Obs. and Inquiries, Vol. 3.) Emphysema is most frequent after a fractured rib, because there is, in this instance a wide laceration of the lungs, tnd no exit for the air ; it is less frequent "n large wounds with a knife, or broad sword, because the air has an open and unimpeded issue; it is again more fre- quent in deep stabs with bayonets, or small swords; and it is peculiarly fre- quent in gun-shot wounds, because the orifice in the skin inflames, and swells, while the wound is wider within. (Jolts Bell on Wounds ofthe Breast.) The symptoms, attending emphysema, are generally the following kind. The patient at first complains of a consider. able tightness of the chest, with pain, chiefly in the situation of the injury, and great difficulty of breathing. This oh struction of respiration gradually in. creases and becomes more and more in- supportable. The patient soon finds him- self unable to lie down in bed, and cannot breathe, unless when his body is in an upright posture, or he is sitting a little inclined forward. The countenance be- comes red and swollen. The pulse, at first, weak and contracted, becomes after- wards irregular. The extremities grow cold, and, if the patient continue unre- lieved, he soon dies, to every appearance suffocated. The emphysematous swelling, where- soever situated, is easily distinguished from oedema, or anasarca, by the crepi- tation, which occurs on handling it, or a noise, Uke that which takes place on compressing a dry bladder half filled with air. (Encyclopedic Methodique; Partie Chi. rurgicale, Art. Emphysema!) The wound of the pleura and inter- costals may sometimes be too small to suffer the air to get readily into the cellu- lar membrane, and to inflate it, but may confine a part of it in the cavity of the thorax, so as to compress the lungs, pre- vent their expansion, and cause the same symptoms of tightness of the chest, quick breathing, and sense of suffocation, which water does in the hydrops pectoris, or matter in the empyema. (Hewson.) To understand, why the air passes at' all out of the wound of the lungs, we must advert to the manner, in which in- spiration and expiration are naturally carried on. It is well known, that in the perfect state, the surface of the lungs always lies in close contact with the membrane lining the chest, both in in- spiration and expiration. The lungs themselves are only passive organs, and are qhite incapable, by any action of their own, to expand and contract, so as to maintain their external surface con- stantly in contact with the inside of the thorax, which is continually undergoing an alternate change of dimensions. Every muscle, that has any concern in enlarg- ing and diminishing the capacity of the chest, must contribute to the effect of adapting the volume of the lungs to the cavity, in which they are contained, as long as there is no communication be- tween the cavity of the pleura, and the external air. In inspiration, tlie thorax EMPHYSEMA. 377 is enlarged in every direction, the lungs are ex ended in the same way, and the air entering through the wind-pipe into the air-cells of these organs, prevents the occurrence of a vacuum. But, in cases of wounds, when there is a free communication between the atmo- sphere and inside of the chest, on this oavity being expanded, the air naturally enters it at the same time, and for the same reasons, that the air enters the lungs through the trachea, and the lung itself remains proportionally collapsed. When the thorax is next contracted, in expi- ration, the air is compressed out of the lung, and also, out of" tiie bag of the pleura, through the external wound, if there be a direct one. In tiie latter cir- cumstance, the emphysematous swelling is never very extensive. But, in the case of a fractured rib, attended with a breach in the pleura costalis, pleura pulmonalis, and some of the air-cells of the lungs, there is no direct communication between the cavity of the chest and the external air; in other words, there is no outward wound in the parietes of Ihe thorax. There, is, however, a pre- ternatural opening formed between the air-cells ofthe lungs and the cavity of the chest, and also another one between the latter space, and the general cellular sub- stance of the body, through the breach in the pleura costalis. The consequence is, that, when the chest is expanded in inspi- ration, air rushes from the wound in the surface of the lungs, and insinuates itself between them and the pleura costalis. The lungs collapse in proportion, and the place, which tliey naturally occupied, when dis- tended, is now occupied by the air. When, in expiration, the dimensions ofthe chest are every where diminished, the air, now lodged in the bag of the pleura, cannot get back into tiie aperture in the collapsed lung, because this is already full of air, and is equally compressed on every side, by that which is confined in the thorax. Were there no breach in the pleura costalis, this ah- could not now become diffused; the muscles of inspira- tion would next enlarge the chest, re- move the pressure from the surface of the wounded lung, more air would be sucked out of it, as it were, into the space between the pleura costalis and pleura pulmonalis, and this process would go on, till the lungs of the wounded side were completely collapsed. But, in the case of a fractured rib, or of a narrow stab, in which there Is also a breach in the pleura costalis, without any free vent out- ward, for tlie air, which gets out of the lung into the cavity ofthe pleura, as soon Vol. I. as the expiratory powers lessen the capa- city of the chest, this air, not being able to get back through the breach in the col- lapsed lung, passes through the lacera- tion, or wound, in the pleura costalis, into the common cellular substance. It is through the communicating cells of this structure, that the air becomes diffused most extensively over the whole body, in proportion as the expiratory muscles continue in their turn to lessen the capacity of the chest, and pump the air, as it were, through the breach in the pleura costalis, immediately after it has been sucked, as it were, out of the wound in the lung, in inspiration. (See John Bell on Wounds of the Breast, Halhday on Em- physema, 1807) To prove that the confinement of air in the chest is the cause of the dangerous symptoms attending emphysema, Mr. Hewson adverts to the histories of some most remarkable cases, published by M. Littre, M. Mery, Dr. Hunter, and Mr. Cheston. (See Mem. del' Acad. Royale des Sciences, for 1713. Med. Observations and Inquiries, Vol. 2, and Pathological Inqui- ries.) In M. Littre's case, the patient, who had been wounded in the side with a sword, could not breathe^w it hout making the most violent efforts, especially, during the latter part of his disease : he died on the fifth day. In M. Mery's case, a man had the fourth and filth true ribs broken by a coach passing over his chest, his respira- tion was much impeded from the first, and became more and more difficult, till he died, which was on the fourth day after the accident. In Dr. Hunter's case, the patient had received a considerable hurt on his side by a fall from his horse. He had a diffi- culty of breathing, which increased in proportion as the skin became elevated and tense; it was laborious as well as frequent. His inspiration was short, and almost instantaneous, and ended with a catch in the throat, which was produced by the shutting of the glottis; after this he strained to expire for a moment with- out any noise, then suddenly opening the glottis, he forced out his breath with a sort of groan, and in a hurry, and then quickly inspired again ; so that his en- deavours seemed to be to keep his lungs always full; inspiration succeeded expi- ration as fast as possible. He said, his difficulty of breathing was owing to an oppression or tightness across his breast, near the pit of the stom..ch. He hud a little cough, which exasperated his pain, and he brought up blood and phlegm 3C 378 EMPHYSEMA. from his lungs. He was relieved by scari- fications, artd recovered. In Mr. Cheston's case, the man had received a blow on the chest. He had a constant cough, bringing up, after many ineffectual efforts, a frothy discharge, lightly tinctured with blood; he seemed to be in the greatest agonies, and under a constant appearance of suffocation. His pulse was irregular, and sometimes scarcely to be felt, his face livid, and, when he was sensible, which was only now and then, he complained of a pain in hi-5 head. On passing a bandage round his chest, with a proper compress to prevent the discharge of air into the cel- lular membrane, and to confine the motion of the thorax, the patient cried out, that he could not suffer it. A strong compression by the hand alone affected him in the same way. Notwithstanding, bleeding, repeated scarifications, and other means, his sense of suffocation, and difficulty of breathing increased. On the fourth day, the air no longer got into the cellular membrane, when on a sudden in- clining his head backward as it were, for the admission of more air, than usual, his breathing became more difficult and inter- rupted, he turned whoUy insensible, and soon afterward^tied. M. Little, M. Mery, and Mr. Cheston, opened their patients after death. M. Littre, besides a wound ofthe lungs and fractured rib, found a considerable quantity of blood in the cavity of the thorax, and was sensible of some putrid air escaping, on his first puncturing the intercostals and pleura. The wounded lobe was hard and black, and the other two of the same side were inflamed. In M. Mery's patient, no blood was extravasated, nor was there any thing preternatural, except the fractured ribs, the wound of the pleura, and that of the lungs. JVfr. Cheston found a fracture of the tenth and eleventh ribs, and a wound of the lungs. The lungs, below the wound, were livid, and more compact, than usual; but every thing else was natural, no ex- travasation, no inflammation, no internal emphysema. Mr. Hewson made experiments on ani- mals to shew, that air in their chests pro- duced great difficulty of breathing, such as occurs in cases of emphysema, and in one case, which he examined after death, air was actually discharged on puncturing the thorax. The object of Mr. Hewson's paper is to recommend making an opening into the chest, for the purpose of giving vent to the air confined in that cavity, just as is done for the discharge of pus, in cases of empyema, and water, in those of hydrops pectoris. In wounds of the lungs, says this au. thor, whether occasioned by fractured ribs, or other causes, when symptoms of tight- ness and suffocation come on, so far should we be from dreading the emphysematous swelling of the cellular membrane, that we should rather consider it, as a favour- able symptom, shewing that the air is not likely to be confined in the thorax ; and so far should we be from compressing the wound to prevent the inflation, or em- physema, that we should rather dilate it (if not large enough already,) or perform the paracentesis thoracis. We may judge ofthe necessity of this operation from the violence of the symptoms, such as the oppressed breathing, &c. For when these are not considerable, and the air gets out of the chest with sufficient freedom, the operation then becomes unneces. sary. The best place for performing the ope- ration, says Mr. Hewson, if the disease is on the right side, will be on the fore-part of tiie chest, between the fifth and sixth ribs ; for, there the integuments are thin, and, in the case of air, no depending drain is required. But, if the disease is on the left side, it will be more advisable to make the opening between the seventh and eighth, or eighth and ninth ribs, that we may be sure of avoiding the pericar- dium. As large penetrating wounds are in- convenient on account of* the air entering by the aperture in such a quantity, as to prevent the expansion of the lungs, a small wound will be eligible, and especially as air does not require a large one for its escape. Mr. Hewson recommends dissect- ing cautiously with a knife, in preference to the coarse and hazardous method of thrusting in a trocar. There is one error, prevailing in Mr. Hewson's paper, for which he has been justly criticized by Mr. John Bell; viz. the idea, that it is possible and proper to make the collapsed lung expand by mak- ing an opening into the chest, in cases of emphysema. Bromfield and B. Bell have both imbibed the same erroneous opi- nions, and proposed plans for exhausting the air and expanding the lung. It is very certain, that it is impracticable to make the collapsed viscus expand, until the breach in it is closed, and this closure is greatly promoted by the quiet state, in which the collapsed lung remains; a state, also, the most favourable for the stoppage of any bleeding from the pulmo- nary vessels. The true object then of making an opening into the thorax, when the symp- toms of suffocation are very violent in EMPHYSEMA. • 379 ca^s of emphysema, is not to obtain an expansion of the lung on the affected side, nor to take the pressure of the air from it; but, to remove the pressure caused on tiie opposite lung by the dis- tention of the mediastinum, and, at the same time, to diminish the pres.sure of the air on the diaphragm. The lung on tbe affected side must continue collapsed, and it is most advantageous, that it should do so. The opposite lung is that, which for a time must of itself carry on respi- ration, and it is known to be fully ade- quate to this function, provided the quan- tity of air, on the other side of the chest, does not produce too much pressure on the mediastinum, and diaphragm. Mr. John Bell concludes his remarks on this subject, with advising the follow- ing practice. 1st. Upon observing the crackling tumour beginning to form itself over a fractured rib, you should make small punctures with the point of a lancet, as in bleeding; and if the point be struck deep enough, the air will rush out audibly. But, as this air was in the thorax, before it came into the cellular substance, it is plain, that the thorax is still full, and that the lung of that side is already collapsed and useless, and must continue so. The purpose, therefore, of making these scarifications, and, espe- cially, of making them so near the frac- tured part, is not to relieve the lungs, but, merely, to prevent the air spreading more widely beneath the skin. 2nd. If, before you arrive, the air shall have spread to very remote parts of the body, as to the scrotum, and down the thighs, it will be easier to make small punctures in those parts, to let out the air directly, than to press it along the whole bodv, till you bring it up to the punctures made on the chest, over tlie wounded part. 3rd. If, notwithstanding free punctures, and pressing out the air.in this way, you should find by the oppression, that either air, or blood, is accumulating within the Cavity of the thorax, so as to oppress not the wounded lung only, which was of course collapsed and useless from the first, but so as to oppress also the dia- phragm, and through the diaphragm to affect also the sound lung; then a freer incision must be made, through the skin and muscles, and a small one delicately into the thorax to let out tiie confined air, or blood. (John Bell) After a few days, the wound, in the collapsed lung, becomes closed by the ad- hesive inflammation around it, so that the air no longer gets out of it into the cavity of the chest, anil any extensive opening may be healed. What air is already there is ultimately absorbed, and tbe lung, ex-. panding in proportion, resumes its ori- ginal functions. Emphysema has been known to arise from the bursting of a vomica, and ulceration of the surface of the lungs; but, tiie air, which escapes, in this instance, cannot find its way into the cavity of the thorax, because the in- flammation, which precedes the abscess and ulceration of the air-cells, closes those wliich are adjacent, and produces an adhesion of the edges of the vomica, or ulcer, to the inner surface of the chest, so as entirely to separate the two cavities. We are not acquainted with any instance of the symptoms, imputed to the confine- ment of air in the chest, originating from suppuration and ulceration of the surface of the lungs; but, Palfyn, Dr. Hunter, and tiie author of the article Emphysema. in the Encyclopedic Methodique, Partie Chirurgicale, have seen cases, in which emphysema has arisen from abscesses of the lungs, attended with adhesion to the pleura, and ulcerations in the situation of such adhesion. In these instances, the pus'having made its way through the pleura and intercostal muscles, the air escapes also through the same track, so as to get into the cellular membrane on the outside of the chest. A violent effort of respiration has, sometimes, produced a certain degree of emphysema, which first makes its appear- ance about the clavicles, and afterwards spreads over the neck and adjacent parts. The efforts of labour have been known to occasion a similar symptom; but, no bad consequences followed. (Medicul Com- munications, p. 176, and Wilmcr's Obs. in Surgery, p. 143.) M. Louis has described an emphysema of this sort, which, oh account of its cause, and the indication, which it furnishes to the practitioner, is highly important. This famous surgeon had occasion to re- mark it in a young girl, who died suffo- cated, from a bean falling into her wind- pipe, and be considers it, as a pathogno- monic symptom of such an accident, con- cerning the existence of which it is so es- sential not to commit any mistake. (See Bronchotomy.) This emphysema made its appearance on both sides of the neck, above tiie clavicles, and came on suddenly, on the third day after the accident. The inspection of the body proved, that the lungs and mediastinum were also in an emphysematous state. The retention of the air, confined by the foreign body, pro- duced, says M. Louis, at each attempt to expire, and, especially, when the violent fits of coughing occurred, a strong propul- sion of this fluid towards the surface of the lung, into the spongy substance 380 EMPHYSEMA. of this viscus. Thence, the air passed into the cellular texture, which unites the surface of tiie lung to the pleura pulmon- alis ; and, by communications from cells to cells, it caused a prodigious swelling of the cellular substance, between the two layers of the mediastinum. The emphy- sema, increasing, at length made its ap- pearance above the clavicles. This tu- mefaction of the lung, and surrounding parts, in consequence of air getting into their spongy, and cellular texture, is an evident cause of suffocation, and, the swelling seems so natural an effect of the presence of a foreign body in the trachea, that one can hardly fail to think it an es- sential symptom, though no author has made mention of it. (Memoires de PAcad. de Chirurgie; Tom. 4, in 4to.) An emphysematous swelling of the head, neck, and chest, has also beep no- ticed in typhoid fevers. Dr. Huxham relates an instance, of this sort, in a sailor of a scorbutic habit. (Medical Ob- servations and Inquiries, Vol. 3, Art. 4.) A case of spontaneous emphysema has like- wise been described by Dr. Baillie. (See Transactions of a Society for the Improve- ment of Medical and Chirurgical Knowledge, Vol.1, p. 202.) A curious example of what has been called, a spontaneous emphysema, is re- corded by Mr. Allan Burns: "The pa- tient was a strong athletic man, who, about six years previous to his applica- tion at the Royal Infirmary, had received a smart blow on the neck, from the keel of a boat. This injury was soon followed by the formation of a firm tense tumour, on the place, which had been hurt. The swelling increased very slowly, during the five years immediately succeeding its commencement; but, during the sixth, it received a very rapid addition to its bulk. At this time, it measured nearly six inches in diameter, seemed to be confined by a firm and dense covering-, and the morbid parts had an obscure fluctuation. From the first to the last, the tumour had been productive of very little pain. " Judging from the apparent fluctua- tion, that the tumour was encysted, it was resolved, at a consultation, to punc- ture the swelling, draw off its contents, and then pass a seton through it. By plunging a' lancet into it, only a very small quantity of blood, partly coagulat- ed, and partly fluid, was discharged,—a quantity so trifling, that, after its evacu- ation, the size of the tumour was not per- ceptibly reduced. A seton was passed through the swelling. At this time, the man was in perfect health. " About ten hours after the operation, the patient was seized with extremete violent rigors, followed by heat, thirst, pain in tiie back, excessive pain in the tu- mours and oppressive sickness. " An emetic was prescribed, but, in- stead of producing vomiting, it operated as a cathartic. To remove tiie irritation the seton was withdrawn. The pain in the tumour, however, and the general uneasiness continued to increase, and thirty hours subsequent to making the puncture, air began to issue from the track of* the seton; and, afterwards the cellular membrane ofthe neck, and ofthe other parts of" the body in succession, be- came distended with a gaseous fluid. In the course of a few hours, after the com- mencement ofthe general emphysema, the man died. " Twelve hours after death, when the body was free from putrefaction, it was inspected. The emphy sema was neither increased, nor diminished since death, and some idea may be formed of its ex- tent, when the scrotum was distended to the size of tlie head of an adult. Even the cavities of the heart, and the canals of the blood-vessels, contained a consi- derable quantity of air. We could dis- cover no direct communication between the tumour and the trachea or lungs, al- though such was carefully sought for." (A. Burns on the Surgical .Unatomy of the Head and Neck, p. 51—53.) From such cases, we may infer, with the preceding writer, that from the mere rup- ture of a few of the bronchial cells, occa- sioned by irregular action of the lungs, or by some other internal cause, a spon- taneous diffusion of air may take place in the cellular texture of the body. Such examples are dependent on the same cause as the emphysema from injury of the lungs ; only the rupture of the bronchial cells in tlie former cases is less obvious. Surgeons often observe a partial em- physema, in cases of gangrene. Here, however, it is hardly necessary to observe, the air is the product of putre- faction, and the disorder has not the smallest connexion with any injury, or disease ofthe air-cells ofthe lungs. The reader may consult, with advan- tage, P Encyclopedic Methodique,PartieChi- rurgicale. Hewson's Paper in Medical Ob- servations and Inquiries, Vol. 3. Mem. tie PAcad. Royale tics Sciences, for 1713. Dr. Hunter in Metlicul Observations and Inqui- ries, Vol. 2. Cheston in Pathological Inqui- ries. A Case in Aber-nethy's Works. John Bell on Wounds ofthe Breast. Halliday on Empliysema, 1807. Allan Bums on the Surgical Anatomy of the Head and Neck, p. 52, Uc. Transactions of a Society for tlie EMP E M P 381 Improvement of Medical and Chirurgical Knowledge, Vol. l,p. 202. Wilmer's Obser- vations in Surgery, p. 143. Richerand's No- sographie C/arurgicale, Tom. 4,p. 164, Edit. 2. Lassus Pathologie Chirurgicale, Tom. 2, p. 321, &c. Edit. 1809. EMPLASTRUM. (from efjcjrXxo-tru, to spread upon.) A plaster. The following are some ofthe most use- ful plasters, employed in surgery. EMPLASTRUM AMMONIACI CUM ACETO. gj. Ammoniaci Jij. Aceti Dis- tillati^iij. Ammoniacum in aceto lique- factum evapora in vase ferreo ad emplastri crassitudinem. EMPLASTRUM AMMONIACI SCIL- LITICUM. 5«. Gumm. ammoniaci ^j. Aceti Scillitici, q. s. ut fiant emplastrum, quo pars affecta tegatur. Mr. Ford has found this last plaster useful in some scrofulous affections. It may be rendered more stimulating by sprinkling it with squills. (Ford on tlie Hip-joint, p. 59) It has been recommend- ed by Swediaur; London Medical Journal, Vol. I, p. 198. The first plaster partakes of the same stimulating property, though in a milder ' degree. EMPLASTRUM AMMONIACI CUM HYDRARGYRO. Discutient. EMPLASTRUM AMMONIACI CUM CICUTA. £. Gum. ammon. 5iij. Succi cicutx spissatae §ij. Aq. litharg. acet. &* . ,. , Dissolve the ammoniacum in a little vinegar of squills, then add the other in- gredients, and boil them all slowly to the consistence of a plaster. This is discu- tient. EMPLASTRUM AMMONLK. *. Sapon. ^ij. Emplastr. litharg. 3jss. Am- mon. mur. ^j. The two first articles are to be melted together, and when nearly cold, the mu- riated ammonia, finely powderetl, is to be added. Its use is to" stimulate the skin, -and excite the action of the absorbents. Hence, it disperses many chronic swell- ings and indurations. EMPLASTRUM CANTHARIDIS VEL LYTTjE. (See Blister.) EMPLASTRUM G ALB ANI COMPO- SITUM. L. P. (Olim emplastrum lithargyri comp) Properties discutient. EMPLASTRUM HYDRARGYRIA. P. ( Olim emplastrum litharg. cum hydrargyro.) Properties discutient. EMPLASTRUM LYTT^fc. L. P.—(See Blister.) EMPLASTRUM PLUMBI. L. P — (Olim emplastrum lithargyri, or diacholon plaster. EMPLASTRUM RES1N-E. L. P.— (Olim emplastrum lithargyri cum resina.) The common adhesive, or sticking plas- ter. EMPLASTRUM SAPONIS. The plas- ter commonly used for fractures. It is also frequently applied to bruised parts, and to many indurations of a chronic nature. EMPROSTHOTONOS. (from t^or- Otv, before or forwards, and reive*, to ex- tend.) A spasmodic, or tetanic, affection, in which the body is bent forwards. EMPYE'MA. (from ev, within, and ttvov, pus, or matter.) A coUection of purulent matter in the cavity ofthe chest. The ancients made use of the word, " empyema" to express every kind of in- ternal suppuration. It was jEtius, who first restricted the term to tiie collections of matter, which sometimes form in the cavity of the pleura, or membrane lining the chest; and all the best modern sur- geons invariably attach this meaning alone to the expression. The operation for empyema properly means the making of an opening into tiie thorax, for the purpose of giving vent to the matter, collected in the cavity of the pleura, though the phrase with several writers denotes making an incision into the chest, in order to let out any effused, or confined fluid, whether matter, blood, an aqueous fluid, or even air. The ne- cessity for having recourse to such an operation, however, does not often present itself. I would not wish to be supposed to assert, that inflammation of tiie lungs, pleura, mediastinum, diaphragm, and even ofthe liver, does not sometimes ter- minate in suppuration. Certainly, the latter event is occasionally produced; but, when it does happen, the matter does not always make its way into the cavity of the chest. Very frequently external ab- scesses form, or the pus is either coughed up, or discharged with the stools. When the surface ofthe lungs and that ofthe pleura costalis have become adher- ent to each other, in tiie situation of the abscess, the pus, always disposed by a law of nature to make its way to the sur- face of the body, occasions ulceration of the intercostal muscles, and collects on the outside of them. An abscess of this kind comes on with a deep seated pain in the part affected; an cedematous swell- ing, which retains the impression of the finger; and a fluctuation, which is at first not very distinct, but, from day to day, becomes more and more palpable, and, at length, leads the surgeon to make an opening. If an opening be not made, when the 382 EMPYEMA. fluctuation becomes perceptible, there is some risk of the matter insinuating itself into the cavity of the pleura, in conse- quence of tiie adhesion being in part de- stroyed by ulceration. M. Sabatier af- firms, that the case may take this course, even when the abscess has been punctured, and while a free external opening exists ; and this experienced surgeon has adduced a case in confirmation of such an occur- rence. (See Medecine Operatoire, Tom. 2, p. 249.) In the same manner, if inflammation should occur in the anterior mediastinum, and end in suppuration, the abscess may possibly burst into neither of the cavities ofthe chest; but, make its way outward, after having rendered the sternum carious, as happened in the example, recorded by Van Swieten. ( Comment, on Boerhaave s 895th Aphorism.) External injuries, such as the perfora- tion of the sternum with a sword, (Van- ilerviel, Obs. 19, Cent. 1.) a contusion, a fracture, or a caries of this bone, may give rise to an abscess in the anterior medias- tinum. Galen has recorded a memorable example, where the abscess was the con- sequence of a wound of the forepart of the chest. After the injury, which was in the region ofthe sternum, seemed to have got quite well, an abscess formed in the same situation, and being opened healed up. The part, however, soon inflamed and suppurated again. The abscess could not now be cured. A consultation was held, at which Galen attended. As the sternum was obviously carious, and the ' pulsation of the heart was visible, every one was afraid of undertaking the treat- ment of the case, since, it was conceived, that it would be necessary to open the thorax itself. Galen, however, engaged to manage the treatment, without making any such opening, and he expressed his opinion, that he should be able to effect a cure. Not finding the bone so extensively diseased, as was apprehended, he even indulged considerable hopes of success. After the removal of a portion of the bone, he saw the heart quite exposed, (as is alleged) by reason of the pericardium having been destroyed by the previous disease. After the operation, the patient experienced a speedy recovery. J. L. Petit met with a case of an ab- scess in the anterior mediastinum, in con- sequence of a gun-shot wound in the si- tuation of the sternum. The injury had been merely dressed with some digestive application ; no dilatation, nor any par- ticular examination of the wound had been made. The patient, after being to all appearances quite well, and joining his regiment again, was soon taken Ul with irregular shiverings,and other febrile symptoms. M. Petit probed the wound, and found the bone affected. As there was a difficulty of breathing, he sus- pected an abscess either in the diploe, kr behind the sternum, and, consequently, he proposed laying the bone bare, and applying a trepan. This operation gave vent to some sanious matter, and, as soon as the inner part of the sternum was per- forated, a quantity of pus was discharged. The patient was relieved, and afterwards recovered. (See Petit's Traite des Mala- dies Chirurgicales, Tom. 1, p. 80.) When, in consequence of inflammation, an abscess forms deeply in the substance of the lungs, the pus more easily makes its way into the air-cells, and tends to- wards the bronchia, than towards the surface of the lungs. In tliis case, the patient spits up purulent matter. When the opening, by wliich the abscess has burst internally, is large, and the pus es- capes from it in considerable quantity at a time, the patient is in some danger of being suffocated. However, if the open- ing be not immoderately large, and the pus, which is effused, be not too copious, a recovery may ensue. Abscesses in the. substance of the diaphragm, and collec- tions of matter in the liver, may also be discharged by the pus being coughed up from tiie trachea, when the parts affected have become connected with the lungs by adhesions, and abscesses of the liver are situated on its convex surface. When the collection of matter in the liver occupies any other situation, the abscess frequently makes its way into the colon, and the pus is discharged with the stools. Several cases of this Kind are related by authors : Sabatier has recorded two in his Mede- cine Operatoire ; Le Dran makes men- tion of others ; and Pemberton, in his book on the Diseases of the Abdominal Viscera, p. 36, relates the occurrence of additional instances of a similar nature. Acute and chronic abscesses not unfre- quently form in the cellular substance, between the pleura and the ribs and in- tercostal muscles. A swelling occurs be- tween two of those bones ; the skin does not undergo any change of colour ; a fluc- tuation is distinguishable, and sometimes an extensive oedema is observable. Such abscesses should be opened; the motions of respiration then both promote the exit of the matter, as well as the contraction of the cavity, in which it was lodged; and the disease, if unattended with caries, generally terminates favourably. It often happens, however, that tlie ribs are carious, and then the cure is more tedious and difficult. A modern writer, indeed, informs us, that, when the inside EMPYEMA. S8J i of the rib is extensively carious, or when serv. 211, vol. 1, in order to prove, that, the caries is near the junction of the bone the pressure of tlie fluid on the lungs may to the spine, the fistula is incurable. (Las- sometimes be so great, as to make them sue Pathologie Clururgicale, Torn. 1, p. 128, collapse, and almost totally obstruct their Edit. 1809^ On the other hand, another function. When, therefore, says Mr. surgeon of vast experience recrtmmends Sharp, the thorax becomes thus expand- us, to endeavour to separate the diseased ed, after a previous pulmonary disorder, bone, either by cutting it away, or em- and the case is attended with the symp- ploying the trepan. (Pelletan's Clinique toms of a suppuration, it is probably Chirurgicale, Tom. 3,p. 253.) Were a part owing to a collection of matter. The pa- of a diseased rib to admit of being sawn tient, he observes, will also labour under away, Mr. Hey's convex saw would be a a continual low fever, and a particular more proper instrument for the purpose, anxiety from the load of fluid. than a trepan. Besides this dilatation of the cavity An abscess of the preceding kind may from an accumulation of the fluid, the be so situated, and attended with such a patient will be sensible of an undulation, pulsation, as greatly to resemble an aneu- which is sometimes so evident, that a rism of the origin of the aorta. An in- by-stander can plainly hear it in certain teresting case of this description is de- motions of the body. Mr. Sharp adds, tailed by M. Pelletan, Tom. 3. p. 254. I that this was the case with a patient of shall now proceed to the consideration of his own, on whom he performed the ope- empyema strictly so called. No surgical ration ; but, the fluid in this instance, he writer, with whom I am acquainted has says, was very thin, being a serous matter, treated, with more discrimination, than rather than pus. Mr. Samuel Sharp, of the symptoms pro- According to the same author, it will duced by collections of matter in the also frequently happen, that though the chest. He remarks, that it has been al- skin and intercostal muscles are not in- most universally taught, that, when a fluid flamed, they will become ccdematous in is extravasated in the thorax, the patient certain parts of the thorax ; or, if they can only lie on the diseased side, the are not oedematous, they will be a little weight of the incumbent fluid on the me- thickened. These symptoms, joined with diastinum becoming troublesome, if he the enlargement of" the thorax, and the places himself on tlie sound side. For preceding affection of the pleura, or lungs, the same reason, when there is fluid in seem unquestionably to indicate the pro. both cavities of the thorax, the patient priety of the operation. But, observes finds it most easy to lie on his back, or to Mr. Sharp, amongst other motives to re- lean forwards, in order that thefluid may commend it upon such an emergency, neither press upon the mediastinum, nor this is one, that if the operator should the diaphragm. But, it is noticed by Mr. mistake the case, an incision of the in- Sharp, that, however true this doctrine tercostal muscles would neither be very may prove in most instances, there are a painful, nor dangerous. (See Critical En- few, in which, notwithstanding the extra- quiry into the present State of Surgery, sect. vasation, the patient does not complain on Empyema.) of more inconvenience in one posture, " The difficulty of lying on the side, than another, nor even of any great dif- opposite to the collection of pus," says Le ficulty of breathing. (See Le Dran's Obs. Dran, "is always accounted a sign of an 217, and MarcHetti 65 ) empyema. This sign, indeed, is in the On this account, observes Mr. Sharp, affirmative ; but, the want of it does not it is sometimes less easy to determine, prove the negative; because, when there when the operation is requisite, than if is adhesion-of the lungs to the mediasti- We had so exact a criterion, as we are ge- mini, the patient may lie equally on both nerally supposed to have. But, says he, sides." (Le Dran's Obs. p, 108, Edit. 2.) though tins may be wanting, there are The explanation of this circumstance, some other circumstances, which will ge- offered by Le* Dran, is, that, when the nerally guide us with a reasonable cer- cyst, in which the matter is contained, is tainty. He states, that the most infalli- between the mediastinum and the lungs, ble symptom of a large quantity of fluid the mediastinum gradually yields to the in one of the cavities of the thorax, is a volume of the pus, in proportion as it is preternatural expansion of that side ofthe formed, and the cyst in which it is con- chest, where it lies; for, in proportion tained becomes dilated; " whence habi- as the fluid accumulates, it will necessa- tude becomes a second nature." Where- rily elevate the ribs on that side, and pre- as, in an empyecal person, in whom the vent them from contracting so much in . lung is not adherent to the mediastinum, expiration as the ribs on the other side, and who lies on the side opposite to that, ilr. Sharp also refers to Le Dran's Ob- on which the collection of pus is situated^ 384 EMPYMLA. the mediastinum is on a sudden loaded with an unusual weight of fluid. (P. 111.) Richerand contends, that the difficulty of breathing, which patients with extra- vasated fluid in the chest experience in lying upon the side, opposite that on which the disease is situated, never origi- nated, as has been commonly taught and believed, from the fluid pressing upon the mediastinum and opposite lung. " I have, (says he) produced artificial cases of hydrothorax, by injecting water into the thorax of several dead subjects, through a wound made in the side. This expe- riment can only be made on subjects, in which the lungs are not adherent to the pa- rietes ofthe chest. In this way, from three to foui* pints of water were introduced. I then cautiously opened the opposite side of the chest -. the ribs and lungs be- ing removed, the mediastinum could be distinctly seen, reaching from the verte- brae to the sternum, and supporting, with- out yielding, the weight of the liquid, in whatever position the body was placed. " It is evident, then, that patients, with thoracic extravasations, lie on the dis- eased side, in order not to obstruct the dilatation of the sound side of the respi- ratory organs, one part of which is already in a state of inaction. It is for the same reason, and in order not to increase the paiii by the tension of the inflamed pleura, that pleuritic patients lie on the diseased side. The same thing is observable in peripneumony; in a word, in all affec- tions ofthe parietes of the chest." (Ri- cherand, Nosographie Chirurgicale, Tom. 4, p. 168, 169, Edit. 2.) It appears to me, that there may be some truth in the foregoing statement; but, the experiments are far from being conclusive, with respect to the assertion, that, in cases of empyema, hydrothorax, kc. the fluid on one side of the chest does not compress the opposite lung. In the first place, the quantity of fluid is fre- quently much larger, than that which Richerand injected. Secondly, although the mediastinum may not be apt to yield at once to the weight of a liquid sud- denly injected into one side ofthe thorax; yet, it may do so by the gradual effect of disease. Thirdly, many of the pheno- mena of emphysema seem adverse to Ri- cherand's inference. Although surgeons should be aware, that "jpatients with empyema can some- times lie in any position, without particu- lar aggravation of the difficulty of breath- ing, yet, it ought to be distinctly under- stood, that the generality of patients with this disease cannot place themselves on the side, opposite to that, on which the collection of pus is situated, without hav- ing their respiration very materially ob- structed. Another circumstance, also, which deserves to be mentioned while we are treating of the symptoms of empyema, is, that the oedema of the integuments is sometimes not confined to the thorax, but extends to more remote parts, on the same side of the body as the collection of matter. Both the foregoing remarks are confirmed by an interesting case, which has been published by Mr. Hey, of Leeds. Sep. 3, 1788, Mr. Hey was desired to visit John Wilkinson, who had been ill ten days of the influenza. The patient was found labouring under a fever, at- tended with cough, difficulty of breathing, and pain in the left side of the thorax. He was bled once; had repeated blisters applied to the chest; and took nitre and antimonials, with a smooth linctus to allay his cough. He was repeatedly relieved by these means, especially by the applica- tion of the blisters; but, repeatedly re- lapsed. At last, he became so ill, that he breathed with the utmost difficulty, and " could not lie on the right side, without danger of immediate suffoca- tion." Mr. Hey found the patient in the state, just now described, on the 17th of Sep. tember. " His face and especially his eyelid were a little swollen on the left side." The left side of the thorax was larger, than the right, and its integu- ments were oedematous. Upon pressing the intercostal muscles, they felt distend- ed ; they yielded a little to a strong pres- sure, but rebounded again. The abdo- men, especially, at its upper part, ap- peared to be fuller, than in the natural state. (See Hey's Practical Observations in Surgery, p. 476.) Another remarkable symptom, which is occasionally produced by collections of matter in the chest, is an alteration in the position of the heart. I have seen a pa- tient in St. Bartholomew's hospital who had so large a quantity of matter in the left bag of the pleura, that it completely displaced the heart, which pulsated against the inside of the chest, at a considerable distance to the right of the sternum. This man's life might probably have been sav- ed, had paracentesis thoracis been per- formed in time. Some suspected an aneurism from the throbbing on the right of the sternum; and the case was not fully understood till after death, when the body was opened. A little attention to the symptoms, however, might have convinced any man of moderate under- standing, that it was an empyema, and that making an opening, for the discharge of tlie matter, afforded the only rational chance of preserving Ufe. There had EMP E N C 385 been pain and inflammation in the chest, followed by shiverings ; there was very great difficulty of breathing ; the heart, which previously used to beat in the 'usual place, no longer did so; but, now, pul- sated on the right side of the thorax. That the heart should be displaced in this manner by any large collection of fluid in the right cavity of the thorax, one would naturally expect; but, it is an oc- currence, that has not been much noticed by surgical writers. M. Larrey, how- ever, has related a highly interesting case, in which it happened. Indeed, not only was the heart pushed considerably to tiie right of the sternum, but, its action was so much impeded by the derangement of its position, that the pulse in the large arteries was thereby rendered extremely feeble. In this instance, also, the dia- phragm had descended so low down, as to force some of the small intestines into the cavity of the pelvis (See Larrey's Metnoires de Chirurgie Militaire, Tom. 3, p. 447, He.) PeUetan has also recorded an example, in which a collection of fluid in the left cavity of the chest displaced the heart, the pulsations of which were perceptible betwixt the third and fourth ribs, of the right side, near the sternum. (Pelletan's Clinique Chirurgicale, Tom. 3. p. 276.) The symptoms of empyema are fre- quently very equivocal, and the existence of the disease is generally somewhat doubtful. Panarolius opened a man, whose left lung was destroyed, at the same time that the thorax contained a considerable quantity of pus. Although the patient had been ill for two months, be had suffered no difficulty of breathing, and had had only a sUght cough. Le Dran , a tumour.) A hernia, formed by a protrusion of a piece of the omentum. (See Hernia.) EP1PLOOMPHALON. (from t*,*Xo*i the omentum, and oyUpaXos, the navel.) An omental hernia, protruding at the na- vel. EP1PLOSCHEOCELE. (from tirt*Xont the omentum,o0-£-to-#,thescrotum,and xnXn, a tumour.) An epiplocele, or omental hernia in the scrotum. EPISTHOTONOS. (from twf triu, for- wards, and rttiu, to extend.) A spasm, by ♦which the body is drawn forwards. EPULIS, (from t*i, upon, and vX»t the gums.) A small tubercle on the gums. It is said sometimes to become cancerous. J.-v E R Y The best plan of cure is to extirpate it with a knife. EPULOTICS. (from i-ryAow, to cica- trize.) Applications conducive to the healing of wounds. ERETHISMUS. (from tPttigo, to irri- tate.) Any thing which causes irritation. Mr. Pearson has described a state of the constitution, produced by mercury, acting on it as a poison. He calls it the mercu- rial erethismus, and mentions, that it is characterized by great depression of strength, anxiety about the prjtcordia, ir- regular action of the heart, frequent sigh- ing, trembling, a small, quick, sometimes intermitting pulse, occasional vomiting, a pale contracted countenance, a sense of coldness; but the tongue is seldom furred, nor are the vital and natural functions much-disturbed. In this state, any sud- den exertion will sometimes prove fatal. Mr. Pearson advises, with a view of pre- venting the dangerous tendency of this af- fection, the immediate discontinuance of the use of mercury; and exposing the pa- tient to a dry cool air. The incipient ere- thismus may often be averted by the cam- phor mixture with large doses of the vo- latile alkali, if mercury be also left off. Sarsaparilla is also beneficial, when the stomach will bear it. (Pearson on Lues Venerea, page 156, &c. Edit. 2) EROSION, (from erodo, to knaw off.) Erpsio. This word is very often used by surgical authors in the same sense as ul- ceration ; viz. the formation of a breach, or chasm, in the substance of parts, by tiie action ofthe absorbents. ERYSIPELAS, (from teva, to draw, and zrtXxx. This sort of erysipelas is far more uiv comrnoa than the foregoing one, and is much more dangerous. The patients often are in a state of delirium, or rather of le- thargy, on the seventh, ninth, or eleventh day, or sometimes a little later. It is chiefly in hospitals that the disorder oc- curs, often appearing there to be epidemic, though it cannot be said to be ever conta- gious. It is particularly prone to attack persons weakened by age or intemperance, children, and dropsical subjects. When 3E 394 ERYSIPELAS. the oedematous erysipelas makes its ap- pearance, as a symptom of some other af- fection, it is not nearly so dangerous as when idiopathic. It is always, however, to be considered as a serious malady, whatever may be its occasional cause. It is more apt, than the acute erysipelas, to shift its situation from the surface of the body to the internal parts. It is also seen affecting one leg, and then the other, seve- ral times in the course of one indisposi- tion. When the brain becomes affected in this manner, delirium, and other most alarming symptoms, are immediately ex- cited. The gangrenous erysipelas bears a con- siderable resemblance to the preceding kind, in regard to the symptoms, with which it makes its attack; but it is much more rapid in its progress. The swelling soon becomes covered with phlyctenae, the basis of which is livid; and sy mptoms of gangrene, attended with a state of the pulse, similar to that which takes place in malignant fevers, are not long before they make their appearsfhce. This spe- cies of erysipelas is very liable to occur on the face, shoulders, and chest. The danger, which attends it, is proportioned to the more or less vigorous state of" the system: the case is often fatal, particu- larly when the disease attacks persons who have been already debilitated by other causes. When it terminates favour- ably, small cavities and sinuses are often found in the cellular substance, which con- tain pus of a bad quality. Irt this sort of case, one or more ulcers form externally, through which considerable sloughs ofthe cellular membrane are discharged. When erysipelas in the legs terminates favourably, it generally leaves those parts more or less affected with an oedematous Bwelling, which it is often veiy difficult to cure. TREATMENT OF EHTSIPELAS. The treatment of erysipelas, as it is re- marked in the Parisian Chirurgical Jour- nal, has varied materially at the different periods ofthe medcal art. Celsus recom- mended bleeding indiscriminately in every species when the strength would permit. JEtius, who founded his opinion on the authority of Galen, never employed the lancet, except in cases of manifest ple- thora : the bilious erysipelas he treated with purgatives. Paulus yEginetus, on the contrary, never exhib ted them, but when, from some obstacle, he was prevented from ordering bleeding; a practice, which, like Galen, he recommended as a general precept. Oribasius recommends medi- cines proper for the evacuation ofthe bile. Avicenna, in adopting this last method, observes, that bleeding is rarely useful, sometimes hurtful; and, yet, at the same time, admits, that there arecases, in which it is indispensible. Actuarius has made nearly the same remarks as Avicenna, and, also, extends the use of purgatives to every species of inflammation. Guy de Chau- liac, Thevenin, Munmck, Sydenham, &c. prescribe bleeding in all species of erysi- pelas, unless the affection is extremely slight. In this opinion they are followed by a crowd of moderns, some ot whom, influenced by the inspection of the blood when it presents what they term a pletho- ric or inflammatory crust, order the bleed- ing to be repeated three or four times. Thevenin sometimes prescribed a gen- tle emetic, but not till after other means had been unsuccessfully tried. Pare has remarked, that the disease generally terminates by vomitings and bilious dejections; but at that time the emetic tartar was not in use; a medicine admirably calculated to accelerate this termination : and now, though the effects of this remedy are known, yet many prac- titioners are afraid to employ it. Stoffl himself never prescribeo it, without the patient being previously prepared. Richter, the celebrated professorof Got- tingen, and one ofthe most judicious Ger- man authors, recommends the exhibition of an emetic on the first attack of a bili- ous erysipelas. He admits that there are cases, though extremely rare, which re- quire bleeding in the first instance. Cullen proposes cooling purgatives in addition to these means, and coincides with the method employed by Selle, who, viewing erysipelas as a species of putrid fever, joins to evacuants the use of bark, wine, and other antiseptics. Bell treats this mode of practice, and the opinion on which it is founded, as purely hypothetical. He prefers the anti- phlogistic regimen and bleeding, but by no means local, as it is generally produc- tive of ulcers difficult to cure. The an- cients appeared to attribute much efficacy to bleeding and the use of purgatives, and even stiU more to topical applications. Some recommend the use of diaphoretics and sudorifics; whilst others, and indeed the greatest number, prescribe relaxing, refreshing, and diuretic, drinks. Alexander of Tralles, after the doctrine of Galen, prescribed only cold water to his patients. He recommended them to breathe fresh air, and to be slightly clothed; and observes, with great judg- ment, that this is the plan that na'ure seems to point out, and supr.ojjts the pro- priety of this method by cubes peculiar to himself. ERYSIPELAS. SS5 Pare also attributed some advantages to fresh air, to wliich he joined the use of cooling medicines, Ike. Sydenham, with the same views, prescribes the use of small beer. Others recommend red wine and water. Thevenin treats obstinate erysi- pelatous affections by means of baths, whey, veal-broth, and cold mineral wa- ters. , Topical applications have been for a long time in general use for the cure of erysipelas; nevertheless, Hippocrates, who speaks frequently of this disease, and who relates many cases of this description in his epidemics, says nothing to. induce a suspicion, that he ever had recourse to local applications. The practice of mo- dern physicians has differed materially; they have been diffuse in the use of lini- ments, fomentations, poultices, and even ointments of every description. It was soon remarked, that otis, ointments, plas- ters, and all fatty substances, were per- nicious in the treatment of erysipelas. Galen made this remark; which, however, did not prevent the use of the emp. dia- palma dissolved in oil of roses. Fabricius Hildanus has seen the use of the oil of roses, continued for some days, produce gangrene, in a case of phlegmonous ery- sipelas. Munnick quotes this case, and Manget reports it at length. The me- dicaments of a benumbing and narcotic quality, recommended by Galen, Paulus Eginetus, and many others, have also tended to produce mortification. Resolvents and repeUents have been generally recommended. Authors, how- ever, agree, that their application is not unattended with danger : for, indepen- dently of tbe fatal consequences not uncommonly apprehended from metasta- sis, it was "objected, that induration or gangrene of the part affected might often be occasioned by their indiscriminate use. A conviction of the truth of this remark induced Paulus Eginetus to reject astrin- gent and spirituous applications, and Avi- cenna to prefer the effusion of cold water on the part to more active applications. For the same reason, oxycrate, a boasted remedy among the Greeks, was preferred to weak solutions of lead, as recommended by Thevenin, and the different infusions of elder-flowers, melilot, and other similar plants, were even in more general use. De Haen employed a decoction of elder- flowers in whey ; sometimes emollients, as warm water, marshmaUow-water, water of frogs spawn. Sec. Hartman attributes the most serious symptoms, and even mortification of tiie part itself to this last application. Cel- sus used cataplasms covered with com- presses, moistened with cold water. Ga- len rendered them resolutive by the ad- dition of oxycrate. Paulus Eginetus re- commended a poultice of barley-meal; Thevenin one made of rye boiled in lime- water ; and Diembroeck one composed of bean-meal and oak-leaves reduced to a powder. But it is superfluous to dwell longer on methods which have proved in* efficacious, and which have been long since abandoned. Cullen, concurring in opinion with all accurate observers on the inutility and danger of every topical application, abso- lutely rejects them. He allows, however, the part affected to be sprinkled with powdered starch, (a practice of late years adopted in England,) to absorb, accord- ing to Mr. B. BeU, the acrid humour, which is furnished, and which tends to produce ulceration. Without doubt, chalk has been employ- ed by some practitioners to answer the same indications. (V. J. Munnick, Chir. lib. i. Manget. Bibl.) B. Bell, who perfectly accords with Cullen, with respect to the injurious ef- fects of local appUcations, yet permits a thin layer of the extract of Saturn to be applied to the part by means of a feather, when the pain is very acute. Richter, so far from approving this practice, views the extractor'Saturn in the same Ught as other astringents, which he observes, often produce fatal consequences. This learned professor, like Selle, Stoll, and other skilful practitioners, makes use of no application whatever to the part. Actuarius observes, also, that local appli- cations are useless in erysipelas, and that the inflammation wUl subside by the use of cathartics alone. Besides the means, which we have pointed out, there was one mentioned by Thavenin, which, during his time, was in very general use : this was the application of blisters. He proposed them with the view of evacuating, or at least diverting, the erysipelatous humour, when they were applied at a considerable distance from the part affected, This recalls to our recollection a case mentioned by Alix, in his Ohsepvata Chi- rurgica, fasc. iii. where blisters were ap- pUed to the legs of a peasant, for a wan- dering and obstinate erysipelas, which had successively occupied the back, the thorax, and tlie face. The erysipelas attacked the feet, and was immediately followed with gangrene. Such is tlie abridged history of what has been written on tlie subject of erysi- pelas. The means related for the cure of the disease may perhaps appear in some degree tedious; but they are more important to recollect, than theoretical S96 ERYSIPELAS. distinctions of the various species of ery- sipelas. Desault may be regarded as having adopted the most judicious and successful mode of treating erysipelas. The follow- ing was the practice, which he pursued in the H6tel Deu. In the bilious erysipelas, whatever de- gree of heat or fever m.-iy exist, he gives, in the first instance, a grain of emetic tartar dissolved in a considerable quan- tity of fluid; the symptoms generally diminish as soon as the effects of the me- dicine have ceased. He has seen them entirely subside, although the medicine produced no other sensible alteration, in the animal economy, than an increase in the secretions of the insensible perspira- tion and urine; sometimes the symptoms resisted these evacuations, and he was obliged to have recourse once or twice, or even more frequently, to the use ofthe emetic-drink. When the erysipelas is cured, and the bitterness in the mouth and fever have subsided, two or three purges of cassia and manna, with a grain of emetic-tartar, are exhibited : during the process of the cure, the patient is or- dered to drink freely of a diluting ptisan, acidulated with oxy mel: as soon as the symptoms are mitigated,the diet of Ihe pa- tient is allowedto be made more nourishing and generous ; for, when it is too rigidly observed, the bilious erysipelas is apt to be produced, particularly in hospitals, where the air, generally speaking, is un- healthy. The bilious erysipelas, however consi- derable its extent, and whatever part it may occupy, yields in a few dnys, to the plan here laid down ; and, in the end, Desault always succeeded in the cure; nor did he recoUect an instance of its re- turn. He invariably observed, that the ca*es of the patients, who had been bled reviously to their admission into the osp'n.d, were more serious and obstinate, particularly, when it had been frequently repeated. The same practice is not rpplicable to the phlegmonous species of erysipelas. In this kind, emetics and other evacuants augment the irritation and tension, al- ready considerable, por should they be had recourse to till the plethora and irri- tation of the patient are diminished by one or more bleedings, according to the urgency ofthe symptoms and the strength of the putient. The bilious erysipelas, which then appears, points out the ne- cessity of evacuations, and the proper time tor their exhibition. During the whole treatment, the patient takes no- thing but a diluting drink, such as whey, or a simple decoction of dog's tooth with oxyniel When erysipelas arose from an internal cause, Desault did not employ any topical application whatever, in either species, but left the part, as much as possible, exposed to the air. But when either bilious or phlegmo- nous erysipelas is consequent to a contu- sion, wound, or an ulcer, regimen and in- ternal medicines, according to Desault, are insufficient, unless topical applica- tions are employed to abate the local irri- tation, and to excite suppuration ; with this view, cataplasms have been employ- ed, and their good effects, he says, have been remarked in a great variety of cases: but he deems this caution essential, viz, that the application ofthe poultice should not extend much below the contused sur- face, or the edges of the wound. If any application is- permitted to lay on the rest of the erysipelatous surface, accord- ing to Desault, it should be aqueous and weak,, such as tlie aq. veg. mm. in com- mon use, made in the proportion of gj. of the extract of Saturn to a pint of water, (See Desault's ParisianChirur.Jtrur. Vol2.) For my own part, I have always been in the habit of applying Goulard's Lo- tion to erysipelatous cases prising from wounds, and other kinds of local irrita- tion; and I have had every reason to think such applications as. beneficial in these affections as in phlegmon. Mr. Pearson prefers mild warm cata- plasms, composed of the powders of ani- seed, fennel, camomile flowers, &c. mixed with a fourth part, or an equal quantity, of bread, and a proper quantity of milk Linseed powder, he says, maysometimes prove a convenient addition. Such writers, as have divided erysipe- las into the acute, adematovs, and gangren- ous, adopt the following modes of prac- tice. The first indication in the treatment of the acute erysipelas, is to lessen the inf flammation by bleeding, which is. to be repeated, more or less, according to symp- toms. Such other means are also to be adopted, as tend to diminish the force of tbe circulation. In short, the antiphlo- gistic plan, in the full sense of the expres- sion, is proper. In general, it is unnecessary to repeat bleeding, in any case of erysipelas, so fre- quently as is done in other inflammatory cases. We ought to be guided, however, in this respect, by the state of the pulse, and other symptoms, never forgetting the patient's age, the degree of strength be- fore the disease, and the situation of the disorder itself. Cater is paribus, the pa- ESC tient will bear bleeding better in the coun- try, and in an open, pure air, than in a large city, and especially in an hospital. The circulation, in the vessels on the surface of the body, should also be pro- moted by diluting beverages, proper doses of nitre, the saline mixture, and, above all, by administering small doses of the antimonial powder, or tartar eme- tic. The belly should be kept open by glysters, and mild laxatives, and, when the patient is very much inconvenienced by the irritation and excessive heat ofthe part affected, small doses of opium may occasionally be given. A gentle emetic very often has an ex- ceedingly good effect in calming the fever, and expediting the cure of the erysipelas, especially after bleeding has been prac- tised. But emetics are not to be conti- nued, when they have a purgative effect. In this complaint, as in every other one, in which the bead is affected, the patient should be made to keep his head, as much as possible, in an elevated position. In the oedematous erysipelas, perhaps, bleeding is never admissible. The loss of even a very small quantity of blood may have the most fatal consequences. One should also be exceedingly sparing of other evacuations. A determination to the skin should in particular be kept up by antimonials, and irritation and pain soothed by administering the spiritus xtheris vitriolic! compositus, aether, cam- phor, opium, &c. When the disorder seems to shift its situation to any internal part, and, par- ticularly, to the brain, blisters should be applied between the shoulders, to the head or legs, without the feast delay. In order to prevent the complaint from terminating in mortification, the patient's strength should be supported by tonic re- medies, such as wine and bark. With regard to the treatment of the gangrenous erysipelas, nothing more need to be said than what is contained in the article on mortification. Consult Desault's Parisian Cldrurgical Journal, Vol. 2. Also OZuvres Chirurgicales de Desault par Bichat, Tom. 2,p. 581, &c. Encyclopedic Methodique, Partie Chirurgi- cale, art. Erysepeie. Cullen's First Unes of the Practice of Physic, Vol. 1. Pearson's Principles of Surgery. Some Parts of Hun- ter's Treatise onthe Blood, Inflammation, &c. Richerand?s Nosographie Chirurgicale, Tom. 1, p. 118, &c. edit. 2. Lassus, Pathologie Chirurgicale, Tom. 1, p. 8, &c. edit. 1809. ERYTHEMA, (from tPv6p»i, red.) A redness of any part. For the erythema mercuriale, see Mercury. ESCHAR, (from (fXxPo«, to form a E X1 397 scab, or crust.) This term is applied to a dry crust, formed by a portion of the solids deprived of life. When any living^ part has been burnt by the actual, or po- tential, cautery, all that has been submit- ted U> the action of this application, loses its sensibility and vital principle, becomes hard, rough on the surface, and of a bl.ick, or grey, colour, forming what is properly named an eschar. This, in short, is only a slough, produced by caus- tics, or actual fire. ESCHAROTICS. (from to-^XPott, to form a crust over.) Applications, which form an eschar, or deaden the surface on which they are put. By escharotics, „ however, surgeons commonly u derstand the milder kind of caustics, such as the hydrargyrus nitratus ruber, xrugo xris, £Jc. EX2ERESIS. (from t^xiPtoi, to re- move.) One of the divisions of surgery adopted by the old surgeons; the term implies the removal of parts. EXCISION, (from excindo, to cut off.) The cutting off any part. EXCORIATION, (from excorio, to take off the skin ) A separation ofthe cu- ticle ; a soreness, merely affecting tiie surface ofthe skin. EXCRESCENCE, (from excresco, to grow from.) A tumour, growing out of, or from any part, and not included in its substance. EXFOLIATION. (from exfolio, to cast the leaf) The separation of a dead piece of bone from the living is termed, exfoliation. One part of a bone is never separated from another by the rotting of the dead part, for that which comes away is as sound as it ever was. Exfoliation takes place soonest in bones, which have the fewest cells, and whose texture is the closest. Before any part of a bone can be thrown off, by exfoliation, it must be dead. But, even then, till the process of exfoliation begins, the bone adheres as strongly, as ever, and would remain for years, before it could be separated by putrefaction alone. Bones are composed of two substances, viz. a true animal mat- ter, and an earthy one, which are onry intermixed with each other. A dead bone acts, on the system, in the same manner, as any other extraneous body. It stimu- lates the adjacent living parts ; in con- sequence of which, such a process is h€- gun, as must terminate in its being thrown off". The effects.of this stimulus are, first, that the living adjacent bone becomes more vascular; a circumstance, which always takes place, when a part has more to do, than is just sufficient for the sup- port of life. Secondly, that tlie earth of 598 EXFOLIATION. the living- part, where it is in contact with the dead bone, is absorbed ; hence, the bone becomes softer, and adheres by its animal matter only. Thirdly, that the living an ma Ipart is at last absorbed along the surf-ace of contact: this part of the process commences long before the last is finished. Both of them begin, first at. the surface, though in their course, they do not every where take place in an equal degree at the same time. Fourthly, in proportion to the waste, made by the last part of the process, a fungus arises from the living surface, and fills up the intermediate space, so that tiiere is no vacuum. These different stages together constitute ulceration. When any part of a bone is once loose, it will be pushed to the surface in the same manner, as most other inanimate bodies would be, and this stage is partly mechanical, and partly a continuation of ulceration. A proof of the third stage, above-mention- ed, may be derived from cases, in which people die, while exfoliation is going on. A small groove, or worm-eaten canal, can then be discovered, which becomes gradually deeper, and follows the irregu- larities of the living and dead surfaces. After the appUcation of the trepan, a cir- cular piece of bone is frequently thrown off, which is always less than the space from which it came. This, however, would never be the case, were there not a loss of substance. (John Hunter.) It was anciently believed, that when- ever a bone was denuded, the exposed surface must necessarily exfoUate, and, this being taken for granted, the old surgeons used to set about bringing on an exfoUation as quickly as possible. For this purpose, the actual cautery was usually applied to the part of the bone, which was uncovered, and, as under such treatment, a portion of the bone was of course killed, and then exfoliated, the prejudiced practitioner believed, that he had only accelerated a process, which must of necessity have followed in a slow and tedious manner. Mr. Hunter very truly remarks, that neither caustics, nor the actual cautery, hasten exfoliation; they only produce death in a part of the bone, which is the first step towards exfoliation. If caus- tics ever hasten exfoliation, when the bone is already dead, it must be by pro- ducing inflammation in the adjacent liv- ing bone this brings about a change in it, and makes it exert a power, which it was incapable of before. Exfoliation is not a necessary conse- quence of a bone being laid bare, and de- prived of its periosteum. Ifthebonebe in other respects uninjured, healthy, and enjoying a vigorous circulation of blood through its texture, granulations will be generated on the surface of such bone, which will cover and firmly adhere to it, without the smallest exfoliation being thrown off; especially, in young subjects. Rut, if caustic, stimulating, or drying applications be made use of, the circuit. tion in tbe surface of the bone will neces- sarily be disturbed and destroyed, and that part of the surface, through which the circulation ceases to be carried on, will be separated, and cast off, by tlie process of exfoliation. If any application to an exfoliating portion of bone be at all efficacious, it must be one, which will stop the mortifi. cation in tfie affected bone, and promote the absorption of those particles of bone, which form the connexion between that which is living and that which is actually dead. And as the bone dies from the same causes, as the soft parts mortify, we should at least follow the same prin- ciples in practice, which we do in the latter instance, and, though from the in- ferior vascularity and vital powers of the bones, we cannot expect surgery to have so much control over their affections', -as over those of the soft parts, yet, every good will be obtained, which it is possible to acquire. Attention to such principles will at least teach us to avoid making the death of part of a bone more extensive, than it would be, if the cautery, caustics, and strong astringents, were not em- ployed. The best mode of attempting to pre- vent an exfoliation from occuring at all on a bone, that has been exposed by a wound, is, to cover the part again, as soon as possible, with the flesh, which bas been detached. This, as we shall notice in the article Head, Injuries of, may gene- rally be practised with advantage, when the scalp has been detached from the cra- nium, provided the flap is still connected with the rest of the integuments. When the exposed bone -cannot be covered, it should be dressed with the mildest and simplest applications, with plain lint, or lint spread with the ungu- entum spermatis ceti. The dead pieces of bone, when very tedious in exfoliating, when wedged in the substance of the surrounding living bone, and when so situated as to admit of being safely sawn, or cut away, may be removed in this manner, as is described in the articles Caries and Necrosis. la such operations, Mr. Hey's saws are emi- nently advantageous. In speaking of necrosis, we shall have occasion to notice the efficacy, which Mr. Crowther has found blisters possess in EXOPHTHALMIA. 399 quickening the cure of necrosis, when kept open by tiie savin cerate, as recom- mended in his work on the white swell- ing. EXFOUATIVUM. (from exfolio, to shed tlie leaf.) A raspatory, or instru- ment for scraping exfoliating portions of bone. EXOMPHALOS. (from £|, out of, and suJpxXof, the navel.) A hernia, protrud. ing at the navel. EXOPHTHALMIA. (from f\, out, and ». well as the success, with which such inju- ries were treated by that eminent military surgeon M. Larrey. When the extravasated matter is com- pletely encysted and circumscribed, it happens, that, as such matter had to over- come the resistance of the parts, before it could be effused, no sooner is a passage 408 EXT EYE afforded for its escape, than the reaction of the separated parts necessarily forces out whatever fluid lies between them, This is a third consequence, which is pointed out by Petit, as resulting fiom the resistance, made by the reciprocal action of the abdominal viscera to extra- vasations. The foregoing remaiks tend to prove, that an extravasation intlieiibdomen, nnd, especially one of* blood, may be as com- pletely discharged, as a collection of fluid in the thorax. The evacuation, at least, may always be easily effected, when the extravasation is bounded on any side by the parietes of the abdomen : a circum- stance, wir.ch must invariably occur, whenever the extravasation is considera- ble. Indeed, Petit adds, that it was al- ways the case, as far as his experience went, even when the effusion was not very copious. It is not enough to make sur- geons understand, that fluids, extravasat- ed in the abdomen admit of being dis- charged by an operation; it is also proper to explain the symptoms, denoting the rases, in which such a proceeding should be adopted. In order to establish tiie signs, where- by we may be certainly assured, that a wound, penetrating "into the abdomen, has been followed by extravasation, we must begin, says Petit, by distinguishing the subsequent? symptoms from those which immediaftly accompany the wound, and which are, properly speaking, the true symptoms, because they are essen- tially owing to the division of the parts affected. The first consequences of this division, are pain, irritation, tension, convulsion, strangulation, and inflamma- tion of the abdomen, the natural sources of the other succeeding symptoms, and wliich vary .-ccording to the situation of the'wouncie'd p-irts that are inflamed, and according to the degree of inflammation. Such are tlie hiccough, Vomiting, cos- tiveness, the suppression or retention of the bile and urine, a violent fever, which generally happens at the beginning, and when the inflammation is arrived to a •certain degree, the concentration of the pulse, which is so low as scarcely to be perceived, faintings, cold sweats. These are the effects o<-' the primary symptoms, which we observe every day in wounds of the abdomen. When the succours of art are season- ably ppplied, we not only get the better of these symptoms, and stop their pro- gress, but often entirely prevent them. Let ns suppose therefore, that by pro- p*?r management, the primary symptoms have b'»en so far remedied, that, in four, six, eight, or ten days after the wound, they are entirely dissipated, or at least much abated: If, continues Mr. Petit, after an intermission of so many days, more or less, the same symptoms return, or with greater violence, without any apparent cause, we may confidently affirm, that these secondary or subse- quent symptoms are owing to an extra- vasation. v One can scarcely be induced to believe at first, that there should be any se- condary symptoms of the extravasation of blood; for, since the extravasation commences from the very moment of the wound, why do not these symptoms com- mence from that instant ? And why do they not increase, in proportion as tlie blood diffuses itself in a larger quantity ? Petit has referred the reason to the following circumstances.: blood extrava- sated in the abdomen, does not give rise to any particular complaints, either by the pressure, wliich it makes, or by its quality; anil, whenever any symptoms are occasioned on the first occurrer.ee of the effusion, they are those of weakness, depending upon the loss of blood to the circulation. The extravasation after- wards becomes entirely circumscribed by the adhesions, produced by the surround- ing inflammation. An additional quan- tity of fluid continues to fie secreted fi-om the vessels into the encysted cavity ofthe effused blood, and, consequently, pain, inflammation, &c. are occasioned by tlie increased distention now brought on. I do not, however, deem Petit's theory of this subject of much importance; per- haps, it is inaccurate; but, the fact it- self, that the symptoms of an extravasa- tion in the abdomen are consecutive, is a piece of information higldy interesting to the practitioner. The foregoing observations are only an abstract of Petit's excellent memoir, which well merits to be attentively pe- rused by every man, who follows the profession of surgery: it is, indeed, one of the most valuable of the essays pub- lished by the French Academy of Surgery. (See Suite de I'Essai sur les Epanchemens par feu M. Petit lefils; in Mem.de PAcad. de Chirurgie, Tom. 4. Edit, in 12mo) Much of this subject is still more particularly considered in tbe article, Abdomen, to which the reader is re- ferred. EYE, Calculus in the interior of. Scarpa has dissected an eye, which was almost entirely transformed into a stony substance. It was taken from the body of nn old woman, and was not above half as large as the other sound one. The cor- nea appeared dusky, and, behind it, the iris, of a very singular shape, was dis- EYE, 4QB tinguishable, being concave, and without any pupil in its centre. The rest of the eyeball, from the limits of the cornea backward, was unusually hard to tbe touch. On making an incision, Scarpa found the sclerotica and choroides, almost in their natural state, and a small quantity of limpid fluid issued from the anterior chamb. scyphus accurate ro- tundo foramine perforabatur, qua nervua opticus subit, ut ed magis induratatn retinam adpareret. " Intra hanc osseam caveam nullum vitreum legitimum corpus, sed nervum, quasi albam, nempe cylindrum reperi- mus, qux per foramen ossei cyathi trans* missa metiens ejus diametrum, denique adhacrebat osseo confuso corpori, quod potuisses pro corrupta lente crystallina habere. Ei corpori undique et ^ris, et processus ciliorum cngnomines, connas- cebantur, et cornea denique ad quam iris pariter conferbuerat. Nunc sive retinam, ut ego persuadeor, sive quidquam atiud fuisse velis. quod in os cavum et hemi- sphxricum mutatum sit, in oculo tamen tenerrima parte corporis indurationem perfectam natam esse adparet; nihil ergo in corpore nostra dari, quod indurari nequeat. Lapillos aliquos in lente crys- tallina repertos fuisse legi. " Ejusmodi autem morbus, nescio an visus sit, qualem hate opportunitas nobis obtulit." (Obs. Pathol. Oper. Min. Obs. 15.) Fabricius Hildanus Lancisi, as quoted by Heister, Morgagni, Morand, Zinn, and Peltier, make distinct mention of calculi in the interiour ofthe eye. (Scarpa sulle Malattie degli Occhi. Ve- nezia. 1802.) EYE CANCER, and Extirpation of. Cancer of the eye may make its attack on both sexes, and at any period of life. It seems, however, that the disease is most frequent in childhood. Experience has shewn, that, at the Hotel Dieu more than one-third of the patients, on whom Desault operated, were under twelve yeara of age. The complaint sometimes comes on after an obstinate ophthalmy ; some- times after a blow on the. eye, after wounds, a staphyloma, and, -often, after fungous excrescences, which form on the surface, or in the interior of the eye*. The disease is said to have been caused by the imprudent employment of topical irritating applications; very frequently the causes are constitutional ones. The following symptoms commonly in- dicate its atuck, and accompany its pro- gress. Head-achs, and an unsual heat in the organ, are the forerunners of the disease. An uneasy itching affects the eye and adjacent parts. The organ fee* quently weeps a -g^eat deal, and from, 3G 410 E Y-E. being from the first irritably sensible of the impression of light, it soon becomes unable to bear it without pain, unless, indeed, some previous disease should have rendered the organ incapable of trans- mitting the rays of light to the retina. To the itching succeeds, at the end of a certain time, a pricking sensation, which is followed by a pain, that is not very acute at first, Jiut, afterwards, becomes extremely poignant and lancinating.— The eye enlarges, and assumes not the red colour of ophthalmy, but a dull hue, ending in a livid, yellowish, or blackish one. Sight becomes obstructed and de- stroyed; the pains grow more acute, and the size of the organ increases, not as in hydrophthalmy, according to its natural dimensions, but, by an unequal enlarge- ment of its surface, which becomes rough and irregular. As the'magnitude of the part increases, so does the hardness. The cornea, after turning whitish, red- dish, and livid, ulcerates and bursts, and fungous growths project from the opening, discharging a purulent fetid sanies. The disease continuing, a manifest disproportion is seen between the eye and the orbit. As in hydrophthalmy, the organ projects out beyond the margin of this cavity, and forms a hideous pro- minence on the face. The portion of the conjunctiva, naturally reflected over the inside of each eye-lid, becomes sepa- rated in consequence of being dragged by the eye, to the front of which it ap- plies itself, forming a reddish kind of band over it. The suppuration puts on a more for- midable aspect. The fungi increase, and become livid and dark-coloured. Hemor- rhages follow, more or less frequently, and copiously. The pairts, now more in- cessant, continually torment the patient, and, if art does not now interfere, the eye-lid? next swell, inflame, and become scirrhous. The lower one, over which the sanies flows, is excoriated ; fungi arise from it; and the disease is propa- gated to the cheek, and nose, so as tp pre- sent, perhaps, one of the most terrible pictures, which external disease can form. The os planum or.the os ethmoides is rendered carious, as well as the os unguis; the pituitary membrane is af- fected; the pains increase, and become general; and the cancerous diathesis afterwards makes its appearance. The progress of the disease does not regularly follow the aboye course. It varies, according as a blow, a disease, or a cancerous disposition, has been the cause. It is enough to state here, how- ever, that the patient is always brought to the grave by a terrible death, if the disease be not extirpated. As surgery possesses no means of curing this afflic- tion, "the only plan is to remove the part affected, and practitioners, more timid in this, than other cases of cancer, never ventured to undertake the extirpation of the eye, till several ages, after they had done that of other cancerous parts. The ancients are silent on this opera- tion, and it is to the German surgery, that we are indebted for the first proposals of the kind. It was, for the first time, practised in the sixteenth century, with a very coarsely constructed instrument, shaped like a spoon, with cutting edges, and, by means of which, the eye was separated from the surrounding parts, and taken out of the orbit. But, this in- strument, invented by Bartisch, was too large to reach to the deep contracted part of the orbit, so that either a part of the disease was left behind, or the thin deli- cate bones of the orbit were fractured, when the instrument was introduced too far. Fabricius Hildanus learnt these in- conveniences from experience, and, to avoid them, devised a sort of probe- pointed bistoury; a better instrument, but not free from objections, and fob- gotten for near a* century afterward*.; surgeons continuing to use sometimes the above spoon, sometimes, various kinds of hooks. Muys, Bartholine, &c. afford examples of operations^ so performed. Bidloo, more judicious, than his prede- cessors, made use of scissars, and a pointed bistoury. His mode of operating, though not very methodical, was crowned with sevVal successes, a circumstance in its favour, as M. Louis has observed. A lancet seemed to Lavauguyon suffi- cient for extirpating the eye, and he is the first French surgeon, who has spoken of this .operation. All the surgeons of that country considered the operation, as useless, cruel, and dangerous, until St. Ives mentioned, that he had done it with success, without, however, describing the plan, which he followed. There are en- graved, in the Institut. Chirg. two tumours of the kind now under consideration, which the author removed with the bistoury, alone, which he thinks quite sufficient, and preferable to the means employed by Bartisycb, Hildanus and Muys. Several' English surgeons, have used a sort of curved knife, an engraving of which is given in B. Hell's system ; but, in dissecting the tumour, this instrument is not so convenient as a straight bistoury. Thus far the plans of operating, ad- vised by authors, were not guided by any fixed rules. M. Louis endeavoured to lay down such rules, and his metiiod has, for EYE. 411 a/long while, been mostly adopted in France. It consists in dividing the attach- ments of the eye to the eye-lids; then those of the small oblique muscle ; next, those of the great oblique muscle; then those of the levator palpebrx superioris, varying according to their insertions, the manner of holding the knife. The eye- ball is afterwards detached, and the four straight muscles, and optic nerve, divided with a pair of scissars. This way of operating, founded upon anatomical principles, seems at first glimpse to offer a method, in wliich, as M. Louis remarks, each stroke of the in- strument is guided by the knowledge of the parts. But it is to be noticed, that these parts, being altered by disease, most commonly do not present the same struc- ture and relations, which they do in the natural state; and that the flattened, lace- rated, destroyed muscles, on their being confused with the eye itself, cannot serve, as in lithotomy, for the foundation of any precept relative to the operation. Besides, why use both the knife and scissars ? The latter instrument is obviously useless, though M. Louis seems to think tiie operation cannot be done without it. The inclination of the outer side of the orbit will always allow a bistoury to be carried to the bottom of this cavity, so as to di- vide from above downwards, the optic nerve/ and muscular attachments, which are to be drawn forward so as to render them tense. Guided by the above principles, De- sault, after having practised, and taught the method of M. Louis, returned to Heister's advice, who wishes only a bis- toury to be employed. To have an ex- act idea 6f the mode of operating, which is always easy and simple wifh this one instrument, we must suppose the carci- noma to be in three different states. 1. When the tumour hardly projects out of the orbi"., so that the eye-Uds are free. 2. When it is much larger, projects consi- derably forward, and pushes in this direc- tion the healthy eye-Uds, wliich are in contact with it, together with a portion of the conjunctiva, which invests them, and is now detached from them. 3. When, in a much more advanced period, the eye- lids participate in the cancerous state. In the first case, the eye-lids must be se- parated from the eye, by cutting through the conjunctiva, where it turns to be re- flected over the globe of the eye. In the second instance, the eye-lids and con- junctiva, which are in contact with the diseased eye, must be dissected from it. In tlie third, these parts must be cut away, together with the eye. (OZuvres Chirurg, de Desault, par Bichat. Tom. 2) After the above observations, it only seems necessary to annex a few brief di- rections for operating. When the eye-ball is exceedingly en- larged, it is necessary to divide the eye- lids at the external angle, in order to faci- litate the operation. The surgeon can in general operate most conveniently when he employs a common dissecting knife, and when his patient is lying down with his face exposed to a goou light. In cutting out a diseased eye, it is necessary to draw the part forwards, regularly as its surrounding attachments are divided, in order that its connexions, wliich are still more deeply situated, may be got at with the knife. This object cannot be very well accomplished with the fingers, or forceps, and, therefore, most surgical writers recommend us, either to intro- duce a ligature through the front ofthe tumour, or to employ a hook, for the pur- pose of drawing the part in any direction, during the operation, which the necessa- ry proceedings may require. When the eye-lids are diseased, they must be re- moved ; but, when prudence sanctions their being preserved,- this is an immense advantage. The eye must not be drawn out too forcibly, before the optic nerve is divided, and care must be taken not to penetrate any of the foramina, or thin parts of the orbit, with the point of the knife, for fear of injuring the brain.— Great care should also be token to leave no diseased parts behind, in the orbit. The hemorrhage may always be securely stopped by filling the orbit with scraped lint. It is constantly' advisable to remove the lachrymal gland, as this part seems to be particularly apt to be the source of such inveterate fungous diseases, as too often foUow the operation. The antiphlogistic treatment is pro- per for a few days afterwards. Some- times, fungous granulations continually form in the orbit, notwithstanding they are repeatedly destroyed, and the patient is at last exhausted. Sometimes, the disease in the orbit extends even to the brain, and produces fatal consequences. When malignant fungous excrescences grow from the cornea alone, it is clearly unnecessary to extirpate the whole eye- ball. For information, relating to the sub- jects of this article/consult particularly Memoire sur plusieurs Maladies'du Globe de I'CEil; au Pan examine particuUerement les cas qui exigent I'extirpation de cet or- gone, et la Methode (Py proceder ; par M. Louis, in Mem. de P Acad, de Chirurgie. Tom. 13, p. 262. Edit, in 12 mo. Bertrandi-, 4162 FEVERS. Traite des Operation* de Chirurgie, p. 519, Edit. 1784, Paris. Subatier, de la Mede- cine, Operatoire, Tom. 3, p. 54, Edit. 1, Richter's Ari/angsgrunde .der Wundarzney- kunst, Band. 3, p. 415, Gottingen, 1795. Memoire sur PExtirpation de PQZil Card. nomuteux in CEuvres Chirurgicales de De- sault par Bichat, Tom-2,p- t02. Richerand, Nosographie Chirurgicale, Tom. 2, p 103, 13c. Edit 2. Ware, in Transactions of the Medical Society of London, Vol. 1. part 1, p. 140, &c. Lassus, Pathologie Chirurgi- cale, Tom. 1 p 450. Edit. 1809. Wardrtp on Fungus Hdtmatades,p. 93, Wc. EYE, DROPSY OF See Hytlrophthal my EYE, INFLAMMATION OF. Sea Ophthalmy. For other diseases of the eye, refer to Amaurosis; Cataract; Cornea ; Encanthis/ Exophthalmia ; Gutta Serena ; Hemeralt. pia; Iris, Prolapsus of; Hypopium / leu- coma ; Nyctalopia,- Pterygium; Pupil, Closure oft Staphyloma, &c. Me. F. FASCIA, (from fascis, a bundle, be- cause, by means of a band, materials are collected into bundles.) A bandage, fillet, or roller. See Bandage. K FEVERS, SURGICAL. Under this head we comprehend two species of fever, viz. the inflammatory, and the hectic, which are particularly interesting to surgeons, because frequently attendant on surgical disorders. We have mentioned, in treating of in- flammation, that a febrile disturbance of the constitution is attendant on every considerable inflammation. In the pre- sent article, we shall endeavour to give some account of the particulars of this disorder. The fever about to be described, is known and distinguished by several names; some calling it inflammatory; gome symptomatic ; and others sympathetic. It is sometimes idiopathic; that is to say, it occasionally originates at the same time with the local. inflammation, and from the same cause-.. (Burns.) In Other instances, and, indeed, we may say, in aU ordinary surgical cases, it is symp- tomatic ; or, in other words, it is pro- duced, not directly by the causes whiehl originally produced the inflammation, but in consequence of the sympathy of the whole constitution for the disturbed state of a part. The idiopathic inflammatory fever is said to be always preceded by chilliness. The symptomatic, or sympathetic inflam- matory fever, sometimes takes place so quickly, in consequence ofthe violence of the exciting cause, or of the local in- flammation, that no preceding coldness is observable. If, however, the local in- flammation be more slowly induced, and, consequently, operate more gradually on the system, then the coldness is evidently perceived. The symptomatic fever, in*, duced by scalding, or burning a part, is quickly produced, and we have very littls time to attend to the period of formation. On the other hand, the symptomatic fever, induced by wounds, is excited more slow. ly, and the period of formation is longer. This fever is not produced, when the in- flammation only affects parts in a slight degree; but, il consequently makes its appearance, if the local inflammation be considerable, or if it affect very ensibU parts. (Burns.). The degree, in, which this fever is excited, does not altogether depend upos the absolute quantity, or violence of tbe inflammation ; but, in a great measure, up- on the degree of the local inflammatory action, compared with the natunal power and action of the part affected Parts, in which the action is naturally low, are extremely painful when inflamed, and the system sympathizes greatly with them. Hence, the constitution is very much affected, when tendons, bones, or liga- ments, are the parts inflamed Severe uv fl.immation of a large joint, every one knows, is apt to excite the most alarming, and even fatal derangement ofthe system. When very sensible parts are inflamed; for instance, the eye ; the' symptomatic fever is generally more considerable, than it would be, were it to arise from an equal quantity and degree of inflammation in a less sensible organ. In common parts, as muscles, cellular membrane, skin, &c. the symptoms will be acute ; the pulse strong and full, and the more so, if the inflammation be near the heart ; but, perhaps, not so quick, as when the part is tar from it. The stomach will sympatiiize less, and the blood will FRVERS. 41$ be pushed farther into* the small vessels. {Hunter.) It the inflammation be in tendinous, ligamentous, or bony parts, the .symptoms will be less acute, the stomach will sym- pathize more, the pulse will not be so full, bat, perhaps, quicker ; there wUl be more irritability, and the blood will not be so much pushed into the small vessels, and, therefore, it will forsake the akin. (Hunter) It seems to be a material circumstance, whether the inflammation is in the upper, or lower extremity; that is, far from, or near to the heart, tor the sympoms are more violent, the constitution more affected, and the power of resolution less, when the- part inflamed is far from the source of the circulation, than when near it, even when the parts are similar, both in texture and use. (Hunter.) If the heart, or lungs, are inflamed, either immediately, or affected, seconda- rily, by sympathy, the disease has more violent effects upon the constitution than the same quantity of inflammation would have, if the part affected were not a vital one, or one with which the vital parts did not sympathize. If the part be such as the vital ones readily sympathize with, then the sympathetic action of the latter wiU affect the constitution as in an inflam- mation of tlie testicle. (Hunter.) In such cases, the pulse is muchquicker and small- er, and the blood is more sizy than if ihe inflammation were in a common part, such as muscle, cellular membrane, and skin. (Hunter.) When the stomach is inflamed, the patient feels an oppression and dejection through all the stages of the inflamma- tion; the pulse is generally low and quick, and the pain obtuse, strong, and oppressing; such as the patient can hardly bear. If the intestines are much affected, the same symptoms take place, especially if the inflammation be in tbe upper part ofthe canal; but, if only tlie colon be affected, the patient is more roused, and the pulse is fuller, than when the stomach only is inflamed. When the uterus is inflamed, the pulse is extremely quick and low. When the inflammation is either in the intestines, testicle, or uterus, the stomach generally sympa- thizes. In inflammation of the brain, the pulse varies more, than in the same affection of any other part; and, perhaps, we must, in this instance, form a judg- ment of the complaint, more from other symptoms, than the pulse. (Hunter) When the inflammation is situated in a part, not very essential to life, and occa- sions the general affection of the system, called inflammatory fever, the pulse is fuller and stronger, than common, and the blood is pushed further into the ex- treme arteries than when tne inflamma- tion is in a vital part. The patient, after many occasional rigors, is at first rather roused. The pui* is, us above described, when the constitution is strong and not irritable; but, if this be extremely irri- table and weak, as in many women, who lead sedentary lives, t: e pulse may be quick, hard, and small, at the commence- ment of the inflammation, just as if vital par's were concerned The blood may also be sizy; but il will be loose and flat on the surface. (Hunter.) We may set down the ordinary symp- toms ot" the inflammatory fever, occurring in consequence of local inflammation in common parts, and in a heal hy habit, as follows: The pulse is fr< queni, full, and strong; all the secretions are diminished; the puient is vigilant and res-l^ss; the perspiration is obstructed, and the skin is hot and dry; the urine i» hi^h-coloured, and small in quantity; the mouth is parched, and the tongue furred; there is an oppressive thirst experienced; dis- turbance of the nervous system; loss of appetite and sle^p; and, in some cases, delirium. OF WHAT IS TO BE DONS FOR THE RELIEF OF TUB 1NFLAMMAT0HX FEVER. Upon this part of the subject very little is to be said; for, as the febrile disturbance of the system is produced, and entirely kept up, in almost every in- stance, by tlie local inflammation, it must be evident, that the means employed for diminishing the exciting cause, are also the best for abating the constitutional effects. Hence, it very seldom happens, that any particular measures are adopted expressly for the fever itself; as this affection is sure to subside in proportion as the local inflammation is lessened, or resolved. But, when the febrile disturb- ance is Considerable, and the inflamma- tion itself is also considerable, the agitated state of the system may have in its turn a share in keeping up, and even increasing, the local affection, and should be quirted as much as possible. However, in these very instances, we should, in all proba- bility, be led to a more rigorous adap- tion of the antiphlogistic plan of treat- ment, from an abstract consideration of the state of the local inflammation itself, without any reference to that of the con- stitution. Indeed, the increased action ot the heart and arteries, and the suppres- sion of the secretions, require the em- ployment of antiphlogistic means, and antunooials, tiie very same things, wliich 414 FEVERS. are indicated for the resolution of the local inflammation itself. Bleeding, purg- ing, cold drinks, low diet; the exhibition of the antimonium tartarizatum, James's powder, or the common antimonial pow- der; and bathing the feet and body in Warm water, are measures, which have the greatest efficacy in tranquillizing the constitutional disturbance implied by the term inflammatory fever. But, I think it right to repeat, that it is hardly ever necessary to have recourse to such an evacuation as general bleeding, merely on account of the fever; as this is only an effect, which invariably subsides, in proportion as the local cause is dinu.- nished, ' HECTIC FEVER. The sympathetic, or symptomatic fe\rer, already described, is an immediate affec- tion of the constitution, in consequence of some local disorder ; the hectic fever is a remote one. When the hectic fever is a consequence of local disease, it has com- monly been preceded by inflammation and suppuration; but, there is an in- ability to accomplish granulation and cicas trization : and the cute, of course, cannot be accomplished. The constitution may now be said to be oppressed with a local disease, or irritation, of wliich it cannot reli'--.e itself. A distinction should be made, between a hectic leva*, arising entirely from a local complaint in a good constitution, which is only disturbed by too great an irrita- tion, and a hectic fever, arising princi- pally from the badness of the constitu- te n ; which does not dispose the parts to heal. In he first species, it is only necessary to remove the part (if remov- able,) and then all will do well; but, in the second, noihing is gained by a re- moval of tiie part, unless the wound, made in he" operation, is much less, und more easy put into a local method of cure; by re-son of whch, the constitu- tion sinks less, under this state and the operation together, than under the former one. Here the nicest discrimination is requisite. (Hunter) The hectic fever comes on at very different periods after the inflammation, and commencement of suppuration, owing to a variety of circumstances. Some con- stitutions having less powers of resist- ance, than i-tiiers, must more easily fall into this state. The hectic fever take* its rise from a variety of causes, but, wliich have* been divided into two species, with regard to diseased part; viz parts called vital, and others not of this nature. Many of the causes of hectic fever, arising from diseases of the vital parts, would not produce this constitutional affection, if they were jn any other part of the body; such, for instance, is the formation of tumours, either in, or so as to press upon, a vital part, or one, whose functions are immediately connected with life. Scirrhi in the stomach, and mesenteric glands; diseased lungs, liver, &c. produce hectic fever very soon. When hectic fever arises from a dis- ease of a part, that is not vital, it com- mences sooner, or later, according as it is in the power of the part to heal, or continue the disease. If the part be far from the source of the circulation, the fever will come on sooner, with the same quantity of disease. When the disease is in parts, which are not vital, and excites hectic fever, it is generally in si- tuations, where so much mischief happens as to affect tlie constitution, and where the powers of healing are little. This is the case with diseases of most joints. We must also include parts, which have a tendency to such specific diseases, as are not readily cured in any situation. Although hectic fever commonly arises from 'some incurable local disease of a vital part^ or of an extensive disease of a common part, yet it is possible for it to be an original disease in the constitution, without any local cause whatever, that we know of. Hectic is a slow mode of dissolution: the general symptoms are those of a low, or slow fever, attended with weakness. But, there is rather weak action, than real weakness ; for, upon the removal of the hectic cause, the action of strength is immediately produced, and every natural function is re-established, however much it was impaired before. The particular symptoms are debility; a small, quick, and sharp pulse; the blood forsakes the skin ; loss of appetite; frequently, a rejection of all aliment from the stomach; wasting; a great rea- diness to be thrown into sweats; spon- taneous perspirations, when the patient is in bed; the urine is pale-coloured, and very copious; and there is often a consti- tutional purging. Hectic fever has been imputed to the absorption of pus into the circulation; but, this cause has been much exag- gerated, as concerned in occasioning many of the bad symptoms, which frequently attack persons, who have sores. The hectic fever almost constantly attends suppuration, when in particular parts, such as vital ones. It also attends many inflammations, before actual suppuration takes place, as in cases of white swelling FEVERS. 415 of the large joints. The same quantity and species of inflammation and suppu- ration in any of the fleshy parts, espe- cially such as are near the source of the circulation, have in general no such effect. Hence, in the first instances, the fever is only an effect on the system, produced by a local complaint, that has a peculiar property. The constitution sympathizes more readily with diseases of vital parts, than with those of any other parts; their diseases are also in general more diffi- cult of cure, than the same affections of parts, wliich are not vital. All dis- eases of bones, ligaments, and tendons, affect the constitution more readily than those of muscleS, skin, cellular membrane, &c. When the disease is in vital parts, and is. such as not to kill, by its first consti- tutional effects, the system then becomes teazed with a complaint, which is dis- turbing the necessary actions of health. In the large joints, a disease continues to harass the constitution, by attacking parts, which have no power, or rather, no dis- position to produce a salutary inflamma- tion and suppuration. Thus, the system, is also irritated by the existence of an incurable disease. Such is the theory of the cause of hectic fever. If the absorption of matter always pro- duced the symptoms, above described, how could any patient, who has a large sore, possibly escape becoming hectic? for, there is no reason to suppose, that one sore ran absorb more readily than another. If absorbed matter occasioned such violent effects as have been commonly ascribed to it, why does not venereal matter do the same ? We often know, that absorption is going on, by the progress of buboes. A large one, just on the point of bursting, has been known to be absorbed, in con- sequence of a few days' sea-sickness. The person continued at sea for four and twenty days afterwards ; yet, no hectic symplqms followed, only the specific con- stitutional effects, which are of a veiy different description. Matter is sometimes formed on the in- side of the veins, when their cavities are inflamed, and this matter cannot fail to get into the circulation ; yet, hectic symp- toms do not arise. Also, very large col- lections of matter, which have been pro- duced without visible inflammation, as many abscesses of the scrophulous kind, are wholly absorbed* in a very .short time, but no bad symptoms are the conse- quence. (Hunter.) Hence, we may conclude, that the ab- sorption of pus has no share in occasion- ing hectic fever. Many arguments might be adduced to shew the absurdity of the doctrine; but, we can here only refer the reader to what Mr Hunter has said far- ther on the subject, in his work on in- flammation. It is much more probable, that the hec- tic fever arises from the effect, which the irritation of a vital organ, or other parts, such as joints, have on the consti- tution, when either incurable in them- selves, or are so for a time to the consti- tution. (Hunter ) ' TREATMENT OT HECTIC FEVER, We have no method of curing the con- sequences above related. All relief must depend on the cure ofthe cause, (viz. the local complaint) or on its removal. Tonic medicines have been recommend- ed, on account of the evident existence of great debility. Antiseptics have also been given, in consequence of the idea that, when pus is absorbed, it makes the blood disposed to putrify. For these reasons, bark and wine have been exhi- bited. Bark will, in most cases, only assist in supporting the constitution. Until the cause is removed, however, there seems no prospect of curing a disorder of the con- stitution. It is true, tonic medicines may make the system less susceptible of the disease, and also contribute to diminish the cause itself, by disposing the local complaints to heal. When, however, the hectic fever arises from a specific disease, such as the venereal, though bark may enable the constitution to bear the local affection better, than it otherwise could do, yet, this medicine can never remove the syphylitic mischief. (Hunter.) No medicine, not even bark itself, has any direct power of communicating strength to the human constitution. All that can be done, in the treatment of hectic fever, when it is thought inexpe- dient, or-impracticable, to remove the morbid part, is to combat particular symptoms, and to promote digestidn. It is by bringing about the latter object, that bark is useful in these cases. The in- fusum qinchonae being more apt to agiee with the stomach, than the decoction, or powder, should generally- be preferred. Nourishing food, easy of digestion, should be frequently taken, in smaU quantities at a time. Nothing is more prejudicial to a weak constitution, than over-loading the stomach. Wine may also be given, but not too freely, and, not at all, if it should create heartburn, as it sometimes does in hectic patients. Ma- deira is less apt to have .this disagreeble effect, than port. In- these cases, it is 416 FIN FIN likewise often found useful to administer" gentle cordial aroma'.c draught-. But, of all medci' es, opium is perhaps ihe most valuable to those, who are afflicted with hectic fever; it alleviates pan, pro- cures sleep, and checks the diarrhoea, which so frequently attends such cases When the local complaint, connected with the fever, is totally incurable, it must, if possible, be removed by a ma- nual operation. Thus, when a diseased joint keeps up hectic fever, and seems to present no hope of cure, amputation must be performed. But, when the local dis- ease holds forth the chance of being cured, provided the state of the constitution were improved, the surgeon is, in this circumstance, to endeavour to supp.irt the patient's strength. Great discretion, however, must be exercised, in deciding how long it is safe to oppose the influ- ence of an obstinate local disease over the svstem, by the power of medicine. Al- though patients, in an abject state of weakness, have oftentimes been restored to health by a removal of the morbid part, yet many have been suffered to sink so low, that> no future treatment could save them from the grave. Clemency in the practice of surgevy, does not consist so much in delaying strong and vigorous measures, as in boldly deciding to put them in execution, as soon as they are indicated. When the hectic fever arises from local diseases in parts, which the consti- tution can bear the removal of, the mor- bid part should be taken away, if it can- not be cured, consistently with the advice already given. When the disease arises from some incurable disease, in an extre- mity, all the abovementioned symptoms cease, almost immediately after the limb has been taken off. A hectic pulse, at one hundred ind twenty, has been known to sink to ninety in a few hours after the removal of the hectic cause. Persons have been known to sleep soundly the first night afterwards, who had not slept tolerably for weeks before. Gold sweats have stopped immediately, as well as those, called colliquative. A purging has immediately ceased, and the urine begun to drop its sediment. (Hunter.) FIBULA, (quasifigilula, fromfigo, to fasten.) So named from its resemblance to a Roman clasp. The smill bone of the leg. (See Fractures and Dislocations.) FICATIO, or FICUS. (a fig.) A tu- bercle about the anus, or pudenda, re- sembling a fig. FINGERS, ABSCESSES OF. (See IVhitlow.) Fingers, Amputation of. (SeeAmputa- tion) Fing«rs, Caries of. In these Cases, tht surgeon is to endeavour to extract the exfoliating portions of bone, immediately they become loose. For this purpose, he is justified in making such incisions, as witl enable him to fulfil the object in view. Until the process of exfoliation is sufficiently advanced, he can do little more, ihan apply simple dressings, and keep the pi-rt in a clean quiet state. When the separation of the dead pieces of bone will certainly destroy the utility of the finger, and convert the part into, an inconvenient, stiff appendage to the hand; or, when the patient's health is severely impaired by the irritation of the disease, the termination of which cannot be expected, within a moderate space of time; amputation is proper. It is a truth, however, that many fingers are amputated, winch might be preserved, and surgeons ought to consider well, be- fore presuming to remove part, which, when curable, may become ofthe greatest consequence, in regard to the perfection of the hand. The bread of many persons, it is well known, depends on the unnviti. lated state of certain fingers. These re- marks are offered, because I have seen several surgeons, fond of seizing every opportunity of cutting their fellow crea- tures, remove fingers, which might have been usefully saved, either, by allotting a little more time for the exfoliation, or by making incisions, and cutting out the dead piece of bone. Fingers, Dislocations of. (See Disloca- tion) Fingers, Fractures of. (See Fracture.) Fingers supernumerary. Children are occasionally bom with more fingers, than are natural, and since allowing the redundant number to remain would keep up deformity, and create future inconve- nience, the surgeon is called upon to am- putate them. The redundant fingers art sometimes with, sometimes without, a nail; are seldom more numerous, than one upon each hand; are generally situ- ated just on the outside of the little fingers; and, as far as my observation extends, are incapable of motion, in con- sequence of not being furnished, like the rest of the fingers, with muscles. The best plan is to cut off supernumerary fingers with a scalpel, at the place, where they are united to the other part of the hand. The operation Should be per- formed, while the patient is in the infant state, that is to say, before the superfluous parts have acquired much size, and whUe the object can be accomplished with the least pain. The incisions ought to be made, so as to form a wound with edges, which will admit of being brough tog e- FISTULA. 417 ther with strips of adhesive plaster. As soon as the dressings are applied, the hemorrhage will almost always cease, without a ligature. FISSURE, (from findo, to cleave asun- der.) A very fine crack in a bone, has thjs term often appUed to it. (See Frac- ture.) FISTULA, in surgery, strictly means a sore, which has a narrow orifice, runs very deeply, is callous, and has no dispo- sition to heal. The name is evidently taken from the similitude, which the long cavity of such an ulcer has to that of a pipe or reed. A fistula commonly leads to tlie situation of some disease keeping up suppuration ; and from which place the matter cannot readily escape. No technical term has been more misapplied, than this ; and no mis-interpretation of a word has had worse influence in practice, than that of the present one. Many simple, healthy abscesses with small open- ings, have too often been called fis- tulous; and, being considered as in a callous state, the treatment pursued has in reality at last rendered them so, and been the only reason of their not having healed. FISTULA IN ANO. See Anus. FISTULA LACHRYMALIS. A dis- iase arising from an obstruction in the ductus nasalis, and preventing the tears and mucus of the lachrymal parts of the eye from descending into tiie nose. No one can have a proper conception of this disorder, without adverting to the anatomy, and functions, of the parts con- cerned. Hence, 1 shall first insert the interesting relation of these subjects, as delivered by Mr. Pott. " That the motions of the eyelids may be performed with the utmost ease, that the tunica 'cornea maybe kept constantly clean, bright, and fit for the transmission of the rays of light, and that dust, and other hurtful particles, may be immedi- ately washed away, the surface of the eye is continually moistened by a fine limpid fluid. " This fluid is derived principally from a large gland, situated under the upper edge of the orbit, near the outer corner of tlie eye, which gland is of the conglo- merate kind, and lies in a small depres- sion ofthe os frontis ; its excretory ducts, or those by which it discharges the se- creted fluid, piercing the tunica conjunc- tiva, just above the cartilaginous borders of the upper eyelids. " While the caruncle was thought to be the secretory organ of the tears, this gland bore the title of glandula innomi- nata ; but, now, that its use and office arc Vot. I. known, it is called glandula lachrymalis. " By irritation from any sharp or poignant particles, a large quantity Aof this fluid is immediately secreted, and by the motion of the eyelids is as imme- diately derived over the surface of* the eye, by which means such particles are washed and wiped off". Sometimes also the passions of the mind produce an im- mediate increase of this lymph, which is, then strictly and properly called tears ; a constant secretion of too large a quantity causes a disease, called epiphora ; and a deficiency of it makes the motions of the lid difficult and painful. " Although the fluid secreted by the lachrymal gland is considerable in quan- tity, yet, when it is not suddenly produced by irritation from without, or passion within, it is so constantly and gradually carried off!, as to create neither trouble, uneasiness, nor blemish. " The edge, or border of each eyelid, is formed by a thin cartilage, tlie figure and consistence of which keep the lids properly expanded; these cartilages are covered by a fine membrane, and are called cilia ; their internal edges do, upon every motion, sweep over every point of the surface of the cornea; this motion, though almost imperceptible, unless at- tended to, is very frequently performed ; and as the secretion of the fluid is al-so constant, the eye is by this means kept always moist, clean and bright. "At the extremity of each of these cartilaginous borders of the eyelids, on the side next the nose, is a small papilla, or eminence ; and in the middle of each of these is a small hole, or perforation, which being made in the cartilage, is not liable to collapse, while the parts are in a sound state, but remains always open; they are called the puncta lachrymalia; and their office is to receive the lachrymal fluid, as it runs off the cornea along the edges of the eyelids, thereby preventing it from trickling down the cheek; and that there may be no impediment to the constant execution of this office, during the time of sleep, as well as that of being awake, the internal edges of the cilia do not come into immediate contact with each other in that point where these ori- fices are. " From each of these puncta lachry- malia proceeds a small membranous tube ; wliich tubes soon enter into, or form a pouch or bag, situated near the inner angle of the eye, just below tiie union of the two lids, under the musculus orbicu- laris palpebrarum ; the bag is called the sacculus lachrymalis, and its office is to receive all the lymph brought by the 3 11 418 FISTULA. puncta and ducts; the upper part of this sacculus lies in an excavation, formed partly by the nasal process of the os maxillare superius, and partly by the os unguis; the lower part of it is confined in a long channel, and forms a tube, or duct, which descending obliquely back- ward, communicates with ihe cavity of the nose, behind the os spongiosum superius, by an opening whose size is somewhat different in different sub- jects. " This passage is called the ductus ad nares or the ductus nasalis, and through it whatever is received by the sacculus from the puncta does, in a healthy and sound state of these parts, pass into the nose. " The membrane which lines this sac- culus and duct, is in its structure much Uke to the membrana pituitaria narium, from the surface' of which a clear viscid mucus is secreted, and by which the sr.c- culus and passages are constantly moist- ened and kept pervious. " While the parts are in a healthy, sound state, the fluid secreted by the lachrymal gland passes off through the puncta, sacculus, and duct, into the nose, without any trouble; but when they are in a diseased state, the case is otherwise. Tbis membrane", like all other vascular parts, is liable to inflammation, by which means it often happens, that it is so thick- ened as to obstruct the nasal duct, and thereby much impede, or totally hinder the passage of any tiling through it; in consequence of which obstruction the sac- culus is filled by its natural mucus, and the derivation of the seri;m from the lachrymal gland through it being thus prevented, it runs oft' from the eyelid down the cheek; this obstruction conti- nuing, and the mucus still lodging, the sacculus is dilated, and produces that tu- mour in the inner cormr of the eye, and that discharge, upnn pressure, which characterise the first state of the disease in question, and, in conjuncticn with several other attending symptoms, prove its seat to be in the lachrymal sac, and nasal duct. '* Although the seat of this disease is the same in almost every subject, yet its appearance is very different in different persons, and under different circum- stances. These variations depend prin- pally on— 1. The degree of obstruction in the nasal duct. 2. The state of the cellular membrane covering the sac. 3. The state of the sacculus itself. 4. That of the bone underneath. 5. The general state and habit of the patient."" " Sometimes a serous kind of deflux- ion, by which the lining of the sac and duct are so thickened as to obstruct, or prevent the passage of the fluid through them into the nose, makes the whole complaint; and the cellular membrane on the outside not being diseased, there is no appearance of inflammation. In this case the duct is stopped, and the sacculus dilated, but without any altera- tion in the colour of the skin; a fulness appears in the cornea of the eye next to the nose ; and upon the application of a finger to this tumour, a clear viscid mucus is discharged, through the puncta lachrymalia; the patient feels no pain, nor finds any inconvenience, except what is produced by the discharge of this mu- cus, and by the trickling of the lymph down the cheek. " In some cases the mucus is not per- fectly and always clear, but is sometimes cloudy, and looks as if it had a mixture of milk or cream in it; at first waking, some of it is generally found in the cor- ner of the eye ; and the eyelashes, being smeared over with it during sleep, most commonly adhere together in the morning. " This is tlie most simple state of the disease, what the French have called the hernia, or hydrops sacculi lachrymalis: it is frequently met with in children who have been rickety, or are subject to glan- dular obstructions: and in this state it sometimes remains for some years, sub- ject to little alterations, as the health or habit shall happen to vary, the sacculus being sometimes more, sometimes less full, and troublesome ; the mucus which is pressed out, is sometimes more, some- times less cloudy, and now and then it is attended with a slight ophthalmy, or an inflammation of the eyelids, but which, by common care, is easily removed. " If the sacculus is not much dilated, the discharge small, and produced only by pressure, the chief inconveniences are the weeping eye, and the gumming toge- ther of the lids, after sleeping: but these, by being attended to, may be kept from being very troublesome ; and, if the dis- ease makes no farther progress, may be so regulated as to render any more pain- ful process totally unnecessary. • As the state and circumstances of this disease are really various, and differ very essentially from each other, the ge- neral custom of calling them all by tbe one name of fistula lachrymalis is absurd. FISTULA. 419 " If tlie dilatation is considerable, the swelling is more visible, and the quan- tity of mucus is larger; it is also in this state more frequently mixt and cloudy, and more troublesome, from the more frequent necessity of emptying the bag; but if the patient be adult, it may, even in this more dilated state of it, be kept from being very inconvenient. " If an inflammation comes on, the tu- mour is thereby considerably increased, the discharge is larger, as well during sleep as upon pressure; the skin cover- ing it loses it natural whiteness and soft- ness, becomes hard, and acquires an in- flamed redness; and with the mucus a mixture of something, which in colour resembles matter, is discharged, especi- ally if the pressure be made with any force, or continued for any time : this circumstance, added to the painful sensa- tion, and inflamed appearance of the parts, Was been productive of a supposi- tion, that in this state there is either an ulcer or au abscess within tiie sacculus or duct." Mr. Pott next attempts to prove, that the contents of the sac are only ot a mu- cous, not a purulent, quality. On quilting this discussion, Mr. Pott remarks, " The inflammation of the cel- lular membrane covering the sac, is a cir- cumstance which makes a considerable difference, both in the appearance of the disease, and in its requisite treatment; in some cases it is confined merely to the surface of tlie tumour in the corner of the eye ; in others it spreads still farther, affecting the eyelids, cheek, and side of the nose. " When the parts are in this state, the mucus within the bag has generally the appearance of being matter, that is, it wears a deep yellow colour, and is of a more thin consistence; if the puncta lachrymalia are naturally large and open, and the inflammation confined to the sur- face of the sac, its contents will pass off pretty freely, and the skin will remain entire; this is what the ancients called the simple, or imperfect, anchylops. " But when tiie skin covering the lachrymal bag has been for some time in- flamed, or, subject to frequently returning inflammations, it most commonly hap- pens, that the puncta lachryinaha are affected by it, and the fluid not having an opportunity of passing off through them, distends the inflamed skin, so that at last it becomes sloughy, and bursts ex- ternally. This is that state ofthe disease x&ch is called perfect aigylops, or xg-y- I«pive inflammation from taking place ; it becomes the cause of suppuration whenever it is diffused, and the irritation is often ro great that it "pro- duces mortification, first in all the cellular membrane, and afterwards in several parts of the sjrin ; all of which, if the pa- tient live, slough away, u aking a free communication between the urethra and external surface, and producing fistulx in , perinxo. However, when the ulceration takes place further back than the portion ofthe urethra, between the glans penis and membranous part of this canal, the ab- scess is generally more circumscribed. The urine sometimes insinuates itself into the corpus spongiosum urethrs, and is immediately diffused through the whole, even to the glans penis, so as to produce a mortification of all those ports. Although the ulceration of the urethra may be in the perinseum, yet the urine ge- nerally passes easily forwards into the scrotum, which contains the loosest cellu- lar substance in the body; and there is always a hardness, extend.ng along the perinaeum to the swelled scrotum, m the track of the pus. Ulceration can only be prevented-by destroying the stricture ; but when the urine is diffused in the cellular membrane, the removal ofthe stricture will generally be too late to prevent all the mischief!, although it will be necessary for the cm- plete cure. Therefore, an attempt should be.made to pass a bougie, for perhaps the stricture may have been destroyed by the ulceration, so as to allow this instrument to be introduced. When this is the case, bougies must be almost constantly used, to procure as free a passage forwards, in the right way, as possible. When the bougie cannot pass, the application of caustic would in many cases be too slow in its operation, and, in others, cannot be tried, by reason of the situation of the stricture. While we are attempting to cure the stricture, antiphlogistic measures, parti- cularly bleeding, are to be adopted. The FISTULA. 427 parts should be exposed to the steam of hot water; the warm bath made use of; opium and turpentine medicines given by the mouth, and in glysters ; with a view of diminishing any spasmodic affection. But, all these proceedings are often in- sufficient, and, therefore, an immediate effort must be made, both to unload the bladder, and prevent the further effusion of urine, by making an opening into the urethra, somewhere beyond the stricture, but, the nearer to it, the better. Introduce a director, or some such in- strument into the urethra, as far as tiie stricture, and make tiie end of it as pro- minent as possible, so as to be felt; which, indeed, is often impossible. If it can be felt, it must be cut upon, and the incision carried on a little farther, towards the bladder, or anus, so as to open the urethra beyond the stricture. This will both al-' low the urine to escape, and destroy the stricture. If the instrument cannot be felt, at first, by the finger, we must cut down towards it; and, on afterwards feel- ing it, proceed as above. When the stricture is opposite the scro- tum, as the opening camiot be made in tliis situation, it must be made in the pe- rinzum, in which case, there can be no direction given by an instrument, as one cannot pass sufficiently far, and the only guide is our anatomical knowledge. The opening being made, proceed as directed in the cure of a false passage. (See Ure- thra, False Passage of.) In whichsoever way the operation is done, a bougie, or a catheter, wliich is better, must afterwards be introduced, and the wound healed over it. When the inflammation, from the extra- vasation of urine, is attended with sup- puration and mortification, the parts must be freely scarified, in order to give vent both to the urine and pus. When there is sloughing, the incisions should be made in the mortified parts. Sometimes, when the urethra is ulcer- ated, and tlie cellular membrane of the penis and prepuce is so much distended, as to produce a phymosis, it is impossible to find the orifice of the urethra. Frequently the new passages for the urine do not heal, on account of the stric- ture not being removed : and even when this has been cdred, they often will not heal, but become truly fistulous, and pro- duce fresh inflammations and suppura- tions, which often burst by distinct open- ings. Such new abscesses and openings often form, in consequence of the former ones having become too small, before the obstruction in the urethra is removed. Such diseases sometimes bring on in- termittent disorders, which do not yield to bark; &ut do not recur, when the fis- tulae, and disease of the urethra, have been cured. In order to cure fistulae in perinaeo, unattended with the above described ur- gent symptoms, the urethra must be ren- dered as free as possible, and, this alone is often enough ; for, the urine finding a » ready passage forwards, is not forced into the internal mouth of the fistulae, so that these heal up. The cure ofthe strictures, however, is not always sufficient, and the following operation becomes indispen- sable. The sinuses are to be laid open.in the same manner as other sinuses, which have no disposition to heal. In doing this, as little as possible of the sound part of the urethra must be opened. Hence, the surgeon must direct himself to the inner orifice of the fistulae, by means of a staff, introduced (if possible) into the bladder, and a probe passed into one of the fistu- lous passages. The probe should be first bent, that it may more readily follow the turns of the fistula. When it can be made to meet the staff, so much the better; for, then the operator can just cut only what is necessary. When the fistula is so straight, as to admit ofa director being introduced, this instrument is the best When neither the probe, nor the director, can be made to pass as far as the staff, we must open tiie sinuses as far as the first instrument goes, and then search for the continuation of. the passage, for the purpose of laying it open. Having divided the fistula:, as far as their termination, in the urethra, a cathe- ter should be introduced, and worn at first, almost constantly This is better than a bougie, which must be frequently withdrawn to allow the patient to make water, and it often could not be introduced^ again without getting entangled in the wounds. Whatever instrument is used for keep- ing the passage clear and open, while the sores are healing, whether the sores are the consequence of the causes of the fis- tula, or the above operation, there is, in many cases, a limited time for its employ- ment. At first, it often assists the cure; but, in the end, it may obstruct the heal- ing, by acting at the bottom of the wound, as an extraneous body. Hence when the sores become stationary, let the catheter be withdrawn, and introduced only occa- sionally. Even after the sores are well, the bou- gie may afterwards be used, in order ,to determine whether the passage is free. from disease. When fistulx in periuxo have been 428 FOM FOB laid open, the wounds are to be at first dressed down to tlie bottom as much as possible, which will prevent the reunion ofthe parts first dressed, and make the granulations shoot from the bottom, so as -to consolidate the whole by one bond of union. (See Treatise on the Venereal Dis- ease, by John Hunter ) Additional obser- vations upon this subject, and, in particu- lar, the opinions of Desault concerning it, will be found in the article, Urinary Abscesses and Fistulx. FISTULA SALIVARY. (See Parotid Duct) FLUCTUATION, (from fiuctuo, to float.) Tbe perceptible motion commu- nicated to any collection of purulent mat- ter or other kind of fluid, by applying some of the fingers of each hand, at a certain distance from each other, to the surface of the tumour, and pressing with them alternately, in such a manner, that the fingers of one hand are to be employed in pressing, while those of the other hand remain lightly placed on another part of the swelling. When the ends of one set of fingers are thus delicately applied, and the surgeon taps, or makes repeated pressure with the fingers of the other band, the impulse, given to the flu id, is immediately perceptible to him, and the sensation, thus received, is one of the principal symptoms, by which practition- ers are enabled to discover the presence of fluid in a great variety of cases. Great skill in ascertaining by the touch the pre- sence of fluid in parts, or being endued with the tactus eruditus, as it is termed, distinguishes the man of experience as remaikably, perhaps, as any quaUty that can be specified. When the collection of fluid is very deeply situated, the fluctuation is fre- quently exceedingly obscure, and some- times not at all distinguishable. In this circumstance, the presence of the fluid is to be ascertained by the consideration of other symptoms. For example, in cases of hydrops pectoris and empyema, sur- geons do not expect to feel the undulation of the fluid in the thorax with their fin- gers ; they consider the patient's diffi- culty of breathng, the uneasiness attend- ing his lying upon one particular side, the cedema of the parietes of the chest, the dropsical affecti >n of other parts, the more raised and arched position of the ribs on the affected side, the preceding rigors, fever, and several other circum- stances, from which a judgment is form- ed, both witli regard to the presence and tlie peculiar nature of the fluid. FOMENTATION. (Fomentatio, Fo- mentum, Folus) By a fomentation, sur- geons commonly mean the appucation of flannel or some other substance, wet with warm water, or some medicinal decoction^ to any part of the body. Fomentations are chiefly of use in surgery in relieving pain, and inflammation, and in promoting suppuration, when this is desirable. Some particular decoctions, however, are used for fomentations, with a view of affecting by means of their medicinal qualities, scrofulous, cancerous, and other sores of a specific nature. We shall just mention a few of the most useful fomentations in common use. FOMENTUM AMMONLE MURI- AT.fi. Hi. Fomenti Communis ifeij. Ammon, u Mur. £y Spirit. Camph. Jij. .irfu- Just before using the hot decoction, add i to it the ammonia muriata, und spirit. Said to be of service to some indolent ul- cers ; and, perhaps, it might be of use in promoting the absorption of somettumours, and suppuration in others. FOMENTUM CICUT.3E. 5,. Fol Cicut. recent, lbj. vel Fol Cicut. exsiccat. 5iij. Aq. Comm. Ifeij. Coque usque reman. ifeij. el cola. This fomentation is considered, as a very proper one for many scrofulous, can- cerous, and phagedenic ulcers. FOMENTUM CHAM.KMELI. *. Lini contusi ^j. Chamxmeli^tJ. Aq. Distillat. Ifevj. Paulisper coque, et cola. This is a common fomentation, for or- dinary purposes. FOMENTUM GALL,£. *. Gallx Con- tusx "fss. Aq. Ferpenti* Ifeij. Macera per horam, et cola. Used for the prolapsus ani. It is sometimes also employed, as a cold application, in cases of hemor- rhoids. FOMENTUM PAPAVERIS ALBI. *. Papav. Alb. Exsiccatt % iv. Aq. Pur. Ifevj. Bruise the poppies, put them in the water-j and boil the liquor, till only a quart remains, which is to be strained This fomentation is a very excellent one, for very painful inflammations of the eyes, • and for numerous ulcers, and other dis- eases, attended with intolerable pain. FONTANELLA. (dim. of fans, a foun- tain.) An issue, so named from its conti- nually running. (See Issue.) FONTICULUS. (dim. of font, a foun- tain ) An issue, so named from its conti- nually running. (See Issue.) FORCEPS, is an instrument much em- ployed in surgery for a variety of pur- poses, and having accordingly various constructions. The general design, how- ever, of every surgical forceps is to take hold of substances, which cannot be con- veniently grasped with the fingers; and, of course, the instrument is always formed on tlie principle of a pair of pincers, hav- ing two blades, either with, or without FRACTURES. 429 handles, according to circumstances. The smallest forceps is that which is employed in the operation of extracting the cata- ract, and wliich is useful for removing any particles of opaque matter from the pupil, after the chief part of the crystal- Une lens has been taken away. Another forceps, of larger size, is that used for taking up the mouths of the ar- teries, when these vessels require the li- gature, in cases of hemorrhage. This in- strument is also frequently employed for taking dressings ofl' sores, removing pieces of -dead bone,-frtreign bodies from wounds, and, particularly, for raising the fibres, which are about to be cut, in all opera- tions, where careful dissection is requir- ed. This forceps resembles that, which is contained in every case of dissecting instruments, and is often called the artery, or dissecting forceps, from its more import- ant uses. Neither of the foregoing forceps is made with handles ; each opens by its own elas- ticity; and the ends of the blades only come into contact, when pressed together by the surgeon. The following kinds of forceps are Constructed with handles, by means of which they are both opened and shut. 1. Tlie common forceps', contained in every pocket case of surgical instruments, and -used for removing dressings from sores, extracting dead pieces of bone, fo- reign bodies, ike. 2. Larger forceps, employed for. ex- tracting polypi. 3. Forceps of different sizes and con- structions, used in the operation of litho- tomy, for taking the stone out ofthe blad- der, or for breaking the calculus, when it is too large to be extracted in an entire state. FRACTURE, (from frangu, to break ) Is a solution of Continuity of one,' or of several bones, produced in general by ex- ternal force, but, occasionally, by the powerful action of muscles, as is often exemplified in the broken patella. The long bones are particularly subject to be broken, and, mostly, at their middle part. They may, liowever, be fractured near their extremities. Sometimes, the same bone is broken in different places, which case is termed a comminuted fracture. Though, when the middle part of a bone is fractured, the ends of the fracture are more apt to be displaced, on account of the contiguous surfaces being less ex- tensive, yet, this kind of fracture is the least dangerous, because the violence, wliich has caused the accident, has sel- dom been applied to the broken part, and consequently, tiie adjacent soft parts are uninjured The middle of a bone also is broken by less force, than any otiier part of it, and the fracture being distant from any joint, no stiffness, nor anchy foois, is likely to result from the injury. Fr.icures are also distinguished into transverse and oblique. Duverney has ad- mitted another ciass, viz. longitudinal ones; but, J. L. Petit has denied ihe pos- sibility of this case, and Boyer, adopts the opinion of the latter, rejecting, as impos- sible, the longitudinal fracture, unless that name be given to longitudinal splin- ters of comminuted fractures. M. Louis positively rejected the possibility of longi- tudinal fractures, since, he thought, that they could not happen, without the bone being at the same time fractured obliquely and transversely. The following case is related by M. Lev-lille, in order to shew, that longitudinal fractures are possible. Circumstances made it necessary for him to amputate the thigh of an Austrian sol- dier, who was put under his care in the year 1800, in consequence of being struck with a ball in the lower third of the leg at the battle of Marengo. The soldier had walked several miles, after receiving the injury, before he arrived at Pavia. The wound appeared simple and likely to heal, as soon as tbe injured portion of the tibia had exfoliated. The event turned out otherwise, and the thigh was amputated. M. Leveille has preserved the tibia, upon which the impression of the ball may be distinguished, and, from this [>oint, run several longitudinal and oblique ines, which extend from tiie lower thu-d towards the upper head of the tibia. These are fissures, which interest the whole thickness ofthe parietes of the me- dullary canal. They have been acknow- ledged to be so by the professors, Dubois, Chaufrier, Dumeiil,Deschamps,andRoux, who were appointed by the Ecole De Me- decine to enquire into the fact. (Leveille, Nouvelle Doctrine Chirurgicale, Tom. 2, p. 158.) The most important division of frac- tures, is into simple and compound. By a simple fracture, surgeons mean a breach in the continuity of" one, or more bones, without any external wound, communi- cating internally with the fracture, and caused by the protrusion of the ends of the broken bone, or bones. By a com- pound fracture, they signify the same sort of injury of a bone, or bones, attended with a laceration of the integuments, which laceration is produced by the pro- trusion of one, or both ends, of the frac- ture. The dangerous nature of compound *♦* 430 FRACTU fractures will be fully understood, when we presently treat separately of this sub- ject. The causes of fractures are divided into predisposing and remote. In the first class are comprehended, the situation and functions of the bones, the age of the patients, and their diseases. Superficial bones are more easily fractur- ed, than those, which ate covered by a considerable quantity of soft parts. The functions of some bones render them more liable to be fractured, than others ; thus the radius, which supports the hand, is more Uable to be fractured, than the ulna. The clavicle, which serves to keep the shoulder in its proper position, and sup- port on its arched extremity all the mo- tions of the upper extremity, is hence very subject to be broken. The Bra- dual increase of the quantity of the phosphate of lime, in the structure of the bones, makes them brittle, in proportion as we advance in years, and, in old age, the proportion of the inorganized to the organized part is so great, that the bones are fractured by the slightest causes. In childhood, the fibrous and organized part bears a greater proportion to the earth, and the bones bfcmg consequently, more elastic and flexible, are not so easily bro- ken, as in old age. Lues venerea, arthritis, cancer, rachitis, scurvy, and scrofula, says M. Leveille, predispose to fractures. B. Bell mentions two venereal patients, of whom the hardest and largest bones were completely broken by the ordinary action of the muscles of the limb. Fabricius Hildanus quotes from Sarrazin, a physician of Lyons, the case of a gouty patient, sixty years of age, who, in putting on his glove, broke his arm ; the fracture havirur been ascer- tained, three days afterwards, to be situa- ted above the elbow. Desault used often to speak of a nuii of Salpetriere, whose arm was broken, as a person was handing her out of a carriage. M. Louis, who was vexed, that no union took place, was not a little" surprised to find her thigh bone experience the same fate, one day as she was changing her posture in bed. It was then that M. Louis learned, that this lady had a cancer in her right breast. M. Leveille assures us, that he has ob- served similar cases in the Hotel Dieu. According to this last writer, the his- tory of two girls is related by Buchner, one of whom died ricketty at the age of sixteen, having broken the femur a short time before her death; and the other, af- ter taking the breast very well for two years, and thriving for a time, became af- fected with rachitis, and met with the same accident as she was merely running along in the street. (Nouvelle Doctrine Chirurgicale, Tom. 2, p. 163 ) Many extraordinary instances of frac- tures from a morbid softness and fragility of the bones are upon record. Suffice it here, to refer to the Philosophical Trans- actions ; Mem de l'Acad. Royale des Sci- ences ; Act. Hafniens ; German Ephem.; Gooch's Chirurgical Works, Vol. 2 ; Sa- viard's Observations Chirurgicales, p. 274, &c. (See also Fragilitus and Molli- fies Ossium). On the subject of fractures, produced by the scurvy, Leveille recommends us to peruse Marcellus Donatus; Saviard's Observations ; Heyne de Morbis Ossium ; Poupart's Works inserted in the Mem. de l'Acad. de Sciences, 1699; and the Treatise pubUshed at "Verona, in 1761, by Jean de Bona. Pare, Platner, CalUsen, and several other writers, have set down cold, as a predisposing cause of fractures. This doctrine has originated from these injuries being more frequent in the winter time, and is quite erroneous, since, in cold countries, the greater number of faljs, which happen in the winter, is a circum- stance, that fully explains why fractures are then more common, than in summer. The remote cause of fractures is exter- nal force, variously applied, in falls, blows, &c. In particular instances, the bones are broken by the violent action of the muscles attached to them ; this is al- most always the case with the fractured patella. The olecranon and os calcis have likewise been broken by a violent contraction ofthe muscles, inserted into them. With respect to the heel, Petit records two instances, one of wliich was communicated to him by Poncelet, and the other seen by himself in Madame La Presidente de Boissire, who met with the accident ki walking a gentle pace in the court of the Hotel de Soubise. When in- jury happens in leaping, or falls from a high situation, M. Leveille thinks it more probable, that a portion of the os calcis is torn off by the powerful action of the muscles of the calf, than that it is broken by any blow immediately on the part. He states, that Desault used frequently to cite two examples of this kind, one of which is recorded in his CEuvres Chirur- gicales. Whether the long bones can be frac- tured by the mere action of the muscles, has been an unsettled point. In the Phi- losophical Transactions, a fracture of the humerus is ascribed to this cause, and M. Botentuit has seen the same accident happen in striking a shuttle-cock with a battledore. According to M. Debeau- marchef, as a man was descending a lad- FRACTURES. 431 der at a quick rate, his heel got entangled in an opening, and he made a violent ex- ertion to avoid falling, the consequence was a fracture of the lower third of the leg. Curet informs us, that a cabin-boy, aged seventeen, made a considerable effort to keep himself from being thrown down by the rolling of the ship, as he was mak- ing water. The femur was fractured by the powerful action of the muscles ofthe thigh. The lad had no fall, and, with some difficulty, supported himself on the other bmb, till he received assistance. We are told, says M. Leveille*, by Pou- pee Desportes, that a negro, about twelve or thirteen years old, was seized with such violent spasmodic contractions of the mus- cles of the lower extremities, that the feet were turned backward, and the neck of each thigh bone was fractured, the ends of the broken bones also protruding through the skin upon the outside of the thigh. A cure was effected, after an ex- foliation. We read, also, in the Melanges des Curieux de la Nature, that during a fit of epilepsy, a child, ten years old, had its left humerus and tibia broken, and, that upon opening the body, other solu- tions of continuity were observed. Doc- tor Chamseru recollects having assisted, at his father's house, in dressing a child, eleven or twelve years old, that had broken the humerus in throwing a stone, a consi- derable distance. (Leveille Nouvelle Doc- trine Chirurgicale, Tom. 2, 'p. 164—166.) For my own part, making all due al- lowance for the inaccuracy of some of the reports made by writers, I think the possi- bility of the long bones being broken by the violent action of the muscles, is suffi- ciently proved. I have never seen but one example of the occurrence; but it was a Very unequivocal one. I once attended at Pentonville, for Mr. Ramsden, an exceed- ingly strong man, who broke his os bra- chii in making a powerful blow, although he missed his aim, and struck nothing at all. The whole limb was afterwards af- fected with vast swelling and inflamma- tion. This man, I remember, was occa- sionally seen by Mr. Welbank, of Chan- cery-lane. ' Some of the symptoms of fractures are very equivocal. The pain, and inability to move the limb, commonly enumerated, may arise from a mere bruise, a disloca- tion, or other cause. The crepitus, the change in the form of the limb, and the shortening of it, are circumstances, com- municating the most certain information; and the crepitus, in particular, is the prin- cipal symptom to be depended upon. The signs of fractures, however, are so exceed- ingly various, according to the bones, which are the subject of injury, that, it cannot be said, that there is any one, wliich is invariably attendant on such cases, and characteristically confined to them. The writers of systems of surgery have usually noticed loss of motion in the injured iimb, deformity, swelling, tension, pain, &c. as forming the general diagnosis of fractures. However, it is easily com- prehensible by any one, acquainted with anatomy, that numerous fractures cannot prevent the motion of the part, nor occa- sion outward deformity; and every sur- geon must know, that, though, at first, there may'be pain in the situation of a fracture, no swelling and tension take place, tiU after a certain period. When, therefore, a Umb is broken, and the event is not manifest from the distor- tion of the part, it is proper, to trace, with the fingers, the outlines of the sus- pected bone ; if it be the tibia, let the sur- geon examine with his fingers, whether there is any inequality along the anterior surface, and along the sharp front edge of that bone. If it be the clavicle, let him trace the superficial course of the bone, in the same attentive manner. Wherever any unusual pain occurs, or any unnatural irregularity appears, then let him try, if a grating, or crepitus, cannot be felt on endeavouring to make one end ofthe frac- ture rub against the other. When the os braehii, or the os femoris, is the sub- ject of enquiry, a crepitus is felt almost as soon as the Umb is touched, and, in the case of the broken thigh, there is a considerable shortening of the extremity, unless sometimes when the fracture is of the transverse kind. But, when there are two.bones, as in tlte leg and the fore- arm, and only one is *roken, the other continues to prevent the limb from being shortened, and thrown out of its natural shape, so that a crepitus can only be felt by a very careful examination with the fingers. I am aware, that considerable harm, and great unnecessary pain, have been occasioned in the practice of surgery, by an over-officious care to feel the grating of fractured bones, and, whenever the case is sufficiently evident in the eyes, I cannot refrain from censuring those practitioners, who indulge their own ill-judged habits, at the expence of torture to the unfortu- nate patient. A fracture is an injury, that is necessarily attended with a great deal of pain, and followed by more, or less swelling, and inflammation; and to in- crease these evds by roughly, or unneces- sarily handling the part, is both ignorant. ly cruel, and, if I may use the expression, unsurgical. In some kinds of fractures, the broken bone is so surrounded with thick fleshy 432 FRACTURES. parts, that it is very difficult to feel a ere- pitus, or ascertain tlie existence ofthe in- jury. Some fractures ot the neck of tbe thigh bone, unattended with much retrac- tion of tbe limb, are instances illustrative of this observation. The prognosis of fractures varies, ac- cording to the bone injured, what part of il is broken, the direction of the breach of continuity, and what other mischief complicates the case. Fractures of bones, which have many strong muscles inserted into them, are m .re difficult of cure, than those of other bones, which have not so many powers attached to them, and ca- pable of disturbing the ends of their frac- tures. Tlie fracture of the middle part of a long bone, is less dangerous, than a simi- lar injury near a joint, with wliich the bone is articulated, for reasons mentioned above. Oblique frnctures are more trouble- some, and difficult of cure, than trans- verse ones, because an oblique surface does not resist the retraction ofthe lower portion of the broken bone, and conse- quently, it is very difficult to keep the ends of the fracture applied to each other, in a proper manner. Fractures complicated with a violent contusion of the soft parts, or with a wound, rendering them compound ones, are much more dangerous, than other ones free from such accidents. Fractures of the leg are generally more serious, than similar injuries of the upper extre- mity. A fracture may be rendered a very dan- gerous case, by being attended with a wound of a large artery. In a debilitated old man, a fracture is less likely to end well, than in a healthy child, or strong young subject. The scurvy is said to retard the formation of callus ; but, it is not true, that pregnancy prevents the union of fractures. Some years ago, I attended for Mr. Ramsden, a woman, in a court leading out of St. Paul's Churchyard, who broke both bones of her leg, when she was several months gone with child. Her pregnan- cy, however, did not appear to be at all unfavorable to the cure, as she got quite weU in the usual time. " It is not ge- nerally settled," says a modern writer, " whether pregnancy should be accounted a complication. I have seen, with some practitioners, a pregnant woman get well ofa simple fracture in the ordinary time." (Leveille, Nouvelle Doctrine Cldrurgicale, Tom. 2, p. 159.) And, in another place, he says, " Contre Popinion de Fabrice de Mlden, I'experience m'aprouve que, chezles femmes grosses, le cal etait aussi prompt d se former, que chez toute autre personnel (Op. cit. Tom. 2, p. 172) There are cer- tain indescribable constitutions, in which bones, more particularly, however, the os brachii, will not un^fe again after being broken. These temperaments are also very various ; at least, I infer so from two subjects, to whom I paid particular atten- tion. One was a strong, robust man, whose chief peculiarity, seemed to be his indifference to pain : he. bad the ends of the broken os brachii cut down to, turned out, and sawn off, by Mr. Long, in St. Bartholomew's hospital, and the Umb af- terwards put in splints, and taken the greatest care of; but no union followed. The other case was a broken tibia and fibula, which remained disunited for about four months; but, afterwards, grew together. The latter subject waaa complete instance of hypochondriasis, - I have since seen a woman, under Sir James Earle, in the above situation, whose -os brachii did not unite in the least, though it had been broken several months. Every attempt to move the bone occasioned ex- crutiating torture. The woman died of some illness in the hospital, and, on dis- secting the arm, tbe cause ofthe fracture not having united, was found to arise from the upper, sharp, pointed extremity of the lower portion of die broken bone hav- ing been forcibly drawn up by the mus- cles, and penetrated the substance of the - biceps, in which it still remained, I am indebted to Mr. Henry Earle for the ac- count of the appearance on dissection. and I do not know, that this kind of im- pediment to .the union of a fracture has been noticed by any writer, except Mr. Charles White, who appears to have con- ceived the possibility of the occurrence* (Cases in Surgery,p. 70. Edit. 1770.) The causes of fractures remaining dis- united, will, according to Richerand, be found to depend, either upon the broken ends of the bone not being properly in contact; upon the limb having been moved too much ; upon the advanced age of the patient; or, upon the general iner- tia of the solids, und languor of the vital properties. (Nosographie Chirurgicale, Tom. 3, p. 37 Edit. 2) It is observed by M. Larrey, that the gun- shot wounds of the extremities, compli- cated with fracture, especially with that of the humerus, received by the soldiers of the French army in Syria, were almost all followed by the formation of acciden- tal joints. The two fragments of the broken bone continued moveable, their asperities and projecting angles having been destroyed by friction, and their ends being rounded and covered with a carti- laginous substance, so as to faciUtate the FRACTURES. 433 motions, which the patients executed in various directions, in an imperfect manner, and without pain. M Larrey acquaints us. sible, it is impossible to m. ud that posi- tion merely by taking such limb up and laying it down again ; from whence it must follow, that such kind of apparatus a« necessitates the surgeon frequently to' disturb the limb, cannot be so good as one that does not; provided the latter will accomplish the same kind of cure as the former: the truth of which position will appear in the most satisfactory man- ner to any, Who will take a view of the method, in which simple fractures ate treated, a* the beforeVnentioned hospi'al. Such application having been made as the surgeon thinks right, the next thing to be done is to put on a proper bandage— That used by the ancients, and by the majority of the present practitioners, is what is commonly called a roller. This is of different length, according to the surgeon's choice, or as it may be used in the form of one, two, or more pieces. Hippocrates used 4hree ; (see Fab. ab Aquapendente, Wiseman, Seniletus, Hilda- nus, Petit, Duverney ;) Celsus six; but the present people seldom use more than one. By such kind of bandage three iuientfens are aimed at, and said to be accomplish- ed, viz. to confine the fracture, to repress or prevent a flux of humours, and to re- gulate the callus, (see Duverney.) but whoever will reflect seriously on this mat- ter, will soon be convinced, thttt although some sort of bandage is necessary in every simple fracture, as well for preserv- ing some degree of steadiness totite limb, as for the retention of i-hc application-;, yet none, nor either of these three ends can be answered merely, or even princi- pally, by bandage of any kind whatever : and therefore, if this should be found to be true, that is, if*it should appear, that whatever kind of delegation be made use of, it cannot be a principal, but only an accessory kind of assistance, and that in a small degree, and veiy little to be de- pended upon, it will follow that such FRACTURES. 439 kind of bandage as is most difficult to be applied with justness and exactitude, such as is soonest relaxed and out of or- der, sucji as stands most frequently in need of renewal, and, in such renewal, is most likely to give pain and trouble, must be more improper and less eligible, than one wliich is more easily applied, less liable to, be out of order, and which can be adjusted without moving the Umb. " The ancient method of applying the roller, in case of simple fracture of the leg or thigh, was to make (see Fab. ab Aqnupendente, and Wiseman,) four or five turns .round the fracture first, and then to continue the bandage upward and downward, until the whole limb was en- veloped properly. This was done in tliis manner with a double view ; to keep the broken ends of the bone in their pi .ce, and to prevent the influx of humour. Mo- dern practitioners, although they have the same ends in view, generally begin their bandage from the inferior extremity of'-he limb, and continue it up to the top. Whether the old or the later method be followed, whether one or more rollers be made use of, the whole is executed while tlie Umb is kept, by iv-ans of the assist- ants, in the same extended posture in which the coaptatiqfi was made, so that the whole bandage is finished before the leg is deposited on the pillow; in the doing all which, if from the tired state of the surgeon, or either of his assistants, or if, from tiie awkwardness, or unhandiness of any of the parties concerned, the true and exact position of the limb be at all deviated from, the ends of the bone will again be in some degree displaced, and the bandage, instead of being of use, wUl become prejudicial, by pressing hard on tlie inequalities ofthe fracture : to which let me add, that the roller, especially when applied to a leg, if it be not put on with due dexterity, that is, if it does not sit perfectly smooth and even, is the most unequal and worst kind of bandage in use. "These objections, however just, are not the least to which the roller in the case of simple fracture of the leg or thigh are liable; lor, as I have already hinted, it must, in a very short space of time, even while the parts surrounding the frac- ture are in the most tender and most pain- ful state, be renew< d, and that more than once; winch renewal c nnot be executed without again taking tiie limb off from the pillow, again committing it to tlie hands of assistants and again running a risk of displacing the fracture : all which, not to mention the repetition of pain to the patient every time such operation is performed, and which must be at least every four or five days, are (as I have al- ready said) very material objections to the roller, even in the most judicious and dexterous hands, and still more so in those of the rude and ignorant. " The prevention of a flux of humOurs to a broken Umb by bandage, is a common phrase: but they who use it have either no idea at all annexed to it, or a very er- roneous one. " If by the points and edges of the bro- ken bone, the muscles and membranes be unavoidably wounded and torn, or if tlie same kind of mischief be incurred by "the inadvertence or indiscretion of the patient, or of those who assisted in getting him home, er from the violence used in ex- tending the limb and setting the fracture, inflammation must be excited, and pain and tumefaction will be the consequence ; and these will continue for some time in every fracture; but that space will be longer or shorter in different cases, and under different circumstances : evacua- tion, rest, and a favourable position of the limb, will, and do in general, remove all these complaints; but bandage can contribute nothing more than by keeping the applications in their proper place ; so far from it, that if the bandage be a roller, it must, by the frequent necessity of its being adjusted, and the frequent motion of the limb, in some degree counteract the proper intention of cure. " The old writers are, in general, very precise as to the number of days during which the roller should be suffered to re- main without being shifted; and the num- ber of times which such shifting should be repeated within the first fortnight.— (See Fab. ad Aquapendente) This exac- titude is by no means necessary: but if the bandage be supposed to be of any use at all, it is obvious, that it ought to be renewed or adjusted as often as it may cease to perform the office for which it is designed, or whenever it shall be found to counteract such office; that is, as often as it shall become so slack as not to con- tain the fructure at all; or whenever the limb shall be so swollen, that the roller makes an improper degree of stricture ; the former genei ally occurs every four or five days; the latter is most frequent with- in the first week. " In most of the w: iters on the subject of fractures, we also find marks or signs laid down for our information concerning the due or undue effect ofthe bandage un the limb. Tiny tell us, that when that part of it which is below the termination uf the roller, does not swell at a\J, that the bandage is not sufficiently strict, and will not retain the fracture; that when 440 FRACTURES. the same part is considerably swollen, or tense, or inflamed, it implies that the binding is too strait; and that a moderate degree of tumefaction is a sign that the deligation is properly executed. (See Fabricius ab Aquapendentc.) " In consequence ot" these precepts, many practitioners look more anx.ously after this degree of tumefaction, than after the true and exact position of the limb ; and cannot be induced to believe, that any thing can be wrong under this appearance ; although, if they would for once assume the liberty of thinking for themselves, they might be convinced, that even this degree of swelling is wrong; that it implies some kind ot obstruction to the circulation, and cannot serve any good purpo-e ; and consequently, tha* as far as it may be supposed to be the eff,-ct of bandage, so far that bandage must be faulty. " The third purpose for which the roller is said to be used, is the regulation and restraint ofthe callus. " If we were to form our notion of cal- lus by what the generality of writers have said on this subject, we should suppose, that it was not only a particular juice al- ways ready for the purpose, but that, if not restrained and regulated by art, it would always flow in such quan'ity, as to create trouble and deformity; that there were specific remedies for increasing or decreasing it; and thai it always required the hand and art.of surgery to manage it. That the callus is so far a particular juice, as that it consists of whatever is destined to circulate through the bones for their particular nourishment, is be- yond all doubt; and that this gelatinous kind of fluid is the medium by which fractures are united, is as true ; but that it requires art to m-inage it, or that art is in general capable of managing and di- recting it, is by no means true. That this callus or uniting medium does often- times create tunyfection and deformity, or even lamenetf,' is true also; but the fault in these cases does not lie in the mere redundance of such juice ; it is de- rived from the nature of the fracture, from the inequality of it when set, and from the unapt position of the broken ends with regard to each other; nor is surgery or the surgeon any otherwise blameable in this case, than as it was or was not originally in their power to have placed them better. It is the inequality ofthe fracture which makes both the real and apparent redundance of callus, and the tumefaction in the place of union. When a bone has been broken transverse- ly, or nearly so, and its inequalities are therefore neither many nor great, when such broken parts have been happily and properly coaptated, und proper methods have been used to keep them constantly and steadily in such state of coaptation, the divided parts unite by the interven- tion of the circulating juice, just as the softer parts do, allowing a-different space of time for different texture and consist- ence. When the union of a broken bone, under such circumstances, has been pro- cured, the place where such union has been made will be very little perceptible, it will be no deformity, nor will it occa- sion any inconvenience. It will, indeed, be discoverable like a cicatrix of a wound in a softer part; but there will be no re- dundance of callus, because none will be waived, neither will there be any neces- sity for any particular management on the part of the surgeon to repress or keep it in order: but when a bone has been br ken very obUquely, or very unequally, when the parts of a fracture are so cir- cumstanced as not to admit of exact co- aptation, when such exact coaptation as the fracture perhaps would have admitted, has not been judiciously made, when from unmanageableness, inadvertence, or spasm, the proper position of the limb has not been attended to or preserved, in all such cases there must .be consider- able inequality of surface; there must be risings on one side, and depressions on another; and in such cases the juices cir- culating through the bone, cannot ac- complish the union in the same quantity, the same time, or in the same manner. The broken parts not being applied ex- actly to eiition? Can moving the limb every two or three days contribute to such inten- tion? must it not, on the contrary, ob- struct and retard it ? Is not perfect quie- tude as necessary toward the union of the bane, in a simple as in a compound frac- ture ? it is true, that in the one there is a wou-ul which requires to be dressed, and tlie motion of the limb may in general be attended with rather more pain than in the other; but does motion in the simple Vojsl, fracture give ease, or procure more expe- ditious union ? " Every benefit then which can be sup- posed to be obtained from the u-e of the common bandage or roller, i^ equally at- tainable from the u*e of that which I have just mentioned, with one additional, and to the patient, most invaluable advantage, viz. that of never finding it necessary to have his leg or thigh once, during the cure, removed from the pillow on which it has been properly deposited. In short, to quit reasoning and speak to fact, it is the constant practice at St. Bartholo- mew's, and attended with all possible success. We always use theeghteen- tailed bandage ; and never move the limb to renew or adjust it. " The parts of the general apparatus for a simple fracture, which come next in order, are the splints. " These are generally made of paste- board, wood, or some resisting kind of stuff, and are ordered to be applied lengthways on the broken limb ; in some cases three, in others four; for the more steady and quiet detention of the frac- ture. " That splints, properly made and ju- diciously applied, are very serviceable, is beyond all douh, but their utility de- pends much on their size, and the manner in wliich they are applied. " The true and proper use of splints, is, to preserve steadiness in the whole limb, without compressing the fracture at all. lly the former they become very as- sistant to the curative intention; by the latter they are very capable of causing pain and other inconveniences; at the s me time that they cannot, in the nature of things, contribute to the steadiness of the limb. " In order to be of any real use at all, splints should, in the case of a broken leg-, reach above the knte, and below the ankle ; should be only two in number/ and should be so guarded with tow, rag, or cotton, that they should press only on the joints, and not at all on the fracture. %. " By this they become really servicea- ble ; but a short splint, which extends only a little above and a little below the fracture, and does not take in the two joints, is an absurdity, and, what is worse, it is a mischievous absurdity. " By pressing on both joints, they keep not only them, but the foot steady; by pressing on the fracture only, they cannot retain it in its place, if the foot be in the smallest degree displaced; but they may, and frequently do, occasion mischief, by rudely pressing the parts covering the 442 FRACTURF.S. fracture against the edges and inequalities of it. " I suppose it will be said, that al- though short splints do not of themselves sustain and keep steady the two joints, and consequently the l.mb, yet that pur- pose in the broken leg may be and is ful- filled by junks, fanons, and other con- trivances : to which I answer, that then tbe short splints are in that case of no use at all, and had better be laid aside; they should be used for no other purpose, but that of keeping the limb steady ; and if they do not answer that end, they are an incumbrance, and multiply the arti- cles in the apparatus for a fractured leg, very unnecessarily. " In the case of a fractured os femoris, if the limb be laid in an extended posture, one splint should certainly reach from tne hip to the outer ankle, and another (some- what shorter) should extend from the groin to the inner ankle. In the case of a broken tibia and fibula, there never cart be occasion for more than two splints, one of which should extend from above the knee to below the ankle on one side, and the other-splint should do the same on the other side. The manner of applying them, if the limb be deposited in a state of flexion, will come under the next ar- ticle. "This, and indeed the most essential article in the treatment of a fracture, is, the position of the limb. Upon the judi- cious or injudicious, the proper or im- proper execution of this, depends the ease ofthe patient during his confinement, and the free use and natural appearance of his limb afterward. " If I meant to describe, or if I approved (pardon the phrase) the common method of placing the broken leg and thigh in a straight manner, this would be the place to mention the many very ingenious con- trivances and pieces of machinery, which practitioners, both ancient and modern, have invented for the purpose of keeping the whole limb straight and steady, that is, of keeping aU the muscles surround- ing the fractured bone constantly upon the stretch, and at the same time, of preventing any inequality in the union of it, and any shoitening of the Umb, in consequence of such inequality. " But as it is. my intention, by these sheets, to inculcate another, and, as it appears to me, a better disposition of the limb, in wluch such boxes, cradles, and pieces of machinery are not wanted, nor can be used, it is needless for me to say any thing about them. " According to this plan, the fractured leg and thigh should be deposited on the pillow, in the very posture in which the extension was made, and the fracture set, that is, with the knee bent. "I have already been so explicit, or perhaps prolix, on the tense and lax state of the muscles, as depending on pos \uv, under the head of extension, that I shall spare the reader, as well as myself, a good deal of trouble by referring b-*ik to that article. All that is there urged, or that can be urged for making the ex en- sion, that is, for s-tting a fracture in such disposition of a limb or its muscles, is equally powerful and conclusive with re- gard to the manner of" depositing and leav.ng it after it has been set. Whatever renders reduction and coaptation easy, must as necessarily maintain e^se during the confinement, preserve rectitude of figure, and prevent displacement. The same principle must act on both occasions; and whether the doctrine be right or wrong, considered by itself, it must be equally so in both circumstances, that is, in the manner of setting a fracture, and in the mainer of depositing tlie limb afterward. In the esse of the fractured os humeri, the only position in which it can with any tolerable convenience to the patient be placed is, with the elbow bent, that very position which necessarily re- laxes and removes all the resistance ofthe surrounding muscles. Daily experience evinces the utility of this, by our very seldom meeting with lameness or de- formity after it, notwithstanding the prevailing apprehension of exuberant cal- lus. " The deformity frequently consequent to the fracture of the bones of the cubit, particularly that of the radius only, will generally, if not always, be found to be in proportion as the muscles concerned in the pronation and supination of the hand happened to be put more or less into a state of action or tension by the position of the limb. " In the thigh, the case is still more obvious, as the muscles are more numer- ous and stronger. " The straight posture puts the major- ity of them into action, by which action that part of the broken bone, which is next to the knee, is pulled upward, and by passing more or less underneath that part which is next to the hip, makes an inequality or rising in the broken part, and produces a shortness of 'he limb. '• In the fracture of both bones of the leg, the case is still the same ; a straight position puts the muscles upon endea- vouring to act; a moderate flexion of the knee relaxes them, and takes off' such propensity. # " The disposition, therefore, ofthe bro- ken cubit ought to be that whicn, by put- FRACTURES. 443 ting the hand into a middle state between pronation and supination, and by bend- ing the fingers moderately, keeps the ra- dius superior to the ulna; or, in other words, ihe palm of the hand should be applied to the breast, the thumb should be superior, the little finger inferior; and the hand should be kept in this posture constantly by means of two splints, which should reach from tiie joint of the elbow on each side, and sho^Jd be extended be- low the fingers; or the same purpose may be still better answered by a simple neat contrivance of the very ingenious Mr. G *och of Norfolk; of which he has given a draught, and which is,preferable to a common splint, by its admitting the fin- gers to be more easily bent. " Extension will be made with more facility, and coaptation more happily ex- ecuted ; a patient will suffer a great deal lest pain during these operations, as well as during the necessary confinement for a broken leg or thigh, and both patient and surgeon will be less likely to be disap- pointed in their intention and wish, that is, the former will be less liable to lame- ness or deformity, when a fractured thigh or leg has been treated in the way I have described, than in the common one. " The resistance necessarily made by the muscles, joined to the great instability of parts in every species to fractured leg or thigh, except in the few where the bones are broken transversely, has con- stantly exercised the invention and inge- nuity of practitioners, in devising means to prevent inequality in the callus as it is called, and shortness and deformity of the limb. Our books abound with draughts and descriptions of machines for this pur- pose; ligatures, pulleys, leaden weights and fracture-boxes, so constructed as to overcome and constantly to resist that ac- tion ofthe muscles surrounding the broken bone, that natural tendency in them to contract, which the extended position of the limb necessarily induces. Every body who has been conversant with matters of this sort knows, that even the best of these various contrivances often prove successless; and every one who will re- flect ever so Uttle, may see why they must be so. That they do prove ineffectual, the number of deformed legs and shorten- ed thighs, which are daily met with, evinces; and that they must frequently prove so, will be obvious to every one, who will consider that the effect can last no longer than the cause is continued, un- less there happens to be some very favour- able circumstance, in the fracture itself What I mean is this; when the reduction of the fracture is set about, the limb is put into such position, that the surrour.d- ing muscles resist the extending force very considerably, and this in proportion to their strength and number: that force is continued and increased till the muscles give way, and tiie resistance being over- come, an opportunity is thereby obtained of placing the ends of the fracture in as apt position with regard to each other as the nature of it will admit. Il" the frac- ture be of the transverse kind, that is, if the ends of* the broken bone be large, and afford a good deal of space for con- tact with each other, such apposition will con'ribute a good deal to the keeping the limb steady, aDd the fricture even; but if the fracture be of the oblique kind, if there be several loose pieces, and conse- quently neither large contact nor stability* from the apposition, or if due extension has not been made, or could not, or if the ends of the bones have not been judici- ously and properly set, the muscles will act as soon as the extension is relaxed, the fracture will be more or less displaced, according to the nature of it, the Umb will be shortened, the time of union will be prolonged, and the place of it (the callus, as it is called,) will be in pro portion more or less unequal. " I take it for granted that it will be asked, have not our ancestors at all times happily redressed fractured legs and thighs, by the method which-they have delivered down to us, and which in the preceding pages I have taken the liberty to object to ? have not such limbs fre- Jniently been rendered as straight, as use- ul, and as little deformed as possible ? I answer, most certainly, ye*.; it is an undoubted truth, and cannot be denied. But in my turn, let me be permitted to ask, whether in the same method, great and even unsurmouniable difficulty is not frequently met with ? whether in many cases the act of setting, as it is called, is not excessively painful at the time, and productive of inflammation and other dis- agreeable s\mptoms afterward ? and, whe- ther, in sp'ilfe of all care, of every con- trivancc, of every species of machinery which has yet been used, broken thighs and legs are not often, very often, left de- formed, crooked, and shortened, and that merely from the action of the muscles, and tbe obbquity or shattered state ofthe fracture ? The fact is notorious, and the sole question is, whether or no a different disposition of the parts> preventing such action and such resistance, will in many instances prevent these evils ? To wliich, from repeated experience, I answer yes. , h* this should be found to be the case in general, of which I make no doubt that it is; if by this metiiod, many of such unfortunate cases, as in the common me- 444 FRACTURES. thod of treatment disappoint both patient and surgeon, should be found in general to succeed so well as to satisfy both, it Will prove all I wish it should prove. Su- perior utility and more frequent success are all I contend for. " Many people did very well under am- putation before the double incision was practised; but is the double incision there- fore no improvement ? The operation for the bubonocele may be performed with that clumsy instrument tin* probe scissars, but is the bistoury therefore nol prefer- able ? A surgeon may cut oft some ounces, or even pounds of flesh from a patient's backside, in order to cure a sinus, but is the cure, by the simple d vision of that sinus therefore not easier or more expedi- tious ? Neitiier of these can, I think, be proved, unless it can at the same time be proved, that pain is no evil, confine- ment not at all irksome, and that defor- mity and elegance of figure are sy nony- mous terms. " Let not the reader fancy that I would dare to amuse him with speculation, or merely specious reasoning on a subject like this.7* What I have said is from ex- perience, repeated exp-rrience, both of" myself and of others, for a considerable length of time past, and on a great vane- ty of >ubjecis ; from an experience which has perfectly satisfied me, and I think will every m;m who will make the (rial fairly and candidly. I do not pretend to say, that by these means every kind of bro- ken bone will infallibly arid certainly be brought to lie smooth, even, and of pro- per length ; if I did, they, who are versed in these things, would know that I said too much : but I will say, (what is suffi- cient for my purpose) that it will not only succeed in all those, in which the old me- thod can ever be successful ; but also in the majority of those in which it is not, nor in the nature of things can. In those fortunate cases, in which either method will do, the old one is fatiguing, inc nvenient, and even sometimes offen- sive, from the sup.ne and confined pos- ture of the patient; whereas that which is here proposed, gives the patient much greater liberty of motion for every pur- pose either of choice or necessity; and in many of those cas.-s, wherein the old method proves most frequently so far suc- cessless, as to leave the limb short, lame, or deformed ; I say, in most of these, the proposed method will not be attended with these inconveniences. " I have already- shkI, that in most cases of broken thigh or leg, tlie method just described will be a*tended with k;reat success ; but tiiere is one particular case in which its utility is still more conspi- cuous ; a case which, according to the general manner of treating it, gives info nite pain and trouble both to the patient and surgeon, and very frequently ends in the lameness and disappointment ot tiie former, and the disgrace and concern of the latter: I mean the fracture ofthe fibula attended with a dislocation ofthe tibia. " Whoever will take a view of the leg of a skeleton, will^ee that although the fibula be a very small and slender bone, and very inconsiderable in strength, when compared with* the tibia, yet the sup. port of the lower joint of that limb (the ankle) depends so much on this slender bone, that without it the body- would not be upheld, nor locomotion per- formed, without hazard of dislocation every moment. The. lower extremity of tins bone, which descends considerably below that end of the tibia, is by sirong and inelastic ligaments firmly connected with the last named bone, and with the astragalus, or that bone of thetaisus winch is principally concerned in forming the joint of ihe ankle. This lower extremity of the fibula has, in its posterior part, a superficial sulcus for the lodgment and passage ofthe iendon> of theperonei mus- cles, winch are here tied down by strong ligamentous capsule, and have then- ac- tion so -determined from this point or angle, that the smallest degree of varia- tion from it, in consequence of external force, must necessarily have considerable effect on the motions they are designed to execute, and consequently distort the foot. Let i^ also be considered, that upon the due and natural state of the joint of the ankle, that is, upon the exact and proper disposition of the tibia and fibula, both with regard to each other and to the as- tragalus, depend the just disposition and proper act.on of" several other muscles of the foot and toes ; such as the gastroc- nemii, the tibialis unticus, and posticus, the flexor pollicis longlis, and the flexor digitorum pedis longus, as must appear demonstrably to any man who will first dissect, and Chen attentively consider these parts. " If the tibia and fihula be both broken, they are both generally displaced in such manner, that the inferior extremity, or that connected with the fbot, -is drawn under that part of the fractured bone which is connected with the knee; mak- ing by tins mr-*ns a deformed, unequal tumefoction in the fractured part, and rendering the broken limb shorter than it ought to be, or thin ,ts fellow. And thi- is generally the case, let the frac;ure*e in what part ot tiie leg *t may. " It the tibia only be broken, and no FRACTURES. 445 act of violence, indiscretion, or inadvert- ence be committed, eitlu-r on the part of the patient or of those who conduci him, •the limb most commonly preserves its figure and length ; the same thing gene- rally happens if the fibula only be broken, in any part of it between its upper extre- mity, and within two or three inches of its lower one. " Two kinds of fractures there are, and only two that I can recoiled (relative to the limbs) wliich do not admit of thebent position of the joints, I mean that of the processus olecranon at the elbow, and that of the patella , hi these a straight posi- tion of the arm atid leg is nece.--.sary ; in the former to keep the fractured parts in contact till they are united; in the latter, to bring them as near to each other as may best serve the purpose of walking afterward.* " With regard to the fracture of tlie patella, an opinion has long and generally prevailed, which seems to me to have no "foundation in truth, or (when duly consi- dered) even in probability; it is, that the great degree of stiffness in the joint ofthe knee, which is sometimes found to be the consequence of this kind of fracture, is * " Although a straight position of the Umb is necessary for the broken patella, yet this very position becomes so upon the same principle, as renders the bent pos- ture most advantageous in the broken tibia and femur, viz. the relaxation of the mus- cles and tendons attached to the fractured bone. " Whoever will for a moment attend to- the disposition of the pieces in a patella, which has been broken transversely, will see how little necessary or useful the many contrivances of bandages, straps, compresses, buckles, buttons, &c. to be found in writers are, especially all that part of them which are applied to the in- ferioriiagment. " By the action of the united tendons of the extensores muscles of the leg, the superior fragment is pulled upward and separated from the inferior, but the latter remains nearly, if not absolutely, where il was before the accident; there is noth- ing to act upon it, and therefore it cannot, nor does i •> move. " The extension of the leg puts the muscles attached to the upper part of the broken bone into a state of relaxation, and prevents their acting ; and though a small compress just above this piece, with a moderate bandage, may be useful to- ''ward retaining it, yet it is the position of • the leg, which must keep the broken piece down, and effect the cure." (Pott.) owing to, or produced by, a quantity of callus falling into it from the edges of the broken bone: and that the nearer the broken pieces are brought to each other, the more l.kely such consequence is " Every part of ths doctrine seems equally absurd. In the first place, the fractured bone is by no means capable of supply ing such a quantity of callus as to produce this end, unless il may be sup- posed to run from ii as solder from a plumber's ladle; in the sec-md pl-ce, if this was the case, the most likely, and in- deed tlie only probable way ot preventing the deposition of such juice, must be by bringing ihe broken pieces into close con- tact ; and in the third piace, there is no authority from the appearance of such joints afier death, (at least as far as my experience goes) to suppose this to be the case, or to countenance such opinion. The cause therefore of this rigidity, which is now and then found to attend the broken patella, must be sought for else- where, viz. in the long rest and confine- ment ofthe joint as a means used by miny to procure exact union ; in mischief done to the ligament, which is foijpied by the united tendons of the four ex'.ensor mus- cles of the leg, at the time of and by the fracture; and in the nature of the frac- ture itself, that is, the manner in which the bone sliall happen to be broken. " But, be all this as it may, the fact undoubtedly is, that they walk best after such accident, whose patella has been broken transversely, and that into two nearly equal fragments; whose confine- ment to tiie bed has been short, that is, no longer than while the inflammation lasted; whose knee, after such period, has been daily and moderately moved; and in whom the broken pieces are not brought into exact contact, but lie at some small distance from each other. " I cannot take leave of tliis subject of simple fractures, without mentioning a circumstance relative to them, wliich al- though, when rightly understood, is of little or no importance, yet by being mis- understood, becomes fi equently of con- siderable consequence. " I mean, the use of the term, rising end of a broken bone. "By tlie expression, any one unac- quainted with these things would be in- clined to think, that the prominent part ofa broken bone rose, or was elevaed from its natural place; and became, by such rising, superior to the otiier part or extremity of the'fracture. This would certainly be the idea of an ignorant per- son, and as such would be of Uttle conse- quence ; but by the practice of many, who call themselves surgeons, it is as certainly 446 FRACTURES. their idea also, and this renders it a mat- ter of great consequence. Many instances are producible, in which our conduct is iu great measure regulated by the Ian- guage which we use. Having no ideas annexed to our words, ie.ds us into ab- surdity and unintelligibilily; but false ones influence us still more, and frequent- ly produce very material errors. "The fistula lachrymalis, the fistula in pennxo, and that in ano, are glaring proofs of this; and my present subject is full as much so: for upon the erroneous idea annexed to the term rising end, stands all the absurd practice of compress, bol- ster, and strict bandage, in the cases of simple fracture. " The truth is, that there is really no riling end to a broken bone; I mean, when applied, as the term usually is, to the leg, thigh, and clavicle. Tiiere is indeed a superior or promineht end or part, and an inferior or depressed one, but the former of these is in its proper place, from which it cannot by art be moved; arid the latter, wiicli is not in ite proper place, is very capable by art of being put into it. " 1'erhaps this may to some appear a mere play of words, a nominal distinction, without a real difference; but when the influence, which a right, or wrong idea of this produces on pracuce, is attended to, the consequence will be obvious and se- rious. " When a collar-bone, os femoris, or tibia and fibula are broken, by the ac- tion ofthe muscles, by tlie motions ot the patient, and by the mere weight of the in- ferior part of the arm, thigh, or leg, the fractured ends of such bones are displac- ed, and always displaced in such manner, that the inequality occasioned necessarily by such displacement, proceeds from the inferior end of the fractured bone being retracted or drawn under the superior; this produces a tumefaction or unequal rising, and ihe uppers extremity of the fracture is therefore called the rising end of it. Now the man who regards tins rising end as that part of the fracture which has by such rising got out ot is place, and not as having accidentally be- come the prominent part merely by the insinuation or retraction of the otiier part underneath it, will go to work with bol- ster, compress, and bandage, in ord«r to bring and keep such end down ; by which means he will give his patient considerable pain, and while he depends on such means alone, will most certainly be frustrated in his intention and expectation, the means not being adequate to the proposed end. But the man who looks on this in the true light, that is, who looks on tlie su- perior part in its proper place, and the interior as being displaced by the weight of the limb, and tiie action ot the muscles, will know, that by the mere position of such limb, he shall be able io lemeuy all the inconvenience and deformity, as far as tliey are by art capably of remedy, without ihe p.*rade or the fatigue ot use- less apparatus. "He will, for example, know that the prominent part of a broken clavicle, that part of it which is next to the sternum, is just where it should be ; and that the inferior part, that winch is connected with the scapula, is out > of its place, by being drawn down by the weight of tlie arm; and therefore instead of loading, as is usual, the prominent part with qu.mtit.es of compress, which never can do any service, he, by a proper eleva- tion of the arm, will bring the lower end upward into contact with the other; and thereby, with very little trouble, easily accomplish what he never can do in any other manner, however operose. " The same thing will happen from the same principles in the leg and thigh; a prominence, or a rising end, there always will be, but that ri.sing end is never to be brought down by any pressure from com- press or bandage; the fallen or inferior one must always be brought up to it by the proper position ofthe rest ot the limb : this will always remove the inequality as far as it is removable, and nothing else can."* • " In a profest regular treatise on this subject, it would be right to take notice of what may be called the infortunia, or accidental evils, which sometimes accom- pany even simple fractures ; such are, dis- ease arising from injury done to the me. dullary membrane, within the bones, in bad habits: hemorrhage, or a species of spurious aneurism, from a wound of the interosseal artery, between the tibii and fibula, or of either of the carpal arteries: mischief from the fracture becoming acci- dentally the seat of the crisis of a fever : deficiency of callus, or the accident of the broken bone not uniting: the fractured limb becoming the seat of an erysipelas^ terminating in a slough of the common membrane and periosteum: \he gelati- nous juice or callus, which should unite the fracture, being in so morbid a state, as to produce a kind of caries with exos- tosis, instead of its doing its proper duty, ike. Of all these there are examples, but they do not come within the plan which I presci ibed to myself when 1 begun tiiese papers." (Pott) FRVCTURES. 447 coMPorsn FRACTmrs. " I use the term compound fracture, (says Mr. Pott) in the sen-e in which the Engl.sh have always used i-.; that is, to imply a broken bone complicated with a wound. " In this kud of c- se the first object of consideratmn is, whether the presei-va- tion ofthe fractured limb can, with safety to the patient's life, be attempted; or, in other words, whether the probable chance of destruction, from the nature and cir- cumstances ofthe accident, is not greater than it would be from the operation of amputati'in. Many things may occur to make this the case. The bone, or bones, being broken into many different pieces, and that for a considerable extent, as happens from broad wheels, or other he.vy bodies of large surface, passing oyer," or falting on such limbs ; the skin, muscles, tendons, &c. being so torn, lace- rated, and destroyed, as to render gan- grene and mortification the most proba- ft'e and most immediate consequence; the extremities of the bones forming a joint being crushed, or as it were comminuted, and the ligaments connecting such bones being torn and spoiled, are, among others, sufficient reasons for proposing and for performing immediate amputation. Rea- sons, whch (notwithstanding any thing that may have been said to the contrary) long and reiterated experience has approv- ed. and which are incapable upon every principle of humanity, or chirurgie know- ledge. • " When a surgeon sap, that a limb, which has just suffered a particular kind of compound fracture, ought rather to be immediately cut off*, than that any attempt should be made for its preservation, he does not mean by so saying that it is ab- solutely impossible for such limb to be pre- served at all events; he is not to be sup- posed to-mean so much in general, though sometimes even that will be obvious; all that he can truly and justly mean is-^hat from the experience of time it hasWeen found, that the attempts to preserve limbs so circumstanced, have most frequently been frustrated by the death of the pa- tients, in consequence of such injury; and that from the same experience it has been found, that the chimce of death from amputation is by no means equal to that arising from such kind of frac- ture. "Every man knows, that apparently desperate cases are sometimes cured,- and that limbs so shattered and wounded, as t render amputation the only probable eans for the preservation ot life, are now and then saved. This is an uncontro- verted fact, but a fact which proves very little against the common opinion; be- cause every man of experience ulso knows, that such escapes are very rare, much too rare to admit of being made precedents, and that the majority of such attempts fail. " This consideration relative to ampu- tation is of the more importance, because it most frequently requires immediate de- termination ; every minute of delay is, in many instances, to the patient's disad- vantage ; and a very short space of time indeed, frequently makes all the differ- ence between probable safety and fataUty. If these cases in general would admit of deliberation for two or three d:ys, and during that time such circumstances might be expected to arise, as ought ne- cessarily to determine the surgeon in his conduct, without adding to the patient's hazard, the difference would be consider- able; the former would not seem to be so precipitate in his determination, as he "is frequently thought to be; and the lat- ' ter, being more convinced of the necessity, would submit to it with less reluctance. But unhappily for both parties, this is seldom the case; and the first opportu- nity having been neglected or not em- braced, we are frequently denied another. Here therefore the whole exertion of a man's judgment is required, that he may neither rashly and unnecessarily deprive his patient of a limb, nor through a false tenderness and timidity, suffer him to perish, by endeavouring to preserve such limb. Siime degree of address is also necessary upon such occasion, in order to convince the patient, that what seems to be detei-mined upon hastily and with pre- cipitation, will not safely admit of longer deliberation. "The limb being thought capable of preservation, tiie next consideration is the reduction of the fracture. The ease or difliculty attending this, depends not only on the general nature of the case, but on the particular disposition ofthe bone with regard to the wound. " If the bone be not protruded forth, the trouble of reducing, and of placing the fracture in a good position, will be much less than if the case be otherwise; and in the case of protrusion or thrusting forth of the bone or bones, the difficulty is always in proportion to the comparative size of the wound, through which such bone has passed. In a compound fracture ofthe leg or thigh, it is always the upper part of the broken bone which is thrust forth. If the fracture be of the transverse kind, and the wound large, a moderate decree of extension wiU in general easily reduce it; but if the fracture be oblique, 448 FRACTURES. and terminates, as it often does, in a long sharp point, tins point very often makes its way through a wound no larger than just to permit such ex'ension. In this case, the very placing the leg in a straight position, in order to make extension, obliges the wound or orifice to gird the bone tight, and makes all that part of Jit, which is out of such wound, press hard on the skin of the leg underneath it. In these circumstances, all attempts for re- duction in this manner will be found to be impracticable ,- the more tiie leg is stretched out, the tighter the bone will be begirt by the wound, and the more it will press on the skin underneath. " Upon this occasion, it is not very unusual to have recourse to the saw, and by that means to remove a portion of the protruded bone. "1 will not say that this is always or absolutely unnecessary or wrong, but it most certainly is frequently so. In some few instances, and in the case of extreme sharp-pointedness ofthe extremity of the bone, it may be, and undoubtedly is right; but, in many instances, it is totally unne- cessaty. " Tlie two most proper means of over- coming this difficulty are, change of pos- ture of the limb, and enlargement of the wound. In many cases the former of these, under proper conduct, will be found fully sufficient; and where it fails, the latter should always be made use of. Whoever will attend to the effect, which putting ihe leg or thigh (having a com- pound fracture and protruded bone) into a straight position always produces ; that is, to the manner in which tiie wound in such position girds the bone, and to the increased difficulty of reduction thereby induced, and will then, by changing the posture of such limb from an extended one, to one moderately bent, observe the alteration thereby made, in both the just- mentioned circumstances, will be satisfied of the truth of what 1 have said, and of the much greater degree of ease and prac- ticability of reduction in the bent, than in the extended position; that is, in the relaxed, than in the stretched state ofthe muscles. Reduction being found imprac- ticable, either by extension or change of posture, the obvious and necessary re- medy for this difficulty is enlargement of the wound. This to some practitioners, who have not seen much of this business, appears a disagreeable circumstance, and therefore they endeavour to avoid it; but their apprehensions are in general ground- less and ill-founded ; in enlarging the wound there is neither difficulty nor dan- ger, it is the skin only which can require division, and in making such wound there can be no pos ible hazard. It is needless to say that the divi ion should be such as to render reduction easy ; or to remind the practitioner, that such enlarged open- ing may serve very good future purposes, bv making way for the extraction ot frag- ments, and the discharge of matter, sloughs, &c. ■* " If the bone be brokertinto several pieces, and any of them be either totally separated, so as to lie loose in the wound, or if they be so loosened and detached, as to render their union highly improbable, all such pieces ought to be taken away ; but they should be removed with all pos- sible gentleness, without pain, violence, or laceration, without the risk of hemor- rhage, and with as little poking into the wound as possible. If the extremities of the bone be broken into sharp points, which points wound and irritate the sur- rounding parts, they must be removed also. But the whole of this part of the treatment ofa compound fracture should be executed with great caution; and the practitioner should remember, that it the parts surrounding the fracture be violat- ed, that is, be torn, irritated, and so dis- turbed as to excite great pain, high in- flammation, &c. it is- exactly the same thing to the patient, and to the event of the case, whether such violence be the ne- cessary consequence of the fracture, or of his unnecessary, and awkward manner of poking into, and disturbing the wound, The great objects of fear and apprehen- sion in a compound fracture, (that is, in the first or early state of it) are, pain, ir- ritation, and inflammation; these are to be avoided, prevented, and appeased by all possible means, let every thing else be as it may; and although certain things are always recited, as necessary to be done, such as removal of fragments of bone, of foreign bodies, ike. &c. &c. yet it is always to be understood, that such acts may be performed without prejudicial or great violence, and without adding at aU to the risk or hazard necessarily incurred by 1^ disease. " Reduction of, or setting a compound fracture is the same as in the simple; that is, the intention in both is the same, viz. by means of a proper degree of extension to obtain as apt a position of the ends of the fracture with regard lo each other, as the nature of the case will admit, and thereby to produce as perfect and as speedy union as possible. *' To repeat in this place what has already been said under the head of Ex- tension would be tedious and unnecessary. If the arguments there used for making extension, with the limb so moderately bent as to rekj the muscles, and take oft FRACTURES. 44*9 their power of resistance, have any force at all, they must have much more when applied to the pres.-nt case : if it be al- lowed to be found veiy painful to extend, or to put or keep on the stretch, muscles which are not at all or but sligh'ly wounded, and only liable in such exten- sion to be pricked and irritated, it is self- evident that it must be much more so when the same parts are torn and wound- ed considerably : when the ends of tiie fractured bone have made their way quite through them, divided the skin, and laid all open to the access of the air. " Every consequence, which does, or may be supposed to flow from wound, pain, or irritation, in consequence of violence, must necessarily be much greater, when a lacerated wound, and that made by the bone, is added to the fracture; not to mention the ills arising from extending or stretching out muscles already torn or half divided. " One moment's reflection must be suf- ficient to convince any reasonable man: but experience is tbe only proper test of all these kinds of things. Let this me- thod of treatment, then, be fairly and properly subjected to it; and if the great advantage of the one over the other does not appear, that is, if the less sensation of pain by the patient, and the more happy, more perfect, and more expeditious ac- complishment of his purpose by the surgeon, do not determine greatly in fa- vour of relaxed position, I am, and have for a considerable length of time, been greatly mistaken. " The wound dilated, (if necessary) loose pieces removed, (if there were any) and the fracture reduced, and placed in the best possible position, the rext thing to be done is to apply a dressing. " On this subject a great deal has been said by writers, particularly by such of them as have implicit faith in external applications ; but, in order to be able to execute this part of the process properly, a man has only to ask himself, What are the intentions which, by any kind of dressing to a compound fracture, £ he means to aim at the accomplishment of? And a rational answer to this will give him all that he can want to know. " The dressing necessary in a com- pound fracture is of two kinds, viz. that for the wound, and that for the limb. By the former, we mean to maintain a proper opening for the easy and free- discharge of gleet, sloughs, matter, ex- traneous bodies, or fragments of bone, and this in such manner, and by such means, as shall give the least possible pain or fatigue, shall neither irritate by ite qualities, nor oppress by its quantity, Vol. X. nor by any means contribute to the de. tention or lodgment of what ought to be discharged. By the latter, our -tim should be the prevention or removal of inflam- mation, in order, if the habit be good, anci all other circumstances fortunate, that the wound may be healed, by what the surgeons call tiie first intention, that is, without suppuration or abscess; or, that not being practicable, that gangrene and mortification, or even very large suppuration may be prevented, and such a moderate and kindly degree of it esta- blished as may be>t serve the purpose of a cure. The first therefore, or the dress* ing for the wound, Can consist of nothing better, or indeed so good, as soft dry lint, laid on so lightly as just to absorb the sanies, but neither to distend the wound, or be the smallest impediment or obsiruc- tion to the discharge of matter. This lint should be kept clear of the edges, and the whole of it should be covered with a pledget spread with a soft easy digestive. The times of dressing must be determined by the nature of the case ; if the discharge be small or moderate, once in twenty-tour hours will be sufficient; but if it be large, more frequent dressing will be necessary, as well to prevent of- fence, as to remedy the inconveniences arising from a great discharge of an irri- tating sharp sanies- "The method of treating the limb, with a view to, the prevention of such ac- cidents and symptoms, as pain, inflim- mation, and laceration of parts, are likely to produce, is different with dift ferent practitioners ; some using from the very first, relaxing, greasy applica-. tions*; others applying medicines of very different nature. Both these may be right conditionally, that s, according to different circumstances in the case, but they cannot be equally so in the same cir- cumstances, " Many practitioners are accustomed to envelope compound fractures in a soft, warm, relaxing cataplasm from the very first: whether the limb be in a tense swollen state, or not. This, if I may take the liberty of saying so, appears to me to be injudicious, When from ne* gleet, from length of time passed without assistance, from misconduct or drunken- ness in tiie patient, from awkwardnes^ and unhandiness in the assistants, or from any other cause, a tension has taken possession of the limb, and it is become tumid, swollen and painful, a warm ca. taplasm is certainly the best and most proper application that can be made, and that for very obvious reasons the state of the parts under these clrcum-i stances is such, that immediate union is. 2M 4*50 FRACTURES. impossible, and nothing but a free and plentiful suppuration can dissipate or re- move impending mischief; every thing therefore which can tend toward relaxing the tense, swollen, and irritable state of the parts concerned, must necessarily be right; the one thing aimed at, (plentiful suppuration) cannot be accomplished without it. But when the parts are not in this state, the intention seems to be very different. To relax swollen parts, and lo appease pain and irritation by such relaxation, is one thing; to prevent in- flammatory defluxion and tumefaction, is certainly another ; and they ought to be aimed at by very different means. In the former, a large suppuration is a necessary circumstance of relief, and the great means of cure; in the latter it is not, and a very moderate degree of it is all that is requir- ed. The warm cataplasm therefore, al- though it be the best application that can be made use of in the one case, is certainly not so proper in the other, as applications of a more discutient kind, such as mixtures of spirit, vini, vinegar and water, with crude sal ammoniac, spirit, mindereri, acet. litharg. and medicines of this class, in whatever form the surgeon may choose. By these, in good habits, in fortunately circumstanced cases, and with the assist- ance of what should never be neglected, (I mean phlebotomy,* and the general an- tiphlogistic regimen,) inflammation may sometimes be kept off, and a cure accom- plished, without large collections or dis- charges of matter, or that considerable degree of suppuration, which, though ne- cessary in some cases, and almost un- avoidable in others, are and must be ra- ther promoted and encouraged, than re- tarded, or prevented, by warm relaxing applications of the poultice kind. "Compound fractures in general re- quire to be dressed every day; and the wounded parts not admitting the smallest degree of motion without great pain, per- fect quietude becomes as necessary as frequent dressing. " The common bandage therefore (the roller) has always in this case been laid aside, and what is called the eighteen- tailed bandage substituted, very judi- ciously, in its place. Of this I have al- ready spoken so largely, as to make repe- tition unnecessary. " Splints, that is, such short ones, as are most commonly made use of in simple fractures, are by all forbid in the com- pound, and that for the same reason which • Bleeding is now not frequently prac- tised, except on very plethoric persons, and out of large cities. ought to have prevented them from hav- ing ever been u.-.cd in tin former, viz. be- cause the probable good to be derived from them can be but little; and the pro- bable mischief is obvious and considera- ble. " But although short splints are for many reasons palpably improper, in both cases, yet those of proper length, those which reach from joint to joint, compre- hend them both, and are applied on each side of the leg only, are very useful both in the simple and in the compound frac- ture, as they may, thus applied, be made to keep the limb more constantly steJdy and quiet, than it can be kept without them. " With regard to position of the limb, I have already been so explicit, when speaking of the simple fracture, that to say any thing more about it here would be an abuse of the reader's time and pa- tience. The only, or the material differ- ence between a simple and a compound fracture, as far as relates to tnis part of the treatment is, that as the parts sur- rounding the broken bone in the latter are more injured, and consequently more Uable to irritation, pain, inflammation, and all their consequences, therefore every method and means, by which the allevia- tion of such symptoms, and the preven- tion of such consequences can be obtain- ed, is still more necessary and requisite, Among these, the posture of the limb is so principal a circumstance, that without its concurrence every other will be fruitless. The points to be aimed at are, the even position of the broken parts of the bone, and such disposition of the muscles sur- rounding them, as is most suitable to their wounded, lacerated state, as shaU be least likeiy to irritate them, by keeping them on the stretch, or to produce high inflammation, and at best large suppura- tion. These, I say, are the ends to be pursued ; and how much the position of the limb does, and must necessarily con- tribute to the advantage, or disadvantage just recited, must be so obvious to any body capable of reflection, that nothing more need be said about it. " At the beginning of these sheets, I have said, that it was not my intention to write a regular treatise, but only to-throw out a few hints which I hoped might prove useful to such as have not yet received better information. The part of my sub- ject at which I am now arrived, does not indeed admit of much more .- a few gene- ral precepts are all which a writer can give; the particular method of conduct- ing each particular case must be deter- nunedhy the nature of that case, and by the judgment of the surgeon. FRACTURES. 4di " Every body knows, or ought to know, that these cases, of all others, require at first the most rigid observance of the anti- phlogistic regimen ; that pain is to be ap- peased, and rest obtained, by anodynes ; that inflammation is to be prevented or re- moved, by free and frequent bleeding, by keeping the body open, and by the admi- nistration of such medicines as are best known to serve such purposes. And that, during this first state or stage, the treat- ment of the limb must be calculated, either for the prevention of inflammatory tumefaction, by such applications as are in general known by the title of discu- tients; or, such tumour and tension hav- ing already taken possession of the Umb, that warm fomentation, and relaxing and emollient medicines are required. "If these, according to the particular exigence of tiie case, prove successful, the consequence is, eithera quiet easy wound, which suppurates very moderately, and gives Uttle or no trouble; or a wound, attended at first with considerable in- flammation, and that producing large suppuration, with great discharge, and troublesome formation and lodgment of matter. If, on the other hand, our at- tempts do not succeed, the consequence b gangrene and mortification. " These are the three general events or terminations of a compound fracture, and according to these must the surgeon's conduct be regulated. " In the first instance, he has indeed nothing to do but to avoid doing mischief, either by his manner of dressing, or by disturbing the limb. Nature let alone, will accomplish her own purpose ; and art has little more to do than to preserve the due position of the fimb, and to take care, that the dressing applied to the wound proves no impediment. " In the second stage, that of forma- tion and lodgment of matter, in conse- quence of large suppuration, all a sur- geon's judgment will sometimes be re- quired in the treatment both of the patient and his injured limb. Enlargement of the present wound, for the more conve- nient discharge of matter ;* new or • " It is a practice with some, from a timidity in using a knife, to make use of bolsters and plaster compresses for the discharge of lodging matter Where ano- ther, or a counter-opening can conve- niently and safely be made, it is always preferable, the compress sometimes acting diametrically opposite to the intention with which it is applied, and contributing to the lodgment by confining the matter ; vbeside which, it requires a greater degree counter-openings for the same purpose, or for the extraction of fragments of broken or exfoliated bone, will very fre- quently be found necessary, and must be executed. In the doing this, care must be taken, that what is requisite be done, and no more; and that such requisite operations be performed with as little dis- turbance and pain as possible; the man - ner of doing business of this kind, will make a very material difference in the sufferings of the patient. " Veiy contrary, or at least very dif- ferent intentions, seem to me to require the surgeon's very particular attention in the two parts of this stage of the dis- ease. " Previous to large suppuration, or considerable collections and lodgments of matter, tumefaction, induration, and high inflammation, attended with pain, irrita- tion, and fever, require evacuation by phlebotomy, an open belly, and antiphlo- gistic remedies, as well as the free use of anodynes, and such applications to the Umb as may most serve the purpose of re- laxation. But the matter having been formed and let out, and the pain, fever, &c. which were symptomatic thereof, hav- ing disappeared, or ceased, the use and purpose of such medicines and such ap- plications cease also, and they ought there-v fore to be discontinued. By evacuation, &e. the patient's strength has necessarily (and indeed properly) been reduced ; by cata- plasm, &c. the parts have been so relaxed as to procure an abatement or cessation of inflammation, a subsidence of tume- faction, and the establishment of a free suppuration; but these ends once fairly and fully answered, another intention arises, which regards the safety and well- doing ofthe patient, nearly, if not fuU as mur-h as the former; which intention will be necessarily frustrated by pursuing the method hitherto followed. The pa- tient now will require refection and sup- port, as much as he before stood in need of reduction ; and the limb, whose indu- rated and inflamed state hitherto required the emollient and relaxing poultice, will now be hurt by such kind of application, and stand in need of such as are endued with contrary qualities, or at least, such as shall not continue to relax. Good Ught, easily digested nutriment, and the Peruvian bark, will best answer the pur- pose of internals ; the discontinuation of the cataplasms, and the application of me- dicines of the corroborating kind, are as of pressure to make it efficacious, than a limb in such circumstances generally can bear" 452 FRACTURES. necessary With regard to externals.* " In short, if there be any rationale in Uie use of the cataplasm in the first stage, its impropriety in the second, must be evi- dent from the same principles. So also With regard to evacuation and the anti- phlogistic regimen, when all the good pro- posed to be obtained by them has been received, a pursuit of the same method must become injurious, and that for the same reason why it was before necessary and benefichl. " A non-attention to this has, I believe, been not infrequently the cause ofthe loss both of limbs and lives. " Every body who is acquainted with BUr-gery knoWs, that in the case of bad compound fracture, attended with large Suppuration, It sometimes happens, even Under the best and most judicious treat- ment, that thedischarge becomes too great for the patient to sustain ; and that, after all the fatigue, pain, and discipline, which he has Undergone, it becomes necessary to compound for life by the loss ofthe limb, j This, I say, doe$ sometimes happen under the best and m*>st rational treatment; but I am convinced that it also is now and then the consequence of pursuing the re- ducing, the antiphlogistic, and, the relax- ing plan too far. I would therefore take the liberty seriously to advise the young practitioner, to attend diligently to his patient's pulse and general state, as well as to that of his fractured limb and WoUnd; and when he finds all febrile Complaint at an end, and all inflamma- tory tumour and hardness gone, and his patient is rather languid than feverish, * " It i« surprising how large and how disagreeable a discharge will be made for a considerable length of time, in some instances, from the detention and irrita- tion of a splinter of bone. If therefore such discharge be made, and there be neither sinus nor lodgment to account for it, and aU other circumstances are favour- able, examination should always be made, in order to know whether such cause does not exist, and if it does, it must be gently and carefully removed" \ " There is one circumstance relative to compound fractures, which perhaps may be deemed worth noticing; which is, that I do not remember ever to have seen it necessary to amputat e a limb for a com- pound fracture, on account of the too great discharge, in which the fracture had been United In all those cases, where the ope- ration has been found necessary on ac- count of the drain, the fracture has al- ways been perfectly loose and disunited." {Poll) that his pulse is rather weak and low than hard and full, that his appetite begins to fail, and that he is inclined to sweat, or purge, without assignable cause, and this in consequence of a large discharge of matter from a limb which has suffered great inflammation, but wliich is now be- come rather soft and flabby, than hard and tumid ; that he will in such circum- stances set about the support of his pa- tient, and the strengthening of the dis- eased limb totis virion*; in which I am from experience satisfied, he may often be successful, where it may not be gene- rally expected that he would. At least, . he will have the satisfaction of having made a rational attempt; and if he is obliged at last to have recourse to ampu- tation, he will perform it, and his patient will submit to it, with less reluctance, than if no such trial had been made. " I have said, that a compound fracture either unites and heals, ns it were, by the first intention, which is the case of some ofthe lucky few, (and was my own;*) or it is attended with high inflammation, multiplied abscesses, and large suppura- tion, demanding all a surgeon s attention and skill, and even then sometimes end- ing in the loss of limb, or life, or both; or, that all our attempts prove fruitless from the first, and gangrene and mortifi- cation are the inevitable consequence of tlie accident. " The two first I have already spoken to, the last only remains. " Gangrene and mortification are some- times per one, which remains stationary. What power, except the muscles, can commu- nicate io the lower portion of the fractured bone, a motion from below upwards ? At one end, attached lo the pelvis; and, at the other, to this part of the bone, the patella, the tibia, and fibula, thev make the former insertion their fixed point, and drawing upward the leg, the knee, and the lower portion of the thigh, they cause directly, or indirectly, the derange- ment in question. In producing this effect, tiie triceps, semitendinosus, semi- membranosus, rectus, gracilis, sartorius, &c. are the chief agents. To show the power of the muscles to displace the ends of such fractures, men- tion is made, in Desault's works by Bichat, of a Carpenter, who fell from a scaffold, and broke Iris thigh. The limb, the next day, was as long as the other; but, tlie man had a complete palsy of his lower extremities, and could not dis- charge his urine. Tiie moxa was applied, and the muscles soon regained their power, and then the shortening of the limb began to make its appearance. Besides the action of muscles, there is another cause producing a derangement ofthe fracture, in the course of the treat- ment. How firm soever the bed may be on which tbe patient is laid, the buttocks, more prominent than the rest ofthe body, soon form a depression in the bedding, and thence follows an inclination in the plane on which the trunk lies; which, gliding from above downward, pushes be- fore it ihe upper end ofthe fracture, and nukes it ride over the lower one. The muscles, irritated by the points of bene, increase their contraction, and draw up- ward the lower part of the bone ; and from this double motion of the two ends of the fracture in opposite directions, their riding over each other results. (Desault, par Bichat) Transverse fractures are less liable to be displaced in the lo-igiiudmal direction of the bone, becau.-e, when once in con- tact, tiie ends of the fracture form a mu- tual resistance to each otiier; the lower one, drawn upward by the muscles, meets with resistance from the upper one, which itself inclined downward by the weight ofthe trunk, pushes the former before it, and thus both retain their position in rela- tion io each other. The deformity of a fractured thigh, in the transverse direction, always accompa- nies that which is longitudinal; but, 460 FRACTURKS. sometimes, it exists alone. This is the quainted with the exact reasons why, and ca»e, when, in a transverse fracture, the precise manner, how, those advantages two ends of" the bone lose their contact; arise. It is true, as already stated, it is one being carried outward, the other in- known in a vague manner, that the ad- ward ; or, one remaining in its place, vantages alluded to, arise from the relasa- while the other is separated. Tlie upper tion of muscles connected with the frac- end of the fracture is not now, as in the tured bone; -Mr. lJott contents himself foregoing instance, motionless in regard to with making mere assertions to this effect, the muscular action ; the contraction of and supporting them upon an appeal to the pectineus, psons, iliacus interims, and experience, leaves the rationale of the upper part of the triceps, deranges it from subject in perfect obscurity. When we its natural direction, and contributes to have practical evidence in favour of any displace it. adoption, and when, at the same time, no The deformity ofthe limb, in regard to rational theory can be formed to coincide its direction, is either the consequence of with it, certainly, it behoves us u> follow the blow, which produced the fracture, the more useful dictates of the former, or, what is more common, of the ill- and to beware of any dangerous hypo- directed exertions of those who cany the thesis into wh'ch too eager a pursuit of patient. Thus we see that an injudi- the latter might allure us. When nunie- cious posture bends the two portions, so runs surgeons, however, are in a state of as to make an angle. (Desault, par Bt- hide termination, nay, what is more ur- chat) geut, when one half of the profession Whatever may be the kind of deformity, seems to be at variance with the olhcr the lower end of the fracture may retain upon appoint important to be decided, the natural position in wluch it is placed, and without ihe prospect of approaching or else undergo a rotatory motion on its harmony of practice, what resource re- axis outward, which is very common, or mains, but that of reason, to instil into inward, which is more unusual. This the mind those facts and principles, by rotation always aggravates the displaced which all must be governed ; and, from a state of the fracture, and should be due observation of which, only one opi- attended to in the reduction. (Desault, nion and practice would result? To rest par Birht.t ) contented with barely knowing, that the Having presented the reader with these superior utility of the bent posture, in accurate remarks on the kinds of derange- the case ofa broken thigh, proceeds ment, to which fractured thighs are sub- from the relaxation of muscles, is to ject, I shall beg his attention to a few remain in a certain state of ignorance, observations of my own, on Mr. Pott's from which, by an unfettered exercise of account of the effects of posture on frac- our own intellects, we might po«sibly tured limbs; on what constitutes the disengage ourselves. Nor will any man chief displacement ofa broken thigh, and of reflection contend that information what muscles can prircipally praduc? so nuked, so void of illustration, is this effect; and, lastly, on the actual con- enough to saturate with full conviction dition of such muscles in the bent posi- that philosophical spirit of enquiry, from tion of the limb. which ihe present enlightened state of 1. Almost every one initiated in the medical science is so eminently derived. surgical profession, imbibes a vague kind And might it not tend to advance, and of information, that relaxation of the very usefully to improve our knowledge muscles,,both in the reduction, and during of the subject, if we could a-scertain more the whole cure of fractures, was what Mr. accurately upon what princip.il the pns- Pott most strenuously recommended as tureof the limb ought to be selected with the proper condition, in which those pow- the greatest possible advantage to the ers ought to be placed, under such cir- patient ? Until that is accomplished, we cumstances; and was what he had in view are acting as mere surgical automatons ; in adopting the bent position forafiac- without true science, and without a ray tured thigh. of judgment. Neither will it be Bati.«. The love of truth, leads me, however, factory to answer, that posture is to be to remark, that this eminent surgeon has determined upon the principle of relax- not availed himself of the light, resulting ing the majority ofthe muscles con- front anatomical enquiries, to elucidate nected with the broken bone. More in the effects ofpostureupon fractured limbs, essentially required to make the solution Though many practitioners may now feel in this way accurate; for, even admitting, persuaded, how much greater the advan- what some may be inclined to doubt, that tages are in the bent, than in the straight tlie bent position does relax more muscles posture of the limb, in the case of a than the straight one, its precision will broken thigh; yet, few are so weU ac- vanish, when we shall have explained, FRACTURES. 461 that certain muscles, moving the thigh- bone, possess much greater power to im- pede tin- favourable coaptation and union of the fracture, than others performing the same office, and of not inferior bulk. I am humbly of opinion, that those prac- titioners, who still adhere to the old plan of placing fractured thighs in the straight posture, have never been struck wi* h this distinction ; and, in contending that their mode of treatment relaxes as many muscles connected with the broken bone as the opposite one, they have not reffected upon what constitutes the re- lative displacement ofthe two ends ofthe fracture. I have heard it more than once remarked, that what Mr. Pott terms the relaxed position of the limb, cannot real- ly merit that application, because there are, perhaps, as many muscles thrown into a state of tension into this very pos- ture, as in the straight one. According to rov ideas, there is some reason in this criticism; but no one must thence infer, that the straight position is equally pro- per; for, provided we shall be able to make out the truth of what has been delivered above, the question under con- sideration will be much altered; and, instead of inquiring, " Are more muscles relaxed in the bent, than in the straight position ?" we must enquire, " Are more of those muscles, possessing most influence over the fracture, relaxed in this or that position of the limb i" Were we to resign the privilege of thinking for ourselves, and implicitly to mould our opinions, according to any au- thority, however high, we should often fell into very avoidable errors. Were we to believe the literal sense of several pas- sages in Mr. I'otl's remarks upon Frac- tures, we should suppose it possible and practicable to relax at once, by a certain posture of the limb, every muscle con- nected with a fractured hone. In the first vol. of his works, page 339, edit. 1783, he observes, in speaking of what must best answer the purpose of incapacitating the muscles from displacing the fracture : " Is it not obvious, that putting the limb into such position as shall relax the whole set of muscles, belonging to, or in connexion with, the broken bone, must best answer such purpose?" and, in the next page, " What is the reason why no man, how- ever superficidlv acquainted with his art, ever finds much trouble insettinga fractur- ed os humeri; is it not both because patient and surgeon concur in putting the arm into a state of flexion, that is, into such a state as relaxes all the muscles sur- rounding the broken bone ?" Also in page 393, he continues, " Change of posture must be the remedy, or rather the placing the limb in such mnmnfi- os to relax all its muscles." That to have all the muscles relaxed in cases of fracture would be de- sirable, were it also practicable, every one will admit; but the possibility of accom- plishing it, so long as different muscles have different uses, different situations, and different attachments to the bones, every one must grant to be no more than visionary. For instance, do not the pa- tient and surgeon, in the case of fractured os humeri, adverted to above, rather con- cur in putting the fibres of the triceps and anconeus into a state of tension, at the same moment that they relax the biceps and brachialis internus ? In short, the indetermination of many practitioners, with regard to the greater propriety of placing a fractured thigh- bone in the bent, than in the straight position, must, in a great measure, be attributed to the imperfect explanations, hitherto offered of the way, in which the former becomes more advaniageous than the latter; especially, if it be true, that i comparative and fair trial in practice would shew, that the bent posture is in no respect inferior to the straight one, and will even succeed in many instances, where deformity, shortening of the limb, and lameness, would be inevitable conse- quences of the other. 2. By what I am now going to remark. I do not mean to question the accuracy of Desault's account of the various kinds of derangement to which a broken thigh is liable. The rising end of the bone has^ now been put into its proper point of view, and even ordinary practitioners are well aware of the erroneous ideas once entertained concerning it, and the more pernicious treatment often had recourse to in consequence. In the fr-ictured thigh, the rising end of the bone is the upper extremity of the fracture, that which is connected with the hip, that which is truly in its' right and natural situation, and that which no surgical means can therefore possibly alter for the better. On the other hand, the lower end of the fraCure, or that which is con- nected with the knee, is iliat whicn is displaced, that winch is drawn n-.ore or less underneath the other extremity of the bone, and that which well-directed surgery can generally set rif-ht again. No doubt c-n, I think, exist about the accuracy of these preceding propositions, when we consider, that the superior por tion of the broken bone is properly arti culated with the acetabulum; that i«s broken extremity is neuhcr removed far ther from, nor nearer to, that cavity than nature placed it, that the position, in which the upper portion of the broken os 462 1RACTURES. femoris is found, is not in the least de- ranged, and precisely such as it has often- times been put into previously to the oc- currence ofthe accident. But, the lower end of the fracture is not only wrong in relation to the upper end, it is out of its due situation in all other respects; it is drawn upward nearer to the pelvis than it ever could be naturally, and hence the limb is shortened; the position, in which it is constantly found, is so deranged, in relation to the pelvis, its axis is so altered, that even were we to overleap the bounds of possibility, and to suppose the> upper end of the fracture brought into apposition with it So situated, we should at the same time be obliged to construct in our wanton imagination a new aceta- bulum, differently situated from the na- tural one for the reception of the head of the bone; or, perhaps, it might best suit such chimera to alter the ordained shape of the thigh-bone. The deviation from the natural and relative situation of the two ends of the fracture, it is then my wish to imply, proceeds, not from any derangement of the upper portion, but, from a retraction ofthe inferior part ofthe broken bone. If it be received as an irrefragable . truth, that the upper extremity of the fracture is not out of its due situation, anil that the lower end is so, it must ne- cessarily follow from the admission of this principle, that the first grand indication m the management of the case, is to put the lower end of the fracture into its right and relative situation, by drawing it downward, and placing it in as perfect apposition, as the nature of circumstances will allow, and not to make any vain attempts to press down the prominent end of the bone; a thing altogether im- practicable and highly improper. Let us now suppose, that the surgeon proceeds to replace the lower end of the fracture, which we *""iave described as be- ing retracted, more or less, underneath the other. Mr. Pott has judiciously remarked, that to impede the accomplishment of this putpose, little or no difficulty can arise from the fracture itself, the broken ends of the bone being of themselves inactive. The muscles must be looked upon as those powers, which can, and do make opposition to the reduction of the frac- ture ; and, when set right, to its conti- nuing so The muscles alone are the powers causing the retraction of the bone and shortening of the limb. It is well, and universally known, that muscles can only contract to a certain length; and, it is upon a knowledge of tliis fact, that the principle and utility of relaxing their fibres are founded; for, in proportion as they become relaxed by the approximation of their attachments, they are partly deprived both of their dispo- sition and power to act. What then is implied by relaxation of a muscle is most simple of comprehension; it is that con- dition, in which its origin and insertion are more or less approximated to each other. We shall now enquire, what muscles are so circumstanced as to be capable of making most resistance to the reduction and coaptation of the fracture; for, should we succeed in ascertaining tliem with precision, it must be a primary con- sideration to relax them, rather than any others, less empowered to do harm; and, after what has been delivered, it seems a most easy matter to determine them. That those muscles, destined to move the os femoris, and affixed only to part of this bone above the situation of a frac- ture, cannot make any opposition to its reduction, nor principally disturb the co- aptation ; and that, therefore, their re- laxation is not what the skilful surgeon ought primarily to aim at, appear to my mind two very manifest propositio* s aris- ing from the facts already premised. But, that he ought to aim principally at the relaxation of those muscles which can concur to retract the lower end ofthe fracture ; all which must necessarily have their insertions below the breach of con- tinuity in the bone, appears to rr.e a fact equally obvious ; and, is what I think not unworthy the attentive consideration of all prac :cal surgeons. My sentiments, however, are not at all repugnant to Desault's description of the derangement; for, I would not take upon me to deny altogether a circumscribed power in muscles attached only to the superior portion of the broken bone to affect the fracture unfavourably, espe- cially, when such fracture is of tlie trans- verse "kind. It is possible, that they may do so ir: a limited degree ; though, I am in- clined to believe, that, in the bent pos- ture, their power o£ acting injudiciously must be so trivial, as to be unworthy of serious notice. The reasons, for my en- tertaining this opinion, I shall explain. When atransvei-.se fracture is reduced, and its broken extremities are placed in even apposition with each other, it is possible to conceive, that the first devia- tion from the proper situation of the two ends of tiie fracture, may arise from the contraction of some muscles, that has only a power of moving the upper portion of the bone, and that, in consequence of the superior end of the fracture being moved, and its resistance taken away, the inferior FRACTURES. 46J end may become more easily retracted. This idea, however plausible it may at first appear, will, upon mature considera- tion, be found in no degree to militate against the opinion advanced, that the muscles attached to the lower portion of the broken bone have most influence over the fracture ; and it is at once obvious, that, witiiout the action of these latter muscles, no retraction of the lower end of the fracture could take place, into whatever position the other might be drawn by the contraction of other muscles. I am also of opinion, that most of those fractures ofthe thigh, which I have seen, have been oblique, and the ample experience of Pott and Desault seems to have made them of a similar sentiment. Whether this remark be true to the extent which I have stated, or not, it must at least be granted, that, in oblique fractures of the thigh, the re- sistance made by the upper end of the fracture to the retraction of the lower, will not be effectual enough to defeat the continual tendency of the muscles to pro- duce that effect. It seems rational to sup- pose, that those few instances, where little difficulty is experienced in maintaining the fracture in a proper state of coapta- tion, and where no retraction happens, are cases of tlie transverse kind, and, consequently, if in such rarer instances alone, and in such instances as conse- quently end well, the muscles attached above the fracture can do harm, it is not of so much importance. Besides, ad- mitting (what indeed I have already ad- mitted) that, in transverse fractures of the thigh, the resistance made by the upper end of the fracture to the retrac- tion of the lower, becomes of consider- able utility, it is evident, that it becomes so only by counteracting the action of those muscles, which tend to draw up- ward the inferior portion of the fractured bone Were it only in our power effec- tually to incapacitate them by posture, or any other means, oblique fractures of the thigh would be no more difficult to unite favourably, than transverse ones. The majority of cases also being oblique, and tiiese being such as so often baffle the surgical art, we can only rely upon our means of diminishing the power of muscles to retract the inferior portion of the fractured bone for the accomplish. ment of a good cure. In the bent position of the limb, let me also enquire, in what direction can the superior end of the fracture be first drawn by the action of muscles? The flexors of tlie thigh being relaxed, we cannot suppose, that they make it project for- ward, as it actually does, or at least has done in every instance of displacement that I have yet seen. It may be suggested, that the adductor muscles may do so; but, as these ought also to be perfectly relaxed in the bent position, they cannot, when the bone is set right, and placed as circumstan- ces demand, do what we are considering. The glutei are tense, and may there- fore be conceived capable of disturbing the coaptation ; but, to appeal to fact, and the incontestable evidence of expe- rience, do we ever find the upper end of the fracture situated either behind, or on the outside of the lower end ? Do we not constantly find it projecting in front, and the latter drawn up more or less be- hind it ? Even supposing the upper end of a transverse fracture were first drawn in a direction backward, would it not rather tend to prevent retraction of the lower end, according to the manner in which it is uniformly found to be dis- placed ? In short, we can account for every thing, relating to the displaced con- dition of the fracture, without having re- course to the doctrine admitting much influence over the fracture to reside in muscles attached only to the superior portion of the fractured bone. If, at the same time, we concede, for the sake of a reconciliation of opinions, that muscles inserted into the os femoris, above the si- tuation of a fracture, may act in some de- gree unfavourably to its union, it yet re- mains a manifest and unshaken truth, that since no posture of the limb will at once relax all its muscles, it is the duty of the surgeon to select that one, which brings with it the greatest share of advantages, and which disarms, as it were, those mus- cles, endued with most power to disturb the union ofthe fracture. What renders the foregoing remarks more deserving attention is, that the ma- jority oi fractures of the thigh-bone hap- pen at some point below the attachment of the gluteus maximus, and that the ma- jority of the muscles, inserted directly into the os femoris, have their attach- ments so high, that they cannot be sup- posed to possess great influence over frac- tures situated at any point much below the trochanters. The psoas magnum and iliacus internus, the glutei, and all the rotators of the thigh-bone outward come within this description, together with, the pectinalis, the superior fibres of the adductor magnus, and all the adductor bievis. What muscles now remain to antago- nize so powerfully the endeavours of the surgeon ? In this general view ofthe sub- ject, the greater part of the triceps will be the only power, inserted immcdiately into the os femoris, possessing consider- able influence; yet, there are several 464 FRACTURES. other very bulky muscles, concerned in the motions of the knee-joint, which may combine very forcibly to retract the lower end of the fracture, and thus resist the reduction and disturb the coaptation, and union of the bone. Such are the extensor muscles ofthe leg, especially, the rectus, as we presently shall explain, and the flexor muscles, sartorius, gracilis, semimembranosus, se- mitendinosus, and biceps. If these are really the muscles, capable of exerting themselves, with most effect, in produc- ing the difficulties accompanying the treatment of" all those fractures of the thigh, which happen below the tendon of the gluteus maximiis, it certainly becomes a matter of considerable importance to observe, if possible, their relaxation, rather than that of any other set of mus- cles, less empowered to do harm. When the fracture is above this point, other muscles come into power, and hence the difficulties augment. J. In noticing the condition, into which the above muscles are put in the bent po- sition of the limb, we shall, as occasion requires, mention those circumstances, which diminish, or increase, their influ- ence over the fracture. The triceps is the principal adductor of the thigh ; it may also, from the nature of its attachments, combine to bring the thigh-bone forward, and hence, bending the thigh must in a certain degree con- tribute to its relaxation. It is probable, that of all the muscles capable of imped- ing, with the greatest effect, the setting of a broken thigh, the triceps) is that, which possesses the highestshare of power considering its vast bulk, and its extensive insertion in the bone. Its perfectly re- laxed state cannot, therefore, be too particularly insisted upon ; it is not enough for this purpose, to bend the thigh upon the pelvis; this alone can only produce a very partial relaxation of its fibres. The patient ought to be placed upon a firm mattress, and, as he lies upon his side with his thigh bent to an acute angle with the trunk, the pelvis is to be turned completely upon its lateral part, and the fractured bone somewhat raised by pil- lows. Thus the os pubis and os ischium (from which the three heads of the tri- ceps arise) will become approximated to the linea aspera, and the ridge above the internal condyle of the os femoris (into which they are inserted) as much as cir- cumstances will permit, and thus the re- laxation of the muscle will be effected. The pectinalis can only be a primary power in disturbing the fracture, when the accident has occurred very high up. As it is an assistant both in the flexion and adduction ofthe thigh, it must be re- laxed in the above position. 1 need only observe further respecting it, that tlie majority of fractures happen below its insertion, and, consequently, in such in- stances, it wiU, with the upper fibres of the triceps, possess no power of displac- ing the lower end of the fracture. The next muscles, claiming our atten- tion, are the extensors of the kg. In considering the effect of tlie action of different muscles upon a fractured thigh-bone, it is useful to carry in our mind the precise direction in wliich the inferior end of the fracture is displaced. We should bear in our recollection, that it is drawn up more or less behind the upper portion of the bone; and muscles, which can most concur to produce such retraction, are those, which can most im- pede the favourable union of the fracture. The situation of the extensor muscles of the leg at once suggests to us, that they cannot produce this effect nearly in so great a degree as the flexors. It is true, that the sartorius is situated in front of the thigh, and has been enumerated as pos- sessing much influence over the fracture ; but, it is to be remembered that the di- rection of its force is entirely changed in consequence of its spiral course, and its passing behind the internal condyle of the os femoris. The rectus may un- doubtedly aid in the retraction of the lower end of an oblique fracture: its power to disturb a transverse one seems doubtful. Being a loose muscle, not at- tached to the thigh-bone, and acting only from two points very remote from e-ich other, viz. the anterior inferior spine of the ilium and the patella, it can on this account exert the strength of every fibre, both above and below the breach of con- tinuity in the bone, in combining to re- tract tiie inferior end of an oblique frac- ture. The vasti and cruralis, on the contrary, being muscles intimately at- tached to the os femoris, and having no origin whatever from the pelvis, can only employ the force of those fibres, which happen to be situated above the fracture in aiding to retract the lower portion of the broken bone. For instance, suppos- ing the fracture to be situated about the middle of the thigh, all those fibres of the vasti and cruralis deriving their ori- gin from the os femoris below tlie breach of continuity in the bone, and inserted into the patella, can obviously have no effect in producing the retraction and dis- placement ofthe inferior end of the fracr ture. This fact must considerably lessen the influence M" these three extensors in acting injuriously toward fractures. FRACTURES. 465 There are yet other circumstances, which must tend to diminish their power. If we reflect upon the lower end ofthe frac- ture, when displaced; if we remmd our- selves, that it is constantly drawn up be- hind the other; it must immediately strike us, that the vasti and cruralis, the fibres of which embrace and adhere so in- timately to the surface of tbe bone, both above and below the fracture, must be more orless detached from their origin, in proportion to the degree of retraction and displacement; that the fibres of the vasti, taking their origin from the lower part of the linea aspera above the frac- ture, must in all probability be detached from such connexion by the retraction of the lower end of the fracture in that si- tuation : and that the fibres ofthe cruralis must at the same time be partially de- tached from their intimate connexion with the anterior surface of tlie bone be- low the fracture. Such separated fibres can exert no power over fractures. When we also reflect, that the fibres of the cru- ratis and the anterior ones of the vasti must inevitably be more or less stretched round the upper end of the fracture, by which the direction of their force upon the lower end must be so changed, that, instead of tending to draw it upward, they can only pull it forward, I think it must be granted that their faculty of ma- terially disturbing a fractured thigh is involved in doubt. The*»rectus is cer- tainly to be considered, in every respect, as one of the primary powers acting in the displacement of fractures, and, as such, it ought to be perfectly relaxed, if other considerations should not forbid it; that is, if we should not throw a larger bulk of muscular fibres, disposed to act unfavourably on the fracture, into a state of tension, by observing its perfect re- laxation, than we should, by such means, relax, and according to our principles, this would undoubtedly happen. Con- sequently, in the bent position of the limb, though we do not completely relax the rectus, since, the knee is bent, at the same time that the thigh is in a state of flexion, yet we must, of necessity, be con- tent with a partial relaxation of its fibres, for the sake of relaxing a more powerful set of muscles next to be considered. It may not however be inapplicable to state, that in the bent position, the anterior in- ferior spine of the ilium is almost, if not quite, as near to the patella as in the straight one, and of course even the rectus must be equally favoured in point of relaxation. TlA vasti and cruralis are tense in the bent position ; but, I cannot consider their power over the ge- nerality of fractures to be of primary im- Voi. I. portance. The tugher the fracture is si- tuated, the less can they exert that little share of influence which they may be supposed to possess ; and accidents of this description, when in a high situa- tion, being always the most troublesome, is a circumstance proving, that it is to other powers we ought to attribute the augmentation of difficulty. The flexor muscles of the leg, above enumerated, are capable of acting very powerfully in resisting the reduction, and disturbing the coaptation of the fracture* For the sake of surveying them more clearly in this surgical point of view, they may be divided into two classes. The first comprehends two muscles aris- ing from the pelvis in front, viz. the gra- cilis and sartorius, which are favoured in all respects by the bent position of the Umb, as well by flexion of the thigh, as by that of the leg ; and also in a very im- portant degree by observing to place the pelvis strictly upon its side, and to raise the thigh by proper pillows. The second class consists of three muscles coming from the tuberosity ofthe ischium behind, viz. the semimembranous,;, semi- tendinosus, and long head of the biceps, being such as are only favoured, with a view to relaxation, by flexion of the knee. That the sartorius and gracilis are in every respect favoured by the bent pos- ture, no one acquainted with the origins and insertions of those muscles ; no one knowing the effect of their action, will feel inclined to deny; and presuming upon the admission of this 'ruth, I shall pass, on to reflect upon the state ofthe three other flexors enumerated above. ..^J In deriving their origin from the tu- berosity of the ischium, they acquire a power of contributing to draw the limb backward, as well as of bending the knee. Hence, their perfect relax- ation is obviously unaccomplished in the bent position. One might even con- jecturt d priori, that they are little, or not in the least, benefited in such con- dition, because bending the thigh may seem to counteract all the good effect, in regard to relaxation, resulting from flex- > ion of the knee. Measurements on tbe skeleton, however, will shew, that the tuberosity ofthe os ischium is approxima- ted considerably more to the heads of tije. tibia and fibula in the bent, than in the straight posture. I may also take the liberty of remarking, that horizontally situated, as the thigh-bone is in the straight position, it cannot be regarded, as affording an equal degree of relaxation to such muscles, as if it actually were in a state of perfect extension. The short head of the biceps will,, in many instances, 30 466 FRACTURES. be enabled to assist in the retraction of the inferior end of the fracture, and it is manifestly relaxed in the bent position. t am not inclined to allow any share of power to reside in the popliteus. Daily experience justifies my laying it down, as a fact, that the higher the frac- ture is situated, ceteris paribus, the great- er is the difficulty experienced in keep- ing it in a state of apposition. In con- templating the subject, upon the prin- ciples advanced in the preceding remarks, we immediately discern the reason of it. When the fracture is very high, almost the whole of the triceps and pectinalis concur to retract the bone. When imme- diately below the trochanters, the glu- teus maximus is to be added to the nu- merous class of muscles, capable of dis- turbing the union of the fracture. When in the neck of tbe bone, the multitude of muscles, inserted into the two trochanters, become enabled to assist in the retraction and displacement of the main portion of the bone. Hence, the immense difficulty to be surmounted in accomplishing the union of such cases, without shortening of the limb, and the foot being distorted outward. In cases of this kind, the short head ofthe biceps, the vasti, and the cru- ralis, wiU, however, have no force over the fracture. When the neck of the os femoris is fractured within the orbicular ligament (which remains entire,) it is clear, that the retraction must be much limited. I might strengthen the preceding ob- servation, that in proportion as the frac- ture is high, the greater is the difficulty experienced in maintaining the ends of thcfracture in contact, by noticing, that I have seen several cases, in which the os femoris was broken very low indeed, and in Which no retraction or displacement whatever happened. Perhaps, these frac- tures might have been of the transverse kind, and, perhaps the greater surface for apposition, on account of the expand- ed form of the bone, at this part, might have had some share in preventing re- traction. B.ut, it must appear certain, that, in such instances, several muscles Would have lost almost, or entirely, their Influence to produce that effect; such as the triceps, pectinaUs, &c. and tbe mus- cles moving the leg, remained the only powers capable of such action. • The position of the fractured os femo- ris, says Mr. Pott, should be on its out- side, resting on the great trochanter; the patient's whole body should be in- clined to the same side; the knee should be in a middle state been perfect flexion, or extension, or half-bent; the leg and foot lying on their outside also, should be well supported by smooth pillows, and 9hould be rather higher in their level, than the ihigh ; one very broad splint of deal, hollowed out, and well covered with wool, rag, or tow, should be placed under the thigh, from above the trochanter quite below the knee; and another somewhat shorter shoulu extend from tlie groin be- low the knee on the inside, or rather in this posture on the upper side The bandage should be of the eighteen-tail kind, and when the bone has been set, and the thigh well placed on the pillow, it should not without necessity (which necessity in this method will seldom occur) be ever moved from it again, until the fracture is united; and this union will always be accomplished, in more or less time, in proportion as the limb shall have been more or less disturbed. (Pott.) Here only two splints are mentioned; the surgeons of the present day always employ four. After placing the patient in a proper position, the necessary ex- tension is to be made. Then the under- splint, having upon it a broad soft pad, and an eighteen-tailed bandage, is to be laid under the thigh, from the great tro- chanter to the outer condyle. The sur- geon, before applying the soap plaster, laying down the tails of the bandage, and putting on the other three splints, is to take care that the fracture lies as evenly as possible. In the positibn for a fractured thigh, Mr. Pott, we find, directs the leg and foot to be rather higher in their level, than the thigh; with what particular design I have not myself been able to make out. Whoever medit-ites upon the consequence of elevating the leg and foot above the level of the thigh, in the bent position, will know, that it is to twist the condyles of the os femoris more outward, than is natural. When a patient is placed, according to Mr. Pott's direction, upon a common bed, the middle soon sinks so much that the leg becomes situa- ted very considerably higher than the thigh, and I am disposed to think, that this is one cause, why so many broken thighs are united in so deformed a man- ner, that the foot remains permanently distorted outward. The great propen- sity of the triceps, and other muscles to produce this effect, may also serve to ex- plain the frequency of the deformity. It is not merely the depression of the middle of the bed which is disadvantageous, as the weight of the patient's body falls more upon one side ofj tbe bed, than the other, in the bent position of the limb, unless the sacking is tight and the mat- tress very firm, it happens, that sucb a declivity is formed, as to render it ex- FRACTURES. 467 eeedingly difficult, if not impracticable, to make the patient continue duly upon his side. It cannot be enjoined too for- cibly, that fractured thighs should al- ways be laid upon beds not likely to sink much. W.ien this happens, no rational dependence can be put in the effica* y of the bent position, and, as Desault has explained, the same thing is hurtful also in the straight posture. From what has been deUvered it may easily be discerned, that inferences from anatomical ciicumstances are in most fractures of the thigh chiefly in favour of the bent position; for it appears, that of all those muscles which have primary in- fluence over the majority of such acci- dents, that is, over all those which occur below the insertion of the gluteus maxi- mus, there is only one muscle, viz. the rectus femoris, that is not more, or quite as much relaxed in it, as in the straight position. Since, however, experience is the great arbitrator of all practical ques- tions, we must still look to it for decisive information, and to form a true judgment in tliis way, the straight and bent posi- tions ought to Be contrasted in every hospital with due attention to all colla- teral circumstances; the progress and termination of every case ought to be re- gistered ; and the comparative view, thus kept up, would quickly diffuse one kind of conviction throughout the profession. The most enthusiastic advocates for the bent position must allow, that it leaves the leg and foot too moveable and unsup- ported, and, that though it may relax the muscles, which have the most power to disturb the coaptation of a fractured thigh, it yet leaves unrelaxed a mass of muscle quite sufficient to displace the ends ofthe bone. Hence, it behoves prac- titioners to endeavour to improve the ap- paratus employed, so that it may make a permanent resistance to the action of the muscles. In the straight position, such resistance may certainly be practised with most effect a-ad convenience. There are sbme very excellent remarks on the treatment of fractured thighs in Les QZuvres Chirurgicales de Desault par Bichat. It is observed, that, if we com- pare the natural powers of displacement with the artificial resistance of most of our apparatuses, we shall find, that the disproportion between such forces is too great to make the former yield to the latter The action of the muscles, how- ever, which is always at first very strong, may afterwards be graduaUy diminished by the extension exercised on them. A power incessantly operating can effect, what another greater power temporardy appUed, cannot at once accompuan, and the compression of circular bandages tends also to lessen the force of the mus- cles. Desault cured in the H-Stel-Dieu an immense number of fractured thighs, without any kind of deformity. It was particularly to the well-combined em- ployment of extension, and compression of the muscles, that such success w*s owing. The advantage of keeomi;- tiie ni, > '■ s a long while extended, i order to tim... ish their power, is especially evident in the reduction of certain dislocations, as those of the shoulder, in which we often cannot succeed till the muscle> have been kept on the stretch for a greater, or lesser time. The fracture of the patella and olecranon equally demonstrau s the utiU- ty of compression for the same purpose; as when the muscles are not compressed by the bandage, they draw upward the fragment of bone with double, 'or triple force. (Dtsault par Bichat.) Against reducing fractured thighs in the bent posture, Desault entertained the following objections: the difficulty of mukuig the extension and counter exten- sion, when the limb is so placed ; the ne- cessity of then applying them to the frac- tured bone itself, instead of a situation remote from the fracture, as, for example, the lower part of the leg; the impossi- bility of comparing with precision the broken thigh with the sound one, in or- der to judge of the regularity of its shape; the irksomeness of this position long con- tinued, though it may at first seem most natural; the inconvenient and painful pressure of a part of the trunk on the great trochanter of the affected side; the derangement, to which the limb is ex- posed when tiie patient has a motion ; the difficulty of fixing the leg firmly enough to prevent the effect of its motion on the thigh-bone; the manifest impos- sibility of adopting this method, when both thighs are fractured; lastly, expe- rience in France having been little in fa> vour of such posture. Also, what is gained by tbe relaxation of some muscles, is lost by the tension of others. For such reasons, (certainly strong ones,) Desault abandoned the bent position, and always employed the straight one, which was advised by Hip- pocrates, and all the Greek physicians. Petit, Heister and Duverney, recom- mend applying the extending means just above the condyles of the os femoris, Dupouy was one of the first to remark, that this practice rendered it necessary to employ very great force, and that it would be better to make the extension from the foot. Fabre takes into consider- ation also the inconvenience of the pre* 468 FRACTURES. sure, made on the muscles, which irritat- ing and stimulating them to action, mul- tiplies the obstacles to setting the frac ture. Desault adopted their doctrine, for nearly the same motives, introduced it at the Hdtel Dieu, and the success he experienced in consequence, did not con- tribute a little to its wider diffusion.— (Desault par Bichat) Desault, as we have stated, preferred the straight posture, and laid his patients on surfaces, not likely to sink with the weight of the body. The feather beds, formerly in common use at the Hotel- Dieu had this inconvenience; for these, in cases of fractures, Desault substituted a firm, tolerably hard mattress, which did not allow the continual change of posture to occur, which a soft bed does. The object of every apparatus being to keep the ends of the fracture from being displaced, the mechanism of every con- trivance, for this purpose, should be di- rected against the causes of the derange- ment. These are, 1. the action of the muscles, drawing upward the lower end "of the fracture; 2. the weight of the trunk propelling downward the upper end. Hence, every apparatus, intended to prevent derangement of a thigh frac- tured obliquely, should, 1. draw and keep* downward the lower end of the fracture; 2. carry and maintain upward the upper end of the fracture, and the trunk, which is above it. This principle is of general application, and only subject to a few exceptions in transverse fractures, at- tended only with derangement in the di- rection of the diameter of the limb, or else none at all. 3. There must also be in the apparatus a resistance to the rota- tion of the lower portion of the broken bone, which will keep the limb steady, even in case of any sudden motion. (De- sault par Bichat.) If we compare the operation of the dif. ferenf pieces of our apparatuses with the above indications, we shall find, that, without permanent extension, they are not very effectual. With regard to band- ages, whether a roller, or eighteen-tailed bandage, be used, they all have one com- mon mode of operating ; they press the muscles towards the ends of the fracture so as to make them form a kind of natu- ral case for the fracture, and thus they make lateral resistance afffeinst the parts. In this manner, bandages materially aid in preventing derangement side-ways, and are particularly useful in transverse fractures. But, what is there to hinder the two inclined surfaces of an oblique fracture from slipping one over the other ? What power is there to keep the limo from receiving the effects of accidental shocks ? Is the pelvis kept back ? Is the action of the muscles resisted ? The bi- ter is indeed somewhat diminished by the pressure, and this is the chief use ot the bandage; but, will such compression be enough to prevent the longitudinal de- rangement of the broken bone, especi- ally, if" the bandage be applied slackly, as some advise ? (Default par Bichat) These remarks apply also to com- presses; petit moyen contre une grande cause. Splints are useful in firmly fixing the limb, and guarding it from the effects of accidental shocks, or of contractions of the muscles. They operate more power- fully, than bandages, in preventing la- teral derangement, and, hence, they suf- fice for transverse fractures, without any permanent extension being employed. They can also resist the rotation of the thigh outward, Or inward. But, when the breach of continuity is oblique,-will they hinder Ihe ends of the bone from gliding over each other, and the conse- quent shortening ofthe Umb ? They ob- viously could only do so, by the friction of the different pieces 'of the apparatus, especially, the tapes, which fasten it, and then, to make the resistance effectual, they must be tied so tightly as to create a danger of" mortification. Will the splints prevent the trunk from descending, and propelling before it the upper end of the fracture ? Will they paralize the action of the muscles on the lower end ? Will they, in short, fulfil all the above indica- tions ? Their use is almost limited to preventing lateral derangement, and stea- dying the limb. Hence, they should extend along the leg, as well as the thigh, which is disturbed by the motions of the lower part of the limb. The pads are chiefly useful in keeping the limb from being galled by the splints, and tend only trivially to keep the frac- ture from being displaced. From the above account, it appears, that the ordinary pieces ef apparatus, which do not execute any permanent ex- tension, may perhaps suffice for trans- verse fractures, which are not common; but, that they are always ineffectual, when the division is oblique, because, they do not fulfil the two-fold indication of drawing downward the lower end of the fracture, and keeping the other one upward. (Desaultpar Bichat.) Desault ascertained, that the object particularly to be aimed at, was such a disposition as that the foot, leg, thigh, and pelvis, should constitute but one whole; so that, though the different parts thereof should be drawn in different di- rections, yet they should still, with re- FRACTURES. 469 spect to one another, preserve the same mutual relation. He invented the fol- lowing apparatus to answer these pur- poses. A strong splint, long enough to extend from the ridge of the os ilium to a certain length beyond the sole of the foot, is a principal part of this apparatus : this spUnt should be two inches and a quarter broad, and have each of its extremities pierced in shape of a mortice, and ter- minated hy a semicircular niche. It is appUed on the exterior side of the thigh, by means of two strong Unen bands, each being more than a yard long. [Dr. Physick has greatly improved this splint by increasing the length of it sufficiently to extend up to the axilla; an account of this improvement is contain- ed in the following extract from Dr. Cald- well's translation of Desault. " Dr. Physick having observed that in the appUcation of Desault's apparatus, the patient was sometimes- injured by the pressure of the strap or roller which pass- es under the tuberosity of the ischium for the purpose of making counter-extension, devised the following method of remedy- ing this inconvenience in which he suc- ceeded to his wishes. "He directed the upper end of the long external splint to be formed like the head of a'crutch, and the splint it- self to be lengthened so as to reach and bear against the axilla of the af- fected side, which must be well de- fended from pressure by a bolster ot flannel or some other soft material. By this expedient the Dr. evidently formed two points, of counter-exten»on, in- stead of one, as in the case in the ap- paratus of Desault. Between these two . points, namely, the axilla and the peri- neum, the same quantity and force ot pressure is, by Dr. Physick's improve- ment, divided, which, in the original apparatus of Desault, is borne by the perineum alone. The risk of excoria- tion and injury to the patient, then, in tlie former case, is to that which he runs in tlie latter, only as one to two, or nearly so. As it is no less the duty ot the surjreon to prevent suffering than it is to remove deformity, or to save lite, Dr. Physick has certainly in this re- spect made an important step in the advancement of his profession. « But there is still another advantage derived from the lengthening of the ex- ternal splint. In the original apparatus of Desault, the strap intended tor coun- ter-extension, by passing no higher up than the spine of the ilium, runs too much across, and therefore acts too much on, the upper part of the ttngh. By this it not only irritates the muscles of tlie part, and induces them to con- tract, but also tends to draw the up- per fragment of the os femoris a little outward, and thus to render the thigh in some measure deformed. But, in the improvement of Dr. Fliysick, tlie strap is secured in a mortice cut iri the external splint, about midway between the spine of the Uium and the axilla. This strap, by being thus carried high- er up on the body, does not run across the thigh at all. It consequentiy presses on and irritates the muscles much less, acts more in the direction of tiie os femo- ris, and has no tendency to draw the supe- rior fragment outward."] The middle part of one of these bands is to be applied to the inside of the thigh, at its upper part; its ends are brought to the exterior side of the thigh, passed through the mortice, and knotted on the semicircular niche. Compresses are to be previously placed under the middle part of the band, in order to prevent any disagreeable pressure ; as well as on the tuberosity of the ischium, which Desault considered as the principal point of ac- tion of this band. The inferior part of the leg is, in the next place, covered with compresses, on which the middle part of the second band is placed: the extremi- ties of this band are crossed on the instep and upper part of the foot, then on the sole, after which they are conveyed out- ward, and one end passed through the mortice and knotted with the other on the niche, with such a degree of force as to pull the inferior portion of the femur downward, and to push the splint up- ward, and, by this means, the pelvis and superior fractured portion.^ On the in- ternal side of the limb is placed a second splint, which extends from the superior part of the thigh, to a certain distance beyond the foot. A third is placed on the anterior part, and extends from the ab- domen to the knee. The "superior ex- tremities of the anterior and exterior splints are fixed by means of a bandage passed round the pelvis. A band, the middle part of wliich is placed under the sole of the foot, and the extremities crossed on its superior surface, and fas- tened to the splints, prevents the motion of the foot, as do also the splints. Before applying the apparatus, the whole limb is to be cofered with com- presses, wet with a solution ofthe acetite of lead. Over these, • Scultetus's band- age is to be put, and a roller round the foot, all moistened in the same manner. For more particulars, the reader is re- ferred to the Parisian Chirurgical Journal, Vol. I. ou les Euvres Chirurgicale* de De- 470 FRACTURES. sault par Bichat; Leeons sur les Maladiet de* Os; Richerand's Nosographie Chirur- gicale, Tom. 3. [The reader must decide for himself between the two opposite methods of treatment here recommended in frac- tures of the lower extremity. The method taught in the University of Pennsylvania is that of Desault improved by Dr. Physick; its success is such, as perfectly satisfies me, and I beUeve most of those who have properly tried it.] Fracture* of the Neck ofthe Thigh-bone. This part ofthe bone may be fractured either by falls on the great trochanter, on the sole of the foot, or the knee. But the first incident produces the injury much more frequently, than the. latter ones. Of thirty cases, which occurred to Desault, four-and-twenty arose from falls on the side. All those inserted by M. Sabatier in his interesting Memoir, were the result of a similar accident. 1. The fracture may take place in the middle of the neck, where there is less thickness, and the texture is not compact, as in the middle of the cylindrical bones, which are so much exposed to fractures. 2. Where it is united to the head of the bone. 3. Where it joins the great trochanter, in which event, the breach of continuity may be on the outside of the joint, wliich happens more frequently, than has been supposed The division is seldom oblique, almost always transverse; the neck being some- times, in the latter case, wedged in the body of the bone, as Desault found in se- veral instances ; a model of one of which, in wax, is preserved in the collection «f L'Ecole de Sante, and the natural specimen of which was in the possession of Bichat The fracture*! of the neck of the thigh- bone is sometimes complicated with that ofthe trochanter major. The diagnosis is occasionally so diffi- cult, that the best-informed practitioners cannot always ascertain the accident with certainty. At the instant of the fall, an acute pain is felt, (sometimes a crack is distinctly heard) and a sudden inability to walk occurs; tbe patient cannot raise himself from the.ground, which, how- ever, is not invariably the case. In the fourth vol. ofthe Mem. de l'Acad. de Chi- rurgie, a case is related, in which the pa- tient walked home after the accident, and even got up the next day. Desault pub- lished a similar example. The locking of one end of the fracture in the other, may offer an explanation of this circum- stance. A shortening of the Umb almost always takes place; but this symptom is more or less striking, according as the breach of continuity is out of the cavity of the orbicular ligament, which then keeps the bone from being retracted; or, as the ex. tremity of the fracture is confined by this ligament. The action of tiie muscles drawing upward the lower end of the fracture, the weight of the trunk propel]. ing downward the pelvis and upper end of the fracture, are tlie two causes of the shortening of the limb. A slight effort suffices, in general, for the removal of this shortening of the limb ; but, the symptom recurs almost as soon as such effort ceases; and Goursault and Sabatier have remarked, that it sometimes does not take place at all, till a long while after the accident. A swelling is observ- able at the upper and front part of the thigh, always proportioned to the retrac- tion, of which it appears to be an effect. The projection of the great trochanter is almost entirely effaced. Directed up- wards and backwards, this eminence be- comes approximated to the crista of the os ilium ; but, if pushed in the opposite direction, it readily yields; and, when arrived at its natural level, the patient becomes capable of moving his thigh. The knee is a little bent. Abdliction of the limb always occasions acute pain. If, while the hand is placed on the great trochanter, the limb is rotated on its axis, tins bony projection may be felt revolving on it self, as on a pivot, instead of de- scribing as in the natural state, the seg- ment of a circle, of which the neck of ihe femur is the radius. This symptom, which was particularly noticed by Desault, is very manifest when the fracture is situ- ated at the base of the neck, less so when at its middle; and it is not very percep- tible when the breach is near the head of the bone In the rotatory motions, the lower fragment rubbing against the up- per one, produces a distinct crepitus, which, however, is not an invariable symptom. The toes are usually turned outward ; a position which Sabatier, 8tc. consider as the inevitable effect of the fracture, though Pare and Petit have noticed, that it did not constantly occur. Two cases adduced by these illustrious surgeons, were not credited by M. Louis; but the experience of Desault has fully confirmed the possibility ofthe occurrence. The position outward is commonly im- puted to the rotator muscles. But, then it is clear, that such position ought al- ways to exist; that aU the muscles, which FRACTURES. 471 proceed from the pelvis to the trochanter, are, with tiie exception of the quadratus, in a state of relaxation, by the approxi- mation of the femur to their point of in- sertion ; and that the contracted muscles would not allow the foot to be so easily turned inward again. It is not more probable that the weight of this part it- self may pull it into the position, in which it is commonly found. It follows from the preceding account, that none of the symptoms of a fracture of the neck of the thigh-bone are exclu- sively characteristic ; that each .consi- dered separately, would be insufficient, and that their assemblage can alone throw light on the diagnosis. In every instance of doubt, however, the sure course must be pursued, and the appara- tus applied, which, though useless, is not dangerous, should the injury not exist, and is indispensably necessary when it does. (Desault par Bichat.) It was at one time supposed, that frac- tures of the neck ofthe thigh-bone could not be cured, without some shortening of the Umb, and lameness, remaining after- wards. Professor Ludwig, Sabatier, and M. Louis, broached this doctrine, and imputed the circumstance to the destruc- tion of the neck of the bone. Desault, however, rarely met with instances of such lameness in his practice, The treatment of these cases is not at all different from that of other fractures of the body of the bone. Most surgeons in this country adhere to Mr. Pott's plan of laying the limb in a bent posture; while, in France, they prefer the straight position, with Desault's apparatus, above described. Fracture ofthe Patella. This bone is almost always broken transversely, and the accident may be oc- casioned either by the action of external bodies, or by that ofthe extensor muscles. In the latter case, the faU is only conse- quent to the fracture, and, as Camper has remarked, is most frequently only an effect of it. For instance, the line of gravity of the body is, by some cause or another, inclined backward; the muscles in front contract to bring it forward again; the extensors act on the patella ; this breaks, and the fall ensues. A sol- dier broke his patella in endeavouring to kick his serjeant; the olecranon has been broken in throwing a stone. A man, at the H6tel-Dieu, fractured both bones of his knee, in the operating theatre there, by the violent spasms of the muscles, which followed an operation for the stone. The force ofthe muscles occasionally rup- tures the common tendon of the extensor muscles, or, what is more frequent, the ligament of the patella. Petit, Desault, and Sabatier, have remarked tiiese occur- rences. The patella can only be broken longitudinally by outward violence. Here it is only necessary to treat of transverse cases. The symptoms are, a considerable se- paration between the two fragments ofthe hone, very perceptible to the finger, when the hand is placed on the knee. This sepa- ration is not occasioned equally by both portions, the upper one, embraced by tlie extensor muscles, is drawn upward very forcibly by these powers, which the pa- tella no longer resists. The inferior por- tion, being merely connected with the li- gament below, is, on the contrary, not moved by any muscle, and can only be displaced by the motions of the leg, to which it is attached. Hence the separa- tion is least when the limb is extended, as it is then only produced by the upper fragment; greatest, when the limb is bent, because both pieces contribute to it; and it may be increased, or diminished, by bending the knee more or less. The diagnosis is also made clearer, by the possibility of moving the two portions of bone transversely, so as to cause a cre- pitus and pain. The swelling of the knee, apt to follow fractures of the pa- tella, may, when very great, obscure the other diagnostic symptoms. The diffi- culty of standing up, and the almost utter inability of walking, in consequence of the extensors not being able to move the leg, unless the fracture be very low down, are other symptoms. The two grand indications, in the treat- ment of the fractured patella, are to over- come the action of the extensor muscles of the leg, and to keep this part immove- ably extended. The latter object is easily accomplished; the first requires, that the contractile force of the muscles should be first lessened, so as to diminish the effort, which they nfake to draw up the superior portion of the bone, and then to oppose to them a mechanical resistance, which, operating in a diametrically opposite di- rection, wUl render their efforts ineffec- tual. The power of the muscles is to be di- minished by relaxing their fibres, which may easily be done, hy bending the thigh on the pelvis, and extending the leg, and by compressing the muscles with a roller. With regard to the mechanical resist- ance, which must operate directly against the contraction of the muscles, and pre- vent them from pulling upward the su- perior portion of the patella it should consist of something placed--and main- 472 FRACTURES. tained above it, with sufficient force to The above method certainly fulfils every keep it from ascending. indication ; and the chief trouble of the Desault used to set a fractured patella surgeon is to keep tlie bandages from be- as follows: one assistant fixes the pelvis, coming too slack". In this country, prac- while another keeps the leg completely ex- titioners overlook many little niceties of tended on the thigh, and this <.,n the pel- apparatus, which the French are, perhaps, vis. The surgeon, standing on the side too fond of, and, in the case of a fractured ofthe fractured limb, is to apply a longi- patella, trust to the roller, applied with tudinal Unen compress to the whole front tolerable tightness, just above the upper ofthe leg and thigh, taking care to make piece of the bone, and then over the knee, two openings in it, corresponding with the in the form of a figure of 8, while the sides of the patella. This strip of Unen limb is kept in the above position, with a is to be then fixed, by two or three turns splint and pillows. of a roller, at the ankle; its lower end The broken patella is almost always then turned up, and the roller also appli- united by a ligamentous substance, in- ed over it. The circular bandage is next stead of a bony one. Pott, and some to be continued to just below the knee, others, thought, that tiiere being corn- when the surgeon is to push upward the monly an interspace afterwards between lower portion of the patella, apply two or the two pieces of the patella, with a cer- three turns of the roller just below it, tain length of the connecting substance in order to fix it; desire an assistant to might be advantageous in the motion of hold the rtfUer, enjoin him, who has the the joint; but Desault always noticed, care of the longitudinal piece of linen, that the greater the distance between the to draw it up firmly, while the iiitegu- two pieces of the bone, the greater was ments are pushed in the same direction, the difficulty afterwards in walking up a lest they should sink between the two. rising, or over an unequal ground. pieces ofthe bone. The fingers ofthe left hand are then to be introduced into Fractures of both Bones of the Leg. the openings of tiie Unen compress, for the purpose of pushing downwards the upper These may be transverse or oblique. part of the patella. ,„ The longitudinal' derangement is much The two pieces being in accurate con- less common than the horizontal or an- tact, the surgeon takes the roller again; gular. "*In the former case, the inferior carries it obliquely behind the ham, brings pieces are almost always drawn outward it up behind the upper part of the bone, and backward, whilst the superior pro- withdraws his fingers, which served to ject internally and forward. The angular keep it down, substitutes for them two or derangement may be produced either by three moderately tight turns of the ban- the action ofthe posterior muscles of the dage, then covers the whole of the knee leg, or the weight of the body, and in and thigh with the same. When arrived either case the-angle will be saUent an- as high as tbe upper part of the Umb, the teriorly. The salient angle may take assistant, who draws the, longitudinal place posteriorly, if the heel be too much piece of linen forcibly upwards, is to turn raised. The derangement in the circum- down its ends over the circles of the rol- ference arises from the incUnation of the ler, with a few turns of which it is then to foot mward or outward, but it most com- be .fixed. The bandage is then to be ap- monly falls in the latter direction. The plied round the limb down to the ankle, longitudinal derangement is extremely where its application is to end. rare,* and cannot easily take place in The separation of the lower fragment transverse fractures, on account of the is further to be prevented by extending considerable extent of the fractured sur- the leg on the thigh, and the muscles re- faces ; but, in oblique fractures, the in- laxed by extending the latter on the ferior pieces are almost always drawn pelvis. Nothing keeps the leg more sure- upward by the action of the posterior ly extended, than a long, strong splint, muscles of the leg, in which position of which Desault next applied to the poste- the parts the lower ends of the superior rior part of the thigh and leg, and fixed portions project anteriorly, and may be there with a roller, while the thigh itself felt by the hand. Sometimes, however, is to be bent by raising the whole limb, when the solution of continuity is ob- from the heel to the top of the thigh, with liquely downward and outward, the an- pillows, which, of course, must form a terior projection will be produced by the gradual ascent from the tuberosity of the -lower pieces. In some cases, the pointed ischium to the foot. . ends of the bones tear and penetrate the Desault used also to keep all the appa- integuments in both kinds of derange- ratus wet with the saturnine lotion. (De- ment, so as to cause a compound frac sauU par Bichat.) ture. FRACTURES. 4*3 The usual symptoms denoting a frac- ture of the leg, are, change of direction and shape of tiie limb, pain, and incapa- bility of motion, mobility of the frac- tured pieces, and a crepitus always dis- tinct, &c. Fractures, which take place near the knee, are not much subject to derange- ment, on account of the thickness of the bone at that part; but are, however, more dangerous than those of the middle part, as being subject to be followed by a stiff- ness of the knee-joint. Fractures of the inferior part are still more dangerous. Oblique fractures are very difficult to be managed; and when their derangement is upward and Outward, the ihteguments are Very apt to be torn by the projecting points of the superior portions of bone. (Bayer.) Fractures of the Tibia. If the fracture take place near the ankle, the great extent of the fractured surfaces prevents any considerable de rangement of the fractured portions; and the fibula acting as a support on the ex- ternal side, Contributes also to this effect. This circumstance renders a diagnosis Of fractures of the tibia often very diffi- cult, and the difficulty is further increased by die little pain and inconvenience pro- duced by such a fracture, with which persons have been known to walk. Whenever tiiere is reason to suspect the accident, in consequence of a blow or a fall on tiief leg, the part should be mi- nutely examined. The fingers are to be moved along the anterior side of the tibia, ^the slightest inequality in which majfljje easily perceived,, on account of its being covered Only by the skin; and the motion of the pieces may be perceiv- ed, by grasping the opposite ends of the bone and pushing them in contrary di- rections. This motion, however, and the crepitus which accompanies it, are very indistinct on account of the fibula not allowing the fractured portions to be suf- ficiently moved on one another. (Boyer.) Fractures of tlie Fibula. Sometimes the foot is turned forcibly inwards of outwards, iri which case, the ligaments of tlie articulati-dti are always strained, and veiy frequently lacerated. It is in a case of this kind, when the foot is forcibly turned outwards, that the fibula is fractured by the pressure of the astra- galus. We have given Pott's account of such accident in the article Dislocation. To the fractures, produced by this Voi. I. cause, are to be added those resulting from a fall, or a blow on the external side of the leg, in which tlie bone always yields in the part to which the force is im- mediately applied. Whatever be /the manner, in which a fracture of the fibula is produced, the pieces are not susceptible of the longitu- dinal derangement; but are in all cases drawn a little towards the tibia, by the muscles placed in the interspace between theui. Hence a fracture of this bone will be b-dst ascertained by pressing the frac- tured portions inward. This symptom, and the consequent crepitus, may be also observed in the abduction and adduction of the foot. These signs are more evident when tiie fracture takes place near the ankle, thah when it happens high up, where the bone is covered with thick mus- cles. (Boyer.) Treatment of Fractures of the Leg. As in cases of fractured thighs, the prac- titioner may adopt either a bent or a straight position ofthe limb. In this coun- try, surgeons mostly follow Mr. Pott's ad- vice, and select the first one, of wliich alone I shall treat. " In the fracture of the fibula only, the position is not of much consequence; be- cause by the tibia remaining entire, the figure of the leg is preserved, and exten- sion quite unnecessary; but still, even here, the laying the leg on its side, in- stead of on the calf, is attended with one very good consequence, viz. that the con- finement of the knee, in a moderately bent position, does not render it so inca- pable of flexion and use afterward, as the straight or extended position of it dpes, and consequently, that the patient will be much sooner able to walk, whose leg has been kept in ihe former posture, than he whose leg has been confined in the latter. " In the fracture of both tibia and fibu- la, the knee should be moderately bent, the thigh, body, and leg, being in the same position as in the broken thigh, if common splirits be used, one should be placed underneath the leg, extending from above the knee to below the ankle, the foot being properly supported by pillows, bolsters, 5tc. and another splint of the same length should be placed on the Upper side, comprehending both joints in the same manner; which disposition of splints ought always to be observed, as to their length, if the leg be laid ex- tended in tlie common way, only changing tlie nominal position of them, as the pos- ture of the leg is changed, and calling 3P 474 FRAC1 what is inferior in one case, exterior in the other; and what is superior in one, in tiie other inferior. " If Mr. Sharp's splints be made use of, there is in one of them a provision for the more easy support of the foot and ankle, by an excavation in, and a pro- longation of the lower, or fibular splint, for the purpose of keeping the foot stea- dy." (Pott) The strong muscles ofthe leg being re- laxed by placing the Umb in the bent po- sition, as advised by Pott, the surgeon is to make such extension as seems requi- site, for bringing the ends of the fracture into even apposition. Then he is care- fuUy to raise tiie leg a little way from the surface of the bed, by taking firmly hold ofthe limb, above and below the fracture, and elevating the broken bones together, in such a way as shall keep both the up- per and lower portions as nearly as pos- sible on the same level. At this moment, an assistant should put, exactly beneath the leg, tbe under splint, which has been previously got ready, by covering it with a soft pad, and laying over this an eigh- teen-tailed baiidage. The limb is now to be gently depressed, tUl it rests on the apparatus. The surgeon, before pro- ceeding further, must once more observe that the ends of the bones are evenly in contact. Being assured of this important point, he is to apply a piece of soap plas- ter, and lay down the taUs of the band- age. Another soft pad, weU filled with tow, is next to be put over the upper sur- face of the leg, and over that the other spUnt, when the straps are to be tight- ened. Fractures of tlie Scapula. The acromion, inferior angle, neck, and coracoid process, are the parts most com- monly fractured. When the acromion is broken, the weight of the arm, and the contraction ofthe deltoid muscle,-draw it downward, while the trapezius and le- vator scapulae draw the rest of the bone upward and backward. The serratus major anticus draws forward the lower angle, when this part is fractured, while the rest of the scapula remains in its na- tural situation; or, if the angular por- tion be considerable, the teres major, and some fibres of the latissimus dorsi, con- tribute to its derangement forward and upward. The pectoralis minor, coraco-brachi- alis, and short bead of the biceps, concur in drawing forward and downward the coracoid process, when it is broken. (Boyer.) When tlie neck of the scapula is frac- tured, the weight of the arm makes it drop down so considerably, as to give tiie appearance of a dislocation ; but, the fa- cility of lifting the os brachii upward, the crepitus, and the falling of the limb downward again, immedia ely it is un- supported, are circumstances clearly marking, that the case is not a disloca- tion. Sometimes great pains, and a cre- pitus, are experienced, on moving the shoulder-joint, after an accident; and yet the spine, that part of the scapula, and all the above parts, are not broken. In tliis circumstance, we may suspect either that a small portion of the head of the os brachii, or a Uttle piece of the glenoid cavity of the scapula, is broken off; which latter occurrence 1 think is not a very uncommon one. Fractures of the acromion are attended with pain, which is increased by the mo- tion of the arm "■ the form of the shoulder is changed; the broken part, which has descended, may be raised, by bringing up tiie elbow close to the side. (Boyer.) When the inferior angle is broken, the part remains motionless, while the rest of the scapula is moved; and it is so se- parated, that no mistake can be made. (Boyer.) Fractures of the spine and body of the bone, are all attended with a crepitus; and, in the first cases, an irregularity in the course of* the spine of the bone may generaUy be easdy felt. TREATMENT. . . When the scapula is fractured longitu- dinally, or transversely, it is merely ne- cessary to fix the arm to the side by means of a bandage, which includes t^arm and trunk, from the shoulder to tne el- bow. Thus the motions of the shoulder, which are only concomitant with those of the arm, are prevented. (Boyer.) When the inferior angle is broken, and drawn downward and forward by the ser- ratus major anticus, the scapula must be pushed toward the fragment, by pushing the arm itself inward, downward, and forward, where it is to be kept with a roller. The fragment is also to be kept backward, as much as possible, with com- presses and a roller. The arm is to be supported in a sling. (Boyer.) The fractured acromion requires the arm to be so raised, that the head of the os brachii will push up the acro- mion, while an assistant pushes the sca- pula forward and downward, in a con- trary direction to that of the arm. To maintain this position, a circular band- age is to be applied round the arm and body. FRACTURES. 475 Desault used to apply also a small pil- low under the axilla, before putting on the bandage, to make the head of the os brachu project more upward, on bringing the arm near the side. Compresses are to be placed on the scapula, which, with this means, and a roller^ are to be kept downward and forward. When the coracoid process is* fractured, the muscles attached to it are to be re- laxed, by bringing the arm forwards to- wards the breast, and confining it there in a sling; while the shoulder is kept downward and forward, and a compress confined just under the broken part, with a roller. The treatment of a fracture of the neck of the scapula consists in raising the shoulder to its proper height; in com- pletely taking off the weight of the arm, by wearing a proper sling, which always supports the limb from the elbow to the fingers; and in entirely preventing all motion of the arm by binding it to the trunk with a roller. Fractures ofthe Clavicle. This bone being long and slender, un- supported at its middle, andprotected ex- ternally only by the integuments', is very often broken. Its serving to keep the scapula at' a proper distance from the sternum, and as a point d'appui for the os- brachii, every impulse of which it receives, makes its fractures still more common. It may be broken at any part; but, its middle, where the curvature is greatest, is most frequently the situation of the injury. It is not very often fractured at its scapulary extremity. However, a di- rect force, falling on the shoulder, may break any part of the clavicle, on which ' it immediately acts. The soft parts, in this kind of case, will also be contused, or even lacerated. A comminuted fracture may be thus occasioned, and, if the violence be very great, the subclavian vessels and nerves may be torn. The fall of a heavy body on the shoulder often gives rise to a pa- ralysis of the arm. When the fracturing force is applied to the ends of the bone, as by a fall on the point of the shoulder, or on the hands, while the arms are extended, the clavicle may be very much bent, and fractured so obliquely, that the broken portions shall protrude through the skin. Fractures of this bone are usually at- tended with derangement of the broken ends, except when the injury takes place at the scapulary extremity, and within the ligament, tying together the clavicle and coracoid process. The external portion of the clavicle is always that which is deranged. The in- ternal part cannot be moved out of its natural situation, by reason of the costo- clavicular ligaments, and of its being drawn in opposite directions, by the ster- no-cleido-mastoideus, and pectoralis ma- jor, muscles. The external portion, drawn down both by the weight of the arm, and the action of the deltoid muscles, and for- ward and inward by the pectoralis major, is carried under toe internal portion which projects over it. The broken clavicle no longer keeping the shoulder at a due distance from the sternum, the arm falls forward towards the breast. The patient finds it impossible to put his hand to his forehead, because this act makes a semi- circular motion of the humerus neces- sary, which cannot be done while that bone has not a firm point d'appui. The shoulder and upper extremity may be observed to be nearer the breast than those of the opposite side. The motion of the pieces of bone on one another may be felt, as well as the projection of the end of the internal portion. When the shoulder is moved, a crepitus may also be perceived, but doing this is productive of great pain, and the diagnosis is so ob- vious, that it is quite unnecessary. The ancients, and many moderns, have supposed, that in order to set a fracture of the clavicle, the shoulder must be drawn back, and fixed in that position. The patient was placed on a low stool, so that an assistant might put his knee between his shoulders, which he drew back at the same time with both hands, while the surgeon applied the bandage, which was to keep the parts in this po- sition. But, in thus drawing the shoul- ders towards one another, the scapula is obviously pushed towards the sternum, and with it the external portion of the clavicle, which passes under the internal one. The figure of 8 bandage has commonly been used for maintaining the parts in this position. While the assistant keeps back the shoulders, as above described, the sur- geon is to apply one end of a roller to the arm-pit on the side affected, and then make it cross obliquely to the opposite shoulder, round which it is to pass, and from this to the other shoulder, about which it is to be rolled in the same man- ner, and crossed afterwards repeatedly before and behind. The tightness, with which it is necessary to apply this band- age, produces a great deal of excoriation about the arm-pits, and the effect is to make the ends of the fracture overlap each other, the very thing which it is wished to avoid. Boyer remarks, that 476 FRACTURES. the iron-cross proposed by Heister, the corselet described by Brasdor in the Mem de PAcad. de Chir. and the leather strap recommended by Brunninghaussen, are only modifications of the figure of 8 bandage, and are not at all better. Extension is to be made, by means of the limb, which is articulated with the fractur*ed bone. This is done by convert- ing the humerus into a lever, by carrying its lower end forward, inward, and up- ward, pushing the shoulder backward, upward, and outward, and putting a cushion in the arm-pit to serve as a fulcrum. Desault used to put in the arm-pit a hair or flock cushion, five or six inches long, and three inches and a quarter thick at its base. Two strings are attached to the corners of the base, placed upward, which cross the hack and breast, and are tied on the shoulder of the other arm. The cushion being thus placed in the arm-pit, ajpd the fore-arm bent, Desault used to take hold of the patient's elbow, and carry it forward, upward, and in- ward, pressing it forcibly against the breast. By this manoeuvre, the humerus carries the shoulder outward, the ends of the fracture become situated opposite each otiier, and all deformity is removed. An assistant is to support the arm in this position, while the surgeon, having a single-headed roller nine yards lohg, is to place one end of it in the arm-pit of the opposite side, and thence apply the band- age over the upper part of the arm, and across the back to the same situ..'.ion. The arm and trunk are to be covered with such circles ofthe roller, as far down as the elbow, drawing the bandage more tightly, the lower it descends. Compresses, dipped in camphorated spirit, are next to be placed along the fractured bone. Desault then used to take a second roller, of the same length as. the first, and put one end of it under the opposite arm-pit, whence it was car- ried across the breast over the compress and fracture, then down behind the shoulder and arm, and, after having assed under the elbow, upward on the reast. Desault next brought it across to the sound shoulder, under and round whic'n he passed it, for the purpose of fixing the first turn. IJe then conveyed the roller across the back, brought it over the compresses, carried it down in front of the shoulder and arm, under the el- bow, and obliquely behind the back to the arm-pit, where the application began. The same plan is repeated, until all the roller is spent. The apparatus is to be secured by pins, wherever they promise to be useful, and the patient's hand is to be kept in a sling. Boyer has invented an apparatus fop fractured clavicles, which is more simple, than that employed by Desault. The cushion is to be applied under the arm. The apparatus consists of a girdle of linen cloth, which passes round the trunk om. level with the elbow. It is fixed on by means of three straps, and as many buckles. At an equal distance from its extremities are placed externally op each side two buckles, two before and two behind the arm. On the lower part of the arm, is to be laced a piece of quilted cloth, five or six fingers broad. Four straps are attached it, which correspond to the buckles on the outside of the gir- die, and serve both to keep the arm close to the trunk, and from moving either backward or -forward. (See Boyer'* Lec- tures upon tlie Diseases of tlie Bones.) Certainly, the methods recommended by Desault and Boyer are very judicious and scientific. They are not, however, much adopted in this country, perhaps in consequence of the universal aversion among English surgeons to all appara- tuses, which are not exceedingly simple. It is to be hoped, at the same time, that, in the treatment of fractured clavicles, they will always attend to the principles, wliich Desault and Boyer have incul- cated. If they understand, why the posi- tion of the arm should be such as these eminent surgeons point out, they wiU have no difficulty in doing what is pro- per, and with a cushion sling, and a cou* pie of rollers, they will easily maintain the proper posture. I cannot quit this subject without cau- tioning the surgeon never to faU into the error of supposing the rising end of a broken clavicle to be the end which is displaced. This is the one, which is truly in its right situation, and which lias, often been made, by injudicious pressure, to protrude through the integuments, as \ my self have seen. FRACTURES Of THE OS BRACHII, OH HUMERUS. This bone may be fractured at any point of its length; in the middle, at either extremity, or above the insertion of the pectoralis major, latissimus dorsi, and teres major. This last case is termed fracture of the neck of the humerus; but that denomination has' not the merit of being strictly anatomical. It is possible, however, that what is strictly called the neck of the humerus may be fracturedi particularly, by a gun-shot wound. By FRACTURES. 477 neck Of the humerus, we understand that circular narrowing, which separates the piberpsities from the head. The fractures of thus bone may be trans- verse or oblique, simple or compound. In short, whatever has been said of the differences of tractures in general, is ap- plicable to those in particular. The same m.y be said of the causes, whether acting qii the extremities pf the hone, or imme- diately on the part fractured- The transverse tractures of the middle part, under the insertion of the deltoid muscle, are attended vithbut a trifling de- rangement. The brachialis internus and the triceps, attached posteriorly and an- teriorly to both fractured portions, coun- teract one another, and aumit oniy a slight angular derangement. When the fractufae takes place above the insertion of the del- toid muscle, tbe interior portion *i*» first drawn outward and then upward on the external side of the superior. Fractures of the humerus, near its lower end, such particularly as are transverse, are not subject to such derangement; an effect Which is to be attributed to the breadth of the fractured surl-aces; to their being covered posteriorly by the triceps muscle, and, anteriorly, by the brachialis internus, which admit only a slight angular de- rangement by the' inferior portion being drawn a little forward. Oblique fractures are always attended with derangement, whatever be the part fractured. The inferior portion being drawn upward by the action of the del- toides, biceps, coraco-brachialts, and long portion of the triceps, glides easily on the superior, and passes above its lower ex*? tremity. Finally, fractures of the neck of the humerus are always attended with de- rangement, which is produced by the ac- tion of the pectoralis major, latissimus dorsi, and teres major, which being at- tached to the lower portion near its supe- rior extremity, draw it first, inward and then up-ward, in which last direction it is Eowerfully urged by the biceps, coracor rachialis, and long portion ot the triceps. The superior portion itself is, in this case, directed a Uttle outward by the action of the infraspinatus, supraspmatus, and teres minor, wliich make the head of the hu: merus perform a rotatory motion in the glenoid cavity. We proceed to examine the different marks, by wliich these fractures may be ascertained. The shortening and change in the di- Bection of the limb, the crepitus, which may be very distinctly perceived by mov- ing the broken pieces in opposite direc- tions, the pain, and impossibiUty of mov- ing the arm, 8tc. joined to tlie history of tiie preceding circumstances, render if easy to establish a diagnosis.. Fractures of the neck ot the humerus are not so easily ascertained, and have been frequently, for want of attention, confounded with luxations of that bone. The diagnostic symptoms of these two affections are however veiy different. When the neck ofthe humerus is frac- tured, a depression is observed at the su- perior extremity and external side of the arm, which is veiy different from that ac- companying the luxation downward and inward of tliat bone. In tbe latter case, under the projection of the acromion, a deep di-pre-^sion is found in the part which tbe head of the humerus naturally occu- pies ; whereas, in the fracture ofthe neck of that bone, the shoulder retains its na- tural form, the acromion does not project, and the depression is found below the point of the shoulder. Besides, in examin- ing the arm-pit, instead of finding there a round tumour formed by the<*iiead ofthe humerus, the fractured and unequal ex- tremity of that bone will be easily distin- guished. The motion of the broken por- tions, and the orepitus, which may be pro- duced by moving them, serve still further to establish the diagnosis. (Boyer on the Bones, Vol 1.) A simple fracture ofthe body ofthe hu- merus is not very dangerous; but, in that near the ends of the bone, there is some reason to expect the neighbouring joint to inflame, and remain stiff for some time after the cure. Irt ordinary fractures of the os brachii, it is usual to apply two pieces of soap- plaster, which together surround the limb, at the situation where the accident has happened. Extension, if necessary, being now made by an assistant, who at once draws the lower port ion of the bone down- ward and bends the elbow, the surgeon is to apply a roller round the limb. ^The external splint is to extend from the acro- mion to the outer condyle, and, being lined with a soft pad, the wood cannot hurt the limb by pressure. The internal splint is to reach from the margin of the axilla to a little below the inner condyle, and is to be well guarded with a pad, filled with tow, or any other soft mate- rials. Some surgeons are content with the ap- plication of two splints; but, though the two, above described, are those on which we are to place the greatest reliance, yet, as the cylindrical form of the arm conve- niently allows us completely to incase this part of the limb in splints, I shall always be anadvocate for the employment of four; one on the outside, one on the inside, one en the front, and another on the back of 478 FRACTURES. tlie arm. These are to be carefully fixed in their respective situations by means of tape. The elbow and whole of the fore-arm are to be quietly and effectually supported in a sling, throughout the whole treatment ofthe case. FRACTTOE OF THE HEAD, OR NECK OF THE OS BRACHII. 1. General Considerations. Chirurgical language here differs from that adopted by anatomists, and, under the name of fracture of the neck of-the humerus, is not meant, that of tlie circu- lar, hardly perceptible depression, which separates the head from the tuberosities of this bone. By this expression, surgeons imply the fracture of that contracted part of the humerus, which is bounded above by these tuberosities, which below is con- tinuous with the body of the bone ; which has the tendons of the pectoralis major, latissimus dorsi, and teres major inserted below it; and which many practitioners extend even as low as the insertion of the deltoid muscle. Indisputable facts, however, prove the possibility of the anatomical neck of the bone being fractured, and C. Larbaud shewed Bichat the humerus of a young man, aged 17, the head of which bone was accurately detached from its body, by a division which had obliquely interested the upper part of the tuberosities. But there are too few instances of this kind, in the records of surgery, to admit of our taking a general view of this sort of frac- ture. 2. Varieties and Causes. The operation of external bodies, active, when driven against the shoulder, passive, when the shoulder or arm is driven against them, is the constant cause of the fracture of ihe neck of the humerus. The solu- tion of continuity, thus occasioned, is sometimes direct, and at other times, tlie result of a contre-coup. The first almost always arises from a fall on the fleshy part ofthe shoulder, and, as the motion must be exceedingly violent to produce this effect through the thick covering formed by the deltoid, this mus- cle is sometimes contused and affected with ecchymosis. Even blood may be ef- fused from some of the ruptured articular veins, or arteries, and form a collection, which Desault has remarked should be speedily opened.* • I must enter my protest against such The counter-fracture arises from a fall on the elbow, when this part is separated from tlie trunk, or else from a fall on the hand, which a natural instinct makes us extend, with the arm and fore-arm, to protect ourselves at the time of falling. 3. Symptoms, &c. The whole of the symptoms of a frac- ture of the neck of the humerus suffi- ciently denote its existence; but, it is not always an easy matter to see this whole, and here more difficulties occur in the diagnosis, than in any other fracture of tlie humerus. There is an acute pain experienced at the moment of the fall; sometimes, the noise of something breaking is heard. There is always a sudden inability to move the limb, which, left to itself, re- mains motionless. But, on externalforce being applied to the member, tliis readily yields, and admits of being moved, with the greatest ease, in every direction. An acute pain attends such motion, which, carried too far, may cause bad con- sequences, as has been observed in patients in whom the fracture has been mistaken for a dislocation. Below the acromion a depression is re- markable, always situated lower down, than that which attends the latter acci- dent. If we place one hand on the head, while the lower part of the bone is moved in various directions with the other hand; or if, while extension is made, an assist- ant communicates to the bone a rotatory motion, the following circumstances are perceived. 1. We discover, that the head of the humerus remains motionless. 2. A more or less distinct crepitus, arising from the two ends of the fracture rubbing against each other. These two symptoms are invariably characteristic of the acci- dent ; but the swelUng of the joint some- times prevents us from detecting them. The ends ofthe fracture are sometimes not at all deranged, and, as then most of the symptoms are absent, the diagnosis is rendered still more difficult. In general, however, the ends ofthe fracture are dis- placed, and, in this circumstance, it is the lower one which is out of its proper posi- tion, and not the upper one, which is of little extent, and is not acted upon by many muscles. The displaced state of the fracture is practice, however; both because I have observed that large extravasations of blood about the shoulder are usually very soon absorbed, and making an opening may do harm, and cannot do good. FRACTURES. 479 generally, not very perceptible, in regard to length, unless the fracture be very oblique, and its pointed spiculje irritate tlie muscles, and make them contract with increased power; or unless the blow, which is very violent, continue to operate after the bone has been broken, and force the ends of the fracture from their state of apposition. In this way, the body of the bone has been known to have been drawn or driven upward, so as to protrude through the deltoid muscle, and integu- ments far above the height of the head of the bone. But commonly, as Petit observes, the weight of the limb powerfully resists the action of the muscles, and the derange- ment of the fracture is more liable to be fcransverse. In this circumstance the lower end of the fracture is displaced outward or inward, and very rarely in any other direction. In the case, which is much the most frequent, the elbow is separated from the trunk, and cannot be brought near it without pain; in the instance of the bone being displaced outward, tiie limb has a tendency to the opposite direc- tion. 4. Prognosis. A fracture of the neck of the humerus is not a serious event, and if, as Heister remarks, prope caput, fracturapejor, et dif- ficiUus curatur, it is less on account of the nature and situation of the disease, than of the difficulty experienced in maintain- ing the ends ofthe fracture in contact. 5. Reduction This object usually presents but few difficulties, and the multiplicity of means formerly employed for its accomplish- ment, serve only to exhibit the useless- ness of such resources. Most of the machines, designed for re- ducing dislocations of tlie humerus, have been applied to this kind of fracture. To such machines succeeded the use of pul- leys, weights suspended to the limb, &c. useless plans, as their only tendency was to increase the natural power, which was always more than sufficient. Petit proposes to reduce the fracture, by first placing the arm at a right angle with the body; and then making exten- sion with the hands of an assistant, ap- plied above the elbow; while the coun- ter-extension is made by another assist- ant, who is to take hold ofthe fleshy part of the shoulder. This method is liable to three kinds of inconveniences. It fatigues and even pains the patient; it lessens the extending powers by bringing them near the moveable point, it irritates such mus- cles as proceed from above to the lower end of the fracture, and thus increases their disposition to contract. Hence dif- ficulties sometimes attended the reduc- tion, which is always simple, when, the trunk being fixed, gentle extension is made on the fore-arm half bent. Desault used to accomplish the reduction in the following way. The patient may either sit upon a chair, or the edge of a bed. The arm is to be a little separated from the trunk, and carri- ed somewhat forward. An assistant is to fix the trunk by drawing towards him the arm of the op- posite side. This mode of making ex- tension is preferable to that commonly employed, and which is effected by ap- plying the hands to the upper part of the affected shoulder. The other being more distant from the resistance, there is no need for exerting so much power; and the patient's body being quite uncovered, the surgeon can conveniently apply the bandage, without deranging the exten- sion. A second assistant extends the fore- arm half bent, which he makes use of as a lever, placing one hand behind the wrist for the purpose of a fulcrum. The other hand, applied to the front and mid- dle part of the fore-arm, and making pres- sure upon it from above downward, re- presents the power. The ends of the frac- ture, which are to be placed in apposition, form the resistance. The relaxation of muscles, produced by the half flexion of the fore-arm, and the position of" the arm a little raised from the side, are peculiarly favourable to this mode of extension, recommended by the ancients and English. This method has also the advantage of leaving uncovered every part of the limb, to which the ap- paratus is to be applied, and thus the as- sistant's hands can remain in the same po- sition during all the time of applying what- ever may be needed. In this way the reduction takes place of itself, on employing a very Uttle force, methodically directed, according as the fracture is displaced inward or outward. If the surgeon put his hands on the situa- tion of tiie fracture, it is rather to examine the state of the ends of the broken bone than to accomplish a thing seldom requir- ed, namely, what is implied by the term coaptation. MEANS OF MAINTAINING THE REDUCTION. All the apparatus for a fracture being only resistances, opposed by art to the powers causing the derangement of the 4S0 FRACTURES. broken part, it follows, that the whole should act in an inverse ratio to such powers. We have seen, that tiiese con- sisted : 1. Ofthe action of external bodies, favoured by the extreme mobility of the arm and shoulder ; 2. Ofthe action ofthe latissimus dorsi, pectoralis major, and teres major, which diajv inward the lower end ofthe fracture, or, what is more com- mon, of the deltoid, which pulls it out- ward ; 3. Ofthe contractions ofthe mus- cles of the arm, which tend to draw a little upward the said end of the frac- ture. Hence, 1. to render the arm and shoul- der immoveable ; 2. to bring either out- ward, or inward, the lower end of the fracture; 3. to draw downward the same ; are the three indications, which every bandage, destined for a fracture of the neck of the humerus ought to fulfil. The last object merits less attention, than the two others, because the weight of the arm is alone almost sufficient for the purpose. Desault used to employ the following ap- paratus for the cure of fractures of the neck of the humerus. 1. Two bandages, one about five or six ells long, the other eight or ten; both being about three finger-breadths wide. 2. Three strong splints of different lengths, and two finger-breadths broad. 3. A linen pillow, three or four inches thick at one of its ends, terminating at the other in a narrow point, and long enough to reach from the axilla to the elbow. 4. A sling to support the fore-arm. 5. A towel to cover the whole of the apparatus. The reduction is to be effected as above explained, and the assistants are to con- tinue the extension. Then the surgeon is to take the first roller, which is to be wet with the aq. veg. min. and is to fix one of its heads by applying two circular turns to the upper part of the fore-arm. The bandage is now to be roUed mode- rately tight round the arm upward, mak- ing each turn overlap two thirds of that ^ which is immediately below it. When the roller has reached the upper part of the Umb, it must be doubled back a few times to prevent the folds, which the inequality of the part would create. The bandage is afterwards to be carried twice under the opposite axilla, and tiie rest of it, rolled up, is to be brought up to tlie top of the shoulder, and committed to the care of an assistant. The first splint is to be placed in front, reaching from the bend of the arm as high as the acromion. The second, on the out- side from the external condyle to the same height. The third, behind, from the olecranon to the margin of the axilla. The pillow, interposed between the arm and thorax, serves as a fourth splint, which becomes useless. An assistant ap. plies these parts of the apparatus, and holds them on by applying his hands near the bend Of the arm, in order not to ob- struct tlie application of the remainder of the bandage. The surgeon takes hold of the bandage again, and applies it over the splints with moderate tightness, and the bandage ends at the upper part of tiie fore-arm, where it begari. The assistants continually keeping up the extension, the surgeon is to place the pillow between the arm and trunk, taking care to put the thick end upward, if the fracture be displaced inward ; but down- ward, if this -hould be displaced out- Ward, which is most common. It is to be attached by two pins to the upper part of the roller. Tlie arm is to be brought near the trunk, and fixed upon (he pillow, by means of the second roller, applied round the arm and thorax, / The turns of this ban- dage should be veiy tight below, and rather slack above, if the fracture should be displaced inward; but, if outward, they should be slack below, and tight above. The fore-arm is to be supported in a sling, and the whole of the apparatus is to be enveloped in a napkin, which will prevent any friction from deranging the bandages. If we compare the effect of the above apparatus, in fulfilling the indications above specified, we shall easily see, that they are very well accomplished. The arm, firmly fixed against the trunk, can only move with it, and then nothing dis- places the lower end of the fracture, which is equally motionless. The shoul- der cannot communicate any motion to the upper end of the fracture. The pil- low, differently disposed, according to the direction in which tile lower extre- mity of the fracture is displaced, serves to keep tliis part in the opposite position. Should this part ofthe bone project in- ward, the thick end of the pillow will remove it further from the chest. The bone will be kept at this distance from the side by the turns of the bandage, which, being very tight downward, will act upon the limb as a lever, the fulcrum for which will be the piUow, and the resistance, the action of the pectoralis major, latissimus dorsi, and teres major. Thus the ban- dage will have the effect of bringing the elbow nearer the trunk, arid move the lower end of the fracture in the opposite direction, so that it may be here consi- dered as an artificial muscle, directly op- posing the natural ones. FRACTURES. 431 When the lower end of the fracture is drawn outward, which is most commonly the case, the contrary effect will be pro- duced, both from the pressure exercised by the bandage on the upper end of the displaced portion of the bone, and from the situation of the elbow, wliich is kept outward by the thick part of the pillow. The outer splint will also prevent the lower end of the fracture from being dis- placed outward, both by its mechanical resistance to the bone, and by compress- ing tbe deltoid muscle, which is the chief cause of the derangement in this direc- tion. All derangement of the lower end of the fracture, forward, or backward, is prevented by the front and back splints. All derangement, in regard to length, already prevented by tiie w-eight of the limb, is still more effectually hindered by the compression exercised on the muscles of the arm, causing such derangement both by the splints and roller. (See Euvres Chirurgitales de Desautt, par Bi- chat, Tom. 1,) FRACTURES OF TIIE LOWER END OF THE OS BRACHII, WITH SEPARATION OF THE CONDrLES. Fractures of the os brachii, with detach- ment of its condyles, seem to have es- caped the notice of most authors, who have written on the diseases of the bones. The ancients have transmitted to us noth- ing upon the subject. Heister only men- tions the fracture of the lower end of this bone, with a view of making an, unfavourable prognosis. This accident is not uncommon, and Desault, in par- ticular, had frequent occasion to meet with it. Whatever the causes of this kind of fracture's may be, they are commonly pro- duced in such a way, that a longitudinal division separates the two condyles from each other, and extending more or less upward, is bounded by another transverse, or oblique division, which occupies the whole thickness of the bone. Hence, there are three different pieces of bone, and two fractures. Sometimes, the division is more simple. Then, taking a direction outward, or in- ward, it crosses obliquely downward the lower end of the os brachii, terminates in the joint, and only detaches one ofthe condyles from the body of the bone. The other remains continuous with it. In the first case, the deformity is great- er, and the fractured part is more move- able. When pressure is made, either before, or behind, on the track ofthe lon- gitudinal fracture, the two condyles oe- coining further separated from each other, \ol. I. leave a fissure between them, and the fractured part is widened. The fore-arm is almost always in a state of pronation. On taking hold of the condyles, and mov- ing them in different directions, a very distinct crepitus is perceived. In the second case, the separation of the condyles from each other is not so easy; but a crepitus can always be dis- tinguished, on moving the detached con- dyle. In one case, in which the exter- nal condyle was the only one broken, De- sault found the limb always supine; a position, in effecting which, the muscles inserted into this part are, doubtless, con- cerned. An acute pain, the almost inevitable effect of bending, or extending, the fore- arm ; the habitual half bent stale of this part of the limb, and sometimes a subse- quent swelling of it, together with more or less tumefaction around the joint, are observable in both kinds of cases. These accidents may also be complicated with wounds, splinters of bone, &c. when the blow has been very violent, or a pointed piece of the bone protrudes through the flesh. pnoGXosis. Almost all writers consider the com- munication of a fracture with a joint, as a fatal kind of complication. Swelling and inflammation of the adjacent parts ; continuance of pain after the reduction ; large abscesses ; even mortification ofthe soft parts, and caries of the bones, are, according to such authors, the almost in- evitable consequences of these fractures, and anchylosis the most favourable ter- mination. Pare, Petit, Heister, Duver- ney, all give this exaggerated picture of these accidents. Analogous fractures of the olecranon and patella shew, that this representation is magnified beyond truth. Modern ob- servation has dispelled the ancient doc- trine of the effusion of callus in the joint, and with it one of the principal causes, assigned by authors for the symptoms they so much dread. The communication of tiie cavity of the joint with the external air might be thought to have more real influence ; but, this can only occur in compound fractures. Desault has often learned from experience, that the contact of air is not so dangerous, as has been sup- posed. The defect in the mode of treatment was, formerly, the general cause of all the ill consequences. Desault has never seen them in his extensive practice. ■JQ 48:: FRACTURES. REBCCTION, AND MANNER OF MA1NTAIN- I>Q IT. The detached condyles, being drawn in opposite directions by the ^muscles of the arm and fore-arm, commonly remain un- moved between these two powers, and are but little displaced. External force may, however, put them out of their proper situation, and they may then become dis- placed forward, or backward, or they may separate from jeach other sideways, leaving an interspace between them. The apparatus, should, therefore, resist thein in these four directions, and this object is easily accomplished by means of four splints, kept on by a roller. The two lateral splints are, in part.cular, neces- sary, when the condyles are separated from the body of the bone, with an inter- space between them. If one of them be still continuous with the humerus, the splint on this side will be of less use. There is no occasion for the apparatus to extend as high as when the arm is fractured higher up. Of what avail, in steadying the fractured part, are the cir- cles of the bandage, applied to the body of the bone, so much above the injury ? Their only utility would consist in re- straining the action of the brachialis and triceps, by compressing these muscles. On the other hand, the roller should be continued over the fore-arm, in order that the joint according to the judicious. precepts of Paulus JEgineta, may corres- pond to the middle ofthe bandage, which is here firmer, than any where else. This method is also of use by producing a gen- tle compression on the muscles implanted into the condyles. Desault recommends having the front and back splints flexible of their middle part, which should be applied to the bend ofthe arm, and elbow. ((Euvres Chirur- gicales de Desault, par Bicliat, Tom 1) The detail of the reduction of the frac- ture, and application of the roller and splint, becomes useless after what has beeen said. A further account may be found in the work mentioned in the pre- ceding paragraph. FRACTURE OF TIIE FORE-ABM. The fore-arm is much more frequently broken, than the arm, because external force operates more directly upon it, than the latter part, especially, in fells, on the hands, which are frequent accidents — Bichat mentions, in Ius account of De- sault's practice, that fractures of the fore- arm often h;-ld the first place in the com- parative table of such cases, kept at the Hotel-Dieu. We know, that the fore-arm is com- posed of two bones, the ulna and radius. The last is much more liable to fractures, than the first one, because it is articulated with the hand by a large surface. All the shocks, received by the latter part, are communicated to the radius. The situa- tion of this bone more immediately ex- poses it to such causes, as may break it ; a circumstance, which we may readily convince ourselves of on the first inspec- tion. Both bones of the form-arm may be broken at the same time, or one alone may be fractured. One fracture has been absurdly termed complete; the other, in- complete. FRACTURES OF BOTH BONES. These may occur at the extremities, or middle of the fore-arm. They are fre- quent at the middle; very common be- low ; but, seldom happen at the upper part of the fore-arm, where the numerous muscles, and the considerable thickness of the ulna, resist causes, which would otherwise occasion the accident. The bones are usually broken in the same line ; but, sometimes, in two different di- rections. The fracture is almost always single ; but, in some instances, it is dou- ble, and Desault, in particular, was one day called to a patient, over whose fore- arm the wheels of a cart had passed, so as to break the bones, at their middle and lower part, into six distinct portions. The middle ones, notwithstanding they were quite detached, united very well, with hardly any deformity. These accidents are most commonly oc- casioned by direct external violence; but, occasionally, they are produced by a coun- ter-stroke-, which is generally the case, when the patient has fallen on his hand. But, in this instance, as the hand is prin- cipally connected with the lower broad articular surface of the radius, this bone alone has to sustain almost the whole shock of the blow, and hence is usually the only one broken. STMPTOMS. It is, in general, difficult to hje deceived by the symptoms, indicating fractures ot the fore-arm. Motion at a part of the limb, where it was previously inflexible ; a crepitus, almost always easily felt; some- times a distinct depression in the situs-. tion of the fracture ; a projection of the ends ofthe fracture beneath tiie skin, but, a less common symptom ; pain produced by moving the part ; a noise sometimes audible to the patient at the moment of the accident; an inability to perform the FRACTURES. 483 motion of pronation and supination ; and an almost constant half-bent state of the fore-arm ; are the symptoms, which, with the phenomena, common to all other frac- tures, characterize this one. These are sufficient to dispel all doubts, which im- mense swelling of tiie limb may create. There *% one case, however, in which, the fracture being very near the wrist- joint, similar appearances to those of a dislocation of this part may arise. But, attention to whether the styloid processes, are above, or below, the deformity, will discover whether the case be a fracture, or dislocation. In a fracture the part is also more moveable, and there is a cre- pitus. (Euvres Chirurgicales de Desault, par Bichat, Tom. 1.) As Boyer remarks, the two cj.'.-j may be distinguished by simply moving the hand, by which mo- tion, if there be a luxation without frac- ture, the styloid processes of the radius and ulna will not change their situation ; but, if a fracture do exist, these pro- cesses will follow the motion of the band. (Boyer, Lepons sur les Maladies des Os, Tom. 1) The connexion ofthe two bones of the fore-arm, by the interosseous ligament, which occupies the interspace by which they are separated, and tlie manner, in which the muscles that are attached to both, are inserted into them, render the derange- ment of the broken pieces in the longitu- dinal direction very difficult; and, in re- ality, a derangement in this direction has been seldom observed,andnever to any con- siderable degree : when it does take ph.ce, it,is to be ascribed to the cause ofthe frac- ture, rather than to muscular contraction. Tlie derangement in the direction of the diameter, on the contrary, always takes place in such a manner, as that the four pieces approach one another, and the in- leroi-seous interspace diminishes, or is entirely obliterated at that part near the seat of the fracture ; which approximation at the ends of the bones causes an evi- dent deformity ofthe part. To tliis must be added the angular de- formity, which the fracturing cause always produces, either forward or backward, ac- cording to its direction. Bo\ er RS$es the following account of the treatment of a fracture ofthe fore-arm, both bones being broken. In order to adjust a fracture of these bones, the fore-arm' is to be bent to a right angle with.the arm, and the hand placed in a position between pronation and supination. The fore-arm and hand being thus placed, an assistant takes hold of the four fingers of the patient, and ex- tends the fractured parts, while another assistant makes counter-extension by fix- ing the humerus with both his bands. By these means, the operator is enabled lo restore the bones to their natural situa- tion, and to push the soft parts into the interosseous space, by a gentle and gra- duated pressure on the anterior and pos- terior sides of the arm. Coaptation is very easy in fractures of these bones, *^s are indeed all the other parts of the ope- ration, in which effort and violence are not at all required. The fracture being thus set, the bones are kept in their place by applying first on the anterior and posterior sides of the fore-arm two longitudinal and graduated compresses, the base of which is to be in contact with the arm. The depth of these compresses should be proportioned to the thickness of the arm, increasing" as the diameter of the arm diminishes. In the next place, the surgeon takes a band- age about six yards long rolled up in one, and makes three turns of it on the frac- tured part, descends then to the hand by circles partially placed over one another, and envelopes the hand by passing the bandage between the thumb and index: the bandage is then carried upward in the same manner, and reflected wherever the inequality of the arm may render it ne- cessary. The compresses and bandage being thus far applied, the surgeon lays on two splints, one anteriorly, the other posteriorly, and passes the part of the bandage that yet remains over them, in such a manner as entirely to cover them. It may not be unnecessary to remark, that the compresses and splints should be of the same length as the arm. It would be useless to employ lateral splints in this case, unless (what is scarcely ever to be expected or met with) a derangement should have taken place in that direction. It is evident, that lateral splints would counteract the compresses and two otiier splints, by increasing the radii-cubital diameter of the arm, and by concurring with the action of the pronaiores to move the pieces into the interosseous space. The surgeon's attention should be most particularly directed to preserve the in- terosseous space; for, if tins be oblite- rated, the radius cannot rotate on tiie cubitus, nor the mot on of pronation or supination be executed; and this object may be obtained with certainty by apply- ing the compresses and splint*-, in such a manner as that the fleshy parts may be forced into, and confined in, the interos- seous space, and by renewing the band. age every seven or eight days. If the fracture be simple, and the con- tusion inconsiderable, the patient need not be confined to bed ; he may be allow- ed to walk about with his arm in a sling. 484 FRACTURES. (Boyer, Lemons sur le* Maladies des Os, Tom. 1.) OF FRACTURES' OF THE RAHIUS. Of all fractures of the fore-arm, this is the most frequent. The radius being al- most the sole support of the hand, and placed in the same line with the humerus, is for both these reasons more exposed to fractures, than the ulna. Fractures of the radius, whether trans- verse or oblique, near ils middle part or extremities, may be caused by a fall or blow on the fore-arm, or, as happens in most cases, by a fall on the palm of the hand. When likely to fall, we extend our arms, and let the hands come first to the ground ; in which case, the radius, press- ed between the hand on the ground, and the humerus, from which it receives the whole momentum of th? body, is bent, and, if the fell be sufficiently violent, broken more or less near its middle part. When, after an accident ot this kind, pain and a difficulty of*performing the motions of pronation and supination supervene, the probability of a fracture of the ra- dius is very strong. The truth is fully ascertained by pressing with the fingers along the external side of the fore-arm. Also, in endeavouring to perform supina- tion or pronation of the hand, a crepitus and a motion of the broken portions will be perceived, if the bone be in reality frac- tured. When the fracture takes place near the head of the radius, the diagnosis is more difficult on account of the depth of soft parts over the bone in that part. In this case, the thumb is to be placed under the external condyle of the os hu- meri, and on the superior extremity ofthe radius, and at the same time the hand is to be brought into the prone and supine positions. If in these trials, always pain- ful, the head ofthe bone rests motionless, there can be no doubt of its being frac- tured. The causes of derangement are here the same as in fractures of the fore- arm, and it can never take place, except in the direction of the diameter of the bOne, and is effected principally by the action of the pronating muscles. The ulna serves as a splint in fractures of the radius; and the more effectually so, as these two bones are connected with one another throughout tlieir whole length. Notwithstanding the evident mechanism, which prevents the longitudinal derange- ment, J. L. Petit has thought that derange- ment possible. (Boyer, Tom. 1.) When only the radius is fractured, no extension is ordinarily requisite. During the treatment the elbow is to be bent, and the hand put in the mid state, between pronation and supination ; th* is to say, the palm of the hand is to face the pa- tient's breast. Having reduced the ends of the fracture, when they appear to be displaced, the soap plaster is to be ap- plied, and over this a slack roller. This bandage is, indeed, of no utili-y ; but, it makes the limb seem to the unknowing by-slanders more comfortable, than if it were omitted, and, as it does no harm, the surgeon may honestly apply it. How- ever, no one can doubt, that tight banda- ges may act very perniciously m fractures of the fore-arm, by pressing the radius and ulna together, causing them to grow to each other, or, at all events, making the fracture unite in an exceed'ngly un- even manner. Only two splints are ne- cessary ; one is to be placed along the in- side, the other along the outside of the fore-arm. Soft pads must always be plac- ed between the skin and the splints, in or- der to obviate the pressure of the hard materials, of which the latter are formed. The inner splint should extend to abojit the last joint of the fingers ; but not com- pletely to the end of the nails; for, many patients, after having had their fingers kept for several weeks, in a state of per- fect extension, have been a very long time in becoming able to bend them again. Sometimes, it may be proper to apply a compress just under the ends of the frac- ture to prevent their being depressed to- wards the ulna too much, the consequence of which has occasionally been the loss of the prone and supine motions ofthe hand. In setting a fractured radius, the hand should be inclined to the ulnar side of tlie fore-arm. OF FllACTCHES OF THE CLWA. Fractures of this bone, less frequent than those of the radius, take place gene- rally at its lower extremity, because it is smaller and less covered at that part, than at any other. A fracture of this bone is almost always the result of a force act- ing immediately on the part fractured; as, for instance, when one falls and strikes the internal side of the fore-arm against a hard resisting body. On applying the hand judiciously on the inside of the fore- arm, this fracture is easily ascertained by the depression in that part, in conse- quence of the inferior portion being drawn toward the radius by the action of the pronator radii quadratus. This derange- ment is in general less, than that which takes place in fractures of the radius. The superior portion of the cubitus re- mains unmoved, as has been well observed by J. L. Petit. In this case, the assistant who makes FRACTURES. 485 whatever little extension may be necessa- ry, should incline the hand to the radial side of the fore-arm, while the surgeon pushes the flesh between the two bones, and applies the apparatus, as in the pre- ceding case. In all fractures of the bones of the fore-arm, and, particularly, in those which are near the head of the* radius, a false anchylosis is to be apprehended, and should be guarded against by moving the elbow gently and frequently, when the consolidation is advanced to a certain de- gree. (See Boyer, Legons sur les Maladies de Os, Tom. 1.) Fractures of tiie fore-arm always re- quire this part to be kept quietly in a sling. FRACTCnES OF THE OLECRANON. The ancients seem to have been little acquainted with fractures of" the olecra- non, on which subject they have been quite silent, unless Paulus iEgineta al- ludes to it in the following passage : Cu- bitus frangitur.....circa partem ad cubiti gi/ibum. Even most ofthe moderns, Petit, ""Duverney, Bell, &c. have not given a sa- tisfactory account of sucb cases. The olecranon may be fractured either at its base, or its extremity; but, the first oc- currence is the most frequent. The di- vision is almost always transverse, though occasionally oblique. The causes, pro- ducing the accident, are, either the action of the muscles, which is a very uncommon one, or external violence, wliich is much more usual. With regard to symptoms, the contrac- tion of the triceps, being no longer resist- ed by being connected with the ulna, draws upward the short fragment, to which it adheres, so as to produce, between it and the lower one, a more, or less evi- dent interspace. This interspace is found situated at the back part ofthe joint, and it may be increased or diminished at will, bv augmenting the flexion ofthe fore-arm, and putting the triceps into action, or else extending the limb. Another symptom, is the impossibility of spontaneously ex- tending the fore-arm, the necessary effect of the detachment ofthe triceps from the ulna. The fore-arm is constantly haft- bent, the biceps, and brachialis having no antagonists. The olecranon is, more or less conspicuously, drawn up higher, than the condyles of the os brachii, which hit- ter parts, on the contrary, are naturally situated higher, than the olecranon, when the fore-arm is half-bent. The upper piece of bone may be moved in every di- rection, without the ulna participating in the motion. Besides these symptoms, we must take into the account, the consider- ate pain experienced, tiie crack some- times distinctly beard by the patient, and the crepitus frequently perceptible. The indications are to pu.'h downward the retracted portion of the olecranon, and to keep it in this position, at the same time, that the ulna is made to meet it, as it were, by extending the fore-arm. De- sault says, however, it should not be com- pletely extended, as when the pieces of bone touch at their back part, they leave a vacancy in front, which is apt to be fol- lowed by an irregular callus, prejudicial to the future free motion of the elbow. Hence, this celebrated practitioner used to put the arm between the half-bent state and extension. This posture, however, would soon be changed, if permanent means were not taken to mainlain it. De- sault, with this view, was in the habit of applying a splint along the fore-part ot the arm. But, position evidently only operates on the lower part of the olecra- non, by approximating it to the upper one. The latter requires also to be brought near the former, and fixed there, which is, doubtless, the most difficult ob- ject to effect, because the triceps is con- tinually resisting. Desault used to adopt the following method : the fore-arm being held in the above position, the surgeon is to begin applying a roller round the wrist, and to continue it as high as the elbow. The skin, covering tins part, being wrinkled in consequence of the extension of the limb, might insinuate itself between the ends of the fracture, and consequently it must now be pulled upward by an assist- ant. The surgeon is then to push the olecranon towards the ulna, and confine* it in this situation with a turn ofthe roller, with which the joint is then to be covered, bv applying it in the form of a figure o'f S. A strong splint, a little bent, just before the elbow, is next to be laid along the arm and fore-arm, and fixed by means of a roller. The apparatus being applied, the whole limb is to be evenly supported on a pillow. It is calculated, that, on an average, the olecranon becomes firmly united about the twenty-sixth day. (Desaul( par B: chat.) EltACTCRES OF THE FINOEIIS. On this subject, we need only remark, that the treatment consists in applying a piece of soap-plaster, rolling tiie part with tape, incasing it in pasteboard, sometimes placing the hand on a flat splint, or finger-board, and always keep- ing the hand, fore-arm, and elbow, wc-1: supported in a tiling. 486 FRACTURES. For Fractui'es ofthe Cranium see Head, Injuries of. [Before concluding this article, it is highly proper to remark, that fractures in the limbs, treated by any of the pre- ceding methods in some instances, do not form a bony union, but leave at the place of fracture a free motion in all directions, and, in fact, a joint. This is a most serious evil, and completely destroys the useful- ness of the limb. In order to obviate tbe evil and produce a bony union of the parts, various remedies have been suggested and employed. " Whether the fractured portions have passed one another, or whether an articu- lation has been formed between the frac- tured surfaces, if the fracture has been already of several months duration, the action ofthe fractured surfaces ought to be revived, by rubbing them forcibly one against the other, in order toexene the degree of inflammation necessary for the generation of calus. The fractured ends of the bones, having by this means acquired a disposition favourable to their agglutina- tion, the apparatus should be re-applied, the extension continued if necessary, and the treatment prolonged until the cure be complete. "If, notwithstanding these means, the pieces do not unite, there remains another and last resource, the cutting off of their extremities. This operation is painful, terrify ing, and of dubious event. Its suc- cess, however, has been frequent enough to warrant the trial. It would be imprac- ticable in fractures ofthe leg or lore-arm, on account of the difficulty of separating from the integuments the two bones of wliich each of these parts is formed, and on account of the numerous nerves and arteries which would be in danger of being wounded by the large incisions necessary for this operation, it is therefore practicable only in the femur and humenis, especially the latter." (Boyer.) Mr. Boyer proceeds to describe the manner of performing this operation, and relates a case in which it w as done. The fracture was in the middle of the hti- merus—The patient aged ihirty-six. Gan- grene came on, and he died on the sixth day! In other cases, amputation has been per- formed. Mr. Hunter proposed exposing the cavity between the ends of the bone, and hoped that this would occasion the necessary degree of inflammation. But a plan has been invented by Dr. Phy.tick, which promises to supersede the horribly cruel and fatal operations hitherto in use, and to procure more effectually, than any ever proposed, the cure of those unfor- tunate patients, in whom the artificial joints are formed. In the Medical Repository, Hexade II. vol. 1. p. 122. is recorded a case of fracture, in which an artificial joint formed which was cured by this re- 'medy. The patient, Isaac Patterson, was admitted into the Pennsylvania Hospi- tal in December, 1802. ""I had seen," says Dr. Physick, " in our Hospital, when a student, in 1785, a case simi- lar to this in every essential circum- stance, in which an incision was made down to the extremities of the fractur- ed bones, which were then sawed off, putting the parts into the condition of a recent compound fracture. No bene- fit, however, was derived from this painful operation; and some months afterwards the arm was amputated. This case had made a strong impres- sion on my mind, and rendered me un- willing to perform a similar operation* I therefore proposed to the medical gentlemen of the hospital, who attended in consultation, that a seton needle, armed with a skein of silk, should be passed through the arm, and between the fractured extremities of the bone, and that the-seton should be left in this situation, until by exciting inflamma- tion and suppuration, granulations should arise on the ends of the bone, which uniting and ossifying, would form the bony union that was wanting. This ope- ration, being agreed to, was performed on the 18th December, 1802, twenty months after the accident. Before passing the needle, 1 directed the assistants to make some extension of the arm, in order that the seton might be introduc- ed as much as possible between tiie ends ofthe bone. Some lintanda pledget were applied to the orifices made by the seton needle, and secured by a roller. " The patient suffered very little pain from the operation. After a few days, the inflammation (which was not great. er than what is commonly excited by a similar operation through the flesh in any other part) was succeeded by a mo- derate suppuration. The arm was now again extended, and splints applied.. The dressings were renewed daily for twelve weeks, during which time no amend- ment was perceived; but soon after- wards, the bending of the arm at the frac'ure was observed to be not so easy as it had been, and the patient com- plained of much more pain than usual, FRiENUM. 487 whenever an attempt was made to bend it at that place. From this time the formation of the new bony union went on rapidly, and on the 4th May, 1803, was so perfectly completed, that the patient could move his arm in all di- rections, as well as before the accident happened. On the 28th May, he was discharged from the hospital perfectly well, and he has since repeatedly told me, that his arm is as strong as it ever was." Dr. Physick has since effected ano- ther cure in the same manner. The operation, however, failed in a case which occurred at Baltimore. Here the cause of failure was, however, evi- dent: The seton remained in the arm but six weeks, and was removed in oonsequence of the patient's ill health. She was very old and sickly. Twelve weeks had elapsed in Patterson's case, before any symptom of amendment was perceived. We would urge, to any surgeon who may be disposed to avail himself of this remedy, the propriety of continuing the seton at least twelve weeks.3 For information on fractures consult particularly, Petit's Traite des Maladies des Os ; Duverney's Traite des Maladies des Os ; W. Sharp in vol. 57. ofthe Pldlosophical Trans, part 2, 1767. Pott's Remarks on Fractures and Dislocation*. Cases in Surge- ry by C. White, F. R. S. Edit. 1770. Bay- er's Lemons sur les Maladies des Os, redi- gees en un Traite complet de ces Maladies, par Richerand, or the English 'Translation by Dr. Farrell; Encyclopedic Methodique, Partie Chirurgicale, Art. Fracture. Cuisse, Omoplate, Ilium, &c. &c. Euvres Chirurgi- entesde Desault, par Bichat, Tom. 1. Parts ofthe Parisian Chirurgical Journal Riche- rand's . Vosographie Chirurgicale, Tom. 3, Edit. 2 Levet lie's Nouvelle Doctrine Chirur- gicale, Tom. 2, 1812. FR.E\TUM LINGUjE. (from/-us mass. Since no intern.d medicines, nor external applicati >ns, afford the least hope of checking any form of the fungus hxmatodes, it is manifest, that, when the distemper of the eye exceeds certain bounds, the miserable patient is placed beyond the reach of any effectual aid from surgery. (See particularly Wardrop's Ob- servations on Fungus Hxmatodea.) Fungus Hxmatodes of the Limbs. 2- In the extremities the disease begins with a small colourless tumour, which is soft and elastic, if there be no th ck cover- ing over it, such as a fascia; but other- wise is tense. A*, first, it is free from un asiness ; but, by degrees, a sharp acute pam darts occasionally through it, more and more frequently, and, at length, be- comes incessant. For a considerable time, the tumour is smooth and ev.-n; but, afterwards, it projects irregularly at one or more points ; and the skin at this place becomes of a livid red colour, and feels thinner In this situation, it easily yields to pressure, but instantly bounds up again. Small openings now form in these pro- jeciions, through which is discharged a thin bloody ma. ter. Almost immediately after these tumours burst, a small fungus protrudes, like a papilla, and this rapidly increases, both in breadth and height, and has exactly the appearance of a car- cinomatous fungus, and frequently bleeds profusely. The matter is thin, and ex- ceedingly fetid, and the pain becomes of the smarting kind. The integuments, for a little way round tiiese ulcers, are red, and tender. After ulceration takes place, the neighbouring glands swell, and assume exactly the spongy qualities of the pri- mary tumour. If the patient still survive the disease in its present advanced pro- gress, similar tumours form in other parts ofthe body, and thep-itient dies hectic After death, or amputation, the tumour is found to con-ist of a soft substance, somewhat like the brain, of a greyish co- lour, ahd greasy appearance, with thin membrane-like divisions running through it, and cells, or abscesses, in different places, containing a thin bloody matter, occasionally in very considerable quan- tity. There does not seem uniformly to be any entire cyst, surrounding the tu- mour ; for, it very frequently dives di.wn betwixt the muscles, or down to the bone, to winch it ofien appears to adhere. The neighbouring muscles arc of a pale colour, and lose their fibrou--. appearance, becom- ing more like ifver, than muscle. The bones are always cano/*s in tiie vicinity of these tumours. The distemper is sometimes caused by , external violence, though in general tiiere * is no evident cause whatever. (Disserta- tions on Inflammation by J. Burns, Vol 2) Mr. Hey has given several cases of the fungus hxmatodes. If we notice, the most particular circumstances, relative to one of these, it willsulfice to inform our render of the form, in wliich this terrible affl ction has presented its-ell in this gen- tleman's practice. A young man, ag-ed twenty-one, two years before applying to Mr. Hey, pur- ee, ved a small swelling* on the inside ofthe right knee, not far from the patella. This tumour was moveable, anil did not im- pede the motion of ihe joint: it was not discoloured, but was painful, when moved, or pressed upon. It continued in ths state half a year, and then the man, hav- ing hurt his knee against a stone, it gra- dually increased in bulk, but did not ex- ceed the size of an egg. The skin was now discoloured with blue specks, which were taken to be veins, lie could still walk will ease, and follow his business, Two months before his admission into the Leeds Infirmary, he met with a fall, and violently bent his knee, but did not strike it against any thing. The tumour began immediately to enlarge ; and, with- in a few hours, it extended halfway up the inside of his thigh. About a fort- night after this accident, the skin burst at the lowest part ofthe tumour, and dis- charged some blood. A dark-coloured fungus, about the size of a pigeon's egg, here made io Leeds. He complained of the greatest uneasiness in the. highest part of the tumour. It had become hot and painful in the night-time, for some days pis:. His pulse was 114 in a minute ; his tongue was clean ; and his appetite had been good, till the last feu days. He had never felt any pulsation in the tu- mour. In a consultation it was determined, tiiat the tumour should be laid open, by cu ting off a portion of the distended in- teguments : and that after removing the contents, if the sac should be found in a sound state, the disease should be treated as a simple wound ; but, it in a morbid state, amputation of the limb should be immediately performed. A large oval piece of the integuments being removed, the tumour w.*.s found lo contain a very large quantity of a sub- stanre, not much mil ke coagulated blood; but more nearly resembl-ng the medul- lary part of the bruin in its consistence and oily nature. It was of a variegated reddish colour, in s-ime parts approach- ing to white, and, ;*..■■ blood issued from it,''Mr. Hey conceived it was organized. This mass was partly diffused through the circumjacent p.'rts in innumerable pouches, to which it adhered, and was partlv contained in large sac of an apo- neurotic texture, which was connected with the capsule of the kneejoint. There was a great and universal effusion of blood, fi-om the internal surface of the sac, and from ths pouches, containing this morbid mass. . ,. Amputation of tlie limb was immedi- ately performed, on finding such to be the nature of the case. Mr. Hey, unfor- tunatelv, however, left a portion of the diseased surface behind on the inner part of the thigh, and hoping, that a small narrow portion of the upper part ot the sac would soon become a clean sore, and not impede the cure, be made the circular incision two inches below its higher part. On examining the amputated limb, the vastus internus was found to be brown, ard much sofer, than the other muscles, which were heal-hv. There were many small portions of blood extravasated in tin- substance of this muscle. The sac was formed ol the aponeurotic covering of the muscle, and ended below where this aponeurosis begins to cover tiie cap- sular lg.ment of the knee The two fungous substances, above described, ap- peared to have been only extensions of tin- morbid mass, where this had made its way through tiie sac and the integuments. Ihe joint of the k >ee, and mu't-cles ofthe leg, were perfectly sound. 1 nerd not deiail all the particulars after the op ration. Suffice it to say, the man suffered a great deal of constitu- tional -ii-oider. After a few weeks, the granulations upon thestump became good, and the cicainzation was nearly, com- pleted at the end of the s>xth week, after the amputation. At this period, that small and superficial portion of the upper part ot the great sac, which Mr. Hey had unfortunately left, was now healed ; but, a tumour, now aboutefour inches in length, and between two and three in breadth, had gradually risen at the lower and under part of the thigh, beneath the ci- catrix. This contained a .soft substance, exactly similar, as far as the touch could discover, to that which had filled the large sac. This tumour became painful, and sometimes discharged a bloody serum, sometimes dark-coloured blood, through lour or five, sinail openings in the c catnx. Mr. Hey laid open the tumour, and re- moved its contents ; but no advantage was gained by this proceeding. The in- terior surface was found to be too much diseased to produce good granulations. Blood continued to ooze out ofthe wound for a few days. Then the inner surface became covered with a blackisii sub- stance, wliich gradually extended itself, anil formed a n-.-w fungus. A variety of escharotics were applied to destroy the fungus and morbid surface ofthe wound ; but to no purpose, the growth of the fungus always exceeded the quantity de- stroyed. Undiluted oil of vitriol, applied freely, h-d very little effect. An attempt was once more made to cut away the disease; but, on examining the wound carefully, after the contained sub- stance was removed, the muscular sub- stance was found degenerated into ah ard mass, which telt s ,mewhat like cartilage. The adipose membrane Was also diseas- ed, and formed into large cells, which had contained the fungous substance. Hence, another amputation seemed the only re- source. After this operation, the whole surfac* 492 FUNGUS of the stump seemed sound, except the principal artery, which was filled with a somewhat stiff matter, resembling coagu- lated blood, which prevented its bleeding. The inside of the vessel, on being touch- ed with the scalpel, felt hard, and com- municated a sensation, like that of scrap- ing bone. The man was sent home, as soon as his state would admit of it; but, he died con- sumptive about six months afterwards. Besides this instance, in the thigh, Mr. Hey relates cases of fungus hxmatodes, situated in the female breast, in' the leg, in the neck (extending from the'jaw to the clavicle, and producing suffocation), on the back part of the neck, on the back part ofthe shoulder, and at the extremity of the fore-arm near the wrist. " If 1 do not mistake, (says Mr. Hey,) this disease not unfrequently affects the globe of the eye, causing an enlargement of it, with the destruction of its internal organization. If the eye is not extir- pated, the sclerotis bursts at the last, a bloody sanious matter is discharged, and the patient sinks under the complaint.*' (P. 283.) Besides some cases, in similar situa- tions, to those mentioned by Mr. Hey, one is related by Mr. Burns, in which the hip-joint was the seat ot this terrible affection. After detailing the progress of the case to the poor man's death, this au- thor states, that he found, on dissection, the hip-joint completely surrounded with a soft matter, resembling the brain, in- closed in thin cells, and here and there cells full of thin bloody water; the head of the thigh-bone was quite carious, as was also the acetabulum. The muscles were quite pale, and almost like boiled liver, having completely lost their fibrous appearance, and muscular properties. The same sort of morbid mischief was also found within the pelvis, most of the inside of the bones, on the affected side, being quite carious. An attempt had been made, before the patient died, to tap the bladder; but, the trocar had only entered a cell, filled with bloody water, and situated in a mass of the soft brain- like substance. We have already said enough, to render the description of the dreadful nature of the fungus hxmatodes tolerably complete. Little can be said of the treatment; for, we know of no one medicine that seems to have the least power of putting a stop to the disease, and we have no reason to believe, that there is ever the smallest Chance even of any spontaneous amend- ment, much less of such a cure. We have seen, that when the chief part of a fungus hxmatodes is cut away, and only a small portion of its cyst is left be- hind, that the fungus is reproduced from this part, and soon becomes as formidable, nay more formidable, than it was before, and this notwithstanding the applicat on of the most powerful escharotics Nehher the hydrargyrus nitratus ruber, tlie hy- drargyrus muriatus, the antimonium mu- riatum, nor the undiluted variolic acid, have always been able to repress the growth of such fungus. (Hey) There is no remedy, that has the power of checking, or removing the complaint. Friction, with anodyne balsams, some- times gives relief in the early stages; but, it does not seem to retard the progress of the disease. In short, the only chance of cure con- sists in extirpating the whole ot the dis- tempered parts, removing not only the soft, brain-like fungous substance, but every particle of the cysts, sacs, or pouches, in which it may be contained. An operation of this kind, however, is only advisable in the early stages, while the disease is entirely local ; for, after the neighbouring glands have become affect- ed, the chance of recovery is almost de- stroyed. It is sometimes difficult, how- ever, to persuade patients at this time to submit to amputation, or extirpation, be- cause the pain and inconveniences are inconsiderable; but, the operation ought to be urged with all the force, which a conviction of its absolute necessity, and, the fatal peril of delay, ought to inspire. The attempts to cure the disease, by cutting it away, have been attended with such ill-success, that some surgeons deem it advisable not to follow this method, but amputate the limb at once. The annexed views of the matter appear to me to be most judicious and rational First, that if an attempt be made to cut away the tumour, and save the limb, the surgeon must be careful to remove, at tlie sinne time, a considerable quantity of the soft parts in the circumference ofthe swe-hi.ig. Secondly, that the earlier this is done, the more likely is it to succeed Thirdly, that after the tumour is taken out, an attentive examination of the surface of the wound should be made, and every suspicious part, or fibre, be cut away. Fourthly, that should the disease still recur, amputation ought to be instantly performed. Fifthly, that caustics should never be appUed to this disease. Sixthly, that, even when one of these operations effectually extirpates the distemper of the limb, the patient's entire recovery is always rendered exceedingly uncertain, by reason of the viscera, and other in- FUNGUS. 493 visible parts, being frequently affected, at the time of the operation, with the same sort of disease. FtJNGCS HSMATODES OF THE TESTICLE. 3. Fungus hxmatodes of the testicle sometimes begins in its glandular part, sometimes in the epididymis. Its pro- gress is slow, and the pain generally not severe. Nor is there, at first, any in- equality, or hardness of the diseased part, nor change in the scrotum. When the testicle has become exceedingly large, it feels remarkably soft and elastic, as if it contained a fluid. Hence, the case has often been mistaken for an hydrocele, and punctured with a trocar. (Wardrop.) Occasionally, when the tumour is large, it i> in some places hard, in others soft. The hydrocele may be known by the wa- ter beginning to collect at the bottom of the scrotum, and then ascending towards the spermatic cord, and by the swelling being circumscribed towards the abdo- minal ring; whereas the fungus hxma- todes begins with a gradual enlargement of the testicle itself, followed by a ful- ness, wliich extends up the spermatic cord. As the disease advances, abscesses form, and the scrotum ulcerates ; but no fungus shoots out. When the inguinal glands become contaminated, they often acquire an immense size ; and when the skin over them bursts, large por ions of them slough away. Fungus hxmatodes ofthe testicle is said to afflict young sub- jects more frequently than old ones. On dissection, the substance of" the diseased testicle is found to present a medullary, or pulpy appearance, generally of a pale brownish colour, though sometimes red. In most cases, the tunica vaginalis and tunica albuginea are adherent togelher ; occasionally, there is fluid between them. The only chance of a curt must be de- rived from a very early performance of castration, before the disease has extend- ed' to the inguinal glands, or far up the spermatic cord. We shall quit this subject with stating some of the principal differences between two diseases, which have been commonly confounded. A scirrhous tumour is, from its commencement, hard, firm, and in- compressible, and is composed of two substances: one hardened and fibrous, the other soft and inorganic. The fibrous matter is the most abundant, consist- ing of septa, which are paler than the soft substance between them. A scir- rhous tumour, situated in a gland, is not capable of being separated from the lat- ter pari, so much are the two structures blended. A scirrhous, in another situ- ation, sometimes cordenses the surround- ing cellular substance, so as to form a kind of capsule, and assume a circum- scribed appearance. When a scirrhous swelling ulcerates, a thin ichor is dis- charged, and a good deal of the hard fibrous substance is destroyed by the ul- ceration ; other parts become affected, and tbe patient dies from the increased ravages of the disease, and its irritation on the constitution, Sometimes, though not always, after a scirrhus has ulcerat- ed, it emits a fungus of a very hard tex- ture. Such excrescence, however, is it- self at last destroyed by the ulceration. Cancerous sores, also, frequently put on, for a short time, an appearance in some places of cicatrization. On the other hand, the fungus hxmatodes, while of mo- derate size, is a soft elastic swelling, with an equal surf-ace, and a deceitful feel of fluctuation. It is, in general, quite cir- cumscribed, being included within a cap- sule. The substance of the mmour, in- stead of being for the most part hard, con- sists of a soft, pulpy, medullary matter, which readily mixes with water. When ulceration occurs, the tumour is not les- sened by this process, as in scirrhus ; but a fungus is emitted, and the whole swell- ing grows with increased rapidity. Can- cerous diseases are mostly met with in persons of advanced age, while fungus hxmatodes generally afflicts young sub- jects. (Wardrop) Se Dissertations on Inflammation, by J. Burns. Vol 2. Hey's Practical Observa- tions in Surgery. Freer on Aneurism, and particularly Observations on Fungus Hema- todes, or Soft Cancer, by James Wardrop. Edin 1809. In the third volume of the Medico- Chirurgical Transactions, about to be published, I believe, some further interest- ing cases of fungus hxmatodes will be laid before the fmblic. A case of this disease is related in Vol. 5, oj the London Medical Journal. It was the consequence of an attempt to cure a ganglion by means ofa seton, and it proved fatal. A case is also related by Mr. Abernethy in Surgical Observations, 1804, p 99. The medullary sarcoma, which is con- sidered by Mr. Wardrop, as the same af- fection as the fungus hxmatodes, is de- scribed in the article, Tumour*. FURUNCULUS. (from furo, to rage.) A boil, so named from the violence of the heat and inflammation attending it. A boil is a circumscribed, very promi- nent, hard, deep-red inflammatory swell- ing, which is exceedingly painful, and commonly terminates in a slow and im- perfect suppuration. The figure of the tumour is generally that of a cone, the bone of which is considerably below 'he 4J4 FURUNCIl.US. surface. Upon the most, elevated point of the boil, there is usually a whitish, or livid pustule, which is exquisitely sen- sible, and immediately beneath this is the seat of the abscess. The matter is mostly slow in forming, is seldom very abundant, never healthy, at first, being always blended with blood. Tbe complaint is seldom attended with fever, except, when the tumour is very large, situated on a sensible part, or when several of these swellings occur at the same time in differ- ent places. In the last circumstance, they often occasion in children, and even in irritable adults, restlessness, loss of appetite, spasms, &.c. They rarely ex- ceed a pigeon's vgg in s-ze, and they may originate on any part of tiie body. Boils commonly arise from constitu- tional causes. Young persons, and espe- cially subjects of full plethoric hab.ts, are most subject to them. The disease is also observed to occur with most fre- quency in the spring. (Laasus, Patholo- gic Chirurgicale, Tom. I,p.l6) Accord- ing to Richerind, the origin of boils de- pends upon a disordered state of the gas- tric organs. (Nosographie Chirurgicale, Tom 1, p. 124, Edit 2.) . The suppuration that attends a boil, is never perfect, and the matter, which forms, is not only tinged with blood, but surrounded with a sloughy substance, which must generally be discharged, be- fore the part affected will suppurate kind- ly, and the disease end. Richter com- pares the slough with a kind of bag, or cyst, and the whole boil with an inflamed encysted tumour. The best plan is mostly to endeavour to make boils suppurate, as freely :is pos- sible, by applying external emollient re- medies. This seems to be the natural course of thed.sease in its progress to a cure, and, indeed, all endeavours to dis- cuss furunculous tumours commonly fail, or succeed very imperfectly; only re- moving the inflammation, and. leaving b< hind an indolent hardness, which occa- sions various inconveniences, according to its situation, every now and then in- flames anew, and never entirely disap- pears, until a free suppuration has been established. In a very few cases, perhaps, it may be proper lo try to discuss boils. For this purpose, besides bleeding, gentle evacu- ations, and a low diet, which are requi- site in this, as well as other local inflam mations, some prescribe as external appli- cations honey strongly acidulated with sulphuric acid ; alkohol; or camphorat- ed oil. But, in the generality of instances, suppuration must be promoted, by the use of emollient poultices. The tumour, when allowed to burst, generally does so at its apex. However, as the opening, which spontaneously occurs, is generally long in forming, aiuf loo small to allow the sloughy cellular substance io be dis- charged, it is always best, as soon as matter is known to exist in the tumour, to make a free opening with a lancet, and immediately afterwards to press out as much of the m-tter and sloughs, as can be prudently done. This having been accomplished, and the rest ofthe sloughs pressed out, as soon as it is practicable, healthy pus will be secreted, and the part will granulate and heal. Until the sup- puration becomes- of the healthy kind, and the sloughy substances are entirely discharged, an emollient linseed poultice is the best application, and when granu- lations begin to fill up tiie cavity, plain lint, and a simple pledget, are the only dressings necessary. Where there is reason to suppose the gastric organs to be in a disordered state, an emetic should be given in the early part of the treatment, and afterwards small repeated doses of any of tlie mild purg- ing salts. When an indolent'hardness continues, after the inflammatory, and suppurative state of boils has been cured, the part should be rubbed with camphorated mer- curial ointment. Besides the above acute boil, authors describe a chronic one, which is said fre- quently to occur, in subjects, who have suffered severely from the small-pox, measles, lues venerea, scrofula, and in constitutions, which have been injured by the use of mercury. The chronic boil is commonly situated upon the extremities, is of the same size us the acute one, has a hard base, is not attended with much pain, nor any con- siderable discolouration ofthe skin, until suppuration is far advanced, and the mat- ter is seldom quite formed, before three, or four weeks. This, like the former, sometimes appears in a considerable num- ber at a time. The discharge is always thinner, than good pus, and when the boil is large, i>nd has been long in sup- purating, a great deal of sloughy cellular membrane must be cast off", before the sore will heal. The principal thing, requisite in the local treatment of all furunculous, and carbuncular tumours, is to make an early free opening into them, and to press out the matter and sloughs, employ ing emol- lient poultices, till all the mor' fied parts are detached and removed, and .tfter- waid.; timpfe dressings. (See Pearaon'* Principles of Surgery. Richter's Anfangs- CANGLION. 495 grunde tier Wundarzn. Band. 1. Lassus, Riclierand Nosograpfue Chirurgicale, Tom Puthologie Chirurgicale, Tom. 1, p. 15. 1, p. 123, Edit, 2.) G. GANGLTON, (yxfyXiov.) \n anatomy, a knot in the course of a nerve ; in surgery, a tumour on a tendon, or apo- neurosis. A ganglion is an encysted, circum- scribed, moveable swelling, commonly free from pain, causing no alteration in the colour of the skm, and formed upon tendons in different parts of the body, but, most frequently, upon the back of the hand, and over the wrist. A French gentleman consulted me some time ago, who had one upon the upper part of his foot, which created a great sensation of weakness in the motion of the foot, and I have taken notice, that ganglions occur particularly often just below tlie kneepan, in housemaids, who are in the habit of kneeling a great deal in order to scour rooms. It is curious to remark, that pres- sure, which is the best common means of getting rid of ganglions, in this instance, appears to act as a cause. These tumours, when compressed, seem to possess considerable elasticity. They often occur uiipreceded by any ac- cident ; frequently, they are the conse- quence of bruises arid violent sprains. They seldom attain, a considerable size, and ordinarily are not painful, though every now and then there are instances to the contrary When opened, they are found to be filled with a viscid transpa- rent fluid, resembling white of e^. if they do not disappear of themselves, or are not cured, while recent, by surgical means, they, in some cases, become so large, that they cause great inconveni- ence, by obstructing the motion of the "" part, and rendering it painful. Discutient applications sometimes suc- ceed in curing ganglions, and, in this country, friction with the ofoum origaiu is a very common method. I have often seen such tumours very much lessened by this plar. of treatment, but seldom cured, and, no sooner has the friction been dis- continued, than the fluid in the cyst has in general accumulated again. ■ Compression is usually more effectual, than discutient liniments. Persons with ganglions have been recommended to rub tuem strongly with their thumb, several times a. day. After this has been re- pealed very often, the tumour is said sometimes to have absolutely disappeared while the friction was employed. But, the best method is to make .continual pressure on ganglions, by means of a piece of sheet-lcid, bound upon the part with a bandage. Tiiere is no objection, ho ever, to using once, or twice a day, in conjunction with this treatment, fric- tions with the oleum ongani, or cam- phorated mercurial ointment, p^ivided these measures together do not seem like- ly t> m;.ke the tumour inflame, an event, which should always be carefully avoid- ed. Ganglions, when irritated too much, have been known to become most malig- nant diseases. Se.tons h. ve been recommended o be introduced through ganglions, with a view of curing them. This metiiod, how* \ er, is not an eligible one, for, il is by no means free fi-.mi danger, as the records of surgery fully sh--w Cancerous dis- eases, and even the fungus hxmatodes {.Med. Journal Vol. 5 ) ii.*ve arisen from the irritation of a seton passed throu-h a ganglion. Frequently, when a ganglion inflames, and ulcerates, the cyst throws out a fun- gus, which is of a very malignant nature. Henc-, the practitioner should avo d making an opening into di? swelling, or tloitig any tiling, which is likely to occa- sion sloughing, or ulceration of the (lis- ease. Ganglions may be cured by pres- sure, of such force, a> to rupture the cyst, and some authors have recommended putting the hand affected upon a table, and then striking the ganglion several times with the fist, or a mallet. The cyst of a recent ganglion may also bo burst, by compressing it strongly with the thumbs, with or without the interven- tion ofa piece of money; the fluid is ef- fused into the adjacent cellular niem- br.-.ne ; and, pressure being now employ. ed, the opposite sides of the cavity he- come united by the adhesive inflamma- tion, and the recurrence of the di-eas** is prevented. (See L' Encyclopedic -Metho- dique, Partie Chirurgicale, art. Ganglion; Lassus, Pathologic Chirurgicale, Tom. 1, /'. 496 G A N GAS 400, fcfe.; Leveille, Nouvelle Doctrine Chi- rurgicale, Tom. 3, p. 7.) In almost every instance, a ganglion may be cured by pressure and friction, and, if not actually cured, the disease may be rendered so bearable by these means, that few patients would choose to have the tumour cut out. Under this plan, the swelling becomes very much di- minished, and, should it enlarge again, the mode of relief is so simple, and the case so little troublesome, that patients generally content themselves with every now and then wearing a p ece of lead on the part. But when ganglions resist all attempts to disperse, or palliate them ; when they become extremely inconvenient, either by obstructing the functions of a joint, or causing pain ; these tumours should be -carefully dissected out, by first making a longitudinal incision in the skin covering them, then separating ti^e cyst on every side from the contiguous parts, and lastly cutting every particle of it off the subjacent tendon, or fascia. The great est care must be taken, not to make any opening in the cyst, so as to let out its contents, and make it collapse; a circumstance, which would render the dissection of it entirely out much more difficult. The operation being accomplished, the skin is to be brought together with stick- ing plaster, and a compress placed over the situation of the tumour, with a view of heaUng the wound and the cavity by adhesion. When the ganglion has burst, or is ul- cerated, it is best to remove the diseased skin, together with the cyst, and of course the incision must be oval, or circular, as may seem most convenient. The grand object is not to allow any particle of the cist to remain behind, as it would be very likely to throw out a fungus, and prevent a cure. In Warner's Cases of Surgery is an account of two consider- able ganglions, which this gentleman thought it right to extirpate. These had become adherent to the tendons of the fingers. Tn the operation, he was obliged to cut the transverse ligament of the wrist, and the patients, who before could not shut their hands, nor close their fingers, •perfectly regained the use of these parts. Mr. Gooch relates a case of the same kind, which had been occasioned by a violent bruise, three, or four, years be- fore. The tumour reached from the wrist to the middle of the hand, and created a great deal of pain. Mr. Gooch extirpated it, and then restored the po- sition of the hand, and free motion of the joint, by the use of emollient appbca- t ions', and suitable pressure, made with a machine constructed for the purpose* Other cases, confirming the safety of cutting out ganglions, are recorded in the London Medical Journal for. 1787, p. 154; and by Eller, in Mem. de l'Acad. des Sciences de BerUn, Tom. 2, ann. 1746. The ganglions, which occur just below the knee, I have seen cured by a little blister applied over them, and kept open with the savin cerate. For information, relative to ganglions, consult Warner's Cases in Surgery. Chi- rurgical Worka of B- Gooch, Vol. 2. p. 376. Heister's Surgery. B. BelPs Surgery. Lat- ta's System of Surgery. L' Encyclopedic Methodique; Partie Chirurgicale; art. Gw ronele. Richter's Anfangagrunde der Wun- darzneykunst, Band. 1. Lassus, Patholo- gic Chirurgicale, Tom 1. p. 399. GANGRjfc'NA ORIS. See Cancrum Oris. GANGRENE, (from yxtva, to feed upon.) Gangrxna. An incipient morti- fication, so named from its eating away the flesh. Authors have generally distinguished mortification into two stages; the first, or incipient one, they name gangrene, which is attended with a sudden dimi- nution of pain in the place affected ; a livid discolouration of the part, which from being yellowish, becomes of a green- ish hue ; a detachment of the cuucle, under which a turbid fluid is effused ; lastly, the swelling, tension, and hard- ness, of the previous inflammation, subside, and, on touching the part, a crepitus is perceptible, owing to tie generation of air in the gangrenous parts. Such is the state, to which the term gangrene is applied. When the part has become quite cold, black, fibrous, incapable of moving, and destitute of all feeling, circulation, and life; this is the second stage of mortifi. cation, termed sphacelus. Gangrene, how- ever, is frequently used synonymously with the word mortification. (See Mor- tification.) GANGRE'NE SCORBUTIQUE DES GENC1VES. See Cancrum Oris. GASTRITIS, (from y«-TJ?f, the sto- mach.) An inflammation ofthe stomach. GASTROCELE. (from yxrqp, the sto- mach, and wXrt, a tumour.) A hernia of the stomach. GASTRORAPH1A, or GASTRonAPHE. (from y«r»jf, the belly, and %xQ*i, a su- ture.) A suture of the belly, or some of ils contents. Although the termgastroraphe, in strict- ness of etymology, signifies no more, than GASTRORAPHIA. 497 sewing up any wound of the belly, yet Mr. Samuel Sharp informs us, that, in his time, the word implied, that the wound of the abdomen was complicated with another of the bowels. The moderns, I think, seem to limit the meaning of the word to the operation of sewing up a wound of tiie parietes of the abdomen. What was formerly meant by gastro- raphe could scarcely ever be practised, because the symptoms laid down for dis- tinguishing when an intestine is wound- ed, do not with any certainty determine in what particular part it is wounded; which want of information, makes it ab- surd to open the abdomen in order to get at it. Hence, the operation of stitching the bowels can only take place, when they fall out of the abdomen, and when we can see where the wound is situated. The circumstances, making the prac- tice of sewing up a wounded intestine proper, are so rare, that Du Verney, who was the most eminent surgeon in the French army a great many years during the wars, and fashion of duelling, de- clared, he never had once an opportunity of practising the g.istroraphe, according to the former acceptation of that word. Upon the supposition of the intestine being wounded in such a manner as to re- quire the operation, Mr. Sharp advises taking a straight needle with a small •thread, laying hold of the bowel with your left hand, and sewing up the wound with the glover's stitch, that is, by pass- ing the needle through the lips of the wound from within outwards all the way, so as to leave a length of thread at both ends, which are to hang out of tiie in- cision of the abdomen. He then directs vou carefully to make the interrupted su- ■ ture of the external wound, and to pull the bowel bv the small threads into con- tact with the peritoneum, for the more readily uniting with it afterwards by ad- hesion ; though he seems to think it would be more secure to pass the threads with the straight needle through the lower edges of the wo*i*ad of the abdomen, which would more certainly hold the in- testine in that situation In about six days, the ligature of the intestine will be loose enough to be drawn away; in the interim, superficial dressings are to be applied, and the patient kept on low diet. . (Sharp) , , j On this operation, we have only to re- mark, that as the oi.ly use of a suture ot the bowel is to keep the wound of it near the external wound, in case anyextrava- sation should occur, this object can be as effectually accomplished by o.iehne stnch, as bv sewing up all the breach in the in- Voi. I. testine, and without being so likely to excite inflammation of the parts. We shall add no more concerning sutures of the-bowels, to what is contained in the articles Abdomen and Hernia. Gastroraphe, or merely sewing up a wound of the parietes of the abdomen, may be done, as Mr. Sharp explains, with the common interrupted suture, (see Su- ture) or with the quilled one, which is better, as follows : A ligature, capable of spUtting into two, has a needle attached to each end of it. The operator is to put the index finger of his left hand into the wound, under the lip furthest from him. This finger is in contact with the peritoneum, in order that it may with the thumb pinch up, and raise the whole thickiv-ss ofthe parietes. With the other hand, one of the needles is to be introduced into the abdomen, guiding its point on the index finger, in order to avoid wounding the omentum, or intestines. The lip of the wound is to be pierced, from within out- ward, about an inch from its edge. The otiier needle is to be passed in the lame way through the opposite lip. Then the two needles are to be cut off. As many such sutures must be made, as the extent of the wound may require. The sides of the wound are next to be brought together, and we are to prepare lo tie the ligatures, not in a bow, in the way ofthe interrupted suture, because the continual action of the abdominal mus- cles might make the ligatures cut their way through the parts. It is better, to divide each end of the ligatures into two portions, and to tie these over a piece of bougie laid along the line at'which the ligatures emerge from the flesh. This is to be done to all tlie ligatures, on one side first. Then the wound being closed, an- other pieceof bougie is to be placed along the other lip of tlie wound, and the op. pogite ligatures tied over it, with suffi- cient tightness, to keep the sides of the wound in contact. This suture is cer- tainly preferable to the interrupted one, because a great deal of its pre*-sure is made on the two pieces of bougie, and of course it is less likely to cut its way out. Its operation is to be assisted with com- presses laid over each side of the wound, and the uniting bandage. Every thing, that puts the abdominal muscles into ac- tion, d<-ags the suture, irritates the wound, and creates a risk of the threads cutting their way thro-igh the part, in which they are introduced; consequently, it must be avoided. To prevent, as much as pos- sible, the exertion of the muscfes, the bowels should be kept open with clysters ; and opium is the best thing for putting a 3S 495 GAS ■stop to the vomiting, sometimes attend- ant on wounds of the abdomen, and pro- ducing very injurious effects, in regard to the wound. In about a week, the sutures may ge- nerally be removed, and sticking plaster alone "employed. As to what more relates to these particular cases, we must refer to Abdomen, Wounds of. It is generally allowed, that sutures are violent means, to which we should only resort, when it is impossible to keep the lips of a wound in contact by the ob- servance of a proper posture, and the aid of a methodical bandage. M. Pibrac be- lieves such circumstances exceedingly un- common, and in his excellent production, in the third volume of tiie Memoirs of the Royal Academy of Surgery, relative to the abuse of sutures, cases are related,^. which fully prove, that wounds of" the belly readily unite by means of a suitable posture and a proper bandage, without having recourse to gastroraphe. These, however, are less decisive and convincing, (if possible to be so) than the relations •of tiie Caesarean operation, the extensive wound of which has oftentimes been healed by these simple means, after the failure of sutures. It is not only possible to dispense with gastroraphe in the treat- ment of wounds of the abd< men, it has ever been manifested, that this operation has sometimes occasioned very bad symp- toms. Under certain circumstances, however, it may be essentially necessary to prac- tise gastroraphe. For instance, were a large wound to be made across the pari- etes of the abdomen, a suture might be- come indispensably requisite, to prevent a protrusion of the bowels. Yet, even in tliis case, the sutures should be as few in - number as possible. A bandage of the eighteen-tailed kind, might prove very useful in a longitudinal wound of the abdomen, and do away -till occasion for gastroraphe. (See ''Skttures.) We shall conclude this article with a fact, perhaps more curious, than instruc- tive, related by M. Bordier, of Pondi- cherry, in the Journal tie Medicine, vi\. 26, 538. An Indian soldier, angry with lis wife, killed her, and attempted to de- stroy himself by giving himself a wound with a broad kind of dagger in' the abdo- men, which caused a protrusion of the bowels. A doctor of the country, being sent for, dissected between tiie muscles and skin, and introduced there a thin piece of lead, which kept up the bowels. The wound soon healed up, the lead having produced no inconvenience. The man was afterwards hung, and M. Bor- dier, when the body was opened, assured G L A himself more particularly of the fact. In- deed, numerous cases prove, that lead may lodge in the living body, without oc- casioning the inconvenience, which re- sults from the presence of almost any other kind of extraneous body. See Le Dran's Operations tie Chirurgie. Sharp's 'Treatise on the Operations of Sur- gery. IJ Encyclopedic Methodique ; Partie Cliirurgicale, art. Gastroraphe ; La Mede- cine Operatoire par Sabatier, Tom 1. GASTROTOMIA. (from Xx?r,e, the belly, and renvoi, to Cut.) The operation of opening the abdomen and uterus. The Caesarean operation. It also signifies opening ofthe abdomen for other purposes. GLAUCOMA, (from yXxvxe\, blue.) A disease ofthe eye, in which the crystal- line lens becomes of a blue, 'or sea green colour. The exact meaning of this-an- cient term, however, is very undetermin- ed; some say, it is a disease of the cry- stalline ; others, that it is an affection of the vitreous humour. Galen in his book de u.inpartium imputes glaucoma to amor- bid dryness of the crystalline ; in which sentiment he has been followed by iEtiu.% and Maltre-Jan, at the commencement of the 18th century. Since, however, the ca- taract has been decidedly ascertained to depend upon a disease of the crystalline ; the term glaucoma, has been reserved for an opacity of the vitreous humour, as we may learn from Heister, Platner, and all tlie oculists, who published about the mid- dle of the last century. Lancisi mentions, that he once found the vitreous humour cartilaginous; and Morand has seen it converted into a stony substance. These instances, and some others, are in favour of the opinion, that glaucoma may arise from an opacity of the vitreous humour. A glaucoma, even ofa confirmed kind, can- not always be easily distinguished from t cataract, especially, while the latter is m an incipient state. It is said, however, that suspicions of the disease may be entertained, when the unnatural colour, which characterizes it, is reflected frdteia deep surface, behind the pupil; whereas the opacity of a cataract is more super- ficial, and nearer to tlie margin of the uvea. Glaucoma is certainly an exceedingly uncommon disease, Authors recommend applying blisters, and giving internally the extract of cicuta, calomel, aiid soap, (F.ncyclopedie Methodique; Partie Chir.) The topical use of aether may also be tried, which we have mentioned, as one of Mr. Ware's remedies for promoting the absorption of cataracts. From our present knowledge of the power of the absorbents to remove opaque G LE G L E 499 substances in the eye, when such are de- tached and loose, as they actually become after being disturbed with a couching. needle, there can be no doubt that, if an opacity of a part of the vitreous humour were to present itself in practice, and not yield to the above means, it would be jus- tifiable conduct, on the part of the sur- g-'on, io endeavour to move such opacity out of the axis of sight, and at all events, to disturb it so freely with a couching needle, as to afford a chance of its befog absorbed. GLAUCOSIS, same as Glaucoma. GLKKT. By the term gleet, we com- monly understand a continued running, or discharge, af.er the inflammatory sy mp- toms of a clap for some time have ceased, being unattended with pain, scalding in making water, GONORRHOEA. See A Treatise on the Venereal Disease, by John Hunter. Also, Swediaw's Practical Observations on Venereal Complaints. GLOSSOCA'TOCHUS. (from yXutrtrx, the tongue; and y.xre^u, to depress.) An instrument for pressing down the tongue; a spatula. The ancient glossocatochus was a sort of forceps, one of the blades of which served to depress the tongue, while tlie other was apphed under the chin. GLOSSOCOMION. (from yXao-trx, the tongue ; and rc.ofi.iu, to guard.) By this Was formerly meant a case for the tongue of a hautboy ; but the old surgeons, by metaphor, used the term to signify a case for a broken limb. GOITRE See Bronchocele. GONORRHOEA, (from yoin, the se- men ; and piUy to flow.) Etymologically, an involuntary discharge of the semen; but always, according to modern surgery, a discharge of a purulent infectious mat- ter, fi-om the urethra in the male, and from the vagina and surfaces of the labis, nymphs, clitoris, &c. in the female sub- ject. This disease occurs, in Latin authors, under the different denominations of go- norrhxa, G. Virulenta, Fluor albus mulig- was. Dr. Swediaur, after censuring the etymological import, as convey ing an er- roneous idea, says, if a Greek name is to be retained, he would call it blennorrhaj- gia, from /3Am«, mucus, and Pta, to flow. However, as most moderns consider the discharge as, pus, not mucus, the etymo- logical import of blennorrhxa is as objec- tionable as that of gonorrhoea. In En- glish, tlie disease is commonly called a clap, from the old French word clapises, which were public shops, kept and in- habited by single prostitutes, and gene- rally confined to a particular quarter of the tow\}, as is even now the case in seve- ral of the great towns in Italy. In Ger- man, the disorder is named a tripper, from dripping; and in French, a chaudepisse, from the heat and scalding in making Water. (Swediaur)' We shall first present the reader with some of Mr. Hunter's opinions, concern- ing the nature of gonorrhoea, its symp- toms, and treatment; and, lastly, take notice of what some other writers have said. When an irritating matter of any kind is applied to a secreting surface, it increases that secretion, ard changes it from its na- tural state to some other. In the present instance, it is changed from mucus to pus. TUl about the year 1753, it was gene- rally supposed, that tiie matter from the uretlira, in a gonorrhcea, arose from ul- cers in the passage; but it was then clear- ly ascertained, that pus could be secreted without a breach of substance. It was first accidentally proved, by dissection, that pus could be formed in the hag of tlie pleura, without ulceration; and Mr. Hunter afterwards examined the urethra of malefactors and others, who were exe- cuted, or died, while known to be affected with gonorehcea, and demonstrated that the canal was entirely free from every appearance of ulcer. The time, when a gonorrhcea first ap- pears, after infection, is very various. It generally comes on sooner, than a chan- cre. Mr. Hunter has had reason to be- lieve, that, in some instances, the disease has begun in a few hours, while, in others, Bix weeks have previously elapsed; but he has known it begin at all the intermediate periods. About six, eight, ten, or twelve days, however, after infection, is the most common period. The surface ofthe urethra is subject to inflammation and suppuration, from va- rious other causes besides the venereal poison; and sometimes discharges happen spontaneously, when no immediate cause can be assigned. Such may be called sim- ple gonorrhcea, having nothing of the ve- nereal infection in them. Mr. Hunter has known the urethra sympathize with the cutting of a tooth, and produce all the symptoms of a gonor- rhoea. This happened several times to the same patient. The urethra is known to be sometimes the seat of* the gout; Mr. Hunter has known it to be the seat of rheumatism. When a secreting surface has once re- ceived the inflammatory action, its secre- tions are increased and visibly altered. Also, when the irritation has produced in- flammation, and an ulcer in the solid parts, a secretion of matter takes place, the intention of which, in both, seems to be to wash away the irritating matter. But, in inflammations, arising from spe- cific, or morbid poisons, the irritation cannot be thus got rid of; for, although the first irritating matter be washed a way, yet, the new matter formed has the same quality as the original had; and there- fore, upon the same principle, it would produce a perpetual source of irritations, even if the venereal inflammation, like many other specific diseases, were not what it really is, kept up by the specific quality of the inflammation itself. This inflammation seems, however, to be only capable of lasting a limited time, the symptoms peculiar to it vanishing of themselves by the parts becoming less and less susceptible of irritation. Tiv* consequent venereal matter can have no GQN0RRH02A. 501 power of continuing the original irrita- tion, otherwise there would be no end to the disease. The time, which the sus- ceptibdity of the irritation lasts, must de- pend upon the difference in the constitu- tion, and not upon any difference in the poison itself. The venereal disease only ceases spon- taneously, when it attacks a'secreting sur- face, and produces a mere secretion of pus, witiiout ulceration. SYMPTOMS OF GOXOIUtHCCi. The first symptom is-generally an itch- ing at the orifice of tiie urethra, sometimes extending over the whole glans. A little fulness of the lips of the urethra, the ef- fect of inflammation, is next observable, and soon afterwards a running appears. The itcliing -changes into pain, more particularly at the time of voiding the urine. There is often no pain till some time after the appearance of the discharge, and other symptoms; and in many gonor- rhoeas, there is hardly any pain at all even when the discharge is very consider- able. At other times, a great degree of soreness occurs long before any discharge appears. There is generally, at tliis time, a particular fulness in the penis, and more especially in the glans. The glans has also a kind of transparency, especiaUy near the beginning of the urethra, where the skin, being distended, smooth, and red, resembles a ripe cherry. The mouth of the uretlira is, in many instances, evi- dently excoriated. The surface of tiie glans itself is often in a half-excoriated state, consequently very tender ; and it se- cretes a sort of discharge. The canal of the uretlira becomes narrower, which is known by the stream of urine being smaller than common. This proceeds from the fulness of the penis in general, and from the lining of the urethra being swollen, and in a spasmodic state. The fear of the patient, while voiding his urine, also disposes the uretlira to contract. The stream of urine is generally much scat- tered and broken, as soon as it leaves the passage. There is frequently some degree of hemorrhage from the urethra, perhaps, from the distention of the vessels, more especially when tiiere is a chordee, or a tendency to one. Small swellings often occur, along the lower surface of the pe- nis, in the course of the urethra. These, Mr. Hunter suspected to be enlarged glands of the passage. They occasionally suppurate, and buret outwardly, but now and then in the uretlira itself. Mr. Hun- ter has also suspected such tumours to be ducts, or lacunx ofthe glands ofthe ure- thra distended with mucus, in consequence of the mouth of the duct being closed, in a manner similar to what happens to the duct leading from the lachrymal sac to the nose, and so as to induce inflamma- tion, suppuration, and ulceration. Hard- ness and swelling have also occurred in the situation of Cowper's glands, and ended in considerable abscesses in the perineum. The latter tumours break ei- ther internally or externally, and some- times in both ways, so as to produce fis- tulx iri perinxo. A soreness is often felt all along the un- der side of the penis, frequently extend- ing as far as the anus. The pain is par- ticularly great in erections ; but the case differs from chordee, the penis remaining straight.—Erections are frequent in most gonorrhoeas, and even sometimes threaten to bring on mortification. As opium is of great service, Mr. Hunter thinks there is reason to suppose them of a spasmodic nature. The natural slimy discharge from the glands of the urethra is first changed, from a fine transparent ropy secretion, to a wa- tery whitish fluid; and the lubricating fluid, which the passage naturally exhales, becomes less transparent; both these se- cretions becoming graduaUy thicker, as- sume more and more the qualities of com- mon pus. The matter of gonorrhoea often changes its colour and consistence, sometimes from a while to a yellow, and often to a green- ish colour. These changes depend on the increase and decrease of the inflammation, and not on the poisonous quality of the mutter itself; for, any irritation on these parts, equal to that produced in a gonor- rhoea, will produce the same appearances. The discharge is produced from the membrane lining the urethra, and from the lacuns, but, in general, only for about two or three inches* from the external orifice. Whenever Mr. Hunter had an opportunity of examining the urethra affected with gonorrhoea, he always found the lacunae loaded with matter, and more visible than in the natural state. Before the time of this celebrated man, it was commonly supposed, that the discharge arose from the whole surface of the ure- thra, and even from Cowper's glands, the prostate and vesiculae seminales. But, if the matter were secreted from all these parts, the pus would collect in the bulb, as the semen does, and thence be emiited in jerks ; for, nothing can be * P. 50 Mr. Hunter says, seldom further than an inch and a half, or two inches at most. This he terms the speci- fic extent of the inflammation. GONORRHCEA. 502 in the bulbous part of the urethra, witii- out stimulating it to action, especially, when in a state of irritation and inflam- mation. When the inflammation is violent, some of the vessels of the urethra often burst, and --^discharge of blood ensues. Some- times 9uch blood is only just enough to give the matter a tinge. The erections often stretch the part so much as to cause an extravasation. When the inflammation goes more deep- ly than the membranous lining, and af- fects the recticular membrane of the ure- tlira, it produces in it an extravasation of coagulable lymph, the consequence of which is a chordee. (See Chordee) Mr. Hunter suspected, that the disease is communicated or creeps along from the glans to the uretlira, or, at least, from the lips of the urethra to its inner surface, as it is impossible, that the infectious mat- ter can, during coition, get as far as the disease extends. He mentions an instance, in which a gentleman, who had not co- habited with any woman for many weeks, to all appearances caught a gonorrhcea from a piece of plaster, which had ad- hered to his glans penis, in a necessary abroad, and which is accounted for by supposing that some person, with a clap, had previously been to this place, and had left behind some of the discharge, and that the above gentleman had al- lowed his penis to remain in contact with the matter,'till it had dried. Many symptoms, depending on the sym- pathy of other parts with the urethra, sometimes accompany a gonorrhcea. An uneasiness, partaking of soreness and pain, and a kind of weariness, are every where felt about the pelvis. The scrotum, testicles, perinaeum, anus^ and hips, be- come disagreeably sensible to the patient, and the testicles often require being sus- pended. So irritable, indeed, are they in such cases, that the least accident, or even exercise, which would have no such effect at another time, will make them swell. The glands of the groin are often affected sympathetically, and even sweU a little, but do not suppurate, as they gene- rally do when they inflame from the ab- sorption of matter. Mr. Hunter has seen the irritation of a gonorrhoea so extensive as to affect with real pain the thighs, but- tocks, and abdominal muscles. He knew one gentleman, who never had a gonor- rhcea without being immediately seized with universal rheumatic pains. When the gonorrhcea, exclusive of the affections arising from sympathy, is not more violent than has been described, it may be called a common, or simple venereal one; but, if the patient is very susceptible of such irritation, or of any other mode of action which may accompany the vene- real, then tlie symptoms are in proportion more violent. In such circumstances, we sometimes find the irritation and inflam- mation exceed the specific distance, and extend through the whole urethra. There is.often a considerable degree of pain in the perinaeum ; and a frequent, though not a constant symptom, is a spasmodic contraction ofthe acceleratores m ins, and erectores muscles. The inflammation, in these cases, is sometimes considerable, and goes deeply into the cellular membrane, without producing any effect, however, except swelling. In other instances, it goes on to suppuration, often becoming one of the causes of fistulas in pennxo. Cowper's glands may hence suppurate, and the irritation is often extended eVeh to the bladder itself. When the bladder is affected, it becomes more susceptible of every kind of irrita- tion. It will not bear tbe usual disten- tion, and, therefore, the patient cannot retain his water the ordinary time, and the moment the desire of making water takes place, he is obliged instantly to make it, with violent pain in the bladder, and still more in the glans penis, exactly similar to what happens in a fit of the stone. If the bladder be not allowed to discharge its contents immediately, the pain becomes almost intolerable ; and even when the water is evacuated, tiiere remains, for some time, a considerable pain, both in the bladder and glans. The ureters, and even the kidneys, sometimes, though rarely, sympathize, when the bladder is much affected. Mr. Hunter had reason to suspect, that the ir- ritation may be communicated to the pe- ritonaeum, by means of the vas deferens. Mr. Hunter mentions a case in which, wfygn the inflammatory symptoms of a gonorrhcea were abating, an incontinence of urine came on ; but, in time, got spon- taneously well. A very common symptom, attending a gonorrhcea, is a swelUng of the testicle. See Hernia Humoralis. Another occasional consequence of a gonorrhcea, is a sympathetic swelUng of the inguinal glands. -(See Bubo.) A hard chord is sometimes observed, leading from the prepuce along the back ofthe penis, and often directing its course to one of the groins, and affecting the glands. There is most commonly a swel- ling in the prepuce, at the part where the chord takes its rise. This §sometimes happens when an excoriation and a dis- charge from the prepuce, or glans penis exist. Fmm the above account, the symptoms 50J GONORRHOZA. of gonorrhoea, in different cases, seem to be subject to infinite variety. The dis- cbarge often appears without any pain; and the cwming on of the pain is not at any stated time after the appearance of the discharge. There is often no pain at all, although the discharge is in consider- able quantity, and of a bad appearance. The pain often goes off, while the dis- charge continues, and will return again. An itching, in some cases, is felt for a con- siderable time, which is sometimes suc- ceeded by pain ; though, in many cases, it continues to the end ofthe disease. On the other hand, the pain is often trouble- some, and considerable, even when there is little or no discharge. Ir. general, the inflammation in the uretlira does not ex- tend beyond an inch or two from the ori- fice ; sometimes it runs all along the ure- thra to the bladder, and even to the kid- neys, -and, in some cases, spreads into the substance of the urethra, producing a chordee. The glands of the uretlira in- flame, and often suppurate ; and Mr. Hun- ter suspected that Cowper's glands some- times do the same. The neighbouring parts sympathize, as the glands of the groin, the testicle, the loins, and pubes, with the upper parts of the thighs, and abdominal muscles. Sometimes the dis- ease appears a few hours after the appli- cation of the poison ; sometimes six weeks elapse first. It is often not possible to de- termine whether it is a venereal or only an accidental discliarge, arising from some unknown cause. GONORRHCCA IN WOSTENV The disease is not so easily ascertained in them as in men, because they are sub- ject to a disorder called fiuor albua, which resembles gonorrhcea. A -discharge sim- ply from women, is lrss a proof of the existence of a gonorrhcea, than even a discharge without pain in men. The kind of matter does not enable us to dis- tinguish a gonorrhcea from a fluor albus ; for the discharge in the latter affection often puts on all the appearance of vene- real nlatter. Pain is not necessarily pre- sent and therefore forms no line of dis- tinction. The appearance of the parts often gives ns but little information ; for, continues Hunter, I have frequently ex- amined the parts of those who confessed all the symptoms, such as increase of discharge,' pain in making water, soreness in walking, or when the parts were touched, vet I could see no difference between tiiese and sound parts. I know of no other way of judging, in cases where there are no symptoms sensible to the person herself, or where the patient han a mind to deny any uncommon symp- toms, but from the circumstances pre- ceding the discharge ; such as her having been connected with men supposed to be unsound, or her being able to give the dis- order to others ; which last circumstance being derived from the testimony of an- other person, is not always to be trusted to, for obvious reasons. From the manner, in which the disease is contracted, it must principally attack the vagina, a part not endowed with much sensation. In many cases, however, it produces a considerable soreness on the inside of the labia, nymphs, clitoris, c*v runculs myrtiformes, and meatus urina- rius. Those parts are so sore, in some cases, as not to bear being touched ; the person can hardly walk ; the urine gives pain in its passage through the urethra, and when it comes into contact with the above-mentioned parts. The bladder sometimes sympathizes, and even the kidneys. The mucous glands on the inside of the labia, often swell, and sometimes suppurate, forming small abscesses, which open near the ori- fice of the vagina. Mr. Hunter states, that the venereal matter fi-om the vagina sometimes runs down the perinsum io the anus, and pro- duces a gonorrhoea, or chancre, in that situation. The disease in women may probably wear itself out, as in men ; but it may exist in the vagina for years, if the testimony of* patients can be relied on. TREATMENT OF GONOHIIHCei. As every form of the venereal disease arises from the same cause, and as we have a specific fof*some forms, we might expect that this would be a certain cure for every one ; and, therefore, that it must be no difficult task to cure the disease, when in the form of inflammation and suppuration in the urethra. Experience, however, teaches us, that the g-onorrhcea is the most variable in its symptoms, while under acme; and the most uncer- tain, with respect to its cure, of any forms of the venereal disease ; many cases ter- minating in a week, while others con- tinue for months, under the same treat- ment. The only curative object is, to destroy the disposition and specific mode of ac- tion «*» tiie solids of tiie parts, and as they become clianged, the poisonous quality of the matter produced will also be de- stroyed. This efforts the cure ofthe dis- ease, but not always ofthe consequences. This fond of the disease is not capable of being continued beyond a certain time in any constitution ; and when it is vio- 5Q4 GONORRHCEA. lent, or of long duration, it is owing to the part being very susceptible of such irritation, and readily retaining it. As we have no .specific remedy for the go- norrhoea, it is fortunate that time alone will effect a cure. It is worthy of consi- deration, however, whether medicine can be of any service. Mr. Hunter is inclined not to think it of the least use, perhaps, once in ten cases. But even tliis would be of some consequence, if the cases ca- pable of being benefited could be distin- guished. The means of cure, generally adopted, are of two kinds, internal remedies, and local applications ; but, whatever plan is pursued, we are always to attend more to the nature of the constitution, or to any attending disease in the parts themselves, or parts connected with them, than to the gonorrhoea itself. When the symptoms are violent, but of* the common inflammatory kind, known from the extent of the inflammation not exceeding the specific distance, the local treatment may be either irritating or soothing. Irritating applications, in these cases, are less dangerous, than when there ex- ists irritable inflammation, and they may alter the specific action ; but, to produce this effect, their irritation must be greater, than that of tlie original injury. The parts will afterwards recover of them- selves, as from any other common inflam- mation. Mr. Hunter believes, however, that the soothing plan is the best at the beginning. If the inflammation be great, and of the irritable kind, no violence is to be used, for it would only increase the symptoms ; nothing should be done that may tend to stop the discharge, as doing so would not put a stop to the inflammation. The constitution is to be altered, if possible, by remedies adapted to each disposition, with a view of altering the actions of the parts arising from such disposition, and reducing the disease to its simple form. If the constitution cannot be altered, no- thing is to be done, and the action is to be allowed to wear itself out. When the inflammation has abated, the cure may be attempted by internal reme- dies, or local applications, not operating violently, which might re-produce the irritation. Gentle astringents may be ap- plied. But, if the disease has begun mildly, an irritating injection may be used, in order quickly to get rid of the specific mode of action. This application will increase'the symptoms for a time; but, when it is left off, they will often abate, or wholly disappear. In such a state of parts, astringents may be used, the dis* charge being now the only thing to be removed. When itching, pain, and other Uncom- mon sensations are felt for some time be- fore the discharge appears, Mr. Hunter diffidently expresses his inclination to recommend the soothing plan, instead of the irritating one, in order to bring on the discharge, which is a step towards the resolution of the irritation ; and he adds, that to use astringents would be bad practice, as, by retarding the discharge, they would protract the cure. When there are strictures, or swelled testicles, astringents should not be used; for, while there is a discharge, such complaints are relieved. Mr. Hunter thus expresses himself in regard to the effect of" mercury in gonor- rhoea : " I doubt very much of mercury having any specific virtue in this species of the disease ; for I find that it is as soon cured without mercury as with it, &c. So little effect, indeed, has this me- dicine upon a gonorrhoea, that I have known a gonorrhoea, take place while (the patr-nt was) under a course of mercuiy, sufficient for the cure ofa chancre. Men have also been known to contract a go- norrhoea when loaded with mercury for the cure ofa lues venerea; the gonorrhoea, nevertheless, has been as difficult of cure as in ordinary cases." Mr. Hunter does not say much in fa- vour of evacuants, diuretics, and astring- ents, given internally. He allows, how- ever, that astringents which act specifi- cally on ^the parts, as the balsams, con- joined with any other medicine, which may be thought right, may help to lessen the discharge, in proportion as the inflam- mation abates. Local applications may be either in- ternal to the uretlira, external to the penis, or both. Those which are applied to the urethra seem to promise most ef- ficacy, because tiiey come into immediate contact with the diseased parts. They may be either in a solid or fluid form. A fluid is only a very temporary applica- tion. The solid ones, or bougies, may remain a long while, but in general irri- tate immediately, from their solidity alone; and, Mr. Hunter says, the less bougies are used, when the parts are in an inflamed state, the better, though he never saw any bad effects from them, when applied with caution. The fluid applications, or injections, in use, are innumerable ; and as gonorrhoeas frequently get well with so many of vari- ous kinds, we may infer, that such com- plaints would, in time, get weU of them- selves. Injections, however, certainly GONORRHCEA. 505 often have an immediate effect on the symptoms, and hence must have power; tnough the one wliich possesses the greatest specific power is unknown. As injections are only temporary applica- tions, they must be used often, especially when found useful, and they are not of an irritating kind. Mr. Hunter divides injections into four kinds, the irritating, sedative, emollient, and astringent. Irritating injections, of whatever kind, act in this disease upon the same prin- ciple ; that is, by producing an irritation of another kind, which ought to be greater than the venereal; by which means the venereal is destroyed and lost, and the disease cured, although the pain and dis- charge may still be kept up by the injec- tion. Those effects, however, will soon go off, when the injection is laid aside. In this way bougies also perform a cure. Most of the irritating injections have an astringent effect, and prove simply as- tringent when mild. Irritating injections should never be used when there is already much inflam- mation ;_ especially, in constitutions, which are known to be incapable of bear- ing much irritation ; nor should they be used when the inflammation has spread beyond the specific distance; nor when the testicles are tender ; nor when, upon the discharge ceasing quickly, these parts have become sore ; nor when tiie peri- nsum is very susceptible of inflamma- tion, and especially if it formerly should have suppurated; nor when there is a tendency in the bladder to irritation, known by the frequency of making water. In mild cases, and in constitutions which are not irritable, such injections often succeed, and remove the disease al- most immediately. The practice, how- ever, ought to be attempted with caution, and not, perhaps, till milder methods have failed. Two grains of the hydrar- gyrus muriatus, dissolved in eight ounces of distilled water, form a very good irri- tating injection; but, an injection of only half this strength may be used, When it is not intended to attempt a cure so quickly. If however, the injection, even in that proportion, gives consider- able pain in its application, or occasions a great increase of pain in making water, it should be diluted. Sedative injections will always be of service, when the inflammation is consi- derable, and they are very useful in re- lieving the pain. Perhaps, the best se- dative is opium, as well when given by the mouth, or anus, as when applied to the part affected, in the form ot an injec- tion. But, even opium will not act as a Vol. I. sedative in all constitutions, and parts ; but, on the contrary, often has opposite efiects, producing great irritability. Lead may be reckoned a sedative, so far as it abates inflammation, while, at the same time, it may act as a gentle astringent. Fourteen grains of saccharum saturni, in §viij of distilled water, make a good se- dative astringent injection. Drinking freely of diluting liquors may, perhaps, have a sedative effect, as it in part removes some ofthe causes of irri- tation, by rendering the urine less stimu- lating to the bladder, when the irritation is there, and to the urethra in its passage through it. Diluting drinks may possi- bly lessen the susceptibility of irritation. The vegetable mucilages of certain seeds and plants, and the emolUent gums are recommended. Mr. Hunter does not en- tertain much opinion of their efficacy, though some of his patients told him they experienced less uneasiness in making water, when their drink was impregnated with mucilaginous substances. EmoUient injections are the most pro- per, when the inflammation is very great; and they probably act by first simply washing away the matter, and then leav- ing a soft application to the part, so as to be singularly serviceable, by lessening the irritating effects ofthe urine. Indeed, practice proves this; for a solution of gum-arabic, milk and water, or sweet oil, will often lessen the pain, and other symptoms, when the more active injec- tions have done notliing, or seemed to do harm. The irritation at the orifice of the ure- thra, is frequently so great, that the point ofthe syringe cannot be suffered to enter. In this case, no injection should be used till the inflammation has abated; but, in the mean while, fomentation may be em- ployed. "* Astringent injections act by lessening the discharge They should only be used towards the latter end of the disease, when it has become mild. But, if the disease should begin mildly, they may be used at the very beginning; for, by gra- dually lessening the discharge, without increasing tiie inflammation, we complete the cure, and prevent a continuance of the discharge called gleet. They will have an irritating quality, if used strong, and hence increase the discharge, instead of lessening it. Mr. Hunter's experience did not teach him, that one astringent was much better than another. The astringent gums, as dragon's blood, the balsams, and the turpentines, dissolved in water; the juices of many vegetables, as oak, bark, Peruvian bark, tormentil root, and, perhaps, all the metalUc salts, 3T 500 GONORRHCEA. as green, blue, and white vitriols; the salts of mercury, and also alum ; pro- bably all act much in the same_ way ; though the mere changing of an injection is often efficacious. The external appli- cations are poultices, and fomentations, which can only be useful when the pre- puce, glans, and orifice of the urethra are inflamed. Since Mr. Hunter's time, many sur- geons have been in the habit of keepiifg the penis, in the incipient inflammatory stage of gonorrhoea, covered with linen, kept continually wet with the saturnine lotion ; a practice which is certainly both rational and beneficial. Mr. Abernethy, in his Lectures on Surgery, speaks in fa- vour of this method. When the glands of the urethra are en- larged, mercurial ointment may be rub- bed on the part; and this will probably be of more service after the inflammation has subsided. TREATMENT OF aONORRHCCA IK WOMEN. This is nearly the same as that of the disease in men, but is more Simple. When the disorder is in the vagina, injections are best; and after them, the parts may be smeared with mercurial ointment, and the external parts washed with the injec- tion. It is almost impossible for the pa- tient to throw an injection into the ure- thra, when it is affected. The same in- jections are proper as for men; but they may be made doubly strong. When the glands of the vagina are enlarged, mer- curial ointment should be freely applied; and when they form abscesses, these should be opened, and dressed. CONSTITOTIONAl TREATMENT OF GONOR- RHOEA. V In many strong plethoric constitutions, the symptoms are violent, and there is a great tendency to inflammatory fever. In such instances, opiate clysters, though at first productive of relief, sometimes occa- sion in the end fever, and consequently aggravate all the symptoms. The balsam capivi, sometimes, in such cases, in- creases the inflammatory symptoms. The treatment of this kind of constitution, consists chiefly in evacuations, the best of which are bleeding and gentle purging. To live sparingly, and, above all, to use little exercise, is necessary. In the weak and irritable constitution, the symptoms are frequently very violent, the inflammation extending beyond the specific distance, running along the ure- thra, and even affecting the bladder. The indication, in this instance, is to strength- en i and bark alone has been known tg effect a cure. All evacuations are hurt* ful. The fever has been known to stop the discharge, relieve the pain in making water, and finally cure the disease. On other occasions, Mr. Hunter has seen all the symptoms of gonorrhoea cease on the accession of a fever, and return when the fever was subdued. In other examples, a gonorrhoea mild at first, has been ren- dered severe by the coming on of a fever, and, on this ceasing, the gonorrhoea has cea-? ed. Although a fever does not always cure a gonorrhcea, yet, as it may do so, nothing should be done while it lasts. If the local complaint should continue after the fever is gone, it is to be treated ac- cording to symptoms. A gonorrhoea may be considerably af- fected by the patient's manner of living, and by other diseases attacking the con- stitution. Most things which hurry or increase the circulation, aggravate the symptoms ; such as violent exercise, drinking strong- liquors, eating strong indigestible food, some kinds of which act specifically on these parts, so as to increase the symptoms more than simply heating the body would do ; such as pep- pers, spices, and spirits. In cases which have begun mildly, in which the inflammation is only slight, or in oihers, in which the violent symptoms have subsided, such medicines as have a tendency to lessen the discharge, may be fiven, together with the local remedies efore mentioned. Turpentines are the most efficacious. Cantharides, the salts of lead and copper, and alum, have also been recommended. Mr. Hunter advises small doses of mer- cury, in consequence ofthe possibility of absorption, and with a view of preventing lues venerea. V TREATMENT Or OCCASIONAL STMPTOMS OS GONORRHCEA. Bleeding from the urethra is sometimes relieved by the balsam capivi. Mr. Hun- ter did not find astringent injections of use. Painful erection* are greatly prevented by taking twenty drops of tinctura opii at bed-time. Cicuta has also some power in this way. Chordee. See this word. Bladder affected. Opiate clysters, tbe Warm bath, and bleeding, if the patient is of full habit, are proper. Leeches may be applied to the perinsum. When this affection lasts a considerable time, and is not mitigated by common methods, Mr. Hunter advises trying an opiate GONORRHCEA. 507 plaster on the pubes, or the loins, where the nerves of the bladder originate ; or a small blister on the perinsum. In an- other place, he mentions bark, cicuta, sea air, and sea bathing, among the proper means. Swelled testicles. See Hernia Humoralit. For a more full account of Gonorrhoea, according to the above doctrines, see a Treatise on the Venereal Disease, by John Bunter, from page 29 to 90. ON THE Q.UESTION, WHETHER GONORRHOEA IS REALLT A FORM OF TUE VENEREA!, DISEASE > The foregoing remarks, and other ones in Mr. Hunter's work, would lead one to believe, that the poison of gonorrhcea and the venereal virus are the same. Here it is our duty impartially to state the argu- ments, which have been urged for, and against, this important doctrine. Mr. Hunter assures us, that he has seen all the symptoms of lues venereal originating from gonorrhoea only; that he had even produced venereal chancres by inoculating with the matter of gonor- rhcea ; and that fie afterwards repeated these experiments in a manner in which he could not be deceived. P. 293, & *eq. Mr Hunter's experiments, it is true, have been repeated with a different re- sult ; but, as an eminent modern writer remarks, can we wonder at this, when we consider from how many causes gonor- rhcea may arise, and how impossible it is to distinguish the venereal from any other I ( Observations an Morbid Poison*, by J. Adams, M D. p. 91. edit. 2.) Another argument adduced by Hunter, in favour of the poisons* of gonorrhoea and chancre being the same, is the proba- bility, that the Otaheitans had the venere- al disease propagated to them by Europe- an sailors, who were affected with gonor- rhoea; for these can hardly be supposed to have had a chancre, during a voyage of five months, without tlie penis being de- stroyed. It is impossible, however, to say what time may elapse, between the application of venereal poison to the penis, and the commencement of ulceration. Therefore, Bougainville's sailors, alluded to by Mr. Hunter, might have contracted the infec- tion at Rio-de-la-Plata ; but actual ulcers on the penis might not have formed till about five months afterwards, When the ship arrived at Otaheite. In attempting to explain why a gonor- rhcea and a chancre do not equally pro- duce lues venerea, and why the medicine which almost universally cures chancre, bas less effect on gonorrhcea, a modern advocate for Mr. Hunter's doctrine says, that we must take into consideration, that tbe seat of the two diseases is differ- ent; that the same cause may produce different effects upon different parts; that the same poison, when mixed with dif- ferent fluids, may be more or less violent in its operation ; and that there may be greater or less attraction of" certain fluids to a part, according to its nature and composition. (Inquiry into some Effect* of tlm Venereal Poison by S. Sawrey, 1802, p. 4.) Mr. Sawrey very truly remarks, p. 6, that if gonorrhoeal matter has clearly and decidedly produced chancre, or contami- nated the system in any one instance, the question is determined. Il could in no instance produce these effects, unless it had the power of doing so. This writer brings forward some cases to shew, that the poison of gonorrhcea may produce gonorrhoea, or chancre; but, the limits of this work only afford room to observe, that these instances are by no means de- cisive of the point, as some objections may be urged against them, as indeed, Mr. Sawrey himself allows. 1'bat Mr. Hunter's cases are inconclusive',1* 1 have endeavoured to explain in the FirH Line* of tlie Practice of Surgery, to which I must refer my readers. Why does not gonorrhoea commonly produce ulceration in the urethra * Mr. Sawrey tries to solve this question, by saying, that the product ofthe venerealin- flammation, the diseased contents of the small arteries of the urethra, are thrown out of these open-mouthed vessels into this canal, without any breach in their texture, which otherwise would be a ne- cessary consequence. Why does not gonorrhcea equally con- taminate the system as chancre ? in go- norrhoea, says Mr. Sawrey, the discharge is very plentiful; it is not, in general, at- tended with ulceration; the poison is much more diluted, and mixed with a mu- cous and puriform fluid. It is deposited in the uretlira, and its lacuns, where little or no pressure is applied, and it finds easy egress out of the canal. In chancre there is breach of substance, the poison is not much diluted, &c. Why does not chancre generally, in the same person, produce gonorrhcea, and gonorrhoea chancre ? Mr. Sawrey, in an- swer expresses his belief, that tiiese in- cidents are not very unfrequent. He says, he has known persons having a chancre, which continued for months, become affected, after that time, with a clap, without any further exposure. His opinion is, that the matter of**" the chancre had insinuated itself into the urethra, and produced the disease j though, he 508 UONOU1UKEA. confesses, many would explain the cir- perfectly clean, chancres will very often cumstance, by supposing that the chancre be produced. He owns a great many and gonorrhcea were both communicated claps are cured without mercury : yet, re- at the same time by two different poisons, peated experience has shewn him, a cure Mr. Hunter remarks, that the presence cannot always be thus accomplished. of one disease renders the adjacent parts Mdd cases, without ulcer or excoriation less suscep-table of its influence. in the urethra, may certainly be radically Mr. Sawrey concludes his second chap, cured without a grain of mercury ; and with inclining to the idea, that the mat- though mercury should be given, it would ter of gonorrhoea is not strictly pus, but not have the least effect: not because the of a more mucous nature than that of a disease does not proceed from a venereal chancre. However, when he mentions poison, but because out of tiie course of chemical attractions, as drawing the poi- the circulation. He contends, that the son from mucus to the urethra, and from . topical use of mercury in injections, acts pus to the dry parts, in order to expiain usefully even in ihese cases. But, when the last of the above questions, every a clap is joined with ulceration in the sober reader must feel sorry, that a work, urethra, it is always cured more safely which contains some really sensible ob- and expeditiously with mercury, and is servations, should comprehend this most frequently incurable without it. A lues unfortunate one. also follows cases attended with ulcers in Mr. Whately has also written, in sup- the urethra. He allows that all claps port of the opinion, that the matter of are not venereal. (See Practical Observa- gonorrhoea and that of chancre, are the tions on Venereal ^Complaints, by J. Swe- same. (See Whately on Gonorrhxa Vim- diaur.) lento.) One argument urged against the iden- Another defender of this side of the tity of gonorrhoeal and chancrous virus, question,is Dr. Swediaur, who endeavours is, that gonorrhoea was not described as to proverthe fallacy of the following posi- a symptom, till nearly half a century after tions: 1. That the poison which produces the other symptoms of the venereal dis-* the clap, does never, like that of chancres, ease were known. Fallopius is among produce any venereal symptoms in the mass the first who observed gonorrhoea, as a or lues itself. 2. That the poison of the clap symptom of the venereal disease. " If, never produces chancres and that the poi- however," says Dr. Adams, " venereal son of chancres neve'- produces a clap. 3. gonorrhcea was unnoticed till about fifty That mercury never contributes to, nor ac- years after the other forms of the disease celerates the cvre of a clap: but, that, on were described, what does this prove, but the contrary, every blennnrrhagia may be that contagious gonorrhoea was so com- ^ertainly cured without mercury, and with- mon, as to be disregarded1 as a symptom out any danger of leaving a lues behind. of the new complaint ? Can there be a His arguments run thus;—the reason doubt, from the caution given by Moses, why claps do not, like chancres, constantly that gonorrhoea was considered as conta- produce the lues, is, that most of them gious in his clays P During the classical excite only a superficial inflammation in age, we find inconveniences of the urinary the memlrr.ne ofthe urethra, without passages, were imputed to incontinence; any ulceration. Hence absorption can- and the police of several states, before the not easily take place, the poison being siege of Naples, made laws for preserv- out of the course of the Circulation. Rut ing the health of such as would content he has seen claps, with an ulcer in the themselves with public stews, instead of urethra, followed by the most unequivocal disturbing the peace of famiUes. This is symptoms of lues itself. He mentions enough to lessen our surprise, -that gonor- the urethra being defended with a large rhcea should be unnoticed for some time quantity of mucus*, as the thing impeding after the appearance of the venereal dis- the common formation of ulcers, which ease. But, so far is it from proving the do occasionaUy occur when the mucus is* two contagions are different, that the not secreted as usual, or is washed away, fairest inference we can draw is in favour He asserts, that in many ca.es, where he of their identity. For, if by this time the had occasion to examine both parties, he venereal disease began to be so far under- was convinced that chancres were com- stood, that secondaiy symptoms were) municated by a person affected with a found the consequence of primary on6s in simple gonorrhcea ; and vice versa, that the genitals, k is most probable that ihe ^ a virulent clap had been tiie consequence first suspicion of venereal gonorrhoea of an infection from a pci son having arose from the occurrence of such se- nurely ..chancres. He says, that if a pa- condary appearances, where no other pri- tient, with a venereal running, does not maty symptoms could be traced." (Adam* take care to keep the prepuce and glans on Morbid Poison*, p. 95, Edit. 2 ) GONORRHCEA. 509 In relating the arguments maintained by the best modern writers, to repel the attacks made on the doctrine, that gonor- rhcea and chancre arise from the same poison, we have* been compelled to dis- close the chief grounds, on which the as- sailants venture to entertain a contrary theory. Mr. B. Bell is the principal author who has written against the opinions maintained by Hunter, Sawrey, Swediaur, Adams, 8cc. Our limits will only allow us just to enumerate a few of his leading arguments. If the matter of gonorrhoea, and that of chancre, were of the same nature, we must admit that a person with a chancre only, can communicate to another, not only every symptom of pox, but of gonor- rhoea; and that another, with gonorrhoea only, can give to all, with whom he may have connexion, cliancres, with their va- rious consequences. This ought, indeed, to be a very frequent occurrence ; where- as, all allow that it is even in appearance very rare. On the supposition of the matter of go- norrhoea and lues venerea being the same, the latter ought to be a much more fre- quent occurrence than the former, from the greater ease with which the matter of infection must, in every instance, be applied to those parts on which it can produce chancres, than to the urethra, where, instead of chancre or ulceration, it almost always excites gonorrhoea. It is difficult to conceive how die matter, by which the disease is communicated, should find access into the urethra; while all the external parts of the penis, parti- cularly the glans, must be easily and uni- versally exposed to it; and yet gonorrhcea is a much more frequent disease than pox. Cases "of gonorrhoea are in propor- tion to those of chancre, according to Mr. B. Bell's experience, as three to one. It is obvious that the very reverse should happen, if the two diseases w*re produced by the same kind of matter. I need not adduce other arguments, as the reader must be already acquainted with any worth knowing, from what is said in the previous part of the present article. Tiie grand practical consideration, de- pending on the possibility of the vene- real disease arising from gonorrhcea, is, whether mercurials should not be exhibit- ed, in all cases, with a view of preventing such a consequence. Waving, on my own part, all attempts to decide the point, whether the matter of a chancre, and that of gonorrhoea, are of the same nature, I shall merely content myself with stating, that as far as my ob- servation and enquiries extend, the ma- jority of the best practitioners of tlie pre* sent day consider the exhibition of mer- cury unnecessary, and consequently, im- proper in cases of gonorrhoea. This fact almost amounts to a proof, that if vene- real symptoms do ever follow a clap, they are so excessively rare, and, I may add, always so .mpuuble to other causes, that the employment of mercury, as a preven- tion, would, upon the whole, do more in- jury than benefit to mankind; and this even admitting (what, in my mind, baa never been unequivocally proved) that the matter of gonorrhcea is really capable, in a very few instances, of giving rise to the venereal disease. The reader must weigh the different arguments himself. Some of Mr. B. Bell's reasoning is certainly untenable, as Saw- rey Ius clearly shewn; but the latter, also, is not invulnerable in many points, which he strives to -defend. The reader is referred, for further in- formation, to A Treatise on the Venereal Disease, by John Hunter ; 1788. Whately on the Gonorrhxa Virulenta ,- 1801. Prac- tical Observations on Venereal Complaint*, by F. Swediaur, M. D. edit. 3. An Enquiry into some ofthe Effects of the Venereal Poi- son, by S. Sawrey ; 1802. Observations on> Morbid Poisons, by J. Adams, M. D. edit. 2. 1807. GORGET. An instrument used in the operation of lithotomy, for the purpose of cutting the prostate gland and neck of the bladder, so as to enable the operator to introduce the forceps and extract the stone. It is, in fact, a sort of knife, at the end of which is a beak,E$bat fits the groove of the staff, and admits of being pushed along it into the bladder. Besides cutting gorgets, constructed for the preceding design, there are also blunt ones, intended to be introduced into the wound, when their concavity serves as a guide for the forceps into the bladder. GRANULATIONS, (from granum, a grain.) The little grain-like, fleshy bodies, which form on the surfaces of ulcers, and suppurating wounds, and serve both for filling up the cavities, and bringing nearer together and uniting their sides. Nature, in bringing parts as nearly as possible to their original state, whose dis- position, action, and structure have been altered by accident, or disease ; and after having, La her operations for this purpose, formed pus, she immediately sets about forming new matter, upon surfaces in which there has been a breach of con- tinuity. This process is called granulat- ing, or incarnation; and the substance formed is called granulations. Granulations are an accretion of ani- 510 GUAIACUM. mal matter upon the wounded, or exposed surface; they are formed by an exudation of the coagulating lymph from the ves- sels ; into which new substance, both the old vessels very probably extend, and in which new ones are formed. Hence gra- nulations are very vascular; indeed, more so than almost any other animal sub- stance. The vessels in granulations pass from the original parts to their basis, and thence towards their external surface, in tolerably regular parallel lines. The sur- fiice of this new substance has the same disposition to secrete pus, as the parts which produced it. The surfaces of gra- nulations are veiy convex, the reverse of ulceration, having a great many small point*, or eminences, so as to appear rough. The smaller such points are, the more healthy ihe granulations. The co- lour of healthy granulations is a deep florid red. When livid, they are un- healthy, and have only a languid circu- lation. Healthy granulations, on an ex- posed or flat surface, rise nearly even with the surface of the surrounding skin, and often a little higher; but, when they ex- ceed this, and take on a growing dispo- sition, they are unhealthy, become soft, spongy, and without any disposition to form skin. Healthy granulations are al- ways prone to unite to each other, so as to be the means of uniting parts. Granulations are not ea ily formed on the side of an abscess, nearest the surface of the body. They are not endowed with the same powers as parts originally formed. Hence they more readily ulcerate, and mortify. The curious mode in wliich granulations contract, when sores are healing, and even for some time after they are healed, we have explained in the article Cicatrization. (See A Treatise on the Blood, Inflammation, &c. by John Hunter, p. 473, el seq. 1794.) GUAIACUM. (from an Indian word.) Many writers of the sixteenth century, contended that guaiacum was a true spe- cific for the venereal disease ; and the ce- lebrated Boerhaave, in the eighteenth, maintained the same opinion. Mr. Pear- son mentions, that when he was first en- trusted with the care of the Lock Hos- pital, in 1781, Mr. Bromfield and Mr. Williams were in the habit of reposing great confidence in the efficacy of decoc- tion of guaiacum wood. This was ad- ministered to such patients as had already employed the usual quantity of mercury; but who complained of nocturnal pains, or had gummata, nodes, ozaena, and such other effects of the venereal virus, con- nected with secondary symptoms, as did not yield to a course of mercurial fric- tions. The diet consisted of raisins, and hard biscuit; from two" to four pints of the decoction were taken-every day; the hot ba-th was used twice a week; and a dose of antimonial wine and laudanum, or Dover's powder, was commonly taken every evening. Constant confinement to bed was not deemed necessary ; neither w- s exposure to the vapour of burning spirit, with a view of exciting perspiration, often practised; as only a moist state of the skin was desired. This treatment was, sometimes, of singular advantage to those who.-e health had sustained injury from the disease, long confinement, and mercury. The strength increased; bad ulcers healed; exfoliations were com- pleted ; and these anomalous symptoms, which would have been exasperated by mercuiy, soon yielded to guaiacum. Besides such cases, in which the good effects of guaiacum caused it to be erro- neously regarded, as a specific for the lues venerea, the medicine was also formerly given, by some on the first attack of the venereal disease. The disorder being thus benefited, a radical cure was considered to be accomplished; and, though fre-1 quent relapses followed, yet, as these partly yielded to the same remedy, its re- putation was still kept up. Many diseases, also, which got well, were probably not really venereal cases. Mr. Pearson seems to allow, that, in syphilitic affections, it may, indeed, operate like a true antidote, suspending, for a time, the progress of certain venereal symptoms, and removing other appearances altogether; but, he ob- serves, that experience has evinced, that the unsubdued virus yet remains active in the constitution. • Mr. Pearson has found guaiacum of little use in pains of the bones, except when it proved sudorific; but, that it was then inferior to antimony, or volatile al- kali. When the constitution has" been impaired by mercury, and long confine- ment, a thickened state of the ligaments, or periosteum1, or foul ulcers, still remain- ing, Mr. Pearson says, these effects will often subside, during the exhibition of the decoction. He says, it will often sus- pend, for a short time, the progress of certain secondaiy symptoms of the lues venerea; for instance, ulcers of the ton- sils, venereal eruptions, and even nodes. Mr. Pearson, however, never knew one in- stance in which guaiacum eradicated the virus ; and he contends, that, its being conjoined with mercury, neither increases the virtue of this mineral, lessens its bad effects, nor diminishes the necessity of giving a cenam quantity of it. Mr. Pear- son remarks, that he has seen guaiacum produce good effects in many patients having cutaneous diseases, the ozaena, and GUN-SHOT WOUNDS. 511 scrofulous affections of the membranes and ligaments. (See Pearson on the Effect* of Various Articles in the Cure of Lues Ve- nerea, edit. 2. 1807. GUM MA, a soft tumour, so named from the resemblance of its contents to gums. GUN-SHOT WOUNDS receive their name from the manner, in which they are produced, being generally caused by hard, •btuse, metallic bodies; projected from cannons, muskets, or some other species of firearm. With such injuries, it is also usual to comprehend a variety of dread- ful accidents arising from the explosion of sheUs, or the violence, with which pieces of stones from ramparts, or splin- ters of wood on board of ship, are driven about. Gunshot wounds are the most considerable of the contused kind; and what is to be said of- them, wUl apply, more or less, to all contused wounds, ac- cording to the degree of contusion. They are particularly characterized by, what the French surgeons are fond of calling, a disorganization of their surface. The ex- cessive contusion, or rather comminution, observable in gunshot wounds, depends upon the rapidity, with which the bodies, occasioning them, are propelled. The parts, touched by the baU, are converted into a blackish slough, the colour of which made our ancestors suppose, that bodies, projected by gunpowder, became heated, and actuatty burnt the fleSh, with which they came into contact. But reason and experience have now proved, that what- ever may be the^ rapidity of a projectile, it never acquires in its passage any percep- tible heat. Indeed, a modern writer as- serts, that such a degree of heat as would be requisite to make a baU burn partly in its passage, would really melt it. (Riche- rand, Nosographie Chirurgicale, Tom. 1, p. 217, edit. 2.) In general, gunshot wounds do not bleed, unless very large blood-vessels were injured ; then- circum- ference is often livid; and the shock, that attends their infliction, is particularly apt to occasion in the Umb, or part, a kind of torpor, which, in many instances, extends itself to the whole system. UntU Ambroise Pare introduced more correct theories upon the subject, ideas, the most false, and errors, highly pre- judicial, prevailed both in the history and treatment of gunshot wounds. Cannon- baUs and bullets sometimes produce most dreadful injury, without occasioning any breach of continuity in the integuments. This observation is so strictly true, that the muscles and bones may actuaUy be crushed and broWen to atoms, without the skin being at aU wounded. Such cases were for a long whde imputed to the violent motion, supposed to be commu« nicated to the air by the ball itself. It was imagined, that this elastic fluid, being rapidly displaced by the shock of the pro- jectile, was capable of making such pres- sure' on surrounding bodies, as to de- stroy their texture. But now could this violent pressure originate in the midst of the open and unbounded air ? If this theory were true, the effect in question would constantly happen, whenever a ball passes near any part of the body. The contrary, however, is so much the case, that pieces of soldiers' and seamens' hats, feathers, clothes, and even of their hair, are shot away in every battle, without any other mischief being done. In consequence ofthe manner, in which such injuries of the soft parts and even of the bones, unattended with any breach in the skin, have been supposed to be pro- duced, they have been erroneously termed wind-contusions. In fact, these cases are now universally acknowledged by all the most accurate observers, never to proceed from the cause, to which formerly they were always ascribed. The air does not move with the same rapidity as tbe baU; but its motion is less in proportion as it is a more subtile matter, and must be too feeble to account for such a violent degree of injury. The air, to which tbe bad must really commu- nicate the greatest motion, is what is di- rectly before it; and this never bruises the part untouched by the ball itself. It is only the air situated lateraUy to the shot, that is imagined to do injury, and it cannot be greatly agitated. The violent consequences of sudden explosions, and the effects produced on the organs of hearing, by strong commotions of the air, prove nothing relative to the point in question. Lastly, experience does not confirm the reality of such wind-contusions, for can- non-balls often tear off whole Aiembers, without tbe adjacent parts being in the least injured. (See Le Vacher, in Me- moires de PAcademie de Chirurgie, torn, 4. p.22.) Neither can this kind of accident be at- tributed to an electrical shock on the parts, in consequence of the ball being rendered electrical by friction in the calibre of the gun, and giving off the elec- tricity as it passes by. (Vide Plenk'* Sammlungen, 1 Theil. p. 99.) Metals never acquire this property from fric- tion. The mischief, imputed to the air, is oc- casioned by the ball itself. Its producing a violent contusion, without tearing the skin, and enUT.ngthe Umb, is to be as- cribed to the oblique direction in which it strikes tiie part, or, in other instances, to the feebleness, with which the bail strikes 512 GUK-SHOT WOUNDS. the surface ofthe body, inconsequence of its having lost the greater part of its mo- mentum, and acting principally by its Weight, being, in short, what is called a spent ball. Da'dy observation evinces, that balls, which obliquely strike a sur- face, do not penetrate, but are reflected; though they may be impelled with the greatest force, and the body struck may be as soft and yielding as water This alteration in the course of the ball, not only happens on the surface of the human body, but also in the substance of a limb which it has entered. A bone, a tendon, &c. may change the direction of a ball which touches ^them at all obliquely*, Hence it is manifest how it happens, that the track of. a gun-shot wound is not always straight, and how balls sometimes run under the integuments nearly all round the body, or a limb. The causes of several of the peculiarities attending gun-shot wounds, as Mr. Che- valier has observed, are to be sought among the laWs, by which moving bodies are governed, and by which, the mecha- nical effect of a ball, propelled against any part of the body, must therefore be determined. The form, the momentum, and the direction of the shot, that is re- ceived ; the position, and the variety of structure, or, in other words, the variety of density and powers of resistance, in the part receiving it, must always be consider- ed, in order to account satisfactorily for the effects, which it produces. The first law, to which this gentleman begs the attention'of his reader is, that a body in motion, striking against any substance, Will communicate a part of its momentum to the substance, against which it strikes; and that this communication will be in a direct ratio to the powers of resistance, which that substance possesses at the time; whether such power of re- sistance be derived from its own density, or bulk, or force of cohesion, or momen- tum ac' ing in a different direction. Hence, if the resistance be equal, or superior to theinomentum, the motion will be stop- ped ; the momentum, in this case, being equally divided between the body im- pelled and the body resisting. If the re- sistance be inferior, the motion will only be lessened; and if, besides being infe- rior, and therefore incapable of stopping the moving body, it also operates in a dif- ferent direction, the future line of motion Will likewise be changed, and fly off from the point, at which it meets with resist- ance, m a fine, which will form an angle with that of the original direction, in which it moved. \ Mr. Chevalier next reminds his reader, that the resistance^ made by any substance to the motion of another, will be greater, or less, cxterisparibus, as the angle of in- cidence approaches to, or recedes from a right angle; and, if it be reflected, and the motion be continued in the same me- dium, the angle of reflect on will always be equal to the angle of incidence. The resistance, made to a moving body, by the density of any medium, in which it moves, will be, cxteris paribus, as the sur- face of the moving body presented to that medium. A dense medium forms a continued re** sistance to' a body propelled with any given velocity ; and, therefore, the more dense the medium, the greater the resist- ance, and the sooner the original momen- tum will be overcome by it. A shot, moving through any medium of uniform density, will also be acted on by the attraction of gravitation, so as to be continually changing the direction in which it moves; and, if* it move in vacuo, or in air, it will describe the curve called a pa- rabola. The commencement of this curve does not take place at the point, at which the gunpowder explodes ; for, within the barrel, and to some distance beyond it, the shot moves forward in a right line, called the line of the impulse of fire, (Ilel- thaitis Lect. 2, p. 187;) which line will ex- tend farthest horizontally, the less the angle of elevation of the piece recedes from an horizontal line. The less of the original impulse is left in a shot still moving, the more liable Will it be to be stopped, or turned out of its course, by any given resistance. Every new resistance, which a shot in motion meets with, as Mr. Chevalier has remarked, will operate so as to produce not only a diminution of its momentum, but, also, a change in its direction ; every fresh resistance being in fact equivalent to a fresh power, acting in a different line from that, in which the shot was pre- viously moving. As. a body, acted on a., once by two powers, will not move in the direction of either, but, in the diagonal of a paralle- logram, of which two sides are formed by the direction and momentum, given by each of those powers respectively; so every change of impulse, or resistance, Will cause the body to move in so manj^ changes of direction, till at length its momentum is overcome, and it becomes quiescent. A continued resistance from a dense medium will be a continued application ofa power, the uniform and equabie ope- ration of which will cause the motion to be curviUneir, the reason of which is suf- ficiently explained by writers on projec- tiles Mr. ChevaUer nest proceeds to explain, GUN-SHOT WOUNDS. 513 th%t a shot, or otiier hard body, falling upon a soft one, as, for example, an adi- pose membrane, or muscle, and stopping there, or lodging in it, still acts m con- formity to the same general law*-, and stops only from the resistance it meets with. If this resistance is made only by the force of cohesion in the adipose mem- brane, or muscle, so much of that cohesion is overcome, as was equal to the momen- tum of the shot, when it impinged against it; and, therefore, so far, and only so far, is its substance broken through or de- stroyed. It" is only on such principles, that we can explain the intricate and varied course and effect of balls in parts of diversified structure, consisting of substances differ- ing in density and powers of resistance. And, though, says Mr. Chevalier, in many cases, a mathematical explication ot the course ofa ball cannot be given ; this arises entirely from the want of data, the laws of matter being fixed and immutable. But, when the data are known, as, for in- stance, the velocity and direction of the shot, the position of the patient, or of the wounded part at the time of the accident, and the structure of the parts penetrated, a much more probable conjecture of the course ofthe ball may generally be form- ed, than if these circumstances had not been regarded. From the foregoing account, as Mr. Chevalier further notices, we may see the reason of the concussion, or shock, which is given, in many instances, to the whole system by gun-shot wounds, and which is represented by the best writers on this subject, to be often attended with grave and even alarming effects, extending not only over the injured part, but affecting the system at large. For, as the resist- ance. to the shot is afforded not only by the texture of the injured part, but, also, in some degree, by the connexion, which this has with other parts, and with the whole body, th»se latter will likewise par- ticipate in the violence ; and they will do it so much the more, in proportion as tiie part immediately wounded has, from its attachments, its texture, elasticity, or un- portance to life, a greater connexion with the stabUity, or with the functions of the rest. Hence, a shot, striking against a tendon, or a bone, in one of the extre- mities, will produce a greater concussion, than if it struck only against softer parts. A shot, striking against a muscle in ac- tion, will produce more concussion, than if it struck against the same part of the same muscle at rest. And a shot, striking the head, or wounding the liver, lungs, or intestinal canal, will generally bring on instantaneous derangement of the whole Voi. I. system, with which the functions of tin sc parts are so closely connected. To all this must be added an alarm, which takes sudden possession of the mind, and is in- creased by the uncertainty of the patient about his real state. Such apprehension, the most determined courage, is not always able to withstand. (See a 'Treatises on Gun-shot Wounds, by Thomas Chevalier, Part 1. sect. 7 ) A ball, when it strikes a part of the body, may cause four kinds of injury. 1. It may only occasion a contusion, without penetrating the part, pn account of its being too much spent, or of the oblique way in wb ich it strikes the surface of the body. 2. It may enter and lodge in the surface of :i part; in which case, the track of the wound has only one aperture. 3. It may pie. ce through and through; and then there are two openings, one at the entrance, the other at the exit ofthe ball. The circumference ofthe aperture, where the shot entered, is usually depressed: that of the opening, from which it came out, elevated. At the entrance, there is commonly more contusion than at thejxit of the ball. The former is generally nar- rower; the latter wider, and more irre- gular, especially when the round smooth figure of the ball has been changed by its having struck a bone. 4. A 6annon-ball may tear off a whole limb. (Richter's An- fangsgrun deder Wundarzneykunst, Ban dl.) figun-shot wounds differ very much, ac- enrmng to the kind of body projected, its velocity, and the nature and peculiarities of the parts injured. The projected bodies are mostly bullets, sometimes cannon- balls, sometimes pieces of broken shells, and very often, on board of ship, splinters of wood. From the contusion, which the parts suffer, on the violent passage of the ball through them, there is most com- monly a part of the solids surrounding the wound deadened, which is afterwards thrown off in the form of a slough, and which prevents such wounds from heahng by the first intention, and makes most of them necessarily suppurate. This does not take place equally in every gun-shot wound, nor in every part of the same wound; and the difference commonly arises from the variety in the velocity ofthe body projected ; for, where the ball has passed with little velocity, which is sometimes the case at their entrance, but, still more frequent at the part last wounded, the in- jury may often be healed by the, first in- tention. (/. Hunter, p. 523.) Foreign bodies are more frequently met with in gun-shot wounds than any others, and are commonly of three kinds. 1. Pieces of clothing, or other things, which the ball forced before it into the Umb. 2. The 3 U jl4 GUN-SHOT WOUNDS. ball itself. 3. "Loose splinters of bone. It is only when the ball strikes a naked part, touches no bone, and goes through and through, that the wound can be free from extraneous matter. Foreign bodies are the cause of numerous unfavourable symptoms, by irritating sensible parts, and exciting pain, inflammation, con- vulsions, hemorrhage, long suppurations, See. They are constantly more productive of such evils, the more uneven, pointed, and hard they are. Hence spiculae of bone are always the most to be dreaded. (Richter.) When a ball strikes a bone, the con- cussion produced is another occasion of bad symptoms, to be added to those already mentioned. When slight, its effects are confined to the injured limb. Sometimes they extend to the neighbouring joints, in which they produce inflammation and abscesses. It is commonly stated, in surgical books, that when a cannon ball tears off' a limb, it produces a mos4 violent concussion of the whole body, anrV a general derange- menttof all its functions. This, however, is by no means always true. I have lately seen, in London, a young- sailor, whose arm was completely torn offat theshouJder, bv a cannon-ball from one of the forts at Guadaloupe, in March 1808; he suffered no dreadful concussion of his body, nor were fes senses at all impaired. This case was very remarkable, as the scapujjf was so shattered, that Mr. Cummings, "of Antigua, was under the necessity of re- moving the whole of it. The patient re- covered in two months. From ihe account I heard, I do not believe the axillary ar- tery bfed immediately after the accident. The young man was lately shewn to the gentlemen of St. Bartholomew's Hospital, quite well. There is one curious effect which occa- sionally follows gun-shot wounds ; but, I do not pretend to understand the rationale of it. viz. inflammation and suppuration of some internal viscus, especially ofthe liver. Several such cases are related in the Mem. de l'Acad. de Chirurgie. From the circumstance of the inner sur- face of gun-shot wounds being more or less deadened, they are late in inflaming. But when a ball "has fractured a bone, which fracture has occasioned great in- jury of" the soft parts, independently of that caused immediately by the ball itself, the inflammation will come on as quickly, as in cases of compound fracture; because the deadened part bears no proportion to the laceration or wound in general. (J. Hunter-, p. 524.) From the same circumstance of a part being often deadened, gun-shot wounds frequently cannot be completely undt-T. stood in the first instance, for, in many cases, it is at first impossible to know what parts are killed, whether bone, ten- don, or soft part. Nor can this be ascer- tained till the slough separates, which often makes the wound much more com- plicated than was previously imagined. For, very often, some viscus, or a part of some viscus, or a part of some large ar- tery, or even a bone, has been killed by the violence. If a piece of intestine has been killed, the contents of the bowel will begin to come through the wound when the slough separates. If a portion of a large blood-vessel be kUled, a profuse, and even fatal hemorrhage may come on, when the slough is detached, although not a drop of blood may have been previously lost. {See Hunter, p. 525) When the ball moves with little velo- city, the mischief is generally less; the bones are not so likely to be fractured; the parts are less deadened, &c. How- ever, when the velocity is-just great enough to splinter a bone, which is touch-. ed, the splintering is generally more ex- tensive, than if the impetus of the ball had been much greater, in which case, it would rather have taken a piece out. When the ball moves slowly, it is more likely to be turned by any resistance it may encounter in its passage through parts, and hence the wound is more likely to take a winding course. When a ball enters a part with great velocity,butis almost spent, when it comes out again in consequence of the resist- ance il has met with, there may be a good deal of sloughing about the entrance, and little or none about the exit, owing to the different degrees of celerity with wliich the ball traversed the parts. (See Hunter.) , Gun-shot wounds may have either one, or two apertures, according as the ball has lodged, or passed quite through the part. In some cases, the openings are diametrically opposite each other; in others they are not so, the direction of the ball having been changed by the re- sistance, which it has met with from a bone, cartilage, tendon, &c Thus a ball has been known to enter just on the inside of the ankle, and come out near the knee, to enter the fore-head and come out at the temple, &c. (Richerand, Nosographie Chirurgicale, Tom. 1, p. 219, Edit. 2.) The opening, where the ball enters, is always smaller than that from which it escapes, and its margin is forced inwards, while the circumference ofthe other aperture is quite prominent. The contusion and in- jury, which the parts suffer, are also greatest about the entrance of the ball, GUN-SHOT WOUNDS 515 owing to the more considerable impetus, with which it moves. The yellowish livid hue, around gun-shot wounds, is a sort of ecchymosis, or extravasation of blood. The injured member is often be- numbed and stupefied, and, when morti- fication occurs, it spreads with extraor- dinary rapidity. When the whole con- stitution is thrown into this kind of tor- por, the most fatal consequences are to be apprehended. " C'est dans cet etat, (says Richerand) que mourut le chevaule*-, ger, dont parle Quesnay; l'eta* d'hebetude itait tel, que cet individu a qui l'on pro- posa l'amputation de la jambe, repondit que ce n £*att pas son affaire " (Noso- graphie Chirurg. Tom. l,p. 221, Edit 2) In cases of gun-shot wounds, sudden shiverings, syncope, and nervous symp- toms are not Unfrequent. Such occur- rences, with other bad effects, made the ancients suspect, that something poison- ous was carried into the wound; an opi- nion, which is now well known to be er- roneous. When there is only one opening, we may infer, that the wound contains a fo- reign body. When there are two aper- tures, the ball has escaped; but, pieces of the clothes, &c. may still be lodged in the part. As the ends of the torn vessels are con- tused and compressed, gun-shot wounds have Uttle propensity to bleed much, and, unless very considerable vessels are lace- rated, they do not bleed at all: sometimes not in this case. The greatest danger of bleeding is always when the dead parts are detached, eight Or ten days after the injury. Angular uneven bodies, such as pieces of iron, cut lead, &c. are more lia- ble to occasion far more dangerous wounds, than round even bodies, like leaden bullets. Wounds occasioned by a small shot, are frequently more perilous, than others produced by larger balls : be- cause their track is so narrow, that it can- not be traced, nor consequently the ex- traneous body itself extracted. Such a shot oftentimes injures a viscus, when tiiere is not the smallest external symp- tom ofthe occurrence. Sometimes a great part of the danger, also, arises from the number ofthe shots which have entered. In a subsequent section of this article, the valuable observations of M. Larrey, upon the question of amputation, in cases of gun-sbot wounds, will be fully de- tailed. TREATMENT OF OOH-SHOT WOOWDS. The first thine in the treatment of a irun-shot wound in one ofthe extremities, is to determine, whether it is most advis- able to amputate the limb immediately, or to undertake the cure of the wound. When a bone, especially at a joint, is very much shattered; when the fleshy parts, particularly the great blood-vessels and nerves, are lacerated; when the whole limb has suffered a violent concussion, and is cold and senseless ; there is no hope of preserving it. In this case, it is the sur- geon's duty to amputate at once, and not to delay till mortification commences. But, besides this violent degree of injury, in which the propriety of amputation is obvious, there are several lower degrees, in which it is often a difficult thing to decide whether amputation is necessary or not. Here the surgeon must look not only to the injury, but also to the patient's constitution, and even to external circum- stances, such as the possibility or impossi- biUty of procuring good accommodation, rest, attendance, and pure air. But it is impossible to determine the necessity of amputation by general rules. In every individual case, the surgeon must consider maturely the particular circumstances, before he ventures to decide. The grounds against the operation are; the pain which it causes at a period when the whole system is disordered by a terrible injury; the privation of a limb ; and fre- quent examples, in which nature, aided by judiciou-i surgery, rep urs the most horrible wounds. The foUowing are the reasons in favour of the operation. By it the patient gets rid of a dreadful contused wound, which threatens the greatest peril, and wliich is exchanged, as it were, for a simple incised one. The pain of amputa- tion is not of more moment than the pain which the requisite incisions, and the. extraction of foreign bodies, would cause in case the operation is abandoned. The wound of amputation is not so much to be apprehended, as experience shews, that incisions, in cases of gun-shot wounds, are not only exempt from parti- cular danger, but are often useful. The loss of the Umb cannot be taken into the account; for, the surgeon only undertakes the operation where he designs to save the patient's Ufe by that privation, and anticipates that the part itself cannot be preserved. Even, if he should deprive the patient ofa limb, that, perhaps, might have been preserved, there is this atone- ment, that he can furnish him with an artificial leg, which often proves far more serviceable, than the lost limb would have proved, had it been preserved. Should the operation be fixed on, it is to be im- mediately performed above the wound. (Richter'* Anfansgrunde der Wundarxney. kunst, Band 1.) When amputation is deemed unneces- 516 GUN-SHOT WOUNDS. sary, the surgeon, according to customary precepts, is to enlarge the wound by inci- sions. Such a dilatation has been said to have numerous advantages; to facili- tate the extraction of foreign bodies; to occasion a topical bleeding, and afford an outlet for the extravasated fluid in the circumference ofthe wound; to convert the fistulous form of the track of the ball into an open wound; and, lastly, to di- vide ligamentous aponeuroses, which otherwise might give rise to spasmodic and other untoward symptoms. More modern experience, however, shews (Hunter, p. 529.) that the utility of such incisions has been overrated; that they generally increase the inflammation, which, in these cases is so much to be apprehended; that wounds which are not dilated, commonly heal more speedily, than others which are; and, that there are only a few cases, in wliich incisions are beneficial. The cases of gun-shot wounds are va- rious. Sometimes the track of the ball lies superficially under the skin, and only has one opening. When it lies in soft parts, and the ball has neither touched a bone, nor a considerable blood-vessel, all incisions are useless, let the wound have one or two apertures. Though dilating the wound has been practised with a view of giving vent to matter, eschars, and fo- reign bodies, and even its whole track has been laid open, when superficial; yet, experience proves the inutility of such steps. As in the skin there is a real loss of substance, arising from a portion being driven inward before the ball, it follows, that the opening of a gun-shot wound must be more capacious than that of a punctured one. By the separation of sloughs,. the wound becomes still more dilated, so that not only matter, but fo- reign bodies which approach the skin, may easily find an exit. Besides, inci- sions commonly close again very soon, and in a few days the wound falls into the same state, as if no dilatation at all had been made. When a cannon-ball has torn off a limb, some advise the amputation of the stump, to procure the patient an even smooth incision, instead of an irregular, jagged, and highly dangerous wound. As the limb has commonly suffered a violent concussion, is almost bereft of sense, and power of motion, and the bone frequently has a fissure extending some way upward, the amputation is also recommended to be done, if possible, above the nearest joint. Others condemn the operation in this in- stance, asserting, that such wounds may sometimes be healed, and that the consti- tution, immediately after such violence, is not in a favourable state for submitting to such a painful measure. But, as when the operation is not done, this kind of in- jury requires large and free incisions, lor the extraction ot foreign bodies, the short- ening of projecting muscles and tendons, the discharge of extravasated fluids and abscesses; and, as these incisions are likely to occasion at least as mucli irrita- tion as amputation itself, witiiout being productive of equal good, the last objec- tion is not very weighty. The operai.on may, al.-o, in many casi s, be delayed un- til the immediate irritation of the injury on the system is over. The occasional healing ol such wounds only proves, that ii is not altogether impossible, in every instance, to effect a cure without amputa- tion. The surgeon can the more readily make up his mind to amputate in this case, as it does not occasion the loss of a limb. However, it is very credible, t at the injury may sometimes be so condi- tioned, and tne circumstances in which the patient finds himself such, that there are good grounds for deeming tiie opera- tion unnecessary, and even pernicious. No one would be justified in amputating above the knee, when the limb is injured at the toot or ankle. In gun-shot wounds, ligamentous fibres, and fasciae, are often found going quite across them. It is advised to divide such parts completely, lest, when ihe wound inflames, they should cause violent spasms and nervous symtoms, and afterwards impede the discharge of idatter and fo- reign bodies. No doubt thus counsel is judicious. However, it is frequently dif- ficult, at first, to discover and divide such parts, and then it is better to deter the incision until one can easily get at them without irritating the wound, and it is manitested, that their remaining undi- vided is the cause of inconvenience. These remarks are, also, applicable to membranous expansions perceptible at the sides of the wound, and to entire fas- ciae, stretched over the inflamed muscles. The extraction of" foreign bodies ranks as one ofthe most urgent motives for the dilatation of the wound, and, no doubt, it is right to remove, at first, as many of them as possible. Their lodgment irri- tates the wound, causes violent nervous and inflammatory symptoms, and copious suppuration; circumstances which the timely extraction of them may prevent. Yet, let it be remembered, that the ex- traction of foreign bodies is frequently attended with immense irritation, and that, while they lie too firmly fixed in parts, it is often a matter of impossibility. After the sloughs have separated, and the wound has become widened, suppuration GUN-SHOT WOUNDS. 517 frequently does not prevail long before the extraneous substances become louse, spontaneously approach the skin, and easily admit of removal without any dila- tation. In cases, where, from necessity, foreign bodies have not been removed at first, no disadvantages have occasionally resulted from their continuance. Hence, it is prudent, at first, to extract only such foreign bodies as are near the external opening, quite loose, and re- moveable without much irritation; or such as press on parts of importance, and, thereby excite dangerous symptoms. The surgeon should avoid interfering with those which are deeply and firmly lodged in ihe wound. He should await suppu- ration, and the detachment of sloughs, and when the foreign bodies become move- able and apparent, he should extract them, with or without an incision, as cir- cumstances may demand. The examina- tion of the wound ought to be made as much as possible with the finger, wluch irritates less, and feels more distinctly, than a probe. A great variety of instru- ments have been devised, either for ascer- taining the position of balls, and other foreign bodies in gun-shot wounds, or for extracting them. But, however nume- rous and diversified bullet-drawers may be, they all admit of being divided into three kinds. The first are constructed on the principle of a pair of forceps. Others are shaped more or less like spoons. And a third description are made on the plan of a cork-screw, or worm. These last are only deaigned for cases, in which the ball is fixed in the substance of a bone, and is quite immoveable; for, if it were lodged in the soft parts, the pressure, re- quisite for introducing the screw into it, would injure and lacerate the parts at the bottom of the wound. Bullet drawers, constructed on the plan of forceps, have the inconvenience of not being adapted for seizing the ball, unless their blades are expanded, which always stretches the wound, and creates a great deal of irrita- tion. Forceps have been contrived with blades, which can be introduced separate- ly, and then joined together with a screw. I do not know, whether there is any such instrument, th t will grasp a ball, without being first expanded; but, it might easily be made, and would be found advan- tageous in military practice. Perhaps, when a ball lies superficially, the fingers, or a small pair of forceps, will serve to extract it most conveniently. In many other examples, bullet drawers, con- structed on the principle of a spoon, are the best, that can be used. Richerand ■peaks of a superior instrument, for the extraction of balls, as follows: " De tous ces instrumens, le meilleur sans doute, est celui de mon illustre collegue dans la ctiaire de Pathologie Chirurgicale, M. Percy, ce chef si distingue de la chirurgie militaire. Son tirebaUe offre la reunion des trois genres; il rempUt a la fois 1' of- fice de pmces -a forceps, de cuillier, et de tirefond." • (Nosographie Chirurgicale, Tom. 1; p. 223, Edit. 2.) The event of the treatment above re- commended, is various. Extraneous sub- stances remaining in the wound, either. loosen gradually, and come into view so as to be easily removeable; or they con- tinue concealed, prevent tlie cure, and give birth lo a fistulous ulcer. In some instances, the wound closes, and the fo- reign bodies remain in the Umb during life, without inconvenience ; and, in other cases, after a time, they bring on a re- newal of inflammation and suppuration. Sometimes a foreign body varies its situa- tion, sinking down, and afterwards making its appearance at a different part, where it may excite inflammation and suppura- tion. • When the ball lodges in the wound, it is usually difficult to trace it, as the parts colL.p-c after its passage. The ball does not regularly take a straight direction through the injured part, but, oftentimes, a very tortuous one. The latter circum- stance is more apt to occur, as the ball is more spent. In every case, in which it is not easily discoverable, all painful ex- aminations should be abandoned, and the foreign body left in its situation, where it rarely creates any trouble. Sometimes, the ball may be both easily found and extracted. At other times it lodges on the opposite side of the limb, closely under the skin. If the integu- ments, under which the ball is lodged, should be so contused that they will pro- bably slough, they are to be considered as already dead, and an opening is to be made in them for the extraction of the ball. But when the ball lies so remotely from the skin that it can only just be felt, and the skin itself is quite uninjured, no counter-opening ought to be made. The wound heals better when tiie ball is leffc in, and far less inflammation takes place in the vicinity of this extraneous body, than about the orifice of the wound. A counter-opening always renders the in- flammation at the bottom of the wound, as great as at its orifice. It is better to let the wound heal up, and extract the ball afterwards. (See Hunter, p 541.) Sometimes the ball penetrates the spon- gy part of a bone, and lodges firmly in it. When it has only entered superficially, it may sometimes be loosened and extracted, by means of an elevator with a thin and *S18 GUN SHOT WOUNDS. somewhat curved extremity, and when it is more firmly fixed, a screw bullet drawer will sometimes serve for its removal. Suould die attempt fail, hope may still be entertained, that, when suppuration takes place, it wiU become loose, and admit of extraction. In case nothing of this kind should occur, some advise the employ- ment of a trepan to remove the ball from its situation. As this cannot be done without great irritation, and experience proves hat a ball may lie in a bone during life, without occasioning unpleasant symp- toms, it is obviously preferable to allow it to remain. (Richter's Anfangsgr. der Wundarzn. Band 1.) Besides these principal circumstances, there are various contingent ones, which often demand a particular mode in mak- ing the incisions, and in the subsequent management. To explain them all here is impossible. Hemorrhage from a torn artery of considerable magnitude, for which a ligature is necessary, may require incisions to get at the vessel. As soon as the requisite incisions are made, and foreign bodies extracted, the prime objects in the treatment of gun- shot wounds are then accomplished, and the rest is, in reality, not different from the surgery of other wounds. With regard to probing gun-shot wounds ; when it is evident that the shot has passed out, and no particular object can be fulfilled by introducing an instru- ment, it is often better to dispense with such exam nations, at least till suppura- tion has come on. Introducing any in- strument is generally productive both of pain and irritation. But wnen the ball, or any other extraneous substance, has lodged in the wound, and its situation is not immediately evident, it will often be advisable to search for it at once, that in order, if its siuation will allow, it may be extracted before inflammation begins. The surgeon, therefore, considering all the circumstances which can assist him in forming a reason ble conjecture of the course ofthe wound, must give to a probe that curvature, or form, which he thinks most likely to pass readily along it, and must then proceed to make the examina- tion. But, when this is very painful, and the course of the wound obscure, it will often be better to desist, and renew the search when suppuration has token place, when it en he undertaken with more ease, and a greater pro -pect of suc- cess. When gun-shot wounds are in- flamed, the tenderness and swelling of the parts are peculiarly strong reasons against painful probings, or efforts For, in the first case, the ball has begun its parabola and, afterwards, the new movement, which the board inconsequence of its resistance and elasticity, commu- nicates to the ball, changes the direction of this-hody, and makes it take a different course. It is to these two angles, more or less open, of incidence and reflection, that according to M. Larrey, the dispersion of the particles of the argillaceous earth is owing, the effect being increased by the instantaneous projection which the point of. the wood, struck by the ball, makes against the clay, by reason of its elas- ticity, while the particles of thi$ earth It- self the more readily sink down again, as they are destitute of* any elastic property. The different movements which the ball describes in its course, and the elasticity ofthe skin, will now enable us to explain, how internal injuries are produced, with- out any external solution of continuity, and often even without ecchymosis. The motion communicated to the ball by tlie power, which projects it, is, for a given space, rectilinear. If, at this instewce, it strikes against the body, it carries tiie part away to an extent proportioned to the mass, with which it touches the part. Bui, the ball, after liaving traversed a certain distance, undergoes, in conse- quence of ihe resistance of tlie air and. the attraction of gravity, a change of mo- tion, and now turns on its own axis, in the diagonal direction. If the shot should strike any rounded part of the body, towards the end of its course, it will run round a great portion of the circumference of the part, by the effect of its curvilinear movement. It is also in this manner, observes M. Larrey, -that the wheiti of a carriage act*-, in pas- sing obliquely over the 'high, or leg, of an individual stretched upon tiie ground. In this case, the results are the same as those, of which we have been speaking. The most elastic parts yield to *he im- pulse of the contusing body; while such as offer resistance, as, for instance, the bones, tendons, muscles and aponeuroses, are fractured, ruptured, and lacerated. For the same reason, it sometimes hap- pens, that the viscera are similarly in- jured. At first sight, all the parts appear to be entire ; but, a careful ex-Tminatton will not let us remain long In doubt about the internal mischief. In this case, an ecchymosis cannot manifest itself out- wardly, because the vessels of the skin, wliich communicate with the internal parts, are ruptured, because the extra- vasation of blood naturally takes place in the deep excavations, occasioned by the rupture of the muscles, and other parts, and because this fluid cannot make its way through the texture of the skin. Such extravasations can only be detected by tlie touch. The foregoingreasoning is supported by experience. How often, says M. Larrey, have we not seen the ball carry away pieces of helmets, hats, cartridge-boxes, knapsacks, or other parts of the soldier's dress, witiiout doing any otiier injury? The same baU, perhaps, takes off his arm, often at a time, when it is closely applied 524 GUNSHOT WOUNDS. to the body of his comrade, anil, yet, the latter does not receive the slightest harm. The shot may pass betwixt the tliighs, and these members hardly exhibit an ecchymosis at the points, which are gently grazed ; the only example, adds M. Lar- rey, in which, ecchymosis does occur. In other instances, the ball severs the arm from the trunk, and the functions of the thoracic viscera are not at ail injured. M Larrey then relates the following case. M Meget, a captain, marching in the front Of a square of men, in the heat ofthe battle of Altzey, 30th March 1795, had his right leg almost entirely earned away by a large cannon-shot, without tiie contiguous limb of his" lieutenant, who was as close as possible to him, receiving the least injury. The violent general commotion excited, and the extreme seve- rity of the weather, made this officer's condition imminently perilous. The pro- gress of the symptoms, however, was checked by amputation, which was in- stantly performed M. Meget was then capable of being conveyed to -.he hospital at Landau, fifteen leagues from the field of battle, where h: got quite well. M. Larrey declines relating numerous Other analogous amputations, which he has been called upon to practise un- der the same circumstances. M. Bufty, a captain of the artillery of the army of the Rhine, was struck by a how'nzer, his left arm being injured, and his head so nearly grazed, that the corner of his hat, which was placed forwards over his face, was shot away as far as the crown. This officer, the skin of whose nose was even torn off, was not deprived of his senses, and he was actually courageous enough to continue for some minutes com- manding his'•<;ompany. At length, he was conveyed to ihe ambulance of M. Lar- rey, who amputated his arm: in about a month, he was well When balls strike parts obliquely, they produce in a lesser degree the effects, which arise from the incomplete collision of a shot: their tortuous course in the substance of a member is subject to curi- ous varieties. But, to return to the object of our pre- sent consideration, M. Larrey expresses his betef, that whai have been errone- ously termed wind contusions, if they are attended with the mischief above speci- fied, require immediate amputation. The leastdelay makes the pattern's preservation extremely doubtful. The internal injury of the member may be ascertained by the touch, by the loss of motion, by the little sensibility retained by the parts.which have been struck; and, lastly, by practising an incision, as already recommended. In order to confirm the principle, which he endeavours to establish, in opposition to many writers, M. Larrey indulges him- self with the following digression. At the siege of Ros>s, two canno- niers, having nearly similar wounds, were brought from the trenches to the ambu- lance, which M. Larrey had posted at the village of Palau. They had been struck by a large shot, winch, towards the termination of its course, had grazed posteriorly both shoulders. In one, M. Larrey perceived a slight ecchymosis over all the back part of the trunk, without any apparent solution of continuity. Res- piration hardly went on, and the man spit up a large quantity of frothy vermi- lion blood. The pulse was small and in- termitting, and the exti entities were cold. He died an hour after the accident, as M. Larrey had prognosticated. This gentle- man opened the body, in the presence of M. Dubois, inspector of the military hospitals of* the army of the eastern Pyrenees. The skin was entire; the muscles, aponeuroses, nerves, and vessels of the shoulders were ruptured and lace- rated, the scapulae broken in pieces, tlie spinous processes of the corresponding dorsal vertebrae, and the posterior extre- mity of the adjacent ribs, fractured. The spinal marrow had, suffered injury ; the neighbouring part of the lungs was lacerated, and a considerable extravasa- tion had taken place in each cavity of* the chest. The second cannonier died of similar symptoms, three quarters of an hour after his arrival at the hospital. On opening the body, the same sort of" mis- chief was discovered, as in the preceding example. In the German campaigns ofthe French armies, M. Larrey has met with several similar cases, and accurate examination has invariably convinced inniof the direct action of a spherical body, propelled by means of gunp iwder. Sixth case. When the articular heads are much broken, especially those which firm the joints of the foot, or knee, and the ligaments, which strengthen these ar- ticulations, .re broken and lacerated, by the fire of a howitzer or by a biscayen, or other kind of ball, immediately amputa- tion, says M. Larrey, is indispensable. According to this experienced writer, the same indication would occur, were the ball lodged in the thickness -fif the articular head of a bone, or were it so engaged in the joint, as not to admit of being extracted by simple and ordinary means. It is only in this manner, that the pa- tients can be rescued from the dreadful GUN-SHOT WOUNDS, 525 pain, the spasmodic affections, the violent convulsions, the acu e fever, the consi- derable tension, and the general inflam- mation of the limb, which, M Larrey observes, are the invariable consequences of bad fractures ofthe large joints. But, adds i his author, if the voice of expe- rience be not Ustened to, and amputa- tion be deferred, the parts become disor- Sanized, and the patient's life is put into nminent peril. It is evident, says he, that, in this case, if we wish to prevent the patient from dying of the consequent accidents, ampu- tation should be performed before twelve, or at most tsventy-four hours,have elapsed: even M Faure himself professed tins opi- nion, in regard to certain descriptions of injury. Seventh case. According to M. Larrey, if a large biscayen, a small cannon-shot, or a piece of a bomb-shell, in passing through the sub-stance of a member, shouldhave exten rveiy denuded the bone, without breaking it, amputation is equally indicated, although the soft parts may not appeal- to have particularly suffered. Indeed, the violent concussion produced by the accident, has shak< n and disor- ganized all the parts ; the medutilary sub- stance is injured, the vessels are lacerated, the nerves immoderately stre died, and thrown into a state of stupor ; the mus- cles are deprived of their tone ; and the circulation and sensibility in the limb are obstructed. Before deciding, h .waver, M. Larrey cautions us to observe atten- tively the symptoms, winch character ze this kind of disorder. Tins case can be supposed to. happen only in the leg, where the bo.ie is veiy superficial, and merely covered at its anterior part with the skin. The following are described as the symp- toms : the limb is insenshle, the foot cold as ice, "-he bone partly exposed, and on careful examination, it will be found that the integuments, and even the peri- osteum, are extensively detached from it. The commotion extends to a consider- able distance; the functions of the body are disordered; and all the secretions experience a more or less palpabl dis- turbance. The intellectual faculties are suspended, and the circulation is retard- ed. The pulse is small and concentrated; the countenance pale ; and tlie ey s have a dull moist appearance. The patient feels such anxiety, that he cannot long remain in one posture, and requests, that his leg may be quickly taken off, as it Incommodes him severely, and he expe- riences very acute pam in the knee. When all these characteristic symptoms are conjoined, says M. Larrey, we should not hesitate to amputate immediately; for, the leg would be attacked with sphacelus the same day, and the patient would certainly perish. M. Larrey next adduces several in- teresting cases in support of the preced- ing observations. , Etglith case When a large gynglimoid articulation, such as the elbow, or espe- cially the knee, has been extensively opened with a cutting instrument, and hood is extravasated in the joint, M. Larrey deems immediate amputation ne- cessary. In these cases, the synovial membranes, the ligaments and aponeu- roses, inflame; the part swells, and ere- thismus rapidly takes place and jcute pains, abscesses, deep sinuses, caries, febrile symptoms and death, are the speedy consequences. M. Larrey has seen numerous subjects die of sucli injuries, on account ot the operation having been postponed with a hope of saving the limb. In his Memoires de Chirurgie Militaire, Tom. 2, some of these are detailed. Although a wound may penetrate a joint, yet, if it be small and unattended with extravasation ot* blood, M L rrey informs us, it will generally heal, pro- vided too much compression be not em- ployed. This gentleman believes in the Common doctrine of the pernicious effect ofthe air on the c vities ofthe body; yet, in this place, a doubt seems io .ft'ect him: speaking of the less danger of small wounds of joints, he says; " a quoi tient cette difference, puisque Pair penetre dans Particulation dans Pun comme duns Pautre cas?' When two limbs have been ai the same time so injured, as *o requ re amputation, we should not be afraid of ampu atmg tlie.n both immediately, without any in- terval. We liave, says M L.nvv, se- veral times performed this double am- putation, with almost as much success, as the ampliation of a single member. He has recorded an excellent case in con- firmation of 'his statement. .Mem. de Chirurgie Militaire, Tom. 2-p. 478) W un a limb is different y injured at the same time in two places, and one of the wounds requires amputation, (sup- pose a wound of the leg with a splintered fracture of the bone, and a second of the thigh, done with a bill, but, without any fracture ot the os femoris, or otiier bad accident) M. Larrey recommends us, first to dress the simple wound of the thigh, and amputate the leg immediately afterwards, if the knee be free from in- jury. When it is necessary to amputate above this joint, the less important wound need not be* dressed, till after the opera- tion, provided it can be comprehended 526 GUN-SHOT WOUNDS. in the section of the. member, or be so near the place of the incision as to alter the indication. When the wound, de- manding amputation, is the upper one, the operation of course is to be done above it, without paying any regard to the injury situated lower down. M- Larrey, however, approves of de- ferring the operation, when dehrium, con- vulsions, and inflammation prevail on the fir-t receipt of the injury. In this circumstance, we are advised to take measures for appeasing these accidents; the progress of nature is to be carefully observed; and the first moment of quiet is to be taken advantage of, for the per- formance of the operation. (See Larrey's Mem. de Chirurgie Militaire, Tom. 2. p. 451, &c) OF GCN'-SHOT WOUNDS, IV WHICH AMPU- TATIOX MAX BE DEFERRED. If, says M. Larrey, it be possible to specify the cases, in which amputation ought 10 be immediately performed, it is impossible to determine d priori those, which will require the. operation subse- quently. One gun-shot wound, for ex- ample, will be cured by ordinary treat- ment, while another, that is at first less severe, will afterwards render amputation indispensable, whether this be owing to the patient's bad constitution, or the fe- brile complaints, which are induced. However this may be, the safe rule for fulfilling the indication, that presents itself, is to amputate consecutively only in circumsraiices, m which, every en- deavour to save the limb is manifestly in vain. Upon this point M. Larrey's doc- trine differs from that of Faure. , The latter practitioner admits ca«es, which he terms cases of the second kind, in which he delays amputation, not with any hope of saving the limb, bu\ in order to let the first symptoms subside. The operation, done between the fifteenth and twentieth day, appears to him less dan- gerous, than when performed immediately after the receipt of (he injury. At the above period, according to M. Faure, the commotion, occasioned by the gun- shot injury is dispelled ; the patient can reconcile himself to amputation, tiie mere mention of which fills the pusiUanimous with terror in a greater or fesser degree; the debility ofthe indivi iual is no objec- tion ; and it is laid down as an axiom " that the consequences of every ampu- tation, done in the first instance, are in general extremely dangerous." In sup- port of his theory, M. Faure adduces ten cases of gun-shot injuries, in which after the battle of Fontenoy, the operation was delayed, in order that it might after- wards be performed with more success : a plan, which, according to the author, proved completely successful. (See Prix ile PAcad. de**Chirurgie, Tom. 8, Edit. tr. 12mo.) This division of the cases for amputa- tion into two classes, not consistent with nature, observes M. Larrey, has been the cause of a great deal of harm. Very of- ten the partisans of M. Faure have not dared to resort in the first instance to amputation, the dangers of which they exaggerate; while, on other occasions, they amputate, consecutively, without any suefcess. The effects of commotion, instead of increasing, says M. Larrey, gradually di- minish and disappear after the opera- tion. The proximate cause of all tiie ill effects of such commotion, is ascribed by this experienced author to the violent percussion of the foreign body, which percussion i6 propagated extensively to every part that is susceptible of it. Ac- cording to toe same writer, it is also ow- ing to the laceration, or incomplete sec- tion of the injured nerves, and the in- flammatory turgescence of the vessels. The speedy amputation of the limb must then produce a favourable change in the whole animal economy. In fact, the tense nerves,on being divided, says he, are setat liberty, and the fluids circulate with great- er facility; the irritation, which always accompanies terrible inj uries, is appeased; and the loaded vessels get rid of" their re- dundant blood, and contract. Constric- tion, inflammation, and erethismtis, which always complicate gre »t lacerated wounds, according to M Larrey, are thus pre- vented. It is then proved, says he, that the commotion, so far from being a counter-,ndication to immediate amputa- tion, is a reason that should incline the surgeon to operate. Such was the senti- ment of La Murtiniere and Boucher. M. Larrey next cites some cases in sup. port of the foregoing observations; but, these 1 shall here omit, in order that the pres-ent article may not be immoderately enlarged. Neither ought the patient's alarm to be a reason for postponing the operation; for, according to M. Larrey, the patient, just after the accident, will be much less afraid of the risk, which he has to encounter, than after the expiration of the first four and twenty hours, when he has had time to reflect upon tlie consequences ofthe injury, or of amputation. This remark has been made by the illustrious Pire. " Experience, agreeing with my theory, (says M. Larrey) has proved both to the army and navy surgeons, that the bad GUN-SHOT WOUNDS. 527 Symptom* which soon follow such gun- shot injuries, as must occasion the loss ofa Umb, are much more to be dreaded, than those of immediate amputation. Out of a vast number of the wounded, who suffer- ed amputation in the course of the first four and twenty hours after the memo- rable naval battle of the first of June, 1794, a very few lost their lives. This fact has been attested by several of our colleagues, and, especially, by M. Fercoc, surgeon of the ship le Jemmappe." The following is said to be an extract from one of his letters. " After the naval engagement on the first of June, 1794, a great number of amputations were done immediately after the receipt of the injuries. Sixty of the patients, whose limbs had been thus cut off", were taken to the naval hospital, at Brest, and put under the care of M. Duret. With the exception of two, who died of tetanus, all the rest were cured ; and there was one, who had had both his arms amputated. The surgeon of the Temeraire, which ship was captured by the English, was desirous in compliance with the advice of their medical men, to defer the operation, which many of the wounded stood in need of, till his arrival in port; but, he had the mortification to see them all die during the passage, &c." M. Larrey next acquaints us, that, when he was* sent to the army of Italy, in 1796, he had also the pain of seeing, in the hospitals, great numbers of the wounded fall "victims to the confidence, which many of the surgeons of that army placed in the principles of M. Faure. General Bonaparte saw, that the ambu- lance volante was the only thing, that, in the event of fresh hostilities, could pre- vent such accidents; and, in consequence of his orders, M. Larrey formed the three divisions d'ambulance which are describ- ed in his Memoires de Chirurgie Mili- taire. , Since this period it has always been customary in the French armies, on the day of battle, to make every preparation for performing amputations as speedily as possible. The mere sight of these ambu- lances, (always attached to the advanced guard,) says M. Larrey, encourages the soldiers, and inspires them with the greatest courage. On this occasion, the following anecdote is cited from Ambrose Pare. This famous surgeon having been ur- gently sent for by the duke de Guise, be- sieged in Metz, to attend the wounded of his army, who were in want of assistance, Ambroise Pare* was shewn to the frighten- ed soldiers, at the breach. Upon this, they immediately filled the air with shouts of the most lively joy, and cried out: " Nous ne pouvons plus mourir, s' il arrive que nous soyons blesses, puisque Pare est parmi nous" Their courage revived, and their confidence in this skilful surgeon, contributed to the preservation of a place, before which a formidable army was de- stroyed. M. Larrey desires us to interrogate the invalids, who have lost one, or two of their limbs, and nearly all will tell us, that they suffered amputation a few mi- nutes after the accident, or in the first four and twenty hours. " If Faure now retains any partisans," says M. Larrey, " I recommend them to repair to the field of battle, the day after an action ; they would then soon be con- vinced, that, without the prompt per- formance of amputation, a great number of soldiers must inevitably lose their lives. In Egypt, this truth was particu- larly manifested." The following communication upbn this point was made to M. Larrey by M. Masclet, a French surgeon on duty at Alexandria. " In the naval hospital of this port, I have seen eleven soldiers, or sailors, who were wounded in the naval action off Aboukir, arid who had suffered amputa- tion in the first four and twenty hours. In five of these ca'ses, the operation had been done on the arm; in two, on the thigh ; and, in three others, on the leg. All these men are recovering. In the army hospital, there have been only three thigh-amputations, which were perform- ed seven or eight days after the battle, - and these three patients died a few days after the operation, although the opera- tion was done methodically, and no grave symptoms prevailed at the time of its per- formance. You see, sir, experience has, in this instance, quite confirmed your principles." hi 1780, during the American war, we are informed by M. Larrey, that the sur- geons of the French army performed a great number of amputations, according to the opinion then generally adopted in France, that the operation should not be undertaken till after the subsidence of the first symptoms. Almost all the pa- tients, thus treated, died after the opera- tion. On tiie contrary, the Americans, who had tbe boldness to amputate im- mediately (or in the first twenty-four hours) upon many of their wounded countrymen, lost only a very few. ' Yet, M. Dubor, at that time surgeon to the Artois dragoons, and from whom M. Lar- rey has collected this fact, relates, that the situation of the hospital for the French 5"S8 GUN-SHOT WOUNDS wounded Was, on many accounts, -he most advantageous. (See Dubor's These Inaugurate soutenne 16 Septembre, 18U3, d PEcole de Strasbourgh.) Admitting, says M. Larrey, that, by a concurrence of fortunate circumstances, which are not always to be calculated upon, some patients escape the dan- ger of the first symptoms, this proves nothing- in favour of doing the operation afterwards ; it must be seen what nature will do towards the event of the case. If, at the end of twenty, or thirty days, the prognostic is as bad as it was previ- ously, amputation cannot be avoided. Thus all the sufferings, which the patient has endured, have been undergone for nothing, and the operation will now be attended with considerable risk, inas- much as the patient may lie in a dan- gerously weakened state. If nature revives at all, no doubt, the success of the operation becomes more probable; but, in this case, the surge n, instead of having recourse to amputation, should redouble his efforts to preserve the Umb. CASES DEMANDINO AMPUTATION CONSE- CUTIVELY. M. Larrey gives us the annexed infor- mation upon this subject. . First Case. A spreading Mortification. If the disorder be owing to an internal and general cause, it would then be rash- ness in the surgeon to amputate before nature had put limits to the disease. This kind of gangrene, according to M. Lar- rey, is distinguished from that, which is named traumatic, by the symptoms, which precede and accompany it. These symp- toms are similar to those, which are ob- served in nervous ataxia, or adynamia. Here the operation ought to be deferred, and endeavours made to combat the ge- neral causes with regimen and internal medicines. But when the gangrene is traumatic, the limb, says M. Larrey, should be im- mediately cut off above the disorganized part. Several facts, in support of this advice, are related by this experienced surgeon in his Memoire sur la Gangrene Traumatique. How contrary this advice to that incul- cated by Sharp, Pott, and all the most eminent surgeons of the present time! Second case. Convulsions ofthe wounded Limb Amputation of the member, per- formed immediately the first symptoms of tetanus manifest themselves, interrupts all communication between the source of the disorder, and the rest of the body. The operation, according to M. Larrey, unloads the vessels, and thus puts a stop to the tension of the nerves, and to the c-nvulsions of the muscles. These first effects, he say s, are followed by a general collapsus, which promotes the excretions, sleep, and the equdibrium of every part of 'he system. The "whole of the momentary pain, caused by the operation, cannot increase the existing irritation: besides the suf- fering*, of tetanus render those of am- putation, more bearable, and lessen their intensity, especially, when the principal nerves of the limb are strongly com- pressed. Third case. Bad State of the Discharge. It often happens, tha*, in gun-shot wounds, complicated with fractures, notwithstand- ing the most skilful treatment, the dis- charge becomes of a bad quality ; the fragments of bone lie surrounded with the matter, and have not the least ten- dency to unite; tije patient is attacked with hectic fever, and a colUquative di- arrhoea Under these circumstances, life may sometimes be preserved by ampu- tation. Fourth Case. Bad state of the Stump. In hospitals, says M. Larrey, the cure of amputations is sometimes prevented by a fever of a bad character. The stump sweUs, the integuments become at first retracted, and then reverted and diseased a good way upward. The wound changes into a fungous ulcer, the cicatrization of which is hindered by the deep disorder of the bone, and the ulceration of the soft parts. The extremity of the bone pro- jects. In order to remedy this last evil, it has been proposed to saw off the pro- jecting part of the Lone, and with tliis, even to amputate all the flesh beyond the level of the skin. M. Larrey condemns such practice as unnecessary and dan- gerous, and he recommends giving na- ture time to effect the exfoliation of the diseased projecting part of the bone, and heal the wound. The foregoing obser- vation's, relative to amputation in cases of gun-shot wounds, are taken from the lat- ter part of the second volume of Lar- rey's Memoires de Chirurgie MiUtaire. GUN-SHOT WOUNDS OF THE ABDOMEN. These cases may be divided into two kinds; one only"penetrates the parietes of the belly, without hurting the contain- ed parts ; the other does mischief also to the viscera. The event of these two kinds of wounds is very different. In the first, Uttle danger is to be expected, if properly treated: but, in the second, the success w'dl be extremely uncertain, fof, in many instances, nothing can be done for the GUN-SHOT WOUNDS. 529 patient, and on other occasions, a good deal of art may be employed with ad- vantage. It is observed by Mr. Hunter, that such wounds of the abdomen as do not injure parts like the stomach, intestines, blad- der, ureters, gall-bladder, large blood- vessels, &c. all which contain particular fluids, will generally end well. But, he adds, that there wiU be a great difference, when the ball has passed with immense velocity, as a slough will be produced; whereas, when the ball has moved with less impetus, there will not be so much sloughing, and the parts will, in some degree, heal by the first intention. Even when the ball occasions a slough, the wouhd frequently terminates well, the ad- hesive inflammation taking place on the * peritoneum, all round the wound, so as to exclude the general cavity of the ab- domen, from taking part in the inflamma- tion. Such is often the favourable event, when the ball, besides entering the ab- domen, has wounded parts Uke the omen- tum, mesentery, &c. and gone quite through the body. (Hunter on Inflamma- tion; Gunshot Wounds, &c. p. 543.) In gun-shot wounds of the belly, an extravasation is apt to take place on the sloughs becoming loose, about eight, ten, twelve, or fourteen days, after the acci- dent ; but, says Mr. Hunter, although this new symptom is in general very dis- agreeable, most of the danger is usually over, before it can appear. In the article, Abdomen, we have de- tailed at large the general principles, which should be observed in the treat- ment of wounds of the belly, and, in or- der to avoid superfluous repetitions, suf- fice it in the present place to refer to that part of the dictionary. .-' For the purpose . of illustrating the mode of treating gun-shot wounds of the abdomen, complicated with injury of the intestines and bladder, I shall lay before the reader the annexed observations from M. Larrey. At the assault of Cairo, 1799, M. N. was shot in the abdomen with a ball, which divided the muscular parietes of tliis cavity on the right side, and a por- tion of the ilium. M. Larrey being upon the field of battle, gave him the first assistance. The two ends of the intestine were protruded, separated from each other, and inflated. The upper end was everted, in such a way, that its contracted edge, like tiie prepuce in a case of para- phymosis, strangulated the intestinal tube. The course of the fecal matter was thus obstructed, and the contents of the bowel accumulated above the constric- tion. Voi. I. Although the patient's recovery was nearly hopeless, both from the nature of tiie wound, and from the debility and cholera morbus, which had already seized him in the short period, that he remained without succour in one of the intrench- ments, M. Larrey was desirous of trying what could be done for so singular a case. This eminent military surgeon first made four small cuts, through the con- stricted part of the intestine, with a pair of curved scissars, and put tiie bowel injo its ordinary state. He passed a ligature through the piece of the mesentery, cor- responding to the two extremities of the bowel. These he reduced as far as the margin of the opening, which he had taken care to dilate, and'the dressings having been applied, he awaited events. The first days were attended with alarm- ing symptoms, wliich, however, after- wards subsided. Those, which depended upon the loss of the alimentary matter, successively abated: and, after two- months, the ends of the ilium were oppo- site'each other, and disposed to become connected together. M. Larrey second- ed the efforts of nature, and dressed the patient with a tampon, or sort of tent, that was occasionally .employed for two> months. The patient was. then discharged from the hospital quite cured. In several instances, say M. Larrey, the signoid flexure of tlie colon, was in- jured, and yet the wounds were cured without any fecal fistulae. At the siege of Acre, three examples occurred ; and, at that of Cairo, two. JM. Larrey toolc care to dilate well the entrance and exit of the ball. Clysters, made of a decoc- tion of linseed, and emollient beverages were frequently exhibited ; and the pa- tients were kept on low diet, and in tiie most quiet state. M. Larrey informs us, that the gun-shot wounds of the bladder, which occurred in Egypt, had for the most part a favourable termination. The most remarkable case was that ofoFrancis Chaumette, a light horseman, who was wounded at the battle of Tabor. The ball passed across the hypogastrium, about one finger-breadth above the pubes, to the point of the left buttock, which corresponds to the ischi- atic notch. The direction of the wound, and the issue of feces and urine from the two orifices, could not let M. Larrey doubt, that the bladder and rectum were injured. M. Milioz, who directed the surgical affairs of the division of the ar- my under Kleber, diligently pursued the same kind of treatment which he had seen M. Larrey adopt at the siege of Acre. During the suppurative stage, the 5 Y 530 GUN SHOT WOUNDS. patient was affected with fever; and, aftev the sloughs were detached, the dis- charge was very copious. A catheter, that was passed into the bladder, pre- vented an extravasation of the urine, and, at the same time, promoted the union of the wound of that viscus. This was healed'the first, and the patient upon his return to Cairo, was quite cured. M. Larrey has recorded several other interesting cases of wounds of the blad- der, to which I must content myself with referring. (See -Memo/res tie Chirurgie Militaire, Tom. 2, p. 160—165. Tom. 3, p. 340, &c. . This experienced military surgeon of- fers the following as a succinct account of the results of such injuries, and the treatment, which is proper. During the first four and twenty hours very Utile urine escapes from gun-shot wounds of tiie bladder, in consequence of the swelling, which almost instantly af- fects the lips of the wound. When the bladder is full, this fluid is only dis- charged at the moment of the accident, and only from the wound, by which the ball has made its exit. An extravasa- tion is prevented by the thick slough, which fills all the track of the injury, and it is not till the deadened parts become loose, that any effusion can happen. Hence, «it is of the highest importance to have an elastic gum catheter intro- duced into the urethra, where it should be kept, and the instrument should be large enough to fill exactly this Canal; for.af at the period, when the sloughs are detached, tiie urirte has not a ready pas- sage outward, it passes through the wound, and is extravasated the more readily, inasmuch as the separation of the sloughs has occasioned many openings, by which the fluid may insinuate itself into the cellular membrane. Hence, gangrenous mischief and death. After having weU dilated the wounds, in order to facilitate the escape of the urine, which might lodge in the track of the ball, a large elastic gum catheter should be introduced and left in the bladder, taking care to withdraw i*, and pass in a clean one every two or three days, so that no incrustations may occur. Emollient clysters, and acidulated de- mulcent drinks are to be prescribed, and the patient is to be kept upon a very low regimen, and in the most quiet state. The dressings are to be simple, and cleanli- ness observed. (Op. cit. T. 2, p. 165— 170.) GUN-SHOT WOUNDS OF TIIE THOH.IX. Wounds of the lungs, abstracted from other mischief, are now well known not to be always fatal. Mr. Hunter had some reason to believe, that wounds of the lungs, made with balls, were gene- rally less dangerous, than such as were made with sharp-pointed instruments; for, he had seen several patients recover, after they had been shot through the lungs, while other persons died of very small wounds of those organs, done with swords and bayonets. Perhaps, one cause of this fact may be owing to the circumstance of gun-shot wounds bleed- ing less, than other wounds, so that there is not so much danger of blood being ef- fused in the cavity of the chest, or the cells of the lungs. The indisposition of the orifice of a gun-shot wound to heal up too soon, is also another circumstance, that must lessen the hazard, as whatever matter happens to be extravasated has thereby an opportunity of escaping. But, from what has been stated, it must not be inferred, that gun-shot wounds of the lungs are not accompanied with a serious degree of danger. Fre- quently, the patient expires instantly, being suffocated in consequence of the hemorrhage from those organs; for, though it be true, that gun-shot wounds generally do not bleed much, when the injured vessels are under a certain size, yet, the contrary is the case, when the wounded vessels are like those, which exist towards the root of the lungs. Gun- shot wounds of the chest also often prove fatal by the inflammation, that is excited Within this cavity. It cannot be supposed, that adhesions take place round the opening of a gun- shot wound in the chest, because the lungs collapse, and become considerably distant from the pleura, whenever a free communication is established between the atmospheric air in the cavity of the thorax. However, as adhesions are ex- tremely common between the outer sur- face of the lungs, and the inner surface of the pleura costalis, they must, in many instances, exist before the receipt of a wound, and of course, prevent the usual collapse of the lungs. The general symptoms, and also the treatment of wounds ofthe chest, are de- tailed in tie article, 'Thorax. Suffice it in ihe present place to observe, that, when a patient has been shot in the chest, the most important indication is to pre- vent and subdue inflammation of the lungs and pleura. In few other cases, can repeated and, large bleedings be so advantageously practised. Tiie patient is also to be kept on the lowest diet, take febrifuge medicines, and, if he be much disturbed with a cough, ti ir une Jambe ecrasee par un Obus, ou petite bombe, par M. Cannae. 5. Sur une Plaie a la partie inferieure et interne de la Jambe faite par un edut de Grenade, sans fracas d'os ; par M. Cannae. 6. Precis tie plu- sieurs Observations sur les Plaies d'armes d feu en differentes parties par M. Borde- nave. All these paper* are insertedin Mem. de l'Acad. de Chirurgie, Tom. 6, in 12mo, and in Tom. 11 of the same edition, are in- serted Memoire sur le traitment des Plaies d'armes, A feu, par M. de la Martin&re, and Memoire sur quelques particularites concernant les Plaiesfaites par arrnes dfeu, par M. Vacher. M. Faure's memoir rela- tive to amputation in cases of gun-shot wounds may be seen in 'Tom. 8, ofthe Rear eil ties Pieces qui out concouru pour le Prix de l'Acad. de Chirurgie, Edit, in 12mo. John Hunter's Treatise on the Blood, Inflam- mation, and Gun-shot Wounds. Richter'* Anfangsgrunde der Wundurzneykunst,Band 1. Schmucker's Chirurgische Wahrnehmun- gen. Richerand's Nosographie Chirurgi- cale, Tom. 1, p. 217, &c. Etlit. 2. Cheva- lier's Treatise on Gun-shot Wounds, Edit. 3. Leveille's Nouvelle Doctrine Chirurgi- cale, Tom. 1, Chap. 8, p. 436, &c. Encyclo- pedic Methodique, Partie Chirurgicale, art. Plaies (Parities a feu. Larrey's Memoires de Chirurgie Militaire. GUTTA SERENA. A term, said to have been first applied by Actuarius to amaurosis, or the species of blindness arising from an insensible state of the re- tina, or optic nerve. (See Amaurosis.) Under this latter head, I have treated of the subject so fully, that it is not my intention to expatiate upon it here. How- ever, as there is one particular case, not noticed in the article, amaurosis, I must take the present opportunity of mentioning it. According to the observations of Mr. Ware, persons, who labour under this disorder, are not unfrequently subject to a particular kind of ophthalmy, which occasions a most excruciating pain, and seems to require a peculiar mode of treat- ment. At the close of the remarks pub- Ushed on the ophthalmy, fistula lacluy- malis, &c. by Mr. Ware, this gentleman has introduced a case of this kind, which was greatly relieved by making a punc- ture through the tunica sclerotica into the ball of the eye with a grooved needle, somewhat larger than a common sized couching needle, nearly in the part, where this instrument is introduced in the operation of depressing the cataract. Through the groove of the instrument, a watery fluid immediately issued, which was not unlike that which Mr. Ware has several times seen effused between the choroid coat and retina after death, in cases of* gutta serena. After the pun of the operation had ceased, the patient be- came quite easy, and the inflammation soon subsided. Since this example, Mr. Ware has performed a similar operation in a considerable number of resembling instances, and in several of them the pro- ceeding has been attended almost imme- diately with manifest good effects. For further information on this subject, the reader must refer to Ware on tlie ope- ration of largely puncturing the capsule of the crystalline humour, &t. and on the Gutta Serena, accompanied with pain and inflam- mation, 1812. END OF THE FIRST VOLUME. ♦ •\ •**- Mei. Wist WZ. *7a C77S^ *o ■■i#& $ ,,. -4* *..;v .>; -% ^v. 4r"* v -'*r.«: ■*S-*v .*'•'■*.,. & "■- -tu'-C ;* i ,**•-: •■"•"r ; ' J1 ■;%■■>* < .*»***'*,-x. VJ, ■i': *** •**■*/ ,-*' > *J"fe' -»>p dR**?^ * ■*-* «' . ..* fl|V - • _ ~n -• »,■* , * ■ 11 ,'' '*■'•'■ * ■ -■ /.' *■* ">"*%"- './,■* <-%-*,''■ :it •#• "^ i'V, -*■ "**;*>• ;*